Erupting Compromised Teeth for Restoration by Dr. Joe Whitehouse

by Dr. Joe Whitehouse

• The tooth was restored without enough ferrule effect, so the crown is in need of being recemented over and over because there’s insufficient retention.
• A root-canaled anterior tooth with a post and core comes out because of a short post and a ferrule issue.
• The patient presents with severe decay or a fracture.
• The root splits because a crown build-up with a post has been torqued out, splitting the root with no option but extraction.

• Durability. How long will what I do last? It would seem that placed crowns are meant to last indefinitely, but when you look at Figs. 1 and 2, you can see the outcomes were not planned properly. This case was only one month old.
• Patient buy-in. In my conversations with patients, I always ask, “How long would you like what I do for you to last?” The more you can make your patients feel involved in their treatment, the more trust is built.
• Function. Will the treatment lead to the patient’s idea of proper functioning? Most patients are going to prefer it if you can put back an individual tooth, rather than creating a bridge. (Think: flossing.)
• Aesthetics. It’s always better when a restored tooth is in the mouth; not planning for the longest term of completed care compromises this. Also, aesthetics around anterior implants can be tricky because the patient always wants the outcome to look at least as nice as it was before the issue of which we are speaking comes up.
• Price. What value are the patients willing to place on the outcome they desire?
• Methodology. Is the patient willing to wear braces to get the best outcome?
• Time frame. How long will it take to get the best outcome (or the one the patient wants)?

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• The process is complete as to movement.
• If you want to move the tooth down/up (for lower anteriors) more, put the wire on top of the bracket for more extrusion for a greater ferrule effect. Remember, as the wire straightens out, it will protrude out the distal side of the outer brackets. Be prepared to trim that back as needed.

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• Crown-to-root ratio. I have researched this with no firm final ratio. I believe that a 1:1 root remaining in the bone to the prepped abutment seems to work. If cuspid rise is your occlusal philosophy, a shortrooted cuspid would need to be evaluated for this technique. Could there be less root in the bone? Perhaps, depending on the occlusion. An upper lateral with no anterior or posterior torque could be OK. A bicuspid with only vertical force should be OK. Occlusion can be adjusted to help with this issue.
• Why not do crown lengthening? I am totally into minimally invasive approaches, and crown lengthening is a bit invasive and may affect the cosmetic view. Certainly, it is appropriate in the posterior, and I have done it there for more ferrule effect; however, in doing crown lengthening, one must consider the bone anatomy of the adjacent teeth. Also, critically, one cannot invade the biologic width—noted to be, on average, 3 mm. I have seen several incoming patients who had chronic inflammation where the margin of the crown was placed too close to the bone, invading the biologic width. These are the cases that should have had eruption as described in this article. (In fact, erupting biologic width crown invasion can be corrected by forced eruption.)
• Up to this point, I have not mentioned a removable appliance technique. Yes, it is possible to erupt with an Invisalign-type appliance or a retainer, but the expense, time and predictability is, in my hands, not worth the effort.

Dr. Joe Whitehouse graduated from the University of Iowa Dental School in 1970. During his career, Whitehouse brought three other practices into his own and adopted a totally minimally invasive approach to dental care. He was a co-founder of the World Congress of Minimally Invasive Dentistry, serving as president for two terms.
Whitehouse also earned a master’s degree in counseling, enabling him to treat many fearful/apprehensive patients without drugs. He has written about dealing with fearful patients and authored articles on minimally invasive dentistry and clinical issues dentists face.