Case Study

A 23 year old pt came in C/O the colour of her upper UR1 incisor which had been root treated when she was 12 due to damage after falling off a horse.
She had no relevant medical history and was a regular attender with good oral hygiene and no other restorations apart from the root treatment and a large composite on this tooth. This discoloured tooth had a shade of A4 whilst her remaining teeth were A2.

A soft tissue examination revealed a discharging sinus above UR1 and a periodontal pocket of 6mm. A periapical radiograph revealed an apparently good length, well condensed RF but a periapical radiolucency of almost 1cm diameter, widening of the periodontal ligament space and mesial bone loss. A diagnosis was made and options discussed with the patient. The diagnosis was a failed root treatment on UR1 with a perio-endo lesion.
Options included

1. No treatment. This was the least acceptable treatment. This is because the
   infection cannot resolve by itself and requires active therapeutic treatment. More importantly, the longer the infection remains, the greater the damage it causes to the underlying tissues and the greater the complications. A periapical infection can be acute or chronic depending on symptoms. In addition, depending on the virulence of the bacteria, the number of bacteria and the resilience of the host defences, different scenarios can arise. These different scenarios can be a periapical abscess, a periapical cyst, a periapical granuloma, a discharging sinus as it was in this case, cellulitis and perio-endo lesions.

2. Referral to an endodontist privately with a view to saving this tooth. Due to the long-standing infection and being extensive, this also was not a good predictable option.
3. Referral to the Royal London Hospital restorative department with a view to saving this tooth. Often treatments outside the scope of general dental practice are referred to the Royal London Hospital dental department together with their team of professors and specialised consultants are able to treat cases of particular difficulty. However the disadvantage is that their waiting lists are prohibitively long and often treatment can take more than 18 months due to even get started. In addition, patients do not want to wait so long and even when treatment does get underway, it takes another 18 months to 2 years for treatment to complete with many visits often up to 3 hours long every single month. If patients live a long way away from the Royal London Hospital then this is an extra disincentive for them to be referred. When considering this option, we always inform patients of the disadvantages and in many cases, they decide not to proceed. However when the patient is agreeable to this option, this is an excellent cost-effective method of the patient receiving advanced treatments that would otherwise not be possible.
4. Removal of the tooth and placement of an immediate denture and in the longer term to consider a new denture as a Valplast. An immediate denture is one where the tooth is taken out at the same visit as the denture is being placed in the mouth. The obvious advantage of this is that the patient does not have to put up with a gap in the mouth as a replacement denture is placed immediately after the tooth has been removed. This occurs in the same appointment naturally. The immediate denture fills in the gap created by the extraction however the technician has to estimate the amount of gum shrinkage will occur as a consequence of an extraction. With all instructions, it always follows that there will be soft and hard tissue loss but exactly the amount of hard tissue and soft tissue mass cannot be accurately predicted. This means that an immediate denture is always a temporary denture. Due to continuous bone resorption,the denture will also become looser over time
and the denture will lose its retention due to the change in the shape of the mouth as a result of the extraction. As a rough approximation, the patient will be able to tolerate an immediate denture for up to 3 months after which time a more permanent solution has to be discussed. One such permanent solution is a Valplast plastic denture which is a thermoplastic flexible denture. It is strong and has good retention but they do pick up stains more readily than their traditional acrylic denture and also further teeth cannot be added on in the future if this is what you may be planning to do.
5. Removal of the tooth and placement of an immediate denture and in the longer term to consider a new denture as a chrome. After a period of about three months, a chrome denture could be one of the choices that can be discussed as a long-term solution for the patient. A chrome denture can be designed so that there is less coverage in the mouth which makes it easier for the patient to talk and eat with. In addition, a chrome denture can have better retention by the use of clasps and occlusal all rest seats. As discussed with Valplast dentures, it is more difficult to add additional teeth in the future with a chrome denture if this is what you may be planning. Chrome dentures are also more costly but there are better for the overall health in the mouth as they are both tissue and tooth borne unlike traditional acrylic dentures which are tissue borne only.

6. Removal of the tooth and placement of an immediate denture and in the longer term to consider a new denture as an acrylic.
7. A fixed prosthesis as an adhesive bridge using metal based wings. An adhesive bridge as very good success rates and although not quite as good as a fixed bridge, the advantage is in terms of biological tooth precedent preservation which is important especially for a younger patient. The initial success rates for adhesive breaches was not very good however due to a better understanding of their mechanical properties and advances in chemical adhesion technology, success rates are very acceptable and these procedures should always be considered first as they have definite biological advantages. In most cases importantly, additional tooth preparation is not even required.
8. A fixed prosthesis as an adhesive bridge using all ceramic wings. Recently there is a trend to use all ceramic materials only. Additional adhesive or acid etch bridges use metal wings but newer materials have started to take all using all ceramic technology. Certainly the aesthetics are better in that the enamel translucency does not become their contraindication but even so not everyone is convinced that an all ceramic bridge is sufficiently strong enough unless the patient has an obvious open bite with minimal occlusal forces.
8. A fixed prosthesis as a fixed bridge using metal based porcelain. Although this was the traditional way of replacing a fixed tooth, it is becoming less acceptable as we now know that 20 to 30% of all prepared teeth will require canal treatment at some point. In addition, the metal based porcelain does not have ideal aesthetic properties especially where the 1.5 mm clearance required is going to be difficult to achieve. Either you get the 1.5 mm clearance required but you could be compromising the health of the pulp or you do not get the clearance required which then causes a
bulky restoration or a restoration with poor aesthetics due to the inability to mask the underlying metal coping. In addition, the aesthetics around the gingival margins are also to worry about because here the porcelain is currently very thin and any gum shrinkage in the future will cause the margin to easily become visible as a black line.
9. A fixed prosthesis as a fixed bridge using all ceramic materials such as Procera or E- Max. All ceramic bridge materials are also on the market however there is certainly cannot be used in high stress areas due to the flexing of the bridge under loading which will cause the pontic and the abutment to separate.
10. An implant with or without bone grafting. This is the most costly and complex way of replacing the tooth. Many complications can occur either with the implant itself but also with the bone grafting. Although most bone grafting is done using synthetic materials, the ideal material to use is the patient’s own bone but not many practitioners use this method so you will have to look around for a surgeon who uses this technique. With the implant, all problems can also arise both with cement returned and screw retained abutments.
11. All the above treatment options to be considered alongside orthodontics to realign her midline to give a more attractive overall cosmetic result. The orthodontics could be in the form of traditional fixed brackets or the newer type of tooth coloured brackets/wires using systems such as 6 Months Smile.
12. The orthodontics could also be in the form of clear aligners such as Invisalign or RX-Aligners.

The likely type of costs was discussed with the pt including which ones were available on the NHS and which ones were private and some as both. Time periods were also discussed with the patient and her social history revealed that she may be getting redundant from her present work so she may have to move areas again. I asked her to carefully think about her options and to come back for a review appointment. She was grateful that I had given her the above options as her previous dentist had not discussed most of the above with her.