Case of the Month - Archive Cases

Aesthetic Rehabilitation of a Periodontally Compromised Dentition.

A Case Presentation by David H. Yu, DDS, MS (Austin, TX)

A 26 year old Hispanic female presents with aggressive periodontitis. She is in good medical health. Social non-smoker and no history nor family history of diabetes nor systemic medical problems. Her chief compliant was “I’m getting married in 8 months and I need to have better looking teeth.” Her periodontal disease was generalized. Pocket depths ranged from 3-8mm with tooth #8 having an 11mm pocket depth. A draining fistula was noted in the vestibule of #8 with Miller’s class 3 mobility, pathologic tooth extrusion, and 80-90% bone loss. Due to the existing infection around tooth #8, the decision was made to accelerate her periodontal therapy to initiate extraction and implant therapy. Her compliance and home care was optimal. Following periodontal therapy her pocket depths decreased to 1-4mm. However, 6-8mm pockets depths and mobility were still present around teeth #9 and 10. These were deemed periodontally hopeless. A supportive periodontal therapy increment of 2 months was recommended.

Tooth #8 was extracted and an immediate implant was placed. A bovine xenograph was utilized to preserve her facial plate. The root of #8 was amputated and bonded to the adjacent teeth for temporization.

At 3 months, the implant was uncovered and temporized. Note the coronal “creeping” of the gingival margin as an ideal characteristic of aesthetic site development.

With #9 as the eventual pontic space, the tooth was kept as a point of reference for immediate implant placement. Following placement, a ridge preservation technique and connective tissue grafting were done to maintain the tissues of the pontic area of #9.

The provisional was fabricated using a bis acryl temporization material and flowable composite onto screw-retained wax-up sleeves. #9 was adjusted to ovate form.

The screw-retained implant-supported provisional bridge was seated with gentle pressure of #9 pontic into the tissues.

At 3 months, the tissues have been maintained. An Erbium:YAG laser was used for aesthetic contouring.

The final Restoration at her 18 month post-op visit shows good tissue form with no inflammation. Her periodontal care has been maintained. Incidentally, her finals were delivered two days prior to her wedding, and she was thrilled with the results!

Discussion: With her chief compliant of aesthetics in mind, this case could only be successfully treated by incorporating all the elements of periodontal plastic surgery. These elements include immediate placement, angulation, depth of placement, soft tissue grafting, ridge preservation, ovate pontic site preparation, laser gingivectomy, and immediate provisionalization technique. The key decision to avoid individual implant units was a critical one due to the potential papilla loss as reported by Tarnow et al in 2003. Peridontists are in the unique position to help create an optimum functional result in the challenging aesthetic zone.

** To submit your case, please send to Dr. David Yu - [email protected]

 

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