Grafting Into An Active Infection?

I sugest that you review some of the orthopedic literaure on grafting into areas of infection. AO-Synthes sales rep could be a resource.

I THINK IT´S NOT A VERY PREDICTABLE PROCEDURE PLACING A POST-EXTRACTION IMPLANT IN AN ACTIVE INFECTION SITE. YOU DON´T NEED TO WAIT FOR 3-4 MONTHS. I USUALLY DON´T WAIT FOR MORE THAN 45-60 DAYS AFTER EXTRACTION OF THE INVOLVED TEETH AND ANTIMICROBIAL TREATMENT, WITH OPTIMAL RESULTS.

Anecdotal data from clinicians at major implant programs suggest that extraction/immediate placement is only 70% successful. I had experienced the same rates over two years. The literature suggests that there is often an epithelial lining, apical granuloma, or antibiotic resistant vegetative forms of bacteria present in the extraction site. For the past year, we have changed our protocol to finishing the osteotomy with an Er,Cr;YSGG laser. This procedure will remove all soft tissue remnants and have a bacteriocidal effect to depth in the bone. Since we have begun using this approach, our success rates have gone back to those of healed sites. While a controlled study is necessary, our early results suggest that lasers can be a valuable adjunct in extraction/immediate placement cases.

I agree that the post-extraction wait time can be 6-8 weeks as mentioned above. As long as there is adequate soft tissue healing and partial healing of the osseous tissue without post-operative complications, I have had very good success. It is against general orthopedic surgical principles to place any implantable device into an infected surgical site (except for perhaps a drain with plans for removal once the infection resolves). The principle of external fixation was conceived to eliminate the need to place fixation hardware into an infected fracture site. Internal rigid fixation often times will become infected and will result in failure of bony healing and necessity of hardware removal if placed in an infected fracture site. This analogy holds true for implant placement into an infected extraction site. There is higher incidence of failure of osseointegration and need for removal of the implant. There is little advantage to rushing the normal healing process by placing an implant at time of infected dental extraction surgery.

I would have no problem in completing the osseous grafting/G.T.R. procedure at the time of extraction and would actually prefer it to a staged procedure due to the increased healing/regenerative potential present. A thorough debridement of the lesion is essential. I would usually complete the fixture placement as a staged procedure 12 to 16 weeks post extraction/grafting depending upon the size of the inital lesion and remaining virgin osseous support.

as per your case you need to wait some weeks because it involves a sinus case and your expects the best result out of a graft plus an implant placement But in cases on implant placement on infected sites you can do it at the same time provided you did a thorough debridement along with laser cleaning and sterilizing the area with antiboitics ans explain it to the patient and get his approval

It is nice to see an open sharing of personal views on this subject, however, we cannot perform surgery based on anecdotal case reports and our own personal feelings derived from scientifically insignificant small numbers of cases that can in no way qualify as controlled studies. If we perform procedures that have not been the subject of peer reviewed studies, aren't we obligated to inform our patients of the experimental nature of the procedure prior to performing their surgery?

I agree with you with regard to lack of peer reviewed research. However, the use of lasers to decontaminate both soft and hard tissue has a fair amount of literature attached to it, especially in Europe (ESOLA). There are several university studies ongoing with regard to the 2780 nm wavelength, diode, and LLT therapy. Both the dental AND orthopeadic literature proves the efficacy of these modalities over a wide range of treatment options. The problem is designing a protocol specifically to extraction/immediate placement cases. I have no doubt that in a couple of years, laser treatment of bone for both decontamination and regenerative therapy will be commonplace in our discipline.

Thanks for sharing the ideas and comments which is highly beneficial to all of us, from my point of view concerning this case i can say, if the periapical infection around this tooth can be bypassed with the implant drill under proper coverage with antibioic or you can open a mucopeiosteal flap to expose the infected cavity to do proper curettage for this area followed by immediate implant placement and bone augmentation with GTR membrane , personally i did few cases by this way with good results. We can think in another way , when we treat patient with infected huge infected periapical odontogenic cyst, we open a mucoperiosteal flap and evacuate the cystic contents then we properly enucleate the cyst wall down to healthy bleeding bone followed by bone augmentation to help bone formation and to restore the ridge contour with very good results. so, the concept could be accepted thanks Dr.Ossama Ghorab

In response to the comment that anecdotal info is not enough to base our sugical decisions on: I agree with you in this case. However, I think anecdotal info is extremely important in this day and age of big pharma influence in the literature. Some studies imply osteonecrosis associated with Fosamax is not a significant problem, yet I hear about cases of it all the time.

I would have to agree with Dr. Magarone above. My reults have been similar. I am attempting to improve my results with the laser too. I would add that placing an immediate implant into an active infection site depends on the size of the abcess. A small PA lesion is fine SOmething larger than about 5 or 6 mm in diamater I start to have pause. The criteria comes down to - can you confidently fully debride the abcess. Probably ideal is to increase the circuference of the original lesion by about 1mm. I have found that larger more chronic abcesses (been there for years) are the one to be wary of.

According to our experience based on 911 implant placements, 62 of them being immediate and placed in more/less inflamated areas, the success rate was the same (98.5 and 98.4 % respectively). More than 80% of immediate implantations were done with grafting procedures. The important facts you have to respect and signposts you have to follow in that cases are: thorough debridement of socket walls and soft tissue fistular tracts,removal of superficial 0.5mm of internal bone layer of the socket with a round bur, copious irigation with saline, achievement of good primary stability in solid apical bone, transgingival healing (immediate gingiva former placement) is desirable, oraly administred antibiotics for 5-10 days. Esthetic problems may occur if you have large buccal plate defects. In that cases we prefer delayed protocol and onlay bone graft 3-4m before implant placement.

yesterday I HAD A CASE ,ALL UPPER 14 TEETH WERE LOSE,AND WERE EXTRACTED ,8 IMPLANTS WERE PLACED ,THERE WAS A LOT OF ACTIVE INFECTION ,V.LITTLE BONE,SO IF I WAIT FOR 15 WEEK,SURLY THERE WILL NO BONE AT ALL.THE DRILLING WERE ALL DEEP IN NEW BONE, ANY COMMENTS

why can't you take care of the 'active'infection first? give the bone time to heal . it seems to me if you don"t take care of the infection first, your not taking care of the problem and only making your patients life hell down the road.

I agree totally with dr Miller. You not only can remove the soft granulation tissues but one can also remove the smearlayer, which normaly have to broken down first before the bone cells can migrate into the area. I use this procedure most times when removing third molars in infected area's with great results. Much faster healing and less complications to the nomal procedures. You can measure that easily in the times patients come to see you with pain or complications after the procedure. With the lasertherapy this is far more less!!

grafting in an infected site mean a compromized area for bone regenration & ther is high percentage of loosing the graft.also ther is adifference between erdication of infected cyst ( which mean localized infection in the cyst) or chronic infection in the bone, in this case the bacteria reside inside the bone it self.in this case I prefer to do delayed/immediate implant mean to wait 6 weeks after extraction & if the implant well have good stability at the time of insertion so we can do implant & grafting @ the same time , if not then grafting first ,3 months later the implant.