Immediate implant placement with immediate provisionalization remains our first choice whenever primary stability allows it — minimizing treatment time, preserving soft tissue architecture, and reducing the number of surgical interventions for the patient. However, clinical reality doesn’t always align with the ideal scenario.
In this case involving the upper left second premolar (#25), extraction revealed insufficient primary stability to safely support an immediate implant with immediate loading. Rather than compromising long-term outcomes for the sake of speed, we opted for a staged approach: socket preservation at the time of extraction, followed by a 4-month healing period to allow for adequate bone regeneration and ridge maturation.
At the 4-month mark, guided surgery was used to place the implant with full precision, leveraging the preserved ridge volume and contour. This allowed us to deliver an immediate provisional restoration at the time of implant placement — combining the biological safety of a delayed protocol with the functional and esthetic benefits of immediate provisionalization.
This case illustrates an important principle: when immediate loading isn’t feasible at extraction, a well-planned staged protocol — socket preservation followed by guided implant placement — can still achieve an immediate provisional outcome, without sacrificing predictability.
Fig.1
The patient came to our visit complaining of spontaneous pain and pain when chewing on tooth no. 25. Apparently no signs were visible other than the presence of a very small opening of a fistula.
Fig.2
A gutta-percha cone inserted into the fistulous path allowed us to highlight an endo-perio lesion associated with a fracture line.
Fig.3
At the end of the arrow it is possible to see the entrance of the fistula.
Fig.4
To preserve the integrity of the gingival tissues, before proceeding with the extraction, a syndesmotome was used to separate the fibers.
Fig.5
To facilitate the extraction, a mechanical percussion instrument capable of easily dislocating the root of the tooth was used.
Fig.6
The extraction is then completed by means of forceps.
Fig.7
Once the extraction is completed, the guided surgery template is inserted and after having verified its correct positioning and stability, the osteotomies can be started with the dedicated drills.
Fig.8
Once the osteotomies are completed, the integrity of the alveolar walls is checked with a periodontal probe.
Fig.9
And at this point the chosen Dental Tech FTK implant 4,25 x 13 mm can be inserted.
Fig.10
Once the surgical guide is removed, it is immediately apparent that the implant is not stable, and the decision is made to remove it and change the surgery to a socket preservation procedure. Then the residual cavity is filled with xenogeneic biomaterial.
Fig.11
The whole thing is then protected with a connective tissue graft taken from the palate.
Fig.12
10 days after surgery, just removed the sutures.
Fig.13
Four months after socket preservation the tissues are mature and the implant can be inserted.
Fig.14
At 4 months after the opt, the filling of the residual socket with the biomaterial is evident.
Fig.15
The CBCT at 4 months also shows the filling of the residual alveolus by the biomaterial.
Fig.16
At the end of the implant insertion, this time with an ideal primary stability, it was also possible to screw the temporary crown unloaded from both the static and dynamic occlusion. The crown, despite having a concave transmucosal path, exerts a slight pressure on the soft tissues which disappears within about ten minutes.
Fig.17
Periapical radiograph at the end of surgery after having also screwed in the temporary abutment, demonstrates the correct contact between the implant and the bone tissue and the correct engagement of the temporary abutment.
Fig.18
9 months later the tissues have matured around the temporary restoration and we are ready to record the definitive impression and transmit both the position of the implant and the shape of the transmucosal path to the technician.
By guiding the tissues with a temporary crown and not with a healing screw, it was possible to obtain an ideal and absolutely natural tissue profile that imitates the same tissues supported by natural teeth.
Fig.19
In situ scanabutment to record the implant position with the digital impression.
Fig.20
In addition to registering the implant, it is important to also give the technician the information on the subgingival profile that we have given to the temporary crown, so that it can be copied at the level of the definitive restoration.
Fig.21
The technician will thus be able to match the temporary restoration to the digital analogue and optimally manage the design of the definitive restoration.
Fig.22
Definitive zirconia ceramic crown screwed onto the implant one year after surgery.
Fig.23
From this perspective, it is even clearer how the correct management of the hard and soft tissues has allowed us to obtain a highly natural result, so much so that the tooth on the implant is practically indistinguishable from the adjacent natural teeth.
Fig.24
X-ray with the definitive crown.
Conclusions
Despite the initial setback of being unable to place the implant at the time of extraction, this case demonstrates how a well-executed, staged surgical protocol can still lead to an outstanding final result. The combination of proper socket preservation, precise guided implant placement, and meticulous management of the emergence profile allowed us to achieve a highly natural and esthetic outcome — one that might have been at risk had we forced an immediate approach without adequate primary stability.
This case reinforces a key clinical takeaway: predictability should never be sacrificed for speed. When the biological conditions for immediate loading aren’t met, a thoughtfully staged workflow — guided by careful planning and attention to soft tissue detail — can still deliver results that meet the highest esthetic and functional standards.
Bibliography
- Redemagni M, Cremonesi S, Garlini G, Maiorana C: “Soft Tissue Stability with Immediate Implants and Concave Abutments.” Eur J Esthet Dent 2009;4:226-235.
- Hinds KF. “Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration”. International Journal of Periodontics and Restorative Dentistry 17.6 (1997): 584-591.
- R Saito H, Chu S, Reynolds M, Tarnow D: “Provisional Restorations Used in Immediate Implant Placement Provide a Platform to Promote Peri-implant Soft Tissue Healing: A Pilot Study “ Int J Period Rest Dent 2016;36:47-52.
