Lesion and Bridge Removed: Place implants or not?

This patient had an extraction rt. lower 1st and 2nd molar 10 yrs ago with pfm bridge from 35 to 38, done at a different office. Now the ceramic has chipped off completely. RCT was done 4 yrs ago via the bridge on 38, elsewhere with an amalgam access cavity closure. The patient is 50 yrs old, post menopausal. No medical complications. Bite is a deep bite. The patient says the lesion was noted at the time of tooth removal 10 yrs ago, and has been under constant monitoring with no change in size or shape. No bony swelling intraorally. Asymptomatic on palpation. I have cut and removed the old bridge and attached xrays and cbct of the same. Another dentist has suggested a new bridge from 35 to 38 with questionable prognosis, or crown for the premolar with implants for 36 and 37 with extraction of the third molar. My questions
1. What is the lesion we are dealing with here?
2. Can we go ahead with implants or is it better to do a new bridge with questionable prognosis?
3. Do we need to do a biopsy?
4. Alternate treatment plans? Please note she does not want a removable prosthesis
Please let me know your thoughts.

30 thoughts on: Lesion and Bridge Removed: Place implants or not?

  1. WJ Starck DDS says:

    It looks like a big old cementoma to me. What is the patient’s race. If it’s been asymptomatic for 10 years it is unlikely that it is anything malignant.

  2. Timothy Carter says:

    If you are skilled enough to place implants you should also be able to perform a biopsy. In my office it would be considered the cost of doing business.

  3. Texas OMFS says:

    Differential would include focal periapical cemental dysplasia vs dense bony island. Does appear to have a radiolucent rim. If redoing bridge then no further intervention required. If planning implants will need CBCT since removal will be required prior to implant placement. Bear in mind will probably necessitate removal of significant amount of bone to access the area with grafting.

  4. Dale Gerke - BDS, BScDent(Hons), PhD, MDS, FRACDS, MRACDS (Pros) says:

    If you need to ask questions about what you should do, then it is time to refer to an appropriate specialist surgeon. I think it is wise and prudent you ask the sensible questions you have. However if your theoretical knowledge requires you to ask questions then your surgical knowledge could also be questioned.
    The lesions should be investigated if implants are to be considered. Depending on the results, I suspect it would be prudent to remove the lesions and graft if it is decided to proceed with implants (which would be the obvious preferred treatment plan if there were no lesions present).
    However, it is interesting that the previous bridge lasted a very reasonable duration and the periodontal health of the supporting teeth seems to be very satisfactory. Therefore in this case it seems viable to strengthen the 38 and place another bridge (albeit this would not be my treatment of choice if the lesions were not present).
    I would therefore conclude that probably the best way to proceed is slowly. Do not “jump” too quickly. Properly investigate the lesions through proper channels. Once the diagnosis and prognosis is known then you can decide if implants are viable. Then you should discuss the situation and all options with the patient. The patient is the one who needs to decide once all the facts are presented to her. I suspect she will not want radical surgery but may consent to a surgeon doing a biopsy.
    In this case I think the most conservative option is likely to be the best option (ie replace the bridge after appropriate restorative work has been done) – despite the fact that normally I would recommend implants. Except for the cost factor, replacing the bridge gives you more options in the future (if required) and does not significantly change the status quo.
    The best test is always to ask yourself: “What would I want done if this was myself, my spouse or my child?” Would you want a specialist to do the necessary, would you want the lesions and prognosis fully investigated before a clinical decision was made?

    • Dr. Suresh says:

      Yes, have taken omfs opinion as well. the 8 is not restorable as there is a vertical root fracture. Hence the bridge option is ruled out. That’s why my doubts regarding alternative treatment options.

  5. Richard says:

    Standard of care is to determine the nature of the lesion by biopsy. Treatment options will be considered after.

  6. Dr Bill Woods says:

    To Waldron, this is a professional site. Read thi guidelines. It’s not fine print. If you cannot be a professional , then please excuse yourself. Your comments have no place here.

  7. OMFS Eric says:

    This is benign for sure. I would remove it mainly as it will be too dense with no blood supply for an implant area. As a surgeon I would approach it from the side, and preserve the ridge crest. Mandibular nerve not an issue with this case. I would then fill it with Puros or human bone of your choice, probably no membrane needed if on the lateral side and the crest is intact. Send it to the pathologist for interest sake. Place your implants a few months later. You could augment the ridge crest when removing the lesion, but your XR shows pretty good width.

    • Comlan Missih says:

      I like this option- As a periodontist and dental implant surgeon, that’s how I will proceed. Most likely nothing malignant but follow the standard of care.
      Remove the lesion, biopsy and do implant later
      If procedure is too technical, refer patient to a specialist with skill set to handle it properly

  8. Paul says:

    A trephine bur could accomplish the need for biopsy and create an osteotomy. If the outcome of the biopsy would not contraindicate placement of an implant, the osteotomy a week or so later would be ready to receive an implant.

  9. sb oms says:

    This is a benign fibro-osseus lesion. Density looks like cementum, so most likely cementoma or other non-aggressive lesion given clinical history. I see hundreds of these a year and with CBCT I have come to be very comfortable working around them and monitoring them. I have removed very few of them, and do less and less each year.
    It presents a treatment dilema. We know almost for certain that the lesion is benign, and if it wasn’t for the fact that it represents a key implant position here, it would probably be left alone.
    If you remove it in total for biopsy, you create a bone defect that will need grafting, and add time and some morbidity to your patients treatment. This is the textbook approach. Rule out and eliminate pathology, and then reconstruct. You cannot be faulted for this.
    I’ve seen cases like this where implants were placed right through these lesions and did just fine. I’m not advocating this, but I have seen it.
    Another possibility, and this covers the obvious ethical issues, you could trephine a 4mm core where your implant osteotomy would be. Send this to a good pathologist with all of your clinical info and old x-rays. When it comes back benign, you could then widen osteotomy and place a 5-6 mm diameter implant. Talk to patient, inform them of the situation and all possible outcomes.
    Make sure consents are in order, and patient is on your side.
    A good case.

  10. Saad Boji says:

    Dear colleagues, I did not see any one writing about Odontoma! I think that this lesion is clearly Odontoma and its removal will be by sectioning it to many pieces not to damage the bone. Also we don’t have any dental history about this area!. did she have any previous lesion in the area? and other questions which could help for the diagnosis. This lesion should be removed prior any implant positioning and its preferable to insert the implant after at least one and a half months not more in addition to grafting preferably TCP (highly absorbable one) or Ethoss (TCP). Then to leave at least 3-4 months. checking the ISQ , then loading the implants.

  11. Matt Helm DDS says:

    Deffinitely benign. Cementoma or dense bony island. Not an odontoma. Both OMFS Eric and sb oms approaches are adequate. I would biopsy just for legal reasons, in the interest of CYA.

  12. Matt Helm DDS says:

    Since you have two lesions there — one in the 7 area and a smaller one in the 8 — be sure to biopsy both.

  13. LSDDDS says:

    Evidence on radiograph of posterior wear. Also history of fractured porcelain and posterior abutment.
    Are we missing something here?

  14. Dr. Suresh says:

    Provisional diagnosis for this is idiopathic osteosclerosis.
    Apparently very common in Asians .
    Awaiting further information

  15. WJ Starck DDS says:

    Cool thanks for the update.

    That was why I was asking for the race of the patient.

    I have never attempted to biopsy something like that in over 30 years of OMS practice (there’s no need to), but I suspect biopsying something like that could be fairly destructive. Despite the fact that it appears to have a radiolucent border, I suspect that once you got in there the whole thing might be indistinguishable from the surrounding bone.

    • Dr. Suresh says:

      In these cases were you able to rehabilitate with implants doc. ?
      Just an idea we are considering. ..why not do just a single implant for the 1st molar inbetween the lesions.without replacement of the 2nd molar. ?
      This may help to avoid unnecessary surgery of the area. …
      Just a thought till the biopsy report comes back

  16. Jawdoc says:

    There is no obvious low-attenuation halo which probably rules out odontoma, cementomas/blastomas & CEmento-osseous dysplasia. That leaves the main culprits of Osteoma and/or Idiopathic OsteoSclerosis. There’s only 1 way to be 100% sure – biopsy.

  17. Luxe says:

    The CBCT could not be of diagnostic help because of the low quality image. Our differentials in radiopaque, slow growing and asx lesions could be: 1) odontoma 2)osteoma 3) condensing osteitis and 4) bony enostosis… We would like to look for radiolucent encapsulations for it to be more or less amenable for excisional or incisional biopsy. I had a case like this in my own clinic and in the CBCT, it doesnt have any radiolucent encapsulations so I decided to go on with the surgery. It turns out during surgery that it is only a bony enostosis. Implant placement was more or less straightforward. Ideally, if it is encapsulated.. I suggest you should push through with the biopsy before deciding in putting dental implants to be safe.

Leave a Comment:

Comment Guidelines: By posting comments you agree to accept our Terms of Use, Disclaimer and Privacy Policy. For more details, read our comment guidelines. Though we require an email to comment, we will NEVER publish your email.
Required fields are marked *

This entry was posted in Clinical Cases, Restorative, Surgical and tagged .