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08 Volume 1 | Issue 1/2015 Journal ofOral Science & Rehabilitation

Immediate replacement of failed dental implants owing to periimplantitis

Abstract

O b j e c t i v e

This work aimed at determining whether immediate implantplacement to replace infected implants can be a treatmentmethod for periimplantitis.

M a t e r i a l s a n d m e t h o d s

Immediate replacement of failed dental implants requires a con-servative implant extraction technique capable of preserving asmuch viable soft and hard tissue as possible. An implant extrac-tion kit was employed to extract safely dental implants failedowing to periimplantitis. The explantation socket was curettedand decontaminated before the immediate placement of newimplants. The implants were then followed clinically and radi-ographically to assess their survival rate.

R e s u l t s

Seven patients were treated to remove nine implants. The faileddental implants were extracted at a torque of 162 ± 41 N cm. Thepresence of dental plaque and metallic contamination due to surface cleaning was detected under a scanning electron micro-scope. The implants were followed for 50 ± 2 months after place-ment and 43 ± 3 months after loading. No implant failure was reg-istered during this period. The mesial bone loss was 1.0 ± 0.8 mmand the distal bone loss was 1.0 ± 0.8 mm.

C o n c l u s i o n

The survival of all implants and the minimal marginal bone losswould support this procedure for the immediate replacementof dental implants in sockets affected by periimplantitis.

K e y w o r d s

Periimplantitis, implant removal, immediate implant place-ment, implant survival.

P e r i i m p l a n t i t i s : I m m e d i a t e i m p l a n t r e p l a c e m e n t

Introduction

The high predictability of dental implants makesthem the first choice for replacing missingteeth.1–3 This, in addition to the long-term suc-cess of implant-supported fixed prostheses,4 re-sults in the wide acceptance of implant therapyamong the general population.

New improvements in clinical protocols canincrease the predictability of implant therapy fur-ther and reduce rehabilitation time and cost. Onesuch improvement is the graftless rehabilitationof missing teeth. Lazzara et al. have introducedthe concept of immediate implant placement af-ter tooth extraction.5 This procedure results in areduction in the number of surgical proceduresand in the time required to complete oral rehabil-itation.5, 6 Also, immediate implant placement isone of the surgical procedures by which toachieve alveolar ridge preservation.4

Published data document the high successrate of immediate implant placement and sup-port the predictability of the technique in the ab-sence of periapical lesions.4, 7–10 Even in the pres-ence of periapical infection, recent research hasshown that immediate placement of dental im-plants is possible provided there is adequatesocket cleaning and decontamination.10–12 In arecent randomized clinical trial, Montoya-Salazar et al. studied the influence of periapicalinfection on the success rate of immediatelyplaced dental implants after tooth extraction.10

The infected sockets were curetted and decon-taminated before implant placement.10 In thegroup of infected sockets, all implants placedwere successfully osseointegrated and loaded.The three-year survival rate was 94.44% withno significant differences when compared withthe noninfected socket group.10

Periimplant mucositis and periimplantitis are inflammatory diseases of bacterial origin, butbone loss only occurs in the case of peri -

Volume 1 | Issue 1/2015 09Journal ofOral Science & Rehabilitation


implantitis.13 The prevalence of periimplantitisvaries between different studies and a preva-lence (implant based) of 6.6–36.6% has beenreported.14–18 Dental implant extraction may beindicated in cases of advanced bone loss aroundthe implant. In these cases, could immediate im-plant replacement be considered?

No study has reported on immediate implantplacement after the extraction of infected dentalimplants. This dearth could be related to the needfor a predictable technique that permits conser-vative implant extraction that preserves most ofthe viable soft and hard tissue. At the same time,the technique should not damage the bony wallsof the socket and thereby compromise the os-seointegration of the new dental implant. A kitfor implant extraction has been developed to ful-fill the above-mentioned requirements and toenhance the possibility of achieving adequateimplant stability.1, 19

A clinical protocol that aims to decrease thebacterial load by curetting and decontaminationof the socket, maintain the regenerative capacityof the surrounding alveolar walls, and achieveprimary stability would result in favorable out-comes for immediate replacement of failed den-tal implants. In this article, we analyze the out-comes of this clinical protocol. To that end, failed,nonmobile, infected dental implants were ex-tracted using an implant extraction kit and new

implants were immediately placed in replace-ment of these. Plasma rich in growth factors wasplaced in the explantation socket before implantplacement. The extracted dental implants wereanalyzed under a scanning electron microscopeand the patients were followed for four years.

Materials & methods

O u t c o m e c r i t e r i a

In order to achieve the objectives of the study, de-mographic and anamnesis data were obtainedfrom the patients’ records. Implant failure wasdefined as any implant lost owing to failure toachieve osseointegration or to loss of acquiredosseointegration. The patient was the statisticalunit for the description of demographic data. Theimplant was the statistical unit for the statisticaldescription of implant location and removaltorque. For the new implants, data on insertiontorque, failure and marginal bone loss were col-lected. Implant length was used as a reference tocalibrate the linear measurements on the digitalpanoramic radiograph. Implant survival rate wasanalyzed using the Kaplan–Meier method. Allthe statistical analyses were performed usingthe SPSS for Windows statistical software pack-age (Version 15.0; SPSS, Chicago, Ill., U.S.).

Fig. 1

(a) A nonmobile implant withadvanced bone loss due toperiimplantitis. (b) Anextraction ratchet placed intothe implant connection. (c)Implant removal by applicationof counterclockwise torque.(d) The dental implant placedafter careful curettage of thesocket.

Fig. 1a b

c d


S u r g i c a l p r o t o c o l

In all of the patients, the same surgical protocolwas followed. All of the patients received pro-phylactic antibiotic medication before and af-ter surgery. Infiltrative anesthesia was admin-istered and incisions were made to elevate afull-thickness flap (Fig. 1). Implant explanta-tion was carried out using an implant extrac-tion kit (BTI Biotechnology Institute, Vitoria,Spain). A ratchet was first engaged into the im-plant connection and the removal torque wasexerted by a wrench in a counterclockwise di-rection, maintaining a perpendicular positionof the assembly in relation to the implant plat-form (Fig. 1).1, 19

After implant removal, the explantationsocket was carefully curetted to remove anygranulation tissue and immediate placement of anew implant was performed only in those sock-ets in which the four bony walls were preserved(Fig. 1). Bone drilling for placement of the newimplant was performed to remove only 0.2–0.5mm of bone. An implant with a wider diame-ter than that of the failed implant was thenplaced using a surgical motor set at an insertiontorque of 25N cm and the implant placementwas then continued manually to finish (Fig. 1).Activated fraction 2 of plasma rich in growth fac-

tors (PRGF-Endoret; BTI Biotechnology Insti-tute, Vitoria, Spain) was placed in the socket be-fore implant placement. The surgical site wasthen covered with a fibrin membrane before flapclosure.

In order to obtain plasma rich in growth fac-tors,20 peripheral blood was extracted byvenipuncture into two 9ml extraction tubes con-taining 3.8% sodium citrate (BTI BiotechnologyInstitute, Vitoria, Spain) and processed accord-ing to the manufacturer’s instructions. To acti-vate platelets and fibrin formation, 50μl of cal-cium chloride solution (PRGF Activator, BTIBiotechnology Institute, Vitoria, Spain) per milli-liter of plasma was employed. Activated fraction1 (platelet count comparable to the peripheralblood) was employed to prepare a fibrin mem-brane that was compressed (Fibrin compactor,BTI Biotechnology Institute, Vitoria, Spain) toprovide a thin and consistent membrane to coverthe surgical site before flap repositioning and su-turing with a 5-0 monofilament nylon suture.Activated fraction 2 (platelet count two to threetimes higher than peripheral blood) was injectedinto the implant bed and was used to humidifythe dental implants before placement. Follow-up visits were scheduled to remove sutures, detect any surgical complications and fabricatethe implant-supported prosthesis.


Fig. 2

Scanning electronmicrographs of five implantsremoved owing toperiimplantitis. All of theimplants showed clear signs ofbacterial contamination andplaque formation,accompanied by vertical boneloss. Full implant images havebeen reconstructed usingthree to five scanning electronmicrographs. The areas wherebone resorption around theimplants occurred arehighlighted (white line). Ascale bar is indicated for everyimplant image.

Fig. 2a b c d e

S c a n n i n g e l e c t r o n m i c r o s c o p y

The extracted implants were studied under ascanning electron microscope (SEM, Quanta200FEG, FEI, Eindhoven, Netherlands). Owing tothe presence of organic components on the sur-face after explantation, the samples were fixedwith a 2.5% glutaraldehyde solution (Sigma-Aldrich, St. Louis, Mo., U.S.) in phosphate-buffered saline (PBS, Sigma-Aldrich, St. Louis,Mo., U.S.) for 8h. The samples were then dehy-drated by sequential immersion in serial dilutedsolutions of 0, 10, 30, 50, 70, 90 and 100% v/v ofethanol in water. Dehydrated samples were thenair-dried, carbon-coated in a sample preparationchamber with a sputtering system (Gatan Alto1000E, Gatan, Abingdon, UK) and examined bySEM. Images were taken at 20 kV accelerationvoltage. The SEM-attached energy-dispersiveX-ray unit served to analyze the elemental com-position of the surface remnants.

Results

Seven patients with nine dental implants failedowing to periimplantitis were treated accord-ing to the previously described protocol. Six pa-tients were females and the mean age was61 ± 4 years. All patients were nonsmokers.

Six of the failed dental implants were in themaxillae. Four of the maxillary implants were inthe anterior region and all of the mandibularimplants were in the posterior region. The aver-

age extraction torque of the failed dental im-plants was 162 ± 41 N cm.

All of the explanted implants were analyzedby scanning electron microscopy. Figures 2and 3 show representative sets of SEM imagesof the explanted implants. All of the implantswere scanned completely at several magnifica-tions. The lower magnification was used to ob-tain a general image of each of the implants ex-tracted (Fig. 2). In these general images, tracesof dental plaque can clearly be observed at the coronal parts of the implants. The area depicted over the implants (white line) corre-sponds to vertical bone defects detected be-fore implant extraction. By increasing the mag-nification, details such as bacterial arrange- ments could be detected (Fig. 3). These weremainly cocci (Fig. 3: g & h) and bacilli (Fig. 3: b–f), although more sensitive techniques areneeded to correctly identify the particular bac-terial taxonomy. Biofilms disrupted by dehy-dration during the preparation of the samplescould also be clearly identified (Fig. 3: d). In a in Figure 3, energy-dispersive X-ray spec-troscopy (EDX) showed the presence of residueof inorganic materials on the implant surface,mainly iron and chrome. These particles couldcome from stainless-steel surgical tools usedto attempt to eliminate the plaque adhering tothe surface. From the image, we can clearly seethat not only did the biofilm remain on the sur-face, but these procedures also left contami-nants on the implant surface. In b in Figure 3, itcan be seen how the plaque preferentially



Fig. 3

Fig. 3

Scanning electronmicrographs showing detailsof the surfaces of the removedimplants shown in Figure 2. Insome cases, EDX wasperformed to determine thecomposition of particles foundon the titanium (Ti) surfaces.Several explants showedabundant microbialcolonization and biofilmformation (b–h). In somecases, attempts atdecontamination could betraced back to the surface ofthe implants: In a, weperformed EDX spot analysisof the particles found on thesurface and found that theycorresponded to surgical tools(stainless steel: Fe, Cr).Bacterial accumulation waspreferential in the rough partsof the implant surfaces(arrows in b and g).

a

b

c

d

g

hf

e


formed on the rougher parts of the surface.Overall, the evaluation of both the post-extrac-tion sockets and the SEM images of the implantsurfaces found that most of the dental plaqueremained adhered to the removed implant sur-faces.

New dental implants were immediatelyplaced at a torque of 36 ± 16 N cm. Only two im-plants were placed at a torque of < 25 N cm.Two short implants of 5.5 mm × 5.5 mm and5.5 mm × 7.5 mm were placed. Three implantswere 8.5 mm in length and had a diameter of4.0, 4.5 and 5.5 mm, respectively. The rest ofthe implants were 10.0–13.0 mm in length and3.75–5.0 mm in diameter, respectively.

The nine implants gave support to a singlecrown, four partial fixed prostheses and four

complete fixed prostheses. All of the partialand complete fixed prostheses were screw re-tained. The implant loading was immediate forthe single crown and delayed for the partial andcomplete fixed prostheses.

The implants were followed for 50 ± 2months after placement (range: 48–52months) and 43 ± 3 months after loading(range: 40–48 months). No implant failure wasregistered during this period. The mesial boneloss was 1.0 ± 0.8 mm and the distal bone losswas 1.0 ± 0.8 mm. The marginal bone loss wasmeasured on radiographs taken after 40 ± 6months of implant loading. Figure 4 shows acase that was treated according to the de-scribed protocol and followed for four years after implant placement.


Fig. 4Fig. 4

(a) Preoperative panoramicradiograph showing thepresence of bone resorptionaround the dental implants inposition #34. (b) The immediate placementof a new dental implant. (c) The provisional prosthesis.(d) The provisional prosthesisone year after seating. (e) The seating of the definitiveprosthesis. (f) The clinical situation fouryears after implant placement.

a

c

e

b

d

f

Discussion

The results of this study support the immediatereplacement of failed dental implants after ex-traction. The clinical protocol followed for themanagement of failed dental implants wouldenhance the possibility of osseointegration ofdental implants placed in infected sites.

The positive outcomes of this protocolcould be related to the decrease in the bacterialload through the removal of the infected im-plant. The SEM analyses showed that bacterialplaque still adhered to the implant surfaceupon removal, and this represents a first step inthe cleaning of the extraction socket. Adequatesocket curettage to remove any granulationtissue and the drilling of the socket would addi-tionally contribute to the mechanical deconta-mination of the socket. Furthermore, place-ment of PRGF-Endoret in the socket could havehad an antimicrobial effect. It has been re-ported that PRGF-Endoret has antimicrobialeffects against Candida albicans, Enterococcusfaecalis, Streptococcus agalactiae, Streptococ-cus oralis, Staphylococcus aureus and Staphy-lococcus epidermidis.21, 22 All of these measureswould reduce the risk of infection and early im-plant failure.

Implant primary stability is crucial for im-plant osseointegration and is the result of me-chanical anchoring (direct contact) of the im-plant to the host bone.23 Implant primary sta-bility serves to prevent excessive implantmicromovements and thus permit implant osseointegration.24 The insertion torque of thedental implants placed in this study was36 ± 16 N cm. Engelke et al. have concludedthat an insertion torque of > 30 N cm is advis-able to obtain adequate primary stability and atorque of ≤ 11 N cm is considered a risk factorthat increases the likelihood of implant fail-ure.25

Different methods to remove osseointe-grated dental implants have been described.Some of them include trephining a bone blockin which the dental implant is present and theuse of a thin bur at low speed with irrigation toseparate the implant from the surroundingbone.1, 19 These methods have the limitation ofbeing traumatic and of jeopardizing the explan-tation socket for future implant placement.

In this study, the use of an implant extrac-tion kit was efficient and minimally invasive inremoving dental implants while preserving the

alveolar bone. This made it feasible to replacethe failed implant immediately. This immediatereplacement of failed implants reduced thenumber of surgical procedures required to treatthe patient.

In a recent study,81 patients were treatedwith the same implant extraction kit to remove158 nonmobile implants from the maxillae andthe mandible.1 With the kit, the conservation ofhard and soft tissue is possible and implant fail-ure can be resolved within a shorter period andat reduced cost by avoiding advanced tissue regeneration techniques.

Conclusion

Atraumatic implant explantation permitted thepreservation of viable tissue and the immediateplacement of a new implant. The implant survivaland marginal bone loss outcomes would supportthe immediate placement of dental implants in asocket affected by periimplantitis.

Competing interests

EA is the Scientific Director of BTI Biotechnol-ogy Institute (Vitoria, Spain) and head of theEduardo Anitua Foundation (Vitoria, Spain).MHA and RT are scientists at BTI Biotechnol-ogy Institute (Vitoria, Spain).



Eduardo Anitua,*†

Mohammad Hamdan Alkhraisat†

& Ricardo Tejero†

*Private practice in oral implantology, Vitoria, Spain†Eduardo Anitua Foundation, Vitoria, Spain

C o r r e s p o n d i n g a u t h o r :

Dr. Eduardo AnituaCalle José María Cagigal, 1901007 VitoriaSpain

T +34 945 16 0653F +34 945 16 [email protected]



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References

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