Geez, I dunno, do you use it during extraction and implant placement?

OH !

David

OK, Ron, I’ll play …

First, it sounds exactly like the majority of MY patients! “Can’t you just glue it back in?” (followed by all the usual reasons why they can’t afford anything else right now, of course.

Given that extraction/implant tx is out of the question, along with seeing a periodontist for CL, I’d probably have a LONG discussion with the patient about how guarded the prognosis is for this tooth no matter HOW it’s treated. Assuming he says, “No, I want YOU to save my tooth,” I’d propose the following and will expect to get flamed for it …

1) Closed CL. I know, I know … really bad idea. However, from the info given, the patient doesn’t want to either endure or pay for a flapped, surgical procedure. Fine, the prognosis is guarded anyhow, so whip out the laser and do your best to remove some bone, clean up the tissue and get some tooth on which to hang a margin.

2) Make a conservative post space for a cast post & core-crown combo

3) Take impression

4) Temporize

[Really Big Disclaimer: I’ve never done closed CL with the laser. Heck, I’ve never done CL of any kind, so this idea is probably so much blather, so take it for what it is.]

However, I DO know patients of this mindset, and they just aren’t into fancy, comprehensive treatment plans. The will, however, love you and pay you a reasonable fee to figure out how to save this tooth, if only for a short time.

Seems like a good opportunity to do a closed CL, save the patient some time and money … but NEVER take pictures of the procedure and post them on anywhere online! 🙂

— Don

Hi Ron,

We all agree on what this patient really needs and we have all had to accomadate patients who want to dictate treatment.

For the discussion I thought I would add the option of ortho extrusion.

If the root length is good and the taper is not extreme extrusion is a great way to get crown length in the esthetic areas. Minimal resection is necessary and preservation of the papillae is easier.

I have never done closed C/L but this looks like cases that have been posted and restored using this method.

The prognosis is poor regardless so I would say least amount of time and money needed is best in this case.

See ya,

Andy

Hi Ron
I would do the same as you did.
It would be interesting to know what you charged for all these procedures compared to what you would charge for an extraction and an implant.
Thanks for posting this case.
Mickey

Ron,

I’ve done a few of these, however with prefab stainless steel and fiber posts. Your patient’s tissue response, by the way, looks “marvelous.” It seems that upper bicuspids and upper laterals seem not to last very long in that 1) the poor crown to root ratios–especially those roots that were already short in the 1st place and 2) the dark forces of occlusion that broke the camel’s back originally seem to find their way back–even when “taken out of occlusion.” So, trying to ensure , especially in the anterior region, the ever important ferrule and thus making a borderline C/R ratio tooth, I end up seeing more than a few coming back with fractured roots. Even though we’ve had a documented discussion about the poor prognosis and consent signed, there is definitely dissappointment on both sides as now that investment is down the toilet and something more expensive must be in the works.

Now I go into the risks, prognosis, etc, and do not many of these any more. I even suggest that they get a 2nd opinion or an opinion they want. I’d rather they get disappointed with someone else down the line than me and I sleep a little better.

Great photography, by the way.

Mossman