Periapical Radiolucency 8, 9

271 Rating(s).


Posted on By Ace Jovanovski In Endodontics

History of trauma ~10 yrs. ago. Came for esthetic consult. 8/9 Splinted for +1 mobility with lingual wire.

CBCT shows thin cortical plates, but well defined apex radiolucency. No symptoms. No fistula/no tenderness to palpation. I have older periapical 2D xrays for comparison.

(Connective tissue will be extended onto 10)

I am suspicious of the apical lesion.

What is the best approach?

Thoughts:

1. If keeping the 8/9: Enucleation/Apicoectomy/histology + bone fill, then NEW CBCT in 4 months, internal bleach, 2 ceramic crowns.

2. If removing 8/9: Enucleation/Apicoectomy/histology + bone fill, then NEW CBCT in 4 months, PET where there is facial bone, proximal PET where there is no facial bone, 2 implants, connective tissue graft.

Smile Photo
Pre-operative

After removing composites
Current Periapical


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7 Comments

2013
2013


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9
8


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CBCT


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Difficult choices. Would consider 2 unit long term splinted temp on existing teeth to evaluate their viability as abutment teeth? Not sure about Tx plan but would add CTG to any plans and include root coverage for left lateral incisor. Not sure about PET here but it is an option for sure. Also, conventional extractions with bone and CTG grafting of sockets. Thanks for sharing. Dr. Salama


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Tricky case because of the high smile line, thin tissue, younger patient.

For sure connective tissue graft with any plan.

My question is: Would it benefit the patient, if the apical granulation tissue would be removed first, then grafted.... that way there is some stable bone apically (albeit D2, D3 grafted bone) to engage an immediate implant in 4 months from now?

I was thinking of grafting, then re-evaluating either way in 4 months, temporizing 8, 9 in the meantime.

If we save 8, 9 are we in the same boat of deciding to extract in 5-10 yrs?

PET is tricky in this case, but I have done proximal pet (Joseph Kan-style) and it has worked well. I don't know how stable the segment will be.


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It seems that they had apicectomy and MTA plugs. The radiolucency is not necessary infection, and can be scar tissue (due to apicectomy w/o GBR).

The root canals seem two be slightly over-prepared (due to re-treatment?) and internal bleaching may further weaken the teeth structure.

It is a tough call, but the incisors already look better after removal of the existing composites. I personally would keep them . As Dr Salama mentioned A connective tissue and a couple of well made provisionals can be helpful for both you and your patient to decide on your next move. Good luck.


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For me, sound smart to do an apicoectomy with augmentation first, and get new bone, and then do an implant. PET and CTG optional.


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Salvin
Brasseler