Perio-Ortho-Endo management of an ectopic canine related with a central incisor with endodontic involvement
I'd like to share this case seeking advice of how wold be the best way to treat this patient, I've been thinking about some ideas, but each treatment plan comes with great compromise, either periodontal, occlusal and of course, esthetic. So I really need from your input here.
28yo male patients complaining of pain related to upper right central incisor, presenting pain to soft pressure at the periapical area, no fistula was evident or any other type of discharge. Antibiotics where prescribed and the patients was referred to endo practice. Periapical rx was a problem because of the overlapping of the ectopic canine, looking like a periapical lesion shared by the apex of both teeth, so CBCT was ordered. Clinical examination revealed mobility type III of the central incisor and a large caries lesion was felt by the explorer below the CEJ in the palatal aspect of the rooth, just where the canine and the central incisor "meet" at the oral cavity.
CBCT revealed the periapical lesion was related only to the central incisor, but also revealed a large bone resorption at the bucal and palatal aspect of it.
Here is where I ask for your kind suggestions... this are the options I've been thinking about and my honest doubts about what wold be best to do:
*Extraction of central incisor and GTR
*Ortho treatment, moving forward the canine and then placing a crown
1.- Wold be best to extract and immediately do GTR, or wait 6week for soft tissue clousure?
2.- What about the periodontal ligament in the facial aspect of the canine? if is lost due to the periapical infection of the central incisor, wold the regenerated bone "attach" to it in order to proceed with the ortho treatment?
3.- What wold be the best timing for the orthodontist to start the treatment? At the same time of the GTR or 6 months after?
4.- Crown of the first right bicuspid to make it look like canine, extraction of the contralateral bicuspid to have a symmetry of the arch.
* Rooth canal tx of the central incisor, expecting to a reduction of the apical lesion or even a complete resolution of if
* Ortho tx, expecting to move the canine to its right position, probably bicuspid extractions wold be needed
*Restore the radicular caries at the central incisor as soon as the canine moves enough to get access to it
1.- Is it even possible to expect a resolution of the periapical lesion?
2.- If so, could we expect a "bone regrowth" around the roots of the central incisor?
3.- If not... can we at least expect a reduction of the bone resorption in order to have a smaller bone defect to regenerate later?
Im a prosthodontist, and of course I'm treating this patient in a multidisciplinary way with a perio, ortho and endo specialist, We all decided that a little help from the dentalxp experts will be very welcome in this case.
I'd like to add that ass you might see from clinical photos, the patient require more treatment prior orthodontics, but the main concern is this particular problem.
Thank you all!