Upper right lateral incisor: Should I wait for implant placement?

In this case, the maxillary lateral incisor was extracted by another dentist 4-months prior, with no grafting.  A large periapical radiolucent lesion was present, as shown on a periapical radiograph.

The current CBCT image shows the cross-section at the middle of the extraction site which is comparable to the mesial and distal cross-sections.  No perforation of the palatal aspect of the site is evident.

How do you recommend that I manage this situation?  Any possibility to obtain enough primary stability with a 13/14mm implant or should I wait more (how long?) for more mature bone and healing to occur?

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21 thoughts on “Upper right lateral incisor: Should I wait for implant placement?

  1. The thing that sketches me out, is that large PARL that is still present and though it could be just decreased bone density or granulation tissue, it could also be cystic in nature. Therefore, I wouldn’t feel comfortable doing any grafting or placing any implants until I was certain what the pathology was. That being said I think your safest bet would be going back in and grafting with GBR if necessary to ensure you dont lose that facial plate which could be disastrous.

  2. I do a lot of immediate cases. This one is pushing it.
    Extract, graft, then scan at 4 months and check for bone healing.
    Also check vitality – pulp status of adjacent teeth before placing any implant.

  3. As a general dentist who places/restores implants, this one is pushing it way too far. Refer. I would certainly check vitality of neighboring teeth which seem in question.
    To my specialist colleagues – what would you recommend if pt opts for a FPD instead of an implant? Monitor or open site, clean it out, and graft ???

    Thanks for posting!

    1. I would not FPD. #6 (UR canine, 13) appears to be a virgin/uncut perfect tooth. I’d never cut away all that perfect enamel and destroy a healthy tooth.

      Implant or RPD or leave the space are the only options. FPD is medieval (1980s) technology.

      1. If an FPD is medieval, what is an RPD, PREHISTORIC? LOL. IMHO, there is still a case for FPD when implants are not a viable option.

  4. The cylindrical ringbone technique is great for these defects published in J Oral Implantology.
    Dennis Flanagan DDS MSc general dentist

  5. It is worth re-considering how to manage the case at the outset. Around the crestal portion of the tooth there appeared to be intact bone. Taking the tooth out means that the crest and the labial plate will tend to disappear very quickly, as did indeed happen.

    I would have flapped the region and opened out a labial window. Obviously the root “gets in the way” of cleaning the lesion out and was the cause of the problem in the first place, so this would have been sectioned off, saving the portion right at the crest to maintain the crestal bone. But, get rid of the crown.

    The region can then be thoroughly debrided. You are right, it is probably cystic. Graft and a membrane, suture the flap back. Let it all heal and wait for good radiographic signs of healing. If this is shown, then remove what is left of the root and place an implant.

    At this point, it would be impossible to stabilize an implant at the crest or apically, so you should consider debriding from a labial approach and following a debridement, grafting protocol. Come back later to place the implant.

    The technique described above has been shown nicely by Dr Marc Fecteau from Quebec on CamlogConnect.com.

  6. I understand that FPD is heresy here but in view of the fact that implant lifespan has been quoted on this board as no longer than ten years on average, the uncertainty of this case and the fact that FPDs have served well for decades one might go conservative with a two unit cantilever FPD off the cuspid rest on the central assuming occlusion propitious.
    Esthetic lab temp has advantage over essix or flipper otherwise.
    I find espousal of conservation of enamel here incongruous in view of wholesale full coverage rape taking place today. Could it be implants are more remunerative.?

  7. J Oral Implantol. 2015 Sep 8. [Epub ahead of print]

    CYLINDRICAL RINGBONE ALLOGRAFT TO RESTORE ATROPHIC IMPLANT SITES.

    Flanagan D(1).

    Author information:
    (1)Connecticut Dental Groups, Pres, n/a, Connecticut Dental Groups.

    Atrophic or severely deficient edentulous single tooth dental implant sites
    require osseous augmentation before any dental implant placement surgery. The may
    be accomplished by several procedures that may need to heal for several months to
    allow for osteogenesis. After the initial site preparation, an implant may be
    placed and then allowed to heal for 3-6 months before the prosthetics are placed.
    This entire procedure may take several months to a year to complete. With the
    technique described herein, these cases were treated with an allograft ring or
    cylinder of bone that allowed immediate placement of an implant. The allograft
    augmentation and implant placement are done at the same appointment. This
    technique shortens treatment time and may be valuable in treatment of failed
    implant sites. Further study is needed to refine and improve this technique.

  8. Enlarge the posted graphic on the right. It show radiolusency at the apex of the canine and the central.
    If I am correct the periapical lessions need to be taken care before grafting.

  9. I have been placing in restoring implants for well over a decade. Implants are a wonderful modality which adds to the services that our patients can receive from our honorable profession.
    Dr. Boomer’s statement that a fixed restoration here is something out of the 1980s and is medieval needs some retort. I have been practicing since the 1970s and have placed many fixed prostheses which replaced a cantilevered lateral with a canine abutment With a canine guided occlusion the lateral is well protected and would be an excellent choice here. This patient would be able to avoid a surgical procedure, a bone graft, a membrane placement, sutures, possible infection, possible perforation of the floor of the nasal cavity, possible dehiscent’s of the labial plate, infection, swelling. If you have a milling machine in your office the case could be finished in one visit. Many of these cases have been functioning well for well over 40 years. I wonder whether an implant would survive the same number of years with such a questionable foundation. Be careful not to discard conventional techniques that have served our patients and our profession well. Implants are a tool not a panacea.

  10. Did no one see the lack of cortical plate on the palatal side of the area from the sagittal view included in the documentation? I would definitely re-enter the area, debride completely, and place a “sandwich” graft with membrane on the perimeter and collagen and/or bone matrix and/or calcium sulfate combination on the inside.Then, wait for resolution and proceed with caution.

  11. Standard routine ( SRP ) case … done and recorded extensively …. Remove tooth tooth leave 3 weeks , soft tissue healing …… then site specific flap , De-granulate with curettes and special burs then place Implant possibly have low PS but no issue . Then graft with BTcP and caso4 ( EthOss in EU ) and load at 10 weeks ……simple 1 surgery , minimal , very predictable and return host back to previous healthy state …….
    Work with host healing think biology…
    Bone ring …… why think biology , we want to help healing not introduce foreign material that never becomes host bone …
    Simple
    Regards
    Peter

  12. Respect the view about FPD. But , but I would never want to cut healthy enamel . Have clinical practice for 40 years , did many bridges but now feel criminal to cut healthy tooth just to replace lost adjacent tooth. All the complications written about implant are just normal . Implant is more predictable & far better mode of treatment for lost tooth/ teeth.
    As far as this case , yes lesion should have been curated at the time of extraction. It may take long time to form the bone. I think the extend of lesion has reduced. I would do osteotomy for insertion of implant – currate granulation from that access & put implant. Or just wait for few more months & check with IOPA. Lesion if reduces – go for Implant.. No bridge please & never cantilever. At any time average Implants have longer life than bridge. It will preserve the bone in healthy condition.

  13. The P/A radiolucencies on several teeth suggest occlusal trauma. It is possible that
    the one on the canine could be related to the previous periapical pathology on the tooth
    that was removed. I would definitely suggest a thorough occlusal analysis before proceeding
    with any implants.

  14. ‘Implant or RPD or leave the space are the only options. FPD is medieval (1980s) technology.’

    What a ludicrous statement. Sometimes I do feel that dentists will try anything to place an implant rather than listening and understanding what a patient wants and needs.

    A 2 unit cantilever bridge even a Maryland if the occlusal scheme is favourable is likely to provide the patient would a good long standing restoration.

  15. I agree with Dr Flanagan. Employment of the ring bone technique could very well help to rehabilitate this patient. If the patient does not have the resources, then a fixed bridge will serve him well. If the patient can’t afford a FPD, then a Maryland bridge or flipper will have to do.
    I too prefer to place an implant, however things are what they are!

  16. Occasionally I go to Osseonews to view the cases presented and consistently I see people posting cases without doing a full workup. I may be overly conservative but I think if you are considering an implant retained restoration in the anterior region, you should be doing some homework before taking the CT scan. Have you heard of the term prosthetically driven implant placement? A CT scan without a radiographic template of the proposed restoration is doing a disservice to the patient. Why not get as much information from the scan to make your life easier and provide the best care for your patient.

    It is sad to see people are not placing enough emphasis on diagnosis and treatment planning. My 2 cents.

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