Received: 11 August 2018 Revised: 20 October 2018 Accepted: 28 October 2018

DOI: 10.1111/cid.12701

ORIGINAL ARTICLE

Buccal bone thickness at dental implants in the maxillary

anterior region with large bony defects at time of immediate
implant placement: A 1-year cohort study
Henny J. A. Meijer DDS, PhD1,2 | Kirsten W. Slagter DDS, PhD2 |
Arjan Vissink DDS, MD, PhD2 | Gerry M. Raghoebar DDS, MD, PhD2

1
Department of Implant Dentistry, University
of Groningen, University Medical Center Abstract
Groningen, Groningen, The Netherlands Background: There is lack of studies regarding preservation and possible changes in BBT at
2
Department of Oral and Maxillofacial Surgery, dental implants.
University of Groningen, University Medical
Purpose: To assess, on cone beam computer tomograms, the presence of bone at the time of
Center Groningen, Groningen, The
Netherlands tooth extraction in the maxillary esthetic region and the mean buccal bone thickness 1 month
Correspondence and 1 year after final restoration placement in patients with large bony defects.
Henny J. A. Meijer, Department of Oral and Material and Methods: In a cohort study, patients were selected presenting a failing tooth with
Maxillofacial Surgery, University Medical a large bony defect (test group [n = 20]: large bony defect, immediate placed implant and delayed
Center Groningen, PO Box 30.001 NL-9700
provisionalization). Results were compared with a group in which patients presented a failing
RB, Groningen, The Netherlands.
Email: [email protected] tooth without or with a small bony defect: (control group [n = 20]: without or small bony defect,
immediate placed implant and delayed provisionalization). Cone beam computer tomograms
were made preoperatively, and 1 month and 1 year after placement of the restoration, and buc-
cal bone thickness was analyzed.
Results: In both groups approximately 1 mm of buccal bone thickness was present after
1 month and 1 year, without a significant difference between the groups.
Conclusion: In patients with large bony defects at a failing tooth it was possible to create a bone
layer buccally of the implant and this bone layer remained stable during a 1-year follow-up;
there were no significant differences between thickness of buccal bone at 1 month and 1 year
in patients with large buccal bony defects and patients without or with small bony defects.

KEYWORDS

bone thickness, cone-beam computed tomography, dental implants, esthetic region

1 | I N T RO D UC T I O N In the esthetic region, there is data regarding buccal bone thick-

ness (BBT) when the tooth is still in situ.7,8 Januário and colleagues7
Immediate implant placement in the esthetic region is stated to showed that the buccal bone wall in most cases was less than 1.0 mm
1–3
be a favorable treatment modality for replacing failing teeth. thick and even in half of the sites 0.5 mm or less. In the study of El
Conversely, there are also studies which conclude to be cautious Nahass and Naiem8 it was reported that usually mean BBT at the cen-
with immediate implant placement, especially if highly esthetic tral and lateral incisors was less than 1.0 mm. Removal of a maxillary
4
demands are involved. Particularly in the esthetic zone, preserva- anterior tooth will lead to significant loss of BBT within a few weeks.9
tion and establishment of labial mucosa and underlying buccal It has been posed that immediate dental implant placement with aug-
bone has been shown to be a key factor in achieving optimal mentation of the space between implant and buccal wall should pre-
5,6
results. vent these dimensional changes, but the results of this preservation

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2018 The Authors. Clinical Implant Dentistry and Related Research Published by Wiley Periodicals, Inc.
Clin Implant Dent Relat Res. 2019;21:73–79. wileyonlinelibrary.com/journal/cid 73
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74 MEIJER ET AL.

technique are contradictory.3,10,11 It is of interest if the original buccal In both the test group and the control group, implants were immedi-
wall still exists in time or disappears and the augmented bone func- ately placed implant and delayed provisionalized.
tions as a new buccal plate at the implant.12 Characteristics at baseline of the study groups are:
If a large bony defect results after extraction, hard and soft tissue
grafting is often recommended in combination with delayed implant • test group (n = 20): mean age in years (range): 43.7 (18-63); male/
placement.13,14 However, there are also studies reporting a favorable female: 11/9; location of implants (central incisor/lateral incisor/
esthetic outcome when placing implants in fresh extraction sockets canine): 12/5/3;
with buccal wall dehiscences.15,16 • control group (n = 20): mean age in years (range): 42.3 (23-66);
The morphological assessment of buccal bone volume before male/female: 8/12; location of implants (central incisor/lateral
placement of dental implants and at dental implants during a follow- incisor/canine): 13/6/1.
up period is of great interest to clinicians to predict reliability of treat-
ment in the esthetic region. Cone-beam computed tomography The time path for both test and control group is illustrated in
(CBCT) has been successfully used for various dental procedures.17 Figure 1. For details with regard of selection of the patients, allocation
The CBCT has also been used to assess buccal bone dimensions prior to the groups, surgical and prosthetic procedures and analysis per-
and after implant placement.18,19 formed see Slagter and colleagues.21,22 A short description is pre-
Despite the interest to clinicians, there is lack of studies regarding sented below.
preservation and possible changes in BBT at dental implants, espe-
cially with large bony defects at the time of immediate implant place- 2.2 | Surgical and prosthetic procedures
ment. One reason is because in analyzing BBT on CBCT's difficulties
Surgical procedures were performed by the same experienced oral
are encountered with standardization of measurements. The use of
and maxillofacial surgeon.
three-dimensional (3D) image diagnostic and treatment planning soft-
20 Failing teeth were removed with a sulcular incision, careful
ware programs could be helpful.
detachment of the periodontal ligament, and use of periotomes, with-
The purpose of the present cohort study was to assess, on CBCT's,
out flap elevation. After removal of the tooth, the alveolus was metic-
BBT at the time of tooth extraction in the esthetic region in patients with
ulously cleansed, and any alveolar debridement was removed with
large bony defects and 1 month and 1 year after final restoration place-
sterile gauze. Before implant placement, bone grafts were harvested
ment and compare it with a group without or with small bony defects.
from the maxillary tuberosity with the use of chisels. The implant site
was prepared on the palatal side of the alveolus according to manu-
2 | MATERIAL AND METHODS facturer protocol using a surgical template for ideal positioning of the
prospective implant crown. The bur used last, depending on diameter
of implant, was placed in the prepared alveolus. Next, the tuberosity
2.1 | Patient selection
bone graft was shaped with forceps to match the labial bony defect.
Forty participants with an implant-supported restoration in the The bone graft was placed in the extraction socket, with the cortical
esthetic region of the maxilla were included in the study, originally side facing the periosteum, under the periosteum covering the labial
part of two randomized controlled trials performed at the University plate defect. A mixture of autologous bone and Bio-Oss spongiosa
Medical Center Groningen in the Netherlands.21,22 These trials got granules (0.25-1.0 mm, Geistlich, Wolhusen, Switzerland) was tightly
approval by the Medical Ethic Board (METC 2010.246) and registered packed into remaining space. The implant (NobelActive, Nobel Biocare
(www.isrtcn.com: ISRCTN57251089). All participants gave written AB, Goteborg, Sweden) was placed at a depth of 3 mm apical to the
informed consent and research was carried out in accordance with most apical aspect of the prospective clinical crown, with the help of
the Declaration of Helsinki. the surgical template. Immediately after implant placement, a corre-
The following group was selected from a study in which patients sponding cover screw was placed. No membranes were used to cover
presented a failing tooth in the maxillary esthetic region with a large the grafted area. To achieve an optimal esthetic outcome, a soft tissue
bony buccal defect21: graft, harvested from the tuberosity region where the bone graft was
taken, was placed on top of the bone graft and implant. The wound
• test group (n = 20): large bony defect was closed with 5-0 nylon sutures. During the 3-month osseointegra-
tion phase, patients were allowed to wear a removable partial denture
and compared with a group selected from a study in which patients not interfering with the wound. After 3 months, the implant was
presented a failing tooth in the maxillary esthetic region without or uncovered by a small incision at the cover screw site, followed by an
with a small bony buccal defect22: implant-level impression. Within 8 hours, a screw-retained provisional
restoration was placed. After a provisional phase of 12 weeks a final
• control group (n = 20): without or small bony defect restoration was placed. Prosthetic procedures were performed by a
single prosthodontist.
A large bony defect was defined as being ≥2 mm and a small bony In the control group (with a small bony defect), the same surgical
23
defect as <2 mm, after the review of Chen and colleagues and con- procedures were performed, with the exception that no bone graft
firmed by the Consensus Statements of Hämmerle and colleagues.24 from the maxillary tuberosity was harvested. Only a mixture of
 17088208, 2019, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.12701 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [31/10/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MEIJER ET AL. 75

FIGURE 1 Schedule of visits and procedures test group and control group

autologous bone and Bio-Oss spongiosa granules (0.25-1.0 mm) was A different procedure was followed for the pretreatment CBCT's
used to fill the remaining space between implant and buccal in which no implant was present yet and MIRIT cannot recognize an
bony wall. implant position. First, both the pretreatment CBCT and the 1-month
CBCT were imported in Maxilim. Both images were aligned by the
computing program. Because the exact position of the implant has
2.3 | CBCT measuring procedure been determined for the 1-month image, it is now possible to imple-

To define the presence and thickness of bone at the time of tooth ment this position in the pretreatment DICOM file. In this way, a com-
bined file has been constructed in which the tooth is still present and
extraction and to measure changes in the BBT over time, CBCT's
an implant has been imported in the exact position where it is going
(iCAT 3D exam scanner, KaVo Dental GmbH, Biberach, Germany)
to be after treatment (Figure 2).
were made before extraction and after 1 month and 1 year after
In NobelClinician, the exact position of the implant, as determined
placement of the final restoration. This scanner was validated for mea-
in Maxilim, was aligned with a planning implant. Buccal bone measure-
suring bone thickness by Fourie and colleagues.25 They reported a
ments, at midline of the implant, were performed with the standard
method error of only 0.05 mm (95 CI 0.03-0.07 mm). Bone thickness
provided measurement options of NobelClinician. The upper 5 mm
measurements were done using 3D image diagnostic and treatment
section of the implant was defined as the area of interest, beginning
planning software (NobelClinician, version 2.1, Nobel Biocare -
at the neck of the implant. Buccal bone measurements (in mm) were
Guided Surgery Center, Mechelen, Belgium). A CBCT imaging and
performed from the radius of the interior contour of the implant to
software protocol, developed and validated by Slagter and colleagues,
the outer surface of the bone. In this way, measuring at the interface
was used.20
between implant and bone, often disturbed by scattering, was
Of each patient, the position of the implant was determined by
avoided. Buccal bone thickness was measured for 5 mm along the axis
importing the 1-month and 1-year CBCT, in DICOM multi-file for-
beginning at the neck of the implant (M0) toward apical (M1, M2, M3,
mat, into an image computing program, Maxilim, version 2.3
M4, M5; Figures 3 and 4).
(Medicim, Sint-Niklass, Belgium). With the concept of multimodality
image registration using information theory (MIRIT) the exact posi-
tion of the implant can be recognized, determined, and implemen-
2.4 | Clinical soft tissue outcomes and esthetic
ted in the patients DICOM files.26 The MIRIT procedure finds its
appearance
base on recognizing image similarities. The degree of similarity To complete insight of the labial aspect of soft tissues at dental
between intensity patterns in two images (one of the implant with implants, the following clinical and esthetic items have been
the dimensions used in the patient and the one of the depicted evaluated:
implant in the DICOM file of the patient) is determined, and conse-
quently, the recognized image is registered automatically into one • change in midfacial mucosal level in mm at 1 year as compared
coordinate system. with the gingival level of the preoperative failing tooth;
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76 MEIJER ET AL.

FIGURE 2 Alignment of images of pretreatment cone-beam computed tomography (CBCT) and the 1-month CBCT by the computing program
Maxilim

• pocket probing depth in mm buccally of the implant at 1 year; 3 | RE SU LT S

• esthetic appearance scored with the pink esthetic score (PES) at
1 year (Belser and colleagues).27 One patient from the control group did not show up at follow-up and
was excluded from further analysis. Five pretreatment CBCT's were
not available (two in the test group and three in the control group).
This resulted in CBCT's of 34 patients available for the present study.
2.5 | Statistical analysis
Median and interquartile ranges, together with means and standard
For comparison between test and control group, the Mann-Whitney
deviations, of bone thickness at M0-M5 at pretreatment, 1 month
U test was performed. A P-value of .05 was considered being statisti-
and 1 year after final restoration placement are depicted per study
cal significance.
group in Table 1.
In patients from the test group, the median distance from the
outer surface of the buccal bone to the surface of the future implant
at all different positions was at pretreatment 0 mm. One year after

FIGURE 3 Measurement on a pretreatment cone-beam computed

tomography from the central axis of a planning implant, placed in the FIGURE 4 Measurement on a 1-month cone-beam computed
position where the actual implant will be after surgery, to the outer tomography from the central axis of a planning implant, placed in the
surface of the buccal bony wall of a failing natural tooth with the position of the actual implant, to the outer surface of the buccal bony
planning program NobelClinician wall at the implant with the planning program NobelClinician
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MEIJER ET AL. 77

TABLE 1 Buccal bone measurements pre-extraction, 1 month and 1 year after dental implant surgery in the test group and control group (test
group: large bony and immediate placement/delayed provisionalization; control group: without or small bony defect and immediate placement/
delayed provisionalization) expressed as median and mean and significant differences between the groups
Test group (n = 18) Control group (n = 16)
Measurements Median (interquartile Median (interquartile
pre-extraction range) in mm Mean (SD) in mm range) in mm Mean (SD) in mm Significance*
M0 (at neck) 0 [0;0] 0.00 (−) 2.14 [1.73;2.61] 2.20 (0.58) P < .001
M1 0 [0;0] 0.00 (−) 2.21 [1.88;2.59] 2.23 (0.47) P < .001
M2 0 [0;0] 0.00 (−) 2.28 [1.67;2.48] 2.17 (0.48) P < .001
M3 0 [0;0] 0.00 (−) 2.23 [1.75;2.35] 2.08 (0.48) P < .001
M4 0 [0;0.72] 0.51 (0.96) 1.99 [1.75;2.35] 1.98 (0.57) P < .001
M5 0 [0;1.49] 0.68 (0.93) 1.99 [1.56;2.50] 1.93 (0.68) P < .001
Measurements 1 month
M0 (at neck) 0.89 [0.74;1.17] 1.08 (0.52) 0.94 [0.54;1.98] 1.27 (0.82) P = .878
M1 1.16 [0.66;1.84] 1.30 (0.63) 1.06 [0.51;2.36] 1.39 (0.95) P = .986
M2 1.15 [0.65;1.60] 1.22 (0.63) 1.48 [0.60;2.25] 1.46 (0.82) P = .463
M3 1.25 [0.73;1.78] 1.28 (0.63) 1.34 [0.57;2.01] 1.39 (0.76) P = .695
M4 1.04 [0.71;1.77] 1.27 (0.71) 1.45 [0.45;1.91] 1.32 (0.75) P = .878
M5 0.81 [0.54;1.69] 1.12 (0.68) 1.21 [0.38;1.63] 1.19 (0.70) P = .986
Measurements 1 year
M0 (at neck) 0.84 [0.64;1.14] 1.01 (0.45) 1.05 [0.57;2.01] 1.24 (0.83) P = .721
M1 1.09 [0.71;1.58] 1.16 (0.57) 1.34 [0.58;2.20] 1.36 (0.79) P = .574
M2 1.05 [0.65;1.63] 1.23 (0.72) 1.43 [0.73;2.28] 1.48 (0.79) P = .403
M3 1.05 [0.55;1.80] 1.26 (0.76) 1.60 [0.65;1.98] 1.39 (0.69) P = .621
M4 0.85 [0.62;1.82] 1.19 (0.74) 1.44 [0.44;1.85] 1.26 (0.70) P = .986
M5 0.86 [0.54;1.69] 1.09 (0.68) 1.31 [0.38;1.63] 1.14 (0.60) P = .932

*Mann-Whitney U test for significant differences between medians of groups at three time points.

definitive crown placement median BBT varied from 0.84 to 1.09 mm. bone plate, which was stable during a 1-year follow-up period. Results
In patients from the control group, the median distance of six posi- were not significantly different from patients without or with small
tions from the outer surface of the buccal bone to the surface of the bony defects.
future implant at pretreatment varied from 1.99 to 2.28 mm. One In the test group, there was no bone present at the first 3 mm at
year after definitive crown placement median BBT was more than the labial side of the future implant position. At positions M4 and M5,
1 mm at all six positions. At 1 month and 1 year, there was not a sig- distance from outer contour of the bone to the surface of the virtual
nificant difference in BBT between the groups. There is not a signifi- implant was small. The next CBCT in this group was taken after
cant difference between BBT at 1 month and 1 year in both the test 7 months. At this time point, 1 month after placement of the defini-
group and the control group. tive restoration, median BBT was approximately 1 mm at any position.
Clinical soft tissue outcomes and esthetic appearance of both Between 7 months and 18 months, BBT remained stable without a
groups are depicted in Table 2. significant difference between the time periods. This means that the
augmented bone functioned as a stable new buccal plate. This out-
come can be compared with results of the case series study of Sarna-
4 | DISCUSSION chiaro and colleagues,16 in which implants were immediately placed in
patients with large buccal defects. At start of the restorative phase,
In patients with large buccal bone defects at time of immediate
after 6 months of healing, at the neck of the implant a mean BBT of
implant placement it appeared to be possible to create a new buccal
3.0 mm was achieved. It must be noted that in the present study this
was much less, being a little bit more than 1 mm.
TABLE 2 Change in midfacial mucosal level (MML) at 1 year as
compared with the gingival level of the preoperative failing tooth, In the control group without or with small bony defects, there
pocket probing depth (PPD) buccally of the implant at 1 year and pink was always bone present before treatment at the buccal side of the
esthetic score (PES) at 1 year of the test group (large bony defect) and future implant position, varying from a median value from outer
control group (small bony defect) contour of the bone to the surface of the virtual implant of
Test group (n = 18) Control group (n = 16) 1.99-2.28 mm. Consistent with the test group, the next CBCT in the
Mean change in −0.2 (0.3) −0.8 (0.9) control group was taken after 7 months. In these 7 months, the
MML in mm (SD)
median BBT diminished significantly with at least 0.5 mm. It could well
Mean PPD in mm (SD) 3.2 (0.8) 3.0 (0.6)
be that the total original wall has been resorbed in these 7 months.
Mean PES (SD) 7.5 (1.6) 7.4 (1.5)
Between 7 months and 18 months, there was not a significant
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78 MEIJER ET AL.

difference in BBT between the time periods, meaning that also in this substitute or even that only a mixture of bone substitute and connec-
group buccal bone remained stable during the first year of follow up, tive tissues is assumed to be bone.
even when the original buccal wall had been resorbed. This could Clinical soft tissue outcomes, being change in midfacial mucosal
mean that the newly augmented bone functioned as a new buccal level and pocket probing depth, showed limited recession in both
plate. Outcomes in the control group are comparable with results of groups and normal probing depth values in both groups. Also esthetic
the study of Mazzocco and colleagues28 in which CBCT measure- appearance, expressed with PES, revealed high scores without a dif-
ments were presented of a group with immediate implant placement ference between the groups. These good clinical features correspond
in cases without bony defects. The method used was superimposition with the presence of buccal bone at the implants in both groups, giv-
of CBCT's. They found a mean diminution of BBT of about 0.6 mm in ing support to the soft tissues.
the first millimeters along the implant axis after 6 months, stating that A limitation of the present study design is the direct comparison
most of the original buccal wall must have been resorbed. A compara- of a group with a large bony defect with a group without or with a
ble result was also found in the present control group. small defect. Although the same outcome measures were used and
At 7 months and at 18 months, BBT was not significantly differ- with the same treatment team and observers, it could be that proce-
ent between patients from the test group and the control group at all dures between the groups differ more than just the augmentation.
six evaluated positions along the implant axis and BBT appeared to be Next to this only a limited sample size was used; to strengthen the
stable. This means that in patients with a failing tooth in the maxillary conclusions more patients are needed.
esthetic region immediate implant placement is possible if initial From this CBCT study can be concluded that:
implant stability can be achieved, irrespective of the presence of a
buccal bone defect. • in patients with large bony defects at a failing tooth, it was possi-
It appeared from the present study that buccal bone thickness at ble to create a bone layer buccally of the implant and this bone
dental implants in the esthetic region was hardly subject to change. layer remained stable during a 1-year follow-up;
This can be called a very favorable outcome, because it means that • there were no significant differences between thickness of buccal
bone thickness achieved at placement of the final restoration remains bone at 1 month and 1 year in patients with large buccal bony
stable. Moreover, if future evaluation with longer follow-up evalua- defects and patients without or with small bony defects.
tions confirms this finding, this means that after finishing treatment
no major complications related to physiologic bone resorption are to
be expected.29 CONFLIC T OF INT E RE ST
However, there are also studies on immediate implant placement The authors have stated explicitly that there are no conflicts of inter-
in the esthetic region, with longer follow-up periods, showing extreme est in connection with this article. Funding for the 1-year clinical study
variation in buccal bone thickness, with even cases without any buccal was obtained by an unrestricted grant from Nobel Biocare Services
bone. Benic and colleagues30 followed 14 patients over 7 years and AG; implant materials were provided (materials grant: 2009-851).
found a median buccal bone thickness of 0.0 mm (mean 0.4 mm).
Groenendijk and colleagues31 reported in a 2-year retrospective study ORCID
on 16 patients a buccal bone thickness of 1.8 mm (varying from 0.9 to
Henny J. A. Meijer https://orcid.org/0000-0003-1702-6031
2.4 mm). Raes and colleagues32 reported on a 8-year prospective
study with 16 patients with immediate placement. Median buccal
bone thickness varied from 0.80 to 1.24 mm along the implant axis RE FE RE NC ES
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MEIJER ET AL. 79

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