|Year : 2021 | Volume
| Issue : 3 | Page : 211-216
Methods of maintaining compromised teeth in adults: A literature review
Department of Restorative Dental Sciences, College of Dentistry, Majmaah University, AlMajmaah, Saudi Arabia
|Date of Submission||29-Apr-2021|
|Date of Acceptance||06-Jun-2021|
|Date of Web Publication||04-Sep-2021|
Department of Restorative Dental Sciences, College of Dentistry, Majmaah University, AlMajmaah 11952
Source of Support: None, Conflict of Interest: None
The proportion of the remaining tooth structure is crucial for the deliberation of whether or not to preserve a damaged tooth among adults. It has been stated in previous studies that in order to assure long-term care, restoration of a badly damaged tooth with a full crown will more frequently than not be needed. There are numerous methods for maintaining compromised permanent teeth. Apical surgery, root resection, crown resection, autotransplantation, orthodontic extrusion and intentional replantation are the methods that have remarkably high success and survival rates when cases are carefully planned and managed appropriately. These methods have greater importance in adolescence compared to adults, as implants should be preferably delayed until the completion of alveolar bone growth. The present review is aimed to discuss case selection and the techniques involved in the different methods used for maintaining compromised teeth, as well as their success rates. Based on the studies covered in this literature review, a survival rate of at least 80% can be expected for compromised teeth that have undergone treatment with these methods.
Keywords: Endodontics, orthodontics, pedodontics, prevention, surgery, trauma
|How to cite this article:|
Alroomy R. Methods of maintaining compromised teeth in adults: A literature review. Adv Hum Biol 2021;11:211-6
| Introduction|| |
What is a compromised tooth?
Regarding tooth, “compromised denotes to any decrease in the operational lifetime of the tooth without any supplementary intervention needed.” If the structure of the tooth is altered, the loss of a substantial amount of natural tooth tissue may change into a deteriorated condition so that its fracture resistance is decreased or leads to pulp death. Dental tissue loss can occur either slowly (e.g., due to disease progress) or abruptly (e.g., by trauma).
| Investigations|| |
For this purpose, during the diagnosis and treatment planning phase, it is necessary to recognize that any tooth is affected indirectly or indirectly at the very beginning, such as destruction of periodontal support, endodontic/periapical condition, damage of tooth tissue, basic weakness (hairline cracks or suspected cusp fractures, posts, etc.,) and extreme occlusal forces.
This determination should be made in light of the history, symptoms and signs and any related investigations and special tests, all of these must be reported in the patient's records, under the examination carried out, outcome and decisions are drawn.
| Endodontics|| |
Assumptions are often taken from a range of dissimilar sources. Few of them are more useful than others. The combination of recorded symptoms, clinical examination and different types of investigations finalise the diagnosis for endodontic care is needed for a tooth, is an example of this.
| Periodontal Assessment|| |
The assessment of the consistent periodontal support of a tooth is compromised between direct observation of inflammatory changes, objective measures of depth of the tooth and other investigations that depend on subjective interpretation of objective evidence like mobility and radiographs.
The presumption that, as soon as it has been fixed, a compromised tooth ceases to be of interest is an easy pit to fall into. Nothing could be further from reality, and indeed, the well-being of any such “at risk” tooth must be checked periodically, and these data must be kept with patients records.
Over the last few years, views regarding the prestige of the root restored by post within the inventory of restorative dentistry and prosthodontics have fluctuated. In the scientific literature, the element that postcrowns attribute highly in unsuccessful work on crowns and bridges has been well reported.
Four main areas of risk
The main area of risk is as followed:
- Angulation of root-leads to perforation
- Length of the roots-affects the retention that leads to documentation and secondary caries development due to microleakage, also interfere with a hermetic seal at the apex
- Strength - It's directly affected by the length, width, design and type of material used for restoration
- Design - Also affected by the type of design used. Various designs are parallel or tapering, threaded or smooth and cast or preformed.
The limitations of restoration must be preinformed to the patient.
The cracked tooth
Perhaps it's a reflection of the period that patients believe and assumes that health-care practitioners to be capable of making reliably specific diagnosis and having “immediate” treatments for whatever complaints they might have. The “cracked cusp” or “cracked tooth” is extremely challenging to diagnose and handle with assurance, and in dentolegal cases, it is also beginning to appear profoundly as a damaged tooth.
| Maintaining Compromised Teeth|| |
There are several methods for maintaining compromised teeth and replacing missing teeth. Recently, dental implants have been further developed and improved and are currently the primary choice of many clinicians for tooth replacement. Nevertheless, an accurate diagnosis and effective treatment plan must be established before a decision can be made between maintaining a compromised tooth and extraction. While dental implants have a high survival rate, tooth extraction is an irreversible procedure. Therefore, potential alternative treatment options, which may facilitate the survival of a tooth (e.g., apical surgery, root resection, crown resection, autotransplantation, orthodontic extrusion and intentional replantation), must be considered carefully; this is particularly important for adolescence, as implants should be preferably delayed until the completion of alveolar bone growth. Therefore, the purpose of this review was to explore the various methods of preserving damaged permanent tooth in adults.
| Assessing the Quantity of Compromised Tooth|| |
The bulk of residual tooth structure is crucial in consideration of whether or not to preserve a damaged tooth among adults. As already mentioned, to ensure long-term care, restoration of a grossly damaged tooth with a complete crown will more often than not be essential.,,, Then, sometimes, a post and core must be positioned. Synchronously, in order to achieve the ferrule effect, coronal dentine should remain. Crown lengthening by the minor surgical process may require coronal dentine from the crown margin for decorated teeth, but such techniques have drawbacks, as the support of adjacent teeth for periodontal tissue can be affected. It is clear that when determining the quality of a tooth for reconstruction, the clinician must determine if the amount of remaining supragingival tooth material is adequate. If it is not possible to obtain a ferrule, the patient must be updated on the doubtful results of the preservation of the crown and should be provided with possible substitute measures, like a traditional bridge, implant, partial denture, or no replacement. While achieving a ferrule effect, the risk of “verticle fracture” must be kept in mind.,,,,,,,
| Assessing the Reliability of Compromised Tooth|| |
It is sensible to analyse not only the amount but also the features of the residual supragingival tooth material. However, attributed to the prevalence of caries or restored caries, a precise analysis by effortless clinical or radiographic evaluation may not constantly be feasible. Therefore, to enable proper evaluation, it is essential to completely remove both existing caries and restorative materials. If a root fracture is doubted or observed at a coronal level, this precaution is extremely important, as its occurrence may infer and leads to a poor prognosis for tooth preservation.
| Evaluating the Diagnosis and Prognosis of Compromised Tooth|| |
It must be emphasised that all diagnostic measures in this perspective are finest performed using magnification and good light under a rubber dam. It is very critical to determine the periodontal tissues. If caries or fractures have progressed to the periodontal ligament and the crestal bone beneath the gingival margin, there are more extensive problems with tooth restoration than those previously explained. It is crucial that restoration is finalized on the unaffected tooth structure in all instances. The tooth cannot be adequately restored if the gingival tissue ranges on the margins of the tooth except the periodontal tissues are apically readjusted. Obviously, in such cases, the lengthening of the clinical crown may be respected, provided that extreme amputation of bone tissue from the neighbouring teeth is not necessary. The definitive restoration should be inserted in a proper place that it does not invade the periodontal tissues so that the width of the attached gingiva is adequate (ca. 3 mm). That's why careful clinical and radiographic assessment is essential. Factors such as the length of the root, the proximity of the adjacent teeth (like interproximal defects), the gap between the margin of the defect and the furcation area and in particular, the space between the apical limit of the defect and the bone must be assessed. Radiographs need to be taken without distortion. It is crucial to assess the amount of bone that needs to be removed when it comes to crown lengthening. Both affected and infected tooth structures must be removed to obtain sound tooth structures.,,,,,,,,,,,,,
| Before the Conclusion to Extract A Tooth is Made|| |
It has been shown that patients with more teeth are also more likely to have a sophisticated quality of life. However, extraction can be compensated with dental implants, although its placement cannot be carried out in adolescence due to uncompleted alveolar bone growth and high costs. Furthermore, peri-implantitis and mucositis affect up to 66% and 80%, respectively, of patients with dental implants., It has been reported that natural teeth, which receive appropriate treatment, can survive longer than implants. The dental implants failure rate was systematically reviewed to range from 0% to 33% over the long-term (i.e., 15 years or more); in contrast, the long-term failure rate of damaged teeth, which were adequately treated and maintained, was determined to range from 3.6% to 13.4%. In addition, Setzer and Kim compared dental implant survival (73%–95.5%) to endodontically treated teeth (89.7%–98.1%). Although in the existence of the aggressive periodontal disease, Graetz et al. have shown that teeth with a questionable (or even poor) prognosis can be retained as long as 15 years. It is an executive choice to remove a tooth and the risk of dental implant failure is greater at the sites of previously failed implants.,, Therefore, the choice to extract a tooth requires careful evaluation. There are many methods to maintain an endodontically treated tooth, even if it has a questionable prognosis. These methods include apical surgery, root resection, crown resection, autotransplantation, orthodontic extrusion and intentional replantation.
| Apical Surgery|| |
Endodontic microsurgery is a minimally invasive procedure that resects only 3 mm of the apex. Apical surgery is considered when a patient has a persistent infection, long post, calcified canal, irretrievable foreign materials, hard cement filling materials, non-negotiable ledges, zips, strips, canal blockages or transportation. Traditional surgery involves retro-preparation using burs and the placement of an amalgam retrograde filling. Furthermore, it does not require the use of magnification of the field like endodontic microsurgery and uses an ultrasonic instrument for retro-preparation; it additionally requires an all-purpose, alumina-fortified material for final cementation and a retro-filling composed of intermediate restorative material or mineral trioxide aggregate. A meta-analysis has reported that traditional apical surgery has a lower success rate (59%) compared to endodontic microsurgery (94%). Song et al. investigated the outcome of endodontic micro-resurgery and reported a 92% success rate. They concluded that micro-resurgery is a valid treatment option that should be considered before proceeding to extraction. While few patients might encounter either mild or moderate pain, swelling and ecchymosis after apical surgery, Tsesis et al. found that 76% of patients did not experience pain within 24 h after surgery and 65% did not have swelling. Their study supported the use of a prophylactic analgesic to alleviate post-operative pain, as well as a cold compresses (every 15 min) to reduce swelling on the day of surgery. Post-operative pain is known to peak on the day of surgery, and swelling is most evident within the first 2 days postoperatively. A previous study conducted by Keiser and Hargreaves supported the use of post-operative long-acting anaesthesia to reduce pain. Maxillary sinus perforation may occur while performing apical surgery on posterior maxillary teeth due to the close proximity of the roots. Such perforation does not require any further surgical management, as it self-repairs. While the placement of a membrane does not improve the rate of self-repair, the prescription of a decongestant is recommended. The administration of antibiotics, however, is controversial., The mandibular canal is nearby the mandibular posterior teeth, and cone-beam computed tomography has been revealed as an excellent tool for the preoperative assessment of its location. Wesson and Gale documented an incidence of 20% for temporary lower lip numbness after apical surgery in mandibular posterior teeth; only 1% of the cases were permanent. Recently, a novel technique using three-dimensional-printed guides and trephine burs has been introduced, which has the potential to lower the risk of nerve damage.
| Root Resection and Crown Resection|| |
The root resection procedure involves removing the affected root completely from the cementoenamel junction, leaving behind the portion of the crown. The indications for this therapy are Class III furcation defects, critical vertical bone loss involving one root, root perforation, root fracture and persistent apical periodontitis., A meta-analysis reported a tooth survival rate of 87.2% following root resection. One of the disadvantages of this therapy is the need to create an undercut area below the crown where the root was resected; this may lead to difficulties in achieving good oral hygiene. However, the prosthodontist can plan the crown preparation to accommodate a final restoration that is optimally contoured to facilitate oral hygiene. The aforementioned meta-analysis also reported a tooth survival rate of 81.2% following crown resection. Notably, this survival rate was lower than that reported for root resection, despite both procedures being clinically similar. Nevertheless, the sample size used in the meta-analysis for crown resection (three studies; n = 111) was much smaller than that used for root resection (nine studies; n = 1127).
| Autotransplantation|| |
Autotransplantation of a tooth is a treatment alternative that includes the extraction of a healthy tooth, which is subsequently transplanted into the socket of an extracted unrestorable tooth. If the donor has a tooth with an open apex, endodontic treatment must be avoided for further root development. However, if the donor's tooth has a closed apex, root canal treatment is necessary to avoid pulp necrosis and periapical inflammation. Lin et al. reported that post-operative root canal treatment for the donor's tooth is linked with a more favourable outcome, compared to pre-operative or extraoral root canal treatment. However, Jang et al. showed that pre-operative root canal treatment led to an improved prognosis if root-end resection was also performed. Autotransplantation is also advantageous in that it preserves the interdental papilla and the alveolar bone. Autotransplantation is an excellent option for teeth involved by extensive decay or severe trauma; it is especially seen in adolescence, as alveolar bone growth is still ongoing. The success and survival rates for this procedure are 96% and 98%, respectively.,,,,,,,,,,,,, The management of post-operative pain and swelling can be addressed as described in the section discussing apical surgery, and the same aforementioned procedures for avoiding injury to the adjacent structures such as sinus and nerves can be utilised for autotransplantation.
| Orthodontic Extrusion|| |
Extraction leads to a deficiency in the alveolar ridges. However, orthodontic extrusion may be considered in cases involving the aesthetic zone, where the placement of dental implants is particularly challenging. This procedure also facilitates the maintenance of the alveolar bone and attached gingiva during their development in adolescence. Although crown lengthening can provide good access for the restorative procedure, it may result in compromised aesthetics if performed in the anterior region. Another advantage of orthodontic extrusion is that it can repair infrabony deformities and relocate the gingival margin., Teeth affected by severe trauma or extensive caries may require extraction. While orthodontic extrusion in such cases may not be sufficient to save the tooth, it can at least maintain the bone and improve the gingival contour prior to the provision of an implant, following the cessation of alveolar bone growth.
| Intentional Replantation|| |
When a tooth must be extracted for periodontal or endodontic reasons, the intentional replantation procedure can be an option before proceeding to the provision of a dental implant. This procedure can be utilised when microsurgery cannot be performed due to anatomical factors. The tooth has to be extracted gently to avoid tooth fracture. Moreover, periodontal ligaments must not be damaged during the procedure because they are important factors for procedural success. Some studies have suggested avoiding surgical elevators and restrict the use of extraction forceps to prevent injury. A meta-analysis has described a survival rate of 88% for this procedure. The mandibular second molar has a thick buccal cortical plate and positioned near to the inferior alveolar nerve and shallow vestibule. In such cases, intentional replantation may be considered, as nonsurgical or surgical root canal treatments are not possible. The prognosis of this procedure is improved with a shorter extraoral time and a greater amount of remaining intact periodontal ligaments following extraction.,,,,,,,,,,, The management of post-operative pain and swelling can be addressed as described in the section discussing apical surgery, and the same aforementioned procedures for avoiding injury to the adjacent structures like sinus and nerves can be utilized for intentional replantation.
| Conclusion|| |
Tooth extraction usually leads to alveolar bone deficiency, and placing a dental implant may require constructive procedures. Dental implantation and subsequent periodontal constructive procedures can be costly. Apical surgery, root resection, crown resection, autotransplantation, orthodontic extrusion and intentional replantation are all more cost-effective procedures than dental implants. Furthermore, they are more suitable for adolescence, as implants should be delayed until the completion of alveolar bone growth. When cases are carefully selected and managed appropriately, a good prognosis can be expected. The clinicians strive to preserve the teeth to a greater extent of challenging clinical conditions, and infected teeth slowly become a growing dento-legal threat. Good communication with the patient is the secret to their successful management, as is discovering new technical resolutions to long-standing clinical problems. It is challenging to try and persuade the patient by minimising the issues and expressing a positive approach to “we have the technology that can deceive and embarrass the most competent of physicians, the extensively repaired or otherwise damaged tooth. Various risks related to these clinical circumstances are increasing in prevalence, can be reduced by a careful approach, accurately reported in the patients” data.
The authors would like to thank the Deanship of Scientific Research at Majmaah University for supporting this work under Project Number No. R-2021-167.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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