Restoration of damaged central from trauma: advice?

I would explain to the patient all possible scenarios following trauma,possible root fracture,resorption,etc. I would splint the tooth to adjacent untraumatized teeth. I would follow the case closely. Done it many times. Good luck

I should note the tooth should be splinted in its proper position. This usually involves pressuring the tooth some as it is bonded.

Ask why the tooth had to have an RCT. Was it caries or another earlier trauma? If so, that wee labial bone may be untrustworthy either to reestablish firmness or to remain should an implant be the forced option .

Gentle extraction, curetting and immediate implant placement (its doable if you angle it correctly) and then a lot of grafting simultaneously with a membrane is the difficult but wise course of action. Bury the implant for a good 3-4 months and then do a staged approach. High smile line females usually have paper thin facial bone plates to begin with. Keeping it any longer means more valuable facial bone will be lost under chronic infection. Or refer this one to a good and experienced OMFS or periodontist. This is NOT an easy case.

This might be an ideal case for Socket Shield, to maintain the buccal bone aspect of bone. Implant placement at time of extraction of the remainder of the tooth. I would TRY to go for immediate load with temp bonded in some way to the adjacent teeth.

Saving this tooth is possible but it will take some doing, as you will have to deal with a few different factors, not the least of which is the poor RCT. Splinting is necessary indeed, but it is only one part of a multifaceted solution. First, you state that “The tooth is mobile and there is swelling around the facial gingiva.” Precisely how mobile is it and precisely where is the swelling, and how large is it? “Around the facial gingiva” isn’t saying much. Are you a novice? Is only the marginal gingiva swollen? Or does the swelling extend to the apical area? What about to the adjacent teeth? These details do matter and will affect treatment decisions as well as prognosis. Ordinarily, post-trauma mobility is nothing new and can be overcome. The reduced amount of available apical bone is inconsequential. The partial loss of the labial bony plate is more indicative of long-standing lingual hyperocclusion (or even bruxism) than it is of trauma. After splinting, you must take the tooth out of occlusion completely, in both centric and protrusion! Ideally the partially lost labial bone should be surgically reconstructed (with at the very least a PRF or, preferrably with an autologous centrifuge PRF), but that is not an absolute must if the tooth regains stability and remains asymptomatic. While we’re on the facial bony plate, also ensure that the remaining bony plate is not fractured at the base. There appears to be a possible fine fracture line extending caudally from the apex about .5-.75mm deep from the labial fold (although it could also be a nutrient canal). Nevertheless you must know what you’re dealing with. If you have no experience with these types of cases let the endodontist make the final determination. This is where we get to the much greater concern, the endo itself, which is central to your chances of saving this tooth. If you want to have a decent chance to save this tooth you must, repeat must, redo that root canal properly. The present root canal was instrumented and filled about 2 mm short of the apex. Note the apical radiolucency. ALSO note the long palatal radiolucency caused by the lack of instrumentation and fill of the 2 collateral lingual canals. If you are not 100% confident that you can access those lingual collaterals under microscope, I strongly suggest you refer the RCT to an endodontist. He may also decide to do a micro-surgery apicoectomy as well. This is a very finicky case, because of the age of the patient, the many details involved and, the guarded long-term prognosis, which you must explain to the patient. As a matter of patient management you should also give her the implant option, but make sure to accentuate that an implant will be more complicated and costly due to the partial loss of labial bone, and thehigh degree of difficulty in ultimately obtaining a perfectly natural cervical gingival line and bony contour which, if not ideal, will definitely stand out like a sore thumb in light of her high lip line. The case is doable. Radiologicaly I don’t see – and you haven’t mentioned – anything grossly out of the ordinary, but it will require patience, and close long-term follow up. Good luck!

“Are you a novice”? Sounds a bit condescending, no? That endo is fine and of no concern. I’m guessing it’s been present for years and has served the patient better than well. When it is suggested that a perfectly funtioning endo fill be redone after years simply due to a radiograph, I turn and run the other way! Your concern here is the swelling at the margin and facial bone loss....both of which are most likely due to a fracture somewhere. Check pocket depths for a noticeable and localized increase in depth which is a telltale sign of vertical fracture. If a horizontal fracture is present that’s almost impossible to determine unless you can directly see it. Time is the great indicator here, in my opinion. However, these things do not usually resolve on their own in my experience. You are most likely looking at what is suggested above regarding extraction and implant placement with some type of bone preservation. Good luck!

hi, endo is bad, 2 mm short, etc etc. getting back to basics -cbct has its place but is not the lend alll obtain 2 to 3 periapical films look for vertical fracture start antibiotics if not retreat endo and establish patentcy, use the endovac system for improved endo outcomes, use calcium hydroxide and an iodophor and temporize with bonded composite access closure splint for 6 weeks obturate when symptom free

I would extract this tooth very carefully, place an implant, graft with bio-is and cover it all with collagen membrane and do the provisional crown at the same time. Follow it clinically and radiografically for 6 months and then close the case with a nice porcelain crown. If you the skill to graft an conjuntive tissue at the same time you can do it. If not, do it after the sixth month of follow-up to assure a proper gengiva to your crown. That's it. No need to complicate more than this.

please under antibiotic coverage extract the tooth do pocket presevation operation aplicate a mary land bridge after 4 months reevaluate the region if bone is ok place an implant very slowly and wait for a longer time then routin periot before doing any prosthetic treatment. Goo Luck

Placing a Maryland Bridge is like building the Great Wall of China across a freeway. The surgical healing site is obscured and the access blocked for any further inspection or treatment. If and when an implant is placed, the bridge is again obstructing free entry to the site so has to be removed and later replaced = tags of composite, dust, noise, mess, uncertain retention and stress. A flipper denture is a better cheaper and more simple option with the instruction to wear it only as a Saturday night special: if you can, take it out. The labial must not have a pink flange as that can attract plaque and somehow a stasis which may encourage bone remodelling? No gum setting, minimal pressure. Most patients get that concept, plus a free interproximal is more easily cleaned with floss or the rim of a bathroom towel.

Based on the information given this is a high risk case and a loss leader in both experienced and novice hands. Lots of really poor advice given. All I know is that the longer this compromised twice damaged tooth remains in the mouth, the bone will continue to be lost. Most likely an untreated avulsion. Refer this young lady to an experienced OMS who will come up an interdisciplinary plan with a prosthodontist. Lots of pitfalls lots of poor advice here. In the long run it will be best for you and patient. How many red flags do you need to list.

Good indication for nasal lift with alveolar grafting apex is adjacent to nasal floor and there is inadequate buccal plate for a socket shield, the mobility is helping the bone loss. Staged treatment here. Needs excellent provisional once bone regenerates then implant placement. Advanced case.