Guidelines for Immediate

Implant Placement in
Periodontally
Compromised Patients
Abstract
C
linicians encounter challenges when placing implants immediately after
extraction in periodontally compromised patients. A study was under-
Othman Shibly, DDS taken in 73 periodontally compromised patients to identify these chal-
Diplomate, American lenges and identify situations in which immediate postextraction placement of
Board of Periodontology
implants in this patient group is not optimal. The study found that immediate
Director, Preventive Den-
tistry implant placement after extraction is not recommended for periodontally com-
Department of Periodon- promised patients with advanced horizontal interproximal bone loss, advanced
tics and Endodontics
furcation involvement, periapical lesions, proximity to the sinus, proximity to
Associate Director, Center for Dental
Studies nerve canals, and limitation in mandibular opening. These results were used to
State University of New York at Buffalo establish suggested guidelines for the placement of implants immediately after
Buffalo, NY extraction in periodontally compromised patients.
Phone: 716.829.3850
Email: shibly@buffalo.edu

Ali Al-Ghamdi, DDS, MS
Assistant Professor and
Consultant in Periodontics
Chairman, Oral Basic and
Clinical Sciences Depart-
ment
Chairman, Saudi Board of Periodontics,
Western Region
Chairman, Saudi Implant Fellowship,
Western Region
Faculty of Dentistry
King Abdul Aziz University
Jiddah, Saudi Arabia
Email: dr_thafeed@hotmail.com
Mohanad Al-Sabbagh,
DDS, MS
Diplomate of American
Board of Periodontology
Director, Graduate Peri-
odontology
University of Kentucky, College of Den-
tistry
Lexington, KY
Phone: 859.257.3003
Email: malsa2@email.uky.edu
W
ith the continued impact of esthetics on dental treatment, the
desire for patients to maintain their dentition is critical. Imme-
diate implants are a 1-stage surgical procedure designed to suc-
cessfully place a dental implant after tooth extraction and site preparation,
reducing the time spent between tooth loss and final restoration placement.
Clinical studies have demonstrated that successful osseointegration and op-
timal esthetics can be achieved with implants placed in fresh extraction
sockets.1-3 For optimal esthetics, provisional restorations along with immedi-
ate implants are acceptable options. Additionally, clinicians have docu-
mented success with these procedures in the molar region. Immediate-loading
implants placed in fresh molar extraction sockets can be used for a variety
of restorations: permanent fixed complete dentures in the maxilla4; 3-unit
fixed partials in the mandible5; and single teeth in the posterior mandible.6
Research demonstrates that selecting the proper patients for this treat-
ment option is crucial for implant success.7,8 Research and clinical experi-
ence from past decades has demonstrated that oral rehabilitation with an
implant-supported prosthesis in the periodontally compromised patient can
be successful.9,10 However, a retrospective study from 1988 to 2004 found
that immediate implants replacing periodontally involved teeth were more
than twice as likely to fail than implants replacing non-periodontally com-
promised teeth.11 A pilot study of immediate-loading “all-in-one” implant
surgeries for periodontally compromised adults yielded an excellent success

Vol. 4, No. 6 (Suppl 1) Dental Learning / June 2010 1

rate, with some precautions for the molar regions.12 A sys-
tematic review of implant patients with periodontal-asso-
ciated tooth loss and those with nonperiodontal-associated
tooth loss demonstrated no difference in 5- to 10-year im-
plant success; however, the risk of peri-implantitis was sig-
nificantly increased in the former patients.13
When initial implant stability has been achieved, the
success of implant survival is increased, even in compro-
mised sites. However, the published research to date has
concentrated on surgical techniques, success rates, or rea-
sons for osseointegration failures14,15 rather than on de-
tails of the inherent challenges to the successful implant
treatment option during surgery. The goals of this study
were to identify the challenges the practitioner is presented
with in placing implants immediately after extraction in
periodontally compromised patients, and to establish
guidelines for immediate implant placement. These results
may help clinicians identify situations when an immedi-
ate implant is not an optimal option for the patient and
when different methods of treatment, such as socket
preservation and delayed implant, should be considered.
Materials and Methods
This study was designed to evaluate immediate loading
of implants placed in the socket after tooth extraction that
required guided bone regeneration. Study participants
were 73 patients between 20 and 90 years of age.
Criteria for inclusion in the study were as follows:
• A history of moderate to severe periodontal disease
based on radiographic and clinical history, with peri-
odontal stability being achieved after active periodon-
tal therapy, according to findings of clinical and
periodontal examinations.
• At least 1 untreatable (hopeless) tooth indicated for
extraction.
• A desire to receive implant placement immediately
after extraction.
Patients were excluded from the study if they were cur-
rent smokers, had uncontrolled diabetes, or had a history
of infective endocarditis. The study was approved by the
University of Buffalo Institutional Review Board, and all
study participants signed an informed consent form.
During the baseline period, participants had preoper-
ative panoramic, periapical, and bite-wing radiographs
2 Dental Learning / June 2010
taken, and probing depths were measured to assess bone
loss. If the patients selected the option of an immediate
implant, they were asked to sign the consent form at that
time.
Amoxicillin (500 mg, 3 times daily for 10 days) was
prescribed for each patient, started 2 days before surgery.
The implant size was selected using the NobelReplace
Straight Groovy system (Nobel Biocare). Patients were
then classified into 2 categories: those who needed to re-
place a posterior hopeless tooth (n = 50) and those who
needed to replace an anterior (hopeless) tooth (n = 23).
A board-certified periodontist performed all surgeries.
At the surgical visit, a full-thickness mucoperiosteal flap
was raised, and the tooth to be extracted was carefully re-
moved with minimal trauma. The socket of the extracted
tooth was then assessed to determine whether immediate
implant placement would have initial stability and proper
implant positioning to meet restorative and esthetic needs.
If the implant could be successfully placed, a protocol of
guided tissue and bone regeneration using demineralized,
freeze-dried bone and a resorbable collagen membrane
was followed.
If placing the implant would not provide initial stabil-
ity or the configuration of the extracted site would not
allow for proper implant positioning, then only socket
preservation techniques were performed, and the patient
was placed into a subgroup for the purpose of this obser-
vational study.
A total of 12 patients did not receive immediate im-
plants after extraction because of reasons related to the
clinical presentation after extraction. The specific challenge
that hindered the implant placement, as well as the need
for tooth extraction, was recorded in the patient’s chart.
This subgroup of 12 patients is described and provided the
data for the guidelines the authors present concerning im-
plant placement in periodontically compromised patients.
Results
Of the 73 patients who participated in the main study,
61 (84% of patients) received an implant immediately
after extraction. Table 1 summarizes the percentages of
immediate implant placement in anterior and posterior re-
gions. Implant placement was more successful in the an-
terior versus posterior region (91% vs 80%).
Vol. 4, No. 6 (Suppl 1)
 Number of Patients With a Tooth Needing Replacement stability. Before implant placement, site development and
Table 1
With Immediate Implant socket preservation were performed (Figure 2).
A total of 3 implants were not placed in the 15 extrac-
Total number Anterior Posterior
of patients teeth teeth tions of lower molars, mainly because of proximity of the
Baseline number 73 23 50 inferior alveolar nerve. Another challenge for placing an
Implant placed 61 21 40 implant in the mandibular molar area was centering the
No implant placed 12 2 10
implant in the socket for restorative needs. To accomplish
Percentage placed 84% 91% 80%
this, an osteotomy must be done in the radicular bone.
Note: Patient subgroup percentages of placement are based on anterior This may not be possible if the radicular bone is not wide
and posterior zone.
enough to engage the implant. Delayed implant placement
was deemed a better option to allow healing of the socket,
The lowest percentage of immediately placed implants enabling a more ideal placement of the implant.
occurred in the maxillary molars (50%), followed by Immediate implantation was prevented in 2 of the 8
mandibular molars (80%) (Table 2). For patients with a mandibular premolars extracted because of proximity of
hopeless tooth in the anterior region, 90% of the maxillary the mental nerve. All 17 immediate implants were suc-
teeth and 100% of the mandibular teeth received immedi- cessfully placed with initial stability in the maxillary pre-
ate implants. One-year follow-up for the 61 patients who molars. One of the second premolars was close to the
received implants demonstrated that only 1 implant failed sinus; successful sinus elevation was performed internally
as a result of acute infection in the early stage of healing. using osteotomes.
Twelve patients not receive implants because of site- Of 23 patients whose treatment plan called for imme-
specific complications (Table 3). The most prominent diate implants in their anterior teeth (21 in the maxilla
challenge to immediate implant placement in this study and 2 in the mandible), the 2 implants not placed were in
was Class II or III furcation involvement zassociated with the maxillary anterior teeth because of inadequate inter-
lack of bone around maxillary molars. Figure 1 catego- proximal bone (Figure 4).
rizes the challenges for implant placement in these 12 pa-
tients. Results for the 12 implants not placed are as Discussion
follows: Dental patients place a high priority on esthetic and
A total of 5 implants were not placed in maxillary mo- functional restorations, leading to a rise in the popularity of
lars, 3 because of severe Class III furcation involvement immediate implants, particularly in anterior teeth; however,
(see Figure 2 for example), and 2 because of extensive pe- immediate implants cannot be achieved in every clinical sit-
riapical lesions next to the sinus (Figure 3). In clinical pre- uation. Preoperative clinical examination, radiographs, and
sentations postextraction of the Class III furcation 3-dimensional imaging are needed to assess the quantity
involvement, it was observed that no inter-radicular bone and quality of bone, as inadequate amounts of either will
was present in the socket to aid in implant anchorage or lead to lowered success rates.16, 17

Table 2 Percentage of implants placed per arch segment.

Maxillary Mandibular
Total Anterior Premolar Molar Total Anterior Premolar Molar
Baseline 48 21 17 10 25 2 8 15
Received implant 41 19 17 5 20 2 6 12
No implant 7 2 0 5 5 0 2 3
Percentage placed 83% 90% 100% 50% 80% 100% 75% 80%

Note: Subgroups’ percentages of implant placement are related to the segment of the arch placed: anterior, premolar, and molar zones.

Vol. 4, No. 6 (Suppl 1) Dental Learning / June 2010 3

 Site-Specific Complications that Prevented Reasons for not placing implants
Table 3
Immediate Implant Placement 5
4

Numbers
Upper Anteriors
Complication Number of 3 Upper Molars
patients affected 2 Lower Premolars
1 Lower Molars
Periapical lesions next to sinus 2
Horizontal severe interproximal bone loss 2 0 t
ity BL en ity ng
Advanced furcation involvement Classes II and III 3 x im lS em im eni
a x
pr
o
xi
m lv
pr
o op
Proximity to inferior alveolar nerve and vo aw
nus p ro
n
in r ve j
mental foramina 4 Si er tio Ne ite
d
nt ca
Limitation of mouth opening 1 a li r L i m
on
t Fu
oriz Challenges
H

A case series report is presented of the 12 patients who
did not receive implants at the time of tooth extraction.
The challenges and recommendations based on the region
of the affected tooth are discussed and a set of guidelines
presented based on the case series findings.
Challenges to Immediate Implantation
Molars
As the literature documents, the maxillary molars rep-
resent the most challenging area for the placement of im-
mediate implants.18-21 Research has demonstrated that
when preoperative radiographs and probing depths indi-
cate bone loss and poor level of bone quality, implant fail-
ure can be anticipated.22 This correlated with the
surgeon’s sensation of limited bone resistance during the
procedure.23 A recent study showed that a surgeon’s tac-
tility of dense or poor bone during implant placement is
comparable to Periotest values, the implant stability quo-
tient and placement torque.24 The failure rate of implants
increases when associated with Lekholm and Zarb classi-
fied type IV bone.25
Of the 10 patients in our study who required an im-
plant in this area, it was decided that immediate implants
would not be possible for 5 of the patients, who were
found to have limited bone resistance. The decision to
place implants in the upper posterior teeth 50% of the
time likely led to a higher success rate, as none of these
implants have failed after a 1-year follow-up. Because of
our small sample size, our findings may not generalize to
other studies. Longer-term observations are essential in
these patients.
In the case shown in Figure 3, a maxillary sinus lift
was considered, as this procedure is not a risk factor for
Figure 1 — Categorization of site-specific challenges.
SBL= severe bone loss.
implant failure.26 Research has demonstrated successful
placement of non-grafted implants along with a sinus
lift27; however, this patient was considered to be better
suited for a delayed approach because of the presence of
a periapical lesion. Periapical lesions require thorough in-
strumentation and curettage before placing the implant.28
One study found a survival rate of 92% for implants in
chronically infected periapical sites29; however, a consid-
eration in the maxillary molar area is that the combina-
tion of curettage and osteotomy could push the infected
tissue through the sinus. The possibility of a sinus infec-
tion could complicate the healing and integration of the
implant, thus increasing the risk of failure.
The main reason for patients not receiving implants in
mandibular molars was the inherent challenge of anatom-
ical structures that are present in the posterior area, such
as proximity of the inferior alveolar nerve. The procedure
usually requires drilling past the socket apex to get the im-
plant engaged in native bone, a difficult step due to the
anatomy of this area. To avoid the inferior alveolar nerve,
cross-sectional imaging and spiral tomography offer reli-
able measurements.30-34 Alternatively, an experienced oral
surgeon may be able to overcome this problem by using a
wider implant, which can provide implant stability by en-
gaging the lateral walls of the socket and not necessarily
the apex of the socket, thus avoiding drilling deeper into
the native bone and reducing the risk of violating the
nerve. In our study, even with radiographic measurements
prior to the procedure, 2 patients experienced paresthe-
sia; 1 regained normal sensation after 2 months, but the

4 Dental Learning / June 2010 Vol. 4, No. 6 (Suppl 1)

A B C other patient felt some degree of paresthesia at her 4-
D E
Figure 2 — (A, B) Tooth number 3 has severe bone loss and
Class III furcation. Based on the guidelines, tooth number 3 is
not a candidate for immediate implant replacement. (C) Socket
after extraction shows no bone left for implant integration be-
cause of the severity of the furcation involvement. (D) Deminer-
alized, freeze-dried bone was placed for socket preservation
protocol. (E) Sutures in place.
A B C plant diameter, with the intention to provide implant sta-
D E F Implants were placed in 100% of the extraction sites
Figure 3 — Posterior tooth (tooth number 3) with periapical le-
sion and sinus proximity: (A) Radiograph before surgery showing
periapical lesion and proximity to sinus. (B) Photograph before
extraction showing tooth fracture. (C) Defect site following ex-
traction. (D) Tooth extracted in pieces because it fractured ini-
tially, with evidence of cyst at apex. (E) Resorbable barrier
placed over allogeneic graft. (F) Sutured tissue.
A B C lar alveolar nerve presented a challenge. For this reason,
D E F
Figure 4 — Anterior tooth (tooth number 8) with interproximal
bone loss greater than 50%: (A) Radiograph before surgery
showing severe bone loss. (B) Tooth before surgery. (C) Tooth
extracted with no complications. (D) Debridement revealing se-
vere interproximal bone loss. (E) Particulate allogeneic bone
graft placed. (F) Provisional removable partial denture in place.
Vol. 4, No. 6 (Suppl 1)
month evaluation.
A challenge in immediate implant placement in a
mandibular second molar occurred in a patient who had
limited mouth opening. Implants require osteotomy past
or close to the apical portion of the socket using a drill
extender. Depending on the implant system, the extender
can be 15 mm to 20 mm in length. When added to a drill
size of 20 mm plus the head of the handpiece, the total
length necessary to perform an osteotomy with proper an-
gulation into a posterior socket is substantial. Therefore,
patient selection for an immediate implant should include
assessment of the temporomandibular joint, related dis-
orders, and degree of mandibular opening before surgery.
The problem may be solved by the use of a different im-
bility by engaging the lateral walls of the socket without
drilling beyond the apex of the socket.
Premolars
of the upper premolars, while the mandible had 75%
placement in the extracted lower premolars (Table 2). One
reason for this difference between maxillary and mandibu-
lar premolars is the presence of anatomical structures. Im-
mediate implants require use of longer implants to engage
the bone beyond the apex to attain initial stability. In the
maxillary premolars, this is not a challenge because it is
not compromised by the proximity to a sinus, and a sinus
lift procedure can be performed if necessary. In the
mandible, however, the mental foramen and/or mandibu-
2 patients did not receive lower premolar implants. Con-
sideration should be given to the fact that osteotomies to
place a wider implant may pose the risk of damaging the
neighboring teeth.
Anterior teeth
In this study there were no challenges for immediate im-
plants in the anterior mandibular region. It should be noted
that this study had a small sample size, however. The sym-
physeal region of bone was of good quality and was well
corticalized. Long-term research of immediate implants in
this area has yielded a 99% success rate after 15 years.35
Dental Learning / June 2010 5
 Table 4 Guidelines for Immediate Implant Placement in Anterior Zone
Class Clinical and radiographic findings
1 Normal periodontium
2 Up to 30% bone loss in interproximal area*
3 30%-50% bone loss in interproximal area*
4 ≥50% bone loss in interproximal area*
5 Any of above hopeless teeth class associated with recession and loss of
keratinized gingiva
6 Any of above hopeless tooth class associated with periapical lesions extending
into interproximal bone
*Percentage of bone loss can be estimated radiographically based on the amount of bone loss related to the root length.
The challenge with the maxillary anterior teeth was in-
terproximal bone loss which makes planning an esthetic
restoration difficult. In this study, 2 maxillary anterior im-
plants were not placed because of inadequate interproxi-
mal bone ≥ 50% of the root length of the extracted tooth.
Sites with partial loss of the buccal
plate in the anterior zone will
result in successful implant
placement only if there is mild or
no interproximal bone loss and
enough keratinized gingiva.
The interproximal bone is critical in the anterior zone to
support the papillae and to provide an esthetic and func-
tional result. When we evaluated the socket after extrac-
tion of tooth number 8, we noticed that there was severe
bone loss beyond 50% of the neighboring teeth (Figure
4). Radiographic evaluation before surgery revealed se-
vere bone loss around tooth number 8, and both mesials
of teeth numbers 7 and 10 had bone loss that exposed
more than 50% of the roots. Placing an immediate im-
plant in such patients would lead to a long crown-to-root
ratio and loss of papillae. For the patients with that clin-
ical presentation, it was decided that site development
procedures and delayed implant placements would be the
beneficial approach. Initial radiographs and probing
depths can reveal interproximal bone loss; however, cau-
6 Dental Learning / June 2010
Immediate implant
Possible
Possible
Possible but not recommended
Not recommended
Not recommended
Not recommended
tion must be taken with radiographic measurements be-
cause they can overestimate bone compared with surgical
measurements.36,37
Sites with partial loss of the buccal plate in the anterior
zone will result in successful implant placement only if
there is mild or no interproximal bone loss and enough
keratinized gingiva. The implant could be placed slightly
more to the palate with the consideration that the final
implant position will allow the restoration to remain es-
thetic and functional. If there is loss of the buccal plate
and associated gingival recession with loss of keratinized
gingiva, it is recommended that the clinician avoid placing
the implant immediately after extraction, and allow for
adequate time for healing.
Guidelines for Immediate Implant Placement in the
Posterior Zone
Immediate implants should not be recommended in
every patient. When replacing posterior teeth, an imme-
diate implant should be avoided for the following reasons:
• Difficulties in positioning the implant in the center of
the socket because of shape and size of radicular bone
and the socket anatomy
• Maxillary molars with periapical lesions adjacent to
the sinus
• Class II and Class III advanced furcation involvement
• Proximity of mandibular premolars and molars to the
inferior alveolar nerve and mental foramina
• Limitation of mandibular opening
• Gingival recession associated with lack of keratinized
gingival.
Vol. 4, No. 6 (Suppl 1)
Guidelines for Immediate Implant Placement in the
Anterior Zone
Immediate implants are more popular in the anterior
area because of esthetic demands; however, practitioners
should not rush into doing immediate implants without a
comprehensive patient evaluation. Based on the findings
in this study, guidelines have been established to classify a
hopeless tooth and whether an immediate implant can be
placed based on its clinical and radiographic presentation
(Table 4).
Conclusion
The small sample size in this study may not provide a
comprehensive picture of the challenges that practitioners
face when placing immediate implants, but the recom-
mendations and guidelines provided should help practi-
tioners choose the right candidate for immediate implants
to ensure more successful treatment outcomes. Clinicians
must use their best judgment to make a final decision, tak-
ing into consideration many influencing factors, such as
malposition of the hopeless tooth in the socket, the size
of the extracted site, and the direction of the neighboring
roots. Orthodontic treatment may be advised to obtain
the ideal treatment outcome. It is worth noting that spe-
cialized procedures exist to help overcome some of these
challenges (eg, lack of keratinized gingiva and bone) by
combining soft-tissue and bone-grafting procedures with
implant placement.38
Acknowledgement: This research was partially funded
by Nobel Biocare and the University of Buffalo Center for
Dental Studies, Buffalo, New York.
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