Placing immediate implant for a tooth with periapical infection?

My patient has a periapical lesion on tooth 14.  He does not want root canal treatment and prefers an implant.  Since there is no bone seen on the periapical radiograph beyond the periapical lesion, would it be advisable to do an immediate implant?  I was planning on doing this with a Nobel Active because of its aggressive threads to achieve primary stability.  Your opinion? What do you advise?

29 thoughts on “Placing immediate implant for a tooth with periapical infection?

  1. Gianluigi Giammaria says:

    why do you want to risk it? extract and wait
    do you want primary stability? you have many possibilities … from Axiom Px (Anthogyr) to Shelta (Sweden e Martina) and many more
    who is the best dental implant? the best is what you like !
    Gianluigi Giammaria
    md, dds
    Pescara, Italy

  2. Rakshith says:

    Thanks, Gianluigi. The patient wants a immediate solution after extraction and not keen on wearing a RPD.

    • CRS says:

      Here is the dilemma the periapical nascent bone on the first premolar has pathology and this is where the osteotomy is extended to give primary stability in an immediate placement. There is no compromise here, obvious, remove, graft , no provionalization and place the implant after healing. I personally disenfect with my ND-Yag laser so that the deep pigmented bacteria are ablated. If the patient wants a resin bonded bridge or Essex for esthetics fine. That’s my advice.

      • CRS says:

        Nothing wrong with root canal option this tooth looks restorable and pathology would be treated conservatively

      • Bruce A Smoler says:

        Concur 100% bone physiology being what it is, who cannot wait a few weeks (6-8 )with socket grafting and PRGF (a bit longer w/o) to have a 30+ year restoration done once with fewer sequelae.

  3. Alex Zavyalov says:

    Based on this X ray I do not see any periapical lesion and the post does not contain any clinical information about periodontitis or the patient complains I doubt that the patient has requested implant insertion and that it is required in this case.

  4. Rossen Smoukov says:

    Hi, Rakshith

    I think you are risking too much with an immediate placement. I would do a pre-extraction course of antibiotics, a perfect periapical clean up after. I like to sterilize those post extr. alveoli with some Braunol. It needs 30 secs in situ to kill all that lives, where it should not :). Let the site drain for 7-14 days, then make your implantation. Heavy treads prefered.
    You can use a temp plastic crown, fixed to adjacent teeth (off occusion).

  5. Lou says:

    When I place an immediate implant I expect to engage apical bone. You may not have any to engage looking at this x-ray. If you do its probably soft. Doesn’t look like the best scenario to me. I would try and talk this patient into RCT and crown. You can do that in a day.

  6. Peter Fairnbairn says:

    Agree with these comments …….. there is a significant area which is up against the sinus … to expect to place immediately is risky ……… very few Surgeons I know can clean this site effectively . We have a simple protocol for these cases with thousands of successes .
    Extract the tooth and allow for a 3 week healing period .
    Then a site specific flap retaining the adjacent papillae and now it will be easier to really clean the site properly ( I like degranulation burs ) … then place and graft simultaneously with a Synthetic particulate graft .
    Load at 10 weeks , routine , predictable

  7. Brian says:

    Patients often want things that just cannot or should not be done. Don’t let the patient dictate incorrect treatment. Wait and place in an ideal situation.

  8. Dr. Gerald Rudick says:

    Your patient has been looking at too many TV commercials featuring a fireman who simply wanted dental implants….that changed his life!!!!

    As great as dental implants are, we on this earth cannot compete with the man upstairs who designed and built us…….. what I am trying to say is simply : -DO NOT COMPETE WITH NATURE!.

    In my opinion, from the single xray you have shown us, I would say that tooth #14 can probably be saved by endodontics, a post and core and a crown……. definitely a lot less money than placing an implant.

    Your patient has to realize that dental implants are not always successful; and they are not trouble free, they require maintenance.

    In my opinion, this patient will haunt you if you do not realize his dream and the result is not perfect…. you wanted to do endo? He refused?….. do yourself a favor and send him to a dentist collegue who you do not like!!!

  9. Carlos Boudet, DDS DICOI says:

    I agree with Peter.
    The periapical lesion ends at the floor of the sinus and is wider than the root, so you will not be able to use that area to engage any bone. But in my hands, I prefer grafting and waiting 3 to 4 months. This allows me to place a regular diameter implant rather than have to place a wider one to engage the walls of the socket (although a few years back, this is what we used to do).
    This also allows for an osteotomy in the ideal location, rather than one that wants to follow one of the roots in a bifurcated premolar, (which this might be) unless you are doing the surgery guided.
    I would also recommend considering endo, but only if there is an adequate ferrule to restore the premolar to a state that would be strong enough for the long term.

  10. Nikos Pontikakos says:

    Patient,unlike customer,is not always right. I agree with previous colleaques who are against immediate placement. I would advise him to endure a rct in order to eliminate the infection (place a, and after a few weeks he will decide whether to keep the tooth or go ahead with the implant.

  11. Jari Laitinen says:

    Dear colleagues,

    past years I have learned to prefer immediate implantation whenever it´s possible. It’s beneficial in preservation of the borderline of bone around the implant neck.

    In this case it’s necessary to clean all inflammatory soft tissue from the alveolus. Sometimes lateral approach is necessary for proper cleaning. With Nobel Active implant stability will be gained to build a kind of immediate temporary crown.

  12. peter liu says:

    doing root canal treatment for this molar tooth that has apical infection plus possible apical calcification may not be a good idea,the long term outcome is questionable. tooth extraction with delayed type of implant placement will be the treatment of choice plus the possibility of crestal sinus lift.

  13. Khalil Ibrahim Saber Karam says:

    There is a nobel approach to provoke healing of periapical tissue hence gain bone and without leaving patient edentulous. It is called “intermediate root canal treatment “.. So you carry on your RCT and wait for resolving of lesion and formation of bone later you can proceed to immediate implant.

    Dr. Khalil

  14. Jean Furuyama says:

    Agree with the others. This is definitely not an immediate placement candidate. Also, please look at the rather large PAP on the first premolar. This needs to be addressed before your place any implant in the area. Does the second premolar also have deep decay on the M (or is it possibly just a shadow?)

  15. Haydar G. Alkhatib B.D.S,H.D.D max fax says:

    RCT, simple orthodontic extrusion , Emax crown , perfect result in the longterm , nothing can be compared to a natural tooth with a periodontal ligament, just my 0.02$

  16. Ash says:

    If you only have to do the implant Vis a Vis an RCT…
    Extract , debride and curett very thoroughly … Meticulous and copious irrigation with chx mouthwash.
    You will have to engage the floor of the sinus for
    Primary stability … With a slight internal lift.. Say 1-1.5mm.
    Post and pre Rx Antibiotics !
    Best of

  17. John T says:

    Am I missing something here? You don’t say how old this man is but judging from his other teeth I guess he is middle-aged. He has an excellent periodontal status. He has an upper first premolar with a small apical granuloma. The crown is heavily restored but there is sufficient crown substance to provide anadequate ferrule. Root treatment is the obvious option.
    You say he doesn’t want root treatment and prefers an implant. My guess is this is because he doesn’t know the facts.
    Any endodontist could root fill this tooth at a single appointment, with an excellent chance of success (i.e. symptom free with resolution of the apical lucency) – say a 90% success rate. Then it’s a matter of routine restoration. If the endo fails an implant is always there as a fallback option.
    Implant option:-
    (a) Can’t be certain but the premolar may be a two-rooter. If so there’s a risk of root fracture needing a transalveolar approach.
    (b) Multi appointment treatment spread over several months.
    (c) Considerably more costly
    (d) There is no implant known to man which has the life expectancy of a natural tooth.
    (e) What would you have in your mouth – a root filled tooth or an implant?

    To me (and to any lawyer) it’s a no brainer; give him the facts and advise him to see an endodontist.

    • STP says:

      ” The crown is heavily restored but there is sufficient crown substance to provide an adequate ferrule”

      I disagree heavily. There is a restoration approximately 5mm’s thick, and the retentive feature is barely 2mm at best. Even Gorilla Glue couldn’t hold a crown on this tooth under normal masticatory function.

      That being said, I don’t place implants into infection ever. Extract, allow to heal, place implant with confidence and success.

      If the patient doesn’t accept your plan then let him go elsewhere. Too risky otherwise, and any solicitor will tell you “a patient cannot consent to malpractice”.

  18. Dr. Matt Helm says:

    This is NOT an implant case. This is a patient MANAGEMENT case!
    It may sometimes be uncomfortable, but we must also be educators for our patients. You need to educate your patient as to why an implant is not beneficial, as per the pitfalls enumerated above by the other posters. Indeed the man above designed us in ways no implant can match. That — along with the other pitfalls and disadvantages to an implant in this case — clearly dictates that a root canal and proper restoration is the treatment of choice. It’s more predictable, and longer lasting than an implant. I also think a standard PFM with a chamfer and deep cervical bevel prep (minimum 1mm subgingivally, consider a slight crown lengthening if necessary) would be more indicated than an eMax crown, due to the metal coping’s role of holding the root together better and the increased mechanical retention that is inherent in such a restoration. It may sound old-school but it’s proven and, more applicable in this case than any bonded resin or procelain crown that sits on a chamfer and does not grasp the root circumferentially.

    Dr’s John Rudick (as always) and John T have hit the nail on the head better than anyone. Additionally, do pay attention to John T’s last sentence about it being a no brainer to any lawyer. Do NOT allow the patient to dictate treatment, or you will do so at your peril if things don’t work out to his complete satisfaction — and with such patients, things generally tend not to work out. Generally patients like this have exagerated expectations. (This guy doesn’t want to sit for an RCT! How well do you think he’ll sit for multiple implant visits? How impatient do you think he’ll become? And how unhappy do you think he’ll be at the slightest thing that doesn’t turn out the way he expects?)
    It sounds like this patient “thinks” he “knows better” than you, the Dr, like most patients who try to dictate treatment when advised to the contrary. Ask yourself if this is a case you want! If this patient refuses — or, worse yet, combats — your well-meaning advice and insists on having it his way, I would take Dr. John Rudick’s advice if I were you. 🙂

  19. Murray Arlin says:

    I will risk going against the majority of opinions on this case. Firstly the tooth is heavily restored and we cannot tell from periapical radiograph alone how extensive the loss of sound tooth structure is so I would not immediately assume that this is not a reasonable extraction and an implant case. As well I think this could be an immediate implant case for 2 reasons. Firstly there are numerous studies indicating one can be successful with immediate implants being placed in the presence of periapical and periodontal infection. Secondly immediate stabilization can likely be achieved with lateral engagement of the extraction socket bony walls likely with utilization of a 5 mm diameter implant. This is a technique I have used successfully for many years. Lastly I would clarify that the numbering system for this tooth i.e. #2.4 is not the European system but the International Numbering System that we also in Canada as well as most of the rest of the world, with the USA being a notable exception.


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