vn76459

J6

U

H

H

g

J

p

D

9

©

0

d

DENTAL IMPLANTS

Oral Maxillofac Surg5:384-392, 2007

Immediate Placement of DentalImplants Into Debrided Infected

Dentoalveolar SocketsNardy Casap, DMD, MD,* Chassiel Zeltser, DMD,†

Alon Wexler, DMD,‡ Eyal Tarazi, DMD,§ and

Rephael Zeltser, DMD�

Purpose: To describe a protocol for the immediate placement of endosseous implants into debridedinfected dentoalveolar sockets.

Patients and Methods: A total of 30 implants were immediately placed into debrided infected sites in20 patients. The pathology at the receptacle dentoalveolar sockets varied, and included subacuteperiodontal infection, perio-endo infection, chronic periodontal infection, chronic periapical lesion, anda periodontal cyst. The immediate placement protocol emphasized the meticulous debridement of theinfected tissues in combination with peripheral ostectomy of the alveoli. Guided bone regeneration wasaccomplished to support bony healing of alveolar defects surrounding the implantation site. Pre- andpostsurgical antibiotic therapy was administered.

Results: All implants but 1 were osseointegrated and functional when followed up after 12 to 72months. One implant was mobile after its immediate restoration and was removed. Complications wererelated 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 completeremoval of all contaminated tissue and the controlled regeneration of the alveolar defect. With thisproposed clinical approach, experienced clinicians may consider immediate implants as a viable treat-ment option in patients presenting with dentoalveolar infections.© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:384-392, 2007
AccqpscFdsttt

ddmUs

*Lecturer, Department of Oral and Maxillofacial Surgery, Hebrew

niversity-Hadassah, Faculty of Dental Medicine, Jerusalem, Israel.

†Private Practice, Jerusalem, Israel.

‡Instructor, Department of Prosthodontics, Hebrew University-

adassah, Faculty of Dental Medicine, Jerusalem, Israel.

§Instructor, Department of Prosthodontics, Hebrew University-

adassah, Faculty of Dental Medicine, Jerusalem, Israel.

�Professor and Head, Department of Oral and Maxillofacial Sur-

ery, Hebrew University-Hadassah, Faculty of Dental Medicine,

erusalem, Israel.

Address correspondence and reprint requests to Dr Casap: De-

artment of Oral and Maxillofacial Surgery, Hadassah Faculty of

ental Medicine, Hebrew University, PO Box 2272, Jerusalem

1120, Israel; e-mail: [email protected]

2007 American Association of Oral and Maxillofacial Surgeons

278-2391/07/6503-0004$32.00/0

poi:10.1016/j.joms.2006.02.031

384

lveolar ridge resorption after tooth extraction mayonsiderably reduce the residual bone volume andompromise the favorable positioning of implants re-uired for optimal restoration.1-3 This is even moreronounced at the anterior maxilla, where ridge re-orption often creates an unfavorable palatolabial dis-repancy between the implant and the prosthesis.ollowing the correct clinical indications, the imme-iate placement of the implants into the extractionockets avoids this undesirable resorption.4,5 Addi-ional benefits, which are also valued by patients, arehe avoidance of a second surgical intervention andhe reduction in rehabilitation treatment time.

Frequently, however, compromised teeth that are in-icated for extraction are involved with infectious con-itions, which conventionally contraindicate their im-ediate replacement with endosseous dental implants.pdated review of the literature on immediate implants

uggests that this procedure should be avoided in the
resence of periapical or periodontal pathosis.6-9

C

CASAP ET AL 385

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

Patient No.(Age/Gender)

DentoalveolarPathology Implant Site

No. ofImplants

ImplantDimensions(mm; L/D) Complications

Follow-UpPeriod

(Months)

1 (44/F) Subacute perio-endoinfection

Posterior maxilla 1 15/3.75 - 72

2 (52/M) Subacute perio-endoinfection


3 (46/M) Chronic periapicallesion

Anterior maxilla 1 16/4.2 - 50

4 (45/M) Chronic periapicallesion


5 (40/M) Chronic periodontalinfection

Posteriormandible &posteriormaxilla

3 13/3.7 - 36

6 (30/F) Subacuteperiodontalinfection



Anterior maxilla 2 15/3.75 Membrane exposure 36

8 (55/F) Chronic periapicallesion

Posteriormandible

1 13/3.75 - 36

9 (67/F) Chronic perio-endoinfection


10 (61/M) Subacuteperiodontalinfection

Anteriormandible

2 13/3.75 - 30


Anterior maxilla 2 13/3.75 - 12; lost tofollow-up

12 (58/F) Chronic periodontalinfectionsecondary to rootsplit

Posteriormandible

1 13/3.7 - 24


Anterior maxilla 1 13/3.75 Deficiency ofattached gingiva

24

14 (52/F) Periapical cyst Anterior maxilla 1 13/3.7 Implant mobilityfollowingimmediaterestoration

–

15 (50/M) Subacuteperiodontalinfectionsecondary to rootsplit



Anterior maxilla 3 13/3.3;13/3.75

- 20


Anteriormandible

2 15/3.75 - 18

18 (36/F) Subacute perio-endoinfection

Anterior maxilla 1 13/3.7 Membrane exposure;pseudomembranous

colitis

18

19 (36/F) Chronic periapicallesion




Abbreviations: L, length; D, diameter.

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

ogbcactsrii

rsacs

pieptp

P

dpondim

ata

tvcudqotspscw

stfebedsiswPpnbAbcGcse

R

a

Fea

386 IMMEDIATE IMPLANTATION INTO DEBRIDED INFECTED SOCKETS

Nevertheless, evidence arising from the treatmentf vertebral osteomyelitis in orthopedic surgery sug-ests that this might be a misconception. Subacuteone infection in vertebral osteomyelitis can be suc-essfully managed by meticulous bone debridementnd antibiotic therapy combined with titanium meshages that provide immediate support and stability forhe weakened vertebrae.10,11 Despite the precedingignificant infectious state, these titanium cages wereeported to achieve radiographic bone fusion, whichs the orthopedic equivalent of osseointegration inmplant dentistry.

Recent experimental studies in animals have cor-oborated this clinical experience and shown thatocket debridement and prophylactic antibiotics cre-te adequate conditions for the bone remodeling pro-ess around immediate implants placed into infectedites.12-15

Based on these observations, we have developed arotocol for the immediate placement of endosseous

mplants into debrided infected dentoalveolar sock-ts. Our objective in this report is to describe therocedure and to report our experience with 20 pa-ients. Two cases at the anterior maxilla, in which therotocol has been successfully applied, are detailed.

atients and Methods

A total of 30 implants were immediately placed inebrided infected sites in 20 patients by the treatmentrotocol detailed below. All patients receiving theutlined treatment had been given a detailed expla-ation and gave their informed consent to the proce-ure. Successful osseointegration of the immediate

mplants was determined in follow-up of 12 to 72onths.

TREATMENT PROTOCOL

The patient is initiated on a daily dose of 1.5 gmoxicillin, or 0.9 g clindamycin in penicillin-sensi-ive patients, 4 days prior to the surgical procedurend maintained on it for 10 days.

Under local anesthesia, a full-thickness mucoperios-eal flap is reflected at the surgical site and the in-olved teeth are extracted with minimal trauma to theortical plates. The extraction sockets are then metic-lously debrided and curetted to remove all theetectable granulation and infected tissues. Subse-uently, a moderate peripheral intrasocket ostectomyf the alveolar bone is accomplished using an oval buro ensure complete elimination of all contaminatedoft and hard tissues. Special attention is given to theeriapical area where ostectomy is performed with amall round bur. The instrumental procedure is con-luded with vigorous irrigations of the surgical site
ith a sterile solution.
CS

The resultant sockets are then prepared by thetandard implant placement protocol, and are ex-ended apically 3 to 4 mm to achieve primary stabilityor the implants. Moderate modifications of the sock-ts may be accomplished at this stage to establish aetter position or angulation for the implants; how-ver, further aggravation of the already existing boneeficiency should be avoided. Thereafter, the endos-eous dental implants are immediately introducednto the prepared sites and evaluated for primarytability. The residual alveolar defect is augmentedith bovine-derived bone mineral (Bio-Oss; Geistlichharma AG, Wolhusen, Switzerland) to achieve com-lete coverage of the immediate implants, and a tita-ium-reinforced expanded tetrafluoroethylene mem-rane (Gore-Tex; WL Gore & Associates Inc, Flagstaff,Z) is secured over the site to commence the guidedone regeneration. The surgical procedure is con-luded by suturing the flap (Gore-Tex sutures; WLore & Associates Inc) to realize soft tissue primarylosure. The healing period is monitored to ensureustained closure of the site and infection-free regen-ration.

esults

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

IGURE 1. Case 1: periapical radiograph demonstrating an appar-nt endodontic-periodontal lesion involving the left central incisor andperiradicular lesion involving the right central incisor.

asap et al. Immediate Implantation Into Debrided Infectedockets. J Oral Maxillofac Surg 2007.

Omms

d

fattc

Fggft

C kets. J

CASAP ET AL 387

ne implant placed at the anterior maxilla was foundobile after its immediate restoration, and was re-oved. This reflects a 96.67% success rate within this

mall patient group.Characteristics of the patients and the details of

IGURE 2. Case 1: A, The surgical site after reflection of the muranulation tissue at the apical area of the right socket and along theranulated and infected tissues. Note the labial fenestration at the apica

orms a 3-wall defect. C, The peripheral ostectomy procedure accompitanium-reinforced membrane secured over the surgical site.

asap et al. Immediate Implantation Into Debrided Infected Soc

entoalveolar pathology, implants, complications and t

ollow-up period are listed in Table 1. The pathologyt the extracted sockets included subacute periodon-al infection, perio-endo infection, chronic periodon-al infection, chronic periapical lesion, and a periapi-al cyst. Implants were immediately placed both in

steal flap and extraction of the maxillary central incisors. Note theall of the left socket. B, The surgical site after debridement of all the

of the right socket and the labial cortical defect at the left socket, whicht the left socket using an oval bur. D, The 2 implants in place. E, The

Oral Maxillofac Surg 2007.

coperiolabial wl arealished a

he mandible and the maxilla, but the majority of

ipdm

pcgcb

at

tr

tmcapp

tigvl

mtt

Fi

CS

CJ

F3s

CS


mplants were placed at the anterior maxilla. All im-lants were titanium-machined self-tapered, and theirimensions were 10 to 16 mm in length and 3.7 to 4.7m in diameter.Guided regeneration membrane was exposed in 2

atients and was treated with a protocol of 0.12%hlorhexidine mouth rinses. Deficiency of attachedingiva was noted in one case. Pseudomembranousolitis developed in one patient as result of the anti-iotic therapy.Following is a detailed description of 2 cases at the

nterior maxilla illustrating the clinical application ofhe described treatment approach.

CASE 1: SUBACUTE PERIODONTAL INFECTION ANDPERIO-ENDO LESION

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

IGURE 3. Case 1: removal of the membrane and exposure of themplants 6 months after the surgical procedure.


FIGURE 4. Case 1: permanent abutments mounted on the implants.

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

eeth had undergone a conventional root canal treat-ent and restoration with porcelain fused to metal

rowns, but subsequently she had root end resectionsnd retrograde fillings due to failure of the root canalrocedure. The apicoectomies were repeated 2 yearsrior to the current presentation.Clinical examination showed a sinus tract traced to

he maxillary right central incisor, while the left max-llary central incisor had an endo-perio lesion. Radio-raphic examination showed an endo-perio lesion in-olving the left central incisor and a periradicularesion involving the right central incisor (Fig 1).

The treatment plan consisted of extraction of theaxillary central incisors and implant-supported res-

oration. At surgery, the sinus tract had subsided afterhe preoperative antibiotic therapy. The teeth were

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


xtracted, and 2 15-mm � 3.75-mm implants (3i Os-

sF(mpmatit

sttwtc

iawth

ai

mt3Iatprmcswb(o

phmwef

Fosti

CS

Fla

CASAP ET AL 389

eotite; Implant Innovations Inc, Palm Beach Gardens,L) were immediately placed after the above protocolFig 2). Six months after the surgical procedure, theembrane was removed and the implants were ex-osed and mounted with healing caps (Fig 3). Oneonth later, the permanent abutments were mounted

nd the implants were loaded with the final restora-ion (Fig 4). At the 3-year follow-up examination, themplants were functioning and osseointegration ofhe implants was shown radiologically (Fig 5).

CASE 2: SUBACUTE PERIODONTAL INFECTION DUETO ROOT FRACTURE AND PERIAPICAL LESION

A 26-year-old female presented with mobility andensitivity of the maxillary right central incisor. Den-al history of the patient showed that 16 years earlier,he 2 maxillary central incisors were traumatized andere treated by root apexification and root canal

reatment, and the tooth crowns were restored byomposite restorations.On clinical examination, the 2 maxillary central

ncisors were discolored, and periodontal pocketingnd crown mobility of the upper right central incisorere noted (Fig 6A). Radiography showed a horizon-

al root fracture of the upper right central incisor with

IGURE 6. Case 2: A, Clinical view demonstrating the discolorationf the 2 maxillary central incisors. B, Periapical radiograph demon-trating a horizontal root fracture, severe bone support loss involvinghe upper right central incisor, and a periradicular radiolucency involv-ng the upper left central incisor.


orizontal bone loss of two thirds of the root support,CS

nd a periapical lesion involving the upper left centralncisor (Fig 6B).

The treatment plan consisted of extraction of theaxillary central incisors and implant-supported res-

oration. Teeth were extracted and 2 implants, 15 �.75 mm and 13 � 3.75 mm (3i Osseotite; Implantnnovations Inc), were immediately placed by thebove-described protocol (Fig 7). Upon removal ofhe sutures, the membrane was found slightly ex-osed and a protocol of 0.12% chlorhexidine mouthinses was initiated. However, the exposure of theembrane was aggravated with time, and it was de-

ided to remove the membrane 2 months after theurgical procedure (Fig 8A). During the membrane’sithdrawal, a heterogeneous mixture of primarilyovine-derived bone mineral particles was foundFigs 8B,C). Subsequently, primary soft tissue closuref the surgical site was achieved.Six months postplacement, the implants were ex-

osed by a minimal crestal incision and mounted withealing caps, and 1 month later the implants wereounted with the permanent abutments and loadedith the final restoration. At the 3-year follow-up

xamination, the implants were functioning and wereully osseointegrated (Fig 9).

IGURE 7. Case 2 A, Clinical view after debridement of all granu-ation and infectious tissue showing a 3-wall residual defect at the rightlveolus. B, The 2 implants in place.


D

omiiad

tpiecwolTtestad

ttip

ooicwqgpbctetptmcg

Fa

C kets. J


iscussion

Clinical reports have suggested that history of peri-dontal or endodontic infections is a predictivearker for implant infection and failure.16-19 This clin-

cal experience has led most clinicians to avoid themmediate placement of endosseous dental implantst infected sites and to consider infection a contrain-ication for immediate implantation.In this report, we have challenged this conven-

ional concept, and argued that under a controlledrocedure, immediate implants may be successfully

ntroduced into debrided infected dentoalveolar sock-ts. Based on the surgical experience with titaniumaging in the management of vertebral osteomyelitis,e developed a protocol that targets the eliminationf the contaminated soft and hard tissues by meticu-

ous debridement and peripheral alveolar ostectomy.his procedure, combined with pre- and postopera-

ive antibiotics, should eradicate the infection andstablish a favorable basis for bone healing and os-eointegration. The presurgical administration of an-ibiotics is vital for the reduction of the infection loadnd is supported by a previous report on the imme-

IGURE 8. Case 2: A, The exposed membrane prior to its removaugmented site demonstrating a heterogeneous mixture consisting prim

asap et al. Immediate Implantation Into Debrided Infected Soc

iate implantation in the presence of periapical pa- a

hosis.20 Consequently, in cases where an acute infec-ion persists in spite of the presurgical antibiotics, themmediate placement of implants should be post-oned and the acute infection treated.Guided bone regeneration has been documented as

ne of the treatment modalities for the regenerationf alveolar defects resulting from plaque-induced peri-

mplantitis.21 Decontamination of the implant’s site,ombined with guided bone regeneration with orithout bone grafting, was reported to create ade-uate conditions for bone regeneration and osseointe-ration despite the previous contamination. In therotocol described herein, the objective of the guidedone regeneration procedure was to facilitate theorrection of the defects of the alveolar bone thatypically accompany unsalvageable infected teeth. Ad-quate bony healing of the alveolar defect is vital forhe osseointegration of the immediately placed im-lant and for its functional stability. Similar to thereatment of plaque-induced peri-implantitis, weaintain that a protocol that completely removes the

ontaminated tissue should allow for successfuluided bone regeneration of the previously infected

e membrane after the reflection of the mucoperiosteal flap. C, Thef bovine-derived bone mineral.

Oral Maxillofac Surg 2007.

l. B, Tharily o

lveolus.

ipOgpoddatptsb

rt

bweekaapsatpsp

fttdol

R

1

1

1

Ffl

CS

CASAP ET AL 391

This report details our experience with 20 patientsn whom a total of 30 implants were immediatelylaced into debrided infected dentoalveolar sockets.ur results suggest a favorable outcome of osseointe-ration of these implants when the described clinicalrotocol is applied. In addition, 2 cases of successfulsseointegration of immediate implants placed intoebrided infected alveoli at the anterior maxilla areescribed. The significant advantage of this treatmentpproach over delayed implantation is the preserva-ion of the alveolar ridge, which allows for more idealositioning of the implants. This, in turn, contributeso improved esthetics, biomechanics, and long-termurvival of the functioning implants. Another notable

IGURE 9. Case 2: A, Clinical view of the final restoration at 3-yearollow-up examination. B, Periapical radiograph at the 3-year fol-ow-up examination demonstrating osseointegration of the implants.


enefit lies in the shorter waiting period until final

estoration, which nowadays is highly favored by pa-ients.

While our experience suggests that implants maye immediately placed into debrided infected alveoli,e advise that this procedure should be limited to

xperienced surgeons who are highly skilled in differ-ntiating and debriding granulation tissue. Competentnowledge in maxillofacial anatomy is essential tovoid violation of adjacent cavities during the intra-lveolus instrumentation. The surgeon must also beroficient in guided bone regeneration procedures tokillfully correct the significant alveolar defects thatre commonly associated with these cases. Subject tohese competencies, skills and adherence to the pro-osed protocol, we maintain that immediate implantshould be considered a viable treatment option inatients presenting with dentoalveolar infections.Successful immediate implantation in debrided in-

ected alveoli depends on the elimination of all con-aminated tissues and the controlled regeneration ofhe alveolar defect. Our detailed protocol outlines aependable procedure for the immediate placementf dental implants into debrided infected dentoalveo-

ar sockets.

eferences1. Bartee BK: Extraction site reconstruction for alveolar ridge

preservation. Part 1: Rationale and materials selection. J OralImplantol 27:187, 2001

2. Yang J, Lee HM, Vernino A: Ridge preservation of dentitionwith severe periodontitis. Compend Contin Educ Dent 21:579,2000

3. Kan JY, Shiotsu G, Rungcharassaeng K, et al: Maintaining andattenuating periodontal tissues for aesthetic implant place-ment. J Oral Implantol 26:35, 2000

4. Schropp L, Kostopoulos L, Wenzel A: Bone healing followingimmediate versus delayed placement of titanium implants intoextraction sockets: A prospective clinical study. Int J OralMaxillofac Implants 18:189, 2003

5. Werbitt MJ, Goldberg PV: The immediate implant: bone pres-ervation and bone regeneration. Int J Periodontics RestorativeDent 12:206, 1992

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

7. Barzilay I: Immediate implants: Their current status. Int JProsthodont 6:169, 1993

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. Werbitt MJ, Goldberg PV: The immediate implant: Bone pres-ervation and bone regeneration. Int J Periodontics RestorativeDent 12:206, 1992

0. Hee HT, Majd ME, Holt RT, et al: Better treatment of vertebralosteomyelitis using posterior stabilization and titanium meshcages. J Spinal Disord Tech 15:149, 2002

1. Liljenqvist U, Lerner T, Bullmann V, et al: Titanium cages in thesurgical treatment of severe vertebral osteomyelitis. Eur Spine J12:606, 2003

2. Novaes AB Jr, Marcaccini AM, Souza SL, et al: Immediate place-ment of implants into periodontally infected sites in dogs: A
histomorphometric study of bone-implant contact. Int J OralMaxillofac Implants 18:391, 2003

1

1

1

1

1

1

1

2

2


3. Papalexiou V, Novaes AB Jr, Grisi MF, et al: Influence ofimplant microstructure on the dynamics of bone healingaround immediate implants placed into periodontally infectedsites. A confocal laser scanning microscopic study. Clin OralImplants Res 15:44, 2004

4. Novaes AB Jr, Vidigal GM Jr, Novaes AB, et al: Immediateimplants placed into infected sites: A histomorphometric studyin dogs. Int J Oral Maxillofac Implants 13:422, 1998

5. Tehemar S, Hanes P, Sharawy M: Enhancement of osseointe-gration of implants placed into extraction sockets of healthyand periodontally diseased teeth by using graft material, anePTFE membrane, or a combination. Clin Implant Dent RelatRes 5:193, 2003

6. Ayangco L, Sheridan PJ: Development and treatment of retro-grade peri-implantitis involving a site with a history of failedendodontic and apicoectomy procedures: A series of reports.
Int J Oral Maxillofac Implants 16:412, 2001
7. Oh TJ, Yoon J, Wang HL: Management of the implant periapicallesion: A case report. Implant Dent 12:41, 2003

8. Karoussis IK, Salvi GE, Heitz-Mayfield LJ, et al: Long-term im-plant prognosis in patients with and without a history ofchronic periodontitis: A 10-year prospective cohort study ofthe ITI Dental Implant System. Clin Oral Implants Res 14:329,2003

9. Polizzi G, Grunder U, Goene R, et al: Immediate and delayedimplant placement into extraction sockets: A 5-year report.Clin Implant Dent Relat Res 2:93, 2000

0. Cosci F, Cosci B: A 7-year retrospective study of 423 imme-diate implants. Compend Contin Educ Dent 18:940, 944,946, 1997

1. Baron M, Haas R, Dortbudak O, et al: Experimentally inducedperi-implantitis: A review of different treatment methods de-scribed in the literature. Int J Oral Maxillofac Implants 15:533,
2000

Documents

vn76459