Can this site be made suitable for an implant?

A 26 year old white female patient in excellent health presents with a missing #30 [mandibular right first molar; 46] and a large radiopaque area. The mandible does not show any expansion and the area is asymptomatic. The mandibular canal appears to traverse through the apical extent of the radiopacity. What do you think this is? I have received opinions of condensing osteitis and odontoma. I thought odontoma, but I am not an oral surgeon. Should this lesion be removed or should I just proceed with the implant installation? Should I expect that the bone in this area will have an increased density like Type I bone?


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29 Comments on Can this site be made suitable for an implant?

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Robert J. Miller
4/21/2013
Appears to be a condensing osteitis. But this lesion should be biopsied prior to implant placement. Use a bone trephine and use a lateral approach to the most coronal segment to be safe. RJM
Robert H
4/21/2013
Thank you.
CRS
4/22/2013
Make your life easier, have a simplant guide made exactly where you want to place the implant II would only biopsy the superior portion of the lesion, and place the implant. If it is a condensing osteitis, it will be very difficult to differentiate what to biopsy. On the ct it looks like there is a margin in the deeper regions but you would not place an implant that deep. Since you have the ct get a guide made. If it integrates you are done. As a general dentist trying to trephine into the lateral cortex of the mandible blindly you could get not trouble and miss the lesion anyway. If it is a complex odontoma there will be enamel which needs to be removed to allow osteointegration . That would be evident clinically and removal would be done when placing the implant. The guide would also help place the implant in as much unaffected bone as possible. I really think you need an oral surgeon on this one sorry. Thanks for reading.
Sam Jain DMD
4/22/2013
Many times we make osteotomies with trephine...in this case use a new sharp trephine with a steady hand and you get normal and abnormal bone in one cyclinder and you would be able to see and touch and look under 20x if you have Global microscope, the kind of stuff we keep wondering about just like we are doing right now. You are gonna send it to the pathology lab. If you feel it feels like hard bone, put the implant but if feels like enamel (very unlikely), do not place implant and send to the dental school omf dept and write a paper, we would all like to read. A very good learning opportunity. If u are in bay area, bring the px to my office and we write paper together. Give me a call. Good learning opportunity. Enjoy Sam Jain DMD Center for Implant Dentistry Fremont CA
CRS
4/22/2013
It just doesn't make sense to blindly cut into the mandibular cortex blindly with a non specific lesion which really won't affect the outcome but so be it. You have the available CT scan to do a guide. I don't understand why patient's don't have a barium lined surgiguide in place when the CT scan is in place so that the lesion can at least be located or avoided radiographically. It is just good surgical planning. Also the density of the area in hershfield units could help aid in the diagnosis. It is a more conservative approach. Also a literature search to see if there are any cases that have implants placed in sclerotic less vascular bone and if osteointegration is affected. The above posts indicate biopsy, why not do it in a skilled,planned manner. These lesions are difficult to visualize,benign and hard to remove that's why they are left in situ. This is difficult to biopsy without a radiographic guide and the bottom line is where the implant will be placed. You started the technology with the CT so learn how to work with a guide otherwise I feel the patient is being exposed to a lot if radiation and a blind biopsy near either the canal or thru the healthy bone, lateral plate, that you need. Just how many of these have you done? Get some help with this to avoid trouble . Thanks for reading ,
Dr. Manish Juneja
4/22/2013
Could this be an enostosis. As Dr. CRS said the Hounsfield unit can help you to find out more about the lesion. You cant take out the entire thing it is around the nerve and damage the nerve. If you biopsy it and you find, it is bone, whats new that you have found? enostosis are type 1 bone- dense bone, less vascularity, less chances of good healing. if the implant is more of in contact with this dense bone, it would be hard to get a good result. A good planning is required to know where the implant will be positioned and what will be the density of bone around. Hope it helps.
greg steiner
4/22/2013
I agree with Dr. Juneja That this is an enostosis also called a bone island. These lesions give a radiographic image of radiating spicules at the margins that blend with the surrounding trabeculae which is pathognomonic. However these lesions are usually congenital or developmental and therefore in this case it would only seem reasonable that the patient would have never developed a tooth in this area if it is an enostosis. I have attempted to place an implant into a smaller enostosis and it failed. The lesion was so hard I have difficulty drilling into it with implant drills. When the implant filed I cut out the enostosis with a high speed drill and the next implant was successful. I do not think you will be able to get a trephine to drill into this bone for a biopsy. If this was my patient I would remove the portion of the lesion where the implant would be placed and graft the area to produce normal trabeculae. Send the removed tissue in for a biopsy to confirm your diagnosis. Greg Steiner Steiner Laboratories
CRS
4/22/2013
I like it
Sam Jain DMD
4/23/2013
People who do not have much experience with trephined would tend to have thoughts like above posters. People who have been working around with these radio opaque lesions would tend to think biopsy is not needed. May be from legal point of view or more so for learning the histology and see it for your self, I would eagerly wait for this px to come to my office and place an implant using my 4.25 ID trephine from ace and drill 11mm for 4.7x10 implant and at the same time get the cyclinder I'd bone to look under my microscope. Why would I do this any other way. This situation is indicated for trephine usage. Common guys lets keep our minds open for learning pearls from each other. Trephine is even more indicated in this kind of situation because with implant drills you would be veered of by hard bone. Sam Jain, DMD (UCONN 2000) Center for implant Dentistry Fremont CA
CRS
4/23/2013
Not sure what the above comment is implying about experience, just because another doctor has a different opinion from yours, does not mean it is invalid. You are still suggesting a blind technique when there is the availability of a CT scan for the guide. This is just basic treatment planning and biopsing for the implant position. Pretty straightforward. I find that the trephines get burned up pretty quickly especially in this type of dense bone. I think that the patient deserves a well thought out approach. Also being your own pathologist is probably not wise either. A patient should not be a learning experience for a relatively new implantologist, it is not about about pearls but about diagnosis and judgment not about how good a trephine is. You need to have a diagnosis for safe implant placement, and know where the implant is planned in relation to the lesion. I actually have done many, many biopsies in the mandible over the years and feel very comfortable sending the specimens out to be decalcified and the cells examined for neoplasia. I don't think your Global microscope with 20x would have the same benefit. So let's keep an open mind "guy" and have respect for one's limitations and a healthy respect for other poster's imput. I had forgotten about the enostosis possibility and appreciate the other posters techniques and imput. Again thank you for taking the time to read, and try not to make it personal. Hopefully as you gain more maturity, humility and experience these posts will have more impact. Thanks
greg steiner
4/23/2013
Dr. Jain a trephine does not cut bone efficiently and generates considerable heat. If you use a trephine to remove hard bone you will have a few millimeters of dead bone both surrounding the outside of the trephine and in the core sample you are taking for analysis. The area of dead bone presents as osteocytes without nuclei because they have been cooked. Whenever I use a trephine for a core sample I always seek to use the smallest trephine possible so I will then be able to remove the cooked bone with my finishing implant drills. Trephines can also mangle the core sample and produce inaccurate information so I now prefer using a long bur in a high speed handpience to get as accurate sample as possible. Greg Steiner Steiner Laboratories.
Sam Jain DMD
4/24/2013
Dr Steiner I know there will be all that cooking of bone and for that you will use chilled saline, brand new trephine. The bigger goal here is to place an implant and not a biopsy (everybody agrees it just a benign hard piece of bone and nothing more than that) and using trephine would prevent you from getting veered off by hard bone and as a side benefit you will get a core for analysis although not perfect. If it was some cancer to be biopsied, then we cooking of bone will have to be considered. The surgical approach/instruments might be different. There is only one place where the implants needs to be placed ie prosthetic center and the thickness of the trephine acts as a guide to keep you in there. You drill to 11mm and take a small molt, hollanback, endo explorer, thin perotome and try to work around the core and you would loosen it out. Then take piezo to grind the bottom further as core could break at 8mm or so. Implant dentistry is awesome. Enjoy
Dr. Alex Zavyalov
4/23/2013
Adjacent teeth have rather big fillings. Simply make a fixed Zirconium bridge rested on inlays without any risk of implant failing.
TOBooth
4/23/2013
its a dense bony island , nothing pathological. Common in 40-50 yr old females!!!
DrT
4/23/2013
Based on the lack of consensus from all of the posters, I would say that if for reason other than medical-legal reasons, I think a biopsy is imperative
M. Pears
4/23/2013
It certainly looks like a dense bone island and these are common in the lower first molar regions . My advice would be please check with your radiologist and get a report from them as they usually comment on these things.
Robert H
4/23/2013
That is the first thing I am going to do.
Dr. Manish Juneja
4/23/2013
this looks certainly an enostosis. And I am not against biopsy. I see several biopsy daily (i am an oral pathologist who also do implants- now how was that! ). My only concern was not inserting the implant in the dense bone as it may not take up as others also agree. A biopsy will again show you dense avascularized bone. If one is able to remove it, send it for biopsy no issues. But question is will you be able to remove it without damaging the nerve and the adjacent bone. i beleive one needs good skills to do that else refer it.
dro
4/24/2013
I think history would be most helpful in planning the next approach. Pre extraction xrays if available or other post exo xrays from prior treating dentists would be indicated prior to beginning significant surgical approaches.
Robert H
4/24/2013
dro, there is no prior history available. The pt is an orphan who was brought here as a teen from eastern europe. I am treating her gratis. I am not even sure if there was an extraction or #30 never developed. Sent scan out to radiologist, waiting for his report.
Peter Fairbairn
4/24/2013
I Agree with Greg , trephining a core can be a little more complicated due to the bone density as well as actially removing the core . Ther have been lots of good points made here on this post . Peter
CR/
4/24/2013
I would be curious how the core would be removed since the inferior portion would be in very dense bone not marrow, and if you go too deep or move the inferior portion you may cause a paresthesia. And you are working blind.
CDS
4/24/2013
Residual postextraction cementoma - it can be dagerous for any implantation. Be carefull!
Sam Jain
4/25/2013
Dr Steiner I know there will be all that cooking of bone and for that you will use chilled saline, brand new trephine. The bigger goal here is to place an implant and not a biopsy (everybody agrees it just a benign hard piece of bone and nothing more than that) and using trephine would prevent you from getting veered off by hard bone and as a side benefit you will get a core for analysis although not perfect. If it was some cancer to be biopsied, then we cooking of bone will have to be considered. The surgical approach/instruments might be different. There is only one place where the implants needs to be placed ie prosthetic center and the thickness of the trephine acts as a guide to keep you in there. You drill to 11mm and take a small molt, hollanback, endo explorer, thin perotome and try to work around the core and you would loosen it out. Then take piezo to grind the bottom further as core could break at 8mm or so. Implant dentistry is awesome. Enjoy
Peter Fairbairn
4/27/2013
Hi Sam , as we all know the denser the bone does not translate to a better Implant site due poor vascularity. I have dealt with a similar case on a good friends wife , and did take a small core (difficult although I take about 20- 30 cores a year for research ) and no issues but when placing the Implant I angled the Implant to avoid the site as can be done here . Have had no issues in a few years but continue to monitor. Regards Peter
Robert H
5/2/2013
Here is the radiologist's report: Mandible: Teeth #17, 30 are missing. The existing mandibular dentition is heavily restored. The bone level of the mandibular dentition is within normal limits. A large, high density area, almost ellipsoid in shape, approximately 14 x 6 mm in dimensions, is identified in the edentulous site of tooth #30 in the right posterior mandible. This high density area appears to be surrounding the right mandibular canal and appears to be in contact with the buccal maxillary cortex. Its appearance is suggestive of a large site of idiopathic osteoporosis or enostosis. These are benign pathological entities that are characterized by dense bone and may require periodic evaluation. Mild atrophy of the edentulous alveolar bone is noted in the site of interest. Adequate alveolar bone height and width is noted. The site does not contra-indicate dental implant placement. However, increased resistance may be experienced during implant site preparation.
Dr. Osbert Usher
5/6/2013
Why all this up and down with implant? Before implants we used fixed bridges, its a enostosis and benign, so why not just place a fixed bridge in the area? Why cause more trauma to the patient when she will be fine with this simple, sure and easier approach.Yes, monitoring should be done on a timely basis.
Robert Hersh
5/7/2013
Because under most circumstances a single crown on an implant will last 2-5 times as long as a 3 unit fixed bridge, with no risk of breakdown of the adjacent teeth, no risk of needing endo on the adjacent teeth, better ability to maintain the health of her teeth and gums. She is only 26 y/o, and in all likelihood she will have to replace a 3-unit FPD at least 2-3 times over her lifespan. Thus, an implant supported crown is the most economical and the least invasive treatment option, if it can be done.
George Mandranis
9/16/2013
not your decision gentleman, its the patients

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