Crown lengthening or dental implant?

A crown lengthening procedure involves surgery to expose the bone and remove at least 2 mm of bone at the fractured area and tapering evenly towards the adjacent teeth, so you do loose bone during the procedure. The tooth has a root canal and is therefore more brittle, so even with the crown lengthening and a crown, it will only be as strong as the residual structure that holds the crown. The picture are not very clear in determining the extent of the damage, but it appears that it can be saved, but the result will not e as strong as an implant supported crown.

correction: "will not be as strong"

Hi, So if #13 crown is deficient and #12 needs a crown, which looks like has enough tooth structure to place a crown. When I have such as scenario, I usually advise my patient as this, Prognosis on #12 is Guarded at best, however if we are going to need a crown on #13, then doing Buccal Crown lengthening which is what it looks like the tooth needs, is definitely something to try because, and this is the main thing, We can do Splintted crowns on #13 and #12. By buddying up the two teeth we can get a good result (i.e. Prognosis becomes Fair) as long as Pt is not a Bruxer and has good oral hygiene, i.e. they will use intra-dental picks to keep the distal of #12 and mesial of #13 clean so that they don't get recurrent caries, and don't grind their teeth. Most of the cases that I have treated this way, work out. By most I mean in 95% of these cases, the patient is able to maintain the teeth for at least 5 years. So, looking at all the work that you need, I would suggest to try the option, you can always take the tooth out and do an implant. If your aesthetic concerns are not too high, i.e. you are not a model who is featured with smiling face, the esthetics, due to bone removal on buccal aspect of #12 will not be affected much. Again this advise is given to my patients with the understanding that because you are going to spend a lot of money on all the other crowns, and this gives you some time to start saving moneys in case you need an implant in the future as the worst case. This treatment modality buys my patients time in case the worst happens, i.e. Pt fractures the tooth further becomes symptomatic and needs Extraction of the tooth. Alternatively, you seem to have crowding, maybe if #12 is extracted, Invisalign or ortho is indicate to get all the teeth in CL-I occlusion which will be better for your overall dental health in regards to Perio issues. My $ 0.02

Sorry, Forgot to add, if the crowns last for only 3 years and Patient ends up needing an implant and a crown, I will credit some of the moneys toward the implant crown. This way we are both becoming partners in your oral health. Of course, part of that understanding is that the Patient won't disappear for 3 years, does n't get any cleanings etc. and then shows up with the crown in hand. Your part of the partnership is to make sure you do all the things that are needed, i.e. keep them clean, good Oral hygiene, flossing etc. to maintain them. After doing all that, sometimes things happen, but we are both then at least give our best to get a good long term result. Additional $0.02 =)

Generally when a periodontist does crown lengthening he/she will extend the bone removal to each of the adjacent teeth so the final result is cleanable. Since the tooth root gets smaller as bone is trimmed away, the risk of fracture is greater and if only one tooth is crown lengthened then you will have gum problems because bone levels will be at different heights. For my money (yes I pay full fee for my dentistry) I want 1 GOOD ( not fair) prognosis, for 10 years NOT 5!! With all the teeth in my mouth, I want the least amount of "maybe" that is feasible. With all due respect to dr Moe, I wouldn't want teeth splinted together in my mouth. Too hard to clean well between splinted teeth. It looks like the x-ray shows an inadequate root canal filling on #13, I would recommend crowning #14 ( literature shows posterior root canal teeth benefit from crowns) and you have a questionable issue with your lower first molar #19. I would have an implant on #13 rather than invest $, energy and money into something that has a Fair or guarded prognosis.

The tooth can be predictable restored, without having to remove 2mm of bone. If the tooth is restored with a bonded core, as per the protocol of Dr. Chasolen, then the tooth can be reshaped, removing the old margins, resulting in a perfectly smooth tooth. Let the flaps mature 3-4 months, then place margins right at the new gingival level. Dr. Danny Melker covers this in detail...look him up. Melker and Chasolen have cases treated this way that have been stable for 30 years.Complications with natural teeth are much easier to deal with than are those with implants and I've been placing implants since 1984.

This is a setup Dr’s. There is no way a dentist would suggest any treatment on #18 without immediately suggesting the extraction of #19. Look at the size of that lesion and the separated instrument in the mesial canal.

I am a firm believer that "Skills" of the doctor matters. So as you see there are many different ideas proposed that for a lay person can be confusing! So if one person can do a certain procedure successfully, this does not mean that everyone else who is going to do that same procedure will get the same outcome. So keep that in mind before you make your final decision. Having said that, You should know that a Panoramic Xray has about 25% distortion, so none on this forum can really evaluate tooth #12 based on what you posted. The Crestal bone is not even visible. The Quality of the root canal cannot be assessed, and both are important to make a fair judgement. The anatomy of tooth #12 is different than #13. Its Kidney shape can significantly affect the outcome of the treatment to save it. The length of the root is important, if after the crown lengthening the remaining root is less than 10 mm, then it should not be done. Did you know among all the teeth in the mouth, root canal treated upper 1st bicuspids have the highest rate for Root Fracture. Another reason why it is important to have two Xrays which you don't. (one PA xray and a Bitewing). Giving the current situation, your age, the cost of the proposed treatment, the tooth anatomy, past treatment history, and limited information you have provided, It is my opinion to spend your money on Dental Implant. If your current dentist is a Master Clinician, then you may expect he will use his knowledge and skills to save it for 5-10 years (only if it’s possible), but even with that the prognosis is guarded. (if he is an average dentist, the prognosis is probably even less than 5 years). But in the hands of a master clinician, the prognosis of extraction and replacement with dental implant, will be excellent probably for the rest of your remaining life. At this age, you don't want to plan to get it redone every 5-10 years. I hope i could help to get to the right answer.

You now know why getting the same answer from multiple dentists is not possible. They all have their own different opinions! The easy answer is yes the tooth can be saved and yes an implant can be placed. Both are possible. However to get a better opinion you should approach a specialist crown and implant dentist (prosthodontist). General dentists will often consider an implant in preference to a properly constructed crown for various reasons. An expert in doing crowns will usually assess the situation from a view point or expertise, experience and more knowledge. In general I would usually restore this tooth – it is standard procedure and not extraordinary. The test is: “What would I do for my spouse or children?” In your case I would definitely aim to save the tooth. If it fails then an implant is a back up option (but not the other way around). You also have other problems to address – hence my comment to seek an expert opinion. I wonder for example if the lower left 12 year molar was extracted or the 6 year molar? As has been commented, it looks like the 6 year molar should have been extracted not the 12 year molar? However only clinical examination will reveal the truth. The other comment about lack of clarity of your presentation is also relevant. No clinician can make a proper diagnosis and offer a firm opinion on the information supplied. In particular, an assessment of the occlusal forces needs to be made (given you have broken the cusp off at least one tooth).

Assuming that the endo's are working, # 12/13/14 are crown restorable. Splinting # 12 to a new crown on # 13 is a good idea. Make sure the lab makes them cleansable ( easily fit an interproximal brush between the two ) The need for crown lengthening is questionable if these teeth are prosthetically splinted to each other. Maybe some electronic gingivaplasty at the time of prepping if need be. All of my crowns ( including badly fractured teeth ) have margins that finish slightly below ( or even above in non-esthetic areas ) the gingival crest . Can't remember the last time I did an "official" crown lengthening. Patient's cring when I suggest crown lengthening and they learn of the price tag. Thousands and thousand of crowns done this way. Save your money for an implant in the # 19 area. # 19 should be extracted ( if it hasn't been already ) due to an apparent failing RCT. Regardless of the treatment performed, the prognosis for any restorative procedure ALWAYS hinges on proper homecare and maintenance.

Your question is generally hotly debated amount dentist. Take it out and implant or restore with root canal, post,crown etc. Your dental problem can be treated either way. Yes the skill and judgement of the treating dentist is very important as to the longevity of the work. The first bicuspid tooth causes dentists and patients many problems. The tooth likes to fracture. Root canals can be difficult to do. It poses many engineering problems for the dentist. Unfortunately nothing in dentistry permanent. No dentist can guarantee his work is permanent. All things considered some restorations can be more dependable than others. Crown lengthening does cost some bone and implants love a lot of bone. A well done implant verses a well done crown on a weakened substructure ten years down the road my moneys on the implant. Good luck with your treatment.

Members on this site don't know you the way your dentist knows you. You either trust your dentist or you do not. I do not like it when patients get onto sites and try to diagnoses and treatment plan their own cases. We only have a little bit of data and you want our advice? With all due respect, I hope my patients never do this to me.

I do not see any evidence that tooth #12 needs a bone trimming procedure. (aka Crown Lengthening) The fracture of the buccal does not appear to have terminated sub gingivally. I would place a rubber dam and bond a fiber post in the palatal canal and bond a new core. Then routine easy peezy simple crown. If that ever fails I would consider an implant.

Additionally there is decay under the crown on tooth 13. This should be addressed ASAP. Hopefully there is enough healthy tooth structure remaining to support a new crown.

lots of back and forth here. I can't tell by panorex. I agree with the dentist who said you need a periapical film and you might need a vertical btwg as well. A good periodontal exam is necessary as well. I could see both approaches. For certain, I would never splint 2 teeth together in this situation. Only will drag down the good tooth over time. you definitely need a good look at #19. Hoping that you mixed up the teeth and that's the one that's already an implant.

Here is one thing to consider. Look at the overall picture of your teeth. Multiple root canals, crowns, failing restorations. Teeth that had been endodontically treated but never crowned. At this point I believe your dentist want you to reach a predictable endpoint for your mouth. The crown lengthening plan will work, but it will most likely need to be redone again at some later point. The implant option statistically will last longer and give you less problems over the next 15-20 years. Not all implants are perfect and they require care and maintenance by you. Ultimately when I look at your mouth I see a patient with a very expensive problem that needs comprehensive care, not one tooth at a time. Find a dentist who is willing to do this all at once and be ready to commit to the work you have ahead.

I agree, this is a difficult case. I like the comments by Perio/Pros. However, all of these comments have valid points. Caution on the treatment of this case. Be ready to defend or to retreat. The patient in this case is one of the biggest variables.

As the subject patient, thank you very much for all the excellent comments! I'm not expecting to get one right answer, but want to understand the issues. I have no longstanding dentist as I recently moved to Penang, Malaysia. Before my move, my dentist of 12 years didn't believe in having crowns put on RCT teeth and it was convenient for me to go along with that, which I think I now regret. It was indeed tooth 18 that cracked below the gum & was replaced with an implant here in Malaysia. The Xray I posted is one year old. Thanks very much for pointing out the issue with #19. So I should try to find someone with the right skills, experience (and ideally knowledge of the latest techniques) if I really want to crown tooth 12 or 13. And even more important, I should find someone who I can work with to address all my outstanding issues. Just after tooth 12 chipped, the dentist who did my #18 implant examined the damage to #12 (and he had the CBCT from a year ago.) He said he could save the tooth (though he'd prefer implant) and told me that if he did crowns, he'd do the crown prep on 12, 13 & 14 (incl. post & cores + old crown removal on 13) in one 2 hour session. Sounds a little aggressive perhaps? Again, I'm very appreciative of all the comments and I've found them extremely helpful.