Articles - Forum Implantologicum

Article

Feature Article

Dec 03, 2025 // 20 min read

The Use of Tissue Level Design Implants in Immediate Protocols

Thomas Gill

Michael Myint

Shakeel Shahdad

DOI: 10.63580/ITI.FI.45761

dental implant tissue level immediate Type 1

Abstract

The tissue level (TL) implant is considered a challenging implant for the esthetic zone as the perceived potential esthetic risk of exposure of the machined collar or metal shine-through commonly drives clinicians to select bone level (BL) design implants, especially for immediate implant placement (IIP) protocols. Despite using BL design implants, studies investigating the outcomes of IIP have reported a high frequency of facial mucosal recession. In our experience, TL design implants provide comparable outcomes and seem to have been unfairly implicated for esthetic failures.

This article provides a narrative review of the evolution of TL implants and outlines the benefits of this design for IIP. Additionally, clinical cases are utilized to highlight the effectiveness of TL implants for IIP in the esthetic zone.

Based on the current evidence, there is a paucity of studies assessing the stability of clinical outcomes for IIP with TL implants in the esthetic zone. The standard indications and contra-indications apply regardless of implant type, and the optimal restoratively driven three-dimensional position of the implant should not be compromised.

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Introduction

The tissue level (TL) implant has been at the forefront of innovation for more than four decades and is one of the oldest and most well-evidenced implants used in modern dentistry. At a time when Brånemark implants followed a fully submerged healing protocol, the one-piece TL (ITI) implants were novel, pushing the boundaries to pioneer transmucosal healing (Brånemark et al. 1969; Buser et al. 1990; Buser et al. 1997; Andersen et al. 2002).

As time progressed, surgical protocols were refined to allow for earlier placement and predictable loading protocols. Over the last two decades, the demands and benefits of immediate implant placement (IIP) have continued to increase from a patient and clinician perspective (den Hartog et al. 2008; Slagter et al. 2014; Huynh-Ba et al. 2018; Morton et al., 2018; Morton et al., 2023). IIP is defined as the placement of a dental implant into a fresh socket on the same day as tooth extraction (Gallucci et al. 2018).

Many readers might find it surprising that several early studies on IIP in the esthetic zone utilized TL implants as this was what was largely available at the time (Lang et al. 1994; Bragger et al. 1996; Andersen et al. 2002; Bianchi & Sanfilippo 2004). In the 1990s, these implants were parallel-sided with passive thread designs and, with developing IIP protocols, were considered technically demanding to place and lacked sufficient primary stability for IIP. From 2000 onwards, bone level (BL) design implants gained preference and have been predominantly used in research studies, with the introduction of implant geometries that offer relatively predictable high primary stability at implant insertion (Cochran et al. 2016; Dard et al. 2016). Until recently, implant geometries that aid immediate protocols have been largely absent from manufacturer portfolios for TL implants, and therefore, modern studies have rarely reported outcomes of TL implants (Wittneben et al. 2023). However, the authors believe TL implants can be successfully and predictably utilized for IIP in the anterior esthetic zone and achieve stable long-term esthetic outcomes.

It is to be reiterated that replacing a single tooth in the anterior maxilla (#15 to #25) with an IIP protocol is a complex procedure. The rules for placing TL immediate implants in the anterior maxillary esthetic zone are similar to those for BL design implants. IIP may be considered the treatment of choice when ideal conditions are present (Wittneben et al. 2023), such as:

Healthy adjacent teeth
Thick gingival phenotype
Intact facial bone >1 mm in thickness
No acute infection or chronic fistula
Ability to place the implant in the correct three-dimensional position for a screw-retained restoration
Ability to achieve primary stability of the implant, which is a fundamental prerequisite if an immediate restoration is expected.

This article aims to discuss the tissue level implant's potential advantages, address concerns about its use, and highlight the esthetic outcomes achievable when immediately placing TL implants in the esthetic zone.

Fig. 1: Overview of tissue level implant macrogeometries offered in Straumann portfolio. Type 1) Parallel-sided passive implant 2) Parallel-sided active implant 3) Coronally tapering implant, 4a & 4b) Fully tapering implant, 5a & 5b) Apically tapering implant

Table 1: Risk assessment for immediate implant placement in single tooth sites (Lambert et al. 2023)

$Fig. 2a: UR3 had fractured subgingivally in an otherwise heavily restored dentition with generalized gingival recession and cervical restorations in UR4$

Fig. 2b: The CBCT shows the presence of <1 mm facial bone thickness and a Class IV root position

Fig. 2c: Definitive restoration and immediate post-restoration radiograph

Fig. 2d: 4-year clinical and radiographic follow-up

Fig. 2e: Maintenance of alveolar convexity after 4 years in function

Fig. 2f: CBCT taken after 4 years shows bone coronal to the rough surface

$Fig. 3a: Pre-operative view of UL2 fractured at the cervical third$ $Fig. 3b: Intra-oral peri-apical radiograph of fractured UL2$

Fig. 3c: The CBCT shows the presence of <1 mm facial bone thickness and a Class IIB root position. A chronic peri-apical lesion is present

Fig. 3d: Immediate placement of TL implant and DBBM-C placed in the gap facially between the implant and the socket wall

Fig. 3e: Collapse of alveolar convexity noted during the provisionalization stage prior to fit of the definitive crown

Fig. 3f: Optimal concave sub-mucosal contour of the definitive crown

Fig. 3g: Occlusal view showing loss of alveolar contour in UL2 compared to UR2

Figs 3h - i: Post-op view after 1 and 2 years

Figs 3j - k: Marginal bone levels after 1 and 2 years

Fig. 4: Ideal 3-dimensional implant position; TL implant should be placed 2 mm apically to the proposed mucosal zenith, >2 mm palatal to adjacent teeth, and >1.5 mm from adjacent teeth

Fig. 5: For immediate placement in the extraction socket, >2 mm horizontal gap should be maintained between the implant and the inner socket wall at the rough surface-machine collar junction

Figs 6a - c: Immediately placed TL (coronally tapered) implants in UR3, UR1 and UL3 for a six-unit implant bridge

Figs 7a - b: Definitive metal ceramic bridge delivered after two months of healing (treated in 2009)

Figs 8a - c: Baseline radiographs 4 weeks after restoration

Figs 9a -c: 15-year follow-up with excellent soft tissue stability

Figs 10a - b: CBCT scan of UR3 and UL3 after 15 years exhibits 3 - 4 mm facial bone at the implant rough surface junction. The bone is maintained coronal to the implant-abutment junction

Fig. 10c: CBCT scan of UR1 shows a lack of facial bone on the same TL implant design as used in the canines

Fig. 10d: Demonstrates the facial malposition of UR1 implant. Had this implant been placed in the highlighted schematic position, it is very likely that this implant would have similar facial bone outcome as the canines

Figs 11a - b: Longstanding conventional metal ceramic crowns. UL2 and UL3 crowns were linked and gross caries was noted under UL3 crown after dismantling of the restoration. UL3 was unrestorable

Fig. 11c: CBCT scan shows a Class IIB root position with <1 mm facial bone, if present

Figs 11d - g: Missing facial plate with a full root-length dehiscence. An internal socket flap elevated along the three facial bone walls to allow for the stabilization of porcine collagen membrane between the flap and the facial bone. Placement of DBBM bone substitute with the implant drill in place. Membrane wrapped over the implant

Figs 11h - j: Clinical outcome at the time of restoration, 1 and 6 years later. Mucosal zenith had stabilized by the end of 1 year and remained stable over the next 5 years. Despite a complete lack of facial bone in a thin gingival phenotype, an excellent PES score is achieved

Figs 11k - m: Radiographs confirm a similar response

Figs 11n - o: Buccal bone thickness <1 mm

Figs 12a – c: Baseline situation of UL1 with subgingival root caries and generalized gingival recession. CBCT scan showing a class III root position and <1 mm buccal bone thickness with a vertical bone loss up to 50% of the root length

Figs 12d - g: UL1 was virtually extracted. The implant shoulder depth planned 2 mm from the mucosal zenith of UR1. To aid 3D visualization, an abutment of known height helps to visualize the optimal implant position. A screw-retained restoration is planned. Implant osteotomy planned along the palatal wall to maintain >2 mm distance from the buccal bone crest. “S” type (collar height 2.8 mm) was selected to compensate for the vertical buccal bone loss and coronally shift the soft tissue to mitigate the soft tissue deficit

Figs 12h - m: Surgical steps for static computer-assisted implant surgery

Figs 12n - p: Immediate provisional restoration on titanium base abutment

Fig. 12s - t: Definitive restoration achieved excellent pink and white esthetics with reversal of pre-operative apically positioned gingival zenith in UL1

Figs 12u - w: Immediate, 6- and 18-month follow-up radiographs

$Figs 13a - b: Baseline clinical scenario with a fracture of a 3-unit maxillary anterior bridge extending from UR1 to UL2 with UR1 and UL2 abutments fractured at the cervical margin in a 64-year-old male$

Fig. 13c: Class I root position and >1 mm buccal bone thickness

Figs 13d - f: Virtual implant planning. UR1 and UL2 were virtually extracted, and apically tapered tissue level implants (Straumann TLC) were planned for both sites. A screw-retained bridge was planned. Implant osteotomy was planned slightly palatal to the root apices whilst maintaining >2 mm distance from the buccal bone crest. An “NT” type (collar diameter 3.5 mm) was selected to allow for narrower emergence and ideally mimicking recession in adjacent teeth

Figs 13g - k: A fully guided placement protocol was implemented. After minimally traumatic extraction of UR1 and UL2, the presence of the buccal wall was confirmed. Implants placed achieving >80 Ncm insertion torque. The horizontal defect grafted up to the implant collar using DBBM-collagen. A 4.5-mm healing abutment placed and additional grafting material placed to support the soft tissues. A cross-suture with 6x0 monofilament nylon placed

Fig. 13m: Six weeks later, a definitive bridge made in monolithic zirconia on titanium base abutments placed

Fig. 13p - q: 1-year radiographs showing stable marginal bone levels at SLA-machine collar junction

$Figs 14a - b: A 73-year-old female with a fractured 3-unit maxillary anterior bridge extending from UL1 to UL3. The abutment teeth (UL1, UL3) had fractured at the gingival level. Another failing bridge, replacing UR1 to UR3, had a ceramic fracture in UR1 and had been repaired with composite resin restoration$

Figs 14c - h: <1 mm facial bone thickness. Apically tapered tissue level implants (Straumann TLC) were planned for UR3, UR1 and UL3 sites for a screw-retained bridge. Implant osteotomy planned palatal to the root apices whilst maintaining >2 mm distance from the buccal bone crest

Figs 14i - k: A fully guided placement protocol was followed. The teeth were extracted with a minimally traumatic technique after sectioning the roots. Facial bone wall was confirmed to be present, and all the sockets were thoroughly debrided. Osteotomy preparation was carried out using the fully guided protocol. Implants were placed through the guide, achieving >80 Ncm insertion torque. 3-mm healing abutments were placed, and grafting with DBBM-C (Geistlich BioOss Collagen block) was performed up to the level of healing abutments. No suturing was required. UL1 socket was also grafted with DBBM-C and a cross suture with 6x0 monofilament nylon over the socket opening

Fig. 14l: Four weeks after healing, a resin provisional bridge was fitted to commence soft tissue conditioning

Fig. 14m: The definitive bridge was made in monolithic zirconia on titanium base abutments. Excellent pink esthetics re-created with TL design implants without any hint of grayish hue from the underlying implant collar. The mucosal zenith in UL3 was more apical than desired. This prosthetic error can be attributed to the overcontoured emergence of UL3. It was accepted, assuming that the mucosa might migrate coronally in the fullness of time

Figs 14n - o: Follow-up after one year shows a well-maintained alveolar convexity around the implants, indicating stability of the peri-implant hard and soft tissues, although no supplemental soft tissue grafting was carried out. However, the UL3 mucosal zenith remained more apical than its contralateral canine

Figs 14p - r: The black highlighted area illustrates the convex overcontoured transmucosal emergence that pushed the mucosa apically. The contour was reduced chairside to a concave shape, and the bridge returned to the patient

Fig. 14s: Four weeks later, the mucosal zenith in UL3 had migrated coronally, allowing for correction of the zenith mismatch between UR3 and UL3. This allowed the soft tissue to “relax” and migrate coronally to correct the deficit and level the zenith with UR3

Figs 14t - v: Radiographs after 2 years show stability of marginal bone levels