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CRACKING THE CRACKED TOOTH DILEMMA
Brent Rundquist, DDS, MS
November 3, 2016
1
Brent Rundquist DDS, MSNovember 3, 2016
Cracking the Cracked
Tooth Dilemma
2
3
The “Classic” Cracked Tooth
“It hurts when I bite on it in just the right spot”
“Cold kind of bothers it too”
4
Proper Nomenclature
Pyorrhea Periodontitis
Gums Gingiva
Cracked ToothSyndrome
??
5
Cracked Tooth Nomenclature❖ SPECIAL COMMITTEE
ON CRACKED TOOTH INITIATIVE
❖ 2015
❖ Committee formed by the AAE to better describe
fractured teeth
❖ Louis H. Berman, Chair
❖ Scott L. Doyle
❖ Gary G. Goodell
❖ Keith V. Krell
❖ H Mark A. Odom, Board Liaison
❖ Helen Jameson, Staff Liaison
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❖ Cracked tooth — A thin surface disruption of enamel and dentin, and possibly cementum, of unknown depth or extension.
❖ Root fracture — A fracture that exists or extends into the root, to include dentin, cementum, and possibly pulp space, which may progress to or from the enamel.
❖ Longitudinal fracture — A root fracture extending in the axial plane within the tooth.
Special Committee on Cracked Tooth Initiative
a) Vertical Root Fractureb) Split Root
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Proper Nomenclature
Pyorrhea Periodontitis
Gums Gingiva
Cracked ToothSyndrome
Cracked Tooth
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Biting Tenderness but no Percussion Tenderness?
❖ Rosen J Pros Dent 1982;47:36-43
❖ “Until infraction has propagated from pulp to PDL, no percussion sensitivity will occur”
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Physiological Dentinal Pain A- fibers
Pathological Pulpal Pain C - fibers
A-Delta Fibers
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A-Delta
A - delta Fast Sharp Well-localized
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Brannstrom Hydrodynamic
Theory of Dentin JOE 1986;12:453-7
Masticatory pain is due to sudden
fractured portions move independently, activating myelinated A-the pulp and creating a rapid, acute pain response. Stimulation of A-
require
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Diagnosing Cracked Teeth
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Most likely – Naturally occurring through normal mastication (Walton and Rivera 2015, Endo Topics)
Thermocycling (Brown, 1972JDR)
Restored teeth 29x more likely to have cracks
than Unrestored teeth (Ratcliffe et al, 2001)
Why Do Teeth Crack?14
Why Do Teeth Crack?Masticatory Parafunctional Habits (Clenching and
Bruxism)Jantarat J, Palamara JE, Messer H. J Dent. 2001 Jul;
29(5):363-70
Masticatory Accidents (Ice, Hard Candy, Corn Nuts, Popcorn Kernels Etc.) DiAngelis AJ. J Am Dent
Assoc. 1997 Oct;128(10):1438-9
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Age of dentin
factor in dentin fracture.
Dentin from patients < 35 vs >55 shows a 50% reduction in strength of >55
Dentin from patients < 35 vs >55 shows 75% reduction in energy require to FX >55
>55 has greater mineral content and avg rate of crack growth 100 X that of <35.
Arola, D. et al. 2012. Endodontic Topics
Why Do Teeth Crack?16
Factor Relative to Cracked teeth
We Agree That Patients Will be Retaining Their Teeth
Longer Over Time...
and
17
Pin Placement (Standlee et al.,1970, JPD)
Cavity preps (Reeh, et al., 1989. JOE,)Endodontic procedures have only a small effect on the tooth, reducing the relative stiffness by
5%. This was less than that of an occlusal cavity preparation (20%). The largest losses in stiffness
were related to the loss of marginal ridge integrity. MOD cavity preparation resulted in
an average of a 63% loss in relative cuspal stiffness.
Why Do Teeth Crack?18
“Nonfunctional cusps are more susceptible to
fracture, especially in Mn
teeth”
Agar et. al J Pros Dent 1988;60:145-7
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Which Teeth are at Greatest Risk for Cracking?
Mn MolarsMx MolarsMx PremolarsMn Premolars
Most
Least
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What are the Treatment Options?1. Extract it
2. Crown it and monitor it for endodontic tx need
3. RCT followed by crown
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TreatmentThe single most important question you
need to ask when treating a cracked tooth is?
Are you going to crown it and monitor it, or do RCT
prior to the crown
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Treatmentmake when deciding how to best treat a cracked tooth
is?
What is the pulpal status of the cracked tooth
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Cracked Tooth Pulpal Digression
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“Full coverage restorations will usually alleviate any pain as long as the crack
does not involve the pulpal tissues”
Seltzer et al Gen Dent 1997;45:148-59
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Reversible pulpitis- no periodontal pockets associated with the crack-
Crown it!Around 20% will eventually need RCT
within a year (Krell and Rivera, 2007. JOE)
Treating Cracked Teeth26
Krell and Rivera JOE 2007;33:1405-7Study of 796 cracked teeth Diagnosed With Reversible Pulpitis, crowned and
Followed for 6 years
Mn 2nd Molars 28% Mx 1st Molar 27% Mx 2nd Molar 25% Mn 1st Molar 17%
No Premolars required follow-up Endo
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Symptomatic Reversible Pulpitis
Symptomatic Irreversible Pulpitis
Short, non-lingering response to cold Lingering pain to cold stimulation
No percussive tenderness Percussion tenderness
No history of spontaneous pain Positive history of spontaneous pain
No history of heat hypersensitivity Heat hypersensitivity worse than cold
No history of need to use OCA’s Pt has been using OCA’s to control pain
Symptoms should not be trending worse over time Symptoms are worsening over time
NO radiographic pathosis evident Radiographic evidence of pathosis is present
DO NOT CROWN A TOOTH WITH SIP!
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Conclusions:*A cracked tooth correctly diagnosed with RP that gets a crown will go on to
need RCT about 20% of the time (premolars excluded)
*Some cracked teeth have a higher risk of needing follow-up RCT than others: Mn 2nd molars greatest, premolars the least
*Older dentin will crack faster and more frequently than younger dentin
*If symptoms resolve after the crown is placed and remain resolved past 6 months, the treatment is likely to be successful
(6 months)
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Q?30
ODONTOGENIC INFECTION: HOW BAD COULD IT BE?
Matthew Karban, DMD, MD Diplomate, American Board of Oral & Maxillofacial Surgery
The Dental Specialists
November 3, 2016
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An everyday infection32
51 yr female, healthy, ASA I
Presented with pain/swelling tooth #30 on a Friday
Seen by endo, opened tooth, purulent drainage encountered
Instrumented canals, calcium hydroxide, cotton/cavit
Sent home with clindamycin
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Over next few days pt has increased swelling, trismus and pain
Antibiotic changed to Augmentin
5 days following endo tx, pt returns, I&D attempted along buccal aspect of tooth, minimal drainage
Condition deteriorates over next 24hrs with dysphasia and increasing submandibular/cervical swelling
Pt referred to OMS for emergency intervention
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Emergency situation
Airway restriction
Inability to swallow
Spreading infection
Inability to open for airway intervention
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Emergency Intervention
Sedation not an option due to airway control
Decision to remove tooth 30
Explore region to provide drainage
Dissection along buccal/lingual aspect and as far posterior as possible under local anesthesia
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Abundant purulence from posterior lingual
1/4" Penrose drains placed buccal/lingual
Sent for immediate CT scan
IV clindamycin
Emergency Intervention37
CT+1cm abscess inferior border/lingual aspect
Decision to take to OR following day, stable overnight, trismus/pain improved
38
OR
GA w/awake nasal intubation
Anesthesia concerned of airway and recommend leaving tube in overnight in ICU!!!!!!!
Thorough dissection of masticatory space with additional purulence, cultures obtained
Neck incision with dissection to inferior border and placement of 2 drains (dependent drainage)
39
40
Hospital
Overnight stay w/o concern
Improvement overnight, dismissed in AM
Drains left in place for 3 days
41
Post op
Loss of soft tissue over lingual aspect of mandible
2x1cm area of exposed lingual bone
Continued low dose abx/Peridex with progressive improvement over following month
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PearlsNever underestimate an infection
Always consider early antibiotics rather than observation
Infections can spread fast
Dysphasia, breathing difficulty or trismus constitute ER visit
Airway is biggest concern
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Thanks!
44
HOW TO BEHAVIOR MANAGE PARENTS: UNDERSTANDING CHANGES IN PARENTAL
ATTITUDE AND EXPECTATIONS
Xu Han, DDS, MS The Dental Specialists Seminar: Dental Dilemas
November 3, 2016
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Discussion Topics:
Changing nature of parenting in America How to assess parents and recognize their needs
3 clinical scenarios How we managed the child
How we managed the parent Review of management techniques
Review of current literature
Summary of key lessons
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Changing nature of parenting in America
Increased focus on parenting
Family trends
Role of stress Impact of culture
What do pediatric dentists think?!
Long, N. Pediatric Dentistry-26:2, 2004 Casamassimo, P et al. Pediatric Dentistry-24:1, 2002
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How to assess parents and manage their needs
What type of parent are they?
Are you listening to the parent’s chief concerns?
What is the parent’s literacy level? Does the parent trust you?
Should the parent be allowed in the operatory?
Are there cultural/language barriers?
Are there parental concerns about special needs?
48
Clinical Scenario 1: RestorativeJonny: Healthy 4 yo Caucasian male
CC: Emergency visit – #T pain with eating for 3 days, no nocturnal/spontaneous pain
Clinical assessment: #T large cavitated lesion, percussion (-), no sinus tract/vestibular swelling, 4 quads of decay
Radiographic assessment: BW: Caries on #I, J, K, L, S, T PA: #T no furcal involvement
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Pulp/SSC
50
Managing cooperation: Jonny
Initial Assessment
Child cooperation: Shed tears during x-rays Non-combative
Responded to directions during exam
Management techniques:
Child: N2O Tell-Show-Do
Distraction Observe eyes for distress
Avoid irreversible treatment
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Managing expectations: Jonny’s mom
Initial Assessment Parent cooperation:
Lenient
Avoid conflict with child
Nice, responsive
Management techniques Parent:
Assess parent style/needs
Address parent questions/concerns
Keep big picture in mind Set expectations
Planned treatment
What if things go South?
52
Treatment outcomePatient cooperation:
Hands-up, shaking head profusely, in tears
Treatment: 0.75 mm occlusal reduction of #T
Deferred pulp/SSC All treatment to be completed in the OR
Patient is not traumatized
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Key Concepts: Jonny
Behavioral Management Techniques (BMT)
Attitude of contemporary parents towards BMT
Effects of parenting style on child’s behavior
54
Behavior Management Techniques
Non-pharmacological Tell-Show-Do
Nonverbal communication Voice control Behavior shaping/reinforcement Modeling Distraction Changing control Protective stabilization*
Pharmacological Nitrous oxide
Conscious sedation* General Anesthesia (GA)*
*Advanced BMT
Oliver, K et al. Journal of Dentistry for Children-82:1, 2015
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Attitude of contemporary parents
Basic methods preferred Advanced methods
Most accepted Pharmacological (sedation/GA)
Acceptance increased over the past 20 years
Least accepted Physical (HoM, restraint)
Active restraint preferred over passive restraint Degree of acceptance related pain/urgency
Eaton, J. Pediatric Dentistry-27:2, 2005 Patel, M. Pediatric Dentistry-38:1, 2016
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Parenting styles & child behavior
Authoritative: “Model parent”
Best behaved child
Authoritarian: “My way or the highway”
Permissive: “Anything you want, dear”
Neglectful: “I don’t care”
Aminabadi, N et al. Pediatric Dentistry-37:4, 2015 Howenstein, J et al. Pediatric Dentistry-37:1, 2015 Darling, N et al. Psychological Bulletin-113:3, 1993 Aunola, K et al. Journal of Adolescence-23:1, 2000
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Clinical Scenario 2: TraumaAbdi: Healthy 5 yo Somali male CC: Emergency visit – Fell on face at school, loose maxillary teeth Clinical assessment:
#E and F have class I mobility #F is extruded by 1 mm #F has mild occlusal interference with opposing, not traumatic
Radiographic assessment: #E and F have external root resorption (consistent with previous trauma) #F has horizontal root fracture in the apical 1/3
Courtesy of Dr. Matthew Nechrebecki
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Extraction
or
No Treatment
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Managing cooperation: Abdi
Initial Assessment
Child cooperation: Visibly anxious
Repeatedly asked me if I was going to pull his tooth
Very cooperative during exam
Management techniques:
Child: Acknowledge child’s concern
Be honest
Distraction-change the subject Tell-Show-Do
Voice control
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Managing expectations: Abdi’s dad
Initial Assessment
Parent cooperation: Concerned but trusting Asked good questions
Reassured his child
Management techniques
Parent: Assess parent style/needs Address language/literacy/cultural concerns Keep big picture in mind
Set expectations Potential extractions
Silent observer
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Treatment outcomePatient cooperation:
Very cooperative, interactive “…but are you going to pull my tooth?”
Treatment: No treatment Thoroughly reviewed trauma sequelae
Discoloration
Pain
Abscess/swelling
Recommended follow-up: 4 weeks
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Key Concepts: Abdi
Parenting attitude towards being in the operatory
Parent compliance with remaining silent
Language, literacy & culture
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Parent in the operatoryPrimary reason parents want to be present
Comfort (~80%)
~2/3 of parents want to be present for: Exam/xrays Filling/crowns/extractions
Sedation/restraint
38% of parents are ok with dentist making unilateral decision on parental presence
Shroff, S et al. Pediatric Dentistry-37:1, 2015
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Parental compliance with remaining silent
78% complied when given written instructions 86% complied when given written + verbal instructions
Parents’ ability to assess dental fear in their child is: poor-fair
Jain, C et al. Pediatric Dentistry-35:1, 2013 Klein, U et al. Pediatric Dentistry-37:5, 2015
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Language, literacy & cultureRecognizing parents with low literacy skills Communicate in simple terms
Don’t use jargon
Use pictures/graphics
Informed parent more likely to accept BMT, regardless of culture Ask if an interpreter is need
Head nodding does not always mean full understanding
Ask for clarification if unsure of cultural preferences
Jackson, R. Pediatric Dentistry-28:1, 2006 Scott, S et al. Journal of Dentistry for Children-128:1, 1998 Abushal, M et al. Journal of Dentistry for Children-70:2, 2003
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Clinical Scenario 3: Special Needs
Rosie: Autism spectrum 3 yo Caucasian female CC: Cavities on front teeth, no pain Clinical assessment:
Caries on #D lingual, #E and M mesial-lingual
Radiographic assessment: Occlusal PA: Consistent with clinical findings BWs: #I distal D1 lesion, multiple posterior E1 lesions
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Restorative in clinic or
Operating Room
70
Managing cooperation: Rosie
Initial Assessment
Child cooperation: Sleepy, irritable
Covered eyes with hands Followed instructions
Management techniques:
Child: Sun glasses
Adjust N2O Very slow LA
Observe eyes for distress
Avoid irreversible treatment
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Managing expectations: Rosie’s mom
Initial Assessment Parent cooperation:
Explained child’s disability Very confident in child’s ability to cooperate Clear, direct with child and provider
Management techniques Parent:
Assess parent style/needs Listen to the parent Ask parent for recommendations Keep big picture in mind Set expectations
Planned treatment
What if things go South?
72
Treatment outcomePatient cooperation:
N2O very helpful
Did not feel LA
Treatment in office: #D lingual composite
#E and F mesial-lingual composite
Next Visit: #I distal composite
73
Key Concepts: RosieParents are well-attuned to their child’s special needs
Listening to parents
Use of restraint: when is it appropriate?
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Parents are well-attuned to their child’s special needs
Parents of autistic children are: Accurate in predicting child’s ability to cooperate for exam & x-rays (>84%)
Variability in how children tolerate dental/oral care Orally averse
Parents physically may restrain their child to brush at home
Waiting room challenge Noise
Duration of wait
BMT is not the same for child with special needs
Marshall, J et al. Pediatric Dentistry-30:5, 2008 Lewis, C et al. Pediatric Dentistry-37:7, 2015
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Listen to the parentsParents want to provide input Discuss options of sedation, GA and restraint with parents
The most acceptable BMT (>90%) for autistic children:
Positive verbal reinforcement Tell-Show-Do Distraction Rewards Hand-holding by parent
Mouth props GA
Marshall, J et al. Pediatric Dentistry-30:5, 2008 Lewis, C et al. Pediatric Dentistry-37:7, 2015
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Use of restraint: when is it appropriate?
Emergency Facial swelling or trauma
When pharmacological methods:
Not available Not accepted by parents
Overall acceptance of passive restraint (papoose):
32%
Acceptance of protective stabilization (ASD):
Parent restraint (84%)
Staff restraint (63%) Passive restraint (54%)
Marshall, J et al. Pediatric Dentistry-30:5, 2008 Brill, W. Journal of Dentistry for Children-2002
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Summary of key conceptsCase 1
Behavioral Management Techniques (BMT) Attitude of contemporary parents towards BMT Effects of parenting style on child’s behavior
Case 2 Parenting attitude towards being in the operatory Parent compliance with remaining silent Language, literacy & culture
Case 3 Parents are well-attuned to their child’s special needs Listening to parents Use of restraint: when is it appropriate?
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Thank you! ☺
80
ESTHETIC EVALUATION OF CANINE SUBSTITUTION VS. IMPLANTS FOR
CONGENITALLY MISSING MAXILLARY LATERAL INCISORS
Benjamin Allen, DMD, MD, MS
November 3, 2016
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IntroductionAgenesis of one or both of the upper laterals affects 2% of the population
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Treatment Options
1. Tooth replacement Usually with implant-borne prosthesis
2. Space closure with canine substitution Ancillary procedures - Tooth recontouring - Cosmetic buildups - Bleaching
83
Schneider et al. 201684
Schneider et al. 201685
Treatment Options
Advantages Can maintain teeth in natural positions Orthodontics may be simpler Less need to alter morphology of other teeth Occlusion? Esthetics?
Tooth replacement
86
Treatment Options
Disadvantages Space maintenance until implant can be placed Implants in the esthetic zone can be unforgiving Retreatment can be difficult Long-term periodontal concerns Cost?
Tooth replacement
87
Treatment Options
Advantages Avoid retention period Periodontal condition Retreatment is easier
Space closure with canine substitution
88
Treatment Options
Disadvantages Ancillary procedures - Canine may be recontoured, bleached, restored - Premolar may be recontoured, restored Occlusal concerns? Poor esthetics?
Space closure with canine substitution
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A Dilemma in DentistryEach has advantages and disadvantages Many factors influence the choice - Age - Sagittal malocclusion - Degree of crowding - Smile line - Tooth size, shape, color In many cases either option would be possible Which one do you prefer?
90
Preference for Tooth Replacement
Preference among general dentists and laypersons to replace the missing tooth - GD 70%, LP 63% Esthetic or functional concerns? - 84% GD cite esthetic concerns Does the literature support this Preference?
Armbruster et al. World Journal of Orthodontics (2005) 6:376-381.
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Schneider et al. 201692
Schneider et al. 201693
Schneider et al. 201694
Schneider et al. 201695
Schneider et al. 201696
Robertsson and Mohlin 2000
Assessed patient satisfaction with esthetics of CS vs. TR, 7 years after treatment completion CS significantly more satisfied with the appearance of their teeth Implants were not used
Robertsson and Mohlin. European Journal of Orthodontics (2000) 22: 697-710
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Armbruster et al. 2005Judged the esthetic outcomes of implants vs. Maryland bridges vs. CS Using intraoral photos Laypersons, general dentists, and orthodontists
LP: CS > nat > MB > Imp GD: nat, CS > MB > Imp Ortho: nat> CS > MB > Imp
Armbruster et al. World Journal of Orthodontics 2005;6:369-375
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Armbruster et al. 200599
Armbruster et al. 2005100
Armbruster et al. 2005101
Armbruster et al. 2005102
Armbruster et al. 2005103
Armbruster et al. 2005104
De-Marchi et al. 2014
Photos of the lower facial third for patients restored with CS or TR (Implant) Dentist, laypersons and the patient Esthetics rated as similar for both treatment modalities
De-Marchi et al. J Prosthet Dent 2014; 112: 540-546
105
De-Marchi et al. 2014106
De-Marchi et al. 2014107
Jamilian et al. 2015
Patients restored with CS or TR (implant) Rated satisfaction with esthetic result 5 years after completion of treatment Satisfaction with esthetics was similar in both groups
Jamilian et al. Progress in Orthodontics 2015;16:2
108
Schneider et al. 2016
Esthetics of natural vs. CS vs. Implants Intraoral photographs Laypersons, general dentists, orthodontists
LP: CS, natural > Imp GD: natural > CS, Imp Ortho: natural > CS, Imp
Schneider et al. AJODO 2016;150:416-24
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Conclusion
In terms of esthetics, CS and TR seem to offer similar results for the treatment of congenitally missing maxillary lateral incisors Esthetic concerns should carry less weight when deciding between these two treatment options
110
ConclusionWhat about this guy?
111
Conclusion
Ed Helms
112
“Excellence is my muse.” -Laurence Rifkin, DDS
drlaurencerifkin.com
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ReferencesArmbruster P, Gardiner D, Whitley J, Flerra J. The congenitally missing maxillary lateral incisor. Part 1: Esthetic judgment of treatment options. World Journal of Orthodontics 2005;6:369-375
Armbruster P, Gardiner D, Whitley J, Flerra J. The congenitally missing maxillary lateral incisor. Part 2: Assessing Dentists’ preferences for treatment. World Journal of Orthodontics 2005;6:376-381
De-Marchi L, Pini N, Ramos A, Pascotto R. Smile attractiveness of patients treated for congenitally missing maxillary lateral incisors as rated by dentists, laypersons, and the patients themselves. J Prosthet Dent 2014;112:540-6
Jamilian A, Perillo L, Rosa M. Missing upper incisors: a retrospective study of orthodontic space closure versus implant. Prog Orthod 2015;16:2
Kokich V, Kinzer G, Janakievski J. Congenitally missing maxillary lateral incisors: Restorative replacement. Am J Orthod Dentofacial Orthop 2011;139:435-445
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ReferencesRobertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Eur J Orthod 2000;22:697-710
Schneider U, Moser L, Fornasetti M, Piattella M, Siciliani G. Esthetic evaluation of implants vs canine substitution in patients with congenitally missing maxillary lateral incisors: Are there any new insights? 2016;150:416-24
Silveira G, Valli de Almeida N, Pereira D, Mattos C, Mucha J. Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A systematic review. Am J Orthod Dentofacial Orthop 2016;150:228-37
Zachrisson B, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: canine substitution. Am J Orthod Dentofacial Orthop 2011;139:435-44
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