Options for #4 Implant?

Based on X ray only I would say the tooth is restorable. A 15-year endo is not an indication to extraction, implant insertion with sinus lifting. If I were the patient I would not agree with this treatment plan.

Sinus lift not required in this case , I think you have plenty of room for 10 or 11 mm implant if not more . Immediate replacement , a good situation for a bicon as the site preparation would just give you enough bone to cover the implant

When a tooth is removed and the floor of the sinus is near the apex of the tooth osteoclasts line the floor of the sinus in the area of the extraction and rapidly resorb bone. So if you remove the tooth and graft and wait for delayed implant placement you will likely require sinus augmentation. In this case you will be able to place a 4.0 X 11 mm immediate implant with good stability but I would not immediately temporize the implant. The osteotomy will require skill because you will need to move the apex of the implant distally toward the sinus floor to avoid tooth #5. While a 4.0 implant will fill most of the socket in the mesial-distal dimension you will have significant voids buccal and lingual. Because you will not have an extended implant you will need those voids to fill with bone that is integrated to the implant surface. I personally would not use a particulate graft material because granules are only used to maintain volume and that is not needed here and there is no proof that any particulate graft material results in integration. So because I don't think there are other viable graft materials in this case I will be self serving and advise you to consider our Socket Graft Putty as it is the only graft material I know of that has been shown to result in integration to immediate implant surfaces. Greg Steiner Steiner Laboratories

The tooth is restorable and will function for a little while. That said, it would best be treated with an implant and crown. No need to worry about a sinus lift. Even it you perforate the sinus by 2 to 5 mm., you will most likely have bone growing to and over the apex of the implant. You may even obtain an inadvertent sinus bump.

Why remove # 2 & 3? And what about a conventional 3(or 4)-unit brigde? Feel like a potential party pooper, but it needed to be said....

treatment planing and decision taking is success key, so first asking that the tooth is restorable ? yes it can but the answer must include for how long? many information must be considered and not only x ray , but if you think that this is only work for few months then the second choice is implant, why not a bridge simply because of the disadvantages of bridge vs implant which is not our point here which protocol then? I prefer in this case delayed immediate and as you mentioned the patient is concern about cost and sinus I think you don need a graft neither sinus lift and there is no need to worry about sinus enlargement( as mentioned in above post) in this short period of waiting which is 4ws . the most important things in this case is first atraumatic extraction,second the direction of implant insertion

OMS - good on you. Although this is an implant forum, all the treatment options should be considered and presented to the patient. Nothing wrong being a party pooper. Implant is not a panacea in dentistry and whole sale sacrifice of teeth is not in the best interest of the patient. It is hard to judge the state of the dentition and the thickness of the antral floor from your recent 'bitewing' radiograph. If #2,#3,#4 are restorable, they may be the best 'implants' the patient has. The bony support of the teeth is good, esp on #3. Richard is right, sinus lift is not required before placing an implant at #4. Make sure that your osteotomy stays clear of the root of #5. You should be able to place a 10 mm implant without much trouble. Good luck.

I agree with OMSresident, why extract #2 & 3? They are both good teeth. Why hurt the patient and over complicate the case?

OMS resident Options are good and I would definitely treat and retain #2 and #3 but it is obvious that #3 is structurally very compromised and overloading this tooth with a bridge would likely lead to its early demise taking the bridge with it. In addition, an implant in #4 would take significant load off #2 and #3 improving their chances for long term success. The only positive with a bridge on natural teeth is that it fills a hole for chewing or esthetics. Everything else a bridge does is negative such as overloading adjacent teeth, compromising oral hygiene, requiring removal of tooth structure for adjacent teeth not to mention the alveolar and gingival resorption in the pontic areas. Many of my referring dentists no long advise bridges for these reasons. Greg Steiner Steiner Laboratories

DRW A root fracture changes everything. Plan on the loss of the buccal and possibly the lingual bone. I would also encourage the removal of this tooth ASAP as a fracture can destroy bone quicker than any other process I know. I would still advise an immediate implant but now your technique and graft material is much more critical. If interested you can visit our photo gallery on our Socket Graft Putty web page for similar cases. Greg Steiner Steiner Laboratories

I still say # 2 and 3 should stay.

As there is a buccal root fracture and the patient has concerns over costs, why not extract the root, graft the area and place a cantilever adhesive bridge allowing the patient time to plan their finances around all the stages of implant restoration.

As a periodontist, I would add my 2 cents....Crown lengthening surgery is a pretty routine procedure in this case. I second the kudos being extended to OMS resident...excellent that you are able to see the alternatives, even if the preferred one does not put some change in your pocket. DrT

A "J" shaped radiolucency is indicative of root fracture. If the lesion is primarily Buccal root, there should be enough rigid interradicular bone to set a Bicon 4.0 or 4.5 diameter implant in a stabile situation. Attention needs to be paid to any perforation as well as cleaning put the infected area and treating with antibiotics or sterile water rinse prior to the graft and implant insertion. You should be able to avoid sinus membrane perforation, but can still proceed if the happens by using Collatape, or Surgicel mesh "bag". Buccal perforation or fistula would need collagen membrane strip inserted Buccal the implant and graft, but likely. Just inside the Buccal root wall with no need to flap. John

I don't believe the #4 is restorable. How long has it been open. Apical migration of bacteria approximately .5 mm per day. After a month retreatment endo poossble. Finically prohibitive. In any case I would not be comfortable sterilizing the remaining canal walls, as this would only weaken and predispose he tooth to root fracture. Without perio charting looking at radiographs and drawing conclusions is dangerous at best. Having said that 4 looks restorable with a conventional approach, no sinus lift. Success heavily dependent on a atraumatic extraction of #4 leaving buccal plate intact.

I SEE I REMOVED#4 AND REPLACEIMPLANT IMEDIATELY AND YOU CAN MAKE SINUS LEFT WITH SAMMER'S WAY BUT AS IF 1 MM OR LESS AND AFTER PUT IMPLANT IN PREPRATION SITE AND ACHIEVE THE SINUS LEFT BY USING IMPLANT INSTEAD OF OSTEOTOME ANDI THINK I WILL GET GOOD STABILITY .

Hello Dr.W Remember that some of the highest implant failure rates occur in sites of previous endodontia. In addition, the posterior maxilla is least predictable. If #4 is fractured, proceed with a periotombe removal with thorough currettage and Chlorhexidene irrigation. You will assess bone quality and volume at this time and have the patient covered with antibiotics. After several weeks proceed with the implant and grafting as needed. IMHO keep it simple.

#4 can be retained with post and Crown Lengthening can extend the ferrule required.. can serve for a fairly good period

You have several issues that will need to be managed separately for an adequate long term result. 1. You have already mentioned that #4 is hopeless. Based on the description, the buccal plate is compromised or will be after extraction. 2. # 3 has violation of the attachment on the mesial. If it is not causing a problem now, it will. Leaving this unattended will cause problems with this tooth as well as the implant. Recommendation: remove #4 and graft the facial plate for a predictable, stable implant. At the time of extraction, extend the incision distally so you can uncover the margin of #3 (not an easy procedure next to an implant site you are trying to develop). After adequate healing, the implant can be placed. After integration, place crowns on 3 and 4 with the appropriate emergence profile. The sinus issue is irrelevant and can be easily managed at the time of implant placement if needed. This is one of those cases that on the surface seems easy, but really has many important considerations. If you don't have extensive surgical expertise in managing complex perio implant procedures you may want to do yourself and your patient a favor by having a periodontist manage the delicate surgery while you manage the restorative. As a periodontist, I see many of these cases after the fact (compromised implants, failing teeth...) They become extremely difficult to manage clinically and quite challenging to make anybody look good.

This is essentially what Peter was alluding to in the previous set of scenarios. Can you explain why you are going to replace the molars? You could get away with placing the implant at the premolar, without a sinus lift. The sinus lift is not a dangerous procedure and if you must ask the question, then you are'nt the doctor for the job. Graft the sinus and the dead spaces around the implant with autogenous or an allograft. This patient should get a second opinion. I can't for the " life of me", understand your philosophy. You know what is even more baffling? You are not the least bit embarrassed to admit what you are doing . Are teeth just white lesions to you? Bv Vinci Oral/Facial Surgery Baton Rouge, La.

Peter Cabera, thank you. You are spot on.

why would you extract teeth that with simple treatment have a 5 to 10 year or better favorable prognosis? The implant may not last that long.

This is a very pertinent question. It seems that many dentists nowadays have forgotten about periodontal therapy as both a useful as well as a predictable mode of therapy. Sadly, I often wonder if the decision to place implants isn't first and foremost driven by financial considerations. I have recently heard lectures by Dr Dennis Tarnow and Dr.Hom-Lay Wang and both of them have said that over 50% of their private practices is currently devoted to treating failing/ailing implants. Yes, dear colleagues, the stark reality is that implants have all kinds of problems; this is certainly born out by many of the cases that we see presented on this very site. Isn't it time for us to return to some of the basics of DIAGNOSIS?? I think so. DrT

Thx Greg Steiner about the "J" shaped radiolucency. I have also seen this formation in "zipped" or long perforations. While other factors could possibly bring this about, in my 41 years of practice and following retreatments and apical surgeries (both specialty and my own) I have never seen a long term survival of this condition. John

Without personal,medical,and dental histories is not possible to say what is best for patient. May be better served by having crown-lengthening and 3 unit bridge from first molar to first bicuspid. Extracting second maxillary molar can improve prognosis of first molar. The tooth with endo should definitely be removed.

Tooth #3 should be crown lengthened so that a new crown could be made that would provide marginal integrity on the mesial. Since you will be doing a crown on #3 anyway, why not do a 3-unit bridge instead of the implant?

Lots of excellent advice from some experienced colleagues.You need to sift through this advice and make a decision based on what has been dicussed and your knowledge and interaction with the patient.

DRW. In answer to your question, "No, I am not referring to implant and or graft success. " To the the contrary, this case looks fine from what limited info we have. I was referring to my having followed serial therapies on teeth which showed "J" shaped radiolucencies at the outset, and having seen them all fail within 3-5 years. It appears to me that "J" shaped radiolucencies are associated with long axis root defects - root fracture, canal zip, or elongated perforations. In most cases, these situations seriously complicate our trying to save the damaged root and implant placement should be considered earlier than in roots without this appearance. Sorry for the confusion. John

Extract #3 and #4, augment #4 socket, place removable temp partial denture. Reevaluate after 4 months healing. Place implants into #3 - #4 sites, sinus elevation at that time if necessary. After 4 months crown implants (and #2 if condition of existing crown warrants).

It must be nice to see things so simply and clearly...I personally don't see as "black and white". DrT