245

Immediate Implant in Maxillary Central

Incisors and Prosthetic Screw Channel:
A CBCT Feasibility Study

Oscar González-Martín, DMD, PhD, MSc1 The anatomy of the anterior max-
Mario Veltri, DDS, Cert Perio, PhD2 illa and its remodeling after extrac-
tions have been assessed in several
studies,1–7 contributing to immedi-
ate implant placement becoming a
viable and documented treatment
option.8 The thickness of the buccal
This study aimed to assess how frequently the maxilla anatomy allows for bone plate is thin in most cases1–3
lingualized immediate implants in the central incisor region with a screw and undergoes postextraction re-
channel that has an ideal distance of 1.5 mm from the incisal margin. The effect sorption2,3; the position of the root
of abutments with angle correction on case selection will also be verified. A
within the bony envelope varies,4,7
retrospective cross-sectional study of 181 CBCT scans was carried out. Using an
implant-planning software, implant placement was simulated in the lingual aspect and the angle formed between
of the socket. The location of the prospective screw channel was registered as the root and the buccal bone has
incisal, lingual, or facial. The angle between the actual screw channel and the been investigated.6 The suggested
position of the ideal one was calculated. The effect of angle correction on allowing indication for immediate implant
an ideal screw channel configuration was computed. Out of 161 eligible cases, replacement of a maxillary incisor
144 presented favorable anatomy for an immediate implant. The screw channel
ranges from < 5% of cases (if a buc-
had an incisal position in 40 cases (28%), a lingual position in 60 cases (42%),
and a facial position in 44 cases (30%). The screw channel could be placed at cal bone with > 1-mm thickness is a
the planned distance from the incisal edge in 35 cases (24%). The position was treatment prerequisite9) to > 80% (if
unfavorable in the remaining 109 cases. In 103 of these cases, an abutment with a favorable sagittal root position is
an angled screw channel could make the conditions feasible. Within the simulated the treatment prerequisite4). In the
conditions, a majority of maxillary central incisors present favorable ridge anatomy latter case, a lingualized position is
for lingualized immediate implant placement. Achieving a proper location of the
recommended in order to stabilize
screw channel requires abutments with angle correction in a majority of cases.
Int J Periodontics Restorative Dent 2021;41:245–251. doi: 10.11607/prd.4564 the implant in the palatal aspect
of the alveolar socket, followed by
grafting with bone replacement
and with connective tissue in case
of a thin fenotype.10 This allows for
enough primary stability as well as a
safe distance from the buccal bone
plate to avoid undue pressure on
Master in Periodontology, University Complutense of Madrid, Madrid, Spain; Department
1 the buccal tissues, optimizing the
of Periodontology, University of Iowa, Iowa City, Iowa, USA; Private Practice, Madrid, Spain. chances to keep the soft tissue out-
2Private Practice, Solihull, United Kingdom.
line unaltered.
Correspondence to: Dr Oscar González-Martín, c/Blanca de Navarra 10, Bajo, 28010, Available information on the
Madrid. Email: [email protected] morphology of the anterior maxilla
is mostly based on linear measure-
Submitted July 17, 2019; accepted September 27, 2019.
©2021 by Quintessence Publishing Co Inc. ments of the bone thickness and

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246

of the angle formed between the impact of angled abutments for tered in the middle of the bony
roots and the ridge. To the present screw retention on allowing for ridge axial plane, then (2) centered
authors’ knowledge, little has been increased case selection. to the midline of one central inci-
presented regarding the simulated sor, parallel to its long axis. A cross-
possibility of immediate implant sectional image of the ridge was
placement in a 3D position that re- Materials and Methods then obtained, displaying the mid-
spects not only the optimal relation point of the tooth and its associated
with the bony contours but, at the This observational cross-sectional bony socket. The cross-sectional
same time, allows for screw reten- study was compliant with STROBE images were screen-captured and
tion with a channel that does not (Strengthening the Reporting of Ob- independently evaluated by two ex-
interfere with the lingual aspect of servational Studies in Epidemiology) aminers (including O.G.M.) to clas-
the incisal edge. Only by pursuing a methods. sify root position and feasibility of
restorative-driven implant position, immediate implant placement. The
with due consideration to the root, examiners were previously calibrat-
socket anatomy, and tooth shape, Patient Selection ed by simultaneous evaluation of 60
is it possible to reach the objective randomly selected images. If any
of a natural-looking restoration that CBCT images (ProMax 3D Classic, disagreements occurred regard-
mimics the original tooth and full Planmeca) from the database of a ing the classification of an image,
buccal contour and preserves the private practice were searched for the image was reevaluated jointly
incisal-edge characteristics. patients who received scans be- by both examiners until agreement
A screw-retained implant resto- tween November 2015 and February was reached. For each central inci-
ration seems desirable to avoid risks 2019 and had healthy maxillary inci- sor, the Sagittal Root Position Classi-
encountered with residual cement sor regions. One of the two centrals fication (SRP) to its osseous housing
and a subsequent peri-implant in- incisors was arbitrarily selected in was defined4 (Fig 1):
flammatory response.11 Further- each case. Images were discarded if
more, excessive proximity of the one of the following exclusion criteria • Class I: The root is positioned
screw channel to the incisal margin applied: presence of image artifacts against the labial cortical plate.
would reduce the porcelain thick- affecting the visibility of the buccal • Class II: The root is centered
ness, which in turn would weaken plate; presence of any prosthetic res- in the middle of the alveolar
and/or limit the esthetic character- torations, as they may have altered housing without engaging
istics of the incisal margin itself. To the axis of the anatomical crown; loss either the labial or the palatal
address this problem, a new angled of bone support due to periodontal cortical plates at the apical
abutment developed for screw re- disease; and presence of apical peri- third of the root.
tention might overcome the un- odontitis or severe root resorption. • Class III: The root is positioned
favorable angulation of the screw against the palatal cortical
channel and its interference with the plate.
incisal margin. Image Analysis • Class IV: At least two-thirds
The purpose of this CBCT study of the root is engaging both
was to assess how frequently the For each study subject, the DICOM the labial and palatal cortical
bony anatomy allows for immediate (Digital Imaging and Communica- plates.
implant placement in the maxillary tions in Medicine) files were pro-
central incisor region when aiming cessed using an implant-planning Implant placement in an ideal
at a correctly configured lingual software (DTX Studio Implant ver- 3D position was then simulated on
screw channel. Additionally, the sion 3.3.2.1, Nobel Biocare). The the planning software. Conical im-
present study aimed to assess the arch form selector tool was (1) cen- plants with a 4.3-mm diameter and

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 247

a b c d
Fig 1 Classification of the sagittal root position of the central incisors: (a) Class I, (b) Class II, (c) Class III, and (d) Class IV.

a length adapted to the root length

were used (NobelActive, Nobel
Biocare). Ideal placement complied
with the following criteria (Fig 2):

• At least 2 mm of engaging
apical bone.
• Lingualized position allowing,
over the entire implant length,
a distance no less than 2 mm
between an intact buccal plate
and the implant .
• A minimum distance of 1 mm
between the implant and the
lingual bone plate over the
entire implant length. Fig 2 Landmarks adopted for implant planning. The red line is 2 mm from the external
surface of the buccal bone (dotted red line). The green line is 1 mm from the external
• Placement of the implant surface of the lingual bone (dotted green line). The blue line indicates a 1-mm subcrestal
shoulder 1 mm below the placement.
buccal bony crest.
• In every case, a screw channel
that was as palatal as possible
was pursued, provided
compliance with the above a lingual, incisal, or buccal posi- not achieved, the screw channel
guidelines. tion (Fig 3). In addition, all cases angle necessary to obtain this safe
were further assessed to discern distance was measured in the plan-
After simulated ideal implant whether they allowed a 1.5-mm ning software. Implants were then
placement, the screw channel posi- distance from the most lingual part grouped according to the degrees
tion of a prospective screw-retained of the tooth incisal edge (ideal po- of discrepancy from the ideal screw-
crown was assessed and classified sition) to the screw channel (Fig 4). channel position.
depending on whether it was in In cases where this distance was

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248

a b c
Fig 3 Possible location of the screw channel depending on the bony ridge anatomy: (a) lingual, (b) incisal, and (c) buccal.

a b c
Fig 4 (a) Ideal screw-channel location allowing a minimum distance of 1.5 mm from the incised margin (0 degrees). (b) Discrepancies 15 to
25 degrees and (c) greater than 25 degrees of the screw channel (blue line) compared to the ideal position (green line).

Data Analysis used to summarize the observed Results

screw channel position. The mean
Descriptive statistics were used to deviation of the screw channel from A total of 181 CBCT datasets
describe the recorded data. Fre- the ideal position was assessed. that presented maxillary incisors
quencies and percentages were were retrieved from the records.

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 249

Table 1 Screw Channel Location for the 144 Feasible Immediate Cases
Screw channel location, n (%)
Deviation from ideal
axis, degrees Lingual Incisal Buccal Total
0 35 (24%) 0 0 35
< 15 24 (17%) 33 (23%) 13 (9%) 70
15–25 1 (0.73%) 6 (4%) 26 (18%) 33
> 25 0 1 (0.73%) 5 (3%) 6
Total 60 40 44
The ideal screw channel position was present in a minority of cases feasible for immediate implant placement (35/144). However, in the vast
majority of feasible cases, the discrepancy of the screw channel position is ≤ 25 degrees.

Images belonged to 57 men and 1). In 35 cases (24%), the ridge anat- Discussion
125 women (age range: 19 to 75 omy allowed for simulated place-
years). The examiners agreed on the ment of an immediate implant with This study assessed the viability of
viability of immediate placement in a screw–channel axis favorable for immediate placement using a dedi-
all but three cases, which were then placement at a safe distance of 1.5 cated planning software for guided
agreed upon via discussion. From mm from the incisal edge (Table 1). implant planning as well as the re-
those datasets, 20 (11%) cases pre- In the remaining 109 cases, immedi- sulting position of the screw channel
sented image-quality exclusion cri- ate implant placement would result and its relation with the incisal mar-
teria. The remaining 161 cases were in an unfavorable screw channel gin. In most cases (89%), immediate
assessed for feasibility of a simulat- position (interfering with the incisal implant placement was considered
ed ideal immediate implant place- margin or facial surface). In 103 of feasible.
ment in the maxillary central incisor these 109 cases, an abutment with Other authors have assessed
position. Of these 161 cases, 133 an angled screw channel could al- the anatomy of the anterior max-
(83%) were classified as SRP Class I; low a correctly designed crown. In 6 illa, focusing on immediate implant
18 (11%) as Class II; 3 (2%) as Class cases, the angle correction required placement. Chung et al6 evaluated
III; and 7 (4%) as Class IV. In 17 of the to reach a safe channel position was simulated implant placement in 250
161 cases (11%), immediate implant greater than 25 degrees, and there- maxillary central incisors. For a simu-
placement was not considered pos- fore they were not considered suit- lated implant with a 5-mm diameter,
sible because the ridge anatomy able for screw retention. The 103 immediate placement was thought
did not fulfill the ideal placement cases requiring angle correction feasible in 82% of cases. This per-
criteria. These cases were: 4/133 of had a mean channel-angle devia- centage is similar to the results of
the SRP Class I ridges (3%); 3/18 of tion of 12.7 degrees from the ideal the present study.
the Class II (17%); 3/3 of the Class position (range: 2.1 to 24.5 degrees). Placement of 183 central inci-
III (100%); and 7/7 of the Class IV Of these 103 cases, 39 had an un- sor implants was also simulated by
(100%). A feasible anatomy for im- corrected screw channel position Gluckman et al,7 who found a Class
mediate implant placement was in- located facially, 39 incisally, and 25 II sagittal root position in 77% of
stead observed in 144 cases (89%). lingually. In the 6 cases not allowing cases, Class III in 11%, and other
The screw channel had an incisal screw retention, the average screw classes were less common. They
position in 40 cases (28%), a lingual channel angle deviation from the noticed how 61% of central inci-
position in 60 cases (42%), and a fa- ideal was 27.8 degrees (range: 25.4 sors had enough apical bone to al-
cial position in 44 cases (30%; Table to 31.6 degrees). low stability for immediate implant

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250

ning process when using the proto-

col for immediate placement.
A successful implant replace-
ment is dependent on a carefully de-
signed prosthetic restoration. In im-
mediate cases, the implant platform
is located approximately 3 mm be-
low the level of the prospective gin-
a b
gival margin.8 For this reason, screw
Fig 5 (a) Thin incisal margin fractured due to interference of the screw channel when using retention may be advantageous, as
the screwdriver. (b) Use of an abutment with angle correction allows relocation of the screw
channel to a safer position for the incised margin. cement remnants can be difficult
to remove and could cause inflam-
mation in the long term.11 Addition-
placement. The difference with the and require guided bone regenera- ally, the screw channel has to be
present data could be due to the tion instead. Second, an ideal simu- positioned with enough clearance
different populations examined; lated placement may be difficult to for adequate ceramic layering of
additionally, in the present study, reproduce with a real-life bone site the cervical margin to obtain struc-
an actual simulation of the implant preparation. Preparation precision tural strength and pleasing esthet-
placement was conducted, rather can potentially be improved if guid- ics. In the present study, this safety
than linear measurements of the ed placement is adopted instead distance has been established as
bony ridge. The sagittal root posi- of a freehand technique, but even 1.5 mm from the incisal margin. In
tion assessed herein is more simi- the former is not devoid of possible fact, 3 mm is the minimum screw
lar to the original data presented spatial errors that could influence channel diameter, and therefore
by Kan and coworkers,4 where, out the outcome.12 1.5 mm seems to be the minimum
of 200 central incisors, 86.5%, 5%, The immediate placement pro- distance that should be respected
0.5%, and 8% were classified as tocol simulated here was based on to avoid fracturing the porcelain
Class I, II, III, and IV, respectively. the use of grafting with bone re- when using the screwdriver, which
The same authors considered im- placement in the gap between the would be a frustrating occurrence
mediate implant placement feasible implant and the buccal bone.8–10 This (Fig 5). This distance can be ful-
in Class I cases, thus resulting in a approach was successful in reduc- filled when ridge anatomy is fa-
similar percentage to what is seen in ing the amount of ridge resorption vorable, which was seen in 35 of
the present study’s CBCT material. that inevitably follows tooth extrac- 144 cases (24%) in the present study.
It is clear that the present and tion and could impact the esthetic The screw channel position was as-
previous studies assessing case outcome.13 Confirmatory data were sessed in previous placement simu-
feasibility for immediate placement later presented, showing how lingual lation studies and was found to be
presented a simulation of ideal placement and the socket grafting located lingually in only 3.6% of cas-
conditions. In reality, it may be dif- protocol (simulated herein) minimize es, facially in 42% of cases, and inci-
ficult to replicate these high case- the ridge anatomy reduction at sites sally in 54.4% of cases.6 The differ-
selection percentages. First, buccal with immediate tooth replacement.14 ence between those results and the
bone thickness is very thin in most The data presented in the present present study, where the desirable
cases,1–3 and therefore a risk exists study provide further insight on the lingual position was more frequent,
that it could be damaged during frequency of case selection in a dif- could be due to the different diam-
the extraction despite the clinician’s ferent population and expand the eter of the implant, which allowed a
best care. This could jeopardize the knowledge on the prosthetic as- more favorable implant placement
feasibility of immediate placement pects to be considered in the plan- angle within the bony ridge.

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 251

8. Kan JYK, Rungcharassaeng K, Deflorian

The present study also shows Achieving a proper location of the
M, Weinstein T, Wang HL, Testori T.
how screw retention feasibility in- screw channel requires abutments Immediate implant placement and
creased to 138 of the 144 cases with angle correction in a majority provisionalization of maxillary ante-
rior single implants. Periodontol 2000
(96%) if an abutment with an angle of cases. 2018;77:197–212.
correction was to be used. Angle- 9. Buser D, Chappuis V, Belser UC, Chen
S. Implant placement post extraction in
correction abutments compensate
esthetic single tooth sites: When imme-
for a ridge anatomy that allows im- Acknowledgments diate, when early, when late? Periodon-
mediate placement but has a 25- tol 2000 2017;73:84–102.
10. Kan JY, Rungcharassaeng K, Lozada
degree discrepancy from the ideal The authors would like to thank Mr Rubén JL. Bilaminar subepithelial connective
axis, and they may represent an ef- García for his help with image editing. The tissue grafts for immediate implant
authors declare no conflicts of interest. placement and provisionalization in
fective solution for widening the in-
the esthetic zone. J Calif Dent Assoc
dication for immediate placement. 2005;33:865–871.
These abutments are provided by 11. Staubli N, Walter C, Schmidt JC,
Weiger R, Zitzmann NU. Excess cement
a vast majority of implant manufac- References and the risk of peri‐implant disease—A
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