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  1. 1. CASE STUDY Tri M. Le, DDS, FAGDComplex Anterior Private Practice Southeast Texas Cosmetic DentistryTreatment Port Arthur, Texas Phone: 409.982.7827 Email: Web site:A Case Report southeasttexascosmetic dentistry. comN umerous innovations in den- sary radiographs, photographs, and After discussing the treatment tal materials and techniques mounted models were taken and care- phases, costs, and time with the have dramatically changed fully analyzed. In this treatment plan, patient, he was appointed for the peri-modern dental practice. In addition, the the root of tooth No. 9 would be cov- odontal plastic surgery phase. Afterpredictability of dental implants and tis- ered with an acellular grafting materi- verbal review of the procedure and pre-sue regeneration has greatly influenced al, Alloderm (BioHorizons, Inc), to medication (patient was to start takingdiagnosis and treatment planning. help correct the severe recession. The amoxicillin 875 mg b.i.d., 48 hoursConsequently, a clinician can be con- crown of tooth No. 7 would be length- before and dexamethasone 4 mg, 24founded by the many valid treatment ened, and new crowns would be hours before), all consent forms wereoptions. Oftentimes, the selected treat- placed on teeth Nos. 6 (to emulate a given to the patient, reviewed, andment is based on financial factors, insur- lateral incisor), 7 (to mimic a central signed. The patient was then given twoance coverage, and time as well as the incisor), 9, and 10, respectively. 200 mg tablets of ibuprofen and wasclinician’s training, comfort zone, and Before proceeding with any treat- instructed to rinse with chlorhexidineavailable referral sources. This article ment, the patient was invited back for 0.12% for 60 seconds. Vital signs,will illustrate one method of solving a an in-depth discussion of the expected including oxygen saturation, werecomplex esthetic puzzle using periodon- outcome. The patient was informed taken and monitored with an electron-tal plastic surgery to complement pros- that it would be impossible to achieve ic blood pressure monitor. The patientthetic rehabilitation. an ideal result because teeth Nos. 6 was then draped for surgery with hair and 7 had previously been reposi- cover and disposable gown. The peri-Case Presentation tioned. Fortunately, the patient’s exist- oral area was then scrubbed with A 50-year-old man of good overall ing low smile line would help mask chlorhexidine 0.12%. Following topi-health presented to the office with a any final restorative imperfections. cal anesthesia, 4% Citanest Plaincomplaint of the greatly compromised After careful analysis of the (Dentsply Pharmaceutical) was givenappearance of his upper anteriors patient’s gingival and osseous architec- for comfort and preliminary anesthesia.(Figure 1). Examination revealed that ture, including information gathered Marcaine 0.5% with 1:200,000 epi-tooth No. 8 was missing and tooth from probing depth records and radio- nephrine (Abbott Laboratories) wasNo. 7 had a composite veneer to make graphs, a surgical guide was made then administered for more profoundit appear as a central incisor. In addi- from the diagnostic model to help anesthesia.tion, tooth No. 9 had a severe facial with the soft-tissue surgical phase of The procedure was initiated withperiodontal defect (Figure 2). The the treatment. In cases such as this, a coronoplasty of the defective crownpatient stated that he was seeking to diagnostic model not only gives a on tooth No. 9 to allow full and pas-improve his appearance with minimal glimpse of the eventual prosthodontic sive insertion of the clear surgical stentcost in time and money, not a restorations, but also provides crucial so that an outline of the desired gingi-“Hollywood smile.” information and guidance on the val margins on teeth Nos. 7 and 9 To arrive at a proper treatment desirable soft-tissue appearance at the could be visualized in situ. This stepplan in such a complex case, all neces- end of treatment. helped finalize how much crown 42 CONTEMPORARY ESTHETICS | SEPTEMBER 2007
  2. 2. CASE STUDY Figure 1—Pretreatment smile view showing Figure 2—Pretreatment view showing severe Figure 3—Retracted view, flap elevated. compromised appearance. facial perioesthetic defect. Figure 4—Retracted view, Alloderm in place. Figure 5—Retracted view, flap re-approxi- Figure 6—Retracted view, 12 weeks after mated and sutured. surgery, showing good healing.lengthening would be needed on (Figure 4). The use of an acellular graft (Figure 5).10-12 Gauze soakedtooth No. 7 and how much graft vol- dermal graft helps eliminate the with saline then was placed onto theume would be needed for tooth No. requirement for palatal donor tissue surgical area with light pressure for9. After this, the gingivectomy was or other intraoral tissue harvesting. 15 minutes to help achieve initial sta-carried out with a Bard-Parker blade This choice of graft material helps bilization and clotting.No.15C (BD) on tooth No. 7. Then reduce chair time, thus avoiding The patient was slowly seatedthe flap was reflected to ascertain the additional discomfort to the patient upright, and postoperative instruc-location of the osseous crest of tooth and is, therefore, a useful method for tions were reviewed with specialNo. 7, in case any osseous resection root coverage.2-9 The flap was then emphasis on rinsing with chlorhexi-was necessary not to violate the bio- repositioned and evaluated for pas- dine 0.12% b.i.d. and warm saltlogic width. sivity with no tension when the inci- water as often as possible. In addi- After the flap had been ade- sion lines were approximated. tion, a supply of microbrushes andquately reflected to allow access to Additional reflection with scoring of instructions on their correct usage wastooth No. 9 (Figure 3), the root was the periosteum ensured proper and given to the patient so that only ascaled with hand instruments and tension-free flap coverage of the sur- microbrush soaked with chlorhexidinethen treated with citric acid. The gical area. The flap was then sutured 0.12% would be used in the surgicalacellular dermal graft material was with 5-0 vicryl (Ethicon, Inc). A sling area for the next 10 days when therehydrated for 10 minutes in a sterile suture with 6-0 gut also was added patient was scheduled for a postopera-saline bath.1 After proper trimming, onto the facial marginal gingiva of tive check-up and suture removal.the graft was placed in the surgical tooth No. 9 to further ensure graft After a waiting period of 3site and adapted to the root of tooth immobilization, which is crucial for months for proper healing (Figures 6No. 9 and adjacent crestal bone the survival and incorporation of the and 7), the patient was appointed for 44 CONTEMPORARY ESTHETICS | SEPTEMBER 2007
  3. 3. Figure 7—Occlusal view, 12 weeks after sur- Figure 8—Occlusal view of the preparations on Figure 9—Retracted view of provisional gery, showing good tissue volume around teeth Nos. 6 through 10. Note the proper healing crowns on teeth Nos. 6 through 10. tooth No. 9. of the graft and the esthetic complexity of case. Figure 10—The final crowns on the model Figure 11—Palatal view of the crowns on the Figure 12—Full smile view, immediately after showing the technician’s skill in compensating model. cementation. for the size discrepancy between teeth Nos. 7 and 9.the prosthetic treatment phase, during and anterior stick-bite impressions were Before the crowns were receivedwhich teeth Nos. 6, 7, 9, and 10 were obtained. A facebow transfer also was from the laboratory, the patientprepared for full crowns with the goal of acquired. The provisional crowns were requested to have his teeth bleached.making tooth No. 6 resemble a lateral then cemented temporarily with Normally, this step is done before theincisor and No. 7 look like a central inci- TempBond Clear (Kerr Corporation). crown preparation step, but at times,sor (Figure 8). Retraction cords, Gingi- After the removal of excess cement and the clinician must work around theBRAID 000 and 00 (Dux Dental), were the retraction cords, the occlusion was patient’s sudden desire. The patient waspacked for 10 minutes, the 00 cords were checked and adjusted with the patient appointed for in-office bleaching withremoved, and an impression was made seated upright. the Zoom! Advanced Power systemwith a custom tray and a polyvinyl silox- The patient was appointed for a (Discus Dental). Alginate impressionsane impression material (Imprint Garant, refinement visit, during which the pro- were made to fabricate at-home bleach-3M ESPE). After a good impression had visionals were touched up. After the ing trays. While the patient’s teeth werebeen obtained, the custom tray for the patient had approved the fit and being whitened in-office, the impres-fabrication of the provisional crowns was appearance of the provisional crowns, sions were poured and the bleachingloaded with Integrity temporary material photographs were taken and alginate trays were made. Opalescence PF 20%(Dentsply Caulk) and inserted over the impressions were made (Figure 9) to be (Ultradent Inc) bleaching gel was dis-preparations. enclosed with the case for the ceramist. pensed with proper instruction for After the provisionals had been Measurements of the length of the cen- home use. The patient was thenproperly shaped and polished, they trals also were documented, and the appointed for a shade-taking visit.were set aside. At this point, the patient patient’s consent to have the treatment At the crown-delivery appoint-was seated upright and posterior bite completed was obtained. ment, the vital signs were acquired and CONTEMPORARY ESTHETICS | SEPTEMBER 2007 45
  4. 4. CASE STUDY Red (Global Dental Products) before Acknowledgments being coated with Gluma De- The author would like to thank sentisizer (Heraeus Kulzer, Inc). The Ann Le for her ever-present support, crowns were then blasted with alu- Tom and Beatrice Dabrowsky, LDT, minum oxide, rinsed, cleaned with RDT of B.I.T. Dental Studio, Dillon, alcohol, dried, and were cemented Colorado, for the beautiful ceramics, with RelyX Unicem (3M ESPE). and all my teachers over the years. After all excess cement was cleaned Figure 13—Retracted view, final crowns off, the patient was seated upright References immediately after cementation. and the occlusion was checked and 1. Henderson RD, Drisko CH, Greenwell H. Root cov- erage using Alloderm acellular dermal graft mate- adjusted. Proper centric occlusion, rial. J Contemp Dent Pract. 1999;1(1):24-30. cuspid, and protrusive guidance were 2. Dodge JR, Henderson R, Greenwell H. Root cover- verified (Figures 12 through 14). The age without palatal donor site using an acellular dermal graft. Periodontal Insights. 1998;5(4):5-8. patient was given detailed instruc- 3. Harris RJ. Root coverage with a connective tissue tions on proper care and mainte- with partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histo- nance of the crowns to ensure logical evaluation of a case report. J Periodontol. longevity. He was then appointed for 1998;69(11):1305-1311. a postdelivery check-up and final 4. Tal H. Subgingival acellular dermal matrix allograft for the treatment of gingival recession: a case Figure 14—Palatal view, final crowns. photographs. At that appointment, report. J Periodontol. 1999;70(9):1118-1124. the patient expressed his happiness 5. Harris RJ. A comparative study of root coverage obtained with an acellular dermal matrix versus a with the final result. connective tissue graft: results of 107 recessiondocumented, and the procedure was defects in 50 consecutively treated patients. Int Jreviewed again with the patient. Before Conclusion Periodontics Restorative Dent. 2000;20(1):51-59. 6. Grisi DC, Molina GO, Souza SL, et al. Comparativeanesthesia administration, the crowns Complex dental rehabilitation 6-month clinical study of a subepithelial connectivewere shown to the patient to have his poses many unique challenges to cli- tissue graft and acellular dermal matrix graft for the treatment of gingival recession. J Periodontol.preliminary approval of the forms and nicians. It tests one’s knowledge, 2001;72(11):1477-1484.shades (Figures 10 and 11). training, integrity, and artistic abili- 7. Mahn DH. Treatment of gingival recession with a After local anesthesia with Cita- ty. With the variety of treatment modified “tunnel” technique and an acellular der- mal connective tissue allograft. Pract Procednest Plain (Dentsply Pharmaceutical) options currently available, treat- Aesthet Dent. 2001;13(1):69-74.and Xylocaine 2% with 1:100,000 epi- ment plans can vary from office to 8. Aichelmann-Reidy ME, Yukna RA, Evans GH, et al. Clinical evaluation of acellular allograft dermis fornephrine (Dentsply Pharmaceutical), office. Differences in training, phi- the treatment of human gingival recession. Jthe temporary crowns were removed losophy, degree of financial motiva- Periodontol. 2001;72(8):998-1005.and the porcelain crowns were tried in. tion, and esthetic perception by the 9. Woodyard JG, Greenwell H, Hill M, et al. The clinical effect of acellular dermal matrix on gingi-The patient was given a hand mirror to dentist as well as the patient also can val thickness and root coverage compared toevaluate the appearance of the crowns affect treatment plans. Further, the coronally positioned flap alone. J Periodontol. 2004;75(1) place. patient’s personality, financial con- 10. Silverstein LH, Kurtzman GM. A review of dental After approval for cementation cerns, and personal situation also suturing for optimal soft-tissue management.was obtained, the crowns were come into play. Nonetheless, with Compend Contin Educ Dent. 2005;26(3):163-166, 169-170.checked for proper fit, interproximal today’s esthetic demand from the 11. Silverstein LH. Essential principles of dental sutur-contact, and marginal seal. Because public as well as great advancement ing for the implant surgeon. Dent Implantol Update. 2005;16(1):1-7.the crowns were ceramometallic, in tissue engineering, clinicians 12. Silverstein LH. Principles of Dental Suturing: Therubber dam isolation was not neces- should consider regenerative peri- Complete Guide to Surgical Closure. Mahwah, NJ:sary. The working area was isolated odontics before extracting teeth and Montage Media;1999. 13. Nevins M. Aesthetic and regenerative oral plasticwith cotton rolls and the prepara- communicate this option to their surgery: clinical applications in tissue engineering.tions were cleaned with Tubulicid patients.13 Gc Dent Today. 2006;25(10):142-146. 46 CONTEMPORARY ESTHETICS | SEPTEMBER 2007
  5. 5. CASE STUDYProduct References Products: Imprint Garant, RelyX UnicemProduct: Alloderm Product: Bard-Parker blade No.15C Manufacturer: 3M ESPEManufacturer: BioHorizons, Inc Manufacturer: BD Location: St. Paul, MinnesotaLocation: Birmingham, Alabama Location: Franklin Lakes, New Jersey Phone: 888.364.3577Phone: 205.967.7880 Phone: 201.847.6800 Web site: site: Web site: Product: IntegrityProducts: 4% Citanest Plain, Citanest Plain, Product: 5-0 vicryl suture Manufacturer: Dentsply CaulkXylocaine 2% with 1:100,000 epinephrine Manufacturer: Ethicon, Inc Location: Milford, DelawareManufacturer: Dentsply Pharmaceutical Location: Somerville, New Jersey Phone: 800.532.2855Location: York, Pennsylvania Web site: Web site: www.caulk.comPhone: 800.225.2787Web site: Products: Retraction cord, GingiBRAID 000 and 00 Product: TempBond Clear Manufacturer: Dux Dental Manufacturer: Kerr CorporationProduct: Marcaine 0.5% with 1:200,000 epinephrine Location: Oxnard, California Location: Orange, CaliforniaManufacturer: Abbott Laboratories Phone: 800.833.8267 Phone: 800.537.7123Location: Abbott Park, Illinois Web site: Web site: www.kerrdental.comWeb site: Product: Zoom! Advanced Power system Manufacturer: Discus Dental Location: Culver City, California Phone: 800.422.9448 Web site: Product: Opalescence PF 20% Manufacturer: Ultradent, Inc Location: South Jordan, Utah Phone: 888.230.1420 Web site: Product: Tubulicid Red Manufacturer: Global Dental Products Location: North Bellmore, New York Phone: 516.221.8844 Web site: Product: Gluma Desentisizer Manufacturer: Heraeus Kulzer, Inc Location: Armonk, New York Phone: 800.431.1785 Web site: 48 CONTEMPORARY ESTHETICS | SEPTEMBER 2007