PAGD Keystone Explorer Winter 2020

Keystone Explorer | Winter 2020 11 Katherine Dangler, DDS, MAGD ALTOONA, PA First, educate the patient on his current habits contributing to the carious lesions. The patient’s main concern is improving his smile. Discuss the advantages and disadvantages of removable vs. fixed options for a better aesthetic outcome. Talk to the patient about the possibility of keeping restorable teeth and managing the periodontal disease. If the patient decides to keep the restorable teeth, then proceed with scaling and root planning, as well as restoring the carious lesions. Discuss the option of replacing #7–10 with an implant supported fixed bridge. In a patient with a high smile line, the biggest challenge is controlling the vertical dimension of bone/soft tissue. Teeth 7,9, and 10 are non-restorable and eventually need to be extracted. When teeth are extracted, 1 mm of vertical soft tissue is lost. Orthodontic extrusion will bring the soft tissue and bone down vertically. Orthodontically extrude teeth #7, 9, and 10 to gain about 2–3 mms of extrusion. After extrusion, teeth 7,9, and 10 will be extracted and implants placed. Implant placement and position should be considered: Implant should be placed 3–4 mm from the desired gingival margin. Adjacent implants make it more difficult to handle the soft tissue and bone. Because of the bone defect present in site #8, an implant there may increase the need for ridge augmentation. So, implants could be placed at either site #7–10 or #7–9. If implants can be immediately loaded, a temporary bridge replacing #7–10 can be placed. In that case, remove the lateral and protrusive movements on the temporary bridge. If implants can’t be immediately loaded, use customizable healing collars to support the soft tissue. A removable prosthesis such as a flipper or essex can be placed over the customized healing collars. Once the implants can be loaded, a temporary bridge replacing #7–10 can be placed to further sculpt the soft tissue. After the implants have finished osteointegration, proceed with the final bridge replacing #7–10. R E SPONS E # 1 dentistry issues Q The radiographic exam reveals that he has non-restorable #7, 9, and 10, plus restorable caries on many other teeth. The TMJ exam is within normal limits. His perio exam shows generalized 4–6mm pockets. Upon evaluation of his full smile, he has a very high smile line and shows 3+mm of gums in the esthetic zone.