This is a very interesting case from a treatment planning point of view.
The patient is a 77-year-old very active female. She is pre-diabetic, but controlled with diet and exercise and is taking a statin.
The patient had a full mouth reconstruction to open her bite about ten years ago. She is currently seeing a periodontist and a general dentist for care. All of her anterior teeth have solid bone support with excellent home care. There were no noted mobilities.
The patient is a “snow bird” and was in Florida over the winter when tooth #25 fractured at the cervical level. The patient was referred to a well-known dentist in Florida for emergency treatment. The Florida dentist discussed with the patient the treatment options and it was decided that the most predictable path was to bridge #24, 25, and 26 together. A post was cemented into tooth #24 and the three-unit bridge was prepared and temporized.
Subsequently, the dentist was unable to remove the temporary bridge, so it was cut off. There was an issue with the all ceramic bridge from the lab, so it was returned for changes and a new temporary bridge was made.
Upon removal of the “new” temporary bridge for the next delivery appointment, the core for tooth #26 was fractured. The root canal treatment on #26 was retreated ten years ago. At this point, the dentist encouraged the patient to have #27 prepared for an abutment crown for the bridge. The patient agreed and tooth #27 was prepped, impression taken, and the temp bridge recemented on the four units.
The world came to a halt with the COVID-19 shutdowns and the patient could not return to cement the final four-unit bridge. The patient needed to return home mid-March (well before the opening of the offices in Pennsylvania). The Florida dentist sent the bridge to her general practitioner dentist at home for final cementation.
When the patient’s dentist in Pennsylvania re-opened and was able to see her, he attempted to remove the temporary bridge and was unable to do so using routine techniques. When the temporary bridge was finally removed, the cores that had been placed in teeth #27 and 25 were broken off and inside of the temporary bridge. In addition, the core fracture of #27 was through the pulp chamber resulting in a pulpal exposure. The RCTx on #25 was compromised and the fill was in a somewhat liquid state. The patient was informed about the situation.
The patient expressed a desire to avoid having any teeth removed. Bearing in mind the recent history of these teeth, what would your treatment plan be? What if cost was a factor? What if cost wasn’t a factor?
Response #1 – Carl Jenkins, DDS, MS, MAGD
This case presents so many clinical challenges in addition to the personal challenges that the patient is facing.
My first recommendation is that the patient needs to decide where she would like to have her dentistry done, in Pennsylvania or in Florida. The case will require time to complete successfully. If she is going to be leaving to go back to Florida I would suggest that she consider either going to Florida early to have her dentistry completed or plan to stay in Pennsylvania until it is satisfactorily finished.
Sadly, I am wondering if this patient is facing more issues. It appears in one of the photos that there are additional cervical caries developing on the buccal margins of #28. Considering the patient’s age and the pattern of decay present, I suspect she may be suffering from xerostomia issues. A lack of saliva or a change in the quality of her saliva may be leading to root caries developing. Certainly a new full mouth series should be exposed to consider the health of all her teeth.
One of the radiographs appears to show the case in good shape while subsequent radiographs are showing caries well below the margins of the existing temp crowns. This is consistent with dry mouth patterns of tooth decay.
The clinical photos appear to show a lack of axial walls for a proper ferrule effect. I understand the desire to include additional teeth for support, but by ignoring this principle I believe the case has a high probability of failure. We all wish that our patients would have a desire to keep their natural teeth. In this case, however, that may not be the wise course of treatment.
Implants never decay and with the high caries rate apparent here I would suggest an implant supported bridge #24–26 to be a better option for long term success. This presents problems for this particular patient due to her lifestyle as a “snow bird.” A frank discussion of treatment risks and the necessary time to complete treatment is essential.
Clinical crown lengthening might be an option to help save the existing teeth, but this would take away bone. If implants are desired later, that would be detrimental. If the patient does prove to have other failing restorations due to cervical caries, then perhaps an implant supported removable or fixed denture might be considered.
I hope these comments are helpful to our colleagues treating this challenging case and I wish this patient well.
Response #2: Dejan Golalic, DMD, MAGD
As a dental practitioner from central PA, I have encountered more than one situation where patients would spend half of the year living in Florida and other half in PA. Providing continuous dental supervision over the care of these patients can present a challenge. Professional, ethical, and legal dilemmas can hover over our responsibility to provide optimal dental care to the patient while having an understanding for their wishes and lifestyle.
In this interesting case, it seems like one clinical decision led to another that resulted in frustrating results for both the patient and operating dentists. In my opinion, the most reasonable way to approach the case is to start with analyzing diagnostic models mounted in “centric relation” in semi-adjustable articulator. The fact that the patient had history of complete mouth rehabilitation, “bite opening,” and severe fracture of the tooth at the gingival level would be an indication for occlusal analysis. If TMJ load test is within normal limits and occlusion can be restored without major changes to the remaining dentition, we can focus our attention to the affected area.
If the patient would decide to accept extractions as a treatment option and had no financial limitations, removal of teeth #24, #25 and #26 with placement of two dental implants and 3-unit bridge #24–26, followed by the post and core and crown fabrication on #27, would provide predictable long term results. As an alternative, we could extract only #25 and fabricate 3-unit bridge #24–26. Complete equilibration and occlusal splint would add to the security of the restorations in the future.
In this case, the patient had desire to avoid extractions. Restoring #24, #25, #26 and #27 with individual post and cores and crowns seems like a logical choice. However, clinical and radiographic appearance of the tooth #25 does not seem to be appealing for fabrication of the new post and crown. In that regard, the concept and technique of root submergence can be applied. We could reduce/decoronate the tooth #25 to the crestal bone level and expect soft tissue closure. The bridge could be fabricated from #24–26 with a pontic #25. Patient would have to accept and consent that eventual extraction of the remaining root #25 in the future would require surgical approach. This concept is less predictable but documented in the literature.
Removing temporary crowns and bridges, especially from teeth that had posts or have compromised and fragile coronal portion of the tooth, should be done with the utmost caution. Application of forceps or excessive force can lead towards inevitable fractures that can be one of the most stressful situations for a dental practitioner. If this occurs, and the marginal integrity of the definitive restoration on remaining tooth structure is not deficient, retrofitting a core of the tooth can be done using the new crown or bridge and dual cure core material in a technique sensitive way. I would advise that dentists consider removing provisional restorations from clinically fragile teeth by carefully sectioning them, using minimal force to remove segments and taking adequate time to do this part of the procedure.
Response #3: Lance Miller, DMD
Judging from the x-rays and what’s noted in the narrative, I’m OK with saving teeth if that is what the patient wants. I don’t love the bone levels for implants in the #24 and 26 positions for a three-unit implant-supported bridge. Splinted crowns from #22–27 will be a nice reliable treatment (#28 is already an abutment for a three-unit and including this tooth would be over-engineering). However, each compromised tooth that received endodontics needs to be retreated. Tooth #24 and 27 should have endodontics due to exposure and fracture during bridge removal. Also, teeth #24–27 need to be evaluated for possible fractures during the removal of temporary bridges that broke their existing core build ups. The existing tooth structure that remains from the full mouth rehab on the anterior teeth is limited and crown preps should be very conservative going forward.
My treatment plan:
Study casts should be taken and mounted to determine occlusion.
Wax up of anteriors that were broken off needs to be made by the dentist or the lab to help the treatment plan and provide the patient with a reliable temporary bridge.
- Endo/retreat teeth #24–27.
- Conservative instrumentation and post placement, passive posts, and internal bonding techniques (i.e dual cure bonding and build up materials) should be used to prevent weakening of the root structure and future root fracture. The passive post is your “rebar” in the core.
- Conservative removal of crowns on teeth #22, 23.
- Temporize teeth #22–27; provide the patient some anterior esthetics during this terrible time.
- Finalize crown preps on #22–27.
- Make sure to have proper crown ferrule 1.5–2 mm. Bone loss in the case will help to achieve this. Remember we are splitting these teeth due to the fact the crown to root ratio isn’t ideal.
- Determine a proper path of insertion, which may have been the reason that the 3 splinted crowns broke in the first place.
- A final temporary bridge will help to reveal under cuts. Also, an alginate and quick plaster cast can be made to reveal areas that composite can be added. This will conserve tooth structure of the anteriors to reach a perfect path of insertion.
- Finalize an all-zirconia splinted crowns #22–27 made with hygienic embrasures.
- Determine occlusion on final prothesis so that canine or posterior group guidance is achieved.
- Have patient wear a night guard and three-month cleanings at first to determine that she is properly cleaning under the splinted areas to prevent future bone loss and failure of the prothesis.
- During any part of the treatment if any of the teeth #24–26 are compromised beyond restorability and need to be extracted, a bridge #22–27 is still a viable option with 1–3 pontics.