- Email: [email protected]
Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses with conventional loading
YIJOM-3256; No of Pages 6
Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2015.09.011, available online at http://www.sciencedirect.com
Clinical Paper Dental Implants
Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses with conventional loading
N. Y. Altintas1, F. Taskesen2, B. Bagis3, E. Baltacioglu4, B. Cezairli1, F. C. Senel1 1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey; 2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erzincan University, Turkey; 3Department of Prosthodontics, Faculty of Dentistry, Katip Celebi University, Izmir, Turkey; 4Department of Periodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey
N. Y. Altintas, F. Taskesen, B. Bagis, E. Baltacioglu, B. Cezairli, F. C. Senel: Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses with conventional loading. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. This retrospective study assessed the success of immediate and nonimmediate implants installed in patients undergoing planned extraction of all remaining teeth and rehabilitation with implant-supported full fixed prostheses. Patients in need of dental implants for full fixed prostheses to replace teeth extracted in the maxilla and mandible were included in this study. Dental implants were installed in the same surgical procedure, immediately at the extraction site, or in healed bone. Implant success, complications, and failures were recorded during follow-up. Forty-one patients with 512 implants were included in the study. Healing progressed uneventfully for 501 installed implants, but nine implants were lost in the non-immediate group and two were lost in the immediate group, during a mean follow-up of 44.9 months. All failures in both groups were observed in the maxilla. The success rate was the same in both groups, at 97.8%. This retrospective analysis showed that with thorough patient evaluation, the extraction of all residual teeth and implant installation in a single surgical procedure is a safe and predictable treatment modality for the successful rehabilitation of the edentulous patient with a fixed prosthesis.
The use of dental implantation to replace missing teeth has increased dramatically in the last decade, providing new treatment planning opportunities, such as 0901-5027/000001+06
implant-supported fixed restorations for fully and partially edentulous patients.1 However, rehabilitation with fixed fullarch implant-supported prostheses with
Key words: dental implant; implant-supported dental prosthesis; immediate dental implantation; extraction socket; delayed; osseointegration. Accepted for publication 16 September 2015
the extraction of all residual teeth requires a lengthy treatment period. Modern hightempo working lives make it difficult for patients to undergo lengthy treatments
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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Altintas et al.
involving numerous sessions. As implant dentistry has developed, various placement and loading protocols have evolved to provide a quicker and easier surgical approach.2 For patients who have their own teeth but who will eventually lose them, and who plan to undergo implant-supported rehabilitation, all residual teeth can be extracted and implants installed in a single procedure. The reported advantages of immediate implant placement include a reduction in the number of surgical interventions, a shortened rehabilitation time, and higher patient satisfaction compared with late implant placement.3–5 Another advantage of implant placement in the extraction socket is the counteracting of the hard tissue resorption that occurs following tooth extraction.6,7 However, some studies have suggested that immediate implant placement in the fresh extraction socket cannot prevent dimensional ridge resorption.8,9 Previous research has shown that survival rates for immediately placed implants are comparable to those of implants placed in healed alveolar bone.8,10 The purpose of this study was to evaluate the success rates of implants placed in fresh extraction sockets in patients undergoing extraction of all residual teeth for rehabilitation with fixed full-arch implantsupported prostheses, and also to compare the success rates of implants placed in fresh sockets with those of implants placed in mature healed bone. Materials and methods
A retrospective cohort study was performed in order to address the proposed study aim. The study sample was derived from the population of patients treated with dental implants at the department of oral and maxillofacial surgery and the department of prosthodontics of the study institution between June 2007 and June 2012. Patient data and files from these two departments were examined in detail. Patients who had undergone previous extraction of all remaining teeth and implant placement in both healed bone and at the extraction sites in the same procedure were eligible for inclusion. Patients were selected on the basis of inclusion and exclusion criteria. Inclusion criteria were the following: age 18 years, systemically healthy, cooperative and likely to maintain good dental health, and adequate bone height for placement of implants with a minimum length of 7 mm. Teeth were extracted due to root fracture, root resorption, root
perforation, a non-ideal crown–root ratio, or a peri-apical pathology. Exclusion criteria were the following: presence of any local or systemic factors that might contraindicate oral surgery, poor oral hygiene, conditions that complicate wound healing such as uncontrolled diabetes, smoking (10 cigarettes a day), pregnancy, a history of drug or alcohol abuse, and an inability or unwillingness to return for follow-ups after occlusal loading. This study was reviewed and approved by the regional ethics committee and adhered to the guidelines of the Declaration of Helsinki.
Fig. 2. Surgical view of implants installed in fresh extraction sites and in healed bone in the mandible.
Preparations for surgery were performed according to standard protocols. A single experienced surgeon performed all operations. Surgical procedures were performed under local anaesthesia with intravenous sedation. A mucoperiosteal flap was elevated. Before implant placement, selected teeth were extracted carefully and multirooted teeth were sectioned to preserve the remaining bone; this was done on the day of surgery, within the same surgical procedure, by the same surgeon. Granulation tissue was eliminated and the implants were placed in the residual bone and in the extraction sockets, achieving primary stability. The longest and widest possible implants were installed in the residual crest and the extraction sockets in order to achieve an aesthetic profile and maximum vertical preservation (Figs 1 and 2). If a gap occurred between the implant surface and the surrounding bone, a mixture of autogenous bone derived from the drilling of the implant beds and allogenic mineralized bone graft (Puros Allograft; Zimmer Dental Inc., Carlsbad, CA, USA) was inserted. In the case of an insufficient bone level in the posterior maxilla for implant placement, a lateral wall approach sinus augmentation procedure was performed and dental
implants were subsequently installed. The mucoperiosteal flap was adapted and sutured with primary closure to allow healing. Following implant placement and suturing, all patients received antibiotic therapy (amoxicillin and clavulanic acid). Antiinflammatory agents (naproxen sodium) and mouth rinse (chlorhexidine gluconate) were prescribed to all patients for 1 week. Sutures were removed 7 days after surgery. The implants were left submerged for 3 months. Removable provisional prosthesis procedures were performed for those patients who were reluctant to be edentulous during this healing period. After the submerged healing period, patients were invited back for second-stage surgery. Following the re-entry procedure, the soft tissues were allowed to heal for at least another 2 weeks before impressions were taken. Definitive abutments were tightened using 35 N cm torque. Implant-supported fixed full-arch prostheses were then fitted for all patients (Figs 3 and 4). In line with the patient follow-up policy for patients receiving dental implants in the clinic, patients were examined at 3-month intervals for 6 months and then at 6-month intervals for 2 years. Radiographic follow-ups were performed for all patients before and after surgery, and all
Fig. 1. Surgical view of implants installed in fresh extraction sites and in healed bone in the maxilla.
Fig. 3. Final prostheses in the same patient.
Surgical procedure
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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Implant placement in fresh sockets vs. healed bone Table 1. Patient and study variables at baseline. Number of patients Number of alveolar arches treated Demographic variables Age, years, mean (range) Male/female Outcome variable Duration of follow-up, months, mean (range)
Fig. 4. View of the smile after delivery of the final prostheses in the same patient.
considered successful if the following parameters were absent: (1) persistent subjective complaints such as pain, foreign body sensation, and/or dysesthesia, (2) peri-implant infection with suppuration, (3) mobility, or (4) continuous radiolucency around the implant. Removed, lost, mobile, or fractured implants were regarded as implant failures. Statistical analysis
Fig. 5. Postoperative radiographic view of the same patient.
patients were evaluated at 6-month intervals for the first 2 years after loading (Fig. 5). Based on the clinical and radiographic criteria described by Buser et al., each implant was classified as successful or as having failed.11 The implant was
The statistical analysis was performed using SPSS version 13.0 software (SPSS Inc., Chicago, IL, USA). Fisher’s exact test was used to evaluate differences between success rates in immediate and non-immediate implants. The results were considered significant at P-values of less than 0.05. The survival of immediate and nonimmediate implants was investigated using the log rank test. Kaplan–Meier survival estimates were calculated. A separate log rank test was used to identify the effect of timing of implant installation on survival. A 5% type I error level was used to infer statistical significance.
41 82 53.82 (22–67) 18/23 44.9 (24–64)
Results
Forty-one patients (23 female and 18 male) ranging in age from 22 to 67 years (mean 53.82 years), who underwent extraction of all remaining teeth for rehabilitation with an implant-supported fixed full prosthesis between June 2007 and June 2012, were included in this retrospective study. The mean duration of followup was 44.9 months (range 24–64 months). Patient and study variables are shown in Table 1. Five hundred and twelve implants were placed in the 41 subjects. Two implant systems were used: 473 were Zimmer dental implants (Zimmer Dental Inc., Carlsbad, CA, USA) and 39 were Straumann SLA Dental Implant System implants (Straumann, Basel, Switzerland). Of these, 93 (18.2%) were placed immediately into fresh extraction sockets and 419 (81.8%) into healed alveolar bone. Two hundred and sixty implants were placed in the maxilla (38 immediate and 222 non-immediate) and 252 in the mandible (55 immediate and 197 non-immediate) (Tables 2 and 3).
Table 2. Distribution of implants placed in the maxilla. Implant (n) Immediate Non-immediate
Central
Lateral
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Total
1 1 0
6 3 3
69 20 49
65 7 58
31 4 27
61 2 59
27 1 26
260 38 222
Table 3. Distribution of implants placed in the mandible. Implant (n) Immediate Non-immediate
Central
Lateral
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Total
2 1 1
7 1 6
54 23 31
61 15 46
32 7 25
61 5 56
35 3 32
252 55 197
Table 4. Distribution of failed implants. Tooth #13 Diameter Length Total Immediate Sinus lift
3.3 12
3.7 11.5 2 0 0
#14
#15
3.3 10
3.7 10 1 0 0
#16 3.7 10
3.7 10 2 2 2
3.7 10
4.1 10 3 0 2
#24
#25
#27
3.7 13 1 0 0
3.7 11.5 1 0 0
4.1 10 1 0 1
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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Only 11 of the 512 implants in the 41 patients were lost (Table 4). Eight implant losses occurred at second-stage surgery before prosthetic treatment and loading procedures, and three implants were surgically removed 1 year after loading. All the implant failures were in the maxilla, none being lost in the mandible. Of the 260 implants in the maxilla, nine were lost in the non-immediate group and two in the immediate group. The two implants that failed in the immediate group were inserted using the sinus membrane elevation procedure. In terms of non-immediate implant failures, two of the nine implants were installed using sinus membrane elevation. The failed implants were replaced with new implants, and bone grafts were applied if necessary. The success rate in the immediate group for all implants was 97.8%, and the success rate in the non-immediate group was also 97.8%. The success rates for implants in the mandible were 100% for both the immediate and non-immediate groups. The success rate of implants in the maxilla was 94.7% in the immediate group and 95.9% in the non-immediate group. The results of the Fisher’s exact test showed no significant difference between the immediate and nonimmediate implant placement groups, which both exhibited significant individual success rates. Kaplan–Meier analysis of survival functions for the immediate and non-immediate implants revealed no significant differences between the two groups over time. Discussion
The extraction of residual teeth and placement of implants in the same surgical procedure represents a successful approach to minimizing the treatment time without reducing predictability with regard to standard protocols, especially in the rehabilitation of patients with full fixed prostheses.12 For the purpose of this study, the primary research question was whether the success rate of implants placed in fresh extraction sockets would be comparable to that of non-immediate implant placement in patients undergoing single-stage surgery for implants supported by full fixed prostheses. The results of this study suggest that (1) there was no difference in success rate between the immediate implant group and the non-immediate implant group, (2) both study groups exhibited significant individual success rates, and (3) the immediate treatment modality is as predictable as conventional implant treatment in patients undergoing a single-stage procedure for
fixed full-arch prostheses. Although the sample undergoing immediate placement was significantly smaller than that undergoing placement in the healed bone, this study was designed to evaluate the implants for implant-supported full-arch fixed prostheses and to categorize the implant placement type in these patients. The results are comparable to those reported in recently published studies concerning immediate implant placement. In a study with a design similar to that of the present study, Penarrocha-Diago et al. reported a higher success rate in the immediate implant group than in the conventional group.4 The study also demonstrated that immediate implant osseointegration can be as successful, or more successful, than non-immediate implantation in the same healing protocol.4 Covani et al. reported that implants placed into fresh extraction sockets exhibited a very high cumulative success rate (97%) over a follow-up period of 4 years.13 Consistent with prior reports, greater success rates for mandibular implants than for maxillary implants were observed in the present study. Lang et al., in a review study, reported that implants in the mandible had a lower estimated failure rate than those placed in the maxilla.14 The greater success rate in the mandible may be attributed to bone type and content, both at the extraction site and in mature bone. The mandible contains a larger proportion of lamellar bone than the maxilla, and the maxillary posterior area comprises bone of type 4 quality, which can affect the primary stability of implants.1,14 Schwartz-Arad et al. reported lower survival rates in the maxilla in both immediate and non-immediate groups, in agreement with the results of the present study.1 In a separate study, the same authors reported that immediate implantation in the posterior mandible resulted in a better prognosis than implantation in the posterior maxilla.15 On the other hand, Cafiero et al. detected no difference in terms of the survival rate between maxillary and mandibular molars after 12 months.16 In the present study, only two implants were lost in the immediate placement group, and the two implants that failed had been implanted with sinus floor augmentation. Immediate implants installed in the extraction site are usually as long and wide as possible in order to achieve primary stability. However, implant placement with sinus floor elevation limits the implant length. The failure of two implants in the immediate group may have been due to lower primary stability of the implants and a lack of bony wall adjacent
to the implant on the apical side of the implant. Fugazzotto and De Paoli extracted maxillary molars while concomitantly augmenting the sinus. These authors placed 167 implants in regenerated bone and reported a cumulative implant success rate of 97.8%.17 In contrast, Bruschi et al. demonstrated that management of the sinus floor procedure in first molar sockets allowed resorbed posterior maxillary alveolar bone to expand both vertically and horizontally, with a 100% implant osseointegration success rate after a mean 9.76 years of follow-up.18 Sinus lift procedures were included in the present study because patients with implant-supported full-arch fixed prostheses were enrolled, and therefore all implants in those patients had to be considered. With immediate implant placement, a gap may occur between the implant installed and the bony wall of the extraction socket. A mixed autogenous and allogenic mineralized bone graft was used in all patients in this study when a gap was observed. In a review of immediate loading of post-extraction implants in the aesthetic area, Del Fabbro et al. reported no significant differences in clinical outcomes in terms of graft type, or between grafted and non-grafted cases.12 These results compare favourably with those of the study by Penarrocha-Diago et al., in which the authors suggested that a gap greater than 2 mm does not seem to influence implant failure.4 Nevertheless, Ortega-Martinez et al. have recommended grafting if the jumping distance between the socket wall and the implant surface exceeds 2 mm.2 Schropp and Isidor have recommended grafting, especially of existing fenestrations, dehiscence, and larger bony defects, but have stated that there is no evidence that any one technique or material is superior to the others.6 The original implant treatment protocol recommended primary covering of the implant with mucosa after placement, in order to protect the implant site against bacterial contamination. However, transmucosal installation of the implant is an absolute treatment option that has been demonstrated to perform as well as the submerged approach.6 In immediate placement, the need for and use of bone graft represents a challenge for transmucosal implants in terms of success or failure. Several studies have reported good results with non-submerged or transmucosal implants.19,20 However, Gokcen-Rohlig et al. have recommended closure of soft tissue over the operation site at which advanced augmentation procedures have
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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Implant placement in fresh sockets vs. healed bone been performed, in order to achieve results similar to those of delayed implantations.3 In the present study, primary closure of the flap was preferred when possible, in order to protect the graft material placed in the gap between the bony wall and immediate implant and to achieve the same surgical conditions as those in the non-immediate group. The patients in this study were all treated with implant-supported fixed full-arch prostheses. The patients’ requirements and needs were considered during treatment planning, and immediate implant installation was decided on in order to achieve a shorter treatment time. Patients find it difficult to wait for up to 6 months for an extraction site to heal, followed by an additional 3–6 months for the implant to osseointegrate. The other advantage of the treatment modality is preservation of the bone and gingival tissues. Following tooth extraction, bone resorption occurs at a greater rate, especially for the first 6 months, unless an implant is installed or a socket augmentation procedure is performed.7 However, Araujo et al. demonstrated that immediate implant placement in a tooth extraction socket is unable to preserve the hard tissue dimensions of the ridge following tooth extraction.9 Lang et al. also reported that implants placed in extraction sockets were unable to prevent soft tissue loss, especially buccal marginal tissue recession.14 Chen et al. reported a significant relationship between the frequency of recession and the buccolingual position of the implant.21 Gingival margins did not play a significant role in the cases in the present study because all patients were treated with implant-supported fixed full-arch restorations. Careful preoperative evaluation of the implant sites and placement of implants in the correct position prosthetically are therefore essential for successful clinical outcomes. Within the limitations of the sample number and absence of detailed postoperative radiographic examination, the extraction of all residual teeth and placement of implants in a single surgical procedure is a safe and predictable treatment modality. Immediate implant placement is as successful as conventional non-immediate implant placement in patients receiving implant-supported fixed full prostheses. The present protocol also offers many advantages to the patient as well as the clinician. Nevertheless, careful patient selection and treatment planning appear to be of critical importance in achieving a predictable treatment outcome. The data from this retrospective
analysis involve only immediate and non-immediate implant success rates at a mean follow-up of 44.9 months. Further studies should include a more detailed analysis, consisting of different prosthetic types and different implantation times (immediate, early immediate, delayed, and mature) and detailed investigation of radiographs to compare hard and soft tissue changes. Funding
This research had no source of funding. Competing interests
The authors declare that they have no conflict of interest. Ethical approval
This study was reviewed and approved by the regional ethics committee, Karadeniz Technical University, Faculty of Medicine Local Ethics Committee (reference number 2012–128). Patient consent
Not required. Acknowledgement. We are grateful to Dr Tamer Tuzuner for the statistical analyses.
References 1. Schwartz-Arad D, Grossman Y, Chaushu G. The clinical effectiveness of implants placed immediately into fresh extraction sites of molar teeth. J Periodontol 2000;71:839–44. 2. Ortega-Martinez J, Perez-Pascual T, Mareque-Bueno S, Hernandez-Alfaro F, FerresPadro E. Immediate implants following tooth extraction. A systematic review. Med Oral Patol Oral Cir Bucal 2012;17:e251–61. 3. Gokcen-Rohlig B, Meric U, Keskin H. Clinical and radiographic outcomes of implants immediately placed in fresh extraction sockets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e1–7. 4. Penarrocha-Diago MA, Maestre-Ferrin L, Demarchi CL, Penarrocha-Oltra D, Penarrocha-Diago M. Immediate versus nonimmediate placement of implants for full-arch fixed restorations: a preliminary study. J Oral Maxillofac Surg 2011;69:154–9. 5. Soydan SS, Cubuk S, Oguz Y, Uckan S. Are success and survival rates of early implant placement higher than immediate implant placement? Int J Oral Maxillofac Surg 2013;42:511–5.
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6. Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. J Oral Rehabil 2008;1:33–43. 7. Bhola M, Neely AL, Kolhatkar S. Immediate implant placement: clinical decisions, advantages, and disadvantages. J Prosthodont 2008;17:576–81. 8. Botticelli D, Berglundh T, Lindhe J. Hardtissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820–8. 9. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006;17:606–14. 10. Paolantonio M, Dolci M, Scarano A, d’Archivio D, di Placido G, Tumini V, et al. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J Periodontol 2001;72:1560–71. 11. Buser D, Janner SF, Wittneben JB, Bragger U, Ramseier CA, Salvi GE. 10-year survival and success rates of 511 titanium implants with a sandblasted and acid-etched surface: a retrospective study in 303 partially edentulous patients. Clin Implant Dent Relat Res 2012;14:839–51. 12. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C, Testori T. Immediate loading of postextraction implants in the esthetic area: systematic review of the literature. Clin Implant Dent Relat Res 2015;17:52–70. 13. Covani U, Crespi R, Cornelini R, Barone A. Immediate implants supporting single crown restoration: a 4-year prospective study. J Periodontol 2004;75:982–8. 14. Lang NP, Pun PL, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res 2012;23(Suppl 5):39–66. 15. Schwartz-Arad D, Gulayev N, Chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923–8. 16. Cafiero C, Annibali S, Gherlone E, Grassi FR, Gualini F, Magliano A, et al. Immediate transmucosal implant placement in molar extraction sites: a 12-month prospective multicenter cohort study. Clin Oral Implants Res 2008;19:476–82. 17. Fugazzotto PA, De Paoli S. Sinus floor augmentation at the time of maxillary molar extraction: success and failure rates of 137 implants in function for up to 3 years. J Periodontol 2002;73:39–44. 18. Bruschi GB, Crespi R, Cappare P, Bravi F, Bruschi E, Gherlone E. Localized management of sinus floor technique for implant placement in fresh molar sockets. Clin Implant Dent Relat Res 2013;15: 243–50.
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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19. Bragger U, Hammerle CH, Lang NP. Immediate transmucosal implants using the principle of guided tissue regeneration (II). A cross-sectional study comparing the clinical outcome 1 year after immediate to standard implant placement. Clin Oral Implants Res 1996;7:268–76. 20. Lang NP, Tonetti MS, Suvan JE, Pierre Bernard J, Botticelli D, Fourmousis I, et al. Immediate implant placement with
transmucosal healing in areas of aesthetic priority. A multicentre randomized-controlled clinical trial I. Surgical outcomes. Clin Oral Implants Res 2007;18:188–96. 21. Chen ST, Wilson Jr TG, Hammerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 (Suppl):12–25.
Address: Nuray Yilmaz Altintas Department of Oral and Maxillofacial Surgery Faculty of Dentistry Karadeniz Technical University 61080 Campus Trabzon Turkey Tel: +90 532 4304384; Fax: +90 462 3773253017 E-mail: [email protected]
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2015.09.011, available online at http://www.sciencedirect.com
Clinical Paper Dental Implants
Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses with conventional loading
N. Y. Altintas1, F. Taskesen2, B. Bagis3, E. Baltacioglu4, B. Cezairli1, F. C. Senel1 1
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey; 2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Erzincan University, Turkey; 3Department of Prosthodontics, Faculty of Dentistry, Katip Celebi University, Izmir, Turkey; 4Department of Periodontics, Faculty of Dentistry, Karadeniz Technical University, Trabzon, Turkey
N. Y. Altintas, F. Taskesen, B. Bagis, E. Baltacioglu, B. Cezairli, F. C. Senel: Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses with conventional loading. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. This retrospective study assessed the success of immediate and nonimmediate implants installed in patients undergoing planned extraction of all remaining teeth and rehabilitation with implant-supported full fixed prostheses. Patients in need of dental implants for full fixed prostheses to replace teeth extracted in the maxilla and mandible were included in this study. Dental implants were installed in the same surgical procedure, immediately at the extraction site, or in healed bone. Implant success, complications, and failures were recorded during follow-up. Forty-one patients with 512 implants were included in the study. Healing progressed uneventfully for 501 installed implants, but nine implants were lost in the non-immediate group and two were lost in the immediate group, during a mean follow-up of 44.9 months. All failures in both groups were observed in the maxilla. The success rate was the same in both groups, at 97.8%. This retrospective analysis showed that with thorough patient evaluation, the extraction of all residual teeth and implant installation in a single surgical procedure is a safe and predictable treatment modality for the successful rehabilitation of the edentulous patient with a fixed prosthesis.
The use of dental implantation to replace missing teeth has increased dramatically in the last decade, providing new treatment planning opportunities, such as 0901-5027/000001+06
implant-supported fixed restorations for fully and partially edentulous patients.1 However, rehabilitation with fixed fullarch implant-supported prostheses with
Key words: dental implant; implant-supported dental prosthesis; immediate dental implantation; extraction socket; delayed; osseointegration. Accepted for publication 16 September 2015
the extraction of all residual teeth requires a lengthy treatment period. Modern hightempo working lives make it difficult for patients to undergo lengthy treatments
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
YIJOM-3256; No of Pages 6
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Altintas et al.
involving numerous sessions. As implant dentistry has developed, various placement and loading protocols have evolved to provide a quicker and easier surgical approach.2 For patients who have their own teeth but who will eventually lose them, and who plan to undergo implant-supported rehabilitation, all residual teeth can be extracted and implants installed in a single procedure. The reported advantages of immediate implant placement include a reduction in the number of surgical interventions, a shortened rehabilitation time, and higher patient satisfaction compared with late implant placement.3–5 Another advantage of implant placement in the extraction socket is the counteracting of the hard tissue resorption that occurs following tooth extraction.6,7 However, some studies have suggested that immediate implant placement in the fresh extraction socket cannot prevent dimensional ridge resorption.8,9 Previous research has shown that survival rates for immediately placed implants are comparable to those of implants placed in healed alveolar bone.8,10 The purpose of this study was to evaluate the success rates of implants placed in fresh extraction sockets in patients undergoing extraction of all residual teeth for rehabilitation with fixed full-arch implantsupported prostheses, and also to compare the success rates of implants placed in fresh sockets with those of implants placed in mature healed bone. Materials and methods
A retrospective cohort study was performed in order to address the proposed study aim. The study sample was derived from the population of patients treated with dental implants at the department of oral and maxillofacial surgery and the department of prosthodontics of the study institution between June 2007 and June 2012. Patient data and files from these two departments were examined in detail. Patients who had undergone previous extraction of all remaining teeth and implant placement in both healed bone and at the extraction sites in the same procedure were eligible for inclusion. Patients were selected on the basis of inclusion and exclusion criteria. Inclusion criteria were the following: age 18 years, systemically healthy, cooperative and likely to maintain good dental health, and adequate bone height for placement of implants with a minimum length of 7 mm. Teeth were extracted due to root fracture, root resorption, root
perforation, a non-ideal crown–root ratio, or a peri-apical pathology. Exclusion criteria were the following: presence of any local or systemic factors that might contraindicate oral surgery, poor oral hygiene, conditions that complicate wound healing such as uncontrolled diabetes, smoking (10 cigarettes a day), pregnancy, a history of drug or alcohol abuse, and an inability or unwillingness to return for follow-ups after occlusal loading. This study was reviewed and approved by the regional ethics committee and adhered to the guidelines of the Declaration of Helsinki.
Fig. 2. Surgical view of implants installed in fresh extraction sites and in healed bone in the mandible.
Preparations for surgery were performed according to standard protocols. A single experienced surgeon performed all operations. Surgical procedures were performed under local anaesthesia with intravenous sedation. A mucoperiosteal flap was elevated. Before implant placement, selected teeth were extracted carefully and multirooted teeth were sectioned to preserve the remaining bone; this was done on the day of surgery, within the same surgical procedure, by the same surgeon. Granulation tissue was eliminated and the implants were placed in the residual bone and in the extraction sockets, achieving primary stability. The longest and widest possible implants were installed in the residual crest and the extraction sockets in order to achieve an aesthetic profile and maximum vertical preservation (Figs 1 and 2). If a gap occurred between the implant surface and the surrounding bone, a mixture of autogenous bone derived from the drilling of the implant beds and allogenic mineralized bone graft (Puros Allograft; Zimmer Dental Inc., Carlsbad, CA, USA) was inserted. In the case of an insufficient bone level in the posterior maxilla for implant placement, a lateral wall approach sinus augmentation procedure was performed and dental
implants were subsequently installed. The mucoperiosteal flap was adapted and sutured with primary closure to allow healing. Following implant placement and suturing, all patients received antibiotic therapy (amoxicillin and clavulanic acid). Antiinflammatory agents (naproxen sodium) and mouth rinse (chlorhexidine gluconate) were prescribed to all patients for 1 week. Sutures were removed 7 days after surgery. The implants were left submerged for 3 months. Removable provisional prosthesis procedures were performed for those patients who were reluctant to be edentulous during this healing period. After the submerged healing period, patients were invited back for second-stage surgery. Following the re-entry procedure, the soft tissues were allowed to heal for at least another 2 weeks before impressions were taken. Definitive abutments were tightened using 35 N cm torque. Implant-supported fixed full-arch prostheses were then fitted for all patients (Figs 3 and 4). In line with the patient follow-up policy for patients receiving dental implants in the clinic, patients were examined at 3-month intervals for 6 months and then at 6-month intervals for 2 years. Radiographic follow-ups were performed for all patients before and after surgery, and all
Fig. 1. Surgical view of implants installed in fresh extraction sites and in healed bone in the maxilla.
Fig. 3. Final prostheses in the same patient.
Surgical procedure
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Implant placement in fresh sockets vs. healed bone Table 1. Patient and study variables at baseline. Number of patients Number of alveolar arches treated Demographic variables Age, years, mean (range) Male/female Outcome variable Duration of follow-up, months, mean (range)
Fig. 4. View of the smile after delivery of the final prostheses in the same patient.
considered successful if the following parameters were absent: (1) persistent subjective complaints such as pain, foreign body sensation, and/or dysesthesia, (2) peri-implant infection with suppuration, (3) mobility, or (4) continuous radiolucency around the implant. Removed, lost, mobile, or fractured implants were regarded as implant failures. Statistical analysis
Fig. 5. Postoperative radiographic view of the same patient.
patients were evaluated at 6-month intervals for the first 2 years after loading (Fig. 5). Based on the clinical and radiographic criteria described by Buser et al., each implant was classified as successful or as having failed.11 The implant was
The statistical analysis was performed using SPSS version 13.0 software (SPSS Inc., Chicago, IL, USA). Fisher’s exact test was used to evaluate differences between success rates in immediate and non-immediate implants. The results were considered significant at P-values of less than 0.05. The survival of immediate and nonimmediate implants was investigated using the log rank test. Kaplan–Meier survival estimates were calculated. A separate log rank test was used to identify the effect of timing of implant installation on survival. A 5% type I error level was used to infer statistical significance.
41 82 53.82 (22–67) 18/23 44.9 (24–64)
Results
Forty-one patients (23 female and 18 male) ranging in age from 22 to 67 years (mean 53.82 years), who underwent extraction of all remaining teeth for rehabilitation with an implant-supported fixed full prosthesis between June 2007 and June 2012, were included in this retrospective study. The mean duration of followup was 44.9 months (range 24–64 months). Patient and study variables are shown in Table 1. Five hundred and twelve implants were placed in the 41 subjects. Two implant systems were used: 473 were Zimmer dental implants (Zimmer Dental Inc., Carlsbad, CA, USA) and 39 were Straumann SLA Dental Implant System implants (Straumann, Basel, Switzerland). Of these, 93 (18.2%) were placed immediately into fresh extraction sockets and 419 (81.8%) into healed alveolar bone. Two hundred and sixty implants were placed in the maxilla (38 immediate and 222 non-immediate) and 252 in the mandible (55 immediate and 197 non-immediate) (Tables 2 and 3).
Table 2. Distribution of implants placed in the maxilla. Implant (n) Immediate Non-immediate
Central
Lateral
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Total
1 1 0
6 3 3
69 20 49
65 7 58
31 4 27
61 2 59
27 1 26
260 38 222
Table 3. Distribution of implants placed in the mandible. Implant (n) Immediate Non-immediate
Central
Lateral
Canine
1st premolar
2nd premolar
1st molar
2nd molar
Total
2 1 1
7 1 6
54 23 31
61 15 46
32 7 25
61 5 56
35 3 32
252 55 197
Table 4. Distribution of failed implants. Tooth #13 Diameter Length Total Immediate Sinus lift
3.3 12
3.7 11.5 2 0 0
#14
#15
3.3 10
3.7 10 1 0 0
#16 3.7 10
3.7 10 2 2 2
3.7 10
4.1 10 3 0 2
#24
#25
#27
3.7 13 1 0 0
3.7 11.5 1 0 0
4.1 10 1 0 1
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Altintas et al.
Only 11 of the 512 implants in the 41 patients were lost (Table 4). Eight implant losses occurred at second-stage surgery before prosthetic treatment and loading procedures, and three implants were surgically removed 1 year after loading. All the implant failures were in the maxilla, none being lost in the mandible. Of the 260 implants in the maxilla, nine were lost in the non-immediate group and two in the immediate group. The two implants that failed in the immediate group were inserted using the sinus membrane elevation procedure. In terms of non-immediate implant failures, two of the nine implants were installed using sinus membrane elevation. The failed implants were replaced with new implants, and bone grafts were applied if necessary. The success rate in the immediate group for all implants was 97.8%, and the success rate in the non-immediate group was also 97.8%. The success rates for implants in the mandible were 100% for both the immediate and non-immediate groups. The success rate of implants in the maxilla was 94.7% in the immediate group and 95.9% in the non-immediate group. The results of the Fisher’s exact test showed no significant difference between the immediate and nonimmediate implant placement groups, which both exhibited significant individual success rates. Kaplan–Meier analysis of survival functions for the immediate and non-immediate implants revealed no significant differences between the two groups over time. Discussion
The extraction of residual teeth and placement of implants in the same surgical procedure represents a successful approach to minimizing the treatment time without reducing predictability with regard to standard protocols, especially in the rehabilitation of patients with full fixed prostheses.12 For the purpose of this study, the primary research question was whether the success rate of implants placed in fresh extraction sockets would be comparable to that of non-immediate implant placement in patients undergoing single-stage surgery for implants supported by full fixed prostheses. The results of this study suggest that (1) there was no difference in success rate between the immediate implant group and the non-immediate implant group, (2) both study groups exhibited significant individual success rates, and (3) the immediate treatment modality is as predictable as conventional implant treatment in patients undergoing a single-stage procedure for
fixed full-arch prostheses. Although the sample undergoing immediate placement was significantly smaller than that undergoing placement in the healed bone, this study was designed to evaluate the implants for implant-supported full-arch fixed prostheses and to categorize the implant placement type in these patients. The results are comparable to those reported in recently published studies concerning immediate implant placement. In a study with a design similar to that of the present study, Penarrocha-Diago et al. reported a higher success rate in the immediate implant group than in the conventional group.4 The study also demonstrated that immediate implant osseointegration can be as successful, or more successful, than non-immediate implantation in the same healing protocol.4 Covani et al. reported that implants placed into fresh extraction sockets exhibited a very high cumulative success rate (97%) over a follow-up period of 4 years.13 Consistent with prior reports, greater success rates for mandibular implants than for maxillary implants were observed in the present study. Lang et al., in a review study, reported that implants in the mandible had a lower estimated failure rate than those placed in the maxilla.14 The greater success rate in the mandible may be attributed to bone type and content, both at the extraction site and in mature bone. The mandible contains a larger proportion of lamellar bone than the maxilla, and the maxillary posterior area comprises bone of type 4 quality, which can affect the primary stability of implants.1,14 Schwartz-Arad et al. reported lower survival rates in the maxilla in both immediate and non-immediate groups, in agreement with the results of the present study.1 In a separate study, the same authors reported that immediate implantation in the posterior mandible resulted in a better prognosis than implantation in the posterior maxilla.15 On the other hand, Cafiero et al. detected no difference in terms of the survival rate between maxillary and mandibular molars after 12 months.16 In the present study, only two implants were lost in the immediate placement group, and the two implants that failed had been implanted with sinus floor augmentation. Immediate implants installed in the extraction site are usually as long and wide as possible in order to achieve primary stability. However, implant placement with sinus floor elevation limits the implant length. The failure of two implants in the immediate group may have been due to lower primary stability of the implants and a lack of bony wall adjacent
to the implant on the apical side of the implant. Fugazzotto and De Paoli extracted maxillary molars while concomitantly augmenting the sinus. These authors placed 167 implants in regenerated bone and reported a cumulative implant success rate of 97.8%.17 In contrast, Bruschi et al. demonstrated that management of the sinus floor procedure in first molar sockets allowed resorbed posterior maxillary alveolar bone to expand both vertically and horizontally, with a 100% implant osseointegration success rate after a mean 9.76 years of follow-up.18 Sinus lift procedures were included in the present study because patients with implant-supported full-arch fixed prostheses were enrolled, and therefore all implants in those patients had to be considered. With immediate implant placement, a gap may occur between the implant installed and the bony wall of the extraction socket. A mixed autogenous and allogenic mineralized bone graft was used in all patients in this study when a gap was observed. In a review of immediate loading of post-extraction implants in the aesthetic area, Del Fabbro et al. reported no significant differences in clinical outcomes in terms of graft type, or between grafted and non-grafted cases.12 These results compare favourably with those of the study by Penarrocha-Diago et al., in which the authors suggested that a gap greater than 2 mm does not seem to influence implant failure.4 Nevertheless, Ortega-Martinez et al. have recommended grafting if the jumping distance between the socket wall and the implant surface exceeds 2 mm.2 Schropp and Isidor have recommended grafting, especially of existing fenestrations, dehiscence, and larger bony defects, but have stated that there is no evidence that any one technique or material is superior to the others.6 The original implant treatment protocol recommended primary covering of the implant with mucosa after placement, in order to protect the implant site against bacterial contamination. However, transmucosal installation of the implant is an absolute treatment option that has been demonstrated to perform as well as the submerged approach.6 In immediate placement, the need for and use of bone graft represents a challenge for transmucosal implants in terms of success or failure. Several studies have reported good results with non-submerged or transmucosal implants.19,20 However, Gokcen-Rohlig et al. have recommended closure of soft tissue over the operation site at which advanced augmentation procedures have
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Implant placement in fresh sockets vs. healed bone been performed, in order to achieve results similar to those of delayed implantations.3 In the present study, primary closure of the flap was preferred when possible, in order to protect the graft material placed in the gap between the bony wall and immediate implant and to achieve the same surgical conditions as those in the non-immediate group. The patients in this study were all treated with implant-supported fixed full-arch prostheses. The patients’ requirements and needs were considered during treatment planning, and immediate implant installation was decided on in order to achieve a shorter treatment time. Patients find it difficult to wait for up to 6 months for an extraction site to heal, followed by an additional 3–6 months for the implant to osseointegrate. The other advantage of the treatment modality is preservation of the bone and gingival tissues. Following tooth extraction, bone resorption occurs at a greater rate, especially for the first 6 months, unless an implant is installed or a socket augmentation procedure is performed.7 However, Araujo et al. demonstrated that immediate implant placement in a tooth extraction socket is unable to preserve the hard tissue dimensions of the ridge following tooth extraction.9 Lang et al. also reported that implants placed in extraction sockets were unable to prevent soft tissue loss, especially buccal marginal tissue recession.14 Chen et al. reported a significant relationship between the frequency of recession and the buccolingual position of the implant.21 Gingival margins did not play a significant role in the cases in the present study because all patients were treated with implant-supported fixed full-arch restorations. Careful preoperative evaluation of the implant sites and placement of implants in the correct position prosthetically are therefore essential for successful clinical outcomes. Within the limitations of the sample number and absence of detailed postoperative radiographic examination, the extraction of all residual teeth and placement of implants in a single surgical procedure is a safe and predictable treatment modality. Immediate implant placement is as successful as conventional non-immediate implant placement in patients receiving implant-supported fixed full prostheses. The present protocol also offers many advantages to the patient as well as the clinician. Nevertheless, careful patient selection and treatment planning appear to be of critical importance in achieving a predictable treatment outcome. The data from this retrospective
analysis involve only immediate and non-immediate implant success rates at a mean follow-up of 44.9 months. Further studies should include a more detailed analysis, consisting of different prosthetic types and different implantation times (immediate, early immediate, delayed, and mature) and detailed investigation of radiographs to compare hard and soft tissue changes. Funding
This research had no source of funding. Competing interests
The authors declare that they have no conflict of interest. Ethical approval
This study was reviewed and approved by the regional ethics committee, Karadeniz Technical University, Faculty of Medicine Local Ethics Committee (reference number 2012–128). Patient consent
Not required. Acknowledgement. We are grateful to Dr Tamer Tuzuner for the statistical analyses.
References 1. Schwartz-Arad D, Grossman Y, Chaushu G. The clinical effectiveness of implants placed immediately into fresh extraction sites of molar teeth. J Periodontol 2000;71:839–44. 2. Ortega-Martinez J, Perez-Pascual T, Mareque-Bueno S, Hernandez-Alfaro F, FerresPadro E. Immediate implants following tooth extraction. A systematic review. Med Oral Patol Oral Cir Bucal 2012;17:e251–61. 3. Gokcen-Rohlig B, Meric U, Keskin H. Clinical and radiographic outcomes of implants immediately placed in fresh extraction sockets. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e1–7. 4. Penarrocha-Diago MA, Maestre-Ferrin L, Demarchi CL, Penarrocha-Oltra D, Penarrocha-Diago M. Immediate versus nonimmediate placement of implants for full-arch fixed restorations: a preliminary study. J Oral Maxillofac Surg 2011;69:154–9. 5. Soydan SS, Cubuk S, Oguz Y, Uckan S. Are success and survival rates of early implant placement higher than immediate implant placement? Int J Oral Maxillofac Surg 2013;42:511–5.
5
6. Schropp L, Isidor F. Timing of implant placement relative to tooth extraction. J Oral Rehabil 2008;1:33–43. 7. Bhola M, Neely AL, Kolhatkar S. Immediate implant placement: clinical decisions, advantages, and disadvantages. J Prosthodont 2008;17:576–81. 8. Botticelli D, Berglundh T, Lindhe J. Hardtissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820–8. 9. Araujo MG, Wennstrom JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006;17:606–14. 10. Paolantonio M, Dolci M, Scarano A, d’Archivio D, di Placido G, Tumini V, et al. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J Periodontol 2001;72:1560–71. 11. Buser D, Janner SF, Wittneben JB, Bragger U, Ramseier CA, Salvi GE. 10-year survival and success rates of 511 titanium implants with a sandblasted and acid-etched surface: a retrospective study in 303 partially edentulous patients. Clin Implant Dent Relat Res 2012;14:839–51. 12. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C, Testori T. Immediate loading of postextraction implants in the esthetic area: systematic review of the literature. Clin Implant Dent Relat Res 2015;17:52–70. 13. Covani U, Crespi R, Cornelini R, Barone A. Immediate implants supporting single crown restoration: a 4-year prospective study. J Periodontol 2004;75:982–8. 14. Lang NP, Pun PL, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res 2012;23(Suppl 5):39–66. 15. Schwartz-Arad D, Gulayev N, Chaushu G. Immediate versus non-immediate implantation for full-arch fixed reconstruction following extraction of all residual teeth: a retrospective comparative study. J Periodontol 2000;71:923–8. 16. Cafiero C, Annibali S, Gherlone E, Grassi FR, Gualini F, Magliano A, et al. Immediate transmucosal implant placement in molar extraction sites: a 12-month prospective multicenter cohort study. Clin Oral Implants Res 2008;19:476–82. 17. Fugazzotto PA, De Paoli S. Sinus floor augmentation at the time of maxillary molar extraction: success and failure rates of 137 implants in function for up to 3 years. J Periodontol 2002;73:39–44. 18. Bruschi GB, Crespi R, Cappare P, Bravi F, Bruschi E, Gherlone E. Localized management of sinus floor technique for implant placement in fresh molar sockets. Clin Implant Dent Relat Res 2013;15: 243–50.
Please cite this article in press as: Altintas NY, et al. Immediate implant placement in fresh sockets versus implant placement in healed bone for full-arch fixed prostheses. . ., Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.09.011
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Altintas et al.
19. Bragger U, Hammerle CH, Lang NP. Immediate transmucosal implants using the principle of guided tissue regeneration (II). A cross-sectional study comparing the clinical outcome 1 year after immediate to standard implant placement. Clin Oral Implants Res 1996;7:268–76. 20. Lang NP, Tonetti MS, Suvan JE, Pierre Bernard J, Botticelli D, Fourmousis I, et al. Immediate implant placement with
transmucosal healing in areas of aesthetic priority. A multicentre randomized-controlled clinical trial I. Surgical outcomes. Clin Oral Implants Res 2007;18:188–96. 21. Chen ST, Wilson Jr TG, Hammerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 (Suppl):12–25.
Address: Nuray Yilmaz Altintas Department of Oral and Maxillofacial Surgery Faculty of Dentistry Karadeniz Technical University 61080 Campus Trabzon Turkey Tel: +90 532 4304384; Fax: +90 462 3773253017 E-mail: [email protected]
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