Implant in Periapical Apthology Site

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IMPLANTS

J Oral Maxillofac Surg69:1623-1627, 2011

The Immediate Placement of Dental

Implants Into Extraction Sites With

Periapical Lesions: A Retrospective

Chart ReviewChristopher Lincoln Bell,* David Diehl, Brian Michael Bell,

and Robert E. Bell, DDS

Purpose: The purpose of this study was to evaluate the success of dental implants placed immediatelyinto extraction sites in the presence of chronic periapical pathology.

Materials and Methods: The charts of 655 patients who had implants immediately placed into fresh

extraction sites were reviewed for the presence or absence of periapical radiolucencies. A total of 922implants were included. Of the 922 implants, 285 were immediately placed into sockets that had chronicperiapical infections. The remaining 637 implants, without signs of periapical pathology, were used asthe control group. Success of the implants was defined as successful osseointegration, successful

restoration, and absence of evidence of bone loss or peri-implantitis. Other variables such as age, gender,smoking, diabetes, bisphosphonate use, lucencies of adjacent teeth, and implant stability at the time ofplacement were also evaluated.

Results: Of the 922 implants, 285 were placed into sockets with periapical radiolucencies. The successrate of implants placed in the study group was 97.5%, whereas the success rate of the control group was98.7%. The difference was not found to be statistically significant. The mean follow-up was 19.75 months,

with a maximum of 93 months and a minimum of 3 months. A statistically higher failure rate was foundfor implants placed adjacent to retained teeth with periapical pathology.

Conclusions: The placement of implants in sockets affected by chronic periapical pathology can beconsidered a safe and viable treatment option. There is a risk of implant failure when placing implantsadjacent to teeth with periapical radiolucencies.

2011 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 69:1623-1627, 2011

Dental implants are a well-established treatment op-tion to restore function in edentulous and partiallyedentulous patients. The original procedure for en-dosseous cylindrical implants as described by Brne-mark and colleagues1 called for implants placed in

healed bone and submersion of the implants for ex-

tended unloaded healing periods. Over time, implant

surgery has evolved, and currently, implant place-

ment into fresh extraction sites in a 1-stage fashion

has proven to be a viable surgical option.2,3

There are some obvious advantages to the place-

ment of implants at the time of extraction including

decreased number of surgical interventions, de-

creased healing time, and possible improved mainte-nance of alveolar architecture.4,5 Gordon L. Douglas

stated that immediate implants ought to have 3- and

4-walled sockets, minimal periodontal bone resorp-

tion, sufficient bone to stabilize the implant, and min-

imal circumferential defects. As long as these prereq-

uisites were met, immediate placement could be

considered a safe and viable procedure.6 In a retro-

spective study performed by Schwartz-Arad and

Chaushu,2 95 immediately placed implants were stud-

ied over a period of 5 years, having a success rate of

approximately 95%. Schwartz-Arad and Chaushu con-

*Student, Brigham Young University, Provo, UT.

Student, Brigham Young University, Provo, UT.

Dental Student, University of California, Los Angeles, Los

Angeles, CA.

Oral and Maxillofacial Surgeon, Private Practice, Tulare, CA.

Address correspondence and reprint requests to Dr Bell: 1080 N

Cherry, Tulare, CA 93274; e-mail: [email protected]

2011 American Association of Oral and Maxillofacial Surgeons

0278-2391/11/6906-0027$36.00/0

doi:10.1016/j.joms.2011.01.022

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mailto:[email protected]:[email protected]


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cluded that, following specific protocols, immediateplacement of implants was a viable option.

It has been shown that implants can be placedsuccessfully into fresh extraction sites. However, can

implants be safely placed in chronically infected ex-traction sockets? Several authors have stated that ex-traction sites should be infection free to place imme-diate implants.7,8 In a study of 30 partially edentulouspatients, 61 transmucosal implants were placed im-mediately in sites with chronic periapical lesions. Ofthose implants, only 1 failed, for a success rate of98.4%. Del Fabbro et al9 concluded that immediateimplant placement in the presence of chronic peri-

apical infection could be considered a safe, effective,and predictable treatment option. Crespi et al10 stud-ied 15 patients with periapical lesions who under-

went immediate implant placement. Fifteen patientswith single-tooth extractions and no periapical pa-thology served as the control. Clinical parameters

such as probing depth, modified plaque index, mod-ified bleeding index, marginal gingiva level, keratin-ized mucosa, and marginal bone levels were evaluated

at baseline and at 12 and 24 months after implantplacement. Both study groups had a survival rate of100%. Several other studies have been performed

with similar results.11-14 The sample size of theseinvestigations has been relatively small. The purposeof this retrospective chart review is to explore the

viability of immediately placed implants into extrac-tion sites with radiolucencies in a large cohort ofpatients.

Materials and Methods

Patient records from a private oral surgery officewere reviewed for all patients having extraction andimmediate implant placement. Two independentevaluators reviewed radiographs and chart notes ofpatients dating from January 2001 to February 2009.

While examining radiographs, the evaluators were

blinded as to whether implants had failed. Parametersthat were evaluated included the following: the pres-ence or absence of periapical radiolucencies on pre-operative Panorex or CT radiographs, preoperative

symptoms, the presence of preoperative soft tissueswelling, implant stability, tooth number and type,graft type, radiolucencies present on adjacent teeth,healing time, patients esthetic complaints, pocketdepth, postoperative pain or infections, bisphospho-

nate use, smoking habits, age, gender, and other ex-isting medical conditions such as diabetes. Chronicperiapical pathology was defined for the purpose ofthis study as a radiographically visible periapical lu-cency on a tooth with carious pulpal exposure orevidence of a failed root canal that was not, per ourrecords, associated with acute pain or soft tissue

swelling. These data were collected and stripped of

identifiers before evaluation. Major variables were

subjected to a 2 or z score statistical analysis. Onlyvariables with P .05 were considered statistically

significant. The internal firewalls used exempt this

study from institutional review.Implant procedures were performed by a single

operator in a private practice setting. Implants were

not placed in patients with soft tissue swelling or

acute pain. The implant placement protocol consistedof a preoperative Peridex oral rinse (3M ESPE Dental

Products, St Paul, MN) and 600 mg of intravenous (IV)

clindamycin. In clindamycin-allergic patients, 2 g of

IV ampicillin was substituted. Teeth were typicallyextracted with forceps or were sectioned and carefully

removed with elevators, with care taken to preserve

surrounding bone. The periapical area was then de-brided with a curette and irrigated. Osteotomies

were performed via standard protocols in all cases,

including surgical stents, slow-speed sequentialdrills, and copious irrigation. Strauman tissue orbone-level SLA (Strauman Dental Implants, Basel,

Switzerland) implants were placed into the pre-

pared osteotomies. Implant stability was monitored andnoted upon placement. Residual sockets were grafted

with platelet-rich plasma (prp) and 100% bone retrieved

from a bone filter used during the osteotomies or with a

combination of bone, xenograft, and prp. Implants wereleft exposed. If a residual socket greater than 1 mm

remained after the suturing, Collatape (Zimmer Dental,

Carlsbad, CA) soaked in prp was placed over the bone

graft to promote soft tissue healing. Implants wereloaded after a 3-month healing period.

FIGURE 1. The upper right lateral incisor postoperatively.

Bell et al. Dental Implants and Periapical Lesions. J Oral Maxil-lofac Surg 2011.

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Results

In total, 922 implants were placed in 655 patients(Figs 1-7). A total of 477 patients had 637 implantsplaced into extraction sites that were not affected byperiapical radiolucencies. Of these 637 implants, 8failed, for a success rate of 98.7% (Table 1). In 256patients, a total of 285 implants were placed intoextraction sites with periapical pathology. Of those

285 implants, 7 failed, for a success rate of 97.5%. Thedifference between the control group and the group

with periapical radiolucencies was not statisticallysignificant. None of the patients had preoperative softtissue swelling. The mean follow-up was 19.75

months (range, 3-93 months).Of the implants, 356 were placed in the mandible:102 anterior teeth, 99 bicuspids, and 155 molars (Figs5-7). Of these, 1 anterior (0.98%), 1 bicuspid (1.0%),

and 2 molars (1.3%) failed. The remaining 566 im-

plants were placed in the maxilla: 270 anterior teeth(Figs 1-4), 203 bicuspids, and 93 molars. Of these, 5anterior teeth (1.8%), 5 bicuspids (2.4%), and 1 molar(1.3%) failed. The difference in the failure rate of the

various surgical sites in the study and control groupswas not found to be statistically significant.

There were 98 implants restored with locators, 133bridge abutments, and 691 single-tooth restorations. Ofthe implants that failed, 12 were single-tooth implants, 2

were bridge abutments, and 1 had a locator attachment,yielding a failure rate of 1.7% for single-tooth implants,

1.5% for bridge abutments, and 1.0% for those withlocator attachments. The differences in failure rates

were not statistically significant for type of prosthesis.Of the implants, 123 were placed in smokers, 46 in

the study group, and 77 in the control group. Of the46 implants with radiolucencies, 2 (4.3%) were lostcompared with 1 (1.2%) in patients without radiolu-

cencies. The results were not statistically significant.

FIGURE 2. The upper right lateral incisor preoperatively.


FIGURE 5. The lower right first molar preoperatively.


FIGURE 3. The upper right lateral incisor with periapicalgranuloma.


FIGURE 4. The upper right lateral incisor at 6-month follow-up.


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Twenty-four of the implants were placed in pa-tients taking bisphosphonates; of those, six had peri-apical radiolucencies. No implants failed in these pa-

tients.Placement of 83 implants was performed in dia-

betic patients, 23 with radiolucencies and 60 withoutradiolucencies. All of the implants were successful.

The initial stability of the implants was evaluated,and the mean stability of the study and control groups

was subjected to a zscore analysis and was not foundto be significant. Torque values ranged from 5 to 45N-cm, with mean values of 30.5 N-cm and 35 N-cm inthe study and control groups, respectively. Interest-

ingly, the failed implants in the control group had amean initial torque of 23.3 N-cm compared with 28.6

N-cm in failed implants in the study group. However,this was not found to be statistically significant, pos-sibly because of the small sample size.

The mean size of lucencies was 2.5 mm. The meansize of radiolucencies within sockets where implantsfailed was 2.4 mm; the difference between the two

was not statistically significant.

In total, 51 implants were placed adjacent to re-tained teeth with periapical radiolucencies, 21 in thestudy group and 30 in the control group. Of the 51implants placed, 4 failed. All 4 of the failed implants

were in the lucency group, giving an 81% success ratein the study group compared with 100% in the con-trol group. Thus implants placed in sockets with lu-cencies adjacent to retained teeth with lucencies had

a significantly higher failure rate.We found that 2 patients (0.7%) in the study grouphad postoperative infections compared with 6 pa-tients (0.1%) in the control group, which was notsignificant. No instances of implant periapical lesions

were detected.There were 125 implants placed in men and 160

placed in women in the study group and 258 implantsplaced in men and 279 placed in women in the

control group. The mean age was 58.4 years in thestudy group and 60.1 years in the control group.There was no correlation between age or gender andimplant failure.

The mean time between implant placement andimplant failure was 2.9 months (range, 1-10 months).

A review of the chart notes showed no estheticcomplaints.

Discussion

This study involved 655 patients and 922 implants.Each implant was placed immediately after the extrac-tion of the tooth. Every implant was placed by asimilar procedure. Each variable mentioned was alsotested with either a 2 test orzscore test to determine

FIGURE 7. The lower right first molar at 6-month follow-up.


Table 1. RESULTS

VariableNo. of

ImplantsNo. of

FailuresSuccess

Rate

No radiolucency 637 8 98.7%Periapical radiolucency 285 7 97.5%Molars with lucency 90 2 97.8%

Molars without lucency 248 1 99.6%Non-molars with lucency 194 5 97.4%Non-molars without

lucency390 7 98.2%

Smokers with lucency 46 2 95.7%Smokers without

lucency77 1 98.8%

Tooth with lucencyadjacent to tooth withlucency

21 4 81.0%

Bisphosphonate-takingpatients with lucency

6 0 100%

Diabetic patients withlucency

23 0 100%


FIGURE 6. The lower right first molar postoperatively.


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statistical significance. It was considered statisticallysignificant only if the P value was less than .05.

All patients received IV antibiotics, and the extrac-tion site for every implant was debrided and irrigated.

It is unknown whether these antibiotics had an effecton implant survival in this study because all studypatients received them. Implants were not placed inpatients with soft tissue swelling or acute pain, andthis study does not, therefore, support placement ofimplants in patients with acute symptoms.

The only variable that significantly affected the out-come in this study was the presence of periapicalpathology in retained teeth adjacent to the implant

being placed. Adjacent lucencies have previouslybeen found to increase implant failure.15,16 Endodon-tic treatment of teeth adjacent to implant sites, espe-cially if those implant sites have teeth with lucencies,should be seriously considered.

The vast majority of implants had an insertion

torque value at or above 15 N-cm. Only 72 implantshad an insertion value between 5 and 14 N-cm. Thefailure rate of these implants was not significantly

higher than that in those with high insertion values,but the number of less stable implants may have beentoo low to show significance.

In this study the question of implant placement intofresh extraction sites affected by periapical pathologyhas been evaluated with several confounding variables.It seems that the immediate placement of implants intosockets affected by chronic periapical pathology can beconsidered a safe and viable treatment option.

References1. Adell R, Brnemark PI, Lekholm U: A 15-year study of osseointe-

grated implants in the treatment of the edentulous jaw. J OralSurg 10:387, 1981

2. Schwartz-Arad D, Chaushu G: Placement of implants into freshextraction sites: 4 to 7 years retrospective evaluation of 95immediate implants. J Periodontol 68:1110, 1997

3. Collaert B, De-Bruyn H: Comparison of Branemark fixture inte-gration and short-term survival using one or two stage surgeryin completely and partially edentulous mandibles. Clin OralImplants Res 9:131, 1998

4. Paolantonio M, Dolci M, Scarano A, et al: Immediate implanta-tion in fresh extraction sockets. J Periodontol 72:1560, 2001

5. Amler MH: The time sequence of tissue regeneration in humanextraction wounds. J Oral Surg 27:309, 1969

6. Douglass GL, Merin RL: The immediate dental implant. J CalifDent Assoc 30:362, 2002

7. Schwartz-Arad D, Chaushu G: The ways and wherefores ofimmediate placement of implants into fresh extraction sites: Aliterature review. J Periodontol 68:915, 1997

8. Becker W, Becker BE: Guided tissue regeneration for implantsplaced into extraction sockets and for implant dehiscences:Surgical techniques and case report. Int J Periodontics Restor-ative Dent 10:376, 1990

9. Del Fabbro M, Boggian C, Taschieri S: Immediate implantplacement into fresh extraction sites with chronic periapicalpathologic features combined with plasma rich in growth fac-tors: Preliminary results of single-cohort study. J Oral Maxillo-

fac Surg 67:2476, 200910. Crespi R, Cappar P, Gherlone E: Fresh-socket implants inperiapical infected sites in humans. J Periodontol 81:378, 2010

11. Bataglion C, Gomes F, Horbylon BZ, et al: Immediate implantsplaced into infected sockets: A case report with 3-year follow-up. Braz Dent J 20:254, 2009

12. Novaes AB, Novaes AB Jr: Immediate implants placed intoinfected sites: A clinical report. Int J Oral Maxillofac Implants10:609, 1995

13. Waasdorp JA, Evian CI, Mandracchia M: Immediate placementof implants into infected sites: A systematic review of theliterature. J Periodontol 81:801, 2010

14. Siegenthaler DW, Jung RE, Holderegger C, et al: Replacementof teeth exhibiting periapical pathology by immediate im-plants. A prospective, controlled clinical trial. Clin Oral Im-plants Res 18:727, 2007

15. Brisman DL, Brisman AS, Moses MS: Implant failures associatedwith asymptomatic endodontically treated teeth. J Am DentAssoc 132:191, 2001

16. Tehemar SH: Factors affecting heat generation during implantsite drilling: A review of biologic observations and future con-siderations. Int J Oral Maxillofac Implants 14:127, 1999

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Implant in Periapical Apthology Site

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