Regeneration with Emdogain or Extract and Implant?

Is the tooth loose and is there bleeding upon probing?

Okay this is what I would do, to try and keep the tooth: LANAP protocol with splinting and taking tooth out of occlusion, regardless of long epithelial attachment success or failure the area will be disenfected and much of that defect will be regenerated. The key is not to remove all the granulation tissue with scaling and root planing. The stabililation if the tooth allows healing. The other option is removal with the ND-Yag disinfection, grafting with membrane if there is no buccal plate and implant after healing. The pappila will regenerate if there is bony support and the fact that there is an adjacent tooth. If not the restoration can have a bit of pink porcelain. Emdogain in my opinion does not work I abandoned it several years ago. Good case for experienced hands in the esthetic zone. Nothing wrong with a resin bonded bridge as an option also depending on what is regenerated. But the inflammation needs to be treated.

To some practitioners, event though the literature does not support it, the laser is the answer to all problems. On the other hand, the literature is replete with studies on the efficacy of Emdogain, used in combination with bone graft materials and membranes, in regenerating lost attachment apparatus. Having said this, if there is already loss of papilla in this case, NO TMT is going to regenerate it. GTR surgery with EMD and bone graft materials can regenerate some of the lost hard structures but that is all. If papillary preservation incisions are used, there should be minimal loss of the soft tissue papilla. Considering the fact that in this instance there is already some loss of bone height on the central incisor, you should expect that there will NOT be full restoration of the soft and hard tissue heights if you decide to extract tooth #7, even if you use a laser in the extraction site. Wouldn't it be nice if lasers solved everything?!!!

Would have be useful to know what is the bone status on the distal aspect of the lateral. In my opinion, in trying to restore the papilla it is going to be equally challenging whether u maintain the lateral incisor 22 with GTR or u extract and replace with an implant, and this is obviously due to the bone loss on the distal aspect of the central. Therefore one should rather assess the predictability of tissue regeneration techniques with a one wall bony defect mesially to the lateral and which are still not very encouraging. U might succeed in improving on the probing depth, bone fill, tooth mobility and on the general periodontal condition but unfortunately, there will be no much improvement on the reconstruction of the papilla.

I think there's a lack of information: it would be great to have a complete periodontal probing of the teeth involved. In any case I think that trying to save the tooth should be the first option, but in the esthetic zone you have to be very expert in the management of the soft tissues that is the key to success in perio regeneratio. EMD and bone graft is of course a good option if joined with one of the well-described kind of papilla preservation flaps by Cortellini & Tonetti.Some of these flaps can coronalize the interdental tissue obtaining some little gain in papilla height. I agree with CRS that first of all inflammation must be corrected with a delicate debridement (in order not to loose interdental tissue that is fundamental for regeneration tecniques). Splinting is also usefull to avoid micro or macro-movements

IF this were my patient I would extract the tooth and debrief the socket with Er,CR:YSGG laser. Make sure there is plenty of bleeding. Put the patient on baby aspirin a week prior if HH allows. Lay very conservative full thickness flap. Build up defect with 50:50 bovine allograft. If you can get tension free primary closure great. If not cover the difference with the chorionic membrane or gore-tex.

From my experience, I would extract the lateral incisor .open a full thickness buccal flap, debride the socket, rinse with peridex, and even a touch of citric acid, drill some small holes in the bone to encourage vascularization. I think growth factors would be beneficial for this case, and drawing blood before the procedure for the purpose of harvesting PRF and pressing the clots to obtain Vitreonectin and Fibranectin to be used as wetting agents for the particulate be it alloplastic or allografic materials. A precut and prefitted titanium mesh in the form of an over the ridge saddle, seated to the ideal height and width of the ridge you are attempting to develop , to be used as a growing chamber is placed following the packing of the particulate mix, covered with the PRF membranes on to the defective area, and the titanium mesh is seated and covered with PTFE to block the holes in the even of early exposure ( which inevitably happens). If the titanium mesh is the rigid type ( Ace Surgical), fastening with tacks or screws is not necessary, as it will be bound down by the gingival mucosa, and will keep its shape throughout the healing period. Restore the esthetics with a bonded denture tooth to the adjacent teeth...and leave for 5-6 months.....if the titanium gets slightly exposed, fold or cut off the exposed edge. The developing bone and soft tissue will grow up against the mesh, and unlike titanium reinforced PTFE, it will hold its shape and will be not be flattened.....removing the mesh at the end of the healing period, will require a plyers or other instrument because it will be firmly bound to the new hard and soft tissue. Gerry Rudick Montreal, Canada