The Process

An implant on the day of extraction: when is it suitable, and what are the risks?

It saves a surgery and shortens the timeline; in return, case selection has to be stricter

Placing the implant at the same time as the tooth is removed is referred to in the literature as 'immediate placement' or 'type 1 placement'. The appeal for the patient is obvious: no second surgery, no months of going around with a gap. The evidence also shows that this route gives good results in a well-selected patient. But the same evidence also reports that implants placed on the day of extraction are lost slightly more often than those placed in healed bone, and that gum recession at the front teeth is more common and less predictable. Three questions decide it: are the walls of the extraction socket intact, is there infection in the area, and can the implant get enough hold from the bone beyond the socket?

Short answer

An implant on the day of extraction means placing the implant into the extraction socket in the same session in which the tooth is removed. It is suitable if the walls of the socket are largely intact, the infection can be cleaned out and the implant can get a firm hold from the bone beyond the socket. In a meta-analysis, survival was 95.2% for implants placed on the same day and 98.4% for those placed in healed bone. At the front teeth the risk of gum recession is higher; this is why case selection is decisive.

What it gains you: One surgery, a shorter total timeline
Survival: 95.2% in a meta-analysis; 98.4% in healed bone
Risk at a front tooth: Gum recession of more than 1 millimetre, median 26% across studies
Infected socket: When cleaned well, results close to those of a non-infected socket

What happens in an extraction socket, and how an implant changes it

When a tooth is removed, the walls of the socket begin to change. In a systematic review pooling studies in humans, six months after extraction the width of the bone had decreased by between 29% and 63% and its height by between 11% and 22%; most of the loss happened in the first three to six months. The idea of an implant on the day of extraction grew out of this picture: the thinking was that if the implant went in straight away, the timeline would be shorter and the area would change less.

The second expectation is not fully met. In implants placed at the front immediately after extraction, even though bone was added, in two retrospective studies the outer bone wall could not be seen on three-dimensional images in 36% and 57% of sites. Gum recession is also greater at these sites. In other words, the implant does not on its own stop the thin layer of bone that wraps the tooth from the outside from resorbing. The real gain of an implant on the day of extraction lies less in preserving bone than in reducing the timeline and the number of surgeries.

On survival, the evidence points in a consistent direction. In a meta-analysis pooling 30 studies, 1,435 patients and 3,049 implants, survival was 98.38% for implants placed in healed bone and 95.21% for those placed on the day of extraction; the difference is significant. In bone loss, implant stability and gum pocket depth, however, there is no difference. The authors recommend that immediate placement be used with care. A Cochrane review, noting that the studies are few and at high risk of bias, also suggests that implants placed on the same day or a few weeks later may carry a higher risk of failure and complications, but may in return give a better aesthetic result.

The meta-analysis does not explain the reason for this difference of about three points, but one possible reason is the shape of the socket. An extraction socket has the shape of the tooth's root, while an implant is a cylindrical or tapered screw. The two do not match exactly; a gap often remains between the implant and the wall of the socket. For the implant to fuse with the bone, it must not move from the first day, which means it must grip firmly in the solid bone beyond the socket. If this hold cannot be achieved, the right decision is not to place the implant that day.

What to do with the gap between the implant and the bone wall is a separate debate. In the literature, this space is often filled with bone graft. In a network meta-analysis comparing randomised studies at the front of the mouth, implants placed without lifting the gum, with the gap filled with graft, came out as the route that best preserved the thickness of the outer bone; adding a soft tissue graft as well kept the gum level more stable, but, with low certainty, at the expense of outer bone thickness. The Cochrane review, on the other hand, states that there is not enough reliable evidence to say when a graft is needed or which technique is superior.

Infection is the obstacle people ask about most. For a long time, not placing an implant into the socket of an infected tooth was accepted almost as a rule. Today the position is more flexible. In a meta-analysis of 9 studies comparing infected and non-infected sockets at the front of the mouth, survival was 97.6% and 98.4%, and there was no significant difference in bone or gum level. Another review of the subject sets out the precondition for this result: thorough cleaning of the socket, scraping away the infected tissue and rinsing with chlorhexidine. The same review also notes that the benefit of systemic antibiotics in this situation has not been proven, and that definitions of infection were unclear across the studies.

The area also changes the outcome. At the front, the issue is aesthetics: in a review of implants after single-tooth extraction, gum recession of more than one millimetre around implants placed on the day of extraction was seen at a median of 26% of sites across studies, with a range of 9% to 41%; for implants placed after waiting a few weeks, this rate was zero in two studies. At the molars, the issue is the width of the socket: in a review covering 20 studies and 1,106 implants, one-year survival was 96.6% and mean bone loss 1.29 millimetres; the difference compared with healed bone was about 0.31 millimetres. The authors find immediate placement at a molar predictable 'in selected cases'.

In full-mouth treatment, the picture works a little differently. Here it is not a single socket but a whole jaw, and some implants can go into extraction sockets and some into healed bone. In a study of 19 patients with 164 implants, 119 of which were placed into extraction sockets, cumulative survival at four years was 95.1%. In plans of this kind, what is decisive is that the hold is taken not from the walls of the extraction socket but from the solid bone deeper in the jaw; the aesthetic concerns that apply to a single tooth move into the background.

When a same-day implant makes sense, and when waiting is better

The decision is often finalised on the day of extraction, once the socket has been seen. The CBCT scan gives an initial idea; the signs below show which way it is leaning.

When it fits

People whose extraction socket walls are intactIt is particularly important for the outer wall to be in place. The picture regarded as low risk at the front is an intact outer wall and thick gum: recent studies use these selection criteria to reduce the aesthetic risk.
People with enough solid bone beyond the socketIf there is bone beyond the root tip or at the sides of the socket in which the implant can grip firmly, the implant does not move from the first day. This is the most basic condition for immediate placement.
Patients who are having all their teeth removed and a full-mouth planDoing the extraction and the implant in the same session can, in full-mouth treatment, remove the need for a second surgery and for months of waiting with a denture. If the hold can be taken from the deep bone of the jaw, the condition of the individual sockets becomes less decisive.
People with limited infection that can be cleaned outLimited infection at the root tip or in the gum may not rule out a same-day implant if it is thoroughly cleaned. At the front, results in infected sockets were found to be close to those in non-infected sockets.

When it doesn't

People with an acute, spreading infectionAn active abscess with signs such as facial swelling, fever or pus discharge is treated first. The good results in the studies relate to limited infection that could be cleaned out.
Front teeth that have lost the outer bone wallIf the outer wall is missing or very thin, the risk of gum recession at the front rises markedly. In this situation, waiting a few weeks and shaping the bone at the same time is more predictable aesthetically.
Wide sockets in which the implant cannot get a firm holdIf there is no bone beyond the root tip, or the socket is very wide for the implant, the implant moves from the first day. An implant that moves has less chance of fusing with the bone.
People with thin gums and a high smile lineIn patients whose gum shows when they smile and whose gum is thin, even one millimetre of recession is visible. The risk should be discussed separately for these patients.

How an implant on the day of extraction is done

The sequence below shows the general course for a single tooth or several teeth. In full-mouth plans, the same steps run together for the whole jaw.

1
Initial assessment with a CBCT scan
The bone beyond the root tip, the thickness of the outer wall and the distance from the nerve and the sinus are measured. This image gives an initial idea of whether a same-day implant is possible, and preparations are made for both scenarios.
2
Removing the tooth while preserving the walls
The aim is to remove the tooth without breaking the walls of the socket; if needed, the roots are separated and taken out one by one. A fracture of one of the walls can change the same-day decision.
3
Cleaning and checking the socket
The infected tissue in the socket is scraped away and the area is rinsed. The surgeon probes the walls; whether the outer wall is in place becomes clear at this step.
4
Preparing the implant site beyond the socket
The implant site is drilled not in the middle of the socket but according to the bone in which the implant will grip firmly. At the front teeth, the implant is usually placed close to the palate side of the socket, leaving a gap between it and the outer wall.
5
Measuring the hold and deciding
The tightness of the implant is assessed as it is placed. If the hold is sufficient, the procedure continues; if not, the area is left to heal without an implant. This is not a failure but part of the plan.
6
Filling the gap and closing the gum
The gap between the implant and the wall is filled with graft where needed, and soft tissue is added if necessary. The gum is closed, or a healing cap is fitted on top of the implant.
7
Deciding on fitting a tooth
Depending on the implant's hold, a tooth can be fitted on it the same day or the fusion with the bone is awaited. Even if a tooth is fitted straight away, that area is protected from hard bites in the first few weeks.

Timings discussed instead of the same day

There are three timings for an implant after extraction. When each one is chosen is explained in detail on our page about how long to wait after an extraction; here we compare them briefly.

Placement a few weeks later

The gum closes, the infection subsides and the bone is still largely in place. In two studies at the front using this timing, no gum recession of more than one millimetre was seen; when the outer wall is shaped by adding bone, it can be seen on imaging in over 90% of cases.

Placement months later, in healed bone

The timing whose survival was found to be higher than same-day placement in the meta-analysis. The price is bone loss: in six months, from about a third to more than half of the width can be lost, and this may then make adding bone necessary.

Preserving the socket, then an implant

The tooth is removed, graft is placed in the socket and the implant is placed months later. It aims to preserve the volume of bone, but it means two separate surgeries and a long wait.

In a full mouth: extraction, implants and final teeth in 3 days

For patients who are having all their teeth removed, the route we work with is doing the extraction and the implants in the same session and fitting the fixed teeth within 3 days, that is 72 hours. The implants are planned so that they take their hold from the deep, hard bone of the jaw; the teeth fitted on the third day are the final teeth.

The risks that stand out with same-day implants

The following are problems that are more common or more pronounced with immediate placement than with implants placed in healed bone.

Early implant loss

In the meta-analysis, the survival difference is about three points: 95.21% against 98.38%. The meta-analysis does not break down the reason for the difference; the authors only recommend that immediate placement be used with care.

Gum recession at a front tooth

With single-tooth implants placed on the day of extraction, recession of more than one millimetre ranged from 9% to 41% across studies, with a median of 26%. Receded gum can reveal the metal or grey shadow of the implant.

Resorption of the outer bone wall

Even with immediate placements supported by graft, in two studies the outer wall could not be seen on imaging at 36% and 57% of sites. Loss of the wall goes hand in hand with gum recession.

Persisting infection

If an infected socket is not cleaned well enough, the infection can continue around the implant. In the studies with good results, the socket was thoroughly scraped and rinsed.

Positioning error

An extraction socket tends to pull the drill in its own direction. If the implant follows the track of the socket, it can be placed too far outwards or at the wrong angle; this puts a strain on both the aesthetics and the tooth to be made on top of it.

The weeks after extraction and implant placement

Healing can be thought of as going through a tooth extraction and implant surgery together; one healing period instead of two.

The first day
Oozing and mild pain are to be expected. Pressing gauze on the area, using a cold compress and not rinsing hard on the first day are the basic rules of aftercare following an extraction.
The first three days
Swelling usually peaks during this period and then goes down. Gentle rinsing with warm salt water and soft foods are recommended; smoking disrupts healing.
The first few weeks
The gum closes around the implant. Even if a tooth has been fitted on it, do not bite into hard food with that area; fusion is still under way.
The first few months
The implant's fusion with the bone is completed. At the front, the settling of the gum level is monitored over the first few years; in studies, recession was measured during this period.

Don't wait if

If you have difficulty breathing, speaking or swallowing. Very large swelling inside the mouth, swelling or pain in the eye, sudden problems with your vision and difficulty opening your mouth also belong in this group. Call 112 or go to the nearest A&E.
If the swelling increases after the third day or you have a fever. Swelling is expected to go down after the first few days. Increasing swelling, a fever or pus discharge suggest infection; contact your dentist the same day.
If the implant or the tooth on it moves. An implant that moves during the fusion period may not have taken hold. Letting your clinic know early gains time to take the load off it.
If the bleeding does not stop with pressure. Heavy bleeding that continues despite pressure with gauze should be assessed, especially if you take blood thinners.
If the gum at a front tooth is receding or the implant's shadow is showing. For recession noticed early, options such as adding soft tissue can be discussed. Waiting narrows the options.

What determines the cost of a same-day implant

You will not find figures here. With immediate placement, these are the items that change the quote:

Graft and adding soft tissue: Whether the gap between the implant and the wall is filled with graft, and whether a soft tissue graft is needed, changes the cost. Part of this decision can only be made during the extraction.
The chance of the plan changing on the day of extraction: If the hold turns out to be insufficient, the implant may not be placed. Ask in advance how payment would be arranged in that case.
Whether a tooth is fitted on the same day: Fitting a tooth straight away needs extra laboratory work and appointments; if you wait, an interim solution comes in between.
Number of implants and a full-mouth plan: Between a single tooth and a full arch, most of the cost is determined by the number of implants and the teeth to be made on top of them.

Frequently asked questions about implants on the day of extraction

Can an implant be placed as soon as the tooth is removed?

Yes, in the right situation. The conditions: the walls of the extraction socket are largely intact, the infection can be cleaned out and the implant can get a firm hold from the bone beyond the socket. The final decision is often made by the picture seen during the extraction.

Can an implant replace an infected tooth on the same day?

It can, with limited infection that can be cleaned out. In a meta-analysis at the front of the mouth, survival was 97.6% in infected sockets and 98.4% in non-infected ones. The precondition is thorough cleaning of the socket. With an active abscess accompanied by facial swelling and fever, however, the infection is treated first.

Is an implant placed on the same day more likely to fail?

It is lost slightly more often. In a meta-analysis pooling 30 studies, survival was 95.21% for those placed on the same day and 98.38% for those placed in healed bone. No difference was found in bone loss. This is why the authors recommend that immediate placement be used with care, in selected patients.

Does a same-day implant prevent bone loss?

Not completely. Even with an implant in place, the outer wall of the extraction socket can continue to resorb; in two studies, the outer wall could not be seen on imaging at 36% and 57% of grafted sites. The gain lies more in the timeline and the number of surgeries.

If I have a same-day implant at a front tooth, will my gum recede?

The risk is higher. In studies, recession of more than one millimetre was seen at a median rate of 26%. Thick gum and an intact outer bone wall reduce the risk. For a single front tooth, it is right to make the decision with your own dentist, discussing this risk.

Can a same-day implant be placed at a molar?

It is done in selected cases. In a review covering 20 studies, one-year survival was 96.6%. Because a molar socket is wide, the bone in which the implant will grip and the filling of the gap are more decisive.

Is a tooth fitted on it the same day?

If the implant has a firm enough hold, one can be fitted; if not, fusion is awaited. This decision is made according to the implant's hold on the day of extraction.

All my teeth are to be removed; can the extraction and implants be done on the same day?

In full-mouth treatment, this is a commonly used route. Where the bone is and how much there is can be seen on a CBCT scan. If you have a panoramic X-ray or a CBCT scan, you can send it through the application form; the image is assessed by the dentist who would carry out the treatment.

Sources

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