Patient with Periodontal Infection: Thoughts on Placing Dental Implant?

I would atraumatically extract, debride thoroughly, pack with spongistan and close with a pedicle ctg. I personally would not do a graft at the time of extraction in this case due to the size of the infection. Re enter at 10-12 weeks place your implant and graft bone, submerged healing. Then palatal incision and roll flap at uncovering. I think this is a case for the old school- give yourself multiple opportunities to supplement tissue both soft and hard tissue. My opinion, and I must stress it is just my personal opinion, is that the time for implantation is either at the time of extraction or after 10 weeks. Also, I would consider using a synthetic graft material rather than a second site to augment. Hope all goes well, mike

1.Extract, debride/curette aggressively. 2.No point in grafting at the extraction time because the graft won't take anyway. 3.No pre-op antibiotics needed, give it after debridement. 4.No soft tissue graft needed. 5.Autogenous bone graft is good, but to harvest bone just for that site is unwarranted. Let the site heal, re-evaluate, before even considering bone graft. Placement and restoring will be the easy part. Extraction will be the hardest part. Good luck on doing atraumatically. (It's good to plan it as an atraumatic extraction, but in my opinion extraction is the least predictable part of the whole implant procedure).

As previous adviser (Mike Ainsworth)make an atraumatic extraction. Then with the use of a dental microscope remove all granulation tissue and with Nd YAG laser sterilize the socket (you may want to use iodine with the laser). At our practice we use PRP (platelet-rich-plasma) by taking blood from the patient half an hour before extraction or surgery. The blood is centrifuged into it's different components. The fibrin is used to make a membrane and the PRP is mixed with synthetic bone. Then we start packing the socket densely with the PRP mix and finish by placing the fibrin-membrane finishing with a few sutures. We find that this procedure result in next to no bone loss, even if the buccal bone have been lost due to trauma or extraction procedures. In your case we would wait 3-6 month before placing the implant.

A piece of advice with the extraction. Use piezo periotomes. It will make your life (and your patient's) alot easier.

Routine root fracture case , always remove ASAP as will lead to significant bone loss . As all ( Ainsworth etc) above have said atraumatic removal important as well as effective curretage . What I routinely do then is leave for 3 weeks ( prior to serious modeling and re-modelling) to attain some soft tissue closure then place and graft with synthetic graft material ( bacterio-static) without the use of autogenous ( Patient has had enough trauma without a secondary site to harvest dead bone !)or a collagen type membrane ( restricts perioasteal blood supply to the healing site ) . Then load at 3 to 4 months dependant onm Patient physiology checking integration with Ostell. Done numerous over last 8 years and shown many extreme cases. Consistent low pain option for the patient. Peter

hey peter, I have not done a 3-5 week exposure for years, I found that people had alot of pain. Though I wasn't using synthetics at the time. What's your experience? I may have been using the wrong protocol or timing - In fact I think a good discussion on this would be beneficial for all of us as certainly for me it's still a foggy area. (best avoided!)

Ainsworth has said it all and further comments only added to this regimen. As Dennis Tarnow has stated many times...'Perform one miracle at a time.' Get the tooth out, curette well, evaluate later for what kind of facial defect you end up with...if any..and place implant with particulate bone.

I recommend grafting the site at the time of extraction as if not, there will be significant facial collapse. Regarding not grafting, as there is infection present, I would point out that as soon as one extracts a tooth or opens a flap, the area is non-sterile. I have socket grafted many cases with purulence at the time of extraction with good results. The key is good degranulation. I would also not recommend a laser or iodine, as you want a good bleeding bone site for healing of the extraction/graft site. I also do not recommend an autograft, as it is traumatic without a clinical advantage in this use. Also, as mentioned above, make sure you have a lot of extraction experience before tackling this case. Good luck.

Remove the tooth as atraumatically as possible, suture closed and allow to heal for 3 months prior to implant placement. There is conflicting reports about allograft augmentation of sockets after extractions.Some research actually shows you get reduced healing and increased bone loss using allograft as opposed to allowing to heal with a good blood clot alone. Of particular concern to me is the presence of all the fungus on the upper lip and chin. Experience shows that presence of facial hair increases substantially the risk of post operative infection when placing implants-be aware when placing the implant after socket healing.In excess of 50%of post-op infections are S Aureus( the nose being the major source), and of these up to 50% are Methecillin resistant.

I agree with D Anson above. Extracting and NOT grafting same day will lead to a facial plate collapse in 3-4 weeks, and further headaches down the way. My way of doing it: 1) Load on antibiotics for 7 day course. CHX rinse regimen. 2) Extract using periotomes, (without raising a flap, if possible) while under the antibiotics 3) Debride very well, make sure it bleeds. 4) Rinse area profusely with sterile saline/CHX 5) Graft with particulate bone graft AND suitable membrane, so that the graft is held in place. Overpack the particulate graft. 6) Loose fitting provisional flipper for 4 months, then place a bone-level implant. I have grafted in moderately infected sites under antibiotics and thorough curettage and seen good results. Autologous bone graft causes another site for pain and management. A bovine xenograft is my personal choice, stabilized with a membrane. Again, many ways to skin a cat. Good Luck!

looks to have plenty of bone apical to the broken tooth and probably has 3 walls to the extraction site. just extract and if the site looks clean and bloody after removing the deseased tissue then graft immediatly with particulate from a bottle and membrane. I would not place the implant at this time. If it does not look good enough, clean it and allow for soft tissue coverage then go back and graft with bone graft from a bottle and place the implant if there is enough good bone, if not graft and wait for healing. I would leave the implant submerged for 5 - 6 months before 2nd stage. There is no need to go to a donor site for the bone graft unless the patient insists on it.

Hi Mike will be out to see you in a few weeks , in root fracture cases to incidence of acute infection is higher thus more caution on immediate placement . Then it is a balance between sof tissue healing and bone modelling , the the 2 to 3 week window . I worry if there is pain the following day ( there never is) at placement. I only use Chlorhexidine as a pre-op mouthwash , once cut I never use it , we want to help the body heal. Even post op NO CHX just salt water rinse . With the next generation synthetic graft materials there is no need for a membrane as the graft is its own membrane ( it sets and is thus stable ,soft tissue cell occlusive yet vascular nano-porous ). As synthetics are bacterio-static there is a reduced chance of the graft becoming infected in these cases as well. This you know Mike as as user and I showed an impressive case of yours in Switzerland last weekend. Peter

Dr Daher on the Bicon webcasts shows several options for this situation, both using Synthograft and a bovine collagen membrane at time of extraction. One option just tucks the membrane down into the Facial socket and bending it over the occlusal portion and tipped with a section if Colla Plug. It can be done with or wthout immediate implant placement. I like to place the implant to help support and form the tissue healing and graft shape. Pre med with antibiotics will put some antibiotic into the graft/blood mix, but they say that placing antibiotics into the graft mix can alter the graft resorption rate. Irrigating the extraction site with sterile water will burst bateria with less interference in vine and graft healing. Of course this is followed by steril saline immediately. The nice thing about this procedure in a case like this one is at you ar "manufacturing" a large area of attached gingiva which may be used upon uncovering to replace what the patient is already missing. Damage to the bone and susequent gr

Hi Peter, It makes sense for re entry after 3 weeks from a biological standpoint. I just had a couple which didn't go well and from then on I decided not to do this technique. I'll do some reading and chat when you are over. I would just like to highlight Johns Manuel point Re: Sterile water, It's a great adjunct and a tip I got a few years back even for normal infected xla, (from where I don't know) and for something so simple it is very effective. From an imperial standpoint, when I started doing this my complication rates went down over night. All the best, Mike

People are so caught up with grafting the defect. Why? So what if there's a defect/collapse after extraction/healing. Let the sucker heal and revaluate. If we are so concern with high failure of immediate implant due to the compromised tissue, then what makes the graft be that much better at being taken by the site? It's the central incisor, so even with resorption on the buccal side, the ridge will still be relatively thick. Evaluate after healing and choose the correct implant diameter. Use one where the concept of "endosseous" is followed (ie. Stick it within the bone/ridge) Also, Base on the pre-op picture, his pre-maxilla is relatively "flat". Good for us since that means we can probably restore it with an angled abutment and correct crown contour. If you are skillful, implant using the cingulum approach, so you can have a higher chance of getting a screw retained crown. If you suck, then you either cement it with implant cement (temp bond) or graft the shit out of it and axial load the sucka. Expect screw loosening cause that's just the nature of the beast. Gingiva margin will look like shit with the screw retained though

Blah, You seem to have many valid, interesting and logical opinions, but respectfuly, your expertise loses some credibility with your street-wise choice of words. It must be a relief that your real name doesn't appear along with your "professional" advice. Just a thought.

To suggest no preop antibiotics is again , absurd. Why not lessen the offending bacterial count. I also encourage preop peridex rinse . There are some good studies ,and in my personal experience grafting the sight with bone(clinda)/prp after the obvious aggressive debridement ,results in in good graft survival. Unfortunately, this is about one of the only true remaining benefits of prp, aside from Improving handleing capacity of your graft material and Improving large facial soft tissue defect repairs. I am not condoning placing implants or grafting patients with active perio dz., I do think ,however ,that with some small localized infections, the benefit outweighs the risk. Two months ago, I placed an implant graft/gtr ,with this same situation on a retired dentist , and I would bet the bank on it's survival. I would not have done this on anyone else. I see our endo colleques doing single stage endo on active periapical infections. I can't imagine that this is such a good idea. B.Vinci G

I like the Tarnow's KISS rule...Keep It Simple, Stupid... :) You can never go wrong taking one step at a time. Remove the tooth, degranulate and irrigate the best you can. Some people will use a laser to remove any left over GRANULOMATOUS tissue (not granulation..that is associated with while the other is associated with infection). Some people will leave it alone after that. Personally, I would be willing to risk it by placing a resorbable membrane (if missing a buccal wall) with some Bio-oss and give the patient post op antibiotics. Good luck

Dr Ares. Unlike most of the self-claimed implantologists out there, I do not act 'better' than most and act all proper because that's not the way I am. Most people on this site write/talk/type proper;professional;experienced, but the fact of the matter is most do not do enough implants to give out advices. I question many of their approaches, which to me, sounds like they have no clue what they are doing and/or simply regurgitating what they learned from 'very expensive' lectures from well-known experts in the field.

routine pre-op anti-biotic is stupid! Especially when it's just a radiolucent leasion. Does nothing. Please tell me the guidelines set by ADA and American Heart Association in regards to prophylatic use of pre-op anti-biotic in dentistry!!!!!

By the way, Tarnow wasn't the first to use the KISS rule.......it's been in the english language for a longgggggg time now.......stop dropping names in order to sound credible.

Preoperative antibiotics is not stupid Mr or Miss Blah, specially in an infected site! I agree with Baker Vinci. It can be prescribed to reduce the possibility of neutralization of the anesthetic solution. As you all probably know, the pH of tissues with infection or even inflammation, is acid (

a pH

My comment got cut off... An acid pH can cause the anesthetic solution to dissociate and form inactive metabolites (up to 99% of the anesthetic). Clinically, that means the patient will not be anesthesized properly and will complain of pain during the extraction. I avoid extracting infected teeth without preoperative antibiotic treatment 1 or 2 days prior.

Dr a. Understands ph and dissociation and the reason the wifes tale came about; re . Don't take an infected tooth. IT'S BECAUSE YOU CAN'T GET YOUR PATIENT NUMB! dr. Blah the reason we make every effort to speak like civilized humans, is because, MOST OF US ARE! The am. Heart assoc. Does not dictate our means of tx localized infections. Nor do they dictate anything we do, but as a guy that delivers both the general anesthetic and does the surgery , they make a lot of good recommendations . Come on , keep it in the park, in bounds, between the gutters, or how ever you want to put it. With regards to numbers of implants; if your placing more than most of us, it is most likely , because you can't say no! You said it earlier, who is going to refuse to put an implant in some one with poor oh? I want remove wisdom teeth if the patient has poor oh. Do I need to explain the physiology of increased inflamation and intraop.bleeding. sorry for all the typos, trying to work out and write. Blah sure makes it easy to spin this thing bv

Want- will not

Also, might I add , this is why we sedate or put people to sleep to do these procedures. Blah, if taking that tooth out is the hardest thing you do , then might I suggest letting the guy next door do it . Wether she be a gp, perio or omfs! Did you really say that grafts don't work, in this scenario! I rode this thing 20 minutes longer than I thought. Bv

By the way Blah, in this case Antibiotic treatment would not be prophylactic.... but therapeutic!

Blah, if you were to read the initial scenario, the patient had purulence . It is frank, malpractice, to tx any other way. You have heard of cavernous sinus thrombosis, Ludwigs angina. Maybe you are blogging too late at night at night. "we all make mistakes" . You have the patient consented, light um up! Bv

keep it simple ext , scrape , bone gtr, antibiotics save yourself from future head ache

One last comment to dr. Blah, you suggest letting the sight contract( heal for several weeks) and come back and graft,with anything but autogenous bone. You show great empathy when you express concern about future trauma. This philosophy exemplifies your lack of experience in trauma care. Attempting to create and maintain lost space in volume grafting, is probably the single most important factor in the success of such procedures. Once you have lost the space, you will never get what you once had. I'm not quoting anyone, I am stating a fact. While harvesting a thimble full of autogenous bone might be traumatic in your hands,relatively speaking the morbity is negligable when you consider the possible single surgery outcome. It is unfair , in my opinion not to at least be able to offer this option to this patient. Autogenous bone is still the gold standard, and if you are placing as many implants as you suggest, I'm going to recommend you add this option to your armamentarium. With sincerest concerns bv

I think the challenge here is to do the "atraumatic" extraction, this wouldn't be priority to me. My priority would be to keep the bone close to the neck of the tooth as much as posible, mesial, lingual, palatal and BUCAL. So first I would give a treatment of Amoxiciline of seven days but in the day four I would perform the surgery. Yes the surgery. First extract the crown with a forceps then do an incision similar as an apicectomy, keeping in place the attached gingiva, doing the incision in the joint of gingiva and mucosa. Then do an osteotomy to reach the apex and in this way helping me pushing it through the socket and helping with an elevator or periotome. Then degranulate and detoxificate with metronidazole solution for 2 minutes Then suture the incision and no grafting, because it can be contaminated. Wait for two weeks, no more than two weeks, so you won't have bone loss, then place an implant a bone level implant 3 mm deeper than the apex. First of all you have to take out all the gingival tissue inside the socket and graft with any thing you want, you have to open again the incision of the apex because you probably do a fenestration with the dental implant and graft the apex and the gaps between the socket and the implant, then if you have more than 45 N/cm2 of initial stability you can do a provitional crown. If you have an inferior torque place a second stage healing screw, and wait for 6 months of osseointegration. In this way you won't loose papila or crestal bone and have no bacteria. Good luck.

Dr. Omar, please tell me that you would at least attempt to deliver the root tip through the socket before you violate the buccal wall. A long small round bur will get this root tip every time, with out removing any bone. Keep the surgery inside the tooth. Again , I'm not quoting anyone. Please go to one of your omfs colleques, and I'm sure one of them will show you how to do this. I would even encourage using some of the new periotomes, before taking the root tip as you described. Bv

I agree, again, with Dr BV...

Sure you can do an attemp. In my hands I have no good results with periotomes. But I would recomend to cut the apex of the tooth with a Zekrya bur in two halfs mesial and distal, so you can extract it in two pieces with an straight thin elevator. But if you can't, then do the first technique.