Failing Central Incisors. How would you treat this case?

414 Rating(s).


Posted on By Howard Gluckman In Anterior/Esthetic

This patient presented with poor aesthetic crowns on the anterior teeth and wanted to have them replaced. She is open to options and money is not a limiting factor in this case.


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52 Comments

Howie. My first consideration would be PET / immediate implants with immediate provisionals. The new gold standard for me.Best regards. Chuck


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Great idea Chuck. But what about the large apical areas and the buccal fenestrations. How would you manage that with the PET


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I am not necessarily concerned with the apical regions. The determining factors for me are the health/stability of the remaining tooth structure and the available bone remaining for ideal implant placement. I would expect the peri-apical regions to heal after the source of infection is removed. If the patient is "on board" I would would let it "play out" one step at a time.You can always extract and graft at any point. I look at cases totally different now.Best regards. Chuck

Fractured tooth with peri apical pathology
PET/ implant / provisional


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chuck this looks ok and there is no problem if the buccal wall is intact but it isn't in this case so one cannot just leave it to resolve. That is what worries me here. How would you approach the apical fenestrations. you can't just leave them


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Just focusing on the centrals and scans, whats left of the root system should be extracted ( complete ) area debridement and re build the buccal w whatever material and technique works for you. IMO start from scratch. Buccal is a mess.
Love to see a simple Xray of the site.

Rocco


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Sorry Rocco I don't take of these cases as CBCT are much more informative. Your idea is a good one though. 1 miracle at a time


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Howard
Clearly scanning is revolutionary. I am still a big fan of probing and simple X-rays for evaluation of inter proximal bone of the neighboring teeth. Mainly because I am accustomed to it and on occasion get more information. I would prefer both...

Thanks, Rocco


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Hi Howard, before, or together with, all the surgical intervention discussed previously... just from a total esthetic/smile design point of view, i.e. tooth composition, proportion and form of a) the centrals and left lateral... appear too narrow, and b) 1st premolars are tucked palatally and break-up transition/integration of anteriors & posteriors... I would consider ortho to unravel and possibly widen the arch form.


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Henry thanks for the commetns. I totally agree with you and ortho was our first point of discussion. The patient is in her late 50's and is not interested in any Ortho. She is "happily married" and is not interested in a larger intervention to imporve what she is happy with. SO we are limited to the aesthetic result we get here.


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Hi Howie;
I agree with Henry.
The 'problem' with surgery guys is that they only see the trees and never the forest. How many implants can I place is what most clinicians see.
"Everyone" pays lip service to 'the cases are restoratively driven' and then they want to place implants before a high level restorative evaluation has been performed.

Everything Henry sees, I see. The maxillary right and maxillary left anterior regions are completely asymmetric with the right side having being in anterior plane and the left side immediately heading towards the posterior plane.
We have tooth size discrepancies and this would be the time to correct it. Teeth are also palatally positioned and do not fill the buccal corridors.
1. Get models, mount the case and analyze tooth size and position.
2. Get an ortho consult with digital impressions
3. The restorative dentist, the captain of the team, meets with the orthodontist and explains the restorative goals to the orthodontist. The orthodontist remains a subcontractor of the restorative dentist and makes no decisions other than those that meet the goals of the restorative treatment.
4. A surgical consult is arranged to permit the surgeon, also a subcontract of the restorative dentist, the opportunity to evaluate the surgical complexities of the case.
5. The case is either waxed up or now a digital wax up is performed to determine the final outcome of the case BEFORE treatment begins.
6. A final consultation is set up with restorative dentist, orthodontist and surgeon to sequence and time treatment.

This is a restorative case with orthodontic and surgical components.


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Totally agree with everythig you hand Henry have said and this was the first choice for us as well. However it is not an option and the patient not interested instead so we need a treatmnet plan that will suite the patients needs in this case. I look forward to your reply.
thanks
Howie


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Gerald. I agree and see what Henry sees also. This is an ideal "set up"'for a multi discipline Perio - Ortho - Prosto approach. Best regards. Chuck


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Wow....good discussion here. Would consider "PET" Partial Extraction Therapies, if I can manage to maintain stability of the segment and manage the open periapical pathologies and labial fenestrations through a Remote Flap (Esthetic Buccal Flap or Apico style Semi-lunar incision in the Mucosa). Mo


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Now we talking Mo. I like it very much


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Please get your orthodontist involved. Best regards. Miguel Hirschhaut


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Miguel we did and the patient is not interested. SO what do you do. Do you find an alternative treatment option for this patient to treat there needs rather than ours or do you refuse to treat the patient. I look forward to your reply. thanks for the comments
Howie


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Howard, as you know there are esthetic options in orthodontics today. If those options are also declined. Then I think having the best interest of the patient in mind. The general principle of "some treatment" is better than "no treatment". This to me is a classical ortho/perio/restorative team case. But giving a bronze medal option type of treatment. Instead of a gold medal type of treatment. Is better than no treatment. My concern with the "no ortho treatment approach" is NOT getting all the functional & esthetic goals. As long as the patient understands the gold medal. He can allways get the bronze one. Poor upper arch form and no interarch coordination is the setback of the "no ortho" option. Upper left lateral is narrower than upper right lateral. Golden proportions are affected all across the antero-superiors. Keep us posted on what you did. Best regards, Miguel


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Miguel I agree totally however I also believe that the patients gold standard and our own gold standard are not that of the patient and although we might perceive it as bronze (and i agree with you on that) the patient may perceive it as gold. I am also not a big one for doing ortho to improve occlusion as I do not see too many cases of brilliant occlusion post ortho and I also see many what we would term disastrous occlusions that are happy and comfortable despite no therapy. I am also not aware of any great long term data to show that this type of occlusion will definitely lead to this type of problem if left for 10 years or longer but I dont read ortho literature so that is most likely why.
thanks for your posts as always
Howie


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Dear Howard. Keep in mind that if you do not treat orthodontically. Crowding is going to be a lot worst in 10 years for sure. If you want long term orthodontic studies. There are plenty in the AJO. Please read the University of Washington studies on crowding and long term stability. I think orthodontics is a great tool for restorative cases. So with all due respect. I do not agree that orthodontics does not accomplish functional occlusion goals. Your amigo, Miguel


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Miguel I agree with you on crowding what I refer to is occlusion. Which are two different things. And to reiterate my stance I would definitely want to do ortho first here.


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Miguel Perhaps you misunderstood what I meant. Crowding is an issue and I totally agree with you. What I am talking about is occlusion only. This is where I have a problem as most cases I see so I am telling you about my personal experience is that when patients have this the "improved occlusion" is not that great either. Then it also begs the question what is a good occlusion. My apologies if you feel I insult your specialty it is not my intention. Just a question about occlusion. It is one that is thrown about a lot and IMHO not well understood.
regards
Howie


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Miguel. Is there anything in the Orthodontic literature regarding passive eruption and or mesial drift over time when implants are included as part of the restorative solution? Occaisionally I have seen open contacts mesial to implants and loss of anterior guidance associated with shortened occlusal edges. I would also be interested in your personal experience as well. Good to have you on the Forum. Best regards. Chuck


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Charles there was a paper presented at the NY nobel conference last year about the fact that there is a situation of late mid facial growth that leads to opening of contacts with implants and I have a number of cases myself. where over time there is a gap appearing between implants and natural teeth in patients 30 -50 yrs old


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Hi Charles. I do not know of any papper on implants and late adult crowding as I think of it. My experience is that if crowding is left untreated will get worst. Late mesial migration or adult onset crowding as I call it. Is only treated through orthodontics and long term retention. In my practice I use an upper retainer for night wear and lower fixed retention for life. Changes occur over time. The only way to avoid them in orthodontics is long term retention. The Seattle group of Little et al gave us great studies on long term stability and the importance of long term retention. Have a great day. Miguel


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Gentlemen; This discussion on "latent growth" and "mesial migration" and "open contacts" after implant placement is a bigger issue than most people are aware. I have seen this personally in our Atlanta practice as was mentioned above. Ortho studies coincide with these findings but people continue to be treated without ANY form of RETENTION devices.....This is a MISTAKE in my opinion and since it takes decades not years it does not seem to be getting the ATTENTION it deserves. If we treat this patient as is and RETENTION is applied as an important aspect of long term therapy then it can be successful although NOT ideal. regards Maurice


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Maurice, I agree with you totally. LONG TERM RETENTION. In my 20 years as an orthodontist I had patients refuse treatment. Than comeback 10 years latter looking worst. Ortho I think is the best way to improve long term periodontal health for the adults as well. It is a matter of informing our patients. Comunication is the name of the game. Miguel


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In so many case we are told, "The patient doesn't want."
Why would quality clinicians agree to treat patients that want minimalist treatment or outcomes? When patients want to control the case so that I will never and can never be proud of the outcome, I simply tell them that I can not be their dentist.

Howard, why would you care so passionately about the surgical aspect when no matter what you do, there are going to be issues with the case down the road as Miguel so clearly indicates?

Learn to do a chairside direct resin mockup so that the patient can SEE how fabulous they can look before you ask them to commit to comprehensive treatment. You have built no value for the patient and therefore she will not buy more than she thinks she needs. Currently when the patient puts on lipstick, she knows that she has no lip support on the left side. Add resin to the left side and let her SEE that she can have a symmetrical lip again.

When dentists start telling their patients "NO" then maybe more patients will say "YES"

In my practice, we never sell the patient a car with only three wheels because that is all the patient thinks they need.


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Gerald. 100 % percent in agreement with you. Besides there are bolton index issues. Golden proportion issues. I think ortho to the patient will be very helpfull. My prosthodontist and implantologist that I work with fully understand the importance of Ortho. Miguel


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Miguel there may be a thousand issues but to try and force a patient into therapy that they don't want or feel they need and is only being done to improve aesthetics that we as practitioners feel will improve their life is in my opinion what I would call a "wallet biopsy". If this patient is happy with their aesthetics then why are we trying to force an issue here. If however it is far more than aesthtics then by all measn try and convince them but this patient is happy as is just has some discomfort on the centrals that have been there for years. In an ideal world yes we would like to make the spaces wider bring the canine in and straighten the arch but im sure you would agree we do not live in an ideal world even though it would make for nice case presentations.


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Miguel there may be a thousand issues but to try and force a patient into therapy that they don't want or feel they need and is only being done to improve aesthetics that we as practitioners feel will improve their life is in my opinion what I would call a "wallet biopsy". If this patient is happy with their aesthetics then why are we trying to force an issue here. If however it is far more than aesthtics then by all measn try and convince them but this patient is happy as is just has some discomfort on the centrals that have been there for years. In an ideal world yes we would like to make the spaces wider bring the canine in and straighten the arch but im sure you would agree we do not live in an ideal world even though it would make for nice case presentations.


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Gerald We do do mocks up and DSD all the time however I totally disagree with you that you should not treat the patient if they dont follow your advice. I have never and will never be that kind of dentist. If that is the way you do it respect to you but the way I build my practice is to make sure that both myself and my patient are on the same track. There are however occasions when I do refuse and that is patient with active perio that only want the implants but refuse the perio then I refuse the treatment but to say that is if a patient does not want the aestheti result you think is best and wont treat them on that basis I think it is arrogant. And im sure you dont mean it absolutely outright either. And another issue is that no matter what I do and no matter what the patient decides I will alwyas treat them with the same passion, enthusiasm and care regardless


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Hi Howard;
If you go to the Mercedes dealer to buy an S550 and you tell the dealer that you will buy the car if they agree to replace the top of the line $400 per tire with an inexpensive $85 tire what do you think they will tell you?

You presented the absolutely perfect case for a discussion on standards because there so many issues with this case. This is not simply a case where the midline is off by .4 mm and one can understand if the patient tells you that I will not spend thousands of dollars and 3 years of my life to gain .4 mm.

I guess the gold standard would be:

"If you place the implant and crown would this be a case that you were so proud of that you would put it on the opening page of your website or post it on Facebook?"


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Gerald your analogy does not make sense for this case. This is not a patient that wants a mercededs for the price of volkswagen. Your argument is that you will not be dictated to by a patient. So you are making sweeping statements that are totally invalid in this case. No one in their right mind would not treat the patient because they wont follow your aesthetic standard. This patient is not asking for cheap treatment, quite the contrary they are wealthy people who can afford whatever treatment plan they decide is right for them. So when a patient comes in with some discomfort in the centrals and we look a t the apical areas and see a major issue and then the treatment of the 2 centrals need to be treated together. Our responsibility is to make sure the patient understands all the options and all the possibilities which has been done in this case. Once you have done this the responisbility passes onto the patient to make decision about treatment. NOW you are right that if a patient refuses trestment that is going to be detrimental to your treatment or to them in the long run I fully agree with you that one says no and they either accept your treatment or they go elswhere. But to say that one should refuse treatment on the basis that they wont accept your aesthetic treatment plan even though it has been presented to them on all levels is beyond comprehension and a little arrogant. I have no doubt that you do not do that in your own practice. SO not all cases are the perfect ones but we accept that and go for Bronze but still do it to the best of our ability and with the same passion as Im sure you do in your practice. But it is good to discuss and point out as there are many out there that hopefully read these ranting we write and learn something from them. But we need to be careful not to pontificate


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Hi Howard
I like the idea of ortho, and when for prosthetical reasons I think I needed, what I say to the patient is
1.- A 2 month ortho , that may be 3.
(The patient thinks that all orthos are 18 months)
May be she is tempted for the reason of the time and with the idea that with extrusion of central incisors aesthetic will be better!
(BTW I expand the 14)
2.- Fixed bridge from canine to canine with RST on central incisors and apicoectomy with my high horizontal incision. ( As Kan mentioned, below lip line)
3.- Total time of treatment: 4 moths.

You change aesthetics, and periapical problems.
If patient doesn´t like. another Crown to 14.

Simple and easy.
If we don´t extrude incisors...gingival level is very high, if we extract incisors we have to do Block graft +CTG to compensate ridge...(to much: RST is quicker, simpler and safer...after apicoectomy)
Hope it works for you
Jorge


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Jorge. Nice solution. Why stop at canine to canine? Best regards. Chuck


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Im all for the ortho option Jorge and we had the consults to look at that as well. This patient does not want ortho its as simple as that. I dont thin refusing the patient treatment is the right way to go as there is a simpler solution that I will post soonthat gave the patient a pretty good aesthetic success and the patient is over the moon.


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Jorge, the ortho that was suggested involved a lot more than 4 months and was more like 2 yrs. We spoke about all the options of invisalign as well as lingual ortho. So I am no expert in the field so im not sure a quicker solution is the answer. I personally would not want my healthy teeth cut down for a bridge and I do draw the line on this in my practice as bridgework IMHO will only lead to further implantology further donw the line or at least further endo. She is happy to have implants so it is my first choice here.
As far as the extrusion is concerned Im not sure it is necessary as the patient has a low lipline. So is there need for adjusting the gingival contour?


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You are right Howard, if the lip line is low, as it is, you don´t need to low the gingival margin...But the new teeth aren´t going to look very narrow? What about the dark lateral incisor?
A crown I suppose...or a veneer.
Apicoectomys...
My concern is that there are very huge post and I don´t trust on them. If I want to pull them out...it is risky. Re-endo?

Waiting for the solution!
Jorge


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Jorge he is happy with implants so that is the route I have chosen. I will show the results tomorrow to keep everything fresh.


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Almost like yours! Gregory


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Gregory. Nice case. It appears you will be adding CTG also? As much as I like this approach, it is not my first consideration anymore. Best regards. Chuck


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Nice resuslt Gregry


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Dr. Gluckman, like you have already done, I would have recommended an orthodontic and restorative consult as they will be needed for an ideal overall outcome. Also, like you, I would not dismiss the patient from my practice if she refused to accept my recommendations. In light of the current evidence of pet's I'm guessing a combination apicoectomy/socket shield/immediate implant/immediate non functional loading would be useful. Apico to remove the diseased hard and soft tissue and SS to preserve the remaining labial plates and architecture since adjacent teeth are to be removed/replaced. I have not done one of these yet, but I would likely try to do this all in one procedure and sequence it as: complete the apicoectomy first, then ss/implant, bone graft from the bottom of the site up until you can see bone coming out the coronal aspect around your implant platform, and provisionalization if adequate primary stability was attained. I'm sure you have already completed this case and am looking forward to your sollution(s). A case well suited to your level of skill! Take care, jb.


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Johnathan spot on. I totally agree with you on all counts and it is exactly as we have done. I will post the case completed with 1 year follow ups CBCT and PAs later and a bronze medal aesthetic result but the patient is over the moon.


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Howie,

stop the suspense!

I know ortho is not an option but if it was- would you consider cleaning out apical areas and the ortho extrusion while apices heal then implants on centrals

if no ortho- how about "veneer" correction of composite touch up like I think Michael Apa showed?


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If it were possible I think I would have liked to pull them down yes for sure. I would definitely have liked to go for gold as it would be an award winner.


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Now listen to the surgeons talking about Ortho solutions....this FORUM is AWESOME!! Mo


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Great stuff and great forum. I would like both Gerald Benjamin and Miguel Hirschhaut to look at the final of the case and see what they think.


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Nice Howard. We would have done it a little different. Integrating ortho in the team approach. Please keep us posted on long term results and long term stability. As I told you earlier in my first post. I am looking 10 years down the road. Specially with everything we know today about late onset adult crowding. Did you read the studies I told you from the Seattle group ? You have an orthodontist friend in Venezuela. Looking forward to meeting you personally in the future. I love interdisciplinary cases and specially anterior ones. I will show you a few in my upcoming Dental XP webinar. I am preparing first all my slides in english for you. Looking forward to your comments about my presentation. Keep in touch. Your amigo, Miguel


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Thanks Miguel. I agree with you and we DID have the ortho input. I look forward to your webinar.
your friend in Sout Africa


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Just remarkable treatment and result. absolutely TOP of the game. Thanks Howard for sharing this surgical "game changer" with us. Mo


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Mo,

thanks for the compliment- I always ask for ortho input and always invite to my study clubs

Howie,

your surgical thinking is remarkable!

Cheers,

Richard


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