So Why Did the Cuspid Fracture and Where Do We Go From Here?

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Posted on By Gerald Benjamin In Occlusion

Another general dentist referred this patient to me when he noted that none of the molars contacted. The 64 year old patient was experiencing pain in the maxillary right cuspid and endodontic therapy was begun. The patient could not be made comfortable and it was determined that the tooth was fractured.

My question to the group would be: "Is it acceptable to place an implant into position #6?

My answer would be:"NO!"
Why did #6 fracture?
1. The patient has no posterior occlusion and #6 was functioning as a primary chewing tooth.
2. The maxillary anterior teeth are in the zone of function and should be moved labially and out of harms way.

Will you place an implant in harms way without correcting the occlusion?
What am I thinking?
1. The patient was referred to the orthodontist but he refused to treat given the loss of bone on the maxillary left molars (Note the palatal recession.)
2. Orthognathic surgery in a 64 year old is not probable.
3. I contacted the orthodontist and proposed that we should extract the left maxillary molars with less than 50% bone support and place implants in a more palatal position in the arch to create posterior contact. I also thought that LO inlays could be placed in the maxillary right two molars and BO inlays placed on the mandibular right molars in an effort to obtain maxillary contact.If this approach was followed, would the orthodontist agree to move the maxillary anterior teeth labially to improve the overbite/overjet issues? He agreed to perform limited orthodontic therapy.
(This case is better viewed on models than as clinical photos)

I am presenting this case because we have had recent discussions about cases where the occlusion had a significant impact on loss of a tooth but many here thought that an implant could safely be placed. If the patient lacks the financial resources is it acceptable to place an implant into position #6 without providing posterior support?

Mounted models demonstrating lack of overjet and no posterior support
Close up of models showing lack of overset

Occlusal view showing missing right cuspid and the maxillary anterior teeth are clearly in the zone of function
Close up of models showing lack of a posterior occlusion


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12 Comments

Hi Gerald,


I agree with you in this case, and have to say there are no 2 identical situations.

Your patient has lost a tooth possibly due to occlusion, the case I showed was a facial trauma.

This case has clear evidence of wear on the front teeth, which will get worse over time.

I presented a case of a deep overbite, with a stable occlusion, good MI, and no signs of tooth structure destruction on the uppers.

I believe you are offering the right solution for your patient.

Thanks


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Hi Andoni;
Having studied extensively with two renown prosthedontists , I come at restorative dentistry from the standpoint of "What caused this problem?" Almost like a 'forensic odontologist,' if you will.

Dentists tend to be doers rather than thinkers (although there are a lot of thinkers on Dental XP).

I look at this forum as a way of making us all better clinicians and from that standpoint...XP is a great success.
Your friend
gerald


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Clinica pictures and FMS would be great. I see your patient had an Ortho in the past and it seems to me position of the teeth are not right. I still would do Ortho, I would expand the lower arch with lower anteriors intrusion. I put upper molars more palatally . I still would place implant on #6 site , but would redesign occlusion. I see also that patient has acid erosion. Gregory


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Gerald,
data you show are missing on pictures and x-ray (do you have any to share?), so it can be difficult to give any opinion about the case.
Just 3 observations and some questions:
-a person of 64 years old with no right cuspid function has been balanced up to now.How do you explain that?
-patient experienced a pain and RCT was performed but she still experiencing pain: was the right diagnosys made at the very beginning?.
There are at least 10 type of pains to differentiate: was it done on this specific case?
Patient received extraction and some orthodontic in the past?
Why it was never considered to replace right cuspid a fundamental key factor for proper occlusal function?
-How is tongue situation and swallowing? What about breathing and head and neck position? And what about perio?
Glad to have your opinion about it.
(I must assume that she has no TMJ disfuctions nor trigger points on major muscle involved on occlusal function)
Armando


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Hi Armando;
I just asked the endodontist about why #6 was lost. It was not a fracture but a resorptive lesion. Periapical pain resolved with the extraction. I have supplied the clinical photos and a panoramic radiograph that you requested.
The cuspid was extracted 3 months ago before the patient entered my practice.


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why are not the rest of the anterior teeth suffering from the same outcome as #6?


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Hi Anoosh; Look at the severe wear on the mandibular incisors. The cuspid was doing the majority of the work. The only other tooth that contacts during mastication in the posterior region was the first bicuspid right behind the lost cuspid.


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Hi Gerald, I would like to complement you on your case. On this implant heavy site we often have too much confidence in using implants in a cavalier way (everything to a hammer is a nail) While patient driven dentistry is mostly what I end up doing, here as the orthodontist is unwilling to treat or the patient unwilling to sit? As a treatment option being a splinted bridge of the anteriors. Not easy for me to get a great feel for this case (bone loss, perio , compromised remaining dentition) but to stabilize this case somewhat. My guess is that everything is going to be a compromise. Nice case.


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Hi Robert; My orthodontist refused to treat when he saw the palatal bone and soft tissue recession. However, when I informed him that one option of treatment involved the removal of #14 and 15 (max left molars) followed by placement of two implants more palatally positioned than the natural teeth and in direct opposition to the mandibular teeth, he was willing to participate in the treatment plan. I would like him to move the maxillary anterior teeth labially to provide a greater freedom of motion. A resorptive lesion ,which resulted in the removal of the maxillary cuspid, is frequently caused by trauma of some kind. I am not sure why some would simply place an implant into a traumatic occlusion without altering that occlusion first. My treatment plan would include: 1. Extraction of 14 and 15 and the placement of 2 implants, placed palatal to their current position to obtain a posterior occlusion. 2. Place onlays on the right molars to obtain occlusal contacts. 3. Have orthodontic therapy to place the maxillary anterior teeth into their correct position and improving the current overbite/overjet 4. Restore the mandibular incisors with Cosmedent Renamel. 5. Place veneers on the maxillary anterior teeth to improve esthetics.


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KLS Martin
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