crown lengthen, endo, build up and crown or extract and implant
After looking at the PA I initially thought extract. But BW better shot. Some form of crown lengthening for sure is needed.
For those of you who are restoring, what type of success rate or percentage are you telling the patient they will have with that treatment? Thanks
On 2/23/2017 at 1:59 pm, Robert Markoff said...Or extract, graft, implant, crown.
Explain it all to the patient and let them decide.
Also do the math, when deciding on endo, p/c, crown vs implant, cost can be similar and prognosis is deciding factor. adding crown lengthening may tip the balance toward implant and prognosis in this case prbably more predictable w/ implant anyway. I would hate to have a patient do 4 procedures to save one tooth and then have issues a few years later and regret not having done the implant in the first place. like it says above, let patient decide but I would lean toward implant
Flem
I would attempt to restore. Furcation area looks intact, extent of break doesn't look bad. I have cases such as this out 10- 15 years and they are still stable. Definitely you need to inform Pt that damage present is significant and that there could be other damage not readily apparent that could cause failure of tooth
the cost differential is not huge and I would feel much better about the long-term prognosis for and implant than a crown-lengthened, endo treated tooth....JMHO
I'm totally with you Greg....and that's how I explain it to patients. Depending on the age of the patient in this scenario, there's almost no question in my mind that even with excellent endo, crown lengthening and a well made crown.....the prognosis for this tooth long-term is guarded. When I run the numbers in discussing this with patients, I tend to explain it from the standpoint of "If I think the prognosis is anything but 'guarded', it might be worth going the endo/perio/crown route...however, since I think the prognosis is guarded and that even my best work won't last as long as I would like it to, in a case such as this, I would extract/graft/implant/crown." Bottom line: in situations such as this....the patient is truly paying for your expertise and opinion. They are in your office and obviously trust you so I am comfortable "guiding" them with the decision. If they say to me "Let's try the endo/perio/crown option", I'm totally ok with that too.
On 2/23/2017 at 2:26 pm, Peter Gardell (Faculty) said...Flem
I would attempt to restore. Furcation area looks intact, extent of break doesn't look bad. I have cases such as this out 10- 15 years and they are still stable. Definitely you need to inform Pt that damage present is significant and that there could be other damage not readily apparent that could cause failure of tooth
Pete, I guess I'm wondering this: people are saying let the patient decide. Well, what are we doing to help them make an informed decision? Potential costs, one success rate over another etc. So what are the chances it lasts 10 years? If it fails then, what time, money and energy will it take to restore then etc. What's the advantages/disadvantages of doing either treatment now? That's what I would like to see discussed. Thanks
Yes explain the costs, explain what is involved in the various option. Give a hard and set " lifetime" to the restoration. I can't Just as I can't give a lifetime estimate to an implant supported restoration.
I feel that this situation is worth the trouble and effort. I would tell them if it was my tooth I would do try to save it. I then show them a x-ray of one of my teeth that split worse than this 12 years ago and is still functioning. after RCT/ Post/cerec.
My biggest concern is the patient's ability to keep things clean in the long run. How well will this patient be able to remove food and debris from that deep margin? If you do crown lengthening and take away soft tissue, what about getting a good emergence profile from the future implant.
I see this being an implant space maintainer (to steal a term from a friend). I think promising nothing, offering to try and save it, while encouraging the patient to consider the long run is the most important thing. I would personally extract this from my own head
And that's the wonderful thing about dentistry....ask 10 dentists for a treatment plan and you'll get 20 different answers.
There are so many variables in cases like this that it makes it very difficult to give the patient a "definitive" answer. Everyone that has commented is correct with their plan. Any decision the patient would make in a case such as this is correct. Mark brought up being able to give patients a more "exact" answer in terms of longevity, success rates, costs, etc. I think the only answer you can definitively respond to in a case such as this is cost. It will be "X" $ for endo/perio/crown today. It will be "Y" $ for extraction/graft/implant/crown today. It will be "X +Y $ for endo/perio/crown today and extraction/graft/implant/crown "X" a number of years from now if the endo/crown fails at a later date. Longevity and success rate estimates are educated guesses at best. Again, most of the patients in your office trust your judgement or they wouldn't be there in the first place. So if you have the same scenario in your mouth, as stated above and you believe endo/perio/crown is the best treatment plan, that's probably what you're going to suggest. If you've seen a lot of situations like this fail over the years and have a good track record with implants, you're probably going to push for that treatment plan. There are dentists out there that would suggest extraction and a bridge....and patients that would choose that option as well. Some might even opt for a removable option. Again, I think as long as we are explaining options clearly and their associated costs, we are doing our job. I think it's very easy to educate most patients. I think it's much more difficult to alter their values and beliefs about how they spend their money.
On 2/23/2017 at 3:24 pm, Robert Markoff said...And that's the wonderful thing about dentistry....ask 10 dentists for a treatment plan and you'll get 20 different answers.
There are so many variables in cases like this that it makes it very difficult to give the patient a "definitive" answer. Everyone that has commented is correct with their plan. Any decision the patient would make in a case such as this is correct. Mark brought up being able to give patients a more "exact" answer in terms of longevity, success rates, costs, etc. I think the only answer you can definitively respond to in a case such as this is cost. It will be "X" $ for endo/perio/crown today. It will be "Y" $ for extraction/graft/implant/crown today. It will be "X +Y $ for endo/perio/crown today and extraction/graft/implant/crown "X" a number of years from now if the endo/crown fails at a later date. Longevity and success rate estimates are educated guesses at best. Again, most of the patients in your office trust your judgement or they wouldn't be there in the first place. So if you have the same scenario in your mouth, as stated above and you believe endo/perio/crown is the best treatment plan, that's probably what you're going to suggest. If you've seen a lot of situations like this fail over the years and have a good track record with implants, you're probably going to push for that treatment plan. There are dentists out there that would suggest extraction and a bridge....and patients that would choose that option as well. Some might even opt for a removable option. Again, I think as long as we are explaining options clearly and their associated costs, we are doing our job. I think it's very easy to educate most patients. I think it's much more difficult to alter their values and beliefs about how they spend their money.
Robert, not even asking for an "exact" answer. I was curious what goes into how practioners let people decide, what info they give them, what bias, not good or bad, one may have to help the patient, etc. Heck, I'm not sure here and I have had almost 40 years of dental experience and I'm going to "explain it all to the patient and let them decide." 
I hear you Mark. I'm at 27 years. I wasn't trying to put words in your mouth. I think what you are talking about boils down to the personal style of the dentist. I once had a patient come in for a 2nd opinion because her previous dentist told her "she HAD to have porcelain veneers done on her upper front teeth". I asked her if they bothered her at all and she said not at all. She didn't even know what veneers were. This was back in the "old" days before there were reality makeover TV shows.
I see some offices where scare tactics are the go-to method. Others have a treatment coordinator come in and hard sell the patient on the most profitable procedure. I tend to use the "if you were my mother/father/brother/sister" phrase a lot. Additionally, I have no problem telling patients that there are certain questions that I simply can't answer. Like "how long will this crown last?"
In situations like this case, many times patients will ask "What happens if I do the endo/perio/crown and I have to have the tooth removed in a few years?" My answer at that point is usually something like "That's why I'm recommending extraction/graft/implant". Assuming most factors of quality being equal, I don't like putting myself in the position of having to say to a patient that the work they spent $3,000-4,000 on a few years ago "failed". Or I'll state it in a such a way as "Well, you can spend the $3,000-4,000 now on endo/perio/crown and see how long things last....but understand that if the endo/crown fails, it will be another $3,000-4,000 for the extraction/implant/crown."
Again, one of the problems in the dental profession is accurate outcome statistics. No one can accurately determine how long the endo/perio/crown option will last in this case. However, I feel 98%-99% accurate in telling this patient that an implant/crown will last them much longer.
That tooth has no periodontal issues. Has our boy Spear says be conservative and save the tooth. I think that's the best option. Teeth fail. So do implants. Save the tooth. RCT crown length and restore.
For all of you advocating herodontics in this case consider the following:
This is not a soft tissue crown lengthening case. In order to achieve adequate ferrule and biological width one would have to remove at least 3mm of bone on the distal aspect of this tooth and blend it into the remaining osseous architecture. This means that one would also remove 3mm of bone off of the mesial aspect of the second molar and that the distal bone level will be significantly below the furcation level. This will invariably lead to periodontal problems on the first molar and possibly on the second molar (even if the RCT and restorative treatment hold up long-term).
The treatment required to save this tooth in this case will actually cause more harm.
TFT = Time For Titanium.
Farhad
Just reading thru thread.... I would be in the camp of saving the tooth... if conventional crown lengthening is "needed" then I'd be conservative about it. But interesting that in all of the discussion--- was there an age mentioned? Maybe I missed it. But it makes me think of my orthopedist telling me I'm "too young" for a knee replacement. 10 year survival would not be a disappointment in restoring this tooth. It's a false choice to have in a "permanent" solution paradigm. What are the consequences of failure of an endo tooth/crown scenario vs implant failure? The consequences of implant failure often leaves a lot more damage to adjacent teeth---- I'd prefer an implant over a bridge for sure... but if it were my tooth, I'd save it for "X" number of years.... whatever X turned out to be.
Mark
On 2/23/2017 at 6:13 pm, Farhad Boltchi (Faculty) said... For all of you advocating herodontics in this case consider the following: This is not a soft tissue crown lengthening case. In order to achieve adequate ferrule and biological width one would have to remove at least 3mm of bone on the distal aspect of this tooth and blend it into the remaining osseous architecture. This means that one would also remove 3mm of bone off of the mesial aspect of the second molar and that the distal bone level will be significantly below the furcation level. This will invariably lead to periodontal problems on the first molar and possibly on the second molar (even if the RCT and restorative treatment hold up long-term). The treatment required to save this tooth in this case will actually cause more harm. TFT = Time For Titanium. Farhad
OK Farhad.... it really does suck to have my last post up while yours came up while typing.... but I'm leaving it up and take the beating...I'll deal with whether your view would have altered my thoughts... it's too late-- I'm dug in....
Mark
Rct cbu and cp for me. Leave the margin at the bone, love zirconia for this too. Tissue just loves accepting it and the bone
will remodel itself. If u get 10 yrs awesome if u don't u tried and put an implant the in.
You are funny Mark.
I have been doing crown lengthening procedures for 26 years now. It's a resective procedure and unfortunately not in just one tiny little spot.
Farhad
I'm in the SAVE IT camp. It's deep in the distal, no secret there. But how many of us who have posted CEREC crowns joking about 'not being able to image subg margins' did crown lengthening before the final crown delivery? So my observations tell me that, while we all seem to agree that crown lengthening is needed, it's only being paid lip service.
I'd let the pt know that while I couldn't give a definitive timeline regarding how long a RCT/Crown would last, I would still choose that option. Know before we begin this journey that this restorative option WILL fail...not a question of if but when. But! Who knows what implant advacnements will come along in the next few years? Or grafting...or bone regeneration...or...
Think back to less than 5 years ago; the digital workflow we take for granted today with Tibases/scanposts wasn't an option. Now it's 'standard' (at least for us here). So who can confidently say what new options will be available in the next 5-10 years? That uncertainty tells me that we should get as much time out of the tooth as we can before we extract the tooth go beyond a point of no return.
Just my .02 (if it's even worth that much).
This case presents the opportunity to have a very good holistic discussion of dental condition, care and outcome. Looking at the rest of the teeth in the pictures and radiographs informs your "co-diagnosis" and "co-treatment planning". The issues of wear, erosion, recession, caries risk, caries presence, restorations(of varying quality of craftsmanship) can be balanced with your awesomeness in restoring any challenging condition. Just because you can doesn't mean you should. Certainly this person has chosen costly restorative dentistry in the past and a very nice CEREC, too. Many of us have restored similar teeth with varying degrees of success; Peter has some great examples of long term success. As Farhad points out, crown lengthening involving 3 mm of bone removal m-d to create the proper predictable, maintainable periodontal condition jeopardizes the second molar in the long run and may contribute to a compromised periodontal implant outcome as John notes. In patients I have treated with similar conditions, some have had a very good long term result and some have not. Oral hygiene seems good and periodontally, the person seems well, guesstimating age as late 40's to early 50's. I wonder how many times it may take to treat this area over the course of a lifetime. I would want to know how the person feels about keeping the tooth, what it means to him, what it would mean to remove it, how he feels about the various procedures/costs associated with each course of treatment. Given the restorations and repeated restorations, an FPD or RPD is contraindicated. His oral hygiene is positive for implant restoration.Temporizing the tooth and stepping back to review the entire mouth and long term goals/concerns/finances,etc is recommended in the short term. Taking the time for this approach can lead to a very successful lifetime relationship with this person.
My recommendation with the above in mind and in dialogue with the person would be to remove the tooth and place an implant. The costs are more related to the long term health of the patient and the area rather than the dollars involved, although that would be part of the discussion. I would review the various restorations and conditions present in the observed area and look at the rest of the mouth in determining a definitive treatment plan.
On 2/23/2017 at 6:50 pm, Peter Gardell (Faculty) said... And I though periodontists saved teeth
Not at the cost of doing harm to adjacent teeth or wiping out more bone over time.
I outlined above what will happen if you do crown lengthening. For all those who wouldn't do crown lengthening in this case: The same thing will happen with the bone remodeling except that it will happen with the development of a significant inflammatory response and a periodontal pocket formation on the distal.
Remember one of the most important points of the Hippocratic Oath: "Primum Non Nocere".
Farhad
On 2/23/2017 at 6:50 pm, Peter Gardell (Faculty) said... And I though periodontists saved teeth
They do-In jars to give to dental students which is where this tooth will end up.
Saving this tooth in the mouth is a dental annuity for the practice, and a dental liability for the patient.
Crown lengthening will need bone removal from both teeth and will need a flap not a laser. Due to the extent of the damage to the tooth and the cost to save it, Ian implant is a better option,
This is a great case. See this every week. Honestly, not sure of the right answer, the entire thread above runs through my mind every time I see this. I am not certain that there is a right answer other than to inform and allow the patient to decide for themselves. How we decide to guide that decision is the hard part.
Guiding that decision is the hard part. I think one of the problems that some dentists have is that they tend to look at cases like this only from a dental perspective. I don't think there's any doubt that this tooth can be "saved". I think the issue becomes more about how patients view the situation if/when the tooth fails. Assuming it's not a geographic success and the patient sticks with you for 20-30 years, the best discussion to have would be "so tell me how long you would like the endo/perio/crown solution to last.....at what point in time would you feel like you got your money's worth?"
If the patient told me, "I'm fine with 5-7 years doc." I'd know that this is a patient that is totally OK with spending $3,000-4,000 on keeping the tooth and that they understand that if/when it fails, they're in for another $3,000-5,000. The problem I have seen over the years is that a lot of people don't always remember the conversation above. They come in in pain or we see the problem on the x-ray and I have to break the bad news to them that it's time to extract and place an implant. Or...they are coming from another dentist and they're pissed off that their work that was supposed to "last a lot longer than it did" has to be fixed.
If I can avoid creating situations in my practice that are going to prevent conversations like this, I'm going to go with what I refer to as the "more permanent solution". Can implants fail? Of course...but that's explained to the patients as well. In this case, given the limited information we have been given, I think the implant/crown solution has a much more favorable prognosis than the endo/perio/crown solution. And that's exactly what I would say to the patient.
Damen-
My guess, after examining the x-rays that you posted, is that this patient is a healthy, non-smoker (obviously) 67 year old male. Probable life span of 90ish. I like to look at where patients might be when something may fail. If he is 80ish when the RCT/Post/Crown fails, what is his access to dental care at that time likely to be? Will he be in a nursing care facility? Will he have good transportation to get dental care? In older individual, I prefer more solid solutions that will last them "as long as they need", so they won't have to deal with it when their health may be in decline. Tough call, but my recommendation is for the Implant. With the fully informed consent of the patient, of course. 
Jay
Based on my experience that is not going to be an easy tooth to extract either. More than likely sectioned buccal lingual through the furcation and some troughing of the roots to get leverage and elevation. Divergent roots. Thin mesial root could fracture. By time that tooth is out there'd be plenty of inadvertent crown lengthening on both 29 and 31. RCT crown lengthen post and core crown and I'd bet you get ten or more years out of it. Curious what Tim Hempton a periodontist in Massachusetts would say here. He lectures extensively on crown lengthening surgeries. Interesting dilemma for sure.
http://jada.ada.org/article/S0002-8177(14)64740-1/fulltext#cesec120
David you are correct with surgical extraction. I spoke with the patient about xx or crown length endo ... I based my decision for xx based clinical judgement and with my "gut". Patient is a male in his 55ish. Non smoker and in good health. I advised him cost would be about the same with both options. I was able to extract with the buccal wall intact but i did have to remove furcal bone and mesial slightly. Next question graft or no graft?
I'm with Marc and I unfortunately see cases like this far too often (almost daily).
The first thing I do with these cases is have an honest discussion with the patient about how we arrived into this position in the first place. Clearly there was an existing restoration that failed; most likely due to recurrent decay that results from poor maintenance or an inability to maintain by the patient. We discuss the depth of the previous margin - now let's place the margin deeper. Do you think you can maintain this margin? How long will the restoration last? When asked, my answer is always - It will last until you can no longer maintain it. This allows the patient to see that the ownership of the problem is theirs and so is the choice for solution to the problem. If you honestly think you can maintain it, then the option to restore exists.
Just because I can fix it, doesn't always mean I should fix it.
Many good thoughts on this. Time for tx plan rationale #21 ;)
A couple commented about wanting to know about the condition of the rest of the mouth. Pet peeve of mine is the new emerg patient asking can you fix this tooth doc? As others said - I can but should I?
The one thing nobody asked for was a health history on this guy! Believe it or not, a big factor in tx planning this!
Two things that jumped out in the pics provided:
1) Tell-tale sign of acid reflux. Look at cupped out premolars. The question: Is this an ongoing issue the patient is aware of? If not, referral is appropriate.
2) Clench/grind is apparent. Look at bone loss and abfractions. Meds involved? Psych issues?
3) Combine 1 and 2 and there is a good chance of sleep apnea. btw those roots and abfractions won't last long with acid reflux.
----
Given all that - Titanium infusion is recommended.
If the patient understands that this will possibly buy him several years... save it. Floss and use that water pick daily. See him on a regular check up. Again.. if this was my tooth... I will try to save my tooth... without hesitation
That distal root is going to fracture sooner than later even IF you can get a good margin placed that deep. If it was me, I would want the implant. That tooth is a ticking time bomb.
On 4/1/2017 at 6:32 am, Thomas Kauffman said...But, my tooth, I would save it. That's just me, but I am betting that Charles or david could probably pull it off. You all need to consider the fact that all Farhad has in his toolbox is a screw driver and a screw.
tk
LOL....The other thing I have in my toolbox is an understanding of biology versus a tooth plumber type of mentality. Saving this tooth will lead to periodontal disease and bone loss not just on this tooth but also on the second molar (in addition to the probable mechanical failure as pointed out above).
Farhad
Interesting discussion. Based on the bone level shown in the BWX I would present the implant option and the restorative option. On the BWX it looks like the margin of the lesion might be 1 mm above bone level which means that 2 mm of bone removal in crown lengthening is necessary. I have restored many teeth like this that are/have been in service 20 to 25 years and counting. Isn't that the experience time Farhad admits to? 
Extensive decay like this shows that the patient's ability to maintain whatever is done is questionable. This patient obviously does not avail himself of regularly scheduled dental care. It has to have taken at least 3 years, and maybe more, for a carious lesion to get this large. Fore sure, the two lesions shown in this patient's radiographs are more than a year old. Therefore, predicting the service life of any dentistry done for this patient is a crap shoot in my opinion. Therefore, my case presentation would include all options, costs, and possible and likely outcomes. And, as has been previously stated, I would emphasize that the service life of whatever treatment is decided upon in this case will depend most heavily upon the patient's ability to maintain it and his willingness to seek regular dental care. I would have all this in writing and have the patient sign and date it. Similar scenario--when a patient has trouble adapting to a denture, he always says that the denture doesn't fit. We all know better than that. When I do a denture I have the patient sign a statement to the effect that he acceptst that I will do everything I can to insure that the denture fits his ridges, but I can't guarantee that he will be able to successfully adapt to using the appliance. I fully buy in to the idea that the patient must take ownership of his/her problem.
Speaking of my own mouth....This is my #19 implant, which has been in place for 22 years now.
And as a contrast this is a crown lengthening case I did last week. Tooth #18 with deep distolingual caries lesion. Radiograph looks benign and no RCT required but the location of the lesion made crown lengthening very challenging (access, no attached gingiva, lingual nerve vicinity, bone level on distolingual close to furcation bone level). Patient was informed of the compromises and I agreed to do the crown lengthening because if this fails it doesn't have an impact on other teeth....But I doubt that this tooth will last 22 years.
Farhad
Hi Tom,
My comments were of course meant in general and not directed towards you or anybody specifically...A CT diagnosis guru like you is certainly not lacking in that area so cancel your psych appointment.
RCT in the above case is still an option. So far the tooth tested vital but we will have to wait 3 months until final restoration so we will see. I will however say that I cursed myself several times during the C.L. surgery for deciding not to extract the tooth.
Farhad
Farhad,
Given the excellent periodontal condition of the tooth you crown lengthened, I would say that tooth has an excellent chance of being in service as long as the patient is alive and kicking. I respect your knowledge and skills but I believe you may be a little quick to apply the hopeless tag. I have my share of herodontics failures, but I have had some successes as well.
TK, we think alike. I know you remember that when we were in the military, endo on second molars was never an option because people function perfectly well on first molar occlusion and we had too few dentists, too few working hours, and too many people to take care of. That being said, in private practice I have done endo on second molars and even a few third molars, but not if there is a mouth full of teeth that require attention and the patient is not rolling in money. because the resources can be more effectively applied between the first molars. Also, I cannot justify replacing second molars with implants, even if the patient can afford it. The risk/reward/benefit ratio plus the degree of difficulty don't add up.
