Written by Alex J. Corsair, DMD Friday, 31 August 2007 19:00
According to Chiche and Pinault, “Four factors of aesthetic composition applied to the smile are (1) frame and reference, (2) proportion and idealism, (3) symmetry, and (4) perspective and illusion.”1 Gingival recession can cause a loss of symmetry and proportion. Crowded anterior teeth may further violate all the factors of aesthetic composition. In cases with both recession and crowding, no one technique can establish ideal dental aesthetics.
The subepithelial connective tissue graft has been used successfully to cover exposed roots and restore keratinized attached gingiva.2 Crowded teeth can be repositioned with orthodontics. Invisalign (Align Technology) is an orthodontic technique that uses clear plastic aligners to position teeth. The ideal position of the teeth is planned on a computer program. The aligners are fabricated on computer-generated models, and the patient changes the aligners every 2 weeks. The dentist and patient can follow the tooth movement on a computer model.3 This is an excellent technique for adult periodontal patients, since it allows the patient to remove the aligners for oral hygiene and during dental visits for scaling.
The following case report illustrates treatment of a patient with combination therapy. Connective tissue grafts and Invisalign were both used to improve the aesthetics of her smile.
Figure 1. Pretreatment, anterior view.
Figures 2a and 2b. Pretreatment, right and left buccal view.
Figures 3a and 3b. Pretreatment, occlusal views.
Figure 4. Connective tissue graft at tooth No. 11.
A 48-year-old female accountant presented with a chief complaint of “gum loss” and unattractive front teeth, which she said made her hesitant to smile (Figure 1).
Clinically, the patient presented with 4 to 5 mm of gingival recession, with the most severe instances on teeth Nos. 6, 7, and 11 (Figures 2a and 2b). Examination of the occlusion revealed tooth No. 9 in buccal version and teeth Nos. 8 and 10 in lingual version due to crowding.
The lower incisors were also crowded (Figures 3a and 3b). Centric occlusion prematurities were present in the anterior. The periodontal examination revealed probing depths within normal limits. However, no attached gingiva was present on the facial of teeth Nos. 6 and 11. Radiographs showed normal bone levels except for teeth Nos. 24 and 25, where bone loss of 50% was present interproximally. The prognosis of these teeth was considered guarded.
The treatment plan included one visit for full-mouth debridement and oral hygiene instruction. She was taught to brush with a mue.
Periodontal surgery was then accomplished for tooth No. 11 with the objective of coverage of the exposed root and restoration of a zone of attached gingiva. A connective tissue graft was obtained from the palate. After conditioning the root with citric acid, the graft was sutured in place with 5-0 chromic gut, and the overlying flap was coronally positioned and sutured with 6-0 nylon sutures (Figure 4). This area was allowed to heal for 6 weeks with the patient abstaining from brushing or eating in this area. Then teeth Nos. 6 and 7 were treated with a connective tissue graft and a coronally positioned flap in the same manner as tooth No. 11. At the same time the root of tooth No. 8 was conditioned with citric acid, and the flap was coronally positioned to cover the exposed root. A connective tissue graft was not required, since adequate attached gingiva was present and recession was 3 mm or less4 (Figure 5).
Figure 5. Subepithelial connective tissue graft, coronally positioned flap.
Figure 6a. Invisalign clinical check. A computer graphic pretreatment. Rectangular attachments on teeth Nos. 3, 28, and 29.
Figure 6b. Invisalign clinical check. A computer graphic post-treatment. Rectangular attachments on teeth Nos. 3, 28, and 29.
Six months after surgery it was determined that the roots had been covered and adequate attached keratinized gingiva restored. The next phase of treatment involved correcting the anterior crowding and unattractive relationships of the incisors.
Invisalign Express was the orthodontic technique chosen to correct her problem. Accurate PVS impressions of the upper and lower teeth were obtained with Aquasil Ultra heavy and light body (DENTSPLY). A bite registration was obtained with Regisil Rigid (DENTSPLY). These materials, along with x-rays and photographs, where sent to Align Technology, which determined that the crowding could be corrected with Invisalign Express. This technique involves only 10 upper and lower aligners. I then submitted a detailed prescription for her orthodontic movement. It was required that attachments be bonded on the facials of teeth Nos. 3, 12, 13, 21, 22, 28, and 29 to help retain the aligners during tooth movement (Figures 6a and 6b). An attachment template is provided to facilitate this process. The patient was required to wear the aligners 22 hours per day. However, the patient can conveniently remove them for eating and good oral hygiene. This technique also allows the dentist to perform periodic scaling when required. This is an ideal technique for the periodontal patient.
Figures 7a and 7b. Post-treatment occlusal views.
Figures 8a and 8b. Post-treatment buccal views.
Figure 9. Post-treatment anterior view.
Periodically, interproximal reduction of tooth structure was required to create more space. The amount of reduction ranged from 0.3 to 0.5 mm in 12 different interproximal spaces. This was done over several visits as prescribed by an Invisalign “Reproximation Chart.” The tooth reduction was done with Neodiamond (Microcopy) fine grit burs and Brasseler diamond strips. Proclination of the upper and lower anterior teeth was also done, resulting in expansion of the arches in the upper and lower anterior region (Figures 7a and 7b).
The Invisalign treatment required about 3 months. Retention was accomplished with bonding of the lower anteriors and a removable retainer in the upper. The patient was quite happy with the results of treatment. Cosmetically, her smile was improved with restoration of normal crown length and elimination of the crowding of the incisors. Periodontal health was improved by restoring attached gingiva and improving her occlusion (Figures 8 to 9).
- Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago, IL: Quintessence; 1994.
- Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56:715-720.
- Align Technology Web site. Available at www.aligntech.com. Accessed August 2, 2007.
- Bernimoulin JP, Luscher B, Muhle-mann HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontol. 1975;2:1-13.
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