Download The Immediate Placement of Dental Implants Into

IMPLANTS
J Oral Maxillofac Surg
69:1623-1627, 2011
The Immediate Placement of Dental
Implants Into Extraction Sites With
Periapical Lesions: A Retrospective
Chart Review
Christopher 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 immediately
into extraction sites in the presence of chronic periapical pathology.
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 922
implants were included. Of the 922 implants, 285 were immediately placed into sockets that had chronic
periapical infections. The remaining 637 implants, without signs of periapical pathology, were used as
the 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 of
placement were also evaluated.
Results: Of the 922 implants, 285 were placed into sockets with periapical radiolucencies. The success
rate of implants placed in the study group was 97.5%, whereas the success rate of the control group was
98.7%. 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 found
for implants placed adjacent to retained teeth with periapical pathology.
Conclusions: The placement of implants in sockets affected by chronic periapical pathology can be
considered a safe and viable treatment option. There is a risk of implant failure when placing implants
adjacent to teeth with periapical radiolucencies.
© 2011 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 69:1623-1627, 2011
Materials and Methods:
Dental implants are a well-established treatment option to restore function in edentulous and partially
edentulous patients. The original procedure for endosseous cylindrical implants as described by Brånemark and colleagues1 called for implants placed in
healed bone and submersion of the implants for extended unloaded healing periods. Over time, implant
*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
surgery has evolved, and currently, implant placement 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 placement of implants at the time of extraction including
decreased number of surgical interventions, decreased healing time, and possible improved maintenance of alveolar architecture.4,5 Gordon L. Douglas
stated that immediate implants ought to have 3- and
4-walled sockets, minimal periodontal bone resorption, sufficient bone to stabilize the implant, and minimal circumferential defects. As long as these prerequisites were met, immediate placement could be
considered a safe and viable procedure.6 In a retrospective study performed by Schwartz-Arad and
Chaushu,2 95 immediately placed implants were studied over a period of 5 years, having a success rate of
approximately 95%. Schwartz-Arad and Chaushu con-
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cluded that, following specific protocols, immediate
placement of implants was a viable option.
It has been shown that implants can be placed
successfully into fresh extraction sites. However, can
implants be safely placed in chronically infected extraction sockets? Several authors have stated that extraction sites should be infection free to place immediate implants.7,8 In a study of 30 partially edentulous
patients, 61 transmucosal implants were placed immediately in sites with chronic periapical lesions. Of
those implants, only 1 failed, for a success rate of
98.4%. Del Fabbro et al9 concluded that immediate
implant placement in the presence of chronic periapical infection could be considered a safe, effective,
and predictable treatment option. Crespi et al10 studied 15 patients with periapical lesions who underwent immediate implant placement. Fifteen patients
with single-tooth extractions and no periapical pathology served as the control. Clinical parameters
such as probing depth, modified plaque index, modified bleeding index, marginal gingiva level, keratinized mucosa, and marginal bone levels were evaluated
at baseline and at 12 and 24 months after implant
placement. Both study groups had a survival rate of
100%. Several other studies have been performed
with similar results.11-14 The sample size of these
investigations has been relatively small. The purpose
of this retrospective chart review is to explore the
viability of immediately placed implants into extraction sites with radiolucencies in a large cohort of
patients.
Materials and Methods
Patient records from a private oral surgery office
were reviewed for all patients having extraction and
immediate implant placement. Two independent
evaluators reviewed radiographs and chart notes of
patients dating from January 2001 to February 2009.
While examining radiographs, the evaluators were
blinded as to whether implants had failed. Parameters
that were evaluated included the following: the presence or absence of periapical radiolucencies on preoperative Panorex or CT radiographs, preoperative
symptoms, the presence of preoperative soft tissue
swelling, implant stability, tooth number and type,
graft type, radiolucencies present on adjacent teeth,
healing time, patients’ esthetic complaints, pocket
depth, postoperative pain or infections, bisphosphonate use, smoking habits, age, gender, and other existing medical conditions such as diabetes. Chronic
periapical pathology was defined for the purpose of
this study as a radiographically visible periapical lucency on a tooth with carious pulpal exposure or
evidence of a failed root canal that was not, per our
records, associated with acute pain or soft tissue
DENTAL IMPLANTS AND PERIAPICAL LESIONS
swelling. These data were collected and stripped of
identifiers before evaluation. Major variables were
subjected to a ␹2 or z score statistical analysis. Only
variables 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 consisted
of 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 typically
extracted with forceps or were sectioned and carefully
removed with elevators, with care taken to preserve
surrounding bone. The periapical area was then debrided with a curette and irrigated. Osteotomies
were performed via standard protocols in all cases,
including surgical stents, slow-speed sequential
drills, and copious irrigation. Strauman tissue or
bone-level SLA (Strauman Dental Implants, Basel,
Switzerland) implants were placed into the prepared osteotomies. Implant stability was monitored and
noted 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 were
left 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 were
loaded after a 3-month healing period.
FIGURE 1. The upper right lateral incisor postoperatively.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
BELL ET AL
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FIGURE 2. The upper right lateral incisor preoperatively.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
Results
In total, 922 implants were placed in 655 patients
(Figs 1-7). A total of 477 patients had 637 implants
placed into extraction sites that were not affected by
periapical radiolucencies. Of these 637 implants, 8
failed, for a success rate of 98.7% (Table 1). In 256
patients, a total of 285 implants were placed into
extraction sites with periapical pathology. Of those
285 implants, 7 failed, for a success rate of 97.5%. The
difference between the control group and the group
with periapical radiolucencies was not statistically
significant. None of the patients had preoperative soft
tissue 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 (Figs
5-7). Of these, 1 anterior (0.98%), 1 bicuspid (1.0%),
and 2 molars (1.3%) failed. The remaining 566 im-
FIGURE 4. The upper right lateral incisor at 6-month follow-up.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
plants were placed in the maxilla: 270 anterior teeth
(Figs 1-4), 203 bicuspids, and 93 molars. Of these, 5
anterior 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 groups
was not found to be statistically significant.
There were 98 implants restored with locators, 133
bridge abutments, and 691 single-tooth restorations. Of
the 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 with
locator 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 the
46 implants with radiolucencies, 2 (4.3%) were lost
compared with 1 (1.2%) in patients without radiolucencies. The results were not statistically significant.
FIGURE 3. The upper right lateral incisor with periapical
granuloma.
FIGURE 5. The lower right first molar preoperatively.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
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DENTAL IMPLANTS AND PERIAPICAL LESIONS
Table 1. RESULTS
Variable
FIGURE 6. The lower right first molar postoperatively.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
Twenty-four of the implants were placed in patients taking bisphosphonates; of those, six had periapical radiolucencies. No implants failed in these patients.
Placement of 83 implants was performed in diabetic patients, 23 with radiolucencies and 60 without
radiolucencies. 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 z score analysis and was not found
to be significant. Torque values ranged from 5 to 45
N-cm, with mean values of 30.5 N-cm and 35 N-cm in
the study and control groups, respectively. Interestingly, the failed implants in the control group had a
mean 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, possibly because of the small sample size.
The mean size of lucencies was 2.5 mm. The mean
size of radiolucencies within sockets where implants
failed was 2.4 mm; the difference between the two
was not statistically significant.
No radiolucency
Periapical radiolucency
Molars with lucency
Molars without lucency
Non-molars with lucency
Non-molars without
lucency
Smokers with lucency
Smokers without
lucency
Tooth with lucency
adjacent to tooth with
lucency
Bisphosphonate-taking
patients with lucency
Diabetic patients with
lucency
No. of
Implants
No. of
Failures
Success
Rate
637
285
90
248
194
390
8
7
2
1
5
7
98.7%
97.5%
97.8%
99.6%
97.4%
98.2%
46
77
2
1
95.7%
98.8%
21
4
81.0%
6
0
100%
23
0
100%
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
In total, 51 implants were placed adjacent to retained teeth with periapical radiolucencies, 21 in the
study group and 30 in the control group. Of the 51
implants placed, 4 failed. All 4 of the failed implants
were in the lucency group, giving an 81% success rate
in the study group compared with 100% in the control group. Thus implants placed in sockets with lucencies adjacent to retained teeth with lucencies had
a significantly higher failure rate.
We found that 2 patients (0.7%) in the study group
had postoperative infections compared with 6 patients (0.1%) in the control group, which was not
significant. 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 implants
placed in men and 279 placed in women in the
control group. The mean age was 58.4 years in the
study group and 60.1 years in the control group.
There was no correlation between age or gender and
implant failure.
The mean time between implant placement and
implant failure was 2.9 months (range, 1-10 months).
A review of the chart notes showed no esthetic
complaints.
Discussion
FIGURE 7. The lower right first molar at 6-month follow-up.
Bell et al. Dental Implants and Periapical Lesions. J Oral Maxillofac Surg 2011.
This study involved 655 patients and 922 implants.
Each implant was placed immediately after the extraction of the tooth. Every implant was placed by a
similar procedure. Each variable mentioned was also
tested with either a ␹2 test or z score test to determine
BELL ET AL
statistical significance. It was considered statistically
significant only if the P value was less than .05.
All patients received IV antibiotics, and the extraction site for every implant was debrided and irrigated.
It is unknown whether these antibiotics had an effect
on implant survival in this study because all study
patients received them. Implants were not placed in
patients with soft tissue swelling or acute pain, and
this study does not, therefore, support placement of
implants in patients with acute symptoms.
The only variable that significantly affected the outcome in this study was the presence of periapical
pathology in retained teeth adjacent to the implant
being placed. Adjacent lucencies have previously
been found to increase implant failure.15,16 Endodontic treatment of teeth adjacent to implant sites, especially 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 implants
had an insertion value between 5 and 14 N-cm. The
failure 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 been
too low to show significance.
In this study the question of implant placement into
fresh extraction sites affected by periapical pathology
has been evaluated with several confounding variables.
It seems that the immediate placement of implants into
sockets affected by chronic periapical pathology can be
considered a safe and viable treatment option.
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