Large cyst: proper treatment plan?

Normally, granulamatous tissue in bone can be thoroughly clean out and you can proceed with bone grafting procedure as long as the surrounding bone is in good condition. However, in your case, there is high chance that the radiolucency is caused by the necrotic upper left lateral incisor (no response to cold test). In this case, I'd perform a perfect RCT on the lateral incisor first. Once you are convinced that the lateral incisor will not cause any infection, you can go ahead and perform the surgery. If the labial plate is missing or damaged, i'd wait on placing an implant but rather just perform socket preservation. I usually use all cortical allograft with particle size .25 - 1 mm. Do not use anything smaller than .25 mm. Studies show that allografts smaller than .25 mm will cause inflammation. In some cases where all the bony housing is intact and if i can achieve excellent primary stability, I place the implant and immediately connect a screw retained provisional crown and get it out of occlusal contacts as done by numerous other dentists around the world.

Remove the lateral there is no bone support and it is displaced by the pathology. Remove and biopsy the cyst, graft and see what you get back, then place the implants. You may want to consider treating the other posterior cysts which would be more amenable to root canal therapy. Not wise in this situation to place implants without knowing the diagnosis, lack of bone and active infection. Not likely for the cyst to resolve with the lateral present with his much pathology. Thanks for reading.

I would be concerned about any cyst displacing a tooth. I agree with delaying any implant placement until something is known about the pathology. JM2C. Bill

There is significant thinning and expansion on the buccal aspect of your lesion, also in one view it looks like there are radiopaque densities occurring within your lesion I would not do anything until you have a full path report. This may not be a radicular cyst. The thinning and the expansion of the buccal aspect of the alveolar crest is concerning. Normally periapical cysts do no cause that much expansion of the buccal plate. What are you doing about the sinus pathology in the frontal sinuses? From the images I can see your sinuses are not well aerated.

Hi, thank you for all your advice. i did the RCT the tooth 22. Surprisingly, the pulp was still vital. I also used a 25 gauge needle to penetrate the cystic area to see if i could draw any fluid out of the cyst. There was no fluid drawn out. I have also advised the patient of the other radiolucency. He is aware of them. Since he is in no pain or problem with sinus, he is not in a rush to get treatment. The reason he came in to get the tooth 21 implant is because it's an insurance case. My next step would be to clean out the cyst, graft the defect and to get a path report. many thanks for advice