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Case Study
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Immediate Loading and Flapless Post-Extraction Single-Tooth Implant Restoration: Advantages and Indications

Learning Objectives:

Thie case presentation describes the use of a flapless immediate loading technique for implant placement. Upon completing this case study, the reader should:

  • Recognize the indications and limitations to the use of a flapless implant placement procedure followed by immediate provisionalization.
  • Understand the role of proper positioning within the vestibular bone crest for restorative success.


In implant dentistry, the extended healing period traditionally associated with prosthetic restoration remains a concern for both patients and clinicians, causing increased anxiety and inconvenience. In the aesthetic zone, delayed implant loading causes increased concern due to aesthetic demands in this region.  The safety and predictability of immediate loading have been demonstrated in a number clinical trials, both for completely edentulous patients and in cases requiring single-tooth restoration.The harmonic combination between the gingival tissues and the crown determine the aesthetic results in dental prostheses. A series of fundamental criteria are used to evaluate oral aesthetics;elements that characterize tissue morphology include: gingival health, interdental closure, gingival zenith, gingival level equilibrium, and interdental contact levels.  

With implant-supported prostheses, obtaining extraordinary aesthetic results may be complicated following tooth extraction due to inevitable alterations to the hard and soft tissues with a loss of the preexisting tissue morphology. The re-establishment of this tissue architecture isthe greatest challenge the professional must overcome in order to obtain pleasing aesthetic results. This can be achieved with the immediate function of implants, guided bone regeneration, or a combination of both. Under certain circumstances, a nonsurgical approach may be adopted (eg, orthodontic extrusion of nonviable teeth), in order to increase the amount of bone and soft tissue at proposed implant sites. Recently, immediate placement and provisionalization of single implants in the maxillary aesthetic zone have been advocated, with successful results. The use of this procedure has demonstrated more favorable aesthetics, as flap elevation can often result in gingival recession and bone resorption around natural teeth. 

To minimize the possibility of postoperative peri-implant tissue loss and overcome the challenge of soft tissue management during or following surgery, the concept of flapless implant surgery has been introduced and clinically applied to both delayed and immediate loading cases. This technique also reduces postoperative complications such as pain and swelling relative to flap elevation. The following clinical presentations depict the use of single-tooth immediate implant restoration in the anterior region with a flapless technique for immediate function.

While the use of an immediately loaded, flapless technique demonstrates considerable predictability, appropriate case evaluation and selection, meticulous treatment planning, and the use of precise surgical and prosthetic techniques are crucial to treatment success.




*Private practice, Cattolica, Italy.


Related Reading:

  1. Salama H, Rose LF, Salama M, Betts NJ. Immediate loading of bilaterally splinted titanium root-form implants in fixed prosthodontics. A technique reexamined: Two case reports. Int J Periodont Rest Dent 1995;15(4):344-361.
  2. Schnitman PA, Wöhrle PS, Rubenstein JE, et al. Ten years results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Impl 1997;12(4):495-503.
  3. Testori T, Meltzer A, Fabbro MD, et al. Immediate occlusal loading of osseotite implants in the lower edentulous jaw. A multicenter prospective study. Clin Oral Impl Res 2004;15(3):278-284.
  4. Degidi M, Piattelli A, Felice P, Carinci F. Immediate functional loading of edentulous maxilla: A 5-year retrospective study of 388 titanium implants. J Periodont 2005;76(6):1016-1024.
  5. Andersen E, Haanaes HR, Knusten BM. Immediate loading of single-tooth ITI implants in the anterior maxilla: A prospective 5-year pilot study. Clin Oral Impl Res 2002;13(3):281-287.
  6. Cooper L, Felton DA, Kugelberg CF, et al. A multicenter 12-mounth evaluation of single-tooth implants restored three weeks after 1-stage surgery. Int J Oral Maxillofac Impl 2001;16(2):182-192.
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  8. Belser UC. Esthetics checklist for the fixed prosthesis. Part II: Biscuit-bake try-in. In: Schärer P, Rinn LA, Koop FR (eds). Esthetic Guidelines for Restorative Dentistry. Chicago, IL: Quintessence Inc, 1982:188-192.
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  11. Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single implants: A surgical and prosthodontic rationale. Pract Periodont Aesthet Dent 2000;12(9):210-218.
  12. Ramfjord SP, Costich ER. Healing after exposure of periosteum on the alveolar process. J Periodontol 1968;38(4):199-207.
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  17. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodont Rest Dent 2005;25(2):113-119.
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  22. Botticelli D, Berglundh T, Linde J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-828.
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