Implant Placement in Infected Sites

Immediate post-extraction implant placement is an accepted protocol that offers a number of advantages including: the preservation of aesthetics, shorter total treatment time, maintenance of socket wall, reduced surgical time, and better actual placement. In addition, it minimizes the number of surgical procedures by combining an extraction with implant placement and bone grafting—all in one appointment. Furthermore, with continuous improvements in implant materials, design, and surface treatment techniques, patients are provided enhanced function, aesthetics, and comfort. However, the concept of immediate placement of dental implants after removal of a tooth with periapical pathology is still a matter of debate.

BACKGROUND
Novaes and Novaes¹ report that success can be achieved in immediate implant placement for replacement of teeth with periapical lesions if certain preoperative and postoperative measures are followed. Such measures include: antibiotics administration, meticulous cleaning, and alveolar debridement, before the surgical procedure.1 It has been shown that use of chemical means can only kill bacteria at a 100-µm level. But, by the use of laser technology, especially the use of hydroacoustic effects, bacteria more than 1,000 µm² can be killed and at the same time a regional acceleratory phenomenon can be initiated.³
Pathogens left in osteotomy sites are dependent on the ability to debride the area, or to disrupt bacterial counts in the osteotomy. Debridement refers to the elimination of bacteria and their related irritants from the osteotomy space. With the use of internally irrigated drills during the preparation of the site, a smear layer forms on the walls of the osteotomy sites. This is just as it does on the dentinal walls of a root canal preparation. Dentinal debris, in a combination with reagent, forms mud. Alveolar mud should be considered a “pathologic cocktail,” as it potentially harbors remnants of bacteria, and their related irritants.⁴
Recently, there has been significant interest in biofilms and their role in endodontics. A biofilm is a structured community of bacteria enclosed in a protective, sticky polysaccharide matrix that adheres to a root canal surface. Further, biofilm fragments have been observed to disrupt, drift, and reattach to any surface. On the external surface, these biofilms are referred to as plaque.⁵ Logically, 3-dimentional (3-D) cleaning procedures should be directed toward disrupting any given biofilm and breaking up this matrix, moving this infected mass into solution so it can be eliminated from the osteotomy site. In the author’s opinion, the factor that has the most effect on this disinfection is the hydroacoustic phenomenon. Compounding the challenge to kill microorganisms is their ability to hide within anatomically complex spaces.⁶

ENTER THE ER,CR:YSGG LASER
The erbium, chromium: yttrium-scandium-gallium-garnet (Er, Cr:YSGG) laser is an FDA-approved laser system for cleaning, shaping, and enlarging the root canal. It is also used for use in osseous, apical, and periodontal surgery. The Er, Cr:YSGG laser can remove calcified hard tissue by emitting a beam of infrared energy at 2.78 µm that works in combination with a water spray. The Er, Cr:YSGG laser has assisted in speeding healing, decreasing postoperative pain, and increasing bone-to-implant contact.
For implant dentistry, the laser can be used to cut flap preparations, detoxify the osteotomy sites, tissue welding, and to start angiogenesis. It does this by using radial firing tips that emit laser, and water energy in a lateral pattern. The energy is to be thought an incredible explosion of water energy like a tsunami wave. Studies done at Temple University have shown the effect of this energy.7 Case reports done by Colonna and DiVito,⁸ reported at the World Clinical Laser Institute meeting, have shown that, by angling the laser tip, laser energy is increased without damaging the canal space. Initially developed to debride the root canal space, in the author’s opinion and experience, one has the perfect tool to disinfect the osteotomy site. Periodontal studies, done independently by Dr. John Hendy,⁹ have demonstrated that this type of laser energy is also beneficial in the elimination of periodontal pockets. Even hopeless teeth have been saved by the use of this device.
The purpose of this article is to show that Er, Cr:YSGG laser is a highly successful technology for placement of immediately loaded implants into infected sites. It will demonstrate the use of computed tomography (CT) technology to achieve proper implant placement, along with the use of Er, Cr:YSGG laser (BIOLASE Technologies) to achieve the detoxifying effect of hydroacoustics.

CASE REPORT 1
Diagnosis and Treatment Planning

Figure 1. Preoperative x-ray of tooth No. 10 (case report 1).

A 42-year-old female presented to our office for evaluation of tooth No. 10 for replacement with a dental implant. The patient’s main complaint involved internal resorption that had reached a stage where the coronal portion of the tooth had become loose. A fistula was present facially on the attached tissue. No pocketing greater than 2 mm was found around the tooth. Radiographically the tooth showed radiolucency in the midroot region at the point of the internal resorption (Figure 1).
The patient’s dental history included numerous previously placed alloys, composite fillings, and crowns. Tooth No. 10 had a history of root canal therapy, completed 15 years prior to this examination. There was no soreness in the muscles of mastication, or any history of tempromandibular disease (TMD) problems. There were no significant medical problems noted on the patient’s health history.
Dental records were obtained including a periapical x-ray of tooth No. 10, a Panorex radiograph, upper and lower alginate impressions, a facebow (Panadent), and clinical photos. A CT scan was taken and then reformatted for use with Simplant software (Materialise). From the Simplant program, the ideal position to place the implant was planned. Hounsfield units were in the range of 800. The Simplant planner showed that the ridge width was 6.78 mm at the crest, and 5.47 mm at the mid-crest region. The length to the floor of the nasal cavity is 18.49 mm. A 3.8 x 13 mm XiVE implant (DENTSPLY Friadent) was selected to fit in the desired space. (As part of the Simplant planner, the clinician can e-mail for the fabrication of the SurgiGuide.) In this case, the diameters of the guides were 1.5, 2.0, and 3.4 mm. After being informed about the pros and cons of every option, the patient opted for an implant supported crown.

Surgical Treatment Phase

Figure 2. Tooth No. 10 was removed atraumatically.	Figure 3. Er, Cr:YSGG laser was used to detoxify osteotomy site.

Figure 4. PepGen P-15 Flow (DENTSPLY Friadent) grafting material being placed.

Figure 5a. Finished case.	Figure 5b. Completed case, 2 months post-op.

The patient rinsed with 0.12% chlorhexidine gluconate oral rinse (Peridex [Omni Preventive Care, a 3M ESPE company]) for 30 seconds. Venipuncture was accomplished in the right antecubital fossa. Intravenous sedation was performed to produce a mildly sleepy state. The drugs used were Benadryl, Nubain, and Versed. On completion of the sedation, cefazolan and dexamethasone were used. Local anesthetic of 20 mg of lidocaine (10 mcg of epinephrine) and 5 mg of Marcaine (5 mcg of epinephrine) were used as well.
The tooth was extracted as atraumatically (Figure 2) as possible using periotomes and proximators to elevate out the root. SurgiGuide was used to place the implant in the most ideal position, starting with a 1.5 pilot drill, followed by 2.0 and 3.0 internally-irrigated drills. Waterlase MD (BIOLASE TECHNLOGIES) was then used, with an MZ-4 tip that has a radial firing tip to allow better detoxification. The laser tip was inserted into the osteotomy at the apex then fired at 1.0 W 18/32 20 Hz, in a clockwise fashion moving coronally, having the tip contact the walls of the osteotomy (Figure 3). About 1 minute was spent detoxifying the osteotomy site. The majority of the time (total time at 60 seconds) was spent in the area of most infection.
PepGen P-15 Flow (DENTSPLY Friadent) (a putty grafting material) was used on the facial of the osteotomy, being careful not to fill the apical aspect of the osteotomy (Figure 4). This would allow the graft material to flow into void areas between the osteotomy and the implant body, as the implant was seated.
The implant fixture that was chosen was a XiVE implant (DENTSPLY Friadent) 3.4 x 13 mm. The osteotomy was under prepped (3.0 mm) to gain better initial stability. The threads of this implant are self-tapping and easily seat with moderate pressure. The base of the implant was seated to crest of the alveolar bone and impressions (Aquasil [DENTSPLY Caulk]) were taken for the laboratory fabrication of a custom post and final crown. A temporary crown (Luxatemp [DMG America]) was then fabricated with a prefabricated putty stint. The temporary was under-contoured and the YSGG used to de-epethialized the keratinized tissue around the implant site. The author has found this procedure to stimulate the growth of the tissue, thus preventing any tissue shrinkage. Finally, the area around the implant was sealed using Per Acryl (GuStitich) cement. Photomodulation (Laser Smile Biolase Technology) was done under pulsed mode, with 1.5 W 30/30 for 30 seconds. Using photomodulation allows the cells to repair themselves quickly and reduces histamine release.¹⁰ Photomodulation energizes the mitochondria within the cells to produce this effect.
The case was seated with the final post and crown in 3 months following the surgical procedure. Note the nice tissue contour in Figure 5a on the day of seating and in Figure 5b at the 2 month post-op follow-up visit.

CASE REPORT 2
Diagnosis and Treatment Planning

Figure 6. Preoperative photo of tooth No. 9 (case report 2), note fistula.

A 38-year-old female presented to our office with tooth No. 9 that had extensive external resorption. An endodontist had told her that the tooth could not be saved. Clinically, the patient presented with a large fistula (Figure 6) in the facial area of the keratinized tissue. The soft tissue exam was normal, with no pockets greater than 3 mm other than tooth No. 9. There was no pain in the muscles of mastication and no history of TMD problems. The patient did not have any medical complications.
Dental records were obtained including: a Panorex radiograph, periapical x-rays, upper and lower alginate impressions, a face-bow (Panadent), and clinical photos. A CT scan was completed to determine the extent of the destruction of the alveolar bone surrounding the tooth. Additionally, if the patient chose to do treatment, the case could be planned using 3-D software (Simplant). After being informed of the pros and cons of every option, the patient opted to have tooth No. 9 extracted and to have an immediate implant placement with an immediate temporary restoration. Then, after 3 months of healing, the permanent restorations would be placed.
Using the Simplant software the ideal position of the implant was determined. A XiVE 4.5 x 13 mm implant was to be used. It was noted that there was a defect in the facial plate (5 mm in width and 4 mm in length). The Hounsvield units noted were in the range of 1,100. This was sufficient enough to be able to do an immediate placement along with a temporary restoration at the time of extraction. It was determined that grafting would need to be done, along with the placement of a resorbable barrier to prevent tissue invagination.

Surgical Treatment Phase

Figure 7. Placing Biomend Extend (Zimmer) in the pouch created in the facial tissue.	Figure 8. Final restoration. Note that the tissue heights between teeth Nos. 8 and 9 match.

The surgical phase of the treatment proceeded, as stated in the previous case. However, in this case the removal of the tooth was accomplished utilizing the Physics Forceps (GoldenMisch). The entire tooth was removed atraumatically (in less than a minute) without damage to the facial plate. The Er, Cr:YSGG laser was then used to detoxify the infection in the coronal one-third of the tooth before making the osteotomy. Finally, after implant placement, the Er, Cr:YSGG laser was used to make a pouch incision for the placement of the barrier membrane (Figure 7) Biomend Extend (Zimmer). PepGen P-15 Flow was placed to fill the void caused by the external resorption.
The case was seated at the 3 month time period. Note how the tissue level was maintained through the surgical procedure (Figure 8). The author attributes this to the stimulating effect that the laser has on the soft tissue.

CASE REPORT 3
Diagnosis and Treatment Planning

Figure 9. Large lingual fracture of tooth No. 13 (case report 3).	Figure 10. Physics forceps (Golden|Misch) were used to atraumatically remove tooth No. 13.
Figure 11. Er,Cr:YSGG is used to detoxify the osteotomy site.	Figure 12. Completed case.

A 53-year-old female had been vacationing in the Caribbean when she had bitten into something hard and damaged a tooth in her upper left quadrant. The patient phoned our office to discuss her situation. After visiting with her, it was confirmed that some type of fracture had probably occurred. When she arrived at the office, some days later, we observed that she had indeed fractured her tooth (Figure 9) mesially-distally, 6 mm below the gingival crest, exposing pulp tissue. The tooth was abscessed due to the trauma and resulting bacterial invasion.
The patient was informed that the tooth would need to be extracted. She was given an option of either placing an implant into position No. 13, or having a fixed bridge. She elected to have an immediate implant placement at the time of extraction. Since we did not have any of the previous mentioned dental records, it was elected to do a pulpectomy and temporarily restore the case until all records could be accomplished. The patient was comfortable for 2 months until we were able to get the surgical procedure completed.

Surgical Treatment Phase
Tooth No. 13 was extracted using the Physics forceps (Figure 10), and the osteotomy was accomplished. The osteotomy site was detoxified using the Er, Cr:YSGG laser (as described earlier) (Figure 11). The implant selected for treatment was a XiVE 4.5 x 13 mm. On surgical placement, an impression was taken for the final restoration, and a temporary post and crown was fabricated on the day of the initial surgery. Postoperatively, the patient experienced no pain and the 3 months healed uneventful.
The case was seated at the 3 months time period. Note the excellent tissue color during the entire healing process and the final results in Figure 12.

CONCLUSION
Immediate implant placement can be accomplished at the time of surgical placement in infected sites. This article described the successful treatment of 3 cases with different levels of infection present in the area of the implant placements.
The author has used this technique for 4 years and has had 2 failures (when using this technique) during this time frame. This is with over 200 fixtures placed (the greater majority being placed in the maxilla) using the described techniques. In one of the failures, the patient had been on biophosphonates for a short period of time.
With all the endodontic literature and research done on the use of hydro-acoustic effect of detoxification, it is the author’s opinion that this technique is a viable adjunct/solution for immediate placement of implants in infected sites. Treatment using this protocol helps our patients achieve immediate aesthetic success.

References

1. Novaes AB Jr, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J Oral Maxillofac Implants. 1995;10:609-613.
2. Moritz A, Jakolitsch S, Goharkhay K, et al. Morphologic changes correlating to different sensitivities of Escherichia coli and enterococcus faecalis to Nd:YAG laser irradiation through dentin. Lasers Surg Med. 2000;26:250-261.
3. Kusek ER. Use of the YSGG laser in dental implant surgery: scientific rationale and case reports. Dent Today. 2006;25:98-103.
4. López-Marcos JF. Aetiology, classification and pathogenesis of pulp and periapical disease. Med Oral Patol Oral Cir Bucal. 2004;9(suppl):58-62.
5. Nair PN. Pathogenesis of apical periodontitis and the causes of endodontic failures. Crit Rev Oral Biol Med. 2004;15:348-381.
6. Nair PN, Sjögren U, Krey G, et al. Intraradicular bacteria and fungi in root-filled, asymptomatic human teeth with therapy-resistant periapical lesions: a long-term light and electron microscopic follow-up study. J Endod. 1990;16:580-588.
7. Gordon W, Atabakhsh VA, Meza F, et al. The antimicrobial efficacy of the erbium, chromium:yttrium-scandium-gallium-garnet laser with radial emitting tips on root canal dentin walls infected with Enterococcus faecalis. J Am Dent Assoc. 2007;138:992-1002.
8. Colonna M, DiVito E. New research and delivery system for endodontics. Lecture presented at: World Clinical Laser Institute Super Symposium; January 25, 2008; San Diego, Calif.
9. Hendy J. Using the MD in the Hygiene Department and other Periodontal applications. Lecture presented at: World Clinical Symposium; 2007; Vail, Colo.
10. Hamajima S, Hiratsuka K, Kiyama-Kishikawa M, et al. Effect of low-level laser irradiation on osteoglycin gene expression in osteoblasts. Lasers Med Sci. 2003;18:78-82.

Dr. Kusek is a 1984 graduate of the University of Nebraska School of Dentistry. A general dentist for more than 25 years in Sioux Falls, SD, he is a Diplomate of the American Board of Oral Implantology/Implant Dentistry and the International Congress of Oral Implantologists, a Fellow of the American Academy of Implant Dentistry, and has earned Mastership in the World Clinical Laser Institute and the Academy of General Dentistry. He is adjunct professor at the University of South Dakota and lectures nationally on YSGG lasers. He can be reached at (605) 371-3443 or via e-mail at implantdental@midconetwork.com.

Disclosure: Dr. Kusek reports no conflict of interest.