Vertical fracture in upper right second premolar associated with bony defect: best management?

Patient suffered a vertical fracture in his maxillary right second premolar. Tooth had root canal treatment approximately 20 years ago and retreated in 2010. Over the last months fistulas developed on both buccal and palatal aspects.

A recent cone beam CT revealed the vertical fracture, deeming the tooth unrestorable. The images also reveal a very thin buccal plate, probably with fenestration and an even larger palatal bony defect.

What would you think the best approach in this situation would be? Extract and graft immediately? Extract and reevaluate the bone volume after a healing period? Would anyone consider an immediate implant? Thank you.




9 Comments on Vertical fracture in upper right second premolar associated with bony defect: best management?

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miguelm
8/22/2015
I would not consider immediate implant placement. Attempt to retrieve apical fractured root remnant delicately, debride well, and irrigate copiously with peridex. Then, I would mix PRGF with 0.5cc encore and graft socket. You most likely have fenestration so you can suture nonresorbable cytoplast membrane without obtaining primary closure with nylon or vicryl. Alternatively, you can only use PRGF. I don't feel comfortable using solely when such defect present.
CRS
8/23/2015
I concur! The only thing I add is disinfection with the Nd-yag laser to kill the deeper bacteria.
PeterFairbairn
8/25/2015
I would use SRP protocol , extract allow for 3 weeks soft tissue healing ,then flap and clean site very well , place Implant and graft .... load at 10 weeks . Will post video case Peter
John Walker
8/26/2015
CRS, I have a PerioLase NdYAG laser. What is your exact protocol for "disinfection with the Nd-yag laser to kill the deeper bacteria"
CRS
8/28/2015
In this case I use the ablation setting first to remove the granulation tissue then disenfect the bony walls with the hemostasis setting. You could also develop the clot for the bone graft since this is a thru and thru defect. You may want to email your instructor from the class for more info. I think this gives better penetration than curretage and chemical disinfection. Laser dosage according to the socket grafting protocol depending on how much tissue is present. Right wavelengths for the job!
Carlos Boudet, DDS
8/27/2015
Immediate placement of an implant in this area is contraindicated in my opinion. The posted images show deficient bone, a dehiscence or fenestration of buccal and lingual walls, and a periapical lesion close to the sinus, which means there is no bone to engage apically other than the sinus floor. The safest way to proceed is to debride and disinfect the site, graft and delay implant placement until there is adequate regenerated bone. The advantage of Peter's procedure is that he can achieve primary closure over his graft, but there may not be enough bone to get primary stability of the implant. Using a cytoplast membrane can avoid a second entry to graft, but has to rely on excellent debridement and disinfection prior to graft placement. The suggestions given are sound, so reevaluate the case and plan the procedure according to the case details and your personal experience and preferences. Good luck!
PeterFairbairn
8/28/2015
Hi Carlos naturally there will be bone issue in this case and primary can be achieved with 1 or 2 threads but it is not necessary due again to material developments . We can routinely now place with no or very low stability graft around the Implant and have 72- 84 ISQ on Osstell in 8-10 weeks .We have a few hundred recorded cases (100% success) and numerous video cases showing both the placement with no stability and the flap raised at 10 weeks with Osstell readings being taken and then the case loaded after a few years . I have posted a video case on the "follow the Pink " site on facebook regards Peter
Dr Krishan Dudeja
9/10/2015
I don't see any rationale in hurrying up the things in this case.Immediate placement is best avoided. Debride the socket,graft it and wait to get adequate bone formation.Definitely agree with the use of laser in these kind of cases.Good luck
Richard Hughes, DDS, FAAI
9/10/2015
I have placed implants in B-L defects larger than this one and grafted with outstanding results. However, I agree with the other doctors. It is best to graft and give it time and revisit later to place the implant(s).

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