RESEARCH PERIAPICAL IMPLANT PATHOLOGY

Harold I. Sussman, DDS, MSD Periapical implant pathology, a distinct dental lesion, is the coalescence of adjacent Downloaded from http://meridian.allenpress.com/joi/article-pdf/24/3/133/2032380/1548-1336(1998)024_0133_pip_2_3_co_2.pdf by guest on 01 October 2021 periapical pathology with the apical segment of a dental implant that results in a common lesion. I present four cases to document two proposed case types: type KEY WORDS 1, implant to tooth, which occurs during osteotomy preparation either by direct trauma or through indirect damage and causes adjacent pulp to undergo Dental implants devitalization; and type 2, tooth to implant, which occurs shortly after placement Osseointegration Periapical pathology of the implant when an adjacent tooth develops periapical pathology, either by Etiology operative damage to the pulp or through reactivation of a prior apical lesion. In Classification both types, the resulting periapical pathology contaminates the fixture and inhibits osseointegration of the implant during stage 1 healing. These two case types are presented to help clarify the use of etiology as the basis of a classification system.

INTRODUCTION eriapical implant pathology Type 1: Implant to Tooth as a distinct entity was first reported as endodontic-im- An implant-to-tooth lesion occurs plant pathology in the den- when the insertion of the implant re- tal literature in 1993.1 The le- sults in tooth devitalization. Possible sion occurs infrequently causes include placement of the im- when implants are placed adjacent to plant at an insufficient distance from Pnatural teeth.2–5 When a periapical lesion the tooth during the osteotomy, over- from a tooth and an implant coalesce, heating of bone during the osteotomy, the bone–titanium interface may become or direct trauma to a tooth root via os- contaminated. Should this occur during teotomy preparation, cutting off the 1,4,5,9 stage 1 healing, the implant will not os- blood supply to the pulp. 6,7 seointegrate. It is recommended that Type 2: Tooth to Implant the fixture be removed as soon as pos- sible so that osteomyelitis does not de- A tooth-to-implant lesion occurs when velop. If left in place, the implant pa- a periapical lesion from a nearby de- thology may cause extensive bone de- vitalized tooth encroaches upon the struction and delay wound healing. If implant and contaminates it. Possible root pathology occurs after implant os- causes could be injury of the pulp from seointegration, performing an apicoec- operative tooth preparation, carious in- Harold I. Sussman, DDS, MSD, is Associate tomy on the implant is a possibility.8 volvement, or external root resorp- Clinical Professor, Department of Periodontics, tion.3,10 In addition, another possible New York University College of Dentistry, CASE PRESENTATIONS New York, NY. He also has a private cause could be the reactivation of a periodontic practice in New York, NY. Send There appear to be two basic pathways dormant periapical lesion and the re- reprint requests to Dr Sussman at 67 Park of periapical implant pathology, im- moval of the periapical endodontic Avenue, Suite 1A, New York, NY 10016. plant to tooth and tooth to implant. seal.2

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134 Vol. XXIV/No. Three/1998 Harold I. Sussman

Case Type Documentation Cases 1 and 2 were both examples of type 1 periapical implant pathology. Case 1 had an inadequate distance be- tween the fixture and the tooth, an overheating of bone during the implant placement, or both (Figs 1–4). Case 2 had direct trauma to the tooth root as

a result of implant placement (Figs 5– Downloaded from http://meridian.allenpress.com/joi/article-pdf/24/3/133/2032380/1548-1336(1998)024_0133_pip_2_3_co_2.pdf by guest on 01 October 2021 8). Cases 3 and 4 were both examples of type 2 periapical implant pathology. Case 3 had exposure of the pulp, which caused periapical pathology leading to contamination of the implant (Figs 9– 12). Case 4 had the periapical seal re- moved, which reactivated a periapical pathology (Figs 13–16). Note that in all of the cases present- ed, the common denominator was that the endodontically treated teeth sur- vived, whereas the associated implant fixtures failed to integrate and were lost, either by removal or exfoliation. This was partly the result of the path- ologic lesion occurring during stage 1 healing.

DISCUSSION Although originally termed endodon- tic implant pathology, there was con-

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FIGURES 1–4. Type 1 lesion: implant to tooth, case 1. FIGURE 1. Radiograph of mandibular implant site. FIGURE 2. Radio- graph of implant placed between canine and central incisor. FIGURE 3. Radiograph of apico-implant radiolucency, indicating devitalization of canine coalescing with apical half of fixture. FIGURE 4. Radio- graph of site 3 months after implant exfo- liation with endodontic filling in the ca- nine. The cortical plate of bone exhibits re- sorption.

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FIGURES 5–8. Type 1 lesion: implant to tooth, case 2. FIGURE 5. Radiograph of mandibular implant site. FIGURE 6. Radio- graph showing implant base inserted through canine apex, demonstrating devi- talization radiolucency. FIGURE 7. Radio- graph of fixture removed and endodontic filling in canine. FIGURE 8. Radiolucency of implant site demonstrating osseous repair 4 months postoperatively.

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FIGURES 9–12. Type 2 lesion: tooth to implant, case 3. FIGURE 9. Radiograph of maxillary implant site. FIGURE 10. Radiograph of implant placed in first molar site. Note pulp exposure in the crown of the second premolar. FIGURE 11. Radiograph of fixture with radiolucency extending from second premolar apex, which now has an endodontic filling. FIGURE 12. Surgical area demonstrating osseous repair 3 months postoperatively, with a four-unit fixed bridge in place. fusion between this condition and the Type 1: Implant to Tooth shortly after placement of the implant failure of endodontic stabilizing pins when an adjacent tooth develops peri- inserted through a root canal into the Type 1 periapical implant pathology or apical pathology, either by operative jaw.1 The origin of this lesion may be a implant-to-tooth pathology, occurs damage to the pulp or through reacti- lesion either at the apex of the implant when osteotomy preparation, either by vation of a previously existing apical or at the apex of the tooth root. If the direct trauma or through indirect dam- lesion. The resulting periapical pathol- two lesions coalesce, contamination of age, causes adjacent tooth pulp to un- ogy contaminates the fixture and in- the implant results. Should this occur dergo devitalization. The resulting hibits osseointegration of the implant during stage 1 healing, osseointegra- periapical pathology contaminates the during stage 1 healing. tion will be prevented, leading to loss fixture and inhibits osseointegration of Note that if there is postextraction of the fixture. the implant during stage 1 healing. residual infection in the medullary There are two main types of peri- Type 2: Tooth to Implant bone, the base of the implant may be- apical implant pathology proposed come contaminated through tracking. here: implant to tooth and tooth to im- Type 2 periapical implant pathology or When this involves an adjacent tooth, plant. tooth-to-implant pathology, occurs the coalescing lesion would fit into the

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FIGURES 13–16. Type 2 lesion: tooth to implant, case 4. FIGURE 13. Radiograph of mandibular canine with recent endodontic filling. FIGURE 14. Radiograph of implant site before placement. FIGURE 15. Radiograph of radiolucent lesion extending from canine apex to lateral surface of adjacent implant fixture. Note loss of gutta percha from root canal. FIGURE 16. Radiograph of surgical site demon- strating osseous repair 3 months postoperatively.

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Journal of Oral Implantology 137 PERIAPICAL IMPLANT PATHOLOGY

type 1 category. There may well be Medical Center) and Dr Dennis Tar- plant pathology: a case report. NY State other causes found that fit into both now (New York University College of Dent J 1997;63:38–40. categories. Dentistry) for their invaluable assis- 6. Branemark PI, Zarb G, Albretsson There are times when the health of tance in preparing this manuscript. T. Tissue-Integrated Prostheses: Osseoin- an adjacent tooth’s pulp is suspect; tegration in Clinical Dentistry. Chicago, pulp testing in these cases is warrant- REFERENCES Ill: Quintessence; 1985;11–70. 7. Lindhe J, Berglundh T, Ericsson I, ed (see Fig 1 and Fig 9). Prophylactic 1. Sussman HI, Moss SS. Localized Lilljenberg B, Marinello C. Experimen- endodontic therapy of a nearby tooth osteomyelitis secondary to endodontic- may be prudent therapy before im- tal breakdown of peri-implant and

implant pathosis: a case report. J Peri- Downloaded from http://meridian.allenpress.com/joi/article-pdf/24/3/133/2032380/1548-1336(1998)024_0133_pip_2_3_co_2.pdf by guest on 01 October 2021 plant placement. periodontal tissues: a study in the bea- odontal 1993;64:306–310. gle dog. Clin Oral Implant Res 1992;3:9– CONCLUSION 2. Sussman HI. Implant pathology 16. associated with loss of periapical seal 8. Reiser GM, Nevins M. The peri- Case examples have been presented to of adjacent tooth: clinical report. Im- apical lesion: etiology, prevention and document two types of periapical im- plant Dent 1997;6:33–37. treatment. Compendium 1995;16:768– plant pathology. I hope that this will 3. Sussman HI. Endodontic pathol- 777. help to clarify this distinct dental le- ogy leading to implant failure: a case 9. Brisman DL. The effect of speed, sion by using the etiologic origin of the report. J Oral Implantol 1997;23:112– pressure, and time on bone tempera- pathology as a basis for this classifica- 115. ture during the drilling of implant tion. 4. Sussman HI. Tooth devitalization sites. Int J Oral Maxillofac Implant 1996; via implant placement: a case report. ACKNOWLEDGEMENTS 11:35–37. Periodont Clin Invest. 1998;20:22–24. 10. Christensen GJ. Tooth preparation I thank Dr Gregory Kazandjian (Man- 5. Sussman HI. Cortical bone re- and pulp degeneration. J Am Dent As- hattan Department of Veterans Affairs sorption secondary to endodontic-im- soc 1997;128:353–354.

DISCUSSION

In ‘‘Periapical Implant Pathology,’’ Dr stage 1 of healing after implant place- AUTHOR’S RESPONSE Sussman describes the periapical im- ment. The review of my manuscript by Dr. plant lesion as ‘‘a distinct dental le- Besides efforts to introduce a new Boskovic, while astute, has one point in sion’’ and explains how etiology influ- classification based on etiology, the au- the second paragraph with which I dis- ences that classification. If we exclude thor should emphasize the need for agree. any other factors that might be respon- endodontic evaluation and, if neces- If an endodontic lesion communi- sible or that might contribute to the sary, treatment–retreatment of the cates with an adjacent implant surface lack of integration (traumatic surgery, teeth adjacent to potential implant during stage 1 healing, even if end- lack of initial stabilization, sufficient sites. To avoid it and prevent it, this odontic therapy were done completely bone in bucco-lingual dimension, etc.), needs to be done before surgical im- and properly at that point, the implant all presented cases have a common de- plant placement. It is especially neces- may still fail to osseointegrate. This nominator: loss of vitality of adjacent sary when we are dealing with peri- may well be the result of irreversible teeth. This is followed by bacterial in- odontally involved teeth, teeth with ex- contamination of the implant surface, vasion of root canal systems that be- isting multiple restorations, and espe- precluding its ongoing integration pro- come a constant source of infection un- cially teeth with root canal therapy cess. less they are thoroughly and properly already done in the past regardless of However, if endodontic lesions are eliminated and obturated. them being asymptomatic. properly and successfully treated prior If endodontic lesions were properly This reminds me once again of the to implant placement, then there and successfully treated (which was importance of proper diagnosis and should be no reason to lose an implant not done in the presented cases accord- treatment planning in addition to im- because of the development of adjacent ing to the radiographic evidence), there plant placement itself. periapical pathology during stage 1 is no reason to lose an implant or have healing. it removed even if it happened during Milos M. Boskovic, D.D.S. Harold I. Sussman, D.D.S.

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