959 D3000 new imprint Word template Vol 13, No 1 (2025) ISSN 2167-8677 (online) DOI 10.5195/d3000.2025.959 http://dentistry3000.pitt.edu Enhancing Immediate Implant Success The Role of Bone Subs/tutes and Local An/bio/cs in Fresh Extrac/on Sites Shefaa H. Alnuamy1, Ihsan A. Kumail2, Salam K. Rasheed2, Hasan Skienhe3 1College of Den*stry, Al Esraa University, Iraq 2College of Den*stry, Al Ayen Iraqi University, Iraq 3Faculty of Dental Medicine, Lebanese University, Beirut, Lebanon Abstract Objec;ve: This study evaluated the effecHveness of bone subsHtutes and local anHbioHcs in enhancing osseointegraHon during immediate implantaHon in fresh extracHon sockets. Ma- terial and Methods: A total of 30 paHents underwent immediate implant placement, divided into three groups: control group receiving no adjuncts, group treated with bone subsHtutes, and group treated with bone subsHtutes combined with anHbioHcs. ATer four months, suc- cess rates were assessed through implant stability quoHent (ISQ) measurements. Results: The current findings indicated significantly higher success rates in the groups receiving ad- junct treatments than in the control, highlighHng the potenHal of bone subsHtutes and anH- bioHcs in promoHng favorable outcomes. Conclusion: This study underscores the importance of personalized treatment approaches that consider paHent-specific factors and the use of adjuncHve therapies to opHmize implant success. Open Access Cita%on: Alnuamy SH, et al. (2025) Ehnancing Immediate Implant Success: The Role of Bone Subs%tutes and Local An%bio%cs in Fresh Extrac%on Sites. Den%stry 3000. 1:a001 doi:10.5195/d3000.2025.959 Received: June 10, 2025 Accepted: June 26, 2025 Published: August 13, 2025 Copyright: ©2025 Alnuamy SH, et al. This is an open ac- cess ar%cle licensed under a Crea%ve Commons AUribu- %on Work 4.0 United States License. Email: shefaa@esraa.edu.iq Introduc)on Immediate implantation after tooth extrac- tion has gained popularity and recognition in modern dentistry. This shift is driven by pos- sible bene;its, including shorter treatment time, preservation of alveolar bone struc- ture, and increased patient satisfaction [1,2]. However, rapid implant placement faces ob- stacles, such as decreased bone density and quality, and the possibility of postoperative infections, which may prevent favorable out- comes [3]. Researchers and physicians have looked into various complementary strate- gies to overcome these issues and improve the success of immediate implantation oper- ations. Among these, the use of bone substi- tutes and local antibiotics have emerged as promising techniques for promoting osse- ointegration while reducing infection risk [4,5]. Bone alternatives, which include mate- rials ranging from synthetic grafts to xenografts, are critical in maintaining alveo- lar ridge dimensions and providing a plat- form for new bone growth [6]. Similarly, the supplementary use of local antibiotics such as chlorhexidine and minocycline has been encouraged to avoid bacterial colonization and infections at the implant site, hence en- hancing overall success rates [7,8]. Despite increasing evidence supporting the ef;icacy of bone replacements and local antibiotics, more research is needed. This involves choosing appropriate biomaterials, antimi- crobial agents, and surgical procedures to improve results and prevent complications [9,10]. Furthermore, taking patient-speci;ic aspects into account, such as overall health and anatomical concerns, is critical for per- sonalizing treatment techniques after imme- diate implantation. Also, the risk of necrosis of the bone is reduced due to the decreased surgical trauma. Moreover, the natural socket rich in periodontal cells and matrix makes healing faster and more predictable [11]. The current in vivo study seeks to critically assess the effect of bone substitutes and local antibiotics in improving the success rate of immediate implantation in fresh extraction sites and to clarify the effectiveness, safety, and therapeutic consequences of various ad- junctive therapies by combining current lit- erature and empirical evidence. Further- more, it intends to give evidence-based rec- ommendations to optimize treatment meth- ods and increase patient outcomes during immediate implantation in fresh extraction sites. Material and Methods A total of 30 male patients, with a mean age of 35 years (range 25-45 years) were in- cluded in this study. All selected patients had three or more unrestorable hopeless Enhancing Immediate Implant Success Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.959 http://dentistry3000.pitt.edu 2 premolar teeth indicated for extraction in the lower arch. Ninety Neodent implants (Grafel;ing, Germany) were used in all pa- tients, and three implants were implanted in each patient. Each patient who signed an informed con- sent form was fully educated about the im- mediate implantation procedures and all the risks involved with this kind of surgery. Grouping of samples The patients were divided into 3 study groups (n=30) according to the following protocol used: Group A (Control): Every patient in this group immediately had one tapered implant in the freshly extracted sockets Group B: Every patient in this group imme- diately received one implant in the freshly extracted sockets. After implantation, a bone substitute (Bioplast-Dent) was added to the gap between the implant and socket wall. Group C: Every patient in this group imme- diately had one implant in the freshly ex- tracted sockets. After implantation, a bone substitute mixed with an antibiotic (lincocin) was added to the gap between the implant and socket wall. Inclusion criteria 1. Patient with good health status. 2. Patient should be between 25-45 3. Reasons for initial tooth extraction (trauma, caries, root resorption, and endo- dontic failure). 4. Presence of adequate gingival architecture with surrounding dentition. 5. Good oral hygiene. 6. Adequate bone volume. 7. Root fracture either vertical/horizontal 8. Teeth which are periodontally involved 9. Chronic periapical/ periodontal infection Exclusion criteria 1. Poor oral hygiene. 2. Chronic or acute systematic disorders (un- controlled diabetes, hemorrhagic diathesis, general or auto immunode;iciency). 3. Poor interest or cooperation from the pa- tient. 4. Existence of non-treated generalized peri- odontitis. 5. Insuf;icient bone volume at the receptor site. 6. Pathological changes at the receptor site (cysts, tumors, osteomyelitis 7. Patient still growing (child or adolescent). 8. Medically allergic and compromised pa- tients. 9. Presence of dehiscence or fenestrations. 10. Heavy smokers, alcohol or drug abusers. 11. Acute periapical/periodontal infections 12. Proximity to vital anatomic structures Implant size selection Radiographic evaluation Bone evaluation at the implant placement site was performed, along with the estima- tion of tooth size to be removed (root length and root width at the CEJ) and the closeness of the implant site to important anatomical structures using OPG, IOPA, and computed tomography scans. The implant size used was determined using these characteristics as a reference. The mandibular cone beam computed tomography (CBCT) was utilized to assess the diameter and length of sockets dimensions. According to the CBCT assess- ments, the socket diameters were 5.5-7 mm in the crestal direction, 3-4 mm in the apical direction, and 10-13 mm in length. Accord- ingly, tapered self-tapping implants were se- lected. The implant diameter in groups B and C was carefully chosen to be 2mm less than the crestal socket width, whereas, in Group A, it was selected to be the same size as the crestal part of the socket. The length of the implants in all groups was chosen to be 1.5 mm below the crestal bone level (Figure 1). Surgical procedure Atraumatic teeth extraction Atraumatic teeth extraction was carried out using periotomes. Teeth were extracted with minimal trauma to the alveolus and rota- tional movement was used to avoid damag- ing the buccal plate(12). Implant insertion Immediately after tooth extraction, the im- plants were placed into the sockets without drilling [12-15]. The implants in group A (control) were inserted into the socket with- out the addition of any bone substitute. In group B the implants were inserted, and the 2mm gap between the implant and socket walls was ;illed with a bone substitute, how- ever in group C the implants were inserted, and the 2mm gap was ;illed with bone sub- stitute mixed with the antibiotic. After implant insertion for the three groups, a slice of absorbable collagen wound dress- ing Zimmer Collagen Plug (USA) was placed over the implant, then the buccal and lingual gingiva were sutured using a reverse cut needle 0\4 silk. Second stage surgery After four months, the implants of all groups were exposed and assessed for osseointegra- tion using resonance frequency analysis (RFA) using an Osstell device (Ab Integration Diagnostics, Gothenburg, Sweden) [16]. It is expressed as an implant stability quotient (ISQ) in units ranging from 1 to 100. Each transducer is calibrated by the manufac- turer, which makes all measurements di- rectly comparable [17-20] (Figure 2). The criteria used to de;ine the success or fail- ure of the implants are as follows: 1- success: ISQ value of 60 or more with no mobility. 2- failure ISQ value less than 60 with mobil- ity Statistical Analysis A chi-square test for independence was con- ducted to compare the success and failure rates among the three implant groups. This test assesses whether significant differences exist in the distribution of success and failure rates among the three groups. Following the chi-square test, pairwise comparisons be- tween the implant groups were performed. These comparisons were conducted using chi-square tests for each pair of groups. The Bonferroni correction was applied to control for the family-wise error rate due to multiple comparisons. The adjusted significance level for each pairwise comparison was set at α′=0.05 / 3 ≈ 0.0167. Results The frequency of successful and failed im- plants for each group was [χ2(2, N=90)=11.607, p=0.003]: Group A: 19 successful implants, 11 failed implants. Group B: 27 successful implants, 3 failed im- plants. Group C: 29 successful implants, 1 failed im- plant. Group A vs Group B: χ2(1,N=60)=7.004, p=0.008. Group A vs Group C: χ2(1,N=60)=9.202, p=0.002. Group B vs Group C: χ2(1,N=60)=0.352, p=0.553. Enhancing Immediate Implant Success Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.959 http://dentistry3000.pitt.edu 3 Discussion The current study showed a signi;icant suc- cess rate of immediate implantation proce- dures done in fresh extraction sites in groups B and C compared to control group A. Thus, the null hypothesis regarding using bone substitutes and local antibiotics to enhance Osseo-integration was rejected. Immediate implantation offered a shortened treatment duration and preservation of alveolar bone structure. Both are essential to get the most effective treatment and functional results. However, many challenges such as bone type and post-operative infection can in;luence the treatment outcome [1,2]. One of the most important factors for the success of osseointegration is implant stabil- ity which can be classi;ied into primary (me- chanical engagement) and secondary stabil- ity (osseointegration) [21]. In the present study, the primary stability was achieved by bone substitutes in groups B and C and by socket walls in group A despite not measur- ing the primary stability. A previous study [22] assessed the stability of a clinically suc- cessful implant employing resonance fre- quency analysis. After a year of loading, the successfully integrated implant had ISQ val- ues ranging from 57 to 82 ISQ. Results of the present study showed ISQ levels between 60 and 81 ISQ with a mean of 70 ISQ after 4 months of immediate implantation in the mandibular arch. Our results agree with those of Balleri et al. [22], Deng et al. [17], and Harirforoush and Arzanpour [18] who suggested that the strong interface between the implant and bone is observed in high ISQ values. However, Kittur et al. [23] stated that despite the osstel being a non-invasive and widely used equipment to asses implant sta- bility, his review revealed that there is no single universally accepted method to deter- mine secondary implant stability. The use of bone substitutes in this study could have played a major role in the success rate of group C compared to group A. There- fore, bone substitutes could provide support for implants surgically implanted without drilling. This could reveal that the primary stability achieved for successful osseointe- gration is supposedly related to bone substi- tutes. This was consistent with several stud- ies that stated that a bone substitute in the ;ixture–socket gap preserved socket volume and supported new bone formation [24,25]. The preservation of the bone structure and minimizing soft tissue trauma was achieved in this study by using atraumatic extraction. So, the gap ;illed by the bone substitute was supported by the alveolar bone and the un- traumatized tissue accelerated the healing process and complication. This was in agreement with Tarnow et al. [26], who stated that atraumatic extraction preserves the integrity of the socket, and the immediate placement of implants into ex- traction sockets with an intact buccal wall al- lows healing and osseointegration. Limitations of the study Despite the positive results of this study, sev- eral limitations need to be considered. The very small sample size and homogeneous pa- tient demographics may restrict the ;indings' application to wider patient populations. Fu- ture research should look into longer follow- ups to verify the instant implantation meth- ods' long-term safety and effectiveness. Ad- ditionally, comparative analyses of different antibiotic combinations and bone replace- ments are required to ascertain the optimal treatment plan based on speci;ic clinical cir- cumstances. Conclusions Within the limitation of this study, bone sub- stitutes are a potentially effective way to im- prove the outcome of immediate implanta- tion treatments after tooth extraction. Com- bining local antibiotics with bone substitutes is an effective way to prevent infection. At- raumatic extraction as a major factor posi- tively affects the success rate of immediate implantation in fresh extraction socket. Conflicts of Interest The authors have no con;licts of interest to declare. Acknowledgements The authors would like to thank the deanery of the College of Dentistry, University of Al- Ayen Iraqi University for its support to per- form the current study. 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The effect of bone grafting and/or provisional restoration on Facial-Palatal Ridge Dimensional Change—A Retrospective Co- hort Study. The International Journal of Periodon- tics & Restorative Dentistry, 34(3), 323–331. https://doi.org/10.11607/prd.1821 Figure 1. Diameter and length of the socket before extraction. Enhancing Immediate Implant Success Vol 13, No 1 (2025) DOI 10.5195/d3000.2025.959 http://dentistry3000.pitt.edu 5 Figure 2. Dental implants 4 months after placement.