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42 CONTEMPORARY ESTHETICS | SEPTEMBER 2007

CASE STUDY

Numerous innovations in den-tal materials and techniqueshave dramatically changed

modern dental practice. In addition, thepredictability of dental implants and tis-sue regeneration has greatly influenceddiagnosis and treatment planning.Consequently, a clinician can be con-founded by the many valid treatmentoptions. Oftentimes, the selected treat-ment is based on financial factors, insur-ance coverage, and time as well as theclinician’s training, comfort zone, andavailable referral sources. This articlewill illustrate one method of solving acomplex esthetic puzzle using periodon-tal plastic surgery to complement pros-thetic rehabilitation.

Case PresentationA 50-year-old man of good overall

health presented to the office with acomplaint of the greatly compromisedappearance of his upper anteriors(Figure 1). Examination revealed thattooth No. 8 was missing and toothNo. 7 had a composite veneer to makeit appear as a central incisor. In addi-tion, tooth No. 9 had a severe facialperiodontal defect (Figure 2). Thepatient stated that he was seeking toimprove his appearance with minimalcost in time and money, not a“Hollywood smile.”

To arrive at a proper treatmentplan in such a complex case, all neces-

sary radiographs, photographs, andmounted models were taken and care-fully analyzed. In this treatment plan,the root of tooth No. 9 would be cov-ered with an acellular grafting materi-al, Alloderm (BioHorizons, Inc), tohelp correct the severe recession. Thecrown of tooth No. 7 would be length-ened, and new crowns would beplaced on teeth Nos. 6 (to emulate alateral incisor), 7 (to mimic a centralincisor), 9, and 10, respectively.

Before proceeding with any treat-ment, the patient was invited back foran in-depth discussion of the expectedoutcome. The patient was informedthat it would be impossible to achievean ideal result because teeth Nos. 6and 7 had previously been reposi-tioned. Fortunately, the patient’s exist-ing low smile line would help maskany final restorative imperfections.

After careful analysis of thepatient’s gingival and osseous architec-ture, including information gatheredfrom probing depth records and radio-graphs, a surgical guide was madefrom the diagnostic model to helpwith the soft-tissue surgical phase ofthe treatment. In cases such as this, adiagnostic model not only gives aglimpse of the eventual prosthodonticrestorations, but also provides crucialinformation and guidance on thedesirable soft-tissue appearance at theend of treatment.

After discussing the treatmentphases, costs, and time with thepatient, he was appointed for the peri-odontal plastic surgery phase. Afterverbal review of the procedure and pre-medication (patient was to start takingamoxicillin 875 mg b.i.d., 48 hoursbefore and dexamethasone 4 mg, 24hours before), all consent forms weregiven to the patient, reviewed, andsigned. The patient was then given two200 mg tablets of ibuprofen and wasinstructed to rinse with chlorhexidine0.12% for 60 seconds. Vital signs,including oxygen saturation, weretaken and monitored with an electron-ic blood pressure monitor. The patientwas then draped for surgery with haircover and disposable gown. The peri-oral area was then scrubbed withchlorhexidine 0.12%. Following topi-cal anesthesia, 4% Citanest Plain(Dentsply Pharmaceutical) was givenfor comfort and preliminary anesthesia.Marcaine 0.5% with 1:200,000 epi-nephrine (Abbott Laboratories) wasthen administered for more profoundanesthesia.

The procedure was initiated withcoronoplasty of the defective crownon tooth No. 9 to allow full and pas-sive insertion of the clear surgical stentso that an outline of the desired gingi-val margins on teeth Nos. 7 and 9could be visualized in situ. This stephelped finalize how much crown

Complex Anterior Treatment A Case Report

Tri M. Le, DDS, FAGD

Private PracticeSoutheast Texas Cosmetic

DentistryPort Arthur, TexasPhone: 409.982.7827Email: [email protected] site:

southeasttexascosmeticdentistry. com


lengthening would be needed ontooth No. 7 and how much graft vol-ume would be needed for tooth No.9. After this, the gingivectomy wascarried out with a Bard-Parker bladeNo.15C (BD) on tooth No. 7. Thenthe flap was reflected to ascertain thelocation of the osseous crest of toothNo. 7, in case any osseous resectionwas necessary not to violate the bio-logic width.

After the flap had been ade-quately reflected to allow access totooth No. 9 (Figure 3), the root wasscaled with hand instruments andthen treated with citric acid. Theacellular dermal graft material wasrehydrated for 10 minutes in a sterilesaline bath.1 After proper trimming,the graft was placed in the surgicalsite and adapted to the root of toothNo. 9 and adjacent crestal bone

(Figure 4). The use of an acellulardermal graft helps eliminate therequirement for palatal donor tissueor other intraoral tissue harvesting.This choice of graft material helpsreduce chair time, thus avoidingadditional discomfort to the patientand is, therefore, a useful method forroot coverage.2-9 The flap was thenrepositioned and evaluated for pas-sivity with no tension when the inci-sion lines were approximated.Additional reflection with scoring ofthe periosteum ensured proper andtension-free flap coverage of the sur-gical area. The flap was then suturedwith 5-0 vicryl (Ethicon, Inc). A slingsuture with 6-0 gut also was addedonto the facial marginal gingiva oftooth No. 9 to further ensure graftimmobilization, which is crucial forthe survival and incorporation of the

graft (Figure 5).10-12 Gauze soakedwith saline then was placed onto thesurgical area with light pressure for15 minutes to help achieve initial sta-bilization and clotting.

The patient was slowly seatedupright, and postoperative instruc-tions were reviewed with specialemphasis on rinsing with chlorhexi-dine 0.12% b.i.d. and warm saltwater as often as possible. In addi-tion, a supply of microbrushes andinstructions on their correct usage wasgiven to the patient so that only amicrobrush soaked with chlorhexidine0.12% would be used in the surgicalarea for the next 10 days when thepatient was scheduled for a postopera-tive check-up and suture removal.

After a waiting period of 3months for proper healing (Figures 6and 7), the patient was appointed for

Figure 4—Retracted view, Alloderm in place. Figure 5—Retracted view, flap re-approxi-mated and sutured.

Figure 6—Retracted view, 12 weeks aftersurgery, showing good healing.

Figure 1—Pretreatment smile view showingcompromised appearance.

Figure 2—Pretreatment view showing severefacial perioesthetic defect.

Figure 3—Retracted view, flap elevated.

CASE STUDY

CONTEMPORARY ESTHETICS | SEPTEMBER 2007 45

the prosthetic treatment phase, duringwhich teeth Nos. 6, 7, 9, and 10 wereprepared for full crowns with the goal ofmaking tooth No. 6 resemble a lateralincisor and No. 7 look like a central inci-sor (Figure 8). Retraction cords, Gingi-BRAID 000 and 00 (Dux Dental), werepacked for 10 minutes, the 00 cords wereremoved, and an impression was madewith a custom tray and a polyvinyl silox-ane impression material (Imprint Garant,3M ESPE). After a good impression hadbeen obtained, the custom tray for thefabrication of the provisional crowns wasloaded with Integrity temporary material(Dentsply Caulk) and inserted over thepreparations.

After the provisionals had beenproperly shaped and polished, theywere set aside. At this point, the patientwas seated upright and posterior bite

and anterior stick-bite impressions wereobtained. A facebow transfer also wasacquired. The provisional crowns werethen cemented temporarily withTempBond Clear (Kerr Corporation).After the removal of excess cement andthe retraction cords, the occlusion waschecked and adjusted with the patientseated upright.

The patient was appointed for arefinement visit, during which the pro-visionals were touched up. After thepatient had approved the fit andappearance of the provisional crowns,photographs were taken and alginateimpressions were made (Figure 9) to beenclosed with the case for the ceramist.Measurements of the length of the cen-trals also were documented, and thepatient’s consent to have the treatmentcompleted was obtained.

Before the crowns were receivedfrom the laboratory, the patientrequested to have his teeth bleached.Normally, this step is done before thecrown preparation step, but at times,the clinician must work around thepatient’s sudden desire. The patient wasappointed for in-office bleaching withthe Zoom! Advanced Power system(Discus Dental). Alginate impressionswere made to fabricate at-home bleach-ing trays. While the patient’s teeth werebeing whitened in-office, the impres-sions were poured and the bleachingtrays were made. Opalescence PF 20%(Ultradent Inc) bleaching gel was dis-pensed with proper instruction forhome use. The patient was thenappointed for a shade-taking visit.

At the crown-delivery appoint-ment, the vital signs were acquired and

Figure 10—The final crowns on the modelshowing the technician’s skill in compensatingfor the size discrepancy between teeth Nos. 7and 9.

Figure 11—Palatal view of the crowns on themodel.

Figure 12—Full smile view, immediately aftercementation.

Figure 7—Occlusal view, 12 weeks after sur-gery, showing good tissue volume aroundtooth No. 9.

Figure 8—Occlusal view of the preparations onteeth Nos. 6 through 10. Note the proper healingof the graft and the esthetic complexity of case.

Figure 9—Retracted view of provisionalcrowns on teeth Nos. 6 through 10.


documented, and the procedure wasreviewed again with the patient. Beforeanesthesia administration, the crownswere shown to the patient to have hispreliminary approval of the forms andshades (Figures 10 and 11).

After local anesthesia with Cita-nest Plain (Dentsply Pharmaceutical)and Xylocaine 2% with 1:100,000 epi-nephrine (Dentsply Pharmaceutical),the temporary crowns were removedand the porcelain crowns were tried in.The patient was given a hand mirror toevaluate the appearance of the crownsin place.

After approval for cementationwas obtained, the crowns werechecked for proper fit, interproximalcontact, and marginal seal. Becausethe crowns were ceramometallic,rubber dam isolation was not neces-sary. The working area was isolatedwith cotton rolls and the prepara-tions were cleaned with Tubulicid

Red (Global Dental Products) beforebeing coated with Gluma De-sentisizer (Heraeus Kulzer, Inc). Thecrowns were then blasted with alu-minum oxide, rinsed, cleaned withalcohol, dried, and were cementedwith RelyX Unicem (3M ESPE).After all excess cement was cleanedoff, the patient was seated uprightand the occlusion was checked andadjusted. Proper centric occlusion,cuspid, and protrusive guidance wereverified (Figures 12 through 14). Thepatient was given detailed instruc-tions on proper care and mainte-nance of the crowns to ensurelongevity. He was then appointed fora postdelivery check-up and finalphotographs. At that appointment,the patient expressed his happinesswith the final result.

ConclusionComplex dental rehabilitation

poses many unique challenges to cli-nicians. It tests one’s knowledge,training, integrity, and artistic abili-ty. With the variety of treatmentoptions currently available, treat-ment plans can vary from office tooffice. Differences in training, phi-losophy, degree of financial motiva-tion, and esthetic perception by thedentist as well as the patient also canaffect treatment plans. Further, thepatient’s personality, financial con-cerns, and personal situation alsocome into play. Nonetheless, withtoday’s esthetic demand from thepublic as well as great advancementin tissue engineering, cliniciansshould consider regenerative peri-odontics before extracting teeth andcommunicate this option to theirpatients.13 lc

AcknowledgmentsThe author would like to thank

Ann Le for her ever-present support,Tom and Beatrice Dabrowsky, LDT,RDT of B.I.T. Dental Studio, Dillon,Colorado, for the beautiful ceramics,and all my teachers over the years.

References1. Henderson RD, Drisko CH, Greenwell H. Root cov-

erage using Alloderm acellular dermal graft mate-rial. J Contemp Dent Pract. 1999;1(1):24-30.

2. Dodge JR, Henderson R, Greenwell H. Root cover-age without palatal donor site using an acellulardermal graft. Periodontal Insights. 1998;5(4):5-8.

3. Harris RJ. Root coverage with a connective tissuewith partial thickness double pedicle graft and anacellular dermal matrix graft: a clinical and histo-logical evaluation of a case report. J Periodontol.1998;69(11):1305-1311.

4. Tal H. Subgingival acellular dermal matrix allograftfor the treatment of gingival recession: a casereport. J Periodontol. 1999;70(9):1118-1124.

5. Harris RJ. A comparative study of root coverageobtained with an acellular dermal matrix versus aconnective tissue graft: results of 107 recessiondefects in 50 consecutively treated patients. Int JPeriodontics Restorative Dent. 2000;20(1):51-59.

6. Grisi DC, Molina GO, Souza SL, et al. Comparative6-month clinical study of a subepithelial connectivetissue graft and acellular dermal matrix graft forthe treatment of gingival recession. J Periodontol.2001;72(11):1477-1484.

7. Mahn DH. Treatment of gingival recession with amodified “tunnel” technique and an acellular der-mal connective tissue allograft. Pract ProcedAesthet Dent. 2001;13(1):69-74.

8. Aichelmann-Reidy ME, Yukna RA, Evans GH, et al.Clinical evaluation of acellular allograft dermis forthe treatment of human gingival recession. JPeriodontol. 2001;72(8):998-1005.

9. Woodyard JG, Greenwell H, Hill M, et al. Theclinical effect of acellular dermal matrix on gingi-val thickness and root coverage compared tocoronally positioned flap alone. J Periodontol.2004;75(1):44-56.

10. Silverstein LH, Kurtzman GM. A review of dentalsuturing for optimal soft-tissue management.Compend Contin Educ Dent. 2005;26(3):163-166,169-170.

11. Silverstein LH. Essential principles of dental sutur-ing for the implant surgeon. Dent Implantol Update.2005;16(1):1-7.

12. Silverstein LH. Principles of Dental Suturing: TheComplete Guide to Surgical Closure. Mahwah, NJ:Montage Media;1999.

13. Nevins M. Aesthetic and regenerative oral plasticsurgery: clinical applications in tissue engineering.Dent Today. 2006;25(10):142-146.

Figure 14—Palatal view, final crowns.

Figure 13—Retracted view, final crownsimmediately after cementation.

CASE STUDY


CASE STUDY

Product ReferencesProduct: AllodermManufacturer: BioHorizons, Inc Location: Birmingham, Alabama Phone: 205.967.7880 Web site: www.biohorizons.com

Products: 4% Citanest Plain, Citanest Plain,Xylocaine 2% with 1:100,000 epinephrineManufacturer: Dentsply Pharmaceutical Location: York, Pennsylvania Phone: 800.225.2787 Web site: www.dentsplypharma.com

Product: Marcaine 0.5% with 1:200,000 epinephrineManufacturer: Abbott LaboratoriesLocation: Abbott Park, IllinoisWeb site: www.abbott.us

Product: Bard-Parker blade No.15CManufacturer: BD Location: Franklin Lakes, New Jersey Phone: 201.847.6800Web site: www.bd.com

Product: 5-0 vicryl suture Manufacturer: Ethicon, Inc Location: Somerville, New Jersey Web site: www.ethicon.com

Products: Retraction cord, GingiBRAID 000 and 00 Manufacturer: Dux DentalLocation: Oxnard, CaliforniaPhone: 800.833.8267Web site: www.duxdental.com

Products: Imprint Garant, RelyX UnicemManufacturer: 3M ESPE Location: St. Paul, Minnesota Phone: 888.364.3577 Web site: www.3m.com/dental

Product: Integrity Manufacturer: Dentsply Caulk Location: Milford, Delaware Phone: 800.532.2855 Web site: www.caulk.com

Product: TempBond ClearManufacturer: Kerr CorporationLocation: Orange, CaliforniaPhone: 800.537.7123 Web site: www.kerrdental.com

Product: Zoom! Advanced Power systemManufacturer: Discus DentalLocation: Culver City, CaliforniaPhone: 800.422.9448Web site: www.discusdental.com

Product: Opalescence PF 20%Manufacturer: Ultradent, Inc Location: South Jordan, Utah Phone: 888.230.1420 Web site: www.ultradent.com

Product: Tubulicid Red Manufacturer: Global Dental Products Location: North Bellmore, New York Phone: 516.221.8844 Web site: www.gdpdental.com Product: Gluma Desentisizer Manufacturer: Heraeus Kulzer, Inc Location: Armonk, New YorkPhone: 800.431.1785Web site: www.heraeus-kulzer-us.com

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