funato.qxd 7/27/07 11:47 am page 312 · classification of immediate implant placement sites the...

The International Journal of Periodontics & Restorative Dentistry

Funato.qxd 7/27/07 11:47 AM Page 312

The key to successful implant therapyin the anterior esthetic region is a har-monious relationship between theimplant-supported restoration and theremaining natural teeth. The creation ofa natural-looking implant restorationdepends not only on the appropriateplacement of an osseointegratedimplant and restoration, but also onthe reconstruction of a natural gingivalarchitecture around the implant that isin harmony with the lip line and face.To achieve this goal, an implant mustbe conceptually planned and placed asa vertical extension of an optimally visu-alized restoration, as described byGarber and Belser in their concept of“restoration-driven implant treatmentplanning.”1,2 This approach involvesthree-dimensional (3D) treatment plan-ning, followed by placement of theimplant in a position that is optimal forboth function and esthetics. The initial3D evaluation of the potential site mustinclude planning for augmentation orpreservation of the existing osseousand gingival tissues around the com-promised tooth. This should be an inte-gral part of the process, because it isknown that extraction is always fol-lowed by some bone resorption, with

Timing, Positioning, and SequentialStaging in Esthetic Implant Therapy: A Four-Dimensional Perspective

Akiyoshi Funato, DDS* Maurice A. Salama, DMD** Tomohiro Ishikawa, DDS*** David A. Garber, DMD** Henry Salama, DMD****

Many articles address the predictability of immediate implant placement intoextraction sockets; however, there are only a few reports that mention the indica-tions and limitations of this technique. The aim of this article is to re-examine specific indications for immediate implant placement and to clarify the timing or“fourth dimension” relative to extraction and implant placement. The expandedconcept of four-dimensional implant treatment planning involves the new axis of time, which must be considered along with the traditional spatial or three-dimensional management of implant positioning. (Int J Periodontics RestorativeDent 2007;27:313–323.)

*Private Practice, Kanazawa, Ishikawa, Japan.**Clinical Assistant Professor, Department of Periodontics, University of Pennsylvania,

Philadelphia, Pennsylvania; Medical College of Georgia; Private Practice, Atlanta,Georgia.

***Private Practice, Hamamatsu, Shizuoka, Japan.****Clinical Assistant Professor, Department of Periodontics, University of Pennsylvania,

Pennsylvania; Private Practice, Atlanta, Georgia.

Correspondence to: Dr Maurice Salama, 600 Galleria Parkway, Suite 800, Atlanta, GA,30339; fax: +404-261-4946.

313

Volume 27, Number 4, 2007


concomitant soft tissue recession.3–5

To achieve the optimal esthetic result,clinicians must go beyond using themost appropriate clinical techniquesand armamentarium and must con-sider a fourth dimension: timing of thetreatment sequence. This additionalcomponent in treatment planningincorporates the optimal sequentialstaging or timing of (1) tooth extraction,(2) preservation or enhancement ofhard and soft tissue, (3) implant place-ment, (4) abutment connection, (5) tis-sue modeling with a provisional and/ora modified abutment, and (6) definitiverestoration. This additional axis of timeis added to the traditional 3D axes anddescribed herein as the four-dimen-sional (4D) concept in implant therapy.

Successful esthetic implant ther-apy, then, has several sequentialobjectives:

1. Restoration-driven 3D implantreplacement, ie, placement of theimplant in the optimal position toeffectively support the restorationand surrounding soft and hard tissue

2. Any necessary reconstruction ofan esthetic gingival soft tissueframe incorporating the harmonyor curvature to the labial free gin-gival margin aspect of the restora-tion with the definitive vertical andbuccolingual presence of adjacentinterdental papillae

3. A provisional restoration to main-tain or modify the degree of cur-vature of the labial free gingivalmargin and provide the necessarylateral support for the interproxi-mal papillae

4. Placement of a definitive restora-tion that is in harmony with the

adjacent natural teeth and sur-rounding soft tissue, with identicalgingival color

The actual timing of tooth extrac-tion, implant placement, and abutmentconnection will ultimately influence thespecific outcome by limiting the num-ber of individual auxiliary procedureswhile enhancing predictability.Conceptually, then, it reduces thepotential number of surgical/restorativeinterventions, shortening the treatmentspan and thereby enhancing estheticpredictability. Immediate implantplacement has been well documentedin the literature, and the data indicatesimilar predictability versus the stagedapproach.6–11 Ongoing improvementsin resorbable membranes have helpedexpand the potential indications forimmediate implant placement withdecreased complications duringguided bone regeneration (GBR).

Today, there is still a dichotomy ofthought regarding the timing of extrac-tion and implant placement, and it isthe authors’ contention that no singlemethod is a panacea; rather, there arespecific clinical indications for each.The aim of this article is to re-examinespecific indications for immediateimplant placement and to clarify thetiming or fourth dimension relative toextraction and implant placement. Theexpanded new concept of 4D implanttreatment planning involves time,which must be included with the tra-ditional spatial or 3D management ofimplant positioning.

The timing of tooth extraction andimplant placement is classified as follows:

• Class 1: Extraction, with immediateimplant placement directly into thealveolar socket via (a) “incisonless”implant placement or (b) the rais-ing of a mucoperiosteal flap andplacement of the implant into theextraction socket concomitant witheither (i) osseous augmentation orGBR or (ii) a connective tissue orallograft.

• Class 2: Early implant placement.The implant is placed after extrac-tion, and soft tissues are allowed toheal for 6 to 8 weeks. GBR can beperformed at the time of extractionand/or at the time of implantplacement.

• Class 3: Delayed implant place-ment. The implant is placed a min-imum of 4 to 6 months after extrac-tion, with preservation of thealveolar ridge using grafting tech-niques and/or GBR, either at thetime of extraction or concomitantwith implant placement. Soft tissuereconstruction in these cases willinvariably be required.

Based on this classification, a toothtargeted for immediate implant place-ment should be diagnosed as nonsal-vageable for the following reasons: (1)endodontic failure, (2) internal and/orroot resorption, (3) subcrestal exten-sive caries, or (4) root fracture.Conceptually, the targeted toothdemonstrates no osseous compro-mise; clinically, the bone on the imme-diately adjacent teeth should be eval-uated as to the relative height of theinterproximal height of bone (IHB),12,13

since it is this IHB on the adjacent tooththat effectively determines the absenceor presence of a natural papilla.

314


Funato.qxd 7/27/07 11:47 AM 14

It has been determined that a dis-tance of 4.5 mm from the desired con-tact point, or from the tip of a papillato the peak of the interproximal heightof bone on the teeth adjacent to theimplant site, is the mean dimensionfor the predictable presence of a “full”papilla.12 Immediate implant place-ment into these types of extractionsockets with four walls shows betteresthetic predictability than the replace-ment of teeth with periodontal com-promise. If the targeted tooth or anyadjacent tooth shows an IHB with adistance in excess of 4.5 mm, thendelayed placement is preferable, withpreemptive orthodontic treatment ofthe tooth to be extracted or subse-quent orthodontic treatment of theadjacent teeth to ensure esthetic pre-dictability. In many cases, orthodonticeruption, as a preliminary step toextraction with immediate implantplacement, even in a type 1 site, pro-vides the clinician the esthetic andmechanical advantages of addedosseous support to compensate forthe bone loss inevitable with extrac-tion. This is particularly necessary inAsian patients, who often haveextremely thin labial plates of bone inthe maxillary anterior region. In thesethin scalloped biotypes, even thougha thin labial alveolar bone is present fol-lowing implant placement, 1 to 3 mmof gingival recession invariably occursover time following the connection ofthe abutment because of remodelingof the hard and soft tissues aroundimplants.14–16

Potential or future extraction sitesare now routinely augmented verti-cally by orthodontics from a class 2 toa class 1 site (based on the classifica-tion system described in next section)when needed.

Classification of immediateimplant placement sites

The classification detailed below andin Table 1 is based on both the osseousand soft tissue levels of the potentialsite at the time of extraction.

• Class 1: The buccal bone is intact,with a thick gingival biotype.“Incisionless” implant placementwithout flap reflection is viable (Fig 1).

• Class 2: The buccal bone is intactwith a thin, more scalloped gingi-val biotype. Incisionless implantplacement is viable, but in combi-nation with a connective tissuegraft or a subsequent secondaryconnective tissue graft (staged)(Fig 2).

• Class 3: The buccal bone is lost,but the implant can still be placedimmediately within the remainingalveolar housing of the extractionsocket, with the necessary osseoussupport provided through regen-eration using a membrane withGBR and incorporating a simulta-neous connective tissue graft.Depending on the degree of com-promise to the buccal plate, thecase may alternatively be handledin a staged approach using asocket augmentation procedureand subsequent implant place-ment. In many instances, especially

Orthodontic extrusion

Salama and Salama17 reported on theadvantages of orthodontic eruption asa preliminary step to implant place-ment. These include the following:

1. It decreases or minimizes the“gap” between the implant bodyand the extraction socket by coro-nally relocating a narrower por-tion of the root for extraction andtherefore resulting in a smaller-diameter socket.

2. It helps enhance primary stabilityin the alveolus by developing thealveolar bone beyond the rootapex.

3. It augments the crestal alveolarbone and overlying gingival tis-sues, decreasing the negativeimpact of postoperative alveolarresorption and gingival recession.

4. By loosening the tooth, it helpsfacilitate extraction.

5. It increases the mitotic turnover ofthe cells in the region, enhancingthe potential for more rapid healing.

Orthodontic eruption should beused to generate at least 2 mm ofadditional vertical gingival tissue ascompared to the adjacent teeth to pro-vide for a harmonious gingival arrange-ment. After a 12-week period of reten-tion, the alveolar osseous crest on thefacial and interproximal aspects is con-firmed by bone sounding. In addition,a computerized tomographic scan canbe performed to evaluate whetherthere is sufficient bone available tofacilitate extraction with immediateimplant placement without resultantesthetic compromise.

315



316


Fig 1a (left) This case is categorized asclass 1. Following orthodontic extrusion, themaxillary left central incisor was extracted.The existing buccal bone was confirmed bybone sounding with a periodontal probe. Athick biotype was diagnosed.

Fig 1b (right) An implant was placed “inci-sionless” without flap reflection, and a pro-visional restoration was placed immediately.

Fig 1c (left) Facial view of the definitiveimplant analog and definitive abutment. Anabutment access hole cannot be seen, con-firming that the extended long axis of theimplant would not be labial to the incisaledge of the restoration.

Fig 1d (right) Facial view of the definitiverestoration.

Table 1 Classification of immediate implant placement

Viable Expected results Indication forimplant placement of immediate immediate

Class Buccal bone technique implant placement implant placement

Class 1 Intact with thick Immediate without Optimal Yesgingival biotype flap reflection

Class 2 Intact with thin Immediate with Good Yesgingival biotype CTG or staged CTG

Class 3 Deficient but implant Simultaneous Acceptable Limitedplacement possible in immediate with GBRremaining alveolar housing and CTG or followedof extraction socket by staged CTG

Class 4 Deficient and Delayed Unacceptable Noimplant may deviatefrom alveolar housing

CTG = connective tissue graft.


317


Fig 2a (left) This case is categorized asclass 2. At the initial examination, an amal-gam tattoo and root fracture were evidentat the maxillary left central incisor.

Fig 2b (right) The amalgam tattoo tissuewas surgically excised, and a subepithelialconnective tissue graft was placed.

Fig 2c (left) Orthodontic eruption of thetooth intended for extraction was per-formed; following confirmation of theresulting bone level, both interproximallyand labially, the tooth was extracted withthe aid of a periotome.

Fig 2d (right) Surgical guide in positionprior to implant placement. The implantwas placed, and an immediate provisionalrestoration, employed for both immediateesthetics and to provide optimal support forthe soft tissues, was placed.

Fig 2e (left) Facial view of the definitiverestoration on the maxillary left centralincisor. A diminished or concave labial con-tour and positive interproximal supportmaintain the form of the free gingival mar-gin and the height of the papillae.

Fig 2f (right) Postoperative radiograph at1 year.


in thin biotypes, this method pro-vides a more predictable and saferoutcome (Fig 3).

• Class 4: The buccal bone is severelycompromised, and implant place-ment within the remaining palatalbone results in a significantly off-axis implant position. In these cases,following extraction, implant place-ment should be delayed. If per-formed immediately, the long axisof the implant inclines toward thebuccal and will result in a significantesthetic compromise of the defini-tive restoration. In these situations,the delayed approach should beused with subsequent 3D bone andsoft tissue augmentation of the defi-cient ridge followed by optimalimplant positioning.

In evaluating a potential site, caremust be taken to ensure that the clini-cian’s attempts to expedite implantplacement within the available bonedo not result in an implant that tends toextrude labially, thereby compromis-

ing the restorative esthetics. The longaxis of the implant should be placed lin-gual to the incisor edge whenever pos-sible to allow for both mechanical andsurgical advantages in the definitiveoutcome. The lab will have more spaceto work with porcelain and to hide theprosthetic components, the restorativeclinician will have more room to estab-lish a proper emergence profile, andthe surgeon will have less pressureplaced onto the labial tissues.

Implant positioning, theresulting long axis, and softtissue considerations

Vertical depth of implant headand direction of long axis

The platform of the implant should belocated 2 to 4 mm below the midfacialaspect of the free gingival margin, withthe extended long axis directedslightly lingual to the incisal edge of thedefinitive restoration (Fig 4). When the

long axis of the implant is inclined labi-ally and projects beyond the incisaledge of the definitive restoration, theresult is that the subgingival contoursof the abutment or restoration will tendto deflect the gingival margin apically,resulting in an unharmonious estheticprofile.18 To correct this problem, theprofile extending from the implanthead to the free gingival marginrequires a straight or negative angula-tion. Immediate placement generallycannot be performd in the wrong posi-tion without esthetic compromise.

Buccolingual position and labialregion

Tarnow et al19 stated that a submergedimplant, following abutment connec-tion, will develop a vertical change in theosseous topography of 1.5 to 2 mmbelow the implant shoulder. In addition,circumferentially, or horizontally, this willcreate crater-shaped or horizontal/lateralbone resorption of 1.3 to 1.4 mm.16

318


Fig 3c Facial view of the definitiverestoration. While an “adequate” estheticoutcome was achieved, a small depressionis evident in the buccal cervical region.

Fig 3a This case is categorized as class 3.Extraction with immediate implant place-ment was performed despite compromiseto the buccal bone, but the implant wasretained within the confines of the alveolarhousing.

Fig 3b Connective tissue grafting in com-bination with GBR was used, incorporatinga resorbable membrane. The connective tis-sue graft was used to optimize the estheticsoft tissue profile.


Grunder et al20 stated that at least 2mm of lateral alveolar bone must bepresent beyond the body of the implantto compensate for the effects of boneremodeling. In the case of extractionwith immediate implant placement, animplant should be placed lingually,avoiding the coronal 5 mm of labialbone and allowing for a gap of less than2 mm, measured laterally from theperiphery of the implant to the labialaspect of the socket. Grunder et al indi-cated that to support the gingival pro-files, at least 2 mm of bone are neces-sary at the head of the implantmeasured laterally to allow for sufficientbone to remain in the esthetic positiondespite the naturally occurring horizon-tal cratering. Therefore, in any extractionwith immediate implant placement,despite the necessity of maximizing thegap at 2.2 mm,21 it may be necessary toincrease the size of this gap and actuallyrefill it with a grafting material.7,22 Thiswill ensure that, following horizontalbone remodeling, 1.5 mm of bone willstill remain lateral to the buccal aspect

evident, then, that prior to implantplacement, a thorough evaluation ofthe periodontal biotype is necessary;with the thin biotype, connective tissuegrafting may be necessary to reducesoft and hard tissue compromise.

Mesiodistal position relative tothe interdental zone

The head of an implant is positionedrelative to the osseous on the directlabial; depending on the implant sys-tem used and particular philosophy, itis placed level or just coronal to it, oreven slightly below the midcrestalbone. Of necessity and because of theflat head design of most implant sys-tems, the interproximal aspect willextend well below the interproximalheight of bone. This distance will varywith the periodontal biotype, endingup considerably deeper in the scal-loped as opposed to the flat biotype.Salama et al12 have developed a clas-sification system for the predictable

of the extraction socket followingresorptionto support the vertical heightof the soft tissue. Implant designs thatreportedly minimize crestal bone loss asa result of the abutment connectionhave recently been suggested.23–25

Elimination of abutment-to-implantmicromovement, development of a hermetic bacterial seal, or the use of“platform switching” (smaller abutmentwith wider implant platform) couldmake esthetic implant treatment—particularly with adjacent implants—more esthetically predictable.24,25

However, the data on these potentialsolutions are still being evaluated.

Maynard and Wilson26 related therisk of potential gingival recession tothe gingival biotype and underlyingalveolar bone. They indicated that abiotype with thin gingival tissue andthin alveolar bone has the highest riskof gingival recession.26 Kan et al27

reported that the thick gingival bio-type has a more coronal level of gin-gival margin, with greater predictabil-ity than thin gingival biotype. It is

319


Fig 4 Examples of the positions of imme-diately placed implants following orthodon-tic extrusion. These positions are classifiedbased on both the osseous and soft tissuelevels at the potential site at the time ofextraction. Ideally, the implant engages thepalatal wall of the extraction socket, and theextended long axis is directed slightly lin-gual to the incisal edge of the definitiverestoration. Immediate placement generallycannot be performed in the wrong positionwithout esthetic compromise.

Ideal position Acceptable positions Wrong position


height of the interdental papillae, asdetermined by the restorative ele-ments on either side of the implantsite (Table 2, Fig 5). The six classifica-tions are differentiated by whether apapilla has a tooth, a pontic, or animplant on either side of it. Their dataindicated that the vertical height fromthe tip of the interdental papillabetween two implants was in excess of2 mm less than that between animplant and a pontic; this resulted in amuch shorter papilla and a longerrestorative contact point.12 This classi-fication system and its associated treat-ment planning algorithm allow the clin-ician to prognostically plan for estheticsoft tissue contours by selecting the

most appropriate fixed restorativeoption based upon the available ver-tical bone support.

The numeric values just describedmay well be a result of the difference inthe attachment modality of soft tissuein the natural tooth or pontic asopposed to the implant, in combina-tion with the result of the remodeling ofthe peri-implant bone following abut-ment connection. The Salama et al12

classification also described the hori-zontal dimension necessary betweenthe restorative elements to facilitatethe predictable presence of a papilla—for instance, the implant-to-implantdimension should, at a minimum, be 3mm, whereas the necessary dimension

between an implant and a tooth can beconsiderably less, at only 1.5 mm.20,28

It is their contention that, with the pres-ent design of implants, the use of apontic between implants improves therelative height of the papillae and theoverall esthetic gingival outcome.23–25

Evolving changes in implant design,such as the single-body design or atwo-piece implant system with a bio-logically “invisible” connection, maydecrease the potential for crestal boneremodeling and resultant soft tissuechanges. In addition, it appears fromthe work of Abrahamson et al29 thatevery incident of abutment connectionand disconnection enhances theprocess of bone remodeling.

The 4D concept in complexcases

In multiple-implant cases associatedwith bone defects (Fig 6), the use ofstrategically timed serial extractions isexceedingly important to support afixed provisional restoration duringridge reconstruction and implant sitedevelopment. Key abutments areselected at optimal positions to sup-

320


Fig 5a (left) Classification of interproximalbone height (IHB). 1 = Optimal result; IHB 2mm from the cementoenamel junction (CEJ)and 4 to 5 mm from contact point. 2 =Unfavorable result; IHB 4 mm from CEJ and5 to 7 mm from contact point. 3 = Severeresult; IHB > 5 mm from CEJ and > 7 mmfrom contact point.

Fig 5b (right) Apical extent of the contactpoint (A), IHB on the natural tooth (B), andIHB on the implant (C).

Table 2 Salama et al12 classification of predicted height ofinterdental papillae

Restorative Proximity Vertical soft tissueClass environment limitations limitations

1 Tooth-tooth 1.0 mm 5.0 mm2 Tooth-pontic N/A 6.5 mm3 Pontic-pontic N/A 6.0 mm4 Tooth-implant 1.5 mm 4.5 mm5 Implant-pontic N/A 5.5 mm6 Implant-implant 3.0 mm 3.5 mm

1

2

3

AA

B

C C C

4.5 mm

3.5 mm


321


Fig 6a Case 4. Preoperative facial view.The maxillary anterior teeth show collapseof the supporting bone.

Fig 6d Implants were placed in the posi-tions of the right first molar, right first premo-lar, right central incisor, and left canine withsinus augmentation and GBR. The right cen-tral incisor site was an immediate placementsite categorized as a class 3. At the rightcanine site, which was categorized as class 1,extraction and immediate implant place-ment were postponed until the previouslyplaced implants were integrated and placedinto function in the provisional prosthesis.The implant was placed toward the palate tosecure a full 2 mm of distance from the labialbone. It was determined that if the existingcontour was maintained, the IHB presenteda high potential to preserve the papillabetween the implants.

Fig 6e Lateral view of the right side afterdefinitive cementation. In the canine area,implant placement allowed for the preser-vation of the tissue around the implant. Thisnatural-looking outcome was achieved byusing the 4D concept.

Fig 6g Postoperative periapical radiographs. The bone crest between the maxillary rightcanine and first premolar was maintained at a higher level than the horizontal platform of theimplant. The appropriate interproximal height of bone was retained in the implant region.

Fig 6b The left central and lateral incisorsexhibit bone resorption beyond the apex.

Fig 6c Three-dimensional image usingcomputer simulation software exhibits thehorizontal and vertical bone defects in theanterior region.

Fig 6f The definitive result. A moderatelynatural appearance was obtained andacceptable interdental papillae maintained.


322


port a splinted full-arch provisionalrestoration while the ineffectual teethare extracted and hard and soft tis-sues are reconstructed; implants arethen placed. Following osseointe-gration, these implants are in turnused to support a new provisionalrestoration or incorporated into theexisting provisional.

The decision needs to be madeon a tooth-by-tooth basis as towhether the remaining teeth that pre-viously supported the provisionalshould be extracted and made into apontic site with socket preservationtechniques or sectioned below thecrest of the ridge and below a con-nective tissue graft to preserve or rede-velop the soft tissue esthetics. Duringimplant placement, these key naturalabutment teeth are used as guides tothe vertical potential for augmentedtissues as well as to the level of verti-cal placement of the implant. The pre-existing IHB on these remaining teethis the limiting factor in the soft tissuepotential for an esthetic restoration.Obviously these key abutments needto be relatively stable to support therestoration. These provisional abut-ment teeth demonstrate the key roleof the fourth dimension of time in 4Dimplant therapy, as the relative timingof the extractions is obviously a keycomponent in predictable implanttreatment planning.

Conclusion

A correct understanding of the indica-tions and classification for immediateimplant placement will dramatically aidthe clinician in determining an appro-priate treatment plan and time framefor individual tooth extractions andimplant placement in single implantcases as well as complex multipleimplant cases. This expansion of the3D “spatial” placement of implantsinto a 4D concept uses timing as a keyvariable in the development of estheticimplant restorations.

Acknowledgments

The authors would like to thank Dr MyronNevins and Dr Yoshiro Ono for their encour-agement and support.

References

1. Garber DA, Belser UC. Restoration drivenimplant placement with restoration-gen-erated site development. CompendContin Educ Dent 1995;16:796–804.

2. Garber DA. The esthetic dental implant:Letting restoration be the guide. J AmDent Assoc 1995;126:319–323.

3. Carlsson GE, Thilander H, Hedgegard B.Histologic changes in the upper alveolarprocess after extractions with or withoutinsertion of an immediate full denture. ActaOdontol Scand 1967;25:21–43.

4. Schropp L, Wenzel A, Kostopoulos L,Karning T. Bone healing and soft tissuecontour changes following single-toothextraction: A clinical and radiographic 12-month prospective study. Int J PeriodonticsRestorative Dent 2003;23:313–323.

5. Nevins M, Camero M, Friedland B, et al. Astudy of the fate of the buccal wall ofextraction sockets of teeth with prominentroots. Int J Periodontics Restorative Dent2006;26:19–29.

6. Lazzara RJ. Immediate implant placementinto extraction sites: Surgical and restora-tive advantages. Int J PeriodonticsRestorative Dent 1989;9:332–343.

7. Wilson TG, Schenk R, Buser D, Cochran D.Implants placed in immediate extractionsites: A report of histologic and histomet-ric analyses of human biopsies. Int J OralMaxillofac Implants 1998;13:333–341.

8. Paolantonio M, Dolci M, Scarano A, et al.Immediate implantation in fresh extrac-tion sockets. A controlled clinical and his-tological study in man. J Periodontol2001;72:1560–1571.

9. Chen ST, Wilson TG Jr, Hammerle CH.Immediate or early placement of implantsfollowing tooth extraction: Review of bio-logic basis, clinical procedures, and out-comes. Int J Oral Maxillofac Implants2004;19(suppl):12–25.

10. Chen ST, Darby IB, Adams GG, ReynoldsEC. A prospective clinical study of boneaugmentation techniques at immediateimplants. Clin Oral Implants Res 2005;16:176–184.

11. Covani U, Barone A, Cornelini R, Crespi R.Soft tissue healing around implants placedimmediately after tooth extraction with-out incision: A clinical report. Int J OralMaxillofac Implants 2004 Jul–Aug;19:549–553.

12. Salama H, Salama MA, Garber D, Adar P.The interproximal height of bone: A guide-post to predictable aesthetic strategiesand soft tissue contours in anterior toothreplacement. Pract Periodontics AesthetDent 1998;10:1131–1141.

13. Grunder U. Stability of the mucosal topog-raphy around single-tooth implants andadjacent teeth: 1-year results. Int JPeriodontics Restorative Dent 2000;20:11–17.


14. Cochran DL, Hermann JS, Schenk RK,Higginbottom FL, Buser D. Biologic widtharound titanium implants. A histometricanalysis of the implanto-gingival junctionaround unloaded and loaded nonsub-merged implants in the canine mandible.J Periodontol 1997;68:186–198.

15. Berglundh T, Lindhe J. Dimension of theperi-implant mucosa. Biological widthrevisited. Clin Periodontol 1996;23:971–973.

16. Small PN, Tarnow DP. Gingival recessionaround implants: A 1-year longitudinalprospective study. Int J Oral MaxillofacImplants 2000;15:527–532.

17. Salama H, Salama M. The role of ortho-dontic extrusive remodeling in theenhancement of soft and hard tissue pro-files prior to implant placement: A sys-tematic approach to the management ofextraction site defects. Int J PeriodonticsRestorative Dent 1993;13:312–333.

18. Saadoun AP, Le Gall M. Selection and idealthree-dimensional implant position in theanterior aesthetic zone. Int Mag OralImplantol 2003;4(4):8–18.

19. Tarnow DP, Cho SC, Wallace SS. The effectof inter-implant distance on the height ofinter-implant bone crest. J Periodontol2000;71:546–549.

20. Grunder U, Gracis S, Capelli M. Influenceof 3-D bone-to-implant relationship onesthetics. Int J Periodontics RestorativeDent 2005;25:113–119.

21. Botticelli D, Berglundh T, Lindhe J.Resolution of bone defects of varyingdimension and configuration in the mar-ginal portion of the peri-implant bone. Anexperimental study in the dog. J ClinPeriodontol 2004; 31:309–317.

22. Saadoun AP, LeGall M, Toutai B. Currenttrends in implantology: Part II—Treatmentplanning, aesthetic consideration, and tis-sue regeneration. Pract Proced AesthetDent 2004;16:707–714.

23. Wohrle PS. Nobel Perfect esthetic scal-loped implant: Rationale for a new design.Clin Implant Dent Relat Res 2003;5(suppl1):64–73.

24. Lazzara RJ, Porter SS. Platform switching:A new concept in implant dentistry forcontrolling postrestorative crestal bonelevels. Int J Periodontics Restorative Dent2006;26:9–17.

25. Baumgarten H, Cacchetto R, Testori T,Meltzer A, Porter S. A new implant designfor crestal bone preservation: Initial obser-vations and case report. Pract ProcedAesthet Dent 2005;17:735–740.

26. Maynard JG Jr, Wilson RD. Physiologicdimensions of the periodontium signifi-cant to the restorative dentist. JPeriodontol 1979;50:170–174.

27. Kan JYK, Rungcharassaeng K, Umezu K,Kois J. Dimensions of peri-implant mucosa:An evaluation of maxillary anterior singleimplants in humans. J Periodontol 2003;74:557–562.

28. Tarnow DP, Cho SC, Wallace SS. The effectof inter-implant distance on the height ofinter-implant bone crest. J Periodontal2000;71:546–549.

29. Abrahamson I, Lindhe J. The mucosal bar-rier following abutment dis/reconnection.An experimental study in dogs. J ClinPeriodontol 1997;24:568–572.

323



funato.qxd 7/27/07 11:47 am page 312 · classification of immediate implant placement sites the...

Documents