Case Studies




Implant Replaces Failed Root Canal Tooth

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



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 dentistís 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 thatís necessary for this patient.


*Photos courtesy of Dr. Robin D. Henderson

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