Treating Around Teeth That May Not Survive

Straight Talk draws its cases and discussions from the Orthotown message boards. Written by the editorial team with the assistance of AI, each article showcases how orthodontists tackle unusual and challenging scenarios.

A 29-year-old woman came in with a simple request. She wanted straight teeth. Her records complicated that request considerably. The upper central incisors had essentially no remaining root structure, and moderate resorption was apparent on several other teeth. Crowding was significant. Her orthodontist had already declined to treat her once, and she had come back anyway, fully briefed on the risk of losing those incisors and needing prosthetic replacement at some point. She signed the consent form and asked to begin. Facial and intraoral photographs, a panoramic film, a periapical of the upper anterior segment, and a lateral cephalogram documented the presentation (Figs. 1-9).

The question posted to the board was narrow. Braces and extractions, or interproximal reduction and aligners? Extractions meant longer treatment and more tooth movement through bone that already showed damage, which was exactly what the treating orthodontist wanted to avoid. Aligners with IPR promised a shorter, lighter course, though they acknowledged limited aligner experience and wanted to know whether that plan could produce an acceptable result at all.

Several Townies read the crowding as decisive. At that severity, they argued, this becomes an extraction case regardless of the root situation, and the way to protect the compromised incisors is not to avoid extractions but to keep those teeth out of the mechanics. Bypass the incisors entirely, resolve the crowding in the posterior segments, then align and retract the anterior teeth as a unit once space exists. Simple forces were the emphasis. Large third-order couples with rapid force decay on incisors with no root reserve invite exactly the outcome everyone is trying to prevent. Thoughtful mechanics, in that view, matter more than the extraction decision itself. Others posted records from their own severe resorption cases to show the approach in practice.

A second group went further and proposed extracting the upper central incisors themselves. The reasoning was pragmatic. Those teeth are unlikely to last, so plan around their absence now rather than spending a full course of treatment protecting them and losing them anyway. Remove the centrals, extract lower premolars to manage the arch relationship, bring the laterals mesially, and let restorative reshape them into central incisors, opening space at the end for veneers or crowns. A real root beats titanium, as one Townie put it. Staging came up repeatedly: Take out one central, close most of that space, then take out the other. For an adult patient concerned about appearance during treatment, a bracketed pontic trimmed progressively smaller as the space closes was offered as a way through the aesthetic gap. Not everyone accepted the reshaping plan; some preferred implants for the missing units. Nor was the objection ignored that this route is more expensive, more restoratively involved, and harder to get right aesthetically than premolar extraction.

The nonextraction camp saw a different case. To them, the crowding read as moderate rather than severe, the chin was strong, and IPR with aligners or light fixed mechanics could reasonably resolve it. Add modest posterior expansion and the arithmetic works. One member suggested running a three-dimensional simulation with IPR and mild expansion before committing to anything, having been surprised by what those setups can absorb. There was a shared instinct across this group toward light forces, short treatment duration, minimal intrusion, and restrained torque, along with a genuine question about what happens to the remaining roots if they are asked to travel any real distance through the alveolus. Whether aligners themselves reduce that risk drew disagreement, with published findings cited on one side and skepticism on the other about whether plastic changes what a tooth actually experiences.

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Underneath the mechanics debate sat a diagnostic gap nobody could close from the records. Was this resorption from prior treatment, from trauma, or were these congenitally short roots? The malocclusion did not suggest previous orthodontics, and one orthodontist noted that congenitally short roots carry no greater likelihood of further resorption, only worse consequences if it occurs. That distinction changes the risk calculus substantially. Oral habits were flagged as worth checking. Regardless of etiology, the monitoring protocol drew broad agreement: periapical films every four to six months, with treatment stopped or modified at the first sign of progression. And more than one Townie insisted the case should not start at all until a perio, implant, and prosthodontic team had weighed in, with the patient prepared for every possible endpoint, including cost and duration.

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In an adult with essentially rootless upper central incisors and real crowding, is the safer plan to relieve that crowding through premolar extraction while keeping the incisors passive and hoping to preserve them, or to accept their loss at the outset and build the treatment around a restorative result? 

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