Treatment Suggestions

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Hi everyone,

I just received this email regarding the management of a patient. Does anyone have any alternate ideas or suggestions?

Thanks!

Rick

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Begin forwarded message:

Rick,

I am attaching an x-ray image of a longtime patient that I would like your opinion on. He is about 22 years old and had orthodontic treatment by Dr xxx when he was a teen. He has a submerged and ankylosed lower left 1st molar that has been a problem all along. The occlusal table is exposed but level with the gingival crest. Maintaining this tooth decay free will be unlikely and restoration will be impractical. I am wondering if you can remove enough of the coronal portion to allow some type of grafting that would cover the tooth and allow a fixed bridge to be placed to replace it as well as address the residual open bite on his left posterior quadrant. Be aware that during his orthodontic treatment Dr xxx attempted to luxate the tooth unsuccessfully for either orthodontic extrusion or extraction. I have already spoken with Dr. xxx who assured me that if pulpal therapy becomes necessary he would be able to do it. Any thoughts on how to treat this tooth? Thanks,

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Rick,

I’ve done similar odontoplasty for a third molar that was in a similar position in relation to the nerve. It’s been 15 years and everything is fine.

The odontoplasty was done so that the occlusal surface was even with or even slightly below the ossous crest. Of course there was no fixed bridge placed. I can see a bit of the tooth structure peeking out even today, but it is non-inflamed.

From the radiograph, a bigger question may be if the patient has enough coronal tooth structure for a crown prep on #18.

Lee

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Rick

The other questions that arise are:
Is there a 3rd molar?
What about the angulation of #18? How will that complicate fabrication of a fixed prosthesis?
IF #19 becomes non-vital and has to be extracted after some amount of decoronation, what then?
I know that Maurice (and others) have shown root submerging to preserve ridge dimensions. How long are those cases out? What have you (Mo and others) done to the coronal portion of the root structure to increase the chance of tissue attachment/adhesion and to prevent infection and/or fistula formation?
This one x-ray raises many questions – great post, Rick.

Bob

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Rick,

Do you intend to perform additional orthodontic treatment?
If the opposing occlusion permits, I would think uprighting
#18 (and improving the position of 20) may permit extrusion. I would at least want to try again.
You really have little downside by trying, because weather it works out or not you would be improving your restorative situation.

Chuck

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Unless there is something unusual on the CBCT, most OMS colleagues would be comfortable removing this tooth and grafting the site. Perhaps a team approach is indicated here?

Rob

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Thanks Rob,

I am a firm believer in the team approach. 100% of our cases are treated in that fashion.

I have not met or examined the patient. According to the notes, he has already been examined by an OMS.

If the tooth is in fact ankylosed and wrapped around or in close proximity to the IAN, would you still feel comfortable removing the tooth and grafting the site?

Rick

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Bob, Chuck and Lee,

Thanks for your input.

I have not met the patient yet, so the information that I have is limited to this one email. I have asked the referring doc to allow me to examine the patient and to take a PreXion CBCT.

Does anyone else have any thoughts?

Rick

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Need a CBCT of the area to identify 3D relationship of apices to the nerve. You might be able to either remove the tooth or resect a lot of it to submerge the apices using delicate surgery and/or piezo surgery. Ideally the whole tooth should be removed. Alternatively, I would try to take out 80% to allow ample space above the tooth to fill in with bone and prevent fistula formation.

This is a young patient and doing a minimal procedure in the name of being “conservative” may in fact commit him to a lifetime of treatment of a chronic problem. Definitive treatment with intelligent risk management is the way I would like to be treated.

Jeff

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Why not think of a restorative solution.That is think of the tooth as an implant and prepare and build up and place a crown. If problems develop you can always cut and submerge in the future.

Len

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Len,

After orthodontics, if the tooth was determined to be ankylosed,
I contemplated a less conventional restorative approach.
Perhaps a 3-unit bridge with limited enamel
preparation of #19 so that a “crown type Pontic” could be bond to #19 and sill be part of the bridge.
Has anyone done anything like this?

Chuck

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I have not been receiving photos from list serve for the past week. Is this a list serve issue or my network?
Thanks,

Mark

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Chuck Why not avoid a bridge and just do modified prep and crown?

Len

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Len,

A conventional crown would most likely require Endodontics, post/core and significant crown elongation.
Elongation would most likely not fair well for the adjacent teeth.
I would probably prefer extraction of #19 vs elongation.

Chuck

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Len,

I just realized, I may have misinterpreted your follow up question.
If you meant attempting a modified prep and just bonding to enamel,
I don’t think it would have enough retention, considering the occlusal forces in the posterior region.

Chuck

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Chuck

I meant if perhaps endo be done and sufficient core build up for retention with light occlusion once ortho uprighting is complete to enable proper interproximal contacts.

Len

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Len,
I still think there would a high risk of fracture.

Chuck

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Chuck Thanks.

Len

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