Chronic endodontic infections are associated with osseous changes in the peri-apical regions. Dental implants are often placed after the extraction of hopeless teeth with periapical infections. This clinical report describes a patient with a radiopaque mass attached to the root apex of the mandibular right second premolar tooth (No. 45). The differential diagnoses of the radiopaque mass were bone- and tissue-borne diseases. Based on the clinical and radiologic findings (bone density and trabeculation of the bone), the definitive diagnosis of the osseous mass was condensing osteitis. The osseous tumor associated with tooth 45 was atraumatically extracted under local anesthesia. Guided bone regeneration was performed immediately after extraction of tooth 45, and a dental implant was placed in the site after 6 months of healing.
Risk factors of localized jaw sclerosis include stress, infection, and/or trauma.1 Apical bone growth occurs due to chronic pulpal inflammation. A low-grade inflammatory stimulus emerging from the pulp that induces the proliferation of osteoblasts results is associated with the etiology of condensing osteitis (CO).2, 3 Histologically, CO is characterized by impaired bone remodeling by de novo bone formation, bone sequestrum, and presence of normal bone marrow exchange with fibrous connective tissue with inflammatory cell infiltrate.4 Radiographically, CO appears as a well-defined uniform dense radiopaque mass at the root apex of the tooth with widening of the periodontal ligament space and loss of lamina dura.5,6 The CO can be differentiated from idiopathic sclerosis with reference to its relation with the pathological lesions of dental pulp.7,8
Researchers have reported that the survival of immediate implants is compromised in extraction sockets associated with chronic apical or periodontal infections.9,10 Lindeboom et al11 examined the effect of infected residual alveolus on the implant survival rate. They concluded that the failure rates of immediate implants placed in infected extraction sockets were higher than those for implants undergoing a delayed placement protocol.11 The decision whether to perform immediate or delayed guided bone regeneration (GBR) and implant placement remains debatable12–14 as the risk of membrane exposure and infection when GBR is accompanied by immediate implant placement in infected extraction sites is inevitable.15,16 The process of GBR with delayed implant placement is a potential treatment for large infected alveolus and sites lacking bone to support the immediate implant. To the author's knowledge from pertinent indexed research, no studies have assessed immediate implant placement after GBR in large infected alveoli lacking osseous support. The purpose of the present study is to report a clinical case of a female patient in whom immediate implants were placed after GBR with delayed implant placement in large infected alveoli lacking osseous support.
The patient was a 49-year-old Caucasian woman who was referred to the implant clinic for extraction of a hopeless mandibular right second premolar (tooth 45) and possible implant placement. The patient wanted to have the tooth extracted and replaced with an implant. The patient had no medical history that could have contradicted the proposed surgical and prosthodontic treatment. The patient reported no history of tobacco smoking and/or alcohol use. The patient did not report any parafunctional oral habits, and her oral hygiene regimen consisted of brushing twice a day with flossing. The patient reported no known drug allergies.
Clinical examination of tooth 45 showed a grade-1 mobility with no pain on stick biting. The soft tissues associated with tooth 45 had a thin gingival biotype with 2 mm of keratinized gingiva. The mid-buccal probing depth was 5 mm, and there was bleeding on probing from the sulcus. According to interdental papilla loss classification,17 the mesial and distal papillae associated with tooth 45 were graded as 2 and 3, respectively, The alveolar bone surrounding tooth 45 was 3 mm on the distal aspect of tooth 44 (mandibular right first premolar), 8 mm on the mesial aspect of tooth 45, 10 mm on the mid-buccal aspect, and 9 mm on the distal aspect of tooth 45.
Radiographic evaluation showed a fractured root-filled tooth 45 with a large well-defined uniform dense radiopaque mass at the root apex. Widening of the periodontal ligaments space and loss of lamina dura of tooth 45 were also observed radiographically (Figure 1a). The 3-dimensional come-beam computed tomographic assessment showed a lack of buccal bone on tooth 45 with a large radiopaque mass attached to the root. The differential diagnosis for the radiopaque mass was CO, cemento-osseous dysplasia, and cementoblastoma. The patient desired an implant after extraction of the hopeless tooth 45 and the missing mandibular right first molar (tooth 46). The dilemma in terms of treatment planning was to decide whether GBR should be performed immediately or delayed after tooth 45 was extracted.
Procedure in detail
The patient read and signed an informed consent form before tooth 45 was extracted, and a preoperative antibiotic cover (2 g of penicillin) was given 1 hour preoperatively. Local anesthesia (2% xylocaine with 1:100 000 epinephrine, Septodont, Inc, New Castle, De) was administered labially and lingually. A full-thickness mucoperiosteal flap was elevated with sulcular incisions around tooth 45 and tooth 44 followed by a crestal incision and 2 vertical incisions mesial to tooth 44 and distolateral to the ascending part of the ramus. Tooth 45 was extracted atraumatically using a periotome, surgical elevator and forceps. A window was opened at the mass area to facilitate the extraction (Figure 1b), and tooth 45 was extracted with the osseous mass attached to the root apex. The extracted tooth 45 and the attached bony mass were sent for histopathological analysis (Figure 1c).
Complete debridement of the extraction alveolus was performed; and the defect size was mapped (Figure 1d). The inferior alveolar nerve (IAN) was exposed apical to the extraction site. An autogenous graft was harvested from the mandibular ramus area using a bone scraper. A collagen-based hemostat (Avitene Microfibrillar Collagen Hemostat; Impladent Ltd, Anaheim, Calif) was placed directly on top of the IAN to isolate the nerve from the bone graft trauma. The particulated autogenous bone graft was mixed with a bovine derived xenograft Bio-Oss (Geistlich Pharma, Princeton, NJ; Figure 1e). The graft was placed within the bony defect of the extraction socket of tooth 45 above the Avitene and on the area of the mandibular right first molar (tooth 46). A resorbable membrane (Bio-Gide, Geistlich Pharma) was placed over the grafted defect and stabilized using periosteal sutures. The flap was readjusted to the original position and sutured using a resorbable (Vicryl Sutures, Johnson & Johnson, New Brunswick, NJ) and nonresorbable (Gore-Tex, Gore Biomedical, Flagstaff, Ariz) sutures. The sutures were removed 2 weeks postoperatively. Postoperative antibiotics (500 mg amoxicillin, 3 times daily for 1 week) were prescribed.
Tooth 45 (measuring 1.5 × 0.5 cm with attached hard tissue at the root measuring 1.2 × 1.2 × 0.5 cm) with attached hard tissue was fixed in formalin and placed in a container labeled with information related to the patient's identification. Histopathological diagnosis of sections from the specimen revealed compact bony lamellae free of atypia suggestive of odontoma. There were no epithelial elements; and the biopsy report was negative for malignancy (Figure 2).
At the 6-month follow-up, the osteotomy was prepared for tooth 45 and tooth 46 based on a clear form surgical template (Figure 1f); and a rootform implant (4 × 11 mm, Astra, Bensheim, Germany) was placed (Figure 1g). The soft tissue healing around the implant and at the donor site was uneventful, with the patient having minimal discomfort.
In the present case report, extraction and immediate GBR were planned to maintain the hard tissue complex, avoid the need for additional surgeries, and shorten treatment time. Complete debridement of the extraction alveolus was prerequested to avoid any infection in the grafted site. A collagen layer has been used above the IAN to protect the nerve from the trauma. Autogenous bone graft mixed with xerograft is often recommended because of the osteogenic, osteoinductive and osteoconductive capacity of the former.18,19 Successful bone healing with an excellent width and complete regeneration of the defect area was created due to the proper technique. Since extracting tooth 45 without disengaging the attached osseous mass (CO) at the root apex was challenging; full-thickness mucoperiosteal flaps with a bony window were created.
Lindeboom et al11 assessed the survival rate of implants placed on chronic infected sites. In this study, 25 implants were placed immediately and the others were placed 3 months after healing.11 The result showed a 100% survival rate of implants loaded with a delayed protocol compared with 92% of immediately placed implants.11 Studies have reported that chronic implant contamination with the periapical pathosis leads to implant failure.20,21 Shaffer et al20 reported the failure rate and complications of 6 series cases of implants immediately placed on the existing infected alveolus. Moreover, in a chart review study by Bell et al,22 the success rate for 922 implants was compromised when the implant was placed on the infected alveolus. Based on a vigilant literature review, the author of the present case report proposes that the clinical decision to perform immediate or delayed implant placement should be based on the existing alveolar bone after complete debriding the tooth socket for proper implant stability and minimizing the risk of microbial contamination of the surgical site via pre- and postoperative antibiotic therapy. Furthermore, the significance of routine postoperative follow-up and regular oral hygiene maintenance for the long-term success and survival of dental implants cannot be overlooked.
Immediate GBR after extraction of the infected tooth with large attached condensing osteitis yielded adequate bony fill and successful width gain of severely resorbed and destructed alveolar ridge.
The author declares that he has no conflict of interest related to the present case report, and there was no external source of funding for the present study.