Compromise approach for PET ? Comments please.

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Posted on By mariano estrada In CBCT & CAD/CAM

28 years old Woman.
Internal reabsorption due to a internal bleaching 3 years ago.
Fistula and partial loss of the buccal bone.

What are the treatment options for this case?

Please give me your opinion.-


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Mariano, Excellent triage in this case. You have certainly thought about this, no doubt for the benefit of your patient. This appears to be a Class 2 defect. In my hands, I would consider a staged approach with flapless extraction, socket grafting with an internal membrane, and a ovate pontic provisional. It is difficult to tell from the CBCT, but if there are normal interproximal periodontal measurements, would proximal shields be a consideration here? Hurzler in 2015, reported that socket shield is successful where there is a buccal vertical fracture. The fracture is removed and thus mesial and distal portions of the shield are maintained. I think this along with Tarnow's collagen cone technique and a delayed Glocker style approach with dual zone grafting may be a consideration. I know this is not exactly an evidenced based approach but no doubt SS and its variations are very promising. Nice thought provoking post. Well wishes and please keep us all updated.


Thanks Terry
Good description of the situation and I agree with
This conservative approach is a sure thing.
The PET in this compromise buccal table the
Long term behavior of the tissues is unpredictable.


Very nice documentation of a moderately challenging case.
it seems that the patient have restorative work done for the neighbour teeth (veneers/crowns), this may actually benefit your outcome later on where it can be adjusted for better esthetic result. The other advantage i this case that it tend to be a thick gingival biotype. This may give you more surgical options (immediate/delayed, hard/soft tissue augmentations) so all the options you listed are possible. I would extract/socket preserve with provisional pontic, then implant later.
Good luck,,


Thanks Mohammed , for your good advise.


Mariano, I agree with Terry and Mohammed and would prefer a staged approach in this case. Prosthetic (with an extended pontic) or surgical socket preservation (IDR, mIVAN, ice cone socket preservation) and later implant placement.
Thank you for sharing!
Best regards


Hi Mariano. Tough case. I think option 2 would be a good option as long as the buccal dehiscence is not too wide once the tooth is extracted. I think PET here with an area of dehiscence against the shield would likely cause an exposure or migration of the shield over time. Regards Naheed


Mariano my friend

Nice case with options- Here is thought....Appears to be a thin biotype- restorations on these teeth- fistula appears to be resolving? but if you extract tooth - cleanout apical percha- huge defect- and monumentous effort to reconstruction - what about doing apicoectomy approach for apical root resection ( ala Snjezana ) and remove percha- graft with sticky bone or just PRF - THEN- ortho extrustion to maintain contours but possibly rebuild or stabilize dehiscence - then options increased-now perform socket shield ? food for thought?




Hi my friend, these are very good options, we did remake the endo and the apical gutapercha was eliminated by the fistula (1 week ago).
We are waiting for the response of the tissues after healing.
We will considere this approach.
Really apreciate it.


Hi Snjezana and Naheed, really
appreciate your comments.
These cases in the anterior area,
They make you ambitious and want to do the immediate placement .
But when conditions are compromise it is better to be conservative.


KLS Martin