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Case Study
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Immediate Loading of Non-Conical Single Implants Placed in Extraction Sockets: A Modified Drilling Sequence

Learning Objectives:

This case presentation describes a surgical rationale and procedure for immediately placed single-tooth implants in postextraction sockets. Upon completing this case study, the reader should:

  • Be able to identify the critical factors that are required to ensure successful outcomes in immediately loaded single-tooth implants.
  • Gain understanding of the aesthetic advantages of placement of implants into fresh extraction sockets.


Dental implant manufacturers have developed specific drilling sequences to ensure optimum results with respect to osseointegration. The recommended drilling procedure, however, accounts for clinical applications where traditional implant loading protocols (which include a healing period prior to restoring the implant and subsequent exposure to occlusal forces) will be followed.  

While immediate loading of a full-arch prosthesis has been shown to be a viable approach,the immediate loading of single implants requires additional considerations. Since splinting cannot be counted on to control occlusal forces under these circumstances, implants placed into extraction sockets that are immediately loaded may require a higher degree of stability to prevent micromotion and fibrous tissue proliferation along the implant surface, which may result in decreased bone-to-implant contact and potential fixture failure. Nevertheless, minimum insertion torque requirements for the successful integration of immediately loaded single-tooth implants placed into fresh extraction sockets remain to be determined. Reports by Wörhle and Cannizaro et al suggest that insertion torques of 45 Ncm seem adequate in terms of achieving sufficient primary stability for immediate loading of single-tooth implants. Conversely, Pinheiro Ottoni et al reported a high degree of failures when implants where placed at 20 Ncm and immediately loaded.  

The following protocol was developed with the purpose of increasing the insertion torque and stability of implants exhibiting a non-conical apical design placed into fresh extraction sockets. Additionally, it should enable clinicians to pursue immediate loading with a provisional restoration.   

Implants exhibiting a non-conical apex may be placed into fresh extraction sockets utilizing a flapless approach and immediately loaded to successfully replace individual teeth. A modified drilling sequence has been proposed to increase torque insertion and improve implant stability. Immediate placement of a provisional restoration may be essential to adequately support the peri-implant tissues. This approach may be particularly advantageous in the anterior maxilla, where maintenance of gingival margin levels is required to achieve a predictable aesthetic result.  




*Director, Postdoctoral Periodontal Prosthesis Program and Clinical Professor, Department of Periodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, PA; private practice, Bryn Mawr, PA.


Related Reading:

  1. Schnitman P, Wöhrle PS, Rubenstein JE, et al. Ten-year results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Impl 1997;12(4):495-503.
  2. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: Ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants 1997;12:319-324.
  3. Balshi TJ, Wolfinger GJ. Immediate loading of Brånemark implants in edentulous mandibles: A preliminary report. Implant Dent 1997;6:83-88.
  4. Ganeles J, Wismeijer D. Early and immediately restored and loaded dental implants for single-tooth and partial-arch applications. Int J Oral Maxillofac Impl 2005;20:769-776.
  5. Testori T, Meltzer A, Del Fabbro M, et al. Immediate occlusal loading of Osseotite implants in the lower edentulous jaw: A multicenter prospective study. Clin. Oral Impl Res 2004;15:278-284.
  6. Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. Pract Periodont Aesthet Dent 1998;10:1107-1114.
  7. Cannizaro G, Leone M, Esposito M. Immediate functional loading of implants placed with flapless surgery in the edentulous maxilla: 1-year follow-up of a single cohort study. Int J Oral Maxillofac Implants. 2007 Jan-Feb;22(1):87-95
  8. Pinheiro Ottoni JM, Lima Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Impl 2005;20:769-776.
  9. Skalak R, Zhao Y. Interaction of force-fitting and surface roughness of implants. Clin Impl Dent Relat Res 2000;2:219-224.
  10. Araújo M, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss collagen on healing of an extraction socket: An experimental study in the dog. Int J Periodont Rest Dent 2008;28(2):123-35.
  11.  Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodont Rest Dent 2006;26(1):19-29. 
  12. Lee EA. Transitional custom autments: Optimizing aesthetic treatment implant-supported restorations. Pract Periodont Aesthet Dent 1999;11(9):1027-1034.
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