IMMEDIATE IMPLANT PLACEMENT

Implant Dentistry

Charles J. Goodacre, DDS, MSD

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

The original Brnemark protocol advocated placing implants into existing edentulous
ridges or extracting severely diseased teeth and placing the implants 6-12 months later,
thereby permitting bone to form in the extraction sockets. However, starting in the
1980s, clinicians and researchers began to report the successful placement of titanium
root form implants into bone sockets immediately after teeth were extracted and now
both data and clinical experience are available.1-35

There are 2 articles16,17 that provide extensive literature reviews and perspective
regarding the issues pertinent to immediate placement of implants into extraction sockets
and these articles are recommended for supplemental reading.

ADVANTAGES OF IMMEDIATE PLACEMENT

When an implant is planned for an area currently occupied by a tooth that must be
removed, it may be advantageous to immediately place the implant when the tooth is
extracted. Immediate placement offers several potential advantages compared to
extracting a tooth, allowing the bone to heal and then subsequently placing the implant.

1. The bone that originally surrounded the tooth is more likely to be preserved.1,5,7,10,16-21
Thin bone (such as the facial bone of maxillary teeth) and interproximal bone can
rapidly disappear after tooth extraction. Placing an implant at the time the tooth is
extracted helps preserve the remaining bone and decreases the need for subsequent
ridge augmentation procedures. This bone preservation has been discussed1,18 in
conjunction with maxillary posterior tooth roots encased in a thin bony housing that
extends into the sinus (reference 1). Months after extraction, implant placement
might not be possible without sinus bone augmentation surgery due to rapid bone loss
and sinus pneumatization that occurs after extraction.
2. More ideal implant positioning is possible.5,7,17,20 For single rooted teeth, the implant
is positioned where the root of the tooth was located which is advantageous unless the
position of the tooth prior to extraction was undesirable. When implants are centered
beneath the crown, there is more favorable loading.18 Also, screw access holes are

1
 more likely to be centrally located18 within the peripheral crown dimensions which
facilitates the fabrication process.
3. The total treatment time is decreased.5,7,9.16,17,20,22,23
4. The number of surgical procedures is reduced.7,9,16,17,22
5. There is a shorter time period when the patient is subjected to the challenges of being
edentulous/wearing a provisional removable prosthesis.4,16
6. The overall cost is reduced.16
7. Soft tissue contours and height are better preserved in esthetic zones.17,18,21,23
8. There is better acceptance of the treatment plan by the patient.9
9. The opportunities for osseointegration are better due to the healing potential of fresh
extraction sockets.7

SCIENTIFIC BACKGROUND

Animal Studies
In 1985, Anneroth et al 35 published results of titanium implants placed into the
mandibular incisor sockets of 4 monkeys. Histologically, the authors demonstrated the
formation of immature bone that was replaced by more mature bone in close
approximation to the implants. In 1989, Woolfe2 presented the successful results of
immediate implantation in dogs (reference 2). In 1990, Barzilay3 published an abstract
that reported good results in monkeys (reference 3). Barzilay et al26,27 subsequently
reported their findings in detail through journal publications.

In 1992, Lundgren et al28 presented the results of placing implants immediately into the
extraction sockets of 4 beagle dogs. After histomorphometric analysis, they reported
31% bone-to-implant contact after 2 months, 65% after 12 months, and 68% after 36
months. They indicated the bone-to-implant interface was the same when the implant
was placed immediately and when the implantation occurred 2 weeks after root
extraction.

Human Clinical Results

There have been a number of clinical papers4-11,21-25,31 that provide data regarding the
success/failure of implants placed immediately into extraction sockets (references 4, 5, 6,
7, 8). There are also studies9,10 that compared immediate implant placement with delayed
placement after bone healing, demonstrating comparable or higher success rates with
immediately placed implants (references 9, 10).

When the data from the clinical studies4-11,21-25,31 are combined, 49 of 1290 implants were
lost (mean of 4%) which validates the high degree of success that can be obtained when
this protocol is properly applied. The implant loss ranged from 0% to 11% in the studies.

Clinical studies6,7,8,10 provide an indication that the success rate in the maxilla may be
lower than the mandible (references 6, 7). The studies5,7,8 also indicate there is
decreased success when the tooth was extracted because of periodontitis than when the
tooth was extracted for other reasons such as trauma/root fracture/caries (references 5,

2
7). It has been stated that implants should not be placed when purulent exudate is
present25 and immediate implants are contraindicated in the presence of acute/subacute
periodontal or periapical infection.22

Clinical Complications
Several complications have been identified in the clinical studies and they include
premature implant exposure through the soft tissue5-7,10,23,25 (fenestration/dehiscence),
fistulas,7 post-operative inflammation,24 post-operative infections,5,22 membrane exposure
before Stage 2 surgery,30 bony dehiscence/perforation of the bony housing during site
preparation,24,30 and parasthesia.7,9

Most of the complications were only reported in 1 or 2 studies and therefore the data is
only suggestive of possible trends. However, premature implant exposure was reported
in several studies. Four studies6,10,23,25 reported the exposure incidence as it related to the
number of implants. Of 331 implants placed, 52 implants became exposed prematurely
in the combined data from the 4 studies (mean incidence of 16%). Two other studies5,7
reported the incidence in relation to the number of patients who experienced premature
exposure. Twenty of 194 patients in the two studies experienced premature exposure
(mean of 10%).

One study7 reported the development of fistulas in 8 of 143 patients (6%). Post-operative
inflammation affected 12% of the surgeries performed in one paper.24 There were two
papers5,22 that presented data on post-operative infections, indicating that 6 of the 112
patients (5%) developed infections in the combined data from both papers. In one of the
papers,22 both of the infected implants were lost. The other paper5 indicated that 4 of the
5 patients with infections had periodontal disease and the implants were eventually lost in
spite of antibiotic treatment.

Becker et al30 reported that 20 of 49 membranes were removed within an average of 84

days after placement. Fourteen were removed because of premature exposure and 6
because of inflammation/infection. The authors indicated that patients should abstain
from wearing any prosthesis for at least 3 weeks. They also recommended that patients
be regularly evaluated for exposure following the placement of soft liners into prostheses.

Bony dehiscence/perforation of the bony housing occurred in 5% of the surgeries,

affecting the facial and lingual walls and the sinus area.24 Another paper30 reported that
26 of 54 implants placed had buccal dehiscences. Because of the decreased implant
success found in a group of patients where there was a bone fenestration or dehiscence
present,11 it may be prudent to discontinue implant placement and allow bone healing to
occur when a fenestration or dehiscence occurs during implant placement surgery
(reference 11).

Parasthesia was reported in 2 studies. In one study,7 two of 143 patients were affected at
implant uncovery but neither of these patients had symptoms after 1 year. The other
study9 reported one implant that had to be removed after 10 days due to pain and mental
nerve anesthesia. The symptoms resolved within one week of removing the implant.

3
CLINICAL PROTOCOL

Antibiotic Coverage
Several authors5,6,9,10,21,22,24,31 have recommended antibiotic coverage be used in
conjunction with immediate implant placement. The antibiotics have typically been taken
both pre-operatively and post-operatively. One regimen30 involved taking 2 grams of a
broad spectrum antibiotic one hour before surgery and continue with 1 gram/day for 5-7
days after surgery. One author administered IV penicillin pre-operatively9 and another
author6 included 8 milligrams of dexamethasone (decreases inflammation) along with the
1 gram of Amoxicillin (or appropriate alternative) pre-operatively. The antibiotic was
continued for 5-7 days and the dexamethasone for 2 days.6

Schwartz-Arad and Chaushu17 provide a table in their literature review article that
summarizes the types of antibiotics and dosages used in a number of studies.

Extraction/Osteotomy
The tooth that is to be removed is carefully extracted so as to preserve surrounding bone
(figures 1, 2). The usual osteotomy procedures are completed so the implant engages the
walls of the extraction socket. Due to differences in the morphology of roots and
implants, the implant may not achieve intimate contact with the incisal/occlusal aspect of
the bony socket (figure 3).

Horizontal Implant-to-Bone Gap

There have been multiple studies12-15 that evaluated the effect of an incisal/occlusal gap
between the implant and surrounding bone. The gap appears to be a factor that can affect
osseointegration. However, the distance where problems are regularly encountered has
yet to be identified (references 12, 13, 14, 15).

Use of Membranes
When there is an incisal/occlusal space between the implant and surrounding bone or
when the implant is not fully encased in bone, membranes have often been used7,20,21,24,29-
32
to generate new bone (figure 4). Bone regeneration was documented in a dog study29
when membranes were used in conjunction with implant placement. The amount of
regeneration was substantial compared to the controls where no membranes were used.
Membranes were also determined to be effective in humans30 with greater bone formation
occurring when the membranes were left in position until Stage 2 surgery.

It was determined that membranes were effective when used in conjunction with a one
stage protocol.31,32

Another study 33 evaluated the use of autogenous bone without a membrane in 30 patients
where 54 implants were placed. Clinically and statistically significant amounts of bone
formed around the implants.

4
 Apical Implant Extension
Multiple clinicians have indicated it is important to achieve primary stability of the
implant in bone6,18,20-22,25,30 by extending the implant apical to the apex of the tooth root
(figure 5). It has been proposed by one author20 that a minimum of 5 millimeters of bone
apical to the tooth apex is essential to ensure engagement of the the implant threads into 3
millimeters of bone. Another author indicates the implant should be extended at least 4
millimeters apical to the root apex.25 Other authors have proposed that the implant
engage at least 2 mm of apical bone,18 at least 3 millimeters,20 and a minimum of 4
millimeters.21 In the anterior mandible, it has been suggested that the implant engage the
inferior cortex whenever possible.22

Soft Tissue Coverage

Primary closure of the soft tissue over the implant has been regarded as one of the
important and desirable aspects of immediate implant placement (figure 6). However, it
can be difficult to achieve because of the space left in the tissue by the extracted tooth.

The success of immediate implantation in conjunction with a one-stage protocol indicates

that complete soft tissue coverage may not be a prerequisite for success.

Implants have been placed immediately into sockets without the use of an incision and a
report of 9 patients34 indicates that implants can be successful without sealing the socket
orifice.

Use of Chlorhexidine
The use of chlorhexidine rinses has been recommended until the sutures are removed.21
Its use has also been advocated for at least 3 weeks31 and when complications occur such
as minor premature implant exposure.6 In one study,31 a 1% chlorhexidine gel was
topically applied twice daily from the time of surgery until restoration.

Healing Period
When using a two-stage protocol, the implant is uncovered after an appropriate healing
period so a healing abutment can be attached. After 2 months of soft tissue healing, the
definitive abutment is placed (figures 7, 8) and a crown fabricated (figures 9, 10).

With a one-stage protocol, the implant is ready for placement of a definitive abutment
after an appropriate healing period.

Recently, there have been changes in the protocol initially used when implants were
immediately placed into extraction sockets. Researchers and clinicians are now placing
implants immediately into extraction sockets and attaching abutments and provisional
crowns/prostheses, thereby permitting immediate loading to occur in conjunction with the
bone healing. For more information, see the section on immediate loading of root form
implants.

5
REFERENCES

1. Wong K. Immediate implantation of endosseous dental implants in the posterior

maxilla and anatomic advantages for this region: A case report. Int J Oral Maxillofac
Implants 1996;11:529-533.

It has been proposed that immediate implant placement has advantages in the posterior
maxilla compared with extracting the tooth and subsequently placing implants.
Immediate placement preserves bone height and allows the implant to be placed into a
greater amount of bone. The bone that houses the root apices of molars (adjacent to
maxillary sinuses) is lost rapidly after extraction. The author discussed the advantage of
using the buccal root sockets of maxillary molars, allowing implants to be placed in close
apposition to the wall of the zygoma. The palatal root socket of the maxillary first
premolar was also used.

2. Woolfe SN, Kenney EB, Keye G, Taylor D, OBrien M. Effect of implantation of

titanium implants into fresh extraction sockets. J Dent Res 1989 (IADR Abstract
#762);68(special issue):962.

Implants were placed immediately into the extraction sockets of 5 dogs. After 4 months
of unloaded healing, the animals were sacrificed and examined histologically. There was
direct bone contact with both the self-tapping implants and the ones that were not
designed for self-tapping. Immediate implantation was a predictable procedure, retaining
over 90% of the osseous tissue present at the most coronal aspect of the implants.

3. Barzilay I, Graser GN, Iranpour B, Natiella J, Proskin H. Histologic and clinical

assessment of implants placed into extraction sockets. J Dent Res 1990;69(special
issue):1452.

Successful results were reported when 40 implants were placed into fresh extraction
sockets of 6 monkeys. They found comparable results between immediate and delayed
implantation and stated that osseointegration may not be needed along the entire implant-
to-bone interface for clinical success.

4. Parel SM, Triplett RG. Immediate fixture placement: A treatment planning

alternative. Int J Oral Maxillofac Implants 1990;5:337-345.

An early report of 13 patients who received 63 implants in the anterior mandible

indicated there were no apparent decreases in implant survival (no implant loss after 1-41
months) and there were significant potential patient benefits. The authors discussed the
potential need for bone reduction (alveolectomy) to assure adequate interarch space for
the prosthesis and the need for patients to be motivated relative to oral hygiene before
initiating treatment (since the patients imminent tooth loss is often related to their lack of

6
care). The authors also discussed the need to evaluate the existing tooth position as it
may have moved and might not be in the best esthetic position for the implant.

5. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets:

Implant survival. Int J Oral Maxillofac Implants 1996;11:205-209.

In this study, 51 patients received implants that had been followed for 1 to 67 months
(mean of 31 months). Of the 109 implants placed, 7 failed (6% overall failure rate).
Sixty-two teeth had been extracted for periodontal reasons and 5 of the 62 immediately
placed implants failed (8%). There were 47 teeth extracted for other reasons and 2 of the
47 failed (4%).

6. Schwartz-Arad D, Grossman Y, Chaushu G. The clinical effectiveness of implants

placed immediately into fresh extraction sites of molar teeth. J Periodontol
2000;71:839-844.

Fifty-six implants were placed immediately into molar extraction sites and evaluated after
a mean follow-up time of 15 months. The cumulative survival rate was 89%.
Immediately placed molar implants had a higher success rate in the mandible than the
maxilla. In the maxilla, 3 of 17 implants were lost (18%) whereas 3 of 39 implants were
lost in the mandible (8%)

7. Grunder U, Polizzi G, Goen R, Hatano N, Henry P, Jackson WJ, Kawamura K,

Khler S, Renouard F, Rosenberg R, Triplett G, Werbitt M, Lithner B. A 3-year
prospective multicenter follow-up report on the immediate and delayed-immediate
placement of implants. Int J Oral Maxillofac Implants 1999;14:210-216.

This paper presented the results of a 3-year prospective study from 12 different centers.
There were 217 implants placed immediately after extraction and 14 of the 217 implants
failed (6%). Forty-seven implants were placed 3-5 weeks after extraction and 3 failed
(6%).

A higher failure rate was found when periodontitis was the reason for extraction (10 of 98
implants failed). There was a 10% failure rate. Only 3 patients who lost an implant had
no history of periodontitis. When teeth were extracted because of caries, 1 of 20 implants
failed (5%). There were no implant failures when the teeth were extracted due to trauma,
root fracture or when periapical inflammatory changes were noted.

There was a slightly higher failure rate (7%) in the maxilla (12 of 165 implants lost) than
the mandible (5%) where 5 of 99 implants were lost. There was a higher failure rate in
the posterior maxilla (11%) than the anterior maxilla (6%), anterior mandible (5%) and
the posterior mandible (5%).
No statistical relationships were established in the study (p>0.05).

7
8. Polizzi G, Grunder U, Goen R, Hatano N, Henry P, Jackson WJ, Kawamura K,
Renouard F, Rosenberg R, Triplett G, Werbitt M, Lithner B. Immediate and delayed
implant placement into extraction sockets: a 5-year report. Clin Implant Dent Relat
Res 2000;2(2):93-99.

This paper reports the 5 year results of the multicenter study discussed in reference 7.
The authors compared immediate and delayed implant placement in 143 consecutively
treated patients (a total of 264 implants). There were no differences between the groups
and the overall survival rate was 92% in the maxilla and 95% in the mandible. The
survival rates did not change between 3 and 5 years. The authors noted a clinical
correlation between failure of implants and the presence of periodontitis as a cause for the
tooth being extracted.

9. Krump JL, Barnett BG. The immediate implant: A treatment alternative. Int J Oral
Maxillofac Implants 1991;6:19-23.

A group of eleven patients who received 41 implants along with mandibular anterior
alveolectomies was compared with a group of 35 patients who received 154 implants
placed into healed bone. No significant differences in implant success were noted.

10. Schwartz-Arad D, Gulayev N, Chaushu G. Immediate versus non-immediate

implantation for full-arch fixed reconstruction following extraction of all residual
teeth: A retrospective comparative study. J Periodontol 2000;71:923-928.

Implants placed immediately into extraction sockets (117 implants placed) had a higher
cumulative 5-year survival rate than those placed into healed bone (263 implants placed).
The increased overall success of the immediately placed implants was attributed to their
higher success rate in the maxilla (95%) versus the standard protocol in the maxilla
(88%). The higher maxillary success rate was due to the enhanced success of immediate
implants placed into the posterior maxilla. No failures occurred in the posterior maxilla
when implants were immediately placed whereas 28% of the delayed placement implants
failed.

11. Becker W, Dahlin C, Lekholm U, Bergstrom C, van Steenberghe D, Higuchi K,

Becker BE. Five-year evaluation of implants placed at extraction and with
dehiscences and fenestration defects augmented with ePTFE membranes: results
from a prospective multi-center study. Clin Implant Dent Relat Res 1999;1(1):27-32.

This multi-center (4 locations) study placed implants immediately into extraction sockets.
In one group of 44 patients, there was a bone fenestration or dehiscence present.
Implants with exposed threads were covered with a barrier membrane to produce guided

8
bone regeneration. In another group of 40 patients, no fenestration or dehiscence was
present around the implants and the 5-year survival rate was 94% for both the maxillary
and mandibular implants. In the fenestration/dehiscence group, the survival rate was
77% for the maxillary implants and 84% for the mandibular implants.

12. Carlsson L, Rstlund T, Albrektsson B, Albrektsson T. Implant fixation improved by

close fit. Acta Orthop Scand 1988;59(3):272-275.

Implant osteotomies (3.7 millimeters in diameter) were formed in the tibias of rabbits.
Implants with 3 different diameters (3.7, 3.0, and 2.0 millimeters) were positioned into
the osteotomies through an external metal plate that assured positional stability of the
implants. The 3.0 and 2.0 millimeter implants had gaps between their perimeter and
surrounding bone.

After bone healing, all of the implants were clinically stable. Histologically, all the 3.7
millimeter diameter implants (no gap present at the time of surgery) had direct bone
contact with the cortical plate. After 12 weeks, 2 of the 3.0 millimeter implants exhibited
bone contact on one side but not the other and the other 2 implants still had a gap all
around that ranged from 0.2 to 0.5 millimeters. None of the 2.0 millimeter implants had
direct bone-to-metal contact.

The authors concluded that the critical gap width for direct lamellar bone apposition to
implants was likely close to the tested 0.35 millimeter gap.

13. Knox R, Caudill R, Meffert R. Histologic evaluation of dental endosseous implants

placed in surgically created extraction defects. Int J Periodont Rest Dent
1991;11:365-376.

The authors evaluated 3 horizontal gaps between the implant and bone in the coronal 4
millimeters of implants placed in 6 dogs. The circumferential gap distances were 0.5,
1.0, and 2.0 millimeters. A control implant was placed with no gap. Both uncoated and
HA-coated implants were tested. When more than a 0.5 millimeter gap was present (that
is either a gap of 1.0 or 2.0 millimeters), a larger implant-to-bone space was noted
histologically and the level where osseointegration was present on the implants was
located farther apically.

14. Akimoto K, Becker W, Persson R, Baker DA, Rohrer MD, ONeal RB. Evaluation of
titanium implants placed into simulated extraction sockets: A study in dogs. Int J
Oral Maxillofac Implants 1999;14:351-360.

Gap distances of 0.5, 1.0 and 1.4 millimeters were created in 10 dogs along with controls
where no gap was present. Clinically, the test sites (where gaps were present) could not

9
be distinguished from the control sites. However, histologically, differences were noted.
Eight of the 20 implants with a 1.4 millimeter gap were not histologically integrated.

15. Wilson Jr TG , Schenk R, Buser D, Cochran D. Implants placed in immediate

extraction sites: A report of histologic and histometric analyses of human biopsies.
Int J Oral Maxillofac Implants 1998;13:333-341.

Five implants were obtained from a human. One had been placed into a mature bone site
and four had been placed immediately into extraction sites. Coronal horizontal gaps of
varying dimensions were present around the 4 immediately placed implants (up to 1.5
millimeters around 2 implants and more than 4 millimeters around the other implants).
All implants became osseointegrated. The authors found the lowest mean bone-to-
implant contact (17%) occurred when the horizontal defect was more than 4 millimeters.
They also stated that membranes were not necessary when horizontal defects were 1.5
millimeters or less.

REFERENCE LIST

1. Wong K. Immediate implantation of endosseous dental implants in the posterior

maxilla and anatomic advantages for this region: A case report. Int J Oral Maxillofac
Implants 1996;11:529-533.
2. Woolfe SN, Kenney EB, Keye G, Taylor D, OBrien M. Effect of implantation of
titanium implants into fresh extraction sockets. J Dent Res 1989 (IADR Abstract
#762);68(special issue):962.
3. Barzilay I, Graser GN, Iranpour B, Natiella J, Proskin H. Histologic and clinical
assessment of implants placed into extraction sockets. J Dent Res 1990;69(special
issue):1452.
4. Parel SM, Triplett RG. Immediate fixture placement: A treatment planning
alternative. Int J Oral Maxillofac Implants 1990;5:337-345.
5. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sockets:
Implant survival. Int J Oral Maxillofac Implants 1996;11:205-209.
6. Schwartz-Arad D, Grossman Y, Chaushu G. The clinical effectiveness of implants
placed immediately into fresh extraction sites of molar teeth. J Periodontol
2000;71:839-844.
7. Grunder U, Polizzi G, Goen R, Hatano N, Henry P, Jackson WJ, Kawamura K,
Khler S, Renouard F, Rosenberg R, Triplett G, Werbitt M, Lithner B. A 3-year
prospective multicenter follow-up report on the immediate and delayed-immediate
placement of implants. Int J Oral Maxillofac Implants 1999;14:210-216.
8. Polizzi G, Grunder U, Goen R, Hatano N, Henry P, Jackson WJ, Kawamura K,
Renouard F, Rosenberg R, Triplett G, Werbitt M, Lithner B. Immediate and delayed
implant placement into extraction sockets: a 5-year report. Clin Implant Dent Relat
Res 2000;2(2):93-99.
9. Krump JL, Barnett BG. The immediate implant: A treatment alternative. Int J Oral
Maxillofac Implants 1991;6:19-23.

10
10. Schwartz-Arad D, Gulayev N, Chaushu G. Immediate versus non-immediate
implantation for full-arch fixed reconstruction following extraction of all residual
teeth: A retrospective comparative study. J Periodontol 2000;71:923-928.
11. Becker W, Dahlin C, Lekholm U, Bergstrom C, van Steenberghe D, Higuchi K,
Becker BE. Five-year evaluation of implants placed at extraction and with
dehiscences and fenestration defects augmented with ePTFE membranes: results
from a prospective multi-center study. Clin Implant Dent Relat Res 1999;1(1):27-32.
12. Carlsson L, Rstlund T, Albrektsson B, Albrektsson T. Implant fixation improved by
close fit. Acta Orthop Scand 1988;59(3):272-275.
13. Knox R, Caudill R, Meffert R. Histologic evaluation of dental endosseous implants
placed in surgically created extraction defects. Int J Periodont Rest Dent
1991;11:365-376.
14. Akimoto K, Becker W, Persson R, Baker DA, Rohrer MD, ONeal RB. Evaluation of
titanium implants placed into simulated extraction sockets: A study in dogs. Int J
Oral Maxillofac Implants 1999;14:351-360.
15. Wilson Jr TG , Schenk R, Buser D, Cochran D. Implants placed in immediate
extraction sites: A report of histologic and histometric analyses of human biopsies.
Int J Oral Maxillofac Implants 1998;13:333-341.
16. Barzilay I. Immediate implants: Their current status. Int J Prosthodont 1993;6:169-
175.
17. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of
implants into fresh extraction sites: A literature review. J Periodontol 1997;68:915-
923.
18. Lazzara RJ. Immediate implant placement into extraction sites: Surgical and
restorative advantages. Int J Periodont Rest Dent 1989;9:333-343.
19. Quayle AA, Cawood J, Howell RA, Eldridge DJ, Smith GA. The immediate or
delayed replacement of teeth by permucosal intro-osseous implants: the Tbingen
implant system. Br Dent J 1989;166:365-370.
20. Werbitt MJ, Goldberg PV. The immediate implant: Bone preservation and bone
regeneration. Int J Periodont Rest Dent 1991;12:207-217.
21. Gelb DA. Immediate implant surgery: Three-year retrospective evaluation of 50
consecutive cases. Int J Oral Maxillofac Implants 1993;8:388-399.
22. Tolman DE, Keller EE. Endosseous implant placement immediately following dental
extraction and alveoloplasty: Preliminary report with 6-year follow-up. Int J Oral
Maxillofac Implants 1991;6:24-28.
23. Schwartz-Arad D, Chaushu G. Placement of implants into fresh extraction sites: 4 to
7 years retrospective evaluation of 95 immediate implants. J Periodontol
1997;68:1110-1116.
24. Gomez-Roman G, Kruppenbacher M, Weber H, Schulte W. Immediate
postextraction implant placement with root-analog stepped implants: Surgical
procedure and statistical outcome after 6 years. Int J Oral Maxillofac Implants
2001;16:503-513.
25. Block MS, Kent JN. Placement of endosseous implants into tooth extraction sites. J
Oral Maxillofac Surg 1991;49:1269-1276.

11
26. Barzilay I, Graser GN, Iranpour B, Proskin HM. Immediate implantation of pure
titanium implants into extraction sockets of macaca fascicularis. Part I: Clinical and
radiographic assessment. Int J Oral Maxillofac Implants 1996;11:299-310.
27. Barzilay I, Graser GN, Iranpour B, Natiella JR, Proskin HM. Immediate implantation
of pure titanium implants into extraction sockets of macaca fascicularis. Part II:
Histologic observations. Int J Oral Maxillofac Implants 1996;11:489-497.
28. Lundgren D, Rylander H, Andersson M, Johansson C, Albrektsson T. Healing-in of
root analogue titanium implants placed in extraction sockets. Clin Oral Impl Res
1992;3:136-144.
29. Becker W, Becker BE, Handelsman M, Ochsenbein C, Albrektsson T. Guided tissue
regeneration for implants placed into extraction sockets: A study in dogs. J
Periodontol 1991;62:703-709.
30. Becker W, Dahlin C, Becker BE, Lekholm U, van Steenberghe D, Higuchi K, Kultje
C. The use of e-PTFE barrier membranes for bone promotion around titanium
implants placed into extraction sockets: A prospective multicenter study. Int J Oral
Maxillofac Implants 1994;9:31-40.
31. Lang NP, Brgger U, Hmmerle CHF, Sutter F. Immediate transmucosal implatns
using the principle of guided tissue regeneration. Clin Oral Impl Res 1994;5:154-
163.
32. Brgger U, Hmmerle CHF, Lang NP. Immediate transmucosal implants using the
principle of guided tissue regeneration. Clin Oral Impl Res 1996;7:268-276.
33. Becker W, Becker BE, Polizzi G, Bergstrom C. Autogenous bone grafting of bone
defects adjacent to implants placed into immediate extraction sockets in patients: A
prospective study. Int J Oral Maxillofac Implants 1994;9:389-396.
34. Schwartz-Arad D, Chaushu G. Immediate implant placement: A procedure without
incisions. J Periodontol 1998;69:743-750.
35. Anneroth G, Hedstrm KG, Kjellman O, Kndell P-, Nordenram . Endosseus
titanium implants in extraction sockets. Int J Oral Surg 1985;14:50-54

12