Question #2: What range of options would you present to this patient?

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1 Question #2: What range of options would you present to this patient? Some highlights of different treatment planning perspectives 1 Tidy up orthodontic treatment before proceeding with any type of treatment,...implant/ FPD/ RPD. Hold off on implant placement for a couple of years. An implant is still a viable option but there is need for further orthodontic refinement so that one could either place a crown or veneer on tooth # There are a number of options available, each with a different biological price. An implant would be ideal since it would not involve reduction of adjacent teeth and the implant would preserve bone in the site of 2.2. Over the course of a life time, the cycle of repetition with a successful implant would probably be much less than any other option except, of course, non-treatment. If, after midline correction, insufficient space is available for an implant, a direct-bonded bridge would be a valid choice. This would involve much less destruction of healthy tooth structure. Given the patient's oral health and age, a fixed porcelain fused to gold bridge would have a profound biological price as well as being much less cost effective due to the repetitive nature of a fixed bridge over the course of an eighty year life span. (Should we all be so lucky!) A removable partial denture would have to be presented as an alternative to the above suggestions, but likely not acceptable to the patient. As well, the expectation of ridge resorption over time must be considered. This could, over the long term lead to loss of bone support about the 2.1 and 2.3. Suggestions to treat the 1.2 would possible involve a direct bonded restoration or bonded porcelain veneer. 3 A 3-unit bridge would be a horrible option in my opinion, and I personally, in this case, would probably refuse to do it. Cutting down those teeth on a young person would not happen in my practice. Similarly, I wouldn't do a partial denture - either flipper or cast metal. The bonded pontic is a much better option, less expensive, and nicer looking. It would be options 1. or 2. for me. I would mention the other options to the patient, in the context of explaining why I would advise against them. Bonding will need to be done to the peg lateral on the other side as well, and a frank discussion

2 on oral hygiene is in order. I would discuss shade with her as well - just in case (!) she decides *after* the crown is in place that she wants "whiter teeth" (not unusual in this age group). If this is a secret wish, I want to know it before we make the crown - not after. She could bleach them first if this is an issue. If not then proceed, but inform her that the shade of the crown will be permanent, and document that discussion. I would also suggest a post-op night guard - great max retainer that will protect her implant crown from any night grinding she may have, or develop later (as well as the bonding on 12) Conventional 3 unit bridge and cast crown on Conventional cantilever bridge using 23 as abutment tooth (assuming the size of clinical crown is adequate) & cast crown on Removable partial upper denture (flipper) 4. Dental implant without grafting 5 dental implant with allograft or autograft to budge buccal plate if necessary... I find that I often don't see concaving of buccal plate in congenital edentulous spaces as typically see in edentulous exodontia sites 6. Nothing if she doesn't mind walking around with missing front tooth 5 1. Do an Invisalign style retainer or a Hawley retainer till patient is done growing. 2. Offer to do a bonded emax Maryland bridge till the patient is done growing. 3. When patient is done growing: a. graft site (if needed), wait 4 months and then place implant. Restore after 3 months of integration. Ensure that spacing between the laterals is as even as possible. #12 looks like a peg so I may chose to veneer that tooth as well at this time. or b. If patient doesn't want an implant, a fixed Maryland bridge from pressed emax may be a good definitive restoration. or c. If patient doesn't want an implant, a fixed bridge with full coverage on #23 with #22 as a cantilever pontic. I may use Nobel zirconia Procera framework as an esthetic substructure. 6 The best option is, by far, the implant. Cost and time may be factors but with virgin teeth on either side it is hard not to stress this to the patient in making a decision. A fixed bridge-maryland style-minimally invasive-minimum preparation of the 21 and 23 is my second option. Occlusion will play an important determining factor as to its long-term success. We have used acrylic denture teeth just bonded to the adjacent teeth with no preparation. This has been an excellent short term solution. We have also used custom lab-fabricated porcelain pontics with small lingual rests

3 or preps similar to class III preps on the distal of 21 and the mesial of 23. The appliance is then bonded in place. This has worked very well with cases of minimal OJ and OB. Traditional full coverage would not be an option that I would present. Third option would be a removable type. Short term or long term solutions can be presented. This is not ideal and I would discourage it as a long term solution. There is still the treatment of the peg lateral tooth 12. Ideal would be the porcelain veneer but depending on age, cost and stability of the occlusion, I may offer composite bonding as an option. As always we would like to confirm that the gingival tissues are healthy and no periodontal treatment is necessary and hygiene maintenance has been maintained. I always discuss bleaching as an option, stressing this is the time to do it and not once the treatment is complete Leave spacing as is: a. provide models with wax-ups to demonstrate proposed aesthetics outcomes; b. using the wax-up, demonstrate the difference between the final aesthetics if 1.2 is crowned and if it is not. 2- Propose to leave the patient in fixed orthodontic treatment for a longer period of time to achieve better 1.2 position and less spacing to accommodate 2.2. Again, I would use models and a wax-up to demonstrate the differences between the existing spacing and the more optimal spacing. 3- Discuss the affect of possible bone grafting, if it is needed and if it is, what the aesthetic concerns would be if not performed 4- if an implant is not ideal, or grafting is not desired, there is a possibility of using a bridge rather than an implant to address the 2.2 space (although I would also have a discussion about the affect of leaving the current spacing versus the proposed ideal spacing as well, and I would also discuss the impact on the adjacent teeth of doing a bridge versus the implant - namely the destruction of "good" tooth structure to simply support the bridge). 5- Depending on the timing of the proposed final outcome of ideal spacing (the increased time needed in fixed orthodontic treatment), if the patient is still quite young, a temporary "Maryland bridge" (wire affixed to the lingual of the 2.1 and 2.3 with a pontic to temporarily replace the 2.2 until final growth has been determined. 6- To be complete, discussion of the use of a partial denture or leaving the spacing as is with no replacement of the 2.2 would be conducted (though not recommended). 8 Based on the above mentioned (question #1) inter-specialty consultation, a consultation with the patient, her parents or guardians, the orthodontist and the restorative dentist would offer the following options:

4 1) Deband now and have an implant placed and restored within 9 months, accepting the aesthetic zone discrepancies and instability of the residual occlusion and the possible necessity to retreat later (with an immovable implant in the wrong position). 2) To deband now and place an acid-etch fixed bridge to replace the 2.2 using lingual retainers on the 2.1 and 2.3 (with lingual enamel reduction in order to preserve the existing occlusal relationships). 3) To have 1.2 endodontically treated and restored given the poor prognosis (without further orthodontic movement, an implant supported restoration is not feasible if the tooth must be extracted). 4) To choose an optimal long term solution involving the following phases: a) Continue the orthodontic treatment to ensure CRO-MIP harmony, to improve the cuspid relationships, to correct the midline discrepancy, to establish golden proportion relationship spacing for 1.2 and 2.2. b) Have articulated casts retaken before debanding to verify occlusal stability and anterior guidance which protects the posterior teeth c) At debanding, preliminary equilibration to remove posterior excursive interferences followed by models for articulated casts for a maxillary Essix provisional retainer replacing teeth 1.2 and 2.2 and a mandibular retainer as recommended by the orthodontist d) Referral to the oral surgeon or periodontist for extraction of 1.2, possible placement of a bone graft in the 1.2 and 2.2 sites and insertion of the Essix provisional retainer e) 3 to 6 month follow-up and periodic retainer adjustments and equilibration f) Referral for possible CBCT scan as well as assessment of high lip line and gingival contours f) Articulated casts for diagnostic wax-up of 1.2 and 2.2 and fabrication of a surgical stent f) Referral to oral surgeon or periodontist for placement of 1.2 and.22 implant fixtures, aesthetic correction of the gingival margins of other maxillary anteriors, if necessary, and modification of the Essix retainer g) 3 to 6 month follow-up and periodic retainer adjustments and equilibration h) Platform level impression to fabricate implant- supported restorations for 1.2 and 2.2 i) Placement of restorations on 1.2 and 2.2 k) Fabrication of maxillary protective bruxism splint for use during sleep. In order to span treatment phases for economic reasons, acid etch bridges replacing 1.2 and 2.2 could be placed until implants can be placed, but this would require removal of enamel of the lingual aspects of teeth 1.1, 1.3, 2.1 and 2.3 which will need lingual veneers once implant-supported restorations for 1.2 and 2.2 can be done.

5 9 OPTION ADVANTAGES DISADVANTAGES A. 2 Individual Ceramic-metal crowns on 2 implants B. Fixed Bridge X-X C. Top removable Partial (P/) in metal or acrylic -Stop bone loss on an edentulous site; -Strongest option who gives back up to 97% of the natural teeth strength; -Does not destroy any dental structure; -Fastest and easiest hygiene to do; individual crowns reproduce natural teeth -longest duration of prosthesis -treatment can be done even in compromised patient; - very esthetic result; -Shorter treatment time and procedure than option A -cheapest option; -does not destroy any dental structure; -Shortest treatment duration -easiest treatment to succeed; does not require a lot of special skills -Will demand bone graft and probably soft tissue graft too, before the implants procedure; - Longer healing time and more surgery procedures; - rejection possible; - unpredictable esthetic result; - most expensive treatment; - may be compromised on contraindicated upon medical condition - most delicate treatment (specialized) to succeed -Could need soft tissue graft before for esthetic needs; -Does not stop bone loss as option A; -not as strong as option A; -OH more difficult to do; -Destroy healthy teeth structure on 4 adjacent and looking healthy teeth; -Long bridge crossing median line, may induce decimentation -usually last years, upon OH measures - requires good technical skills from the operator -damages supporting tissues, teeth, mucosa and gums -harder to keep clean -does not promote self-esteem especially in young patients