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DENTAL IMPLANTS J Oral Maxillofac Surg 65:384-392, 2007

Immediate Placement of Dental Implants Into Debrided Infected Dentoalveolar Sockets Nardy Casap, DMD, MD,* Chassiel Zeltser, DMD,† Alon Wexler, DMD,‡ Eyal Tarazi, DMD,§ and Rephael Zeltser, DMD储 Purpose: To describe a protocol for the immediate placement of endosseous implants into debrided

infected dentoalveolar sockets. Patients and Methods: A total of 30 implants were immediately placed into debrided infected sites in

20 patients. The pathology at the receptacle dentoalveolar sockets varied, and included subacute periodontal infection, perio-endo infection, chronic periodontal infection, chronic periapical lesion, and a periodontal cyst. The immediate placement protocol emphasized the meticulous debridement of the infected tissues in combination with peripheral ostectomy of the alveoli. Guided bone regeneration was accomplished to support bony healing of alveolar defects surrounding the implantation site. Pre- and postsurgical antibiotic therapy was administered. Results: All implants but 1 were osseointegrated and functional when followed up after 12 to 72 months. One implant was mobile after its immediate restoration and was removed. Complications were related to the use of guided bone regeneration. Deficiency of the attached gingiva was noted in 1 case. The treatment approach is illustrated in 2 anterior maxilla cases with 3-year follow-up. Conclusions: Successful immediate implantation in debrided infected alveoli depends on the complete removal of all contaminated tissue and the controlled regeneration of the alveolar defect. With this proposed clinical approach, experienced clinicians may consider immediate implants as a viable treatment option in patients presenting with dentoalveolar infections. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:384-392, 2007 Alveolar ridge resorption after tooth extraction may considerably reduce the residual bone volume and compromise the favorable positioning of implants required for optimal restoration.1-3 This is even more pronounced at the anterior maxilla, where ridge resorption often creates an unfavorable palatolabial discrepancy between the implant and the prosthesis. Following the correct clinical indications, the immediate placement of the implants into the extraction sockets avoids this undesirable resorption.4,5 Additional benefits, which are also valued by patients, are the avoidance of a second surgical intervention and the reduction in rehabilitation treatment time. Frequently, however, compromised teeth that are indicated for extraction are involved with infectious conditions, which conventionally contraindicate their immediate replacement with endosseous dental implants. Updated review of the literature on immediate implants suggests that this procedure should be avoided in the presence of periapical or periodontal pathosis.6-9

*Lecturer, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah, Faculty of Dental Medicine, Jerusalem, Israel. †Private Practice, Jerusalem, Israel. ‡Instructor, Department of Prosthodontics, Hebrew UniversityHadassah, Faculty of Dental Medicine, Jerusalem, Israel. §Instructor, Department of Prosthodontics, Hebrew UniversityHadassah, Faculty of Dental Medicine, Jerusalem, Israel. 储Professor and Head, Department of Oral and Maxillofacial Surgery, Hebrew University-Hadassah, Faculty of Dental Medicine, Jerusalem, Israel. Address correspondence and reprint requests to Dr Casap: Department of Oral and Maxillofacial Surgery, Hadassah Faculty of Dental Medicine, Hebrew University, PO Box 2272, Jerusalem 91120, Israel; e-mail: nard@md.huji.ac.il © 2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6503-0004$32.00/0 doi:10.1016/j.joms.2006.02.031

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Table 1. PATIENT CHARACTERISTICS AND DETAILS OF DENTOALVEOLAR PATHOLOGY, IMPLANTS, COMPLICATIONS AND FOLLOW-UP PERIOD

Implant Site

No. of Implants

Implant Dimensions (mm; L/D)

Complications

Follow-Up Period (Months)

Posterior maxilla

1

15/3.75

-

72

Posterior maxilla

2

15/3.7

-

60

Anterior maxilla

1

16/4.2

-

50

Posterior maxilla

1

16/3.7

-

42

Posterior mandible & posterior maxilla Anterior maxilla

3

13/3.7

-

36

2

15/3.75

-

36

Anterior maxilla

2

15/3.75

Membrane exposure

36

Posterior mandible Posterior maxilla

1

13/3.75

-

36

1

13/3.75

-

30

Anterior mandible

2

13/3.75

-

30

Anterior maxilla

2

13/3.75

-

Posterior mandible

1

13/3.7

-

12; lost to follow-up 24

Anterior maxilla

1

13/3.75

Deficiency of attached gingiva

Anterior maxilla

1

13/3.7

Subacute periodontal infection secondary to root split Subacute periodontal infection Chronic periodontal infection Subacute perio-endo infection

Posterior maxilla

1

13/3.7

Implant mobility following immediate restoration -

Anterior maxilla

3

13/3.3; 13/3.75

-

20

Anterior mandible Anterior maxilla

2

15/3.75

-

18

1

13/3.7

18

Chronic periapical lesion Chronic periodontal infection

Anterior maxilla

1

13/3.75

Membrane exposure; pseudomembranous colitis -

Posterior maxilla

1

10/4.7

-

12

Patient No. (Age/Gender)

Dentoalveolar Pathology

1 (44/F)

Subacute perio-endo infection Subacute perio-endo infection Chronic periapical lesion Chronic periapical lesion Chronic periodontal infection

2 (52/M) 3 (46/M) 4 (45/M) 5 (40/M)

6 (30/F) 7 (26/F) 8 (55/F) 9 (67/F) 10 (61/M) 11 (30/M) 12 (58/F)

13 (23/F) 14 (52/F)

15 (50/M)

16 (34/F) 17 (58/M) 18 (36/F) 19 (36/F) 20 (53/M)

Subacute periodontal infection Subacute periodontal infection Chronic periapical lesion Chronic perio-endo infection Subacute periodontal infection Chronic periodontal infection Chronic periodontal infection secondary to root split Subacute periodontal infection Periapical cyst

Abbreviations: L, length; D, diameter. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

24 –

24

18


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Nevertheless, evidence arising from the treatment of vertebral osteomyelitis in orthopedic surgery suggests that this might be a misconception. Subacute bone infection in vertebral osteomyelitis can be successfully managed by meticulous bone debridement and antibiotic therapy combined with titanium mesh cages that provide immediate support and stability for the weakened vertebrae.10,11 Despite the preceding significant infectious state, these titanium cages were reported to achieve radiographic bone fusion, which is the orthopedic equivalent of osseointegration in implant dentistry. Recent experimental studies in animals have corroborated this clinical experience and shown that socket debridement and prophylactic antibiotics create adequate conditions for the bone remodeling process around immediate implants placed into infected sites.12-15 Based on these observations, we have developed a protocol for the immediate placement of endosseous implants into debrided infected dentoalveolar sockets. Our objective in this report is to describe the procedure and to report our experience with 20 patients. Two cases at the anterior maxilla, in which the protocol has been successfully applied, are detailed.

Patients and Methods

The resultant sockets are then prepared by the standard implant placement protocol, and are extended apically 3 to 4 mm to achieve primary stability for the implants. Moderate modifications of the sockets may be accomplished at this stage to establish a better position or angulation for the implants; however, further aggravation of the already existing bone deficiency should be avoided. Thereafter, the endosseous dental implants are immediately introduced into the prepared sites and evaluated for primary stability. The residual alveolar defect is augmented with bovine-derived bone mineral (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland) to achieve complete coverage of the immediate implants, and a titanium-reinforced expanded tetrafluoroethylene membrane (Gore-Tex; WL Gore & Associates Inc, Flagstaff, AZ) is secured over the site to commence the guided bone regeneration. The surgical procedure is concluded by suturing the flap (Gore-Tex sutures; WL Gore & Associates Inc) to realize soft tissue primary closure. The healing period is monitored to ensure sustained closure of the site and infection-free regeneration.

Results All implants except 1 achieved osseointegration and were functioning in a 12- to 72-month follow-up.

A total of 30 implants were immediately placed in debrided infected sites in 20 patients by the treatment protocol detailed below. All patients receiving the outlined treatment had been given a detailed explanation and gave their informed consent to the procedure. Successful osseointegration of the immediate implants was determined in follow-up of 12 to 72 months. TREATMENT PROTOCOL

The patient is initiated on a daily dose of 1.5 g amoxicillin, or 0.9 g clindamycin in penicillin-sensitive patients, 4 days prior to the surgical procedure and maintained on it for 10 days. Under local anesthesia, a full-thickness mucoperiosteal flap is reflected at the surgical site and the involved teeth are extracted with minimal trauma to the cortical plates. The extraction sockets are then meticulously debrided and curetted to remove all the detectable granulation and infected tissues. Subsequently, a moderate peripheral intrasocket ostectomy of the alveolar bone is accomplished using an oval bur to ensure complete elimination of all contaminated soft and hard tissues. Special attention is given to the periapical area where ostectomy is performed with a small round bur. The instrumental procedure is concluded with vigorous irrigations of the surgical site with a sterile solution.

FIGURE 1. Case 1: periapical radiograph demonstrating an apparent endodontic-periodontal lesion involving the left central incisor and a periradicular lesion involving the right central incisor. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.


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FIGURE 2. Case 1: A, The surgical site after reflection of the mucoperiosteal flap and extraction of the maxillary central incisors. Note the granulation tissue at the apical area of the right socket and along the labial wall of the left socket. B, The surgical site after debridement of all the granulated and infected tissues. Note the labial fenestration at the apical area of the right socket and the labial cortical defect at the left socket, which forms a 3-wall defect. C, The peripheral ostectomy procedure accomplished at the left socket using an oval bur. D, The 2 implants in place. E, The titanium-reinforced membrane secured over the surgical site. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

One implant placed at the anterior maxilla was found mobile after its immediate restoration, and was removed. This reflects a 96.67% success rate within this small patient group. Characteristics of the patients and the details of dentoalveolar pathology, implants, complications and

follow-up period are listed in Table 1. The pathology at the extracted sockets included subacute periodontal infection, perio-endo infection, chronic periodontal infection, chronic periapical lesion, and a periapical cyst. Implants were immediately placed both in the mandible and the maxilla, but the majority of


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FIGURE 3. Case 1: removal of the membrane and exposure of the implants 6 months after the surgical procedure. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

implants were placed at the anterior maxilla. All implants were titanium-machined self-tapered, and their dimensions were 10 to 16 mm in length and 3.7 to 4.7 mm in diameter. Guided regeneration membrane was exposed in 2 patients and was treated with a protocol of 0.12% chlorhexidine mouth rinses. Deficiency of attached gingiva was noted in one case. Pseudomembranous colitis developed in one patient as result of the antibiotic therapy. Following is a detailed description of 2 cases at the anterior maxilla illustrating the clinical application of the described treatment approach. CASE 1: SUBACUTE PERIODONTAL INFECTION AND PERIO-ENDO LESION

FIGURE 5. Case 1: A, Clinical view of the restored implants at the 3-year follow-up visit. B, Three-year postsurgical radiograph demonstrating osseointegration of the implants.

A 30-year-old woman presented with sinus tract of the apical site of the maxillary central incisors. She reported that 11 years earlier the 2 upper incisor

Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

FIGURE 4. Case 1: permanent abutments mounted on the implants. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

teeth had undergone a conventional root canal treatment and restoration with porcelain fused to metal crowns, but subsequently she had root end resections and retrograde fillings due to failure of the root canal procedure. The apicoectomies were repeated 2 years prior to the current presentation. Clinical examination showed a sinus tract traced to the maxillary right central incisor, while the left maxillary central incisor had an endo-perio lesion. Radiographic examination showed an endo-perio lesion involving the left central incisor and a periradicular lesion involving the right central incisor (Fig 1). The treatment plan consisted of extraction of the maxillary central incisors and implant-supported restoration. At surgery, the sinus tract had subsided after the preoperative antibiotic therapy. The teeth were extracted, and 2 15-mm ⍝ 3.75-mm implants (3i Os-


CASAP ET AL

FIGURE 6. Case 2: A, Clinical view demonstrating the discoloration of the 2 maxillary central incisors. B, Periapical radiograph demonstrating a horizontal root fracture, severe bone support loss involving the upper right central incisor, and a periradicular radiolucency involving the upper left central incisor.

389 and a periapical lesion involving the upper left central incisor (Fig 6B). The treatment plan consisted of extraction of the maxillary central incisors and implant-supported restoration. Teeth were extracted and 2 implants, 15 ⫻ 3.75 mm and 13 ⫻ 3.75 mm (3i Osseotite; Implant Innovations Inc), were immediately placed by the above-described protocol (Fig 7). Upon removal of the sutures, the membrane was found slightly exposed and a protocol of 0.12% chlorhexidine mouth rinses was initiated. However, the exposure of the membrane was aggravated with time, and it was decided to remove the membrane 2 months after the surgical procedure (Fig 8A). During the membrane’s withdrawal, a heterogeneous mixture of primarily bovine-derived bone mineral particles was found (Figs 8B,C). Subsequently, primary soft tissue closure of the surgical site was achieved. Six months postplacement, the implants were exposed by a minimal crestal incision and mounted with healing caps, and 1 month later the implants were mounted with the permanent abutments and loaded with the final restoration. At the 3-year follow-up examination, the implants were functioning and were fully osseointegrated (Fig 9).

Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

seotite; Implant Innovations Inc, Palm Beach Gardens, FL) were immediately placed after the above protocol (Fig 2). Six months after the surgical procedure, the membrane was removed and the implants were exposed and mounted with healing caps (Fig 3). One month later, the permanent abutments were mounted and the implants were loaded with the final restoration (Fig 4). At the 3-year follow-up examination, the implants were functioning and osseointegration of the implants was shown radiologically (Fig 5). CASE 2: SUBACUTE PERIODONTAL INFECTION DUE TO ROOT FRACTURE AND PERIAPICAL LESION

A 26-year-old female presented with mobility and sensitivity of the maxillary right central incisor. Dental history of the patient showed that 16 years earlier, the 2 maxillary central incisors were traumatized and were treated by root apexification and root canal treatment, and the tooth crowns were restored by composite restorations. On clinical examination, the 2 maxillary central incisors were discolored, and periodontal pocketing and crown mobility of the upper right central incisor were noted (Fig 6A). Radiography showed a horizontal root fracture of the upper right central incisor with horizontal bone loss of two thirds of the root support,

FIGURE 7. Case 2 A, Clinical view after debridement of all granulation and infectious tissue showing a 3-wall residual defect at the right alveolus. B, The 2 implants in place. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.


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IMMEDIATE IMPLANTATION INTO DEBRIDED INFECTED SOCKETS

FIGURE 8. Case 2: A, The exposed membrane prior to its removal. B, The membrane after the reflection of the mucoperiosteal flap. C, The augmented site demonstrating a heterogeneous mixture consisting primarily of bovine-derived bone mineral. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

Discussion Clinical reports have suggested that history of periodontal or endodontic infections is a predictive marker for implant infection and failure.16-19 This clinical experience has led most clinicians to avoid the immediate placement of endosseous dental implants at infected sites and to consider infection a contraindication for immediate implantation. In this report, we have challenged this conventional concept, and argued that under a controlled procedure, immediate implants may be successfully introduced into debrided infected dentoalveolar sockets. Based on the surgical experience with titanium caging in the management of vertebral osteomyelitis, we developed a protocol that targets the elimination of the contaminated soft and hard tissues by meticulous debridement and peripheral alveolar ostectomy. This procedure, combined with pre- and postoperative antibiotics, should eradicate the infection and establish a favorable basis for bone healing and osseointegration. The presurgical administration of antibiotics is vital for the reduction of the infection load and is supported by a previous report on the immediate implantation in the presence of periapical pa-

thosis.20 Consequently, in cases where an acute infection persists in spite of the presurgical antibiotics, the immediate placement of implants should be postponed and the acute infection treated. Guided bone regeneration has been documented as one of the treatment modalities for the regeneration of alveolar defects resulting from plaque-induced periimplantitis.21 Decontamination of the implant’s site, combined with guided bone regeneration with or without bone grafting, was reported to create adequate conditions for bone regeneration and osseointegration despite the previous contamination. In the protocol described herein, the objective of the guided bone regeneration procedure was to facilitate the correction of the defects of the alveolar bone that typically accompany unsalvageable infected teeth. Adequate bony healing of the alveolar defect is vital for the osseointegration of the immediately placed implant and for its functional stability. Similar to the treatment of plaque-induced peri-implantitis, we maintain that a protocol that completely removes the contaminated tissue should allow for successful guided bone regeneration of the previously infected alveolus.


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restoration, which nowadays is highly favored by patients. While our experience suggests that implants may be immediately placed into debrided infected alveoli, we advise that this procedure should be limited to experienced surgeons who are highly skilled in differentiating and debriding granulation tissue. Competent knowledge in maxillofacial anatomy is essential to avoid violation of adjacent cavities during the intraalveolus instrumentation. The surgeon must also be proficient in guided bone regeneration procedures to skillfully correct the significant alveolar defects that are commonly associated with these cases. Subject to these competencies, skills and adherence to the proposed protocol, we maintain that immediate implants should be considered a viable treatment option in patients presenting with dentoalveolar infections. Successful immediate implantation in debrided infected alveoli depends on the elimination of all contaminated tissues and the controlled regeneration of the alveolar defect. Our detailed protocol outlines a dependable procedure for the immediate placement of dental implants into debrided infected dentoalveolar sockets.

References

FIGURE 9. Case 2: A, Clinical view of the final restoration at 3-year follow-up examination. B, Periapical radiograph at the 3-year follow-up examination demonstrating osseointegration of the implants. Casap et al. Immediate Implantation Into Debrided Infected Sockets. J Oral Maxillofac Surg 2007.

This report details our experience with 20 patients in whom a total of 30 implants were immediately placed into debrided infected dentoalveolar sockets. Our results suggest a favorable outcome of osseointegration of these implants when the described clinical protocol is applied. In addition, 2 cases of successful osseointegration of immediate implants placed into debrided infected alveoli at the anterior maxilla are described. The significant advantage of this treatment approach over delayed implantation is the preservation of the alveolar ridge, which allows for more ideal positioning of the implants. This, in turn, contributes to improved esthetics, biomechanics, and long-term survival of the functioning implants. Another notable benefit lies in the shorter waiting period until final

1. Bartee BK: Extraction site reconstruction for alveolar ridge preservation. Part 1: Rationale and materials selection. J Oral Implantol 27:187, 2001 2. Yang J, Lee HM, Vernino A: Ridge preservation of dentition with severe periodontitis. Compend Contin Educ Dent 21:579, 2000 3. Kan JY, Shiotsu G, Rungcharassaeng K, et al: Maintaining and attenuating periodontal tissues for aesthetic implant placement. J Oral Implantol 26:35, 2000 4. Schropp L, Kostopoulos L, Wenzel A: Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: A prospective clinical study. Int J Oral Maxillofac Implants 18:189, 2003 5. Werbitt MJ, Goldberg PV: The immediate implant: bone preservation and bone regeneration. Int J Periodontics Restorative Dent 12:206, 1992 6. Schwartz-Arad D, Chaushu G: The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 68:915, 1997 7. Barzilay I: Immediate implants: Their current status. Int J Prosthodont 6:169, 1993 8. Becker W, Becker BE: Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case report. Int J Periodontics Restorative Dent 10:376, 1990 9. Werbitt MJ, Goldberg PV: The immediate implant: Bone preservation and bone regeneration. Int J Periodontics Restorative Dent 12:206, 1992 10. Hee HT, Majd ME, Holt RT, et al: Better treatment of vertebral osteomyelitis using posterior stabilization and titanium mesh cages. J Spinal Disord Tech 15:149, 2002 11. Liljenqvist U, Lerner T, Bullmann V, et al: Titanium cages in the surgical treatment of severe vertebral osteomyelitis. Eur Spine J 12:606, 2003 12. Novaes AB Jr, Marcaccini AM, Souza SL, et al: Immediate placement of implants into periodontally infected sites in dogs: A histomorphometric study of bone-implant contact. Int J Oral Maxillofac Implants 18:391, 2003


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13. Papalexiou V, Novaes AB Jr, Grisi MF, et al: Influence of implant microstructure on the dynamics of bone healing around immediate implants placed into periodontally infected sites. A confocal laser scanning microscopic study. Clin Oral Implants Res 15:44, 2004 14. Novaes AB Jr, Vidigal GM Jr, Novaes AB, et al: Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J Oral Maxillofac Implants 13:422, 1998 15. Tehemar S, Hanes P, Sharawy M: Enhancement of osseointegration of implants placed into extraction sockets of healthy and periodontally diseased teeth by using graft material, an ePTFE membrane, or a combination. Clin Implant Dent Relat Res 5:193, 2003 16. Ayangco L, Sheridan PJ: Development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: A series of reports. Int J Oral Maxillofac Implants 16:412, 2001

17. Oh TJ, Yoon J, Wang HL: Management of the implant periapical lesion: A case report. Implant Dent 12:41, 2003 18. Karoussis IK, Salvi GE, Heitz-Mayfield LJ, et al: Long-term implant prognosis in patients with and without a history of chronic periodontitis: A 10-year prospective cohort study of the ITI Dental Implant System. Clin Oral Implants Res 14:329, 2003 19. Polizzi G, Grunder U, Goene R, et al: Immediate and delayed implant placement into extraction sockets: A 5-year report. Clin Implant Dent Relat Res 2:93, 2000 20. Cosci F, Cosci B: A 7-year retrospective study of 423 immediate implants. Compend Contin Educ Dent 18:940, 944, 946, 1997 21. Baron M, Haas R, Dortbudak O, et al: Experimentally induced peri-implantitis: A review of different treatment methods described in the literature. Int J Oral Maxillofac Implants 15:533, 2000

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© 2007AmericanAssociationofOralandMaxillofacialSurgeons 0278-2391/07/6503-0004$32.00/0 doi:10.1016/j.joms.2006.02.031 384 JOralMaxillofacSur...