Case 17

A Loose Anterior Tooth

RUPERT AUSTIN AND DEBORAH BOMFIM

Summary aware of an unpleasant taste that appears to emanate intermit-

A 25-year-old man presents at your general dental practice
with a loose anterior tooth. Identify the cause, and summa-
rize the treatment options.
tently from his upper front teeth.
Dental History
The patient had been a regular attender at another dental prac-
tice for many years until he recently moved to your area. He is
motivated and does not wish to lose any teeth.
Four years previously, the lateral and central incisors had
been fractured in an accident at work. Both teeth sustained
enamel–dentine coronal fractures with no pulp involvement
but were initially left untreated. Several months later, another
dental practitioner provided a root canal treatment on the
upper central incisor and some direct resin composite restora-
tions on both teeth, and shortly afterwards the patient asked for
the lateral incisor to be crowned because he was unhappy with
its appearance.

Medical History
The patient has insulin-controlled diabetes. Otherwise he is fit
and well.
Examination
Extraoral Examination
No submandibular or cervical lymph nodes are palpable.

• Fig. 17.1 Periapical radiograph of the mobile maxillary left lateral
incisor.
History
Complaint
The patient complains of a loose tooth and points to his upper
left lateral incisor which is crowned. He says it is uncomfortable
when it moves and has become so mobile that he is concerned
that it may fall out.
History of Complaint
The patient has noticed that the tooth has become progressively
looser over the last few months and would like a replacement.
There has been no pain associated with the tooth, but he is
Intraoral Examination
The patient has an extensively restored dentition, with a metal
ceramic crown on the upper left lateral incisor and a large resin
composite restoration on the upper left central incisor. There is no
evidence of caries on any teeth, and generally the periodontal con-
dition is good, with generalized pocket probing depths of 2–4 mm.
There is supra- and subgingival plaque associated with the crown
margin of the upper left lateral incisor and localized erythema
and delayed bleeding on probing around the gingival margin. The
crown is grade II mobile; however, there are no increased probing
depths associated with the upper left lateral incisor. The adjacent
teeth are firm. No sinuses are present to explain the bad taste, and
no swelling or pus is detected on periodontal probing or palpation.
 hat Additional Questions Might You Ask?
W
What Was the Nature of the Previous Trauma? Different
patterns of dental trauma (e.g. crown fractures, crown and
root fractures, root fractures, luxations, avulsion, etc.) have

95
96 C ASE 1 7 A Loose Anterior Tooth
varying sequelae requiring a wide variety of management
strategies. The history of the initial trauma suggests that
the patient’s teeth suffered crown fractures only without
any luxation injury or pulp/root involvement; however, the
delayed provision of endodontic treatment suggests that
possibly the root canal and/or the periodontal ligament may
also have been affected by the trauma.
Did You Recently Notice the Mobility Suddenly Increase
or Hear a Crack From the Tooth? The increased mobility
without evidence of periodontitis suggests a recent root
fracture, which may be secondary to the provision of the
restorations and/or endodontic treatment. The patient did
not notice any movement of the teeth at the time of the injury
and is not sure why the root canal treatment was needed. The
patient did not notice any sudden increase in mobility or hear
a recent crack from the tooth.
How Would You Clinically Assess the Possibility

of Root Fracture?
By determining the axis of rotation of the mobile crown.
Apply digital pressure forwards and backwards to identify
how far down the root the axis of rotation appears to be.
If when moving the crown bubbles of saliva are produced
at the gingival margin, this would be an indicator of a root
fracture communicating with a periodontal pocket or the
gingival crevice.
When you palpate the crown, you find that the crown
appears to rotate bucco-cervically about a point 2–3 mm below
the gingival margin. No such bubbles are seen at the crown
margin.
On the Basis of What You Know So Far, What are the
Likely Causes?
Having excluded mobility caused by periodontitis and cor-
onal bone loss, the two possibilities that remain the most
likely are resorption or root fracture. The mobile tooth is
rotating about a point just below the gingival margin, so
either process must affect the coronal part of the root.
Resorption of the apical half of the root would move
the axis of rotation of the remaining tooth coronally. There
would have to be extensive resorption to cause this degree
of mobility and raise the axis of rotation so far. Resorption
is a recognized complication of trauma to teeth, and so this
would be the most likely cause.
Root fracture is possible. No fracture was noted but
the marked mobility would be consistent with the root
fracture of the coronal part of the root. If there is a root
fracture it would appear to be independent of the original
trauma. Teeth that suffer coronal fractures do not usually
suffer root fractures as well because most of the energy is
absorbed by fracturing the crown. However, if a root frac-
ture had been present for the last 4 years, it might have
triggered slow resorption, combining both possible caus-
ative factors.
An unsuspected lesion may have destroyed the bone
and/or the tooth root apically, leaving support only coro-
nally. The tooth would then be mobile, whereas the
periodontal ligament would remain intact in the mid- and
coronal-third. The commonest lesion to do this would be a
radicular cyst arising on a nonvital tooth.
Finally, a neoplastic lesion remains a remote possibil-
ity. However, this seems most unlikely because there is
no expansion and the adjacent teeth are not displaced or
mobile.
Investigations
What Investigations Would You Carry out? Why?
Any Problems with Interpreting These Results?
See Table 17.1.
On performing the tests of tooth sensibility, you find that it is
impossible to obtain a response from both the upper left central
and lateral incisors. All other anterior teeth respond normally
to sensibility testing.
The Periapical Radiograph is Shown in Fig. 17.1.
What Do You See?
The left lateral incisor is crowned. The core material appears
to communicate with the pulp chamber/coronal one-third
of the root canal; however, no root canal filling is evident.
The middle third of the root shows a large oval radiolucency,
which appears to fill the entire middle third of the root canal
and extends laterally to replace the full width of the root
dentine and communicate with the periodontal ligament.
The margins of the defect are smooth and sharply defined.
The lamina dura around the apex appears intact. The bone
level mesially and distally is coronal to the defect, and there
is no evidence of either horizontal or vertical bone loss. Very
little root dentine remains below the crown and gingival
margin.
The upper left central incisor is root filled, with an appar-
ently radiolucent restoration. The root filling appears well
condensed and extends very close to the ideal level api-
cally; however the gutta percha is close to the pulp cham-
ber coronally which may suggest a poor coronal seal. The
root appears to have a curve at the apex. There is a poorly
defined radiolucency around the apex mostly on its mesial
side, where the lamina dura is missing.
The canine has a mesial radiolucency, indicative of caries,
and its apical lamina dura is indistinct. However, no obvi-
ous periapical radiolucency is present.
What is Wrong with the Radiograph in Fig. 17.1?
This radiograph is of suboptimal quality because of posi-
tioning issues, in that not all of the central and lateral
incisors are visible, as well as issues with film processing
artefact. A regular pattern is superimposed over the whole
film, suggesting that this is not a digital radiograph. This
artefact may be caused by some wet film processors that use
woven nylon bands to transport the film between solutions
during development of the film. If these bands are dirty or
worn, their surface texture transfers an imprint onto the
film. A less marked example of the same artefact is shown
in Fig. 35.3.

TABLE
17.1   Investigations To Be Carried Out
Test Reason
Sensibility To check the sensibility of all four upper and lower
testing incisors and canines (excluding any known
root-filled teeth), either thermal (usually cold
testing) or electrical stimuli may be used. Late
loss of sensibility is a complication of trauma
and any one of these teeth could have periapical
infection and be the cause of the bad taste.
The sensibility of the lateral incisor needs to be
known, to plan treatment once the diagnosis is
established.
Long cone To detect the possible causes and assess bone
periapical levels around the teeth. To determine the pulp
radiography canal morphology in case root canal treatment
is required, and the root morphology in case
extraction is necessary.
Another uniform artefactual pattern results from expos-
ing the wrong side of an intraoral conventional film packet
to the beam. The embossed metal backing foil casts a pat-
terned shadow onto the film, and the shielding causes an
additional underexposure, differentiating this artefact from
the one illustrated.
Digital radiography helps prevent this type of artefact
from occurring. However, digital radiographs can result in
other types of artefacts, for example, those related to the
type of sensor (phosphor plate or charge-coupled device).
Diagnosis
What are Your Provisional Diagnoses?
Extensive internal resorption of the maxillary left lateral
incisor. The central incisor has a failed root filling with a
periapical granuloma or abscess, possibly associated with
microleakage resulting from a poor coronal seal. The cause
of the taste could be intermittent drainage of pus from this
periapical lesion, plaque trapped in the resorption defect or
caries on the mesial surface of the upper left canine.
What Types of Dental Resorption are There? What
are Their Characteristic Features?
Resorption is the process of removal of dental hard tissues
by osteoclasts. There is usually some form of repair by either
reactionary dentine or bone. This repair may lead to anky-
losis. All resorption is identical in its basic process, but it is
convenient to subdivide resorption into clinically relevant
types. Resorption may be classified by location (i.e. internal
or external), as well as by aetiology (i.e. inflammatory or
replacement). All types may be transient or progressive.
Internal root resorption starts on the pulpal aspect of
dentine. It typically affects the middle third of the root and
forms a well-demarcated defect with a smooth symmetrical
CASE 17 A Loose Anterior Tooth 97
Problems
Electric pulp tests are notoriously difficult to perform on
crowned teeth and the results must be interpreted with
caution. The lateral incisor has a metal ceramic bonded
crown and the ceramic will insulate the tooth while the
metal layer will diffuse the applied voltage and conduct
the stimulus to the gingiva. The patient may mistake a
gingival sensation for a vitality response.
Thermal pulp testing is also unreliable on teeth with
indirect restorations involving ceramic, as the thermal
conductivity of ceramic is poor.
Root fractures may be difficult to identify if the fragments
are not separated. A second view at a slightly different
angle (e.g. upper standard occlusal or bisecting angle
periapical) may allow detection of a root fracture, which
is invisible in the first. Alternatively 3D radiography in the
form of small-volume, high-resolution CBCT may help
identify fractures, resorption and extent of any periapical
pathology.
shape. Internal resorption indicates that the pulp is vital and
that, provided the lesion has not perforated the root, the
process will be halted by root canal treatment.
External root resorption starts on the surface of the
tooth, usually on the root but occasionally on the crown
of unerupted teeth. A microscopic degree of superficial
external root resorption can occur normally and is usually
repaired by cementum. Greater apical root resorption may
be seen radiographically, most commonly on teeth that have
been moved orthodontically. Extensive apical resorption
may accompany periapical inflammation or infection on
nonvital teeth. A nonvital pulp may trigger external resorp-
tion of the middle or coronal one-third of the root by pro-
ducing noxious byproducts, which diffuse outwards to the
periodontal ligament along the dentine tubules. External
cervical root resorption usually starts just below the gingival
margin and may affect one or many teeth that may be other-
wise healthy and vital. Radiographically, the early stages may
mimic the appearance of an infra bony periodontal pocket.
All types of external resorption are irregular in outline, and
extensive lesions often spare a thin layer of dentine around
the pulp so that the pulp can remain vital until a late stage,
even if the defect communicates with a periodontal pocket.
Inflammatory root resorption is associated with detect-
able inflammation and may be internal or external. This
may be evident radiographically, as radiolucency in the adja-
cent bone, or clinically as redness. The inflammatory type of
resorption has the positive aspect that removal of the cause
of the inflammation (i.e. infected necrotic tissue) may halt
the resorption.
Unfortunately, this is not entirely predictable. Many cases
of so-called inflammatory resorption, both internal and
external, are not associated with significant inflammation
clinically or histologically and are perhaps better regarded
as idiopathic.
98 C ASE 1 7 A Loose Anterior Tooth
Replacement root resorption is root resorption starting
externally accompanied by progressive replacement of the
tooth by bone. It is often associated with ankylosis and is a
complication of luxation injuries, particularly intrusion and
avulsion. Inflammation is absent; therefore, treatment must
be directed at removing the resorptive tissue itself, which
has a less predictable outcome. Internally, the pulp canal
space may be filled with tertiary dentine, which is known as
pulp canal obliteration, and is not a true form of resorption.
What Causes Resorption?
Resorption and repair may be physiological or pathologi-
cal processes on both the external surface of the root and
internally. Internally pulpal surface resorption is pathologi-
cal; however, repair is one of the pulp’s natural responses to
injury, as in the case of tertiary dentine formation. External
resorption is known to follow damage to the cementum layer
or loss of vitality of cementum, which triggers osteoclastic
activity, which is why external resorption is very common
after an avulsion injury. External cervical root resorption is
assumed to be primarily inflammatory in aetiology, caused
by the periodontal flora, though this does not explain cases
where multiple lesions affect several otherwise healthy teeth.
Internal resorption may follow loss of the predentine
layer separating pulp from dentine, but the causes of this loss
are unknown. A degree of pulp inflammation and increased
pulp pressure are thought to be possible trigger factors.
What are the Features of Resorption?
• A symptomatic (unless an inflammatory cause is symp­
tomatic)
• Internal resorption occurs in vital or partially vital teeth
• External resorption may develop on vital or nonvital
teeth
• Resorption itself does not compromise vitality until the
pulp communicates with the oral environment
• Usually slow and intermittent, occasionally very rapid
• Mobility or pathological fracture
• External cervical root resorption and extensive internal
resorption appears as a ‘pink spot’, which is pulp/granu-
lation tissue visible through the crown
• Ankylosis (continuity of tooth and bone) is the sequelae
of replacement resorption
• Radiolucency and loss of tooth substance are the radio-
graphic signs.
What are the Signs of Ankylosis?
•  ack of normal mobility
L ceramic or metal-ceramic materials could potentially be
• High pitched metallic percussive sound
• Infraocclusion (submerging tooth in the growing jaw)
• Sometimes identifiable radiographically as a bridged
periodontal ligament
• Patchy ‘moth-eaten’ root surface/lamina dura.
What are Your Definitive Diagnoses in This Case?
The maxillary lateral incisor has internal resorption, prob-
ably as a late sequela of the previous trauma or restoration
of teeth. Resorption is advanced, and the root has suffered a
pathological fracture making the coronal fragment mobile.
The maxillary central incisor has a persistent periapical
periodontitis despite root canal treatment, suggesting a lack
of an efficient coronal seal. In addition, the restorative prog-
nosis of the tooth is questionable, depending on whether a
ferrule is present.
There is a carious lesion present on the upper left canine.
Treatment
How Would You Manage the Lateral Incisor in
the Short Term and the Long Term?
The prognosis for the lateral incisor is poor, and it requires
extraction. It cannot be restored because the resorption
has involved the periodontal ligament around much of the
tooth circumference. A tooth with a more localized perfora-
tion might be repaired surgically. However, in combination
with the necessary root canal treatment, this would be heroic
treatment with an unpredictable chance of success at best.
Surgical repair is more suitable for external cervical resorp-
tion, as opposed to middle third internal root resorption.
Postextraction alveolar bone healing and remodelling
will need to occur prior to definitive replacement; therefore,
a provisional restoration will be required.
What are the Immediate Replacement Options for
the Lateral Incisor?
• A vacuum-formed clear Essix retainer with an acrylic
tooth in the lateral incisor position
• An acrylic removable partial denture, Every-type or
spoon design major connector
• A minimal preparation bridge of a cantilever design with
a resin composite pontic for ease of adjustment after
extraction
• The existing crown could be splinted to the adjacent
teeth using a fibre-reinforced resin composite splint.
What are the Definitive Replacement Options?
Minimal preparation adhesive bridge replacing the lateral
incisor, of a cantilever design with a retainer on the canine.
This would require the carious lesion in the canine to be
small and for there to be sufficient occlusal clearance for the
retainer.
A conventional cantilever bridge using the canine as
the abutment, is a possibility; however, this is a more inva-
sive option than a minimal preparation bridge. Either all-
used, each with advantages and disadvantages.
A conventional cantilever bridge using the upper left
central incisor as the abutment would be a less predictable
option. The failed root filling in the central incisor would
require retreatment, which would have a less certain out-
come than de novo endodontics. Initially an investigation
of the restorability of the tooth would involve removal of
the pre-existing restoration and assessment of the amount of
remaining tooth structure to ascertain if there was sufficient

tooth tissue for at least a 2-mm ferrule. If there was less than
4 mm of coronal dentine, then a post would be required
to provide additional retention for the crown retainer. This
would require a parallel-sided, cast or preformed post and
core to support a single cantilever pontic replacing the lat-
eral incisor. Using a post crowned tooth as a bridge retainer
has a relatively high failure rate; indeed, post retention is
best avoided in all bridge designs. If an orthograde repeat
root canal treatment is not successful in healing the periapi-
cal infection, then an apicectomy will have to be consid-
ered for this tooth; and if it is performed, the root length
available for a post will be reduced. Therefore, considering
these complicating factors together with the time necessary
to ensure apical healing (up to 4 years), this suggests that the
central incisor is probably not suitable as a bridge abutment
in this scenario.
A single tooth implant crown would be possible; how-
ever, the patient’s diabetes would ideally need to be well
controlled to ensure a predictable outcome. Diabetes is
not an absolute contraindication for implant provision,
but the possibility of delayed healing in diabetes, in the
maxillary site (where implants have a reduced survival
rate), means that an implant might not be recommended.
Further discussion of anterior single tooth implants will be
found in Case 35.
CASE 17 A Loose Anterior Tooth 99
When managing trauma cases, comprehensive note
keeping and documentation are essential to support optimal
decision making and communication with the patient and
clinical colleagues and also in the event of medico-legal sce-
narios. Depending on the nature and severity of the trauma,
legal proceedings may be entered into, and clinical record
keeping may form a part of the legal case. Therefore, the his-
tory of the trauma should be recorded as completely as pos-
sible. In addition, with regard to complex clinical scenarios
such as this, effective liaison with specialist colleagues may
be required, especially if three-dimensional (3D) cone beam
computed tomography (CBCT) or endodontic surgery may
be required. Adjunctive clinical photography with suitable
consent forms signed would also be a sensible option in
cases such as these.
For this case, a specialist endodontic option was sought, and
the outcome was that both the central and lateral incisors had a
poor prognosis and were not amenable to endodontic treatment.
Therefore, following discussion with the patient regarding the
replacement options, the teeth were extracted and replaced with
two separate cantilever-design minimal preparation bridges, by
using the upper right central incisor as the abutment to replace
the upper left central incisor and the upper left canine as the
abutment to replace the upper left lateral incisor.