Author: DR. RATNADEEP PATIL, DR. ANJALI DILBAGHI.
Smile Care Clinic Pvt. Ltd., Mumbai, India



Replacement of hopeless teeth with implant restorations has undergone significant progress since the introduction of osseo integrated implants and over time, implant surgery has evolved. Currently, implant placement into fresh extraction sites in a 1-stage fashion has proven to be a viable surgical option^1,2.There are some obvious advantages to the placement of implants at the time of extraction including better visualization and planning of prosthetic restoration, decreased number of surgical interventions, decreased healing time, possible improved maintenance of alveolar architecture ^3,4 and better patient compliance. It is also easier to manipulate the placement and position the implant with respect to the crest of the ridge as required by specific implant systems .As long as certain prerequisites are met, immediate placement could be considered a safe and viable procedure ⁵.

Several authors have stated that fresh extraction sites should be infection free to place immediate implants ^6,7 However, other recent studies ,including a retrospective study by Bell in 2011 reviewed patients who had implants immediately placed into fresh extraction site for the presence or absence of periapical radiolucencies, evaluated implant placement into fresh extraction sites affected by periapical pathology seem to suggest immediate placement of implants into sockets affected by chronic periapical pathology to be a safe and viable treatment option^8,9,10 This includes lesions caused by vertical root fracture, endodontic failures and caries( 11,12) The pathology at the receptacle dentoalveolar sockets could be varied and could include sub acute periodontal infection, perio-endo infection, chronic periodontal infection, chronic periapical lesion, and a periodontal cyst ¹⁰

A systematic independent review of articles published from 1982 up to and including November 2009 suggests implants can be placed into sites with periapical and periodontal infections. The sites must be thoroughly debrided prior to placement. Guided bone regeneration is usually performed to fill the bone-implant gap and/or socket deficiencies. Administration of pre- and postsurgical antibiotic therapy is required ¹³ A study published in May 2011 suggests implants immediately placed in sites demonstrating periapical pathology yielded results comparable to those immediately placed in pristine sites. The difference in survival rates was not statistically significant ¹⁴

The presence or absence of periapical and/or periodontal inflammatory lesions prior to defect debridement plays no role in the determination of whether or not to immediately insert an implant. Rather, it is the morphology and quantity of residual alveolar bone in the extraction socket area that determines whether or not an implant will be placed at the time of tooth extraction. If implants are to be placed at the time of maxillary or mandibular molar tooth extraction, the clinician must be able to insert such implants in ideal restorative positions.

Implant placement at the time of mandibular molar extraction should never be attempted if there is any doubt about the ability to place an ideal dimension implant in the appropriate restorative position and attain primary stability. In such a situation it is better to first perform regenerative therapy at the time of tooth removal and place the implant in a subsequent surgical session ¹⁵

All mandibular multi-rooted teeth are hemisected prior to removal. Specifically designed periotomes are used to effect atraumatic tooth extraction. It is imperative that the surgical site is assessed after tooth removal and defect debridement is accomplished. Once the tooth has been sectioned and each root has been independently and carefully extracted, implant placement should proceed in one of the following manner:

1. If the most crestal aspect of the interradicular bone is at least 3-mm-wide mesio-distally and if debridement of periapical lesion has resulted in loss of interradicular bone at the apical area keeping the crestal interradicular bone intact: An initial guide bur is used to apically extend the initial osteotomy if required. A tapered osteotome is inserted into the osteotomy and moved mesio-distally and bucco-lingually to expand the osteotomy site. Sequential drilling with alternating use of tapered osteotomes are utilized to prepare the osteotomy to depth. The chosen implant is inserted into the osteotomy appropriate regenerative materials are placed, and the flaps are sutured. Following maturation of the regenerating hard tissues, the implant is ready for restoration

2. If the interradicular bone does not demonstrate a mesio-distal dimension of at least 3 mm, or if the mesial and/or distal aspects of the interradicular septum are lost during site preparation: Following tooth hemisection and extraction, the depth and position of a guide pin are verified radiographically. When continued site preparation will result in loss of the mesial and/or distal aspects of the interradicular bone the bur has a tendency to chatter and “walk out of” the osteotomy into one of the root sockets, due to loss of the mesial and/or distal bony retaining wall(s). A variable pressure drilling technique is utilized to overcome this problem.¹⁶

The bur enters the interradicular bone at an angle, with the base of the bur engaging the lateral wall of the most apical extent of the osteotomy preparation. As the bur achieves a set point in the interradicular bone, it is straightened up and osteotomy preparation is begun. As osteotomy preparation continues, the mesial and/or distal aspects of the interradicular bone will be lost. In such a situation, pressure is applied against the buccal or lingual aspects of the interradicular bone as the bur enters the area. This pressure stabilizes the bur and allows the clinician to accomplish osteotomy preparation in an apical direction, thus stabilizing the bur and eliminating “chatter” as the bur enters the wider apical aspect of the interradicular bone. This same variable pressure joined technique is utilized with each subsequent bur.

Case reports with 1 year follow up of these techniques:

Apart from technical variations at extraction site, implant selection, design and neck diameter, implant body diameter and configuration and restorative options offered by the implant system are critical for the success of the procedure.

Using the techniques described ensures ideal implant positioning at the time of mandibular molar extraction ¹⁶. Thus, immediate extraction and immediate implant placement seems to offer a better cost benefit ratio to the clinician as well as to the patient and should be considered as a predictable treatment option.

Fig. 1: CAse 1A Preoperative	Fig. 1: CAse 2A Preoperative
Fig. 1: CAse 1B Immediate Post Surgery	Fig. 1: CAse 2B Immediate Post Surgery
Fig. 1: CAse 1C One year recall	Fig. 1: CAse 2C One year recall

References:

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2. Collaert B, De-Bruyn H: Comparison of Branemark fixture integration and short-term survival using one or two stage surgery in completely and partially edentulous mandibles. Clin Oral Implants Res 9:131, 1998
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