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.
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