Save or Extract the Implant?

Is this case a joke?

From the submitted materials it seems that there is significant pathology going on with probable loss of buccal plate. This is a very challenging case even in experienced hands since you are starting behind the eight ball. I would start with a CT scan to determine the amount of bone loss caused by the pathology. I would remove the teeth, disinfect with the 1064 laser and graft with non resorbable membrane, prgf and human bone. An Essex then a resin bonded bridge until healing is complete. #8 and 9 are challenging even with perfect bone. I think that the laterals may have drifted due to the cyst? But I can't tell on the film quality. Ortho might be needed to correct this. So I would start with a good quality CT scan get the pathology out of there and repair the long standing damage with bio active materials. All the patient will need initially is excellent provisionals during healing. This is an advanced case.

hello from what I see ,i'm not afraid of pathology. I would disinfect the canals try to stop drainage and sinus tract,if I succeed then obturate with MTA. This should be the easy way before continuing to heavy solutions.

I'm very sorry but as an Endodontist i have to oppose your opinion. If you succeed to disinfect the canal than one year 5 or 12 years don't matter , we see in the literature and daily practice lesions even big sized healing. you don't need laser,if disinfection succeeds bone will grow. This is the essence of endodontics treating and healing the periapical disease. yes it can fail but than there is no big difference between 12 and 13 years. The essence of endodontics treating periapical lesions.

No opinion on the speciality of endodontics but thus particular case has a very long history of a draining fistula and most likely a significant buccal plate defect. The original canals were not filled and to compound the problem apicoectomies were done. I would consider this case an example if what not to do and the history supports my viewpoint, ie chronic draining fistula. I think a CT is indicated to see the damage. The patient in this case with a protracted infectious process in my opinion requires definitive management, removal of the pathology and repair ie grafting. It has nothing to do with defending the daily practice of endodontics and in my experience with this type of case the way to go, the patient has had this failing condition for a long time. Periapical cystic lesions have a very poor blood supply, I find your comment 'if disinfection succeeds bone will grow" in this particular case is a long shot. Sorry you may have taken my opinion personally, I actually work very closely with my endodontic colleagues and confer with them quite often in joint treatment of patients. Thanks for reading.

I dont see any evidence of apical retro fills and the current obturation is very poor in filling the canals. Would suggest open the teeth, clean out the obturation material irrigate it well with NaOCL and EDTA then fill to the radiographic apex with CaOH and let it heal for a few weeks. pt comes back no pain then flush out the CaOH and place a good obturation into it verified that its sealed to the apex

I have been practicing Periodontology and implantology for 25 years. There was a time when I would have "considered" salvaging 8 & 9. One of the luxuries of practicing for so long is you get to learn from your mistakes. (I guess that's why they call it practicing.) With that said, 8 and 9 are all done. Get the out, big flaps, get the huge cyst out, graft, gtr. Wait 4-6 months and then put in two beautiful, sterile titanium implants. A CBCT would be nice pre-op to see where the heck the cyst extends to, (ie. sinus, nasal fossa etc..) I as well work in a group practice with an endodontist, I show him the radiographs and he agreed, those teeth are soaked with bacteria.

I don't see condemning tooth #9. Furthermore, how do we know there is an apical cyst and severe loss of the buccal plate? I agree to take a CT scan and pending what I saw I would opt for conservative tmt, ie endo at least on tooth #9 and either endo on #8 or an apico. Why subject this pt to implants immediately...as if there will be no issues or complications with 2 extractions, socket grafting and 2 implants.

Dr T, I think there is external resorption on #9 on the distal aspect. Even if you could sterilize these canals, how can you create an apical seal without surgery? Honestly, there is no way those teeth should last long term. Both from a endodontic and restorative standpoint.

I side with treating these teeth. There is a high enough probability of success. If conditions were complicated and iffy I'd understand opting for titanium. It shouldn't take long to see if initial therapy is leading to some resolution, starting with closure of the fistulae. I don't like the crystal ball that approaches this as certain failure... way too many similar cases have been resolved over the years to consider treatment of these teeth unreasonable dental therapy. I don't comprehend the claim of performance of apicoectomies. Who could see these abominations of root canal therapies and say a surgical approach is what is needed?...and then leave them looking like that?...Was the dentist's name Mengele by any chance? BTW, I don't see any obvious reason these 2 teeth even needed RCT... mesio-incisal fractures that don't appear to have involved pulp without help from a handpiece (ie. in the 2D xray image)... I wouldn't mind stringing up the joker that collected a fee for those terrible excuses for RCT. Meanwhile, I support the idea that conservative treatment is in order at this point.

I would recomanded to reatret Rct # 9 ,#8 and # 8 you can do a combination with apico and retrograde filling I think you have a lot posibillity of sucsess Good luck

As a general dentist who places a lot of implant and has a lot experience with grafting etc I think it would be best to consider referring this patient for consultation with Endo, OMFS +/- Perio. Some very wise people, much older than I taught me a few things: 1/ You cant be everything to everyone 2/ This is my favourite, Sometimes you make more money from the cases you turn away - that way there is no refunds, no excuses no problem. I value my heart tissue and stomach lining, some cases are might be easy or challenging but if the patient doesnt get the result they invisage for whatever reason or you start something and it opens Pandora's box - you have a shit fight and possible legals. Sometimes even if your 99% sure you can do it, if theres 1% chance you cant nail it like a boss, dont do it. Just my opinion, FWIW

1. From restorative view, the root is so hollow due to huge wide current canal, it is weak and has risk of fracture after restoration. If endo, it will be much more weak. 2. From endo view, even with great extra effort put into it and best result achieved, the result you provide to the restorative is the weak teeth with external resorption on one tooth. Do we think such poor result worth our great extra effort and risk of unpredictability in endo? 3. From implanting view, highly predictable result, high confidence in final tx quality without risk of miserable failure in the pass of endo and restorative all the way to years after tx. 4. From pt-doc relationship view, we should not expect any sympathy if pt angry at us or sue us if we choose to put our pt trust and our reputation in high risk to provide unpredictable result, as an expert in this field. 5. As responsible pro both legally and ethically, we need to fully and detail enough disclose all and every risks and reality of exist poor condition from endo, restorative, all the way to years after tx, and option of implant. Knowledge pt will decide for himself and judge your professionalism from yr rec. Unknowledge pt might bite you back if you screw up since you are the doc. 6. Fully agree Dean.

Without knowing how high the lip line, and whether the patient has thin or thick gingival phenotype I am not so sure we can say that 2 adjacent implants will lead to a highly predictable, high quality, highly esthetic result

If the teeth are not mobile and the gingival is sound, I would retreat the teeth endodontically. Determine if the fistulas resolve. If they do not, then remove the teeth and proceed with immediate grafting or placement or first socket preservation. Definitely detoxify the sites prior to grafting and or implant placement.

This case deserves a chance with conservative Endo. The Endo presented here is terrible. Then if it fails, pull out all the stops with extraction, grafting and implants. 12 years is not beyond the shelf life for endodontic treatment.

It's easy to criticise the dentist who root filled these teeth, but don't forget he was working on a technically very difficult case and with a nervous child. The situation now is (a) wide canals with unacceptable root fillings and open apices. The teeth have allegedly been apicected but I think "nibbled" would be a better description (b) a large cyst on UR1. However well UR1 is root filled there is no prospect of spontaneous resolution of this cyst (c) I agree with Robert Hughes that so long as the teeth are not mobile they are worth saving. A CT scan will tell you nothing more than you can glean from the OPT and clinical examination and certainly won't influence the treatment.. Suggested treatment plan: (a) Book this man for cyst enucleation, apicectomies (with fairly conservative resection of the apices), and retrograde root filling with MTA. The cyst cavity does not need grafting as the literature shows that this does not alter the prognosis. Warn the patient that UR2 may be devitalised by the surgery and if so will need orthograde root filling a.s.a.p. post operatively. (b) Ask the dentist to re-root fill the teeth a day or so preoperatively. It does not matter if the apical seals are less than perfect as the teeth will be apicected and retrograde filled in any case. The important task is to debride and obturate the bulk of the canals as well as possible. I don't see this as a particularly complex case: it is the sort of minor operation any oral surgeon would be familiar with. If all goes well the teeth should survive at least another decade.

Again, I suggest to endodontically retreat teeth #8 and #9. Give this case ample time to heal before starting restorative treatment. I assume the patient has lost a lot of bone. I do agree to culture for anaerobes, aerobes, fungus and anctinomyces. I would give this a guarded prognosis and hope for the best. If endodontic treatment does not work then take care of the titanium deficiency.

I agree with those of you who are arguing in favour of preserving UR1, UL1 by improving their endodontic status, but if you examine the OPT properly (and for that matter the periapical view) you will see a very large cyst on UR1 obliterating most of the right premaxilla. It extends from the midline to UR4,3. The complete loss of trabeculation centrally confirms that there is a full thickness bucco-palatal dehiscence. There's no need to waste money on a CT to prove the point. There's also no practical prospect of this disappearing spontaneously however well UR1 is root filled. It needs to be surgically enucleated and it would be common sense to retrogradely obturate the UR1, UL1 apices at the same time.

So at this point treatment must have been rendered. What was the outcome?