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Cannot bite on the bicuspid tooth - Courtesy ROOTS

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From: Terry Pannkuk
Sent: Tuesday, September 22, 2009 7:19 AM
Subject: [roots] Another odd consult today

Patient: 66 year old female.
Medical History: unremarkable
Chief Complaint: can't bite on the bicuspid tooth.
Dental History:  I treated an upper bicuspid a few years ago
and examined a lower bicuspid on the opposite side
which was vertically split and needed to be extracted.

Perio: gingiva inflamed, average hygiene, no pockets.

Mobility: Class 2 (adjacent teeth normal)

Percussion: severe (adjacent teeth slight)

What's the plan? What should be considered? 
What is odd about this case? - Terry

Hi Terry:
poor C/R ratio? loose misplaced post? ill fitting crown margins?
poor malocclusion needing ortho that patient refused because she 
liked her 6 front teeth? just the usual suspects.
Now if the 2nd premolar needs endo, I make sure no one put a 
tiara on it..))

my plan?
I remove the crown and check for fractures....if no cracks, 
Post/buildup and ortho until the occlusion is addressed - ahmad

This is one answer if you don't want to try and move that tilted 
bicuspid a mile through bone. :)

Other alternatives would be to leave the tilted bicuspid alone and 
just place one implant. If she wants to wait indefinitely until she 
gets tired of the food impaction/difficult cleaning....not a bad 
idea for this economy. :):):)

What I didn't say was that the first molar tested negative to cold 
and the EPT; it's going to be watched, probably previously pulp 
capped with a dead or minimally alive pulp.  If stripping back the 
over contoured mesial contact of the crown ends up ruining the crown 
there is a good chance it will need endo.

Ortho up righting and one implant is a nice idea but she isn't 
interested in ortho. I'd also worry about EICR trying to aggressively 
move that one in.  She needs to be worked up by her general dentist, 
possibly have an ortho consult before I touch her or proceed.  
I don't place implants in maloccluded areas until the restorative 
dentist and orthodontist work out a final comprehensive plan.  
This may not be a case for me in my role as an endodontist depending 
upon the desire to do forensics on the first bicuspid - Terry

Is that a retained deciduous canine? - Craig

No, just extra bone; I don't really see to many cases like this with 
extra space and no history of teeth. I really don't know what it is 
and I'm curious if anyone else has an idea. Usually alveolar bone and 
teeth go together. Doesn't seem to be an expanding lesion. 
The malocclusion has existed her entire life. If it was due to recent
bone expansion I would investigate for something like Paget's Disease.  
She has no other symptoms and the malocclusion is of long-standing 
origin, so it isn't - Terry
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