3 weeks after Extraction of Central Incisor with Piezo. Part 1

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Posted on By Maurice Salama In Failures

3 weeks after Extraction of Central Incisor with Piezo the patient presents for 2nd opinion with infection and large bone sequestrum from area. Thoughts, concerns, options & solutions. Prognosis of adjacent teeth?? How would try to regenerate such a large 3D defect? Dr. Salama

Bone Sequestrum
PA Sequestrum

Removal of loose Spicules
PA 2 Months


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34 Comments

Some questions to ask: Any systemic condition? Use of bisphosphonates? Prior infection? Use of antibiotics? Adequate irrigation with piezo?
Regards,
Sormani.


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No relevant medical history. Young healthy male. It appears to me as necrosis caused by overheating perhaps utilizing the piezo incorrectly.
Dr. S


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Mo did they report that the Piezo was used during the extraction process. Could it have been a traumatic extraction that broke the palatal wall off and then failed to remove a mobile piece of bone?


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DR Salama;but what u think about bone ring??about this site?


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BONE rings are a disaster in the medium to long term I would advise yous tay away from them


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well I would only think of either Heat from the piezo (not enough Irrigation) or acute Infection during extraction•
I would go for antibiotic therapy followed by or block graft OF Cours after ensuring there is no system conditions


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Maurice, Unfortunately this isn't the first time I've seen this occur with improper use of a piezo. If that was the only factor,
I would have recommended placing dfdba - fdba and or prf when sequestration bone was removed? Thanks for sharing. Chuck.


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With severe infection present, suppuration and very poor tissue quality, no bone grafting was performed at that time.
Maurice


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I agree Mo. One miracle at a time. Placing a bone graft into a infected site is a disaster waiting to happen


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Maurice, Even under those conditions, placement of high turnover materials to facilitate a clot /hold space (with Augmentin use) still makes sense to me. The infection present shouldn't be a problem with the materials I suggested, so long as the socket remains open and allowed to heal without restriction. I have been routinely placing DFDBA into infected extraction sockets without complication. In fact, over the last 20 years have yet to have a "dry socket" with this approach. Chuck


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well I guSs with such an infection a graft Will not be placed before l to 2 month


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Overheating is also with piezo possible.
Good instrument in wrong hands.
I have posted similar bone spicules in dentalxp a couple of months ago. Healing for at least 6 months. Augmentation in your skilled hands must not be a problem.


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BIG DEFECT. I would love ideas and what is the prognosis of adjacent teeth??
Dr. Salama


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Dr. S, what are probings on adjacent teeth also is there mobility? What is occlusion like? I am potentially thinking graft with the use of BMP 2 after some healing time to ensure necrosis is complete. Fabricate a temp with ribbond which could also serve as a splint for adjacent teeth(if their prognosis is realistic), and evaluate healing in 6mo.


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Brian;
Great questions. Probing on adjacent teeth significant, 9-11mm interproximally facing the extraction site. Mobility upon presentation was 2+. The tooth that was extracted was not reported as Ankylosed? Did have internal-external resorption.
Dr. Salama


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What was the extraction like? Was this tooth ankylosed to the bone? Is there a possibility that the alveolar process actually fractured during the extraction? Even with poor irrigation the maxilla is highly vascular and bone necrosis is very unlikely. Although many of the colleagues on the thread may be concerned on how to restore the defect i am more interested to know why this happened.


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Tamer; Yes, always be a good diagnostician and investigator.
Dr. Salama


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Dr.Maurice the CBCT shows Labial Bone on Both adjacents do you think a one wall defect FaCing the extraction site is enough to Cause a 2 plus mobility?


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Sherif; Look at the PA Film. The differences in thresholds sometimes causes "cone" to show on the 3D image.
Dr. S


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Could someone please explain what dfdba-fdba and bmp2 is ? also what would be considered a good piezo unit to buy ?
Thanks
David


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David, dfdba is dry freezed demineralized bone allograft and dfba is dry freezed bone allograft, bmp-2 refers to bone morphogenic protein 2 which actually is produced via recombinant DNA technology. I think the two more popular Piezo brands are Acteon and Mectron, if I am not mistaken. Will.


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mectron i dont like i have mectron and now i think by Surgybone or Acteon.thnk u


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Dr.Maurice,

This is quite tough, I would approach such case with caution. Another possible reason for this breaking of the labial plate during extraction and Dentist just put it back thinking that It will heal, poor infection control measure during extraction....etc.

I would not graft initially, just remove the sequstrum and clean the site and step back waiting for healing, the defect is already significantly big, I would not expect the bone loss would proceed any worse. I would relief the next mobile teeth from occlusal contact and splint them with a Maryland bridge which will extend one tooth beyond the mobile teeth on each side and replace the missing tooth. Assess the prognosis of the two mobile teeth for some time before give any definitive treatment plan.

Omar


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uggg... tough case... With negative medical history... my thoughts are related to overheating with peizo.... have seen this first hand... with the peizo i doubt there would have been fracture of plates but is possible.. Would of also had to consider osteomyelitis... as had this happen to me in a posterior case that turned very very messy! Real question is now what do you do? adjacent teeth are severely compromised..... glad i am not doing this case! cant wait to see how it turns out!


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Difficult case indeed but if we think what can be done now, for me is more clear thinking that:
1 I wouldn't like to put an implant replacing n9 tooth whith such neighbors, mobility and probably endo-perio contamination. Also grafting with cementum walls side by side seems not possible.
2 CTG n9 area for future esthetics
3 8 and 10 extraction Gbr and more Ctg.
4 after 3months implnt placement in 8 and 10 sites, with or without immediate load depending on th previous regeneration results
5 Bridge between implants (after gum remodelation).
This is apredictable and step by step approach.


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As clinicians we are very fast to think in term of techniques, materials and instruments...sometimes we want to "Fix" and "help" biology, but.... how often we think out of the box is key.
What if we let the body do that marvelous process called: Healing...in the mean time we place a bonded tooth or any other form of device to temporarily replace #9 and patiently wait....I know we live in times of just clicking bottoms and making things happen....

I would recommend to review this amazing work by Dr. Funato and Dr. Ishikawa. They explain how timing is so important for Comprehensive planning (is not only about materials and techniques)

4D Implant Therapy: Esthetic Considerations for Soft-Tissue Management: 1st Edition by
Akiyashi Funato,
Tomohiro Ishikawa


But don’t be satisfied with stories, how things
have gone with others. Unfold
your own myth, without complicated explanation ...
–- Rumi, “Unfold Your Own Myth”

Thank you and happy smiles!


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Steve, I too enjoy Rumi, and did in fact have a smile after reading your post. Having said that, one of the "myths" in implant and reconstructive therapy is that we can regenerate any deficiency. Only Dr. Campos, among the respondents above, was really concerned about the adjacent teeth enough to include them in his prognostic and therapeutic deliberations. Its important to remember, that once the interproximal bone of the adjacent teeth are compromised to a sufficient degree, they must be included in the treatment plan to the extent that reflects the patient's own esthetic expectations.
BTW, our team also published on the timing of implant therapy in the IJPRD with Dr. Funato and Ishikawa's team and the article can be found on this site's article archive.


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Maurice or Henry, Are probing depths under these conditions necessarily indicative of PDL levels and potential for repair. Although not encouraging, I would have to say probing and mobility levels at this stage of repair shouldn't necessarily indicate need for extraction. Chuck.


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Chuck and all; Let's wait for my posting of Part 2 to answer your questions. Very interesting, does the radiograph really show PDL level or just bone level?
good thinking. Maurice


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It seems that there are two separate but connected issues:

1. Prognosis of #8 and #10: If in the worse case scenario, the teeth are deemed hopeless, extraction is inevitable. Therefore, you have a justification to prepare the teeth and use conventional fixed prosthodontics. Perhaps the teeth stabilize and have a guarded prognosis; perhaps they don’t stabilize and they later become extracted. But nothing was lost in preparing them (unless surgery and orthodontics can completely restore the defect).


2. Papilla: If soft and hard tissue augmentation can achieve enough stable vertical tissue height; an ovate pontic can be used and generate papilla fill. If not, artificial pink can be used following gingivectomy and gingivoplasty - hiding the gingivo-restorative junction below the lip line. This was published by Team Atlanta in 2009 with Christian Coachman in IJPRD – a wonderful three part series.

I don’t believe any combination of surgery and orthodontics can completely repair such a large defect to later place an implant in site #9, and it be restored esthetically (papilla and gingival zeniths). I also don’t believe any combination of surgery and orthodontics can provide enough stable soft tissue that an ovate pontic will maintain a papilla - as contact point to bone will likely be greater than 6 mm.

I believe artificial papilla and tissue can provide an esthetic result. This can be attempted easily and inexpensively with acrylic and resin following similar diagnostic protocols from the article – wax up the proper tooth morphology, position, etc; back fill in with pink. Prepare and provisionalize the teeth (the provisional having pink resin and artificial papilla). Evaluate the mobility and prognosis of #8 and #10 several months later.


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Jose; Great thinking and review of potential options. Thus far, we have gained bone at apical portion of adjacent roots by stabilization and healing. As Chuck mentioned radiographic bone loss does not assess the viability of the PDL. We have stabilized adjacent teeth and performed a large CTG ridge augmentation to improve tissue health, KT and Levels. Will now consider future options.
The adjacent teeth are now + to 1 mobility from 2+! Certainly viable. We will consider ortho extrusion of Lateral Incisor, followed by 3D Bone Graft in area of defect, followed by implant placement. Lateral incisor may have to sacrificed after orthodontics and we may consider RST (Root Submergence Technique) here with ovate cantilever pontic.
thanks Dr. S


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Maurice,

Shot in the dark question- with your ortho experience - If you are thinking about submerging 7- what do you think about mesial movement to develop bone- or not enough left to do? could you intrude then mesialize?


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Good idea Richard....but first need to stabilize ans Wait and allow for maximum natural healing progress. regards Mo


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Mo do we have CBCT after 3-4 months of healing. I always wait for full healing of these sits then re xray as sometimes the bone just needs time to reconstruct itself. Once that is done then I would assess the condition and decide on the treatment going forward


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