Insight 93 — An Anterior Tooth with Extensive Destruction: Composite, Crown, or Implant?

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Clinical Explanation

Question

In anterior teeth with extensive destruction, how do we decide whether to rebuild them with composite, place crowns, or extract them and replace them with implants?

I rebuilt this patient’s tooth with composite two months ago. At the time, I told the patient that extraction and an implant would be preferable, but that I could rebuild it without promising how long it would last. Do you think I should now recall the patient for a crown? The patient is about to get married and is worried that the tooth will come off on the wedding day.

Answer

First, we need to assess the amount of remaining tooth structure through a clinical examination and a periapical radiograph. The final assessment takes place after caries removal, because what matters is the amount of sound tooth structure and the ferrule remaining after caries removal.

In this case, based on the images, I do not consider composite or a laminate veneer appropriate. The choice between a crown and extraction also depends on the remaining ferrule; simply being able to fabricate a crown for a tooth does not mean that it will be reliable. If an adequate ferrule remains after caries removal, particularly on the palatal side, retaining the tooth with a crown can be considered.

Surgical crown lengthening may be suggested to create a ferrule. However, this option needs to be assessed in the context of an anterior tooth, weighing its costs and consequences against the benefit of retaining the tooth. Personally, I do not consider surgical crown lengthening appropriate for a single anterior tooth, particularly a single central incisor.

Forced eruption is another option. If the patient is interested, I refer them to an orthodontist to assess it. I do not take sole responsibility for both interrelated parts of treatment: orthodontic movement and prosthetic reconstruction.

If suitable conditions for retaining the tooth cannot be achieved, my choice in this case is extraction and replacement with an implant.

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