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Emergency-turned-cosmetic Case by Bradley Blair, DDS

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A 41-year-old patient was referred by his girlfriend (a current patient) to re-cement his loose bridge. From what I understood, the bridge is about five years old and the lower incisors were removed for cosmetic reasons and the bridge attached to virgin lower cuspids. The uppers were originally traumatized in an auto accident when he was a kid.

After addressing the aesthetic emergency, we had some time to talk about other things. When I met the patient, he handed me what appeared to be gutta purcha sticking out from those crowns (Fig. 1).

The clinical situation showed obvious leackage, decay, lack of ferrule and very thin soft tissue on the facial, as well as inflammation (Fig. 2).

Fig. 3: Retracted, in occlusion

Figs. 4 & 5: At rest, full smile

Fig. 6: Left retainer, periapical radiolucency and a portion of a fractured lentulo in there

Fig. 7: Right retainer, radiolucency here too

Fig. 8: One too long, one way too short

Fig. 9: Left central now non-vital, too

Fig. 10: Upper arch, mirror view

Fig. 11: Lower arch mirror view

Fig. 12: His full series

This man is a computer engineer, so a smart guy. I showed him a few things on the X-rays and I think he figured out what was going on. We talked about treatment plans only in the abstract— fixed, removable, implants, etc.

The biggest challenge is the lower anterior bridge. Lengthening the crowns enough to get ferrule would completely destroy the gingival architecture.

#8 looks to me to be gutta purcha, although about 5mm short of the apex.

#7, I’m not sure about. Looks to have a textured, almost braided suface.

Any removable option is out.

The lower cuspids are probably restorable as stand-alone teeth, with some perio help, but doubtful as bridge abutments. It failed once and now there is less to grab on to. He told me that the previous temp “fell off every day,” and he even had to try to mix his own temp cement just to look presentable. He told me that he had a plan but got frustrated that he gave up for a couple of years. I don’t blame him.

I considered implants in the lateral spots and four-unit bridge off those and then restoring canines as single units. Assuming crown lengthening, grafting or adding connective tissue might be necessary.

I sent this to the periodontist, Dr. Mark Klabunde.

After talking with him, we decided on the following plan:

Do an i-CAT to verify, but probably a couple of 3mm implants in the lower ridge for an implant bridge. Retreat all those poor endos, crowns on lower cuspids (unless they turn out to not be restorable), crown lengthen upper incisors and new crowns.

Phasing is going to be a challenge because if I bring the uppers back into position, I will have to either grind the lower or just go ahead and make the new lower provisional bridge.

The challenge with this guy is that treatment has to be done in big chunks. I can't disassemble multiple anterior teeth without plans to put him back together. So this day was to remove the old crowns and retreat the endos, which was interesting. Post #9, post and part of a file or something #7 and regular endo #9. The retreats had an initial size of about a #60, so before anyone accuses me of over-enlarging...(Fig. 13).

Here are our initial preps. Very conservative margin design so Dr. Klabunde can reshape when he does the surgery (Fig. 14).

Jet Acrylic provisionals made from my lab’s wax-up. Very low lip line, perhaps acquired. But among the lessons here is that due to the very dark prep colors, we'll have to use a material that’s fairly opaque. We're doing the lowers next week (Fig. 15).

That pink gutta percha-like piece was pretty stiff, not like regular gutta percha. The two posts came out fairly easily with ultrasonic, but the long serrated thing... I’m not sure what the previous guy was doing there (Fig. 16).

Used FiberKor posts and Build-It FR buildups on the lower cuspids. At the time of implant placement, crown lengthening and biologic shaping were to be done on these teeth (Figs. 17 & 18).

Used alginate impression, Parkell Mach2 Die Silicone model for indirect fabrication. I usually fabricate my temps directly, even with Jet, but for such a long span, this is a big hunk of acrylic. It shrinks, it stinks. Besides, while I was making his teeth, the patient ran a few errands and came back in half an hour. Adjusted and polished with pumice and denture shine. I was all set to do some Laneesc staining, but it didn't show even a little, so I didn't.

Yes, the gingival aspect looks closed between the teeth. Because of zero visibility and small ridge, this is essentially a single large pontic shaped to look like multiple teeth. We'll see how he does with it and if we have to, change it (Fig. 19).

And so here we are now. We shorted the upper centrals a little, but that is a work in progress as well. We are making such large changes, that it is sort of trial and error (although I didn't call it that in front of him.) Off to my friendly neighborhood periodontist, Dr. Klabunde (Fig. 20)!

When I got in this morning, I took a clear Vacuform of the original bridge and placed it on a model with the bridge removed.

What I see is that four incisors place the teeth very far facial relative to the remaining bone. So either the implants would have to be angled quite facially, the pontics will essentially be cantilevered anteriorly, or we go with 3 pontics versus 4. Of course, this means increased overjet.

Here is something a little interesting, relative to my observations about the lower incisors. I make a Siltech matrix of the original, fourincisor bridge and compared to the one using only three. You can see that with the extra tooth, we have an anterior cantilever problem with the teeth far ahead of where the bone is (Fig. 21 & 22).

Plan for canines is for stand-alone teeth. With the perio surgery, I am hoping to get enough ferrule.

I saw him once to adjust the provisionals and will see him again Monday. We’ll take an alginate of the corrected provisionals and use that to generate a surgical guide for the implants. I wanted to see where the teeth will be, so that I can tell Dr. Klabunde where I need the implants to be.

Upper crown lengthening with root reshaping and grafting around the cuspids, I think.

Lower implants placed, grafts. Today he’s in for his four-week provisional reline of the uppers.

You can see the extra length on the incisors and the acrylic has been shortened just a tad to keep it away from the soft tissue (Fig. 23). The periodontist reshaped the roots when it was flapped. He had really dark teeth (Fig. 24).

The upper provisionals remarginated and polished (Fig. 25).

So, here is today’s tip to “remarginize” the temps. Instead of lining the interior of the acrylic (that almost always keeps it from completely seating and you have to adjust the occlusion), load a large Monoject irrigating syringe with a thin mix of Jet and squirt around the margins of the teeth, much like when you take an impression. Then seat your provisionals on top the teeth. The acrylic with flow into the sulcus (enough) and the bite won’t be high.

The lowers are a little high-and-dry, but we have implants healing under there and it doesn't show. This is the fun part of dentistry! I learned this way from Strupp also. And have stopped using bisacryl. It’s great for single units, routine prep and cement three weeks later, but not for cases where the provisionals will be removed and replaced multiple times.

If you hate Jet intra-oral, try the fast set Jet Set. Sometimes what works well for me is to make it all direct, then to compensate for shrinkage and inaccuracy, ream it out and do a quick reline.

For lower implants healing time I go with what the periodontist tells me. Depends on quality of bone. For upper tooth perio or restorative, I prefer three months minimum, sometimes up to six months for very visible, critical aesthetic anteriors.

You need to generate a model of some type—alginate or substitute, hydrocolloid or alginate or whatever—quick setting modeleither Snap Stone or Parkell Mach2 silicone.

You'll need a matrix or carrier of some type of your wax-up or pre-op, either Siltech putty or a Vacuform clear matrix.

If you have a perfect impression, then you'll not need any refinement. If you're like me, you'll often need to perfect some areas. If you have never used a resin called Super T, get some. Super extra fast set and Super hard acrylic. Mix a small amount and put it on the prep margin with a small brush. Seat the temp and clear enough of the extra so it doesn't get locked in. This stuff is so hard that you can trim and polish to a sharp knife edge if that's what you want.

Very lightly ream out the Intaglio (I just like that word) to make room for cement and use a thin mix of Durelon.

This guy was the nicest to work with and had zero problems or complaints. He wore the temps for a very long time and there were some things that I wanted to change (length for example) (Fig. 27), but no, he wanted his finals exactly like this. Exactly. Like this. Custom titanium abutments. No decay on those cuspids, even though it looks suspect here. Sorry for the shallow depth of field (Fig. 26).

Keeping the upper cuspids intact meant we had to match shade on those. (Fig. 28)

Needs to work on the home care a little, as I assure you that the upper incisor crowns are 1mm supra gingival. I left a spec or two of cement that I later went back to get (Fig. 29). The upper anteriors were e.max cut back and layered.

In our treatment planning hierarchy, emergency treatment always comes first. Once that initial issue has been dealt with, although not definitively, further consideration must be given to a comprehensive approach. Why did this happen? How can we prevent further problems? What does the patient desire as the final outcome? What are the consequences of limited treatment and what are the options?
  Author's Bio
Dr. Bradley Blair practices general dentistry in Columbus, Ohio, and is proud to be a second-generation dentist. Dr. Blair is a graduate of the L.D. Pankey Institute and has been a member and frequent presenter to the Central Ohio Study Club and Ohio Dental Club. He lives with his wife, Susie, and their two grown children. Correspondence may be sent to columbusdentist@gmail.com. Acknowledgements: Dr. Mark Klabunde for his periodontal and implant surgery expertise and treatment planning collaboration, and Roe Dental Laboratory for technical support and guidance.

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