Replacement of endodontically-treated failing UR1 with dental implant?

I have treatment planned this patient for extraction of UR 1 [#8] and replacement with an implant.  The tooth has had conventional endodontic therapy and then an apicoectomy.  It has significant hard and soft tissue loss, advanced mobility and a periapical radiolucent lesion.  It has a terminal prognosis. What is best to do here? Would it be better to extract the tooth, debride the socket and do socket preservation and allow the socket to heal and later install the implant?  Would it be better to go back in a second time to do ridge augmentation and later install the implant?  Or would it be better to extract the tooth, immediately install the implant at that time and do bone graft?

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42 thoughts on “Replacement of endodontically-treated failing UR1 with dental implant?

  1. Based on the 3 or 4mm gingival recession on the failing tooth an immediate implant is a definitive no.
    Based on the periapical and periodontal pathosis (together) I would exo and wait about one month for soft tissue to heal and then raise a flap sparing the papilla, debride and place implant in ideal position, graft, membrane (or not) and provisional composite bonded to the adjacent teeth. Wait 4-6 months, no rush, and do the screw retained provisional.

  2. Just a consideration…”keep it simple”….immediate extraction and a Transitional Removable Partial” (a flipper)….will provide a nice service for the patient and “cost effective”

  3. I would bond #8 to adjacent teeth and then with flap retraction , remove most of the root with bone graft and FGG .Wait about two months and then you can do immediate implant . I would never remove 8 and wait even with bone graft .

  4. Extraction followed by careful and detailed debridement followed by an osseous graft with a PTFE membrane. Allow healing for a month and remove sutures and membrane. The graft most likely will shrink and after 3 to 4 months an implant can be placed with additional osseous graft to make up for the shrinkage.
    The benefit of this approach is duration from start to restoration. Suture material is essential at the initial graft and membrane placement to avoid complications.
    Obviously this not the only way to treat this condition but most likely the shortest.

  5. Extract, debride, bone allograft under a resorbable membrane with a subepithelial CT graft over the membrane and across the top of the socket tucked under the palatal tissue with primary gingival flap covering most of the gingival graft. Whether a vertical incision is used depends on need for flap mobility and need for access apically. Temporary tooth replacement must exert no pressure onto the grafted site labially or coronally. Stability of graft site is key. Allow 6 months healing and maturation then place implant with or without additional bone/gingival augmentation.

  6. I would consider extract, allow 6 weeks of soft tissue heal to gain soft tissue. Reenter after 6 weeks and graft with allograft/bonvine, and a resorbable membrane. This may need additional bone at the time of implant placement. Explains to this patient that this is considered advanced and complex treatment and prepare for stage and multiple treatments.

  7. Interesting to see the different treatment plans. Here’s my contribution.
    (a) Forget about ortho extrusion. This would be a slow and expensive way of extracting the tooth.

    (b) I agree with Jerry – take the tooth out and fit a denture

    (c) I agree with Periogirl (Intriguing Nom de Plume by the way. Fancy a date?) – wait at least six weeks for the soft tissues to heal before ridge augmentation, preferably with a small autograft corticocancellous bone block. Adjust the denture to avoid any pressure on the graft. Wait for consolidation then place implant, probably with some further modest augmentation with particulate xenograft. If you put in any graft material bury the implant. After 6+ weeks expose implant and place an abutment and temporary crown. Once the gingiva has stabilised replace the temporary crown with a ceramic permanent crown.

    Being realistic this will all take about a year, but you are working in a highly aesthetically sensitive area and cannot afford a compromised result.

    1. Thanks for the compliment John T, I am blushing 🙂
      I apologize for all the typing errors in my post, and thanks for expanding on my reply. See you on the forum 🙂

    2. Forced extrusion is neither slow nor expensive. This tooth will be moved within 7-10 days. Then extract, cut the root so that a slim margin of periodontal cells remain on the root stem and replace it in the only apically derided socket. Bond to the adjacent teeth for 8-10 weeks and you will have gained bone and harmonised the gum line. Have a look at TMC by Stefan Neumeier/Komet. It’s the perfect case for that technique. if you fill the defect with prf/prgf/cgf after debridement you’ll have a better healing response.
      I’d upload some case photos but there’s no option for that here.
      Sunny regards from Mallorca/Spain
      Oliver

      1. To upload case photos, use the Post a Case” link that is on the menu on every page to add a new case to the site, or you can log into your account, and then come back to this page and use the upload image button which is available to logged in users, to upload your images to this post via a new comment.

  8. This is incredibly difficult! So many factors to consider, soft tissue loss, hard tissue loss, periapical issues and it’s a front tooth.
    With all due respect, refer to a periodontist for the surgical phase of treatment. I’m a big fan of shared liability. Put this most difficult surgical situation in the hands of someone who has done it before, preferably a whole bunch, so patient can get the best outcome. Then watch was she or he does as a learning experience. Also follow along with the post op so you know what to expect the next time you see this situation.

    1. I agree. Lets not be cavalier about this case. There is absolutely no buccal/labial plate of bone. You are looking at a block graft or particulate graft with a membrane or mesh, whichever works in your hands. Lots of healing time and soft tissue to consider. I would recommend working closely with a specialist, have lunch or an after work meeting and discuss the management of this case, and learn!

  9. I agree with mwjohnson. Refer everything other than the composites and amalgams if you are still using it. Occasionally do a crown but only on a single tooth in the posterior area.
    We have a system in our country that at times looks embarrassing. We have so many specialists that the general dentist is basically an individual invented for the purpose of promoting dentistry and referrals. The obvious reason is our dental schools. One spends four years learning how to fill a hole and recognize when a tooth has a cavity.
    I my humble opinion, this is a system that serves a money making pyramid not the patient we are so frequently concerned about. In addition, the dental schools seem to work very hard on selecting the best students possible while a kid out of high school could learn in a short time how to fill a hole. There are so many contradictions in the way dentistry functions that when I hear these comments like the one made by mwjohnson it infuriates me. The bottom line is that there are many general dentists very capable to provide services at the level the so called specialists can and in some cases even better. A great deal depends on motivation and the opportunities to learn after dental school are enormous.
    To those general dentists who listen to these suggestions of referral, I hope it motivates you to learn and ignore the so called specialists. Make referrals as frequently as you take vacations if you learn and achieve confidence. To someone like mwjohnson i have a message, don’t be presumptuous when someone asks for an opinion. You know nothing about the individual but you offer advice. Shame on you.

    1. Dear Jar – This case is indeed complex and I agree this needs to be performed in expert hands. Now is the expert hands that of a specialist, or that of a highly trained dentist – only the doctor asking our opinion will know how well trained he is. Based on the fact he is asking whether this can be an exo and immediate implant – it makes me believe he is not as experienced as he should be to handle this treatment. I’m sure I am not the only one thinking this, and the suggestion of don’t get in over your head, do this with a periodontist and learn from this case so in due time you can do these on your own, is not a bad suggestion!!

      Your comment “I hope it motivates you to learn and ignore the so called specialists.”. This statement is a dangerous one, and very ignorant might I add.

    2. Respect, dr Jar.
      There are specialists who can do nothing, and general dentist very meticulous.
      On the other hand, i believe that the person who posted the case understands that one must have done a couple of soft tissue manipulation and grafting procedures before working such a case.

    3. Bravo!! This is NOT a complex case. I am a general dentist and have treated similar cases very simply and without complication. BTW–what, specifically, do you referral advocates see that intimidates you? I am very curious. Extraction is likely the most difficult aspect of this case.

  10. in addition to the others:
    first take a CBCT to find out your bone volume.
    find out alveolus emergence profile for implant, screw retained crown.
    have an idea of the width and length of implant to know how much to graft.
    remove tooth, debride, I would flap with verticals to create coverage of added materials
    decorticate
    use a pilot osteotomy to confirm emergence profile and volume of labial graft
    take an x ray and note osteotomy depth to nasal spine
    allograft/xenograft with prf membranes and hydrate with gf
    CT graft if you feel necessary, I use dermis graft to cover and gain soft tissue bulk
    tacking a collagen membrane will maintain space also. too many movable parts looses graft
    score periosteum , spread and advance flap to closure.
    bond clinical crown to adjacent
    wait 6 months
    place implant
    wait 4 months
    uncover, develop soft tissue emergence 2-3 weeks with temp
    make final Ti/zirconia abutment from platform level impression
    place abutment, make lab or nice chairside temp. crown for final tissue contour
    final impression at platform level, send back abutment, lab makes zir. crown
    place original temp crown at this time, lab needs abutment
    place and torque abutment, ptfe to space, cement w/resin no excess technique
    fill access with filled resin
    equilibrate
    your case does not look high profile, but when you get an esthetic zone case, all the steps I listed will be needed for case acceptance.

  11. Hi all
    Let us focus on science and not other opinionated stuff.
    Can you give us more information on smile line , decent PA showing nasal cortex .

    I agree predominantly people hate immediate placement here . Multiple surgeries and re entries
    can be troublesome too especially to soft tissue .

    I would probably use the nasal and palatalcortex place immediate implant and bury it.
    Reality is not that bad and believe me if you got the graft and soft tissue wrong you had it .
    I prefer one single shot at this combined with ST augmentation like CT graft or even VIP CT graft .

    1. I agree. If one extracts that tooth and leaves it be for awhile, they’ll not be able to regain the soft tissue nor the requisite bone volume. Needs to be grafted with bone and VIP CT upon extraction. You’re correct, it’s one shot unless you want to do a lot of surgeries to rebuild bone and tissue later. I know by experience!

  12. This forum is for the experienced and inexperienced as well as for us implant nerds. Working closely with a specialist is not a bad idea; however, neither is working with a colleague who has done a few thousand of these…fyi. Everyone has some great ideas which is why I am so glad to have read you alls’ (yalls…cause I rep the south) methodologies.
    I love dream dds opinion but a CT scanner is $120k, he may not have one. This case can be done in a day you all (yall). Full thickness flap, (Prior to lifting flap do not engage or cut through papilla but initiate flap in between the papilla) debride very very well via currette. It should be the cleanest bone in the world after debridement. No soft tissue should be present around the recipient site.. Make the patient aware that #7 (UR2) may be compromised due to infection spreading, or casualty of trauma secondary to treatment of 8. (You may have to also due an incisal nerve removal via #8 bur and cautery in case you enter the incisalpalatine canal. This is no problem but be prepared to lift the palatal tissue remove incisal canal contents and graft). Buccally/ Facially make sure you perforate the boney buccal plate to allow for osteoblast to enter graft site, use a 3.5x by at least 12-15mm active implant, if you have the bone. Make sure you use a versah oseocondensyfing bur. THE KEY IS TO ENGAGE AS MUCH APICAL BONE AS POSSIBLE. After placing implant graft. Make sure you have torque Ncm2 over 35mm. Make sure you undermine the flap to cover, because you should be adding a lot of bone.
    Salvin has a 40 dollar Calcium hydroxide, you can mix with metronidazole 150mg(if allergic use Clindamycin150mg), along with Zenograft and DFDB .5 to 1 gram. Its all about getting your bone graft mix on baby. Make sure your graft is soaked with blood from the recipient perforating site, prior to covering with $40 cytoflex removable membrane from osteogenics. Cover implant with cover screw prior to adding graft. (same appointment) Then uncover to add temporary crown abutment, of which you can build up with a composite crown to build emergence profile…Perforate the membrane and screw abutment screw through membrane, assure primary closure is going to be key. Don’t play around..make sure you have primary closure with tension free flap is imperative… I like PFTE sutures. DO NOT cut frenum if you dont have to…Use as a blood source. Keep tooth out of occlusion of course x 4months until you place permanent crown. A Cerec milling unit enables you to do a crown same day out of occlusion…
    side note…Using Versah Burs and active implant may get you 60plus Ncm2.
    3months later fabricate a real crown…BTW
    Now…after saying all that….You can play it safe by grafting, (Essex crown) waiting 4 months, place implant, wait 3 months, place crown…if you want your choice. This is an easy case either way. I would encourage you to take every Mike Pikos’s class you can take in Tampa Florida. He is a surgeon who doesn’t mind teaching enthusiast of implants how to be better.
    You can practice on a Pig Jaw from a local butcher shop prior to doing this case…I would Purchase an ellman radiolase unit to assist in a bloodless field surgeries for undermining soft tissues and in case you get squirters.
    Let us more be encouraging on this site and encourage those who have questions…No question is dum or wrong. The team approach is the reason he is asking our opinions which is all they are, opinions. There is a million ways to treat this case. Perio girl I loved your last comment…#noyoudidnt#snapsnap

  13. The placement of a solid and stable implant here is not a problem. There is bone to stabilize the implant apical to the incisor and a particulate graft can be used to build facial bone. The problem is making the result look good. How much concern does the patient have with having one incisor appear to be a little longer at the gum line than the adjacent teeth. Manipulation of the gingiva in this area to achieve a perfect “normal” look may not be the patient’s primary concern. If your patient expects perfection refer the case to a periodontist. A reasonable result can be achieved with extraction, graft with a membrane, and then bonding the coronal part of the extracted tooth or a denture tooth as a temp fixed bridge. The implant can be placed after a few months healing of the bone graft. The use of the bonded temp over the newly placed implant will prevent trans tissue loading and provide a comfortable functional tooth while waiting for healing. At second stage, when uncovering the implant, do not use a tissue punch. Make the incision at the lingual not directly over the center of the implant be careful to preserve the papilla on the adjacent teeth. Do a full thickness flap reflecting toward the facial and slide the flap down to provide additional gingiva to cover the facial aspect of the implant and abutment. This should give you a few more mm of facial gingiva to help cover the implant and abutment so that the new tooth does not look so long.

  14. Sorry Dr Allington, I totally disagree with your treatment plan. Trying to do all this in one session is asking for trouble. It is perfectly clear from the photograph that there is inadequate soft tissue coverage and there is a total dehiscence of the labial cortical plate. Placing an implant, slopping a load of foreign material over its labial surface, and placing an abutment and crown (which can allow ingress of infection via the gingival crevice into the graft material) as a one stage procedure is highly risky. Now that I have retired from clinical practice I do a lot of dental negligence work and this sort of gung-ho approach to dental implant work provides a steady income source.

    However, I agree that a preliminary CBCT scan “to find your bone volume” is a waste of time. The photo says it all. Taking an x-ray to diagnose the lack of bone is a bit like the way they weigh pigs in Kentucky – hunt about for a rock which looks about the same weight as the pig and then guess the weight of the rock!

    1. John T
      Your comment is greatly appreciated. I don’t know about the field of medicine but I do know a little about dentistry. Dentists have always taken the word practice literally and practice. If one day someone would introduce into the dental practice placements of rings in the lip, dentist would have a ball. There would be numerous discussions of the best ways to do it. That is just the way we are as people. Dentists have been trained to be craftsman before some science was introduced. There is a lot to be said about dentistry in general and I enjoyed reading the last paragraph of you comment.

    2. If you are “slopping a load of foreign material” in a socket, please work on your technique. If you are not managing the “ingress of infection” with antibiotic/antibacterial you will end up testifying against yourself.

  15. Go ahead roll the dice make sure you charge for all the revisions. This is my area of subspeciality I figured out how to lick this clinical scenario. I would not recommend any of these treatment modalities. Seen this time and time again and these are the clinical situations that I fix with my experience I’ve posted how I would treat but get too much pushback from the posters. Understanding of surgical protocol is key can’t get it in a weekend course. And by the way I’ve had failures in this scenario the bacteria has had a long head start in this localized chronic osteomyelitis. Unless you are comfortable managing that it will be a long expensive journey.

    1. I agree with CRS, a healthy site must be established to place the implant into, and the aesthetics will require surgical skill and knowledge that comes only with experience and training. If your patient has a low lip line and a heavy mustache and is not looking for perfect even gingiva it is a much easier case to do than if you are treating a lipstick model. As I wrote in a post above, be sure to understand what your patient expects the result to be BEFOR you proceed, and if you can not make it look good refer.

      1. I don’t think you will be doing anything to interfere with their modeling career! Not hard to guess what they want here.

  16. I have the identical case that I completed two years ago with an excellent result….I have a series of photos and xrays to present that takes you through all the steps………how might I put them on this site?

    1. To add your photos, you can either simply, use the Post a Case” feature to add a new case to the site, or you can log into your account, and then come back to this page and use the upload image button which is available to logged in users, to upload your images to this post via a new comment.

  17. To Periogirl.
    It looks like you have some strong feelings about specialists and are charged to jump to conclusions. There is also a possibility that you have some problems with reading comprehension.
    The fact is that the one question brought on by our colleague has generate a flood of responses is an indication that when it comes to a craft there are always going to be many solutions to a single problem. Science does not offer a single solution either. The field of implantalogy is fairly new (far from the days of GV Black) and evolving just about daily. We are all learning regardless of our place in dentistry and to assume that a specialist is better or more knowledgable in that area is a very ignorant (to use your words). For some of us dentistry is a second or third degree. I admire your pride of your academic accomplishments but let us be reasonable about assumptions of the capabilities of others.

  18. SCMdds bring out the most important points of this case, soft and hard tissue graft first in this esthetic critical area, may need revision even two times to made it perfect for implant placement, but I recommed to use PRF to improve this outcome, as a rule, no short cut in implant dentistry if you want the case come out good.

  19. Agreeably the case is complex. An ideal esthetic outcome is unlikely, even with staged procedures to facilitate the reconstruction. The patient’s concerns and esthetic expectations should be a primary consideration when determining how far to go with the tissue regeneration. Perhaps it would be wise to “achieve one miracle at time.”
    My general thoughts: this is not an immediate placement case. I would remove the tooth, create a bonded provisional connected to 7 & 9. Accomplish initial osseous and soft tissue regenerative phase. Pending the outcome of such, proceed with implant placement and further regenerative procedures, utilizing the fixture to support the augmentation tissues. Again consulting the patient at each phase as to the approximate desire of the outcome achieved. Proceeding to the definitive prosthesis for the implant when the patient agrees to do so. I am a GP involved in implantology, whom collaborates with his specialist colleagues as well. My initial training came under the personal mentorship of my senior periodontist, to whom I am most grateful for his guidance, trust and belief that I was capable of accomplishing an excellent outcome.

  20. seems like JAR has a bit of a chip on his shoulder! Not sure how he made a connection between dental school and filling holes in teeth and how that relates to placing implants in the incredibly challenging anterior esthetic zone when there’s bony defects, soft tissue loss etc. There is no doubt that a well trained generalist can accomplish exactly the same thing as a specialist. However, most specialists treat these difficult situations more frequently than a general dentist and have had an additional 2-6 years of study so have made multiple mistakes and learned along the way. As specialists we delve into the nuances of our specialty, something that busy general dentists don’t have the time to do. Since we only do one phase of dentistry we can concentrate on what the research has to say and evaluate new materials. We can then pass this experience and advanced knowlege on to our colleagues. Therefore, rather than flipping out and getting defensive, a good GP should have an open mind and a willingness to learn that often times comes from a specialist. Who taught your perio classes, endo classes and surgical classes in dental school? Specialists. Who taught your two day implant class? Probably a specialist. And when I talk of specialists, I’m referencing our laboratory colleagues as well. They are a valuable specialist in their own right. So, JAR, relax, take a deep breath and learn from your colleagues in your community (unless you’ve alienated them all) We are here to help, not hinder your progress.

    May I suggest a great reference book to help determine your comfort and skill level. It is by ITI and called “The SAC classification in Implant dentistry”. SAC stands for straightforward, advanced and complex and gives guidelines on how to treat each situation. A wonderful text.

    1. A few things that every dentist should understand before preaching:

      Implant placement is not a specialty. General dentists can read and use a computer and go to continuing education and research topics.
      Restoration is a critical part of the implant scenario. Perhaps a broad view of the full treatment and patient insight is more valuable than placement “expertise.” You need to see the immediate and sequential results of final restoration.
      Some dentists would like to make implant placement appear as difficult and intimidating as possible.
      All dentists placing implants started out with one implant case. Every implant case is unique. There are many acceptable approaches to every case. No one dentist has begun to understand the limits and tolerances of implants and implant placement, we all have a lot to learn.
      Everyone has an opinion–realize that’s all it is. Yes, breathe.

      1. Implant dentistry is a specialty. See ABOI. It has been recognized in Florida, California and Texas as a specialty after some very costly legal cases (costly to the state dental boards). The ADA has recently enacted resolution 65 that also changes the landscape on specialty boards. I cannot imagine any state dental board going after a doctor that has ABOI Diplomate status and advertises as a specialist in implantology because of the precedence of the legal cases in other jurisdictions.

  21. I’m afraid the last three postings on this thread are straying away from the point at issue. The polemics of superspecialisation versus general practice are irrelevant. Just for the record implant dentistry is not a recognised subspecialty in the UK or, so far as I am aware, in any other EU country.

  22. Hi John , yes not sure where all the competition comes from when I started only the GDP’s did Implants but times change as as they were seen to be successful everyone feels they should be the “specialist ” .
    It is essentially a restorative procedure but has a little of a few other areas of Dentistry .
    Anyway all that is off topic and not of interest .
    As for the case a few like this and would just follow my routine protocol , extract heal for 4 weeks place and graft ( with stable synthetic as want host bone ) , then load 10 weeks later.
    Lots of other things will work but I stick to what is very predictable in my hands …
    Peter

  23. Some good news about this case:
    – lots of attached gingiva around the failing tooth
    – the untreated decay on the lateral matches happily with the ugly shade of the central, some harmony in this patient. I’m not joking, what can we do if not improve it.
    I will not tell you what to do, only what I’ve done in a similar case some months ago:
    – extraction, cleaning of the alveola + antibiotic cone inside, flipper tooth.
    – 2 weeks after, bio-col technique, and before filling, the future implant hole was drilled, apical and palatal of the alveola. This drilled bone was mixed with the graft, as you figure.
    – take care that the flipper doesn’t push on it, e.t.c…
    – one month later, vertical gingival graft (Gamborena technique, very easy)
    – flipper adjustments…
    – 3 months later, implant placement, provisory tooth on it bonded to the other central.

    Thanks to all for this nice discussion, knowledge, science, some romance it seems, and lots of fun.

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