Sophisticated Cosmetic Dentistry
In today’s climate of sophisticated dentistry and extremely high patient expectations, it is essential for the restorative dentist to avail herself of the not only the most advanced techniques in restorative dentistry but to also combine these techniques with those available from complementary disciplines within dentistry. The integration of multidisciplinary dentistry allows for the execution of the optimized treatment plan when carefully strategized in terms of patient scheduling and expectations.
Various disciplines may be necessary to allow for the idealized treatment to be successfully completed. These disciplines may include orthognathic surgery, orthodontics, endodontics, periodontal therapy and soft-tissue management to provide for optimal gingival contours, now recognized as “pink esthetics”.
It is not an uncommon occurrence in dentistry to encounter a patient who is expecting a perfect esthetic result, however, it is far less frequently that dentists encounter a patient who is also willing to undergo the necessary pre-prosthetic preparation to allow for the creation of the foundation upon which the restorative dentist can build the desired prosthesis which is optimized in both esthetics and function.
When evaluating today’s discipline of cosmetic dentistry, it is recognized that manipulation of tooth structure is in itself insufficient to create a beautiful smile. Management of the gingival tissue is now recognized as integral to an idealized esthetic result. Pink esthetics involves the idealized placement of the gingival margin and the avoidance of excessively long or short teeth as a result of poor positioning of gingival levels. It also refers to the presence of an adequate interdental papilla, which must be addressed to avoid any resultant “black triangles” between teeth. The presence of these black triangles is the natural sequelae of periodontal disease and the illusion of absence of disease is a primary key to any esthetics, whether in dentistry or any other aspect of beauty
Presented here is a case study of the combined disciplines of restorative dentistry, orthodontics and periodontics facilitated by the use both conventional periodontal surgery and the use of the erbium yag Key 3 laser (Kavo) to correct iatrogenic damage from improper endodontic post placement which resulted in deep subgingival post perforation and chronically inflamed gingival tissues, Restorations placed on other teeth concurrent to the above mentioned perforated tooth were less than ideal marginal contours the result of which was chronically inflamed marginal gingival.
This patient presented for a consultation about improvement of her dental esthetics with respect to maxillary anterior teeth. The patient’s previously virgin dentition was severely damaged as a result of sudden loss of consciousness after bathing and subsequent impact on a bathtub wall. The patient awoke in the hospital to find that several of her front teeth were broken and others luxated out of position. Due to the urgency of the situation, her dentist restored the broken teeth of 12,11,21,22 following immediate endodontic treatment of these teeth.
Due to the haste in which these teeth were restored, the final result was less than ideal and the restoring dentist replaced these restorations six months after the initial restorations. However, it was not until the completion of the second treatment was completed that it was observed that the canines were luxated and healed out of position, hence the midline was restored in a canted manner and subsequently so too was the occlusal plane which had been straight prior to the bathtub incident.
After a few years of dissatisfaction with both the esthetic failure and gingival inflammation, the patient presented for a consultation to determine a possible retreatment which would address her concerns.
Examination including full periodontal charting and a full mouth series of radiographs revealed chronically inflamed gingival tissue circumferential of her anterior restorations as well as the presence of a 7 mm pocket in the position of tooth 12 distal with moderate mobility. Radiographically, this deep pocket could be attributed to the perforation of the endodontic post.
Upon recognition of the patient’s poor periodontal condition, the patient was referred to a periodontist for treatment of her generally poor periodontal condition as well as her deep periodontal defect in the 12 distal aspect of this tooth.
Prior to the completion of the 12-22 with placement of interim restorations with sound and smooth margins to facilitate the healing from periodontal therapy.
Periodontal therapy initially consisted of scaling and root planing accompanied with subgingival irrigation, chorhexidine rinses, systemic antibiotics combined with instructions in bacterial control techniques including the use of stimudents, and a sulcabrush.
At periodontal reassessment 3 weeks following, the patient presented with decreased bleeding, increased soft tissue tone and soft tissue shrinkage due to the almost complete reduction in inflammation. However, this shrinkage resulted in papillary blunting, the opposite of the desired result for a good esthetic result. Fortunately, due to the asymmetry presented in the marginal gingival tissue levels, the patient required crown lengthening which upon healing would allow for the recreation of fully intact papillae in all areas with the exception of the distal of tooth 12 which demonstrated severe loss of the interdental papilla. Due to the extent of the periodontal defect on 12, even crown lengthening could not result in the creation of a sufficiently large enough papilla to close the interdental space. However, tooth 12 now appeared to be in good gingival health with pocketing in the area of 3-4mm on the distal aspect and mobility was diminished to within normal values. The patient also perceived no discomfort on probing.
At this time in the treatment, the patient was officered the opportunity to undergo further treatment to restore the papilla. However, due to upcoming social obligations, the patient stated that she believed that the absence of the papilla was of minor concern and wished to proceed with the final restorations for the anterior teeth. The patient was then restored with porcelain restorations on teeth 13-23 (the Maxillary cuspids now part of the treatment plan to correct the canting due to previous luxation. At the time of insertion of these porcelain restorations, the patient departed satisfied with the result esthetically and very pleased in terms of her periodontal health.
As per human nature, less than one year subsequent to the placement of the final restorations, the patient returned for further evaluation of the site of 12 distal and stated that she was now unhappy with the defect and wished to undergo new treatment that would attempt to correct this area of concern.
It has been shown that when the measurement from the contact point to the crest of bone was 5 mm or less, the papilla was present almost 100% of the time. When the distance was 6 mm, the papilla was present 56% of the time, and when the distance was 7 mm or more, the papilla was present 27% of the time or less.
With this knowledge, it became evident that unless the interproximal bone levels could be increased coronally, that the creation of a papilla in this area would highly unpredictable.
The creation of increased interproximal bone levels through grafting has also been shown to be unpredictable. However, it has been shown that interproximal bone levels can be increased by means of orthodontic eruption.
Though the patient had already undergone three attempts at reconstruction, when faced with the long term absence of the papilla in the area of 12 distal, versus the placement of orthodontic brackets to forcible erupt tooth 12 and attempt to bring with the attachment, the patient decided that she would pursue the orthodontic option to attempt final correction of this iatrogenic problem.
Brackets were placed from teeth 13 to 23. A .012 nickel titanium was used to place gentle extrusion forces. As the tooth was erupting, the patient returned to the office every 2-3 weeks for incisal edge reduction of 12 to avoid occlusal interferences and the unsightly appearance of an excessively long tooth. As there was an approximately 3 mm defect in the interdental area, it was deemed that tooth 12 would require approximately 3 mm of eruption. At the completion of the eruption, however, due to the crown root ratio, eruption of 2 mm was deemed to be the safe limit for extrusion. At the completion of the eruption, there still remained a small periodontal defect; however, this was easily addressed by the placement of the contact point on the distal of the replacement veneer on tooth 12 apically 1 mm from the idealized contact position. Though the adjacent teeth were etched with hydrofluoric acid to allow for bracket bonding, this etched appearance was eliminated at the completion of treatment through the use of porcelain polishers and no restorations other than that of tooth 12 required replacement.
As tooth 12 erupted and the distal interproximal bone levels were increased coronally, so to was the mesial interproximal bone level of 12. To address this increased bone level on the mesial aspect (which in fact resulted in too large a papilla with insufficient space and hence apparent swelling) and return it to a desirable level, this interproximal bone was reduced by means of transmucosal osteotomy with the use of the erbium yag laser on only the distal of this tooth.
This procedure consisted of measuring the interproximal bone level by means of sounding the bone with a periodontal probe with the patient anaesthetized. As stated above, the ideal bone level for papilla fill is 4-5 mm apical to the contact level. Hence the bone was removed with the use of the laser and the chisel prism, placed subgingivally transmucosal to the desired depth. Upon healing, the patient experienced no pain or adverse effects and healed uneventfully.
Tissue healing and maturation from the laser osteotomy occurred while tooth 12 remained fixated with the orthodontic appliance. Upon completion of retention, the heavily adjusted porcelain restoration on 12 was replaced with a temporary restoration to evaluate esthetics and subsequently with the final restoration.
In conclusion, to allow for idealized results, it is often necessary to implement interdisciplinary treatment. Ideal treatment for this patient proved to be a long road requiring not only dental expertise but strong patient compliance. Patient selection is crucial to successful treatment in cases such as these. A journey of several years including multiple restorations, multiple surgeries and orthodontic treatment allowed for a successful outcome, however, careful case planning and diligence were of pinnacle importance.
J Periodontol. 1992 Dec;63(12):995-6. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla.
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Pt’s photo as she looked 30years ago
Photos of patient as she presented for consultation
Radiiograph showing perforation on distal of 12
Appearance of defect after periodontal therapy and at the beginning of the orthodontic eruption phase of treatment
Note improvement of gingival defect on distal of 12 at completion of ortho treatment
Pt wearing temporary crown
Try in stage of treatment. At this point the lab needed instruction as how to move contact point more apically to close the gingival embrasure
Final crown. Note the absence of the black triangle. Though this is not a perfect restul, it is a major improvement of the original gingival contour
Final restorations at the completion of treatment