Featured Case 12/20: SMILE RECONSTRUCTION

Patient:

Hope, a 25-year-old.

The problem:

• Missing her front tooth/teeth and has a significant recession of gum tissue.
• Hope was told by previous dentists the tooth next to the missing tooth also needed to be extracted.
• The only solution offered was a removable partial denture to replace the 2 missing teeth.
• Previous dentists informed her that no other options were feasible in her case.

Patient History:

• Hope experienced blunt facial trauma as a child.
• This resulted in injury to her upper jaw and front teeth.
• 3 years before seeing us, her dentist extracted tooth #8 (Right central incisor) due to infection.
• They informed her that #7 also needed to be removed and a partial denture was her only available option for tooth replacement.
• She was distraught and dejected over her condition and the lack of aesthetic and permanent options.

Pertinent Information:

• Aesthetic cases like this can be deceptively the most challenging.
• Clearly, this presented both a functional and aesthetic problem for this young and attractive young lady.
• She presents with a composite (involving 3-dimensional hard and soft tissue) defect of her upper anterior jaw that was visible when smiling.
• Composite defects in the “smile zone” are very challenging to recreate natural-appearing tissue replacement.
• One of the most challenging elements of smile reconstruction is vertical tissue regeneration—particularly the interdental papillae (pointy gums between teeth).
• 2 implants next to each other in the anterior are frequently positioned with less than 3 mm between implants.
• When there is less than 3 mm between implants, it is relatively impossible to re-create any semblance of a papilla.
• Reconstruction is ultimately designed to recreate natural-appearing hard (bone and teeth) and soft (gums/gingiva) tissue that is aesthetic, functional, and lasting.

Procedures:

• The patient started with orthodontics (braces) to extrude or bring down tooth #7 and the associated gingival (gum) tissue.
• The crown on #7 was removed and the root retained to preserve the regional bone.
• A “tenting” screw was placed at site #9 to support the overlying tissue reconstruction.

• A soft tissue graft was performed to reconstruct the gingival architecture in the area.

• After soft tissue healing, a dental implant was placed at site #8.
• A temporary prosthesis was attached to implant #8 with a cantilevered tooth (pontic) #7.
• This temporary prosthesis was critical to developing and shaping the gingival architecture in preparation for final teeth.
• A final restoration was then placed by her primary dentist.

Commentary:

• The best chance for a good outcome is achieved with an interdisciplinary approach to treatment.
• These cases involving front teeth defects are some of the most difficult of all facial reconstructive procedures.
• A well-orchestrated and coordinated plan is conducted by close and explicit communication by all treatment team members.
• These cases require careful attention to minor details by each team member.
• Having realistic expectations is essential for a satisfied patient experience.
• We spent a significant amount of time preparing Hope to understand what was realistically achievable and what to expect along the way.
• Sometimes, the success of such a case depends on the acceptance of biological limitations.
• Communicating these limitations before embarking on treatment is critical to a satisfactory patient experience.
• The experience of the treatment team and how planning is communicated are critical elements of success.