immediate loading of dental implants placed in ...dental implants; immediate...

Immediate Loading of Dental ImplantsPlaced in Periodontally Infectedand Non-Infected Sites: A 4-YearFollow-Up Clinical StudyRoberto Crespi,* Paolo Cappare,* and Enrico Gherlone*

Background: The aim of the present study is to comparethe outcomes of immediate loading of implants in replacingteeth with and without chronic periodontal lesions at 4 yearsof follow-up.

Methods: Thirty-seven patients were included in this study.A total of 275 implants were placed and immediately loadedin extraction sockets, 197 in periodontally infected sites(infected sites group [IG]), and 78 implants in non-infectedsites (non-infected sites group [NG]). Marginal bone levelsand clinical parameters (plaque accumulation and bleedingindex) were evaluated at baseline and 12, 24, and 48 monthsafter implant placement. Comparisons between IG and NGvalues over time were performed by the Student two-tailedt test.

Results: At 48 months of follow-up, the IG presented a sur-vival rate of 98.9% because two implants were lost 1 month af-ter placement; the NG reported a survival rate of 100%. Themarginal bone level was 0.79 – 0.38 mm for the IG and 0.78 –0.38 mm for the NG, plaque accumulation was 0.72 – 0.41for the IG and 0.71 – 0.38 for the NG, and the bleeding indexwas 0.78 – 0.23 for the IG and 0.75 – 0.39 for the NG. No sta-tistically significant differences were reported between the IGand NG over time and between time points.

Conclusion: At 48 months of follow-up, dental implantsthat were placed and immediately loaded in periodontallyinfected sockets showed no significant differences com-pared to implants placed in uninfected sites. J Periodontol2010;81:1140-1146.

KEY WORDS

Dental implants; immediate denture; infection; tooth socket.

To preserve the alveolar bone levelfrom the collapse of healingevents,1,2 different authors3-6

placed dental implants into fresh extrac-tion sockets and obtained high successrates. Moreover, immediate loading (anocclusal load applied to temporarycrowns positioned immediately to im-plants) was carried out on implants placedin fresh extraction sockets from premolarsto premolars to reduce treatment time.7-10

The survival rate of 100% that was re-ported in these studies encouraged the useof an immediate-restoration procedure ofimplants placed in fresh extraction socketsto replace missing teeth. The immediate-function protocol may also be an impor-tant measure for achieving improvedesthetic outcomes.7,10

Despite the contraindication of place-ment of fresh-socket implants in infectedsites,11,12 more recent clinical studies13-15

reported excellent clinical results of im-plants placed immediately in periodon-tally infected sites.

There are also several reports on theuse of immediate implants after theextraction of endodontically compro-mised teeth. Siegenthaler et al.16 andLindeboom et al.17 reported that the im-mediate placement of a dental implant inan extraction socket with a periradicularinfection does not have a higher rate ofcomplication than one placed in an unin-fected site. Novaes et al.18 confirmed that

* Department of Dentistry, Vita Salute University, San Raffaele Hospital, Milan, Italy.

doi: 10.1902/jop.2010.090666

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the presence of periapical lesions may not representa contraindication if appropriate clinical proceduresare followed to clean and decontaminate the surgicalsite. Rosenquist and Grenthe12 confirmed that imme-diate implant placement after the extraction of teethwith a root fracture or resorption has a higher successrate than that of periodontally compromised teeth.However, only a few studies13-16 regarding fresh-socket implants in infected sites were published,and, to our knowledge, no prospective randomizedstudies have been conducted to determine the possi-bility of this surgical procedure. The purpose of thisprospective 4-year study was to compare the out-comes of immediately loaded implants placed for sin-gle, partial, and complete rehabilitation immediatelyafter the extraction of teeth with and without chronicperiodontal lesions after a flapless procedure.

MATERIALS AND METHODS

Patient SelectionBetween February 2005 and October 2005, 37 pa-tients (23 females and 14 males; age range: 32 to71 years; mean age: 52.5 years) were selected for thisprospective study and treated by one oral surgeon(RC) and one prosthetic specialist (EG) at the Depart-ment of Dentistry, San Raffaele Hospital. A total of275 implants in extraction sockets; 197 implantsin periodontally infected sites (infected sites group[IG]), and 78 implants were placed in non-infectedsites (non-infected sites group [NG]).

The following inclusion criteria were adopted: goodgeneral health, no chronic systemic diseases, thepresence of hopeless teeth requiring extraction, ‡3mm of bone beyond the root apex, and the presenceof four bony walls of the socket. Immediate loadingwas performed when an insertion torque ‡35 Ncmwas achieved. Exclusion criteria were: the presenceof chronic systemic disease, smoking >10 ciga-rettes/day, bruxism habits, uncontrolled diabetes,coagulation disorders, alcohol or drug abuse, and re-duced compliance after oral hygiene sessions.

The local ethical committee approved the study,and all patients gave their informed written consentfor immediate implant placement.

Surgical ProtocolOne hour prior to surgery, the patients received 1 gamoxicillin and 1 g amoxicillin twice a day for a weekafter the surgical procedure. Surgery was performedunder local anesthesia.†

A total of 197 teeth were extracted for periodontalreasons, 20 teeth were extracted for endodontic rea-sons, 39 teeth were extracted because of root decay,and 19 teeth were extracted because of root fracture(Table 1). The procedure was performed without mu-cogingival flap elevation, and a periodontal probe‡

was used to verify the presence of the four wallsof the fresh sockets (Figs. 1A and 1B). Many socketspresented different wall heights, so the buccal heightwas a little different from mesial or distal heights, butdeep dehiscences or fenestrations were excluded inthis clinical study. All granulation tissue was carefullyremoved from the sockets and rinsed using a physio-logic solution.

The implant site was prepared with standard drillsfollowing the palatal bony walls as guides, and the api-cal portion of the implant was always placed ‡4 mmbeyond the root apex. To ensure primary stability,the drilling protocol included underpreparation ofthe implant sites without screw tapping or counter-sinking.9 The coronal margin of the fixture was lo-cated at the buccal level of the bone crest.

A screw-shaped implant§ with a machined neck for0.8 mm and a rough-surface body with a progressive-thread design and external hexagon was used for allimplant placements. Implant size and insertion posi-tions are presented in Table 1. After surgery, a chlor-hexidine mouthwash was prescribed twice daily forthe next 15 days.

Prosthetic ProtocolAfter the surgical procedure, all patients immediatelyreceived temporary abutments and prosthetic resto-rations (Fig. 1C).9 Prefabricated acrylic-resin crownswere used for single-tooth replacements. For partialor complete temporary prostheses, fixed temporaryrestorations with a fiber-reinforced framework werecustom fit with acrylic resin around the margins orthe abutment and affixed with temporary cement.i

Distal cantilevers were avoided. All temporary crownswere in full contact in centric occlusion. Occlusal sur-faces were flattened to reduce horizontal relations. Allpatients consumed a soft diet (avoiding bread andmeat) for 2 months.

Follow-UpFollow-up visits were performed by a dental hygienist(Elisabetta Polizzi, Department of Dentistry, San Ra-faele Scientific Institute, Milan, Italy) every 6 monthsafter implant placement. The following clinical pa-rameters were checked: plaque and bleeding indicesat four surfaces around the implants, pain, occlusion,and prosthesis mobility.19-21 Success criteria were im-plant stability and the absence of radiolucency aroundthe implants, mucosal suppuration, and pain.10

RadiographsIntraoral digital radiographs¶ (Fig. 2) were taken atbaseline and 12, 24, and 48 months after implant

† Optocaine, Molteni Dental, Scandicci (FI), Italy.‡ Hu-Friedy PGF-GFS, Hu-Friedy, Chicago, IL.§ Titanium Plasma Spray, Sweden-Martina, Padova, Italy.i Temp Bond, Kerr Manufacturing, Romulus, MI.¶ Schick CDR, Schick Technologies, Long Island City, NY.

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placement. Periapical radiographs were taken per-pendicularly to the long axis of the implant witha long-cone parallel technique using an occlusal tem-plate to measure the marginal bone level. A radiolo-gist (PC) twice measured the changes in marginal

bone height over time: hemarked the reference pointsand measured lines on thescreen interactively (the nu-meric value of measurementswas reported by software#).The implant height (a known di-mension) was used for calibra-tion. The marginal bone levelwas considered from the refer-ence point represented by themore coronal portion of the im-plant in contact with the bone tothe point where the bone tissuemet the implant surface at themesial and distal sites. Differ-ences of bone level were mea-sured by software** (Fig. 3).

The intraexaminer error wascalculated by comparing thefirst and second measure-ments with a paired t test ata significant level of 5%. No sta-tistically significant differencewas calculated between values(P >0.05).

Placement of the DefinitiveProsthesisThree months after implantplacement, temporary crownsand abutments were removed.Transfer copings were insertedinto the internal hexes of theimplants with a seating instru-

ment and secured with abutment screws. Impressionswere made with a polyether material†† using an

Figure 1.A) Radiograph of teeth with advanced periodontal disease. B) Clinical view of tooth extraction. C) Implantplacementwith screwed temporary abutments. D)Clinical view of final abutments. E) Final prosthesis after5 months.

Table 1.

Implant Positions and Dimensions for IG and NG

IG NG

Implant Size (mm) Implant Size (mm)

Implant Position 5.0 · 13 3.75 · 13 Total Implants (n) 5.0 · 13 3.75 · 13 Total Implants (n)

Incisors 67 14 81 21 8 29

Canines 24 5 29 7 1 8

Premolars 62 25 87 33 8 41

Total 153 44 197 61 17 78

# Schick Technologies.** Schick Technologies.†† Impregum; ESPE, Seefeld, Germany.

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individual impression tray. Prepared definitive metalabutments were screwed onto the osseointegrated im-plants (Fig. 1D).

Five months after implant placement, definitivemetal-ceramic restorations were cemented onto thedefinitive abutments (Fig. 1E). The occlusal contactswere distributed over the arch with anterior guidance(group guidance in lateral excursions), with light con-tact on the distal cantilevers for full-arch prostheses.

StatisticsDedicated software‡‡ was used for all statistical anal-yses. Clinical parameters were calculated for each im-plant and were reported as the mean – SD at baselineand at 48 months of follow-up. Radiographic bonelevel values (mesial, distal, and mean bone loss), werecalculated for each implant and were reported as themean – SD at baseline and at 12, 24, and 48 months(Fig. 3). To compare differences between IG and NGdata at every time point, a Student two-tailed t test wasadopted; P <0.05 was considered the threshold forstatistical significance.

RESULTS

Surgical and Prosthetic ProcedureAfter 48 months of follow-up, implants of the NG re-ported a survival rate of 100%. In the IG, the survivalrate was 98.9% because two implants were lost1 month after placement and were replaced 2 monthslater, one implant presented peri-implantitis 3 yearsafter placement. No pain or final prosthesis mobilitywas recorded. There was a suitable wound healingaround temporary abutments with a fine adaptationto the temporary crown. Minor swelling of gingivalmucosa was present in the first days after surgical pro-cedures; no mucositis or flap dehiscence with suppu-ration was found. The final ceramic-fused-to-metalrestorations were cemented 5 months after implantplacement.

Clinical ParametersAt baseline, plaque accumulation was 0.48 – 0.31 forthe IG and 0.53 – 0.37 for the NG; at 48 months, it was0.72 – 0.41 for and 0.71 – 0.38, respectively. At base-line, the bleeding index was 0.53 – 0.26 for the IG and0.49 – 0.38 for the NG; and at 48 months, it was 0.78 –0.23 and 0.75 – 0.39, respectively. No statisticallysignificant differences between IG and NG values werereported for plaque accumulation (P >0.05; P = 0.55 at48 months) and the bleeding index (P >0.05; P = 0.32at 48 months). Moreover, for the IG and NG, no statis-tically significant differences between time pointswere reported (P >0.05; the most marginal P valuewas for the bleeding index for the NG: P = 0.11). Thesefindings confirmed the maintenance and health overtime of peri-implant soft tissues.

RadiographsRadiographic results are reported in Table 2. Baselinemarginal bone levels were 1.01 – 0.37 mm for the IGand 1.03 – 0.36 mm for the NG. Both the IG and NGshowed good maintenance of bone levels, which re-sulted in a mean bone loss at 48-months of follow-up of 0.79 – 0.38 mm for the IG and 0.78 – 0.38mm for the NG. Non-statistically significant differ-ences between IG and NG values (P = 0.54 at 48months) were reported. Moreover, for the IG andNG, non-statistically significant differences betweentime-point values (P = 0.23 for the IG and P = 0.18for the NG) were reported. These findings confirmedthe hard tissue maintenance over time.

DISCUSSION

In the present study, the bone-healing process wassuccessful for immediately loaded implants placedin fresh sockets for single, partial, and complete reha-bilitations. The implants placed after extraction ofteeth with periodontal lesions presented marginalbone levels similar to the implants positioned into

Figure 2.A) Radiograph 12 months after implant placement. B) Radiograph 4years after implant placement.

‡‡ SPSS 11.5.0, SPSS, Chicago, IL.


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non-infected sites because non-statistically signifi-cant differences between IG and NG values (P >0.05)were reported; moreover, an enhancement of the min-eralization process of marginal bone around implantsover time was observed.

The same results were reported by Villa andRangert,22 who evaluated the survival rates of imme-diate and early loaded implants placed immediatelyafter extraction of teeth with endodontic and peri-odontal lesions, after socket irrigation with an antibi-otic solution. After 1 year, no signs of infection aroundthe implants were detected; furthermore, there wasa tendency toward less bone loss with the flapless pro-

tocol (mean bone loss: -0.74 [1.34] mm) than withthe flap protocol (mean bone loss:-1.02 [1.60] mm).

These successful results can probably be explainedby biologic events during healing process, dependingon biomechanical, surgical, and medical principles,the implant stability, load control, and the inflamma-tory response.

In human studies,15,16,22 implants were immedi-ately placed after extraction of teeth with signs ofchronic periapical periodontitis,15 pain, periapical ra-diolucency, fistula, and suppuration,16,22 the muco-periosteal flap was elevated for granulation tissuedebridement, and the bone-healing process was ob-tained. It was concluded that for those implants withprimary stability, the immediate placement into in-fected sites did not lead to an increased rate of com-plications and rendered an equally favorable typeof tissue integration of the implants. Extraction ofthe involved teeth with socket degranulation led tothe eradication of the cultured microorganisms,15

and immediate implant placement may be beneficialin maintaining the integrity of the extraction socketsand contribute to the maintenance of the interdentalpapillae around implant restorations.23

In a prospective study, Kan et al.24 evaluated 35threaded, hydroxyapatite-coated implants that wereplaced and provisionalized immediately after each fail-ing tooth had been removed, and after 12 months, allimplants remained osseointegrated with minimal mar-ginal bone-level changes (–0.26 – 0.40 mm mesiallyand –0.22 – 0.28 mm distally). In a similar study,Cornelini et al.7 reported no implant failure at 12 months;radiographs revealed a mean bone resorption of 0.5mm after 1 year, and the mean variation of gingival levelcompared to the neighboring teeth was -0.75 mm.

The minimum marginal bone-level change re-ported in the present study after 48 months may havebeen due to the flapless implant surgery because flap

Table 2.

Radiographic Results (marginal bone levels; mean – SD) at 48 Months FromImplant Placement

Time Mesial Bone Loss (mm) Distal Bone Loss (mm) Mean Bone Loss (mm)

IG (n = 197 implants)Baseline 0.98 – 0.32 1.04 – 0.42 1.01 – 0.3712 months 0.75 – 0.42 0.79 – 0.37 0.77 – 0.3924 months 0.79 – 0.45 0.80 – 0.51 0.82 – 0.5248 months 0.71 – 0.45 0.76 – 0.32 0.79 – 0.38

NG (n = 78 implants)Baseline 1.00 – 0.34 1.07 – 0.38 1.03 – 0.3612 months 0.84 – 0.43 0.88 – 0.51 0.86 – 0.4724 months 0.83 – 0.47 0.85 – 0.46 0.84 – 0.4648 months 0.75 – 0.39 0.81 – 0.38 0.78 – 0.38

Figure 3.Graphic representation of marginal bone levels in IG and NG overtime (in mm).


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reflection induces tissue loss, which negatively influ-ences implant esthetic outcomes.25,26 Conversely,by using a flapless procedure, a bone regain of 3mm around exposed threads was reported.15,27,28

CONCLUSIONS

The immediate placement of implants in chronicallyinfected sockets may not be necessarily contraindi-cated if appropriate clinical procedures like antibioticadministration, meticulous cleaning, and alveolar de-bridement are performed before the implant surgicalprocedure; and from the data of this present study, forthose implants where primary stability was achieved,the immediate implant placement in periodontally in-fected sockets did not induce an increased rate ofcomplications and rendered an equally favorable softand hard tissue integration of the implants.

Unfortunately, the data regarding the bone-healingprocess around implants immediately placed in peri-odontally infected teeth are limited. Therefore, furtherstudies are mandatory to evaluate clinical and histo-logic outcomes.

ACKNOWLEDGMENT

The authors report no conflicts of interest related tothis study.

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Correspondence: Dr. Roberto Crespi, Department ofDentistry, Vita Salute University, San Raffaele Hospital,Via Olgettina N. 48, 20123 Milan, Italy. E-mail: [email protected].

Submitted November 30, 2009; accepted for publicationMarch 12, 2010.


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