NYU College of Dentistry
International Implantology Week
Debate Over Delayed vs. Immediate Implants
NEW YORK -The debate over implants has become a
“Tower of Babel,” where there is a good amount of
data, but limited definitive studies to guide surgeons
in their decisions on immediate (compared with de-
layed) implant placement in the anterior, according to
a speaker at the 2011 International Implantology Week
hosted at New York University College of Dentistry and
sponsored by Zimmer Dental.
Maurizio Tonetti, DMD, PhD, who is Director of the
European Research Group on Periodontology and Editor
of the Journal of Clinical Periodontology, cited data from
several studies, including one from his group, that com-
pared immediate and delayed implant placement. In a
Cochrane Database review, 2 randomized controlled tri-
als compared immediate versus delayed implants in 126
patients and found no statistically significant differences.
In that analysis, published in 2010, the research-
ers noted: “There is insufficient evidence to determine
possible advantages or disadvantages of immediate,
immediate-delayed or delayed implants, therefore these
preliminary conclusions are based on few underpow-
ered trials often judged to be at high risk of bias. There
is a suggestion that immediate and immediate-delayed
implants may be at higher risks of implant failures and
complications than delayed implants. On the other
hand, the esthetic outcome might be better when plac-
ing implants just after teeth extraction. There is not
enough reliable evidence supporting or refuting the need
for augmentation procedures at immediate implants
placed in fresh extraction sockets or whether any of the
augmentation techniques is superior to the others.”
Dr. Tonetti cited other published data that examined
the operating surgeon’s evaluation of the technical diffi-
culties surrounding immediate versus delayed surgeries,
and both were felt to be similar in difficulty. Patients
did not report major differences in discomfort following
the surgeries, nor did they state a preference for either
delayed or immediate procedures.
“My interpretation of this information from the pa-
tients is that much of the pressure that we feel to do im-
mediate placement, thinking the patient is the one that
wanted it is incorrect,” Dr. Tonetti said. “That is our
interpretation. We are being pushed by the competitive
environment we work in.”
Dr. Tonetti also showed new data indicating that
immediate implants are associated with higher rates
of surgical complications and that these complications
translate into suboptimal soft-tissue esthetics.
Other Factors to Guide Surgical Options
Dr. Tonetti reminded the clinicians in attendance
that age, weight, inadequate blood supply, immune re-
sponse, chronic diseases, radiation, and cigarette smok-
ing all should be considered when deciding when to
place implants. All of these factors have an influence
on the wound healing process. He reminded clinicians
Dental Learning
about the importance of limiting wound contamina-
tion: oral surgical wounds are contaminated but careful
hygiene measures and prior periodontal treatment de-
crease bacterial load and improves outcome.
Surgical factors also play a role in healing, including
how the surgery is performed, from incision direction to
tissue removal. Choice of closure method plays a role,
as well. He offered this pearl: “Both sides of the closure
should be immobilized, with no micromovement. Mi-
cromovement causes stress on the wound.”
Dr. Tonetti said that differences among suturing
products, and even the surgeon’s technique alone can
influence time to healing. He showed data from re-
searchers in Norway that compared different types of
suture materials, with different diameters and condi-
tions, which concluded that smaller sutures were related
to less infiltrate. He said technique is particularly impor-
tant, as the Norwegian research indicated that if sutures
are not placed 2 mm apart from either the margin or the
other suture, the suture “is lost in the early days.” He
also noted that this data showed that silk more easily
facilitated bacterial migration than other materials.
Dr. Tonetti reminded clinicians that there are 2 issues
that clinicians need to be mindful of during surgery—
the first being wound infection, the second being wound
dehiscence. He cited data that showed the minute that
the flap is elevated, half the blood supply is eliminated.
Other studies that use Doppler imaging have demon-
strated gingival blood flow changes following periodon-
tal access flap surgery.
Dr. Tonetti said that even the side of the tooth that
is being operated on can influence surgical outcomes.
He cited data that showed blood has a better chance
of perfusion on the palatal side than the buccal side. In
other words, surgical flap design for implant placement
is very important and not only a necessary step to get to
the bone and place the implant.
Read the Data, Bring to Practice
Summarizing his presentation, Dr. Tonetti urged the
clinicians in attendance to remain aware to the latest
published clinical data, and incorporate study findings,
like the ones he cited, into clinical practice. He also em-
phasized the need for surgical training on flap design,
soft tissue handling, and suturing to obtain good clinical
outcomes that patients expect, and described programs
designed to improve these skills.—Colleen Platt
Maurizio Tonetti, DMD, PhD
Maurizio Tonetti, DMD, PhD, is Director of the Euro-
pean Research Group on Periodontology and Editor
of the Journal of Clinical Periodontology.
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