I wanted to share with you a case that presented to my office a few months ago and see what your opinion would be about the best approach for treatment.
With this case the patient presented with a central incisor that had previously been treated with an endo, post, core build-up and crown. The problem was that something was loose. In this particular case the margins were not supragingival so it was hard to tell what exactly was loose!
In a case like this, either the entire tooth, post core and crown is loose or the post core and crown is loose, or maybe just the crown is loose.
I really could not tell during the emergency visit so I decided to reappoint the patient a few days later when I had more time to assess the situation and provide some form of treatment.
At the next appointment I tried to remove the crown and the post, core, and crown came out in one piece. You can see by the photo that there is not very much remaining tooth structure and minimal ferrule. The remaining root has a small amount of recurrent decay but no mobility and normal periodontal architecture.
I provided the patient the following options for treatment:
- Remove the remaining root, graft and place an immediate implant.
- Remove the remaining root, graft the socket and plan to place an implant 3 months later.
- Remove the remaining root, graft the socket and prepare the adjacent teeth for a fixed bridge
- Remove the remaining root and prepare the adjacent teeth for a fixed bridge without grafting the socket
- Remove the remaining root and place an RPD.
- Recement the post, core, and crown
- Crown lengthening surgery followed by a new post, core and crown
As you can imagine giving the patient a list of options like this is important for informed consent but can lead to confusion for the patient to make a decision.
In a case like this the patient will inevitable ask you what you would recommend for the treatment if this were your tooth.
What I would like to know is how you would treat this patient. I gave the patient 7 options for treatment and I would like to find out your treatment recommendation if this was your patient. You can leave your treatment choice and comments using the link above this post.
Next week I will share with you the treatment the patient has received for this case.
Daisy C. See on May 25, 2021
The work I would do might be the last treatment the tooth can receive. It is at the situation at not very much remaining tooth structure, minimal ferrule and it also noted, the remaining root has a small amount of recurrent decay but no mobility and normal periodontal architecture. Radiographically, the root length is not symmetrical with the adjacent incisor, slight extrusion and happened. There is also a break in the lamina dura at the apical third of root portion, somewhat radioluscency can be seen, though no pain was mentioned, maybe negative to percussion (asymptomatic). My treatment will depend on the eagerness of the patient to keep it and the budget the patient has. I will try to explain everything with the patient that longevity is not guaranteed. I will still give the patient 2 remaining option for him to decide:
1. After crown lengthening, add ferrule then I will put FiberSite Post produced by Megadental Italia and then put a no contact non- metal crown. 2. Remove the remaining root, graft the socket and place RPD and plan to place an implant 6-8 months later for full recovery.
Eftekhar Arshadi on April 21, 2021
Hello Dr Phelan
An ordinary and every day case. Good educational case for us. Thank you for sharing it. It seems to me the pt is a grinder and the crown has a tight contact with # 25,26 this culd be the reason for lose crown. It needs probing to check biological width and the reason for black mark on BuccaL. I would give the pt the following treatment plan.
1- check the endo
2- crown crown lengthening
3- post and core # 8 with all ceramic crown
4- porcelain venners # 6,7, 9,10,11 and lower from 22-27 correcting anterior bite and guiadance.
Vladimir Dincic on January 30, 2021
Hi everyone, I believe that we have to try to save any tooth that has good periodontal architecture, with no fractures of the root, so the option number 7 would be my choice with crown lenghtening surgery followed by new post, core and crown but first i would do endo retreatment because of the protocole that any endo treatment that is older than 6 months should be retreated
Albana on January 18, 2021
Good done but i would prefer a little gingivectomy before.to reshape dhe aspect of vestibular margin.the rest,super.
Mandla Simelane on January 8, 2021
Assuming intact apical/ periapical integrity and no root fracture, and patient had asked me what will I do, I will give the patient the following options and base them on the longevity, conservation, and the predictability of the outcome;
1. Crown lengthening and provision of a post crown – Warn patient that since a lot of work has been done on the tooth / remaining tooth structure , this treatment may come under due stress and fail prematurely.
2. Extraction/ socket grafting / preservation and provision of an implant either immediate or 3 months later
Babak Teshfam on November 28, 2020
In my humble opinion our treatment depend on some measurement like how much of tooth structure will be remaining after removing the infected dentin.how long the tooth will be top prepare after having at least 2mm ferrule structure and a definite finish line. If everything meet my standards of treatment I will go with crown lengthening followed by post and core and crown.But otherwise I will go with placement of implant which the options that you gave to the patient depends on the collusion type of person, oral hygiene , medical history.If it was nothing to be worried about I will choose an Extraction and immediate implant placement following a graft placement.
Loudine Van Wyk on August 5, 2020
I will try new core and post, with the core and post cemented as a single, bonded unit. I like fiber Site post which transfer the forces into the base of the core for compromised roots.
Loudine on August 5, 2020
I will try new core and post, with the core and post cemented as a single, bonded unit. I like fiber Site post which transfer the forces into the base of the core for compromised roots.
Khawla aboudiab on August 5, 2020
Hi Dr,
I would go with crown lengthening , fiber post , 2-3 pins , build up and new crown.
Helene on May 31, 2020
Depends the age of the patient and the age of the post and core and crown. Ideal would be to extract if there was enough maxillary bone to support an implant but if time was an issue( or age) I would recement the existing P&C and crown. Not sure what the post was made of so may consider new post & core with glass resin posts if the recementing should fail soon Also, not sure why it was loose to begin with, trauma? time?
Diana Muzic on May 21, 2020
I will recement post, core and crown.
DR MD TARIQUZZAMAN on May 18, 2020
Hello Dr
I would go for extraction and followed by immediate implant with GBR.
John Epperson on April 6, 2020
Needed: 3-D scan showing buccal bone thickness.
At the time of extraction, If the root can be removed atraumatically and the socket is healthy, with no loss of buccal bone, then place an immediate implant, use clear plastic retainer with a cosmetic tooth #8. Restore after integration. Otherwise , extract, graft, implant after healing.
Long term replacement.
Ted Margel on March 28, 2020
Depending on the patients age (appears relatively younger) and expectations, I would favour the immediate extraction with grafting and provisional. IMO, a new post, core crown will only give you another 5-10 years of service.
Dominique on March 22, 2020
Give all above options (with the exception of #6, patient would return in a couple of days, disrupting their schedule and yours) with the understanding that the prognosis is undetermined.
However, in my 27 years of experience, I believe that those options would yield a less than ideal long-term result. If it were my tooth, I’d extract, graft, place an implant in 3 months… all due to “the rule of ferrule”, continued trauma to the bone, better esthetics and tissue health, time, finances and longevity.
However, I’m just a Dental Assistant.
Ross on March 18, 2020
All of the above plus Option 8: non-metallic post with “composite resin crown” + – crown lengthening
Lana on March 9, 2020
I think I will preserve with crown lengthening and fiber post &build up
Then crown , I don’t like metal posts any more
But we have to till the patient that the prognosis is questionable because we don’t have enough ferrule
Navneet Rai on February 29, 2020
Extraction,Gbr if buccal wall is missing. Place implant,since looks like a guarded prognosis
Mansi Ghanshani on February 14, 2020
Hello Doc,
I would do crown lenghthening followed by custom post & core & crown for the above patient.
Ivan Ho on November 3, 2019
Option 1
Rumisa on January 8, 2020
Hi Dr
love the clarity of ur cases
I would surely go with the same treatment but additionally I would also do small amount of crown lengthening as I could see that there is a provision for that in gumline.
For me priority is to save what is natural.
Evelyn Estefan on July 30, 2020
Hello Dr. Phelan,
Seeing the above X-ray, I would take the conservative approach to re-cement , nonetheless give patient all options.
Have them Sign consent of risk of failure and possible outcomes.
Should they request recement Option, then
Take EOC pictures
Intraoral 3 D image, I use Cerec
PA X-ray and Pano
Perform ADA
D4211 1 tooth
D2954 Post Core
D2920 Recement crown
Sigh treatment Plan as well.
Anesthesia, Light electrogingivectomy with ultra fine tip to expose outermost margin.
Try in crown fit at margin If all good then proceed to
Clean canal then irrigate with Endo irrigators Hypochlorite
remove snare layer with EDTA dual then CHX 2%
Check for root caries If all clear place non metallic post cemented with infinity or such
Make core build with core paste white from Denmat Try in crown again Check for Inter proximal contact point tightness With a floss marked with articulating paper, recement crown with very light functional Occlusion and check for early contacts and equilibrate,recomend a functional protective guard if needed.
Thank you.
Evelyn Estefan, DDS
Anita on August 28, 2020
I would try to find out the cause of failure for this post restoration like any premature contact or high points and go for new post restoration.