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Function, Aesthetics and Biomimetics in the Interdisciplinary Treatment: Concerning a Clinical Case
AbstractThe evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects.
An adult patient’s aesthetic and functional rehabilitation present an even more difficult challengefor the dental professional, particularly in those situations where the treatment involves anintimate collaboration between different specialties, demanding a critical planning.
We will present a clinical case which involved an interdisciplinary approach, where the operative sequence and the multidisciplinary approach exerted in this case illustrates the importance of specialised knowledge and professional communication.
Key words: Aesthetics, Periodontics, Implantology, Orthodontics, Interdisciplinary approach.
IntroductionAn adult patient’s aesthetic and functional rehabilitation presents a challenge for the dentistry professional, particularly in those situations where the treatment involves an intimate collaboration between several specialties, demanding a critical planning. It is therefore important to define in what way aesthetic, periodontal, implantology and orthodontic specialists should connect in order to properly achieve the proposed goals.
As an example of an interdisciplinary treatment, we present a complex clinical case in an adult patient where periodontal, implantology, prthodontic and prosthodontic treatment were involved.
Case DescriptionA fifty-eight year old female patient consulted us to replace her missing teeth and to improve her smile’s appearance. This is a case of a patient with high expectations and a philosophical personality according to House’s classification.1
In medical terms, she was diagnosed as an ASA patient type 1,2 not presenting any associated pathology and not being under any kind of medication. She was non-smoker and had a moderately stressful life style.
Extra-orally, we can observe in figures 1 and 2 that the patient presents a facial type with normal patterns and a straight profile. It is also obvious in figure 1 that the patient presents a low smile line.
Dr. Faria Almeida RicardoDDS, MSc Periodontology
- Associate Professor, Faculty of Dentistry, Univ. of Oporto
Dr. Falcão Costa CarlosDDS, MSc Esthetic Dentistry
- Teacher at Fernando Pessoa Univ.
Dr. Pinho Monica DDS, MSc Orthodontics
- Teacher at Fernando Pessoa Univ.
Mr. Perez Lopez Javier Ceramist, Lugo
Dr. Afonso Pinhão Ferreira Orthodontics
- Full Professor, Faculty of Dentistry, Univ. of Oporto
(Figure 2) Initial lateral profile
(Figure 1) Initial anterior profile
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During intraoral examination we could observe the presence of posterior bite collapse with decreased occlusal vertical dimension resulting from the loss of posterior teeth number 14, 15, 24, 25, 26, 46 and 36, and from the mesioversion of teeth 47 and 37, as well as the extrusion of tooth 16 (Figs. 3-5). It was also possible to detect the presence of localized gingival recessions both in the upper and lower arches.
The intraoral examination also showed an increased overjet due to labial inclination of upper anterior segment with an increase of the horizontal overbite, which resulted in the absence of the anterior guide during protrusive movement. At the same time, we could observe the presence of a parafunction (bruxing habit), since there is a clear wear at the upper anterior teeth’s incisal edge (Fig. 6).
After examination of the upper anterior segment, gingival asymmetry was observed, especially at teeth 11 and 21, as well as presence of interincisal diastema that might have been caused by the labial movement of these teeth (Fig. 3) and/or the loss of teeth posteriorly. The upper anterior teeth present themselves with an inadequate height – width proportion and the incisors show a somewhat triangular shape.
The periodontal examination showed moderate generalized chronic periodontitis, with Plaque index values of 80% and Bleeding of 48% (Dicotomic Index). One can verify, as mentioned earlier, the presence of multiple areas of gingival recession. The microbiological analysis allowed to observe the presence of periodontal pathogens of endogenous character,3 therefore not presenting an increased risk in terms of response to the periodontal treatment.
In the initial radiographic examination, it was possible to confirm the presence of periodontal pathology, with a moderate radiographic horizontal bone loss except for tooth 27, which presents a circumferential defect. The detected bone loss is worsened due to the mal-positioning of some teeth (Fig. 7). We could also observe the clear buccalization of the antero-superior teeth in the lateral cephalometric projection (Fig. 8).
DiagnosisThe patient can be diagnosed with:- Moderate Generalized Chronic Periodontitis.- Bite Collapse Syndrome with buccal inclination of the anterosuperior teeth and presence of inter-incisive diastema.- Extrusion and mal-positioning of several teeth as well as posterior edentulism.- Bruxism.- Asymmetry of the anterior gingival margins and incorrect width-length ratio of anterior teeth.
Treatment OutcomeAfter the analysis of the presented case we can summarize our treatment plan as follows:
1- Treatment of the periodontal pathology.2- Alignment of the remaining molars and increase of the vertical dimension.3- Retrusion of upper incisors decreasing the horizontal overbite and reestablishment of an adequate anterior guide.
(Figure 3) Intra-oral 1
(Figure 4) Intra-oral 2
(Figure 5) Intra-oral 3
(Figure 6) Wear of incisal edges
(Figure 7) Panoramic view
(Figure 8) Lateral cephalometric view
(Figure 9) Pre-operative, upper right quadrant
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4- Closure of the interincisal diastema and gingivoplasty.5- Reconstruction of the lost dental structure of the upper anterior segment.6- Replacement of the lost teeth.7- Treatment of the occlusal parafunction.
Treatment PlanHence our treatment plan consisted of the following, according to the sequence we have described:1- Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatment.2- Placement of osseointegrated implants in the sites of 14, 15, 24 and 25.3- Setting of provisional fixed partial prosthesis over implants on 14, 15, 24 and 25 for orthodontic anchorage.4- Bimaxillary orthodontic treatment with fixed appliances.5- Extrusion of tooth 47.6- Placement of implant in the area of 46.7- Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26.8- Rehabilitation of the anterosuperior sector with ceramic veneer.9- Placement of centric relation occlusal splint.
1- Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatmentThe goal of the periodontal treatment was to eliminate the opportunistic microorganisms that might impede, if not treated, any kind of interdisciplinary therapeutic approach.
The initial or hygienic stage aims to eliminate the etiologic cause of the periodontal disease; eliminating all the bacterial deposits, as well as the plaque retaining factors. During this stage, we proceeded with the patient’s motivation, instructing her on oral hygiene techniques.
Therefore, in theory, with the basic periodontal treatment we should get:- A reduction of the Bleeding Index to values equal or inferior to 25%.- A total elimination of gingival pockets with probing depth of over 5 mm.- Reduction of the furcation lesions.- The elimination of pain since the only pain that the patient had was due to periodontal problems.- Starting to achieve the patient’s functional and aesthetic satisfaction.
At the same time, we must have the ability to effectively control the risk factors associated with chronic periodontal disease, such as bacterial plaque, tobacco and uncontrolled diabetes.4 In this particular case, the need to improve the used oral hygiene techniques was to promote a better plaque control. From the above mentioned risk factors, bacterial plaque was the only one initially present. In terms of active treatment, we proceeded with the root planing in the sites with probing depth of over 3 mm. Forty-five days after the basic stage’s completion, we proceeded to the re-evaluation of the performed treatment.
(Figure 10)Implants placement in positions 14 & 15 with
immediate sinus lifting
(Figure 11)Post-operative photo of
implants in positions 14 & 15 after suturing
(Figure 12)Incision for upper left
quadrant
(Figure 13) Flap reflection
(Figure 14)Sinus lifting
(Figure 15)Bio-Oss application
(Figure 16)Suturing
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Re-evaluation aimed to assess the results of the established treatment and to plan the need for additional periodontal treatment (surgical, for example) or supporting periodontal treatment. In the analyzed clinical case, and considering the good results obtained (plaque index values and bleeding inferior to 20%) with the initial treatment it was possible to move the patient to a supporting periodontal treatment program. The periodicity of the appointments relative to the program is dependent on the present risk factors, on the degree of initial bone loss presented and on the treatment’s complexity to be executed in interdisciplinary terms. For this patient periodontal supporting appointments with a 2-month periodicity5 were prescribed.
2- Placement of osseointegrated implants in positions 14, 15, 24 and 25Considering the edentulous spaces and bearing in mind the orthodontic movement to be performed it was decided to proceed with the placement of osseointegrated implants in the position of teeth 14, 15, 24 and 25 in the maxilla and tooth 46 in the mandible. The decision was made in order to maintain teeth 27 and 47 as orthodontic anchorage and to re-evaluate their status after orthodontic treatment ends.
For both sides in the maxilla, the need to perform sinuselevation was verified, although on the right side such procedure was performed at the same time of the implant placement,6 as there was over 6 mm of residual bone (Figs. 9-11),7 but on the left side, the necessity to perform a previous elevation of the maxillary sinus floor arose as we did not have sufficient alveolar bone to achieve primary stability, and afterwards (6 months) we proceeded with the placement of the implants (Figs. 12-16).8
3- Setting of provisional fixed partial prosthesis over implants 14, 15, 24 and 25 for orthodontic anchorageAfter the implants’ osseointegration period (6 months), we proceeded with a casting and record registration for the fabrication of a fixed partial prosthesis, screwed in metal-acrylic, allowing, on one hand, the re-establishment of a suitable vertical dimension and on the other hand, an additional anchorage during the execution of the orthodontic treatment.
4- Bimaxillary orthodontic treatment with fixed appliancesThe orthodontic treatment began with the alignment of mandibular teeth (Fig. 17). In a later stage, already with a steel rectangular arch, of a bigger gauge, the verticalization of tooth 47 was initiated, resorting to an open spring of nickel-titanium. After tooth 47 verticalization, the alignment of maxillary teeth was initiated (Fig. 18).
This arch being leveled and aligned, we proceeded with the recoil of the anterosuperior sector, with steel contraction arches and resorting to the anchorage provided by the implants previously placed in teeth positions 14, 15, 24 and 25 (Fig. 19). The canine neutroclusion was achieved and improved in an initial stage through the use of triangular rubber bands placed bilaterally (Fig. 20).
(Figure 17) Alignment of mandibular teeth
(Figure 18) Initiation of maxillary teeth alignment
(Figure 19) Stainless steel contraction arches
(Figure 22) Implant placement in the position of tooth 46
Depth
GM
GM
Depth
Tooth #
123 312 113 122121111122 111 432
17 16 1112131415 21 22 23 262524 27
233 543223221321222223322 323
Depth
GM
GM
Depth
Tooth #
459 211 232 211122132112 132 213
47 46 4142434445 31 32 33 363534 37
388 223213111121123111221 213
122 211212
122122222
(Figure 21) Periodontal chart: tooth # 47 had mobility grade II
(Figure 20) Triangular rubber bands placed bilaterally
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5- Extraction of tooth 47As previously anticipated, tooth 47 extraction was decided due to its periodontal bad condition (Fig. 21).
6- Placement of implant in the position of 46Besides the implant at the site of tooth 46 and since tooth 47 extraction was performed, the possibility of also placing an implant at the site of this last tooth was taken into consideration. Nevertheless, the bone availability was limited and it would imply the use of guided bone regeneration technique which was not accepted by the patient at this stage of the treatment. The risk that might exist from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment (Fig. 22).
7- Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26Right after the bimaxillary fixed orthodontic appliances removal (that were used for 18 months), as well as after the osseointegration period of the implants placed in the mandibular arch, we proceeded with the definitive impressions using an elastomeric material, as well as to the collection of intermaxillary registrations which allowed the elaboration of structures built in metal-ceramics, which were cemented over prefabricated intermediate abutments. As for the second quadrant, we decided for an implant-supported structure design over implants in positions 24 and 25 and a cantilevered pontic at the level of tooth 26 (Fig. 23).
8- Rehabilitation of the anterosuperior sector with ceramic feldspar veneersAfter the removal of the fixed appliances we also proceeded with the anterosuperior segment rehabilitation. In order to do so, we performed a previous waxing up, in order to be able to visualize the intended final result. This wax up also made possible the attainment of an in-mouth “Mock-up ” , as well as it functioned as a guide during all the dental preparation process, creation of temporary restorations and the execution of ceramic feldspar veneers (Fig. 24).
The dental preparation based on the previous wax up insured a thickness of approximately 0,5 mm in buccal and 2 mm in the incisal 1/3 in order to assure a suitable thickness for the feldspar ceramic. The vestibular and palatal finish line was a deep chamfer to assure an easier positioning of the definitive restorations and to promote a higher marginal integrity after the definitive cementation (Figs. 25, 26).
In these areas in which the preparation included the exposure of dentin, we recommend the use of an immediate dentinal sealing technique by applying phosphoric acid and a dentinal adhesive (of fourth or fifth generation) on areas of exposed dentin, where after a first cycle of 20 seconds curing an oxygen inhibitor (glycerine gel) was applied in order to perform a second cycle of curing, assuring a total sealing of the exposed dentinal tubules. We also intended, by doing this, to increase final adhesion values during the cementation of the ceramic feldspar veneers.
After the dental preparation, we proceeded with the definitive casting as well as with the intermaxillary registrations, determining the vertical dimension of the occlusion to be used.
(Figure 24)Waxing up of the antero-
superior segment
(Figure 26)Deep chamfer
vestibular & palatal finish line
(Figure 25)Preparation of the upper
anterior teeth
(Figure 29)Centric relation occlusal
splint
(Figure 28)Extra-oral view
(Figure 27) Final cementation of ceramic feldspar
veneers
(Figure 23)Fabrication of fixed partial dentures.
Tooth # 26 replaced as a cantileverd
pontic
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The cementation technique included the acid conditioning of both enamel and dentin with phosphoric acid and of the interior surface of the veneers with hydrofloric acid. We proceeded with the silanization of the interior surface of the veneers, placed an adhesive of fourth generation on the restorations and on teeth without curing, used a photo-curable micro-hybrid resin cement and performed the final cementation (Figs. 27, 28).
9- Placement of centric relation occlusal splintDespite the thought that the incisal and canine guides’ re-establishment will solve the parafunction problem, we decided to produce an occlusal splint that will allow, on one hand, to reduce the parafunctional habits’ effects and that will simultaneously allow it to function as a retainer for the orthodontic treatment performed at the maxilla (Figs. 29, 30).
DiscussionAfter the clinical case treatment, the main discussion topics are:1- no placement of implant at the site of tooth 26, 2- the possible extraction of tooth 27 and the extraction of tooth 47.
As to what concerns tooth 26, no implant was placed because the initial planning foresaw the extraction of tooth 27, which would make the implants location to be at 24, 25 and 27. However, and since the tooth was maintained as a result of the periodontal treatment, a cantilever was made supported on the 24 and 25 implants. Obviously, and once the case was finished, we could claim that it might have been preferable to place them at the sites of the 24 and 26. Nevertheless, the performed treatment did not present any kind of problem as far as the long term predictability is concerned.
Relatively, tooth 47 had to be extracted due to periodontal causes. The ideal would have been to also place an implant at that level. However, as above mentioned, the bone availability was limited and it would imply the use of guided bone regeneration technique, not accepted by the patient at this stage of the treatment. The risk that might derive from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment.
ConclusionThe evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects. Naturally, the excellence of the results demands an interdisciplinary approach, consolidated in a close collaboration between the different protagonists where the patient’s motivation and availability is pivotal. The therapeutic planning, the operative sequence and the pluridisciplinarity exerted in this case illustrate the importance of specialised knowledge and professional communication.
(Figure 33) Pos-operative lateral cephalometry
(Figure 31) Post-operative anterior view
References1. House MM. Full denture technique. In: Conley FJ, Dunn AL, Quesnell AJ, Rogers RM,
editors. Classic prosthodontic articles: a collector’s item. Vol III. pp 2-24. Chicago: American College of Prosthodontists, 1978.
2. Keats, AS. The ASA classification of physical status--a recapitulation. Anesthesiology. 1978 Oct;49(4):233-6.
3. van Winkelhoff AJ, Rams TE, Slots J. Systemic antibiotic therapy in periodontics. Periodontol 2000. 1996 Feb;10:45-78.4. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Periodontol 2000. 2006;40:107-19. 5. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of
orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop. 1989 Sep;96(3):191-8
6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994 Feb;15(2):152, 154-6, 158 passim; quiz 162.
7. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants. 1998;13 Suppl:11-45.8. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986
Apr;30(2):207-29.
(Figure 32) Post-operative lateral view
(Figure 30) Splinting of lower anterior teeth
25Smile Dental Journal Volume 4, Issue 3 - 2009
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