Dental implants have revolutionized the field of prosthetic rehabilitation, offering a predictable and durable solution for the replacement of missing teeth. Among various indications for dental implants, the aesthetic zone—typically encompassing the maxillary anterior region—presents unique clinical challenges. Achieving optimal aesthetic and functional outcomes in this area necessitates precise surgical and prosthetic planning. The timing of implant placement after tooth extraction is a critical variable influencing success, and two main approaches—immediate and delayed placement—are commonly practiced.

Immediate implant placement, defined as placing the implant directly into the extraction socket during the same surgical session, offers several theoretical advantages. These include the reduction in treatment time, the preservation of alveolar bone and soft tissue architecture, and improved patient satisfaction by avoiding multiple surgeries [1]. It also allows clinicians to utilize the native socket anatomy for ideal implant positioning. However, concerns regarding primary stability, risk of peri-implant infections, and potential for compromised aesthetic outcomes remain debated, especially in the thin buccal bone of the anterior maxilla [2].

In contrast, delayed implant placement involves placing the implant after a healing period of 3 to 6 months post-extraction, allowing soft and hard tissue maturation. This approach is traditionally regarded as more predictable due to the healing and remodeling that occur before implant placement, which may reduce the risk of complications [3]. Nonetheless, it may result in increased bone resorption and soft tissue collapse, especially in cases lacking ridge preservation measures [4].

The decision between immediate and delayed implant placement is not merely surgical but multifactorial. Factors such as the integrity of the socket, the presence of infection, soft tissue biotype, patient expectations, and aesthetic demands play a role in the clinical decision-making process. Notably, the aesthetic zone is particularly susceptible to even minor changes in soft tissue contour or papilla height, which can significantly affect the final outcome [5]. Therefore, timing becomes crucial not only for osseointegration but also for long-term soft tissue stability and overall satisfaction.

Several studies have reported comparable survival rates between immediate and delayed implants [6], but variations in aesthetic outcomes, peri-implant tissue behavior, and patient-reported satisfaction warrant further investigation. Furthermore, advances in biomaterials, guided bone regeneration, and immediate provisionalization have redefined the limitations traditionally associated with immediate placement [7].

This prospective clinical study aims to perform a comparative evaluation of immediate versus delayed implant placement in the aesthetic zone. It focuses on primary outcomes such as implant survival rate, peri-implant soft tissue changes, marginal bone levels, and aesthetic scores. By providing evidence-based insights into the benefits and limitations of each approach, the study aspires to guide clinicians in making optimal choices tailored to individual patient needs, particularly in demanding aesthetic regions.

Study Design and Ethical Approval

This prospective clinical study was conducted in the Department of Prosthodontics and Implantology. Ethical clearance was obtained from the Institutional Ethical Review Board prior to patient recruitment. All participants were informed of the study objectives and procedures and provided written informed consent.

Study Population and Inclusion Criteria

A total of 40 patients aged between 20 to 55 years were enrolled in the study, with each patient requiring the replacement of a single tooth in the maxillary anterior region (central incisors, lateral incisors, or canines).

Patients were selected based on the following inclusion criteria:

• Non-smokers or light smokers (<10 cigarettes/day)
• Good oral hygiene (Plaque Index <1)
• Adequate bone height (≥10 mm) and width (≥6 mm) at the implant site
• Healthy adjacent teeth and periodontium
• Intact facial bone wall at the extraction site
• Absence of systemic conditions contraindicating implant placement (e.g., uncontrolled diabetes)

Exclusion Criteria

• Acute infection or abscess in the extraction socket
• History of radiation therapy to the head and neck
• Severe parafunctional habits (e.g., bruxism)
• Poor oral hygiene or non-compliance with oral hygiene instructions
• Pregnancy or lactation

Study Groups

Patients were divided into two groups using block randomization:

• Group A (Immediate Placement Group): 20 patients underwent implant placement immediately following tooth extraction.
• Group B (Delayed Placement Group): 20 patients underwent implant placement after a healing period of 12 weeks post-extraction.

Surgical Protocol

All procedures were performed under strict aseptic conditions using local anesthesia (2% lidocaine with epinephrine 1:100,000). In Group A, a minimally traumatic extraction was performed without flap elevation. Following extraction, the socket was curetted, and the implant was placed using a conventional drilling protocol. The gap between the implant and socket walls was filled with xenograft bone substitute and covered with a resorbable collagen membrane.

In Group B, atraumatic extraction was followed by a 12-week healing period. At the time of implant placement, a full-thickness flap was raised, the osteotomy was prepared, and the implant was placed in healed bone.

In both groups, implants were placed with an insertion torque of ≥35 Ncm to ensure primary stability. Immediate temporization with a non-functional provisional crown was done in both groups to guide soft tissue healing and support aesthetics.

Implant System Used

All patients received titanium implants from the same manufacturer ([insert brand name]) with similar dimensions (3.5 mm diameter and 11 mm length) to eliminate bias related to implant design.

Postoperative Care and Follow-Up

Postoperative antibiotics (amoxicillin 500 mg TID for 5 days) and analgesics (ibuprofen 400 mg TID) were prescribed. Patients were instructed to use chlorhexidine mouthwash for 10 days. Follow-up was conducted at 1 week, 1 month, 3 months, and 6 months.

Outcome Parameters

Primary and secondary outcomes were recorded at baseline and at 6 months post-placement:

• Implant survival rate (presence of mobility, pain, infection)
• Marginal bone level changes (measured via standardized periapical radiographs using parallel technique)
• Pink Esthetic Score (PES) to assess peri-implant soft tissue aesthetics
• Modified Plaque Index and Bleeding Index
• Patient satisfaction scores using a Visual Analog Scale (VAS)

Statistical Analysis

Data were analyzed using SPSS version [insert version]. Descriptive statistics were calculated for all variables. Independent t-tests and Chi-square tests were used to compare continuous and categorical variables between groups. A p-value <0.05 was considered statistically significant.

A total of 40 patients were enrolled and equally distributed into two groups: Group A (Immediate Implant Placement) and Group B (Delayed Implant Placement). The baseline demographic characteristics between the two groups were statistically comparable. The mean age was 34.2 ± 7.5 years in the immediate group and 35.6 ± 6.8 years in the delayed group (p = 0.56). Gender distribution was similar with 12 males and 8 females in the immediate group and 11 males and 9 females in the delayed group (p = 0.75). The distribution of implant sites (central, lateral, canine) also showed no significant difference (p = 0.89), ensuring comparability in anatomical positioning across the groups [Table 1].

Evaluation of marginal bone loss at six months showed that both groups experienced minimal bone resorption. The immediate implant group exhibited a mean bone loss of 0.56 ± 0.18 mm, while the delayed group showed a slightly lower mean loss of 0.48 ± 0.20 mm. However, this difference was not statistically significant (p = 0.12), suggesting comparable preservation of peri-implant bone in both groups over the six-month period [Table 2].

Aesthetic evaluation using the Pink Esthetic Score (PES) at six months revealed favorable soft tissue outcomes in both groups. The immediate implant group recorded slightly higher scores in all aesthetic parameters, with a total mean PES of 6.9 ± 1.1 compared to 6.5 ± 1.3 in the delayed group. Parameters such as mesial and distal papilla, mucosal curvature, and level of facial mucosa showed no statistically significant differences (p > 0.05 for all), indicating that immediate implant placement did not compromise aesthetic outcomes [Table 3].

Patient-reported outcomes, assessed using a Visual Analog Scale (VAS), demonstrated high satisfaction in both groups. Patients in the immediate group rated aesthetic outcome at 8.5 ± 0.9, comfort at 8.2 ± 1.0, and overall satisfaction at 8.4 ± 0.8. The delayed group reported slightly lower but still satisfactory scores of 8.2 ± 1.1 for aesthetics, 7.9 ± 1.2 for comfort, and 8.1 ± 1.0 for overall satisfaction. None of these differences reached statistical significance (p > 0.05), confirming comparable patient-perceived outcomes between the two approaches [Table 4].

Table 1: Baseline Demographics

Table 2: Marginal Bone Loss (mm)

Table 3: Pink Esthetic Score (PES)

Table 4: Patient Satisfaction Score (VAS)

This prospective clinical study aimed to compare the outcomes of immediate and delayed implant placement in the maxillary aesthetic zone, focusing on peri-implant marginal bone loss, soft tissue aesthetics, and patient satisfaction. The findings suggest that both approaches yielded comparable clinical and aesthetic outcomes, with no statistically significant differences in the evaluated parameters at six months post-implantation.

The preservation of marginal bone is crucial in implant dentistry, especially in the aesthetic zone, where even minimal resorption can compromise outcomes. In the present study, mean bone loss in the immediate group was 0.56 ± 0.18 mm, while in the delayed group it was 0.48 ± 0.20 mm at six months, with no significant difference (p = 0.12). These values are consistent with previous studies that report bone loss ranging between 0.4–0.9 mm for both placement protocols within the first year of function [7,8]. This suggests that when proper surgical techniques are followed, immediate placement can maintain bone levels nearly as effectively as delayed protocols, provided that primary stability is achieved and the extraction socket is intact.

Immediate implant placement has historically been approached with caution due to concerns over compromised osseointegration, particularly in sockets with facial bone defects or infection. However, studies such as those by Lang et al. and Chen et al. have shown that when atraumatic extraction and appropriate grafting techniques are employed, immediate implants can result in predictable outcomes with high survival rates [9,10]. In this study, all immediate implants were placed in sites with intact buccal plates, and bone grafts were used to fill the gap between implant and socket wall, likely contributing to the minimal bone loss observed.

Aesthetic evaluation using the Pink Esthetic Score (PES) revealed slightly higher but statistically insignificant scores in the immediate group (mean 6.9) compared to the delayed group (mean 6.5). Aesthetic outcomes in the anterior maxilla depend heavily on soft tissue contour and papilla presence. The results align with the findings of Belser et al., who emphasized the importance of flapless procedures and immediate provisionalization in maintaining soft tissue architecture [11]. The use of non-functional temporaries in both groups may have helped preserve or contour the soft tissues adequately, contributing to similar PES scores. Moreover, the lack of significant differences in individual parameters such as papilla fill and mucosal level suggests that both protocols, when executed with precision, can achieve high aesthetic success.

Patient satisfaction remains a key determinant in the success of implant therapy, particularly in cases involving the visible anterior zone. The high VAS scores recorded in both groups across aesthetics, comfort, and overall satisfaction indicate favorable acceptance of both protocols. Patients in the immediate group demonstrated slightly higher scores, potentially due to the reduced number of surgical visits and faster restoration of function and appearance. These findings are in accordance with those of Raes et al., who reported that patients receiving immediate implants showed increased satisfaction during the early phases of healing [12].

From a clinical standpoint, the decision between immediate and delayed placement should be individualized, based on factors such as socket morphology, patient health status, aesthetic expectations, and operator expertise. While this study supports the viability of immediate implants in favorable conditions, it also highlights that delayed placement remains a highly successful approach when soft tissue conditions or bony architecture are less than ideal. This flexibility allows clinicians to tailor treatment plans based on case-specific needs without compromising outcomes.

A key strength of this study is its controlled, prospective design, allowing for standardized protocols and consistent follow-up. Both groups used implants of similar design and dimension, minimizing confounding variables. Furthermore, the study excluded patients with high-risk factors such as poor oral hygiene, systemic disease, or parafunctional habits, thereby isolating the effect of timing on implant success [13-15].

However, some limitations warrant mention. The follow-up period of six months, while adequate to assess early bone remodeling and soft tissue healing, does not provide insights into long-term stability or prosthetic complications. Future studies should include extended follow-up to evaluate crestal bone maintenance, aesthetic scores over time, and implant survival beyond the first year. Additionally, three-dimensional imaging such as CBCT would have provided more accurate volumetric assessment of bone changes, which was beyond the scope of this study.

In conclusion, both immediate and delayed implant placements in the aesthetic zone resulted in comparable outcomes in terms of bone preservation, aesthetic appearance, and patient satisfaction. With appropriate case selection and surgical planning, immediate implants can offer the added advantage of reduced treatment time without compromising clinical success. These findings support the inclusion of immediate placement as a reliable option in anterior implant rehabilitation.

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