JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

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Immediate Implants Placed Into Infected Sites:

A Clinical Report
Arthur B. Novaes, Jr, DSc/Arthur B. Novaes, DSc

Placement of immediate implants is a routine clinical procedure. However,

certain clinical conditions, especially the presence of infected sites, are
considered to be contraindications for the immediate implant. Based on clinical
experience, it is proposed that if certain preoperative and postoperative steps
are carefully followed and meticulous debridement of the alveolus is done
during the surgical procedure, immediate implants can be successfully placed
into chronically infected sites. The advantages of this procedure are discussed.
(INT J ORAL MAXILLOFAC IMPLANTS 1995;10:609613)
Key words: Gengiflex membrane, guided bone regeneration, immediate implants, infected
site

A decade ago, when a tooth was indicated for removal and was to be replaced by an
endosseous implant, common clinical procedure required that a healing period
varying from 6 to 12 months be respected before implant placement.1,2 In the last
few years, following studies in animals3,4 and clinical investigations in humans,5-10
placement of implants immediately following extractions has been performed with
success and with many advantages over the previous protocol.11 However, this
procedure cannot be used in every clinical situation. The presence of chronic
infection is one of the unfavorable situations most commonly cited. Barzilay11
reported that teeth with periapical pathosis or active periodontal disease are not
candidates for immediate implants. Becker and Becker7 agree with this report. Other
authors12-14 have reported that infected teeth were extracted and implants placed
following periods of weeks or months.
Based on clinical evidence, the present report suggests that implants can be
placed into chronically infected sites with success if certain preoperative and
postoperative steps are followed.

Case 1
A 38-year-old man presented with a history of external root resorption on the mesial
surface of the maxillary right central incisor dating back to January 1985 (5 years).
Following a history of endodontic treatment, retreatment, and periapical surgery
performed with restoration of the external resorption, in May 1990, the patient
complained of tooth mobility, spontaneous bleeding, and recurrent abscesses.
Clinical examination identified a degree 3 mobility, a deep periodontal pocket on the

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

mesial surface (both buccally and palatally), bleeding on probing, and suppuration.
Radiographically, the tooth showed a periapical lesion even though it had been
treated endodontically, an amalgam restoration on the mesial root surface where the
external root resorption had occurred, and severe bone loss (Fig 1a).
After careful extraction of the tooth, it was noted that while a good portion of the
buccal wall of the socket had been destroyed by the inflammatory process, the other
walls were almost intact (Fig 1b). The surgical procedure followed the protocol
described in previous reports.9,10 The socket was thoroughly debrided and rinsed
with sterile saline. A 3.3 15-mm IMZ implant (Interpore International, Irvine, CA)
was placed according to recommended protocol (Fig 1c). Porous hydroxyapatite
(Interpore) was deposited over the exposed surfaces of the implant (Fig 1d) and
covered by a Gengiflex membrane (BioFill Produtos Biotecnologicos, Curitiba,
Paran, Brazil).9,10 The flaps were sutured by proximal interrupted sutures without
complete closure of the wound. The patient was placed on 312 mg (500.000 IU)
penicillin V every 8 hours for 10 days, starting 24 hours before the procedure, and
then on 100 mg doxycycline once a day for another 21 days. The patient was also
instructed to use a solution of 2% chlorhexidine (Hibitane, ICI, London, England)
topically twice a day throughout the healing period. After 6 weeks, the membrane,
which was covered by soft tissue during the healing process, became exposed, and it
was removed 2 weeks later.
Stage 2 surgery was performed 7 months later, and at reentry a small portion of
the buccal aspect of the titanium plasma spray (approximately 1 mm) was still
exposed (Fig 1e). Additional porous hydroxyapatite was used to cover the exposed
portion of the implant and to correct a concavity on the buccal surface to improve
the final esthetic result. The second-phase healing screw was placed and the flaps
were sutured. The implant was immobile, one of the criteria for success according to
the parameters established by Albrektsson et al.15 These clinical observations, plus
the 11-month postoperative radiograph (Fig 1f), indicated that osseointegration had
been achieved.

Case 2
A 49-year-old woman was referred because of a root fracture on the mandibular
right second premolar. The radiograph (Fig 2a) revealed a fractured tooth, the
presence of root resorption, and a radiolucent area surrounding the root, suggesting
the presence of infection. A 4.0 11-mm IMZ implant was placed following the
surgical protocol indicated previously. The implant was placed in the receptor site.
Although an osseous defect existed on the buccal aspect, the implant was immobile
because of its apical anchorage and by the three remaining bone plates. The buccal
defect was filled with porous hydroxyapatite and then covered by a Gengiflex
membrane. The same postoperative care described in case 1 was followed.
The second-phase surgery was performed 6 months after the initial surgical
procedure. A full-thickness flap was raised to uncover the implant and adjacent

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

bone. After reflection of the flap, the implant could not be seen. Mineralized tissue
had completely covered the implant. The surgical stent was used to localize the area
where the implant had been placed and the covering bone was removed with the
assistance of burs and chisels until the first-phase healing screw was uncovered.
Figure 2b shows a 2-year postoperative radiograph of the implant that had been
loaded for 14 months, suggesting that the presence of chronic infection at the
beginning of treatment did not affect the final result.

Case 3
A 40-year-old woman was referred for treatment of a fractured maxillary right
central incisor. The tooth had a porcelain crown with a post and core, evidence of
previous endodontic therapy, and a periapical lesion (Fig 3a). The treatment protocol
described for the other patients was followed. Following careful extraction of the
tooth, it was noted that the buccal wall of the alveolus had been destroyed. After
meticulous debridement, a 4.0 13-mm IMZ implant was placed. Primary stability
was achieved as the result of anchorage of the implant into healthy bone apical to the
alveolus and by the support given by the three remaining walls. The buccal wall was
reconstituted by porous hydroxyapatite, the area was covered by a cellulose
membrane, and the flaps were sutured. The membrane was removed at the
second-phase surgery 6 months after implant placement. Figure 3b is a 7-month
postoperative radiograph showing that to date the procedure has been successful.
This case has been described in detail in a previous publication9; it supports the
concept presented in this paper.

Discussion
Since publication of the findings of Lazzara5 and others,6-10 the placement of
immediate implants has become a routine clinical procedure. In a recent publication
reporting on 50 consecutive immediate implants followed for 3 years, Gelb16
suggests that the procedure is predictable both functionally and esthetically.
However, other authors7,12-14 consider the presence of infection to be a
contraindication for the procedure. This significantly reduces the indication for
immediate implants, since many teeth that are to be extracted are associated with
infection. The protocol normally followed in these patient situations includes
extraction of the tooth, treatment of the alveolus with guided tissue regeneration,
bone grafts, or debridement, and placement of the implant following a healing period
that varies from weeks to months.12-14 Although sometimes necessary, this latter
procedure has disadvantages, such as multiple surgical procedures and the
discomfort associated with each procedure, prolongation of treatment, and,
depending on how the alveolus was managed postextraction, ridge resorption.
The cases described here suggest that if surgery is adequately performed and
proper preoperative and postoperative care is provided, immediate implants can be
placed successfully into chronically infected sites. It should be emphasized that the
cause of the infection must be the diseased toothbe it periodontally or

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

endodontically involved, or the result of fractureand that during surgical treatment

the cause of the infection, ie, the tooth, is removed. In addition, the patient must be
placed on penicillin V 24 to 48 hours before the procedure and maintained on the
medication for 10 days, so that bacterial contamination is eliminated or reduced and
the host cells can deal with the residual situation. Another important part of the
surgical treatment is the complete, thorough debridement and rinsing of the alveolus.

Conclusion
The cases presented demonstrate that if the appropriate procedures are carefully
followed, chronically infected sites may not necessarily be contraindications for the
placement of immediate implants. Other factors must be considered, such as the
extent of bone resorption and whether the angle of implant placement, determined by
the morphology of the defect, will allow an eventual esthetic restoration. The
potential placement of implants into infected sites will significantly increase the
indications for immediate implants, which can benefit patients and professionals.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

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1. Ohrnell LO, Hirsch JM, Ericsson I, Brnemark P-I. Single tooth rehabilitation using
osseointegration. A modified surgical and prosthodontic approach. Quintessence
Int 1988;19:871877.
2. Anneroth G, Hedstrom KG, Kjellman O, Kondell PA, Norderam A. Endosseous
titanium implants in extraction socketsAn experimental study in monkeys. Int
J Oral Surg 1985;14:5054.
3. Dahlin C, Sennerby L, Lekholm U, Linde A, Nyman S. Generation of new bone
around titanium implants using a membrane technique: An experimental study in
rabbits. Int J Oral Maxillofac Implants 1989;4:1921.
4. Becker W, Becker BE, Handelsman M, Celletti R, Ochsenbein C, Hardwick R,
Langer B. Bone formation at dehisced dental implant sites treated with implant
augmentation material: A pilot study in dogs. Int J Periodont Rest Dent
1990;10:93101.
5. Lazzara RJ. Immediate implant placement into extraction sites: Surgical and
restorative advantages. Int J Periodont Rest Dent 1989;9:333339.
6. Nyman S, Lang NP, Buser D, Bragge U. Bone regeneration adjacent to titanium
dental implants using guided tissue regeneration: A report of two cases. Int J Oral
Maxillofac Implants 1990;5:914.
7. Becker W, Becker BE. Guided tissue regeneration for implants placed into
extraction sockets and for implant dehiscences. Surgical techniques and case
reports. Int J Periodont Rest Dent 1990;10:377391.
8. Balshi TJ, Hernandez RE, Cutler RH, Hertzog CF. Treatment of osseous defects
using Vycril mesh (Polyglactin 910) and the Brnemark implant. Int J Oral
Maxillofac Implants 1991;6:8791.
9. Novaes AB Jr, Novaes AB. IMZ implants placed into extraction sockets in
association with membrane therapy (Gengiflex) and porous hydroxyapatite: A
case report. Int J Oral Maxillofac Implants 1992;7:536540.
10. Novaes AB Jr, Novaes AB. Bone formation over an IMZ implant placed into an
extraction socket in association with membrane therapy (Gengiflex). Clin Oral
Implants Res 1993;4:106110.
11. Barzilay I. Immediate implants: Their current status. Int J Prosthodont 1993;6:169
175.
12. Lundgren D, Nyman S. Bone regeneration in 2 stages for retention of implants.
Clin Oral Implants Res 1991; 2:203207.
13. Werbitt MJ, Goldberg PV. The immediate implant: Bone preservation and bone
regeneration. Int J Periodont Rest Dent 1992;12:207217.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

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14. Wilson TG Jr. Guided tissue regeneration around dental implants in immediate and
recent extraction sockets: Initial observations. Int J Periodont Rest Dent
1992;12:185193.
15. Albrektsson T, Zarb GA, Worthington P, Eriksson RA. The long-term efficacy of
currently used dental implants: A review and proposed criteria of success. Int J
Oral Maxillofac Implants 1986;1:1125.
16. Gelb DA. Immediate implant surgery: Three-year retrospective evaluation of 50
consecutive cases. Int J Oral Maxillofac Implants 1993;8:388399.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

Fig. 1a (Left) Case 1 preoperative radiograph.

Fig. 1b (Below) Alveolus prior to the

placement of the implant. Note that the buccal plate has been destroyed by the
inflammatory process.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

Fig. 1c Implant in place. A portion

of its buccal surface remained exposed.

Fig. 1d Porous hydroxyapatite

placed over the exposed surface of the implant.

Fig. 1e (Above) Six-month reentry.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

Fig. 1f (Right) Eleven-month postoperative

radiograph showing good bone healing.

Fig. 2a (Left) Case 2 preoperative radiograph.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

Fig. 2b (Below) Two-year

postoperative radiograph suggesting good-quality bone around the implant.

Fig. 3a (Left) Case 3 preoperative radiograph.

JOMI on CD-ROM, 1995 May (609-613 ): Immediate Implants Placed Into Infected Sites

Copyrights 1997 Quint

Fig. 3b (Right) Seven-month postoperative

radiograph.