Incisive nerve issues: place implant or bridge?

I have a 20-year old male patient that presented with an asympotmatic swelling in 21 ( left upper central incisor) for the past 3 yrs, following a traumatic injury sustained while playing. Patient has no pain. I planned to do an extraction of 21 with curettage and graft placement, and then delayed placement of the implant as 2nd stage, subsequent to graft integration. However, the CBCT revealed nerve involvement. Now I’m in a dilemma, as to whether to risk implant placement or go with a conventional bridge? What is your suggestion?



19 thoughts on: Incisive nerve issues: place implant or bridge?

  1. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    I am not able to ascertain enough detail from the scans you provided to give you a definitive answer.
    However this case really exemplifies a very important point. If you are not certain, refer to a specialist – at least for an opinion and probably treatment. Provided the adjacent teeth are in good condition and do not require treatment, why would you settle for a lesser treatment plan of crowns and bridge when ideally you could place an implant and crown?
    If you are not confident or capable of doing the implant because of a possible complication (and I congratulate you for hesitating because of this) , why not refer to a specialist to place the implant and then you finish the prosthetic work? This would provide the patient with a good standard of care, you avoid any possible medico-legal problems and you are still very much involved with all of the treatment.

  2. Dr. K says:

    From the CT scan it appears the abscess and the nerve canal can’t be differentiated in a few different cross sections. In other cross sections it’s clear where the nerve canal is. Personally I would extract the tooth and bone graft with membrane ( if needed). Do a follow up CT scan in roughly 4-6months and then decide whether to proceed with implant. Have patient were a removable appliance in the interim.

  3. Doc says:

    I would wait a couple of years before placing an implant in a 20 year old male due to likely incomplete skeletal growth.

  4. Erik says:

    Aren’t we talking about the nasopalatine nerve that travels through the incisive canal? Let the patients best interest dictate what needs to be done. If you are hesitant to place an implant but you know in your heart that is the best option, refer to a specialist that is comfortable. There is nothing wrong with picking and choosing the cases you do carefully.

  5. David Levitt says:

    Take a look at the angulation of the socket. If your Implant follows that path you will end up with a 45degree custom abutment. That would have chronic screw loosening and other problems. If you place the implant at a Mote favorable angle you will avoid the canal but perforate the bucal plate. So.,,,, Extract the tooth, flap the area, fenestrate the bucal plate and continue the graft onto the facial. Cover the graft with a collagen membrane. At 3 months repeat the scan to see if the bone width and angulation is favorable. If it appears you still will involve the canal uncover the canal at the time of implant placement, take a #2 surgical length round bur and team put the canal. You will encounter bleeding for a short while but the arteriales wil retract and tsmponade. Pack the canal with graft material. Yes the central papilla and a portion of the palate will be forever numb but had any patient ever complained about that? No. I’ve severed that nerve a thousand times. If you are a GP (you sound like one) this is a great case to spread your wings. Get some training in grafting techniques. This is a great case to take yourself to the next level. If you want to take a course from me look up the Perio institute (Perio.com) Bone grafting
    Level 2). I’m not the only instructor out there. Caligornia Implant institute is good. Misch institute is good. Let us know how it goes. I’m rooting for you.

  6. Oliver Scheiter says:

    I am completely d’accord with the recommendations of referral to a specialist. Just not with the discipline. Am I the only one thinking “ENDO”? Sounds very much like a sterile necrosis.
    You can avoid a great deal of desaster by RCT, even if it ends in microsurgical apiceptomy. This way the tooth can be held for at least a couple more years, the defect will heal, the skeletal situation will not be a topic anymore and even the incisive canal might not be a problem. Why did you watch this for three years?

    • Raj says:

      Fully agree with you Oliver Scheiter. Endo will be a great option to allow the peri apical area to heal. Whether to do a peri apical surgery or extract and place an implant is a decision which can be made after a follow up cbct. I’ve seen many big lesions disappear with a good non surgical endo alone!

  7. Dr J says:

    If the tooth has good bone support and the tooth is in good condition structurally, try root canal therapy first. Take new CBCT in 3 months to assess bony defect. If the nerve is still involved in bony defect, refer to specialist to repair and graft to prevent any nerve damage. If bony site can be grafted with out nerve damage, i would plan for a Apicoectomy and retrofil , clean out bony defect , graft socket. Wait 3 months and assess. If this fails then Implant , but i would wait until the patient at least 25-28 years of age.

  8. Kevin Frawley DDS says:

    I agree that I have never had a complication from obliterating the incisive canal. In this case I would use the tooth as the temp by bonding it in place after cutting off the root. I would clean out the granulation tissue and the nerve and graft the area. Be sure you have a good site before placing the implant.

  9. Dr Manjunath P N says:

    obviously if the patient has elected for implant supported crown, you need to remove the tooth, debride thoroughly with copious irrigation & do socket preservation. later after 4 – 6 months of healing again get the CBCT to evaluate the volume of the bone for implant treatment planning.

  10. pascal valentini says:

    there is no risk to remove the nerve with curettes and to fill the gap with any biomaterial you want after implant placement

  11. Matt Helm DDS says:

    Oliver Scheiter congrats for making the most sense here! Endo was my very first thought. In fact, endo should’ve been done long ago, as soon as the patient presented with the first post-traumatic symptoms. His previous dentist unfortunately failed him twice: once because he didn’t do the endo timely, as soon as the swelling appeared, and a second time for observing a growing swelling for so long and not doing the endo or, at least referring the patient for endo.
    That said, and, having treated a great many trauma patients in an MVA trauma practice for many years, and having done hundreds of trauma-related endo cases (which is why endo was my first thought) I see no reason why endo in this case would not solve the problem in a most conservative, practical, and elegant non-invasive manner, even with this swelling. This tooth most likely suffered a sterile compression necrosis, secondary to direct dramatic trauma. I.e.: the sudden violent traumatic compression of the apical circulatory/nervous bundle caused a total and permanent interruption of the intra-canal circulation, resulting in nerve necrosis (now absent blood supply), ultimately leading to the swelling which was caused by the chronic, slow progressing infection, inevitable with a necrotic nerve. The slow progression of the infection resulted in the slow erosion of the bony socket around the root (as is even evident from the CBCT), and this facilitated slow drainage of the infection via the periodontium. This slow drainage through the socket resulted in the absence of painful symptoms, because there was no intrabony pressure build-up.
    Properly done endo will solve the problem, even if it ultimately necessitates an apicoectomy, which it may not, with proper concurrent antibiotic management, possibly associated with a conservative local curretage of the gross swelling. There is also an intrapulpal stone in the canal, which may, or may not have been a contributing factor.
    Since the patient is a 20 year old male and, since bone growth has not yet finalized — and will not do so for another 3-5 years — endo is by far the safest and best treatment option.
    Jumping to an implat at this stage is premature, precarious, and impredictable to say the least. We must remember the patient’s best interests in the long term. Should the endo fail, an implant can be attempted any time thereafter, after a simple extraction with no initial graft, to allow the bone to heal on its own initially. But if the endo works — which is should! — don’t be surprised if that tooth is still in that socket 10-15 years from now, even if the root suffers some apical resorbtion in the meantime!
    As an adjuvant to the endo, if the swelling shows no signs of subsiding at all in 4-6 weeks, do an apico with a full thickness flap from the free gingival margin (not a semi-lunar incision), thorough curettage, Clyndamicin irrigation, and bone augmentation (with a labial membrane if needed) to improve the tooth’s bony support, if the resulting bony defect is way too large and if most of the labial plate is compromised. Otherwise let the bone fill in and heal on its own.

    • Oliver Scheiter says:

      Thank you Matt,
      Nice detailed explanation. I am in full agreement that high quality RCT will solve the case most likely without the need for surgery.
      Sunny regards from Mallorca
      Oliver

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