Placing Implant in Cystic Area?

Anon. asks:
Recently we extracted a lower left second premolar [#20] which had a huge periapical odontogenic cyst. Although the tooth previously had root canal treatment, the cyst persisted and eventually we had to extract the tooth. By means of a Full Thickness Flap, we completely enucleated the cystic epithelial lining . The lining did not come out in one piece, since it was infected. However we were able to get down to the bare bone. We did not graft with mineralized particulate bone, nor did we place a resorbable membrane. We did achieve primary closure of the surgical site.

After six months, we plan to place an implant in the area of the second premolar with grafting if necessary. Should we have grafted that area with Bio-Oss [Osteohealth, an osteoconductive bone substitute] and covered with a resorbable collagen membrane BioGide [Osteohealth]at the time of the surgery and then obtained primary closure? Would this give us a more predictable result?

10 thoughts on “Placing Implant in Cystic Area?

  1. You’ll find some clinicians who thoroughly debride and graft at time of extraction. I prefer to extract and have the patient back in approx. 5-7 days for socket grafting. IMO, this decreases the likelihood of infection and has worked well for me. I use mfdb .50cc from Salvin (www.salvin.com). Costs about $49. Cover with a collagen membrane (I like collagen tape from ace surgical) for about 10 bucks and suture. You should have good bone in 3-4 months.

    If the buccal plate was intact after extracting, you probably will not need a bone graft if you wait 6-7 months before placing the implant.

  2. Paul, i have found as long as the entire site is clean and you are dealing with a cyst that is from inflamation, you will have not problem what ever you fill the site with. When I extract the tooth I like to maintain the mucogingival junction and width of Attached gingiva for future implant placement. I Fill the socket with Curasan TCP and cover this with a Teflon memebrane CBR200 by Cytoplast. Teh white teflon with show through where the socket was and the tissue will start growing over the membrane i temove the sutues and the membrane in two weeks and the bone graft is already in a hardened state. I see the pat in a month and i have a beautiful pink site for an perfectly placed implant. Good luck and you may want to biopsy the cyst to make sure of what it truely is for a piece of mind thing.

  3. I would have grafted at the time of extraction for a very predictable result. You may have a large defect to deal with later, especially if you have lost buccal plate, that you may not have had to deal with if you grafted at the time of cyst removal. Good luck.

  4. Paul, you recommended using .5 cc of mfdb from Salvin. Is that LifeNet OraGraft mineralized cortical freeze dried bone?

  5. after 2-6 months after the extraction, i generally use, if it’s necessary, pure beta tricalcium phosphate (mixed with blood). I have some good results
    ( I apologize for my bad English )

  6. A new ( 2 years ) Swiss product Easygraft ( DS ) is very good graft material in this situation as it has a bacteriostatic ( scidal in initial stage) poly-lactide coating (Beta Tri Ca ) with a bio-linker to stabalize the material which has allowed us to use it in these situations with immediate placement , and defect graft without the need of a membrane.
    Had some great results in these difficult situations

  7. had a failed implant in a similar scenario- tooth #28 with large apical lesion . extracted and grafted with DBX- no buccal defect. implant placed 4 months later and failed. removed implant and grafted site. waited 9 months to place next implant and it was fine. my suspicion is that if i would have waited longer ( as the original implant placed in all grafted material ) the original implant would have been ok. my suggestion would be if the implant – apical portion – is not going to be in native bone to allow site to heal a little longer.

  8. A true odontogenic cyst is relatively easy to enucleate as it has defined borders and a relatively thick epithelial lining. However, you state that you were not able to remove the lining because it was infected. Without a biopsy, it would be impossible to identify as of odontogenic origin. More likely, because it was associated with a failed root canal, it is an apical granuloma. If the osteotomy is not debrided completely, this chronic inflammatory tissue will interfere with bone regeneration and, if an implant is immediately placed, osseointegration. If you are debriding solely with surgical curettes, you must get aggressive down to bleeding bone followed by copious irrigation. An advantage is treatment of the site with lasers (diode or preferably an erbium). This will have a bacteriocidal effect and upregulate osteoblastic activity. However, do not use Bio-Oss in these sites as it does not resorb and will decrease the amount of vital bone where the implant is to be placed. As stated previously, we use bTCP or ReOss (PLA/calcium phosphate) bone grafts. These materials will resorb completely, potentiate osteoblastic activity, and have a bacteriocidal effect from release of free cytosolic calcium.
    RJM

  9. a periapical radiolucency should diagnosed first. what ever is inthere should be identified. then depending on the size of the defect and the amount of bone surrounding you should think about the best grafting materila , i.e, autogenic vs non auto.

    small defects,

  10. I disagree with all of these comments,according to researches(pubmed 2008) and clinical trial and my experience the success rate for putting implant simultaneously in the infected socket is as the same as healthy socket,however the point is in the preparation of the socket by laser and carefully curretting the area in addition by using bio oss and membranne to achieve a good primary stability.
    Dr.Anooshah Hajiheshmati
    implantologist

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