Adjacent teeth have advanced periodontal disease: recommendations?

Here's what I would do (stolen from Dr Tarnow!) Extract the teeth and socket graft with primary closure. Wait 16weeks, do a simultaneous implant placement with lateral wall lift. Look it up on line, DentalXP, you do the lift, then place the implants under the membrane and pack the bone around the end of the implants. The 4mm of alveolar base bone gained from the initial socket grafts will give you primary stability. I would not do a Summers lift with such thin bone and a shallow floor. The Lateral will be easier. Good luck. Get the patient on oral hygiene and Peridex.

Where did we fall off the wagon here? What happened to treatment of periodontitis and regenerative procedures? These teeth do not appear to in imminent need of extraction. How about referring this case to a periodontist either for maintenance or definitive treatment if you are unwilling or inexperienced in treating this disease process? Or have we evolved past the need for the specialty of periodontics? If this is the case, why don't we just start extracting teeth and place implants at will? RJM

I am wondering when did you insert this implant. if you inserted it before a long time ago then the advanced periodontitis of adjacent teeth is an allarm for you to do somthing before the periodontitis affect the implant. but if the periodontal state of adjacent teeth is this at the time of implant insertion then it is a big mistake of you the insertion of implant in area of bad periodontal condition

Dear colleagues, Thank you very much for your comments. Dr. Salim maybe misunderstood my question. The implant at tooth 24 was placed 5 years ago. It's still OK now. My question is taking out all teeth 25, 26, 27 than place implant or try to keep them. And doctors, tell me your experience when do sinus lifting near the old sinus lifting before. Is it the same or more difficult to detach the sinus membrane? Thank you very much. Dr. Tri Dung.

We have not fallen off the wagon, there comes a time when the teeth are not salvageable. if you retain these teeth much longer there will not be enough basal bone to work with. Extraction and regenerating the bone is the way to go. I see this often, a well meaning practioner will try to keep the teeth when it would be clinically better to extract and regenerate. It' s a judgement call, you can't get adequate regeneration with the teeth still there exposing your graft to the oral flora.

Chronic infection must be totally cleared for implant to integrate. In some cases this can be done immediately, but extracting and delaying a couple of months is nice insurance against bacteria in your graft or implant site. I don't know what type of grafting material was used here, do you? If it is of the type that does not resorb, you'll have reduced circulation in this site. How about placing a short implant, 5-6 mm or even 8 mm long? Bicon has a 4.5x6.0 mm and a 5x6 mm that would work well if you have the ridge width. If not, one of the 4.0 mm widths might work. I think grafting a graft is risky business and would avoid it if you can. Short implants should give you that option. As for sinus membrane lifting in scarred areas, the longer it's been since the sinus injury, the easier it will usually be to separate the membrane. However, this case looks a bit fuzzy on your x-ray, which could reflect a fibrous graft/ membrane interface which will definitely not allow the membrane to lift. You'd have to dissect the graft particles from the membrane...

It will certainly be hard to maintain these teeth in the long term. When they are removed there will be consolidation of the crestal bone, meaning that more bone will be available for implant stabilization. Socket regeneration would add considerable time and not much additional support. Ten weeks healing is generally sufficient. Where minimal residual bone is present then ultrasonic channel preparation is the simplest and safest. Tapered, rounded-end osteotomes can then raise the sinus floor safely and be used for graft placement. It is important to not create a full-size channel because it is distinctly advantageous to use a tapered implant into a reduced size channel. This way as the implant is taken to place the bone is compressed and implant stability enhanced. This is a relatively simple protocol but very effective.

Great discussion, thanx for posting, definitely dilemma time!

Before deciding to condemn or save the teeth, a charting exam is needed. Treatment planning without a complete periodontal exam does the patient no good. If we could see, in addition to the radiographs and photos provided, the probing depths, furcation involvements, mobility, attachment levels, etc., we could give good advice.

The patient has proven that she can't clean her natural dentition and now you are going to splint your implants ? Just because you are removing the teeth doesn't take away the etiology of the Perio disease. You are asking for it. Get them cleaned up, as they are and have then prove to you that they can clean themselves before doing anything . The extraction and graft procedure will have a much better outcome. If they comply, I would place the implants at the time of extraction. Bv

Dear my colleagues, Thank you very much for your all comments. I took out 3 teeth on Monday this week. I think my decision is right because the residual bone is not so much. And my plan is waiting 02 months for gum healing then CT scan and implant treatment later. Hope to hear from all of you in future. Best regards, Dr. Tri Dung.

Did you provide any Perio treatment prior to the extractions and did you graft the sites? If with what? Bv

Dear Dr. Baker, Thank you for your comment. I didn't provide any perio treatment. The reason is that the tooth 25 and 26 are hopeless teeth and no reason to keep them. The question is the tooth 26. However, keeping only tooth 26 seems not so good for patient future. I didn't graft the sites because I had the plan to do sinus lifting 02 months later. I don't believe the socket preservation is good for this patient. Best regards, Dr. Tri Dung.

I'm not trying to be disrespectful, but do you not believe active Perio disease is a contraindication for implants? Certainly you are aware that the more bone you have between the alveolus and the floor of the sinus, the more stable the implants will be. I get a lot of sour responses from my colleagues when I ask them to clean the patient, before embarking on these procedures. My goal is to create the "perfect" environment, or as close as we can get. I'm certain you will find the extraction and grafting process most predictable when the tissue is not friable and not full of granulation tissue. Just a suggestion. B Vinci

Part of active perio treatment is removing hopeless teeth before all the basal bone is lost.In my experience treating the teeth that have a good prognosis and removing the teeth that are seeding the oral pathogens seems to be the right balance. I've also retained hopeless posterior teeth to temporarily retain posterior vertical dimension while I'm waiting for osteointegration. It's always a judgement call, I've seen patients become "born again" periodontal maintainers even when they have lost teeth due to perio.Of course I agree with you about the perio risk, now we see perio issues crop up about eight years after implant placement. There is a whole crop of literature on this now as more patients have implants, I guess it's some kind of progression in implant management. Great comments.

Dear Nguyen I would have grafted the defects at extraction, I find that this is key for a great result.Full thickness flap graft the buccal plate wit bioactive materials maybe a Teflon membrane to keep the base. If you don't have this skill set learn it or refer it and watch the technique. Just extracting you will have collapse and resorption it will be more difficult regaining the bone.You need primary closure. I see this often the dds thinks they are doing the right thing, I have to go back and correct the bone loss when it could have been done at the extraction.

A good thread of these discussions relates to the expediency and effectiveness of therapy. When removing teeth with furcation defects most of the "defects" that remain will tend to be four-wall around each of the roots. In short they will fill rapidly with bone. In this case all one needs is sufficient bone to stabilize the coronal part of an implant being placed at the same time as an internal sinus lift is being performed. This too is a predictable and relatively simple procedure. So removal of the teeth followed two months later by an internal sinus lift would seem to be entirely reasonable, quite expedient and cost effective. To make the plan any more complex is unnecessary.

I am a periodontist. Tooth # 13 looks like an endo failure and certainly needs to be removed as it threatens the longevity of the implant #12. There is no advantage to keeping #15 as you stated that it is unopposed so it should be removed as well. #14 could last years with the adjacent teeth gone and proper periodontal care. This is a common sense approach to the problem. As long as #14 is properly treated and maintained, the surrounding bone will not be lost. If something happens in the future you can still implant #14 and grafting the socket in the future would be no harder than grafting it today. A cone beam study of the #13 site would be beneficial because it is really difficult to tell much about the sinus/alveolar bone interface on the view we are looking at. There might be some bad surprises in an area that has had a chronic endo failure sitting there for who knows how long.

Untreated periodontal disease with no maintenance or oral hygiene will result is widespread inflammation throughout the alveolus and horizontal bone loss. If the disease is treated and maintained even if you get progression over the years the bone loss will be vertical and limited to bone adjacent to the tooth. Therefore treating #14 even if it is lost in the years to come will not reduce the amount of bone for implant placement. The rational of removing teeth because they have periodontal disease and you want to preserve the bone would most likely lead you to remove all of this patients teeth. #14 has been in the pateints mouth for about 50 years. Do you think our implants will last 50 years? Greg Steiner Steiner Laboratories