Dental Trauma to Smile Make-over By Saskia Vaughan, DDS, MAGD PATIENT AFTER PHOTO ABSTRACT Often, in cases where multiple clinicians contribute to the outcome of the case, end results are compromised. This case shows what can be achieved when the general dentist is able to have better control over the results by offering expanded services.
INTRODUCTION Many general dentists experience frustration when they refer patients to specialists. This frustration comes from losing control over the outcome of the case. The general dentist has a unique perspective on treatment planning that stems from being continually exposed to all disciplines of dentistry. On the other hand, specialists become focused solely on their specialty and tend to neglect other facets that are integral to the success of the case. This is especially profound in cases that are esthetically demanding.
CASE REPORT The patient is a 44 year old female with a history of dental trauma to her tooth #8, 20 years previously. She presented to my office, reporting that her tooth #8 had been discolored for a long time, but at this time it has also become mobile. She also let me know that she has never been happy with the look of her left canine because it appears like she is missing a tooth. The examination of her oral condition reveals: complete horizontal root fracture of tooth #8 and a lingually displaced #11.
TREATMENT PLANNING A complete examination was performed which included a panoramic, cephalometric, four bitewing radiographs, a full set of intraoral and extraoral photographs, examination of the teeth and other oral structures, and periodontal charting. (Figure 1). The following observations were generated: Tooth #8 is discolored and has a vertical root fracture with internal resorption evident. Tooth #11 is lingually displaced in the upper arch. The patient is missing teeth #1, 2, 3, 14, 15, 17, and 18. Teeth #31 and 32 are periodontally involved. Tooth #31 has deep decay approaching the pulp. Tooth #30 has occlusal decay. Tooth #16 has drifted mesially into the #15 position. Treatment goals are to bring the patient into a first molar occlusion, level and align the arches, and to replace tooth #8. The treatment plan that was developed in accordance with the patient wishes is as follows. First, restore tooth #30 with composite resin restoration. Second, referral to an oral surgeon for atraumatic extraction and bone grafting for ridge preservation of tooth #8, as well as extraction of teeth #32 and 31. Third, bands and brackets to level and align the arches. Fourth, implants to replace teeth #8,14 and 3.
CASE REPORT (CONTINUED) Figure 1
METHODS AND MATERIALS Two challenges presented themselves in carrying out the treatment plan. In order to achieve the desired level of esthetics in restoring anterior teeth, it is extremely important to achieve gingival contours that mirror the gingival architecture across the midline. In order to achieve this, the patient was banded and bracketed before surgery. A temporary tooth with the desired contours in all three dimensions was made out of composite resin. The tooth was affixed to the arch wire at the time of surgery to extract teeth #8, 31 and 32. The gingival surface of the temporary for tooth #8 was adjusted as needed during orthodontic treatment and the healing phase of the #8 extraction and bone graft site. (Figure 2). The second challenge was being able to move #11 buccally and have the correct root inclination to create a canine eminence. In order to achieve this, the surgeon was instructed to perform alveolar corticotomies in the labial bone overlying tooth #11. (Figure 3).
Figure 2
Figure 3
DISCUSSION As seen in Figure 4, the fabrication of a custom temporary to help shape the bone and gingival during the healing phase can be extremely successful. This technique helps create interproximal papilla and pleasing gingival contours. The alveolar corticotomy procedure is very beneficial in accelerating orthodontic movement by taking advantage of the regional acceleratory phenomenon, or RAP, in bone. This technique was pioneered by the Wilcko brothers who named the procedure Wilckodontics. Figure 5 shows the amount of orthodontic movement that was achieved in just three months following the corticotomy procedure. The final records in this case reflect the success in creating a canine eminence in the #11 area. (Figure 6).
Figure 4
CASE REPORT (CONTINUED) Figure 5
Figure 6
CONCLUSION This case underscores the importance of controlling the details of the position of the teeth and contours of the periodontium in a smile makeover case. The timing of the use of a correctly contoured temporary during the healing phase and coticotomy procedures to facilitate RAP, in conjunction with orthodontics, is essential in a case like this. In these situations, a general dentist who is familiar with advanced techniques in periodontics, orthodontics, as well as other dental specialties, is uniquely positioned to meet the patient’s needs in the best possible way. I attribute the continuing education gained during my attendance of the Texas AGD MasterTrack® for giving me the confidence to pursue further educational endeavors to be able to offer my patients expanded services to include orthodontics as part of cosmetic dentistry services.
REFERENCES Gingival Conditioning in an Implant – Supported Prosthesis: A Clinical Report, Flavio Domingues das Neves et al . Journal of Oral Implantology, Vol 39:Issue 4:pages 483-485. August 2013. Wilckodontics- A Novel Synergy in Time to Save Time, K Sirisha et al. J Clin Diagn Res 2014 January; 8(1): 322-325. Published online 2014 January 12. Wilckodontics: A Multidisciplinary Treatment Approach in Dentistry. Kumar,S et al. International Journal of Research and Development in Pharmacy and Life Sciences. , October - November, 2015, 4(6), 1801-1807 About Dr. Saskia Vaughan Saskia C. Vaughan, DDS, MAGD earned her Bachelor of Science in Animal Science from Texas A&M University in 1984. She earned her Doctor of Dental Surgery degree from Baylor College of Dentistry in 1989. In 2008, she was awarded Fellowship in the Academy of General Dentistry. She became a Master of the Academy of General Dentistry in 2011. In 2015, she received a Lifelong Learning and Service Recognition Award. Dr. Vaughan has been in private practice in Mineral Wells, Texas since 1989.
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