The implant should be placed inside the incisal line angle of the adjacent teeth. This will ensure adequate facial bone thickness for long-term stability and keep the implant from protruding too far facially (Figure 4).
Maintain a space of at least 1.5 mm from adjacent tooth to the implant. Depth of implant placement should be 3 to 4 mm below the cementoenamel junction of the adjacent teeth or the free gingival margin. Maintaining this depth will give enough “running room” to create the proper emergence profile (Figure 5).8
The size of the implant should be determined by the amount of space between the adjacent teeth and available bone around the implant. Traditional protocol called for the widest diameter implant to be placed into the socket so as to obliterate the socket. It is now understood that a minimum of 1.5 mm of space between the implant and the adjacent must be maintained with at least 1 mm of bone circumferentially around the implant.
Maintain at least 2 mm of facial bone thickness for long-term esthetic stability.9 Having a narrower diameter implant placed at the time of extraction will leave a gap between the implant and buccal plate.
This gap, if less than 2 mm, does not require any bone grafting. If the gap distance is greater than 2 mm, grafting is recommended.10 As a result of the thin buccal plate remaining after extraction, grafting the void as well as the facial bone is carried out regardless of the space between the implant and bone. This means having to raise a flap to graft the facial plate to ensure a minimum of 2 mm of facial bone thickness (Figure 6).
To maximize esthetics, the patient’s natural tooth can be used as a provisional. If the root is cut off and the tooth hollowed out, it can be relined over the temporary abutment (Figure 7). A temporary abutment supported the cemented natural provisional during healing (Figure 8). Maximum soft tissue support maturation is achieved after 4 months. The natural provisional allows for proper emergence development.
A radiograph and photograph after final crown insertion (Figure 9 and Figure 10) verified the preservation of bone and soft tissue support. According to Tarnow and colleagues, papilla formation will occur if the distance from the contact point to the interproximal crest of bone is 5 mm or less.11
Immediate implant placement can be a predictable procedure provided that certain guidelines are followed. This treatment option, along with provisionalization, will enhance and preserve osseous and gingival architecture for long-term stability. Though this procedure can be technique sensitive, it goes without saying that proper treatment planning and case selection will allow for optimal results that will give maximum function and esthetics.