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March 2009 | Dental Products Report “Too often in patient care, procedures can be performed to save teeth that not every dentist is either aware of or chooses to not apply. Here you can find two case examples where teeth were condemned that were, ultimately, savable by using known techniques.” —Dr. Joe Whitehouse, team lead
Periodically, a patient will request to save a tooth/teeth that another dentist has condemned. The patient has lacked trust in the first opinion or has, in some cases, an unrealistic hope of preventing a loss. When these patients show up, the first order of Minimally Invasive Dentistry (MID) is to be perceived as trustworthy by listening to the patient’s perceptions of the last encounter. With the understanding of the patient’s goals, especially the hoped-for outcome of the current problem, the patient will be open to the possibility of an outcome different from what was communicated to him or her previously. In some cases the previous dentist is correct, but as you will see in the two cases presented in this article, the prescribed extractions were not MID, and the eventual outcome in each case was of great relief to the patient. Case one The patient found me through my Web site with the thought that she did not want to lose tooth No. 6. I knew the previous dentist wanted to extract the tooth because the patient showed up with a temporary partial to be used after the extraction (Fig. 1). After examination of the tooth and x-ray it was apparent the previous dentist did not suggest super-eruption of the root, either from possible ignorance or a lack of interest in undertaking the procedure. This may not occur often, but when it does it reflects poorly on our profession. When the procedure of super-eruption was offered to the 60+-year-old patient, i.e. wear braces, she accepted. The reason for the condemnation of the tooth was, as seen in the x-ray in Fig. 2, where decay breakdown was evident on the mesial. As can be seen on the initial treatment, brackets were placed on subject tooth No. 6 and the neighbors, tooth Nos. 5 and 7. By placing the brackets as shown in Fig. 3, super-eruption of No. 6 will take place. The transeptal fibers must be severed with either a scalpel (Figs. 4 and 5 of a different case) or with a laser, which is a better method and the one I use. If the fibers/ligament are not severed, the tooth will erupt bringing the bone with it. In this case the root is what must come down alone. Any anterior brackets will suffice, but it is better to use the brackets meant for each tooth. The brackets on the proximal teeth are bonded at mid-tooth or lower with the subject tooth’s bracket placed as close to the gingival margin as practical (Fig. 3). A Nichol titanium wire is used, and dependant upon how fast one desires to erupt the tooth, the wire sizes range from .014, .018, or a rectangular .018 X .022. The wire is iced, as shown in a different case in Fig. 6, to get it flexible to get into the central bracket. Once the brackets are in place (see Fig. 3 again) with a severed ligament and the tooth significantly reduced incisally, the patient will be instructed to return at the point the erupting tooth touches the tooth below. The speed of eruption varies from patient to patient and can be very quick if a more powerful wire is used. Periodically, as the tooth is erupted, reduction of the incisal will be needed until the eruption is adequate for a proper ferrel effect. Fig. 7 shows the final erupted position with the needed ferrel effect. It is critical to hold this position while the ligament reorients itself and bone fills in at the apex. I usually wait three months before preparation, because to prep sooner risks the tooth being pulled slightly back up into the socket with the crown incisal advancing upward and not where intended. The preparation (Fig. 8) shows how the eruption provided the needed abutment characteristics that will allow for the longevity the patient desires, and Fig. 9 shows the crown in place. Thus, a tooth that had been condemned was saved. Case two A patient came to the office through a referral to find out if he needed to lose tooth No. 3 which had been condemned by an endodontist. There was a complete fracture of the tooth through the middle (Fig. 10) and upon anesthetizing the patient, Fig. 11 shows the fracture opened up. Fortunately, where possible, hemi-sections are a common treatment for such teeth, and this was one of those cases. Because the buccal roots were intact and unaffected by the fracture, the patient was offered these choices with a MID philosophy in mind: extract the tooth placing a bridge or implant; OR removing the lingual root, do a root canal on buccal roots, post and core, and a crown. The patient chose the later course, because he wanted his tooth, and especially, did not want the neighboring teeth reduced for abutments. One may ask: What is the prognosis of this latter choice? I believed it was good considering the patient had no perio problems and total non-mobility. Therefore, the patient was elated that the tooth could be saved. The treatment began with the extraction of the lingual root (Fig. 12). Once the root canals were complete, the post was placed in one root with a resulting core being built up (Fig. 13) and a crown prepared. A bone graft using J. Morita’s Foundation collagen-based bone filling augmentation material (jmoritausa.com) was placed in the socket. The socket healed nicely (Fig. 14) and that set the stage for placement of the final crown (Fig. 15). Summary So what is the moral of these stories? No. 1 is too many teeth may be condemned that need not be. If a MID approach is part of your office philosophy, you will always be looking to apply the least invasive approach to help the patient reach his or her dental goals. Second, if you are not aware of those techniques that might save a given tooth, might you consider referring the patient to someone who does know more, and ultimately, go out and learn what you need to know for application to cases like these? If any of this sounds judgmental, it is meant to be. During my 38 years of practice I have heard and seen too many instances where invasive dentistry has been done that need not have been done. I put my learning curve on a higher level to enable me to provide the kind of care rendered in these cases, and a MID approach is truly appreciated by very deserving patients.
The take-aways
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