Articles - Forum Implantologicum

Article

Feature Article

Aug 13, 2025 // 14 min read

Post-Extraction Immediate Implant Placement in the Anterior Maxilla – An Update

implant esthetics Type 1A immediate implant placement in the esthetic zone soft tissue management implant 3D positioning

Abstract

Recent advances in clinical techniques and biomaterials have enhanced the predictability of immediate implant placement in the anterior maxilla where esthetic outcomes are important. When implant placement is combined with an immediate provisional crown (Type 1A), significant patient-centered benefits may be anticipated. At the most recent ITI Consensus Conference in 2023, it was recommended that the Type 1A approach be considered the treatment of choice if ideal clinical conditions have been satisfied. In this article, an update on clinical recommendations, advantages and disadvantages of this approach are presented. Two cases illustrate the clinical steps.

Password

Introduction

Immediate implant placement is defined by the ITI as a technique in which a dental implant is inserted into an extraction socket immediately after tooth extraction, and as part of the same surgical procedure (Hammerle et al. 2004). This approach has gained popularity due to its potential to reduce treatment time, preserve alveolar bone, and enhance esthetic outcomes. This technique deviates from the original treatment protocols in which implant placement is delayed until the extraction site has substantially healed.

Research over the last 2 decades has demonstrated that immediate implants, when properly planned and executed, can achieve similar survival, functional and esthetic outcomes to implants placed in healed sites (Chen et al. 2004; Chen et al. 2009). Advances in dental implant macro-morphology, surface modifications, implant alloys, connections, abutments, and restorative materials have contributed to the success of accelerated treatment protocols (Morton et al. 2023).

The patient-centered benefits of immediate implant placement can be further enhanced when a provisional crown is connected to the implant soon after it is placed. This approach is referred to as immediate implant placement with immediate loading (Type 1A protocol). This treatment approach has been the subject of numerous clinical studies conducted in different patient groups and has demonstrated good clinical outcomes under optimum conditions and if specific requirements are met. According to the findings of the 7th ITI Consensus Conference (Morton et al. 2023), the Type 1A protocol for teeth in the anterior maxilla should be considered a complex procedure. However, due to the significant patient-centered benefits, it should be considered the treatment of choice if ideal conditions are met. These conditions are as follows:

Healthy adjacent teeth
Intact facial bone
No acute infection
Ability to place the implant in the correct three-dimensional position for restoration
Anticipated stability of the implant to allow immediate restoration

Fig. 1: This periapical radiograph shows the intact bone peaks at the mesial and distal of the maxillary left lateral incisors. The risk of recession of the papilla is minimized when the bone peaks are intact

Fig. 2: The proximal bone at the teeth adjacent to this upper right lateral incisor have receded. There is a significant risk of recession of the papilla following implant placement

Fig. 3: CBCT scan of an upper lateral incisor. The upper lip and tongue have been retracted, and the teeth are out of occlusion. The facial and palatal bone walls can be seen clearly, as well as the thickness of the facial and palatal soft tissues

Fig. 4: The insertion torque following placement of this implant was between 35 and 50 Ncm

Fig. 5: Occlusal view of an immediate provisional crown attached to an implant that was placed immediately into an extraction socket. As can be seen from the articulating paper marks, the occlusion has been adjusted to remove centric or protrusive occlusal contacts on the provisional crown

Fig. 6: Fractured root revealed during orthodontic treatment

Fig. 7: Delivery of the root following extraction of the root with a low trauma technique

Fig. 8: Inspection of the socket confirmed that the facial bone was intact

Fig. 9: Correct 3D positioning of the implant (BLT implant, Straumann Group, Basel, Switzerland), with the implant positioned slightly palatally, thereby respecting the facial gap. The technique was executed by using a sharp pilot drill palatal to the extraction socket in order to create a starting point and correct positioning of the implant

Fig. 10: A 3-4 mm gap was achieved between implant and facial bone

Fig. 11: A connective tissue graft was placed using a tunneling technique to maintain ridge contour on the facial aspect

Fig. 12: The facial gap was filled with Cerabone (botiss, Germany) biomaterials after connecting the temporary abutment. An apical infection was detected during the surgery and was removed through an additional horizontal incision

Fig. 13: A prefabricated composite crown was connected to the temporary abutment

Fig. 14: The provisional crown was prepared chairside

Fig. 15: The provisional crown with mesial and distal wings to support the restoration with the adjacent teeth. Also visible is the healing of the apical incision performed to remove the apical infection

Fig. 16: The 3-month post-operative appearance of the provisional crown

Fig. 19: The final restoration at time of insertion

Fig. 20: The peri-apical radiograph at the one-year post-operative review

Fig. 21: The maxillary right central incisor at presentation. The crown had previously dislodged and had been temporarily re-cemented

Fig. 22: Periapical radiograph of the maxillary right central incisor at initial presentation

Fig. 23: Preliminary CBCT examination showed the presence of an intact facial socket wall (1 mm thickness), absence of apical pathology and sufficient apicopalatal bone for an implant to be placed with stability. In the saggital view, the root is positioned against the facial cortical bone (Class 1 according to Kan et al. 2011)

Fig. 24: Implant planning was completed on computer software (coDiagnostiX, Dental Wings, Straumann Group, Basel, Switzerland). A 12-mm length (3.75-mm diameter) implant was selected (BLX implant, Straumann Group, Basel, Switzerland) and positioned with the axis of the implant emerging through the cingulum of the anticipated implant crown. The implant shoulder was positioned 3.5 mm from the anticipated midfacial mucosal margin. At this level, the implant shoulder was 1 mm apical to the facial bone crest. At the implant shoulder, a gap of 2.5 mm was present between the implant shoulder and the internal aspect of the facial socket wall

Fig. 25: A surgical guide was designed. A bone-anchored template fixation pin was incorporated into the design to minimize the risk of rotation of the surgical guide when in use. As the planned provisional crown is prefabricated, even the slightest amount of rotation could affect the final fit of the provisional crown

Fig. 26: Occlusal view of the guide design. Observation windows were incorporated into the design to allow verification that the guide was correctly seated at the time of surgery

Fig. 27: The guide was then constructed with 3D printing. A 5-mm diameter sleeve was incorporated into the guide for the drill handles

Fig. 28: The maxillary right central incisor was carefully extracted in a flapless procedure. Care was taken to minimize facially directed forces to preserve the facial bone plate

Fig. 29: Facial view of the maxillary right central incisor site following extraction of the tooth

Fig. 31: The surgical guide was tried in and the accurate seating was verified. The bone-anchored template fixation pin was secured into position

Fig. 32: The osteotomy was then prepared according to the digital plan using the corresponding drill handles and twist drills until the final drill diameter of 3.2 mm was completed

Fig. 33: The TorcFit™ Guided Implant Driver was attached to the BLX implant

Fig. 34: The implant was inserted through the surgical guide. The implant achieved a high final insertion torque of approximately 50 Ncm

Fig. 35: A direct screw-retained CAD-CAM-fabricated provisional restoration using a pre-fabricated Ti-Base (Straumann BLX crown variobase - 3.8 mm diameter / 2.5 mm GH / 5.5 mm AH). This abutment was planned pre-extraction in the CoDiagnostiX software program and the provisional crown form designed and milled prior to implant placement. The provisonal crown was cemenented to the T-Base prior to surgery

Fig. 36: Initial trying in of the prefabricated provisional crown to confirm correct seating, rotational timing. The proximal surfaces of the crown were adjusted for light proximal contacts. The occlusion was assessed to confirm absence of centric, protrusive and lateral occlusal contact

Fig. 37: A healing abutment was then attached to the implant and the facial marginal defect grafted with a bone graft with a low substitution rate (Bio-Oss Collagen, Geistlich Pharma AG, Wolhusen Switzerland). The graft was placed to the level of the facial bone crest

Fig. 38: Excess grafting material was carefully removed

Fig. 39: A porcine-derived resorbable collagen matrix was trimmed and prepared (Fibrogide, Geistlich Pharma AG, Wolhusen Switzerland) for insertion into the facial soft tissue zone between the bone crest and in the mucosal margin

Fig. 40: The provisional crown was then carefully inserted to secure the collagen matrix in position

Fig. 41: Final seating of the provisional crown. The resorbable collagen matrix was held in position by the contour of the provisonal crown, and did not need to be secured with sutures. The suture in the vestibule was used to close the mucosal fenestration from the bone fixation screw in the surgical guide

Fig. 42: Occlusal view of the seated provisional crown. The abutment screw was torqued to 35 Ncm. The screw hole was sealed with Teflon tape and a temporary filling material (Cavit, 3M Australia)

Fig. 43: Radiographic control following connection of the provisional crown

Fig. 44: Clinical situation three months after implant placement and connection of the provisional crown. Note the healthy soft tissues

Fig. 45: Occlusal view three months after implant placement and provisional crown

Fig. 46: The definitive crown incorporating an RB Variobase. For fabrication of the definitive restoration, the form of the I-pSC was copied, with some minor modifications to further improve the tooth form, and using the identical abutment as used in the I-pSC. The facial surface was slightly reduced to allow for a direct build of ceramic to complete the color and final contours. The crown was milled from a monolithic (layered) zirconia puck. After the fit to the abutment was verified, the crown ceramic build was completed. The abutment ‘chimney’ was prepared by treating the outer surface with a aluminous oxide (50 micron) spray, then ultrasonically cleaned in distilled water. Both the treated surface of the Ti-Base (2.5 mm GH / 5.5 mm AH) and the internal surface of the Zr crown had a bonding agent applied (‘MonoBond Plus’ – Ivoclar) and ‘MultiLink’ (Dual cure resin cement – HO) was used as the luting agent

Fig. 47: Review at one year after implant placement showing the definitive crown replacing the maxillary right central incisor

Fig. 49: Periapical radiograph of the maxillary right central incisor implant one year after placement. Note the ideal marginal bone configuration, and the radiographically healthy peri-implant bone condition

Fig. 50: CBCT image of the implant obtained one year after surgical placement. A thick facial bone wall was present in the coronal region of the implant, with the facial bone crest located coronal to the implant abutment junction

Fig. 51: Axial CBCT view of the implant showing a thick facial bone wall (Acknowledgement: Dr. Anthony Dickinson, Melbourne for the prosthodontic management)