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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5223_Библиотеки_им_академика_М_И_Перельмана.pdf
5
IMMEDIATE IMPLANT PLACEMENT IN INFECTED MOLAR SITES
88
impact of expected postsurgical crestal bone loss.
No standard antibiotic protocol exists for managing
infected sites, and indeed whether antibiotic usage
is needed provided that debridement is sucient
has not been investigated. Greenstein and Tarnow37
have published a recent literature review on antibiotic regimens and suggested that a single loading
dose is sucient for implant placement in medically
t patients receiving implants in noninfected sites.
Submerged site healing appears not to be needed. Nor
is peri-implant gap grafting always needed, provided
that adequate stability and good peri-implant ap
adaptation is achievable around an appropriate healing abutment. e use of autologous PRF clots at the
time of implant placement needs further investigation, as it may oer considerable advantage in combatting retained bacteria and accelerating vascularization
and bone healing during initial osseointegration.38
Clinical Protocols for Immediate Implants in Infected Molar Sites
Careful planning in advance of placing IMIs is essential and should include 3D radiographic assessment
using CBCT to reveal tooth and socket anatomies; the
interseptal bone volume and its usefulness in stabilizing an IMI; the presence, thickness, and height of
the buccal cortical plate; as well as the proximity of
vital structures. Clinical assessment should include
evaluation of the periodontal status of the condemned
tooth and its neighbors as well as determination of
whether the infection is quiescent. For mandibular
molars, the distance between the root apices and the
mandibular nerve canal should be no less than 4 mm.
For maxillary molars, the presence of a substantial
interradicular septum (IRS; type A) should be noted.
e distance between the apical portion of the septum
and the maxillary sinus should be sucient to avoid
invading the sinus domain by no more than 3 to 4
mm if indirect sinus oor elevation is planned, and
the sinus should be healthy and functional.
While the absolute need for antibiotic usage has not
been established, our protocol has been to administer
2 g of amoxicillin 1 hour before surgery.37 Performing
apless surgery will help to minimize loss of alveolar
bone during postoperative alveolar ridge remodeling. Decoronation of the molar and separation of all
roots using rotary instruments and generous saline
irrigation will facilitate their removal individually
and atraumatically. Curettage of the alveolus after
extraction, especially in the presence of apical lesions,
must be carried out scrupulously and completely.
Magnication devices and proper illumination will
facilitate this crucial step, as will special drill kits such
as the ultra-coarse diamond ones. ese are specially
engineered to quickly grab and remove granulation
tissue and underlying aected bone as well as creating
multiple bleeding points in the alveolus.
Some clinicians have included decontamination of
infected sockets with Er,Cr:YSGG 2780-nm lasers,
39,40
or irrigation of the debrided sockets with peroxide or
chlorhexidine,41 but we have not included either of
these extra steps, as there are no data conrming them
to be benecial compared to their nonuse. With maxillary molar sites, IMIs ideally will be positioned at the
center of the IRS. A slight underpreparation (eg, 0.3
mm) of the osteotomy relative to the intended implant
diameter will help to ensure adequate initial implant
stability, achieving an initial torque of between 25
and 30 Ncm. Ideally, the implant platform should be
positioned at least 1.5 mm subcrestally both buccally
and palatally. Provided that there is sucient IRS to
stabilize the implant, localized indirect sinus oor
elevation with osteotomes or specialized osseodensifying burs42 can be used to allow implants of appropriate lengths to be used (see also chapters 7 and 11).
For mandibular molars, having a substantial IRS
is much less likely, and therefore technique modications such as drilling the osteotomy through the
tooth before removing its roots and/or using a
wider-diameter implant stabilized by the buccal and
lingual bony buttresses (see also chapter 8) may be
the preferred approach. With both maxillary and
mandibular IMIs, it is important to have sucient
peri-implant keratinized soft tissue for long-term
patient comfort and stable crestal bone. Generally,
IMIs will be placed without raising a mucogingival
ap, and if there is concern about the thickness and/
or width of keratinized gingiva (both should be ≥ 2
mm), soft tissue grafting can be done at the time of
implant placement using, for example, the so-called
“socket seal” technique by covering the implant with
a soft tissue graft from the patient’s palate.43 Alternatively, a membrane can be created by attening autologous PRF clots (PRGF or CGF), placing them over the
89
Sample Cases
implant healing screw, and securing them with
sutures.
35,36,44,45
Sample Cases
Case 1: Chronically infected maxillary fi rst molar
is patient presented with a failed endodontic treatment of a nonrestorable maxillary right rst molar
with a large apical radiolucency (Fig 5-2a). ere
were no signs of swelling or purulence. Using a apless approach, the tooth was partially sectioned and
removed atraumatically revealing type B interseptal/
furcal bone46 (Figs 5-2b to 5-2d). Following socket
debridement, an implant was successfully placed into
the IRS with dehiscences on the buccal and palatal
aspects of the furcal bone. Despite the large gaps, no
corrective grafting was done (Fig 5-2e). e site was
covered with PRGF brin clots stabilized with sutures
(Fig 5-2f). e 1- and 2-week postoperative clinical
images are seen in Figs 5-2g and 5-2h, where soft
tissue coverage is progressing well despite evidence
that the patient had continued smoking cigarettes. A
radiograph taken after 3 months of site healing (Fig
5-2i) showed the root sockets to be healing well. Figure
5-2j shows the clinical status of soft tissue healing at
5 months, at which time the reentry and restoration
were performed. e de nitive restoration is shown
clinically and radiographically after 1 year in function
in Figs 5-2k and 5-2l.
FIG 5-2 (a) A nonrestorable maxillary rst molar required extraction. (b) is maxillary rst molar showed failure of its endodontic
treatment with a chronic rarefying osteitis, which in its chronicity had caused a periosteal reaction, lifting the sinus oor. (c) e tooth
was sectioned and removed and clearly had been infected for some time. (d) Following extraction, the IRS bone that remained was
considered type B.
46
a
b
c d
5
IMMEDIATE IMPLANT PLACEMENT IN INFECTED MOLAR SITES
90
Case 2: Nonrestorable, nonvital
mandibular first molar with
periapical rarefactions
A 47-year-old woman presented with a necrotic
mandibular left rst molar exhibiting discomfort
upon chewing. e preoperative radiograph showed
some apical sclerosis, suggesting that the infection had been present for some time (Fig 5-3a). e
crown was sectioned away to allow the two roots to be
removed separately using a apless technique. Despite
the narrow IRS, drilling into it was possible (Fig 5-3b).
ge f
h i j
k
l
FIG 5-2 (cont) (e) An implant was successfully placed into the IRS bone with dehiscences mesially and distally. Despite the large gaps,
no corrective grafting was done, and after placing a healing screw, the site was left to heal without sutures. (f) e remaining gaps were
lled with several autologous PRF clots stabilized by sutures. (g) At the 1-week postoperative visit, the wound shows exuberant granulation tissue formation and coverage of the implant. Evidence of cigarette smoking can be seen, as soft tissue hyperkeratosis was the
likely reason for supercial avascularity of the surface of the granulation tissue. (h) e continuing site healing at 2 weeks. (i) is
radiograph taken 3 months postoperatively shows the root sockets to be healing well. e implant was placed without apical grafting,
and in this lm, you can see the layering eect of the new bone forming around the implant apex in the former area of periosteal reaction
to the infection. (j) is clinical image shows the soft tissue healing at 5 months. Note that minimal change in buccopalatal dimension
has occurred despite the fact that no gap grafting was done. (k) A clinical image of the implant restoration after 1 year in function. (l)
e radiograph of the restored implant after 1 year in function shows stable crestal bone.
91
Sample Cases
Once the osteotomy was completed, an implant
with aggressive threads was inserted and largely
contained by the IRS bone, thereby eliminating the
need to involve bone apical to the former root apices
for added stability (Fig 5-3c). e gaps and root sockets were lled with autologous PRF clots (PRGF)47
prepared chairside from the patient’s venous blood
and covered with another PRGF clot attened to
form a membrane. After 4 months, the implant was
restored, taking advantage of the platform-switch
feature of the implant to minimize future bone loss.
Figure 5-3d provides the radiographic status of the
restored implant after 14 months in function.
Case 3: Mandibular molar with
endodontic complications
is patient presented with a failed endodontic treatment on a mandibular second molar with radiographic
evidence of a periapical lesion that had progressed
quite close to the mandibular canal (Figs 5-4a and
5-4b). After atraumatic tooth removable and curettage, the operator elected to place the IMI into the
distal root socket to maintain a healthy distance from
the implant that had previously been placed at the
rst molar site. To avoid damaging the inferior alveolar nerve (IAN), the distal root apex was not instru-
FIG 5-3 (a) is mandibular rst molar became nonvital
due to advanced caries and showed periapical radiolucencies
at both root apices. (b) Following atraumatic tooth extraction,
osteotomy preparation focused on the IRS. (c) is immediate postsurgical radiograph shows the implant to be wellpositioned within the IRS. (d) A radiographic image of the
restored implant at 14 months.
a b c
d
5
IMMEDIATE IMPLANT PLACEMENT IN INFECTED MOLAR SITES
92
mented or drilled, leaving the implant to be secured
laterally by the socket walls (Fig 5-4c). Platelet clots
were used to ll the mesial root socket. e position-
ing of the IMI allowed a prosthesis design that could
easily be cleaned by the patient (Figs 5-4d to 5-4f).
FIG 5-4 (a) e mandibular right second molar showed failure of its endodontic treatment with development of a periapical rarefaction
in close proximity to the IAN. After failure of an attempt to perform a retreatment, the decision was made to extract and place an IMI.
(b) ese CBCT cuts conrm that the periapical lesion was quite close to the mandibular canal. (c) e operator opted to place the IMI
in the distal root socket of the second molar, choosing a 12-mm-long implant with a 2-mm machined collar to leave it supracrestal and
avoid damage to the mandibular nerve. (d) A posttreatment radiograph taken at 1 year in function. Note the stable crestal bone levels
but slow healing of the mesial root socket of the second molar. e IMI used had a long machined collar to allow nonsubmerged healing.
(e and f) e clinical situation after 1 year in function.
a
b
c d
e f
93
Sample Cases
Case 4: Nonvital maxillary first molar
with chronic infection that appears
to have penetrated the sinus floor
is patient presented with hopeless teeth in the
maxillary left quadrant, including her second premolar and second and third molars. e second molar had
a large periapical lesion aecting its palatal root that
seemed to have penetrated into the maxillary sinus
(Fig 5-5a). Once the teeth were removed, the second
molar was seen to have an IRS suitable for an IMI (Fig
5-5b). After partially preparing an osteotomy in the
IRS, a PRF clot was inserted to act as an interface as
the sinus oor was upfractured by osteotomes (Fig
5-5c), following which the implant was inserted (Figs
5-5d to 5-5f). e purpose of using the clot was to
provide antibacterial and bone-promoting benets
in healing the compromised sinus.
a
FIG 5-5 (a) is preoperative radiograph shows a maxillary second molar to be nonvital with an apical granuloma that has likely pene-
trated the sinus oor. (b) Following removal of the teeth, the IRS of the second molar appears adequate in volume to receive an IMI. (c)
Immediate implants were placed using routine procedures at the premolar and third molar sites, following which an autologous PRF
clot was inserted using osteotomes into the second molar site before doing an indirect sinus oor elevation. (d) e immediate postoperative radiograph image verifying that the second molar implant has penetrated the sinus oor. (e) A radiograph at 12 months in
function showing the implants with separate, nonsplinted crowns and all with platform switching to help in stabilizing crestal bone
levels. Bone has formed around the implant apex in response to the sinus membrane elevation and insertion of the autologous PRF
clot. (f) An occlusal view of the denitive implant crowns.
b
c
d
e f
5
IMMEDIATE IMPLANT PLACEMENT IN INFECTED MOLAR SITES
94
a
b
c
d
e f
FIG 5-6 (a) is maxillary rst molar showed failure of its endodontic treatment with a large chronic rarefying osteitis, which in its
chronicity had caused a periosteal reaction, lifting the sinus oor. (b) Following extraction, the IRS that remained was considered type
B.
46
(c) An implant was successfully placed into the IRS bone with dehiscences buccally and palatally. No corrective grafting was done,
and after placing a healing screw, the site was left to heal without sutures. (d) is radiograph taken 32 months postoperatively shows
the root sockets to be healing well. Although the implant was placed without apical grafting, one can see a layering eect of the new
bone forming around the implant apex in the former area of periosteal reaction to the infection. (e) is clinical image shows the soft
tissue healing at 3 months. Note that minimal change in buccopalatal dimension has occurred despite the fact that no gap grafting was
done. (f) e clinical image 1 year after implant restoration showing excellent buccal tissue contour.
95
Sample Cases
Case 5: Maxillary first molar with
chronic infection and sinus floor
reaction
is patient presented with a failed endodontic treatment of the maxillary right rst molar that had led to
a large apical radiolucency (Fig 5-6a). ere were no
signs of swelling or purulence. e apical pathology
had been present long enough to put pressure on the
sinus oor and cause a periosteal bone reaction. Using
a apless approach, the tooth was removed without
diculty, revealing a type B IRS (Fig 5-6b).46 Following socket debridement, an implant was successfully
placed into the IRS with dehiscences on the buccal and
palatal aspects of the furcal bone. No gap grafting was
done, and after placing a healing screw, the site was
left to heal without sutures (Fig 5-6c). A radiograph
taken after 3 months’ site healing (Fig 5-6d) showed
the root sockets to be healing well. e implant had
been placed without apical grafting, and in Fig 5-6d,
one can see the layering eect of new bone forming
around the implant apex in the former area of periosteal reaction to the infection.At this time (Fig 5-6e),
the keratinized soft tissues can be seen to be abundant
and healthy, and the clinical image of the restored
implant is shown in Fig 5-6f.
Case 6: Infected molar managed
with an IMI in combination with GBR
Figure 5-7 demonstrates a case using GBR to help
stabilize an IMI placed in type B IRS.
a b
c d
FIG 5-7 (a) is infected endodontically treated molar was condemned. (b) Clinically, there was
evidence of a draining sinus buccally. (c) It was possible to stabilize the implant in the type B septum
despite the total loss of buccal bone. (d) GBR using particulate allograft and a resorbable membrane
was needed to reconstruct the damaged alveolar ridge buccal to the implant.
5
IMMEDIATE IMPLANT PLACEMENT IN INFECTED MOLAR SITES
96
Conclusion
Despite early concerns about placing immediate
implants into chronically infected tooth sockets,
multiple studies have shown this not to be a signicant contributor to complications or implant failure.
Chronic large endodontic infections may be the most
likely to fail, probably due to their specic microbial
populations. However, certain issues must still be
addressed with controlled clinical investigations, such
as when to use systemic antibiotics, whether laser
socket decontamination is of signicant value, if topi
cal antimicrobial agents such as chlorhexidine should
be used to irrigate the sites, and whether introduction of autologous PRF preparations should become
routine procedure.
e f
FIG 5-7 (cont) (e) A large-diameter healing abutment was used to help in securing the membrane and to allow nonsubmerged healing
with nonocclusal loading. (f) A panoramic radiograph taken immediately following the surgery shows the extent of the defect managed
with GBR. A second implant was used to replace the second premolar during the same procedure. (g) is radiograph at 1 year in function
shows ongoing bone remodeling in the formerly infected socket. (h) A clinical photograph of the implant-supported two-unit prosthesis
after 1 year in function. (Case provided by Dr Ali Akbar Khoshkhounejad, Tehran, Iran.)
g h
97
References
KEY POINTS
• Most published data relate to largely asymptomatic chronically infected sites.
• Investigation into the cause of the infection hopefully will help to determine it as primarily
endodontic, root fracture, primarily periodontic, or combined endo-perio.
•
For large, long-standing endodontic lesions, consideration should be given to the possibility
of Actinomyces infections with microbiologic sampling of the lesions.
•
Generally, although not confirmed to be necessary by published controlled study data,
systemic antibiotic usage is undertaken preoperatively, oftentimes for several days before
tooth extraction, especially with large periapical lesions.
• As with all IMIs, flapless surgery, separation of molar roots, and atraumatic extraction are
recommended.
•
After extraction, meticulous socket debridement is necessary using both curettes and
large-diameter rotary burs.
• Decontamination with chlorhexidine solution or using lasers has been proposed but is not
substantiated in random controlled clinical studies.
•
Consideration should be given to slightly underpreparing osteotomies (eg, 0.3 mm) to
ensure high initial stability.
• Inserting autologous PRF clots to the osteotomies immediately before implant placement
will provide some further antibacterial impact and encourage faster bone healing.
• As always, high initial implant stability is crucial for success.
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