art-Alecsandru-Ionescu
ORAL IMPLANTOLOGY
IMMEDIATE IMPLANT PLACEMENT IN FRESH EXTRACTION SOCKETS USING THE OPEN
Original Article
HEALING TECHNIQUE AND TISSUE LEVEL IMPLANTS
Alecsandru Ionescu1,2a , Aliona Dodi1b , Vasileios Panagopoulos1c , Mihnea Ioan Nicolescu3,4d* , Augustin Mihai2e,
Gabriela Tănase2f
1
Aesthetics One Dental Center, Bucharest, Romania
2
Implantology Division, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
3
Histology Division, Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
4
Radiobiology Division, Victor Babes National Institute of Pathology, Bucharest, Romania
a
DDS, PhD student
b
DDS
c
DDS, MD, OMFS, PhD
d
DDS, MD, OMFS, MSc, PhD, Lecturer
e
DDS, PhD, Professor
f
DDS, PhD, Lecturer
ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(1).art.5
Introduction: Correctly managed, immediate implant placement into fresh extraction OPEN ACCESS This is
socket is a favorable treatment option in order to reduce the overall treatment time and to an Open Access article under
the CC BY-NC 4.0 license.
increase the patient's comfort and satisfaction.
Methodology: Atraumatic extractions (N = 42) with socket preservation were performed Peer-Reviewed
Article
in n = 40 patients (0.74 sex ratio) followed by immediate placement of tissue level implants.
Post extraction sockets were filled with either platelet-rich growth factors (PRGF) clots, Citation: Ionescu A, Dodi A,
Panagopoulos V, Nicolescu MI,
or deproteinized bovine bone granules, or both; then covered by collagen resorbable Mihai A, Tănase G. Immediate
membrane or cyanoacrylate and left exposed during healing. The pre-loading need for implant placement in fresh
extraction sockets using the open
additional augmentation was assessed clinically and radiologically, using CBCT scans at healing technique and tissue
level implants. Stoma Edu J.
t = 6 months. The success and survival rate were evaluated by control CBCT scans at a 4 2019;6(1):36-41.
year follow-up.
Received: February 21, 2019
Results: This analysis showed that “open healing” technique allowed uneventful healing Revised: March 22, 2019
and sufficient bone formation in combination with immediate placement of soft tissue Accepted: March 26, 2019
Published: March 27, 2019
level implants, a survival rate of 100% and a success rate of 95.2% at a 4 yr follow-up. There
were no significant differences regarding crestal bone level stability around the implants *Corresponding author:
Dr. Mihnea Ioan Nicolescu
with the different augmentation materials. Histology Division, "Carol Davila"
Conclusion: Immediate placement of tissue level implants in fresh post extraction sockets University of Medicine and
Pharmacy Bucharest, 8, Eroilor
using “open healing” approach can be favorable from both a clinical and radiological point Sanitari Blvd, District 5
of view considering the results at 4 years. In addition, soft-tissue problems associated RO-050474 Bucharest, Romania
Tel/Fax: +40722767260, e-mail:
with extensive flap mobilization and tension may be avoided and the 3D architecture of mihnea.nicolescu@umfcd.ro
hard and soft tissues surrounding the implant may be maintained due to the tissue level Copyright: © 2019 the
implants design in accordance with the biological width when restored. Editorial Council for the
Keywords: Immediate implant placement; open healing; flapless; biological width. Stomatology Edu Journal.
1. Introduction alveolar ridge. A recent systematic review analyzed
Nowadays the first choice treatment option after the three-dimensional changes in bone tissue after
extraction of failing teeth is represented either immediate installation of a single implant in a fresh
by immediate implant placement or by a socket extraction socket, reaching a clear conclusion that
preservation procedure [1,2]. Correctly managed, bone remodeling occurs after tooth extraction even
immediate implant placement into fresh extraction with immediate implant insertion [7]. One other recent
socket is a favorable treatment option in order to reduce systematic review described the effects of implants
the overall treatment time and to increase the patient's with different connections on the crestal bone level
comfort and satisfaction [3]. Oral implantology has in relation with the surgical procedure after at least
been intensively researched in basic as well as in clinical 12 months of functional loading. The conclusion was
grounds [4]. In order to improve and accelerate healing that platform-switched implants showed greater
of both hard and soft tissues after immediate implant crestal bone preservation than non-platform-switched
placement, substitutes including growth factors and implants. There was no significant difference in the
biomaterials have been traditionally employed and crestal bone loss with one- versus two-stage placement
membranes were introduced to separate tissues [5]. or the use of immediate versus delayed loading.
It has been previously reported [6] that immediate Although there were statistically significant differences
implantation will not prevent resorption of the favoring immediate implant placement, as well as
36 Stoma Edu J. 2019;6(1): 36-41 http://www.stomaeduj.com
IMMEDIATE IMPLANT PLACEMENT IN FRESH EXTRACTION SOCKETS USING
THE OPEN HEALING TECHNIQUE AND TISSUE LEVEL IMPLANTS
favorable outcomes for crestal bone level changes, the
Original Article
Table 1. Surgical site position.
small differences may not be clinically relevant because
A.
of high heterogeneity among studies [8].
Bone site Number of Sites
However, the use of immediate implantation techniques
without raising a muco-periosteal flap, combined with Maxilla 23 (54.8%)
a bone graft in the gap left between the implant and Mandible 19 (45.2%)
the post extraction socket walls, led to osseointegration B.
accompanied by high stability of bone and the resulted Site region Number of Sites
soft tissue [7-9]. On the other hand, the use of tissue Anterior 22 (52.4%)
level implants is beneficial for the surrounding soft and Lateral 20 (47.6%)
hard tissues, especially when inserted with a flapless
approach. Furthermore, the “open healing” technique the outcome of the surrounding bone at 12 and 24
used as an alternative ridge augmentation procedure, month after loading.
maintains a high stability of the crestal bone level as well
as the architecture of the soft tissue after the healing
period, with a good outcome even when resorptions of 2. Materials and Methods
the buccal bone were present prior to extraction [10]. This retrospective study evaluated patients treated
According to the literature, a classification system for between 2014-2018 in a private dental practice. The
management of molar extraction sockets is based upon study protocol is in accordance with the Helsinki
the morphology of the septal bone and its influence on Declaration of 1975, revised in 2000 and was approved
the implant’s primary stability. Implants may be placed by the Ethics Committee. Every person involved in
predictably into molar sockets when initial stability can the study signed an informed consent. Patients with
be obtained within the septal bone, either entirely (Type hopeless teeth with indication for extraction and
A socket) or partially (Type B socket), or by engaging implant therapy were recommended for the study.
the walls at the periphery of the socket (Type C socket). If primary stability could not be achieved or if the
Otherwise, a delayed protocol should be utilized [11]. buccal bone plate was missing, such as there were
When it comes to monoradicular sites, especially in no conditions to stabilize the implant in the healing
the esthetic zone, a simplified socket classification phase, a delayed protocol was followed. The sites with
and repair technique was described: Type 1 - labial indication for two stage approach were excluded from
bone plate and associated soft tissues are completely this study. There were 40 patients (sex ratio 0.74), with
intact; Type 2 - soft tissue is present, but a dehiscence 42 surgical sites that met the conditions for immediate
osseous defect exists that is indicative of the partial implant placement. After the teeth were extracted
or complete absence of the labial bone plate; Type atraumatically, the extraction sockets were cleaned, and
3 - midfacial recession defect is present, representing all granulation tissue was removed carefully.
the loss of the labial bone plate and soft tissues [12]. A We included surgical sites from the anterior and
further classification of Type 2 socket defects where the lateral regions of both maxilla and mandible (location
soft tissue is present but a dehiscence osseous defect frequency is detailed in Table 1 - A, B). Both smokers
was later used to quantify the absence of the labial (23.8%) and non-smokers (76.2%) were included in the
bone plate: Type 2A - absence of the coronal one-third study. Surgical interventions were performed according
of labial bone plate of the extraction socket 5 to 6 mm to our standard procedures. Tooth extraction was
from the free gingival margin; Type 2B - absence of the performed atraumatically, the roots where separated
middle to coronal two-thirds of the labial bone plate of and extracted one by one in order to preserve the
the extraction socket approximately 7 to 9 mm from surrounding walls and interradicular septum. Of all
the free gingival margin; Type 2C - absence of the apical the surgical sites, there were 2 sites that had two
one-third of the labial bone plate of the extraction surrounding walls, 3 sites with three surrounding walls,
socket 10 mm or more from the free gingival margin the rest of the alveoli having all 4 surrounding walls. A
[13]. tissue level implant was inserted into the neoalveolus
This study shows the rationale behind immediate created in the post extraction socket according to the
placement of a tissue level implant in the fresh initial 3D planning. Tissue level implants with similar
extraction socket in conjunction with the “open healing” Titanium alloy composition were used in all cases, 40
technique, showing not only the advantages of tooth sites received standard 4.8 mm diameter platform
extraction with minimal damage to the surrounding conical implants (TRI Octa, TRI Dental Implants AG,
anatomic structures, but also how to maintain the Hünenberg, Switzerland) and 2 sites received wide
implant surrounding hard and soft tissues three- neck 6.5 mm diameter platform cylindrical implants
dimensional architecture, following the guidelines TissueLevel StandardPlus WN® (Straumann AG, Basel,
previously reported in the literature [14]. Switzerland).
The aim of this retrospective analysis is to validate the Both implant types had a 1.8 mm high polished collar.
protocol of immediate implant placement into fresh The implants were placed having the polished collar at
extraction sockets using open-healing approach and the same level with the cement-enamel junction (CEJ)
non-submerged (tissue-level) implants and to evaluate level of adjacent teeth, with respect to the biological
Stomatology Edu Journal 37
IMMEDIATE IMPLANT PLACEMENT IN FRESH EXTRACTION SOCKETS USING
THE OPEN HEALING TECHNIQUE AND TISSUE LEVEL IMPLANTS
the appointment until after six months due to personal
Original Article Table 2. Grafting material.
reasons.
Grafting Material Number of Sites
The CBCT scans were performed with the same
Bio-Oss 31 (73.8%)
investigation unit Cranex 3D (Soredex, Helsinki, Finland/
Copios 7 (16.7%)
KaVo Dental Gmbh, Biberach, Germany) and analyzed
Bio-Oss + PRGF 3 (7.1%)
with the OnDemand 3D software (CyberMed, Yuseong-
No grafting material 1 (2.4%)
gu, Daejeon, Korea).
Table 3. Membrane type.
Membrane type Number of Sites
3. Results
Histoacryl 19 (45.2%)
During the observation period, a total of 41 patients
Bio-Gide 18 (42.9)
with 43 surgical areas were treated with immediate
PRGF 3 (7.1%)
implant placement in the post extraction site using the
No membrane 2 (4.8%)
open-healing technique. One patient did not show up
width protocol. The implant was installed in the septum for prosthetic treatment, so we excluded him from the
in 4 sites, in other 3 sites the neoalveolus were created study. Therefore, the analysis included 42 surgical areas
along the socket walls and in 35 sites new alveolae in 40 patients (42.5% male and 57.5% female). The nean
were created in another axis than the roots axis. In 2 patient age was 50.2 ± 16.0 years (aged 28-81 years).
of the sites in the molar region of the maxilla, internal The clinical outcome was observed, checking
lifting of the sinus membrane was performed in the parameters such as inflammation, swelling, pain
same stage with implant insertion in the septum. No and soft tissue secondary healing. The patients were
flap or deperiostation were performed in any of the scheduled at the specified time frame, 6 months before
42 sites. The gaps of the alveolae where fulfilled either loading, for the CBCT scan in order to analyze the
with deproteinized bovine bone granules (DBBO), bone volume, crestal bone loss and the possibility of
with plasma rich in growth factors (PRGF) clots scheduling the implant loading procedures. All implants
(Endoret - PRGF®, BTI Biotechnology Institute, Vitoria- were loaded, using fixed single unit or multiunit
Gasteiz, Spain) mixed with DBBO or PRGF clots alone. cemented restorations, respecting the biological width
The gaps were covered with a resorbable collagen protocol [16]. CBCT control scans were performed at 24
membrane (RCM) or with a PRGF fibrine membrane. and 48 months follow-up. Success and survival rates
The membranes were stabilized with a PTFE continuous were analyzed using the Buser criteria: (1) Absence of
suture (Coreflon®, Implacore Sp. z o.o. Poznań, Poland) persistent subjective complaints, such as pain, foreign
that was applied to the free gingival margins. In caset body sensation, and/or dysesthesia; (2) Absence of
the gap between the implant neck and the gingival periimplant infection with suppuration; (3) Absence
margin was less than 4 mm, a layer of cyanoacrylate was of mobility; (4) Absence of continuous radiolucency
applied instead of the membrane and no suture was around the implant [17]. From the 42 sites, only 2 (two)
applied. There was one single site that neither received cases needed additional surgery after clinical and CBCT
a graft material nor a membrane. observation at 6 months. Both sites were in the premolar
We used the following biomaterials: DBBO: Bio-Oss® area, one in the maxilla and one in the mandible,
(Geistlich Pharma, Wolhusen, Switzerland), Copios® underwent the same procedure, using the exact same
(Zimmer Biomet Dental, Palm Beach Gardens, FL-USA) biomaterials (BioOss and BioGide). Both patients were
and RCM: Bio-Gide® (Geistlich Pharma, Wolhusen, suffering from the same systemic disease, Hepatitis, Type
Switzerland), Socket Repair Membrane® (Zimmer C Virus. There was no relevant correlation with other
Biomet Dental, Palm Beach Gardens, FL-USA), factors. Of these 2 cases, one required additional bone
Histoacryl® (B. Braun Medical, Melsungen, Germany) augmentation procedure and the second one just a soft
(Tables 2 and 3). tissue remodeling procedure, yielding a survival rate of
The patients received a specific scheme for control and 100% and a success rate of 95.2% at the control time of
follow up appointments. Clinical observations were 6 months after initial surgery. The CBCT scans showed
made at 24 h, 48 h, 7 days and 14 days. The suture was a stable bone dimensions at 24 and 48 months follow-
removed after 21 days. Antibiotics were prescribed for up intervals with a bone preservation of 98.9 ± 0.7%
prophylactic reason. Indications for cleaning and special and 98.1 ± 0.9% compared with initial measurements.
care of the clinical sites were given. Painkillers and non- The results were analyzed and interpreted by the same
steroidal anti-inflammatories were recommended just clinician, in order to eliminate deviations. The bone
when needed. The suture removal took place after three parameters measured on CBCT scans showed stable
weeks. In order to allow maturation of the bone and results for all three bone levels mean values (buccal and
soft tissue, the sites were allowed to heal for at least six oral bone plate height, and crest width – Table 4).
months before loading. We have chosen this aspect of To sum up, the atraumatic extraction (Fig. 1) was
the protocol based on previously success rate reported followed by the tissue level implant insertion in the
in the literature [15]. The case where no grafting septum (Fig. 2). The “Open healing” technique is shown
material or membrane were used was planned to be at one day, two days and three weeks in Fig. 3. Follow-
loaded after three months, but the patient postponed ups at one and three years (Fig. 4), as well as 4 years
38 Stoma Edu J. 2019;6(1): 36-41 http://www.stomaeduj.com
IMMEDIATE IMPLANT PLACEMENT IN FRESH EXTRACTION SOCKETS USING
THE OPEN HEALING TECHNIQUE AND TISSUE LEVEL IMPLANTS
Original Article
Table 4. CBCT bone level measured parameters.
Mean Std. Deviation Minimum Maximum
BP-height 13.55 2.90 4.08 17.71
Initial
OP-height 14.34 2.90 3.03 20.70
BP-height 13.73 1.74 10.70 17.17
After loading
OP-height 14.26 1.87 8.97 18.99
1 year after BP-height 13.61 1.78 10.68 17.03
loading OP-height 14.07 1.82 8.94 18.87
4 years after BP-height 13.26 1.85 10.59 16.43
loading OP-height 14.02 1.71 8.89 16.13
BP = buccal bone plate, OP = oral bone plate. All measurements in mm.
Figure 1. Atraumatic extraction (a,b). Neoalveolus preparation in the Figure 3. Open healing. Resorbable collagen membrane stabilized by
septum (c,d). PTFE continuous suture (a). Healing at 24h (b), 48h (c) and 3 weeks (d).
Figure 4. Follow-up at 12 months (clinical – a,b and radiological – c) and
at 36 months (clinical – d,e and radiological – f).
Figure 2. Bovine bone granules filling the alveolae (a,b). Tissue level
implant inserted in the septum (c,d).
(Fig. 5) shape the picture of one of the cases that were
successfully addressed using the protocol described in
this study.
In our study, all implants obtained a good primary
stability. The treatment was judged to be successful
if implant loading was possible with no additional
augmentation needed and implants were in place at Figure 5. CBCT scan before surgery (up) and at 4 years follow up (down),
the follow-up intervals, thus a success rate of 95.2%. showing implant position in the septum.
The survival rate after criteria described by Buser et al in especially when immediate loading is intended.
1997 was 100% [18]. Positive results regarding the possible implant
stability can lead to immediate implant insertion as
the first choice clinical procedure instead of a delayed
4. Discussions two-stage approach. Such a delayed-approach
In order to facilitate the implant therapy, ridge treatment sequence encompasses several steps
resorption caused by tooth extraction should be over an extended period of time and appointments,
limited or even eliminated. The evaluation of bone not only for the practitioner, but also for the patient.
quality during treatment planning is mandatory Barone et al. [19] showed that regenerative techniques
Stomatology Edu Journal 39
IMMEDIATE IMPLANT PLACEMENT IN FRESH EXTRACTION SOCKETS USING
THE OPEN HEALING TECHNIQUE AND TISSUE LEVEL IMPLANTS
(GBR) were able to limit resorption of the alveolar crest avoided. The clinical significance of the combination of
Original Article after implant placement in a fresh extraction socket. the “open healing” technique, with immediate implant
On the contrary, Hsu et al. [20] demonstrated in an placement of a tissue level implant into a fresh extraction
experimental study that the placement of implants socket with partial or complete loss of the buccal bone
and deproteinized bovine bone granules into fresh plate has significant benefits for both the clinician and
extraction sockets generates significant buccal bone the patient: treatment procedures are reduced to fewer
loss as well as low osseointegration. Other clinical appointments, the overall time of the treatment is
studies [21–23] used GBR techniques to fill the gap reduced and the tridimensional architecture of the soft
between bone and implant. and hard tissues is maintained, including the possibility
Our study showed that placing a bone graft into the of regenerating the buccal bone plate when missing.
residual gap around a post-extraction socket is helpful Further scientific studies need to be conducted to
for limiting the amount of facial-palatal contour change reinforce our clinical results.
from the FGM to more apical reference points. In a
retrospective cohort study conducted by Tarnow et
al. the conclusion stated was that all post-extraction Author contributions
implant placement without flap elevation demonstrated All the authors participated in establishing the concept
some negative contour change (facial collapse) relative and protocol. AI, AD, VP performed the surgical
to the adjacent contralateral control tooth. However, the procedures. MIN, AM, GT participated in data gathering,
change was minimal compared to previous studies where analysis and interpretation. All the authors participated
full periosteal flaps were elevated for ridge augmentation in critically revising the manuscript.
after teeth extraction. According to these authors, the
key elements in preserving ridge contour are protection,
containment and maintenance of the bone graft during References
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Alecsandru IONESCU
DDS, PhD Student
Aesthetics One Dental Center
Bucharest, Romania
CV
Dr. Alecsandru Ionescu graduated from the Faculty of Dentistry, “Carol Davila” University of Medicine and Pharmacy Bucharest,
Romania (2001). He is a member of the board of the Society for Esthetic Dentistry in Romania (SSER). He is also the co-founder
of Quintessence International Romania and a founding member of the Romanian Society for Digital Dentistry. He is an active
member of IADFE, ESCD, EAO and ICOI. Dr. Ionescu’s main lecturing topics focus on minimally invasive approaches in oral
surgery and implantology. He is an international speaker, author of different articles and a co-author of the “Comprehensive
Esthetic Dentistry”, the first volume by Romanian authors published by Quintessence International in 2015, translated into
Chinese in 2017. He works in Bucharest in his private clinic and training center “Aesthetics One".
Questions
1. In which situation is immediate implant placement possible?
qa. When primary stability can be obtained;
qb. In type A socket;
qc. In all socket types;
qd. After all granulation tissue is removed and the alveolae are cleaned.
2. Buser criteria for survival and success are:
qa. Absence of any postoperative edema;
qb. Absence of mobility;
qc. Absence of continuous radiolucency around the implant;
qd. Absence of periimplant infection with suppuration.
3. The following is true about immediate implantation:
qa. It reduces the overall treatment plan;
qb. It stops the postextractional bone loss;
qc. It can be done in conjunction with the open healing technique;
qd. The polished collar must be placed at the same level as the cement-enamel junction.
4. To facilitate implant placement:
qa. Tooth extraction must be atraumatic;
qb. Postextractional bone loss must be minimized;
qc. A mucoperiosteal flap should be raised;
qd. Additional augmentation should be performed.
Stomatology Edu Journal 41