10.59987/ads/2015.1.29-34
Aim. The aim of this research was to assess periimplant bone remodeling of post-extractive implants over 2 years.
Material and methods. 30 patients meeting pre-established inclusion criteria were enrolled for the study. One implant for each patient was inserted in the post-extraction sockets according to a defined surgical protocol (atramautic extraction, curettage of extraction socket, implant insertion, grafting with collagenated cortico-cancellous porcine bone, and a trimmed collagen membrane to completely cover the socket, suture). A temporary adhesive bridge, with an adequate profile, was bonded to the adjacent teeth. X-ray evaluation with a standardized stent was carried out at different times. Measurements were obtained from the implant edge to the bone peak. The values obtained at time 0 and at 2 years were compared by t-student test.
Result. Our results showed that after one year 73% of patient had 0 mm of bone reabsorption, 20% of patient had 0 mm ≤ x ≤ 0.5mm, 7% of patient had 0.5 mm ≤ x ≤ 2 mm of bone reabsorption. After two years 62% of patient had 0 mm of bone reabsorption, 24% had 0 mm ≤ x ≤ 0.5mm, 14% had 0.5 mm ≤ x ≤ 2 mm. Conclusions. The results showed no significant differences in bone reabsorption in most patients over 2 years.
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Annali di stomatologia
bone remodeling
Postextractive implants in aesthetic areas: evaluation of perimplant bone remodeling over time
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Original Article
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bone remodeling
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Postextractive implants in aesthetic areas: evaluation of perimplant bone remodeling over time
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                                                                                             Original article



    Postextractive implants in aesthetic areas:
    evaluation of perimplant bone remodeling over time




                                                                                                i
                                                                                              al
                                                                                           on
    Michele Mario Figliuzzi, DDS, PhD                    Key words: dental implants, post-extractive im-
    Amerigo Giudice, DDS, PhD                            plants, immediate loading, bone remodeling.
    Maria Giulia Cristofaro, DDS, PhD
    Delfina Pacifico, DDS
    Pasquale Biamonte, DDS                               Introduction




                                                                                  zi
    Leonzio Fortunato, DDS, PhD
                                                         Dental implants can be placed in edentulous sites at
                                                         different times after tooth extractions. Some Authors




                                                                     na
    Department of Periodontics and Oral Sciences, Uni-   (1) have indicated that the immediate placement
    versity “Magna Graecia” Catanzaro, Italy             could offer advantages including time saving. An im-
                                                         mediate implant is placed in an extraction socket as
                                                         part of the same procedure. In the past, clinicians al-
    Corresponding author:                                lowed a socket healing time of up to 12 months or




                                                           er
    Michele Mario Figliuzzi                              longer before placing implants to restore an edentu-
    Department of Periodontics and Oral Sciences, Uni-   lous space (2), leading to compromised comfort,
    versity “Magna Graecia” Catanzaro                    function, and aesthetics for the patient.
    Via De Maria, 9


                                                    t    To overcome this limitations, an immediate ap-
    89900 Vibo Valentia, Italy
    Phone: +39 0963 592568
                                                 In      proach was introduced (3) despite some potential
                                                         disadvantages. The possible lack of keratinized mu-
    E-mail: figliuzzi@unicz.it                           cosa for flap adaptation makes primary closure
                                                         more difficult to achieve and the incongruity of size
                                                         and shape between implants and extraction sockets
                                                 ni
    Summary                                              presents challenges for primary implant stability.
                                                         While initial implant stability is obtained by intimate
    Aim. The aim of this research was to assess peri-    contact with the newly formed bone in healed sites,
                                     io

    implant bone remodeling of post-extractive im-       residual bony defects always exist around implants
    plants over 2 years.                                 in immediate implantation. Consequently, primary
    Material and methods. 30 patients meeting pre-es-    stability is only achieved by anchoring the implant in
    tablished inclusion criteria were enrolled for the   the apical bony region (3-4 mm), where cancellous
                           iz



    study. One implant for each patient was inserted     bone predominates.
    in the post-extraction sockets according to a de-    Some studies with a mean follow-up time of 3 years
    fined surgical protocol (atramautic extraction,      evaluated marginal bony alterations (4-9). It is
           Ed




    curettage of extraction socket, implant insertion,   known that post-extractive implants do not prevent
    grafting with collagenated cortico-cancellous        bone resorption (10). Such biological changes im-
    porcine bone, and a trimmed collagen membrane        ply higher risk of marginal mucosal recession after
    to completely cover the socket, suture). A tempo-    immediate implant placement, with possible aes-
    rary adhesive bridge, with an adequate profile,      thetical damage especially when the facial socket
    was bonded to the adjacent teeth. X-ray evalua-      wall and tissue biotype are thin (11). Bone remod-
IC




    tion with a standardized stent was carried out at    eling can be associated with three dimensional im-
    different times. Measurements were obtained          plant position, presence/absence of platform
    from the implant edge to the bone peak. The val-     switching, absence of facial bony wall, inter im-
    ues obtained at time 0 and at 2 years were com-      plant/tooth distance.
C




    pared by t-student test.                             It has been stated that a certain width of peri-implant
    Result. Our results showed that after one year       mucosa is required to enable a proper epithelial-con-
    73% of patient had 0 mm of bone reabsorption,        nective tissue attachment. In case of inadequate di-
    20% of patient had 0 mm ≤ x ≤ 0.5mm, 7% of pa-       mension, crestal bone reabsorption will occur to en-
                                                         sure the appropriate biological width. Recent studies
©




    tient had 0.5 mm ≤ x ≤ 2 mm of bone reabsorption.
    After two years 62% of patient had 0 mm of bone      have shown that for all two-piece implants, the bone
    reabsorption, 24% had 0 mm ≤ x ≤ 0.5mm, 14%          crest level changes seem related to the microgap po-
    had 0.5 mm ≤ x ≤ 2 mm.                               sition (12, 13).
    Conclusions. The results showed no significant       Histological and radiographic studies by Herman et
    differences in bone reabsorption in most patients    al. have proven that a crestal bone loss of about 2
    over 2 years.                                        mm occurs with the submerged, two-pieces ap-

    Annali di Stomatologia 2015; VI (1): 29-34                                                               29
    M.M. Figliuzzi et al.


    proach, dependent on the microgap, and minimal or          and postoperative antibiotic therapy (1 g amoxicillin
    no reabsorption occurs with non-submerged, one-            or 300 mg clindamycin) for further 4 days. All pa-
    piece implants (14). They demonstrated that a              tients rinsed for 1 minute with chlorhexidine mouth-
    rough/smooth border on the surface of one-piece im-        wash 0.2% prior to surgery (and twice a day for the
    plants determines the crestal bone levels adjacent to      following 3 weeks), and were treated under local




                                                                                                         i
    such implants. Regarding platform switching Calvo-         anesthetic using lidocaine with adrenaline 1:50.000.




                                                                                                       al
    Guirado et al. (15) evaluated the survival rates at 12     All surgical procedures were undertaken by one sur-
    months of a platform switched implant placed in the        geon. All the patients were treated with the same
    anterior and premolar areas of the maxilla and imme-       surgical technique (periotomes were used around




                                                                                                    on
    diately restored with single crowns. They concluded        each single selected tooth); moreover the extraction
    that the implants remained stable over the course of       socket was thoroughly curetted and irrigated with
    12 months and had an overall survival rate of 96.7%.       sterile saline solution. To preserve vestibular bone
    Minimal crestal bone loss was recorded around the          plate, some teeth extractions were performed using
    surviving implants.                                        piezoelectric tips (Piezosurgery, EX2,Mectron,




                                                                                           zi
    Furthermore, based on the finding that the bone crest      Italy). Implants (Sweden Martina, Due Carrare,
    was more apically located at sites with <3 mm inter-       Padova, Italy) were inserted placing the shoulder
    implant distance than at sites where the implants          edge 1 mm deeper the cortical margin of palatal




                                                                             na
    were standing >3 mm apart, Tarnow et al. (16) sug-         plate (Figs. 1, 2). Subsequently, the residual gaps
    gested that not only vertical bone loss but also lateral   were filled and slightly condensed with collagenat-
    bone loss at implants could have an effect on the lev-     edcortico-cancellous porcine bone (MP3, Osteobiol-
    el of the bone crest between two implants.                 Tecnoss, Coazze, Italy), and a trimmed collagen




                                                                 er
    The aim of this research is focusing on the perimplant     membrane (Evolution, Osteobiol-Tecnoss, Coazze,
    bone remodeling of post-extractive implants over two       Italy) was used to completely cover the socket. The
    years.




                                                         t
    Materials and methods
                                                      In
    Trial design
                                          ni
    Participants:
    Selected patients for the study meet the following in-
    clusion criteria:
                                 io

    - good health conditions (no systemic diseases in-
        cluding diabetes, rheumatic diseases, neoplasia)
    - non smokers or smokers less of 15 cigarettes a day
    - presence of adequate cortical bone at vestibular
                            iz



        and palatal plates (at least 2 mm)
    - presence of adjacent teeth
    - sufficient vertical amount of bone (at least 3 mm
          Ed




        of residual bone evaluated thorough CT dental
        scan) to insert a stable post-extractive implant.
    Exclusion criteria were:
    - pregnancy and lactation                                  Figure 1. Implant placement after extraction.
    - assumption of drugs such as biphosfonates which
        could negatively influence bone healing
IC




    - active periodontitis.
    All patients required teeth extractions due to root
    fractures, destructive caries, endodontic failures.
    Each patients signed an informative approval form
C




    before acceptance of treatment. The research was
    conducted with the approval of local ethical commit-
    tee nr. 926 of October 2010 and in accordance with
    the Helsinki Declaration.
©




    Surgical procedures

    All patients received prophylactic antibiotic therapy
    (2 g of amoxicillin or 600 mg clindamycin - if allergic
    to penicillin) 1 hour before the extraction procedure      Figure 2. X-ray evaluation immediately after placement.

    30                                                                             Annali di Stomatologia 2015; VI (1): 29-34
    Post-extraction implants in aesthetic zones


    soft tissues were only undermined and no releasing            X-ray evaluation
    incisions were performed. Platelet-rich fibrin (PRF)
    membranes were prepared and used for better heal-             X-ray evaluation was carried out at different timing:
    ing of soft tissues. The collagen membrane was left           - time 0 at implant insertion
    intentionally exposed to the oral cavity and stabi-           - 1 year after implant insertion




                                                                                                             i
    lized by sutures.                                             - 2 years after implant insertion.




                                                                                                           al
    All patients were instructed to continue with prophy-         Digital intra-oral periapical radiographs were taken
    lactic antibiotic therapy; naproxen sodium 550 mg             (70 KVp, 7 mA) using a parallel cone technique with a
    tablets were prescribed as an anti-inflammatory to be         digital sensor (Schick Technologies, Long Island City,




                                                                                                        on
    taken 2 times a day for as long as required. The tem-         NY, USA). A paralleling device and individualised bite
    porary prosthetic restoration was bonded to the adja-         blocks, made of polyvinyl siloxane impression materi-
    cent teeth with a light-curing composite which was,           al (Flexitime, Heraeus/Kulzer, Hanu, Germany), were
    subsequently, carefully polished. The profile of a tem-       used for the standardization of the x-ray geometry.
    porary restoration was adapted to the edentulous              Bone loss was measured by using the radiographs




                                                                                               zi
    space withflat profile at the buccal and proximal sites.      taken at 0, 12 and 24 months after implant insertion
    This modified pontic profile would support the soft tis-      (Figs. 6, 7). The marginal bone height (MBL) was set
    sues thus allowing for a more natural shape of the




                                                                                na
    gingivae and papillae; sutures were removed after 7
    days.
    Clinical follow up was performed until 24 months after
    surgery (Figs. 3-5). Three months after surgery final




                                                                     er
    prosthetic restoration was delivered (Figs. 4, 5).




                                                             t
                                                          In
                                                 ni

                                                                  Figure 5. Clinical condition after 90 days.
                                     io
                           iz
           Ed




    Figure 3. Clinical condition of site after 30 days.
IC




                                                                  Figure 6. Bone remodeling after 1 year.
C
©




    Figure 4. Clinical condition after 90 days and insertion of
    abutment.                                                     Figure 7. Bone remodeling after 2 years.


    Annali di Stomatologia 2015; VI (1): 29-34                                                                       31
    M.M. Figliuzzi et al.


                                                                                                                                                                                               as the distance between the implant-abutment con-



                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.2


                                                                                                                              1.2
                                                                                                                                                                                               nection and the most apical point of the marginal
                                                                                                                                                                                               bone level. Calibration was performed using the
                                                                                                          mm


                                                                                                                              mm
                                                                                                                                                                                               known thread-pitch distance of the implants (pitch =
                                                                                                          1


                                                                                                                              1
                                                                                                                                                                                               1.0 mm). Previously known values, such as fixture di-




                                                                                                                                                                                                                                          i
                                                                                                                                                                                               ameter and length, were used for calibration when the
                                                                                                          mm


                                                                                                                              mm




                                                                                                                                                                                                                                        al
                                                                                                          1.5


                                                                                                                              1.5
                                                                                                                                                                                               threads were not clearly visible on the radiographs.
                                                                                                                                                                                               Measurements were taken to the nearest 0.1 mm us-
                                                                                                          mm


                                                                                                                              mm

                                                                                                                                                                                               ing computer software (UTHSCSA Image Tool, Ver-
                                                                                                          2


                                                                                                                              2




                                                                                                                                                                                                                                     on
                                                                                                                                                                                               sion 3.00, University of Texas Health Science, San
                                                                                                                                                                                               Antonio, TX). Bone changes were measured at the
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.4


                                                                                                                              1.4




                                                                                                                                                                                               mesial and distal peri-implant sites, and their average
                                                                                                                                                                                               values were used calculating distance between corti-
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.7


                                                                                                                              1.7




                                                                                                                                                                                               cal edge and the fixture abutment junction. All mea-




                                                                                                                                                                                                                           zi
                                                                                                                                                                                               surements were taken by one examiner who was not
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.8


                                                                                                                              1.5




                                                                                                                                                                                               involved in performing the surgical treatment. The val-
                                                                                                                                                                                               ues obtained at time 0 and at 2 years were compared




                                                                                                                                                                                                             na
                                                                                                                                                                                               by test t-student.
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.8


                                                                                                                              1.8
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.4


                                                                                                                              1.4




                                                                                                                                                                                               Results




                                                                                                                                                                                                 er
                                                                                                          mm


                                                                                                                              mm




                                                                                                                                                                                               Thirty-nine patients were initially screened for eligibility;
                                                                                                          2


                                                                                                                              2




                                                                                                                                                                                               however, 9 patients were excluded from the study be-
                                                                                                                                                                                               cause missing adjacent teeth and no integrity of the
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.6


                                                                                                                              1.6




                                                                                                                                                                                              tbuccal bone plate immediately after extractions; 3 pa-
                                                                                                                                                                                           In  tients refused to be enrolled in a prospective study.
                                                                                                          mm


                                                                                                                              mm




                                                                                                                                                                                               Thirty patients (18 females and 12 males, mean age of
                                                                                                          1.5


                                                                                                                              1.5
    Table 1. Mean values for mesial and distal bone reabsorption for each implant at Time 0 and Time 2.




                                                                                                                                                                                               48 ± 11.6 years) were considered eligible and were
                                                                                                                                                                                               consecutively enrolled and treated. No patients drop-
                                                                                                          mm


                                                                                                                              mm
                                                                                                                              1.8




                                                                                                                                                                                               ped out from the study and the data from all patients
                                                                                                          2




                                                                                                                                                                                          ni
                                                                                                                                                                                               was evaluated in the statistical analysis. Eleven teeth
                                                                                                          mm


                                                                                                                              mm
                                                                                                          1.3


                                                                                                                              1.3




                                                                                                                                                                                               (33%) were removed using a piezosurgery tip to reduce
                                                                                                                                                                                               the risk for buccal plate fracture and thus reducing the
                                                                                                                                                                                          io

                                                                                                                                                                                               risk for further bone loss.
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                          1.6


                                                                                                                              1.6


                                                                                                                                                  1.8


                                                                                                                                                                      1.8




                                                                                                                                                                                               All treated sites allowed the placement of 3.75 or
                                                                                                                                                                                               4.25 mm implants. Implants were torqued at 30 N
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm




                                                                                                                                                                                               cm2. No complications were recorded during the heal-
                                                                                                                                                  1.4


                                                                                                                                                                      1.4




                                                                                                                                                                      iz
                                                                                                          2


                                                                                                                              2




                                                                                                                                                                                               ing period.
                                                                                                                                                                                               The mean values for the mesial and distal bone reab-
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                          1.4


                                                                                                                              1.4


                                                                                                                                                  1.6


                                                                                                                                                                      1.3




                                                                                                                                                                                               sorption for each implant at Time 0 and Time 2 (Tab.
                                                                                                                Ed




                                                                                                                                                                                               1) were compared by test t-student and show that
                                                                                                                                                                                               there were no significant differences in bone reab-
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                          1.7


                                                                                                                              1.4


                                                                                                                                                  1.6


                                                                                                                                                                      1.6




                                                                                                                                                                                               sorption after two years of implant insertion (p=
                                                                                                                                                                                               0.5855) (Tab. 2).
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                          1.3


                                                                                                                              1.3


                                                                                                                                                  1.5


                                                                                                                                                                      1.5




                                                                                                                                                                                               All data were also selected and divided in three differ-
                                                                                                                                                                                               ent categories:
IC




                                                                                                                                                                                               I patients who did not have bone remodeling
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                                                                  1.7


                                                                                                                                                                      1.7




                                                                                                                                                                                               II patients who had up to 0.5 mm of reabsorption
                                                                                                          2


                                                                                                                              2




                                                                                                                                                                                               III patients who had a reabsorption from 0.5 mm to
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm




                                                                                                                                                                                                   2 m.
                                                                                                          1.6


                                                                                                                              1.6


                                                                                                                                                  1.8


                                                                                                                                                                      1.8
C




                                                                                                                                                                                               The results for each groups are summarized in Fig-
                                                                                                                                                                                               ures 8, 9.
                                                                                                          mm


                                                                                                                              mm


                                                                                                                                                  mm


                                                                                                                                                                      mm
                                                                                                          1.5


                                                                                                                              1.5


                                                                                                                                                  1.3


                                                                                                                                                                      1.3
©




                                                                                                                                                                                               Discussion
                                                                                                          mean values at T0


                                                                                                                              mean values at T2


                                                                                                                                                  mean values at T0


                                                                                                                                                                      mean values at T2




                                                                                                                                                                                               Literature data showed that implants placed immedi-
                                                                                                                                                                                               ately in fresh extraction sockets represent a reliable
                                                                                                                                                                                               procedure. Some authors indicated a low annual fail-
                                                                                                                                                                                               ure rate of 0.82% (95% CI: 0.48-1.39%) resulting in a
                                                                                                                                                                                               survival rate of 98.4% at 2-year (16). In systematic re-

    32                                                                                                                                                                                                              Annali di Stomatologia 2015; VI (1): 29-34
    Post-extraction implants in aesthetic zones


    Table 2. T-student test from values at T0 and T2.

                             mean                 Dev. Standard       T                  Degrees of freedom              P
    values at T0             1.6 mm               0.2613              0.5484             58                              0.5855
    values at T2             1.5633 mm            0.2566




                                                                                                              i
                                                                                                            al
                                                                  faces. The small bony changes were in accordance
                                                                  with those reported in the RCT by Canullo et al. (23),




                                                                                                         on
                                                                  which showed that after about 2 years of loading, the
                                                                  platform-switching group experienced bone loss of
                                                                  0.25 mm mesially and 0.36 mm distally; the bone loss
                                                                  was more significant in the platform-matching group,
                                                                  reaching 1.13 mm and 1.25 mm on mesial and distal




                                                                                               zi
                                                                  surfaces, respectively. On the contrary, in the study by
                                                                  Crespi et al. (22), no significant differences in the bony
                                                                  changes between the two groups were found. The




                                                                                na
                                                                  bone loss ranged 0.73-0.84 mm at the 1- year follow-
                                                                  up and 0.68-0.80 mm at the end of the second year.
    Figure 8. Results after 1 year.                               Basing on our results, it should be hypothesized that
                                                                  platform switching could minimize bone remodeling af-
                                                                  ter prosthetic loading. In addition, also bone grafting




                                                                    er
                                                                  may have contributed to reduce bone remodeling. The
                                                                  placement of graft material has been indicated as an
                                                                  ideal procedure in order to maintain adequate bone
                                                                  levels, as demonstrated by Iasella et al. (24). Compa-


                                                              t   rable results have been found using similar techniques
                                                           In     by Serino et al. (25) and Camargo et al. (26), who con-
                                                                  cluded that a slight bone loss at buccal and lingual as-
                                                                  pects may occur despite preservation procedures.
                                                                  This remodeling in response to inadequate blood
                                                 ni
                                                                  supply becomes more critical in the buccal region for
    Figure 9. Results after 2 years.                              characteristics naturally inherent to this region’s na-
                                                                  ture and anatomy (27). Current scientific literature re-
                                                                  ports that an alveolar ridge preservation technique
                                      io

    views (17, 18), survival rates and complication occur-
    rence of fixed dental prosthesis, formerly “fixed partial     has some benefits including less ridge reabsorption
    dentures” (FPDs) and single crowns supported by               of the post-extractive sites (28), but emphasises that
    post-extractive implants were estimated. The 5-year           a complete preservation of the buccal area is never-
                           iz



    survival rate of implants was >95% and that of FPDs           theless difficult (28). This fact could explain the bone
    and SCs were approximately 95%. Technical and bio-            remodeling up to 1 mm which we observed.
    logical complications were reasonably prevalent. In the       This research has some limitations. First of all the ab-
           Ed




    review concerning peri-implant diseases (19), it was          sence of a control group (only ridge preservation)
    found that after 5-10 years of function, peri-implant         makes our research partially elusive. Furthermore,
    mucositis occurred in approximately 80% of subjects           the study includes in the same group mandibular and
    and in 50% of implants. Peri-implantitis was found in         maxillary implants.
    28-56% of the subjects and 12-43% of the implants. In         Our results need to be confirmed by other researches
    this research no complications from a technical or a bi-      with a major numbers of mandibular and maxillary im-
IC




    ological point of view were observed. In addition, our        plants included in separated groups, and with a con-
    research highlighted bone changes similar to other            trol group.
    studies (20). Generally, immediate implants in most
    studies experienced bone loss. The 1-year studies that
C




    the bone loss was less than 1 mm (range: gain 1 mm-           References
    loss 0.98 mm) in the first year, and longer-term studies
    demonstrated that after the first functioning year bone        1. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus state-
    levels became stable (19). Our data indicated slightly            ments and recommended clinical procedures regarding the
                                                                      placement of implants in extraction sockets.Int J Oral Max-
©




    higher changes but similar at 1 and 2-year follow up.
                                                                      illofac Implants. 2004;19 Suppl:26-8.
    Three studies (21-23) reported changes of marginal             2. Adell R, Lekholm U, Rockler B, Brånemark PIA 15-year study
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    ately restored implants using the platform-switching              lous jaw.Int J Oral Surg. 1981 Dec;10(6):387-416.
    method. In the study of Calvo-Guirado et al. (21), the         3. Schulte W, Kleineikenscheidt H, Lindner K, Schareyka R. The
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    Annali di Stomatologia 2015; VI (1): 29-34                                                                                33
    M.M. Figliuzzi et al.


     4. Becker W, Becker BE, Hujoel P.Retrospective case series                 servation period of at least 5 years.Clin Oral Implants Res.
        analysis of the factors determining immediate implant place-            2004 Dec;15(6):667-76.
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        810-1.                                                                  tential of growth factors for localized alveolar ridge aug-
     5. Huys LW. Replacement therapy and the immediate post-ex-                 mentation: a systematic review.J ClinPeriodontol. 2008




                                                                                                                          i
        traction dental implant. Implant Dent. 2001;10(2):93-102.               Sep;35(8 Suppl):255-81.




                                                                                                                        al
     6. Bianchi AE, Sanfilippo F. Single-tooth replacement by im-         19.   Zitzmann NU, Berglundh T Definition and prevalence of peri-
        mediate implant and connective tissue graft: a 1-9-year clin-           implant diseases. J Clin Periodontol. 2008 Sep;35(8 Sup-
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        77.                                                               20.   Fransson C, Lekholm U, Jemt T, Berglundh T. Prevalence




                                                                                                                     on
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    34                                                                                            Annali di Stomatologia 2015; VI (1): 29-34
