 This
case displays a typical presentation of a failed root
canalled tooth replaced with an implant.
This patient is a 30 year old Asian-American mother with
a failing root canal on tooth #8. In the pre-operative
panoramic radiograph on November 6, 2007 (Figure 1),
there is a significant vertical angular bony defect on
the mesial of #8. Notice there is normal and healthy
bone at the CEJ of the adjacent teeth.
The treatment plan was to remove #8, place an immediate
implant, and perform a bone graft with a membrane. A
temporary partial denture (flipper) was to be placed immediately for protection and esthetics.
At the time of surgery, local anesthesia was established
with 2 carpules of 1.8 cc 4% septocaine with a buccal
infiltration and a lingual incisive nerve block. The PDL
fibers were released and the tooth was removed in one
piece. The socket was inspected and debrided to remove
remaining PDL fibers (Figure 2). As
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shown by the
radiographs, there was an angular vertical bony defect
on the mesial aspect of the socket sloping from the
palate as well. Palatal and mesial bone loss was
present.
With further inspection of the extracted tooth, a large
piece of calculus was present on the mesial and palatal
surfaces of the root but not present on the other
surfaces, see Figure 3-6. Overall, the patient had
minimal subcalculus and good periodontal support.
A Straumann Bone Level, 4.8 x 10 mm implant was placed
at the appropriate vertical height as well as in the
three dimensional zone (Figure 7). A Puros allograft
 was
placed on the facial, lingual, and mesial aspect of the
implant and the entire area was covered with an Ossix
resorbable collagen membrane.
The area was sutured completely with a Vicryl resorbable
suture and a flipper was adjusted and fitted so as to
not place any vertical pressure on the area while it is
healing (Figure 8). Healing progressed without
complications for 3 months before uncovering the
implant. Figure 9 shows two months post op and healing
well.
The area was anesthetized with the same amount of local
anesthesia as before and a laser was used to uncover the
implant. A cementable abutment was placed to the
recommended final torque. A protective cap was placed
over the abutment to keep the tissue from collapsing
into the space (Figure 10). The patient was then sent to
her general dentist’s office for impressions and a
temporary crown.
A permanent porcelain fused to metal crown was cemented
with good contacts, margins and esthetics. The x ray in
Figure 11 shows a small gap under the crown, less than
ideal but should be okay. Note the filling in of the
vertical bony
 defect. There will be more radiopacity and
an increase in bone density with time, maturity and more
calcium. The lack of papillary fill is not a concern at
this time (Figure 12). Over the next year there will be
noticeable filling of the area which will achieve better
overall contour.
The palatal subcalculus and root canal therapy
contributed to the bony defect and eventual tooth loss.
I think there may have been an occlusal problem to begin
with that started it all. While this is a good example
of typical case where several techniques were used to
give an esthetically pleasing smile, it is important to
note that often it is not just one thing that can cause
a break down of periodontal support, all things must be
considered. Normal oral
 hygiene
and regular maintenance appointments are all that’s
necessary for this patient.
*Photos
courtesy of Dr. Robin D. Henderson
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