A cone-beam computed tomography analysis of the buccal bone wall of immediate

implants placement in the esthetic zone of the maxilla: a retrospective cohort study1

Análise tomográfica de feixe cônico da parede óssea vestibular de implantes imediatos em

área estética da maxila: uma coorte retrospectiva

Análisis tomográfico por haz cónico de la pared ósea vestibular de implantes inmediatos en

el área estética de la maxila: una cohorte retrospectiva

Juliana da Silva Neves2

Ain Yamazaki3

Eduardo José Veras Lourenço4

Mayla Kezy Teixeira Villa Verde5

Daniel de Moraes Telles6

ABSTRACT The objective of this observational clinical study was to analyze the thickness of the buccal bone wall around implants placed immediately with immediate provisionalization in the esthetic region of the maxilla using tomographic imaging. A sample was obtained from a prospective clinical study involving single-unit immediate implant placement and provisionalization and consisted of 17 patients with a mean age of 54.35 (±13.33) years. A total of 20 implants were placed, with a follow-up period ranging from 1 to 4 years (mean: approximately 3 years); 12 implants were placed in men and 8 in women. Cone-beam computed tomography (CBCT) scans were analyzed using Galileos Implant software to measure the thickness of the buccal bone wall at the level of the implant shoulder and at 2 mm, 4 mm, and 6 mm apical to it. The height of the bone crest relative to the implant shoulder was also evaluated. The mean thickness of the buccal bone wall was 1.92 mm at the level of the implant shoulder. At this same level, the integrity of the buccal bone wall of the extraction socket significantly influenced both bone thickness (p = 0.002) and bone crest height (p = 0.003), with higher mean values observed when the buccal wall remained intact. Neither the diameter of the implant placed, nor the patient’s gingival phenotype influenced buccal bone thickness or bone crest height. Overall, the technique employed promoted the formation of bone-like tissue in an adequate volume on the buccal

1 The translation of the article is the sole responsibility of the authors. Translations of excerpts from works written in another language, when rendered into English, are likewise the responsibility of the authors, unless a different authorship is declared.

2 Doutoranda em Prótese Dentária, Departamento de Prótese Dentária, Universidade do Estado do Rio de Janeiro, RJ, Brasil. E-mail: [email protected]. ORCID: https://orcid.org/0009-0005-4911-2796.

3 Doutoranda em Prótese Dentária, Departamento de Prótese Dentária, Universidade do Estado do Rio de Janeiro, RJ, Brasil. E-mail: [email protected]. ORCID: https://orcid.org/0000-0002-8750-9170.

4 Professor Associado de Prótese Dentária, Departamento de Prótese Dentária, Universidade do Estado do Rio de Janeiro, RJ, Brasil. E-mail: [email protected]. ORCID: https://orcid.org/0000-0002-7163-8138.

5Professora Adjunta de Prótese Dentária, Departamento de Prótese Dentária, Universidade do Estado do Rio de Janeiro, RJ, Brasil. E-mail: [email protected]. ORCID: https://orcid.org/0000-0003-2356-5787.

6 Professor Titular de Prótese Dentária, Departamento de Prótese Dentária, Universidade do Estado do Rio de Janeiro, RJ, Brasil. E-mail: [email protected]. ORCID: ttps://orcid.org/0000-0001-9576-4342.

aspect of the implant, and the integrity of the buccal bone wall of the extraction socket was the factor that most strongly influenced the quality of the peri-implant hard tissue. Keywords: Dental Implants. Immediate Dental Implant Loading. Cone-Beam Computed Tomography.

RESUMO O objetivo desta pesquisa clínica observacional foi analisar a espessura da parede óssea vestibular de implantes imediatos com provisória imediata na região estética da maxila por meio de medições tomográficas. Foi obtida uma amostra de uma pesquisa clínica prospectiva com implante e provisionalização imediatos unitários, composta por 17 pacientes com idade média de 54,35 (± 13,33). Foram instalados 20 implantes, com acompanhamento de 1 a 4 anos (tempo médio de 3 anos), sendo 12 instalados em homens e 8 em mulheres. Tomografia computadorizada de feixe cônico (TCFC), o software Galileos Implant foi utilizado para medir a espessura da parede óssea vestibular no nível do ombro do implante e a 2mm, 4mm e 6mm a partir dele. A altura da crista óssea em relação ao ombro do implante também foi avaliada. A espessura média da parede óssea vestibular foi de 1,92mm no nível do ombro do implante, mesmo nível onde a integridade da parede óssea vestibular do alvéolo influenciou a espessura óssea (p=0,002) e altura da crista óssea (p=0,003), resultando em médias maiores quando intacta. O diâmetro do implante instalado e o fenótipo gengival do paciente não influenciaram na espessura nem na altura da crista óssea. Em uma análise geral, a técnica empregada permitiu formação de tecido semelhante a osso em volume adequado na vestibular do implante e a integridade da parede óssea vestibular do alvéolo foi o que mais influenciou a qualidade do tecido duro peri-implantar. Palavras-chave: Implantes Dentários. Carga Imediata em Implante Dentário. Tomografia Computadorizada de Feixe Cônico.

RESUMEN El objetivo de este estudio clínico observacional fue analizar el espesor de la pared ósea vestibular alrededor de implantes colocados de forma inmediata con provisionalización inmediata en la región estética del maxilar mediante imágenes tomográficas. Se obtuvo una muestra procedente de un estudio clínico prospectivo de colocación y provisionalización inmediata de implantes unitarios, compuesta por 17 pacientes con una edad media de 54,35 (±13,33) años. Se colocaron un total de 20 implantes, con un período de seguimiento de 1 a 4 años (media: aproximadamente 3 años); 12 implantes fueron colocados en hombres y 8 en mujeres. Las imágenes de tomografía computarizada de haz cónico (TCHC) fueron analizadas mediante el software Galileos Implant para medir el espesor de la pared ósea vestibular a nivel del hombro del implante y a 2 mm, 4 mm y 6 mm en dirección apical a partir de este. También se evaluó la altura de la cresta ósea con respecto al hombro del implante. El espesor medio de la pared ósea vestibular fue de 1,92 mm a nivel del hombro del implante. En este mismo nivel, la integridad de la pared ósea vestibular del alvéolo de extracción influyó significativamente tanto en el espesor óseo (p = 0,002) como en la altura de la cresta ósea (p = 0,003), observándose valores medios más elevados cuando la pared vestibular se encontraba intacta. Ni el diámetro del implante colocado ni el fenotipo gingival del paciente influyeron en el espesor óseo vestibular ni en la altura de la cresta ósea. En términos generales, la técnica empleada favoreció la formación de tejido similar al hueso en un volumen adecuado en la superficie vestibular del implante, y la integridad de la pared ósea vestibular del alvéolo de extracción fue el factor que más influyó en la calidad del tejido duro periimplantario. Palabras clave: Implantes Dentales. Carga Inmediata del Implante Dental. Tomografia Computarizada de Haz Cónico. INTRODUCTION

Immediate implant placement is a safe and predictable technique for rehabilitating

teeth indicated for extraction, particularly in esthetic regions (Slagter et al., 2014).

However, it does not completely prevent buccal bone remodeling (Araújo et al., 2005; Tan

et al., 2012), recession of the buccal gingival margin, or possible medium- and long-term

esthetic complications (Chen; Buser, 2014), which are naturally expected after tooth

extraction, as demonstrated in animal studies (Araújo; Lindhe, 2009).

Nevertheless, similar or better esthetic outcomes were found when peri-implant soft

tissue was evaluated one year after immediate implant placement with immediate

provisionalization, compared with cases restored at a later stage, in the randomized clinical

studies by Arora and Ivanovski (2018) and Puisys et al. (2022).

The use of cone-beam computed tomography (CBCT) with lip retraction (Januário

et al., 2008) enabled more complex analyses of peri-implant tissues, particularly the area

buccal to the implant, as well as of factors that may influence treatment success (Degidi et

al., 2013; Groenendijk et al., 2020; Zuiderveld et al., 2021; Staas et al., 2022). This type of

analysis is considered one of the main tools for evaluating the behavior of hard and soft

tissues associated with dental implants (Levine et al., 2022a; 2022b; Groenendijk et al.,

2023).

Therefore, the objective of this observational clinical study was to longitudinally

analyze the buccal bone wall around immediately placed implants with immediate

provisionalization in the esthetic zone of the maxilla using tomographic measurements.

MATERIALS AND METHODS

Study Design and Population

This retrospective cohort with tomographic evaluation included 17 individuals who

were treated with immediate placement of 20 dental implants and immediate

provisionalization in the esthetic zone of the maxilla between 2018 and 2022, with

follow-up ranging from 1 to 4 years (mean follow-up, 3 years) after implant placement.

They were systemically healthy, were 27 to 74 years of age, and included both sexes (10

men and 7 women).

The study was approved by the Research Ethics Committee of Veiga de Almeida

University, Brazil (CAAE 0069831800005291), and the participants signed an informed

consent form in accordance with Brazilian National Health Council Resolution No.

466/2012 (supplemented by Resolution No. 510/2016) of the Ministry of Health.

The following inclusion criteria were applied:

• ​ Immediate implants placed at least 1 year previously in the esthetic zone of the

maxilla (up to the second premolar).

• ​ Implant-supported crown with an adequate emergence profile.

• ​ Healthy peri-implant tissue.

The exclusion criteria were:

• ​ Presence of a systemic condition or use of medication that could interfere with

bone metabolism.

• ​ Peri-implantitis associated with the implant to be analyzed.

• ​ Smokers of more than 10 cigarettes per day.

• ​ Pregnant or breastfeeding women.

Tomographic Analysis

The tomographic examination was performed to analyze the behavior of

peri-implant tissues at the end of the follow-up period.

The CBCT scans were standardized and acquired using an Orthophos SL scanner

(Dentsply Sirona, Charlotte, NC, USA), with a 5.0 cm field of view (FOV) and a voxel

size of 0.08 mm. Participants used a plastic lip retractor and positioned the tongue toward

the posterior portion of the palate, both intended to displace the soft tissues away from the

maxillary arch (Januário et al., 2008). The images were analyzed in Galileos Implant

software (Dentsply Sirona, Charlotte, NC, USA) by a previously calibrated examiner.

Calibration was performed by measuring bone thickness on 10 other images at a 7-day

interval, and the intraclass correlation coefficient was greater than 0.99.

The central position of the implant was used as the reference, and the sectional

plane was adjusted according to its long axis with the aid of superimposition of a virtual

implant template analogous to the implant placed, provided by the software to assist with

the linear measurements (Figure 1).

Buccal bone plate thickness was obtained by a linear measurement, in millimeters,

between the external bone surface and the implant surface at the level of the implant

shoulder and at 2 mm, 4 mm, and 6 mm from it (Figure 2). If any portion of the implant

projected beyond the bony envelope, the measurement was assigned a negative sign,

indicating that it was outside the bone.

Buccal bone crest height was obtained by a linear measurement, in millimeters,

between the most coronal portion of the bone crest and the implant shoulder (Figure 2). If

the bone crest was positioned apical to the implant shoulder, a negative sign was assigned.

Collected Data and Previous Procedures

The buccal bone wall of the dental socket (BBW) was evaluated on the CBCT scan

obtained before tooth extraction and implant placement. It was considered present when it

was intact or showed up to 3 mm of bone loss, and absent when associated bone loss was

>3 mm.

The initial gingival phenotype (GP), before implant placement, was determined

according to probe transparency through the gingiva after insertion of a millimeter

periodontal probe into the gingival sulcus and according to the width of keratinized

gingiva, measured as the extent of keratinized tissue between the gingival margin and the

mucogingival junction. A thin gingival phenotype was identified when the probe was

visible through the gingiva and/or the width of keratinized gingiva was less than 2 mm. In

the thick gingival phenotype, the probe shadow was not visible, and the width of

keratinized gingiva was greater than 2 mm.

All implants were placed by a single experienced operator immediately after

atraumatic, flapless tooth extraction, with a mean subcrestal position of 2 mm relative to

the proximal bone crests, following the manufacturer's recommendations. All were

Neodent® Helix Grand Morse implants (double taper and internal connection) and were

preselected according to the initial tomographic examination. Implant diameters ranged

from 3.5 mm to 4.3 mm, and lengths ranged from 11.5 mm to 18 mm. In all cases, the

space between the implant and socket was filled with the bone substitute Alobone®

(Osseocon, Rio de Janeiro, RJ, Brazil).

A connective tissue graft (CTG) was used in conjunction with implant placement,

with the palate as the donor site (harvested using a double-bladed scalpel), in cases in

which the width of keratinized gingiva was less than 2 mm or the participant had a high

smile line, using the tunneling technique.

All implants received immediate provisional crowns on a universal abutment or

titanium base. Patients were instructed to rinse with 0.12% chlorhexidine solution twice

daily for 7 days, take amoxicillin 500 mg three times daily for 7 days, and use an analgesic

in case of pain.

After 4 months, once the peri-implant soft tissues had been adequately conditioned,

treatment proceeded with a definitive porcelain crown. Patients were followed annually for

up to 4 years.

Statistical Analysis

A descriptive analysis of the results was performed. Data from the linear bone

measurements were analyzed according to variables that could affect the outcome, such as

the integrity of the buccal bone wall before implant placement, the use of a connective

tissue graft, and the type of initial gingival phenotype, among others.

The data were tested for normality using the Kolmogorov-Smirnov test. Samples

with a normal distribution were then analyzed using parametric tests (Student's t test).

Samples without a normal distribution were analyzed using nonparametric tests

(Mann-Whitney U test). Normally distributed samples with three groups were analyzed

using ANOVA.

A significance level of 5% and a statistical power of 80% were adopted. Statistical

analyses were performed using SPSS, version 25 (IBM Corporation, Armonk, NY, USA).

RESULTS

General data on the patients and implants, as well as their distribution, are

presented in Table 1.

Mean bone thickness values at the different implant levels are presented in Table 2.

Pairwise comparisons among the thickness measurements showed no statistically

significant differences.

When evaluated according to the regions in which the implants were placed, the

premolar group showed greater mean bone thickness than the incisor group at all analyzed

levels, with statistically significant differences only at the implant shoulder (p=0.001) and

at 2 mm (p=0.045) (Graph 1).

divided according to the presence or absence of the socket buccal bone wall before implant

placement. The presence of the wall influenced bone thickness at the implant shoulder

(p=0.002).

used, no statistically significant differences in thickness were observed along the implant,

although the 3.75 mm diameter implants resulted in greater mean bone thickness values

(Table 3).

The gingival phenotype before implant placement did not influence buccal bone

plate thickness along the implant, with no statistically significant difference between thin

and thick phenotypes at the analyzed levels. However, greater mean bone thickness values

were observed in the thin phenotype (Table 4).

crest showed a difference between the group with an intact buccal bone wall, with a mean

height of 2.19 mm, and the group with a defect (p=0.003). The different implant diameters

did not influence bone crest height or bone formation, nor did the different gingival

phenotypes (Table 5).

The stability of peri-implant tissues around immediately placed implants is a

concern for many researchers. In this study, we found mean bone thickness values similar

to those reported in previous studies using comparable methodologies that analyzed both

sockets with an intact buccal bone wall and sites with defects, with and without connective

tissue grafting (Cosyn et al., 2016; Buser et al., 2017; Groenendijk et al., 2020; Lee et al.,

2020; Zuiderveld et al., 2021; Levine et al., 2022; Qian et al., 2023).

The mean bone thickness values found are consistent with those of similar studies.

At the implant shoulder in particular, this study found a mean thickness of 1.92 mm, close

to the 2.12 mm reported by Degidi et al. (2013), 1.7 mm by Levine et al. (2022), and 2.4

mm by Staas et al. (2022).

The difference in bone thickness at the implant shoulder and at 2 mm between the

tooth groups may be related to the inclusion of different maxillary regions in the sample, in

which the extracted teeth had different root anatomies as well as distinct bone

characteristics. Premolar regions have sockets with a greater buccolingual dimension than

incisor regions, which consequently favors a larger horizontal gap between the implant and

the buccal bone wall during placement, resulting in greater bone thickness (Ferrus et al.,

2010).

The different implant diameters used did not influence buccal bone thickness or

bone crest height, as also reported in the study by Levine et al. (2022). This may be

explained by the fact that implant diameter was selected considering the cervical diameter

of the tooth to be restored and, especially, the socket diameter, to ensure a space of at least

2.0 mm between the implant and the inner surface of the buccal bone wall. Regarding

vertical positioning, the objective was to provide a distance of 3.0 to 4.0 mm from the

gingival margin (Morton et al., 2014).

Bone thickness at the implant shoulder was influenced by the integrity of the buccal

bone wall, with a mean of 2.8 mm in the group with the wall present and 0.6 mm in the

group with a defect. Qian et al. (2023) found a mean bone thickness of 2.01 mm at the

implant shoulder in a sample with a mean buccal bone plate defect of 5.08 mm, differing

from the results of the present study. This divergence between studies may be related to the

surgical approach and to the use of a bone substitute with a collagen membrane and

connective tissue grafting in all cases treated by Qian et al. (2023). In a systematic review,

Seyssens, De Lat and Cosyn (2021) highlighted the relevance of connective tissue grafting

in situations at risk of tissue recession, such as cases with bone thickness below 0.5 mm,

with the aim of improving peri-implant tissue stability.

The same pattern was observed for bone crest height, in which pre-existing defects

resulted in a negative mean (-0.35 mm), indicating that, in some cases, the bone crest was

apical to the implant shoulder and suggesting that bone formation had not occurred. Pohl et

al. (2020) also observed similar behavior but found no difference between groups with and

without a buccal wall in a pilot study without any type of graft. In similar studies that used

the integrity of the socket buccal bone wall as a criterion, mean values of 2.21 mm were

reported by Degidi et al. (2013) and 0.3 mm by Levine et al. (2022), whereas the mean in

the present study under the same condition was 2.19 mm.

Gingival phenotype did not affect the bone measurements; however, in a clinical

study, Zuiderveld et al. (2021) demonstrated that phenotype influenced changes in bone

thickness after 1 year. The sample size may have contributed to the lack of a statistically

significant difference in the present study. In addition, connective tissue grafting was

selectively indicated in patients with a thin phenotype and a high smile line, based on

studies with similar characteristics by Levine et al. (2022a) and Araújo et al. (2026).

The main limitations of this sample include its still limited size, which increases the

probability of a Type II error in subgroup analyses. Follow-up ranged from 1 to 4 years

(mean, 3 years), requiring caution when generalizing tissue behavior to longer periods.

Tomographic evaluation was concentrated at the end of the follow-up period, precluding a

paired linear comparison with an immediate postoperative examination. CBCT

measurements assess the thickness of the buccal radiopaque image, which includes both

native/remodeled bone tissue and integrated particles of the bone substitute used.

FINAL CONSIDERATIONS

Overall, the technique allowed volumetric maintenance/stability of the radiopaque

buccal contour produced by the implant-biomaterial complex. The integrity of the socket

buccal bone wall was the factor that most strongly influenced the quality of the

peri-implant tissues.

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