Journal of Dental Sciences (2011) 6, 53e60

available at www.sciencedirect.com

journal homepage: www.e-jds.com

Case Report

Immediate implant placement and provisionalization

with simultaneous guided bone regeneration in the
esthetic zone
Chih-Long Chen 1, Chih-Ling Chang 1,2, Shih-Jung Lin 1,3*

1
Department of Dentistry, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
2
Department of Dentistry, National Yang-Ming University, Taipei, Taiwan
3
College of Medicine, Chang Gung University, Taipei, Taiwan

Received 4 November 2010; accepted 10 January 2011

Available online 21 March 2011

KEYWORDS Abstract The procedure for immediate implant placement and provisionalization is time-
guided bone saving, possibly with only one surgical intervention required, although allowing maximal pres-
regeneration; ervation of peri-implant tissues. In this case, we extracted a fractured maxillary right central
immediate implant; incisor of a 46-year-old woman with high esthetic expectations, and a transmucosal implant
immediate was immediately installed. Simultaneous guided bone regeneration was performed to correct
provisionalization the defects at the facial side of the socket and augment the alveolar ridge horizontally.
Primary stability of the implant body and wound closure without tension were confirmed.
Connection of a 15
angled abutment and fabrication of a provisional acrylic resin crown
without occlusal contact were also completed in the same appointment. After intensive
follow-up and soft-tissue molding for 6 months, the customized zirconia abutment and all-
ceramic crown were definitively fabricated. During the 18-month follow-up period, the patient
was satisfied with the esthetic and functional results.
Copyright ª 2011, Association for Dental Sciences of the Republic of China. Published by
Elsevier Taiwan LLC. All rights reserved.

Introduction

Restoration of missing teeth in the esthetic zone is a great

challenge for dental practitioners. Implant-supported fixed
* Corresponding author. Department of Dentistry, Shin Kong Wu prostheses are usually attempted before other options
Ho-Su Memorial Hospital, No. 95-B1, Wenchang Road, Shilin such as conventional bridges or removable dentures to
District, Taipei 111, Taiwan. Tel.: þ886 2 28332211x2170. avoid damage to adjacent teeth and provide better chew-
E-mail address: louissj.lin@msa.hinet.net (S.-J. Lin). ing function.

1991-7902/$36 Copyright ª 2011, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.
doi:10.1016/j.jds.2011.01.001
54 C.-L. Chen et al

The number of osseointegrated implants used in par- finishing a full-veneer crown restoration. She was in good
tially edentulous patients has drastically grown since the general health, and her medical history was unremarkable.
1980s. An implant-supported crown to replace a single Her previous dental history showed that she had high
tooth gap is the most frequent indication today for implant esthetic expectations. It was noted that the patient had
therapy.1 Although the main objective of restoring poste- a low smile line (Fig. 1A) and a thin, scalloped gingival
rior sites is to reestablish masticator function, there is less biotype (Fig. 1B). A clinical inspection of the oral cavity
concern about esthetics. In addition, implant practitioners revealed a gingival swelling on the facial side of tooth 11,
encounter increasing numbers of implants that need to be which had been restored with a provisional resin crown.
placed in the anterior esthetic zone with high esthetic This symptomatic tooth had been treated with forced-
expectations from patients. Advanced periodontitis, eruption and crown-lengthening procedures to correct
unrestorable caries, fractures, and traumatic injuries are a subgingival caries and expose an adequate sound tooth
the most common reasons for missing anterior teeth. structure for a ferrule effect 5 years previous. A cast
Various risk factors which may compromise the predict- postecore and single crown were also fabricated at that
ability of the esthetic results should be assessed in detail time. She was under prosthodontic retreatment because of
before commencing treatment procedures.2 the previous crown having become dislodged. Slight
Nowadays, shortening the overall treatment period and palpation and percussive discomfort with an isolated deep
minimizing the number of surgical interventions in implant clinical probing depth of 8 mm of the midfacial gingiva
dentistry are expected by patients and clinicians. Tradi- were found on examination. One of the neighboring teeth,
tional guidelines advise a 2e3-month period of socket the left central incisor, had been restored with an all-
remodeling after tooth extraction and an additional 3e6 ceramic crown but was free of caries and periodontal
months of load-free healing that were essential for problems. However, there was a discrepancy between the
osseointegration in the 1980s.3 Alternative protocols such crown height of both central incisors, because tooth 11 was
as immediate implant placement at the time of extraction4 shorter by about 0.5 mm at the gingival level than the
and a method of early implant insertion after a few weeks contralateral tooth. The periapical radiograph demon-
of soft-tissue healing5 have been used for about 20 years. strated a filled root canal cemented with a large metal
The advantages of only one surgical procedure and reducing postecore (Fig. 1C). Radiopaque material protruding from
the overall treatment time have encouraged clinicians to the root apex and no apical radiolucency were also
immediately install implant fixtures into extraction shown. Vertical bone levels of adjacent roots were well
sockets.6 Simultaneous guided bone regeneration (GBR) maintained.
procedures, using bone grafts and barrier membranes, are The clinical diagnosis of tooth 11 was a vertical root
usually necessary in such a situation to correct peri-implant fracture. Immediate implant placement and provisionali-
defects and/or to augment surrounding tissues. This zation were the recommended treatment because of the
approach can also achieve successful treatment outcomes patient’s desire for a minimal number of surgical inter-
with high predictability and a low risk of complications, ventions and the maintenance of an esthetic appearance
both from functional and esthetic points of view.5 during the treatment procedures. The clinical and radio-
Fixed and removable interim restorations placed in logical findings in this patient added up to the esthetic risk-
anterior implant sites during the healing phase provide profile analysis2 (Table 1), and the results showed that this
esthetic relief and protect tissues. The appearance of case was to be considered medium- to high-risk because of
metal or resin connectors in fixed partial dentures and the several unfavorable conditions. The patient was informed
inconvenience of removable dentures can bother patients about all relevant aspects of the proposed treatment, and
with high esthetic and psychological demands. The place- she agreed to it.
ment of a temporary restoration connected to the fixture The first step was the careful extraction of tooth 11
on the day of implant surgery may partially resolve this under local anesthesia using a 2% lidocaine solution with
problem. The shape of the peri-implant soft tissue is also a vasoconstrictor. The metal postecore was dislodged at
achieved more quickly using provisional crowns than with the beginning of this procedure, and then a full-thickness
healing caps.7 Several clinicians have designed immediate flap extended to the adjacent teeth using a sulcular incision
provisional crowns without functional contact to reduce the was raised to extract the residual root (Fig. 2A). Buccal
possibility of early implant failure.8,9 With careful case bony dehiscence and a vertical fracture line of the root
selection, this treatment protocol can serve as a predict- were clearly observed. Root fragments were carefully
able procedure with high survival rates. removed with a periotome and appropriate forceps
The purpose of this article is to present a case of (Fig. 2B). The extraction socket was thoroughly debrided
immediate implant placement combined with simultaneous with caution to prevent infection and a thin buccal plate
GBR to correct a severe buccal dehiscent defect followed (of <1 mm thick) with dehiscence, 3 mm wide, and 5 mm
by immediate provisionalization. The short-term results deep was identified (Fig. 2C).
met the patient’s esthetic, functional, and psychological Implant bed preparation was completed after standard
demands in a reduced treatment period. protocols using incremental sharp spiral drills and copious
chilled saline. An ideal three-dimensional implant position
was obtained mesiodistally, orofacially, and coronoapi-
Case report cally3 (Fig. 2D). In the buccopalatal position, the drilling
point was 3 mm above the root apex palatally, and it was
A 46-year-old female non-smoking patient complained of prepared with a round bur. The drill was extended 3e4 mm
mild discomfort and gingival problems at tooth 11 before apically to obtain primary stability. In the coronoapical
Immediate implant and provisionalization 55

Figure 1 Extraoral and intraoral views of an 46-year-old woman before treatment. (A) Low smile line of the patient. (B) The
clearly visible gingival swelling facially of tooth 11. (C) Large metal postecore cemented into the root canal of tooth 11 on per-
iapical radiography.

position, the implant platform was planned to be located then undertaken using bone grafts and a collagen mem-
approximately 2e3 mm apical to the midfacial mucosal brane. Bone substitute (Sinbone HT, Purzer Pharmaceu-
margin of the future implant crown. A 12-mm tapered tical, Taipei, Taiwan) was applied directly to the denuded
effect with a rough surface (sand-blasted, large grit, and implant surface, and the marginal gap between the buccal
acid-etched, SLA) ITI Taper-Effect implant (Institute plate and implant surface was filled (Fig. 3B). Placement of
Straumann, Waldenburg, Switzerland) was put in place bone substitutes was also gradually extended to the
(Fig. 3A). The fixture achieved excellent primary stability. periphery, and an “overbuilding” convexity at the site of
A combined bony defect at the buccal site including tooth 11 was achieved. A bioabsorbable collagen membrane
a dehiscence-type defect and a 1-mm horizontal gap (Periaid, Collagen Matrix, Franklin Lakes, NJ, USA) cove-
between the residual buccal plate and implant body was red the bone fillers (Fig. 3C), and soft-tissue closure in
found. The exposed surface was still within the alveolar a non-submerged approach was secured with 5-0 sutures
housing of the premaxilla. A localized GBR procedure was (Fig. 3D).

Table 1 The current patient’s individual esthetic risk profile.

Esthetic risk factors Low Medium High
Medical status Healthy patient and intact Reduced immune system
immune system
Smoking habit Non-smoker Light smoker Heavy smoker
(<10 cigarettes/day) (>10 cigarettes/day)
Patient’s esthetic expectations Low Medium High
Lip line Low Medium High
Gingival biotype Low scalloped, thick Medium scalloped, High scalloped, thin
medium thick
Shape of tooth crowns Rectangular Slightly triangular Triangular
Infection at implant site None Chronic Acute
Bone level of adjacent teeth 5 mm to contact point 5.5e6.5 mm to 7 mm to contact point
contact point
Restorative status of Virgin Restored
neighboring teeth
Width of edentulous span One tooth (‡7 mm) One tooth (<7 mm) Two or more teeth
Soft-tissue anatomy Intact soft tissue Soft-tissue defects
Bone anatomy at Alveolar crest without Horizontal bone deficiency Vertical bone deficiency
alveolar crest bone deficiency
56 C.-L. Chen et al

Figure 2 Surgical procedures of immediate implantation. (A) Full-thickness flap and a visible vertical fracture line of the root and
buccal dehiscent bony defect. (B) Complete tooth extraction. (C) Imperfect thin buccal plate with dehiscence and circumferential
defects. (D) Ideal three-dimensional implant position.

A 15
angled temporary abutment was simultaneously No complications were noted during the postsurgical
inserted and tightened to 15 N cm, and the screw-access healing period. After several appointments for temporary
channel was closed with a temporary restoration (Caviton, crown adjustments and the soft-tissue conditioning phase,
GC Corp., Tokyo, Japan) (Fig. 4A). A postoperative peri- the implant site had favorably healed by 6 months (Figs. 5A
apical radiograph confirmed the appropriate implant posi- and 5B). A periapical radiograph also confirmed that the
tion and gap-free seating of the temporary abutment implant was well-integrated (Fig. 5C). Subsequently, the
(Fig. 4B). A acrylic resin crown fabricated chair-side was temporary abutment was replaced with a screw-retained
cemented into the implant abutment and adjusted with no mesostructure made of zirconia (Fig. 6A) and a definitive full-
occlusal contacts (Fig. 4C). The patient received analgesics ceramic crown was cemented onto it (Fig. 6B).
and antibiotics for 3 days postsurgically. In addition, she The 18-month follow-up examination revealed stable,
was instructed to use a 0.1% chlorhexidine digluconate rinse healthy peri-implant soft tissue (Fig. 7A). The patient was also
twice daily and avoid tooth brushing at the surgical site. satisfied with the esthetic outcome (Fig. 7B). Radiographic

Figure 3 Implant installation. (A) An ITI TE implant was screwed in. (B, C) Correcting the defects and augmenting the ridge by
guided bone regeneration procedures. (D) Soft-tissue closure in a non-submerged manner.
Immediate implant and provisionalization 57

Figure 4 Immediate provisionalization. (A) Connection of a 15
angled abutment and closure of the screw channel. (B) Post-
operative radiograph. (C) Cementation of a chair-side fabricated temporary crown.

integration between the bone and implant was also confirmed Bränemark’s protocol required submucosal healing for 3e6
by periapical radiography (Fig. 7C). months, although Schroeder’s permitted transmucosal heal-
ing for 3e4 months.10 From failing natural tooth extraction to
complete reconstruction with an implant-supported pros-
Discussion thesis, the traditional time-consuming protocol was ack-
nowledged to be empirical in nature.11 Apart from successful
Osseointegration is recognized as a stable, predictable, and osseointegration, implant practitioners and researchers were
desirable biological interface in implant dentistry. Early trying to minimize treatment times in accord with patients’
publications on osseointegration suggested principles and interests. The procedures of immediate implant placement
techniques to predictably achieve this result including and provisionalization were recently tested in several case
minimal trauma, precise ostectomy preparation, sterile series using modern implants.12,13 Cornelini and colleagues13
technique, suitable biomaterials, and stress-free healing.3 used the same ITI Taper-Effect implants installed in the

Figure 5 Six months after implant surgery and the period of soft-tissue molding. (A) Facial view of healed surgical site. (B) The
local anatomy showing convexity in the alveolar crest. (C) Confirmation of a well-integrated implant in this radiograph.
58 C.-L. Chen et al

Figure 6 Definitive prosthodontic restoration. (A) Replacing the temporary abutment with a zirconia mesostructure.
(B) Cementation of a full-ceramic crown.

maxilla and mandible. Most of the 22 teeth were premolars, the impression material. The primary stability could have
although nine of them were incisors. No GBR procedures were been damaged during the removal of the impression tray,
performed when bone defects were <2 mm, and they and this might have seriously jeopardized the implant
obtained a satisfying result of a 100% survival rate in a 1-year success. For the same reason, clinical preparation of pre-
observation period. Other studies also showed high survival formed abutments using handpieces should also be avoided
rates ranging 93.5%e100% with follow-up periods of 6e52 because they can produce vibration damage, although
months, irrespective of the brand of dental implants, there is no published literature concerning the possible risk
although none of these was a randomized controlled study. and how it affects the primary stability. Careful presurgical
Therefore, it could be concluded that immediate implant analysis and precise three-dimensional implant positioning
placement and provisionalization are practical protocols with are therefore very important. Any inaccuracies will
high short-term survival rates in some situations. complicate the immediate restorative procedures and even
The definition of immediate restoration/provisionaliza- affect the final functional and esthetic outcomes. Fortu-
tion is a restoration inserted within 48 h of implant place- nately, the standardized 15
angulated abutment was
ment but not in occlusion with the opposing dentition.14 selected in this case and connected to the ideally posi-
The interval is reserved for laboratory procedures. In the tioned implant with no adjustment, which facilitated the
present case, we fabricated the provisional restoration fabrication of a cement-retained temporary restoration.
directly at the chair-side because of probable risks of In addition to saving time, the potential to maximally
impression taking. The impression material could have preserve hard and soft tissues is another rationale for
flowed into the submucosal area and have directly con- immediate implant and provisionalization. The original
tacted the flared-shaped implant neck. In other words, the midfacial gingival and interdental papilla can be mechan-
coronal portion of the fixture might have become stuck to ically supported by the provisional restoration and GBR

Figure 7 Eighteen-month follow-up. (A) Stable and healthy tissue around the implant. (B) Patient smiling with satisfaction.
(C) Successful osseointegration confirmed in a periapical radiograph.
Immediate implant and provisionalization 59

procedures. In a very recent review article,15 the result still The thin gingival biotype and triangular crown shape of
indicated a mean peri-implant bone loss ranging from 0.2 to the patient represented high-risk characteristics for
0.5 mm and an average midfacial gingival recession of esthetic implant therapy. In contrast to a thick biotype,
0.55e0.75 mm. Kan et al.16 reported a mean loss of papilla thin and friable gingiva has a greater possibility of reces-
height of 0.39e0.53 mm. The most obvious recognizable sion, loss of papilla height, and resorption of the underlying
soft-tissue change in this reported case was a reduction in alveolar volume.28 Findings of Botticelli et al. strongly
papilla height between the two central incisors. No clini- indicated that immediate implant placement might not
cally notable midfacial gingival recession was found. This prevent physiologic modeling/remodeling that can occur on
imperfect result may have been the cause of the restor- the ridge after tooth removal.29 The change in the vertical
ative status of the adjacent tooth and the surgical trauma bone level was more pronounced at the buccal than the
to the offending papilla. lingual aspect of the ridge because of the early disap-
Treatment outcomes of immediate implants can be pearance of the bundle bone which occupied a large frac-
affected by the presence of a previous infection17 and soft- tion of the marginal portion of the buccal bone wall.
tissue dehiscence over the extraction site,18 especially when Therefore, special procedures should be modified to make
non-resorbable barrier membranes are used for guided bone great efforts to preserve the existing hard and soft tissues
regeneration.19,20 In such cases, chronic infection caused by at the implant sites such as using minimally traumatic
root fracture carries a medium risk for complications with surgical and regenerative techniques. Bone preparation
esthetic significance.2 There is, however, still controversy should be relocated palatally to avoid jeopardizing the
about whether implants placed into sockets with a chronic integrity of the buccal wall of the socket and perforating
infection have an increased rate of early failure. Lindeboom the facial bone. A void maintained between the implant
and coworkers21 clearly demonstrated a higher failure rate in body and buccal wall was grafted with bone particles as
cases with existing periapical lesions, whereas another study described above. This method can maximally leave the thin
did not indicate a significant difference.22 There is still a lack buccal wall undamaged. Additional grafting of the external
of definitive evidence regarding the effect of the local surface of the buccal bone wall was shown to slightly
pathology on the survival of immediate implants. A more- increase or at least maintain the horizontal dimension of
rational approach seems to be to delay implant installation in the alveolar bone. This compensated for the resorption of
sites with acute inflammation. The other point of concern, the naturally thin bone wall, and we decided not to perform
soft-tissue dehiscence at the implant site with GBR, is asso- an adjunctive connective tissue graft.
ciated with reduced volumes of regenerated bone in peri- In conclusion, immediate implant installation and provi-
implant defects.19,20 However, this complication can mostly sionalization combined with simultaneous guided bone
be avoided by using collagen membranes23 as shown in this regeneration in postextraction sockets with bony defects are
case. appealing to clinicians. According to the literature, high
Exposure of implant threads because of insufficient implant survival rates and predictable good esthetic
alveolar ridge width might lead to high implant failure outcomes can be achieved with short-term follow-up.
rates.24 Depending on the size and morphology of the defect, Although postextraction bone remodeling will occur irre-
various augmentation procedures can be used. The critical spective of the placement of an implant,29,30 the time saved
requirement for implant success is to achieve initial implant is truly a great advantage for patients and implant practi-
stability before any augmentation procedures, because tioners. Because of a lack of long-term results, this protocol
osseointegration cannot be achieved in mobile implants.25 should be used with caution, and a number of guidelines and
Among the various graft materials, autografts are regarded prerequisites need to be seriously considered. More long-
as the gold-standard bone graft material for GBR because of term perspectives and controlled clinical studies are needed
their osteogenic, osteoinductive, and osteoconductive to guarantee the success of this approach, especially for
properties. Because of a limited amount of available autog- esthetic outcomes.
enous bone in the adjacent area and the avoidance of
a second surgical wound, we alternatively grafted depro-
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