Tips for extraction and immediate implant placement?

why not just do endo?

Do you really need to extract that tooth? Is the tooth decay infraosseous? If it is and you believe it's the best option curette and do not insert the implant within the root direction. Insert it within the correct direction and make sure you have a decent buccal bone plate. The blood released with the curettage will take care of the osseous regeneration on the mesial side. Forget about grafting. BTW half the root or 1/4 of it is most likely vital so don't worry about infection.

Grafting infected sites, especially ones that were endo'd is not predictable. Curette the socket and prescribe antibiotic for 10 days.

Implant insertion with bone-socket correction (due to root curvature) is more risky than trying to use the tooth after Endo. Moreover, too many the dentist questions mean he wants to choose the way he does not know well.

It appears that you have approximately 3mm bone loss on the distal. Remove the mesial portion of the crown and this tooth should roll out to the mesial. To preserve the bone I would not raise gingival flaps. If the tooth comes out without significant damage to the socket walls place the implant and graft the buccal, lingual and distal defects and cover with a membrane or seal. Because you will have buccal and lingual defects this is not a good place for immediate temporization. The reason dentists say not to graft infected sites is because they are using cadaver or cow bone that becomes infected. Find a bone graft that does not have trabecular pores and your graft will not become infected. Greg Steiner Steiner Laboratories

I agree with the decision to extract and replace with an implant. Although restoring this tooth is possible, it will not result in a strong long term restoration due to the fact that the tooth is destroyed on the distal to the level of the bone and to have an adequate ferrule around the tooth you would need to remove bone with crown lengthening osseous surgery. Also, you would need to make a crown for the tooth after the root canal therapy and this would remove most of the small amount of tooth structure left on the mesial. As to your other concerns, do not remove the buccal cortical plate, use a periotome to slowly detach the root from the periodontal ligament and then you can gently tease the root out towards the mesial. If you choose to place an implant immediately remember that you do not have to select an implant so wide that it fills the socket completely. The radiograph does not show infection that would contraindicate this. Also acceptable is a more conservative route of waiting for soft tissue closure (about 4 weeks) and do delayed placement which allows the implant to osseointegrate submerged (covered). This is preferred if you loose part of the buccal plate and have to graft. Good luck!

Carlos, forget about ferrule forming. It’s an obsolete (only for metal) approach. Today’s fiber posts/composites materials eliminate the need in it completely and it’s not necessary to lengthen the crown part of the tooth. Implant decision is “the last chance” after all possible ways of conservative treatment are exhausted.

B-TCP is just as susceptible to infection as allograft . Come on Steiner!!!

UNDN etc , not as far as I see it as well , there is a fundamental difference as BTcP is fully bioabsorbed and does not have a bovine or human HA component which does not resorb . The ideas of mixing anti-biotics in the graft materials comes from the KEY speakers employed by the manufacturers of these materials so I suspect they have seen a few things . Dr Steiner knows more on this subject than most and no I do not Know him but try to understand. Peter

Dr.Steiner. Autogonous bone is the gold standard and that has macro pores. Therefore allograft oes swell. Are you really going to try to dispute human anatomy being inferior to YOUR product? Right, of course you are.....conflict of interest Steiner

Dr. Schwartz, Autogenous bone is the gold standard! It is completely resorbable. After the degradation you will have patients own bone. With allografts or bovine materials you have only a filler as unresorbable hydroxyapatite. No patients own bone at all. If those materials get infected the patients will have really bad problems. With x-rays you cannot the the differences between patients or foreign hydroxyapatite. Maybe B-TCP is resorbable. I do not know exactly the literature.

invest in the physics forceps. theyve made my life easier.

Some people have suggested saving tooth. Give the patient options risks and benefits. Informed consent informed consent informed consent. Write it in the patient's chart. Now to answer your question, what if the patient wants do an implant in this particular situation? Is an immediate implant possible? Yes even if there is an infection as long as you clean it out sufficiently. This xray doesn't show an infection. What would I suggest on immediate placement in this situation? A couple of things: 1. If the buccal bone is thin on the apical area, you may want to aim slightly palatal with your initial drill as if you are doing an anterior tooth. 2. If the buccal bone is thick, you might be able to go directly through the apex of the socket. But you should palpate the buccal ridge to make sure you don't perforate. You need an additional 3mm peri apical stability. So choose the length of your implant wisely. 3. Or, you can attempt to reshape and widen the socket to fit a wider 5 or 6 mm implant. Some implant systems, like MIS, give finishing drills to shape the osteotomy for the implant and usually works as the implant fits like a glove. Also, make sure the patient knows that doing an immediate might now work and that a traditional slower pace of healing will be needed.

I would agree and would not with the extraction of that tooth ,but if do extract this tooth so i prefer the immediate implantation ,and after the extraction i will ablate with ER.YAG laser to the cervix of the socket to stimulate tissue regeneration and minimize bone resorption .

I am concerned that someone thinks ferrules are obsolete. Chris has wisdom, the other opinion is typically overzealous.

I think the Easy X-Trac (made by A.Titan) would be perfect for this extraction.

If theres any doubts about an immediate procedure or perhaps your level of experience, why not extract, socket graft & go back later?

Despite the above comments, I think you are absolutely correct to plan an implant for the site. Endo is questionable and there is little tooth structure to place a crown on. Despite what any "expert" claims, dentin bonding does not hold up over time. The post will become loose and either dislodged or crack the brittle tooth. Endo is an interim stop-gap to an implant in this case. It is a bitch of an extraction, but I'd rather do it wen the patient is younger than older. Try using peritomes and a mallet - see how much you can get out from the top. If you have a broken tip left, elevate a small flap from the buccal, just enough to drill a hole at the apex, then use an instrument to force, pop the root segment down. Curette out the area, fill with bone and place a L-T membrane and carefully close with 6.0 sutures. Prepare a 4.0 osteotomy and place an immediate 4.5 implant 13-15 mm in length. Pre.med the patient with Cleocin. You should be able to restore in 3 mos.

It looks like a RCT was started prior. If so, and it has been a considerable time. I would extract and cover pre and post op with antibiotics. These old incomplete endos are chocked full of bacteria. I had a similar situation in the past and the patient went septic fast. If it does not have an old incomplete endo then pre op antibiotics, extract, degranulate, detox, decorticitate and graft. You may consider implant placement at the same time. I use Osteogen for forced mineralization.

This is not a difficult extraction. Peritomes are the way to take this tooth out with are without a mallet,I like to use hand pressure for better control. Take your time work all 360 degrees of the tooth until you notice movement . Do not try to remove till mobilized. if you can't do this send it out for the extraction. Then do the implant shortly after. As for endo and restoration I would prefer to see the patient invest in something that has a better longterm prognosis.

I agree w/ Osurg

This is fairly straightforward. Extract the tooth atraumatically (this is the hardest part of the process with this root anatomy) and immediate implant placement (do not let the drill guide you but you guide the drill in the direction you desire). I see nothing to indicate infection on the xray. Should be a homerun. Good luck.

In my opinion, if there is a 360, 1mm 3D ferrule the tooth should be retained, with cast post core or fiber/composite core. An immediate implant also seems good option. There is plenty of bone.

Have you considered orthodontic extrusion? Cheap, easy, fast and preferable if you save the tooth. I've done it and that will save the patient time and money . If there is a crack, then atraumatic extraction. Do nothing to the buccal plate. If you place an immediate implant, initial stability is a given "must". JMHO. Bill

I noticed that separate discussions threads have appeared in the case. Exploring the how to do it thread has thrown up the discussion on grafting and how differing materials work (+how infection might change this). I have never met Greg Steiner or Dr A but to me and from a biological viewpoint they are presenting a credible argument. We should remember that products and materials reach the market for many reasons with success measured in many ways. Companies will view success differently to a clinician. What this means is that "successful" products will be copied and in turn copies copied and (hopefully) at each stage some refining takes place. Often this route means we end up somewhere we never intended to go and I would suggest to you that an element of this determines bone grafting “opinion” in implant dentistry today...... it seems to me that we started with autogenous bone. We then needed some kind of stabilising materials which also kept out the soft tissue and the membrane market appeared. Products were then launched to supplement the autogenous bone (allograft/xenograft/synthetic) and the dental bone graft market formed (DBG). By default to make it easier to sell to dentists these products were presented in similar forms as the autogenous bone (particulates, blocks etc) and the differentiation was made on how similar to human bone the DBG was. Look at the terminology - porosity, pore size, surface area, etc are all parameters which could be compared . Clinicians gained success this way and reduced the content of autogenous bone and increased the amount of DBG. In the next step companies introduced resorbable membranes to replace the non resorbable membranes. Pretty much this is where we are today perhaps with the addition of materials to accelerate aspect of the process now also being considered so we end up also needing a vehicle (carrier) for a drug or a cell or something else. may be we have lost sight of the objective! Surely this is to place and support a functional implant in bone. Each material can be made differently and we must be sure we understand what we are using and what it will (and will not) achieve for us. Porous non resorbable materials held in place with collagen sheets are helpful/ Other materials and protocols exist which may achieve something more appealing.

Dr. Steiner: "Forced Mineralization" is a term. I prefer OSTEOGEN. You can use whatever you want.

Oralsur. , you are quite the diplomat! Send it out for the extraction and then do the implant. This is in no ones best interest, with the exception of the guy learning to place implants. If the removal of this tooth, is not in the practitioners "arsenal of treatment options", then the potential sinus lift, implant, bone graft and GTR, as well as the management of any complications, is definately not. Yes, this is obvious, but if you are going to go through the trouble of performing dental/alveolar surgery, you need to be proficient in the fundamentals, at least. The extraction can be done in 45 seconds, with a pediatric upper forcep. The hardest part of this case, is tx planning, apparently. Then keeping the membrane in tact, if that procedure is chosen. Poster, I am not attacking you, but will pose the question. Would you be comfortable having some one place this implant, immediately after saying, I can't remove your single rooted tooth?bv

I think you should extrude the tooth and save it, we do it all the time, sometimes with minor crown lengthening afterward if needed for restorative purposes. I wouldn't want to lose that nice long root if it was my tooth! How old is this patient? Do they smoke? Systemic illnesses? Consider the patient in terms of the overall picture first, of course.

Forget the endo . This tooth would require crown lengthening which would compromise the bone around all teeth in the quadrant if done properly . Advise the patient ahead of time that there is NO guaranty that you will be able to do an atraumatic extraction. So you might want to have a stayplate made ahead of time in case it is an esthetic consideration . Attempt to extract the tooth atraumatically ( I have had a lot of success using the Schumaker luxater set ) But hey whatever works . It is NOT going to be an easy extraction and this is where most of your effort and time is going to be spent . 1- If you are lucky and the tooth comes out without damaging the buccal plate , then proceed with an immediate implant placement , staying away from the buccal plate and drilling more to the palatal . Make sure you get a long enough implant to engage at least 3 mm past the apex to get good initial stability . place a temporary abutment with temporary crown for 3 mos. 2- If you damage the buccal plate durung the extraction then you should of course forget about immediate implant placement and proceed to graft the area . There are two ways of doing this . You can as described above wait 2 weeks and go back in with your choice of graft material , use a collagen membrane and get primary closure . Or you could graft the area and cover it immediately with a titanium reinforced cytoplastic membrane adapted and cut to form a proper ridge . This membrane from Osteogenics is great because you can leave it exposed with no need for primary closure ! Just remove it after 3 weeks and the patient will be ready for implant placement 3 months later . Absolutely no need to wait to place the graft or implant immediately as there is no evidence of active infection here . If it was infected , NEVER place either , especially the graft material . It will get infected and get rejected ( Did that , been there :-) ) . Hope this helps . Good luck .

Again, the Easy X-Trac would be the ideal method of extraction.

Eric If you never graft an infected site you are obviously not a periodontist. Every periodontal lesion is infected and they are grafted regularly. If you are regularly getting graft site infections it is your materials and methods not the grafting. I never leave an open socket and can't remember the last time I had a post operative graft site infection. Greg Steiner Steiner Laboratories

remember: implant is not the gold standard. try endo. implant is the last choice, even if the natural tooth prognosis is not good.

Dr. Steiner your comments to Eric are on the mark.

I would do the basic thing and go for a root canal therapy as we all know nothing is better that a natural tooth. I would perform rct and put a nic ecrown there.

Jim, that's worth more than two cents! Bv

This is single rooted tooth, therefore give no buccal movement during extraction. As distally there is no contact point, you can use fine straight elevator (warwickjam) mesially just to feel a luxation (np need to use it deeper. Inspite of being curved root mesially, it may rotate (because the root is approximately circular). This tooth may even be lifted with the help of same elevator initially used, or with the help of thick sickle scaler. As per radiographic picture it is unlikely that you encounter with any significant periapical pathology, thus a little curettage with saline irrigation is sufficient after extraction. Implant can be placed then judiciously, with the added advantage of available healthy bone of approximately 1/2 the length of root.

Save the tooth- endo is VERY predictable. Yes you do need to know how to put in a decent post. Incredibly good chance if well done you will not have to ask the question for another 10-20 years time by which time we might have better evidence based answers! (and if all fails then you still have the implant option - if the implant fails it would be pretty hard to put the root back in and place a post and crown on it)

The above makes some sense, in my little opinion, but this is almost" likened", to the prophylactic mastectomy and reconstruction, because the patient has cystic dz and a family hx of breast ca. Just sayin! Bv

The exo may not be as easy as it looks. Conservative dentistry is the way to go. Is endo always successful? Not always, as we know, as there are occasional fractures and cracks that occur . If you can squeeze out another 10-20 years with endo, an amalgam core placed deep into the chamber ( no post)and a crown , why not give the patient the option and go from there. Crown lenghtening is not always required, but you'll need to get a good ferrule around the core. I'm betting that the rest of her dentition is in pretty good shape.

This is a very simple/complex case. Atraumatically remove the tooth use periotomes or remove a small amount of bone from the mesial and distal to save the buccal plate. Graft with bottle bone, close primarily with a small flap or use bio-coll technique. The graft is really just a spacer to prevent resorption the bone cells come from the blood clot and socket walls. Wait 16weeks and place the implant in straight. Let heal, restore! The most important things are saving the buccal plate and grafting.It's not as easy as it looks trust me!

I am amazed at the range of answers that have been given. The periapical shows the tooth is badly damaged and it usually looks worse in the mouth. Let's be practical. The only way you can restore this tooth with a decent restoration is with an adequate ferrule. Crown lengthening surgery is not indicated mostly for esthetic reasons. So this means forced eruption with orthodontics. I do this procedure in my office, but when you tell the patient that he or she needs endodontics, then a post and core, then orthodontic forced eruption, then a crown and this will result in a tooth that is adequately restored but compromised in root size and strength, and give the patient the alternative of an implant supported crown with it's inherent benefits and strength, the implant always wins.

Based on the questions you are asking, you need to refer this case to someone who can manage it.