Treating contaminated dental implants is going to be an increasingly common treatment modality dentists offer in the future. Currently, there is little research to show what is the best treatment for the implant that has been exposed to the oral environment. In my experience, these contaminated implants can lose bone fast, sometimes faster than periodontitis patients.

This systematic review looks at 14 studies comparing means to clean contaminated titanium implants. The most common ways to clean the contaminated surfaces were: air-abrasives, plastic and metal tipped ultrasonics, metal hand scalers, and titanium brushes. Keep in mind that all of these studies are in vitro.

Some take homes from the various studies:

Air abrasives with sodium bicarbonate powder is capable of removing all viable cells.
No real difference in effectiveness of plastic covered or metal ultrasonic tips
Ultrasonic scalers show a significant decrease in biofilm covered areas
Steel/carbon curette seems to be the least effective means of cleaning a titanium surface
Rotating titanium brush shows a significant decrease in residual biofilm areas

My personal take-home from all these studies is that air abrasion, titanium brush, and ultrasonics are effective at cleaning titanium surfaces IN VITRO. IN VIVO, may be a different experience. Peri-implantitis usually creates a circumferential defect that tapers toward the implant as it moves apically. This creates a difficult lesion to gain access to and clean properly, even when properly flapped.

My guess is that the titanium brush and ultrasonic will be the easiest to use under surgical conditions and the air abrasive will be the least convenient due to the grit and mess in a flapped surgical site.

The authors conclude that there is still a lot of work needed in this area. I agree

Louropoulou A, Slot DE, Van der Weijden F. The effects of mechanical instruments on contaminated titanium dental implant surfaces: a systemic review. Clin. Oral Impl. Res. 00, 2013, 1-12

Fetner and Hartigan periodontics and implants has been serving the Jacksonville community for over 25 years. The practice is family owned and operated, and is always on the cutting edge of dental technology.

I recently saw Paul Fugazzotto speak at the American Academy of Periodontology anual meeting in Philadelphia. Paul is an excellent speaker and a big proponent of immediately placed molar implants. I believe he even said that 95% of the time, he will place an immediate implant post molar extraction! I thought his would be a good opportunity to look at his papers on the subject.

The first paper describes his immediate implant technique in mandibular molars with 341 implants placed and the second paper describes the technique in maxillary molars with 391 implants placed. Both papers were written in 2008 and published in Journal of Periodontology.

First, let's start with the technique:

1) The molar is extracted in an attempt to retain as much interradicular bone as possible. If bone has to be removed then an immediate implant is aborted.

2) Pilot drill is started at an angle for stability and then brought up to the proper angle. Up to a 2.2mm twist drill is used

3) Osteotomes are used to widen the osteotomy sequentially until the proper width and depth for implant placement

4) Implant is placed to the the most coronal bone level of the interradicular bone.

5) If the surrounding horizontal defect remaining was >3mm the site is grafted with a membrane. If the defect is <3mm the site is left to heal. Primary closure was obtained on all implants and they were exposed 3-6 months post op.

6) The implant is allowed to heal and is restored normally.

Results: In the mandible, two implants failed with 339 remaining in function for up to 6 years. In the maxilla, two implants were also lost with 389 remaining in function. This gives a survival rate of 99.1% and 99.5%, respectively. Success rates were not given in the study.

Take home: The pros of this procedure are shorter wait time for final prosthesis 6 months down to 3 as long as they are uncovered in 3 months. Shorter wait time is better for the referring dentist, and the patient. In the hands of Dr. Fugazzotto, there does not seem to be any difference in the survivability of the implants placed with this technique.

The cons of the procedure is that it seems very technique sensitive. To make the proper osteotomy in the interradicular bone can be difficult. Maintaining proper angulation can be difficult with immediate implants. Obtaining primary closure following an extraction involves large flap advancement which can be difficult to obtain and will lead to a decrease in keratinized gingiva.

I think that it is a very interesting technique and should be considered in the appropriate circumstances.

Sources:

Fugazzotto PA: Implant placement at the time of maxillary molar extraction: treatment protocols and report of results. J Periodontol 2008;79:216-223

Fugazzotto PA: Implant placement at the time of mandibular molar extraction: description of technique and preliminary results of 341 cases. J Periodontol 2008; 79: 737-747