Immediate Implant Placement in an Extraction Socket with Complete Buccal Bone Loss

• Case Title: Immediate Implant Placement in an Extraction Socket with Complete Buccal Bone Loss: A Case Report
• Patient Profile: Female in her 40s, non-smoker, systemically healthy; presented with localized advanced periodontitis in the right maxillary premolar area, exhibiting Grade III tooth mobility and functional impairment. Immediate treatment was initiated following non-surgical periodontal stabilization.
• Lead Specialist: Dr. Lizhao Teng
• Implant Specifications: Hydrophilic Dental Implant System, 3.75 × 10 mm
• Treatment Approach: Immediate Placement + Palatal-Oriented Anchoring + Guided Bone Regeneration (GBR)

Case Summary:

This clinical case demonstrates immediate implant placement in a compromised premolar extraction socket with a complete loss of the buccal bone wall (buccal plate). By strategically anchoring a high-strength, reduced-diameter (3.75 × 10 mm) hydrophilic implant against the preserved palatal bone wall and performing simultaneous Guided Bone Regeneration (GBR), the surgical team achieved predictable primary stability and optimal spatial clearance. Short-to-mid-term follow-up at 7 months confirmed favorable osseointegration, stable maintenance of the grafted bone volume, and favorable soft tissue architecture without postoperative complications.

• Ethical Considerations: Written informed consent was obtained from the patient for the publication of this clinical case report and any accompanying intraoral images.
• Author Contributions: LT performed the surgical procedures and clinical management; the clinical data was compiled and analyzed for publication.
• Conflicts of Interest: The authors declare no conflicts of interest related to this case report.

• Anatomical Diagnostic Assessment: Clinical examination revealed Grade III tooth mobility (Miller classification) at Tooth 14 (FDI; Universal #4). CBCT sagittal section analysis confirmed a complete loss of the buccal bone wall with a vertical bone defect depth of approximately 8 mm. Following atraumatic extraction, the palatal root alveolar housing was found to retain adequate, high-density bone support.
• Rationales for Immediate Placement: Although immediate implant protocols traditionally favor avoiding the original extraction socket to prevent unfavorable positioning, in this case, a palatal-oriented trajectory aimed toward the socket was deliberately selected. Clinical evaluation dictated that anchoring into the remaining palatal wall offered a favorable prognosis, high predictability, and optimal overall benefit for the patient.
• Surgical Protocol & Flap/Suture Design: Following atraumatic tooth extraction, a sulcular incision with minimal mucoperiosteal reflection was utilized to expose the defect boundaries while preserving the papillae. The socket was thoroughly debrided and irrigated. Following implant placement and GBR grafting, the site was closed stress-free using 5-0 PTFE sutures. Sutures were removed at 2 weeks postoperatively without wound dehiscence.
• Palatal-Oriented Trajectory: To engage native bone without risking further buccal plate violation, the implant was angled slightly toward the solid palatal wall while maintaining alignment with the overall socket trajectory. This provided a firm mechanical anchor and achieved an insertion torque of >35 N·cm.
• System-Specific Diameter Selection (3.75 mm vs. 4.1 mm): In this specific implant system, standard-diameter premolar implants constructed from pure titanium are typically 4.1 mm. By leveraging the enhanced mechanical strength of the hydrophilic implant system, Dr. Teng safely selected a 3.75 mm diameter. This guaranteed a critical safety clearance (≥ 1.5 mm) to adjacent root surfaces, maintained adequate inter-implant spacing, and optimized the overall buccolingual position. Furthermore, this reduced-diameter fixture demonstrated favorable cutting efficiency, facilitating smooth insertion without clinical difficulty and minimizing the risk of directional deviation during placement.
• Perioperative Medication Protocol: Systemic antibiotic prophylaxis (Amoxicillin 500 mg, t.i.d.) was prescribed starting 1 hour preoperatively and continued for 5 days postoperatively. Pain management was managed with Ibuprofen (400 mg p.r.n., max 3 doses/day). Chlorhexidine gluconate (0.12%) mouthwash was instructed b.i.d. for 14 days, starting 24 hours post-surgery to prevent early clot disruption.

• Graft Integration & Tissue Contour: At the 7-month postoperative review, CBCT imaging and clinical inspection confirmed favorable bone graft integration and osseous healing. The deproteinized bovine bone mineral (DBBM) graft mixed with autogenous bone chips remained stable beneath the resorbable collagen membrane, showing favorable facial volume restoration.
• Soft Tissue & Aesthetic Assessment: At the 7-month review, the peri-implant soft tissue demonstrated clinically satisfactory esthetics, achieving a Pink Esthetic Score (PES) of 11/14 and a White Esthetic Score (WES) of 9/10, with restored interdental papillae and no mucosal recession or peri-implant inflammation.
• Tooth 14 (FDI) — Outcome: The regenerated buccal bone wall maintained structural integrity, restoring proper facial contour and peri-implant soft tissue profile with favorable soft-tissue volume.
• Tooth 15 (FDI) — Outcome: Fully osseointegrated, with no clinical abnormalities detected, exhibiting minimal mean mesial/distal marginal bone remodeling (≤ 0.5 mm) and no peri-implant inflammation.
• Restoration Schedule & Longitudinal Follow-Up: Final crown placement and functional loading are scheduled at approximately 8 months post-surgery, with further long-term clinical and radiographic evaluations planned at 12 months.

Immediate implant placement in sockets with severe buccal bone loss can yield predictable, favorable aesthetic outcomes when paired with palatal-oriented engagement, reduced-diameter high-strength implants, and a reliable GBR protocol. This strategy successfully balances primary stability with the biological space required for bone and soft-tissue regeneration.

Furthermore, this treatment modality may serve as a valuable reference for similar clinical scenarios involving severe buccal plate defects, provided that sufficient palatal/apical bone anchorage and strict infection control are maintained.