managing the buccal gap and plate of bone...implant placed into extraction socket at site no. 12....

Continuing Education

Managing the Buccal Gapand Plate of Bone:

Immediate Dental Implant Placement

Authored by Gary Greenstein, DDS, MS, and John S. Cavallaro Jr, DDS

Course Number: 159

Upon successful completion of this CE activity 2 CE credit hours may be awarded

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LEARNING OBJECTIVESAfter participating in this CE activity, the individual will learn: • Available information in the literature regarding clinicalmanagement of the buccal gap.

• Practical guidelines for managing the buccal gap.

ABOUT THE AUTHORSDr. Greenstein is a clinical professor ofthe department of periodontology at theCollege of Dental Medicine, ColumbiaUniversity, NY. He maintains a privatepractice in surgical implantology andperiodontics in Freehold, NJ. He can be

reached at [email protected].

Disclosure: Dr. Greenstein reports no disclosures.

Dr. Cavallaro is the director of the implantFellowship program and associate clinicalprofessor of prosthodontics at the Collegeof Dental Medicine, Columbia University,NY. He maintains a private practice insurgical implantology and prosthodontics

in Brooklyn, NY. He can be reached at [email protected].

Disclosure: Dr. Cavallaro reports no disclosures

INTRODUCTIONWhen a dental implant is placed into a fresh extractionsocket, the space between the implant periphery andsurrounding bone is called the gap or jumping distance.1

The gap consists of 2 dimensions: horizontal defect widthand vertical defect height (Figure 1). The term jumpingdistance refers to the ability of bone to bridge thehorizontal gap and fill the void. A gap can occur on any

aspect of an immediately placed implant: buccal, lingual,or proximally.

The main objective of immediate im plant placement isto provide an osseointegrated fixture suitable for anaesthetic and functional restoration. Bone fill in the gapbetween the implant and the peripheral bone is important.The buccal aspect of an implant is of great concern,especially in the aesthetic zone, because the buccal bonyplate is usually thin2,3 and its resorption can result in soft-tissue recession (Figure 2).4 Surgical management of thebuccal gap to obtain an optimal result is controversial andconfusing with respect to the best techniques to achievethe following: optimal bone fill in the gap, most coronallevel of bone-to-implant contact (BIC), and the leastamount of buccal bone loss and soft-tissue recession.

This article is a literature review which was undertakento evaluate available information regarding clinicalmanagement of the buccal gap. Background information ispresented, and data pertaining to gap management andlimitations of our knowledge are discussed to developpractical guidelines for handling the buccal gap.


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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant PlacementEffective Date: 03/1/2013 Expiration Date: 3/1/2016

Figure 1. Implant placed into extraction socket at site No. 12. Buccal gapwidth is 3.5 mm and vertical depth is 7 mm. Smaller and shallower gapon the palatal side of the implant.

Figure 2. Implant inserted into extraction socket (site No. 6) with a thinlabial bony plate. Placement was too labial. As the area healed, bone waslost in a vertical direction and resulted in soft-tissue recession.

BACKGROUND INFORMATIONExtrapolating Data from Animal Models to Humans—To attainhistological evidence concerning the best methods to managethe buccal gap and adjacent bone, experimental studies wereconducted in animal models. In this regard, Pearce et al5

concluded that dogs have the most similar bone structure tohumans with respect to microstructure, macrostructure, bonecomposition, and bone remodeling. Nevertheless, there aredif ferences in the size and shape of bones in canines andhumans. Further more, a dog’s bone has a higher mineraldensity and re models faster than humans. It was concludedthat dog models may be used in experimental investigations toassess aspects of wound healing; however, it is only an ap -proximation of what occurs in humans.

Immediate Implant Survival Rates—The survival rates ofimmediately placed im plants into fresh extraction sockets andhealed ridges are similar (97.3% to 99%).6,7 This finding isalso true with respect to immediate placement of implants intoinfected sites8,9 or locations with periapical lesions.10

Typical Healing of an Extraction Socket—Sockets normallyfill in with bone, but they are associated with a mean 1.24 mmvertical bone loss (range: 0.9 to 3.6 mm) and an average 3.79mm horizontal bone reduction (range 2.46 to 4.56 mm) after 6months.11 However, these means for bone loss represent datawhen teeth were extracted and flaps were usually elevated.Resolution of a socket is caused by a combination of bone filland resorption of the bony crest adjacent to the socket.

Socket Healing After Immediate Implant Placement—Numerous investigations confirmed that immediate implantplacement is associated with bone loss. This has beendocumented in experimental studies in dogs12-15 and humanclinical trials.16-19 The amount of bone loss varies and isdependent on many factors (to be discussed). In general thereis a decrease of vertical bone height and an even greaterhorizontal bone loss. The amount of alveolar bone resorptionis larger on the buccal than the lingual aspect of an implant,because the buccal plate is typically thinner.20,21

DATA PERTAINING TO GAP FILL AND BUCCAL PLATEBONE LOSS: ANIMAL STUDIES AND HUMANCLINICAL TRIALSExperimental Animal Studies (Usually Dogs)Studies conducted in animals confirmed that immediately

placed implants in fresh extraction sites integrated with thebone.22-26 Akimoto et al27 created defects 0.5 to 1.4 mmaround machined implants and noted that all defects healed,regardless of size. However, the distance between the bonemargin and where the BIC started was directly related to gapsize. The larger the gap, the farther the first BIC was from thebone margin. Botticelli et al1 assessed the healing responsearound implants when created defects (sizes one to 1.25 mm)were treated with and without barriers and the implants weresubmerged. The defects healed with bone and the BIC againstsandblasted, large-grit, acid-etched surfaced im plants wassimilar to the control sites where an implant was placed into ahealed ridge. They concluded that a defect > one mm may healwith a high degree of osseointegration. It was noted thatprevious as sessments employed ma chined surfaced implants,whereas the latter study used rough surfaced implants.

In another dog study, Botticelli et al28 demonstrated thatcreated defects ranging from 1.25 to 2.25 mm around animmediately placed implant spontaneously filled with newbone. They29 noted artificially created de fects healeddifferently than natural gaps that oc cur after implantplacement. It was concluded that created defects healedcompletely, whereas natural gaps partly repaired. There fore,extra polation of data with respect to healing at sites wherede fects were created versus natural gaps must beinterpreted cautiously, be cause they may not represent thesame healing response temporally or physically.

Araújo et al12,20 published a series of papers consistentlydemonstrating that in dogs, after immediate im plants wereinserted and the flaps were re placed, the gap (size was < 2mm) be tween the implant and the bone filled in; however, thehorizontal width and level of the vertical height of the buccalplate of bone were reduced. Of particular interest was a paperthat as sessed the impact of de proteinated bovine bonematerial (DBBM) collagen on the gap (one to 2 mm wide and3 mm deep) around im mediately placed im plants.30 Theynoted bony plates of grafted sites were thicker and bone levelswere more coronal than sites that were not grafted.

Recently, Caneva et al15,31-33 conducted a series ofexperimental studies in dogs to investigate techniques withrespect to limiting the amount of buccal plate resorption thatoccurs when implants are installed immediately after anextraction. Their investigations provided the following re sults:


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Managing the Buccal Gap and Plate of Bone: Immediate Dental Implant Placement

DBBM particles in conjunction withcollagen barriers helped preserve thealveolar process, but mostly in ahorizontal dimension, not vertically;31

a resorbable material without amembrane was not capable ofcompletely maintaining the buccalcrest of bone;32 implants should beplaced lingually to the center of thesocket and one mm deeper than thealveolar crest to limit exposure ofbuccal threads;15 wider implants,which were close to the buccal plate,caused greater bone loss buccallythan narrower im plants.33

Favero et al34, in a dog model, re -ported the following results: lingualplacement of the implant reducedbuccal bone resorption and recession,and use of collagen barriers withDBBM did not improve results whencompared to no additional treatment. Itwas suggested the thickness of thebuccal plate, which was approximatelyone mm, contributed to the finding thatbone grafts and barriers provide noadditional benefit with respect toinhibiting bone resorption.

Human InvestigationsIn 1998, Wilson et al35 supplied thefirst human histological documenta-tion that osseointegration occurredbetween the newly formed bone inthe gap and an immediately placedim plant. Subsequently, Wilson et al36 assessed roughsurface implants (N = 10) where the gap was covered witha connective tissue graft and the area was covered with aflap. Osseo integration, BIC, and bone fill were similar whengaps were < 1.5 mm and > 4 mm.

Paolantonio et al37 evaluated the healing responsewhen implants were placed in healed bone and when theywere placed in extraction sockets and the gap was ≤ 2 mm.

No bone grafts or barriers were used before implants weresubmerged under the soft tissue. Biopsies revealed bone fillin the gap, and there was no difference between test andcontrol sites.

Subsequently, Botticelli et al16 as sessed 21 sites in 18humans with re spect to gap healing around rough surfaceddental implants that were not submerged. The flaps wereplaced next to the abutment portion of the implant exposed


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A. WITH FLAP ELEVATION ADVANTAGE DISADVANTAGE

1. No additional treatment (no bone graft or barrier used)

(a) Flap placed over the defect Covers defect This may require flap advancementincreased morbidity (edema and ecchymosis) Soft tissue may invade gap

(b) Flap positioned at bone crest, Easier Plaque and food may get trapped leaving the gap exposed in void if coagulum is not retained

2. Bone graft placed into the defect with or without growth factors

(a) Flap placed over the defect Covers defect This may require flap advancement increased morbidity (edema and ecchymosis)Soft tissue may invade bone graft

(b) Flap positioned at bone crest, Easier Plaque and food may get trapped leaving the gap exposed in void if coagulum is not retained

3. Barrier placed over defect

(a) Flap advancement is usually Covers barrier Increased morbidity (edema and necessary to attain primary closure ecchymosis)

(b) No flap advancement and use of Easier Nonresorbable barrier—nonresorbable or resorbable barrier exposure/infectionor connective tissue graft Resorbable barrier—fragments in

mouth

4. Barrier placed over bone graft

(a) Flap advancement is usually Covers barrier Increased morbidity (edema and necessary to attain primary closure ecchymosis)

Nonresorbable barrier—exposure/infection

(b) No flap advancement and use of Easier Nonresorbable—exposure/infectionnonresorbable or resorbable barrier Resorbable barrier—fragments in or connective tissue graft mouth

5. Temporization of implant and abutment

Supports soft tissue Additional work at time of surgery

B. NO FLAP ELEVATION ADVANTAGE DISADVANTAGE (FLAPLESS IMPLANT INSERTION)

1. The gap is left open with no additional therapy

Easier Plaque and food may get trapped in void if coagulum is not retained

2. Bone is placed within the gap

Bone particles may be displaced

3. Temporization of implant and abutment with either of the above

Supports soft tissue Additional work at time of surgery

Table. Possible Therapies Available to Treat the Buccal Gap After Immediate ImplantPlacement: With and Without Flap Elevation

to the mouth. No bone or barriers were employed. Eight of9, defects initially ≥ 3 mm in width, were completely filledwith bone. The vertical bone crest resorption amounted to0.3 (buccal), 0.6 (lingual/palatal), 0.2 (me sial), and 0.5(distal), and 56% of the horizontal width. No biopsies weredone. There are 2 criticisms of the clinical study by Botticelliet al.16 It is possible that the BIC was more apical thanother sites where implants were placed into healed ridges,and the clinical examination did not confirm thatosseointegration occurred. How ever, as previously in-dicated in a histological assessment in dogs, Botticelli et al38 found that defects lateral to rough sur face implantsregenerate with prop er os seo integration, whereas smoothsurfaced implants repaired with connective tissue betweenthe bone and im plants. It has been suggested that therough surfaces provided a better surface for clot stabilityand maturation.39

In a prospective study, Chen et al4,40 also reported that thesmall defects with respect to height and width aroundnontextured implants could be eliminated without the use of amembrane and/or a bone graft. Sim ilarly, Covani et al41

confirmed that defects could be resolved in humans withoutbarriers or bone graft materials if the defect was < 2 mm wide.

Recently, Tarnow and Chu42 provided histologicalevidence of defect fill and osseointegration in a gapadjacent to an immediate implant that was 4 mm wide. Inthis single case report, no flap was elevated, and the de fectwas allowed to heal by secondary intention withoutplacement of a bone graft or a barrier. It was suggested thatif the gap is allowed to heal by secondary intention (nocoverage of the gap with a flap) then the gap size may notinterfere with bone fill and osseointegration.

TREATMENT OPTIONS WITH AND WITHOUT FLAPELEVATIONFlap ElevationIn conjunction with immediate im plant placement, there is adiversity of available techniques to manage the buccal gapwhen a flap is elevated to place an implant.

Remarks in the Table pertain to situations where thebony plate is intact and does not require a regenerativeprocedure to treat a dehiscence or bone fenestration.

With respect to submerged versus non submerged im plant

protocols after immediate implant placement, the data indicatethat both techniques can be used successfully, dependingon the situation and preference of the clinician.43,44 Asubmerged protocol usually re quires flap advancement toattain primary closure over an immediate implant. If anonsubmerged procedure is utilized, the flap is typicallyreplaced adjacent to the healing abutment or temporarycrown, or the gap can be left uncovered. If a permanentabutment is used, it will not have to be removed (avoidsdisrupting the junctional epithelium), and thereby may helpreduce recession.45,46

FlaplessIf a flap is not elevated to place a dental im plant, severaltherapeutic choices are available to deal with the gap (Table).How ever, despite a flapless approach, remodeling of theosseous crest occurs. Teeth derive their blood supply from3 sources: periodontal ligament, peri osteum, and the endo -steal marrow spaces.47 Tooth extraction eliminates the bloodsupply to the bone from the periodontal ligament and resultsin horizontal and vertical bone loss.20,48

In general, elevation of a flap without tooth extraction re -sults in a mean bone loss of 0.5 mm.49,50 The amount ofosseous resorption is usually greater over the buccal aspectof roots than interproximally, where the bone is thicker.Disturbance of the periosteum inhibits the blood supply tothe bone and it takes several days before normal bonevascularization is resumed. Pertinently, several authorssuggested that avoidance of flap elevation reduced boneloss and recession after tooth removal and immediateimplant placement in humans51 and animal experimentalstudies.52-54 In contrast, other human55-57 and experimentalstudies58-60 determined that even with a flapless approach,the amount of bone loss was similar with and without flapelevation (Figures 3a to 3d). Recently, Grunder61 reportedthat with a flap approach, the amount of buccal soft-tissuerecession was 1.06 mm. Despite these conflicting data, it isthe authors’ opinion that if the tissues are left undisturbed(no flap elevation), there is a better chance to have less soft-tissue recession. This concept is also supported by thefinding that even if there is bone loss, it does not necessarilyresult in alterations of the gingival contour as seen inperiodontal patients.


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OTHER FACTORS THAT CAN AFFECTHEALING OF THE GAP AND ADJACENTSOFT TISSUESize of Horizontal Bone Gap—The gap sizeis an important determinant with respect to predictability of spontaneous bone fill.The critical gap size that allows unaidedhealing has not been determined, becausethere are variables that can affect the result. However, in humans, gaps < 2 mmusually heal without allografts, xeno grafts,and barriers when im plants are sub-merged37,40,41,62,63 or nonsubmerged(Figures 4a to 4f).4,38

In dogs, investigators noted that biggergaps have a greater potential for in-complete fill; therefore, they suggested bio-material filler would be beneficial in largegaps.18,27,64,65 How ever, when evaluatingthe data in humans, different techniquesresulted in bone fill without bone grafts indefects ≥ 3 mm.16,35,36,42 Tarnow andChu42 reported bone fill in a gap that was 4 mm wide. The gap was not grafted andthe defect was allowed to heal by second-ary intention (no flap elevation or coverage of gap). Incontrast, Botticelli et al16 did not graft, but replaced theflaps against healing abutments and 8 of 9 defects thatwere initially ≥ 3 mm filled with bone. Others noted bone fillin 4 mm gaps that were covered with a connective tissuegraft and the flap.35,36 Thus, there appears to be adiscrepancy with respect to how large a gap will healspontaneously and under what conditions.

Biomaterials—Chen and Buser66 reviewed the literatureregarding the effectiveness of placing biofillers in the gap. Theyconcluded that most in vestigations employed combinations ofa bone graft material and/or barrier membrane (expandedpolytetrafluorethhylene-PTFE or collagen bar rier) to enhanceregeneration. The most commonly used biofiller was DBBM,which was employed alone and in conjunction with resorbableand nonresorbable barriers. Other graft materials usedincluded autogenous bone, demineralized freeze-dried bone,and hydroxyapatite. All the techniques provided clinically

acceptable defect resolution, and it was noted thataugmentation procedures reduced horizontal bone resorption,but not crestal bone loss.

Recent studies in dogs focused on the use of DBBM.Araújo et al30 demonstrated that use of DBBM versus nobiofiller resulted in the BIC being more coronal and thebuccal plate thicker. After employing DBBM, Caneva et al31

also reported a more coronal level of BIC, and Chen et al4

noted a 25% re duction of horizontal bone loss. It appears thatdifferent materials can be used, but the one currentlyreceiving the most attention is DBBM. A possible explanationfor this is that in Europe, human allograft material is notallowed to be used in humans. Cur rently, there is nopreponderance of data indicating that one type of graftmaterial is superior to others.

Thickness of the Buccal Plate of Bone—Buccal platethickness affects the degree of buccal plate resorption afterimmediate implant placement. In a dog model, it was


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Figure 3a. Occlusal view of immediateimplants placed at site Nos. 3 and 5 using a nonsubmerged protocol with no flap reflection.

Figure 3b. Periapical radiograph ofinserted implants in Figure 3a.

Figure 3d. Periapical radiograph offinal fixed prosthesis, demonstratingexcellent bone levels in relation tohealed implants.

Figure 3c. Definitive fixed prosthesis in place;implants are stable, soft tissue is healed, andthere is a good aesthetic result. However, visualobservation comparing Figure 3c to Figure 3areveals that the buccal width appears to bereduced, reflecting bone loss during extractionsocket healing even without flap reflection.

a b

c d

determined that if the buccal plate was > one mm, there wasless bone resorption compared to sites with a ≤ one mm thickbony plate.18 In addition, Ferrus et al18 suggested that thewider the buccal bony plate, the greater the fill of thehorizontal gap. In humans, Spray et al67 noted after toothextraction that buccal plates > 2 mm thick did not usuallyresorb vertically, whereas socket walls < 2 mm widedemonstrated bone loss (Figure 5). It was advised by severalauthors that if the buccal bone thickness is not one to 2 mm,hard-tissue augmentation was recommended63,67,68 tomaintain the level of the osseous crest.

Buccolingual Position of Implants—There are a fewways the spatial relationship between the implant and thebuccal plate can be affected: positioning of the implant andselection of its diameter. Pertinently, the closer the implant

is to the buccal plate, the greater the amount of boneresorption that occurs.15,34,69 Furthermore, use of largeimplants to fill the alveolus, which encroaches on the buccalplate, results in additional bone loss as opposed toretaining bone. Ulti mately, room must be left to allow for thehorizontal influence of the implant.70


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Figure 4a. Occlusal view of immediate implantplaced at site No. 13 with a flapless approach. Thelabial gap is 2 mm wide and the palatal gap is onemm. The implant was placed slightly palatally andone mm apical to the intact buccal osseous crest.

Figure 4c. Occlusal view of definitive restorationdemonstrating minimal loss of facial soft tissue.

Figure 4b. Periapical radiograph of the implantdepicted in Figure 4a. Nobiomaterial was placed intothe gap during surgery.

Figure 4d. Facial view demonstrates noapparent loss of vertical height of midlabial softtissue.

Figure 4e. Periapical radio -graph of completed restorationdepicting preservation ofinterproximal bone levels.

a cb

ed f

Figure 4f. Patient’s smile-line on crown insertion day.Note slight blanching of soft tissue.

Figure 5. Occlusal viewdepicting a dentalimplant placed into afresh extraction socketwhich had a thick labialplate of bone.

Concerning soft-tissue levels, im plants placed buccallymanifested 3 times more recession than lingually placedimplants (1.8 versus 0.6 mm).71 However, lingualpositioning of an implant needs to be taken intoconsideration with respect to prosthetic concerns.34

Number of Bony Walls—With re spect to defectmorphology, the most favorable healing is in 3-walleddefects,72 which is similar to the gap between the bone andthe implant surface. If left undisturbed, the gap will fill in witha clot, and 3 walls provide better clot containment thandefects with fewer walls.

Implant Surfaces—The stability of the clot will beimpacted by the implant surface.39 Textured implantsurfaces provide greater surface area and improved levelsof osseointegration compared to machined surfaces. Whenplacing immediate implants, healing is better with texturedsurfaces (eg, increased bone to implant contact) asopposed to smooth surfaces.38,62

Role of Adjacent Teeth—In a dog model, Favero et al73

reported immediate implants placed in several adjacentsockets manifested more bone loss than implants whichwere inserted into a single socket adjacent to teeth.Apparently, the presence of adjacent teeth retarded boneloss with respect to the interproximal bone, and this findingis in agreement with other authors.29,59

Biotype—If buccal bone does not resorb, soft tissue willnot recede. In contrast, the crestal labial bone can resorband the soft tissue may not recede. In this regard,numerous investigations assessed the effect of the biotypeon recession, and the results have been conflicting. Whena thick versus a thin biotype were compared afterimmediate implant placement, several authors reported in -creased recession when there was a thin biotype.66 Othersnoted there was no difference in the amount ofrecession.4,71 Lee et al74 reviewed the data on this subjectand concluded that a thin biotype predisposes an individualto recession and loss of papillae.

Temporization With and Without Bone Grafting—Immediate insertion of implants with provisionalization mayenhance soft-tissue contours.75,76 Tarnow77 and Chu et al78

also favored temporization in conjunction with a bone graftto fill the gap. In addition, it was suggested to add bone

coronal to the osseous crest to help support the gingivalcontour. A clinical trial substantiating these findings was justcompleted and the technique is referred to as dual-zonesocket management (personal communication with Dr.Tarnow, January 2013).

DISCUSSIONManagement of the buccal gap and reducing buccal plateresorption are important considerations when contemplatingimmediate implant placement. Procedures to handle the gapwhen the buccal plate is intact have varied depending onwhether the implant was placed with or without flap elevation.The 8 possibilities of therapy are listed in the Table. Inaddition to these methodologies, soft-tissue augmentation(eg, connective tissue graft) can be provided on the buccalaspect depending on the aesthetic de mands of the case.61 Ingeneral, in the aesthetic zone it is preferable not to elevate aflap if the buccal plate is intact. Some techniques can bedone alone (ie, adding a biomaterial) or in combination withother procedures (biomaterial filler plus a barrier). Studieshave clarified that if the gap is < 2 mm, no additionaltherapy is needed to en hance gap fill; however, concomitantresorption of bone occurs and the magnitude of thisalteration is related to buccal plate thickness, im plantpositioning, and whether a flap is elevated. Some authorssuggest adding a biomaterial to inhibit horizontal boneresorption. It appears that a certain amount of crestal boneloss occurs after an extraction due to loss of blood supplywhen the periodontal ligament is eliminated. Differences infindings between studies with respect to gap fill can beattributed to different gap sizes, dissimilar thicknesses of the buccal plate and implant positioning, and varioussurgical modalities. There fore, it is difficult to comparestudies. This is further complicated by the fact thatextrapolating data from dog models to humans can only bedone conceptually without specificity regarding themagnitude of measurements.

Based upon the collective information in the literature, thenext section provides conclusions and guidelines forimmediate implant placement with respect to managing abuccal gap after immediate implant insertion when the buccalplate is present. If a buccal plate is dehisced, it is necessary to


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address this issue with a bone regenerationprocedure at the time of implant placement orsubsequently in a delayed procedure.79,80

CONCLUSIONS AND GUIDELINES FORTREATING THE BUCCAL GAP AFTERIMMEDIATE IMPLANT PLACEMENT

1. Do not elevate a flap when placing animplant in the aesthetic zone, therebyreducing the risk of recession. If increasedaccess for visualization is desired, raise onlya lingual flap.

2. Gaps < 2 mm wide will usually healspontaneously without placing a biomaterial.66

If the gap is > 2 mm, spontaneous boneregeneration is less predictable. If the gap is < 2 mm, the gap can be left open and it will fillwith a clot, or a biomaterial can be added toocclude the gap (Figures 6a to 6d). If abiomaterial is placed, some collagen material(eg, CollaCote [Zimmer Dental]) can be placedon top of the material to inhibit exfoliation of thematerial before a fibrin clot forms. If a flap israised for implant placement and the gap is< 2 mm, the flap can be replaced either overthe gap28,30,37 or at the buccal crest ofbone. If the flap covers the graft material, itwill not exfoliate. Placement of a provisional crown on aninterim or definitive abutment also can provide protection forthe graft material. It has been suggested that it is better toleave the gap uncovered, thereby retarding the connectivetissue and epithelium from interfering with initial populationof the site with bone progenitor cells.77

3. Bone fill can occur in defects > 3 mm withoutplacement of bone grafts or use of barriers.16,42 However, itappears that the greater the gap size the greater thepotential for incomplete fill of the defect.

4. Gaps adjacent to nonsubmerged and submergedimplants heal similarly.43

5. Thin buccal bony plates resorb and result in loss ofcrestal bone height (approximately one mm) and horizontalbone width.4 Studies have shown that approximately 33%of the patients manifested gingival recession on the buccal

aspect (approximately one mm) after immediate implantplacement.4,71 If the buccal wall is thick (> one mm), theremay be limited resorption. One mm recession was alsonoted when a connective tissue graft was placed.61

6. If a biomaterial is inserted in a gap which is < 2 mm,the data indicate that there will be crestal bone loss, but thehorizontal width (contour) will be maintained better.4,12,31

7. Numerous materials were in vestigated as fillers forthe gap. How ever, deproteinized bovine bone has beenused in the most studies.66

8. The exact relationship between bone modeling andrecession is un clear; however, with increased boneresorption, there is usually increased recession.4,66

9. The implant should be placed 2 mm from the buccalplate to avoid en croaching on the buccal plate and therebycontributing to resorption.4


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Figure 6a. Clinical view of a dental implantplaced into a socket with a gap of ~ 2 mm;a biomaterial (xenograft) was placed.

Figure 6b. A piece of CollaPlug (ZimmerDental) was placed over the implant andbiomaterial; 2 sutures were used to securethe collagen plug.

Figure 6c. Periapical radiographtaken at the completion of theextraction and implant insertionprocedure.

Figure 6d. Final abutment removed after being inplace for 3 months (6 months post insertion of theimplant and biomaterial) to demonstrate excellentsoft-tissue contour.

a b

d

c

10. Oversized implants should be avoided, becausethey may encroach on the buccal plate.4,21

11. Place implants one mm subcrestally to account forcrestal bone resorption.4,20 Crestal bone resorption can bedecreased with platform switching.81,82

12. Biomaterials can be placed without a barrier, therebyavoiding flap elevation. However, if a defect is very large or ifthere is a bone dehiscence, it may be beneficial to use abarrier, and this would necessitate elevating a flap in order toachieve wound closure.

13. With a flapless approach, it was suggested thatoverfill of the gap with deproteinated bone helps supportthe soft tissue and reduces recession and bone loss whenit is done in conjunction with an abutment and temporarycrown.77 This statement is based upon an investigation thatwas just completed.

14. Only histological studies can confirm that osseo-integration was achieved when the buccal gap fills with bone.However, a functional and stable implant over a period of timecan be interpreted as a successful clinical outcome.

ADDENDUMWith respect to vertical bone loss when flap versus flaplessprocedures were compared, it was noted that there wasconflicting information. However, with regard to horizontalbone loss, several recent articles have indicated that if aflap is not raised there is greater preservation of thehorizontal bone width.83-85

REFERENCES1. Botticelli D, Berglundh T, Buser D, et al. The jumping

distance revisited: an experimental study in the dog.Clin Oral Implants Res. 2003;14:35-42.

2. Januário AL, Duarte WR, Barriviera M, et al. Dimensionof the facial bone wall in the anterior maxilla: a cone-beam computed tomography study. Clin Oral ImplantsRes. 2011;22:1168-1171.

3. Katranji A, Misch K, Wang HL. Cortical bone thicknessin dentate and edentulous human cadavers. JPeriodontol. 2007;78:874-878.

4. Chen ST, Darby IB, Reynolds EC. A prospectiveclinical study of non-submerged immediate implants:clinical outcomes and esthetic results. Clin OralImplants Res. 2007;18:552-562.

5. Pearce AI, Richards RG, Milz S, et al. Animal modelsfor implant biomaterial research in bone: a review. EurCell Mater. 2007;13:1-10.

6. Lang NP, Pun L, Lau KY, et al. A systematic review onsurvival and success rates of implants placedimmediately into fresh extraction sockets after at least1 year. Clin Oral Implants Res. 2012;23(suppl 5):39-66.

7. Ortega-Martínez J, Pérez-Pascual T, Mareque-BuenoS, et al. Immediate implants following tooth extraction.A systematic review. Med Oral Patol Oral Cir Bucal.2012;17:e251-e261.

8. Waasdorp JA, Evian CI, Mandracchia M. Immediateplacement of implants into infected sites: a systematicreview of the literature. J Periodontol. 2010;81:801-808.

9. Crespi R, Capparè P, Gherlone E. Immediate loadingof dental implants placed in periodontally infected andnon-infected sites: a 4-year follow-up clinical study. JPeriodontol. 2010;81:1140-1146.

10. Crespi R, Capparè P, Gherlone E. Fresh-socketimplants in periapical infected sites in humans. JPeriodontol. 2010;81:378-383.

11. Tan WL, Wong TL, Wong MC, et al. A systematicreview of post-extractional alveolar hard and softtissue dimensional changes in humans. Clin OralImplants Res. 2012;23(suppl 5):1-21.

12. Araújo MG, Wennström JL, Lindhe J. Modeling of thebuccal and lingual bone walls of fresh extraction sitesfollowing implant installation. Clin Oral Implants Res.2006;17:606-614.

13. Vignoletti F, de Sanctis M, Berglundh T, et al. Earlyhealing of implants placed into fresh extractionsockets: an experimental study in the beagle dog. II:Ridge alterations. J Clin Periodontol. 2009;36:688-697.

14. De Santis E, Botticelli D, Pantani F, et al. Boneregeneration at implants placed into extraction socketsof maxillary incisors in dogs. Clin Oral Implants Res.2011;22:430-437.

15. Caneva M, Salata LA, de Souza SS, et al. Influence ofimplant positioning in extraction sockets onosseointegration: histomorphometric analyses in dogs.Clin Oral Implants Res. 2010;21:43-49.

16. Botticelli D, Berglundh T, Lindhe J. Hard-tissuealterations following immediate implant placement inextraction sites. J Clin Periodontol. 2004; 31:820-828.

17. Sanz M, Cecchinato D, Ferrus J, et al. A prospective,randomized-controlled clinical trial to evaluate bonepreservation using implants with different geometryplaced into extraction sockets in the maxilla. Clin OralImplants Res. 2010;21:13-21.


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18. Ferrus J, Cecchinato D, Pjetursson EB, et al. Factorsinfluencing ridge alterations following immediateimplant placement into extraction sockets. Clin OralImplants Res. 2010;21:22-29.

19. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate orearly placement of implants following tooth extraction:review of biologic basis, clinical procedures, andoutcomes. Int J Oral Maxillofac Implants.2004;19(suppl):12-25.

20. Araújo M, Lindhe J. Dimensional ridge alterationsfollowing tooth extraction. An experimental study in thedog. J Clin Periodontol. 2005;32:212-218.

21. Caneva M, Salata LA, de Souza SS, et al. Hard tissueformation adjacent to implants of various size andconfiguration immediately placed into extractionsockets: an experimental study in dogs. Clin OralImplants Res. 2010;21:885-890.

22. Alliot B, Piotrowski B, Marin P, et al. Regenerationprocedures in immediate transmucosal implants: ananimal study. Int J Oral Maxillofac Implants.1999;14:841-848.

23. Barzilay I, Graser GN, Iranpour B, et al. Immediateimplantation of pure titanium implants into extractionsockets of Macaca fascicularis. Part II: histologicobservations. Int J Oral Maxillofac Implants.1996;11:489-497.

24. Becker W, Becker BE, Handelsman M, et al. Guidedtissue regeneration for implants placed into extractionsockets: a study in dogs. J Periodontol. 1991;62:703-709.

25. Caudill RF, Meffert RM. Histologic analysis of theosseointegration of endosseous implants in simulatedextraction sockets with and without e-PTFE barriers. 1.Preliminary findings. Int J Periodontics RestorativeDent. 1999;11:207-215.

26. Knox R, Caudill R, Meffert R. Histologic evaluation ofdental endosseous implants placed in surgicallycreated extraction defects. Int J PeriodonticsRestorative Dent. 1991;11:364-375.

27. Akimoto K, Becker W, Persson R, et al. Evaluation oftitanium implants placed into simulated extractionsockets: a study in dogs. Int J Oral MaxillofacImplants. 1999;14:351-360.

28. Botticelli D, Berglundh T, Lindhe J. Resolution of bonedefects of varying dimension and configuration in themarginal portion of the peri-implant bone. Anexperimental study in the dog. J Clin Periodontol.2004; 31:309-317.

29. Botticelli D, Persson LG, Lindhe J, et al. Bone tissueformation adjacent to implants placed in fresh

extraction sockets: an experimental study in dogs. ClinOral Implants Res. 2006;17:351-358.

30. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen inthe buccal gap at immediate implants: a 6-monthstudy in the dog. Clin Oral Implants Res. 2011;22 :1-8.

31. Caneva M, Botticelli D, Pantani F, et al. Deproteinizedbovine bone mineral in marginal defects at implantsinstalled immediately into extraction sockets: anexperimental study in dogs. Clin Oral Implants Res.2012;23:106-112.

32. Caneva M, Botticelli D, Stellini E, et al. Magnesium-enriched hydroxyapatite at immediate implants: ahistomorphometric study in dogs. Clin Oral ImplantsRes. 2011;22:512-517.

33. Caneva M, Botticelli D, Rossi F, et al. Influence ofimplants with different sizes and configurationsinstalled immediately into extraction sockets on peri-implant hard and soft tissues: an experimental study indogs. Clin Oral Implants Res. 2012;23:396-401.

34. Favero G, Botticelli D, Favero G, et al. Alveolar bonycrest preservation at implants installed immediatelyafter tooth extraction: an experimental study in thedog. Clin Oral Implants Res. 2011 Dec 6. [Epub aheadof print]

35. Wilson TG Jr, Schenk R, Buser D, et al. Implantsplaced in immediate extraction sites: a report ofhistologic and histometric analyses of human biopsies.Int J Oral Maxillofac Implants. 1998;13:333-341.

36. Wilson TG Jr, Carnio J, Schenk R, et al. Immediateimplants covered with connective tissue membranes:human biopsies. J Periodontol. 2003;74:402-409.

37. Paolantonio M, Dolci M, Scarano A, et al. Immediateimplantation in fresh extraction sockets. A controlledclinical and histological study in man. J Periodontol.2001;72:1560-1571.

38. Botticelli D, Berglundh T, Persson LG, et al. Boneregeneration at implants with turned or rough surfacesin self-contained defects. An experimental study in thedog. J Clin Periodontol. 2005;32:448-455.

39. Davies JE. Mechanisms of endosseous integration. IntJ Prosthodont. 1998;11:391-401.

40. Chen ST, Darby IB, Adams GG, et al. A prospectiveclinical study of bone augmentation techniques atimmediate implants. Clin Oral Implants Res.2005;16:176-184.

41. Covani U, Cornelini R, Barone A. Bucco-lingual boneremodeling around implants placed into immediateextraction sockets: a case series. J Periodontol.2003;74:268-273.


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42. Tarnow DP, Chu SJ. Human histologic verification ofosseointegration of an immediate implant placed into afresh extraction socket with excessive gap distancewithout primary flap closure, graft, or membrane: acase report. Int J Perio dontics Restorative Dent.2011;31:515-521.

43. Cecchinato D, Olsson C, Lindhe J. Submerged or non-submerged healing of endosseous implants to beused in the rehabilitation of partially dentate patients.J Clin Periodontol. 2004;31:299-308.

44. Astrand P, Engquist B, Anzén B, et al. Nonsubmergedand submerged implants in the treatment of thepartially edentulous maxilla. Clin Implant Dent RelatRes. 2002;4:115-127.

45. Abrahamsson I, Berglundh T, Lindhe J. The mucosalbarrier following abutment dis/reconnection. Anexperimental study in dogs. J Clin Periodontol.1997;24:568-572.

46. Abrahamsson I, Zitzmann NU, Berglundh T, et al. Themucosal attachment to titanium implants with differentsurface characteristics: an experimental study in dogs.J Clin Periodontol. 2002;29:448-455.

47. Dento-osseous structures, blood vessels, and nerves.In: Nelson SJ. Wheeler’s Dental Anatomy, Physiology,and Occlusion. 9th ed. St. Louis, MO: SaundersElsevier; 2010.

48. Schropp L, Wenzel A, Kostopoulos L, et al. Bonehealing and soft tissue contour changes followingsingle-tooth extraction: a clinical and radiographic 12-month prospective study. Int J PeriodonticsRestorative Dent. 2003;23:313-323.

49. Donnenfeld OW, Hoag PM, Weissman DP. A clinicalstudy on the effects of osteoplasty. J Periodontol.1970;41:131-141.

50. Wilderman MN, Pennel BM, King K, et al.Histogenesis of repair following osseous surgery. J Periodontol. 1970;41:551-565.

51. Job S, Bhat V, Naidu EM. In vivo evaluation of crestalbone heights following implant placement with‘flapless’ and ‘with-flap’ techniques in sites ofimmediately loaded implants. Indian J Dent Res.2008;19:320-325.

52. Fickl S, Zuhr O, Wachtel H, et al. Tissue alterationsafter tooth extraction with and without surgical trauma:a volumetric study in the beagle dog. J ClinPeriodontol. 2008;35:356-363.

53. Barros RRM, Novaes Jr AB, Papalexiou V. Buccal boneremodeling after immediate implantation with a flap orflapless approach: a pilot study in dogs. Int J Dent

Implants and Biomaterials Titanium. 2009;1:45-51. 54. Blanco J, Nuñez V, Aracil L, et al. Ridge alterations

following immediate implant placement in the dog: flapversus flapless surgery. J Clin Periodontol.2008;35:640-648.

55. Maló P, Nobre M. Flap vs. flapless surgical techniquesat immediate implant function in predominantly softbone for rehabilitation of partial edentulism: aprospective cohort study with follow-up of 1 year. EurJ Oral Implantol. 2008;1:293-304.

56. Nickenig HJ, Wichmann M, Schlegel KA, et al.Radiographic evaluation of marginal bone levelsduring healing period, adjacent to parallel-screwcylinder implants inserted in the posterior zone of thejaws, placed with flapless surgery. Clin Oral ImplantsRes. 2010;21:1386-1393.

57. De Bruyn H, Atashkadeh M, Cosyn J, et al. Clinicaloutcome and bone preservation of single TiUnite™implants installed with flapless or flap surgery. ClinImplant Dent Relat Res. 2011;13:175-183.

58. Caneva M, Botticelli D, Sulata LA, et al. Flap vs.“flapless” surgical approach at immediate implants: ahistomorphometric study in dogs. Clin Oral ImplantsRes. 2010;21:1314-1319.

59. Araújo MG, Lindhe J. Ridge alterations following toothextraction with and without flap elevation: anexperimental study in the dog. Clin Oral Implants Res.2009;20:545-549.

60. Becker W, Wikesjö UM, Sennerby L, et al. Histologicevaluation of implants following flapless and flappedsurgery: a study in canines. J Periodontol.2006;77:1717-1722.

61. Grunder U. Crestal ridge width changes when placingimplants at the time of tooth extraction with andwithout soft tissue augmentation after a healing periodof 6 months: report of 24 consecutive cases. Int JPeriodontics Restorative Dent. 2011;31:9-17.

62. Im SU, Hong JY, Chae GJ, et al. The evaluation ofhealing patterns in surgically created circumferentialgap defects around dental implants according toimplant surface, defect width and defect morphology. J Korean Acad Periodontol. 2008;38(suppl):385-394.

63. Juodzbalys G, Wang HL. Soft and hard tissueassessment of immediate implant placement: a caseseries. Clin Oral Implants Res. 2007;18:237-243.

64. Polyzois I, Renvert S, Bosshardt DD, et al. Effect ofBio-Oss on osseointegration of dental implantssurrounded by circumferential bone defects of differentdimensions: an experimental study in the dog. Clin


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Oral Implants Res. 2007;18:304-310.65. de Barros RR, Novaes AB Jr, Queiroz A, et al. Early

peri-implant endosseous healing of two implantsurfaces placed in surgically created circumferentialdefects. A histomorphometric and fluorescence studyin dogs. Clin Oral Implants Res. 2012;23:1340-1351.

66. Chen ST, Buser D. Clinical and esthetic outcomes ofimplants placed in postextraction sites. Int J OralMaxillofac Implants. 2009;24(suppl):186-217.

67. Spray JR, Black CG, Morris HF, et al. The influence ofbone thickness on facial marginal bone response:stage 1 placement through stage 2 uncovering. AnnPeriodontol. 2000;5:119-128.

68. Kazor CE, Al-Shammari K, Sarment DP, et al. Implantplastic surgery: a review and rationale. J OralImplantol. 2004;30:240-254.

69. Tomasi C, Sanz M, Cecchinato D, et al. Bonedimensional variations at implants placed in freshextraction sockets: a multilevel multivariate analysis.Clin Oral Implants Res. 2010;21:30-36.

70. Vela X, Méndez V, Rodríguez X, et al. Crestal bonechanges on platform-switched implants and adjacent teethwhen the tooth-implant distance is less than 1.5 mm. Int JPeriodontics Restorative Dent. 2012;32:149-155.

71. Evans CD, Chen ST. Esthetic outcomes of immediateimplant placements. Clin Oral Implants Res.2008;19:73-80.

72. Kim CS, Choi SH, Chai JK, et al. Periodontal repair insurgically created intrabony defects in dogs: influenceof the number of bone walls on healing response. JPeriodontol. 2004;75:229-235.

73. Favero G, Lang NP, Favero G, et al. Role of teethadjacent to implants installed immediately intoextraction sockets: an experimental study in the dog.Clin Oral Implants Res. 2012;23:402-408.

74. Lee A, Fu JH, Wang HL. Soft tissue biotype affectsimplant success. Implant Dent. 2011;20:e38-e47.

75. El Chaar ES. Immediate placement andprovisionalization of implant-supported, single-toothres torations: a retrospective study. Int J Perio donticsRestorative Dent. 2011;31:409-419.

76. Kan JY, Rungcharassaeng K, Lozada JL, et al. Facialgingival tissue stability following immediate placementand provisionalization of maxillary anterior singleimplants: a 2- to 8-year follow-up. Int J Oral MaxillofacImplants. 2011;26:179-187.

77. Tarnow D. Immediate vs. delayed socket placement:what we know, what we think we know and what wedon’t know. Presented at: American Academy ofPeriodontology Annual Meeting; November 14, 2011;Miami Beach, FL.

78. Chu SJ, Salama MA, Salama H, et al. The dual-zonetherapeutic concept of managing immediate implantplacement and provisional restoration in anteriorextraction sockets. Compend Contin Educ Dent.2012;33:524-532, 534.

79. Buser D, Chen ST, Weber HP, et al. Early implantplacement following single-tooth extraction in theesthetic zone: biologic rationale and surgicalprocedures. Int J Periodontics Restorative Dent.2008;28:441-451.

80. Elian N, Cho SC, Froum S, et al. A simplified socketclassification and repair technique. Pract ProcedAesthet Dent. 2007;19:99-104.

81. Atieh MA, Ibrahim HM, Atieh AH. Platform switchingfor marginal bone preservation around dentalimplants: a systematic review and meta-analysis. J Periodontol. 2010;81:1350-1366.

82. Rodríguez-Ciurana X, Vela-Nebot X, Segalà-Torres M,et al. The effect of interimplant distance on the heightof the interimplant bone crest when using platform-switched implants. Int J Periodontics Restorative Dent.2009;29:141-151.

83. Vera C, De Kok IJ, Chen W, et al. Evaluation of post-implant buccal bone resorption using cone beamcomputed tomography: a clinical pilot study. Int J OralMaxillofac Implants. 2012;27:1249-1257.

84. Degidi M, Daprile G, Nardi D, Piattelli A. Buccal boneplate in immediately placed and restored implant withBio-Oss® collagen graft: a 1-year follow-up study. ClinOral Implants Res. August 13, 2012. doi: 10.1111/j.1600-0501.2012.02561.x. [Epub ahead of print]

85. Brownfield LA, Weltman RL. Ridge preservation withor without an osteoinductive allograft: a clinical,radiographic, micro-computed tomography, andhistologic study evaluating dimensional changes andnew bone formation of the alveolar ridge. JPeriodontol. 2012;83:581-589.


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POST EXAMINATION INFORMATION

To receive continuing education credit for participation inthis educational activity you must complete the programpost examination and receive a score of 70% or better.

Traditional Completion Option:You may fax or mail your answers with payment to DentistryToday (see Traditional Completion Information on followingpage). All information requested must be provided in orderto process the program for credit. Be sure to complete your“Payment,” “Personal Certification Information,” “Answers,”and “Evaluation” forms. Your exam will be graded within 72hours of receipt. Upon successful completion of the post-exam (70% or higher), a letter of completion will be mailedto the address provided.

Online Completion Option:Use this page to review the questions and mark youranswers. Return to dentalcetoday.com and sign in. If youhave not previously purchased the program, select it fromthe “Online Courses” listing and complete the onlinepurchase process. Once purchased the program will beadded to your User History page where a Take Exam linkwill be provided directly across from the program title.Select the Take Exam link, complete all the programquestions and Submit your answers. An immediate gradereport will be provided. Upon receiving a passing grade,complete the online evaluation form. Upon submitting the form, your Letter Of Completion will be providedimmediately for printing.

General Program Information:Online users may log in to dentalcetoday.com any time inthe future to access previously purchased programs andview or print letters of completion and results.

POST EXAMINATION QUESTIONS

1. What is the jumping distance?

a. Space located only on the buccal surfaces betweenthe implant and the tooth.

b. Space between the implant periphery andsurrounding bone.

c. Space located only on the lingual surfaces betweenthe implant and the tooth.

d. Space located only on the proximal surfaces betweenthe implant and the tooth.

2. Which plate of bone is usually the thinnest aroundan immediate implant?

a. Buccal.

b. Lingual.

c. Proximal.

d. Both a and b.

3. After an extraction how much bone loss (mean)occurs on the buccal and lingual aspects of theextracted tooth after 6 months?

a. 3.79 mm vertically and 1.24 mm horizontally.

b. 1.79 mm vertically and 3.24 mm horizontally.

c. 3.24 mm vertically and 1.79 mm horizontally.

d. 1.24 mm vertically and 3.79 mm horizontally.

4. What is the major benefit of not elevating a buccalflap when placing an immediate implant?

a. Helps preserve aesthetics.

b. Does not reduce vascularity over the buccal plate.

c. Probably reduces the amount of recession.

d. All of the above.

5. After immediate implant placement, what size gapswill usually heal spontaneously if left untreated?

a. 2 mm.

b. 3 mm.

c. 4 mm.

d. 5 mm.

6. What does buccal plate thickness influence?

a. Amount of keratinized tissue.

b. Amount of recession.

c. Amount of bone resorption.

d. Both b and c.

7. How does implant position of an immediate implantin the maxilla affect the results?

a. If too far lingual, it is prosthetically unacceptable.

b. If too close to the buccal plate, it will induce boneresorption.

c. If it is angled, it will fail.

d. Both a and b.


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8. What type of defect is a buccal gap if the socketwalls are intact?

a. One wall.

b. Two walls.

c. Three walls.

d. Moat defect.

9. Is there a benefit to placing a bone graft in the gap ifit is large?

a. Usually no.

b. Usually yes.

c. Never.

d. Only if it is < 2 mm.

10. Since there is usually some vertical bone lossassociated with immediate implant placement, it is agood idea to place the implant platform where?

a. At the crest of bone.

b. One mm supracrestally.

c. One mm subcrestally.

d. It doesn’t matter if the buccal plate is thin.

11. When comparing healing in the gap aroundsubmerged and nonsubmerged implants, whichstatement is true about submerged implants?

a. They heal better than nonsubmerged implants.

b. They heal worse than nonsubmerged implants.

c. They heal the same as nonsubmerged implants.

d. There is delayed healing.

12. Textured surfaced implants provide whichadvantages compared to smooth surfaced implants?

a. Decreased surface area for more osseointegration.

b. Increased bone to implant contact.

c. Decreased clot retention.

d. Decreased probing depths.

13. Some authors suggest overfilling the buccal gap withdeproteinated bone in conjunction with an abutmentand a temporary crown to achieve which outcome?

a. Help support soft tissue.

b. Reduce recession.

c. Both a and b.

d. Increased keratinized tissue.

14. When extrapolating data from a dog model to humans,which statement is true?

a. It is only an approximation of what occurs in humans.

b. It is exactly what happens in humans.

c. Dogs’ remodel overall healing is slower that humans.

d. Dogs’ bones are the same size as humans.

15. According to Botticelli et al, which statement is trueabout how artificially created defects (1.25 to 2.25mm) heal in a dog model?

a. The buccal aspect of created defects partially heal.

b. The lingual asect of created defects partially heal.

c. Created defects heal partially.

d. Created defects heal completely.

16. When can a clinician be sure completeosseointegration occurred along the entire implantsurface?

a. When the buccal gap fills with bone.

b. Only histological assessment can confirm this finding.

c. When there is a lack of mobility.

d. When bone fills the buccal gap and there is a lack ofmobility.


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managing the buccal gap and plate of bone...implant placed into extraction socket at site no. 12....

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