Open Journal of Stomatology, 2013, 3, 392-396 OJST Published Online October 2013 (
Effect of immediate implant placement and
loading on soft tissue management
Erdem Özdemir1*, Yener Oguz2
1Metin Kasapoğlu Caddesi, Yeşilbahce Mah. No: 59/9 PK. 07160 Muratpaşa, Ankara, Turkey
2Department of Oral Maxillofacial Surgery, Dentistry Faculty, Baskent University, Ankara, Turkey
Received 11 August 2013; revised 21 October 2013; accepted 28 October 2013
Copyright © 2013 Erdem Özdemir, Yener Oğuz. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
The recent article describes immediate implant place-
ment and loading in the anterior segment. The main
aim of this treatment option was to deliver provi-
sional prosthesis to the patient in the same day of
surgery, form papilla contours, and eliminate waiting
of osseointegration time and the second surgery.
Keywords: Immediate Implant Placement; Provisional
Denture; Papilla Forming
Traditionally, when incisors are lost in the anterior max-
illa, canines/premolars-supported fixed partial denture is
the mandatory treatment option. The number of lost teeth,
the length of the arch, and the mobility of the abutment
teeth should be carefully considered before deciding the
number of abutments [1]. Furthermore, fixed partial den-
tures in the anterior maxilla cause increased bending
forces than the anterior mandibula because of the larger
curve. In case all maxillary incisors are lost, the pontics
will lie outside of the inter-abutment axis line and the
forces will act as a lever arm that operates the torquing
forces on the canines/premolars [1]. In such cases, im-
plant treatment options, which also eliminate the prepa-
ration of teeth, become a viable treatment option for pa-
tients [2].
Teeth loss will decrease the bone level of the extrac-
tion site and the surrounding soft tissue volume [3], with
significant tissue loss in the first month; this will keep
decreasing for at least six months [4]. In the healed sites,
because of decreased bone height, shorter implants can
be placed and longer crowns should be designed because
of the lost soft and hard tissues. This short-implant/
long-crown combinations can face some mechanical
problems and result in bone resorption, which can cause
implant failure. The loss of soft tissue will result in lost
interdental papillae. Interdental papillae loss will also
affect the esthetic configuration [5]—“black triangle”
areas that affect the esthetic dental harmony which can
be observed between the crowns [6]. The lack of inter-
dental papillae will also result in phonetic problems and
food impaction [6].
Immediate implant placement terminology describes
implant placement following tooth extraction immedi-
ately into extraction cavity. Immediate implant place-
ment has favorable outcomes [7]—decreasing the treat-
ment time, decreasing the number of surgeries, and de-
creasing the risk of hard and soft tissue resorption [8,9].
In other words, it was shown that immediate implant
placement at the extraction sites preserves the bone and
soft tissue volume [10-12]. In the cases, primary stability
can be observed, and immediate loading protocol can be
executed in the anterior sites. At least a 32 - 35 Ncm
torque is required for the single implants’ immediate
loading [13,14]. Mozatti et al. [15] showed in their ret-
rospective study that immediate implant placement and
loading have successful long-term results as compared to
delayed implant loading. Juodzbalys and Wang [16]
placed implants into extraction sockets and followed for
one year. They found that the implant success rate was
100% and the keratinize soft tissue volume was suffi-
cient with 92.9%.
Immediate implant placement and delivery of provi-
sional crowns in the same day of surgery provide imme-
diate comfort to the patients, keep the teeth in place and
support the lip [17]. Following extraction, immediate
implant placement and loading support the hard and soft
dental tissues at the extraction sites [18,19]. Provisional
crowns maintain and reshape the soft tissue contours
during healing [20]. Di Alberti et al. [21] showed in their
study that immediate implant loading in the anterior
maxilla preserves the interdental papillae and supports
the soft tissue contours. In another study, it was shown
that immediate implant placement and loading main-
E. Özdemir, Y. Oğuz / Open Journal of Stomatology 3 (2013) 392-396 393
tained the papillae and peri-implant soft tissue contours.
[22] However, it is known that esthetics can be improved
by conditioning the area beneath the pontic that is predi-
cated on convex shape and applying positive pressure
This article describes immediate implant placement
and loading in the anterior maxilla following extractions
of maxillary incisors. At two different times, provisional
fixed partial dentures were fabricated; the first one was
finished immediately after surgery and the second one
was produced at a dental laboratory after the sutures
were removed. The aims of provisional restorations were
achieving a positive pressure on the soft tissue and re-
shaping it to the new esthetic configuration.
A 52-year-old woman presented to the Prosthodontics
department of Baskent University Umitköy Clinic with
esthetic problems related to the maxillary anterior region;
she had also lost her maxillary first, second and man-
dibular first molars. There was a fixed partial denture
that was supported with maxillary incisors for about
seven years. The patient had gingival problems, such as
bleeding, and was also unhappy with the smell and the
view of “black triangles” between the crowns (Figure 1).
After inspection and radiographic evaluation of teeth
(Figure 2), it was seen that the surrounding bone levels
of the central and lateral incisors were decreased. Imme-
Figure 1. The intraoral view of teeth before the treatment.
Figure 2. The panoramic radiograph of patient before implant
diate implant placement and loading after the incisors’
extraction and placing implants for the first and second
molars in the maxillary and tooth-supported fixed partial
denture for the mandibular posterior site was recom-
mended to the patient. The treatment options were ac-
cepted by the patient. A maxillary impression was taken
with an irreversible hydrocolloid material (Blueprint
Cremix; Dentsply DeTrey, GmbH, Konstanz, Germany)
and poured with Type IV dental stone (Amberok;
Anadolu Dental Products, Istanbul, Turkey) to obtain a
stone model. A sheet of 0.0035-inch-thick bleaching tray
material (Regular Soft-Tray, 0.0035 inch; Ultradent
Products, Inc) in the forming frame of the vacuum ma-
chine (UltraVac Vacuum Former; Ultradent Products,
Inc) was fixed to the stone model to fabricate the provi-
sional denture after implant placement. The central and
lateral incisors in the anterior maxillary were extracted,
the buccal plates of the extraction sockets were preserved,
and two dental implants were placed into the extraction
sockets of the lateral incisors (Tapered Screw-Vent; 3.7
mm × 12 mm (TSVB), 4.1 mm × 12 mm (TSV4B),
Zimmer Dental Inc.). A torque of at least 30 Ncm was
obtained with a torque wrench (TW 30, Zimmer Dental
Inc.) and after immediate placement, primary stability
was controlled with horizontal and rotational movements
of the implants. The extraction sockets of the central
incisors were sutured with bioresorbable material (Vicryl
4.0 polyglactin 910; Johnson & Johnson Intl, St. Stevens,
Woluwe, Belgium). Temporary abutments (HLPT
Hex-Lock Plastic Temporary Abutment, Zimmer Dental
Inc.) were mounted (Figure 3) to the implants and an
open tray impression was taken by using a polyether
silicone material [24,25] (Impregum Penta Soft, 3 M
Espe, St Paul, Minn.). Following the impression, the im-
plant analogs (Implant analog, IA3, Zimmer Dental Inc.)
were mounted to the temporary abutments and the im-
pression was poured with a Type IV dental stone (Am-
berok; Anadolu Dental Products, Istanbul, Turkey). The
areas that would be beneath the pontics on the model,
were scraped to 1 mm and the temporary abutments were
prepared. The anterior incisors of the sheet material was
filled with auto-polymerizing acrylic resin (Protemp 3,
Temporization Material, 3M Espe, St Paul, Minn) and
Figure 3. Provisional abutments were placed before taking
impression, following immediate implant placement.
Copyright © 2013 SciRes. OPEN ACCESS
E. Özdemir, Y. Oğuz / Open Journal of Stomatology 3 (2013) 392-396
seated on to the model; just before the polymerization
finished, the sheet material was removed. Following the
polymerization of the acrylic resin, the provisional den-
ture removed from the sheet material. The abutments
were then transferred to the mouth, as in the model, and
the provisional denture was adjusted to the abutments.
Provisional cement (TempBond Clear; Kerr Corporation,
Orange, Ca) was mixed and loaded into the provisional
crowns; these provisional crowns were placed on to the
abutments and just before the setting of the cement, the
provisional denture was removed, the excess cement was
cleaned around the abutments/crowns, and the provi-
sional denture was placed again. Pontics applied a posi-
tive pressure on the soft tissue (Figure 4).
One week after surgery, the provisional denture and
sutures were removed. The transfer posts (Fixture mount,
replacement retaining screw, FMT3, Zimmer Dental Inc.)
were remounted on to the implants and an impression
was taken with polyether silicone material. The casts
were articulated in a semiadjustable articulator (Protar
Evo 2; Kavo, Biberbach, Germany) and an interocclusal
centric relation record. The temporary abutments were
remounted on to the maxillary cast and the new provi-
sional fixed partial denture was produced in the labora-
tory with auto-polymerizing acrylic resin (Jet Set-4,
Lang Dental Mfg. Co. Inc., Wheeling, Ill), according to
the healed soft tissue areas. During the six months of
osseointegration, the patient was followed with recall
appointments every two months, and at every appoint-
ment, the provisional denture was removed and adjusted
according to the healed soft tissue areas, polished, and
recemented. Oral hygiene instructions were given to the
Figure 4. The provisional denture is in place. This view was
obtained after 1 week of implant placement.
patient, which included tooth brushing and daily flossing.
At the six-month follow-up appointments, a panoramic
radiograph was taken (Figure 5) and intraoral examina-
tion was geminated, no complications were noted. The
provisional denture was removed and the soft tissue had
healed and matured with adequate volume (Figure 6).
The transfer posts (Fixture mount, replacement retaining
screw, FMT3, Zimmer Dental Inc.) were mounted to the
implants and a closed-tray impression was taken with the
addition of silicone (Express; 3M ESPE, St Paul, Minn.).
An elastomeric material for gingival reproduction
(Gi-Mask, Coltene/Whaledent) was injected around the
impression and implant analogs (Implant analog, IA3,
Zimmer Dental Inc.) were assembled to transfer posts
before obtaining the model. An irreversible hydrocolloid
impression (Blueprint Cremix; Dentsply De Trey, GmbH,
Konstanz, Germany) was made of the opposing man-
dibular dentition. The casts were articulated in a semiad-
justable articulator (Protar Evo 2; Kavo, Biberbach,
Germany) with facebow transfer and an interocclusal
centric relation record.
Prefabricated abutments (Hex-lock contour abutments,
straight, MHLAS, Zimmer Dental Inc.) were selected
and prepared. The metal coping for the definitive resto-
ration was fabricated with base metal alloy (Wiron 99,
composition%: Ni: 65, Cr: 22.5, Mo: 9.5, Si: 1, Nb: 1, Fe:
0.5, Ce: 0.5, C: max. 0.02; Bego Dental). Low fusing
porcelain (Omega 900; VITA Zahnfabrik) was applied to
the metal coping. The definitive crown was evaluated
Figure 5. Panoramic radiograph after implant placement.
Figure 6. Healed interproximal soft tissue was matured and
demonstrated adequate volume.
Copyright © 2013 SciRes. OPEN ACCESS
E. Özdemir, Y. Oğuz / Open Journal of Stomatology 3 (2013) 392-396 395
intraorally and proper occlusion was achieved. The de-
finitive crown was cemented with glass ionomer cement
(Ketac Cem; 3M ESPE) (Figure 7).
Immediate implant placement and loading have gained
popularity in the rehabilitation of the anterior maxilla.
Shortening the time period and eliminating second-stage
surgery, delivering provisional dentures to the patient in
the same day of surgery, contouring and creating the soft
tissue are some of the benefits of immediate implant
placement and loading, compared to the conventional
implant treatment methods [5]. Usually anterior seg-
ments (between premolars) should be selected for imme-
diate implant placement and loading. In the present
clinical report, the maxillary anterior incisor teeth were
extracted and two implants were placed into the lateral
teeth extraction sockets and loaded in the same day of
In the present case, soft tissue loss around the crowns
(Figure 1) and decreased bone heights around the roots
belonging to the maxillary incisors (Figure 2) can be
seen. Extracting the incisors and waiting for the healing
period before implant placement would cause an increase
in bone and soft tissue resorption. This will affect the
implant and crown lengths. As mentioned before,
short-implant and long-crown combinations will result in
mechanical risks and an unaesthetic view. It was reported
that implants placed in extraction sockets have similar
outcomes as placement in healed sites [5]. For healing
site implant placement, 4 - 6 months are needed for os-
seointegration after the healing of extraction sockets [8].
Alternative provisional dentures for the anterior regions
at the time of osseointegration were described earlier,
such as removable partial dentures and resin-bonded
fixed partial dentures [7,14]. But a removable partial
denture is not usually a tenderness choice for patients
and resin-bonded fixed partial denture is not convenient
for the loss of four teeth in the anterior maxilla; therefore,
immediate loading is beneficial to patient satisfaction.
However, provisional crowns can create soft tissue con-
Figure 7. Definitive crowns in place.
tours by applying pressure [14]. Jacques et al. [20] de-
scribed a technique for the improvement of soft tissue
beneath the pontics by applying pressure. It is recom-
mended that 3 - 5 mm soft tissue thickness is required to
reshape by applying pressure [20]. In the present case, it
is clearly seen that after the extraction of teeth, the pa-
pillae between the extracted central and soft tissues
around the extracted areas are enough to form by apply-
ing pressure (Figure 3). Polyether impression material
was preferred to obtain a detailed and nonfunctional soft
tissue impression [24]. Polyether is a flowable impres-
sion material that under pressure displaces the soft tissue
minimally at the time of taking the impression [25]. In
the present case, the provisional denture was delivered in
the same day of extraction and is more effective in shap-
ing the soft tissue contour and the interdental papillae
during healing. Chen and Buser [17] evaluated the aes-
thetic outcomes of implants placed in the extraction sites,
and according to their review, midfacial recession after
the immediate implants is a higher risk (more than 1
mm). However, Cosyn et al. [2] found papillae regrowth
and a low risk for advanced midfacial recession. This
result is also similar to Block et al.’s and Van Kasteren
et al.’s results [18,19]. These contrast findings may be
the result of gingival biotype selection. A thin gingival
biotype can be the cause of midfacial recession. In a re-
cent case, the gingival biotype of the patient was an ex-
ample of thick-flat gingival biotype, which was classi-
fied by De Rouck et al. [12], and is more resistant to
recession after implant placement. A criticism for the
present case is the cemented provisional restorations.
Immediately following the cementing of the provisional
restoration, it was removed, the excess cement was
cleaned, and the restoration placed back. The interposing
of the cement into the gingival sulcus was interrupted.
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