LITERATURE REVIEW

Postextraction Implant in Sites With Endodontic Infection

as an Alternative to Endodontic Retreatment: A Review of
Literature
Stefano Corbella, DDS, PhD*
Silvio Taschieri, MD, DDS
Igor Tsesis, DMD
Massimo Del Fabbro, PhD

The aim of this literature review is to evaluate the outcomes of implants placed after extraction of teeth with
infections of endodontic origin. An electronic search was performed through electronic databases (Medline and
Embase) using the terms ‘‘immediate implant,’’ ‘‘post-extractive implants,’’ ‘‘endodontic infection,’’ ‘‘infected
site,’’ and ‘‘extraction socket’’ combined with the use of Boolean operators (‘‘AND’’ and ‘‘OR’’). Only articles on
human subjects were considered. At least 12 month of mean follow-up was required for inclusion. No restriction
was placed regarding study design. Ten studies were included in this review. Survival rates ranged from 92% to
100%. A total of 497 implants were placed in sites with endodontic infection. In nine studies the use of bone
substitutes was associated with immediate implant placement. Because of the low number of included studies
and the heterogeneity of study design, more well-designed studies are required to assess the relevance of this
treatment alternative.

Key Words: dental implants, postextraction sockets, apical periodontitis, immediate implants, treatment
planning

INTRODUCTION for both,3,5 and no significant difference in outcomes

between procedures was found.4,5 Endodontic sur-

O
rthograde primary endodontic ther-
apy is an effective treatment, as
indicated by systematic reviews re-
porting success rates ranging be-
tween 31% and 100%1,2; the variabil-
ity was mainly due to the inclusion criteria of the
studies and to the adopted criteria of success. In
cases of failures with persistent periradicular lesions,
secondary endodontic treatment was recommended,
and those outcomes were investigated in systematic
reviews.3,4 Reported success rates for nonsurgical or
surgical secondary treatment are greater than 70%
Department of Biomedical, Surgical and Dental Sciences,
Università degli Studi di Milano, IRCCS Istituto Ortopedico
Galeazzi, Milan, Italy.
* Corresponding author, e-mail: stefano.corbella@unimi.it
DOI: 10.1563/AAID-JOI-D-11-00229
gery performed with a modern technique, that is,
with the aid of microinstruments, magnification
devices, and retrograde canal preparation through
the use of ultrasonic retrotips, has been reported to
achieve a success rate greater than 90% after 1 year.6
When the tooth pathologic condition cannot be
solved with endodontic retreatment (either ortho-
grade or retrograde) or in the presence of root
fractures that become evident during diagnostic or
treatment phases, the extraction of the involved tooth
becomes the most indicated solution. Tooth extrac-
tion and immediate placement of dental implant in
the extraction socket is a viable and effective
technique in anterior zones7,8 and posterior regions,
though many requisites need to be considered.
The presence of active infection in the extraction
site is considered one of the main contraindications

Journal of Oral Implantology 399

Implant in Infected Sites
to immediate implant insertion in the socket because
of the increased possibility of infection spreading to
peri-implant tissues during the healing period.9–11
Animal studies showed that the presence of peri-
odontal or endodontic infections, even in the active
phase, did not compromise the osseointegration of
immediately placed implants and did not reduce the
bone-to-implant contact after the healing phase.12–16
The aim of this study was to review the existing
literature about the immediate placement of
implants in endodontically infected sites in humans
and to discuss the clinical and scientific implications
of this treatment modality.
MATERIAL AND METHODS
An electronic search was conducted in Medline and
Embase for the period from January 1966 to August
2011 using a combination of different searches
using the terms ‘‘dental implants,’’ ‘‘immediate
implant,’’ ‘‘extraction socket,’’ ‘‘infected teeth,’’
‘‘infected site,’’ and ‘‘infected socket.’’ The initial
search yielded 264 titles and abstracts, which were
independently screened by two reviewers (S.C. and
S.T.). No restriction was placed regarding the
language and the study design. For clinical studies,
a minimum mean follow-up of 12 months was
considered for inclusion. Only studies with a clear
description of causes of teeth infections were
included to allow the analysis. Animal studies were
excluded from this review.
By screening titles and abstracts, a total of 10
articles were found that met the inclusion criteria.17–26
The 2011 study by Truninger24 presented updated
data from the same cohort of patients treated in the
2007 study by Siegenthaler21; therefore, only the
most recent study was considered.
Data extracted were (1) implant survival, defined
as the implant in function without pathologic
processes ongoing at the time of the investigation;
and (2) reasons for tooth extraction, which were
classified as endodontic cause, periodontal cause, root
fractures, or combined endodontic-periodontal cause.
RESULTS
Clinical trials
Data from clinical trials are summarized in Table 1.
Considering all the included studies, a total of 523
400 Vol. XXXIX /No. Three / 2013
implants were inserted in infected sites in 410
patients. The follow-up varied from 3 to 117 months
from loading. Guided bone regeneration was
performed in all studies with the exception of
one23 to compensate for gaps between the fixtures
and socket walls. The survival rate of the treatment
was high in all evaluated studies, ranging from 92%
to 100%.
Table 2 reports the nature of lesions affecting
treated teeth, which were purely endodontic in
82.3% of cases. Periodontal lesions were diagnosed
in 12.8% of sites, while root fractures and endo-
perio lesions were less represented (1.4% and 1.0%,
respectively).
Because of the different nature of periodontal
and endodontic lesions, a separate analysis of
implants placed only in sites with endodontic or
endo-perio infection was performed (Table 3). A
total of 497 implants were placed in sites with
endodontic infection. The surgical protocol always
included an accurate debridement of the sockets
after teeth extractions.
The case series presented by Novaes Jr and
Novaes17 was the first scientific article describing
the immediate insertion of implant in infected sites.
Three cases were presented with endo–perio
lesions and root fractures associated with endodon-
tic infections. In one of the described cases
suppuration was observed. The teeth were extract-
ed following a strict atraumatic protocol. An
accurate debridement of sockets was then per-
formed. Guided bone regeneration was also used to
compensate for bone resorption due to chronic
infection of the site. Follow-up time for the 3 cases
varied from 7 to 24 months and was uneventful.
Years later other researchers18 compared the
insertion of immediate implants in sites with
chronic infections with a delayed implant insertion.
After randomization, 50 implants were placed in
maxilla: 25 were immediately placed after tooth
extraction in sites affected with chronic periapical
pathosis, and 25 were placed after a healing period
of 3 months (control group). Guided bone regen-
eration was always performed in the first group.
One year after the surgery the survival rate in the
experimental group was 92%, which was not
significantly different from that of the control
group.
Casap and coworkers19 described and analyzed
the immediate placement of dental implants into
 Corbella et al

TABLE 1
Summary of data from clinical trials*
No. of Guided Tissue Survival
Study Type of Study No. of Patients Implants Regeneration Loading Follow-up (%)
Novaes Jr et Case series 3 3 Yes Delayed 7–24 mo 100%
al17 (6–7 mo)
Lindeboom et Prospective 25 treated with 25 Yes Delayed 1y 92%
al18 randomized immediate implants
Casap et al19 Prospective 20 30 Yes Delayed (6 12–72 mo 96.67%
mo)
Villa et al20 Prospective 33 76 Yes Immediate 1y 97.40%
(,36 h)
Del Fabbro et Prospective 30 61 Yes (PRGF) Delayed 1y 98.4%
al22 (3–4 mo)
Crespi et al23 Prospective 30 (15 with teeth 30 No Delayed (3 2y 100%
randomized with root fractures mo)
and/or caries; 15
with teeth with
periapical chronic
lesions)
Truninger et Prospective 13 with sites with 13 Yes Delayed (3 3 y 100%
al24 randomized periapical pathology mo)
Bell et al25 Retrospective 256 285 Yes (PRP þ aut) Delayed (3 3–93 mo 97.5%
mo)
Fugazzotto26 Retrospective NR 64 Yes Delayed 24–117 mo 98.1%
(3–7 mo)

*NR indicates not reported; PRGF, platelet rich in growth factors; PRP þ aut, platelet rich plasma þ autogenous bone.

infected sockets (with chronic or subacute infec-
tions and initially affected by subacute periodontal
infection, chronic periodontal infection, and end-
odontic periapical lesions) after accurate debride-
ment. Of the initial 30 implants placed in 20
patients, only one was lost in the follow-up period,
which varied from 12 to 72 months after surgery.
Another implant was removed because it showed
mobility after prosthetic restoration. Surgical com-
plications, such as membrane exposure, were also
reported, but they were always correlated to guided
tissue regeneration procedures. Of the 10 implants
placed in endodontically infected sites, only one
implant was lost during the observation period.
In 2007, Villa and Rangert20 published their
clinical investigation about the immediate and early
function of implants placed in extraction sockets of
infected maxillary teeth. A total of 76 implants were
inserted in 33 patients with teeth considered
hopeless because of endodontic lesions, periodon-

TABLE 2
Clinical trials: Implant distribution by nature of the infection
Type of Lesion
Total No. Endodontic Periodontal Endo-perio Root Fracture
Study of Implants % (No.) % (No.) % (No.) % (No.) Not Specified
17
Novaes Jr et al 3 33.0% (1) 66.0% (2)
Lindeboom et al18 25 100% (25)
Casap et al19 30 16.7% (5) 66.7% (20) 16.7% (5)
Villa et al20 76 20.0% (15) 72.3% (55) 7.7% (6)
Del Fabbro et al22 61 100% (61)
Crespi et al23 30 50.0% (15) 50.0% (15)
Truninger et al24 13 100% (13)
Bell et al25 285 100% (285)
Fugazzotto26 64 100% (64)
Total 587 82.3% (483) 12.8% (75) 1.0% (6) 1.4% (8) 2.6% (15)

Journal of Oral Implantology 401

Implant in Infected Sites

TABLE 3
Clinical trials: Survival rates considering only implants placed in endodontically infected sites
Study Implants % Follow-up % Survival Weight
17
Novaes Jr et al 3 100% 7–24 mo 100% 0.006
Lindeboom et al18 25 100% 12 mo 92.0% 0.050
Casap et al19 10 33.0% 18–72 mo 90.0% 0.020
Villa et al20 21 27.6% 12 mo 100% 0.042
Del Fabbro et al22 61 100% 12 mo 98.4% 0.123
Crespi et al23 15 50.0% 24 mo 100% 0.030
Truninger et al24 13 100% 36 mo 100% 0.026
Bell et al25 285 100% 3–93 mo 97.5% 0.573
Fugazzotto26 64 100% 24–117 mo 98.1% 0.129
Total 497 3–117 mo 97.5% 1

tal lesions, or root fractures. Immediate loading of
inserted implants was performed within 36 hours of
surgery. After 1 year of function, 2 implants were
lost, resulting in a 97.4% survival rate. No sign of
infection was observed in peri-implant tissues. No
failure occurred among the 21 implants placed in
sites with periapical lesions. The authors concluded
that the presence of infection in the site of the
insertion is not associated to an increase of the risk
of implant failure.
Del Fabbro and coworkers22 published the
results of their prospective study investigating
success and survival rates of implants placed in
fresh extraction sockets with chronic endodontic
infection. Sixty-one implants were placed immedi-
ately after teeth extractions and accurate debride-
ment. Only one implant failed because of infection
2 months after insertion. All patients reported full
satisfaction with the treatment. Bone resorption,
measured through radiographic examination, was
0.41 6 0.22 mm.
Crespi et al23 inserted 15 immediate implants in
sites with chronic endodontic infection and 15 in
patients with teeth extracted because of caries or
root fractures. After 3 months, implants were loaded
and follow-up visits were scheduled up to 24
months. Cumulative survival rate was 100% in both
groups. Soft and hard tissue healing around
implants was equal between the 2 groups.
In 2011, Truninger et al24 published the 3-year
results of the comparative study in which the 1-year
results were previously published in 2007.21 Thir-
teen implants placed in infected sites (8 of which
presented suppuration before tooth extraction)
were successful after 3 years from placement.
In 2011, Bell and coworkers25 reported data from
a retrospective investigation of 285 implants placed
in sites with chronic endodontic infections. The
follow-up varied from 3 to 93 months. The
cumulative survival rate for implants in infected
sites was 97.5%, which was not significantly
different from the survival rate of implants placed
in sites without infection.
Another retrospective comparative investiga-
tion26 reported long-term data for implants placed
in sites with periapical infection. A 100% survival
rate was observed for 64 implants with a follow-up
varying from 24 to 117 months, which was not
significantly different with respect to the outcome
of implants placed in healed sites.
Eight of the included studies described the
application of guided bone regeneration tech-
niques with the use of resorbable and nonresorb-
able membranes in conjunction with autologous
or etherologous bone filler as described in Table
4.17–20,22,24–26 In 2 studies, platelet concentrates
were used in the surgical procedure.22,25 No
differences were reported in terms of implant
survival rates.
Antibiotic prophylaxis was administered in 7
studies with different modalities (Table 4).17–20,22–24
In one study, antibiotic therapy was generally cited
without any specification,25 and in another study it
was not reported.26 Antibiotic therapy was pre-
scribed in 7 studies after surgical treatment.17–20,22–24
DISCUSSION
The success of primary endodontic treatment was
influenced and determined by many factors that
may influence the outcome of this procedure.2
Presence or absence of periapical lesion (identified

402 Vol. XXXIX /No. Three / 2013

 Corbella et al

TABLE 4
Clinical trials: Description of surgical regenerative technique and preoperative antibiotic prescription*
Study GTR Antibiotics
17
Novaes Jr et al Porous hydroxyapatite þ Gengiflex membrane 312 mg (500 000 IU) penicillin V every 8 h for 10
d, starting at 24 h, then 100 mg doxycycline
once a day for another 21 days
Lindeboom et al18 Autogenous corticocancellous bone þ BioGide Prophylactic regimen with 600 mg clindamycin
Casap et al19 DBBM þ Reinforced e-PTFE 1.5 g amoxicillin or 0.9 clindamycin 4 d before
surgery and for 10 d after
Villa et al20 Autogenous bone alone (n ¼ 8); DBBM þ 1 g amoxicillin twice a day for 1 d before and
Collagen membrane (n ¼ 19) for 5 d after surgery
Del Fabbro et al22 PRGFÀ clot as a covering membrane Prophylactic regimen with 2 g amoxicillin þ
clavulanic acid
Crespi et al23 Not reported 1 g amoxicillin 1 h before surgery, then 1 g
twice a day for a week after surgery
Truninger et al24 DBBM þ Collagen membrane 750 mg amoxicillin 1 h before surgery and for 5
d
Bell et al25 Platelet-rich plasma þ Autogenous bone þ Intravenous antibiotics (in general)
Xenograft
Fugazzotto26 Mineralized or demineralized freeze-dried bone Not reported
allograft or DBBM

*GTR indicates guided tissue regeneration; DBBM, deproteinized bovine bone mineral; e-PTFE, expanded-polytetraflu-
oroethylene; PGRF, platelet rich in growth factors.
ÀPRGF System IV, BTI Biotechnology Institute, Vitoria, Alava, Spain.

through radiographs) in the apical portion of teeth,
an adequate coronal restoration, and a correct and
complete filling of the root canal extending within 2
mm from the radiologic apex could significantly
influence the outcome of primary endodontic
treatment.2 Similar criteria were also considered as
positive prognostic factors for nonsurgical retreat-
ment, although the scientific literature is scarce.3,5
Tsesis and colleagues6 reported high success rates
for endodontic surgery performed using a modern
microsurgical protocol. However, most of the
prospective controlled studies included in evi-
dence-based systematic reviews estimate the treat-
ment effect in an ideal situation as they are
normally carried out using a standardized protocol
with selective inclusion criteria, experienced surgical
teams, and controlled variables. Therefore, such
studies do not closely reflect the everyday clinical
practice in which there is a much larger variability in
study parameters.
Some epidemiologic studies reported the success
rate of endodontic orthograde treatment by pre-
senting retrospective data from large sample popu-
lations. In 2007, Chen and colleagues27 reported that
5 years after endodontic treatment, 89.7% of teeth
were healthy and there were no complications,
demonstrating a high success rate of the treatment
even when the techniques are performed by
different dentists. In this study, the tooth retention
rate was 92.9%, which was comparable with rates
reported in previous studies.28,29 These results were
confirmed by another more recent study.30
Hence, endodontic primary and secondary
treatment could also be considered viable treat-
ment options in cases with persistent apical
periodontitis. In treatment planning, however, the
heterogeneity of the reported results should be
taken into consideration together with patients’
expectations.
Recent reviews evaluated nonsurgical endodon-
tic treatment versus single-tooth implants.31,32 They
concluded that implants and nonsurgical endodon-
tic treatment followed by prosthetic restoration are
both excellent treatment modalities, and the choice
of the treatment plan should not be based on
outcomes evaluation only.31
Other factors, such as the impossibility of
achieving an optimal coronal seal with the post-
endodontical restoration, root fractures that may be
evident during periapical surgery, or failures of
endodontic surgery, may lead to tooth extraction
and replacement with implants. Also patients’
preference has to be considered to fully satisfy
their expectations and obtain better compliance.

Journal of Oral Implantology 403

Implant in Infected Sites
Immediate implant placement in fresh extraction
sites is a viable technique with success rates
comparable to those of implants inserted in healed
sites.10 Presence of active infection was considered
one of the major contraindications of immediate
postextraction insertion of implants.9–11
The scientific literature on immediate implants in
infected sites is poor. Only 10 studies were found
and included. Clinical studies reviewed in the
present study reported high survival rates, compa-
rable with those reported in studies describing
immediate implant insertion in noninfected post-
extraction sites.33
In all studies, tooth extraction was always
described as atraumatic, and an accurate debride-
ment of the residual socket was reported to be
necessary to thoroughly remove the lesion, reduc-
ing the risk of early infection of the tissues
surrounding the implant. Furthermore, none of
the authors of the included studies reported that
presence of suppuration was correlated with an
increased failure rate. So, an accurate and complete
lesion debridement, associated with antibiotic
prophylaxis and therapy, appears to be sufficient
to avoid perisurgical infective complications and
massive bone loss.
Eight studies reported the use of guided bone
regeneration to fill gaps between implant and
socket and to treat bone dehiscences due to the
previous inflammatory process, if present. No
differences were highlighted in implant survival
rates using different materials and techniques for
guided bone regeneration, even if it was observed
that exposure of nonresorbable membrane could
have a negative effect on implant osseointegration.
This may be considered a relative contraindication
in this treatment protocol.
Notwithstanding the limitations of this review
related to the small number of studies, the
heterogeneity of protocols, the size of samples,
and the follow-up period, the present analysis could
be useful for quantifying the evidence on major
therapeutic alternatives for endodontists. In gener-
al, the decision-making process should not only rely
on the success rates of the treatment and on the
available evidence but must also take into account
the patients’ expectations and preference as well as
the surgeon’s skills and attitudes. A clear difference
in success rates among surgical retreatment,
nonsurgical retreatment, and immediate implant
404 Vol. XXXIX /No. Three / 2013
insertion in endodontically infected sites is still not
demonstrated. Hence, tooth preservation should be
considered the primary treatment option in cases of
infected hopeless teeth; thus, immediate implant
placement represents an increasingly accepted
treatment option.
CONCLUSIONS
Immediate implant insertion in infected sites could
be considered a viable alternative to secondary
endodontic treatment. More well-designed, ran-
domized, controlled trials with a longer follow-up
are required to confirm implant insertion in infected
extraction sockets as a safe procedure with long-
term, high success rates.
ABBREVIATIONS
GBR: guided bone regeneration
NR: not reported
PRGF: platelet rich in growth factors
PRP þ aut: platelet rich plasma þ autogenous bone
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