Introduction

Immediate implant placement (IIP) has emerged as an appealing treatment protocol for patients requiring tooth replacement in the esthetic zone. Especially when combined with immediate provisionalization, the advantages include minimal surgical interventions and shorter treatment times to achieve function and esthetics. A systematic review concluded that properly executed immediate implant placement and provisionalization in the maxillary esthetic zone can achieve excellent and stable esthetic outcomes and high survival rates [1]. However, many factors, including primary implant stability, soft tissue phenotype and stability, peri‐implant bone preservation, and patient expectations need to be carefully considered [2, 3]. Attaining adequate primary stability is crucial, as IIP presents unique challenges often with limited opportunities for bone engagement primarily apically and/or into the socket palatal wall necessitating careful surgical planning and execution [4]. For this reason, early implant failure may be more common with IIPs compared with delayed implant placements [5–7].

Regarding stability of peri‐implant soft tissues, long‐term studies have highlighted potential unfavorable changes following immediate implant placement, including recession of the mid‐facial mucosa and adjacent papillae [8, 9]. This may occur to a lesser extent when the implant is provisionalized, since the original contours of the soft tissues are immediately supported by the restoration [10, 11]. Preserving peri‐implant bone is also a key consideration with IIP. A combination of flapless surgery, palatal implant positioning and leaving adequate gaps for hard tissue grafting between the buccal crest and the implant helps to maintain and even increase buccal bone [9, 12, 13]. However, complete preservation of hard and soft tissue architecture after implant placement may be impossible due to the inevitable bone remodeling following tooth extraction [14–16]. In view of this, analyzing the linear mid‐facial mucosa level and buccal bone thickness using cone beam computed tomography (CBCT) measurements are critical outcome parameters [5].

IIP with immediate provisionalization is generally favored by patients because of its minimally invasive nature and reduced treatment time compared with traditional delayed procedures [17]. However, because the implant is not yet osseointegrated, the provisional restoration must be free of any occlusal contacts and the patient’s cooperation is needed to avoid the restoration during biting and chewing.

Positive results with IIPs from long‐term (≥ 10 years) prospective studies are important to provide practitioners and patients with confidence in the treatment procedures, but thus far, data from 5 years after IIP with immediate provisionalization are scarce, being limited to three studies [8, 18, 19]. Notwithstanding the limited number of long‐term studies, the existing studies show very limited peri‐implant bone loss, stable peri‐implant soft tissues, limited biological and technical complications, and satisfied patients. Thus, together with positive results of medium‐term studies, a growing consensus has formed that IIPs, in combination with immediate provisionalization, may be the treatment of first choice for single failing teeth in the maxillary esthetic zone. However, it must be recognized that IIP with immediate provisionalization may not be indicated in the presence of significant bony and/or soft tissue defects remaining after tooth removal. In such cases, immediate implant placement with delayed provisionalization or delayed implant placement have shown their merit [20]. To assist clinicians in choosing the right options, aprotocol for IIP treatment in the maxillary esthetic zone has been developed [21]. The possible steps for making a rational decision are outlined below.

Preoperative Screening

Diagnosis and Planning Procedures

In a recent consensus conference, IIP in combination with immediate provisionalization was classified as a complex procedure that should be performed only by clinicians highly experienced in surgical and restorative implant procedures. These clinicians should have skills specific to tooth extraction and immediate implant placement, hard and soft tissue augmentation procedures, and immediate provisionalization of implants. A team approach is often needed. A thorough clinical examination should be performed for the proper assessment of the patient and implant site [22]. Thereafter, strict diagnostic criteria and precise treatment protocols need to be followed to obtain an optimal and stable result. Intraoral radiographs and CBCT of the intended treatment site are essential to determine whether there is sufficient apical bone (≥ 4 mm) remaining to stabilize an implant, no or only small defects in the buccal socket wall, and a non‐compromised, periodontal attachment level at the adjacent teeth. To plan for the optimal implant positioning in three dimensions, impressions or intraoral scanning, and wax or digital set‐ups performed to be able to create an accurate surgical guide/template. [19]

Surgical Procedures

Our preference is for patients undergoing IIP to start prophylactic antibiotic treatment 1 day before the surgery (amoxicillin 500 mg, three times daily for 7 days), together with intraoral disinfection twice a day using 0.2% chlorhexidine mouth rinse. After administering local anesthesia, the condemned tooth is carefully removed without raising a flap. The alveolus is carefully inspected to determine the condition of the socket walls and thoroughly debrided of residual granulation tissue, following which the manufacturer’s osteotomy drilling protocol is initiated with a pilot drill and “semiguided” (use of guide for burs but not implant insertion) surgical template. During each drill step, residual bone chips can be collected from the burs and stored in sterile saline. The osteotomy often must be positioned slightly palatal to the axis of the original root leaving at least a 2‐mm distance/gap between the implant and buccal crest. The last‐used implant drill is placed into the osteotomy as a space maintainer while the gap is packed with a 1 : 1 mixture of autologous bone (residual bone chips collected from the burs during osteotomy) and anorganic bovine bone. The graft material should be compacted firmly to avoid leaving voids. Next, the drill is carefully removed, and the implant placed 3–4 mm apical to the restorative zenith point of the future crown and torqued to 45 Ncm. The implant should have a thread design with sharp edges and a cutting apex to achieve adequate initial stability. An implant‐level open‐tray impression then is made with a vinylpolysiloxane precision impression material, and the impression sent to a dental laboratory for manufacturing of the provisional restoration. Alternatively, an intraoral scan can be used for the same purpose. A sterile resorbable gelatin sponge secured with a healing abutment is used to protect the graft material until an acrylic provisional restoration supported by a screw‐retained stock titanium abutment can be delivered (within 24 hours) and torqued to the manufacturer’s recommended level. This initial prosthesis is meticulously checked to ensure that it is free from centric and eccentric jaw movements, and the patient is advised to avoid excessive chewing forces during the entire healing period. Finally, postoperative CBCT is recommended to verify acceptable implant positioning and adequate post‐insertion buccal bone thickness.

Prosthetic Procedures

Two weeks after implant placement and provisionalization, the patient is recalled for follow‐up and, all being well, booked in 3 months for an open‐tray implant level impression using a polyether precision impression material or again an intraoral scan. The definitive screw‐retained restoration consists of a titanium base with zirconia abutment. Porcelain is fused to the base. At crown insertion, the retention screw is tightened to the manufacturer’s recommended torque value, after which a final intraoral radiograph and CBCT are obtained to serve as a reference for future bone level and buccal bone thickness comparisons.

Follow‐up

Generally, patients are scheduled for routine maintenance recalls yearly, at which time inspection of the restoration, occlusion and peri‐implant soft tissues is carried out, and the stability of implant and restoration checked and verified with radiographs. Following this, CBCT is scheduled every 5 years.

Case Presentation Two

A 21‐year‐old woman was referred to our department for dental implant treatment at both maxillary central incisor sites due to external root resorption. Six years previously, following traumatic avulsion, the teeth had been reinserted, splinted, and endodontically treated. The medical history was unremarkable. The intraoral examination of the two teeth revealed slight discoloration (Figure 3.1.2.a). Using analogue planning, it was judged that there were suitable conditions to place immediate implants with anatomical non‐occluding provisional restorations. Radiographs showed root resorption defects, but no periapical inflammation (Figure 3.1.2b). Both teeth were removed without raising a flap (Figure 3.1.2c), and two 4.3/18 mm Nobel Active Internal RP implants placed palatally taking care to leave 2‐mm buccal gaps between each implant and its corresponding buccal bone plate (Figure 3.1.2d). These gaps were grafted using Bio‐Oss Spongious granules, 0.25‐1 mm, (Geistlich Pharma AG, Wolhusen, Switzerland) and impressions taken for the fabrication of the transitional individual crowns. Finally, autogenous connective tissue grafts taken from the palate were inserted under the buccal gingival margins to improve the phenotype and sutured (Figure 3.1.2e). Provisional restorations were manufactured by the dental laboratory; straight screw access holes were positioned palatally (Figure 3.1.2f).

The provisional restorations were placed (Figures 3.1.2g,h). Figures 3.1.2i,j show the clinical and radiographic status of the IIP sites at the 2‐week postoperative visit, while Figures 3.1.2k,l show the clinical condition of the soft tissues at the 3‐month appointment for impressions for the definitive crowns (Figure 3.1.2m). The final outcomes at 2 weeks and 5 years following crown insertion are shown as Figures 3.1.2n,o. Finally, Figures 3.1.2p,q,r documented the stable bone levels 2 weeks, 1 year and 5 years following final crown delivery.

Case Presentation Three

A 28‐year‐old man was referred to our clinic for implant treatment at the maxillary left central incisor 2 days following an accidental elbow bump that resulted in a horizontal root fracture and mobile crown (Figure 3.1.3a). The tooth had undergone root canal treatment 10 years previously, following an earlier accident. Otherwise, the dental and medical histories were non‐contributory. The intraoral examination revealed a highly mobile crown but healthy soft tissues with minimal recession, and the site (Figure 3.1.3b) was judged to be suitable for IIP treatment with an anatomical non‐occluding provisional crown. Radiographic analysis showed no periapical inflammation and an intact buccal bone wall (Figure 3.1.3c). In this case, a full digital workflow was followed in treatment planning and for all prosthetic procedures (Figure 3.1.3d). It combined information of the patient’s hard and soft tissues by integrating intraoral scans with the CBCT data, facilitating prosthetically driven implant placement. A surgical guide was developed digitally (Figure 3.1.3e) and produced by three‐dimensional printing (Figure 3.1.3f), as was the transitional restoration (Figure 3.1.3g). At the surgical appointment, the tooth was removed gently without raising a soft tissue flap (Figure 3.1.3h). An osteotomy was created using the prepared surgical guide for a 4.3/18 mm Nobel Active Ti Ultra RP implant, leaving the standard buccal gap and its grafting with hard tissue particulate (Bio‐Oss Spongious granules, 0.25–1 mm, Geistlich Pharma AG, Wolhusen, Switzerland), while leaving the final implant bur in position (Figure 3.1.3i), followed by freehand implant insertion (Figure 3.1.3j). Next, a prosthetic abutment was inserted (Figure 3.1.3k) to receive the transitional crown (Figure 3.1.3l). After confirming the fit of this crown, it was removed to trim away the “wings” and fine tune its shape to ensure that its cervical region (Figure 3.1.3m) provided proper support for the original gingival margins on all aspects (Figure 3.1.3n). The baseline radiograph after insertion of this crown is shown in Figure 3.1.3o. After 3 months of site healing, a digital impression of the site with a scanning body in place (Figure 3.1.3p) was used to assist in fabrication of the definitive restoration seen in Figure 3.1.3q after 1 year of function. Finally, radiographs are included at the time of final restoration insertion (Figure 3.1.3r) and after 1 year in service (Figure 3.1.3s).

Case Presentation Four

This final example of single IIP treatment was provided for a 26‐year‐old man whose maxillary left first bicuspid tooth (Figure 3.1.4a) with a large composite restoration had fractured at bone level. His medical history was non‐contributory. Radiographic analysis revealed a deeply fractured crown, making traditional restoration unpredictable (Figure 3.4b). There was no apparent periapical pathosis and an intact buccal bone wall (Figure 3.1.4c). After detailed explanation of benefits and risks of possible treatment options, the patient chose an implant‐supported restoration as replacement. A full digital workflow was followed for case planning and management (Figure 3.1.4d). The surgical guide was planned (Figure 3.1.4e) and fabricated (Figure 3.1.4f).

At surgery, the tooth was removed without flap elevation (Figure 3.1.4g) and the surgical stent used to guide development of the osteotomy (Figure 3.1.4h). The final bur was used to fill the osteotomy while the gap grafting (Bio‐Oss Spongious granules, 0.25–1 mm, Geistlich Pharma AG, Wolhusen, Switzerland) was accomplished (Figure 3.1.4i) and the implant (4.3/15 mm Nobel Active TiUltra RP) inserted (Figure 3.1.4j). The preformed transitional with lateral wings was fitted onto an abutment and secured with light‐cured resin after which the restoration was removed, trimmed, and contoured chairside to provide support for the pre‐extraction soft tissue profile (Figures 3.1.4k,l). A postoperative radiograph of the IIP and transitional restoration is provided in Figure 3.1.4m. The corresponding radiograph taken at insertion of the final crown is shown in Figure 3.1.4n, while the clinical status 3 months later is shown in Figure 3.1.4o. Finally, Figure 3.1.4p show the stable bone levels after 1 year of clinical function with the definitive crown.

Discussion

Immediate implant placement with immediate provisionalization often appears to be the ideal solution for single failed teeth in anterior maxilla but, in reality, it is a very technique‐sensitive treatment, which should not be undertaken by the average dental practitioner. A great deal of research on the subject has been published, although a new assessment of work listed in Scopus using bibliometric network analysis suggests that only approximately 16% of published findings can be considered level 1 evidence [23] (well‐designed, randomized, prospective clinical trials) [24], which is far less than the much higher levels of research data published in other areas of dental implant and periodontal research. The qualities of approximately 40% of IIP published results indexed in Scopus were considered to be level III or IV, comprising mainly case series and retrospective reports. However, the report also emphasized that there is an exponential annual growth rate of 7% new data being published.

Our approach in this chapter has been to focus on more or less straightforward cases of IIP with immediate transitional restoration [25]. Our examples included cases where only one, or in one instance two, single teeth were treated and for all the cases, extractions were flapless and minimally traumatic, with all four socket walls including the crucial buccal bone wall remaining intact. Soft tissues were primarily of thick phenotype and minimal facial recessions existed pretreatment. Attention was paid to pre‐extraction radial tooth root positioning to be able to direct osteotomy preparation towards the palatal bone thereby gaining high initial implant stability [26]. Carefully prepared, occlusally non‐loaded, transitional crowns were inserted more or less immediately post‐surgery to maintain support of the existing soft tissue profiles. Clinicians considering placing IIPs in their patients would do well to approach only this sort of case when they are considering “immediacy” for their implant patients.

Conclusions

Placing immediate dental implants in the maxillary esthetic zone is not for the inexperienced. Ideally, it will include careful treatment planning, including CBCT assessments of bony housing and existing radial tooth root positioning, soft tissue profile and phenotype, and periodontal attachment status of adjacent teeth. The treatment should be offered to compliant patients with a history of appropriate regular dental care who have reasonable esthetic expectations.