What is the optimal course of action to restore #10 and possibly #9?

I have a 60 yo female with no medical complications. She has a moderate bruxing problem that she refuses to address. She has had an existing crown on #10 (maxillary left lateral incisor; 22) with a post and core for over 15 years. The first radiograph was taken in 1-27-09. She presented about 6 months ago with a loose post and crown. I told her that she needed to extract the tooth and place an implant because I could clinically see a buccal vertical root fracture. She said that was asymptomatic and wanted to temporarily recement the post crown and would get the definitive treatment done soon. I did not take an x-ray at this appointment. She now shows up 6 months later on 9-3-13 and the post is loose again and she now has a buccal abscess. I placed her on amoxicillin 500mg tid for 10 days. I re-cemented the core/crown and took an impression so that I could make an Essix appliance for when the extraction and grafting occur. She has a relatively high smile line. #10 probes deeper than 12 mm on the buccal and mesial. #9 (maxillary left central; 21) probes less than 3mm on the distal even though it looks like there is major bone loss around the distal of that tooth.

My plan of action is to extract #10 and evaluate if there is any bone on the distal of #9. If there is no bone then I will extract #9 also and curette and rinse the site well. The Essix appliance will be placed and she will continue her course of amoxicillin. She will then come back in 5 days and I plan to graft the site using Rocky Mountain Particulate bone with a Osteogenics Ti-250 Titanium-Reinforced membrane with tacks to allow the bone to develop without being disturbed. I will also place PRF over the bone as well as over the membrane to help accelerate the healing. The tissue will be released to allow passive primary closure and the tissue will be reapproximated and sutured with PTFE sutures. An implant will be placed in the #9 position after 5 months of healing and prosthetically I will have a 2 unit cantilever bridge from #9 to 10.

There are many alternatives but I may also place the implant in #9 position on the same day that I graft to reduce surigical interventions.

I look forward to other opinions on how to treat this problem or to affirm that what I am planning is a prudent course. Thanks for all of your excellent knowledge and help.

1-27-09 1-27-09
9-3-13 9-3-13
#10 abscess

15 Comments on What is the optimal course of action to restore #10 and possibly #9?

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CRS

9/12/2013

If it were me I would remove #10 currette and graft the area with a teflon membrane and graft the distal of #9. Let it heal with an essex in place. Then evaluate for an implant #10. I would give #9 a chance since removal may create a papilla issue.

Kaz

9/12/2013

I am not sure if there is any PDL or even some bone left on the distal. Should I curette the distal very well or just leave any tissue that may still be present to potentially allow the bone graft to heal to what is left? At the crest the probing is 3mm and healthy, not sure what lies below until I open it up.

greg steiner

9/12/2013

You have an intact pdl on #9 as confirmed by the 3 mm probing. The bone is gone due to the root fracture and abscess on #10 but the periodontal ligament is still present. I can assure you that if you remove #10 and do not touch the root of #9 you will get regeneration of bone on the distal surface of #9 as if the lesion had never occurred. Remove # 9 and everything will collapse. In this case you need to facilitate the regenerative process not interfere with it. An allograft which blocks the regenerative process and produces sclerotic bone through a type of scarring is the wrong choice if you want bone to grow on #9 and in the socket. Extract #10 curette everything except the surface of #9. Donâ€™t open any flaps. Graft with resorbable synthetic graft material that will not interfere with regeneration. Cover the graft material with either a tissue graft from the palate or a synthetic barrier. Greg Steiner Steiner Laboratories

CRS

9/12/2013

The problem is that if you don't raise a papilla sparing flap at extraction you can't see the morphology of the defect and get all the epithelium out and whether the defect goes thru to the palate. I have had the opposite experience than Greg has had, I get a better clinical result with cadaver bone mixed with prgf and a barrier membrane to prevent collapse and get a labial plate back. I've had poor results with synthetics so I only use human allograft. It resorbs as the synthetics do and I get bleeding healthy bone which is easy to drill thru. Now I would remove the epithelium with the ablation setting of my periolase and do a thermally generated clot with the graft. I don't understand the five day wait you can clean up the area with a local antibiotic or hydrogen peroxide. The defects on these fractured teeth can really fool you and diseased epithelium can be left behind which can cause the implant to fail. I would just graft the distal of #9 make some labial perforations.

greg steiner

9/13/2013

CRS I respect that there are different ways to treat the same lesion. Successful tissue regeneration requires that the tissue you leave behind is vital and unaltered. Don't you think a laser on ablation will leave a layer of devitalized bone? You have stated that allografts are resorbable. As you know I have challenged the restorability of allografts before and to date no one in this worldwide forum has ever produced a study that concludes that allograft are resorbable. Let's not bore the audience so if there are valid studies that show resorption of allografts I will accept it and this topic can be put to rest. No criticism just friendly discussion. Greg Steiner Steiner Laboratories

CRS

9/13/2013

An nd-yag targets pigmented tissue not bone the settings sterilize pigmented bacteria you may be confusing the tissue melting properties of a diode laser epithelial tissue is removed and granulation tissue is left behind sterile. It works well a different paradigm. I am very comfortable with the results

CRS

9/14/2013

Dear Greg , I respect your opinion. As a simple surgeon over the years of clinical experience pretty much everything other than a xenografts or foreign body is resorbed by the body and replaced by bone. I'm not sure what a "bone scar" is but when I go back into grafted sites there is bleeding bone and the implants do well. The old iliac crest grafts and ribs have resorption trying to actually graft live cells. A rib behaves like a rib is what we used to say when after three years it would be gone. I think that whatever material is used as long as the space is maintained,infection and epithelial in growth prevented and the site is kept immobile bone most likely will regenerate. Everything else is marketing products and I appreciate your passion. There are many products out there and it is exciting to try new techniques but I think as individuals we need to use what works best in our hands and clinical practice. I am excited about the nd-yags since they seem to be unique in targeting the pigmented bacteria which contribute to peri implantitis and have a deeper penetration and variable pulse duration. In the big picture if we use the knowledge of biology and physiology combined with accepting our limitations I think that our patients will be well served. We can learn from the new products and techniques coupled with the experience of us old timers, specialists generalists and restoring doctors. I hope someday to visit your lovely facility in Hawaii there is an OMS review course there next Feb! mahalo!

greg steiner

9/14/2013

CRS Dinner is on me. Greg

Peter Fairbairn

9/16/2013

Here is my 2 cents worth on this case , had a busy week . Do Not remove the central as the bone loss can be regenerated when you place and graft in the lateral site . This is not a complex situation and the pdl will regenerate as the same time . I do these cases routinely and will post an extreme case where the bone was lost to the apex of the adjacent tooth , now 5 years later it is back to where we expect and the pdl has fullly regenerated . Once the source of the infection ( lateral ) is removed the body will want to heal , help it. This leads to membranes whilst they are fun to play with I feel they hinder the bodies ability to heal by restricting the vital periosteal blood supply to the graft site . They also hinder the induction Stroma; cell derived Factor 1 in the periosteum which is important in mesenchymal cell presence in a damaged bone site ( Zhao , Watanabe et al Bone pgs 864- 877). This case is complicated by the aesthtic demands of a high lip line , keep it simple to reduce bone loss and difficult remedies later Peter

Peter Fairbairn

9/16/2013

Totally in agreement with Greg and his comments Peter

John L Manuel, DDS

9/17/2013

Great comments so far. In addition, I am thinking one should evaluate the occlusion in this type of case. Usually, you'll find the lower buccal segments forward with that forward cuspid occluding almost entirely on that poor upper later incisor. You'd rarely see such a fracture and trauma if the only oppostion was a lower incisor. So, whatever prosthetic path you choose, that upper lateral needs to be protected from that lower cuspid force. Maybe patient is a Class III, maybe narrow Maxilla, maybe Division 2 premaxilla ... Without occlusal adjustment and nighttime protection, that lower cuspid will just keep beating the tar out of your new implants. John

IRWE DDS

9/17/2013

This is one case where I would suggest a tooth borne bridge as a back up depending on the occlusion and if she is a smoker.

Mark Montana

9/17/2013

Occlusion didn't kill this tooth, it was already a zombie. 90% of the clinical crown was missing and 50% of the root volume; it was a shell of a root leveraged by a large post. That it lasted 15 years is wonderful and despite it's supernova exit, it was still a success. Keep #9 for sure, it should do well without its noxious neighbor. I'd probably bond a composite tooth in place as a temp once the initial surgical episode is completed since it will likely be several months before reentering the site; the patient will be much happier.

Baker Vinci

9/21/2013

I'm confused as to why removing #9 is being considered . If you have a fair cbct, you will know what is going on at the distal. Even if there is a bit of bone loss, removing the tooth is not the answer, in my opinion. Getting the low grade infection, can allow immediate placement of #10, when it is removed. The orthopaedic literature, strongly suggest that grafting and placement of hardware, does quite well in the face of the low grade infection. I don't know the specifics or the mechanism associated with this suggestion, but I would guess that it has something to do with recruitment. Our literature suggest that bone grafting and placement of implants in infected sites, is positively influenced by our blood derived enhancement products. I have good success, while invoking this method. B Vinci

Baker Vinci

9/22/2013

Excuse the sloppy response. I did not see, of look at the photo of the purru lent abscess, before I responded. I would not place an implant in that site, upon extraction of the tooth. Bv

What is the optimal course of action to restore #10 and possibly #9?

15 Comments on What is the optimal course of action to restore #10 and possibly #9?

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