Advanced local bone loss around abutment tooth: opinions?

Multiple issues. This is a long span fixed bridge and I have always considered upper first premolars to have a 'design flaw' anatomically. Primary occlusal trauma also comes into play. You may find the anterior abutment/crown is loose and there then is a continuous percolation of bacteria. This has become a combined Endo/Perio. I don't think the root is fractured, but is clearly hopeless. How long was the bridge there? Perio disease can be very site specific.

Agree with you my friend. Endo-perio lesion is the most likely cause.

Either endo perio or root fx...probably the former. Since this has become a chronic lesion, the Px for resolution is very slim. Extraction is indicated.

If this was an endo-perio lesion caused by pulpal necrosis (firstly endo then perio lesion associated) it would be easy to try to resolve (not easy to resolve but easy to try). But this is clearly a perio (vital pulp) or perio-endo (necrotic pulp) lesion so waste of time trying to solve this. I would section the bridge, extract the 1st bicuspid + graft with fully resorb (special attention must be taken debriding that nasty dirty hole) do implant in second bic and 1st molar and do a temporary bridge with the 1st bic in cantilever. Soft occlusion on 2nd bic and 1st molar, no occlusion on 1st bic and 6 months later do implant on 1st bic. Thanks for posting.

CLEARLY perio-endo??...I beg to disagree. In a mouth which is otherwise healthy periodontally, on a tooth with a full crown...my tentative dx is ENDO-perio

I agree with extraction, graft including EMD and GBR membrane, and implants in edentulous site under old FPD and cantilever temp. Later, maybe 4-6 months , place implant in graft area. I don't really believe it is endo because of lesion touching apex and not actually above and circumferential like we usually see. Probably some type of perio granuloma induced by , maybe cement or toothpick/food??? Endo Ice test may tell of vitality?

The first bicuspid has an Endo-perio lesion. Occlusal trauma may be an issue. Section the distal abutment, if it's not mobile and extract the bicuspid. The boney defect is through and through (palatial and buccal bone involvement). Graft with membranes and particulate graft, detox, decorticitate. L-PRF could be used or a nonresorbable membrane. You may be able to place an implant at the time of extraction and graft, depending upon the presentation and you skill level. If the bone is wide enough, root forms could be placed in the second bicuspid and first molar site or prepare the site for implant placement.

An immediate implant in a site of chronic infection with extensive bone loss??? I have to wonder if this is truly in the patient's best interest.

what amazes me is how little the PDL space is widened on the abutment molar, I would imagine on such a cantilever the molar would be mobile. I do not think it was hyper occlusion.

History of present manifestations will go a long way in diagnosing exactly whether its endo perii or perio endo or combined!! if any previous history of sensitivity then or pain then sure its endo perio but if its only pain n no sensitivity then its perio endo.. Over crwn prepratn cud b d reason Failure to achieve Gp function cud b reason of ist pm n high occlusion as ths tooth gen gets poor anatomic design in lab n satisfies fpd principles. Rest tt plans has been discussed ..choose wisely gud luc

Consider a Bx of that soft tissue, perhaps. One never knows.

Kenneth, that is an excellent suggestion, thank you. I am going to move forward with that.

A provisional cantilever holds some risk. I would like to believe I would be able to completely graft the first bicuspid with adequate and healthy bone in order to eventually place an implant in this position. My experience has been mixed, however. The best source of bone cells to replenish this site will come from the bony walls and it will grow into the area replacing the graft material over time. The larger the graft, the longer the time required to replace, and greater chance complete fill will not occur. You are also making the assumption that the bone volume distal to the first bicuspid is adequate to place two implants accurately spaced and immediately strong enough to not only support provisional crowns, but a cantilever acrylic FPD. Should one of these implants have it's initial stabilization disrupted, osseous integration will not follow. Also, fixed provisionals in an area where you may need access to manage complications, is itself a complication. I would go with a removable acrylic provisional for these reasons.

Let me share a few pearls from my experience, definitely extract and send for biopsy C&S, I have been surprised with results, take a little of the bone also. Make sure this is well disinfected I use a Nd Yag laser since it has the right wavelength and penetration depth a diode or erbium is not as effective. Be cautious with an impant in this area, perhaps wait until the path comes back. Grafting is fine at surgery. I had another thought, this could be a perio endo and the tooth would have been mobile but the bridge is holding it in so the odd clinical presentation. My concern is that a future implant placed here may be a set up for a Periimplantitis down the road. My personal protocol is extract, biopsy, graft with particulate and laser generated clot, Essix provisional to keep pressure off the graft. You could try LANAP in this area but the tooth appears hopeless and it is a terminal abutment.

Firstly I guess it's perio problem. As everyone know 1st bicuspid has a depression/ groove on root surface bucco lingually. That groove is hardly controlled/ maintained periodonticlly. Secondly it may caused from endo as resulted from heat necrosis during crown preparation or over prep. My only idea. Wish you have way out of puzzle.

I agree with those that urged biopsy. This bone loss is atypical and a little scary. I'd want to rule out other pathology cuz it looks like something else is going on...if not local, then maybe a sign of something systemic. (Of course there isn't the same concern if you already know what the problem is, like maybe a visible, complete vertically fractured root.)

That thickened cementum or old, thickened PDL area is reminiscent of some Drug Induced Osteo Necrosis areas I've seen, although they appear on a series of roots So some investigation of why the thick, acellular layer around root? What meds is/has pt been on over last decade?

I appreciate the remarks regarding the possibility of a drug induced bone necrosis however wouldn't something of systemic origin present in more than one area in the mouth? And why the limited presentation to the #12 area, having not progressed over what has been a period of years to #11 and the bone in the area of #13?

I agree with your assumption, but have had some cases with isolated expression of the acellular matrix, of which your X-Ray is reminiscent. These were also in the 12-14 area. I have seen DIOJN where areas a acellular matrix just crop up in a few isolated areas. That radiopaque enlargement could be cementoma? Anyway, it's not the normal response to perio/Endo abscess. All it takes is an insult/ irritation to the area to launch destruction: cement, toothpick piece, packed food, etc.. I only mention this as a possibility to be ruled out by someone more knowledgeable.

Expression of the drug induced necrotic bone is favored on the bone sites with highest rates of remodeling. Intra-orally, this is the Lingual Plate of lower molars as well as areas overloaded from imbalanced occlusal loads, bruxism, etc. The Bicuspid in this patient is heavily loaded as an abutment, but something such as heavy Buccal interference/nite grinding could stimulate the necrosis. While some patients do show generalized radio graphic evidence, a common situation is for the radioluscencies/opacities to arise in primarily in heavily loaded bone. So occlusal load management is critical in maintenance.

Though it may seem hopeless you could take a shot and try to salvage it as long as patient is informed, Before implants became so commonplace I have tried to save these situations and some amazingly came back. Endo, root-plane, equilabrate aggressively.

is it possible to tell is there any pus discharge or edema in this site

My evaluation leads to a suspicion of a chronic asyntomatic presentation, with a fair stability of the bridge. Given the generally healthy perio condition , i'd rate this endo - perio. If on consultation the pte is willing , I would first try doing endo therapy through the crown on # 12 along with careful debrement. . I have had some extreme perio recovery with splinting to maintain primary stability. Folow up 3 montyly periapical x rays could yield some encouraging results.