Labial plate loss: why?

The Buccal plate is often very thin over the maxillary anteriors and any issues can lead to a dramatic loss as a result . I think this is a perio / endo lesion with an occlusal issue , where you could try RCT initially but possibly will need removal . I would use my usual protocol , extraction leave 3-4 week healing period , small flap , clean well , place and graft ( I use EthOss ) as per my videos on this site . Regards Peter

One factor I can think of is prior orthodontic treatment. To answer why one could speculate with reasonable assumption but never be sure unless there is something scientific in literature. From clinical experience I observed that thin buccal plates that are a result of orthodontics resorb. It could be from vascular constriction. That is why in case of implant placement it is suggested to assure a reasonable thickness of buccal and lingual plates.

The labial plate is the most vulnerable that's why abscesses tend to drain that way. If there is significant bleeding granulation tissue you could LANAP it take it out of occlusion and get a few millimeters of bone. Don't see the need for a RCT on a vital tooth. The worse thing you could do is flap it and try to graft, the blood supply would be compromised and it won't work.Also root planing will pretty much remove any regenerative tissue. If you elect to extract then graft with an allograft and cover with a teflon membrane good luck.

I agree with Trauma From Occlusion, and recommend taking it out of function, but I disagree with endo. He says the tooth is vital. Flap it, clean it, Ethoss. The OP new the right answer. He just needed confirmation.

Is there suppuration? If not, this is strictly TFO. Balance your occlusion (I recommend full occlusal equilibration to prevent recurrence), debride and graft. I don't recommend S/RP because you can get reattachment if you maintain the cementum. Good luck and show us a follow up regardless of outcome. Not enough people tell us how things work out. -J

I would want to have a better xray of the area....to include the apex of the canine as well. What test was done to say the lateral is vital? Sometimes pulp testers can be misleading.... I would verify the vitality by drilling a small hole in the cingulum without anaesthetic and see if there is a reaction before you enter the pulp chamber...... if there is sensitivity, place a small restoration and close the hole you made....if there is no reaction, then endodontics is required. I question the vitality......

what about a CBCT to first evaluate the bone volume around this tooth and the adjacent ones.... As Ninja says, there is a chance of that being a result of some orthodontics a long time ago placing this tooth out of the skeletal envelope.... If that is the case, probably pushing the font teeth slightly lingually, (with a slight stripping first) will get everything back to normal for the long term.... Kust a no non sense approach.

Many thanks to everybody who very kindly proffered their opinions, am most grateful. As I see it, the problem is angiogenesis and revasularizing from adjacent bone and periosteum. This is my main enquiry....if my colleagues are hostile to GBR, then I will take their guidance seriously . There are many cases on this web site alone showing dramatically good results from GBR . Re vitality, I used cold spray and it was responsive , but I will do a test cavity after electric test. CT referral was suggested , declined. Perio probe and GP use are good enough to map out this case. I do ortho, mainly Damon and I understand the issue of expansion based space gain and fenestration. I will go back and have another look based on all the advice suggested, and thanks again.

Excellent comments already made; it seems your attempts to seek best care are ultimately being hindered by the patient's reluctance/refusal of 3D imaging. CBCT is most certainly indicated here and can be a powerful patient education tool. A complete understanding of the problem leads to proper choice of treatment - every surgeon wants the best idea of what will be encountered when the flap is laid back before treatment even starts. FWIW. I have successfully treated cases with similar appearance and presentation (to the degree that makes them similar) with PRF and laser-assisted microsurgery, details of which are too long to relate here. "Success" being defined as elimination of any sign if infection and reduction of probing depths to "normal", 2-3 mm. That being said, any procedure has its limits, and the more severe the damage to supporting tissues, i.e. the longer this condition remains untreated, the less likely any approach is going to resolve the problem. Carl Misch was adamant about not "watching" cases like this; "supervised neglect" was his term; ultimately, however, the patient makes our choices for us, and all we can do is make them aware if the consequences of their decision. This is the patient's problem, not your own. I'm immediately suspicious of an occlusal/parafuntional component, as has been previously stated. The patient's refusal of CBCT may be an indication that they don't truly value what is at stake. I hope you are able to sway them; perhaps referral and another opinion might ultimately lead them to accept an intervention for a chronic infectious process that quite possibly threatens adjacent teeth. All the best to you and your patient.

Any history of trauma as falling, hitting etc to the tooth or face? Cold test might give fault positive response possibly due to moisture, secondary canal, abscess fluidity etc. Take PA X-rays more parallel, with different angles to exam the intact and/or any connection of the apical lamidura & radiolucency? Orther possible diagnoses : trauma- endo-Perio lesion or vertical crack tooth. Treatment options : RCT and/or open flap for visible exam the root and RP. I think these treatments seems more conservative than going straight to extraction.

Thanks Wesley and LT for excellent input, will check it ...