Vertical fractures and implant placement: feedback?

Last Updated: Sep 17, 2019

I have a 55y/o male with controlled diabetes presents with the following findings as seen in Figures 1 and 2. The patient denied any symptoms on #15 [maxilary left second molar; 27]. The patient agreed for me to extract #15 and eventually replace it with an implant in the future. In 4/2013 I extracted the tooth and attempted to do a bone graft with membrane. Upon extracting the tooth I noted that the distal buccal root was fractured resulting in excessive amounts of periapical granulation tissue. I attempted to place the graft by aggressively curreting to remove as much tissue as possible so that the graft would have a bony contact. One week after the extraction the patient calls and reported swallowing the membrane. I took a radiograph (Figure 2) and you can see that some of the graft is still present in the extraction site and it just appears to be “floating” with no bony development. Can you do site preservation in cases like these where there is excessive granulation tissue due to root fractures, periodontal disease, or teeth with periapical infections? Or should I wait till after the area has healed? Is there any way to improve bone density in the extracted #15 site for future implant placement? Now I have a similar situation for tooth #4 [maxillary right second premolar; 14] (Figure 3). What should I do in this case to improve the prognosis for an implant in the future?

4-17-2013

9-4-2013

9-4-2013-2

7 Comments on Vertical fractures and implant placement: feedback?

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Carlos Boudet DDS

09/17/2013

Prematurely loosing the membrane exposes the graft, and you will loose graft material. You do not specify the type of graft or the membrane that you used and that is relevant. Something you can do to prevent loosing the membrane is tucking it well under the edges of the flap and securing it with sutures to the tissue besides using criss-cross sutures across the top. Release the periosteum to obtain primary closure or cover with autologous membrane (l-prf) for rapid soft tissue growth and epithelialization. Choose your graft material according to the walls of the defect, and the length of lime until the implant is placed. Longer period of time requires a slower resorbing material or you will loose ridge height and width Good luck!.

CRS

09/17/2013

With large defects I would recommend primary closure and growth factors being sure to repair the buccal defect. These need to be flapped open to be able to visualize any bony defects and remove all the pathology. There probably wasn't enough bone to retain the membrane, primary closure is indicated. You may want to refer these more complex cases so that the patient doesn't have to go thru two procedures. I see this often. What concerns me is your comment floating graft with no bony development after one week seems to indicate you may not understand the graft biology.

09/18/2013

Just for clarification, the second x-ray was taken 9/13 approximately 5 months after the extraction, not 1 week later. So for area #15 you would suggest referral to Oral surgery for grafting? Or will the bone density increase over time? What about tooth #4, would you also extraction and then suggest primary closure with growth factors? or could you graft the site with Bio-Oss and membrane? Is it advisable to graft areas with periapical radiolucencies or is there a chance the graft get infected from the periapical infections? I appreciate any info that you can give me. Thanks

Carlos Boudet DDS

09/19/2013

If you would like to preserve as much of the ridge as possible after an extraction you need to procees and graft the aocket defect. When the socket has an active infection you can treat with antibiotics and return to the area in two to three weeks after the infection has subsided to place the graft. If the infection is chronic, with granulomatous tissue, you can proceed to graft safely after you have thoughroughly debrided and disinfected the area. Good luck!

CRS

09/20/2013

Thanks for the clarification. I would advise referring and having both sites grafted by an OMS or periodontist who has experience with growth factors an more complex grafting. That initial site is fixable but it will have to be opened and grafted. There is no blame or shame working with a trusted colleague. It will be more profitable for you to restore these more complex cases vs nursing them along and you will be a hero to your patient! That's what I love to do, make my restoring doc's life easier! I would never try to place a restoration or immediate temp, it would be scary for me, I really respect what you do well! Thanks for being brave enough to post and learn!

Richard Hughes, DDS, FAAI

09/19/2013

Why BioOss? It's just a filler that does not resorb to turnover and make bone. Use one of the synthetics such as OsterGen, which will turn over and yield bone.

greg steiner

09/28/2013

No patient wants to have a tooth extracted and walk around with an open wound and then return for a second surgery for a graft and then have to heal from another wound. In addition if you leave the socket open for a few weeks the bone has necrosed and the damage is done. With two traumatic events that cause much of the alveolar resorption may get more resorption than if you did not reenter. The only reason you don't put the graft in at the time of extraction is because you are using graft materials that can get infected. Use modern graft materials that are antimicrobial by design and there is no need to delay grafting. With modern materials and methods any general dentist who can remove teeth can graft sockets just as well as a specialist. Greg Steiner Steiner Laboratories

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