Purpose: While immediate implant placement has demonstrated a high degree of clinical success, questions remain about whether immediate placement of implants into sites demonstrating periapical pathology will result in treatment outcomes equivalent to those attained when implants are placed into sites that do not demonstrate periapical pathology. Materials and Methods: A retrospective study was carried out of patients who presented with periapical pathology and were treated with tooth extraction, defect debridement, and immediate implant placement between 1994 and 2008. All immediately placed implants were followed for a minimum of 24 months after restoration. Implant survival was assessed with the Albrektsson et al criteria and using measurements from the osseous crest to the most coronal extent of the rough surface of the implant on the midbuccal aspect of the implant. A classification system for periapical lesion morphology is also proposed. Results: Four hundred eighteen implants were placed. They were followed for a mean of 67.3 months. Five implants were either lost or demonstrated progressive bone loss beyond acceptable levels, resulting in a cumulative survival rate of 97.8%. Conclusions: Implant placement at the time of extraction of teeth demonstrating periapical pathology will result in implant survival rates comparable to those of implants placed immediately into sites without periapical pathology. Keywords: dental implants, immediate implants, periapical lesions