resultados clínicos y estéticos en implantes postextracción - chen, 2009 .pdf
TRANSCRIPT
Advances in biomaterials and clinical techniqueshave facilitated significant expansion in the indi-
cations for dental implant therapy. In the beginning,the replacement of already missing teeth, eg, in eden-tulous patients, dominated daily practice. Today,many patients present for treatment to replace teeththat first need to be extracted before implants can beplaced. This provides clinicians with the opportunityto decide on the timing of implant placement aftertooth extraction.1,2 This decision is critical, since it hasa significant influence on treatment outcome.2 Arecent systematic review of randomized controlled
trials (RCTs) identified only two studies of immediateimplants that fulfilled the inclusion criteria.3 Althoughthis review concluded that implants placed into freshor healing sockets was a viable treatment option,more research was required.
The aim of this paper was to review the literaturepertaining to implants placed in postextraction sites,and to identify the level of evidence and clinical out-comes for the different time points of implant place-ment following extraction.
MATERIALS AND METHODS
An electronic search of the dental literature usingPubMed was undertaken to identify papers pub-lished in English between January 1990 and May2008, using the following search terms: dentalimplant, extraction, socket, immediate implant, immedi-ate placement, delayed implant, delayed placement,and late placement. A hand search of the followingjournals was undertaken: Clinical Oral ImplantsResearch, International Journal of Oral & MaxillofacialImplants, International Journal of Periodontics &Restorative Dentistry, Journal of Periodontology, Journalof Clinical Periodontology and Clinical Oral Implants
186 Volume 24, Supplement, 2009
1Senior Fellow, Periodontics, School of Dental Science, Universityof Melbourne, Parkville, Victoria, Australia.
2Professor and Chairman, Department of Oral Surgery and Stomatology, School of Dental Medicine, University of Bern,Bern, Switzerland.
The authors reported no conflict of interest.
Correspondence to: Dr Stephen Chen, 223 Whitehorse Road,Balwyn, VIC 3103, Australia. Fax: +61 3 9817 6122. Email:[email protected]
This review paper is part of the Proceedings of the Fourth ITI Con-sensus Conference, sponsored by the International Team for Implan-tology (ITI) and held August 26–28, 2008, in Stuttgart, Germany.
Clinical and Esthetic Outcomes of Implants Placed in Postextraction Sites
Stephen T. Chen, BDS, MDSc, PhD1/Daniel Buser, DMD, Prof Dr Med Dent2
Purpose: The aim of this review was to evaluate the clinical outcomes for the different time points ofimplant placement following tooth extraction. Materials and Methods: A PubMed search and a handsearch of selected journals were performed to identify clinical studies published in English thatreported on outcomes of implants in postextraction sites. Only studies that included 10 or morepatients were accepted. For implant success/survival outcomes, only studies with a mean follow-upperiod of at least 12 months from the time of implant placement were included. The following out-comes were identified: (1) change in peri-implant defect dimension, (2) implant survival and success,and (3) esthetic outcomes. Results and Conclusions: Of 1,107 abstracts and 170 full-text articles con-sidered, 91 studies met the inclusion criteria for this review. Bone augmentation procedures are effec-tive in promoting bone fill and defect resolution at implants in postextraction sites, and are moresuccessful with immediate (type 1) and early placement (type 2 and type 3) than with late placement(type 4). The majority of studies reported survival rates of over 95%. Similar survival rates wereobserved for immediate (type 1) and early (type 2) placement. Recession of the facial mucosal marginis common with immediate (type 1) placement. Risk indicators included a thin tissue biotype, a facialmalposition of the implant, and a thin or damaged facial bone wall. Early implant placement (type 2and type 3) is associated with a lower frequency of mucosal recession compared to immediate place-ment (type 1). INT J ORAL MAXILLOFAC IMPLANTS 2009;24(SUPPL):186–217
Key words: bone grafts, early implant placement, esthetics, immediate implant, implant survival
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and Related Research. In addition, the reference lists ofrecent review papers were searched for additionalcitations.1,2,4–8 Papers accepted for publication werealso included.
Selection of StudiesAll clinical studies of implants in postextraction sitesthat included 10 or more treated patients were evalu-ated. For studies reporting on success and survivaloutcomes, only studies with a mean follow-up periodof at least 12 months from the time of implant place-ment were included.Where a follow-up publication ofa previous study was identified, the most recent studywas included.
Studies were excluded if the mean follow-upperiod was not stated. In studies that reported oncases with different implant placement times aftertooth extraction, studies were excluded if the datadid not permit a differentiation of the placementtime in subjects and sites.
Evaluation of Treatment OutcomeThe following treatment outcomes were recorded:
• Change in peri-implant defect dimension, either as areduction in defect area (mm2 or %), defect height,width, and/or depth (mm or %), or as the changein the number of exposed implant threads. The fol-lowing parameters were recorded: study design,implant surface, number of patients and implantsites, timing of implant placement after toothextraction, implant sites, augmentation method,healing protocol (whether submerged or transmu-cosal), concomitant use of systemic antibiotics,healing time from implant placement to surgicalreentry, and postoperative complications.
• Implant survival, recorded either as an overall sur-vival rate or cumulative survival rate. Loading pro-tocol and complications during the follow-upperiod were also recorded, in addition to the para-meters listed above.
• Esthetic outcomes. The following parameters wererecorded: descriptive soft tissue outcomes,esthetic indices, recession of the mucosa andpapillae (in mm or % change), changes in probingdepths or attachment levels, radiographic changesof the proximal bone, loading protocol, patient-evaluated esthetic outcomes, and complicationsduring the follow-up period.
DefinitionsIn the literature, a number of descriptive terms havebeen used to describe when implants are placed aftertooth extraction.The terms immediate, recent, delayed,
and mature were introduced to describe the timingof placement in relation to soft tissue healing and thepredictability of guided bone regeneration.9 The termlate was used to describe time intervals of 6 monthsor more after extraction.10 More recently, the termearly has been used to describe implant placementafter initial soft and hard tissue healing but beforecomplete healing of the socket has occurred.5,11,12
The imprecise nature of these descriptive terms inthe dental literature was discussed at the Third ITIConsensus Conference in 2003, and a new classifica-tion system for timing of implant placement aftertooth extraction was proposed.13 A slight modifica-tion to the classification was made in a 2008 ITI publi-cation, the ITI Treatment Guide, Vol 3 (Table 1).2 Thisclassification system was based on the desired clinicaloutcome of the wound-healing process, rather thanon descriptive terms or rigid time frames followingextraction. Type 1 placement refers to placement ofan implant on the same day as tooth extraction andas part of the same surgical procedure. Type 2 place-ment occurs when the implant is placed after soft tis-sue healing, but before any clinically significant bonefill occurs within the socket. In contrast, type 3 place-ment is defined as placement of an implant followingsignificant clinical and/or radiographic bone filling ofthe socket. In type 4 placement, the implant is placedinto a fully healed site. This classification was vali-dated in a recent review paper.1 The authors of thepaper felt that the classification was an appropriatemeans for describing the timing of implant place-ment in postextraction sites, as it accounted for varia-tions in the healing capacity of individuals.
Although this classification system has clarifiedthe terminology for implant placement in postextrac-tion sites, various descriptive terms remain in wideuse in the dental implant literature. Therefore, to
The International Journal of Oral & Maxillofacial Implants 187
Group 4
Table 1 Classification and Descriptive Terms forTiming of Implant Placement After Tooth Extraction(from Chen and Buser2)
Classifi- Descriptive Desired clinical cation terminology outcome
Type 1 Immediate placement An extraction socket with nohealing of bone or soft tissues
Type 2 Early placement-with A postextraction site withsoft tissue healing healed soft tissues but without(typically 4 to 8 wk of significant bone healinghealing)
Type 3 Early placement-with A postextraction site withpartial bone healing healed soft tissues and with(typically 12 to 16 wk significant bone healingof healing)
Type 4 Late placement (more A fully healed socketthan 6 mo of healing)
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avoid ambiguity with respect to the timing of implantplacement after extraction, the descriptive terms andclassification adopted in the Third ITI TreatmentGuide, Vol 3, were used simultaneously in this review.2
The term postextraction sites was used to describecollectively fresh and healing extraction sites thatpermit implants to be placed immediately (type 1),early after soft tissue healing (type 2), and early afterpartial bone healing (type 3).
RESULTS
A total of 1,107 abstracts and 170 full-text articleswere evaluated. Of these, 91 studies met the inclusioncriteria for this review. Data were extracted from thestudies and tabulated.
Regenerative Outcomes of PostextractionImplantsThere were 28 studies reporting on healing of peri-implant defects in postextraction sites ( Table 2).Eleven comparative studies were identified, of which7 were RCTs.14–20 Four were prospective and retro-spective studies.21–24 The remaining 17 studies wereprospective and retrospective case series, the major-ity of which investigated immediate placement (type1).25–38 Three studies reported on treatment out-comes with early placement (type 2).39–41
How Effective Are Bone Augmentation Proce-dures? The majority of studies used combinations ofbone grafts and/or barrier membranes to promotebone regeneration in peri-implant defects. The mostcommonly used augmentation material was depro-teinized bovine bone mineral (DBBM), eitheralone31,33 or in conjunction with expanded polytetra-fluoroethylene (e-PTFE) membranes15 or collagenmembranes.21,22,24,30,32,40,41 Other augmentationmaterials included autogenous bone alone,17,26
e-PTFE barrier membrane alone,27,29 freeze-drieddemineralized laminar cortical bone membrane,34
composite graft of polymethyl methacrylate and cal-cium hydroxide,36 and hydroxyapatite alone.16
Despite the heterogeneity of the evaluated bone-augmentation techniques and variations in methodsfor quantifying defect fill, all studies reported signifi-cant fill of the peri-implant defects, resulting in clini-cally acceptable resolution of the defects.
Five RCTs have provided data to compare differentaugmentation techniques (Table 3).14–16,19,20 In a studycomparing defect height changes with immediateplacement (type 1), defect reduction was significantlygreater when an e-PTFE membrane was combinedwith demineralized freeze-dried bone allograft(DFDBA) than for an e-PTFE membrane alone after 6
months of submerged healing (5.68 ± 1.4 mm vs 3.18± 2.8 mm; P < .04).14 In a study of 83 patients compar-ing a hydroxyapatite graft and a resorbable polymermembrane with immediate placement (type 1) andsubmerged healing, no significant differences wereobserved in defect height resolution. Residual defectheight for both groups was between 0.70 and 0.80mm (P = .772).16 In a study comparing four differentaugmentation techniques (e-PTFE membrane alone,e-PTFE membrane and autogenous bone, resorbablepolymer membrane and autogenous bone, and auto-genous bone alone) with a nonaugmented controlgroup, no significant differences were observed withrespect to reduction in defect height and orofacialdefect depth after 6 months of healing with immedi-ate placement (type 1).19 However, sites treated withthe addition of a membrane (e-PTFE or resorbablepolymer) showed greater reduction in the mesiodistalwidth of the peri-implant defect. A study of immedi-ate placement (type 1) with transmucosal healingreported no significant differences in defect heightand depth reduction when comparing two augmen-tation methods (DBBM and collagen membrane, andDBBM alone) to a nonaugmented control group.20
The results of these controlled clinical studies aresupported by retrospective and prospective casesseries studies with immediate (type 1) and early (type2) implant placement. Without exception, these stud-ies showed statistically and clinically significant reso-lution of the peri-implant defects. There is strongevidence to suggest that bone augmentation proce-dures are effective in promoting bone fill and defectresolution in peri-implant defects with both surgicalapproaches—immediate (type 1) and early (type 2)placement.
Are Bone Augmentation Procedures Necessary?Recently, several studies reported on healing out-comes without the use of barrier membranes andbone grafts within the peri-implant defects in postex-traction sites.19,20,23,35,37–39 In two separate studies,Chen et al reported that various combinations of bar-rier membranes and/or bone grafts and substitutesachieved similar defect resolution when compared tononaugmented control sites that were allowed toheal with a blood clot alone.19,20 Defect height reduc-tions between 68% and 83% were reported. Nir-Hadar et al reported that after 3 to 6 months ofsubmerged healing, the residual vertical defect wasless than 0.5 mm with early placement (type 2), irre-spective of whether an initial orofacial defect waspresent or not.39 Complete defect resolution wasobserved with immediate placement in a prospectivestudy in 10 patients.35 In this study, the peri-implantdefects were less than 2 mm in the orofacial dimen-sion. The same authors compared the outcomes of
188 Volume 24, Supplement, 2009
Chen/Buser
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The International Journal of Oral & Maxillofacial Implants 189
Group 4
Tabl
e 2
C
linic
al S
tudi
es R
epor
ting
on
Hea
ling
of P
eri-i
mpl
ant
Def
ects
Ass
ocia
ted
wit
h Im
plan
ts in
Pos
text
ract
ion
Sit
es
No.
of
Pla
cem
ent
pati
ents
tim
eS
tudy
Impl
ant
(No.
of
afte
r A
ugm
enta
tion
H
ealin
gD
efec
t
Stu
dyde
sign
surf
ace
impl
ants
)ex
trac
tion
met
hod
prot
ocol
chan
ges
Gel
b (1
99
3)2
5
Bec
ker
et a
l (1
99
4)2
6
Lang
et a
l (1
99
4)2
7
Bec
ker
et a
l (1
99
4)2
8
Nir-
Had
ar e
t al
(19
98
)39
Häm
mer
le e
t al
(19
98
)29
Nem
covs
ky e
t al
(19
99
)30
Nem
covs
ky e
t al
(20
00
)31
Nem
covs
ky e
t al
(20
00
)40
Nem
covs
ky e
t al
(20
00
)32
Van
Ste
enbe
rghe
et a
l (2
00
0)3
3
Pros
p C
S
Pros
p C
S
Pros
p C
S
Mul
ticen
ter
Pros
p C
oS
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Turn
ed
Turn
ed
TPS
Turn
ed
Turn
ed
TPS
TPS
and
HA
SB
E an
d TP
S
SB
E an
d TP
S
Vario
us (m
icro
-te
xtur
ed, T
PSan
d H
A)Tu
rned
35
(50
)
30
(54
)
16 (2
1)
40
(49
)
14 (2
1)
10 (1
1)
29
(33
)
24
(26
)
21 (2
8)
61 (6
1)
15
(21
)
Type
1
Type
1
Type
1
Type
1
Type
2(6
to 8
wee
ks)
Type
1
Type
1
Type
1
Type
2(5
to 7
wee
ks)
Type
1
Type
1
e-PT
FE m
embr
ane,
DFD
BA
graf
t or
e-PT
FE m
embr
ane
+ D
FDB
A gr
aft
Auto
geno
us b
one
chip
s
e-PT
FE m
embr
ane
only
e-PT
FE m
embr
ane
only
No
augm
enta
tion
e-PT
FE m
embr
ane
only
DB
BM
onl
y in
sm
all (
size
of d
efec
tsno
t spe
cifie
d) d
efec
ts
DB
BM
and
reso
rbab
le c
olla
gen
mem
-br
ane
in d
ehis
cenc
e de
fect
s >
4 m
mD
BB
M o
nly;
inta
ct b
one
wal
ls
DB
BM
and
reso
rbab
le c
olla
gen
mem
-br
ane;
deh
isce
nce
defe
cts
wer
e al
l >
4 m
m o
r ha
d >
25
% o
f the
impl
ant
surf
ace
expo
sed
DB
BM
and
reso
rbab
le c
olla
gen
mem
-br
ane
(mem
bran
e no
t use
d w
hen
all
bone
wal
ls w
ere
inta
ct)
DB
BM
with
no
mem
bran
e
Sub
mer
ged
Sub
mer
ged
Tran
smuc
osal
Sub
mer
ged
Sub
mer
ged
Tran
smuc
osal
Sub
mer
ged
Sub
mer
ged
Sub
mer
ged
Sub
mer
ged
Sub
mer
ged
100
% th
read
cov
erag
e fo
r al
l tec
hniq
ues
exce
pt in
one
cas
e of
a n
o-w
all d
efec
t tre
ated
with
DFD
BA
graf
t onl
y, 7
6%
cov
erag
eM
ean
initi
al d
efec
t hei
ght 5
.5 ±
3.0
mm
redu
ced
to 0
.5 ±
1.0
mm
at
reen
try*
Mea
n in
itial
oro
faci
al d
efec
t wid
th 3
.7 ±
2.1
mm
redu
ced
to 0
.2 ±
0.8
mm
*2
0/2
1 s
ites
with
com
plet
e bo
ne re
gene
ratio
n
At s
ites
with
no
early
mem
bran
e re
mov
al (N
= 2
9):
mea
n in
itial
defe
ct h
eigh
t of 4
.9 ±
2.5
mm
redu
ced
to 0
.1 ±
0.4
mm
at r
eent
ry†
At s
ites
with
ear
ly m
embr
ane
rem
oval
(N =
20
): m
ean
initi
al d
efec
the
ight
of 6
.4 ±
4.3
mm
redu
ced
to 2
.4 ±
3.3
mm
†
Mea
n in
itial
ver
tical
def
ect 2
.5 ±
0.3
7 m
m re
duce
d to
0.3
6 ±
0.6
4m
m w
hen
a ho
rizon
tal (
orof
acia
l) de
fect
was
pre
sent
*M
ean
initi
al v
ertic
al d
efec
t 3.8
6 ±
0.5
8 m
m re
duce
d to
0.4
8 ±
0.2
5m
m w
hen
a ho
rizon
tal (
orof
acia
l) de
fect
was
abs
ent*
Mea
n in
itial
hor
izon
tal (
orof
acia
l) de
fect
1.6
± 1
.73
mm
redu
ced
to0
.02
± 0
.02
mm
*M
ean
initi
al v
ertic
al d
efec
t 4.7
± 1
.3 m
m re
duce
d to
2.1
± 0
.8 m
mat
reen
try†
94
% d
efec
t vol
ume
fill†
No
mem
bran
e si
tes:
Mea
n in
itial
def
ect h
eigh
t 1.9
± 1
.16
mm
redu
ced
to 0
.3 ±
0.4
6 m
m a
t ree
ntry
†
Mem
bran
e si
tes:
Mea
n in
itial
def
ect h
eigh
t 4.6
± 1
.18
mm
redu
ced
to 0
.7 ±
0.7
mm
at r
eent
ry†
Mea
n in
itial
def
ect h
eigh
t 2.6
± 1
.72
mm
redu
ced
to 0
.6 ±
0.7
0 m
m†
For
sing
le im
plan
ts: M
ean
initi
al d
efec
t hei
ght 6
.7 ±
2.2
3 m
mre
duce
d to
0.6
± 0
.69
mm
at r
eent
ry
Mea
n in
itial
def
ect a
rea
23
.7 ±
11
.49
mm
2re
duce
d to
0.7
± 0
.99
mm
2at
reen
try
For
adja
cent
impl
ants
: Mea
n in
itial
def
ect h
eigh
t 6.4
± 1
.03
mm
redu
ced
to 0
.8 ±
0.2
7 m
m a
t ree
ntry
Mea
n in
itial
def
ect a
rea
20
.67
± 4
.4 m
m2
redu
ced
to 0
.6 ±
0.4
0m
m2
at re
entr
yVe
rtic
al g
ain
in b
one
betw
een
1.5
and
3.6
mm
Mea
n in
itial
def
ect h
eigh
t 3.8
± 0
.6 m
m re
duce
d to
1.1
± 0
.3 m
m a
tre
entr
y
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190 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 2
con
tinu
ed
Clin
ical
Stu
dies
Rep
orti
ng o
n H
ealin
g of
Per
i-im
plan
t D
efec
ts A
ssoc
iate
d w
ith
Impl
ants
in P
oste
xtra
ctio
n S
ites
No.
of
Pla
cem
ent
pati
ents
tim
eS
tudy
Impl
ant
(No.
of
afte
r A
ugm
enta
tion
H
ealin
gD
efec
t
Stu
dyde
sign
surf
ace
impl
ants
)ex
trac
tion
met
hod
prot
ocol
chan
ges
Ros
enqu
ist a
ndAh
med
(20
00
)34
Häm
mer
le a
nd
Lang
(20
01)41
Cov
ani e
t al
(20
03
)35
Yukn
a et
al
(20
03
)36
Bot
ticel
li et
al
(20
04
)37
Cov
ani e
t al
(20
07
)38
Stu
dy d
esig
n: P
rosp
= p
rosp
ectiv
e; C
oS =
coh
ort
stud
y; C
S =
cas
e se
ries.
Impl
ant
surf
ace:
tur
ned
= e
quiv
alen
t to
mac
hine
d su
rfac
e; T
PS
= t
itani
um p
lasm
a-sp
raye
d; H
A =
hyd
roxy
apat
ite-c
oate
d; S
LA =
sur
face
san
dbla
sted
with
larg
e-gr
it an
d ac
id-e
tche
d;S
BE
= s
andb
last
ed a
nd a
cid-
etch
ed.
Pla
cem
ent
time
afte
r ex
trac
tion:
Typ
e 1
= im
med
iate
pla
cem
ent
at t
he t
ime
of e
xtra
ctio
n; T
ype
2 =
ear
ly p
lace
men
t af
ter
initi
al s
oft
tissu
e he
alin
g; T
ype
3 =
ear
ly p
lace
men
t af
ter
subs
tant
ial b
one
heal
ing;
Type
4 =
late
pla
cem
ent
afte
r co
mpl
ete
heal
ing
of t
he r
idge
.A
ugm
enta
tion
met
hod:
e-P
TFE
= e
xpan
ded
poly
tetr
aflu
oroe
thyl
ene
mem
bran
e; D
BB
M =
dem
iner
aliz
ed b
ovin
e bo
ne m
iner
al; D
FDB
A =
dem
iner
aliz
ed f
reez
e-dr
ied
bone
allo
graf
t.*S
igni
fican
t w
ithin
-gro
up c
hang
e fr
om b
asel
ine
(P<
.05)
.† S
igni
fican
t w
ithin
-gro
up c
hang
e fr
om b
asel
ine
(P<
.01)
.
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Turn
ed
TPS
SB
E an
d TP
S
HA
SLA
TPS
25
(34
)
10 (1
0)
10 (1
5)
23
(30
)
18
(21
)
20
(20
)
Type
1
Type
2(8
to 1
4w
eeks
)
Type
1
Type
1
Type
1
Type
1
Free
ze-d
ried
dem
iner
aliz
ed h
uman
lam
inar
cor
tical
bon
e us
ed a
s a
bar-
rier
mem
bran
eD
BB
M a
nd re
sorb
able
col
lage
n m
em-
bran
e
No
augm
enta
tion;
mar
gina
l def
ects
betw
een
sock
et w
all a
nd im
plan
tw
ere
no m
ore
than
2 m
mC
ompo
site
of p
olym
ethy
l met
hacr
y-la
te a
nd c
alci
um h
ydro
xide
No
augm
enta
tion
No
augm
enta
tion
Mem
bran
e le
ftex
pose
d
Tran
smuc
osal
Sub
mer
ged
Sub
mer
ged
Sem
isub
mer
ged
Sub
mer
ged
Mea
n in
itial
def
ect h
eigh
t of 8
.5 m
m re
duce
d to
0.3
mm
at r
eent
ry
Mea
n in
itial
ver
tical
def
ect h
eigh
t red
uced
from
7.8
± 1
.9 m
m to
2.5
± 0
.6 m
m†
Def
ect a
rea
redu
ctio
n of
86
± 3
3%
; 8/1
0 s
ites
had
100
% d
efec
tar
ea re
duct
ion
No
resi
dual
bon
e de
fect
s ob
serv
ed; d
ista
nce
betw
een
faci
al a
nd li
n-gu
al b
one
wal
ls re
duce
d fr
om 1
0.5
± 1
.5 m
m to
6.8
± 1
.3 m
m (3
5%
chan
ge)
Oro
faci
al in
tern
al s
ocke
t dim
ensi
on re
duce
d fr
om 6
.9 to
0 m
mEx
tern
al r
idge
wid
th d
ecre
ased
from
9.1
± 2
.4 m
m to
8.4
± 1
.9 m
m(P
= .0
8)
Def
ect h
eigh
t red
uctio
n: m
esia
l 1.6
± 3
.8 m
m; f
acia
l 5.5
± 2
.3 m
m;
dist
al 0
.4 ±
2.3
mm
; lin
gual
3.5
± 2
.7 m
mD
efec
t wid
th re
duct
ion:
mes
ial 0
.3 ±
0.8
mm
; fac
ial 1
.5 ±
0.7
mm
;di
stal
0.1
± 0
.8 m
m; l
ingu
al 1
.1 ±
0.8
mm
Mea
n re
duct
ion
in c
rest
al b
one
heig
ht w
as 0
.8 m
m (0
mm
in 3
8%
of
site
s, >
0 to
1 m
m in
47
% o
f site
s, >
1 to
2 m
m in
15
% o
f site
s)
186_4a_Chen.qxd 9/10/09 10:16 AM Page 190
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
The International Journal of Oral & Maxillofacial Implants 191
Group 4
Tabl
e 3
C
ontr
olle
d C
linic
al S
tudi
es C
ompa
ring
Dif
fere
nt A
ugm
enta
tion
Met
hods
Use
d w
ith
Impl
ants
Pla
ced
into
Pos
text
rati
on S
ites
Pla
cem
ent
Expe
rim
enta
lpr
otoc
ol/
Stu
dy a
im/
grou
ps a
ndR
eent
ry p
erio
dIm
plan
the
alin
g pr
otoc
ol/
outc
ome
augm
enta
tion
N
o. o
fN
o. o
f fo
llow
ing
Stu
dysu
rfac
ecl
inic
al in
dica
tion
sva
riab
les
met
hods
pati
ents
impl
ants
plac
emen
tR
esul
ts
Ghe
r et
al
(19
94
)14
Zitz
man
n et
al (
19
97
)15
Pros
per
et a
l (2
00
3)16
TPS
and
HA
Turn
ed
San
d-bl
aste
d
Type
1/S
ubm
erge
d/M
axill
ary
ante
rior
and
prem
olar
site
s;m
andi
bula
r can
ine,
prem
olar
and
mol
arsi
tes
Type
1, 2
, 3, 4
/Sub
-m
erge
d/M
axill
ary
and
man
dibu
lar
site
s-al
l loc
atio
ns
Type
1/
Sub
mer
ged/
Max
illar
y an
dm
andi
bula
r m
olar
site
s
RC
T/To
com
pare
two
bone
aug
men
-ta
tion
met
hods
at
two
impl
ant s
ur-
face
s/C
hang
e in
defe
ct h
eigh
t and
cres
tal b
one
leve
ls
RC
T/To
com
pare
bone
aug
men
tatio
nus
ing
a re
sorb
able
colla
gen
mem
bran
ew
ith a
non
re-
sorb
able
e-P
TFE
mem
bran
e in
asp
lit-m
outh
ran
dom
-iz
ed s
tudy
/Cha
nge
in d
efec
t are
a
RC
T/To
com
pare
two
bone
aug
men
ta-
tion
met
hods
in c
on-
junc
tion
with
aw
ide-
diam
eter
impl
ant (
5.9
mm
)/Pr
imar
y ou
tcom
eva
riabl
e-ch
ange
inde
fect
hei
ght
Gro
up 1
: TPS
sur
face
and
e-PT
FE m
embr
ane
only
Gro
up 2
: TPS
sur
face
and
e-PT
FE p
lus
DFD
BA
Gro
up 3
: HA
surf
ace
and
e-PT
FE m
embr
ane
only
Gro
up 4
: HA
surf
ace
and
e-PT
FE p
lus
DFD
BA
Each
pat
ient
requ
ired
atle
ast t
wo
imm
edia
teim
plan
ts; o
ne s
ite ra
n-do
mly
rece
ived
are
sorb
able
col
lage
nm
embr
ane
and
the
othe
r site
a n
onre
-so
rbab
le e
-PTF
E m
em-
bran
e (p
rovi
ded
ther
ew
as 1
4 m
m o
f spa
cebe
twee
n th
e tw
o si
tes;
ifle
ss th
an 1
4 m
m th
esa
me
mem
bran
e w
asus
ed fo
r bot
h si
tes)
.D
BB
M w
as g
raft
ed a
tbo
th s
ites
Gro
up 1
: HA
graf
t onl
yG
roup
2: R
esor
babl
epo
lym
er m
embr
ane
only
Gro
up 1
= 1
0G
roup
2 =
10
Gro
up 3
= 1
0G
roup
4 =
10
25
83
pat
ient
sto
tal
No.
of p
atie
nts
in e
ach
grou
pno
t sta
ted;
all
patie
nts
belo
nged
toth
e sa
me
trea
t-m
ent g
roup
/S
ome
patie
nts
rece
ived
mor
eth
an 1
impl
ant
Gro
up 1
= 1
1G
roup
2 =
12
Gro
up 3
= 1
0G
roup
4 =
10
84
Type
1 =
27
Type
2, 3
, 4(b
etw
een
6 w
kan
d 6
mo
afte
rto
oth
extr
ac-
tion)
= 1
7H
eale
d si
te(m
ore
than
6m
o af
ter e
x-tr
actio
n) =
40
Gro
up 1
= 5
6G
roup
2 =
55
6 m
o
4 m
o in
the
man
dibl
ean
d 6
mo
in th
e m
axill
a
4 y
from
plac
emen
t;al
l pat
ient
sco
mpl
eted
the
4-y
fol-
low
-up
No
diff
eren
ces
betw
een
impl
ant s
urfa
ces
Mea
n de
fect
hei
ght r
educ
tion:
Non
-DFD
BA
graf
ted
=3
.18
± 2
.83
mm
; DFD
BA
graf
ted
= 5
.68
± 3
.45
mm
(P
< .0
4)
Mea
n cr
esta
l bon
e lo
ss fr
om m
ost c
oron
al b
one
cres
t:N
on-D
FDB
A gr
afte
d =
1.5
9 ±
1.6
6 m
m; D
FDB
A gr
afte
d=
1.5
3 ±
1.3
8 (N
S)
Mea
n cr
esta
l bon
e lo
ss fr
om m
ost a
pica
l par
t of c
rest
:N
on-D
FDB
A gr
afte
d =
0.1
1 ±
2.7
6 m
m; D
FDB
A gr
afte
d=
–1.3
9 ±
2.7
6 (i
e, g
ain
in c
rest
al b
one
heig
ht)
(P<
.02
)M
ean
defe
ct a
rea
redu
ctio
n:
e-PT
FE m
embr
ane:
78
± 5
0.2
%C
olla
gen
mem
bran
e: 9
2 ±
19
.3%
(P<
.00
01)
Mea
n de
fect
are
a re
duct
ion
in th
e pr
esen
ce o
f aw
ound
deh
isce
nce:
Fo
r co
llage
n m
embr
ane
No
dehi
scen
ce (n
= 3
9):
94
± 1
9.0
%;
Deh
isce
nce
(n =
4):
87
± 1
8.9
% (N
S)
For
e-PT
FE m
embr
ane
No
dehi
scen
ce (n
= 2
3):
98
± 9
.8%
Deh
isce
nce
(n =
18
): 6
5 ±
68
.4%
(P=
.01
)
Res
idua
l ver
tical
def
ect h
eigh
t:G
roup
1: r
ange
0.7
0 to
0.8
0 m
m
Gro
up 2
: ran
ge 0
.73
to 0
.80
mm
(P
= .7
72
)
186_4a_Chen.qxd 9/10/09 10:16 AM Page 191
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
192 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 3
con
tinu
ed
Con
trol
led
Clin
ical
Stu
dies
Com
pari
ng D
iffe
rent
Aug
men
tati
on M
etho
ds U
sed
wit
h Im
plan
ts P
lace
d in
to P
oste
xtra
tion
Sit
es
Pla
cem
ent
Expe
rim
enta
lpr
otoc
ol/
Stu
dy a
im/
grou
ps a
ndR
eent
ry p
erio
dIm
plan
the
alin
g pr
otoc
ol/
outc
ome
augm
enta
tion
N
o. o
fN
o. o
f fo
llow
ing
Stu
dysu
rfac
ecl
inic
al in
dica
tion
sva
riab
les
met
hods
pati
ents
impl
ants
plac
emen
tR
esul
ts
Cor
nelin
i et a
l(2
00
4)1
8
Che
n et
al
(20
05
)19
Che
n et
al
(20
07
)20
Impl
ant s
urfa
ce: T
urne
d =
equi
vale
nt to
mac
hine
d su
rfac
e; T
PS =
tita
nium
pla
sma-
spra
yed;
HA
= hy
drox
yapa
tite-
coat
ed, S
LA =
sur
face
san
dbla
sted
with
larg
e-gr
it an
d ac
id-e
tche
d.Pl
acem
ent p
roto
col (
plac
emen
t tim
e af
ter
extr
actio
n): T
ype
1 =
imm
edia
te p
lace
men
t at t
he ti
me
of e
xtra
ctio
n; T
ype
2 =
ear
ly p
lace
men
t aft
er in
itial
sof
t tis
sue
heal
ing;
Typ
e 3
= e
arly
pla
cem
ent
afte
r su
bsta
ntia
l bon
e he
alin
g; T
ype
4 =
late
pla
cem
ent a
fter
com
plet
e he
alin
g of
the
ridge
. Stu
dy d
esig
n: R
CT
= ra
ndom
ized
con
trol
led
tria
l; C
CS
= c
ontr
olle
d cl
inic
al s
tudy
; CoS
= c
ohor
t stu
dy;
CS
= c
ase
serie
s. A
ugm
enta
tion
met
hod:
e-P
TFE
= ex
pand
ed p
olyt
etra
fluor
oeth
ylen
e m
embr
ane;
DB
BM
= d
emin
eral
ized
bov
ine
bone
min
eral
; DFD
BA
= de
min
eral
ized
free
ze-d
ried
bone
allo
graf
t;TC
P =
beta
tric
alci
um p
hosp
hate
.*T
he a
utho
rs re
port
ed s
tand
ard
erro
r; s
tand
ard
devi
atio
n w
as d
eriv
ed fr
om d
ata
pres
ente
d in
the
pape
r.
SLA
Turn
ed
SLA
Type
1/T
rans
mu-
cosa
l/M
axill
ary
and
man
dibu
lar
cani
nes
and
prem
olar
s
Type
1/S
ub-
mer
ged/
Sin
gle-
toot
h im
plan
ts in
the
max
illar
y an
te-
rior
and
prem
olar
regi
ons
Type
1/T
rans
mu-
cosa
l/S
ingl
e-to
oth
impl
ants
in m
axil-
lary
ant
erio
r an
d pr
emol
ar s
ites
RC
T/To
com
pare
the
effe
ct o
f dem
-in
eral
ized
bov
ine
bone
as
an a
djun
ctto
reso
rbab
le c
olla
-ge
n fo
r bo
ne a
ug-
men
tatio
n at
imm
edia
te im
plan
ts
RC
T/To
com
pare
the
effe
ct o
f var
ious
bone
aug
men
tatio
npr
oced
ures
on
heal
-in
g of
the
peri-
impl
ant m
argi
nal
defe
ct/P
rimar
y ou
t-co
me
varia
bles
-de
fect
hei
ght,
wid
th,
and
dept
h ch
ange
san
d re
sorp
tion
ofth
e fa
cial
bon
e w
all
RC
T/To
com
pare
the
effe
ct o
f var
ious
bone
aug
men
tatio
npr
oced
ures
on
heal
-in
g of
the
peri-
impl
ant m
argi
nal
defe
ct/P
rimar
y ou
t-co
me
varia
bles
-ch
ange
in d
efec
the
ight
, wid
th, a
ndde
pth,
and
faci
alcr
esta
l bon
e
Test
gro
up: D
BB
M a
ndre
sorb
able
col
lage
nm
embr
ane
Con
trol
gro
up:
Res
orba
ble
colla
gen
mem
bran
e on
ly
Gro
up 1
: e-P
TFE
mem
-br
ane
only
Gro
up 2
: Res
orba
ble
poly
mer
mem
bran
eon
lyG
roup
3: R
esor
babl
epo
lym
er m
embr
ane
and
auto
geno
us b
one
Gro
up 4
: Aut
ogen
ous
bone
onl
yG
roup
5: N
o au
gmen
ta-
tion;
con
trol
Max
illar
y an
terio
r an
dpr
emol
ar s
ites
Gro
up 1
(n =
10
):D
BB
MG
roup
2 (n
= 1
0):
DB
BM
and
reso
rbab
leco
llage
n m
embr
ane
Gro
up 3
(n=1
0):
No
augm
enta
tion;
con
trol
Test
gro
up =
10
Con
trol
gro
up=
10
Gro
up 1
= 1
2G
roup
2 =
11
Gro
up 3
= 1
2G
roup
4 =
14
Gro
up 5
= 1
2To
tal =
62
Gro
up 1
= 1
0G
roup
2 =
10
Gro
up 3
= 1
0
Test
gro
up =
10 Con
trol
gro
up=
10
Gro
up 1
= 1
2G
roup
2 =
11
Gro
up 3
= 1
2G
roup
4 =
14
Gro
up 5
= 1
2To
tal =
62
Gro
up 1
= 1
0G
roup
2 =
10
Gro
up 3
= 1
0
6 m
o
2 y
aft
erlo
adin
g
6 m
o
Mea
n ra
diog
raph
ic c
rest
al b
one
loca
tion
from
impl
ant
shou
lder
, bas
elin
e to
6 m
o:Te
st g
roup
: 1.7
mm
vs
1.8
mm
Con
trol
gro
up: 2
.2 m
m v
s 2
.1 m
mM
ean
prox
imal
muc
osal
mar
gin
leve
ls c
oron
al to
the
shou
l-de
r at 6
mo:
Buc
cal
Test
gro
up: 2
.6 m
m
Con
trol
gro
up: 2
.3 m
m (P
< .0
1)
Ling
ual
Test
gro
up: 1
.3 m
mC
ontr
ol g
roup
: 1.1
mm
(P<
.01
)M
ean
bucc
al m
ucos
al m
argi
n le
vels
cor
onal
to th
e sh
ould
erat
6 m
o:Te
st g
roup
: 2.1
mm
Con
trol
gro
up: 0
.9 m
m (P
< .0
5)
Def
ect h
eigh
t red
uctio
n (%
):G
roup
1: 7
4.9
± 2
7.8
*; G
roup
2: 6
9.1
± 2
7.6
; Gro
up 3
: 83
.1±
23
.8; G
roup
4: 7
5.3
± 2
0.9
; Gro
up 5
: 73
.6 ±
24
.1 (N
S)D
efec
t dep
th (o
rofa
cial
) red
uctio
n (%
):G
roup
1: 7
3.6
± 3
0.3
; Gro
up 2
: 75
.8 ±
34
.3; G
roup
3: 8
9.7
± 19
.9; G
roup
4: 7
5.6
± 2
6.0
; Gro
up 5
: 69
.7 ±
44
.2 (
NS)
Def
ect w
idth
(mes
iodi
stal
) red
uctio
n (%
):G
roup
1: 6
7.3
± 2
3.6
; Gro
up 2
: 60
.6 ±
35
.9; G
roup
3: 7
1.2
± 2
9.2
; Gro
up 4
: 34
.1 ±
28
.3; G
roup
5: 7
3.6
± 2
4.1
(P<
.01
betw
een
grou
ps; G
roup
1 d
iffer
ent f
rom
Gro
ups
4 a
nd 5
,G
roup
2 d
iffer
ent f
rom
Gro
up 4
, Gro
up 3
diff
eren
t fro
mG
roup
s 4
and
5)
Mea
n ch
ange
in v
ertic
al d
efec
t hei
ght:
Gro
up 1
: 81.
2 ±
5.0
%; G
roup
2: 7
0.5
± 1
7.4
%; G
roup
3: 6
8.2
± 1
6.6
% (N
S)M
ean
chan
ge in
def
ect d
epth
(oro
faci
al):
Gro
up 1
: 71.
7 ±
34
.3%
; Gro
up 2
: 81.
7 ±
33
.7%
; Gro
up 3
: 55
.0 ±
28
.4%
(NS)
At s
ites
with
inta
ct b
one
wal
ls, m
ean
chan
ge in
faci
al c
res-
tal b
one
heig
ht: G
roup
1: 1
.1 ±
1.2
mm
; Gro
up 2
: 1.0
± 0
.6m
m; G
roup
3: 1
.3 ±
0.9
mm
(NS)
At s
ites
with
inta
ct b
one
wal
ls, m
ean
horiz
onta
l res
orpt
ion
of th
e fa
cial
bon
e: G
roup
1: 1
3.9
± 1
6.7
%; G
roup
2: 2
3.8
±2
3.4
%; G
roup
3: 4
8.3
± 9
.5%
(P=
.015
; Gro
up 3
sig
nifi-
cant
ly g
reat
er th
an G
roup
s 1
and
2)
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type 1 and type 2 placement, and concluded thatboth approaches resulted in complete defect fill.23 Ahuman histologic study confirmed that spontaneousbone regeneration occurred in experimental peri-implant defects that were less than 2 mm in width,and that the newly regenerated bone became inte-grated with the previously exposed implant surface.42
Covani and coworkers observed that completedefect fill occurred in the peri-implant gaps followingtype 1 and type 2 implant placement.23,35 The initialperi-implant gaps were 2 mm or less, and all sites hadintact bone walls. These observations are corrobo-rated by human histologic studies that have shownspontaneous bone regeneration and osseointegra-tion when peri-implant defects were less than 2 mmin a horizontal dimension.42–44 In contrast, two stud-ies examining healing outcomes when the initial peri-implant gaps were more than 2 mm reported thatnot all sites healed with complete bone fill. Botticelliet al demonstrated that 25% of sites with initial orofa-cial gaps of 2 to 3 mm healed completely, comparedto 78% of sites with initial gaps of less than 2 mm.37
Schropp et al observed that only 52% of sites with aninitial orofacial defect depth of 4 to 5 mm healedspontaneously in the presence of intact bone walls.17
Summarizing these studies, there is evidence toshow that peri-implant defects with gaps of less than2 mm following type 1 and type 2 implant placementmay heal with spontaneous bone regeneration anddefect resolution. However, gaps of 2 mm or more inthe orofacial dimension show clearly reduced pre-dictability for spontaneous bone regeneration.
Do Implants Prevent Resorption of the Ridge inPostextraction Sites? Recent clinical and experimen-tal studies have demonstrated that healing in postex-traction sites is characterized by bone regenerationwithin the socket and external dimensional changesdue to bone resorption and bone modeling.45–47 Aseries of well-designed experimental studies in acanine model have demonstrated that implantsplaced into extraction sockets of mandibular premo-lar teeth did not prevent these resorptive and model-ing changes from taking place.48,49 The result is areduction in the orofacial dimension of the ridge anda loss of crestal bone height, predominantly at thefacial aspect of the ridge.
Several studies have provided clinical data on thedimensional changes that occur adjacent to implantsin postextraction sockets when no augmentation wasperformed.35,37,38 In a prospective study, the distancebetween the facial and lingual bone walls changedfrom 10.5 ± 1.5 mm to 6.8 ± 1.3 mm (35% reduction ininitial orofacial width) after 6 months of submergedhealing.35 In this study, implants were placed intoextraction sockets (type 1 implant placement) in max-
illary and mandibular anterior and premolar sites. Afurther prospective study reported on type 1 place-ment of 21 implants in 18 patients.37 Implant siteswere confined to maxillary and mandibular anteriorand premolar sites. After 4 months of submergedhealing, the implant sites were reentered andchanges in the dimensions of the ridges wererecorded. External bone resorption and modelingresulted in a reduction in the orofacial crest width of56% on the facial aspect and 30% on the lingualaspect. The height of the crestal bone was reduced by0.2 to 0.6 mm. In a similar prospective study, Covaniand coworkers reported a mean loss in facial crestalbone height of 0.8 mm after 6 months of submergedhealing following type 1 placement in 20 patients.38
Implant sites included maxillary and mandibular ante-rior and premolar sites. Although 38% of the sitesshowed no change, 47% had between 0 mm and 1mm of loss, and 15% had between 1 and 2 mm of loss.
These studies provide strong evidence that type 1placement per se does not prevent vertical or hori-zontal resorption of the ridges in postextraction sites.
Does Bone Augmentation Prevent Ridge Resorp-tion with Postextraction Implants? Three RCTs14,19,20
and one prospective clinical case series36 reported onthe effect of bone augmentation on external dimen-sional changes with postextraction implant placement.
In a study of 40 patients, vertical resorption of thefacial crestal bone was similar for sites treated with ane-PTFE membrane alone or an e-PTFE membrane andDFDBA (1.59 ± 1.7 mm vs 1.53 ± 1.4 mm) for type 1placement after 6 months of submerged healing.14
Similar changes in facial crestal bone height wereobserved in a study of 30 patients who received 30immediate implants and transmucosal healing.20
After a healing time of 6 months, vertical resorptionof the facial bone was 1.1 ± 1.2 mm for peri-implantdefects grafted with DBBM, 1.0 ± 0.6 mm for sitesaugmented with DBBM and collagen membrane, and1.3 ± 0.9 mm for nonaugmented control sites. Therewere no significant differences between groups. Theresults of these two studies are similar to results fromstudies of nongrafted postextraction implant siteswith respect to vertical crestal bone resorption.37,38
A study of various augmentation techniques withtype 1 placement showed that although defect fillwas similar, dehiscence defects showed significantlygreater horizontal resorption than sites with intactbone walls.19 In another study by the same authors,significantly less horizontal resorption of the facialbone occurred when the peri-implant defects weregrafted with DBBM (13.9% to 23.8%) compared to thenonaugmented control group (48.3%).20 Similarly,Yukna and Castellon reported that following type 1placement and grafting of the peri-implant defects
The International Journal of Oral & Maxillofacial Implants 193
Group 4
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with a composite of polymethyl methacrylate andcalcium hydroxide, the external dimensions of thesockets changed only slightly, from 9.1 ± 2.4 mm to8.4 ± 1.9 mm (an 8% reduction in orofacial ridgewidth) after 6 months.36 Both these studies usedbone fillers with a low substitution rate.
These studies provide strong evidence that boneaugmentation following type 1 placement reduceshorizontal resorption of the facial bone. However,these augmentation procedures appear not to influ-ence vertical resorption of the facial bone.
Does Damage to or Loss of the Facial Bone AffectRegenerative Outcomes? In postextraction sites, lossof one or more of the socket walls is a common obser-vation. In a retrospective study of 75 patients, only 10out of 31 extraction sites (32%) had intact bonewalls.21 The majority of extraction sites presentedwith damage to the socket walls, with two-wall (52%of sites) or no-wall/one-wall (16% of sites) defects.Theauthors also reported that the proportion of two- andthree-wall defects diminished as the time after toothextraction increased. In an RCT, 60 out of 92 type 3and type 4 implant placement sites had peri-implantdefects. Of these, 48 were three-wall defects and 12were dehiscence or two-wall defects.17
Several studies were identified that reported ontreatment outcomes in postextraction sites in the pres-ence of dehiscences of the socket walls.17,19,20,25,30,40 Intwo RCTs of type 1 placement using various augmen-tation techniques, sites with dehiscence defectsachieved similar defect fill compared to intact sites.19,20
However, greater horizontal resorption of the facialbone occurred in the presence of a dehiscence, despitebone augmentation.19 In a prospective study of type 1placement in 35 patients, 100% implant thread cover-age was achieved in all sites except one site with a no-wall defect morphology, which achieved only 76%coverage.25 In this study, DFDBA was used alone or incombination with an e-PTFE membrane. A study oftype 1 implant placement in 29 patients receiving 33implants showed significant gain in crestal boneheight at dehiscence sites using DBBM and collagenmembrane.30 The resultant ridge height was similar tothat observed in sites that initially had intact bonewalls. In a study of type 2 implant placement in whichall 28 implant sites in 21 patients presented with dehis-cence defects, a defect area reduction of 97% wasreported using DBBM and collagen membrane.40 Again in crestal bone height of 6 to 7 mm was recorded.
In contrast to these studies, Schropp et al reportedthat a trend toward greater bone fill was observed atsites with intact bone walls compared to sites withdehiscence defects.17
These studies provide strong evidence that boneaugmentation following type 1 and type 2 placement
is effective in reconstructing the damaged facialbone. However, with type 1 placement, greaterresorption of the facial bone was shown to occur inone RCT. This may have significant implications foresthetic outcomes. A recent study reported a highincidence of recession of the facial mucosa in thepresence of defects of the facial bone with type 1placement, despite bone augmentation using DBBMand collagen membranes.50
Does Timing of Implant Placement Affect theRegenerative Outcome? There were six studies thatprovided comparative data on the effect of timing ofimplant placement on regenerative outcomes (Table4).15,17,21–24
Three studies compared immediate (type 1), early(type 2 or 3), and late (type 4) implant placement. In asplit-mouth randomized study of dehiscence defectsaugmented with DBBM, Zitzmann et al reported lessdefect area reduction with healed sites (80% fore-PTFE membrane and 90% for collagen membrane)compared to immediate and healing sites (85% to94% for e-PTFE membrane and 95% to 97% for colla-gen membrane) in 25 patients.15 Similarly, in a retro-spective study of 75 patients by the same authors,defect area reduction was significantly better withtype 1 and types 2 and 3 implant placement (92% ±20.8% and 92% ± 20.7%, respectively) compared totype 4 (80% ± 34.1%).21 The authors suggested thatthe difference was attributable to the greater propor-tion of one-wall/no-wall defects found with type 4placement compared to immediate and early place-ments, which had a greater proportion of two-walland three-wall defects. In another retrospective study,the use of DBBM and collagen membrane resulted inless defect area reduction with type 4 placement(87.6% ± 11.5%) compared to type 1 (90.2% ± 9.1%)and type 2 (95.6% ± 8.7%) placement.24 Type 2 place-ment achieved the best regenerative outcome in thisstudy.
Two studies compared types 1 and 2 implant place-ment. In a prospective study using DBBM and collagenmembrane to manage dehiscence defects, signifi-cantly greater defect area reduction was observedwith type 2 placement (91.2% ± 9.1%) compared toimmediate placement (type 1; 77.4% ± 17.0%) in maxil-lary molar sites.22 Covani et al reported that both type1 and type 2 placement in sites with intact bone wallsachieved complete defect fill in the absence of simul-taneous bone augmentation procedures.23
One RCT compared early placement in 46 patientswho received single-tooth implants in maxillary andmandibular anterior and premolar sites.17 Implantswere placed a mean of 10 days after extraction (range3 to 35 days) in the test sites (23 implants in 23patients). In control sites (23 implants in 23 patients),
194 Volume 24, Supplement, 2009
Chen/Buser
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The International Journal of Oral & Maxillofacial Implants 195
Group 4
Tabl
e 4
Clin
ical
Stu
dies
Com
pari
ng D
iffe
rent
Tim
es A
fter
Ext
ract
ion
and
Thei
r Ef
fect
on
Hea
ling
of P
eri-I
mpl
ant
Def
ects
No.
of p
atie
nts
(No.
of i
mpl
ants
) by
plac
emen
tR
esul
ts fo
r pl
acem
ent
tim
e af
ter
toot
h ex
trac
tion
tim
es a
fter
too
th e
xtra
ctio
nmet
hod
Stu
dy
Impl
ant
Type
s 2
(h
ealin
g O
bser
vati
on
Type
s 2
S
tudy
desi
gnsu
rfac
eTy
pe 1
and
3Ty
pe 4
prot
ocol
)pe
riod
Type
1an
d 3
Type
4
Zitz
man
n et
al
(19
97
)15
Zitz
man
n et
al
(19
99
)21
Nem
covs
ky
and
Artz
i (2
00
2)2
2
Cov
ani e
t al
(20
04
)23
Nem
covs
ky
et a
l (2
00
2)2
4
RC
T
Ret
ro C
S
Ret
ro C
S
Pros
p C
S
Ret
ro C
S
Turn
ed
Turn
ed
Mic
roro
ugh,
HA
and
TPS
NR
HA
and
TPS
25
* (2
7)
75
* (3
1)
19
(23
)
33
(20
)
19
/23
25
* (1
7)
75
* (2
3) (
plac
e-m
ent t
ime
afte
rex
trac
tion
from
6w
k to
6 m
o)
24
(31
)(4
to 6
wk)
33
(20
) (6
to 8
wk)
25
/39
(4 to
6 w
k)
25*
(40)
75*
(48)
(pla
cem
ent
time
afte
rex
trac
tion
> 6
mo)
– –
22
/40
DB
BM
and
eith
er n
on-
reso
rbab
lee-
PTFE
or
reso
rbab
leco
llage
n m
em-
bran
e (ra
ndom
lyal
loca
ted)
DB
BM
and
reso
rbab
le c
olla
-ge
n m
embr
ane
(sub
mer
ged)
DB
BM
and
reso
rbab
le c
olla
-ge
n m
embr
ane
(sub
mer
ged)
No
augm
enta
-tio
n(s
ubm
erge
d)
DB
BM
and
reso
rbab
le c
olla
-ge
n m
embr
ane
(sub
mer
ged)
4 to
6 m
o
4 to
6 m
o
6 to
8 m
o
4 m
o m
an-
dibl
e, 6
mo
max
illa
6 to
8 m
o
Def
ect a
rea
redu
ctio
n85
% fo
r e-P
TFE;
95%
for c
olla
gen
mem
-br
ane
Def
ect a
rea
redu
ctio
n92
% ±
20.
8%
Def
ect m
orph
olog
y:no
-wal
l/1-
wal
l def
ect:
16%
2-w
all d
efec
t: 52
%
3-w
all d
efec
t: 3
2%
Def
ect h
eigh
t red
uc-
tion
77.4
% ±
17.
0%§
Def
ect a
rea
redu
ctio
n90
.2%
± 9
.1%
§
(All
site
s pr
esen
ted
ini-
tially
with
deh
isce
nce
defe
cts)
Faci
al to
ling
ual r
idge
wid
th c
hang
e fr
om10
.0 ±
1.5
mm
to8.
1 ±
1.3
mm
†
Com
plet
e de
fect
fill
Def
ect h
eigh
t red
uc-
tion
77.4
% ±
16.
9%§
Def
ect a
rea
redu
ctio
n90
.2%
± 9
.1%
§
Def
ect a
rea
redu
ctio
n 94
% fo
re-
PTFE
; 97%
for c
olla
gen
mem
bran
e
Def
ect a
rea
redu
ctio
n9
2%
± 2
0.7
%
Def
ect m
orph
olog
y:no
-wal
l/1
-wal
l def
ect:
39
%2
-wal
l def
ect:
55
%3
-wal
l def
ect:
6%
Def
ect h
eigh
t red
uctio
n91
.2 %
± 9
.1%
§
Def
ect a
rea
redu
ctio
n 9
7.2
% ±
3.9
%§
(All
site
s pr
esen
ted
initi
ally
with
dehi
scen
ce d
efec
ts)
Faci
al to
ling
ual r
idge
wid
thch
ange
from
8.9
± 2
.4 m
m to
5.8
± 1
.3 m
m†
Com
plet
e de
fect
fill
Def
ect h
eigh
t red
uctio
n88
.8%
± 1
5.3%
§
Def
ect a
rea
redu
ctio
n95
.6%
± 8
.7%
§
Sign
ifica
ntly
gre
ater
def
ect a
rea
and
heig
ht re
duct
ion
reco
rded
for
early
pla
cem
ent (
type
2) c
om-
pare
d to
the
othe
r 2 tr
eatm
ent
grou
ps
Def
ect a
rea
redu
c-tio
n 80
% fo
r e-P
TFE;
90%
for c
olla
gen
mem
bran
e
Def
ect a
rea
redu
c-tio
n 8
0%
± 3
4.1
%
Def
ect m
orph
olog
y:no
-wal
l/1
-wal
lde
fect
: 92
%Tr
end
tow
ard
less
succ
essf
ul o
utco
me
of ty
pe 4
com
pare
dto
type
s 2
/3 a
ndty
pe 1
pla
cem
ents
com
bine
d (P
= .0
5)
– –
Def
ect h
eigh
t red
uc-
tion
75
.2%
± 1
8.0
%§
Def
ect a
rea
redu
c-tio
n 8
7.6
% ±
11.
5%
§
Aug
men
tati
onm
etho
d
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196 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 4
con
tinu
ed C
linic
al S
tudi
es C
ompa
ring
Dif
fere
nt T
imes
Aft
er E
xtra
ctio
n an
d Th
eir
Effe
ct o
n H
ealin
g of
Per
i-Im
plan
t D
efec
ts
No.
of p
atie
nts
(No.
of i
mpl
ants
) by
plac
emen
tA
ugm
enta
tion
R
esul
ts fo
r pl
acem
ent
tim
e af
ter
toot
h ex
trac
tion
met
hod
tim
es a
fter
too
th e
xtra
ctio
n
Stu
dy
Impl
ant
Type
s 2
(h
ealin
g O
bser
vati
on
Type
s 2
S
tudy
desi
gnsu
rfac
eTy
pe 1
and
3Ty
pe 4
prot
ocol
)pe
riod
Type
1an
d 3
Type
4
Sch
ropp
et a
l (2
00
3)17
Stu
dy d
esig
n: R
etro
= r
etro
spec
tive;
Pro
sp =
pro
spec
tive;
RC
T =
ran
dom
ized
con
trol
led
tria
l; C
S =
cas
e se
ries.
Impl
ant
surf
ace:
Tur
ned
= e
quiv
alen
t to
mac
hine
d su
rfac
e; T
PS
= t
itani
um p
lasm
a-sp
raye
d; H
A =
hyd
roxy
apat
ite-c
oate
d; S
LA =
sur
face
san
dbla
sted
with
larg
e gr
it an
d ac
id-e
tche
d.P
lace
men
t tim
e af
ter
extr
actio
n: T
ype
1 =
imm
edia
te p
lace
men
t at
the
tim
e of
ext
ract
ion;
Typ
e 2
= e
arly
pla
cem
ent
afte
r in
itial
sof
t tis
sue
heal
ing;
Typ
e 3
= e
arly
pla
cem
ent
afte
r su
bsta
ntia
l bon
e he
alin
g;Ty
pe 4
= la
te p
lace
men
t af
ter
com
plet
e he
alin
g of
the
rid
ge.
Aug
men
tatio
n m
etho
d: e
-PTF
E =
exp
ande
d po
lyte
traf
luor
oeth
ylen
e m
embr
ane;
DB
BM
= d
emin
eral
ized
bov
ine
bone
min
eral
; DFD
BA
= d
emin
eral
ized
free
ze-d
ried
bone
allo
graf
t; TC
P =
bet
a tr
ical
cium
pho
spha
te.
– =
Due
to
the
stud
y de
sign
, the
re w
ere
no d
ata
for
this
par
amet
er.
NR
= n
ot r
epor
ted.
* In
dica
tes
tota
l num
ber
of p
atie
nts
in t
he s
tudy
.†
Sig
nific
ant
with
in-g
roup
diff
eren
ces
(P<
.05)
.‡
Sig
nific
ant
with
in-g
roup
cha
nge
from
bas
elin
e (P
< .0
1).
§S
igni
fican
t be
twee
n-gr
oup
diff
eren
ce (P
< .0
5).
RC
TAc
id-e
tche
d–
Gro
up 1
: 23
(23
)ea
rly p
lace
men
t(m
ean
10 d
; ran
ge3
to 1
5 d
aft
erto
oth
extr
actio
n)
Gro
up 2
: 23
(23
)ea
rly p
lace
men
t(t
ype
3 -
mea
n14
.1 w
k; r
ange
65
to 1
38
d a
fter
toot
h ex
trac
tion)
–Au
toge
nous
bone
in d
ehis
-ce
nce
site
s(s
ubm
erge
d)
3 m
o–
Def
ect h
eigh
t red
uctio
n:G
roup
1: 4
8%
Gro
up 2
: 34
% (n
o si
gnifi
cant
dif-
fere
nces
bet
wee
n gr
oups
)D
efec
t wid
th (m
esio
dist
al) r
educ
-tio
n:G
roup
1: 4
8%
Gro
up 2
: 39
% (n
o si
gnifi
cant
dif-
fere
nces
bet
wee
n gr
oups
)D
efec
t dep
th (o
rofa
cial
) red
uctio
n(fo
r site
s w
ith in
tact
faci
al b
one,
ie, 3
-wal
l def
ects
onl
y):
Gro
up 1
: 59
%G
roup
2: 7
7%
(no
sign
ifica
nt d
if-fe
renc
es b
etw
een
grou
ps)
–
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implants were placed a mean of 14.1 weeks followingextraction (range 9.3 to 19.7 weeks). Most sites didnot receive bone grafts or membranes; three controlsites received autogenous bone chips to cover dehis-cences of the facial bone. The authors reported nostatistically significant differences in defect height,width, and depth reduction between the two groups.
These studies provide strong evidence that aug-mentation procedures are more successful withimmediate (type 1) and early (types 2 and 3) implantplacement than with late placement (type 4). There issome evidence to show that regenerative outcomesare better with type 2 placement compared to type 1placement in the presence of dehiscence defects ofthe bone. However, with intact bone walls, type 1 andtype 2 placement achieve similar results with respectto fill of the peri-implant defect.
Does the Healing Protocol (Submerged VersusTransmucosal Healing) Affect Treatment Outcome?Most studies used a submerged healing protocol fol-lowing implant placement. In five studies that used atransmucosal healing protocol,18,20,27,29,41 the healingoutcomes appeared to be similar to reports fromstudies using a submerged approach. No studieswere identified that directly compared submergedwith transmucosal healing for postextractionimplants.
Evidence is lacking to demonstrate the superiorityof one healing protocol over the other with respectto healing of peri-implant defects with postextractionimplants.
What Are the Postoperative Complications withPostextraction Implants? The majority of studieswith postextraction implants reported the occur-rence of postoperative complications. Although notcommon, the most clinically significant complicationwith type 1 placement was postoperative infection orabscess formation leading to implant loss.19,51–56
The most common complication reported wasdehiscence of the wound and exposure of e-PTFEmembranes when submerged healing was used withimmediate implants.15,19,25,28,30,31,33–35,52,57–60 Threestudies reported on the rate of complications with e-PTFE membranes,58,59,61 which ranged from 4.3% to48% of sites. Studies with reentry defect data showedthat this complication was associated with impairedhealing and reduced bone fill in the peri-implantdefects.15,28 Premature membrane exposure andinfections in 15% to 20% of sites were reported instudies of type 1 placement using transmucosal heal-ing when e-PTFE membranes were used.27,29 In stud-ies using collagen membranes combined with bonegrafts and bone substitutes, wound dehiscences werealso reported.30–35,62,63 These studies reported com-plication rates ranging from 4.2% to 36.7%.
Since 1998, there has been a clear trend in studydesigns to use resorbable collagen membranesrather than e-PTFE membranes for bone augmenta-tion. In the event of wound dehiscences, collagenmembranes have been associated with less adversehealing outcomes. A split-mouth study which com-pared e-PTFE membranes with collagen membranesdemonstrated that when wound dehiscencesoccurred, bone fill was significantly better in siteswith collagen membranes than in sites with e-PTFEmembranes.15 Furthermore, the healing outcomeswere similar in sites with collagen membranes,whether or not a wound dehiscence occurred.
Other complications reported with type 1 place-ment included postoperative pain,38,52,64 sloughing ofthe flaps,30,31 postoperative bleeding,31 and temporaryparesthesia.65,66 Absence of complications with type 1implants was reported in only seven studies.26,38,67–71
Only two studies reported on complications withtype 2 placement. These included postoperativeinfection and necrosis of the flap in 2 out of 10patients (20%)41 and postoperative bleeding.31 Nocomplications were reported in two studies with type2 placement and submerged healing.39,72
Two studies provided comparative data on post-operative complications with postextraction implantsplaced with submerged healing. In a split-mouthstudy comparing type 1 and type 4 placement, pre-mature implant exposure occurred in 7 out of 14 sites(50%) with type 1 placement compared to 4 out of 14sites (28.8%) with type 4 placement. Bone augmenta-tion with particulate hydroxyapatite was under-taken.73 In a retrospective study in which autogenousbone chips were grafted into peri-implant defects,premature implant exposure occurred in 10.2% ofsites with type 1 placement compared to 11.8% ofsites with type 4 placement.74
There were no studies that compared the rate ofpostoperative complications between type 1 andtype 2 or 3 implant placements.
The evidence is clear that postoperative complica-tions are common with immediate placement. Themost common complication is dehiscence of thewound when either collagen or e-PTFE membranes areused in conjunction with submerged healing. There isstrong evidence to show that in the presence of awound dehiscence, collagen membranes result in bet-ter bone regeneration and defect fill compared to e-PTFE membranes. There were no comparative data forcomplication rates between type 1 and type 2 or 3implant placements.
Do Systemic Antibiotics Enhance the TreatmentOutcome? The majority of studies included systemicantibiotics that were prescribed perioperativelyand/or postoperatively. Amoxicillin was the most
The International Journal of Oral & Maxillofacial Implants 197
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commonly prescribed antibiotic. There were no stud-ies that reported on the influence of systemic anti-biotics on the outcome of bone augmentationprocedures, or on the occurrence of postoperativecomplications.
Survival Outcomes of Postextraction ImplantsA total of 54 papers reporting on survival out-comes of postextraction implants were identified(Table 5). There were 24 prospective and 11 retro-spective studies; of these, the majority reported onsurvival outcomes with type 1 implant place-ment.25,27,50–52,54–56,58,59,61,63,64,67–71,75–85 Four studiesprovided data on type 2 placement.11,39,72,86
There were 19 studies that provided data com-paring different placement times after extraction(Table 6). Of these, only two were RCTs87,88 and twowere controlled clinical studies.73,89 The remainingstudies were prospective and retrospective caseseries studies.53,57,65,66,74,90-99
What Are the Survival Outcomes of Postextrac-tion Implants? The data on survival outcomes of pos-textraction implants were predominantly derivedfrom studies with type 1 implant placement. Moststudies (35 studies) were short term, with mean obser-vation periods of 1 to 3 years. Survival rates rangedfrom 65% to 100% (median 99%), with 25 studiesreporting survival rates of 95% or higher. Ten studieshad mean follow-up periods of 3 to 5 years. Survivalrates over this period ranged from 90% to 100%(median 95.5%). Only 3 studies were published withfollow-up periods of greater than 5 years; survivalrates for these studies ranged from 92% to 97%(median 95%).
Seven studies reported on survival after earlyimplant placement (type 2), six of which were short-term studies of 1 to 3 years. One study provided com-parative data between type 1 and type 2 placementover 4 years. The survival rates for type 2 placementranged from 91% to 100% (median 100%).
There were only two studies that reported data onearly implant placement with partial bone healing(type 3).The survival rates were 96% and 100%.
Due to the heterogeneity of the studies withrespect to implant surfaces, loading protocols, andthe relatively short-term observation period for themajority of studies, the data should be interpretedcautiously. However, it appears that survival rates forpostextraction implants are high, with the majority ofstudies reporting survival rates of over 95%.
Does Timing of Implant Placement Influence Sur-vival Outcomes? Of the 19 studies with comparativedata, most compared type 1 and type 4 implantplacement (11 studies). Three studies compared type1 and type 2 implant placement. Two studies com-
pared type 2 and type 3 implant placement, and onestudy compared type 1 and type 3 implant place-ment (two of these studies were RCTs).87,88 One studyhad comparative data on type 1, type 2, and type 4placement. The majority were short-term studies.Four studies reported follow-up periods of 3 to 5years, whereas only one study had a follow-up time ofover 5 years. In one retrospective study with compar-ative data, it was unclear when implants were placedafter tooth extraction.94
Type 1 Versus Type 4 Implant Placement. All studiescomparing type 1 to type 4 implant placement wereeither retrospective or prospective cohort or caseseries studies. In seven studies with conventional ordelayed loading, survival rates of type 1 implantsranged from 90% to 100% (median 99%) compared to60% to 100% (median 94%) for implants with type 4placement.64,73,90,91,96–98 In six studies of immediaterestoration of single-tooth, short-span, and full-archreplacements, the survival rates of immediate implants(type 1 placement) was 65% to 100% (median 91%)compared to 94% to 100% (median 95%) for implantswith type 4 placement.53,66,92,96,98,99 In one retrospec-tive study providing data on three placement proto-cols, type 1 and type 2 implant placement had highersurvival rates (99% and 100%, respectively) than type 4implant placement (81.8%).57
There is evidence to show that postextractionimplants have survival rates similar to implants inhealed sites. With immediate loading, type 1 implantsmay have lower survival rates than implants placedinto healed sites.
Type 1 Versus Type 2 Implant Placement. Two short-term retrospective studies57,95 and one prospectivecohort study with a 5-year follow-up65 provided com-parative data on type 1 and type 2 placement. Sur-vival rates for type 1 implant placement ranged from90% to 99% (median 90%) compared to a range of90% to 100% (median 94%) for type 2 placement.Thus, implants placed with an immediate or early(type 2) protocol appear to have a similar survivaloutcome. In two studies, increased failure rates werenoted in patients with a history of periodontitis.65,94
Type 1 Versus Type 3 Implant Placement. Compara-tive data for type 1 and type 3 implant placementwere examined in only one study, which was anRCT.88 A total of 50 patients were selected, each witha single tooth site with radiographic evidence ofchronic apical periodontitis. The patients were ran-domly allocated to receive either immediate place-ment or placement 12 weeks after extraction (type 3).A submerged healing protocol was used and patientswere followed up for 12 months. The survival rates ofimplants placed immediately were 92% and 100% fortype 1 and type 3 placement, respectively.
198 Volume 24, Supplement, 2009
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The International Journal of Oral & Maxillofacial Implants 199
Group 4
Tabl
e 5
Clin
ical
Stu
dies
Rep
orti
ng o
n S
urvi
val O
utco
mes
wit
h P
oste
xtra
ctio
n Im
plan
ts
Stu
dy d
esig
n/N
o. o
fP
lace
men
tpa
tien
tsti
me
afte
r Im
plan
t (N
o. o
fIm
plan
t A
ugm
enta
tion
met
hod/
Load
ing
prot
ocol
/ O
bser
vati
on
Sur
viva
l S
tudy
toot
h ex
trac
tion
surf
ace
impl
ants
)si
tes
Hea
ling
prot
ocol
Res
tora
tion
typ
epe
riod
rate
(%)
Gel
b (1
99
3)2
5
Lang
et a
l (1
99
4)2
7
Ros
enqu
ist
and
Gre
nthe
(1
99
6)51
Peco
ra e
t al
(19
96
)52
Cos
ci a
nd
Cos
ci (1
99
7)5
8
Sch
war
tz-A
rad
and
Cha
ushu
(1
99
7)6
2
Nir-
Had
ar e
t al
(19
98
)39
Bec
ker
et a
l (1
99
9)5
9*
Gru
nder
(2
00
0)8
6
Sch
war
tz-A
rad
et a
l (2
00
0)6
3
Huy
s (2
001
)67
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Ret
ro C
S/
Type
1
Ret
ro C
S/
Type
1
Ret
ro C
S/
Type
1
Ret
ro C
S/
Type
1
Pros
p C
S /
Type
2
(4 to
8 w
k af
ter
extr
actio
n)Pr
osp
mul
ticen
-te
r C
oS/T
ype
1Pr
osp
CS
/Ty
pe 2
(8 w
kaf
ter
extr
actio
n)R
etro
CS
/Ty
pe 1
Ret
ro C
S/
Type
1
Turn
ed
TPS
Turn
ed
TPS
HA
Turn
ed a
ndH
A
Turn
ed
Turn
ed
Turn
ed
Turn
ed a
ndH
A
TPS
35
(50
)
16 (2
1)
51 (1
09
)
31 (3
2)
35
3 (4
23
)
49
(85
)
14 (2
1)
40
(49
)
10 (1
0)
43
(56
)
147
(55
6)
Max
illar
y an
d m
andi
bula
ran
terio
r tee
th a
nd p
rem
o-la
rs, a
nd m
andi
bula
r mol
ars
Max
illar
y in
ciso
rs, c
anin
es,
prem
olar
s, a
nd m
andi
bula
rpr
emol
ars
NR
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, pre
mol
ar,
and
mol
ar s
ites
NR
Max
illar
y an
d m
andi
bula
ran
terio
r, pr
emol
ar, a
nd m
olar
site
sAl
l are
as
All a
reas
Sing
le-to
oth
repl
acem
ent
Max
illar
y ce
ntra
l and
late
ral
inci
sors
Max
illar
y an
d m
andi
bula
rm
olar
site
s on
ly
NR
e-PT
FE m
embr
ane
alon
e, o
r D
FDB
Agr
aft a
lone
, or
e-PT
FE m
embr
ane
com
bine
d w
ith D
FDB
A gr
aft/
Sub
mer
ged
e-PT
FE m
embr
ane
alon
e/Tr
ansm
ucos
al
No
augm
enta
tion
in m
ost c
ases
;e-
PTFE
mem
bran
e in
5 p
atie
nts/
Sub
mer
ged
e-PT
FE m
embr
ane
in 1
0 s
ites/
Sub
mer
ged
e-PT
FE m
embr
ane
for
site
s w
ithin
tact
bon
e w
alls
; hyd
roxy
apat
ite o
rD
FDB
A gr
aft a
nd c
olla
gen
mem
-br
ane
for
sock
et w
all d
efec
ts o
rap
ical
fene
stra
tion/
Sub
mer
ged
Auto
geno
us b
one
chip
s/S
ubm
erge
d
No
augm
enta
tion/
Sub
mer
ged
e-PT
FE m
embr
ane
alon
e/S
ubm
erge
de-
PTFE
mem
bran
e an
d D
BB
M/
Sub
mer
ged
Auto
geno
us b
one
whe
n re
quire
d;e-
PTFE
(2 s
ites)
and
col
lage
n m
em-
bran
es (6
site
s) /
Sub
mer
ged
Com
posi
te p
olym
er g
raft
/S
ubm
erge
d
Conv
entio
nal/
Sing
le-to
oth
rest
orat
ions
Del
ayed
/Sin
gle-
toot
h,sh
ort-s
pan
pros
thes
es,
shor
t-spa
n to
oth-
impl
ant
pros
thes
esCo
nven
tiona
l in
the
man
-di
ble;
del
ayed
in th
e m
ax-
illa/
Res
tora
tion
type
NR
NR
/Sin
gle-
toot
h re
stor
a-tio
ns
NR
/Res
tora
tion
type
NR
NR
/Res
tora
tion
type
NR
Del
ayed
/NR
NP/
Sing
le-to
oth
repl
ace-
men
tsD
elay
ed/S
ingl
e-to
oth
repl
acem
ents
Del
ayed
/Sin
gle-
toot
h an
dsh
ort s
pans
Conv
entio
nal/
Bal
l-re
tain
ed o
verd
entu
res,
shor
t-spa
n pr
osth
eses
,im
plan
t-too
th p
rost
hese
s,si
ngle
cro
wns
Mea
n 17
mo
(ran
ge 8
to4
4 m
o)
Mea
n 3
0.3
mo
(ran
ge21
to 4
2 m
o)
Mea
n 3
0.5
mo
(ran
ge 1
to 6
7 m
o)
Mea
n 16
.3 m
o af
ter
load
ing
Ran
ge 1
to 7
y
Ran
ge 4
to 7
y
12
mo
5 y
1 y
aft
er lo
adin
g
Mea
n 15
mo
(ran
ge 4
to6
0 m
o)
Ran
ge 7
to 1
0 y
98
100
93
.6
96
.9
99
.5
95
aft
er5
y
95
.2
93
.9
100
89
.3
96
.6
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200 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 5
con
tinu
ed C
linic
al S
tudi
es R
epor
ting
on
Sur
viva
l Out
com
es w
ith
Pos
text
ract
ion
Impl
ants
Stu
dy d
esig
n/N
o. o
fP
lace
men
tpa
tien
tsti
me
afte
r Im
plan
t (N
o. o
fIm
plan
t A
ugm
enta
tion
met
hod/
Load
ing
prot
ocol
/ O
bser
vati
on
Sur
viva
l S
tudy
toot
h ex
trac
tion
surf
ace
impl
ants
)si
tes
Hea
ling
prot
ocol
Res
tora
tion
typ
epe
riod
rate
(%)
Gom
ez-R
oman
et
al (
20
01)61
†
Gol
dste
in e
t al
(20
02
)68
Artz
i et a
l (2
00
3)6
9
Kan
et a
l (2
00
3)76
Cov
ani e
t al
(20
04
)54
Bia
nchi
and
S
anfil
ippo
(2
00
4)10
6
Can
gini
and
C
orne
lini (
20
05
)77
Cor
nelin
i et a
l (2
00
5)7
0
Vand
en B
ogae
rde
et a
l (2
00
5)5
5
Bar
one
et a
l (2
00
6)5
6
Ferr
ara
et a
l (2
00
6)7
8
Fuga
zzot
to
(20
06
)79
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1Pr
osp
CS
/Ty
pe 1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Ret
ro C
S/
Type
1
Pros
p C
CS
/Ty
pe 1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Grit
bla
sted
and
acid
-et
ched
Turn
ed
TCP
blas
ted
HA
TPS
TPS
SLA
SLA
Tita
nium
oxid
e co
ated
TPS
Grit
-bla
sted
/ac
id-e
tche
d
SLA
104
(12
4)
38
(47
)
10 (1
2)
35
(35
)
95
(16
4)
116
(116
)
32
(32
)
22
(22
)
19
(50
)
18
(18
)
33
(33
)
83
(83
)
All s
ites
Max
illar
y si
tes
Max
illar
y m
olar
site
s on
ly
Max
illar
y in
ciso
r and
can
ine
site
s
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
All s
ites
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes;
all
teet
h ha
d pe
riodo
n-ta
l def
ects
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y an
terio
r and
pre
-m
olar
site
s, a
nd m
andi
bula
rpr
emol
ar a
nd m
olar
site
s
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y fir
st a
nd s
econ
dm
olar
s
Auto
geno
us b
one
(9 s
ites)
, HA
(24
site
s), e
-PTF
E m
embr
ane
(17
site
s)/T
rans
muc
osal
DFD
BA
and
reso
rbab
le p
olym
erba
rrie
r m
embr
ane/
Sub
mer
ged
DB
BM
or
TCP/
Sub
mer
ged
No
augm
enta
tion/
Tran
smuc
osal
No
augm
enta
tion
at 5
8 s
ites
with
inta
ct b
one
wal
ls; a
utog
enou
s bo
nech
ips
and
reso
rbab
le m
embr
anes
in 1
05
site
s w
ith d
ehis
cenc
e an
dfe
nest
ratio
n de
fect
s/Tr
ansm
ucos
alN
R/S
ubm
erge
d
Enam
el m
atrix
der
ivat
ive
(18
site
s);
reso
rbab
le c
olla
gen
mem
bran
e (1
4si
tes)
/Tra
nsm
ucos
al
Res
orba
ble
colla
gen
mem
bran
e/Tr
ansm
ucos
al
Auto
geno
us b
one
in 3
-wal
l def
ects
;au
toge
nous
bon
e an
d re
sorb
able
poly
mer
mem
bran
e fo
r 1
- and
2-
wal
l def
ects
/Tra
nsm
ucos
alN
o au
gmen
tatio
n (a
ll si
tes
with
inta
ct b
one
wal
ls a
nd m
argi
nal
gaps
< 2
mm
)/Tr
ansm
ucos
alO
sseo
us c
oagu
lum
if a
mar
gina
lga
p w
as p
rese
nt/T
rans
muc
osal
Oss
eous
coa
gulu
m o
r de
min
eral
-iz
ed b
one
mat
rix p
aste
with
reso
rbab
le o
r tit
aniu
m-re
info
rced
e-
PTFE
mem
bran
e/S
ubm
erge
d
NR
/Sin
gle-
toot
h, p
artia
l,an
d fu
ll ar
ches
NR
/Sin
gle-
toot
h re
plac
e-m
ents
NR
/Sin
gle-
toot
h an
dex
tend
ed s
pans
Imm
edia
te re
stor
atio
n/Si
n-gl
e-to
oth
repl
acem
ents
Imm
edia
te re
stor
atio
n/Si
ngle
-toot
h re
plac
emen
ts
Del
ayed
/Sin
gle-
toot
hre
plac
emen
ts
Del
ayed
/Sin
gle-
toot
hre
plac
emen
ts
Imm
edia
te re
stor
atio
n/
Sing
le-to
oth
repl
acem
ents
Imm
edia
te a
nd e
arly
load
-in
g/Sh
ort-s
pan
to fu
ll-ar
chre
stor
atio
ns
Imm
edia
te re
stor
atio
n/Si
ngle
-toot
h re
stor
atio
ns
Imm
edia
te re
stor
atio
n/Si
ngle
-toot
h re
stor
atio
ns
Del
ayed
/Sin
gle
rest
ora-
tions
Mea
n 2
.6 y
(up
to 6
.3 y
)
Mea
n 3
9.4
mo
(ran
ge 1
to 5
y)
2 y
1 y
4 y
1 to
9 y
12
mo
12
mo
18 m
o
12
mo
4 y
Mea
n 1
2.4
mo
infu
nctio
n
97
100
100
100
97
100
100
100
100
94
.5
94
.0
100
186_4a_Chen.qxd 9/10/09 10:16 AM Page 200
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The International Journal of Oral & Maxillofacial Implants 201
Group 4
Tabl
e 5
con
tinu
ed C
linic
al S
tudi
es R
epor
ting
on
Sur
viva
l Out
com
es w
ith
Pos
text
ract
ion
Impl
ants
Stu
dy d
esig
n/N
o. o
fP
lace
men
tpa
tien
tsti
me
afte
r Im
plan
t (N
o. o
fIm
plan
t A
ugm
enta
tion
met
hod/
Load
ing
prot
ocol
/ O
bser
vati
on
Sur
viva
l S
tudy
toot
h ex
trac
tion
surf
ace
impl
ants
)si
tes
Hea
ling
prot
ocol
Res
tora
tion
typ
epe
riod
rate
(%)
De
Kok
et a
l (2
00
6)8
0
Wag
enbe
rg a
nd
Frou
m (2
00
6)81
‡
Cov
ani e
t al
(20
07
)82
Juod
zbal
ys a
nd
Wan
g (2
00
7)8
3
Sam
mar
tino
et a
l (2
00
7)71
Kan
et a
l (2
00
7)5
0
Sch
war
tz-A
rad
et a
l (2
00
7)6
4
Cre
spi e
t al
(20
07
)12
3
Villa
and
Ran
gert
(2
00
7)8
4
Caf
iero
et a
l (2
00
8)10
0
Fuga
zzot
to
(20
08
)60
Fuga
zzot
to
(20
08
)101
Ret
ro C
S/
Type
1
Ret
ro C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1R
etro
CS
/Ty
pe 1
Pros
p C
S/
Type
1
Ret
ro C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
S/
Type
1
Pros
p C
oS/
Type
1
Ret
ro C
S/
Type
1
Ret
ro C
S/
Type
1
Tita
nium
-ox
ide
grit-
blas
ted
Turn
ed a
ndun
spec
ified
roug
h-su
r-fa
ced
impl
ants
San
dbla
sted
and
acid
-et
ched
NR
SLA
(53
im-
plan
ts) a
ndgr
it-bl
aste
d/ac
id-e
tche
d(3
4 im
plan
ts)
Tita
nium
oxid
e co
ated
NR
TPS
Tita
nium
oxid
e co
ated
SLA
SLA
SLA
28
(43
)
591
(1,0
91)
10 (1
0)
12
(14
)
55
(83
)
23
(23
)
87
(210
)
27
(15
0)
33
(10
0)
82
(82
)
38
6 (3
91)
33
5 (3
41)
Max
illar
y an
terio
r and
pre
-m
olar
site
s
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y ce
ntra
l and
late
ral
inci
sors
Max
illar
y an
d m
andi
bula
rin
ciso
r, ca
nine
, and
pre
mol
arsi
tes
Max
illar
y ce
ntra
l and
late
ral
inci
sors
, and
can
ines
Max
illar
y an
d m
andi
bula
ran
terio
r tee
th a
nd p
rem
o-la
rs, a
nd m
axill
ary
mol
ars
All s
ites
Max
illar
y in
ciso
rs, c
anin
es,
and
prem
olar
s
Max
illar
y an
d m
andi
bula
rm
olar
s
Max
illar
y fir
st a
nd s
econ
dm
olar
s
Man
dibu
lar f
irst a
nd s
econ
dm
olar
s
NR
/Tra
nsm
ucos
al
Min
eral
ized
FD
BA
and
reso
rbab
lepo
lym
er m
embr
ane/
Sub
mer
ged
NR
/Sub
mer
ged
DB
BM
and
reso
rbab
le c
olla
gen
mem
bran
e/S
ubm
erge
dN
o au
gmen
tatio
n (a
ll m
argi
nal
gaps
wer
e ≤
2 m
m)/
Tra
nsm
ucos
al
Auto
geno
us b
one
or D
BB
M a
ndre
sorb
able
col
lage
n m
embr
ane/
Tran
smuc
osal
DB
BM
and
aut
ogen
ous
bone
mix
-tu
re/
Tran
smuc
osal
Auto
geno
us b
one
chip
s/Tr
ansm
ucos
al
Auto
geno
us b
one
and
DB
BM
/Tr
ansm
ucos
al
DB
BM
and
reso
rbab
le c
olla
gen
mem
bran
e w
hen
mar
gina
l gap
s >
1m
m/
Tran
smuc
osal
DB
BM
or
dem
iner
aliz
ed b
one
putt
y,an
d tit
aniu
m re
info
rced
e-P
TFE
mem
bran
e/S
ubm
erge
dD
BB
M o
r de
min
eral
ized
bon
e pu
tty,
and
titan
ium
-rein
forc
ed e
-PTF
Em
embr
ane
at s
ites
with
mar
gina
lga
ps >
3 m
m/S
ubm
erge
d
Imm
edia
te re
stor
atio
n/
Sing
le-to
oth
rest
orat
ions
Del
ayed
/ R
esto
ratio
n ty
pe N
R
Del
ayed
/ Si
ngle
rest
orat
ions
Del
ayed
/ Si
ngle
rest
orat
ions
Early
/Sin
gle-
and
mul
tiple
-to
oth
repl
acem
ents
Imm
edia
te re
stor
atio
n/
Sing
le-to
oth
rest
orat
ions
Imm
edia
te re
stor
atio
n/
Sing
le-to
oth
and
shor
t-sp
an re
stor
atio
nsIm
med
iate
load
ing/
Fu
ll-ar
ch m
axill
ary
and
man
dibu
lar r
esto
ratio
nsIm
med
iate
and
ear
ly lo
ad-
ing/
Sing
le-to
oth,
par
tial,
and
full-
arch
rest
orat
ions
Early
/Sin
gle-
toot
h re
stor
a-tio
ns
NR
/Sin
gle
(387
impl
ants
)an
d sp
linte
d re
stor
atio
ns(4
impl
ants
)N
R/S
ingl
e-to
oth
and
splin
ted
rest
orat
ions
12
to 3
0 m
o (n
o m
ean)
35
% fo
r 1 y
46
% fo
r 2 to
5 y
19%
for 5
to 1
1 y
12
mo
12
mo
afte
r loa
ding
2 y
12
mo
Mea
n 15
.6 ±
12
.6 m
o(r
ange
6 to
52
mo)
18 m
o
12
mo
12
mo
Mea
n 4
0.3
mo
Mea
n 3
0.8
mo
90
.7
95
100
100
96
.6
100
97.
6
100
97.
4§
100
99
.5
99
.1
186_4a_Chen.qxd 9/10/09 10:16 AM Page 201
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202 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 5
con
tinu
ed C
linic
al S
tudi
es R
epor
ting
on
Sur
viva
l Out
com
es w
ith
Pos
text
ract
ion
Impl
ants
Stu
dy d
esig
n/N
o. o
fP
lace
men
tpa
tien
tsti
me
afte
r Im
plan
t (N
o. o
fIm
plan
t A
ugm
enta
tion
met
hod/
Load
ing
prot
ocol
/ O
bser
vati
on
Sur
viva
l S
tudy
toot
h ex
trac
tion
surf
ace
impl
ants
)si
tes
Hea
ling
prot
ocol
Res
tora
tion
typ
epe
riod
rate
(%)
Bus
er e
t al
(20
08
)11
Bar
one
et a
l (2
00
8)8
5
Bus
er e
t al
(20
09
)72
Stu
dy d
esig
n: P
rosp
= p
rosp
ectiv
e; R
etro
= re
tros
pect
ive;
RC
T =
rand
omiz
ed c
ontr
olle
d tr
ial;
CC
S =
con
trol
led
clin
ical
stu
dy; C
oS =
coh
ort s
tudy
; CS
= c
ase
serie
s.Im
plan
t sur
face
: Tur
ned
= eq
uiva
lent
to m
achi
ned
surf
ace;
TPS
= ti
tani
um p
lasm
a-sp
raye
d; H
A =
hydr
oxya
patit
e-co
ated
; SLA
= s
urfa
ce s
andb
last
ed w
ith la
rge-
grit
and
acid
-etc
hed.
Plac
emen
t tim
e af
ter
extr
actio
n: T
ype
1 =
imm
edia
te im
plan
t pla
cem
ent;
Type
2 =
ear
ly im
plan
t pla
cem
ent w
ith s
oft t
issu
e he
alin
g; T
ype
3 =
ear
ly im
plan
t pla
cem
ent w
ith p
artia
l bon
e he
alin
g;Ty
pe 4
= la
te p
lace
men
t in
a fu
lly h
eale
d si
te.
Augm
enta
tion
met
hod:
e-P
TFE
= ex
pand
ed p
olyt
etra
fluor
oeth
ylen
e m
embr
ane;
DB
BM
= d
emin
eral
ized
bov
ine
bone
min
eral
; DFD
BA
= de
min
eral
ized
free
ze-d
ried
bone
allo
graf
t;FD
BA
= fr
eeze
-drie
d bo
ne a
llogr
aft;
TCP
= be
ta tr
ical
cium
pho
spha
te.
Load
ing
prot
ocol
: acc
ordi
ng to
the
ITI C
onse
nsus
Con
fere
nce
(20
03
).12
4N
R =
not
repo
rted
.*
This
stu
dy re
pres
ents
the
5-y
ear
follo
w-u
p; 1
-yea
r re
sults
wer
e pu
blis
hed
in B
ecke
r et
al (
19
94
).28
‡Th
is s
tudy
incl
udes
dat
a fr
om a
pre
viou
s re
port
by
the
sam
e au
thor
s: W
agen
berg
and
Gin
sber
g (2
001
).12
6
§S
urvi
val r
ate
is fo
r a
subs
et o
f 76
out
of 1
00
impl
ants
in 3
3 p
atie
nts,
that
wer
e pl
aced
in in
fect
ed e
xtra
ctio
n so
cket
s.
Ret
ro C
S /
Type
2 (4
to 8
wk
afte
r ex
trac
tion)
Pros
p C
S/
Type
1
Pros
p C
S /
Typ
e2
(4 to
8 w
k af
ter
extr
actio
n)
SLA
TPS
SLA
45
(45
)
12
(12
)
20
(20
)
Max
illar
y an
terio
r and
pre
-m
olar
teet
h
Max
illar
y pr
emol
ar s
ites;
all
site
s re
quire
d si
mul
tane
ous
sinu
s flo
or e
leva
tion
usin
gos
teot
omes
Max
illar
y an
terio
r and
pre
-m
olar
teet
h
DB
BM
and
col
lage
n m
embr
ane;
graf
t app
lied
to m
argi
nal d
efec
tsan
d ex
tern
al s
urfa
ce o
f the
faci
albo
ne/S
ubm
erge
dC
ortic
o-ca
ncel
lous
por
cine
bon
ean
d co
llage
n ge
l, an
d re
sorb
able
mem
bran
e/Tr
ansm
ucos
al
DB
BM
and
col
lage
n m
embr
ane;
graf
t app
lied
to m
argi
nal d
efec
tsan
d ex
tern
al s
urfa
ce o
f the
faci
albo
ne/S
ubm
erge
d
Early
/Sin
gle-
toot
h re
stor
a-tio
ns
Del
ayed
/Sin
gle-
toot
hre
stor
atio
ns a
nd m
ultip
leim
plan
t pro
sthe
ses
Early
/Sin
gle-
toot
h re
stor
a-tio
ns
23
pat
ient
s fo
r 2 y
16 p
atie
nts
for 3
y6
pat
ient
s fo
r 4 y
18 m
o
12
mo
100
91.7
100
186_4a_Chen.qxd 9/10/09 10:16 AM Page 202
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
The International Journal of Oral & Maxillofacial Implants 203
Group 4
Tabl
e 6
Clin
ical
Stu
dies
wit
h C
ompa
rati
ve D
ata
on S
urvi
val O
utco
mes
wit
h D
iffe
rent
Impl
ant
Pla
cem
ent
Tim
es A
fter
Ext
ract
ion
No.
of p
atie
nts
Aug
men
tati
on
Load
ing
(No.
of i
mpl
ants
)m
etho
dpr
otoc
ol/
Sur
viva
l rat
e (%
)
Stu
dy
Impl
ant
Type
s 2
(h
ealin
g re
stor
atio
nO
bser
vati
on
Type
s 2
S
tudy
desi
gnsu
rfac
eTy
pe 1
and
3Ty
pe 4
prot
ocol
)ty
pepe
riod
Type
1an
d 3
Type
4
Yukn
a
(19
91)7
3
Cra
nin
et a
l (1
99
3)9
0
Wat
zek
et a
l (1
99
5)5
7
Poliz
zi e
t al
(20
00
)65
†
Sch
war
tz-A
rad
et a
l (2
00
0)74
Jo e
t al
(20
01)91
Cha
ushu
et a
l (2
001
)53
Mal
o et
al
(20
03
)66
Nor
ton
(20
04
)92
Got
fred
sen
(20
04
)93
Evia
n et
al
(20
04
)94
Perr
y an
d Le
nche
wsk
i (2
00
4)9
5
Pros
p C
CS
Pros
p C
CS
Ret
ro C
S
Pros
p C
oS
Ret
ro
Ret
ro C
S
Ret
ro
Pros
p C
S
Pros
p C
S
Pros
p C
S
Ret
ro C
S
Ret
ro C
S
HA
Poly
crys
talli
neAl
umin
aC
eram
icH
A an
dtu
rned
Turn
ed
Turn
ed a
ndH
A
NR
HA
Turn
ed
Tita
nium
oxid
e gr
it-bl
aste
d
Tita
nium
oxid
e gr
it-bl
aste
d
HA
and
turn
ed
NR
14 (1
4)
30
* (2
5)
20
* (9
7)
143
* (1
46
)
43
* (1
17)
75
* (8
1)
20
* (1
9)
76*
(22
)
25
* (1
6)
–
100
(10
0)
44
2*
(32
2)
– –
20*
(26)
(6 to
8 w
k af
ter
extr
actio
n)14
3* (3
4)(3
to 5
wk
afte
rex
trac
tion) – – – – –
Gro
up A
: 10
(10)
4 w
k af
ter e
xtra
c-tio
nG
roup
B: 1
0 (1
0)12
wk
afte
rex
trac
tion
49 (4
9) (p
lace
-m
ent t
ime
afte
rex
trac
tion
NR
)44
2* (7
77)
(8 to
12
wk
afte
rex
trac
tion)
14 (1
4)
30*
(5)
20*
(11)
–
43*
(263
)
75*
(205
)
20*
(9)
76*
(94)
25*
(12)
– – –
HA/
Sub
mer
ged
No
augm
enta
tion/
Tran
smuc
osal
e-PT
FE m
embr
ane
with
DB
BM
or
hydr
oxya
patit
egr
afts
/Sub
mer
ged
Com
bina
tions
of e
-PTF
Ean
d co
llage
n m
em-
bran
es, a
utog
enou
s bo
nean
d D
FDB
A/S
ubm
erge
dAu
toge
nous
bon
e/S
ubm
erge
d
No
augm
enta
tion/
Tran
smuc
osal
Auto
geno
us b
one/
Tran
smuc
osal
NR
/Tra
nsm
ucos
al
NR
/Tra
nsm
ucos
al
e-PT
FE m
embr
ane
only
/S
ubm
erge
d
NR
/Sub
mer
ged
NR
/Sub
mer
ged
Del
ayed
/Spl
inte
d br
idge
s
Del
ayed
/Res
tora
tion
type
NR
Del
ayed
in th
e m
axill
a; c
on-
vent
iona
l in
the
man
dibl
e/Fu
ll-ar
ch fi
xed
rest
orat
ions
Del
ayed
in th
e m
axill
a; C
on-
vent
iona
l in
the
man
dibl
e/Si
ngle
-toot
h, p
artia
l and
full-
arch
rest
orat
ions
Conv
entio
nal l
oadi
ng in
the
man
dibl
e; d
elay
ed in
the
max
-ill
a/Fu
ll-ar
ch re
stor
atio
nsIm
med
iate
and
del
ayed
load
-in
g pr
otoc
ols
used
/R
esto
ratio
n ty
pe N
RIm
med
iate
rest
orat
ion/
Sing
le-to
oth
rest
orat
ions
;si
tes
NR
Imm
edia
te re
stor
atio
n in
73
patie
nts/
Sing
le-to
oth
and
shor
t spa
nsIm
med
iate
rest
orat
ion/
Sing
le-to
oth
rest
orat
ions
Del
ayed
/Sin
gle-
toot
h re
stor
a-tio
ns
Conv
entio
nal/
Res
tora
tion
type
NR
Conv
entio
nal/
Res
tora
tion
type
NR
Mea
n 16
mo
(rang
e8
to 2
4 m
o)M
ean
85 m
o (ra
nge
not s
tate
d)
Mea
n 27
.1 m
o(ra
nge
4 to
83
mo)
60 m
o af
ter f
unc-
tiona
l loa
ding
5 y
Mea
n 40
mo
Mea
n 13
mo
(rang
e6
to 2
4 m
o)
1 y
Mea
n 20
.3 m
o(ra
nge
13 to
30
mo)
In fu
nctio
n fo
r 15.
7m
o (ra
nge
8 to
27
mo)
5 y
Mea
n 2.
6 y
34.5
mo
(rang
e 5.
8to
67.
4 m
o)
– –
100
93
.6 – – – – –
100
85
.7
90
100
92
.0
98
.9
90
.4
96
98
.9
82
.4
100
97.
6 –
85
90
100
60
.0
81.8 –
89
.4
93
.9
100
94
.7
95
.2 – – –
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204 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 6
con
tinu
ed C
linic
al S
tudi
es w
ith
Com
para
tive
Dat
a on
Sur
viva
l Out
com
es w
ith
Dif
fere
nt Im
plan
t P
lace
men
t Ti
mes
Aft
er E
xtra
ctio
n
No.
of p
atie
nts
Aug
men
tati
on
Load
ing
(No.
of i
mpl
ants
)m
etho
dpr
otoc
ol/
Sur
viva
l rat
e (%
)
Stu
dy
Impl
ant
Type
s 2
(h
ealin
g re
stor
atio
nO
bser
vati
on
Type
s 2
S
tudy
desi
gnsu
rfac
eTy
pe 1
and
3Ty
pe 4
prot
ocol
)ty
pepe
riod
Type
1an
d 3
Type
4
Sch
ropp
et a
l (2
00
5)8
7
Deg
idi e
t al
(20
06
)96
Lind
eboo
m
et a
l (2
00
6)8
8
Fuga
zzot
to
et a
l (2
00
7)9
7
Deg
idi e
t al
(20
07
)98
Sie
gent
hale
r et
al (
20
07
)89
Hor
witz
et a
l(2
00
7)9
9
Stu
dy d
esig
n: P
rosp
= p
rosp
ectiv
e; R
etro
= r
etro
spec
tive;
RC
T =
ran
dom
ized
con
trol
led
tria
l; C
CS
= c
ontr
olle
d cl
inic
al s
tudy
; CoS
= c
ohor
t st
udy;
CS
= c
ase
serie
s.Im
plan
t su
rfac
e: T
urne
d =
equ
ival
ent
to m
achi
ned
surf
ace;
TP
S =
tita
nium
pla
sma-
spra
yed;
HA
= h
ydro
xyap
atite
-coa
ted;
SLA
= s
andb
last
ed w
ith la
rge-
size
d gr
it an
d ac
id-e
tche
d su
rfac
e;S
BE
= s
andb
last
ed a
nd a
cid-
etch
ed.
Pla
cem
ent
time
afte
r ex
trac
tion:
Typ
e 1
= im
med
iate
pla
cem
ent
at t
he t
ime
of e
xtra
ctio
n; T
ype
2 =
ear
ly p
lace
men
t af
ter
initi
al s
oft
tissu
e he
alin
g; T
ype
3 =
ear
ly p
lace
men
t af
ter
subs
tant
ial b
one
heal
ing;
Type
4 =
late
pla
cem
ent
afte
r co
mpl
ete
heal
ing
of t
he r
idge
.A
ugm
enta
tion
met
hod:
e-P
TFE
= e
xpan
ded
poly
tetr
aflu
oroe
thyl
ene
mem
bran
e; D
BB
M =
dep
rote
iniz
ed b
ovin
e bo
ne m
iner
al; D
FDB
A =
dem
iner
aliz
ed f
reez
e-dr
ied
bone
allo
graf
t; H
A =
hyd
roxy
apat
ite.
Load
ing
prot
ocol
s ac
cord
ing
to t
he IT
I Con
sens
us C
onfe
renc
e (2
003)
.124
– =
due
to
the
stud
y de
sign
, the
re w
ere
no d
ata
for
this
par
amet
er.
NR
= n
ot r
epor
ted.
*Ind
icat
es t
otal
num
ber
of p
atie
nts
in t
he s
tudy
.† T
his
stud
y re
pres
ents
the
5-y
ear
follo
w-u
p; 3
-yea
r re
sults
wer
e pu
blis
hed
in G
rund
er e
t al
(199
9).1
27
RC
T
Pros
p C
S
RC
T
Ret
ro C
S
Ret
ro C
S
Pros
p C
CT
Acid
-etc
hed
Mix
ed: t
urne
d,TP
S an
d ac
id-
etch
edSB
E
SLA
Vario
us s
ur-
face
s
SLA
Sand
blas
ted
and
acid
-et
ched
23
(23
)M
ean
10 d
afte
r ex
trac
-tio
n (r
ange
3–1
5 d
)6
7 (6
7)
25
(25
)
22
(39
)
1,06
4*(4
16)
34
(34
)
19
* (4
1)
23 (2
3)(3
mo
afte
rex
trac
tion)
–
25 (2
5)(1
2 w
k af
ter
extr
actio
n)
– – – –
–
44 (4
4) –
39 (1
30)
All p
atie
nts
on b
isph
os-
phon
ate
ther
apy
1,06
4*(6
58) –
19*
(33)
Type
1—
no a
ugm
enta
tion;
Type
3—
aut
ogen
ous
bone
par
ticle
s if
defe
cts
pres
ent/
Sub
mer
ged
NR
/Tra
nsm
ucos
al
Part
icul
ate
auto
geno
usca
ncel
lous
bon
e an
dre
sorb
able
col
lage
nm
embr
ane/
Sub
mer
ged
Dem
iner
aliz
ed b
one
mat
rixbl
ocks
with
type
1 p
lace
-m
ent,
and
reso
rbab
le o
re-
PTFE
mem
bran
es
NR
/Tra
nsm
ucos
al
DB
BM
and
reso
rbab
leco
llage
n m
embr
ane
NR
/Tra
nsm
ucos
al
Conv
entio
nal/
Sing
le-to
oth
rest
orat
ions
Imm
edia
te re
stor
atio
n/Si
ngle
-toot
h re
stor
atio
ns
Del
ayed
/Sin
gle-
toot
h re
stor
a-tio
ns
NR
Imm
edia
te re
stor
atio
n/R
esto
ratio
n ty
pe N
R
Conv
entio
nal/
Sing
le-to
oth
rest
orat
ions
Imm
edia
te lo
adin
g/
Sing
le-to
oth,
par
tial a
nd fu
ll-ar
ch re
stor
atio
ns
2 y
5 y
12 m
o
12 to
24
mo
Mea
n 3
y
12 m
o
12 m
o
96 –
100 – – – –
91 92
.5
92
100
90
.2
100
65
–
100
P<
.05
–
100
93
.9 –
94
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Type 2 Versus Type 3 Implant Placement. One studycompared the outcomes of 10 implants placed4 weeks after extraction in 10 patients, with 10implants placed 12 weeks after extraction in anothergroup of 10 individuals.93 The survival rate was 100%for both groups after 5 years of function. One RCTcompared the outcomes of different early placementtimes over a 2-year observation period.87 A total of 46subjects each received a single implant, either 3 to 15days (mean 10 days) or 3 months after extraction(type 3 placement). The survival rates were 91% fortype 2 and 96% for type 3. It should be noted thatimplant placement between 3 and 15 days afterextraction is unlikely to have been accompanied bycomplete soft tissue healing, and therefore does notfulfill the definition of early placement with soft tis-sue healing (type 2) adopted in this review.
Does Implant Surface Affect Implant Survival? Avariety of implant surfaces were used in the studiesreviewed, with many studies reporting the use ofmixed implant systems and surfaces. Implants with amachined surface were widely used prior to the year2000; subsequently, the majority of studies utilizedroughened surfaces. Survival rates for machinedimplant sur faces ranged from 93.6% to 100%(median 95%).25,39,51,59,65,66,68,86 Survival rates forhydroxyapatite (HA)-coated implants were 82.4% to100% (median 99.5%).53,58,73,76 Survival rates reportedin studies that used implants with a titanium plasma-sprayed surface (TPS) ranged from 94.5% to 100%(median 97%).27,52,56,67 In studies using implants witha sandblasted and acid-etched surface (SLA), survivalrates of 99.1% to 100% (median 100%) werereported.23,60,70,77,79,89,97,100,101
Due to differences in study design and follow-upperiods, no direct conclusions can be drawn from thedata. However, there was a trend toward slightlylower survival rates for implants with a machined sur-face (median survival rate 95%) and highest survivalrates for implants with an SLA surface (median sur-vival rate 100%). No studies were designed to com-pare the survival of implants with different surfaces inpostextraction sites. One retrospective studyreported no differences in survival outcomesbetween implants with machined and roughenedsurfaces.81
Does Systemic Antibiotic Therapy Improve Sur-vival Outcomes? The majority of studies reported thatsystemic antibiotics were prescribed. However, theantibiotic regimen varied considerably between stud-ies. Penicillin was the most common antibiotic pre-scribed. There were no studies that evaluated survivaloutcomes with and without systemic antibiotic ther-apy. In one retrospective study, implant survival wassignificantly influenced by choice of antibiotics.81 Fail-
ure rates were higher in patients who were allergic topenicillin and were prescribed alternative antibiotics.
What Are the Potential Risk Indicators for Sur-vival of Postextraction Implants? Several factorshave been considered as potential risk indicators forfailure of postextraction implants.
Chronic Periodontitis. In a retrospective study of1,091 implants in 591 patients who were observed fora period of 1 to 11 years, an overall survival rate of 95%was reported.81 The authors reported that there weresignificantly more failures in men than in women, inthose who were prescribed alternative antibiotics topenicillin, in implants in mandibular anterior sites, andin tooth sites with chronic periodontitis. Three otherstudies identified chronic periodontitis as a risk indica-tor.51,65,94 A higher failure rate was also noted in peri-odontitis sites irrespective of the timing of placementafter extraction.65,94 In a study of implants placed into76 extraction sites with infection (55 chronic peri-odontitis, 15 endodontic pathology, and 6 root frac-tures) in 33 patients, two implants failed during the12-month follow-up. The failed implants were in sitesaffected by chronic periodontitis.84
Periapical Pathology . The data for survival ofimplants in sites with apical pathology are contradic-tory. Two controlled studies have been publishedcomparing sites with periapical pathology. In the RCTof Lindeboom et al described previously, the authorsreported that the survival rate was lower for type 1compared to type 3 implant placement.88 In a con-trolled clinical study, type 1 implant placement wascompared in 17 tooth sites with apical pathology and17 sites without apical pathology in 32 subjects.89
After 12 months, the survival rates for both groupswere 100%. It should be noted that 5 sites (4 with api-cal pathology and 1 without apical pathology) werewithdrawn due to lack of initial implant stability.
Immediate Loading. The data on survival of imme-diately loaded implants placed into postextractionsites are unclear. Although high survival rates rangingfrom 91% to 100% (median 100%) were reported in anumber of prospective case series studies of immedi-ate restoration of single-tooth, short-span, and full-arch cases,55,56,64,70,76,78,80,102 comparative studieshave reported lower survival rates of 65% to 100%(median 91%) for type 1 implants compared to 94%to 100% (median 95%) for implants with type 4 place-ment for similar clinical indications.53,66,92,96,98,99 In astudy in which implants were placed into extractionsockets of teeth with chronic periodontitis, a muchlower survival rate was observed with type 1 place-ment (65%) compared to implants placed into healed(type 4) placement sites (94%).99
Implant Sites. The majority of reports with type 1placement were confined to single-root extraction
The International Journal of Oral & Maxillofacial Implants 205
Group 4
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sites in the maxillary and mandibular anterior andpremolar regions. Several studies provided data onimplants placed into multiroot extractionsites.60,63,69,79,100,101 The survival rates of 89% to 100%(median 99.5%) were similar to the results forimplants in single-root extraction sites.
Systemic Risk Factors. One study reporting on theeffect of systemic conditions on postextractionimplant survival was identified.97 In this retrospectivestudy comparing type 1 and type 4 implant place-ment, no postoperative complications or implant fail-ures were observed in 61 patients who were on oralbisphosphonate therapy.
Esthetic Outcomes of Postextraction ImplantsEsthetic outcomes of postextraction implants werereported in 17 prospective20,50,56,66,70,72,76–78,82,
83,86,88,93,103–105 and 7 retrospective studies.11,80,106–110
(Table 7).Esthetic outcomes were reported as changes in
the position of the midfacial mucosa and papillae,width of keratinized mucosa, radiographic location ofthe proximal bone, esthetic indices, and patient- andclinician-rated esthetic results. The majority of studiesreported on outcomes with single-tooth implantrestorations, predominantly in the maxillary anteriorand premolar regions.
The majority of studies were short term, with fol-low-up periods of 12 to 24 months. Three studiesreported on esthetic outcomes after mean observa-tion periods of 4 to 5 years.20,78,93 One study provideddata on a subset of patients who were followed for 6to 9 years.106
What Tissue Alterations Occur with PostextractionImplants? Changes in the level of the midfacialmucosa and height of the papillae have been reportedin studies using different placement protocols.
Midfacial Mucosa. Three studies reported thatmean recession of the midfacial mucosa rangingfrom 0.5 to 0.9 mm (median 0.75 mm) occurred withtype 1 implant placement.70,76,107 One of these stud-ies used an immediate restoration protocol in whichimplants were placed without elevation of surgicalflaps.76 In a retrospective study of type 1 implantplacement without flap elevation in 85 single maxil-lary central and lateral incisor sites in 85 patients,mean recession of 4.6% of the length of the adjacentmaxillary central incisor was reported.110 With type 2placement, one study reported 0.6 mm of recessionof the facial mucosa.86 In a study comparing type 2and type 3 placement, mean recession of 0.6 mm and0.7 mm was reported, respectively. Over 5 years, fur-ther recession of 0.3 mm occurred in the type 2placement group, whereas a reduction in recession of0.3 mm was observed in the type 3 placement
group.93 These dimensional changes are similar tothose found in reports of single-tooth implants inhealed sites (type 4 implant placement).111–113
In addition to mean values, which express the mag-nitude of change, frequency analyses provide a usefulway to examine the trends in soft tissue recession.107
Frequency of recession with type 1 placement wasreported in eight studies.20,50,83,88,103,104,107,110 Reces-sion was reported in a high proportion of sites, rang-ing from 8.7% to 45.2% (median 39%). Five studiesreported that recession of 1 mm or greater wasobserved in 8% to 40.5% (median 21.4%) ofsites.50,83,88,103,107 In one study in which type 1implants were placed without elevation of surgicalflaps and restored 3 months later, recession of morethan 10% of the length of the adjacent reference max-illary central incisor occurred in 18% of sites.110
One retrospective case series study with 45 single-tooth implants using early placement (type 2)showed a low incidence of recession after 2 to 4 yearsof follow-up.11 This low incidence of recession wasconfirmed in a prospective study of type 2 placementby the same authors.72 Only one out of 20 sites (5%)exhibited recession, and this was between 0.5 and 1.0mm. In contrast, a prospective pilot study comparingtype 2 and type 3 placement reported a much higherfrequency of recession in both treatment groups. Theauthors observed that the clinical crowns of theimplant restorations were longer than the contralat-eral natural teeth in 9 of 10 and 8 of 10 sites, respec-tively. The difference in frequency of recessionreported in these studies may be due to the differentapproaches to bone augmentation used by theauthors. Gotfredsen used e-PTFE membranes whendefects of the facial bone were present, but with noadjunctive bone grafts.93 In addition, the utilizationof e-PTFE membranes required a second open flapprocedure for membrane removal, causing additionalmorbidity and local bone resorption. In contrast,Buser and coworkers grafted the peri-implant defectsand external surfaces of the facial bone with DBBMand covered the graft with a resorbable collagenmembrane, which did not require a second open-flapprocedure.12,72 DBBM is a xenograft reported to havea low substitution rate114 and therefore exhibits lowdimensional change over time.
There were three studies of type 1 placement withimmediate restoration that reported on changes tothe midfacial mucosa. Kan et al reported that meanrecession of 0.5 ± 0.53 mm occurred after 12months.76 Wohrle observed that recession of 1 mm to1.5 mm occurred in 2 out of 14 (14.3%) sites.103 In aprospective study in which type 1 implants withdefects of the facial aspect were immediatelyrestored, recession of greater than 1.5 mm was
206 Volume 24, Supplement, 2009
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The International Journal of Oral & Maxillofacial Implants 207
Group 4
Tabl
e 7
Clin
ical
Stu
dies
Rep
orti
ng o
n Es
thet
ic P
aram
eter
s w
ith
Pos
text
ract
ion
Impl
ants
Hea
ling
No.
of
prot
ocol
/pa
tien
tsC
hang
e in
mid
faci
al m
ucos
aC
hang
e in
Stu
dy
Pla
cem
ent
load
ing
(No.
of
Follo
w-u
ppa
pilla
e Es
thet
ic
Stu
dyde
sign
prot
ocol
prot
ocol
impl
ants
)pe
riod
Freq
uenc
yM
ean
heig
htou
tcom
es
Woh
rle
(19
98
)103
Gru
nder
(2
00
0)8
6
Kan
et a
l (2
00
3)76
Mal
o et
al
(20
03
)66
Bia
nchi
and
S
anfil
ippo
(2
00
4)10
6
Got
fred
sen
(20
04
)93
Pros
p C
S
Pros
p C
S
Pros
p C
S
Pros
p C
S
Ret
ro C
S
Pros
p C
S
Type
1
Type
1
Type
1
Type
1
Type
1
Type
2 (4
wk
afte
rex
trac
tion)
and
Type
3 (1
2 w
kaf
ter
extr
actio
n)
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/D
elay
ed
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/D
elay
ed
Subm
erge
d/D
elay
ed
14 (1
4)
10 (1
0)
35 (3
5)
67 (8
5)
22 (2
2) te
stsi
tes
(con
-ne
ctiv
e tis
-su
e gr
afts
at th
e tim
eof
impl
ant
plac
emen
t)20
(20)
cont
rol s
ites
Type
2: 1
0(1
0)
Type
3: 1
0(1
0)
1 to
3 y
12
mo
12
mo
12
mo
6 to
9 y
5 y
14.3
%; r
eces
sion
1 to
1.5
mm
NR
NR
Muc
osal
rece
ssio
nob
serv
ed in
1 p
atie
nt
6- to
9-y
ear f
ollo
w-u
p:R
eces
sion
> 1
mm
in5%
of t
est a
nd 2
0% o
fco
ntro
l site
s
Rec
essi
on a
t bas
elin
e:Ty
pe 2
: 9/1
0 cr
owns
long
er th
an c
ontr
ol to
oth
Type
3: 8
/10
crow
nslo
nger
than
con
trol
teet
h
NR
0.6
mm
(med
ian
0.5
mm
;ra
nge
0 to
1.5
mm
)
0.5
± 0.
53 m
m
NR
NR
Type
2: 0
.6 ±
1.2
mm
incr
ease
d by
0.3
± 0
.5m
m a
fter
5 y
Type
3: 0
.7 ±
1.4
mm
redu
ced
by 0
.3 ±
0.6
mm
afte
r 5 y
NR
NR
Patie
nt e
valu
atio
n of
est
hetic
out
-co
me
(Rat
ing
0 to
10
; 0 =
tota
llyun
satis
fied,
10
= to
tally
sat
isfie
d):
33
/35
pat
ient
s w
ere
tota
lly s
atis
fied
with
the
esth
etic
out
com
e (r
ated
10
)2/
35 p
atie
nts
rate
d th
e ou
tcom
e as
9M
ean
patie
nt-ra
ted
esth
etic
out
-co
me
9.9
Den
tist e
valu
atio
n at
1 y
:Ex
celle
nt 1
8/6
7 p
atie
nts
Goo
d 41
/67
Acce
ptab
le 6
/67
Una
ccep
tabl
e 2
/67
Patie
nt e
valu
atio
n at
1 y
:Al
l pat
ient
s w
ere
satis
fied
with
the
esth
etic
out
com
e N
R
Patie
nt e
valu
atio
n ba
sed
on a
Vis
ual
Anal
og S
cale
(VAS
):Ty
pe 2
: 9.8
(ran
ge 9
.1-1
0.0
)Ty
pe 3
: 8.8
(ran
ge 5
.1-1
0.0
)D
entis
t eva
luat
ion
usin
g th
e sa
me
VAS:
Type
2: 5
.9 (r
ange
2.9
-9.5
)Ty
pe 3
: 8.4
(ran
ge 6
.1-9
.7)
NR
Mea
n re
cess
ion
ofpa
pilla
0.4
mm
(med
ian
0.5
mm
;ra
nge
0 to
1 m
m)
Mea
n re
cess
ion
ofpa
pilla
0.5
3 ±
0. 4
mm
(mes
ial);
0.3
9 ±
0.4
mm
(dis
tal)
NR
NR
Gai
n in
pap
illa
heig
htof
0.3
± 0
.4 m
m fo
rty
pe 2
; gai
n of
1.0
±0.
7 m
m fo
r typ
e 3
betw
een
base
line
and
5 y
186_4a_Chen.qxd 9/10/09 10:16 AM Page 207
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
208 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 7
con
tinu
edC
linic
al S
tudi
es R
epor
ting
on
Esth
etic
Par
amet
ers
wit
h P
oste
xtra
ctio
n Im
plan
ts
Hea
ling
No.
of
prot
ocol
/pa
tien
tsC
hang
e in
mid
faci
al m
ucos
aC
hang
e in
Stu
dy
Pla
cem
ent
load
ing
(No.
of
Follo
w-u
ppa
pilla
e Es
thet
ic
Stu
dyde
sign
prot
ocol
prot
ocol
impl
ants
)pe
riod
Freq
uenc
yM
ean
heig
htou
tcom
es
Can
gini
and
C
orne
lini
(20
05
)77
Cor
nelin
i et a
l (2
00
5)7
0
Sch
ropp
et a
l (2
00
5)10
4
Bar
one
et a
l (2
00
6)5
6
Lind
eboo
m
et a
l (2
00
6)8
8
De
Kok
et a
l (2
00
6)8
0
Ferr
ara
et a
l (2
00
6)7
8
Che
n et
al
(20
07
)20
Juod
zbal
ys a
ndW
ang
(20
07
)83
Pros
p C
CS
Pros
p C
S
RC
T
Pros
p C
S
RC
T
Ret
ro C
S
Pros
p C
S
RC
T
Pros
p C
S
Type
1
Type
1
Mea
n 10
d po
stex
-tr
actio
nTy
pe 3
Type
1
Type
1 a
ndTy
pe 3
Type
1
Type
1
Type
1
Type
1
Tran
smuc
osal
/D
elay
ed
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/Co
nven
tiona
l
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/D
elay
ed
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/Co
nven
tiona
lSu
bmer
ged/
Del
ayed
32 (3
2)
22 (2
2)
Mea
n 10
dpo
stex
trac
-tio
n 23
(23)
Type
3: 2
3(2
3)18
(18)
Type
1: 2
5(2
5)Ty
pe 3
: 25
(25)
20 (2
5)
33 (3
3)
19 (1
9)
12 (1
4)
12
mo
12
mo
2 y
12
mo
Mea
n1
2.4
mo
6 to
30
mo
4 y
4 y
12
mo
NR
NR
8.7%
exp
osur
e of
met
alm
argi
n
Wid
th o
f ker
atin
ized
muc
osa
3.3
± 0.
5 m
m; n
osi
gnifi
cant
cha
nge
from
base
line
26%
site
s w
ith re
cess
ion
No
rece
ssio
n in
56%
of
type
1 p
lace
men
ts a
nd84
% o
f typ
e 3
Rec
essi
on 0
to 1
mm
in28
% o
f typ
e 1
plac
emen
tsan
d 16
% o
f typ
e 3
Rec
essi
on 1
to 2
mm
in8%
of t
ype
1 pl
acem
ents
(non
e fo
r typ
e 3)
NR
NR
33.3
% o
f site
s w
ith re
ces-
sion
21.4
% w
ith re
cess
ion
of 1
to 2
mm
0.2
± 1.
5 m
m a
t site
str
eate
d w
ith e
nam
elm
atrix
der
ivat
ive
and
0.9
± 1.
3 m
m a
t site
s w
ith c
ol-
lage
n m
embr
ane
Mea
n re
cess
ion
0.75
mm
NR
NR
NR
NR
NR
NR
NR
NR
NR
All p
atie
nts
wer
e hi
ghly
sat
isfie
dw
ith th
e es
thet
ic o
utco
me
All p
aten
ts w
ere
satis
fied
with
the
esth
etic
out
com
e
NR
NR
Patie
nt-ra
ted
esth
etic
out
com
e;S
core
of 9
.3 ±
0.6
5 (u
sing
a 1
0-
poin
t sca
le, w
ith 0
= c
ompl
etel
yun
satis
fact
ory
and
10 =
com
plet
ely
satis
fact
ory)
NR
Pink
Est
hetic
Sco
re (P
ES)†
of 1
1.1
64
.3%
of c
ases
with
inco
mpl
ete
mes
ial a
nd d
ista
l pap
illae
42
.9%
of c
ases
with
alv
eola
rpr
oces
s de
ficie
ncy
NR
Jem
t Pap
illa
Inde
x*:
Scor
e 2:
61%
of p
apill
aeSc
ore
3: 3
9% o
f pap
illae
No
scor
es o
f 0, 1
, and
4
Jem
t Pap
illa
Inde
x*:
Sco
re 2
: 33
% o
f pap
il-la
eS
core
3: 8
% o
f pap
illae
NR
Jem
t Pap
illa
Inde
x*:
Scor
e 2
in 2
2% o
f typ
e1
and
28%
of t
ype
3im
plan
t pla
cem
ent s
ites
Scor
e 3
in 7
8% o
f typ
e1
and
72%
of t
ype
3im
plan
t pla
cem
ent s
ites
Jem
t Pap
illa
Inde
x*:
Scor
e 1:
64%
of p
apill
aeSc
ore
2: 3
2% o
f pap
illae
Scor
e 3:
4%
of p
apill
aePa
pilla
e w
hen
initi
ally
pres
ent w
ere
neve
r los
t
NR
Jem
t Pap
illa
Inde
x*:
Scor
e 2:
64%
of p
apill
aeSc
ore
3: 3
6% o
f pap
illae
186_4a_Chen.qxd 9/10/09 10:16 AM Page 208
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
The International Journal of Oral & Maxillofacial Implants 209
Group 4
Tabl
e 7
con
tinu
edC
linic
al S
tudi
es R
epor
ting
on
Esth
etic
Par
amet
ers
wit
h P
oste
xtra
ctio
n Im
plan
ts
Hea
ling
No.
of
prot
ocol
/pa
tien
tsC
hang
e in
mid
faci
al m
ucos
aC
hang
e in
Stu
dy
Pla
cem
ent
load
ing
(No.
of
Follo
w-u
ppa
pilla
e Es
thet
ic
Stu
dyde
sign
prot
ocol
prot
ocol
impl
ants
)pe
riod
Freq
uenc
yM
ean
heig
htou
tcom
es
Cov
ani e
t al
(20
08
)82
Kan
et a
l (2
00
7)5
0
Ste
igm
ann
et a
l (2
00
7)10
5
Evan
s an
d C
hen
(20
08
)107
Deg
idi e
t al
(20
08
)108
Deg
idi e
t al
(20
08
)10
9
Bus
er e
t al
(20
08
)11
Bus
er e
t al
(20
09
)72
Pros
p C
S
Pros
p C
S
Pros
p C
S
Ret
ro C
S
Ret
ro C
S
Ret
ro C
S
Ret
ro C
S
Pros
p C
S
Type
1
Type
1
Type
1
Type
1
Type
1/
Type
4
Type
1
Type
2
Type
2
Subm
erge
d/D
elay
ed
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
NR
/Con
vent
iona
l
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Tran
smuc
osal
/Im
med
iate
rest
orat
ion
Subm
erge
d/Ea
rly
Subm
erge
d/Ea
rly
10 (1
0)
23 (2
3)
10 (1
0)
42 (4
2)
45 (5
2)
49 (1
52)
45 (4
5)
20 (2
0)
12
mo
12
mo
24
mo
Mea
n1
9 m
o
2 to
6 y
24
mo
2 to
4 y
12
mo
Mea
n 4.
1 m
m w
idth
of
kera
tiniz
ed m
ucos
a on
the
faci
al a
spec
t34
.8%
rec
essi
on ≥
1.5
mm
; 8.3
% o
f site
s w
ithV-
shap
ed d
efec
ts o
f the
faci
al b
one‡
42.8
% o
fsi
tes
with
U-s
hape
dde
fect
s of
the
faci
al b
one;
100%
of s
ites
with
UU
-sh
aped
def
ects
of t
hefa
cial
bon
eN
R
45.2
% re
cess
ion
0.5
mm
21.4
% r
eces
sion
1.0
mm
19.1
% re
cess
ion
≥ 1.
5m
mN
R
NR
NR
NR
NR
NR
NR
Mea
n re
cess
ion
0.9
±0.
78 m
m
NR
NR
NR
Mea
n di
ffere
nce
betw
een
test
and
con
tral
ater
al n
at-
ural
teet
h 0.
18 m
mO
ne s
ite w
ith re
cess
ion
of0.
5 to
1.0
mm
NR
NR
All p
atie
nts
extr
emel
y sa
tisfie
d w
ithth
e es
thet
ic o
utco
me
Sub
ject
ive
Esth
etic
Sco
re (S
ES)§
82
% s
atis
fact
ory
(sco
res
I and
II)
18%
uns
atis
fact
ory
(sco
res
III a
nd IV
)
NR
Mul
tiple
adj
acen
t im
plan
ts
No
rece
ssio
n of
the
mid
faci
alm
ucos
a w
as o
bser
ved
Mea
n m
odifi
ed P
ES||
of 8
.1(o
ut o
f 10
)M
ean
WES
¶of
8.6
5(o
ut o
f 10
)
NR
NR
9/1
0 s
ites
with
slig
htbl
untin
g of
the
papi
llae
Mea
n re
cess
ion
ofpa
pilla
0.5
± 0
. 52
mm
(mes
ial);
0.5
± 1
.0 m
m(d
ista
l)Je
mt P
apill
a In
dex
for
type
1 a
nd ty
pe 4
impl
ant p
lace
men
t com
-bi
ned:
Scor
e 1
: 14
.5%
of
papi
llae
Scor
e 2:
50%
of p
apill
aeSc
ore
3: 3
5.5
% o
fpa
pilla
eC
ombi
ned
Jem
t Pap
illa
Inde
x sc
ores
2 a
nd 3
decr
ease
d w
hen
two
impl
ants
wer
e pl
aced
≥ 4
mm
apa
rt w
hen
the
bone
cre
st to
con
tact
poin
t bet
wee
n to
impl
ant c
row
ns w
as
> 6
mm
NR
NR
186_4a_Chen.qxd 9/10/09 10:16 AM Page 209
© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
210 Volume 24, Supplement, 2009
Chen/Buser
Tabl
e 7
cont
inue
dC
linic
al S
tudi
es R
epor
ting
on
Esth
etic
Par
amet
ers
wit
h P
oste
xtra
ctio
n Im
plan
ts
Hea
ling
No.
of
prot
ocol
/pa
tien
tsC
hang
e in
mid
faci
al m
ucos
aC
hang
e in
Stu
dy
Pla
cem
ent
load
ing
(No.
of
Follo
w-u
ppa
pilla
e Es
thet
ic
Stu
dyde
sign
prot
ocol
prot
ocol
impl
ants
)pe
riod
Freq
uenc
yM
ean
heig
htou
tcom
es
Che
n et
al
(20
09
)110
Stu
dy d
esig
n: P
rosp
= p
rosp
ectiv
e; R
etro
= r
etro
spec
tive;
RC
T =
ran
dom
ized
con
trol
led
tria
l; C
CS
= c
ontr
olle
d cl
inic
al s
tudy
; CS
= c
ase
serie
s.P
lace
men
t tim
e af
ter
extr
actio
n: T
ype
1 =
imm
edia
te p
lace
men
t at
the
tim
e of
ext
ract
ion;
Typ
e 2
= e
arly
pla
cem
ent
afte
r in
itial
sof
t tis
sue
heal
ing;
Typ
e 3
= e
arly
pla
cem
ent
afte
r su
bsta
ntia
l bon
e he
alin
g;Ty
pe 4
= la
te p
lace
men
t af
ter
com
plet
e he
alin
g of
the
rid
ge.
Aug
men
tatio
n m
etho
d: e
-PTF
E =
exp
ande
d po
lyte
traf
luor
oeth
ylen
e m
embr
ane;
DB
BM
= d
epro
tein
ized
bov
ine
bone
min
eral
; DFD
BA
= d
emin
eral
ized
fre
eze-
drie
d bo
ne a
llogr
aft;
HA
= h
ydro
xyap
atite
.Lo
adin
g pr
otoc
ols
acco
rdin
g to
the
ITI C
onse
nsus
Con
fere
nce
(200
3).12
4
NR
= n
ot r
epor
ted.
*Pap
illa
Inde
x S
core
as
desc
ribed
by
Jem
t (1
997)
.118
† PE
S =
Pin
k E
sthe
tic S
core
of
Furh
ause
r et
al (
2005
): S
even
var
iabl
es a
sses
sed
in r
elat
ion
to r
efer
ence
too
th a
nd a
ssig
ned
scor
es o
f 0,
1, o
r 2
out
of a
tot
al p
ossi
ble
scor
e of
14,
for
i, s
hape
of
mes
ial p
apill
a;ii,
sha
pe o
f di
stal
pap
illa;
iii,
leve
l of
soft
tis
sue
mar
gin;
iv, s
oft
tissu
e co
ntou
r; v
, alv
eola
r pr
oces
s de
ficie
ncy;
vi,
soft
tis
sue
colo
r; v
ii, s
oft
tissu
e te
xtur
e.12
1
‡ Deh
isce
nce
defe
ct o
n fa
cial
asp
ect
of t
he im
plan
t cl
assi
fied
as: V
-sha
ped,
nar
row
def
ect
isol
ated
to
faci
al s
urfa
ce o
f im
plan
t on
ly; U
-sha
ped,
wid
e de
fect
ext
endi
ng p
roxi
mal
ly in
to t
he m
esia
l or
dist
al a
spec
ts o
fth
e to
oth
to b
e ex
trac
ted;
UU
def
ect,
wid
e de
fect
ext
endi
ng t
o an
d in
clud
ing
the
mes
ial o
r di
stal
sur
face
s of
the
adj
acen
t te
eth.
102
§ S
ubje
ctiv
e E
sthe
tic S
core
(SE
S):10
7I =
ver
tical
fac
ial c
hang
e w
as 0
.5 m
m o
r le
ss a
nd la
bial
tis
sue
fulln
ess
was
in h
arm
ony
with
the
adj
acen
t te
eth;
II =
ver
tical
fac
ial c
hang
e w
as b
etw
een
0.5
and
1.0
mm
and
the
faci
al t
issu
e fu
llnes
s w
as in
har
mon
y; II
I = v
ertic
al f
acia
l cha
nge
was
bet
wee
n 1.
0 an
d 1.
5 m
m o
r th
e fa
cial
tis
sue
appe
ars
defic
ient
in c
onto
ur; I
V =
ver
tical
fac
ial c
hang
e w
as g
reat
er t
han
1.5
mm
and
ade
ficie
ncy
in f
acia
l tis
sue
cont
our
was
not
ed.
|| Mod
ified
Pin
k E
sthe
tic S
core
(mod
PE
S) o
f Fu
rhau
ser
et a
l (20
05)12
1 : F
ive
varia
bles
ass
esse
d in
rel
atio
n to
ref
eren
ce t
ooth
and
ass
igne
d sc
ores
of
0 , 1
, or
2 ou
t of
a t
otal
pos
sibl
e sc
ore
of 1
0, f
or i,
sha
pe o
fm
esia
l and
dis
tal p
apill
ae; i
i, le
vel o
f so
ft t
issu
e m
argi
n; ii
i, so
ft t
issu
e co
ntou
r; iv
, alv
eola
r pr
oces
s; v
, sof
t tis
sue
colo
r an
d te
xtur
e.¶
Whi
te E
sthe
tic S
core
(WE
S):
Sco
res
of 0
, 1, a
nd 2
ass
igne
d ou
t of
a t
otal
pos
sibl
e sc
ore
of 1
0, f
or I,
too
th f
orm
; ii,
toot
h vo
lum
e/ou
tline
; iii,
col
or; i
v, s
urfa
ce t
extu
re; a
nd v
, tra
nslu
cenc
y.72
# Tis
sue
leve
l cha
nge
expr
esse
d as
a p
erce
ntag
e of
the
leng
th o
f th
e ad
jace
nt m
axill
ary
cent
ral i
ncis
or w
hich
ser
ved
as t
he r
efer
ence
.
Ret
ro C
STy
pe 1
Tran
smuc
osal
/Ea
rly85
(85)
26
mo
At 4
4 si
tes
with
initi
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observed in 34.8% of sites.50 Chen et al observed thatmucosal recession occurred soon after restoration ofthe implants, and then remained stable between the1-year and 3-year recall periods.20
One RCT compared type 1 and type 3 placementin sites with radiographic evidence of chronic periapi-cal periodontitis.88 Absence of recession was noted inonly 56% of immediate implant (type 1) sites, com-pared to 84% for early placement (type 3). Recessionof 1 to 2 mm was observed in 8% of type 1 implantsites. In contrast, there were no sites with recession of1 to 2 mm in the type 3 placement group.
In an RCT comparing implant placement soonafter tooth extraction (mean 10 days) with earlyplacement after partial bone healing (type 3), reces-sion of the mucosal margin resulting in exposure ofthe metal margin of the implants was observed in8.7% of implants in each of the two groups after 2years.104 The height of the implant crowns was sub-jectively determined to be too long in 17% of the 10-day postextraction sites and 20% of type 3 implantplacement sites, and too short in 30% of type 3implant placement sites. The crowns were of anappropriate height in 83% of the 10-day postextrac-tion sites and only 50% of type 3 implant sites.
Data on long-term outcomes are limited. However,one study provided data on a subset of patients whowere followed for 6 to 9 years, with implants placed inboth anterior and posterior sites.106 Twenty-twopatients received 22 single-tooth type 1 implants thatwere submerged at the time of surgery using connec-tive tissue grafts. Twenty patients with 20 immediateimplants that were placed without the use of connec-tive tissue (CT) grafts served as controls. Between 6and 9 years following surgery, the proportion of siteswith recession greater than 1 mm (in relation to adja-cent teeth) was 5% in test sites compared to 20% incontrol sites. It was not possible to distinguishbetween anterior and posterior sites from the study.
From these studies, it can be concluded that reces-sion of the midfacial mucosa, even when combinedwith grafts of bone or bone substitutes, is a commoncomplication with type 1 placement. The recessionoccurs soon after restoration of the implants. Reces-sion of 1 mm or more was observed in a high propor-tion (range 8% to 40.5%; median 21.4%) of sites. Thisdimensional change may lie within the visual thresh-old of detecting a difference in mucosal levels.115
Mucosal recession would therefore be expected tohave an adverse effect on esthetic outcomes, as moststudies reported that implants were placed in themaxillary anterior and premolar sites. Recession wasalso observed with immediate restoration ofimplants, and implants placed without elevation ofsurgical flaps.
Early placement (type 2 and type 3) may also beassociated with recession. However, there is evidenceto suggest that early placement with soft tissue heal-ing (type 2) is associated with a relatively low inci-dence of recession when implant placement iscombined with GBR procedures using DBBM. There isevidence that early placement with partial bone heal-ing (type 3) is associated with a lower frequency ofrecession compared to type 1 placement.
Papillae. With type 1 placement, a mean loss ofpapilla height of between 0.5 and 0.6 mm wasreported in three studies.76,86,107 Changes in papillaheight were similar for conventional loading andimmediate restoration protocols. In a prospectivestudy of type 1 placement using the crown of thenatural tooth as an immediate restoration, slightblunting of the papilla was reported in 9 out of 10treated sites.105 In a retrospective study of type 1placement with immediate restoration, 64% of sitesachieved a satisfactory papilla form.80 Loss of papillaheight was accompanied by a reduction in the heightof the proximal crestal bone of 0.3 to 1.9 mm (median1.2 mm).56,66,70,76,83,105 Less than ideal papilla fill wasreported for adjacent implants when the interimplantdistance was less than 2 mm.109
Four studies used the Papilla Index of Jemt todescribe the form of the papillae with immediateplacement.70,83,88,108 The results were variable. In thefour studies, a score of 3 (indicating complete fill ofthe proximal embrasure space) was recorded in 35%to 78% (median 37%) of sites. A score of 2 (indicatingthat half or more of the papilla height was present,but not 100%) was recorded in 22% to 64% (median55%) of sites. A score of 1 (indicating that less thanhalf of the papilla height was present) was onlyrecorded in one study, affecting 14.5% of sites108;three studies reported that no sites recorded a scoreof 1. In studies of immediate restoration ofimplants70,108 there was no clear advantage overstudies using conventional loading protocols83,114
according to this index.Two studies provided comparative data on differ-
ent placement times after extraction. One RCTreported that the risk of a missing papilla or negativepapilla form at the time of restoration was 7.2 timesgreater for type 3 compared to type 2 implant place-ment (33% of sites vs 8% of sites, respectively).104
However, after 1.5 years there was no differencebetween the groups (8% for type 2 placement and 3%for type 3 placement). Overall, 5% of sites had a scoreof 0, 35% had a score of 1, and 60% had a score of 2.Another RCT comparing type 1 and type 2 implantplacement showed no difference between treatmentgroups.88 Studies of type 4 implant placement havereported similar variations in papilla fill.116,117
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The main disadvantage of the Papilla Index ofJemt118 is that scores are based on the degree of fillof the embrasure space after the crown has beenattached to the implant, and not on a comparisonwith the pretreatment form and height of the papillaprior to tooth extraction. Implant crowns will oftenhave an altered width and contact area to compen-sate for a reduction in height of the papilla.119 Thismakes it difficult to compare results between studieswith this index. Several studies reported that the formof the papilla improved over time with postextractionimplants,80,104 a phenomenon also reported withtype 4 placement.116–118
The results of these studies show that type 1placement is associated with recession of the papil-lae.The majority of sites achieved fill of the interproxi-mal embrasure space of at least half of the height, butachieving complete fill was variable.There is evidenceto suggest that the final form of the papillae withtype 1 placement using immediate restoration andconventional loading is similar. Similar outcomeshave been reported with type 4 placement. Two RCTsprovide strong evidence that the final form of thepapillae is independent of the timing of implantplacement after tooth extraction.
Width of Keratinized Mucosa. Three studiesreported on the width of the keratinized mucosa onthe facial aspect following type 1 placement. Themean width was 3.3 mm and 4.1 mm in two stud-ies.56,82 In a third study, 92.9% of sites had a width ofkeratinized mucosa greater than 2 mm.83 Thesedimensions are in accord with studies of type 4implant placement.116,119 The width of keratinizedmucosa was greater when type 1 implants were sub-merged using connective tissue (CT) grafts, com-pared to sites that did not receive CT grafts.106
What Factors Are Associated with Recession ofthe Mucosa? Several factors have been associatedwith recession of the peri-implant mucosa.
Tissue Biotype. With type 1 placement, sites with athin tissue biotype had a higher frequency of reces-sion of > 1 mm than sites with a thick tissue bio-type.20,76,107
Facial Bone Wall. Kan et al reported that damage tothe facial bone wall encountered at the time of type 1placement represented a significant risk factor formucosal recession.50 In 23 patients, implants wereplaced into fresh extraction sites with a damagedfacial bone wall. The defects were grafted with DBBMand covered with a resorbable membrane. The resultsindicate that the risk of recession increased with thewidth of the dehiscence of the facial bone. Only 8.3%of sites with narrow (V-shaped) defects exhibitedrecession of 0.5 mm or more. Recession for sites withwide (U-shaped) defects and defects that involved
the adjacent teeth (UU-shaped defects) was 42.8%and 100%, respectively.
The thickness of the facial bone at the time ofimplant placement may be an important factor. In anRCT, Chen et al noted three residual defect types fol-lowing type 1 placement.20 Sites that healed withcomplete bone fill or a residual craterlike defect hadan initial thickness of the facial bone of 0.7 to 0.9 mmand recorded vertical loss of crestal bone height of0.3 to 0.9 mm at reentry. In contrast, sites that healedwith a dehiscence defect initially had a facial bonethickness of 0.5 mm and recorded vertical crestalbone loss of 2.1 mm at reentry. Thus extraction sock-ets with thin facial bone lost more vertical height andhad less bone fill than sites with thicker bone.
Orofacial Position of the Implant Shoulder. The orofa-cial position of the implant shoulder in the extractionsocket with type 1 placement is strongly associatedwith mucosal recession. In three studies, implants thatwere placed facially within the sockets had a higherfrequency and greater magnitude of recession thansites where implants were more palatally posi-tioned.20,107,110 At sites with recession, the implantshad a significantly greater orofacial defect depth of2.3 mm compared to 1.1 mm for sites with no reces-sion.20 This is consistent with the observation that aperi-implant gap with type 1 implant placement isrequired to minimize compression of the facial bonewall on inserting the implant, and to allow boneregeneration in the gap to establish a thicker facialbone wall.120 These clinical observations have beencorroborated in an experimental study of implants infresh extraction sockets in a canine model.49 Less ver-tical crestal bone loss was observed when the peri-implant defects were wide, compared to sites wherethe defects were less than 2 mm in width.
What Are the Outcomes Based on EstheticIndices? Esthetic indices were used in four studies.Based on the Pink Esthetic Score (PES),121 a meanscore of 11.1 (out of a maximum 14) was reported in aprospective study of 14 immediate implants in 12patients.83 In this study, 64.3% of cases had incom-plete fill of the papillae, and 42.9% had deficiencies inthe alveolar process. In a retrospective study of 85maxillary central and lateral incisors, a mean PES of10.95 was recorded.110 Optimum esthetic results wereachieved in 21.23% of sites (PES scores of 13 and 14).Suboptimal esthetic outcomes (PES scores of 8 and 9)were seen in 22.3% of sites. Using an alternative scor-ing system, 82% of sites had a satisfactory estheticoutcome with type 1 placement in a retrospectivestudy of 42 implants in 42 patients.107 A total of 18%of sites had an unsatisfactory outcome, mainly due torecession of the midfacial mucosa. In a prospectivecase series study with 20 single-tooth implants using
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early placement (type 2), the 12-month results exhib-ited a mean modified PES index of 8.1, and a meanWES index of 8.65 (both out of a maximum of 10).72
Studies reporting on patient-evaluated estheticoutcomes generally reported that patients werehighly satisfied with the results with immediate (type1) placement56,66,76,105 and early placement (type 2and type 3)104 irrespective of the loading protocol.
Although there has been increased interest in andreporting of esthetic outcomes with postextractionimplants since the Third ITI Consensus Conference in2003, there are still relatively few studies at the cur-rent time that evaluate esthetic outcomes usingobjective parameters.
CONCLUSIONS
Regenerative Outcomes of PostextractionImplantsFrom the studies reviewed, it can be concluded that:
• Bone augmentation procedures are effective inpromoting bone fill and defect resolution in peri-implant defects following immediate (type 1) andearly (type 2) placement.
• Peri-implant defects associated with immediate(type 1) and early (type 2) placement may healspontaneously when the peri-implant defect isless than 2 mm in width and the facial bone wall isintact.
• Immediate placement does not prevent vertical orhorizontal resorption of the ridges.
• Bone augmentation combined with immediateplacement may reduce horizontal resorption, butdoes not prevent vertical resorption of the facialbone.
• Bone augmentation procedures are more success-ful in combination with immediate (type 1) andearly (type 2 and type 3) placement compared tolate placement (type 4).
• Evidence is lacking to demonstrate the superiorityof one placement protocol over the other withrespect to healing of peri-implant defects withpostextraction implants. However, there is someevidence to show that regenerative outcomes arebetter with early placement (type 2) compared toimmediate placement (type 1) in the presence ofdehiscence defects of the facial bone wall.
• Postoperative complications are common withimmediate placement.
• The efficacy of concomitant antibiotic therapywith regard to healing of postextraction implantshas not been demonstrated.
Survival Outcomes of Postextraction Implants
• The survival rates for postextraction implants arehigh, with the majority of studies reporting ratesof over 95%.
• Immediate (type 1) and early (type 2) placementprotocols have similar survival rates.
• There is some evidence to suggest that implantswith a machined surface have a lower survival out-come than implants with a roughened surface.
• There is no evidence to show that systemic antibi-otics affect the survival outcome of postextractionimplants.
• A history of chronic periodontitis is a risk indicatorfor survival of postextraction implants.The evidencefor periapical pathology and immediate restorationas risk indicators is contradictory. Evidence for sys-temic factors as risks for implant survival is lacking.
Esthetic Outcomes of Postextraction Implants
• Tissue alterations leading to recession of the facialmucosa and papillae are common with immediateplacement.
• There is evidence that early placement (type 2 andtype 3) is associated with a lower frequency ofmucosal recession compared to immediate place-ment (type 1).
• Risk indicators for recession with immediate place-ment include a thin tissue biotype, a facial malpo-sition of the implant, and a thin or damaged facialbone wall.
• There is evidence to suggest that immediaterestoration and conventional loading protocolsappear to have similar outcomes with respect tosoft tissue alterations.
• Although patient-evaluated esthetic outcomeswith postextraction implants are generally favor-able, there are relatively few studies that evaluateesthetic outcomes using objective parameters.
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