Unconventional Implant Placement Part III: Implant Placement Encroaching upon Residual Roots – A Report of Six Cases Serge Szmukler-Moncler, DDS, PhD;*† Mithridade Davarpanah, MD;*‡ Keyvan Davarpanah, DDS;*§ Nedjoua Capelle-Ouadah, DDS;*¶ Georgy Demurashvili, DDS;*,** Philippe Rajzbaum, DDS, PhD;*††

ABSTRACT Background: When a residual root is found in the way of a planned implant placement, invasive surgery is usually performed in order to remove it. Consequently, implant therapy is rendered more complex and lengthy. Purpose: We present 6 cases treated according to an unconventional protocol in which invasive surgery was avoided by allowing the implants to encroach upon the residual roots in order to permit a prosthetically driven surgery. Materials and Methods: Six patients were treated with 7 implants placed through a residual root (4 in the mandible and 3 in the maxilla). The residual roots had to be clinically and radiographically asymptomatic and covered by bone or healthy gingiva. The radiographic follow-up ranged from 20 months to 9 years. Results: Healing was uneventful. Implants were clinically stable, and radiographic examination did not show any unusual feature at the root-implant interface. Conclusion: Several types of new implant-tissue interfaces were created in addition to the classical implant-bone interface, but this did not seem to jeopardize implant integration. Reports of more cases with a longer follow-up are needed before this protocol can be endorsed for routine application. Nonetheless, if confirmed as acceptable, this protocol might open intriguing possibilities; it might also lead to revision of one of the leading concepts in dental implantology. KEY WORDS: implant-bone interface, implant-cement interface, implant-dentin interface, mineral integration, osseointegration, paradigm shift, residual roots

INTRODUCTION

discovers an asymptomatic residual root beneath the crestal bone. Often, the ignored root is in the path of a planned implant placement; this complicates an otherwise simple treatment. Two options are left to the implantologist who faces such a situation. One is to tilt the implant in order to avoid encroaching upon the residual root. The second is to remove the residual root, fill the created defect, wait for bone healing, and then insert the planned implant. The first approach may be relevant when a large adjacent edentulous area is available. The second is very invasive, as the crest and the bone beneath must be removed; it may require a guided tissue regeneration procedure that increases the overall treatment time and involves larger expenses. The patient may thus desire a more straightforward solution; the simplest would be to place an implant through the residual root without removing it. However, practitioners rarely consider this approach

It sometimes happens that patients are seeking rehabilitation of an edentulous space and the practitioner *Researcher, Excellence in Dentistry Research Group, American Hospital of Paris, Paris, France; †visiting professor, Oral Biotechnology Laboratory, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy; ‡head, Oral Rehabilitation Center, American Hospital of Paris, Paris, France; §assistant, Department of Prosthetics, Bretonneaux Hospital, Paris Descartes University, Paris, France; ¶ clinical monitor, Excellence in Dentistry Research Group, American Hospital of Paris, Paris, France; **assistant, Department of Prosthetics, Charles Foix Hospital, Paris Descartes University, Paris, France; †† fellow, Oral Rehabilitation Center, American Hospital of Paris, Neuilly sur Seine, France Corresponding Author: Prof. Serge Szmukler-Moncler, Im Hinterstück 32, CH-4107 Ettingen, Switzerland; e-mail: ssm@ bluewin.ch © 2014 Wiley Periodicals, Inc. DOI 10.1111/cid.12256

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because it is generally accepted that implants should come in contact only with bone to the exclusion of any other dental tissue, including residual roots.1 However, one can find in the international literature a growing corpus of papers dealing with implants placed in contact with tissues other than bone.1–9 Since 2009, our group has been publishing case reports of implants placed through ankylosed and impacted teeth.10–14 For both of these clinical indications, the implants were placed in contact with tissues other than bone. In the case of ankylosed teeth, 6 implants have been followed for a period of time ranging from 12 to 49 months.10 The implants placed through impacted teeth have now been followed up for 8 or 6 years.11–13 All these implants are clinically stable and asymptomatic; they do not display any unusual clinical or radiographic characteristics. Placing an implant through a residual root is considered a third clinical application12 of the principles that guided the previous placement of implants through ankylosed and impacted teeth.10,11 The aim of this paper is, therefore, to report on 6 patients who have been treated over the years according to a non-invasive alternative protocol permitting immediate treatment of edentulous sites by placement of an implant through the residual roots. MATERIALS AND METHODS Inclusion Criteria and General Requirements Conduct of the treatment adhered to the tenets of the latest version of the Declaration of Helsinki released by the World Medical Association. In addition, for patients to undergo this unconventional treatment, the following conditions had to be met: 1. Patients had to be healthy and able to maintain good hygiene. 2. Implant therapy had to be indicated (all implant characteristics are given in Table 1). 3. The residual root had to be asymptomatic and free of surrounding pathology as determined clinically and radiographically. It could not be in communication with the oral cavity. It had to be covered by bone or at least be under a healthy gingiva. 4. When treatment planning was discussed with the patient, it was explained that extraction might be complex and invasive; it would require an additional augmentation procedure before implant placement that would delay implantation by at least 6 months.

5. The patient had to request an alternative, less invasive option to deliver the implant-supported prosthesis. 6. After explanation of the protocol and its deviation from standard care, the patient had to accept the risk of implant failure. In case of implant failure, the classical treatment with augmentation procedure would be performed at no additional cost. 7. An informed consent form had to be signed. All patients received standard antibiotic prophylaxis (amoxicillin/clavulanic acid, 2× 1 g/day for 6 days; Augmentin, GlaxoSmithKline, Marly-le-Roi, France). Case Presentation Case 1. A 66-year-old woman attended because of a failing tooth-retained bridge in the left posterior area of the mandible. The second molar and second premolar supported the bridge. The radiographic examination revealed a root fragment remaining from the first molar (Figure 1A). The patient was unaware of it; it was asymptomatic and covered by bone. The endodontic treatment was incomplete toward the apex (Figure 1A); the apical portion of the root canal was deemed calcified. The treatment planned for this posterior segment consisted of extracting the failing teeth and placing three implants. Prosthetically driven implant placement would lead the two distal implants to encroach upon the residual root. The treatment was therefore further discussed with the patient. It was explained that the standard method of care would require removing the root before placing the implants, filling the created defect, and waiting for healing. This would delay the treatment by at least half a year. A shorter alternative protocol would be to place the implants encroaching upon the root. Several implants placed in contact with dental tissues had been successful without deleterious reactions.10–12 However, this protocol was not the standard of care. Should any problem occur, the implants would be removed and the standard procedure would be applied. The patient accepted in order to speed up the treatment. Three implants were placed following the standard drilling sequence recommended by the manufacturer (all implants placed in this report were manufactured by 3i, Palm Beach Gardens, FL, USA). The mesial implant encroached upon the coronal mesial part of the residual

F

F

M

F

M

F

1

2

3

4

5

6

18

51

44

62

59

66

66

Age

45/29

24/12

15/4

11/8

45/29

37/19

36/18

Site (FDI/ADA)

Tip of mesial root

2/3 apical root

2/3 palatal root

1/3 apical root

2/3 apical root

1/2 apical root

1/2 apical root

Characterization of Residual Root

Retained root of ankylosed deciduous molar, no visible PDL

Retained root covered by bone, no visible PDL

Retained root covered by bone, PDL visible

Residual root covered by gingiva, PDL visible

Retained root covered by bone, PDL visible

Residual root covered by bone, PDL visible

Residual root covered by bone, PDL visible

No endodontic material

No endodontic material

Endodontic material

No endodontic material

Endodontic material

Partial endodontic material

Partial endodontic material

Endodontic Material

3

6

Prevail 4/3 × 11.5

Full Osseotite Ø 4 × 10

6

0

3

4.5

4.5

Tapered Prevail 6/5 × 13

NT Osseotite Ø 4 × 15

Full Osseotite Ø 4 × 11.5

NT Osseotite Ø 4 × 11.5

NT Osseotite Ø 4 × 11.5

Inserted Implant

Unloaded Healing Period (Months)

3 years

3 years

3 years

5 years

20 months (6 years)*

9 years

9 years

Last Radiographic Follow-Up

*Patient 2 was lost to radiographic follow-up after 20 months because she moved abroad. At the 6-year control, the implant was asymptomatic and functional. FDI = World Dental Federation; ADA = American Dental Association; PDL = periodontal ligament.

F

Sex

1

Patient Number

Description of the Local Situation

TABLE 1 Characteristics of Residual Roots and Implants

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Bone-Implant Interface

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Root-Implant Interface

No visible change

No visible change

No visible change

Possible partial resorption

No visible change

No visible change

No visible change

Modification of Root Fragment

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A

B

C

Figure 1 Patient 1. A, Preoperative radiograph with the residual root. B, Postoperative radiograph with the implant encroaching upon the residual root. C, Radiograph at the 9-year follow-up. The two distal implants suffered crestal bone loss but are clinically asymptomatic.

root, and the distal implant encroached upon the apical third of the root (Figure 1B). A period of 4.5 months was allowed for transmucosal healing before checking for implant integration.

Case 2. A 59-year-old woman attended because she perceived mobility of her tooth-retained bridge in the right posterior part of the mandible. A four-unit bridge was found relying on the first premolar and the second molar; two pontics were present. The anterior pillar had suffered heavy bone loss (Figure 2A); the prosthesis was hopeless. A residual root was also found at the level of the second premolar; it was asymptomatic and covered by bone. The bridge was sectioned and the premolar extracted. After socket healing, rehabilitation of the posterior edentulous area was undertaken. Three implants were planned; one of them had to encroach upon the residual root. In order to avoid an invasive surgery and speed up the treatment, the implant was placed despite coming in contact with the root (Figure 2B). A period of 3 months was allowed for transmucosal healing before checking for implant integration. Case 3. A 62-year-old man attended to rehabilitate his incisor area in the maxilla; immediate temporization was requested by the patient. The left central incisor was missing (Figure 3A); periapical radiographs showed advanced crestal bone loss at all remaining incisors. Also, an asymptomatic residual root was found at the missing central incisor site (Figure 3A). Three implants were planned to meet the biomechanical challenge; the medial implant was to come in contact with the residual root. The root fragment was clinically stable; it was not removed to avoid jeopardizing implant primary stability, and it put into question the prospect of immediate temporization. The standard drilling sequence was not altered; the implant was subsequently placed in contact with the residual root (Figure 3B). An impression was immediately taken to swiftly prepare the temporary prosthesis; the latter was delivered after 2 days. Case 4. A 44-year-old woman was seeking rehabilitation of her second right maxillary premolar following a previous extraction due to root fracture (Figure 4A) during which the palatal root was not removed. An implant was placed in contact with the apical part of the palatal root (Figure 4B); it was left to heal in a nonsubmerged way for 6 months. Case 5. A 51-year-old male patient attended with a temporary tooth-supported prosthesis intended to rehabilitate the right side of the maxilla. The canine and the

Implant Placement Encroaching upon Residual Roots

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B

C

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the posterior region. The mesial implant was first placed, encroaching upon the residual root. It was left to heal transmucosally. Sinus grafting was simultaneously performed to provide enough bone height for two further implants to be placed (Figure 5B). After 6 months of bone healing, the two distal implants were inserted, and osseointegration was obtained after an additional 6 months of healing. Case 6. A 18-year-old girl attended while undergoing an orthodontic treatment due to agenesis of the lateral incisor and ankylosis of her deciduous second molars. Extraction of the latter was previously performed to draw the posterior area backward; the aim was to prepare FDI site 35 (ADA 29) to receive a single implantsupported crown. The radiographic examination showed the presence of an extremity of the deciduous mesial molar root (Figure 6A); it was in the way of the planned implant placement. It was ignored, and the implant was placed according to the prosthetic requirements; the residual tip was encroached upon (Figure 6B). A healing period of 3 months with a transmucosal abutment was prescribed. Clinical and Radiographic Evaluation of the Implants A tight follow-up schedule was kept during the integration period (1, 2, 3, and 6 months). Implants were clinically and radiographically evaluated at the end of the healing period, at 6 months, and at annual recall thereafter. Clinical Evaluation

Figure 2 Patient 2. A, Preoperative radiograph with the residual root. B, Postoperative radiograph with the implant encroaching upon the residual root. C, Radiograph at the 20-month follow-up. The patient was lost to follow-up for a time because she moved abroad.

second molar supported the bridge involving three pontics. The periapical radiograph indicated the presence of a residual root at the second premolar level (Figure 5A). Three implants were planned to rehabilitate

The survival criteria listed by Buser and colleagues15 and Cochran and colleagues16 were followed: (1) absence of clinically detectable implant mobility; (2) absence of pain or any subjective sensation; (3) absence of recurrent peri-implant infection. Radiographic Evaluation Radiographic evaluation was performed on periapical radiographs. It included (1) checking for the absence of continuous radiolucency around the implant; (2) observation of any abnormal reaction at the bone-implant interface; (3) observation of any unusual reaction at the root-implant interface.

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B

C

Figure 3 Patient 3. A, Preoperative radiograph with the residual root. B, Postoperative radiograph with the implant encroaching upon the residual. C, Radiograph at the 5-year follow-up.

RESULTS All implants healed uneventfully. Clinical stability was checked at the end of the 3- to 6-month integration period. Afterward, the classical prosthetic steps were undertaken and the prostheses were delivered. The immediately loaded implant (patient 3) continued to function over 6 months; subsequently, the final prosthesis was prepared following the classical prosthetic steps. All implants have now been followed clinically and radiographically for at least 3 years (Figures 3C, 4C, 5C and 6C) and up to 9 years (Figure 1C), except in patient 2, who was lost to radiographic follow-up at 20 months (Figure 2C) because she moved abroad. At the 6-year control, the patient confirmed that the implant was functioning and that she had no complaints. In patient 1 after 9 years, the area around the medial implant displayed crestal bone loss down to the second thread; the area around the distal implant lost bone on three threads on both the mesial and the distal sides (Figure 1C). In patient 3, the residual root seemed to be fragmented (Figure 3C). Otherwise, no unusual radiographic feature could be observed at the root-implant interface. DISCUSSION Amazingly, the topic of residual roots and their epidemiology has not been addressed so far in the indexed international literature; however, our clinical experience attests the paucity of their occurrence.

When confronted with a residual root, most implantologists are of the opinion that the root fragment must be removed before placing an implant.1 The present accepted paradigm dictates that implants must be placed exclusively in contact with bone. This excludes any contact with any other remaining dental tissue. This report of cases is the first paper to address an unconventional protocol where implants are placed through a residual root. Only clinically and radiographically asymptomatic residual roots were included. In addition, the roots had to be covered by crestal bone or at least by healthy gingiva. The presence of a filling endodontic material did not affect the decision of whether or not to encroach upon the root fragment; it was not considered as a critical parameter and was ignored. The integration periods were not significantly altered, and healing was uneventful for all implants. All implants in this study have now been in place for at least 3 years, and no implant failed within this up-to9-year period of follow-up. Both 9-year implants in contact with the root displayed bone loss down to the second and third threads, and the gingiva seems to have come into contact with the residual root. It makes sense to assume that the observed vertical bone defect is not related to the presence of the root fragment, because bone loss is similar at the implant sides that have not been in contact with the residual root (Figure 1C). In addition, the contact of the gingiva with the root should

Implant Placement Encroaching upon Residual Roots

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These clinical and radiographic findings are in line with our previous data dealing with implants placed through impacted or ankylosed teeth.10–14 In these two indications, the implants also came into contact with dental tissues and healing was uneventful. No unusual

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B

C

C

Figure 4 Patient 4. A, Preoperative radiograph with the premolar before undergoing extraction. B, Postoperative radiograph with the implant encroaching upon the palatinal root. C, Radiograph at the 3-year follow-up.

not be detrimental, as this is what is aimed at when the decoronation principle is applied to take advantage of the root submergence technique for pontic site development in esthetic implant therapy.17

Figure 5 Patient 5. A, Preoperative radiograph with the residual root. B, Postoperative radiograph with the implant encroaching upon the residual root. C, Radiograph at the 3-year follow-up.

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Figure 6 Patient 6. A, Preoperative radiograph with the residual root. B, Postoperative radiograph with the implant encroaching upon the residual root. C, Radiograph at the 3-year follow-up.

radiographic feature could be observed on the periapical radiographs either. The rationale for bringing implants into contact with other tissues than bone has been elaborated elsewhere.10–14 The decision of whether to embark on an unconventional route depends on the potential risks and the expected benefits. The benefits have been previously addressed. The potential risk involved primary failure during the integration period and secondary failure after loading in the longer term. An additional concern would be to face an implant periapical lesion, a feature also known as apical peri-implantitis.18–21 Occurrence of the latter is rare; reported frequencies are low, for example, 0.26% (10/3,800),18 0.4% (22/5,500),21 and 1.3% (7/539).19 It tends to appear during the integration period rather than at a later stage.19–21 Some authors link it to a history of an obvious endodontic pathology of the extracted tooth,19 while others state that it is multifactorial20 or simply related to contamination of the apical portion of the bed during implant placement surgery.21 No implant in this series displayed the characteristic radiographic or clinical features related to this pathology. When facing such a case, cone beam computed tomography should be performed to check for the presence of any indication of infection that could be missed on periapical radiographs.22,23 In the absence of postoperative inflammation, the short-term risk of implant failure because of a lack of integration is low; there is a growing body of histological data showing that the contact of an implant with a tissue of dental origin results in the creation of a stable interface, at least during the healing period.1–9 At places where the implant surface comes into contact with dentin or cement, the surface is covered by a new layer of a mineralized cementlike material.7–9 Implant surfaces in contact with the periodontal ligament may be covered by a periodontal ligament-like structure4 that does not extend far away from the pristine periodontal ligament. Concomitantly, osseointegration is achieved at the rest of the implant surface, which is in contact with bone.1,4,7–9 This means that implants placed in contact with fragments of dental tissues achieve a mixed interface: on one hand, the classical osseointegration is obtained on the part of the implant surface that comes in contact with bone; on the other hand, a mineral integration is gained at the places in contact with the nonbony mineralized tissues.24 The term “mineral integration” was coined in order to broaden the concept of

Implant Placement Encroaching upon Residual Roots

osseointegration, as the latter relates only to the boneimplant interface and does not involve the other implant interfaces, with dentin and cement.24 As for the long-term outcome, the present data cover at least 3 years and reach a high of 9 years. They are in line with the results obtained for implants placed in contact with impacted teeth that have been followed for up to 8 years13 and for implants placed through ankylosed teeth that have been followed for up to 42 months.10 The fact that no implant failed means that the mixed implant interface is capable of sustaining the loading forces exerted on the prostheses. The clinical incidence of residual roots is low; however, when the site occupied by a residual root needs implant treatment, the standard protocol is rendered invasive, lengthy, and less affordable. The possibility of encroaching upon the residual root without jeopardizing implant prognosis would simplify treatment and, if shown to produce acceptable outcomes, could become a standard procedure. So far, the number of implants followed in this indication is limited; in addition, the inclusion/exclusion criteria need to be refined and better identified. Therefore, these cases do not allow any conclusion to be drawn by the dental community. More cases with clearer inclusion/exclusion criteria and longer followups are warranted before the alternative procedure can be used in routine treatment; however, this approach might open intriguing possibilities. Finally, it might also show that there might be room for a further paradigm shift. ACKNOWLEDGMENTS The authors wish to thank Dr Truong Nguyen for coining the term “Mineral integration” while spending long discussion evenings to find the correct term describing this new histological reality. Assistants Aurélie, Vanessa, Alexandra, Vida, Sabrina and Kim are deeply acknowledged for their efficient daily presence. Gomtessa Consiglio is showed gratitude for helping with the good writing skills. REFERENCES 1. Gray JL, Vernino AR. The interface between retained roots and dental implants. A histologic study in baboons. J Periodontol 2004; 75:1102–1106.

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2. Buser D, Warrer K, Karring T, Stich H. Titanium implants with a true periodontal ligament: an alternative to osseointegrated implants? Int J Oral Maxillofac Implants 1990; 5:113–116. 3. Buser D, Warrer K, Karring T. Formation of a periodontal ligament around titanium implants. J Periodontol 1990; 61:597–601. 4. Warrer K, Karring T, Gotfredsen K. Periodontal ligament formation around different types of dental titanium implants. I. The self-tapping screw-type implant system. J Periodontol 1993; 64:29–34. 5. Parlar A, Bosshardt DD, Unsal B, Cetiner D, Haytaç C, Lang NP. New formation of periodontal tissues around titanium implants in a novel dentin chamber model. Clin Oral Implants Res 2005; 16:259–267. 6. Dao V, Renjen R, Prasad HS, Rohrer MD, Maganzini AL, Kraut RA. Cementum, pulp, periodontal ligament, and bone response after direct injury with orthodontic anchorage screws: a histomorphologic study in an animal model. J Oral Maxillofac Surg 2009; 67:2440–2445. 7. Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The socket-shield technique: a proof-of-principle report. J Clin Periodontol 2010; 37:855– 862. 8. Schwarz F, Mihatovic I, Golubovic V, Becker J. Dentointegration of a titanium implant: a case report. Oral Maxillofac Surg 2013; 17:235–241. 9. Bäumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hürzeler M. The socket-shield technique: first histological, clinical, and volumetrical observations after separation of the buccal tooth segment – a pilot study. Clin Implant Dent Relat Res 2013. doi: 10.1111/cid. 10. Davarpanah M, Szmukler-Moncler S. Unconventional implant treatment. I. Implant placement in contact with ankylosed root fragments. A series of 5 case reports. Clin Oral Implants Res 2009; 20:851–856. 11. Davarpanah M, Szmukler-Moncler S. Unconventional implant treatment. II. Implant placed through impacted teeth. 3 case reports. Int J Periodontics Restorative Dent 2009; 29:405–413. 12. Szmukler-Moncler S, Davarpanah M. Reliability of the rootimplant interface in unconventionally placed implants: an up to 6-year follow-up of 23 implants covering 3 distinct clinical applications. Clin Oral Implants Res 2009; 20:814. 13. Davarpanah M, Szmukler-Moncler S, Davarpanah K, et al. Unconventional transradicular implant placement to avoid invasive surgeries: toward a potential paradigm shift. Rev Stomatol Chir Maxillofac 2012; 113:335–349. 14. Szmukler-Moncler S, Davarpanah K, Davarpanah M, Rajzbaum P, Capelle-Ouadah N, Demurashvili G. Implants in contact with tissues other than bone. Is there room for a potential paradigm shift? Swiss Dental J 2014; 124: 149–164.

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15. Buser D, Mericske-Stern R, Bernard JP, et al. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life table analysis of a prospective multi-center study with 2359 implants. Clin Oral Implants Res 1997; 8:161–172. 16. Cochran DL, Buser D, ten Bruggenkate C, et al. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res 2002; 13:144–153. 17. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodontics Restorative Dent 2007; 27:521–527. 18. Reiser GM, Nevins M. The implant periapical lesion: etiology, prevention, and treatment. Compend Contin Educ Dent 1995; 16:768–770. 19. Quirynen M, Vogels R, Alsaadi G, Naert I, Jacobs R, van Steenberghe D. Predisposing conditions for retrograde peri-implantitis, and treatment suggestions. Clin Oral Implants Res 2005; 16:599–608. 20. Romanos GE, Froum S, Costa-Martins S, Meitner S, Tarnow DP. Implant periapical lesions: etiology and treatment options. J Oral Implantol 2011; 37:53–63.

21. Peñarrocha-Diago M, Maestre-Ferrín L, Peñarrocha-Oltra D, Canullo L, Piattelli A, Peñarrocha-Diago M. Inflammatory implant periapical lesion prior to osseointegration: a case series study. Int J Oral Maxillofac Implants 2013; 28:158–162. 22. Patel S, Wilson R, Dawood A, Mannocci F. The detection of periapical pathosis using periapical radiography and cone beam computed tomography – part 1: pre-operative status. Int Endod J 2012; 45:702–710. 23. Patel S, Wilson R, Dawood A, Foschi F, Mannocci F. The detection of periapical pathosis using digital periapical radiography and cone beam computed tomography – part 2: a 1-year post-treatment follow-up. Int Endod J 2012; 45:711–723. 24. Szmukler-Moncler S, Davarpanah M, Davarpanah K, Rajzbaum PH, Demurashvili G, de Corbière S. Mise en place d’implants au contact d’un tissu autre qu’osseux. L’intégration minérale, esquisse d’une possible évolution de paradigme en implantologie. In: Davarpanah M, SzmuklerMoncler S, Rajzbaum P, Davarpanah K, Demurashvili G, eds. Manuel d’implantologie clinique. Concepts, intégration des protocoles et esquisse de nouveaux paradigmes. Paris: CdP Editions, 2012:597–611. In French.

Unconventional Implant Placement Part III: Implant Placement Encroaching upon Residual Roots - A Report of Six Cases.

When a residual root is found in the way of a planned implant placement, invasive surgery is usually performed in order to remove it. Consequently, im...
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