Immediate implantation in infected sites: a mastered clinical challenge

Immediate implantation has become a common procedure, appreciated for its ability to reduce treatment time and limit post-extraction tissue resorption. However, its implementation remains complex when facing sites presenting active periapical pathology coupled with a loss of the buccal bone plate. While these conditions were long considered contraindications, the evolution of debridement and guided bone regeneration (GBR) protocols now allows for the expansion of clinical indications.

The objective of this case report is to document the management of a compromised anterior maxillary site, characterized by a periapical infection and a cortical bone defect. The study illustrates the feasibility of a combined approach associating meticulous curettage, GBR using bovine bone substitute and an absorbable membrane, as well as a non-functional immediate temporary restoration. This protocol aims to validate the maintenance of the emergence profile and the success of osseointegration despite an initially infected environment and a deficient bone volume.

Methodology

This clinical case report details the surgical and regenerative protocol applied to a 40-year-old male patient presenting Grade I mobility (Miller classification) and periapical lesions of 3 to 5 mm in diameter at the level of the maxillary central incisors (11, 21). The therapeutic approach is based on immediate extraction-implantation combined with guided bone regeneration (GBR).

• Preoperative protocol: Prescription of antibiotic therapy (Amoxicillin 500 mg + Clavulanic acid 125 mg) initiated 24 hours before the procedure for a total duration of 7 days.
• Surgical procedure: Atraumatic extractions of teeth 11 and 21, followed by meticulous alveolar curettage to remove granulation tissue and saline irrigation. A mucoperiosteal flap was reflected to visualize the buccal bone defects.
• Implant phase: Preparation of osteotomy sites along the palatal aspect to engage native bone beyond the apex. Placement of two 4.2 × 12 mm implants (BioHorizons) with an insertion torque > 32 Ncm.
• Bone regeneration: Filling of the jumping gap and buccal defects with deproteinized bovine bone (Bio-Oss®) and application of an absorbable collagen membrane (Bio-Gide®).
• Prosthetic phase: Placement of an immediate non-functional temporary restoration to stabilize soft tissues and maintain the emergence profile.

L'évaluation du succès a été réalisée par suivi clinique et imagerie (radiographies rétro-alvéolaires et CBCT) afin de confirmer l'ostéointégration et la stabilité des volumes osseux avant la pose de la prothèse finale.

Surgical procedure results

The procedure achieved the immediate clinical objectives despite the presence of periapical lesions and buccal bone defects. Primary stability, a sine qua non condition for immediate implantation, was obtained thanks to apical anchoring in the native bone, beyond the lesion area.

Sur le plan qualitatif, les observations peropératoires et les résultats immédiats ont confirmé :

• Elimination of the pathology: Meticulous curettage allowed for the complete removal of granulation tissue from the extraction sockets.
• Management of bone defects: Filling the "jumping gap" and vestibular dehiscences using the Guided Bone Regeneration (GBR) technique allowed for the stabilization of the graft under the collagen membrane.
• Surgical closure: Achieving tension-free primary closure was performed using a coronally repositioned flap, secured with 3-0 non-absorbable sutures.
• Aesthetic restoration: An immediate temporary restoration was placed at the end of the surgery to meet the patient's psychological and aesthetic requirements.

La préparation du site a également inclus une antibiothérapie prophylactique (Amoxicilline 500 mg + acide clavulanique 125 mg) débutée 24 heures avant l'acte chirurgical.

Clinical analysis and perspectives

This clinical case demonstrates the feasibility of immediate implantation in the aesthetic zone, even in the presence of combined obstacles: a periapical pathology (3 to 5 mm lesion) and a buccal bone defect. Success relies on a rigorous protocol including meticulous curettage of the granulation tissue and achieving high primary stability (>32 Ncm). The engagement of 4.2 x 12 mm implants into the native bone beyond the apex proves to be decisive in securing the site despite the initial infectious environment.

The study also highlights the crucial role of guided bone regeneration (GBR). The combination of a particulate bovine xenograft and an absorbable membrane allowed for the effective treatment of buccal dehiscences, with the graft serving as an osteoconductive scaffold. This approach validates recent data suggesting that apical pathology is no longer an absolute contraindication, provided that the bacterial load is controlled and the mechanical stability of the surgical site is ensured.

However, the scope of these results is limited by the study design (single case report). Although immediate temporary restoration was used to support soft tissues and preserve the gingival emergence profile, long-term success requires validation on larger cohorts. For the practitioner, the clinical implication is direct: the success of immediate implantation in an infected site depends on the triptych of exhaustive curettage, strong primary stability, and simultaneous bone volume management via GBR.

Summary of results

This clinical case demonstrates the viability of immediate implantation despite a 3 to 5 mm periapical lesion and a buccal cortical defect. Thanks to exhaustive debridement, a palato-apical anchorage ensuring a torque > 32 Ncm and simultaneous GBR (Bio-Oss/Bio-Gide), the 4.2 x 12 mm implants achieved complete osseointegration confirmed clinically and radiographically at 6 months.

In concrete terms, for the practitioner:

• Overcome periapical contraindication: Local infection no longer prohibits immediate implantation if you perform meticulous curettage of granulation tissue combined with prophylactic antibiotic therapy (Amoxicillin 500mg + CA 125mg) started 24 hours before the oral surgery.
• Secure primary stability: In the presence of bone defects, prepare your osteotomy beyond the apex into native bone and towards the palatal aspect to ensure the stability necessary for the success of the procedure.
• Manage the vestibular defect with GBR: Do not delay surgery in case of dehiscence; the use of a xenograft and an absorbable membrane is sufficient to stabilize the bone volume and maintain an aesthetic emergence profile.

Technical lexicon of the study

Periapical lesion: Radiolucent area located at the apex of the root (3 to 5 mm in this case), indicating endodontic pathology or root canal treatment failure, requiring meticulous curettage of the granulation tissue before implantation.

Guided Bone Regeneration (GBR): Surgical procedure using grafting materials (xenograft) and a barrier membrane to reconstruct bone defects, such as the loss of the buccal plate observed in this patient.

Primary stability: Initial mechanical anchorage of the implant measured during insertion. In this report, a torque value greater than 32 Ncm was achieved by anchoring the implant into the native bone beyond the apex of the socket.

Vestibular plate defect: Loss of bone substance (dehiscence or fenestration) at the level of the external wall of the socket, complicating immediate implantation and requiring GBR management to ensure soft tissue support.

Xenograft (deproteinized bovine bone): Bone substitute of animal origin used as an osteoconductive scaffold to fill the "jumping gap" (space between the implant and the alveolar walls) and peripheral defects.

Absorbable collagen membrane: Biological barrier used to isolate the graft site, stabilize the filling material and prevent the invagination of epithelial tissues during the bone regeneration phase.

Emergence profile: Gingival and prosthetic contour at the marginal gingiva passage. Its preservation is a key objective of immediate implantation associated with a temporary restoration or soft tissue maintenance.

Information intended for healthcare professionals. This content may contain errors or truncated summaries. We recommend always verifying with the original source article. Delynov disclaims all responsibility regarding the use of this information. This document is not intended for patients or the general public.