CONS ESSAYS- ROUND 3

Topic 7

A healthy 35 year old patient attends c/o history of pain LLQ. The pain can be spontaneous
and worse at night (wakes the patient up). Pain medication does not alleviate the pain.
Patient is medically fit and well.
Radiograph shows a LL6 with extensive caries under existing restoration with pulp proximity
and PA radiolucency in relation to the MB root apex. No furcation involvement or other bone
loss pattern noted. Describe your clinical tests, diagnosis, management, treatment options
and rationale behind each.

History

The starting point would be to take an extensive history which will include a pain history
entailing the details covered by SOCRATES. Socrates stands for site, onset, character, radiation,
associated factors/symptoms, time/duration, exacerbating/relieving factors and severity. We
are already provided with some of this information from the history. An accurate pain history is
crucial to the correct diagnosis along with radiographs which we are provided with also. When
taking a pain history it is imperative that this is done in an objective manner- asking questions
that allow the patient to describe their symptoms rather than ‘telling them what they may be
feeling’. Other useful questions to ask would include whether the tooth is painful to bite on,
whether hot and cold or sweet exacerbate the pain and whether the pain has changed in any
other way since onset.
From the history we have so far, many of the patient’s symptoms are characteristic of the
diagnosis of irreversible pulpitis. These include spontaneous pain which is worse at night
(therefore keeping the patient awake at night) as well as difficulty locating the pain. We are yet
uncertain of the character and duration of the pain- i.e. whether it is dull and long lasting or
sharp and short. The PA radiolucency in relation to the MB root apex of the LL6 also suggests
progression to irreversible pulpitis and suggests that the pain is associated with this tooth.
However, the issue is that irreversible pulpitis is more of a concept rather than a well-defined
clinical condition and therefore in diagnosing a tooth as being at the irreversible stage of
pulpitis cannot be carried out without various tests and even then the diagnosis carries an
element of uncertainty.
Pulpitis is usually chronic and progresses intermittently and unpredictably with or without acute
phases. There is loss of vitality- which is deemed as the irreversible phase, when the pulp
becomes damaged beyond a point of healing, potentially due to pressure from inflammation
which compresses the pulpal veins and arteries.
Extraoral and intraoral examination
Extraoral examination includes assessing the temporomandibular joints as well as facial
symmetry and checking to see if the submental, submandibular and cervical nodes are
palpable. Intraoral examination should involve notes on overall oral hygiene including gingival
health, BPE measurements, charting that shows whether the dentition is heavily restored or
not, whether there are any missing teeth and any other relevant information. Although we
know that the LL6 is restored, it is important to know what type of restoration i.e. composite,
amalgam, crown etc since this would make a big difference when it comes to treatment
planning and choosing the best course of action. Quite often it is useful to understand the
status of the opposing tooth to the one that is suspected to be the culprit i.e. in this case the
assumption from the radiograph would be that it is the LL6 that is problematic so checking the
status of the opposing tooth will also be beneficial. Periodontal probing is around all teeth,
particularly the LL6 is necessary to give indications of loss of attachment. Previous periodontal
treatment or pocketing could have exposed a canal, thus allowing bacterial ingress into the
pulpal area, therefore, identification of such pocketing or access around teeth are worth noting.
We know from the PA radiograph that there is extensive caries under an existing restoration on
the LL6- an idea of the size of this restoration would be beneficial, however we know it has pulp
proximity and therefore can be assumed to be fairly large. Caries under the restoration is
indicative of secondary infiltration post restoration and since there is radiolucency in relation to
the MB root apex, this can be suggestive of active infection that is travelling towards the apex.
There is no furcation involvement or other bone loss pattern noted in the radiograph which
may mean that the periodontal status is otherwise fair- however this can only be assessed more
clearly with accompanying bitewings for a full overview.
Investigations
Firstly, the teeth should be percussed to determine if any are tender. It is always necessary to
use a control for comparison purposes, which would be a healthy, adjacent tooth. If there is
tenderness, this indicates that there is inflammation in the periodontal ligament and be
indicative of a diagnosis of either late stage irreversible pulpitis or a necrotic pulp.
The second investigation would involve palpation of the mucosa over the apical region of the
tooth. This exercise gives an indication of the extent of spread of infection as tenderness in this
area means that the inflammation has extended from the periodontal ligament to the
surrounding bone. Again, a control must be conducted on apparently healthy, adjacent teeth. It
is necessary to palpate the lower molar apices lingually as well as buccally.
The mobility of the tooth in question should be assessed along with all other teeth within the
dentition. There can be a slight increase in mobility if the periodontal ligament is inflamed. The
tooth may be raised in the socket if there is an acute inflammation.
It is also necessary to look for a sinus associated with the LL6 tooth as this would indicate
periradicular infection. It is imperative to look in the lingual mucosa region as well as buccal
since the apices of lower molars are closer to the lingual area than buccal.
It is necessary to test for pulp vitality. This can be done using hot and cold thermal testing,
electrical pulp testing as well as the use of a test cavity with LA if other methods are not
conclusive. It is best to use the method that is known to provoke pain in the patient i.e. if they
have sensitivity to hot or cold then this measure can be used. However, there are some
problems with the presently available pulp testing methods- the prime problem being that
these methods are not a true indicator of the vitality of the pulpal tissues. We are truly
interested in the state of the blood circulation of the pulp tissues, however current methods
can only establish whether nerve supply exist, which is a problem because after trauma, a vital
pulp may exist without a viable nerve supply. Thus, a vital tooth will not respond to a pulp test
and you will get a false result. With reference to the particular case we have, the LL6 is
multirooted with radiolucency at the apex of MB root apex. This means we could get a false
positive result on vitality testing where there is a remainder of vital tissue. It is therefore
necessary to test at several sites, over each root, on exposed dentine if possible. It is also
possible that inflammation can alter sensation or cause sensation to be incorrectly localised.
With any type of vitality testing it is necessary to conduct control tests as well.
Diagnosis
Based on the history given so far, it is safe to assume that the patient has irreversible pulpitis.
Treatment options
There is always the option of doing nothing, however, this would result in further spread of
infection to other teeth and loss of the tooth in question. Since it is the first molar, this tooth is
important for masticatory function and therefore an attempt to preserve it is the rational first
choice. This of course depends on the patient’s cooperation and motivation along with the
status of the remaining dentition. Extraction is an option, however, as mentioned already, this
shouldn’t be the first choice of action.
Assuming the tooth is to be conserved, the alleviation of pain is the first priority. Since there is
irreversible pulpitis, the only appropriate treatment is extirpation of the pulp which requires
cleaning and shaping the root canals to ensure no bacterial remnants remain. Of course, prior
to this, an access cavity has to be made which means the restoration has to be removed. If this
is a crown, then of course there will be considerations e.g. is the patient prepared to lose this
restoration, when was the crown placed to begin with and was this done properly? Once an
access cavity is made, the secondary caries has to be completely excavated before accessing
the canals, as we don’t want this bacteria to travel further into the canals. A root canal dressing
of calcium hydroxide can be placed to inhibit further bacterial growth and thereafter a suitable
temporary dressing will protect the tooth until definitive treatment. The patient will then
require obturation of the root canals and a definitive coronal restoration. Coronal coverage can
be achieved through either a composite build up, onlay or full crown coverage to provide
protection against occlusal forces. The previously existing restoration e.g. whether it was a
composite, amalgam or crown would affect the choice of crown coverage. If there was
previously an amalgam, this would affect the remaining coronal structure, weakening it. In the
case that once all infected tooth tissue is removed, if only a stump remains, a post and core
could be considered- there are 2 types; fibre post and core or cast metal post and core. It is
crucial to use a unit that comprises of two shorter posts as opposed to a single post and core in
the largest, straightest root. This will help prevent/ reduce the chances of a root fracture from
internal stresses, whilst maximising the retention. However, in most cases, a post crown is not
indicated in molar teeth due to the risk of root fracture and perforations.
Topic 8

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Topic 9

A regularly attending patient, age 54, presents with a previously restored, vital upper right 1st
premolar fractured across the palatal aspect with 40% of supra-gingival tooth structure
remaining and all of the buccal wall intact. Symptoms include sensitivity to hot and cold for a
few seconds duration. There is a history of two recurrent fractures of this restoration in the
past 12 months. Patient’s medical and periodontal history is nil of note. There was no history of
trauma.
How would you manage this patient?

Firstly, it is important to understand the reason for the history of recurrent fractures of this
restoration as this is the most striking feature of the patient-related information we have so far.
What is the nature of fracture?
Is the tooth previously endodontically treated?

Poor adhesion between tooth and restoration

Crack propagation
Occlusal
Nature of build-up of composite restoration
What is the status of the opposing tooth? Amalgam?

Sensitivity to hot and cold for a few seconds = dentine exposure

Topic 10

A young adult patient presents with congenitally missing upper left lateral incisor. Discuss the
management

The starting point- detailed history, Extraoral and intraoral examination

To begin the assessment of this patient we need the following information: patient’s main
complaint, history of complaint, medical history, extraoral and intraoral examination. Although
it may seem obvious that the complaint is the missing left lateral incisor, this may not
necessarily be the case- the missing lateral incisor could have caused a midline diastema
between the upper central incisors which could be the patient’s presenting complaint. It is
always necessary to record what the patient’s complaint is before continuing our own
diagnostic examinations as this helps address the patient’s issue and manage expectations from
the beginning. A thorough history including a medical history will help when treatment
planning. Family history of maternal/paternal missing teeth gives further indication of the
condition being genetic in origin.

During the extraoral exam, it would be useful to note the skeletal class, facial symmetry, TMJ
status and muscular movement along with the normal lymph nodes check. Intraorally, we need
a record of the appearance of the dentition as a whole, the status of the soft tissues, general
oral hygiene, gingival health, perio status and existing restorations. A noteworthy observation
would be the relationship between the gingival margin of the maxillary canine if erupted in the
space normally occupied by the lateral incisor and its relationship with the gingival margin of
the maxillary central incisor. Is the gingival relationship normal, where the gingival margins are
at the same level or is the relationship more like a maxillary central incisor and maxillary lateral
incisor where the lateral incisor gingival margin is more incisal than the gingival margin of the
maxillary central incisor? In a record of the status of the remaining dentition, it would be useful
to note any changes to the neighbouring teeth as a result of the missing lateral incisor e.g. is
the canine mesially inclined or rotated? Study models would also be useful at this point for
treatment planning.

Useful investigations

The vitality of the upper anterior teeth can be tested to exclude incidental loss of vitality and to
ensure no endodontic treatment is required. There should be no unsuspected loss of vitality
that could compromise the subsequent treatment plan.
A panoramic view radiograph is also necessary to provide a general survey of all teeth which
helps rule out any significant periodontal bone loss, helps determine whether the lateral
incisors are in fact present but unerupted, exclude any supernumerary teeth or cysts as well as
confirm the presence or absence of the third molars. The panoramic view will help confirm the
diagnosis of congenitally missing lateral incisor. Because there is usually superimposition in the
incisor region, we require an upper standard occlusal view or periapical view of this area. We
may also require further imaging to define the caries status.

As previously already mentioned, we require study models that should be mounted on an

articulator to assess the occlusal relationship and assist in the production of a diagnostic wax-
up if this is to be required.

Confirmation of congenitally missing upper left lateral incisor

Congenital absence of teeth results form disturbances during the initial stages of formation of a
tooth- in the initiation and proliferation phases. A unilateral absence of maxillary lateral incisor
is usually associated with small or microdontia contralateral incisor.

Treatment options

Create space for the lateral incisor

One option is to create space for lateral incisors. This can be done by placing the canine at its
natural position if it has drifted mesially and then filling the void left by the missing lateral
incisor with either a tooth-supported restoration or an implant. Such space creation by
orthodontic treatment involves a protracted phase of orthodontics and is costly. It would
however, produce the best results. If this approach is to be considered then the question arises-
how much space is necessary for the missing lateral replacement? Several methods can be used
to derive the answer. The first one is the golden proportion rule, which requires each anterior
tooth to have a with ratio of 1:1.618 to the tooth adjacent to it. Another method could be using
the contralateral incisor as a reference but this may not be suited if the contralateral incisor is
itself malformed. The most predictable guide would most likely be the use of a diagnostic wax-
up.

The space created for the lateral incisor can be replaced using various restorative options- a
resin-bonded fixed bridge, conventional full-crown fixed bridge or a cantilever fixed bridge. The
biggest consideration when deciding which option to use would be conservation of tooth
structure. The ideal solution would be one that is least detrimental to abutment teeth whilst
also satisfying both the functional and aesthetic objectives. The resin-bonded bridge option of
course has the benefit of being the most conservative with regards to remaining tooth
structures. Factors affecting the success of a resin-bonded fixed bridge include thickness,
mobility, position and translucency of the abutment teeth as well as the overall occlusion. A
deep overbite is also unfavourable for this option, with a higher incidence of failure. Debonding
is also a problem when the abutment teeth have increased inclination and if this should
happen, there is risk of an area of stagnation below one of the retainers and the risk of caries.

The long-term success of the cantilever fixed bridge option is dependent on the occlusal forces
applied on the pontics, with heavy occlusal loading causing early failure. The abutment teeth
also need to be radiographed to assess root and pulp status.

The fixed-fixed bridge option is the least conservative of tooth tissue as both abutment teeth
require preparation, however, this is the sturdiest of all. With this option, it is vital to verify a
common path of insertion and hence the preparation between the long axis of central incisor
and the labial surface of the canine must be parallel when viewed frontally. Laterally, the long
axis of the canine and the labial surface of the central incisor must be parallel.

There is also the option of replacing the lateral incisor with an implant after space has been
created using orthodontics. This is of course a favourable option as it means that no adjacent
tooth preparation is required, preserving as much natural tooth structure as possible. There are
various factors that need to be considered when placing implants in young patients such as the
time of implant placement, space needed apically and coronally, maintaining the space needed
before implant placement and the height of gingiva. Implants can only be an option after
vertical growth of the jaw stops otherwise there can be infraocclusion of the implant leading to
unaesthetic gingival architecture. The lateral incisor may need to be maintained using a
temporary pontic. It is necessary to have sufficiently wide labiopalatal dimensions of the
alveolar ridge to allow correct placement of the implant, if placed too labially then the thin
buccal bone can resorb and the gingiva will appear gray in colour. A downfall of this method is
that you need to wait to intervene until the patient is old enough to place implants.
Additionally, there is likelihood of apical migration of the gingiva and bone which may mean
that additional grafting is required overtime to achieve aesthetic results.

Orthodontic space closure

Another option would include the use of orthodontics to close the lateral incisor space by
moving the canine until it is adjacent to the central incisor and then modifying the shape of it to
look like the lateral incisor through a process called canine substitution. This can be done by
grinding the tip of the canine and placing composite to disguise it as a lateral incisor. The
benefit of this method is that the space closure results in permanent results and long-term
stability. The early mesial movement of the canine results in maintenance of the alveolar bone
height in the region. Also the patient keeps their natural teeth so any repairs or replacements
required with a prosthetic appliance is avoided, hence a reduced cost of treatment when
spread over the years. A more natural look can also be established as a natural gingival margin
can be achieved which can change in synchrony with the patient’s own teeth over a lifetime,
resulting in a natural look with normal aging.

However, there are various problems with this option. Although credit has been given to the
permanence of this treatment option, as with any orthodontic work, there is tendency for the
work to be reversed if the anterior teeth reopen. This can be overcome with a palatally bonded
flexible-spiral wire retainer but is an additional consideration that has to be made.
Furthermore, the lateral incisor has a convexity that is more subtle than that of the canine.
Also, whilst the lateral incisor only has one place, the canine shows two planes mesiodistally.
The lingual surface of the canine would also need to be reshaped to achieve the appropriate
overjet and overbite relationship. Even with all these modifications, the problem lies in that, if
too much recontouring is required, this could cause dental hypersensitivity if a significant
amount of enamel has to be removed, exposing dentine.

The colour of the canine can also cause problems. This is because the canine is usually two
shades darker than the central incisor. Also, with modifications made to the canine in terms of
recontouring and flattening a prominent labial convexity, this can exaggerate the colour
discrepancy, especially if dentine is exposed. This problem can be solved by bleaching of the
tooth, however, a recontoured canine may have thin enamel which increases the risk of post-
bleaching sensitivity. Another orthodontic consideration would be the placement of the bracket
in canine substitution as this varies from other cases. The bracket must be placed using the
gingival margin as a guide rather than with the incisal edge of the canine as a reference point.
This is because the lateral incisors should have a gingival zenith that is 0.5-1mm lower than that
of the central incisors. Another problem is that with this approach, the palatal cusp of the first
premolar tooth is often visible and therefore compromises appearance which in turn usually
means that the premolar often has to be recontoured as well.

Adhesive restoration for space closure

Composite can be added to the central incisor and the canine to reduce the space that would
be occupied by the lateral incisor. Whilst this is a conservative option and technically simple, it
may not result in complete closure if there is a wide diastema and therefore may not yield
acceptable results.

In conclusion, there are various options outlined for treating the congenitally missing upper left
lateral incisor. Whether to opt for space closure or space opening is a decision that can only
fully be made when information on the occlusal relationships and radiographs are available for
further analysis, however, one thing to remember is that there is a likelihood of needing more
than one specialty to chip in with their skills- e.g. orthodontist and restorative specialist, and
therefore, it is necessary to communicate the sequence of treatment, interact during treatment
and evaluate progress as treatment continues. This will allow achievement of optimal aesthetic
results for the patient whilst also maintaining the long-term dental health of the patient.