Abstract
Six dental implants in six patients with periapical lesions were inserted and underwent trepanation and thorough curettage. During surgery, the lesion area was irrigated with copious natural saline and chlorhexidine and the bone defects were treated with tetracycline paste. The six implants were stable and asymptomatic postoperatively. The implants were loaded after 3 months. Radiologically, the radiolucency in the apical part disappeared gradually. These prostheses have functioned satisfactorily with no further complication during the follow-up period. For cases in which small lesions initially appear soon after implant placement, trepanation and curettage of the periapical lesion without resection of the apical part of the implant or bone substitute material and/or autogenous bone grafting is an effective management option. A rapid and exact diagnosis is important for treating implant periapical lesions.
Dental implants are now being accepted by more edentulous and partially edentulous patients. Following the increasing popularity of implants, some case reports have suggested that implant periapical lesion is a possible cause of dental implant failure .
Implant periapical lesion is also called ‘apical peri-implantitis’ or ‘retrograde peri-implantitis’ in the literature . The first case was described by M c A llister et al. in 1992 . It was defined as bone loss limited to the apical segment of an otherwise osseointegrated implant by R eiser et al. in 1995 and was often diagnosed as a radiolucency surrounding the implant apex .
Implant periapical lesions are classified as inactive (not infected) and active (infected). An inactive lesion is clinically asymptomatic peri-apical radiolucent, which is usually caused by placing implants shorter than the drilled cavity . It is not a true lesion and therefore does not require treatment (unless its size increases), only control . An active lesion is always accompanied by clinical symptoms such as pain, tenderness, swelling, and/or the presence of a fistulous tract . Clinically, an implant periapical lesion commonly means the active lesion .
The prevalence of implant apical lesions is 0.26% , but they are always unpleasant and exacerbation of the lesions may lead to the mobility of the implant and even implant removal . Recently, the prevention and treatment of implant apical lesions has been paid more attention by clinic researchers, but because of the low prevalence most reports are case studies. Different treatments have been introduced, but the phase, level and size of the lesion were not considered in these managements.
The authors describe six cases of active implant periapical lesions, at an early stage and small size, in their clinic that were treated by trepanation and curettage of the lesion and had effective results.
Case report
From January 2006 to December 2009, 2987 ITI system implants were placed in the authors’ department of implantology. All these implants were placed 3 months or more after teeth were extracted. There were six dental implants in six patients with periapical lesions, of which five implants were from the authors’ department, and one (also ITI system implants) was from another hospital. Parameters for each patient were recorded ( Table 1 ), including implant position and characteristic, reason for tooth loss, condition of adjacent teeth and timing of initial symptoms.
| Age | Sex | Implant position | Implant length (mm) | Reason for tooth loss | Condition of adjacent teeth | Antibiotics used after implant placed | Initial symptom time (days after implant placed) | Patient source | Consequence | Followed period (months) | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Apical lesions | Periodontitis | |||||||||||
| 1 | 36 | F | 46 | 10 | Apical lesion | No | No | No | 10 | Our department | Healed | 18 |
| 2 | 42 | M | 36 | 12 | Fracture | No | No | No | 7 | Other hospital | Healed | 30 |
| 3 | 57 | M | 46 | 10 | Apical lesion | Y | No | Y | 23 | Our department | Healed | 18 |
| 4 | 47 | M | 46 | 10 | Periodontitis | No | Controlled | Y | 10 | Our department | Healed | 36 |
| 5 | 39 | M | 46 | 10 | Apical lesion | No | No | Y | 12 | Our department | Healed | 12 |
| 6 | 41 | F | 35 | 12 | Apical lesion | No | No | No | 14 | Our department | Healed | 30 |
Five patients presented with pain 7–14 days postoperatively; the other one about 1 month postoperatively. The pain was intense and constant. Clinical examination showed all six dental implants were immobile. Swelling, reddening and tenderness, to different extents, were observed in the local mucosa of the implant periapical areas ( Fig. 1 ). The mucosa around the implant neck appeared pink without swelling, the probing depth was 2–4 mm, and bleeding on probing to the pockets was negative. The implants were dull to percussion, whilst the adjacent teeth were positive. Panoramic radiographs showed radiolucency surrounding the implant apices, and lesions were limited to the apices of implants ( Fig. 2 ).
The patients presented to the authors’ department shortly after initial symptoms. Trepanation and thorough curettage were performed ( Fig. 3 ). Antibiotics (cefuroxime 1.5 g twice a day and metronidazole 100 ml every day in a vein) were prescribed before and after surgery.
