Broken crown at 21: How would you approach this case?
This 55 y/o male patient presents with the chief complaint of broken off crown #21. His medical history is multiple sclerosis and depression. He takes texidera, klonipin, effexor and smokes marijuana. Tooth #21 broke off at the gum line and patient wants to place an implant. The existing mandibular bridge from 22-28 is failing with open margins but periodontally stable. 22, 27, and 28 are the only teeth supporting lower bridge. There is severe overbite and maxillary teeth very long and soft tissue thin and inadequate. Maxillary bridge is implant supported. Implants are at #5,6,7,8,9,11,12,13. Implants were placed and restored by previous dentist in 2008. Patient was unaware of any problems with upper arch and can only afford to restore lower arch at this time. How would you approach this case?
15 Comments on Broken crown at 21: How would you approach this case?
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Albert Internoscia
9/15/2015
I would love to comment on this case but without a Panoramic Xray, Cone beam or FMS it would be all speculation. From what I can see from the photos, posterior occlusion is compromised so an occlusal photo and a photo of mounted models would be a good starting point.
OsseoNews
9/16/2015
Thanks for the comment. We have added the panoramic xray for this case. Please see the case gallery above.
Albert Internoscia
9/16/2015
I would consider the option of removing the lower bridge and teeth and replacing with a Hybrid Bridge over 4 or 5 implants. This will allow you to restore the posterior occlusion and open vertical.
Peter h.Liu
9/16/2015
Most people at this age cant tolerate sudden change of bite opening,therefore,opening the vertical isn't an option at this point.Cost wise,I would put in 2 Implants on lower Rt.take out tooth 21 and replaced with an immediate implant,do bone block graft on lower Lt. molar area to increase the vertical for molar Implant.
SFDIndy
9/17/2015
After discussing ALL of the aforementioned findings, if the patient's chief complaint remained #21, I would address his chief complaint. Extract #21 and place the implant. If the lower bridge fails in the future, #21 implant can become part of a 4 implant hybrid bridge.
Gregori Kurtzman, DDS, MA
9/22/2015
Endo treat the remaining 4 mandibular teeth place fiber post cores and a a new bridge
Sharon Goodwin
9/22/2015
Hi Gregory;Thanks for your interesting response to this case! I was just wondering why you decided to opt for root treating the remaining 4 lower teeth and redoing the bridge vs doing a hybrid and allowing the vertical dimension to be opened? Do you think it would be a problem in a case like this to open the vertical improve anterior occlusion?
Thank you!!!
Gregori Kurtzman, DDS, MA
9/22/2015
His med hx and smoking concerns me with regard to how implants will integrate. so since the roots are good length I say preserve them and less issues
You can open the bite when you redo the bridge on the natural teeth.
SFDIndy
9/23/2015
Why would you endo 22, 27 and 28?
Gregori Kurtzman, DDS, MA
9/23/2015
Precautionary as I think they have a higher chance of flaring up when the teeth are reprep and decay removed to do the new bridge
Gregori Kurtzman, DDS, MA
9/22/2015
Oh with regards to the upper arch the issue IMHO is lack of attached gingiva and the implants may have been placd too buccal and this adding to the situation
Sharon Goodwin
9/22/2015
Thanks Gregory!!!
Dr Bob
9/23/2015
What does the patient want? It also appears that perhaps there has been in the past some dental neglect on the part of the patient. Was he in a situation that caused this to happen or was it on his part?. What was the cause of the fracture of the bicuspid? Why is there so much inflammation of the gingival tissue on the maxillary teeth? How much can the patient afford to spend on this treatment? Considering the medical and behavioral history redoing the bridge on natural teeth will in a short time result in a failure. SFDIndy has a good suggestion. I would also explain to the patient that the condition of the remaining dentition is not ideal and he has problems that will lead to failure in time. Then present the options and have the patient decide what option to follow and sign a consent form. I would also consider referral to a periodontist at least for evaluation CYA.
Adildental
9/23/2015
This case needs to be treated as a temporary lower arch reconstruction by either a root canals for all the lower teeth then place a bridge 21-28 then a partial denture until the patient decide to have the upper teeth repositioned or extraction of all the lower teeth level the bone and place 5-6 implants might be short ones in the molar area and reconstruct the whole arch with fixed prosthesis. That should be done after a denture fabrication and some attachments as an interim period.
Dr. Rodger Uchizono
9/29/2015
Just out of curiosity to the previous posters, why not just do the endodontic treatment on #21, restore with a post/buildup/crown and save this patient all of the above mentioned treatments? His medical and dental histories indicate the need for minimal intervention that solves the current problem.
-RodgerU
