Page 6 - SPRING 2016

BAD TO THE BONE!!

INFECTED SOCKETS & IMMEDIATE

IMPLANTS: A Case Report

By Aeklavya Panjali, DDS, MSc., FAGD, DICOI

ABSTRACT cases is to minimize trauma and reduce healing shrinkage result-
Immediate implant placement has both social and economic ing from the inflammation and infection. Infection in supporting
advantages. The overall treatment time is reduced, a second sur- tissue can be reduced in several ways. It is reported that local
gical intervention is avoided, and there is a decrease in rehabilita- administration of glucocorticoid dexamethasone reduces the bone
tion treatment time because it minimizes the number of surgical resorption processes by preventing macrophage and osteoclast
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procedures by combining extraction, implant placement, and bone activation. 14 Therefore, local delivery of an anti-inflammatory
grafting (if needed) into one appointment. Less evident advan- drug at the implant site may reduce potential loss of implant sta-
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tages include improved implant survival rates, enhanced hard and bility during healing. However, no study has confirmed, with a
soft tissue maintenance, and the ability to place the fixture in an control and a test group, the benefits of local delivery of anti-
ideal axial position. 3 inflammatory drugs after the immediate insertion of implants in
infected sites.
Frequently, compromised teeth that are indicated for extraction
are enveloped in infection, which conventionally contraindicates The normal socket healing process after tooth extraction main-
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immediate replacement with endosseous dental implants because tains periosteal cells lining the socket, infected or non-infected,
of the risk of microbial interference with the healing process. 4, 5 and has great potential to regenerate bone and surrounding tissue.
The big debatable question is whether the presence of periodontal There are two studies 15, 16 which show that the immediate place-
or endodontic infection compromises immediate implant place- ment of a dental implant in an extraction socket with a peri-radic-
ment success and whether it is advised to combat the socket infec- ular infection does not have a higher rate of complication than one
tion prior to immediate placement. There is this general belief placed in an uninfected site. Therefore, based upon our knowledge
amongst clinicians that an infected site cannot be utilized for of yesterday, we started a study with a hypothesis and developed
immediate implant placement. This case study represents success- a treatment protocol that will allow successful integration of
ful placement in an infected site without curettage. implants in infected sites.

INTRODUCTION CASE REPORT
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Bell and colleagues , Fugazzotto , and Jofre and colleagues stat- A patient presented with a chief complaint of pain associated with
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ed that implants can be immediately placed in infected sites with tooth #9 with intermittent foul-smelling taste after meals. A peri-
high rates of success when following a protocol that includes apical radiograph revealed a widened periodontal space with no
antibiotic therapy, debridement, asepsis of the compromised tis- mobility, sharp pain on biting the stick, and fenestration in the
sue, and high primary implant stability. Considering only the facial bone (Figure 1). Diagnosis of a non-restorable, cracked
human case series, the treatment protocol of most studies enclosed tooth with a periapical lesion was made. Further investigation
included socket debridement, curettage, the use of systemic revealed a vertical crack. The patient was presented with several
antibiotics, and postsurgical chlorhexidine rinses varying from 1 options and chose to go with immediate implant placement. Since
to 8 weeks. Many performed guided bone regeneration (GBR) there was intermittent drainage, it was determined that there was
procedures. Some studies included peripheral intra socket ostec- some bacteria present at the site. Since grafting in infected sites
tomy, plasma rich growth factor (PRGF) coating of the implant, 9 may cause reinfections or graft resorption, we decided not to
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combination of bone, xenograft and platelet-rich plasma, antibi- graft. Therefore, modification to the protocol was made wherein
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otic solution irrigation of the socket, 10,11 socket irrigation with we excluded all forms of GBR and guided tissue regeneration
chlorhexidine 0.12%, 8,12 and the use of an erbium laser using photo (GTR). Since the facial bone was only 0.53mm (Figure 2) we
acoustics to reduce the bacteria in osteotomy sites that were decided not to perform curettage. A flapless, atraumatic extraction
infected by apical pathology. Our goal in immediate implant was done to maintain the socket dimensions (Figure 3). No curet-
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A B

Figure 1. A. Periapical showing moderate enlargement of Figure 2. Pre-operative measure- Figure 3. Post extraction intact socket with
the PDL space in the apical third. B. CBCT with enlarged ment of coronal facial bone thick- pilot osteotomy.
PDL space and facial fenestration in the apical third. ness measuring 0.53mm.

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