townie clinical An Alternative to Crown Elongation - Dentaltown - Where The Dental ... · 2005. 3. 4. · Society of Periodontology and the Dodecanese Dental Association. Dr. Vergoullis

92 dentaltown.comMarch 2005

Orthodonticstowntownie clinical

In the case following, a crown elongation of tooth #31 would expose the tooth’s furcation and possibly compromise #30.Periodontist Dr. Daniel Melker has posted a different approach on dealing with these cases and I was really amazed by hisbeautiful results. Here, I share another way to achieve this difficult mission.

I am a periodontic resident, so I hope my orthodontist friends forgive me for getting into their field. Dentaltown hasshown me that knowledge is attainable for everybody who wishes to go after it.Any comments are more than welcomed.

Yiannis Vergoullis, DDS

An Alternative to Crown Elongation

Figure 1: #31 exhibits a restorativemargin to the bone

Figure 2: Ortho extrusion was initi-ated and the crown was grounddown to give 2 mm clearance fromthe opposing dentition

Figure 3: Lingual view

Ioannis Vergoullis, DDS received his DDS degree from the School ofDentistry, University of Athens, Greece. Currently, he is studying peri-odontics and implant surgery, as well as a Master of Science in OralBiology at Louisiana State University. Dr. Vergoullis is a member ofthe American Academy of Periodontology, the Academy ofOsseointegration, the Western Society of Periodontology, the Southern

Society of Periodontology and the Dodecanese Dental Association. Dr.Vergoullis can be found on the message boards of Dentaltown.com or through e-mailat [email protected].

As posted on the Case Presentation section of www.dentaltown.com, followed by Townie Comments

Figure 4: 5 weeks from day 0

Figure 5: 8 weeks from day 0, minorosseous recontouring performed

Figure 6: 10 days post sx

Figure 7: 3 weeks post sx Figure 8: 3 weeks post sx Figure 9: 5 months from day of orthoinitiation. PDL width indicates thatmost likely tooth is ready to go forfinal PFM

Figure 10: 8 month re-call

senor | Total Posts: 317 | Posted 11/11/2004 6:00:40 PM Dang nice work there! What is the approximate fee? Did

you and [if so] how often did you adjust the occlusion?Where did you learn the technique?

Vergoulisi | Yiannis | Total Posts: 25 | Posted 11/11/20047:07:21 PM

Thanks Senor. I am resident at LSU, so itonly cost him $200 now in private practice Ireally don’t know if it’s worth it for me to dothis case since it really needs several post-opappointments and takes longer time than any sxI do. I did the case just for the fun of it. My

Program Director guided me and I read some articles fromhim (Yukna) and others (Kokich, etc). I was checking occlu-sion every 2 weeks.

yahu | Total Posts: 195 | Posted 11/11/2004 7:26:08 PMNice! I like to ortho extrude when I can. I think the

ortho guys are happy to let us do it. I don’t think they like tomess with it. This is an often overlooked tx. Good work.

Alexander Vasserman DDS, BS | Total Posts: 1145 | Posted11/11/2004 8:41:26 PM

This is a handy technique in the old arma-mentarium. I assume both molars were extrudedat the same time. Why the band? Whatgauge/type wire? And, how did you know itwould be sufficient to anchor on just 2 teeth?This is very interesting.

Vergoulisi | Yiannis | Total Posts: 25 | Posted 11/11/200411:18:11 PM

Alexander, I used NiTi .016. I banded the3rd molar because it was very difficult to place abracket that would stay on this tooth. All teethinvolved had normal mobility (less than Class IMiller) and so enough perio support to with-stand the forces with no adverse effects.

However, I was following up the case every 2 weeks in order tohave control over that. Only #31 was extruded, that was thegoal and I think no extrusion is evident to the other molars.

ekrause | Total Posts: 13873 | Posted 11/12/200412:13:28 AM

You’ve extruded the furcation right out ofthe bone and gingiva! Yikes!

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Townie Comments as posted on the CasePresentation section of www.dentaltown.com:An alternative to crown elongation

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Danmelker | Danny | Total Posts: 1404 | Posted 11/12/2004 4:09:35 PM Excellent option! Those of us who fully do not understand ortho must realize the bone will come coro-

nally with the furcation if there is no pathology during tooth movement. Great case and great result. Wouldbe interesting if there would be a way to do both procedures, ortho and root reshaping, to see which wouldbe easier.

ekrause | Total Posts: 13873 | Posted 11/12/2004 6:02:10 PM In this case, the bone didn’t come up with the tooth, at least not in the furcation area. Look at the buc-

cal pictures from before and after.

vergoulisi | Yiannis | Total Posts: 25 | Posted 11/12/2004 9:39:27 PM Ekrause, unfortunately the sx photo is not great but you can see, or trust me, that there is no furca

involvement. Also the clinical post-op photo and x-ray are not suggestive of what you say. What you seesupraG is the root trunk and the furca covered with gingiva and PPD 1 mm. Is it an ideal situation? No,but think how we started and the fact that the pt has good OH, is 45-years-old with no perio dz so I thinkthe px is favorable overall but only the long-term follow up can prove me right or wrong.

danmelker | Danny | Total Posts: 1404 | Posted 11/13/2004 2:01:23 PM Endo? I would worry a little about the endo and keep a close eye on it. Short fills.

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Alexander Vasserman DDS, BS | Total Posts: 1145 | Posted 11/13/2004 9:23:27 PMThere was no furcation involvement, the tooth extruded with the furcation so if you did a cross section

you would see a figure 8 root surrounded by bone no furcal involvement. Ortho is one way to eliminate fur-cal involvement because as you extrude the tooth bone comes with it. I think that this is just great treatmentplanning, thinking outside the box.

ekrause | Total Posts: 13873 | Posted 11/13/2004 10:31:44 PMLook at the bone levels on the radiographs, before and after. Look at figure 2 vs figure 8. The furcation

is clearly visible there in figure 8.

Alexander Vasserman DDS, BS | Total Posts: 1145 | Posted 11/14/2004 4:20:47 PM On figure 5 it is filled with bone.

drjcann | Total Posts: 3063 | Posted 11/14/2004 7:51:43 PMEric it is hard for me to tell, but it appears there may be some furcation involvement. I think perio

should have been done after extrusion was done. Then the furcation could have been reshaped a la Danny,and then it would be of no concern. Even though that was done, the only other options were to have thetooth extracted or place a crown on a build-up, which is a bad option. This tx allowed a good margin to beobtained, and a nice restoration will keep this tooth fine for a long time.

jrtmolar | Jason | Total Posts: 4378 | Posted 11/14/2004 8:11:26 PM Drjcann, why isn’t “conventional” crown lengthening a tx option? The only advantage to the tx per-

formed here is esthetic and at a second molar I’m personally not all that concerned.

doctored | Total Posts: 4706 | Posted 11/14/2004 11:46:17 PMInteresting discussion. I think it was a good idea to extrude this tooth. Like Danny said the tissue will

follow in the absence of pathology. I do not understand why osseous recontouring was done after the toothwas extruded. It seems contrary to the initial effort. It looks like the tooth was a good candidate for rootreshaping without bone removal. I also agree the endo is showing signs of periapical pathology. It would bewise not to place a crown with permanent cement until the status of the endo is better revealed. If it weremy tooth I would want a crown placed with temp cement ASAP. It would be a shame to see this root frac-ture after all the effort to save it. The crown could always be removed and the endo [is] re-treated, if needed.

yahu | Total Posts: 195 | Posted 11/15/2004 6:40:51 PMIn general, if you extrude quickly you can leave the bone there and CL may not be needed post ortho. If

done more slowly, the bone comes with it. CL may be needed b/c there may have been no biowidth to start.The dif with ortho extrusion is not just esthetics but you have a more favorable crown to root ratio in the end.

vergoulisi | Yiannis | Total Posts: 25 | Posted 11/18/2004 2:42:22 PMJason keep in mind you cannot make definitive dx from an x-ray and I am telling you that there was no

clinical furcation involved. Moreover at sx entry there was no open furcation involvement either. Like theyalready said, controlled ortho eruption is not only done for esthetic reasons but for many other reasons aswell, one of them is when a sx will compromise the furcation of the tth (for other indications, see the classicarticle by Salama, et al on site preparation prior to implant placement).

Ed, the RCT was done prior to the extrusion by an endodontist. I would not start moving any tooth ifthere was any chance of active infection present. The sx is done to reshape the interproximal bone that usu-ally has some irregularities after the extrusion, in order to avoid an environment “susceptible” to futurepocket formation.