Two paths to the implant
When a tooth cannot be saved and is to be replaced by an implant, there are two temporal approaches. With the immediate implant, the implant is placed in the same session in which the old tooth was extracted. With the delayed implant, the practice waits until the extraction wound has healed and places the implant only after that.
Both procedures are established and have very high success rates in the right indications. The choice depends on bone situation, soft tissue, infection status and aesthetic demand. This article explains both concepts and shows in which constellations which path is medically sensible.
What an immediate implant is
An immediate implant is placed directly after extraction into the still fresh socket. The wound is not released for healing first but is directly fitted with the implant.
The sequence in one session:
- Extraction: gentle, with minimal bone trauma. The bone around the socket must be preserved.
- Cleaning of the socket: granulation tissue and inflammation residues are completely removed.
- Implant bed preparation: usually somewhat deeper and in a more favorable axis than the original root.
- Implant placement: with sufficient primary stability in the bone.
- Bone augmentation if needed: the gap between implant and socket wall is filled with bone substitute material.
- Provisional restoration: either a directly loaded provisional build-up or a healing cap for covered healing.
Healing takes three to four months as with the delayed implant before the definitive crown is placed.
What a delayed implant is
With the delayed implant, the bone is first allowed to fully heal after extraction. Only after three to six months is the implant placed into the healed bone.
The sequence in two separate phases:
- Phase 1: Extraction with possibly socket preservation (filling the socket with bone substitute material to prevent bone loss). Healing six to twelve weeks for soft tissue, four to six months for full bone consolidation.
- Phase 2: Implantation into the healed bone, identical to standard implantation. Healing three to four months, then crown.
In total the treatment from extraction to finished crown takes between eight and twelve months.
Comparison by criteria
Treatment duration
Immediate implant: four to five months from extraction day to finished crown.
Delayed implant: eight to twelve months from extraction day to finished crown.
The time advantage of the immediate implant is significant. Patients have the definitive restoration sooner.
Number of surgeries
Immediate implant: one surgical session (extraction and implantation in one).
Delayed implant: two surgical sessions (extraction, later separate implantation).
Here too the immediate implant has the advantage of reduced procedures.
Bone preservation
Right after an extraction the bone begins to shrink. In the first six months the socket loses up to 50 percent of its width and about 25 percent of its height if left untreated.
The immediate implant plus bone substitute material in the gap can mitigate this shrinkage process significantly by supporting the bone in its original shape.
With delayed implant, socket preservation in the first phase prevents bone loss to a similar extent. Those who omit socket preservation often have additional bone augmentation need with the delayed implant.
Success rates
In studies both procedures show high survival rates. Immediate implants in suitable indications reach survival rates of 94 to 98 percent over five years. Delayed implants are in the same range, with survival rates of 95 to 98 percent over five years.
The decisive factor is not the timing but the indication. An immediate implant in a poorly suited constellation has a significantly worse prognosis than a delayed implant in the same constellation.
Aesthetics in the front area
In the visible front area the immediate implant is often aesthetically advantageous because it supports the gum line and tends to preserve the original papilla (the gum between the teeth). A gap after extraction lets the papilla shrink, which is later difficult to reconstruct.
Prerequisites, however, are sufficient bone and healthy soft tissue.
Costs
Concrete amounts vary by complexity. Bandwidths are in the article on the cost of an implant.
Rough tendency: The immediate implant saves a separate surgery but may need additional bone substitute materials. In total, costs are often comparable or slightly cheaper than the delayed implant plus socket preservation.
When an immediate implant makes sense
Bone is intact
The socket walls must be fully preserved. If the buccal (lip-facing) bone wall breaks during extraction or has already melted away through chronic inflammation, the immediate implant is not possible.
No acute inflammation
With chronic apical periodontitis (inflammation at the root tip), the infestation must be carefully cleaned. A massive acute infection with pus is a contraindication for immediate implantation. Here it is first healed and then implanted.
Front area with aesthetic demand
When the gap is in the visible area and the gum is to be preserved, the immediate implant has clear advantages.
Patient wants brisk treatment course
Anyone who does not want to accept a gap for months professionally or privately benefits from the immediate implant with provisional on the same day. An immediately loadable restoration requires sufficient primary stability of the implant and is not possible in every constellation.
When a delayed implant makes sense
Acute or chronic infection
With a strongly inflamed socket, periapical abscess or advanced periodontitis, the delayed implantation is the safer choice. The bone is first healed and stabilized, then implanted.
Disrupted bone anatomy
When after extraction the bone is insufficient or the axes are unfavorable, a phase of bone healing with possible augmentation can improve the prerequisites. Only after that is implantation done.
Risk patients
With systemic risk factors like uncontrolled diabetes, bisphosphonate therapy or heavy smoking, the two-stage approach is safer. Each treatment step is healed and assessed individually.
Complex bone reconstruction
When extensive bone augmentation (e.g. sinus lift, augmentation of an entire region) is needed, the bone is usually first built up, healed and then the implant placed.
How Resident makes the decision
We make the decision not based on patient preference alone but on the basis of careful diagnostics:
- Clinical examination of the affected tooth and the surrounding tissue.
- 3D image (CBCT) for exact assessment of bone availability, root anatomy and neighboring structures.
- Assessment of the socket walls intraoperatively after extraction. If the buccal wall is intact and all prerequisites fit, the immediate implant comes into consideration.
- Written treatment plan with both options if both are possible. More on this in the article on the cost estimate.
- Recommendation based on medical safety and aesthetic result.
Complex implant treatments, especially in the front area or with bone augmentation, are treated at our Bellevue location by Dr. Dejan Dragisic, oral surgery specialist. More on this on the implant spoke Bellevue and in the article on peri-implantitis, which describes the long-term care of implants.
Arrange an appointment for an initial consultation. We discuss the options without pressure and with the time needed for a well-founded decision.