Continuing Education

Course Number: 159

Managing the Buccal Gap

and Plate of Bone:
Immediate Dental Implant Placement
Authored by Gary Greenstein, DDS, MS, and
John S. Cavallaro Jr, DDS

Upon successful completion of this CE activity 2 CE credit hours may be awarded

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Managing the Buccal Gap
and Plate of Bone:
Immediate Dental Implant Placement
Effective Date: 03/1/2013 Expiration Date: 3/1/2016
LEARNING OBJECTIVES
After participating in this CE activity, the individual will learn:
Available information in the literature regarding clinical
management of the buccal gap.
Practical guidelines for managing the buccal gap.
ABOUT THE AUTHORS
Dr. Greenstein is a clinical professor of
the department of periodontology at the
College of Dental Medicine, Columbia
University, NY. He maintains a private
practice in surgical implantology and
periodontics in Freehold, NJ. He can be
reached at ggperio@aol.com.
Disclosure: Dr. Greenstein reports no disclosures.
Dr. Cavallaro is the director of the implant
Fellowship program and associate clinical
professor of prosthodontics at the College
of Dental Medicine, Columbia University,
NY. He maintains a private practice in
surgical implantology and prosthodontics
in Brooklyn, NY. He can be reached at docsamurai@si.rr.com.
Disclosure: Dr. Cavallaro reports no disclosures
INTRODUCTION
When a dental implant is placed into a fresh extraction
socket, the space between the implant periphery and
surrounding bone is called the gap or jumping distance.1
The gap consists of 2 dimensions: horizontal defect width
and vertical defect height (Figure 1). The term jumping
distance refers to the ability of bone to bridge the
horizontal gap and fill the void. A gap can occur on any
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Continuing Education
Figure 1. Implant placed into extraction socket at site No. 12. Buccal gap
width is 3.5 mm and vertical depth is 7 mm. Smaller and shallower gap
on the palatal side of the implant.
Figure 2. Implant inserted into extraction socket (site No. 6) with a thin
labial bony plate. Placement was too labial. As the area healed, bone was
lost in a vertical direction and resulted in soft-tissue recession.
aspect of an immediately placed implant: buccal, lingual,
or proximally.
The main objective of immediate implant placement is
to provide an osseointegrated fixture suitable for an
aesthetic and functional restoration. Bone fill in the gap
between the implant and the peripheral bone is important.
The buccal aspect of an implant is of great concern,
especially in the aesthetic zone, because the buccal bony
plate is usually thin2,3 and its resorption can result in soft-
tissue recession (Figure 2).4 Surgical management of the
buccal gap to obtain an optimal result is controversial and
confusing with respect to the best techniques to achieve
the following: optimal bone fill in the gap, most coronal
level of bone-to-implant contact (BIC), and the least
amount of buccal bone loss and soft-tissue recession.
This article is a literature review which was undertaken
to evaluate available information regarding clinical
management of the buccal gap. Background information is
presented, and data pertaining to gap management and
limitations of our knowledge are discussed to develop
practical guidelines for handling the buccal gap.

Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
BACKGROUND INFORMATION
Extrapolating Data from Animal Models to HumansTo attain
histological evidence concerning the best methods to manage
the buccal gap and adjacent bone, experimental studies were
conducted in animal models. In this regard, Pearce et al5
concluded that dogs have the most similar bone structure to
humans with respect to microstructure, macrostructure, bone
composition, and bone remodeling. Nevertheless, there are
differences in the size and shape of bones in canines and
humans. Furthermore, a dogs bone has a higher mineral
density and remodels faster than humans. It was concluded
that dog models may be used in experimental investigations to
assess aspects of wound healing; however, it is only an ap-
proximation of what occurs in humans.
Immediate Implant Survival RatesThe survival rates of
immediately placed implants into fresh extraction sockets and
healed ridges are similar (97.3% to 99%).6,7 This finding is
also true with respect to immediate placement of implants into
infected sites8,9 or locations with periapical lesions.10
Typical Healing of an Extraction SocketSockets normally
fill in with bone, but they are associated with a mean 1.24 mm
vertical bone loss (range: 0.9 to 3.6 mm) and an average 3.79
mm horizontal bone reduction (range 2.46 to 4.56 mm) after 6
months.11 However, these means for bone loss represent data
when teeth were extracted and flaps were usually elevated.
Resolution of a socket is caused by a combination of bone fill
and resorption of the bony crest adjacent to the socket.
Socket Healing After Immediate Implant Placement
Numerous investigations confirmed that immediate implant
placement is associated with bone loss. This has been
documented in experimental studies in dogs12-15 and human
clinical trials.16-19 The amount of bone loss varies and is
dependent on many factors (to be discussed). In general there
is a decrease of vertical bone height and an even greater
horizontal bone loss. The amount of alveolar bone resorption
is larger on the buccal than the lingual aspect of an implant,
because the buccal plate is typically thinner.20,21
DATA PERTAINING TO GAP FILL AND BUCCAL PLATE
BONE LOSS: ANIMAL STUDIES AND HUMAN
CLINICAL TRIALS
Experimental Animal Studies (Usually Dogs)
Studies conducted in animals confirmed that immediately
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placed implants in fresh extraction sites integrated with the
bone.22-26 Akimoto et al27 created defects 0.5 to 1.4 mm
around machined implants and noted that all defects healed,
regardless of size. However, the distance between the bone
margin and where the BIC started was directly related to gap
size. The larger the gap, the farther the first BIC was from the
bone margin. Botticelli et al1 assessed the healing response
around implants when created defects (sizes one to 1.25 mm)
were treated with and without barriers and the implants were
submerged. The defects healed with bone and the BIC against
sandblasted, large-grit, acid-etched surfaced implants was
similar to the control sites where an implant was placed into a
healed ridge. They concluded that a defect > one mm may heal
with a high degree of osseointegration. It was noted that
previous assessments employed machined surfaced implants,
whereas the latter study used rough surfaced implants.
In another dog study, Botticelli et al28 demonstrated that
created defects ranging from 1.25 to 2.25 mm around an
immediately placed implant spontaneously filled with new
bone. They29 noted artificially created defects healed
differently than natural gaps that occur after implant
placement. It was concluded that created defects healed
completely, whereas natural gaps partly repaired. Therefore,
extrapolation of data with respect to healing at sites where
defects were created versus natural gaps must be
interpreted cautiously, because they may not represent the
same healing response temporally or physically.
Arajo et al12,20 published a series of papers consistently
demonstrating that in dogs, after immediate implants were
inserted and the flaps were replaced, the gap (size was < 2
mm) between the implant and the bone filled in; however, the
horizontal width and level of the vertical height of the buccal
plate of bone were reduced. Of particular interest was a paper
that assessed the impact of deproteinated bovine bone
material (DBBM) collagen on the gap (one to 2 mm wide and
3 mm deep) around immediately placed implants.30 They
noted bony plates of grafted sites were thicker and bone levels
were more coronal than sites that were not grafted.
Recently, Caneva et al15,31-33 conducted a series of
experimental studies in dogs to investigate techniques with
respect to limiting the amount of buccal plate resorption that
occurs when implants are installed immediately after an
extraction. Their investigations provided the following results:
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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
DBBM particles in conjunction with Table. Possible Therapies Available to Treat the Buccal Gap After Immediate Implant
collagen barriers helped preserve the Placement: With and Without Flap Elevation
alveolar process, but mostly in a A. WITH FLAP ELEVATION ADVANTAGE DISADVANTAGE

horizontal dimension, not vertically;31 1. No additional treatment (no bone graft or barrier used)

a resorbable material without a
membrane was not capable of
completely maintaining the buccal
crest of bone;32 implants should be
placed lingually to the center of the
socket and one mm deeper than the
alveolar crest to limit exposure of
buccal threads;15 wider implants,
which were close to the buccal plate,
caused greater bone loss buccally
than narrower implants.33
Favero et al34, in a dog model, re-
(a) Flap placed over the defect
(b) Flap positioned at bone crest,
leaving the gap exposed
2. Bone graft placed into the defect with or without growth factors
(a) Flap placed over the defect
(b) Flap positioned at bone crest,
leaving the gap exposed
3. Barrier placed over defect
(a) Flap advancement is usually
necessary to attain primary closure
Covers defect This may require flap advancement
increased morbidity (edema and
ecchymosis)
Soft tissue may invade gap
Easier Plaque and food may get trapped
in void if coagulum is not retained
Covers defect This may require flap advancement
increased morbidity (edema and
ecchymosis)
Soft tissue may invade bone graft
Easier Plaque and food may get trapped
in void if coagulum is not retained
Covers barrier Increased morbidity (edema and
ecchymosis)

ported the following results: lingual (b) No flap advancement and use of Easier Nonresorbable barrier
nonresorbable or resorbable barrier exposure/infection
placement of the implant reduced or connective tissue graft Resorbable barrierfragments in
mouth
buccal bone resorption and recession,
4. Barrier placed over bone graft
and use of collagen barriers with
(a) Flap advancement is usually Covers barrier Increased morbidity (edema and
DBBM did not improve results when necessary to attain primary closure ecchymosis)
Nonresorbable barrier
compared to no additional treatment. It exposure/infection
was suggested the thickness of the (b) No flap advancement and use of Easier Nonresorbableexposure/infection
nonresorbable or resorbable barrier Resorbable barrierfragments in
buccal plate, which was approximately or connective tissue graft mouth
one mm, contributed to the finding that 5. Temporization of implant and abutment
bone grafts and barriers provide no Supports soft tissue Additional work at time of surgery
additional benefit with respect to B. NO FLAP ELEVATION ADVANTAGE DISADVANTAGE
inhibiting bone resorption. (FLAPLESS IMPLANT INSERTION)
1. The gap is left open with no additional therapy
Easier Plaque and food may get trapped
Human Investigations in void if coagulum is not retained
In 1998, Wilson et al35 supplied the 2. Bone is placed within the gap
first human histological documenta- Bone particles may be displaced
tion that osseointegration occurred 3. Temporization of implant and abutment with either of the above
between the newly formed bone in Supports soft tissue Additional work at time of surgery
the gap and an immediately placed
implant. Subsequently, Wilson et al36 assessed rough No bone grafts or barriers were used before implants were
surface implants (N = 10) where the gap was covered with submerged under the soft tissue. Biopsies revealed bone fill
a connective tissue graft and the area was covered with a in the gap, and there was no difference between test and
flap. Osseointegration, BIC, and bone fill were similar when control sites.
gaps were < 1.5 mm and > 4 mm. Subsequently, Botticelli et al16 assessed 21 sites in 18
Paolantonio et al37 evaluated the healing response humans with respect to gap healing around rough surfaced
when implants were placed in healed bone and when they dental implants that were not submerged. The flaps were
were placed in extraction sockets and the gap was 2 mm. placed next to the abutment portion of the implant exposed

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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
to the mouth. No bone or barriers were employed. Eight of
9, defects initially 3 mm in width, were completely filled
with bone. The vertical bone crest resorption amounted to
0.3 (buccal), 0.6 (lingual/palatal), 0.2 (mesial), and 0.5
(distal), and 56% of the horizontal width. No biopsies were
done. There are 2 criticisms of the clinical study by Botticelli
et al.16 It is possible that the BIC was more apical than
other sites where implants were placed into healed ridges,
and the clinical examination did not confirm that
osseointegration occurred. However, as previously in-
dicated in a histological assessment in dogs, Botticelli
et al38 found that defects lateral to rough surface implants
regenerate with proper osseointegration, whereas smooth
surfaced implants repaired with connective tissue between
the bone and implants. It has been suggested that the
rough surfaces provided a better surface for clot stability
and maturation.39
In a prospective study, Chen et al4,40 also reported that the
small defects with respect to height and width around
nontextured implants could be eliminated without the use of a
membrane and/or a bone graft. Similarly, Covani et al41
confirmed that defects could be resolved in humans without
barriers or bone graft materials if the defect was < 2 mm wide.
Recently, Tarnow and Chu42 provided histological
evidence of defect fill and osseointegration in a gap
adjacent to an immediate implant that was 4 mm wide. In
this single case report, no flap was elevated, and the defect
was allowed to heal by secondary intention without
placement of a bone graft or a barrier. It was suggested that
if the gap is allowed to heal by secondary intention (no
coverage of the gap with a flap) then the gap size may not
interfere with bone fill and osseointegration.
TREATMENT OPTIONS WITH AND WITHOUT FLAP
ELEVATION
Flap Elevation
In conjunction with immediate implant placement, there is a
diversity of available techniques to manage the buccal gap
when a flap is elevated to place an implant.
Remarks in the Table pertain to situations where the
bony plate is intact and does not require a regenerative
procedure to treat a dehiscence or bone fenestration.
With respect to submerged versus nonsubmerged implant
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Continuing Education
protocols after immediate implant placement, the data indicate
that both techniques can be used successfully, depending
on the situation and preference of the clinician.43,44 A
submerged protocol usually requires flap advancement to
attain primary closure over an immediate implant. If a
nonsubmerged procedure is utilized, the flap is typically
replaced adjacent to the healing abutment or temporary
crown, or the gap can be left uncovered. If a permanent
abutment is used, it will not have to be removed (avoids
disrupting the junctional epithelium), and thereby may help
reduce recession.45,46
Flapless
If a flap is not elevated to place a dental implant, several
therapeutic choices are available to deal with the gap (Table).
However, despite a flapless approach, remodeling of the
osseous crest occurs. Teeth derive their blood supply from
3 sources: periodontal ligament, periosteum, and the endo-
steal marrow spaces.47 Tooth extraction eliminates the blood
supply to the bone from the periodontal ligament and results
in horizontal and vertical bone loss.20,48
In general, elevation of a flap without tooth extraction re-
sults in a mean bone loss of 0.5 mm.49,50 The amount of
osseous resorption is usually greater over the buccal aspect
of roots than interproximally, where the bone is thicker.
Disturbance of the periosteum inhibits the blood supply to
the bone and it takes several days before normal bone
vascularization is resumed. Pertinently, several authors
suggested that avoidance of flap elevation reduced bone
loss and recession after tooth removal and immediate
implant placement in humans51 and animal experimental
studies.52-54 In contrast, other human55-57 and experimental
studies58-60 determined that even with a flapless approach,
the amount of bone loss was similar with and without flap
elevation (Figures 3a to 3d). Recently, Grunder61 reported
that with a flap approach, the amount of buccal soft-tissue
recession was 1.06 mm. Despite these conflicting data, it is
the authors opinion that if the tissues are left undisturbed
(no flap elevation), there is a better chance to have less soft-
tissue recession. This concept is also supported by the
finding that even if there is bone loss, it does not necessarily
result in alterations of the gingival contour as seen in
periodontal patients.
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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
OTHER FACTORS THAT CAN AFFECT
HEALING OF THE GAP AND ADJACENT a b
SOFT TISSUE
Size of Horizontal Bone GapThe gap size
is an important determinant with respect
to predictability of spontaneous bone fill.
The critical gap size that allows unaided
healing has not been determined, because
there are variables that can affect the Figure 3a. Occlusal view of immediate Figure 3b. Periapical radiograph of
result. However, in humans, gaps < 2 mm implants placed at site Nos. 3 and 5 using a inserted implants in Figure 3a.
nonsubmerged protocol with no flap reflection.
usually heal without allografts, xenografts,
and barriers when implants are sub- c d
merged37,40,41,62,63 or nonsubmerged
(Figures 4a to 4f).4,38
In dogs, investigators noted that bigger
gaps have a greater potential for in-
complete fill; therefore, they suggested bio-
material filler would be beneficial in large
gaps.18,27,64,65 However, when evaluating
the data in humans, different techniques
Figure 3c. Definitive fixed prosthesis in place; Figure 3d. Periapical radiograph of
resulted in bone fill without bone grafts in implants are stable, soft tissue is healed, and final fixed prosthesis, demonstrating
defects 3 mm.16,35,36,42 Tarnow and there is a good aesthetic result. However, visual excellent bone levels in relation to
observation comparing Figure 3c to Figure 3a healed implants.
Chu42 reported bone fill in a gap that was reveals that the buccal width appears to be
4 mm wide. The gap was not grafted and reduced, reflecting bone loss during extraction
socket healing even without flap reflection.
the defect was allowed to heal by second-
ary intention (no flap elevation or coverage of gap). In acceptable defect resolution, and it was noted that
contrast, Botticelli et al16 did not graft, but replaced the augmentation procedures reduced horizontal bone resorption,
flaps against healing abutments and 8 of 9 defects that but not crestal bone loss.
were initially 3 mm filled with bone. Others noted bone fill Recent studies in dogs focused on the use of DBBM.
in 4 mm gaps that were covered with a connective tissue Arajo et al30 demonstrated that use of DBBM versus no
graft and the flap.35,36 Thus, there appears to be a biofiller resulted in the BIC being more coronal and the
discrepancy with respect to how large a gap will heal buccal plate thicker. After employing DBBM, Caneva et al31
spontaneously and under what conditions. also reported a more coronal level of BIC, and Chen et al4
66
BiomaterialsChen and Buser reviewed the literature noted a 25% reduction of horizontal bone loss. It appears that
regarding the effectiveness of placing biofillers in the gap. They different materials can be used, but the one currently
concluded that most investigations employed combinations of receiving the most attention is DBBM. A possible explanation
a bone graft material and/or barrier membrane (expanded for this is that in Europe, human allograft material is not
polytetrafluorethhylene-PTFE or collagen barrier) to enhance allowed to be used in humans. Currently, there is no
regeneration. The most commonly used biofiller was DBBM, preponderance of data indicating that one type of graft
which was employed alone and in conjunction with resorbable material is superior to others.
and nonresorbable barriers. Other graft materials used Thickness of the Buccal Plate of BoneBuccal plate
included autogenous bone, demineralized freeze-dried bone, thickness affects the degree of buccal plate resorption after
and hydroxyapatite. All the techniques provided clinically immediate implant placement. In a dog model, it was

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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement

a b c

Figure 4a. Occlusal view of immediate implant Figure 4b. Periapical Figure 4c. Occlusal view of definitive restoration
placed at site No. 13 with a flapless approach. The radiograph of the implant demonstrating minimal loss of facial soft tissue.
labial gap is 2 mm wide and the palatal gap is one depicted in Figure 4a. No
mm. The implant was placed slightly palatally and biomaterial was placed into
one mm apical to the intact buccal osseous crest. the gap during surgery.

d e f

Figure 4d. Facial view demonstrates no Figure 4f. Patients smile-line on crown insertion day.
apparent loss of vertical height of midlabial soft Note slight blanching of soft tissue.
tissue.

Figure 4e. Periapical radio-

graph of completed restoration
depicting preservation of
interproximal bone levels.

determined that if the buccal plate was > one mm, there was
less bone resorption compared to sites with a one mm thick
bony plate.18 In addition, Ferrus et al18 suggested that the
wider the buccal bony plate, the greater the fill of the
horizontal gap. In humans, Spray et al67 noted after tooth
Figure 5. Occlusal view
extraction that buccal plates > 2 mm thick did not usually depicting a dental
resorb vertically, whereas socket walls < 2 mm wide implant placed into a
fresh extraction socket
demonstrated bone loss (Figure 5). It was advised by several which had a thick labial
authors that if the buccal bone thickness is not one to 2 mm, plate of bone.

hard-tissue augmentation was recommended63,67,68 to
maintain the level of the osseous crest.
Buccolingual Position of ImplantsThere are a few
ways the spatial relationship between the implant and the
buccal plate can be affected: positioning of the implant and
selection of its diameter. Pertinently, the closer the implant
is to the buccal plate, the greater the amount of bone
resorption that occurs.15,34,69 Furthermore, use of large
implants to fill the alveolus, which encroaches on the buccal
plate, results in additional bone loss as opposed to
retaining bone. Ultimately, room must be left to allow for the
horizontal influence of the implant.70

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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
Concerning soft-tissue levels, implants placed buccally
manifested 3 times more recession than lingually placed
implants (1.8 versus 0.6 mm).71 However, lingual
positioning of an implant needs to be taken into
consideration with respect to prosthetic concerns.34
Number of Bony WallsWith respect to defect
morphology, the most favorable healing is in 3-walled
defects,72 which is similar to the gap between the bone and
the implant surface. If left undisturbed, the gap will fill in with
a clot, and 3 walls provide better clot containment than
defects with fewer walls.
Implant SurfacesThe stability of the clot will be
impacted by the implant surface.39 Textured implant
surfaces provide greater surface area and improved levels
of osseointegration compared to machined surfaces. When
placing immediate implants, healing is better with textured
surfaces (eg, increased bone to implant contact) as
opposed to smooth surfaces.38,62
Role of Adjacent TeethIn a dog model, Favero et al73
reported immediate implants placed in several adjacent
sockets manifested more bone loss than implants which
were inserted into a single socket adjacent to teeth.
Apparently, the presence of adjacent teeth retarded bone
loss with respect to the interproximal bone, and this finding
is in agreement with other authors.29,59
BiotypeIf buccal bone does not resorb, soft tissue will
not recede. In contrast, the crestal labial bone can resorb
and the soft tissue may not recede. In this regard,
numerous investigations assessed the effect of the biotype
on recession, and the results have been conflicting. When
a thick versus a thin biotype were compared after
immediate implant placement, several authors reported in-
creased recession when there was a thin biotype.66 Others
noted there was no difference in the amount of
recession.4,71 Lee et al74 reviewed the data on this subject
and concluded that a thin biotype predisposes an individual
to recession and loss of papillae.
Temporization With and Without Bone Grafting
Immediate insertion of implants with provisionalization may
enhance soft-tissue contours.75,76 Tarnow77 and Chu et al78
also favored temporization in conjunction with a bone graft
to fill the gap. In addition, it was suggested to add bone
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Continuing Education
coronal to the osseous crest to help support the gingival
contour. A clinical trial substantiating these findings was just
completed and the technique is referred to as dual-zone
socket management (personal communication with Dr.
Tarnow, January 2013).
DISCUSSION
Management of the buccal gap and reducing buccal plate
resorption are important considerations when contemplating
immediate implant placement. Procedures to handle the gap
when the buccal plate is intact have varied depending on
whether the implant was placed with or without flap elevation.
The 8 possibilities of therapy are listed in the Table. In
addition to these methodologies, soft-tissue augmentation
(eg, connective tissue graft) can be provided on the buccal
aspect depending on the aesthetic demands of the case.61 In
general, in the aesthetic zone it is preferable not to elevate a
flap if the buccal plate is intact. Some techniques can be
done alone (ie, adding a biomaterial) or in combination with
other procedures (biomaterial filler plus a barrier). Studies
have clarified that if the gap is < 2 mm, no additional
therapy is needed to enhance gap fill; however, concomitant
resorption of bone occurs and the magnitude of this
alteration is related to buccal plate thickness, implant
positioning, and whether a flap is elevated. Some authors
suggest adding a biomaterial to inhibit horizontal bone
resorption. It appears that a certain amount of crestal bone
loss occurs after an extraction due to loss of blood supply
when the periodontal ligament is eliminated. Differences in
findings between studies with respect to gap fill can be
attributed to different gap sizes, dissimilar thicknesses of
the buccal plate and implant positioning, and various
surgical modalities. Therefore, it is difficult to compare
studies. This is further complicated by the fact that
extrapolating data from dog models to humans can only be
done conceptually without specificity regarding the
magnitude of measurements.
Based upon the collective information in the literature, the
next section provides conclusions and guidelines for
immediate implant placement with respect to managing a
buccal gap after immediate implant insertion when the buccal
plate is present. If a buccal plate is dehisced, it is necessary to
 Continuing Education

Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
address this issue with a bone regeneration
procedure at the time of implant placement or a b
subsequently in a delayed procedure.79,80

CONCLUSIONS AND GUIDELINES FOR

TREATING THE BUCCAL GAP AFTER
IMMEDIATE IMPLANT PLACEMENT
1. Do not elevate a flap when placing an
implant in the aesthetic zone, thereby
reducing the risk of recession. If increased Figure 6a. Clinical view of a dental implant
placed into a socket with a gap of ~ 2 mm;
access for visualization is desired, raise only a biomaterial (xenograft) was placed.
Figure 6b. A piece of CollaPlug (Zimmer
a lingual flap. Dental) was placed over the implant and
2. Gaps < 2 mm wide will usually heal c biomaterial; 2 sutures were used to secure
66 the collagen plug.
spontaneously without placing a biomaterial.
If the gap is > 2 mm, spontaneous bone
d
regeneration is less predictable. If the gap is
< 2 mm, the gap can be left open and it will fill
with a clot, or a biomaterial can be added to
occlude the gap (Figures 6a to 6d). If a
biomaterial is placed, some collagen material
(eg, CollaCote [Zimmer Dental]) can be placed
on top of the material to inhibit exfoliation of the
material before a fibrin clot forms. If a flap is
raised for implant placement and the gap is Figure 6c. Periapical radiograph Figure 6d. Final abutment removed after being in
< 2 mm, the flap can be replaced either over taken at the completion of the place for 3 months (6 months post insertion of the
extraction and implant insertion implant and biomaterial) to demonstrate excellent
the gap28,30,37 or at the buccal crest of procedure. soft-tissue contour.
bone. If the flap covers the graft material, it
will not exfoliate. Placement of a provisional crown on an aspect (approximately one mm) after immediate implant
interim or definitive abutment also can provide protection for placement.4,71 If the buccal wall is thick (> one mm), there
the graft material. It has been suggested that it is better to may be limited resorption. One mm recession was also
leave the gap uncovered, thereby retarding the connective noted when a connective tissue graft was placed.61
tissue and epithelium from interfering with initial population 6. If a biomaterial is inserted in a gap which is < 2 mm,
of the site with bone progenitor cells.77 the data indicate that there will be crestal bone loss, but the
3. Bone fill can occur in defects > 3 mm without horizontal width (contour) will be maintained better.4,12,31
placement of bone grafts or use of barriers.16,42 However, it 7. Numerous materials were investigated as fillers for
appears that the greater the gap size the greater the the gap. However, deproteinized bovine bone has been
potential for incomplete fill of the defect. used in the most studies.66
4. Gaps adjacent to nonsubmerged and submerged 8. The exact relationship between bone modeling and
implants heal similarly.43 recession is unclear; however, with increased bone
5. Thin buccal bony plates resorb and result in loss of resorption, there is usually increased recession.4,66
crestal bone height (approximately one mm) and horizontal 9. The implant should be placed 2 mm from the buccal
4
bone width. Studies have shown that approximately 33% plate to avoid encroaching on the buccal plate and thereby
of the patients manifested gingival recession on the buccal contributing to resorption.4

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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
10. Oversized implants should be avoided, because
they may encroach on the buccal plate.4,21
11. Place implants one mm subcrestally to account for
crestal bone resorption.4,20 Crestal bone resorption can be
decreased with platform switching.81,82
12. Biomaterials can be placed without a barrier, thereby
avoiding flap elevation. However, if a defect is very large or if
there is a bone dehiscence, it may be beneficial to use a
barrier, and this would necessitate elevating a flap in order to
achieve wound closure.
13. With a flapless approach, it was suggested that
overfill of the gap with deproteinated bone helps support
the soft tissue and reduces recession and bone loss when
it is done in conjunction with an abutment and temporary
crown.77 This statement is based upon an investigation that
was just completed.
14. Only histological studies can confirm that osseo-
integration was achieved when the buccal gap fills with bone.
However, a functional and stable implant over a period of time
can be interpreted as a successful clinical outcome.
ADDENDUM
With respect to vertical bone loss when flap versus flapless
procedures were compared, it was noted that there was
conflicting information. However, with regard to horizontal
bone loss, several recent articles have indicated that if a
flap is not raised there is greater preservation of the
horizontal bone width.83-85
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9
Continuing Education
5. Pearce AI, Richards RG, Milz S, et al. Animal models
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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
18. Ferrus J, Cecchinato D, Pjetursson EB, et al. Factors
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28. Botticelli D, Berglundh T, Lindhe J. Resolution of bone
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29. Botticelli D, Persson LG, Lindhe J, et al. Bone tissue
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10
Continuing Education
extraction sockets: an experimental study in dogs. Clin
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30. Arajo MG, Linder E, Lindhe J. Bio-Oss collagen in
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32. Caneva M, Botticelli D, Stellini E, et al. Magnesium-
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33. Caneva M, Botticelli D, Rossi F, et al. Influence of
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34. Favero G, Botticelli D, Favero G, et al. Alveolar bony
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35. Wilson TG Jr, Schenk R, Buser D, et al. Implants
placed in immediate extraction sites: a report of
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Int J Oral Maxillofac Implants. 1998;13:333-341.
36. Wilson TG Jr, Carnio J, Schenk R, et al. Immediate
implants covered with connective tissue membranes:
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37. Paolantonio M, Dolci M, Scarano A, et al. Immediate
implantation in fresh extraction sockets. A controlled
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2001;72:1560-1571.
38. Botticelli D, Berglundh T, Persson LG, et al. Bone
regeneration at implants with turned or rough surfaces
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39. Davies JE. Mechanisms of endosseous integration. Int
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40. Chen ST, Darby IB, Adams GG, et al. A prospective
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41. Covani U, Cornelini R, Barone A. Bucco-lingual bone
remodeling around implants placed into immediate
extraction sockets: a case series. J Periodontol.
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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
42. Tarnow DP, Chu SJ. Human histologic verification of
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fresh extraction socket with excessive gap distance
without primary flap closure, graft, or membrane: a
case report. Int J Periodontics Restorative Dent.
2011;31:515-521.
43. Cecchinato D, Olsson C, Lindhe J. Submerged or non-
submerged healing of endosseous implants to be
used in the rehabilitation of partially dentate patients.
J Clin Periodontol. 2004;31:299-308.
44. Astrand P, Engquist B, Anzn B, et al. Nonsubmerged
and submerged implants in the treatment of the
partially edentulous maxilla. Clin Implant Dent Relat
Res. 2002;4:115-127.
45. Abrahamsson I, Berglundh T, Lindhe J. The mucosal
barrier following abutment dis/reconnection. An
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46. Abrahamsson I, Zitzmann NU, Berglundh T, et al. The
mucosal attachment to titanium implants with different
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47. Dento-osseous structures, blood vessels, and nerves.
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48. Schropp L, Wenzel A, Kostopoulos L, et al. Bone
healing and soft tissue contour changes following
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49. Donnenfeld OW, Hoag PM, Weissman DP. A clinical
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50. Wilderman MN, Pennel BM, King K, et al.
Histogenesis of repair following osseous surgery.
J Periodontol. 1970;41:551-565.
51. Job S, Bhat V, Naidu EM. In vivo evaluation of crestal
bone heights following implant placement with
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52. Fickl S, Zuhr O, Wachtel H, et al. Tissue alterations
after tooth extraction with and without surgical trauma:
a volumetric study in the beagle dog. J Clin
Periodontol. 2008;35:356-363.
53. Barros RRM, Novaes Jr AB, Papalexiou V. Buccal bone
remodeling after immediate implantation with a flap or
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11
Continuing Education
Implants and Biomaterials Titanium. 2009;1:45-51.
54. Blanco J, Nuez V, Aracil L, et al. Ridge alterations
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versus flapless surgery. J Clin Periodontol.
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55. Mal P, Nobre M. Flap vs. flapless surgical techniques
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bone for rehabilitation of partial edentulism: a
prospective cohort study with follow-up of 1 year. Eur
J Oral Implantol. 2008;1:293-304.
56. Nickenig HJ, Wichmann M, Schlegel KA, et al.
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57. De Bruyn H, Atashkadeh M, Cosyn J, et al. Clinical
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Implant Dent Relat Res. 2011;13:175-183.
58. Caneva M, Botticelli D, Sulata LA, et al. Flap vs.
flapless surgical approach at immediate implants: a
histomorphometric study in dogs. Clin Oral Implants
Res. 2010;21:1314-1319.
59. Arajo MG, Lindhe J. Ridge alterations following tooth
extraction with and without flap elevation: an
experimental study in the dog. Clin Oral Implants Res.
2009;20:545-549.
60. Becker W, Wikesj UM, Sennerby L, et al. Histologic
evaluation of implants following flapless and flapped
surgery: a study in canines. J Periodontol.
2006;77:1717-1722.
61. Grunder U. Crestal ridge width changes when placing
implants at the time of tooth extraction with and
without soft tissue augmentation after a healing period
of 6 months: report of 24 consecutive cases. Int J
Periodontics Restorative Dent. 2011;31:9-17.
62. Im SU, Hong JY, Chae GJ, et al. The evaluation of
healing patterns in surgically created circumferential
gap defects around dental implants according to
implant surface, defect width and defect morphology.
J Korean Acad Periodontol. 2008;38(suppl):385-394.
63. Juodzbalys G, Wang HL. Soft and hard tissue
assessment of immediate implant placement: a case
series. Clin Oral Implants Res. 2007;18:237-243.
64. Polyzois I, Renvert S, Bosshardt DD, et al. Effect of
Bio-Oss on osseointegration of dental implants
surrounded by circumferential bone defects of different
dimensions: an experimental study in the dog. Clin

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Oral Implants Res. 2007;18:304-310.
65. de Barros RR, Novaes AB Jr, Queiroz A, et al. Early
peri-implant endosseous healing of two implant
surfaces placed in surgically created circumferential
defects. A histomorphometric and fluorescence study
in dogs. Clin Oral Implants Res. 2012;23:1340-1351.
66. Chen ST, Buser D. Clinical and esthetic outcomes of
implants placed in postextraction sites. Int J Oral
Maxillofac Implants. 2009;24(suppl):186-217.
67. Spray JR, Black CG, Morris HF, et al. The influence of
bone thickness on facial marginal bone response:
stage 1 placement through stage 2 uncovering. Ann
Periodontol. 2000;5:119-128.
68. Kazor CE, Al-Shammari K, Sarment DP, et al. Implant
plastic surgery: a review and rationale. J Oral
Implantol. 2004;30:240-254.
69. Tomasi C, Sanz M, Cecchinato D, et al. Bone
dimensional variations at implants placed in fresh
extraction sockets: a multilevel multivariate analysis.
Clin Oral Implants Res. 2010;21:30-36.
70. Vela X, Mndez V, Rodrguez X, et al. Crestal bone
changes on platform-switched implants and adjacent teeth
when the tooth-implant distance is less than 1.5 mm. Int J
Periodontics Restorative Dent. 2012;32:149-155.
71. Evans CD, Chen ST. Esthetic outcomes of immediate
implant placements. Clin Oral Implants Res.
2008;19:73-80.
72. Kim CS, Choi SH, Chai JK, et al. Periodontal repair in
surgically created intrabony defects in dogs: influence
of the number of bone walls on healing response. J
Periodontol. 2004;75:229-235.
73. Favero G, Lang NP, Favero G, et al. Role of teeth
adjacent to implants installed immediately into
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Clin Oral Implants Res. 2012;23:402-408.
74. Lee A, Fu JH, Wang HL. Soft tissue biotype affects
implant success. Implant Dent. 2011;20:e38-e47.
75. El Chaar ES. Immediate placement and
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restorations: a retrospective study. Int J Periodontics
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76. Kan JY, Rungcharassaeng K, Lozada JL, et al. Facial
gingival tissue stability following immediate placement
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implants: a 2- to 8-year follow-up. Int J Oral Maxillofac
Implants. 2011;26:179-187.
12
Continuing Education
77. Tarnow D. Immediate vs. delayed socket placement:
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dont know. Presented at: American Academy of
Periodontology Annual Meeting; November 14, 2011;
Miami Beach, FL.
78. Chu SJ, Salama MA, Salama H, et al. The dual-zone
therapeutic concept of managing immediate implant
placement and provisional restoration in anterior
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2012;33:524-532, 534.
79. Buser D, Chen ST, Weber HP, et al. Early implant
placement following single-tooth extraction in the
esthetic zone: biologic rationale and surgical
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2008;28:441-451.
80. Elian N, Cho SC, Froum S, et al. A simplified socket
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81. Atieh MA, Ibrahim HM, Atieh AH. Platform switching
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J Periodontol. 2010;81:1350-1366.
82. Rodrguez-Ciurana X, Vela-Nebot X, Segal-Torres M,
et al. The effect of interimplant distance on the height
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2009;29:141-151.
83. Vera C, De Kok IJ, Chen W, et al. Evaluation of post-
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Maxillofac Implants. 2012;27:1249-1257.
84. Degidi M, Daprile G, Nardi D, Piattelli A. Buccal bone
plate in immediately placed and restored implant with
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Periodontol. 2012;83:581-589.

Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
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POST EXAMINATION QUESTIONS
1. What is the jumping distance?
a. Space located only on the buccal surfaces between
the implant and the tooth.
b. Space between the implant periphery and
surrounding bone.
c. Space located only on the lingual surfaces between
the implant and the tooth.
d. Space located only on the proximal surfaces between
the implant and the tooth.
13
Continuing Education
2. Which plate of bone is usually the thinnest around
an immediate implant?
a. Buccal.
b. Lingual.
c. Proximal.
d. Both a and b.
3. After an extraction how much bone loss (mean)
occurs on the buccal and lingual aspects of the
extracted tooth after 6 months?
a. 3.79 mm vertically and 1.24 mm horizontally.
b. 1.79 mm vertically and 3.24 mm horizontally.
c. 3.24 mm vertically and 1.79 mm horizontally.
d. 1.24 mm vertically and 3.79 mm horizontally.
4. What is the major benefit of not elevating a buccal
flap when placing an immediate implant?
a. Helps preserve aesthetics.
b. Does not reduce vascularity over the buccal plate.
c. Probably reduces the amount of recession.
d. All of the above.
5. After immediate implant placement, what size gaps
will usually heal spontaneously if left untreated?
a. 2 mm.
b. 3 mm.
c. 4 mm.
d. 5 mm.
6. What does buccal plate thickness influence?
a. Amount of keratinized tissue.
b. Amount of recession.
c. Amount of bone resorption.
d. Both b and c.
7. How does implant position of an immediate implant
in the maxilla affect the results?
a. If too far lingual, it is prosthetically unacceptable.
b. If too close to the buccal plate, it will induce bone
resorption.
c. If it is angled, it will fail.
d. Both a and b.
 Continuing Education

Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement
8. What type of defect is a buccal gap if the socket 13. Some authors suggest overfilling the buccal gap with
walls are intact? deproteinated bone in conjunction with an abutment
a. One wall. and a temporary crown to achieve which outcome?

b. Two walls. a. Help support soft tissue.

c. Three walls. b. Reduce recession.
d. Moat defect. c. Both a and b.
d. Increased keratinized tissue.
9. Is there a benefit to placing a bone graft in the gap if
it is large? 14. When extrapolating data from a dog model to humans,
a. Usually no. which statement is true?

b. Usually yes. a. It is only an approximation of what occurs in humans.

c. Never.
d. Only if it is < 2 mm.
10. Since there is usually some vertical bone loss
associated with immediate implant placement, it is a
good idea to place the implant platform where?
a. At the crest of bone.
b. It is exactly what happens in humans.
c. Dogs remodel overall healing is slower that humans.
d. Dogs bones are the same size as humans.
15. According to Botticelli et al, which statement is true
about how artificially created defects (1.25 to 2.25
mm) heal in a dog model?

b. One mm supracrestally. a. The buccal aspect of created defects partially heal.

c. One mm subcrestally.
d. It doesnt matter if the buccal plate is thin.
11. When comparing healing in the gap around
submerged and nonsubmerged implants, which
statement is true about submerged implants?
a. They heal better than nonsubmerged implants.
b. The lingual asect of created defects partially heal.
c. Created defects heal partially.
d. Created defects heal completely.
16. When can a clinician be sure complete
osseointegration occurred along the entire implant
surface?

b. They heal worse than nonsubmerged implants. a. When the buccal gap fills with bone.
c. They heal the same as nonsubmerged implants. b. Only histological assessment can confirm this finding.
d. There is delayed healing. c. When there is a lack of mobility.
d. When bone fills the buccal gap and there is a lack of
12. Textured surfaced implants provide which mobility.
advantages compared to smooth surfaced implants?
a. Decreased surface area for more osseointegration.
b. Increased bone to implant contact.
c. Decreased clot retention.
d. Decreased probing depths.

14
 Continuing Education

Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement

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Dental Association to assist dental professionals in
indentifying quality providers of continuing dental
What aspect of this course was most helpful and why?
education. ADA CERP does not approve or endorse
individual courses or instructors, nor does it imply
acceptance of credit hours by boards of dentistry. What topics interest you for future Dentistry Today CE courses?
Concerns or complaints about a CE provider may be
directed to the provider or to ADA CERP at
ada.org/goto/cerp.

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