J Periodontol • June 2010

Review
Immediate Placement of Implants Into Infected Sites:
A Systematic Review of the Literature
Jonathan A. Waasdorp,* Cyril I. Evian,† and Martine Mandracchia‡

Background: Immediate implant placement of dental implants into fresh

extraction sockets was shown to be a predictable and successful procedure
when proper protocols were followed. Placement into infected sites has
been considered a relative contraindication. However, data from animal re-
search, human case reports and case series, and prospective studies showed
similar success rates for implants placed into infected sites compared to im-
plants placed in non-infected or pristine sites. The focus questions addressed

T
he immediate place-
in this review are: Does the presence of infection compromise the osseointe- ment of dental im-
gration of immediate placement of implants? Does the presence of infection plants into fresh
compromise immediately placed implant success? What protocols have extraction sites has been
been used to address the infection prior to immediate implant placement? shown to be a predictable,
Methods: A systematic search of MEDLINE/PubMed articles published successful procedure1-3
from 1982 up to and including November 2009 was independently performed when proper protocols
by two investigators (JAW and CIE). The search strategy used combinations are followed. A reduc-
of the following terms: dental implants, immediate, immediately, extraction, tion of treatment time
infection, infected, and pathology. The search included data from animal and number of proce-
and human studies. The selection criteria excluded animal studies that did dures and the ability to
not include a pristine control group and human case reports and case series place the fixture in an
with <1 year of follow-up. All prospective human studies were included. Stud- ideal axial position are
ies were limited to those published in the English language, and review article major advantages of this
data were excluded. technique.3,4 Oftentimes,
Results: The search strategy initially yielded 417 references. After screen- the clinical situation of
ing the abstracts for those related to the focus questions, 12 publications qual- teeth requiring extraction
ified for inclusion. The majority of studies examined sites with chronic and implant placement
periapical infection; however, the classification of infection was often vague exhibit periapical and/
and not categorized to be related to the outcome. The data from animal stud- or periodontal pathology.
ies demonstrated high levels of implant survival, although conflicting data Various authors have sug-
showed that the bone-to-implant contact may be impaired. Human studies gested that immediate
showed high levels of implant survival consistent with therapy in non-infected placement of an implant
sites, but evidence was limited to a small number of studies and patients. into an infected site is
Thorough debridement and the use of systemic antibiotics were employed contraindicated,5,6 as sites
in all studies. exhibiting pathology have
Conclusions: Evidence suggests implants can be placed into sites with been thought to compro-
periapical and periodontal infections. The sites must be thoroughly debrided mise osseointegration.7
prior to placement. Guided bone regeneration is usually performed to fill the Alsaadi et al., in a large
bone–implant gap and/or socket deficiencies. Although controversial, sys- consecutive case study,
temic antibiotics should be used until further controlled trials prove otherwise. noted a greater tendency
J Periodontol 2010;81:801-808. toward implant failure in
sites with apical lesions,8
KEY WORDS
especially with machined-
Dental implants; infection; pathology; tooth socket. surface implants. Addition-
ally, cases of retrograde
peri-implantitis have been
* Private practice, King of Prussia, PA.
† Private practice, King of Prussia, PA.
‡ Department of Cariology and Comprehensive Care, New York University, New York, NY. doi: 10.1902/jop.2010.090706

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Immediate Placement of Implants Into Infected Sites Volume 81 • Number 6

thought to result from placement into such sites.9,10
Periodontal infection has also been correlated with an
increased risk of implant failure.11,12 More recent
literature, however, has investigated placement into
sites exhibiting periapical pathosis with successful
outcomes.13,14 However, the diagnosis of infection
is often clinically based; clearly, periapical lesions
which present with a similar radiographic appearance
can differ histologically (Table 1).15 The purpose of
this article was to review the literature regarding
treatment outcomes of immediate implant placement
into sites exhibiting pathology and provide recom-
mendations for treatment.
MATERIALS AND METHODS
Focused Questions
Does the presence of infection compromise the os-
seointegration of immediately placed implants? Does
the presence of infection compromise immediate im-
plant placement success? What protocols have been
used to address the infection prior to immediate im-
plant placement?
Search Protocol
The MEDLINE/PubMed databases of the National
Library of Medicine, Bethesda, Maryland, were used
to search for relevant articles. The databases were
searched for articles dating from 1982 up to and in-
cluding November 2009. No hand searches were per-
formed. The following searches were performed using
different combinations of the following key words and
search terms: dental implant, immediate, immedi-
ately, extraction, infected, infection, and pathology.
Eligibility Criteria
The criteria for an immediately placed implant fol-
lowed the criteria defined by Hammerle et al.3 Eligibil-
ity criteria included both animal and human studies
and excluded any review articles or those not pub-
lished in the English language. The publication’s in-
tervention had to be the placement of an implant
into a site classified as having infection (periapical,
endodontic, perioendodontic, and periodontal), and
the main outcome variable (implant survival or suc-
cess) had to be related to the presence of infection.
A control group was defined as a pristine or non-
infected site. Human case reports and case series
were limited to those with >1 year of follow-up after
implant placement. All prospective human studies
were included. Animal studies were excluded if they
did not include a control. Studies were evaluated
for classification of infection, treatment rendered,

Table 1.
Periapical Pathology of Teeth That Present With Radiolucency

Pathology Clinical Features Histologic Features

Periapical granuloma (also known as
chronic apical periodontitis)
Periapical abscess
Periapical cyst (also known as a radicular
cyst and apical periodontal cyst)
Periodontal abscess
Associated with non-vital teeth. May
arise after quiescence of a periapical
abscess and can transform into a
periapical cyst. Usually asymptomatic.
Associated with non-vital teeth.
Symptomatic or asymptomatic.
Usually asymptomatic unless acute
exacerbation or cyst reaches a large
size. Associated tooth is non-vital.
Zone of gingival enlargement along the
lateral aspect of a tooth. Erythema
and edema are often present. Lesion is
often characterized by throbbing pain,
purulence, lymphadenopathy, and
gingival sensitivity. Often treated with
systemic antibiotics when fever is
present.
Inflamed granulation tissue surrounded
by a connective tissue wall. Tissue
contains lymphocytic infiltrate that
may be intermixed with neutrophils,
plasma cells, and histiocytes.
Acute inflammation with the presence
of neutrophils often mixed with
inflammatory exudate, necrotic
material, and bacteria.
Lined by a stratified squamous
epithelium. Lumen filled with fluid and
cellular debris. May contain dystrophic
calcification, red blood cells,
cholesterol clefts, multinucleated giant
cells, and hemosiderin.
Tissue characterized by features of
periodontitis along with acute
inflammation with the presence of
neutrophils.

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J Periodontol • June 2010
pharmacotherapeutic agents used, histologic out-
come when available, and implant survival and/or
success.
Titles and abstracts obtained via the search strat-
egy were screened by two authors (JAW and CIE)
and checked for agreement. Letters to the editor, re-
view articles, and those not published in the English
language were excluded. The full text of the articles
was read and evaluated against the eligibility criteria.
Disagreement between the authors was resolved
verbally.
RESULTS
The search strategy initially yielded 417 references.
The two reviewers (JAW and CIE) independently
screened the abstracts for those articles related to
the focus questions. Fifteen publications initially qual-
ified for inclusion and were selected for a full-text re-
view. Of these studies, six were animal studies,16-21
and nine were human studies.13,14,22-28 One human
case report28 was excluded because it was not pub-
lished in English. Two animal studies20,21 were ex-
cluded because they compared the integration of
two implant surfaces without a control group.
Data From Animal Studies
The data from the four animals studies16-19 are shown
in Table 2. Novaes et al.16 were the first to study the
immediate placement of implants in surgically cre-
ated periapical lesions in a canine model. Periapical
lesions were induced by cutting off the crowns at
the cemento-enamel junction, removing pulpal tis-
sue, and allowing the canals to be exposed to the oral
Table 2.
Animal Studies
Animal Number of Number of
Study Model Subjects Implants
Novaes et al., 199816 Dog 4 28
Novaes et al., 200317 Dog 5 40 (20
non-infected periodontitis
controls)
Marcaccini et al., Dog 5 40 (20
200318 (same study non-infected periodontitis
as reference 17) controls)
Chang et al., 200919 Dog 4 24
BIC = bone-to-implant contact; NSD = no significant difference.
Waasdorp, Evian, Mandracchia
cavity for 9 months. Radiographs showed evidence of
periapical pathology, and purulent exudate was pres-
ent at the time of extraction. The animals were placed
on antibiotics 4 days prior to surgery and continued on
antibiotics for 4 days postoperatively. After tooth ex-
traction, the sockets were debrided and rinsed with
a tetracycline solution prior to implant placement.
All implants healed without complications and were
clinically integrated, but histomorphometric analyses
revealed a greater bone-to-implant contact (BIC)
(38.7% versus 28.6%) in the control group. The differ-
ence was not significant.
Chang et al.19 also studied immediately placed im-
plants into induced periapical lesions in a dog model.
Additionally, at the time of extraction, a 6-mm defect
was created in the buccal cortical bone to simulate
periradicular surgery. One test group received a poly-
tetrafluoroethylene (PTFE) membrane to cover the
osteotomy, and the other test group had no barrier.
Animals were provided antibiotic coverage for 5 days,
and the sockets were debrided and cleaned by osteo-
tomy and curettage. All implants had clinically inte-
grated, and radiographs showed bone healing in all
groups. However, the control group showed greater
BIC (76.3%) versus both experimental groups
(59.5% in the membrane group; 48.6% in the non-
membrane group). The difference was statistically
significant between test and control groups, but not
between the two test groups.
Novaes et al.17 studied immediate placement into
ligature-induced periodontitis sites compared to
healthy controls in a split-mouth dog model. After
tooth extraction, curettage of the alveolus was
Type of
Infection Treatment Outcomes
Induced periradicular Debridement, rinse with Zero failures and NSD in
lesion versus tetracycline solution, BIC in the experimental
healthy sockets and antibiotic coverage. group.
Ligature-induced Curettage of alveolus and Zero failures and NSD in
antibiotic coverage. BIC in the experimental
group (66.0% versus
62.4%).
Ligature-induced Fluorescein angiography Slower healing initially and
of Novaes et al., NSD after 12 weeks.
2003 cohort.17
Induced periradicular Osteotomy and curettage, Zero failures, less BIC in
lesion versus placement with or experimental groups,
healthy sockets without membranes, and less BIC in the
and antibiotic coverage. non-membrane group.
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Immediate Placement of Implants Into Infected Sites
performed prior to implant placement. There were
zero failures in either group, but BIC was non-signifi-
cantly greater in the control group. In a second arm of
this study, Marcaccini et al.18 performed fluorescence
radiography during implant healing. Slower initial
healing was noted, but the difference was not signifi-
cant after 12 weeks.
Data From Human Studies
The data from the eight human studies13,14,22-27 are
shown in Table 3. Novaes and Novaes23 published
the first case report in which three patients each re-
ceived one immediately placed implant into an infected
site. The sites were categorized as having recurrent
endodontic infection with periapical radiolucency.
The treatment after extraction consisted of debride-
ment, a saline rinse, simultaneous guided bone regen-
eration (GBR), and a 31-day course of antibiotics
(penicillin V for 10 days starting 1 day preoperatively
and doxycycline for another 21 days). These three
patients demonstrated 100% implant success and
provided proof of principle for this treatment. The
authors23 noted that the patient ‘‘must be placed on
penicillin V 24 to 48 hours before the procedure
and maintained on the medication for 10 days.’’
Villa and Rangert25 treated 20 consecutive private-
practice patients in whom mandibular interforaminal
implants were immediately placed into sites with end-
odontic and periodontic lesions. The implants were
immediately loaded (within 3 days) with a full-arch
prosthesis. Like the previous case report,23 a high
level of implant survival (100%) was observed in this
cohort.25 The same group26 evaluated 100 immedi-
ately placed implants (76 placed into infected sites)
in 33 patients placed into maxillary sites. Infections
were categorized as endodontic, periodontic, or root
fracture. Treatment included socket debridement,
bone curettage, antibiotic irrigation with rifamycin,
simultaneous GBR with autogenous or anorganic
bovine bone with a collagen barrier, and a cortisone
injection into the soft tissue after suturing. These
implants were also immediately loaded (within 3
days) with a full-arch fixed prosthesis, and the pa-
tients were placed on amoxicillin beginning 1 day
prior to the procedure and continuing for 5 days post-
operatively.
Casap et al.24 placed a total of 30 implants into in-
fected sites in 20 patients. The infections varied and
included a periodontal cyst and subacute periodontal,
perioendodontic, chronic periodontal, and chronic
periapical infections. The authors outlined a treatment
protocol that began with administration of amoxicillin,
or clindamycin in sensitive patients, 4 days prior to the
procedure and maintained for 10 days. After extrac-
tion, the sockets were debrided, and a peripheral in-
trasocket ostectomy was performed followed by
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Volume 81 • Number 6
sterile solution irrigation. Defects were augmented
with anorganic bovine bone, and a titanium-reinforced
expanded PTFE membrane was secured. One implant
failure was observed after 12 to 72 months of follow-
up; the implant was mobile after immediate restora-
tion. Complications included a deficiency in attached
gingiva, membrane exposure, and pseudomembra-
nous colitis.
Naves et al.13 published a case report of three im-
plants immediately placed into sites with chronic peri-
apical pathology and failing endodontic treatment.
Patients began antibiotic coverage 1 hour before sur-
gery and continued for 7 days. Treatment included
a secondary apical access flap for thorough debride-
ment and GBR with a xenograft and bioabsorbable
barrier. The 3-year follow-up demonstrated that the
implants were successful with no signs of radio-
graphic or clinical pathology.
Like the case reports and case series, prospective
studies demonstrated positive results. Lindeboom
et al.22 published the first prospective, randomized
study evaluating implants placed immediately into
infected sites. Fifty patients who presented with one
tooth demonstrating chronic periapical pathology
were randomized into two groups: an immediate
placement group and a delayed placement (healing
period of 12 weeks) group. Patients were premedi-
cated with clindamycin 1 hour preoperatively.
Twenty-five implants were placed in each group. Af-
ter extraction, the sockets were thoroughly debrided,
and tissues were collected for microbial analysis.
GBR with autogenous bone and a collagen mem-
brane was performed, primary closure was achieved,
and the implants were allowed to heal for 6 months.
Overall, two of the immediately placed implants
were lost, resulting in a 92% survival rate versus
100% survival rate for the group who received de-
layed-placement implants. Mean implant stability
quotient values, gingival esthetics, periapical cultures,
and radiographic parameters were not significantly
different.
Seigenthaler et al.27 also demonstrated favorable
results in a prospective, controlled clinical trial. Sev-
enteen consecutive patients had implants immediately
placed into sites demonstrating pain, periapical radio-
lucency, fistula, suppuration, or a combination of
these characteristics. Another 17 patients with imme-
diately placed implants into sites without periapical
pathology served as control subjects. All patients pre-
medicated with amoxicillin 1 hour before surgery
and continued for 5 days postoperatively. After ex-
traction, granulation tissues were removed, and the
site was rinsed. GBR was performed with depro-
teinized bovine mineral, and a collagen barrier was
applied. Implants were loaded after 3 months, and
a semisubmerged healing was implemented when
J Periodontol • June 2010 Waasdorp, Evian, Mandracchia

Table 3.
Human Studies

Number of Number of Follow-Up Type of

Study/Type Patients Implants (months) Infection Treatment Outcomes Miscellaneous
Novaes et al., 3 3 7 to 14 Recurrent Debridement, saline 100% survival –
1995;23 case endodontic and rinse, GBR, and 31
report periapical days of antibiotics.
radiolucency
Villa and 20 97 15 to 44 Endodontic and Socket debridement, 100% survival –
Rangert, periodontic bone curettage,
2005;25 antibiotic irrigation,
private- and GBR with
practice placement. After
case series suture, cortisone
injection into soft
tissue and
post-surgery
antibiotics. Full-arch
immediate loading.
Lindeboom 50 25 immediately 12 Chronic Antibiotics 1 hour 92% survival in Microbes cultured
et al., 2006;22 placed into periapical before surgery, the test group from sockets.
prospective, infected sites; pathology socket and 100% F. nucleatum and
randomized 25 delayed degranulation, and survival in the P. micra were
trial placement GBR. control group. most prevalent.
after NSD in soft
3 months and hard tissue
parameters,
except for less
mid-buccal
recession in the
delayed group.
Siegenthaler 34 29 (13 test and 12 Periapical Antibiotics 1 hour 100% survival and Two post-surgical
et al., entered; 16 control pathology before surgery, NSD in hard infections in test
2007;27 29 sites with no with pain, chlorhexidine and soft tissue sites, one in control.
controlled completed presence of radiolucency, rinse, socket parameters Surgical intervention
clinical trial infection) fistula, debridement, between test required in 1 test
suppuration, or GBR, and and control site and 1 control
a combination antibiotics 5 days sites. site with resolution,
post-surgery. but decreased
marginal bone levels
in both.
Villa and 33 100 maxillary 12 Endodontic, Socket debridement, 97.4% survival –
Rangert, (24 in periodontic, or bone curettage,
2007;26 healed root fracture antibiotic irrigation,
private- sites) and GBR with
practice placement. After
case series suture, cortisone
injection into soft
tissue, post-surgery
antibiotics. Full-arch
immediate loading.
Casap et al., 20 30 12 to 72 Subacute 14 days of 97.7% survival One
2007;24 case periodontal, antibiotics, pseudomembranous
series chronic debridement, colitis, one
periapical, peripheral membrane
chronic intrasocket exposure, and
perioendodontic, ostectomy, GBR, one deficiency of
chronic and primary attached gingiva.
periodontal, and closure.
a periapical cyst

805
Immediate Placement of Implants Into Infected Sites
Table 3. (continued )
Human Studies
Number of Number of Follow-Up
Study/Type Patients Implants (months)
Naves et al., 1 3 36
2009;13
case
report
Del Fabbro 30 61 10 to 21
et al.,
2009;14
prospective
GBR = guided bone regeneration; – = not applicable; F. nucleatum = Fusobacterium nucleatum; P. micra = Parvimonas micra; NSD = no significant difference;
PRGF = plasma rich in growth factors.
possible. Four test patients and one control patient
had to be withdrawn because of a lack of primary
stability. The remaining 29 implants demonstrated
a 100% survival rate 1 year after placement.
In a prospective study, Del Fabbro et al.14 evalu-
ated immediate placement into sites with chronic
periapical infection in combination with plasma rich
in growth factors (PRGF). Thirty patients were in-
cluded in the study, and 61 transmucosal implants
were placed. Patients premedicated with amoxicillin
and clavulonic acid 1 hour prior to surgery. After ex-
traction, the sockets were thoroughly degranulated.
Implants were coated in PRGF, and placement was
performed in conjunction with a PRGF clot, which
was also used as a barrier membrane. Implants were
semisubmerged, and surgical reentry was performed
3 to 4 months later. Of the 61 implants, one failure was
observed for a survival rate of 98.4% at a mean follow-
up of 18.4 months. The one failure occurred in a
smoker and was mobile after 2 months.
DISCUSSION
Previous reviews1,2 demonstrated similar success
rates between immediate and delayed placement of
implants, but a paucity of long-term data and evalua-
tion of clinical factors other than implant survival lim-
ited conclusions.29 Unlike previous reviews, the focus
of this article was on studies where the outcome mea-
sure was dependent on the presence of infection. One
major drawback to a review of this type of treatment
is that there are studies30,31 in which implants were
placed immediately into infected sites, but the out-
come measures were not based on the presence of
infection. Perhaps the most major limitation of this
review is that the classification of infection was often
vague and varied among the studies. Furthermore,
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Volume 81 • Number 6
Type of
Infection Treatment Outcomes Miscellaneous
Chronic Antibiotics 1 hour 100% survival –
periapical before surgery
and 7 days
post-surgery,
apical access flap
with debridement
of lesion, and GBR.
Chronic Socket debridement 98.45% –
periapical and PRGF coating survival
(histologic of implant.
granuloma)
the outcome measures were often not related to the
type of infection. Clearly, as more research is needed,
a clear-cut classification system needs to be imple-
mented with clinical evaluation related to a more spe-
cific pathology. Histopathologic data, when possible
to obtain, would be ideal.
In terms of periapical infection impairing the pro-
cess of osseointegration, the data from two dog stud-
ies16,19 show a decrease in BIC compared to implants
placed in non-infected sites. The difference was statis-
tically significant in one study19 but not in the other
study.16 Ligature-induced periodontitis lesions17
were shown to not adversely affect osseointegration
in dogs as measured by BIC. However, fluorescent mi-
croscopy revealed a slower initial bone healing in the
infection group.18 The final outcome was not different
between the groups. However, data from human stud-
ies32,33 suggested that periodontitis as a reason for
extraction may adversely affect implant survival. Re-
gardless of the differences in BIC values, which were
significant in one study,19 no implant failures were ob-
served in any of the animal models.
Data from human case series and prospective con-
trolled trial studies in this review demonstrated high
levels of implant survival in the presence of periodon-
tal and periapical infections. However, in a study by
Lindeboom et al.,22 there was a 92% survival rate of
immediately placed implants versus a 100% survival
rate of delayed-placement implants. Additionally,
there was more buccal marginal tissue recession
noted in the group who received immediately placed
implants. The authors22 surmised that this was due to
the increase in keratinized tissue during socket wound
healing. The flora cultivated from the infected sites re-
vealed Gram-negative species typically associated
with a root-canal infection.34
J Periodontol • June 2010
The treatment protocol of each study included in
this review included complete and thorough debride-
ment of the socket and the use of systemic antibiotics.
Like a previous review showed,1 aggressive antibiotics
were used in most studies in immediately placed im-
plants. It is assumed that antibiotics are usually used
to suppress the residual infection that was not re-
moved during debridement or to decrease bacterial
amounts preoperatively. Reviews concluded that sys-
temic antibiotics should not be recommended in the
endodontic treatment of teeth exhibiting acute apical
periodontitis35 and in endodontic therapy in gen-
eral.36 However, other intracanal antimicrobials are
used to eliminate bacteria. Also, extractions are
routinely performed without systemic antibiotics.
Although these studies demonstrated successful
results, commentaries37,38 showed that controversy
exists regarding the use of antibiotics with this proce-
dure. Additionally, a current study39 and systematic
review40 suggested that the benefits of antibiotic pro-
phylaxis in pristine sites remain unclear and may not
be needed. Because all of the human studies13,14,22-28
implemented systemic antibiotics, and GBR was per-
formed in most cases, the success of this protocol and
low rate of infections may be related to their use.
Available evidence suggests using an antibiotic when
immediately placing implants into infected sites. More
research is needed in relating antibiotic use to the type
of infection (e.g., periodontal or periapical infection)
and whether thorough debridement and/or peripheral
ostectomy are sufficient.
CONCLUSIONS
Limited short-term data from animal and human stud-
ies suggested that the immediate placement of im-
plants into infected sites is a viable, predictable
treatment. Conflicting results from animal studies16,17
showed osseointegration, as measured by BIC, may
be impaired in periodontitis and apical lesions. How-
ever, implant survival was not compromised in these
studies.16,17 Complete debridement of the socket
prior to implant placement is a critical component
to treatment. Primary implant stability was achieved
in all cases of unsplinted implants. Although contro-
versial, the use of systemic antibiotics is recommen-
ded for this procedure until future evidence proves
otherwise. Future research should be directed toward
implementing a more specific classification system of
the existing pathology with histopathologic data when
possible.
ACKNOWLEDGMENT
The authors report no conflicts of interest related to
this review.
Waasdorp, Evian, Mandracchia
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Correspondence: Dr. Jonathan A. Waasdorp, MS 10112,
Valley Forge Circle, King of Prussia, PA 19406. Fax: 610/
783-7829; e-mail: waasdorp@comcast.net.
Submitted December 14, 2009; accepted for publication
January 25, 2010.