Received: 22 June 2017 Revised: 26 June 2018 Accepted: 9 August 2018

DOI: 10.1111/cid.12669

ORIGINAL ARTICLE

Single tooth implants in the esthetic zone following a two-

stage all flapless approach: A retrospective analysis
Lukas Hingsammer DDS, MD, PhD1,2 | Bernhard Pommer DDS, PhD1 |
1 1
Rudolf Fürhauser DMD, MD | Georg Mailath-Pokorny DDS, MD, PhD |
Robert Haas DDS, MD, PhD1 | Dieter Busenlechner DDS, PhD1

1
University Hospital of Zurich, Department of
Cranio-Maxillo-Facial and Oral Surgery, 8091 Background: Due to chronic inflammation or trauma facial bone is frequently missing after tooth
Zurich, Switzerland loss in the esthetic zone. As a consequence, procedures to augment or at least to preserve bone
2
University Hospital of Linz, Department of are frequently necessary prior to implant placement.
Maxillofacial Surgery, Linz, Austria
Purpose: The aim of this retrospective case series is to demonstrate the applicability of a staged
Correspondence
all-flapless concept to establish satisfactory implant restorations following situations of partial
Lukas Hingsammer, Academy for Oral
Implantology, Lazarettgasse 19/DG, A-1090 missing facial bone in the esthetic zone.
Vienna, Austria. Materials and Methods: Radiological/clinical data of 25 patients were analyzed and an esthetic
Email: [email protected] evaluation of 24 patients was performed. The staged concept included ridge preservation at
time of tooth extraction and delayed guided implant placement. Marginal bone loss was mea-
sured radiologically and esthetic evaluation was performed based on standardized photographs
using the Pink Esthetic Score as well as the Papilla Index.
Results: Implant success rate revealed 100%. The mean radiological peri-implant marginal bone
loss measured 1.16 mm (SD: 0.16). Regarding the esthetic outcome 71% of patients were evalu-
ated with a Pink Esthetic Score higher or equal to 10 constituting satisfactory esthetics (median
pink esthetic score: 10). The mean follow-up time for clinical and radiographic analysis was
1.3 years (SD: 0.6 years) and 1.2 years (SD: 0.6) for esthetic evaluation.
Conclusion: Although marginal bone loss cannot be avoided, the staged concept of flapless ridge
preservation and subsequent delayed flapless guided implant placement carries the potential to
improve esthetics of single-tooth implants in the anterior maxilla.

KEYWORDS

bone augmentation, bone loss, clinical study, extraction socket, flapless implant surgery

1 | I N T RO D UC T I O N strict selection criteria together with a high level of surgical expertise

are needed to consider it as a satisfying treatment strategy.3,7 Accord-
Even after atraumatic tooth loss the residual alveolar bone undergoes ing to the International Team of Implantology, the augmentation of
a remodeling process coming along with changes of the anatomical the socket and delayed implant placement in situations of missing
conditions.1,2 Especially in the esthetic zone the appearance of the facial bone following tooth extraction is recommended.3 Socket aug-
soft tissue represents a major aspect of implant success and can be mentation techniques, mainly using an autologous or xenogeneic
considered as one of the main motivating factors for patients to call material aim to prevent physiological loss of hard and soft tissue vol-
for implant therapy in this region.3,4 Thus, clinicians must consider the ume following tooth extraction.5 In metric dimensions, ridge preserva-
mid- and long-term perspectives of soft and hard tissue alternations tion procedures are shown to decrease the alveolar ridge resorption in
especially when restoring single tooth sites in the esthetic zone.5,6 horizontal and vertical dimensions by 1 mm, on average.8 Although
Although immediate implant placement gained increasing popularity bone resorption can be decreased, it cannot be completely

Clin Implant Dent Relat Res. 2018;1–8. wileyonlinelibrary.com/journal/cid © 2018 Wiley Periodicals, Inc. 1
2 HINGSAMMER ET AL.

diminished.8–11 Furthermore, ridge preservation procedures are canine),2 implant provided for at least 6 months,3 no prior implant
reported to improve esthetical outcomes. 9,12–15
In a long-term analy- placed in this region,4 definitive restoration provided,5 current and
sis over 10 years the effectiveness of ridge preservation was shown. baseline (time point after implant placement) radiographs of the
The peri-implant marginal soft tissues supported by regenerated bone implant region6 guided implant insertion 7
implants from Nobel Bio-
showed adequate stability with a low risk for mucosal recessions. 16
care (Nobel Biocare, Gothenburg, Sweden) and8 exclusively for the
Thus, multiple techniques of ridge preservation, including flapless and esthetic evaluation: current photographs of the esthetic situation.
flap raising approaches, have been introduced.8,17–19 In any situation, Exclusion criteria1: nontreated periodontal disease2 reduced general
flap raising is considered to come along with increased postoperative health3 fully intact facial bone wall4 major hard tissue defects5 general
19–21
morbidity as well as moderate esthetic results. Flapless contraindications for oral surgery Ethical approval was obtained from
approaches showed highly satisfactory esthetics and are reported to the local ethical committee and patients gave their informed consent.
3,11,15
cause less recessions of the mid-facial mucosa. Therefore, in The study was conducted following the STROBE checklist. In all
order to avoid flap raising and to facilitate the insertion of the implant patients, the ridge preservation was performed in situations of type II
in a preoperative planned position, guided implant placement using sockets according to Elian and colleagues reflecting a partially reduced
4
stereo-lithographic templates are utilized. Especially in the esthetic buccal lamellar following the extraction of a single tooth.25 Both pro-
zone guided implant placement is recommended as it allows a more cedures, the augmentation of the socket as well as the insertion of
precise implant placement regarding the ideal prosthetic axis com- the implant were performed by one of three experienced surgeons.
pared to free-handed insertion.4,22 Furthermore, flapless template-
guided implant placement is discussed to increase patients' accep-
tance rate.23 Although multiple approaches to achieve satisfactory
3 | RI D G E P R E S E R V A T I O N P R O C E D U R E
esthetics in situations of partial missing facial bone walls have been
After flapless atraumatic extraction of the tooth, the ridge preserva-
described, the ideal treatment concept is not yet found.19,24 However,
tion procedure was performed. First, the alveolar socket was cleaned
flapless ridge augmentation and flapless templated guided insertion
with a sharp spoon and rinsed with sodium chloride solution 0.9%
are considered to come along with convincing esthetic results.3,4
then the augmentation material was inserted. In all cases, 100 to
Thus, the study aims to test the null hypothesis that the concept
200 mg of Bio-Oss Collagen (Geistlich Pharma AG, Wolhuser, Swit-
of flapless socket augmentation at the time of tooth extraction fol-
zerland) was used to fill the empty socket (Figure 2A). To isolate the
lowed by flapless implant placement using stereo-lithographic tem-
socket and to prevent wash out of the inserted biomaterial, primary
plates results in satisfactory esthetic results in the majority of cases.
closure via two different approaches was performed. Either an autolo-
gous soft tissue punch (Figure 2B) with a diameter of 8 mm, obtained
2 | MATERIALS AND METHODS from the palate, or a resorbable collagen matrix, Mucograft (Geistlich
Pharma AG, Wolhuser, Switzerland) was applied to cover the socket.
Records of patients treated at the Academy for Oral Implantology, Single sutures were used to hold the Mucograft or the soft tissue
Vienna between 2010 and 2014 were retrospectively screened and autograft in the right position. Following the socket augmentation, all
study population was enrolled according to clear defined inclusion patients received an adhesive bridge as a temporary restoration
and exclusion criteria. Initially, 58 patients with ridge preservation in (Figure 2C).
the anterior maxilla were screened. Thirty-three did not meet the
inclusion criteria, so finally 25 patients were clinically as well as radio-
logically and 24 patients were esthetically assessed (Figure 1). The 4 | IMPLANT PLACEMENT
inclusion criteria were1: flapless ridge preservation following atrau-
Following the protocol of NobelGuide and NobelClinican planning
matic extraction of a single tooth in the anterior maxilla (canine to
software (Nobel Biocare, Gothenburg, Sweden) individual surgical
templates with guide sleeves were obtained to allow a precise place-
ment of the implant in the pre-surgically planned position. The preop-
erative planning and the surgical procedure are reported in detail
elsewhere.4 According to the concept of delayed implant placement,
flapless implant bed preparation and guided insertion of the implant
was performed 4 to 5 months following ridge preservation.26 Implants
inserted with a torque of at least 30 Ncm were provided with non-
occlusal loaded provisional crowns immediately after implant place-
ment. If implants revealed poor primary stability (<30 Ncm) adhesive
bridges were installed. Following the platform switching concept the
definitive restorations were cemented on individual zirconia abut-
ments (NobelProcera, Nobel Biocare, Gothenborg, Sweden) using
implantatlink semi classic, (DETAX, Ettlingen, Germany) after a wear-
FIGURE 1 Patient drop out following the screening process ing period of 5 to 6 months.
HINGSAMMER ET AL. 3

at the distal and mesial side of the implant. MBL computation fol-
lowed commonly used methods.14 To allow exact metric measure-
ment on the digital images the measuring scale of the software was
calibrated for each image separately by comparing actual and radio-
graphic implant length. Besides MBL, the horizontal distance from the
implant neck to the adjacent mesial and distal tooth was recorded.
Two independent clinicians performed the digital measurements.

6 | ES THE TIC EVAL UAT I ON

Standardized high-resolution intraoral photographs were taken

using a Canon EOS 5D MK III (equipped with MacroLens EF
100 mm 1:28 and Macro Ring Lite MR-14EX; Canon Corp. (Tokyo,
Japan) to allow esthetic evaluations according to the pink esthetic
score (PES) and the papilla index (PI).28,29 The PES assesses seven
variables of which each is rated with a 2-1-0 score, with 2 being
the best and 0 being the poorest score (Figure 3). The highest pos-
sible score, indicating perfect soft tissue esthetics is therefore
14.29 The PI served to assess the height of the peri-implant papilla
(Figure 4).28 To ensure interexaminer reproducibility the esthetic
evaluations were performed by two independent clinicians who
were familiar with the used indices and scores but had not been
involved in the treatment protocol.

7 | STATISTICAL ANALYSIS

This study aims to test the null hypothesis of satisfactory esthetic

outcomes using stereo-lithographic templates and a staged all flap-
less augmentation and implant placement concept in the majority
of treated patients against the alternative hypothesis of not achiev-
FIGURE 2 Procedure of ridge preservation. A, Insertion of ing satisfactory outcomes in the majority of cases. For statistical
deproteinized bovine mineral (BioOss) into the fresh extraction analysis, the software Graph Pad Prism 6.0 (Graph Pad Software,
socket, (B) covering the filled extraction site with a tissue punch form Inc., California) was used. A P value of <.05 was considered to proof
the palatine; closure with single stiches, (C) an iodine strip fixed onto
statistical significance. The chi-square test served to test differ-
the donor site of the tissue punch at the palatine; an adhesive bridge
ences between independent nominal data assuming equal distances
from tooth 11 to 13 as a temporary restoration during the healing
period [Color figure can be viewed at wileyonlinelibrary.com] between groups. As this study was of rather exploratory nature no
adjustments for multiple comparisons were made. If not stated oth-
5 | CLINICAL AND RADIOLOGIC erwise, means of mesial and distal measurements were used. The
EVALUATION Wilcoxon rank sum test was used to test differences between
groups. Continuous data is reported in form of mean and standard
The values of the clinical probing depths were collected to the nearest deviation, whereas PES and PI are described as median and inter-
0.5 mm using a manual probe (PCPUNC 15, Hu-Friedy, Leimen, Ger- quartile range (IQR). Absolute and relative frequencies were used
many at six peri-implantary sites (buccal, mesiobbuccal, distobuccal, to describe categorical data. The nonparametric Spearman correla-
palatal, mesiopalatal, and distopalatal). The patients' records were sys- tion coefficient (rs) served to test association between various
tematically screened according to patient and implant related parame- parameters. Interrater agreement was assessed using kappa
ters including age, gender, cause of tooth loss, smoking, diabetes, (no agreement = 0; perfect agreement = 1).

history of periodontitis, long-term medication, and implant site, diam-

eter, length, and socket sealing material. Based on the criteria estab-
8 | RE SU LT S
lished by Smith and Zarb implant failures were assessed.27 Periapical
intraoral radiographs were taken of the implants at baseline and at
least 6 months after implant insertion with the definitive restoration
8.1 | Study population
provided. Radiographic software SIDEXIS (Sirona Dental GmbH, Wals, A clinical and radiologic evaluation of 25 as well as an esthetic
Austria) served to measure the radiographic marginal bone loss (MBL) rating of 24 patients was performed. The study population
4 HINGSAMMER ET AL.

FIGURE 3 PES ratings and their frequency within each of the seven variables pink esthetic score (PES 1 = mesial papilla, PES 2 = distal papilla,
PES 3 = level of soft-tissue margin, PES 4 = soft-tissue contour, PES 5 = alveolar process deficiency, PES 6 = soft-tissue color, and PES 7 = soft-
tissue texture) of which each is rated with scores from 0 to 2 [Color figure can be viewed at wileyonlinelibrary.com]

consisted of 9 male and 16 female patients recorded to be in time for clinical assessment was 1.3 years (SD: 0.6) after implant inser-
good general health with an average age of 42.48 years (SD: tion. The mean values of the clinical probing depths at six sites around
15.22; range: 19-73 years). Taking the patients' medical history, the implant measured buccal 1.1 mm (SD: 0.3), mesio-buccal 2.1 mm
three patients were identified as smokers (12%). No patient suf- (SD: 1.0), disto-buccal 1.9 mm (SD:0.8), palatal 1.4 mm (SD: 0.5),
fered from diabetes or periodontitis and none of them had to mesio-palatal 2.0 mm (SD: 1.2), and disto-palatal 2.3 mm (SD: 1.1;
take any long-term medication. The reasons for tooth loss were Figure 5). The mean probing depth around all implants was 1.8 mm
trauma (2 patients, 8%), crown/root fractures (9 patients, 36%), (range: 0.5-4 mm; SD: 0.7). No significant difference between probing
or endodontic failure (14 patients, 56%). In average, implant sites could be detected (P > .05).
insertion was performed 4.6 months (SD: 0.9) following ridge
preservation. All patients were provided with implants from Nobel
Biocare Replace System (conical connection or tapered groovy)
(Nobel Biocare, Gothenburg, Sweden), featuring a TiUnite surface.
Twenty-four implants were placed in the incisor region (96%) and
only one fixture was inserted in the canine region (4%). Nineteen cen-
tral Incisors (76%), five lateral incisors (20%), and one canine (4%)
were replaced. Implant length was 16 mm, 13 mm, and 11.5 mm in
1 (4%), 18 (72%), and 5 (20%) cases, respectively. The implant diame-
ter measured 3.5 mm in 16 (64%) and 4.3 mm in 9 (36%) cases. The
mean intraoperative measured insertion torque was 39.2 Ncm (SD:
11.8). In 20 cases, an insertion torque ≥30 Ncm was recorded. Thus,
80% of patients (n = 20) were provided with non-occlusal provisional
crowns immediately after implant insertion. About 20% of patients
(n = 5) received adhesive bridges due to insufficient primary implant
stability. Following a mean wearing period of 5.4 months (SD: 0.4) the
definitive crowns were cemented.

FIGURE 4 The papilla index ratings for the mesial and distal papilla.
8.2 | Clinical assessment 0 = no papilla present, 1 = less than half of the papilla height present
(convex nature of the adjacent tissue), 2 = more than half of the
In all cases, the ridge preservation surgery, the consecutive implant
papilla height present, but not to the full extent of the contact point
placement surgery and the prosthetic restoration occurred without
(papilla not in complete harmony), 3 = papilla fills the entire proximal
any complications. No implant failure was documented in the patients' space and is in good harmony, and 4 = papilla is hyperplastic [Color
records revealing a 100% implant success rate. The mean follow-up figure can be viewed at wileyonlinelibrary.com]
HINGSAMMER ET AL. 5

to their full extent (PI = 2). Less than half of the papilla height was
present in 4% of distal and 0% of mesial papillae (PI = 1). No papilla
was evaluated with a score of 0 (absent papilla) or 4 (hyperplastic
papilla; Figure 4). For the PES scores, interrater agreement was
87.5% (mean κ = 0.68; SD: 0.17) and for the PI ratings it was 87.5%
(mean κ = 0.65; SD: 0.19). The esthetic indices (PES and PI) did not
correlate with the radiological measured MBL around the implant
nor with any other potentially influencing parameter (Table 1).
Patient as well as implant specific characteristics including age, sex,
reason of tooth loss, implant type, closing material, and time point
of restoration did not show an influence on PES nor on MBL using
univariate regression analysis.

FIGURE 5 The mean measured probing depth at six sites

9 | DI SCU SSION

8.3 | Radiologic assessment A PES of 10 or higher represents satisfactory esthetic results and
The mean follow-up time for radiographic assessment was 1.3 years a PES of 7 is considered as the threshold of clinical acceptabil-
(SD: 0.6). Peri-implant MBL measured 1.27 mm (SD: 0.25 mm) at the ity.20,30 Thus, 71% of the restorations in the present analysis
mesial site and 1.05 mm (SD: 0.14 mm) at the distal site (P = .44). revealed satisfactory results. To allow a better interpretation of
Pooling the mesial and distal values results in a mean overall MBL of the obtained results comparison with different treatment con-
1.16 mm (SD: 0.16; Figure 6). The mean radiological measured dis- cepts was performed (Table 2). Following immediate implant

tance from the implant neck to the neighboring tooth was 2.18 mm placement with simultaneous socket augmentation in situations of

(SD: 0.14) at the distal site and 3.16 mm (SD: 0.21) at the mesial site. intact buccal bony walls a satisfaction rate of 100% and following
immediate implant placement without any augmentation proce-
The distance to the adjacent tooth did not show any correlation with
dure a rate of 78% is reported.31,32 The comparison of these
measured MBL (Table 1).
results with present data using chi-square test would not reveal
any significant difference P = .102 and P = .674, respectively.
8.4 | Esthetic outcome According to Buser and colleagues immediate implant placement
Photographs used for esthetic evaluation were taken 1.2 years (SD: is applicable in ideal clinical conditions, including a fully intact
0.6) following implant placement. Assessment of 24 implant supported facial bone wall with a thick wall phenotype (>1 mm) and a thick
restorations revealed a median PES of 10 (IQR: 9-12) and a median PI gingival biotype.3 Due to the fact that this study included only
of 3 (IQR: 2.5-3) for both the mesial and distal papilla. A total of 71% patients with a partial missing buccal lamellar immediate implant
of patients (n = 17) revealed a PES higher than 9 (Figure 7). Frequency placement cannot be considered as an alternative treatment
distribution of PES ratings are illustrated in Figure 3. About 75% of option in this study population. Beside short term analyses, a
the mesial and 79% of the distal papillae filled the entire proximal recent study evaluating long-term esthetical outcomes following

space and were in good harmony (PI = 3). About 25% of mesial and immediate placed implants reported a complication rate of 47% in

17% of distal papillae were present to more than their half but not well-selected patients (intact buccal lamellar and thick biotype).6
Following these findings, the question raises whether immediate
implant placement should be recommended in the esthetic zone
even in patients with low esthetic risk profiles. Implant treatment
in conjunction with guided bone regeneration (GBR) using autolo-
gous and xenogeneic bone material covered with a resorbable
collagen membrane revealed 67%24 and 47%19 satisfactory
esthetic results. Looking at the outcomes reported for delayed
implant placement following autologous bone grafting (ABG) an
overall advantage of the presented concept is visible. However,
ABG procedures are performed in situations representing an
advanced horizontal facial bone defect (≤3 mm orofacial width of
the ridge).14,19,20,24
Comparing flapless and flap raising concepts, a comparative
analysis of Table 2 shows that flapless procedures result in more

FIGURE 6 The mean radiological measured mesial, distal, and overall favorable outcomes compared to flap raising approaches
peri-implant marginal bone loss. No significant difference between (P < .0001; weighted by sample sizes). Although flap elevation
medial and distal marginal bone loss exists; ns, not significant and consecutive primary closure of the soft tissue are described
6 HINGSAMMER ET AL.

TABLE 1 Parameters tested for correlation (Spearman's correlation coefficient r) on esthetic index values (PES, pink esthetic score; PI, papilla
index) and marginal bone loss (MBL)
PES PI MBL
r P r P r P
PES 0.51 .012 −0.23 .286
PI 0.51 .012* −0.32 .126
MBL −0.23 .286 −0.32 .126
Region −0.08 .727 −0.38 .065 0.28 .175
Gender −0.29 .168 0.06 .763 0.08 .693
Smoking 0.02 .923 −0.09 .679 −0.12 .560
Distance to adjacent tooth −0.03 .900 0.19 .369 −0.19 .353
Probing depth −0.12 .569 0.07 .736 0.05 .808
Socket sealing material 0.22 .303 0.06 .784 −0.08 .720
Implant diameter 0.16 .445 0.02 .912 0.14 .518
Implant length −0.13 .543 −0.03 .904 0.19 .360

*Indicating statistical significance.

to have little effect on bone resorption around extraction sites,33 influence the appearance of the papillae.14,39 Correlation tests
authors support the opinion that the maintenance of the buccal does not indicate any influence of the used socket sealing mate-
34
keratinized gingiva is more reliable using flapless approaches. rial neither on the PES (P = .303) nor on the PI (P = .784). Never-
Furthermore, flapless implant placement is reported to be advan- theless, the costs for the partially used artificial collagen
tageous for preserving crestal bone and mucosal health justifying membrane have to be weighed against the higher patients' dis-
the better esthetic results.13,18 When interpreting the results of comfort, caused by the harvesting of a palatine punch. However,
this study one should consider that from an esthetic point of results regarding correlations are limited by the number of study
view the replacement of incisors is more delicate than that of participants. The immediate restoration of implants with non-
canines or premolars.19 In fact, 96% of the evaluated implants occlusal loaded provisional crowns is reported to come along with
were placed either in the region of the medial or lateral incisor. high patient satisfaction and good esthetic as well as clinical
Thus, comparison is not possible without restrictions and
between-study comparisons have to be interpreted with caution.
Even the definition of a partial missing facial bone wall in this
study allows variations of bone quality and quantity which could
potentially influence the outcome. The peri-implant bone loss
measured in this study is consistent with values reported in litera-
ture.19,24,30 Histomorphometric analysis, evaluating the resorption
of deproteinized bovine bone mineral (DBBM) in a porcine cal-
varia augmentation model, revealed that more than 50% of the
augmented DBBM has been resorbed after 12 weeks.35 Never-
theless, extraction sockets augmented with a xenogeneic material
reveal decreased loss of bone at the buccal plate than nonaug-
mented sites.8,36 In the esthetic zone, sufficient bone and stable
marginal bone levels are considered essential to establish optimal
esthetics.3 Following the data of this study, MBL did not correlate
with the values of the esthetic indices, neither with the PES
(P = .286) nor with the PI (P = .126). As no excessive MBL was
noticed within the investigated restorations, papilla height, and
overall esthetics are expected to be more influenced by the shape
of underlying bone than of the quantity.14 The preservation of
the peri-implant papilla is reported to be highly influenced by the
attachment level of the adjacent teeth and the horizontal implant
tooth distance.37,38 Against this assumption, in the present study
FIGURE 7 Total pink esthetic score (PES) divided in clinical
no correlation between the horizontal distance from the implant
satisfactory and unsatisfactory results. PES of 10 to 14 = satisfactory;
to the adjacent bone and peri-implant papilla presence could be
PES 0 to 9 = unsatisfactory. A total of 71% of patients were
detected (P = .353). Thus, these results confirm the findings of evaluated with a PES higher or equal 10 and 29% had a PES lower or
various authors that tooth-implant distance does not inevitably equal 9 [Color figure can be viewed at wileyonlinelibrary.com]
HINGSAMMER ET AL. 7

TABLE 2 Comparing the yielded results with the esthetic outcomes following different treatment concepts

Satisfactory
Surgical Follow-up esthetics Unsatisfactory
Studies approach n (years) Mean PES  SD (PES 10-14) esthetics (PES 0-9)
Early and delayed implant
placement, simultaneous GBR
with autologous + xenogeneic
bone
Cosyn et al.18 Flap 17 2.5 9.7  2.3 47% 53%
Hof et al.43 Flap 15 3.8 9.4  2.2 67% 33%
Delayed implant placement
following ABG
Cosyn et al.18 Flap 13 2.5 9.0  1.7 38% 62%
Hof et al.14 Flap 60 4.2 11.5  0.7 60% 40%
Pieri et al. 20
Flap 29 5.0 8.6  1.6 17% 83%
Hof et al.43 Flap 64 3.5 10.2  2.1 75% 25%
Delayed implant placement, no augmentation
Lai et al.45 Flap 29 0.7-1.0 9.5  2.3 45% 55%
Delayed implant placement, no
augmentation
Fürhauser et al.4 Flapless and guided 27 2.3 10.6  2.2 63% 37%
Immediate implant placement, simultaneous socket augmentation
Juodzbalys and Wang31 Flapless 12 1.0 11.1  1.3 100% 0%
Immediate implant placement, no
augmentation
Chen et al.32 Flapless 85 2.2 11.0  1.7 78% 22%
Delayed implant placement following socket augemntation
Present study Flapless and guided 24 1.2 10.5  2.3 71% 29%

ABG, autologous bone grafting; GBR, guided bone regeneration.

results.40 Thus, it became common routine for primarily stable CONFLIC T OF INT E RE ST
implants in the esthetic zone.41 Precise preoperative implant posi- The authors do not have any financial interests, either directly or indi-
tion planning in respect of the future prosthetic situation is rectly, in the products or information listed in the paper.
essential to achieve functionally and esthetically optimal restora-
tions.42 Beside the favorable flapless approach, virtual treatment
ORCID
planning software and stereo-lithographic templates are consid-
ered to increase the accuracy of implant placement compared to Lukas Hingsammer http://orcid.org/0000-0003-2730-8745

nonguided, freehand insertion. 22

Inaccuracies of the implant posi- Bernhard Pommer http://orcid.org/0000-0002-2617-0353

tion are shown to result in compromised esthetics.4,44 Thus, espe-

cially within limited bone levels in the esthetic zone template-
RE FE RE NC ES
guided implant insertion is favored.4 Without a doubt the number
1. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth
of samples, the use of two different socket sealing materials and
extraction. J Prosthet Dent. 1967;17(1):21-27.
various implant dimensions, the fact that not all patients were 2. Farmer M, Darby I. Ridge dimensional changes following single-tooth
treated by the same surgeon as well as the retrospective study extraction in the aesthetic zone. Clin Oral Implants Res. 2014;25(2):
272-277.
design constitute limitations of the study, requesting further stud-
3. Buser D, Chappuis V, Belser UC, Chen S. Implant placement post
ies to proof the reported findings. However, for practitioners the extraction in esthetic single tooth sites: when immediate, when early,
evaluation of a two-stage, flapless surgical concept is of special when late? Periodontol 2000. 2017;73(1):84-102.
4. Fürhauser R, Mailath-Pokorny G, Haas R, Busenlechner D, Watzek G,
interest as it supports decision making.
Pommer B. Esthetics of flapless single-tooth implants in the anterior max-
illa using guided surgery: association of three-dimensional accuracy and
pink Esthetic score. Clin Implant Dent Relat Res. 2015;17:e427-e433.
5. Araújo MG, da Silva JCC, de Mendonça AF, Lindhe J. Ridge alterations
1 0 | CONC LU SION following grafting of fresh extraction sockets in man. A randomized
clinical trial. Clin Oral Implants Res. 2015;26(4):407-412.
In conclusion, a staged all flapless approach including ridge preserva- 6. Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn H, Cleymaet R.
A 5-year prospective study on single immediate implants in the aes-
tion and delayed template-guided implant placement, in situations of
thetic zone. J Clin Periodontol. 2016;43(8):702-709.
initially partial missing facial bone walls, is considered to achieve satis- 7. Barone A, Toti P, Marconcini S, Derchi G, Saverio M, Covani U. Esthetic
factory esthetic outcomes in the majority of patients. outcome of implants placed in fresh extraction sockets by clinicians with
8 HINGSAMMER ET AL.

or without experience: a medium-term retrospective evaluation. Int J Oral implants). In: Esposito M, ed. Cochrane Database of Systematic Reviews.
Maxillofac Implants. 2016;31(6):1397-1406. Chichester, UK: Wiley; 2010:CD005968.
8. Pommer B, Heuberer S, Nahler L, Watzek G. How much bone loss can 27. Smith DE, Zarb GA. Criteria for success of osseointegrated endoss-
be prevented by alveolar ridge preservation? Systematic literature eous implants. J Prosthet Dent. 1989;62(5):567-572.
review and meta-analysis. ImplantNews. 2012;9(6):795-799. 28. Jemt T. Regeneration of gingival papillae after single-implant treat-
9. Cosyn J, Cleymaet R, De Bruyn H. Predictors of alveolar process ment. Int J Periodontics Restor Dent. 1997;17(4):326-333.
remodeling following ridge preservation in high-risk patients. Clin 29. Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G.
Implant Dent Relat Res. 2016;18(2):226-233. Evaluation of soft tissue around single-tooth implant crowns: the pink
10. Aimetti M, Manavella V, Corano L, Ercoli E, Bignardi C, Romano F. esthetic score. Clin Oral Implant Res. 2005;16(6):639-644.
Three-dimensional analysis of bone remodeling following ridge augmen- 30. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed
tation of compromised extraction sockets in periodontitis patients: a ran- in postextraction sites. Int J Oral Maxillofac Implant. 2009;24:186-217.
domized controlled study. Clin Oral Implants Res. 2017;29(2):202-214. 31. Juodzbalys G, Wang H-L. Soft and hard tissue assessment of immedi-
11. Fickl S, Zuhr O, Wachtel H, Stappert CFJ, Stein JM, Hürzeler MB. Dimen- ate implant placement: a case series. Clin Oral Implants Res. 2007;
sional changes of the alveolar ridge contour after different socket preser- 18(2):237-243.
vation techniques. J Clin Periodontol. 2008;35(10):906-913. 32. Chen ST, Darby IB, Reynolds EC, Clement JG. Immediate implant
12. Raes F, Cosyn J, De Bruyn H. Clinical, aesthetic, and patient-related placement Postextraction without flap elevation. J Periodontol. 2009;
outcome of immediately loaded single implants in the anterior maxilla: 80(1):163-172.
a prospective study in extraction sockets, healed ridges, and grafted 33. Vittorini Orgeas G, Clementini M, De Risi V, de Sanctis M. Surgical
sites. Clin Implant Dent Relat Res. 2013;15(6):819-835. techniques for alveolar socket preservation: a systematic review. Int J
13. Cosyn J, Pollaris L, Van der Linden F, De Bruyn H. Minimally invasive Oral Maxillofac Implant. 2013;28(4):1049-1061.
single implant treatment (M.I.S.I.T.) based on ridge preservation and 34. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Sur-
contour augmentation in patients with a high aesthetic risk profile: gical protocols for ridge preservation after tooth extraction. A system-
one-year results. J Clin Periodontol. 2015;42(4):398-405. atic review. Clin Oral Implant Res. 2012;23(Suppl 5):22-38.
14. Hof M, Pommer B, Strbac GD, Suto D, Watzek G, Zechner W. Esthetic 35. Busenlechner D, Tangl S, Arnhart C, et al. Resorption of deproteinized
evaluation of single-tooth implants in the anterior maxilla following bovine bone mineral in a porcine calvaria augmentation model. Clin
autologous bone augmentation. Clin Oral Implant Res. 2013;24(Suppl Oral Implants Res. 2012;23(1):95-99.
A):88-93. 36. Cardaropoli D, Cardaropoli G. Preservation of the postextraction alve-
15. Thalmair T, Fickl S, Schneider D, Hinze M, Wachtel H. Dimensional olar ridge: a clinical and histologic study. Int J Periodontics Restor Dent.
alterations of extraction sites after different alveolar ridge preserva- 2008;28(5):469-477.
tion techniques—a volumetric study. J Clin Periodontol. 2013;40(7): 37. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP,
721-727. Malevez C. Clinical and radiographic evaluation of the papilla level
16. Roccuzzo M, Gaudioso L, Bunino M, Dalmasso P. Long-term stability adjacent to single-tooth dental implants. A retrospective study in the
of soft tissues following alveolar ridge preservation: 10-year results of maxillary anterior region. J Periodontol. 2001;72(10):1364-1371.
a prospective study around nonsubmerged implants. Int J Periodontics 38. Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal
Restor Dent. 2014;34(6):795-804. distances between adjacent implants and between a tooth and an
17. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G. implant on the incidence of interproximal papilla. J Periodontol. 2004;
Socket preservation using bovine bone mineral and collagen mem- 75(9):1242-1246.
brane: a randomized controlled clinical trial with histologic analysis. Int 39. Ryser MR, Block MS, Mercante DE. Correlation of papilla to crestal
J Periodontics Restor Dent. 2012;32(4):421-430. bone levels around single tooth implants in immediate or delayed
18. Cosyn J, De Bruyn H, Cleymaet R. Soft tissue preservation and pink aes- crown protocols. J Oral Maxillofac Surg. 2005;63(8):1184-1195.
thetics around single immediate implant restorations: a 1-year prospec- 40. Hui E, Chow J, Li D, Liu J, Wat P, Law H. Immediate provisional for
tive study. Clin Implant Dent Relat Res. 2013;15(6):847-857. single-tooth implant replacement with Brånemark system: preliminary
19. Cosyn J, Eghbali A, De Bruyn H, Dierens M, De Rouck T. Single implant report. Clin Implant Dent Relat Res. 2001;3(2):79-86.
treatment in healing versus healed sites of the anterior maxilla: an aes- 41. Gjelvold B, Kisch J, Chrcanovic BR, Albrektsson T, Wennerberg A.
thetic evaluation. Clin Implant Dent Relat Res. 2012;14(4):517-526. Clinical and radiographic outcome following immediate loading and
20. Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Esthetic outcome and delayed loading of single-tooth implants: randomized clinical trial. Clin
tissue stability of maxillary anterior single-tooth implants following Implant Dent Relat Res. 2017;19(3):549-558.
reconstruction with mandibular block grafts: a 5-year prospective 42. Drago CJ. Prosthodontic complications related to compromised
study. Int J Oral Maxillofac Implant. 2013;28(1):270-280. implant placement. J Oral Maxillofac Surg. 1994;52(1):15-22.
21. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Immediate func- 43. Hof M, Tepper G, Koller B, Krainhöfner M, Watzek G, Pommer B.
tional loading of implants placed with flapless surgery versus conven- Esthetic evaluation of single-tooth implants in the anterior mandible.
tional implants in partially edentulous patients: a 3-year randomized Clin Oral Implants Res. 2014;25(9):1022-1026.
controlled clinical trial. Int J Oral Maxillofac Implants. 2018;23(5):867-875. 44. Ersoy AE, Turkyilmaz I, Ozan O, McGlumphy EA. Reliability of implant
22. Nickenig H-J, Wichmann M, Hamel J, Schlegel KA, Eitner S. Evaluation placement with stereolithographic surgical guides generated from
of the difference in accuracy between implant placement by virtual plan- computed tomography: clinical data from 94 implants. J Periodontol.
ning data and surgical guide templates versus the conventional 2008;79(8):1339-1345.
free-hand method—a combined in vivo—in vitro technique using 45. Lai H-CC, Zhang Z-YY, Wang F, Zhuang L-FF, Liu X, Pu Y-PP. Evalua-
cone-beam CT (part II). J Cranio-Maxillofacial Surg. 2010;38(7):488-493. tion of soft-tissue alteration around implant-supported single-tooth
23. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on restoration in the anterior maxilla: the pink esthetic score. Clin Oral
pain experienced in implant placement using an image-guided system. Implant Res. 2008;19(6):560-564.
Int J Oral Maxillofac Implants. 2006;21(2):298-304.
24. Hof M, Pommer B, Ambros H, Jesch P, Vogl S, Zechner W. Does timing
of implant placement affect implant therapy outcome in the aesthetic
zone? A clinical, radiological, aesthetic, and patient-based evaluation. Clin
How to cite this article: Hingsammer L, Pommer B,
Implant Dent Relat Res. 2015;17(6):1188-1199.
25. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket Fürhauser R, Mailath-Pokorny G, Haas R, Busenlechner D. Sin-
classification and repair technique. Pract Proced Aesthet Dent. 2007; gle tooth implants in the esthetic zone following a two-stage
19(2):99-104. quiz 106. all flapless approach: A retrospective analysis. Clin Implant
26. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV.
Dent Relat Res. 2018;1–8. https://doi.org/10.1111/cid.12669
Interventions for replacing missing teeth: dental implants in fresh
extraction sockets (immediate, immediate-delayed and delayed