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Case Conference Orthodontics Restorative Dentistry Supporting Your Practice

How would you treat this case?

bigstock-Aqua-Web-Button-49311The following case was presented by a general dentist:

27 year-old Indian male. Patient had ortho treatment done 2 years ago with another dentist. Just after 2 days of debonding of brackets, patient had a fall with sustained tooth injuries to his upper front teeth 11,21,22 causing them to extrude in a retrolined inclination. Patient was treated by an oral surgeon at a private hospital and the patient’s pictures after 2 year plus are shown. Patient claims there were no follow ups after admission in the hospital.

 

Ortho Case 1

 

 

 

 

Ortho Case 2

 

 

 

 

 

 

Patient’s concerns: unsightly look on his upper teeth and wants them fixed.

11 is discoloured. 11,21,22 are all retruded. No  mobility, no pain on percussion, no sinus on all 3 teeth. Patient has a reverse over jet. 13 has spacing, (presume  due to its relapse of ortho treatment). Molars on left and right are all in class 1 occlusion.

Peri apical x ray- I think there is external resorption on 11 and 21.

11 definitely needs RCT. Pulp revasculation possible on 21,22 teeth?

My questions are :

  1. Can I align his tooth into position (correcting his reverse overjet) and closing spaces on 13 with ortho?
  2. What are the risks and complications that can occur and what do I tell the paetient about what to expect with ortho?
  3. What would be the best treatment and treatment options  that I can consider for this patient? The patient inquired if crowning or bridge will help. Will porcelain on labial bulk be too much?

Thank you, 

Email your response to oasisdiscussions@cda-adc.ca 

 

15 Comments

  1. DJ September 8, 2014

    My suggestions:

    RCT on 11 and 21, possibly 12 internal bleaching and if patient is not satisfied, then ceramic restorations for esthetic purposes.If required, ceramic restorations only after ortho is completed.

    Explain risks of external resorption and of other teeth requiring RCT. Explain these risks relative to an alternate treatment plan of extractions and implants (not recommended as 22 is also in crossbite and removal is definitely not recommended).

    Lower anterior incisal edges may need contouring – explain this possibility to the patient as part of the treatment plan.

    Reply
    1. KO September 8, 2014

      Ask him if he is concerned about the cross bite?? He may only be concerned with the colour. As long as there are no interferences, he may be stable enough in this position and then you wouldn’t need ortho. It has been 2+ years after all.
      RCT and internal bleaching may be adequate. Regardless, I would do that first and see if there is going to be any ext resorption after the endos.

      Reply
      1. TA September 9, 2014

        I believe that it would be worthwhile attempting to correct the crossbite of 11,21 and 22 once the pulpal and endodontic concerns have been addressed. Tooth movement would be slow with light forces. He would have to be advised that the resorption may increase with ortho but since it appears to be mostly tipping it may be minimal. However the resorption may progress in any case and at least the alveolar bone topography would be more favourable after crossbite correction.

        Reply
  2. Anonymous September 9, 2014

    Blunting or external resorption could also be secondary to orthodontics. Did teeth 12,11,21,22 all test non vital? I suggest obtaining previous records from orthodontist and dentist for comparison of root form prior to preceding with RCT.
    Next step would likely be orthodontics followed by fixed restorations or internal bleaching.

    Reply
    1. Dr. J. A. Purc September 10, 2014

      I like the comment from anonymous.The models at the start of tx to the finished case will show the alignment of the anterior teeth. The ceph will show the inclination of the upper anteriors. By moving the upper anteriors out of crossbite on the models will show how much space has occured, and if the anteriors are going to be stable in the new position. Patient feedback on tx with the models will dictate how to procede. An endo and ortho consult should be set up, and a prostdontist may need to see the patient as well.

      Reply
  3. SC September 9, 2014

    Considering long term prognosis, my inclination is to suggest extraction and implant placement. The current PAP, bone loss, reverse overjet do not bode well occlusally. Given his age, a more costly, but better long term solution should be offered.

    Reply
  4. MH September 9, 2014

    Rct all the necessary teeth, than just crown them and give him an end to end bite after adjusting the lower anteriors for room and levelness. Forget the ortho, you are opening up a can of worms.
    Its really a simple case to treat.

    Reply
  5. David September 9, 2014

    This is a very good case situation that one (as a GP family dentist) can either make it very easy or make it difficult on oneself.

    Here is the easy way: I would handle this case by involving two specialists: a certified orthodontist but first, … an endodontist. All upper incisors need to be investigated in terms of their vitality anyway as they all received the traumatic blow.

    The #11 really is the issue here, …. yes, the mal-occlusion needs to be addressed but reading into the chief complaint, the patient’s main concern is the esthetics of his smile, … which really means that VERY dark tooth #11 that has hemoglobin/bilirubin –blood by-products– stained (internally) dentin. So, .. buy the patient time: MAKE THAT DARK TOOTH the original colour again. Ortho can always be done down the road of time or even not at all. The issue here is to make the patient happy. That is all.

    Here’s the deal: DO NOT CROWN NOR EXTRACT ANY TEETH. JUST DON’T. If you do, …. you are married to this case. A wonderful result can be obtained by performing an endodontic procedure on the central incisor. But try to resist the urge to do it yourself, even though it is a easy one (single canal, straight anatomy, etc).
    Here is the reason why: I have a real good rapport with my endodontists in my city (Kelowna). I do not just send them the hard molar root canals that are calcified. Once in a while, send the endodontists an easy case, …. they will love you for that…… After the endodontist of your choice performs the root canal treatment, then he/she can & will do an internal bleaching technique. It will work. Really it will. I have had even darker internally stained (worse) cases than this one.

    The endodontist likes to feel like the hero once in a while and what I mean by this is that they do not do many cosmetic cases. The two endodontists in Kelowna (Drs Mike Rampado and Mike Matwychuk) are well known for successfully bleaching teeth (internally) back to (almost) their original colour (as the adjacent central incisor. I can remember one case that the endodontist actually got the dark tooth even whiter than the adjacent teeth, .. which resulted in me providing the patient with an at-home bleaching kit. Needless to say the patient was actually very, very happy. Also, … this dark tooth will NOT require a crown AT ALL. Really it doesn’t, .. even if it will have the completed endodontic treatment. Too many dentist GP’s are crowning teeth that do not need a crown at all, … even an endo’ed tooth.

    Not all GP dentists know this but if they were to tackle the internal bleaching themselves on an endodontically treated maxillary incisor, there is the possiblity of causing cervical internal resorption if the concentration of the bleach is slightly off/too strong which will lead to an extraction scenario. If you are a busy enough dentist, …refer this one out.

    If the patient was in the chair my conversation would go something like this: “John, your traumatize dark tooth (and adjacent teeth that are out of position) is a bit of a challenge, but a real good result can be achieved without breaking your bank account. Let’s worry about the orthodontist later, … let’s address that dark tooth. It needs a root canal. But even though it is a straightforward tooth to perform a root canal on, .. it may be wiser to refer this situation to the specialist so he can do it and then at the same time, he can also INTERNALLY bleach this tooth at the end of the endo appointment. Think of this tooth as a Ferrari. I am the Ford Dealer. We both want you to have this tooth for the rest of your life if we approach it the proper way. The endodontist’s fees are not much higher than mine, … maybe 10 to 15% higher, but money well spent. Then we will worry about the out of position teeth at a later date. What are your thoughts, John?”

    And that is how I would handle this case.

    –David–
    (Kelowna GP)

    Reply
  6. David September 9, 2014

    (Ooops… a typo above in my reply. there is no chance of “internal” resorption due to not having any vital nerve tissue. I typed a little too fast. I meant to say external cervical resorption at bone level, due to the potentially strong internal bleaching procedure. )

    Reply
  7. AM September 9, 2014

    Given the significant midline discrepancy I suggest you re-evaluate the occlusion. It is likely class III on the right and class I on the left which is a significantly more complicated malocclusion to correct…

    Reply
  8. noah weiszner September 9, 2014

    Something is missing in this history.
    Did he not see the orthodontist after the injury or in consultation with the OS?
    What exactly did the OS do?
    Not convinced that the cross bite was due to trauma, possibly ortho?
    Discuss with whomever did the ortho as to how it was finished.
    If 11 is non-vital than endo and internal bleaching would be my first treatment.
    What exactly would he like to improve?
    I would also refer him for an ortho consult.
    There may be some ankylosis so I would not mess with ortho.
    Basically this is a difficult case and I would refer it out.

    Reply
  9. AM September 9, 2014

    I would start with a complete diagnostic treatment plan, including a full mouth series, panoramic radiograph, mounted study casts on an articulator, full mouth photos, and complete periodontal and endodontic exam. This will take time – but – I’m sure that you want to do your best to provide the best treatment for this patient.

    I’d also include a limited FOV CBCT of the anterior segment to ensure that none of the anterior teeth are fractured. That is a significant amount of horizontal movement sustained by the anterior maxillary segment, and it wouldn’t surprise me if one or more of those teeth may have suffered a horizontal fracture. The diagnostic ability of a CBCT cannot be understated. It’d be a shame to endodontically treat #12/11, and then have them fail 2 years down the road due to a hidden fracture that was not realized by a PA radiograph alone.

    After you have determined the exact periodontal and endodontic diagnosis of the entire dentition, I’d then move onto restoring the dentition to address the patient’s chief complaint (which was touched on by KO-is the patient happy w/ the negative horizontal overjet?). This may include orthodontics or a bridge/implant if one of those anterior teeth is fractured.

    The exact pulpal and periradicular status of at least all the anterior maxillary and mandibular teeth must be determined before moving to the next stage!

    If you determine that the maxillary anterior teeth are restorable (w/endodontics), the next stage could be to request a Kesling setup (ortho waxup) of the anterior dentition from the lab (on an articulator). http://www.scielo.br/pdf/dpjo/v17n3/26.pdf BTW, get them to duplicate the original stone casts and complete the ortho “waxup” on the duplicates.

    This will give you an idea of how the case will look like after basic orthodontic tooth movement. Risks of orthodntic movement: Google it: http://www.aso.org.au/docs/orthodontics/Risks.htm

    Following orthodontic treatment – esthetic restorative treatment (internal/external bleaching, veneers, crowns) can be applied to pretty the patient’s smile.

    The best treatment will be determined, again, when the status of the anterior teeth is determined. Post the CBCT when you get it.

    Hope this helps.
    AM

    Reply
  10. DS September 10, 2014

    This is obviously a complicated case with a possible underlying skeletofacial disharmony. A comprehensive evaluation of not just his present occlusion and pulpal health is required here in order to determine what the patient’s concerns are and what his treatment goals are along with all risks and complications associated with his care. Request his post-treatment orthodontic records (prior to the trauma) and determine where the teeth originally were and the post-tx ob/oj relations. A cephalometric analysis to evaluate his underlying skeletal balance along with a full facial evaluation to determine any soft tissue / profile/ smile height issues should be undertaken. Referrals to an orthodontist, oral and maxillofacial surgeon and endodontist may be the best approach to treat this patient to allow him to make an informed treatment decision as to how he would like to proceed with his care in treatment of this complex malocclusion.

    Reply
  11. Greg W September 10, 2014

    Something is up with this case. It almost appears to me that the upper 4’s have been extracted from the photo. The immediate esthetic issue is fairly simple to correct. RCT with internal bleaching-give it some time! Discuss with the patient exactly what his needs are though. The ortho on the other hand could be a very difficult case. This IMHO should be an ortho referral. Even that endo isn’t going to be as straight forward as it looks, a good apical seal may be difficult without extruding a significant amount of material through the apex!

    Reply
  12. jean marc retrouvey September 10, 2014

    Being an orthodontist interested in comprehensive treatments, I would argue that one photo and on radiograph do not allow me to present a reliable diagnosis and treatment plan. Full records are necessary.
    First assessment would be endodontics, then orthodontics. A diagnostic wax up of the final occlusion would then determine the probability of a positive and stable outcome.
    Restorative dentistry would obviously be involved during the orthodontic planning stages and course of treatment.

    Reply

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