Case 44 | Prosthodontic Award 2015 | Greece
Dr. Theodora Diamantatou
Pathological tooth migration in the maxillary anterior area
Prosthodologist: Dr. Diamantatou T.
Periodontologist: Dr. Kotsani A.
Ortodontist: Dr. Karamesinis K.
Endodologist: Dr. Diamantopoulou V.
A 55-year-old Caucasian female patient was referred to the post-graduate department of Prosthodontics of University of Athens for the management of the flared anterior teeth and the edentulous sites. The patient had a medical history of psoriasis (without medical treatment), hypercholesterolaemia (LIPITOR®) and she was a cigarette smoker (25cig/d).
Last time she visited a dentist (2003) she began a full-mouth treatment, but she abandoned the effort due to personal reasons.
In 2012, when our team assumed the case, the maxillary incisors showed pathologic labial migration as a result of severe bone resorption.
Clinical examination revealed a high lip-line and medium-thick tissue biotype. Site 12 showed a significant tissue defect. No problems presented in the area of the existing implants.
The following procedure of registrations was assisted of face bow and an anterior deprogrammer.
During the analysis of the study casts and the images of the patient from the past, our team decided to preserve the “dental personality” of this case by maintaining the four anterior clinical crowns of the casts. In order to succeed that, the incisors were cut and transferred to the desirable position.
The comparison of the scanned initial casts and diagnostic wax-up revealed the intense migration of the teeth.
Taking under consideration the above-mentioned issues, the following treatment plan was proposed:
- Implant-supported FPDs: #16-15-(14), 24-(25)-26
- Orthodontic treatment in the anterior teeth. During this phase the tooth #22 would be preserved to simplify the procedure of favorable distribution and esthetic alignment of available space in the anterior maxillary area.
- Permanent splinting of anterior teeth (after the extraction of #22) with M/C FPD: #13-12-11-21-(22)-23
- Implant-supported crowns: #36, #46
- Metal-ceramic FPD: #33-(32)-(31)-(41)-(42)-43
- Metal-ceramic crowns: #35, 34,44,45
The treatment plan began with the extraction of teeth with hopeless prognosis and the placement of provisional restorations. At this point the problem that came up was the debonding of the metal post from tooth #45. After the assessment of the remaining dental substance, it was decided to extract the root #45 and place one more implant in the area.
The orthodontic treatment ended after 9 months and the anterior teeth were initially stabilized by means of a lingual splinting wire to ensure retention and avoid the rebound effect. The comparison of cephalometric analysis revealed that dental class of the patient was transformed to Angle’s class I, in contrast to her skeletal classification.
Tooth #22 was extracted and the provisional bridge on the anterior sextant was placed. Despite our proposition to correct surgically the gingival margin of the anterior teeth, the patient declared her satisfaction of the esthetic result achieved with the provisional restoration and her desire to avoid any more interventions.
In order to preserve the aesthetic and functional outcome of the provisional restorations, registrations of border movements and customization of the articulator preceded the final impressions. A series of registrations of the existing vertical dimension of occlusion followed, they were transferred to the articulator and the incisal table was customized accordingly. The final restorations were mimicking the shape and size of the provisional.
The patient was pleased with the final result and although she never quitted smoking, she complied with proper oral hygiene and the recall program. In year 2015 she keeps smiling with confidence.