Hopeless/Non-Restorable #8

Nice job Dr. Carter, Yes, that tooth is salvageable with one caveat, In order for Pt to maintain i.e. not break the tooth again, and not keep needing to return for repeated cementation, which pisses patients off a lot, I would have recommended doing splintted crowns on #8 and #9 since 9 is going to need something in next and splintting would buy peace of mind. That would make the prognosis better for long term retention, otherwise, Pt might go to bite something and do the same thing again with that tooth. Excellent job with helping Pt hopefully maintain the tooth at least for 5 years. My $0.02

The tooth appears unrestorable due to lack of ferrule. Crown lengthening attenuates the crown root ratio and places an increased load on the remaining root. It is likely the post or root will fracture within 3 years.

So the questions is: What is the long term prognosis? And at what cost? Even with your crown lengthening there is not enough clinical crown length for dependable retention of a new crown. The patient will need a root canal then a direct or indirect post to get enough retention. What is the cost? How much did you charge for crown lengthening? How much is a root canal and a post and a new crown? The patient has spent all this money and the foundation is still extremely weak and prone to failure. Are you sure this is the best treatment? A single implant would cost about the same and be multiple times stronger than an endodontically treated tooth with minimal ferrule. Also, splinting 8 and 9 would help in the short term but not in the long term. What happens when #8 cement bond breaks? How do you get the crowns off to recement #8? Will the patient even know it's loose or will it only be discovered when there is recurrent decay under the crown? All these questions should be answered before a final treatment is determined. The patient should be brought into the conversation as well and the risks and benefits of each treatment discussed. Hopefully you discussed this option with your referring dentist as well. A quick way to lose a good referral is to undermine their treatment plan. Thank you for posting this. Hopefully it will help other practitioners in their differential diagnosis and treatment planning of the fractured tooth.

This particular 72y/o retired pharmacology PhD was eager to save his tooth and not have an implant. Good point but I covered the obvious. With good technique a bonded core eliminates a lot of these issues. It has been shown by Dr. Strupp/ Chasolen/ Melker that these cases can be successfully maintained for 25+ years........ with good restorative technique. The real problem lies in the trend towards restoration of titanium vs. teeth. Much easier to restore titanium!

When there is a possibility of saving a natural tooth....then go for it...…. and in my practice, I extend a courtesy to the patient, that if the natural tooth after having endodontics, a post and core and a crown does not last at least two years, then I will extend a portion of the fees paid toward what the implant replacement will be....hopefully it will not be necessary, and the patients are always grateful with this kind of arrangement..... assuming that the #8 is considered by itself, and in not some kind of splinting arrangement......by the by, look at the #9, there are craze marks in the enamel, and it may be on its way to fracturing as well.

A typically simple post-and-core case after root endo. The tooth is definitely salvageable with a good long term prognosis. It is nothing to discuss for certified prosthodontist.

Great case. I’ve did a similar case a few year.s ago.We discussed all of the options and cost was a factor and he wanted to keep his own teeth. We did a composite build up, left some room on the lingual, orthodontically extruded it, got a the 2-3mm ferrule and did a pfzirconia crown. Unfortunately despite all of that and some very careful crown work it fractured after 2 years, which was disappointing. I think what really did did it was the lack of occlusal support in the rest of his dentition.

Bravo! More teeth should be saved in this manner.

The discussion on this so far purely implant dominated forum is now taking a new but very good U-turn. At least we now seem pro to consider including alternative options for teeth that so far have been sacrificed with the option of titanium. Presenting all options with cost and risk benefits of each to patients and believing and remaining current and upto-date in the wonderful restorative work possibilities will certainly bring some input to us to proceed further what is a patient-centered therapeutic approach.

Many issues with this case. The main problem here is lack of adequate tooth structure. Following are points that should be considered: 1. Ferrule. 2mm is not sufficient for adequate ferrule. A comparison of publications will demonstrate that gains in stability start to decrease when abutment length reaches 3-3.5mm, so I would teach my residents this as a minimum. Posts increase retention but do not increase resistance. Restorations with posts have a lower survival rate. 2. Occlusion. Ferrule studies are typically done in vitro and do not take into account the patient's occlusion. In this case, the photographs seem to indicate that the patient may have a significant overbite, which will add to the risk of displacement or fracture. 3. Biologic width violation. The restorative dentist will most likely extend the preparation margins more subgingivally in an attempt to increase abutment length. Very often these situations end in a violation of the biologic width. 4. Forced eruption. If the patient insists on saving the tooth, Forced Eruption is an alternative worth considering, particularly taking into account the length of the root. Treatment will be prolonged, since a 3 month stabilization period is required following orthodontics. Performing fiberotomies during the tooth movement will prevent coronal migration of the attachment apparatus and eliminate the need for subsequent crown lengthening. The resulting alteration in the crown to root ratio per se is not a problem, but rather the potential for lack of stability. Besides, there is no agreement in the literature with regards to acceptable crown to root ratios, and a number of Perio-Pros publications have shown excellent long term survival of restored teeth with healthy but reduced periodontiums and much less than ideal crown to root ratios. This tooth has a long root and therefore stability should not be a problem. 5. Implant. I would argue that properly placing an immediate implant and provisional in this case is technically more demanding than saving the tooth. However, taking into account the survival risks and prognosis, it would be the option I would choose.

Crown lengthening, endo, bonded core, bonded crown all done well verses an implant supported crown. In 5 to 10 years my moneys on the implant supported crown. Dr Carter you are a skilled clinician. Good you listened to your patients desire to save the tooth. If the patient understands the risk and is willing to accept the consequences of a possible failure you have a green light to proceed. I would splint the two centrals in my practice. Good luck with the case.

This tooth need RCT/ custom post and core and will excellent prognosis. I place a lot of implants and this case would be best handled by traditional dentistry! Thanks

Not sure how so many can make judgement calls on this case with out all the information . Seeing just one section of the mouth and decided what is best . NO CT taken to decide angulation or treatment of an implant placement . No occlusion perspective at all , Just the obvious wear . The mans health . The prognosis of the remaining dentition . Seen way to many failing implants or problematic angulation issues and or proper tissue management . To say did he do the right or wrong thing . The correct thing is he gave options and informed patient .

Another good case which has prompted good discussion. I would never have considered an implant as an option in this case. Even if the patient was younger I would have restored. In this case, unless the patient lives more than another 25 years then I would expect a post crown to last a life time if done properly. If the patient was younger I would expect around 20-30 years life from the restoration and then possibly only requiring a crown replacement. The only debate in my mind would be whether to do elective endo. I have done it both ways (pins and direct boned resin core or wrought post and cast core) and I have found that pins and resin core have a slightly higher failure rate over 15 years). So I would probably consider endo and post and core a better option but it depends on the bite and whether the patient is a bruxer. I point out however that when I do such a restoration, I remove only a minimal amount of root structure (the widest post I use is 1.5 mm and the smallest is 1.2 mm) and I would use all the existing coronal structure for resistance and retention form. I also only use 50% or less of the root length (certainly not two thirds which used to be the recommended ratio). I am not sure how much bone some dentists want but my experience would indicate there is more than enough for a life time in this case. Similarly there is more than enough tooth structure to restore. I would view this as a simple restorative case. I never recommend any particular restoration method unless I feel it has at least 85% prognosis for 15 years (in some cases a life time). Obviously there are many things to consider when assessing each percentage prognosis. In this case my estimate would be 95% survival rate for at least 15 years. My guess for the majority of my patients is that they will live to 85 years old, and consequently my treatment plans are orientated around having them retain their remaining dentition to that age. So in this case my bet is that the patient will be happy with Timothy’s treatment option.

I agree the tooth is savable as long as ferrule can be achieved and osseous crown lengthening is key. But IMHO endo needed as a post is needed to have sufficient core for the crown. I am not a fan of short prep in anterior with not much more than 4mm from the margin due to off axis loading when occluding. I also prefer tapered fiber posts to metal posts

Lots of interesting comments whether to save or not, however you are avoiding the biggest question. The dentist referred the patient to you for extraction and implant placement and you opted to change the treatment plan and even refer to Endo as well. This is poor communication and the patient is the one who will suffer here. Additionally, your crown lengthening will not fail but the crown will and who will the patient call when that happens? You clearly have the right and duty to not perform treatment that you disagree with but this is not the way to do it. I imagine you will not be getting many referrals from this dentist moving forward.

Would it be possible to ask the primary dentist for sharing some photographs and xrays of this case post op..? Also showing the occlusion. ..?

I was not surprised that the majority of responses were in favor of extraction and implant. I personally would have performed the endodontic treatment, bonded fiber post and composite core placement while the dam was sill in place, minimal crown lengthening surgery and immediate provisional in one visit. 8 weeks later I would make the final impressions and two weeks later deliver the crown. Having restored hundreds of very similar situations this way I would not be surprised to see this restoration service for the remainder of his life. FWIW I have been placing implants for the past 13 years and place many immediate implants.

I believe all are not happy with your choice to change a treatment plan that is not wrong to something that was your unsolicited opinion. It is wonderful you place many implants and read about restoration. But, the referring dentist probably does at least 1000 posts and crowns a year and reads a lot about implants! Let’s see the pictures 3 months post restoration. I am guessing the gingival contour is irregular and the margins to the PFM on #7 are clinically apparent making this a poor choice. You should invite the pt for a post op check up and repost. Good luck

I am not sure if it due to an established relationship I have with my referring docs or if they are just genuinely good people and open to discussing different options/alternatives. This discussion has taken a bad turn by some who seem offended by the very nature of my presenting an alternative to a patient that was referred to me. In this case, and many others over the years, I see the referral and upon listening to their chief complaint might discover another previously unmentioned alternative to treatment. It is also important to add that many times patients provide me with slightly different information than they do the GP and vise versa thus making it a "TEAM Approach". Under these circumstances I will call the the referring doc, which I work with about 40, and make sure we are all on the same page before presenting the options to the patient. With this approach I have not run into problems and more times than not it turns into a learning experience for either myself or the referring doc. I have had many of cases where I discover from the referring doc that I have missed a valuable piece of info and often times the doc realizes that I present an option which they did not consider (this case for example). It has not been a problem as we have not allowed our own egos to interfere with the "TEAM Approach".

this would be Essix provisional, root canal, PET, bonded Flexi-Flange extending into the root below alveolar crest level at least as far as it extends above alveolar crest level, core, bonded Lithium Disilicate crown in my practice. I place a fair number of implants since 2000.

Two very useful resources to know more about “when to save or remove a tooth” are: 1. Kendrick S, Wong D. When to restore or extract—a clinical guide. Inside Dentistry. 2011;7(1):42-50. 2. Bernstein SD, Horowitz AJ, Man M, et al. Outcomes of endodontic therapy in general practice: a study by the Practitioners Engaged in Applied Research and Learning Network. J Am Dent Assoc. 012;143(5):478-487

Looking at the comments on this post it would appear as if many people view traditional as dentistry as disposable. I think it is safe to say that 20-30 years ago this particular case would be salvaged with endo, post/core, and crown with the intention of the restoration having a long serviceable life. Now because of implants we have a better option and we seem to prioritize it referring to it as better and more definitive. I have been doing this long enough to see problems with both teeth and implant supported restorations. What I have realized is that "tooth born problems" are much easier and less time consuming to remedy than "implant born problems". If salvaging teeth can improve quality of life and provide a good service why jump to an implant when another option exists? There are a number of reasons, I think, which include but not limited to: 1. Patient preference/desire 2. Doctor preference 3. Ease of restoring implant vs. tooth 4. Perceived invincibility of implant restoration 5. Fun and cool to place implants vs. old and boring to salvage teeth 6. Let me try out this new technique I just learned I often joke with other docs about the fact that every time I open a vial to place an implant that vial has an expiration date on it....... Does that mean that I need to be recalling all of my patients and removing these expired implants? (Just a joke as I know the FDA requires an expiration date on all devices so please spare yourselves the opportunity to jump on this). When making decisions and discussing with my referrals I always consider the cost (time and $) of repairing the inevitable end of the serviceable restoration. If a reasonable degree of service can be anticipated from a tooth born restoration then it is my opinion that this future problem will be much easier to address than that of an implant restoration. In other words I like to give teeth a chance but sometimes, as we all know, the tooth does not stand a chance. This is coming from me "Tim Carter" who used to say "A root canal is never complete until it is obturated with a titanium screw". Everything has problems and I like to consider how that problem will be addressed but in the end it is all abut meeting the patient's desire which might require us to avoid the temptation to resort to our "go to remedy".

I agree with Dr. Flanaghan. Show me this tooth in 5 years, if it is still there.

Timothy, you are correct about the U-turn in the conversation. I suspect egos are getting in the way here. Well done for opening up this thought process. It is worrying that many comments say this tooth is not salvageable. I would put this tooth in the simple complex restoration category and it is a concern that so many seem to feel it cannot be saved. This may be due to: lack of clinical expertise, lack of experience in observing success rates of various methods over decades, lacking of undergraduate training skills, clinical bias for whatever reasons. Nevertheless it is sad that some are so adamant that saving the tooth will lead to certain failure. Prior to implants being viable and readily available, virtually every dentist would have restored this tooth (some well and some badly). In almost all cases, if they restored it well, this patient would most likely have died with the restoration in place. The reality is that none of us know exactly what the result will be – whether restored or implanted. We can only reflect on statistical data (mostly not our own but other operators) or our own experience (or other operators’ who we have observed). So in truth we are all going to provide our “best guess” – and for a variety of reasons - some will be able to provide a better guess than others. There will always be a wide number of opinions between dentists (we are a strange group who love arguments – many times just for the sake of it) but it is always wise to consider others’ opinions and most certainly consider alternative treatment plans. In this case the possible post-op problems of restoring the tooth are real and obvious. But the risks are minimal if you restore well and design and engineer the restoration well. Clearly all aspects need to be taken into consideration (occlusion, number of remaining teeth, perio, age, etc). However let us not be naive about the possible problems of placing an implant. There is an acknowledged failure rate of 5% (I know a good operator will have less than this – but for a fair comparison to crown failures you have to review the stats across the board). There is also only a success rate of 55% to 65% (again I know some will have a higher success rate – but you can only compare across the board). The real worry with peri-implantitis is that in some case we do not really understand why it happens (I realise that many times we do know why) and more importantly - treatment is difficult, costly and many times unsuccessful. So both approaches have risks which are substantially reduced with good diagnosis of all problems and also if the operator is well skilled. I say again, it comes down to the best guess after considering all the options and circumstances. The concern for me (with this current discussion) is the apparent haste some are advocating an irreversible option because they feel the tooth is doomed to failure when in my opinion, in skilled hands, restoration is very viable. Secondly, there seems to be a group who feel that implants are perfect and are oblivious to the fact that once an implant is placed the alternatives may be markedly reduced if failure eventuates.

the main issue is the surrounding dentition. There is very poor support so any restorative plan has a questionable prognosis. Yes, lets see the final restorative photos. why Dr. Carter would you think your opinion over rides the referring Dr. and patient decision to extract and place an implant. That was the decision the DR. and Patient agreed on . Lets face it ,neither option is predictable long term without consideration of the rest on the occlusion which is failing.

Some had asked to see post op images 3 years out (expecting the treatment to fail within 3 years). I was able to contact the patient and have him come in for photos which are 33 months post restoration (Sorry but it is 3 months shy of the 3 years). After my last visit he was sent back to his referring/restorative dentist to have the final restoration completed which she did 33 months prior to this attached photo.

Photo attached

This is Tim Carter posting I am not sure why it posts as Anon

Bravo! Periodontists save teeth. Strupp, Chasolen and Melker (the periodontist working with both of these excellent prosthodontists) can show cases like this that have held steady for 30 years. A natural tooth generally trumps an implant. A natural tooth has epithelial attachment, connective tissue attachment, PDL, Lamina Dura, excellent blood supply of the surrounding bone and the full complement of elastic fibers around the neck of the tooth. An implant has an epithelial attachment, little or no connective tissue attachment, no intervening PDL, no Lamina Dura, a reduced blood supply (no LD and PDL) and reduced elastic fibers around it: these factors render implants more susceptible to inflammatory breakdown (peri-implant mucositis or peri-implantitis) which is much harder to control than inflammatory breakdown around a natural tooth. I've been placing implants since 1984 and would much rather deal with complications affecting a natural tooth.