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Journal of Oral Science & Rehabilitation No. 1, 2018

I m m e d i a t e i m p l a n t s i n t h e e s t h e t i c a r e a Fig. 3 Fig. 3 Tooth socket after careful atraumatic extraction of the root remnant. immediate provisional restoration allows for minimal disturbance of the soft tissue during healing, and as a consequence, it could be expected that the undisturbed soft tissue will result in better maintenance of the bone level position.31 4 . I m p l a n t p l a c e m e n t t e c h n i q u e Several factors are involved in the esthetic suc- cess of an immediate implant, among which the most important is certainly an appropriate implant positioning. A useful tool in the decision process during the evaluation of the extraction socket hard tissue for possible implant placement is the classification of Juodzbalys et al.32 Once the alveolus is deemed adequate for the purpose, the implant placement should be performed as carefully as the already discussed atraumatic tooth extraction. A strict and standardized pro- tocol should be followed that considers the pecu- liar anatomical features of a post-extraction socket, especially in the esthetic areas. The implant site has to be prepared position- ing the drills so that they follow the palatal bony wall as a guide and using the apical bone as much as the residual bone height allows. The residual apical bone will provide most of the necessary anchorage and stability for the implant. For this reason, the length of the implant should be accu- rately chosen accordingly during the planning. Once the implant site has been prepared, a peri- odontal probe should be used to verify the integ- rity of the walls. Finally, the implant must be placed with the platform at the marginal level of the buccal bone wall. The palatally oriented preparation of the oste- otomy is dictated by the anatomy of the post- extraction socket. The buccal wall of the socket is generally very thin and in the esthetic areas is generally less than 1 mm. 33 According to Huynh-Ba et al., in the upper anterior area, this bone is equal to or less than 0.5 mm thick in 64.1% of cases.34 Although early studies sup- ported the hypothesis that immediate implant placement could preserve the initial alveolar crest dimension,35–37 later human and animal model studies showed that the ridge will not maintain its original shape for longer than 3–4 months after immediate implant placement.17, 28 For these reasons, it is important to keep a pal- atally oriented positioning, because the unavoid- able resorption of the very thin buccal wall might compromise the success and the long-term survival of the implant if placed in close proxim- ity to the buccal aspect (Figs. 4 & 5). 5 . T h e c r i t i c a l d i s t a n c e a n d g a p f i l l i n g According to many authors, the need to graft the gap between the implant and the buccal socket wall is guided by the length of this space.38, 39 The critical distance, beyond which a graft is strongly suggested, is considered to be 1.5 mm. 38, 39 Several approaches have been proposed to fill the gap around implants, aimed at preserving or improving the dimension and contour of the ridge after tooth extraction and immediate implant placement.39, 40 Different studies have shown that the use of bone substitutes might also modify the pattern of bone remodeling.41, 42 Journal of Oral Science & Rehabilitation Volume 4 | Issue 1/2018 19

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