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.
Gladys on November 3, 2019
Options 2
Thanks
sushmitha Jeeri on July 1, 2019
Hey Dr. phelan, I would do option one or save the tooth depending on the finances. But I would inform the patient that prognosis is fair to poor. I have a question do we discuss with the patient about the grey area?
Noha on June 1, 2019
Thanks for sharing Dr Phelan. I have no experience in Implants however I am learning about them. Assuming patient is medically fit and the bite isn’t with interferences, and depending to finances I would go with option 1 or 2. Thanks
Peter Smyth on March 3, 2019
Good job.
If the patient is not concerned with aesthetics of the grey root showing through then keep the tooth as it appears there is enough root structure to ferrule, however, I would get a CBVT. Assess the root proximity to the lateral and any fractures. It’s likely there was movement as the screw post was into the GP. Bonded gold post and core with new PFM would be quite adequate. Otherwise remove root. Graft and delay implant placement.
Gladys on November 3, 2019
Options 2
Thanks
Idrees on March 1, 2019
Option 7 I think it’s a metal post so replace with fiber post
Mandla Simelane on February 10, 2019
It will depend on risk assessment and cost factors- Put it differently- on Bio-Psycho-Socio-Economic status of the patient.
Angela Lowe-Ho on May 2, 2019
Another option is to clean out the post space, irrigate sodium Hypochlorite 4%, EDTA, bond ribbond in post space, extend the ribbond
also to be a core, doubled up and build a composite crown so long as you get the occlusion free and create enough space. This option would be helpful for a patient with limited finances and not wanting a removable partal denture. The dark neck area would need to be opaqued out.
Dhouha s toma on November 26, 2018
Hello dr Stephen
Though iam not officially a dentist till now
But i think we have to extract it then we do an implant
Thanx for sharing this case
Dr hafsa al idrissi on October 27, 2018
I would explain both long term prognosis and short term, providing the options of saving the tooth by placing post core and crown or extracting the tooth , socket preservation, provisional removable prosthesis (6-8) and after than place an implant with a screw retained provisional ( make sure it’s off loaded) . Wait for the healing period and contour the Pontic area every 3 weeks to shape the emergence profile of the tooth implant supported in the future. And finally when implant is osseointegrated take impressions for the crown.
Theingi on September 8, 2018
I will remove the caries and recement the new post, core and crown. The gingival height is quite the same as adjacent tooth so I won’t do the crown leangthening procedure if I can completely remove the caries.
Margarita Aleksanyan, DDS, AAACD on May 1, 2018
I agree with Dr. Ferres. There are also couple other considerations – gingival height of #8 is more coronal than #9. Pt. also has a thick gingival architecture which is great. Some gingival recession after immediate implant placement and provisionalization will happen. Most likely we can achieve the same gingival height on #8 as it is on #9. If that’s not the case, pt. has gingival recession on the left side and if necessary slight crown lengthening can happen on the right side.
One new method that Dr. Salama was describing in his recent presentation was partial root extraction. With this method very thin (1 mm of buccal root portion) is remained in the socket and it actually preserves the buccal bone and gingival recession. Not very many surgeons are currently implementing that technique though.
pooja on February 14, 2018
Hello
I would suggest for option 2 if patient is ready for implant and a treatment plan which has best success rate.
Option 7 has very little rate for getting best result as there is very less tooth structure left and part of it has caries .so after cleaning out the decayed part I feel to reatian a post is challenging and also needs crown lengthening which will disturb gingival contour with adjacent teeth.
Dr.shubana on December 23, 2017
cleaning the caries then option 7
H on November 22, 2017
I would assess if there is a vertical root fracture . If not, crown lengthening can be achieved by removing soft tissue only and not bone it seems from the X-ray., preserving the 1:1 crown root ratio. I would inform the patient of the unpredictability of option 7, if they opt for it, it could be tried , I would say Grafting and implant 3 months later is more predictable though.
Dr kavita on November 22, 2017
The treatment depends on the patient’s general health , age factor, and willing for surgery or not and mainly cost. Keep all this factor we can take decition and if try to save the patient natural remaining root / tooth structure we can save and do the needfull, if patient ask anything about asurity of the treatment for any 10% failure case we have to think about patient convenient treatment.
Anisa on October 28, 2017
Crown lengthening surgery followed by a new post, core and crown ,
fariha khan on October 8, 2017
will go with option 7
fariha khan on October 8, 2017
as you have already mentioned that the tooth is not mobile with normal PDL and little recurrent caries so i would go with option 7 crown lengthning and then new post core and crown.
fariha khan on October 8, 2017
as you have already mentioned that the tooth is not mobile with normal PDL and little recurrent caries so i would go with option 7 crown lengthning and then new post core and crown
Clara Iwuoha on October 4, 2017
From the assessment you gave; The root is not mobile and has normal periodontal architecture, I will opt for option 7,that is,Crown lengthening surgery followed by a new post ,core and crown.Thanks for sharing your experience with me
luis marroquin on September 18, 2017
Dear
Thanks for sharing these cases with us
3 options:-
1 extrusion, new casted post and core, and crown
2 .7
3, implant
Imad rekab on September 10, 2017
Hello Dr. Stephen
What you should do if it is your tooth
May be if I am the patient , I will go for the first option to rebuild the tooth
with post and core and a crown, and I’ll keep in mind the treatment may not
last long . But I’ll give the tooth a chance .
But the question is ? Not all patients understand this option if the treatment fails.
So he will come to the clinic carrying his crown and he will tell you this is your treatment
So I’ll prefer to go for grafting the socket and immediate implant placement to be on the safe side .
lone Snedker on August 7, 2017
The X ray does not show endo problems as such, so why reendo? The only reason is exposure because of the lost crown. Is there an infraction? Due to a metal screw? If the patient is not concerned about the difference in gingival level, why no make a new post and a titanium crown? And make clear that later an implant can be necessary. But make sure there is no infraction
Mariel Nanut on June 29, 2017
Not option 1 :it’s a very wide root and near 12. Not a bridge . Not a RPD. I would recement with temporary cement and re endo.Wait some weeks.If it’s ok : option 7 and rh incisal 13 12 21 22 23 with composite or porcelain veneers (ay least 21 with porcelain veneer :it is better for the esthetic.Thank you !!!!!
Doris Ferres on June 28, 2017
Case to be handled with a very good plan. The number one priority is the preservation of the existing gingival architecture which looks great at this time. First: with a: CBCT, determine existing bone, If bone allows, atraumatic extraction and immediate implant placement, that would be the way to go since it would be the best to preserve the esthetics. 2. Wax up model to be used merging the CBCT with it to create a surgical guide for implant placement in the correct spot. Consider placing implant closer to the palatal wall and bone graft as needed to preserve bucal bone Remembering the 2mm rule surrounding implant for the prevention of bone loss. Also placing implant 3 mm from desired final gingival margin level will render a great result. And finally: a good screw retained temporary.
Sumaiya on June 28, 2017
I would go for option 6 or 7, depending which one has less disadvantages
Sean Harris on June 28, 2017
Option 6
I have this very same problem with my own tooth! Minus the decay. I don’t want a bridge or denture. If the root ever fractures I will go for implant. I brux and at present the tooth is on a fibre post. Last time it came loose the direct core actually deboned from the post. Some dodgy dentist in Florida stuck it back with a think cement. It didn’t fit. He ground the heck out of it. It’s still there 2 years on!!!
Adil Majid on June 27, 2017
Could you do a Richmond crown with a beveled margin to gain increased ferrule/retention, while dropping the margin slightly? It seemed like there was a little room to prep further sub-g and not violate biological width on the radiograph
Aya on June 27, 2017
Option #7
Dr Teresa DeStefano on June 27, 2017
Wax up/ surgical guide/ Scan- then decide if immediate ext/ implant placement/ immed provisional ( screwed in) is feasible.
Alexander Swinkels on June 12, 2017
The gumline of 11 is lower than that of 21. There are No apical inflamtions or anything so my choice would be crownlenghtening, endo- revision, post/core and a New crown. The best implant is still No implant.
FOUAD MEDOUAR on May 25, 2017
Dear Dr Stephen.
Sorry for my english I’m francophone. I saw your video and I want to thank you for sharing it with us it’s really helpful. I think it depends firstly of the finances of a person. The best solution would be solution 2. But I learned at the University of Paris 6 that the best implant was our root. The disadvantage is the blackness of the root which can be solved by an zyrconia inlay core and a non-metal restoration (ceramic). The problem is high rate of fracture for porcelain-veneered zirconia-based restorations that varies between 6% and 15% over a 3- to 5-year period, while for ceramo-metallic restorations the fracture rate ranges between 4 and 10% over ten years ( Zirconia in fixed prosthesis. A literature review (Rubén Agustín-Panadero, Juan L. Román-Rodríguez, […], and Antonio Fons-Font)
For this reason, I prefer the solution 1 and 2.
Dr Fouad Medouar
Aimn Abbasi on May 24, 2017
Hi,
If the caries is not soft and arrested, option #6 and re-eval to start off with; Option #7 is a viable option but the black triangle might arise as an issue with less inter dental papilla fill, which again depends on the crestal bone height and contact point, Option #1 looks feasable since esthetic zone and if #6 does not work successfully,
One option not mentioned could be Decoronation with bridge.
Thanks,
Steven Foxn DDS, FACD on May 22, 2017
Since we do not have information on the patients occlusion, parafunction, vertical and horizontal overlap, no clinical exam or articulated diagnostic casts, we are limited.
We all know the problems of this type of care. One item we forget about is the elastic modulus of the tooth. If I remember back to dental school, the elastic modulus is a value used to measure the rigidity of the teeth. For human teeth, indicates the ability of enamel and dentin to resist elastic deformation.
As the tooth looses enamel/dentin, its ability to resit elastic deformation decreases, the tooth becomes more “flexible”. As the tooth becomes more flexible, it may reach a level which breaks the cement bond, leading to recurrent caries and/or loss of restoration.
We have all restored teeth with extensive tooth loss which have suffered from loss of restoration or recurrent caries. Now there is a responsibly of the patient with home care which is also an important factor said.
Clinical studies with teeth restored endodontics, post and and crown, show similar longevity as single implants. But the tooth in the example has most if not all the enamel and dentin removed, compromising restorability.
If we do opt for post/core buildup and appropriate crown, we most certainly must have crown lengthen. Can periodontist provide enough for an adequate ferrule? AND, the crown lengthening will change the gingival architecture, and the anterior esthetics.
With all that said, I would opt for extraction and Implan
Marwa on May 22, 2017
Option7
Marwa on May 22, 2017
Option 7
Dr. TALAL on May 21, 2017
I would go for the following option,
Remove the remaining root, graft the socket and plan to place an implant 3 months later.
Raza siddique on May 21, 2017
I will go with option 1 .
Zartaj on May 20, 2017
Extraction followed by grafting and immediate implant is my choice!
Zartaj on May 20, 2017
Extraction followed by grafting and immediate implant.
DrSubasinghe on May 19, 2017
Seems like there is a fracture and some inflammation in the buccal region. In this scenario, I would remove the root very carefully, then leave it for 6-8 weeks with one course of antibiotics starting 1 hour prior to extraction.
Thanks will take a CT and plan the treatment. Will provide temporary solution via palatal implant, stick truck, partial!
Cheers
J
Thank you Dr.Phelan
Dr Nagarathna PJ on May 18, 2017
I would like to go with the last option but doubtful about the retention at core?even after crown lengthening. In that case option 1 is better
mydentalcareguide.com on May 8, 2017
Before your dentist can even consider pulling your tooth, certain steps must first be taken. Doing so not only helps to insure that your extraction will go as safely and uneventfully as possible but also that your tooth was removed for good reason.
Maitri on March 30, 2017
Patient will be very concerned about loosing his front tooth but decisions would depend on expectations, time frame ,how cosmetically inclined the patient is and of course finances.
Looking at the photos , left central and lateral have higher gingival margins compared to right central and lateral.
Hence crown lengthening will be a good option . Lasers could be used to contour right lateral as well.
There is wear of Incisal surfaces of all incisors – veneers with adjacent teeth would look good!!!
A. O. H. A on November 2, 2019
I will extract remaining tooth, graft and place implant in 3months.
Another option will be to extract and prepare the adjacent tooth for a fixed bridge.
Meenu on March 29, 2017
1. Extraction followed by grafting and immediate implant.
srikanth aluru on March 20, 2017
Consider extraction grafting and immediate implant placement, provided a satisfactory primary stability is achievable.
Ashish on March 16, 2017
I would like to opt for option 5 followed by option 2
Johann E. on February 10, 2017
Hi there,
Thanks for sharing this challenging case that can come to every dentist in a daily consultation.
Of course checking med history is mandatory.
Depends also on your own ability and the financial possibilities of patient. Does the blue-ish aspect of gingiva bother the patient?
I would not advice patient to remain as it is but would still re-cement on the day of assessment to allow for time to reflect on the part of the patient.
I would recommend later immediate placement of an implant with bone grafting and handling of the gingiva in the different stages following. The question is: what would patient gain from a delayed approach with grafting? If infection is what motivates you to delay, It is not absolutely the case here from what I can see.
Seeing so much decay on the remaining root means I would not advice for redoing endo + new post & core.
It would be impossible for me to promote a fixed bridge in this situation even though preps could be envisioned to put veneers on other teeth if occlusion allows and further evaluation shows it to be necessary.
Good luck in taking care of this patient!
Jakob Lempert on January 24, 2017
Good temporery cemention. Check carefully occlusion and articulation, dont forget protrusion. Follow symptoms. If everything seems ok then follow option 7. If symptomer that could be endo-like, then re endo. Otherwise go to option 2
But With 6-8weeks of healing before implant. Implants are ment to replace MISSING teeth not teeth that can be treated otherways
Kurt Marler on December 6, 2016
Depending on age and med history , and how much gingiva shows when smiling are factors. Crown lengthening
would give the pt a few more years if age or med history is a factor. Otherwise bone graft and delayed implant.
Sylvia Kowalewski on December 3, 2016
1)Recement post,core and crown,present as a temporary measure with a possibility of infection due to likely contaminated endo .
That will give patient time to make a well informed choice .
2)Crown lengthening would even out the levels of both centrals,endo retreatment (?),new post core and crown
3)immediate or delayed implant
Compare costs of above 2 and 3.
Implants are great but there are also failures and as a time progresses there are all new improvements