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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 218-221

Rehabilitation with immediate implants in periapical-infected sites: A case series

1 Department of Dentistry, VSS Institute of Medical Sciences and Research, Burla, Odisha, India
2 Department of Prosthodontics and Crown and Bridge, SCB Dental College and Hospital, Cuttack, Odisha, India

Date of Submission11-Jul-2019
Date of Decision01-Aug-2019
Date of Acceptance01-Aug-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Anisha Avijeeta
Department of Dentistry, VSS Institute of Medical Sciences and Research, Burla, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_76_19

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Conventionally, before placing dental implants, the compromised teeth are removed, and the extraction sockets are left to heal for several months. However, in the recent past, to preserve the alveolar bone level from collapsing and to reduce treatment time and procedures, tooth extraction is followed by implant placement immediately without waiting for the site to heal. The situation becomes critical with the presence of periapical pathology as it may cause failure of implant due to the presence of remnants of infection. This case series shows the survival of immediate implants placed in postextraction-infected sites and restored with cemented crowns.

Keywords: Bone graft, dental implants, immediate implant placement, infected extraction sites

How to cite this article:
Sasmal AR, Garhnayak L, Avijeeta A, Sahu J. Rehabilitation with immediate implants in periapical-infected sites: A case series. Indian J Dent Sci 2019;11:218-21

How to cite this URL:
Sasmal AR, Garhnayak L, Avijeeta A, Sahu J. Rehabilitation with immediate implants in periapical-infected sites: A case series. Indian J Dent Sci [serial online] 2019 [cited 2020 Sep 24];11:218-21. Available from: http://www.ijds.in/text.asp?2019/11/4/218/268423

  Introduction Top

With the introduction of the concept of osseointegration by Branemark, the placement of dental implants has revolutionized the treatment option for replacing missing teeth, restoring the function, comfort, speech, and esthetics. Conventionally, before placing dental implants, the compromised teeth are removed, and the extraction sockets are left to heal for several months to 1 year.[1] However, following tooth extraction, the apicocoronal and buccolingual dimensions of the alveolar ridge considerably gets reduced, thus reducing the residual bone volume and compromises the optimal restoration by interrupting favorable positioning of the implants.[1],[2] To overcome the shortcomings of longer treatment time in the conventional technique, the strategy of placement of implants immediately after tooth extraction has been a widely accepted protocol.[3]

The placement of implants into extraction sockets was first reported by Lazzara in 1989.[4] Immediate postextraction implant placement has considerable advantages such as preservation of esthetics, maintenance of socket walls, and shorter treatment time by combining extraction, implant placement, and bone grafting in one session.[2] One disadvantage of the technique is the potential for implant contamination due to the presence of remnants of infection during the initial healing period.[5] Alsaadi et al.,[6] in a large consecutive case study, noted a greater tendency toward implant failure in sites with apical lesions, especially with machined surface implants.

However, various studies [7],[8] on immediate implant placement into extraction sockets have shown successful and predictable clinical outcome. Cornelini et al.,[9] in their clinical trial, have demonstrated the successful outcome of dental implants immediately placed in fresh extraction sockets, with or without the use of membranes or regenerative procedures. Lazzara, in his clinical study, showed that the use of guided bone regeneration (GBR) can result in bone-forming cells that populate the peri-implant space. Recently, it has been observed that the use of a barrier membrane is not always necessary, especially in the presence of small bone defects that do not exceed 2 mm.[10] However, the problem still occurs when the bone defects are >2 mm and cannot heal spontaneously. Hence, this present case series depicts the immediate implants placed in fresh extraction sockets with clinical signs of periapical pathology with and without the use of barrier technique.

  Case Reports Top

Case 1

A 35-year-old male patient reported to the Department of Prosthodontics, SCB Dental College and Hospital, Cuttack, Odisha, India, with the complaint of replacement of upper front tooth. However, clinical and radiological evaluation revealed periapical radiolucency w.r.t. root stump 21 [Figure 1]a and [Figure 1]b. After the discussion of various treatment modalities with the patient, 21 was scheduled for extraction followed by the placement of immediate endosseous implant. Informed consent was obtained from the patient. Prophylactic antibiotic (2 g amoxicillin, 1 h before surgery) was prescribed. A full-thickness flap was reflected under local anesthesia (lignocaine 2% and lignox 2% A; IndocoRemedies Ltd, India). The root stump was extracted, and the socket was thoroughly debrided with curettes, followed by irrigation with normal saline. The osteotomy site was initiated more palatally with sharp-pointed lance drill at a speed of 1500 rpm under irrigation. Standard drilling procedures were performed, and site preparation was extended apically 3–4 mm beyond the socket to achieve primary stability for the implants. Then, the implant (4 mm × 13 mm) (TSIII SA fixture, Osteem Implant Co, Busan, Korea) was screwed at a torque of 30–40 N-cm [Figure 1]c and reconstruction of labial defect made by bone augmentation, i.e., by GBR technique using resorbable membrane (Healiguide; Advanced Biotech Products Ltd, India) and xenograft (Osseograft; Advanced Biotech Products Ltd., India) [Figure 1]d and [Figure 1]e. The flap was repositioned using interrupted sutures (Ethicon; Johnson and Johnson Pvt. Ltd., India). Postoperative instructions were given, and sutures were removed after 10 days. Postoperative follow-up visits were made, and oral hygiene instructions were emphasized. The patient was recalled after 6 months for the prosthetic procedures, and the implant was assessed clinically and radiographically for any signs of previous periapical pathology. Customized cast abutment screwed over the implant and porcelain-fused-to-metal (PFM) crown cemented [Figure 1]f.
Figure 1: (a) Preoperative view. (b) Preoperative radiograph showing periapical pathology. (c) Suitable size of implant placed into osteotomy site. (d) Guided bone regeneration done with bone graft. (e) Guided bone regeneration done with membrane placement. (f) Postoperative view

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Case 2

A 35-year-old female patient reported to the department of prosthodontics for the replacement of lower missing front teeth. On examination, 31 41 was found to be missing and 32 42 was periodontally compromised. After discussion of various treatment modalities, the patient opted for implant-supported prosthesis. Informed consent was obtained and the patient was scheduled for immediate implant placement following extraction of 32 42 [Figure 2]a. After following all standard protocols, extraction was done atraumatically using periotomes. Osteotomy site prepared straight through the middle of the socket and extended apically 3–4 mm beyond the socket. Tapered screw implants (3 mm × 11 mm, 3 mm × 13 mm) (TSIII SA fixture, Osteem Implant Co, Busan, Korea) were installed, [Figure 2]b and primary stability 20–30 Ncm was achieved. As jumping distance was <2 mm and no bone defect was present, there was no necessary for any regenerative procedure. Site was closed using sutures, and postoperative instructions were given. Clinically and radiologically, implants were assessed after 3 months. Implant-supported PFM bridge was cemented with resin cement [Figure 2]c.
Figure 2: (a) Intraoperative view after flap reflection. (b) Implant placed. (c) Postoperative view

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Case 3

A 50-year-old male patient was referred to the department of prosthodontics for immediate solution for 45 root stump. Radiographical evaluation revealed periapical radiolucency. After discussing various treatment plans, it was decided to extract and place endosseous implant immediately and informed consent was taken. After following all standard protocols [Figure 3]a and [Figure 3]b, implant (3.5 mm × 11.5 mm) (TSIII SA fixture, Osteem Implant Co, Busan, Korea) was placed 2 mm below the cervical junction of the adjacent teeth [Figure 3]c. The gap between the socket and implant (jumping distance) was filled with bone graft (Osseograft; Advanced Biotech Products Ltd., India), and cover screw placed. Then flap was repositioned with sutures, and postoperative instructions were given. Following 3 months of the healing period, second-stage surgical procedure was performed with the placement of a healing abutment on the implant. Implant assessment is done both clinically and radiographically. Implant level impression was made after 2 weeks from the second surgical procedure and screw retained PFM crown attached [Figure 3]d.
Figure 3: (a) Preoperative view. (b) Socket after debridement. (c) Implant placed into osteotomy site. (d) Postoperative view

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  Discussion Top

Immediate placement of dental implants into fresh extraction sockets was shown to be a predictable and successful procedure when proper protocols were followed. Placement of implants in infected sites was considered a relative contraindication. The concept of placement of dental implants immediately after the removal of a tooth with periapical pathology is an issue of discussion. Literature suggests that periapical pathology may be a cause of implant failure.[11],[12],[13]

Periapical lesions are areas of inflammatory reactions to various antigens present in infected root canals; histological examination of these lesions reveals the presence of granulation tissue infiltrated by immunocompetent cells such as lymphocytes, plasma cells, macrophages, polymorphonuclear leukocytes, and mast cells. Microorganisms located at the apical part of the root canal system are usually delineated from the inflamed periradicular tissues, either by a dense accumulation of polymorphonuclear neutrophils or by an epithelial plug at or near the apical foramen.[14],[15]

Novaes et al. stated that if standard protocols such as antibiotic administration, meticulous cleaning, and alveolar debridement are performed, placement of immediate implants in sites with periapical pathology may not be necessarily contraindicated.[16] A randomized study carried out by Lindeboom et al. showed a success rate of 92% for the immediate implants and 100% for the delayed implants (placed 3 months postextraction). Hence, they concluded that immediate implant placement can be a predictable treatment option for replacement of teeth with periapical lesions.[5]

The above cases even after 1 year showed no clinical and radiological bone loss and are still under follow-up. A meticulous curettage and debridement of the socket was done after extraction as the implants were placed in sockets with periapical lesions. All the patients were prescribed antibiotic prophylaxis for the support of the reduction of infection. The implants were placed 3–5 mm apically to the extraction socket for obtaining primary stability. When a gap of more than 2 mm is present between the implant and cortical bone, there is less likely possibility of spontaneous bone formation. Hence, bone grafting is advised.[17] In case 1, in order to facilitate the healing in infected socket and correction of the labial defect, the procedure was supplemented with GBR. In case 3, since the jumping distance was more than 2 mm, bone graft was added. All the implants were loaded 3 months after installation.

Hence, our case series demonstrates that immediate implant placement in infected extraction sockets can be successful, provided that thorough protocol is followed.[1],[18] However, more randomized controlled clinical trials with a longer follow-up are required to confirm this procedure as a safe treatment. With the trend of shortening treatment time and reducing patient discomfort/inconvenience, immediate loading implant has reemerged as an alternate strategy and has shown promising and predictable results. However, it is important to note that a meticulous case selection is still needed to integrate this treatment into daily practice.

  Conclusions Top

The proposed protocol used in this case series presented a successful outcome, achieving the elimination of the infection and immediate dental implant placement with good functional and esthetic outcomes. However, this hypothesis must be verified by additional clinical comparative trials before routine adoption in implant dentistry.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Chrcanovic BR, Martins MD, Wennerberg A. Immediate placement of implants into infected sites: A systematic review. Clin Implant Dent Relat Res 2015;17 Suppl 1:e1-e16.  Back to cited text no. 1
Del Fabbro M, Boggian C, Taschieri S. Immediate implant placement into fresh extraction sites with chronic periapical pathologic features combined with plasma rich in growth factors: Preliminary results of single-cohort study. J Oral Maxillofac Surg 2009;67:2476-84.  Back to cited text no. 2
Marconcini S, Barone A, Gelpi F, Briguglio F, Covani U. Immediate implant placement in infected sites: A case series. J Periodontol 2013;84:196-202.  Back to cited text no. 3
Lazzara RJ. Immediate implant placement into extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43.  Back to cited text no. 4
Lindeboom JA, Tjiook Y, Kroon FH. Immediate placement of implants in periapical infected sites: A prospective randomized study in 50 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:705-10.  Back to cited text no. 5
Alsaadi G, Quirynen M, Komárek A, van Steenberghe D. Impact of local and systemic factors on the incidence of oral implant failures, up to abutment connection. J Clin Periodontol 2007;34:610-7.  Back to cited text no. 6
Siegenthaler DW, Jung RE, Holderegger C, Roos M, Hämmerle CH. Replacement of teeth exhibiting periapical pathology by immediate implants: A prospective, controlled clinical trial. Clin Oral Implants Res 2007;18:727-37.  Back to cited text no. 7
Jung RE, Zaugg B, Philipp AO, Truninger TC, Siegenthaler DW, Hämmerle CH. A prospective, controlled clinical trial evaluating the clinical radiological and aesthetic outcome after 5 years of immediately placed implants in sockets exhibiting periapical pathology. Clin Oral Implants Res 2013;24:839-46.  Back to cited text no. 8
Cornelini R, Cangini F, Martuscelli G, Wennström J. Deproteinized bovine bone and biodegradable barrier membranes to support healing following immediate placement of transmucosal implants: A short-term controlled clinical trial. Int J Periodontics Restorative Dent 2004;24:555-63.  Back to cited text no. 9
Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling around implants placed into immediate extraction sockets: A case series. J Periodontol 2003;74:268-73.  Back to cited text no. 10
Kan JY, Shiotsu G, Rungcharassaeng K, Lozada JL. Maintaining and attenuating periodontal tissues for aesthetic implant placement. J Oral Implantol 2000;26:35-41.  Back to cited text no. 11
Quirynen M, Vogels R, Alsaadi G, Naert I, Jacobs R, van Steenberghe D. Predisposing conditions for retrograde peri-implantitis, and treatment suggestions. Clin Oral Implants Res 2005;16:599-608.  Back to cited text no. 12
Pal US, Singh N, Singh R K, Mohammad S, Malkunje LR, Loan PA. Evaluation of stability of immediately placed implants in infected sockets. Eur J Gen Dent 2013;2:46.  Back to cited text no. 13
  [Full text]  
Wallstrom JB, Torabinejad M, Kettering J, McMillan P. Role of T cells in the pathogenesis of periapical lesions. A preliminary report. Oral Surg Oral Med Oral Pathol 1993;76:213-8.  Back to cited text no. 14
Siqueira JF Jr. Endodontic infections: Concepts, paradigms, and perspectives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:281-93.  Back to cited text no. 15
Novaes AB Jr., Vidigal Júnior GM, Novaes AB, Grisi MF, Polloni S, Rosa A. Immediate implants placed into infected sites: A histomorphometric study in dogs. Int J Oral Maxillofac Implants 1998;13:422-7.  Back to cited text no. 16
Chen ST, Wilson TG Jr., Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 Suppl: 12-25.  Back to cited text no. 17
Crespi R, Capparè P, Gherlone E. Immediate loading of dental implants placed in periodontally infected and non-infected sites: A 4-year follow-up clinical study. J Periodontol 2010;81:1140-6.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]


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