Clinical Continued »
already mentally assessed. Example one A 46 year-old man fell off a mountain bike and partially avulsed tooth 11 and deco- ronated 12, with fracture extending palatally subgin- givally. Both teeth were vital with no restorations before. His arch was intact, he had good oral health, no perio and no bruxing habit. There was a medium to high smile line. (Figs 9 and 10). As part of emergency
treatment, tooth 11 was imme- diately repositioned, while a glass ionomer was used over the vital fracture in tooth 12.
Treatment options Further options for tooth 12 were then discussed with the patient. These were: 1. Direct build-up with composite resin Compromises:
• Minimal enable for bonding • Likelihood of devitalisa- tion. This could be managed by
Elective RCT for post-reten- tion of coronal restoration (composite, veneer or crown). 2. Full crown Compromises:
• Insufficient coronal tooth
structure for 2mm ferrule • Insufficient tooth struc- ture for bonding all ceramic restoration. The s e compromi s e s could be managed by crown lengthening or ortho- dontic extrusion to create sufficient tooth structure for ferrule. Due to a high smile line, only orthodontic extru- sion would be acceptable.
Alternative treatment options A number of other possible treatment options were considered. All of these involved the extraction of tooth 12. 1. Partial denture Compromise: denture is
removable. 2. Resin bonded bridge Compromise: challenging
aesthetically and likely to have visible tissue loss 3. Conventional fixed bridge Compromise: tooth 11
already comprised, unneces- sary destruction of tooth 13. 4. Implant crown Compromise: possible
additional surgery, chal- lenging with high smile line and requires greater invest- ment in the first instance. Choosing a solution Outlining these options only involved a 10-minute conver-
sation but it meant that the patient was taking active responsibility for the treat- ment he chose. In this case, the patient
chose to electively have the remaining root root-filled and a fibre post placed to carry, in the first instance, a composite resin restoration. Tooth 11 was also root-filled
in the knowledge that this tooth will most likely be lost to external resorption in the future (Fig 11). The treatment option that
we probably already knew from the outset to be the most practical option was there- fore explained to the patient in a way that allowed him to accept the compromises. Theoretically, this should allow an easier passage to the next line of treatment when the tooth fails and has to be removed.
It is also important to
remember that just because we ourselves might not go through a particular treat- ment or do not have the skill-set or experience to provide a particular aspect of that treatment, we should not fail to offer it. Orthodontic extrusion,
for example, may seem to us as an unnecessary delay to providing the treatment and possibly not worth it, but it is the patient that needs to make this choice (Figs 12 and 13). Accepting compromises
on the patient’s behalf, however, will ultimately end up with an unhappy patient and the possible loss of the relationship.
® This article was submitted by Edinburgh Dental Specialists.
“Outling these options only involved a 10-minute conversation, but it meant that the patient was taking active responsibility for the treatment he chose”
Fig 8
High smile line showing shine through of dark root and metal based restorations which are overcontoured
Fig 9 Repositioned tooth 11 and decoronated 12
Fig 10 Decoronated 12, 11 has been repositioned
Fig 11
11 and 21 both root filled, 21 has a fibre post and composite resin restoration
50 Scottish Dental magazine
Fig 12 Unrestorable subgingival fracture
Fig 13
Orthodontic extrusion to bring palatal margin in to restorative zone
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