Which tooth first? Treatment planning a mouth full of cracked and weak teeth

According to the flowchart, the first thing we’d treat is caries or pulpitis, but as he was a new patient who hadn’t been to a dentist for years, we agreed to start with the single broken tooth as a way to ease back into treatment and then treat the lower left molars.

Diagnoses

Fractured 46 due to horizontal structural compromise.

Reversible pulpitis 37 and/or 36 due to horizontal structural compromise secondary to likely cracks or secondary caries.

Other SC teeth at high risk of cracks and caries: 16 and 47.

Initial treatment Plan

We agreed to reinforce and protect the 46 first, and then the lower left molars, followed by the other SC teeth.

But which order?

• 46: filling > 2mm, cusps <3mm, cracks: yes, and depth <4mm [3/4 red flags + a typical occlusion]
• 37: filling > 2mm, cusps <3mm, cracks: yes, and depth <4mm [3/4 red flags + a heavy occlusion]
• 36: filling > 2mm, cusps <3mm, cracks: yes, and depth <4mm [3/4 red flags + a typical occlusion]
• 47: filling > 2mm, cusps >3mm, cracks: yes, and depth <4mm [2/4 red flags + a heavy occlusion]
• 16: filling > 2mm, cusps <3mm, cracks: yes, and depth >4mm [4/4 red flags + a typical occlusion]

The guide put 37, 47 and 16 in the high-risk group. The 36 and 46 were moderate risk on paper, but as the 46 had already broken, and he’d been away from the dentist for ten years, we agreed to start there as a gentle first appointment. The 37 and 36 were causing his symptoms, so they were planned next. That left the 16, which was high risk but not bothering him, until last. All the appointments were completed within two months.

Definitive treatment plan

1. 46 onlay (prep carried out, and as patient coped well with treatment, he agreed to book the tooth behind soon, so both onlays could be fitted together)
2. 47 onlay 
3. 37 & 36 onlay preparations
4. 16 onlay

Due to all teeth being pretty damaged, the restorative decisions were straightforward – so we just picked the ones bothering the patient first and completed the restorations in a logical order.

In case you’d like to see the finished result:

Any questions? Get in touch! Thanks, Amber

About Amber

Dr Amber Aplin is a dentist, educator, and founder of The Gentle Touch in Kelso, Scotland. She teaches biomimetic dentistry and therapist-led care to practices across the UK.

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