Overerupted tooth and root surrounded by periapical lesion: Best treatment plan?

Are you ready for some "pearls?" Here goes, carefully remove the tooth, curette,use a little chorhexidine to disinfect.(The perio guys like tetracycline,either or) Here's the important part, the buccal plate.Look at the defect, if you can place a Teflon membrane such Cytoplast to cover the defect an close it primarily with the flap you will have a nice result. The graft should be Demineralized cortical-cancellous allograft, Mineross or Allosorb (Reimser). The nice thing about the Teflon is that if your flap breaks down of you can't get primary closure it will guide the soft tissue and preserve the graft. Just have patient keep it clean with peridex (dab with q-tip)Check out the Cytoplast website or call a rep for literature. Use an Essex appliance Not a flipper it will ruin the graft and smash it! Wait 14-16 weeks place the implant, if you try an immediate you are hoping for two things growing bone and osteointegration! Great case good luck, you're welcome!

Based on adjacent teeth significant bone atrophy the best chance for success you’ll have if perform a Ribbond single-visit bridge, not an immediate implant installation. Palatal surface is free from occlusion and it’s a perfect case for splinting all frontal teeth.

Immediate implant in this area necessitate the inserttion of the implant in the palatal wall of the socket and that will incline the implant with the abutment more labially, this will complicate the esthetic result because #8 and #10 are inclined palataly. Grafting and waiting for 4 months will give more flexibility with the insertion of the implant in more desire inclination but we may loose the interdental papilly after 4 months so you can use an avoid pontic with rochet bonding attachment, this bridge will also protect the graft from any movement.

Are you guys kidding? It looks to me like there is no bone on the mesial of the lateral. I don't care what you graft with you will not get any bone to grow up the side of that lateral. We need more info to give you any meaningful advice. Has the perio condition been stabilized?

Oddly enough you will , the body wants to heal , I have hundreds of well documented cases to show it ( I can post one where the bone was lost to the Apex of the adjacent tooth and 4 years later is still back to where it should be and yes with a new PDL. Materials and techniques have moved on since the 80s . Remember to always place the " gold Standard " graft material , yes the IMPLANT at the time of brafting . Think about it . Regards Peter

Another aspect to assess besides the perio is the bite (occlusion looks scary ) with the interferences and parafunctions. Peter

I think that staging the treatment with placing the implant after the graft has healed will be more successful,there is a lot of bone loss and it would be wise to see how much healing you get. The titanium is inert and the graft bone will have to heal around it. The body is being asked to do two things,regrow bone and osteointegrate. I tell my patients one miracle at a time,it also gives time to assess the periodontal response and the patients home care. I personally would not put all my eggs in one basket and do everything at once. And I have seen bone regrow along adjacent teeth but it is not 100percent so that's why I stage it. Hope this is helpful,good luck!

Here's what I would do: Elevate flap MAINTAINING THE PAPILLAS (do the gingivectomy in a woman's nice hip-thigh curve format if you understand what I mean). You will notice you will have palatal bone and the buccal bone is lost. Curette "violently". Insert implant palatally (keeping in mind you will have a screw retained prosthesis) and do insert a 13 or 15mm implant so that you can have a nice apex stability (submerge a bit: 1mm is just fine) and screw a long healing cap. OK, so now you have +/- 5mm of the implant inserted buccally and like 8mm exposed. Use a nice round surgical bur and start cutting the bone adjacent to the adjacent teeth so that you can have a nice flat bone (remember you have the periodontal ligament close). Now, measure the interdental flat space (horizontally) and you have three choices to get a nice bone block: raise a palatal flap and get it off the palat; get it off the mental area; get it off the posterior mandibular area. I prefer the mental area but the patient won't prefer that the later days. Your choice here. Get a nice bone block with the horizontal distance you measured previously. Here you can use either a tungsten pointy bur or a disc bur for the straight hand piece or whatever you find helpful. I prefer a pointy tungsten bur. Curette with caution not to damage vessels/nerves of the surrounding teeth to get some soft bone. This soft bone will cover the implant buccally and the bone block will be fixed on top of it. Now take your time to beautifully insert the block. If you don't have a bone block screw kit well buy it already. It is very important to have it. Drill the first hole in the left side of the block with the help of a bone block holding forceps and insert the first screw not entirely. Drill the second hole (in the right) and insert the second screw. Attach the screws (I prefer medical stainless steel screws) carefully until you feel a bit torque. Confirm block tightness with a bit of violence (if it has to detach well detach now!). Smooth the vertexes of the block with a ronguer and a bone file. Make some periosteal release cuts so that you can close the flap with 5/0 or 6/0 sutures with absolutely no pressure at all. Now comes the trick: remove the healing cap and place a temporary cylinder and apply a bit of acrylic resin. Remove the cylinder, reinsert the healing cap and shape the resin to the temporary titanium cylinder so that you can mimic the extracted tooth wideness bucolingually and mesiodistally. Again take your time to smoothen a LOT its surface and cut the temporary cylinder/resin to the height of the remaining gingiva. Just to have that gingiva nice and ready to place a temporary 4/6 months later. For now you can surely place a flipper (sure you can) as long as: - it is not on occlusion; - it is not contacting the gingiva ; - you have a good contact acrylic in the palat. Hope this helps

Hi Peter, I'd love to see some cases where you grew bone up a root.

Hi Dr Millar I have alreaady posted a case here ( under a loose reference to all on four which was not ideal ) which shows this but will do another this week ( been a bit busy ) . Generally we do a case or 2 a week like this and conssitently get the required outcome . But as with Golf it can take practice ( like dentistry I am only a mediocre ( 15 Hcp ) golfer ) so not saying to the surgeon whoose case this is that this is how he should proceed as an easier case ( shot ) would be better to start with . But preservation is the better route . I will be speaking and showing a number of these cases as usual about once a month around the world so maybe we can chat. Kind Regards Peter

Assuming the laeral is stable and not perio involved significantly, I would consider traditional C&B to jump the X-bite on the lateral and improve esthetics from 7-10. A graft would still be helpful and with the patient in temp C&B you could still place an implant assuming you get the desired result. If the lateral is bad I would add the cuspid into the picture. Good luck.

Hi Peter, I can't find your case on Osseonews. Do you have somewhere else we can see your cases? Thanks

Hi Tim and CRS , third from top of page about 4 pages back in cases . Not the ideal but can put together 10 or 20 cases on Keynote and send to you in doing a slightly worse cases ( lateral is mobile ) right now . A bit busy as speaking next week and have not prepared , but will be at Zurich Uni speaking in Jan , the US in Feb and here again in March. Can also post a case study ( pub in EDI journal ) which has now been loaded 6 years showing long term retention of the restored bone . REagrsd Peter

Hi Tim I agree it contradicts what we have been taught but we have seen it consistently . We can even see the reformation of the pdl again not what we would expect as they is no treatment of the tooth suface . I have a case which is 4 years loaded now which had loss to the apex of the adjacent tooth which is very interesting. You can e-mail me and I can send a keynote of cases as I said just need a bit of time as busy next week. Regards Peter