From: Sergiu Nicola
To: ROOTS
Sent: Tuesday, January 19, 2010 1:58 PM
Subject: [roots] dramatic consult of the day

How would you approach a case like this (endo/implant/perio algorythm)
From my point of view this case overwhelms me.
The only complaint of the patient is esthetics (don't ask why she came to me ) - Sergiu




I am amazed by the variety of challeging cases in your practice - August Colpaert

At any rate it looks rather good comparing to this mess. I don’t know whether it makes you calm down :) - Ilya



She needs new crowns and retreatment.

I would:

1) remove the crowns
2) do the retreatment/surgery
3) Every tooth that is fractured is lost obviously and needs to be replaced.
4) Create temporary crowns
5) See what the soft tissue does, when healing
6) Probably place a connective tissue graft on the buccal side of the roots.
7) pray & hope that all previous steps work out ok.

-  Rafaël

OMG! It will be extremely challenging to get the esthetics wright here, wathever treatment option you choose.
I would go for extraction and an amazingly good implant-guy. He can then wonder upon how to deal with the bone
and soft tissue loss... ;-) - Bart

Sergiu,  Very difficult case!!! My preliminary thoughts would be:

Initial consults with perio and pros specialists so they know all their restorative and non-endo options.

For the endo option
1. Remove crowns/posts and assess restorability. If not restorable or cracked then extract.
2. If teeth restorable, complete endo retreatment
3. Permanent post and cores with good temp crowns
4. Apical surgery in conjunction with periodontist to do soft tissue surgery/CT graft and any other necessary
   hard or soft tissue augmentation
5. Final crowns once soft tissue has stabilised

Of course patient needs to have alternative options (such as that suggested by Bill Cohen) given to them with
consultations at each respective specialist. I think most importantly in these cases the patient needs to have
realistic expectations of the aesthetic end result because if they are expecting 100% normal soft tissue they
will probably be disappointed no matter what road they decide to take. Good luck! - Jonathan

thank you all for the feedback

I am allready analysing the case with a very good implantologist, from my point of view those 2 teeth are out:)
it seems that the grafting will be the big issue, too much of a vertical defect.

I'll update this case everytime something will be done - Sergiu