Guidelines for Immediate Implant Placement in Periodontally Compromised Patients

Abstract
Othman Shibly, DDS Diplomate, American Board of Periodontology Director, Preventive Dentistry Department of Periodontics and Endodontics Associate Director, Center for Dental Studies State University of New York at Buffalo Buffalo, NY Phone: 716.829.3850 Email: shibly@buffalo.edu Ali Al-Ghamdi, DDS, MS Assistant Professor and Consultant in Periodontics Chairman, Oral Basic and Clinical Sciences Department Chairman, Saudi Board of Periodontics, Western Region Chairman, Saudi Implant Fellowship, Western Region Faculty of Dentistry King Abdul Aziz University Jiddah, Saudi Arabia Email: dr_thafeed@hotmail.com Mohanad Al-Sabbagh, DDS, MS Diplomate of American Board of Periodontology Director, Graduate Periodontology University of Kentucky, College of Dentistry Lexington, KY Phone: 859.257.3003 Email: malsa2@email.uky.edu

linicians encounter challenges when placing implants immediately after

extraction in periodontally compromised patients. A study was undertaken in 73 periodontally compromised patients to identify these chal-

lenges and identify situations in which immediate postextraction placement of implants in this patient group is not optimal. The study found that immediate implant placement after extraction is not recommended for periodontally compromised patients with advanced horizontal interproximal bone loss, advanced furcation involvement, periapical lesions, proximity to the sinus, proximity to nerve canals, and limitation in mandibular opening. These results were used to establish suggested guidelines for the placement of implants immediately after extraction in periodontally compromised patients.

ith the continued impact of esthetics on dental treatment, the desire for patients to maintain their dentition is critical. Immediate implants are a 1-stage surgical procedure designed to successfully place a dental implant after tooth extraction and site preparation, reducing the time spent between tooth loss and final restoration placement. Clinical studies have demonstrated that successful osseointegration and optimal esthetics can be achieved with implants placed in fresh extraction sockets.1-3 For optimal esthetics, provisional restorations along with immediate implants are acceptable options. Additionally, clinicians have documented success with these procedures in the molar region. Immediate-loading implants placed in fresh molar extraction sockets can be used for a variety of restorations: permanent fixed complete dentures in the maxilla4; 3-unit fixed partials in the mandible5; and single teeth in the posterior mandible.6 Research demonstrates that selecting the proper patients for this treatment option is crucial for implant success.7,8 Research and clinical experience from past decades has demonstrated that oral rehabilitation with an implant-supported prosthesis in the periodontally compromised patient can be successful.9,10 However, a retrospective study from 1988 to 2004 found that immediate implants replacing periodontally involved teeth were more than twice as likely to fail than implants replacing non-periodontally compromised teeth.11 A pilot study of immediate-loading all-in-one implant surgeries for periodontally compromised adults yielded an excellent success
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rate, with some precautions for the molar regions.12 A systematic review of implant patients with periodontal-associated tooth loss and those with nonperiodontal-associated tooth loss demonstrated no difference in 5- to 10-year implant success; however, the risk of peri-implantitis was significantly increased in the former patients.13 When initial implant stability has been achieved, the success of implant survival is increased, even in compromised sites. However, the published research to date has concentrated on surgical techniques, success rates, or reasons for osseointegration failures14,15 rather than on details of the inherent challenges to the successful implant treatment option during surgery. The goals of this study were to identify the challenges the practitioner is presented with in placing implants immediately after extraction in periodontally compromised patients, and to establish guidelines for immediate implant placement. These results may help clinicians identify situations when an immediate implant is not an optimal option for the patient and when different methods of treatment, such as socket preservation and delayed implant, should be considered.

Materials and Methods

This study was designed to evaluate immediate loading of implants placed in the socket after tooth extraction that required guided bone regeneration. Study participants were 73 patients between 20 and 90 years of age. Criteria for inclusion in the study were as follows: A history of moderate to severe periodontal disease based on radiographic and clinical history, with periodontal stability being achieved after active periodontal therapy, according to findings of clinical and periodontal examinations. At least 1 untreatable (hopeless) tooth indicated for extraction. A desire to receive implant placement immediately after extraction. Patients were excluded from the study if they were current smokers, had uncontrolled diabetes, or had a history of infective endocarditis. The study was approved by the University of Buffalo Institutional Review Board, and all study participants signed an informed consent form. During the baseline period, participants had preoperative panoramic, periapical, and bite-wing radiographs

taken, and probing depths were measured to assess bone loss. If the patients selected the option of an immediate implant, they were asked to sign the consent form at that time. Amoxicillin (500 mg, 3 times daily for 10 days) was prescribed for each patient, started 2 days before surgery. The implant size was selected using the NobelReplace Straight Groovy system (Nobel Biocare). Patients were then classified into 2 categories: those who needed to replace a posterior hopeless tooth (n = 50) and those who needed to replace an anterior (hopeless) tooth (n = 23). A board-certified periodontist performed all surgeries. At the surgical visit, a full-thickness mucoperiosteal flap was raised, and the tooth to be extracted was carefully removed with minimal trauma. The socket of the extracted tooth was then assessed to determine whether immediate implant placement would have initial stability and proper implant positioning to meet restorative and esthetic needs. If the implant could be successfully placed, a protocol of guided tissue and bone regeneration using demineralized, freeze-dried bone and a resorbable collagen membrane was followed. If placing the implant would not provide initial stability or the configuration of the extracted site would not allow for proper implant positioning, then only socket preservation techniques were performed, and the patient was placed into a subgroup for the purpose of this observational study. A total of 12 patients did not receive immediate implants after extraction because of reasons related to the clinical presentation after extraction. The specific challenge that hindered the implant placement, as well as the need for tooth extraction, was recorded in the patients chart. This subgroup of 12 patients is described and provided the data for the guidelines the authors present concerning implant placement in periodontically compromised patients.

Results
Of the 73 patients who participated in the main study, 61 (84% of patients) received an implant immediately after extraction. Table 1 summarizes the percentages of immediate implant placement in anterior and posterior regions. Implant placement was more successful in the anterior versus posterior region (91% vs 80%).

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Table 1

Number of Patients With a Tooth Needing Replacement With Immediate Implant Total number of patients 73 61 12 84% Anterior teeth 23 21 2 91% Posterior teeth 50 40 10 80%

Baseline number Implant placed No implant placed Percentage placed

Note: Patient subgroup percentages of placement are based on anterior and posterior zone.

The lowest percentage of immediately placed implants occurred in the maxillary molars (50%), followed by mandibular molars (80%) (Table 2). For patients with a hopeless tooth in the anterior region, 90% of the maxillary teeth and 100% of the mandibular teeth received immediate implants. One-year follow-up for the 61 patients who received implants demonstrated that only 1 implant failed as a result of acute infection in the early stage of healing. Twelve patients not receive implants because of sitespecific complications (Table 3). The most prominent challenge to immediate implant placement in this study was Class II or III furcation involvement zassociated with lack of bone around maxillary molars. Figure 1 categorizes the challenges for implant placement in these 12 patients. Results for the 12 implants not placed are as follows: A total of 5 implants were not placed in maxillary molars, 3 because of severe Class III furcation involvement (see Figure 2 for example), and 2 because of extensive periapical lesions next to the sinus (Figure 3). In clinical presentations postextraction of the Class III furcation involvement, it was observed that no inter-radicular bone was present in the socket to aid in implant anchorage or

stability. Before implant placement, site development and socket preservation were performed (Figure 2). A total of 3 implants were not placed in the 15 extractions of lower molars, mainly because of proximity of the inferior alveolar nerve. Another challenge for placing an implant in the mandibular molar area was centering the implant in the socket for restorative needs. To accomplish this, an osteotomy must be done in the radicular bone. This may not be possible if the radicular bone is not wide enough to engage the implant. Delayed implant placement was deemed a better option to allow healing of the socket, enabling a more ideal placement of the implant. Immediate implantation was prevented in 2 of the 8 mandibular premolars extracted because of proximity of the mental nerve. All 17 immediate implants were successfully placed with initial stability in the maxillary premolars. One of the second premolars was close to the sinus; successful sinus elevation was performed internally using osteotomes. Of 23 patients whose treatment plan called for immediate implants in their anterior teeth (21 in the maxilla and 2 in the mandible), the 2 implants not placed were in the maxillary anterior teeth because of inadequate interproximal bone (Figure 4).

Discussion
Dental patients place a high priority on esthetic and functional restorations, leading to a rise in the popularity of immediate implants, particularly in anterior teeth; however, immediate implants cannot be achieved in every clinical situation. Preoperative clinical examination, radiographs, and 3-dimensional imaging are needed to assess the quantity and quality of bone, as inadequate amounts of either will lead to lowered success rates.16, 17

Table 2

Percentage of implants placed per arch segment. Mandibular Anterior 21 19 2 90%

Maxillary Total Baseline 48 Received implant 41 No implant 7 Percentage placed 83%

Premolar 17 17 0 100%

Molar 10 5 5 50%

Total 25 20 5 80%

Anterior 2 2 0 100%

Premolar 8 6 2 75%

Molar 15 12 3 80%

Note: Subgroups percentages of implant placement are related to the segment of the arch placed: anterior, premolar, and molar zones.

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Table 3

Site-Specific Complications that Prevented Immediate Implant Placement Numbers

Reasons for not placing implants

5 4 3 2 1 0
Upper Anteriors Upper Molars Lower Premolars Lower Molars

Number of patients affected Periapical lesions next to sinus 2 Horizontal severe interproximal bone loss 2 Advanced furcation involvement Classes II and III 3 Proximity to inferior alveolar nerve and mental foramina 4 Limitation of mouth opening 1 Complication

t ity BL ng en ity ni m m im lS i e e x a x o lv o m op pr pr xi vo e aw in ro us j v p n r n d er Si Ne tio ite nt m ca li i r a L t Fu on riz Challenges o H

A case series report is presented of the 12 patients who did not receive implants at the time of tooth extraction. The challenges and recommendations based on the region of the affected tooth are discussed and a set of guidelines presented based on the case series findings.

Figure 1 Categorization of site-specific challenges. SBL= severe bone loss.

Challenges to Immediate Implantation Molars

As the literature documents, the maxillary molars represent the most challenging area for the placement of immediate implants.18-21 Research has demonstrated that when preoperative radiographs and probing depths indicate bone loss and poor level of bone quality, implant failure can be anticipated.22 This correlated with the surgeons sensation of limited bone resistance during the procedure.23 A recent study showed that a surgeons tactility of dense or poor bone during implant placement is comparable to Periotest values, the implant stability quotient and placement torque.24 The failure rate of implants increases when associated with Lekholm and Zarb classified type IV bone.25 Of the 10 patients in our study who required an implant in this area, it was decided that immediate implants would not be possible for 5 of the patients, who were found to have limited bone resistance. The decision to place implants in the upper posterior teeth 50% of the time likely led to a higher success rate, as none of these implants have failed after a 1-year follow-up. Because of our small sample size, our findings may not generalize to other studies. Longer-term observations are essential in these patients. In the case shown in Figure 3, a maxillary sinus lift was considered, as this procedure is not a risk factor for

implant failure.26 Research has demonstrated successful placement of non-grafted implants along with a sinus lift27; however, this patient was considered to be better suited for a delayed approach because of the presence of a periapical lesion. Periapical lesions require thorough instrumentation and curettage before placing the implant.28 One study found a survival rate of 92% for implants in chronically infected periapical sites29; however, a consideration in the maxillary molar area is that the combination of curettage and osteotomy could push the infected tissue through the sinus. The possibility of a sinus infection could complicate the healing and integration of the implant, thus increasing the risk of failure. The main reason for patients not receiving implants in mandibular molars was the inherent challenge of anatomical structures that are present in the posterior area, such as proximity of the inferior alveolar nerve. The procedure usually requires drilling past the socket apex to get the implant engaged in native bone, a difficult step due to the anatomy of this area. To avoid the inferior alveolar nerve, cross-sectional imaging and spiral tomography offer reliable measurements.30-34 Alternatively, an experienced oral surgeon may be able to overcome this problem by using a wider implant, which can provide implant stability by engaging the lateral walls of the socket and not necessarily the apex of the socket, thus avoiding drilling deeper into the native bone and reducing the risk of violating the nerve. In our study, even with radiographic measurements prior to the procedure, 2 patients experienced paresthesia; 1 regained normal sensation after 2 months, but the

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Figure 2 (A, B) Tooth number 3 has severe bone loss and Class III furcation. Based on the guidelines, tooth number 3 is not a candidate for immediate implant replacement. (C) Socket after extraction shows no bone left for implant integration because of the severity of the furcation involvement. (D) Demineralized, freeze-dried bone was placed for socket preservation protocol. (E) Sutures in place. A B C

other patient felt some degree of paresthesia at her 4month evaluation. A challenge in immediate implant placement in a mandibular second molar occurred in a patient who had limited mouth opening. Implants require osteotomy past or close to the apical portion of the socket using a drill extender. Depending on the implant system, the extender can be 15 mm to 20 mm in length. When added to a drill size of 20 mm plus the head of the handpiece, the total length necessary to perform an osteotomy with proper angulation into a posterior socket is substantial. Therefore, patient selection for an immediate implant should include assessment of the temporomandibular joint, related disorders, and degree of mandibular opening before surgery. The problem may be solved by the use of a different implant diameter, with the intention to provide implant stability by engaging the lateral walls of the socket without drilling beyond the apex of the socket.

Premolars
D E F

Figure 3 Posterior tooth (tooth number 3) with periapical lesion and sinus proximity: (A) Radiograph before surgery showing periapical lesion and proximity to sinus. (B) Photograph before extraction showing tooth fracture. (C) Defect site following extraction. (D) Tooth extracted in pieces because it fractured initially, with evidence of cyst at apex. (E) Resorbable barrier placed over allogeneic graft. (F) Sutured tissue. A B C

Implants were placed in 100% of the extraction sites of the upper premolars, while the mandible had 75% placement in the extracted lower premolars (Table 2). One reason for this difference between maxillary and mandibular premolars is the presence of anatomical structures. Immediate implants require use of longer implants to engage the bone beyond the apex to attain initial stability. In the maxillary premolars, this is not a challenge because it is not compromised by the proximity to a sinus, and a sinus lift procedure can be performed if necessary. In the mandible, however, the mental foramen and/or mandibular alveolar nerve presented a challenge. For this reason, 2 patients did not receive lower premolar implants. Consideration should be given to the fact that osteotomies to place a wider implant may pose the risk of damaging the neighboring teeth.

Anterior teeth
Figure 4 Anterior tooth (tooth number 8) with interproximal bone loss greater than 50%: (A) Radiograph before surgery showing severe bone loss. (B) Tooth before surgery. (C) Tooth extracted with no complications. (D) Debridement revealing severe interproximal bone loss. (E) Particulate allogeneic bone graft placed. (F) Provisional removable partial denture in place.

In this study there were no challenges for immediate implants in the anterior mandibular region. It should be noted that this study had a small sample size, however. The symphyseal region of bone was of good quality and was well corticalized. Long-term research of immediate implants in this area has yielded a 99% success rate after 15 years.35

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Table 4 Class 1 2 3 4 5 6

Guidelines for Immediate Implant Placement in Anterior Zone Clinical and radiographic findings Normal periodontium Up to 30% bone loss in interproximal area* 30%-50% bone loss in interproximal area* 50% bone loss in interproximal area* Any of above hopeless teeth class associated with recession and loss of keratinized gingiva Any of above hopeless tooth class associated with periapical lesions extending into interproximal bone Immediate implant Possible Possible Possible but not recommended Not recommended Not recommended Not recommended

*Percentage of bone loss can be estimated radiographically based on the amount of bone loss related to the root length.

The challenge with the maxillary anterior teeth was interproximal bone loss which makes planning an esthetic restoration difficult. In this study, 2 maxillary anterior implants were not placed because of inadequate interproximal bone 50% of the root length of the extracted tooth.

Sites with partial loss of the buccal plate in the anterior zone will result in successful implant placement only if there is mild or no interproximal bone loss and enough keratinized gingiva.
The interproximal bone is critical in the anterior zone to support the papillae and to provide an esthetic and functional result. When we evaluated the socket after extraction of tooth number 8, we noticed that there was severe bone loss beyond 50% of the neighboring teeth (Figure 4). Radiographic evaluation before surgery revealed severe bone loss around tooth number 8, and both mesials of teeth numbers 7 and 10 had bone loss that exposed more than 50% of the roots. Placing an immediate implant in such patients would lead to a long crown-to-root ratio and loss of papillae. For the patients with that clinical presentation, it was decided that site development procedures and delayed implant placements would be the beneficial approach. Initial radiographs and probing depths can reveal interproximal bone loss; however, cau-

tion must be taken with radiographic measurements because they can overestimate bone compared with surgical measurements.36,37 Sites with partial loss of the buccal plate in the anterior zone will result in successful implant placement only if there is mild or no interproximal bone loss and enough keratinized gingiva. The implant could be placed slightly more to the palate with the consideration that the final implant position will allow the restoration to remain esthetic and functional. If there is loss of the buccal plate and associated gingival recession with loss of keratinized gingiva, it is recommended that the clinician avoid placing the implant immediately after extraction, and allow for adequate time for healing.

Guidelines for Immediate Implant Placement in the Posterior Zone

Immediate implants should not be recommended in every patient. When replacing posterior teeth, an immediate implant should be avoided for the following reasons: Difficulties in positioning the implant in the center of the socket because of shape and size of radicular bone and the socket anatomy Maxillary molars with periapical lesions adjacent to the sinus Class II and Class III advanced furcation involvement Proximity of mandibular premolars and molars to the inferior alveolar nerve and mental foramina Limitation of mandibular opening Gingival recession associated with lack of keratinized gingival.

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Guidelines for Immediate Implant Placement in the Anterior Zone

Immediate implants are more popular in the anterior area because of esthetic demands; however, practitioners should not rush into doing immediate implants without a comprehensive patient evaluation. Based on the findings in this study, guidelines have been established to classify a hopeless tooth and whether an immediate implant can be placed based on its clinical and radiographic presentation (Table 4).

4.

Nordin T, Graf J, Frykhom A, et al. Early functional loading of sand-blasted and acid-etched (SLA) Straumann implants following immediate placement in maxillary extraction sockets. Clinical and radiographic result. Clin Oral Implants Res. 2007;18:441-451.

5.

Cornelini R, Cangini F, Covani U, et al. Immediate loading of implants with 3-unit fixed partial dentures: a 12-month clinical study. Int J Oral Maxillofac Implants. 2006; 21:914-918.

6.

Cornelini R, Cangini F, Covani U, et al. Immediate restoration of single-tooth implants in mandibular molar sites: a 12-month preliminary report. Int J Oral Maxillofac Implants. 2004;19:855-860.

Conclusion
The small sample size in this study may not provide a comprehensive picture of the challenges that practitioners face when placing immediate implants, but the recommendations and guidelines provided should help practitioners choose the right candidate for immediate implants to ensure more successful treatment outcomes. Clinicians must use their best judgment to make a final decision, taking into consideration many influencing factors, such as malposition of the hopeless tooth in the socket, the size of the extracted site, and the direction of the neighboring roots. Orthodontic treatment may be advised to obtain the ideal treatment outcome. It is worth noting that specialized procedures exist to help overcome some of these challenges (eg, lack of keratinized gingiva and bone) by combining soft-tissue and bone-grafting procedures with implant placement.38
7.

McNutt MD, Chou CH. Current trends in immediate osseous dental implant case selection criteria. J Dent Educ. 2003;67:850-859.

8.

Laine P, Salo A, Kontio R, et al. Failed dental implants clinical, radiological, and bacteriological findings in 17 patients. J Craniomaxillofac Surg. 2005;33:212-217.

9.

Ellegaard B, Baclum V, Karring T. Implant therapy in periodontally compromised patients. Clin Oral Implants Res. 1997;8:180-188.

10. Baelum V, Ellegaard B. Implant survival in periodontally compromised patients. J Periodontol. 2004;75:1404-1412. 11. Wagenberg B, Froum SJ. A retrospective study of 1,925 consecutively placed immediate implants from 1988 to 2004. Int J Oral Maxillofac Implants. 2006;21:71-80. 12. Machtei EE, Frankenthal S, Blumenfeld I, et al. Dental implants for immediate fixed restoration of partially edentulous patients: a 1-year prospective pilot clinical trial in periodontally susceptible patients. J Periodontol. 2007;78:1188-1194. 13. Schou S, Holmstrup P , Worthington HV, et al. Outcome of implant therapy in patients with previous tooth loss due to periodontitis. Clin Oral Implants Res. 2006;17(suppl 2):104-123. 14. Esposito M, Hirsch J, Lekholm U, et al. Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature. Int J Oral Maxillofac Implants. 1999;14:473-490. 15. Fleming TF. Periodontitis. Ann Periodontol. 1999;4:32-38. 16. Jacobs R, van Steenberghe D. Radiographic Planning and Assessment of Endosseous Oral Implants. New York: Springer-Verlag; 1997. 17. Jacobs R. Preoperative radiologic planning of implant surgery in compromised patients. Periodontol 2000. 2003;33: 12-25.

Acknowledgement: This research was partially funded

by Nobel Biocare and the University of Buffalo Center for Dental Studies, Buffalo, New York.

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