Immediate implant placement is appealing to patients because it shortens the duration of treatment and the time the patient spends in a temporary restoration. While this strategy facilitates an efficient treatment protocol, comprehensive treatment planning is essential to success, and in some cases site development may be required in advance of implant therapy.
In the following case report, surgery was performed several months prior to extraction to address a periapical pathology that occurred following a failed apicoectomy. Immediate implantation would have been contraindicated without prior removal of amalgam remnants and elimination of the active infection. Further, grafting the periapical defect in advance of surgery maximized the amount of bone for the eventual implant, helping ensure the primary stability needed for a predictable outcome.
Grafting the periapical defect in advance of surgery maximized the amount of bone for the eventual implant.
A female patient presented with a maxillary lateral incisor crown on tooth #10 that was luted with temporary cement and had repeatedly debonded from the endodontically treated tooth, causing the patient to seek consultation. Radiographic evaluation revealed failing endodontic treatment and the presence of a periapical infection, along with a previous apicoectomy procedure. The tooth was deemed non-restorable. The patient agreed to a treatment plan in which the amalgam that was used to fill the root-end cavity was removed, the periapical defect grafted, and the site allowed to heal prior to extraction and immediate implant placement. This approach was taken because immediate implantation is not recommended when an active infection is present, and addressing the bone defect prior to implant surgery would serve to increase initial stability.
At the next appointment, a flap was reflected coronal to the mucogingival margin, the amalgam and granulation tissue were removed from the root tips, and the remaining exposed root structure of the tooth was thoroughly cleaned. After grafting the apical defect with cortico/cancellous allograft material, the flap was sutured and the site was allowed to heal for approximately four months.
When the patient returned for the extraction of the maxillary lateral incisor, the soft tissue and bone grafting site had healed well. The tooth was carefully extracted using a surgical elevator. After thorough cleaning and socket curettage, the labial plate was inspected and found to be intact, allowing for the immediate placement of a Hahn™ Tapered Implant (Glidewell Direct; Irvine, Calif.).
The implant osteotomy was positioned to allow approximately 2 mm of bone to the facial and palatal of the implant shoulder. The 3.5 mm x 13 mm Hahn Tapered Implant was initially inserted with a handpiece and threaded into final position with a torque wrench. The implant’s dual-lead thread design contributed to favorable primary stability, and a healing abutment was connected to the implant. Note that the small gap between the implant and the facial wall was grafted with cortico/cancellous allograft material.
The patient returned several months later for evaluation and exhibited excellent tissue health and implant stability. A closed-tray final impression was made and submitted for fabrication of the final restoration. To ensure an esthetic result in the smile zone, a custom zirconia hybrid abutment and BruxZir® Anterior crown were digitally designed and milled. The restoration was delivered without the need for adjustment and established precise margins, a natural emergence profile and lifelike esthetics.
When extraction with immediate implant placement is desired at the site of a failed apicoectomy, the presence of a periapical pathology and active infection are obstacles that can be overcome. Surgical intervention and bone grafting can be performed in advance of tooth extraction in order to resolve the infection and develop the site for immediate implantation, helping ensure the bone volume needed for high primary stability. This approach facilitates immediate implantation for patients who would otherwise be contraindicated for such treatment and demonstrates the versatility of implant therapy, as a unique treatment plan can be crafted to address the challenges of any given case.