Puzzle: Do you treat this malformed mandibular incisor?

Terry Pannkuk, DDS, MScD Complications: Advanced Management


Patient: 8 year-old male with a noncontributory medical history

Chief Complaint: asymptomatic

Dental History: The patient was referred by a prosthodontist working with an orthodontist in the management of the patient’s mixed dentition. The mandibular right central incisor (tooth #25) was malformed from the time of eruption and there was concern about the pulp status and the potential for orthodontic movement and restoration.

Significant Findings: Clinical and radiographic findings revealed an anomalous crown-root of the mandibular right central incisor (tooth #25) which was out of occlusion. The adjacent right lateral incisor (tooth #26) was not full erupted and was the only tooth which responded negatively to the electric pulp test in the sextant. Cold thermal testing revealed equivocal responses in all the teeth tested. Slight percussion sensitivity was localized to tooth #25 and the periodontal findings of tooth #25 revealed normal pocket depths but bleeding upon probing.

What is your diagnosis, prognosis, and treatment plan?

Pulp and Periradicular Diagnosis:

Tooth #25: Normal pulp status with a normal periapical periodontium
Tooth #26: Normal immature pulp with immature developing root and a normal apical periodontium

Treatment Prognosis:

Tooth #25: Guarded
Tooth #26: Good

Treatment Plan: Orthodontic space maintenance, tissue management, and no planned endodontic therapy on any teeth.

Special Considerations of Performed Treatment:

A young child presenting with a malformed tooth with malocclusion in a mixed dentition presents as a diagnostic and treatment dilemma. In this instance the young boy presented with an extremely anomalous crown (tooth #26) with gingival inflammation related to the abrupt crown-root contour combined with the patient’s difficulty maintaining oral hygiene. The failure of tooth #26 to respond to the electric pulp test was not uncommon for a tooth partially formed as it had a wide open apex and likely does not have a mature pulp circulation with C fibers formed. The CBCT scan showed the three-dimensional anatomy of the malformed tooth.

Endodontic treatment was unnecessary and the discomfort was likely periodontal in origin. The root apices were not formed and it was highly unlikely that the pulps would be prone to necrosis without some vector of contamination (i.e. caries or a crack). The pulp circulation was judged to be within normal limits in both teeth.

Recall: There were no plans to re-evaluate any of the teeth for endodontic treatment unless symptoms developed indicating a need.

Key Learning Points:

  1. The first tenet of treatment planning is to do no harm. No treatment is often the best treatment for teeth in a developing dentition which have not fully developed and erupted into adult occlusion

  2. It is not uncommon for developing teeth with immature pulps to respond negatively to pulp tests. It is very rare for a tooth with a wide open apex to become necrotic because of the excellent apical circulation and compliant tissue.

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Commenting Guidelines Please make scholarly cited references or expert opinions suitable for publication. The comments can either be "pro" or "con" with references to the treatment philosophy. We encourage objectivity and detailed demonstration of knowledge/literature.
Oliver Pontius commented 9 years ago.

What is your treatment approach of the malformed crown as it will compromise the patients hygiene, esthetics and probably lip profile.

Terrell Pannkuk commented 9 years ago.

At this patient's young age they are not worried about esthetics as there are typically missing teeth during a mixed dentition anyway. The goal is to leave it alone and make sure the space is maintained as long as possible before extracting it (which is the end plan when he's older and all teeth are erupted). The universal consensus amongst the entire treatment team was to emphasize oral hygiene and ride it as long as possible.

Terrell Pannkuk commented 9 years ago.

I'll try to get a clinical photo (didn't have one), but the tooth is flat to the gumline and not particularly prominent or that visible.

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