Case 94: Going the Extra Mile in Anterior Esthetic Treatment

• Wants a wider smile.
• Wants wider centrals and longer laterals.
• Dislikes the position of tooth no 27.
• Dislikes all the Class V composites and feels they make her teeth look long and unnatural.

Extraoral/Facial

• Within normal limits (WNL).

TMJ/Mandibular Range of Motion/Muscles of Mastication and Facial Expression

• TMJ evaluation: Grating on right side.
• History of TMD and utilization of appliances to relieve pain.
• Range of mandibular motion WNL. No deviation on opening/closing.
• Pain on palpation of the right and left mid-portion masseter muscles.
• Mild pain on palpation of the right and left lateral pterygoid muscles.

• Poor for teeth nos. 8 and 9.
• Good for all other teeth.

Phase I: Address Failing Teeth

• Extract teeth nos. 8 and 9 and socket graft with rhBMP-2 and cancellous allograft.
• Fabricate a provisional bridge across teeth nos. 7–10 with ovate pontics to maintain soft tissue form.

Phase II: Diagnostic Work-up

• Obtain a complete set of radiographs, a CBCT scan, clinical and periodontal charting, and diagnostic models mounted with facebow and CR bite records.
• Formulate a comprehensive treatment plan based on consultation between restorative, periodontal, and orthodontic specialists.

Phase III: Periodontics/Orthodontics

• Perform surgically facilitated orthodontic therapy (SFOT) to allow for expansion orthodontia.
• Complete guided bone regeneration procedure in the anterior maxilla for development of future implant sites nos. 8 and 9 at the time of SFOT surgery.
• Complete connective tissue grafting to gain attached tissue and root coverage at sites nos. 21, 22, and 27.

Phase IV: Implant Placement

• Re-image the maxillofacial complex following SFOT and site development at teeth nos. 8 and 9. Determine final plans post bone reconstruction.
• Complete guided implant placement at sites nos. 8 and 9 along with contour bone grafting and/or connective tissue grafting, as needed.

Review of Treatment Goals

The patient presented with an initial concern about the appearance of her smile and a fistula at tooth no 8. She completed orthodontic therapy in 7th grade but was elbowed in the mouth a few years later and sustained an injury that went untreated for 2 years and ultimately required root canal therapy on teeth nos. 8 and 9, followed by a tissue graft. At age 20 she had veneers placed on those teeth. Four years later she had root exposures, and new veneers were placed on teeth nos. 7–10. In 2011, the veneers on teeth nos. 8 and 9 were replaced with crowns. In 2012, she awakened one day in an open locked condition.

The immediate goal of treatment was to deal with the failing and infected teeth nos. 8 and 9. Once that situation was stabilized, the functional goal was to provide a long-term solution for the replacement of missing teeth nos. 8 and 9 and correct the malocclusion. The patient’s esthetic goals were to make the anterior teeth wider and longer, create a wider smile, correct the malpositioned tooth no. 27, and replace the unesthetic Class V restorations.

Phase I: Tooth Extraction and Provisionalization

Teeth nos. 8 and 9 were extracted, the sockets were preserved with rhBMP-2 and cancellous allograft, and a provisional from teeth nos. 7 to 10—with nos. 8 and 9 functioning as ovate pontics—was delivered.

Phase II: Surgery

Surgically facilitated orthodontic therapy (SFOT) was initiated with corticotomies and decortication of the maxilla and mandible with the goal of expanding the arch forms and optimizing the transverse, A-P, and maxillomandibular relationships. SFOT was performed using mineralized freeze-dried bone allograft (FDBA) and Bio-Oss (Geistlich) combined with platelet-rich fibrin. Interpositional connective tissue grafting comprising autogenous tissue and Emdogain (Straumann) was undertaken for mucogingival augmentation in the areas of teeth nos. 21, 22, and 27. Horizontal and vertical tissue engineering via rhBMP-2 and cancellous allograft was completed at the sites of teeth nos. 8 and 9 for edentulous ridge augmentation.

Phase III: Implant Placement

Eight months after completion of the SFOT, implants were placed (guided) at the nos. 8 and 9 sites via CBCT static guides. Contour bone grafting was performed using small-particle xenograft (Bio-Oss) + barrier membrane (Bio-Gide, Geistlich) for optimal peri-implant bone volume in combination with autogenous connective tissue for soft tissue volume. Hard and soft tissue grafting at the time of implant placement was performed to optimize the pink esthetic volume and position.

Phase IV: Placement of Healing Abutments

Four months later, temporary healing abutments were placed as “tent poles” on the nos. 8 and 9 implants and covered with an additional connective tissue graft.

Phase V: Implant Uncovering

Three months later, the nos. 8 and 9 implants were uncovered, and aberrant frenum tissue was removed.

Phase VI: Implant Provisionalization (2015)

Following healing from implant uncovery, the provisionalization phase of the case ensued. This required several appointments for seating provisionals and working with contours to groom the soft tissues. The goal was to complete the case with conventional prosthetics, but despite all efforts the final bone topography did not support ideal tissue positions.

This case did not turn out as originally planned, which is the primary reason we decided to present it here. Relatively complex treatment was rendered with the goal of obtaining ideal arch forms, maxillomandibular relationship, anterior-protected articulation, and especially the intrinsic proportions of the teeth (white esthetics) by optimizing the position of the pink esthetics developed through reconstructive hard and soft tissue surgery.

The objectives of employing SFOT as part of the interdisciplinary therapy were the following:

• To put the teeth in the correct position for facial esthetics and function.
• To transform and enhance the dentoalveolar bone phenotype in order to make goal no. 1 possible without creating iatrogenic periodontal problems.
• To optimize anterior-protected articulation parameters.
• To reduce the incidence of orthodontic relapse by ensuring that the teeth were completely housed in alveolar bone following orthodontic expansion.
• To optimize airway conditions by increasing the oral cavity volume.

From a surgical perspective, our plan and sequence seemed ideal, well-crafted, and novel. However, by taking on more complex treatment, we also suffered the equally complex problems that are highlighted here:

• During the orthodontic expansion, which was undertaken to obtain the width required for the digital smile-designed central and lateral incisors, the bone anatomy flattened and the interproximal peaks of bone supporting the papillae were compromised.
• Healing from the maxillary SFOT and guided bone regeneration (GBR) surgery using tissue engineering progressed uneventfully. However, because of the need for primary wound closure in the anterior maxilla, the flap was significantly advanced for tension-free closure, and consequently the mucogingival junction became distorted.
• As space for the central incisors was developed, we lost vertical bone height, further complicating our efforts to maintain the interproximal peaks of bone at the sites of nos. 7–8, 8–9, and 9–10. Ideally, a secondary GBR surgery might have been considered to gain more ideal crestal bone volume in both vertical and horizontal dimensions and, ultimately, support the desired pink esthetics.

In such complex and demanding GBR surgery, it is common to encounter mucogingival problems. Usually, these require soft tissue augmentation by means of a strip graft, or apical repositioning of the flap. In this case, we decided to correct the volume deficiency with a second attempt at interpositional connective tissue grafting because the implants appeared to have favorable circumferential bone volume following the contour bone grafting that was performed simultaneous with connective tissue grafting and guided implant placement. At the implant augmentation surgery, some shrinkage in bone or soft tissue volume was expected. The problem in this case is that despite multiple attempts to gain the ideal volume, we came up short. After orthodontia and several surgeries, the risk of depleting the emotional currency of the patient threatened to become a management issue (a subject that is not often discussed), especially considering that significant prosthodontic procedures were required before case completion. In retrospect, it may have been more ideal to either (1) limit the expansion that occurred and use the same tooth proportions, which would have necessitated smaller-diameter implants, or (2) consider a secondary GBR procedure to better support the soft tissue parameters. In fact, forced eruption of tooth nos. 8 and 9 could have been considered to gain some soft tissue volume before extractions were performed. Originally, we had also discussed the option of resecting the anterior maxilla to allow for a planned pink porcelain hybrid design, but we decided against it because we believed that the regeneration needs could be met.

When it came to uncovering the implants, we were faced with a continuing pink esthetic volume deficiency and an aberrant frenum with unfavorable muscle position. We decided to uncover the implants and place an autogenous soft tissue graft to prevent the frenum from re-attaching as well as improve the surface characteristics of the anterior gingiva. This created a less-than-ideal outcome and did not solve the volume deficiency from which we needed to recover. The prosthesis design we ended up with also will require more demanding maintenance and patient hygiene and will increase the risk of peri-implant problems if the patient is unable to maintain an optimal plaque control regimen. Multiple appointments were made in the provisionalization phase to attempt to gain optimal tooth form and proportion using natural tooth form before we decided on the addition of pink porcelain to compensate for peri-implant deficiencies. Multiple appointments and videos of the patient speaking were also needed to optimally position the incisal edges in the smile design of this case. The videos helped confirm the decision to use pink porcelain and composite for optimal pink contours (see video on page 13).

In the final analysis, the patient ended up with a beautiful result, although not what was originally planned or intended. Our goal in presenting this case is to show the everyday realities of complex interdisciplinary treatment planning and highlight how a team manages adversity when nature and biology undermine our best planning efforts.

George Mandelaris, DDS, MS, is in private practice in Chicago, Park Ridge, and Oakbrook Terrace, Illinois. He limits his practice to periodontology, dental implant surgery, bone reconstruction, and tissue engineering surgery.

Nader Sharifi, DDS, MS, currently maintains a full-time private practice of prosthodontics in Chicago’s downtown loop.