On November 29, 1969, one of the best known rock and roll bands, The Rolling Stones, released an album called Let It Bleed. On it, the words ring out:
"You can't always get what you want! But if you try sometimes, you just might find You get what you need!"
Sometimes this happens in clinical dentistry as well. We can plan how we're going to treat a patient with the best intentions, but sometimes things don't quite unfold the way we hope. In this kind of situation, we have to "think outside the box," or to use a football analogy, we have to punt.
This article deals with such a case. From the beginning of caring for Diane, her situation was filled with challenges. I tried to look into the future and plan what I considered to be the best treatment option. At the same time, I also had to respect her decisions; she decided to opt for a "plan B" alternative that I thought we should be able to accomplish, even though it was not my first choice.
DIAGNOSIS AND TREATMENT PLANNING
The Story Unfolds
The story unfolds starting in June of 1998. Diane presented with a crown that had recurrent caries under the facial margin on her upper left central incisor (tooth No. 9). She also had a composite filling with recurrent decay in her left lateral incisor (tooth No. 10) (Before Image). In our new patient intake interview, she said she was troubled by the appearance of tooth No. 9 and did not want to lose it. She also reported that she had a "cavity around the crown one time before," had root canal therapy (RCT), and "some sort of operation on that tooth."
A complete medical, social, and familial history was taken and clinical and radiographic examinations performed. Periodontal, temporomandibular joint, soft-tissue, and oral cancer examinations revealed no findings. Radiographs demonstrated that tooth No. 9 had periapical pathology, a previously done apicoectomy with retrograde amalgam, and a crown over a core with a post that was far too short. Tooth No. 10 had endodontic treatment and a composite restoration (Before Image and Figure 1).
|Before Image. Preoperative photo (1998).||After Image. Full-face photo at one year.|
After careful analysis of my findings, I thought it best to remove tooth No. 9, place an osseous graft, and have bone fill in to bring the ridge closer to proper anatomic form. Grafting might need to be done more than once; I felt strongly this would be the best way to minimize further bone loss in the No. 9 area. This would also give us a more aesthetic ridge for either an implant or a pontic site for a fixed bridge. I thought we'd re-evaluate the situation several months after the extraction and first graft, and then decide on the next steps. During that time, a flipper would be provided for Diane to wear. I considered orthodontic exrusion of the remaining root of tooth No. 9, but it seemed that the root was too short and the procedure was not predictable in view of the history of the tooth. Removing tooth No. 9 was not what the patient wanted, but I thought doing this was the best way to improved health in the area of No. 9.
The plan regarding tooth No. 10 was to see if it could be restored with a new composite restoration. However, I wouldn't know how extensive the decay was until removing the old restoration. After much thought, I prepared my notes, models, and thoughts for my presentation to Diane.
I was confident that I had come up with the best options in this technically challenging situation, but disturbed that these options didn't satisfy Diane's personal goal of keeping her left central incisor. I thought she'd understand why it was important to grow more bone in the area so we could then move forward with either an implant or bridge. After speaking with her, I thought she understood all I had said. I thought we were on our way until she said, "But I'm not ready to lose that tooth now. Can't you just make me a new crown?"
I thought for a moment and told her that I could, but I didn't think it was the best way to go. I reiterated the need to maintain existing bone and regrow new bone. To no avail, Diane was fixated on keeping her central incisor, if at all possible. We decided I'd remove her old crown and evaluate what was underneath. Then, if it were possible, the tooth would be kept and I would deliver a new crown. In addition, the composite restoration would be removed in her lateral incisor and then we would decide what that tooth needed to bring it back to optimum form and function.
Using a KaVo air-driven high-speed handpiece with a Revelation diamond No. 856-016 chamfer bur (SS White Burs), I sectioned and removed the old crown on tooth No. 9. It was clear there had been a lot of destruction of the underlying tooth structure. In order to achieve hemostasis subgingivally, viscous 20% ferric sulfate (ViscoStat [Ultradent Products]) in a DentoInfusor (Ultradent Products) was rubbed onto the tissue surfaces to arrest the bleeding (Figure 2). Vigorous washing, drying, and placement of a knitted retraction cord (Ultrapak [Ultradent Products]) provided a clear field in which to evaluate and possibly rebuild No. 9 internally (Figure 3). Tooth No. 10 revealed lots of decay under the old restoration, and it was decided that a post and core, followed by a crown, would be best solution for this tooth.
|Figure 1. Preoperative radiograph (1998).||Figure 2. Achieving hemostasis.|
|Figure 3. Retraction cord placed: Note severe coronal destruction.||Figure 4. Final preparations after post placement.|
|Figure 5. Temporary crowns cemented.||Figure 6. PFM (high noble) crowns cemented.|
After phosphoric acid-etching, washing, and drying, a bonding agent (Clearfil Photo Bond [Kuraray]) was applied and then passive parallel posts (Integra Posts [Premier Dental Products]) were cemented into both teeth with a 2-component (base/catalyst) composite resin cement (IntegraCem [Premier Dental Products]). Final preparations (Figure 4) were accomplished with diamond chamfer burs. A full-arch polyether impression (Impregum Penta Medium Body [3M ESPE]) in a disposable tray (COE Spacer Tray [GC America]), an impression of the lower arch (taken with Position Penta Quick [3M ESPE], a vinyl polysiloxane [VPS] alginate substitute), and a bite registration (O-Bite [DMG America]) were taken. Using a gingival shade guide (IPS Gingiva [Ivoclar Vivadent]), we selected a pink shade that came as close as possible to matching Diane's gingival color. Temporary crowns were cemented (Figure 5), and several weeks later the final restorations were placed (Figure 6).
Following the Case for 10 Years
Over the course of 10 years, Diane stayed on a regular maintenance schedule. We saw her at least twice a year for a comprehensive re-examination, prophylaxis, and x-rays when appropriate. During the last 2 of the 10 years, we noticed tooth No. 9 was beginning to extrude. In conversation with Diane, I said I noticed that her left front tooth was looking a bit longer and I was concerned. She said she had noticed this too and asked what was happening, and what could be done to correct it (Figure 7). It was apparent that the tooth had loosened and the supporting bone had deteriorated further. The prognosis for tooth No. 9 was, at this point, hopeless.
|Figure 7. Preoperative photo in 2008; tooth No. 9 was now extruded.||Figure 8. Tooth No. 9 was extracted and a temporary partial inserted.|
|Figure 9. One of several bone graft surgeries. (Courtesy of Dr. Rosenstein, NY.)||Figure 10. Implant surgical positioning stent.|
|Figure 11. Palatal bone lacking; implant placed to facial. (Courtesy of Dr. Rosenstein, NY.)||Figure 12. Photo showing the patient's low lip-line.|
At a subsequent consultation, Diane finally decided to have tooth No. 9 removed. We discussed the need for regenerating bone in the area and that it would have to be done multiple times over the course of a year to achieve a reasonably aesthetic result. She understood, and was okay with this. I referred her to a talented periodontist, Dr. Peter Rosenstein, of Suffern, NY. He and I talked about what was needed to regain hard- and soft-tissue architecture in order for an implant to be placed. He met with Diane, she agreed to the treatment that he proposed, and the process began.
At a subsequent visit, Dr. Rosenstein removed tooth No. 9, any and all granulation tissue, and inserted Diane's flipper (Figure 8); to be worn during the time it would take to regenerate the deficient ridge. I modified the tissue side of the flipper after each bone graft; this is because the flipper was made before the extraction and would not fit without cutbacks/relining after each periodontal surgery. After a year and several surgeries (Figure 9), Diane's ridge looked acceptable and Dr. Rosenstein was ready to place an implant using the surgical guide that I fabricated for him (Figure 10). All implants should be placed using a surgical guide; this facilitates the subsequent restorative phase with the abutment and crown predictably ending up over an implant in the desired and preplanned location.
On the day of implant placement, Dr. Rosenstein discovered that there was insufficient bone where I wanted to have the implant placed (Figure 11). He discussed this with Diane and suggested one more graft procedure to regenerate additional bone. She said she would not go through any more surgery. He then placed the implant in an area with the most bone, which was far too facial. (To read Dr. Rosenstein's full article for his portion of this case, visit dentistrytoday.com. A summary of his contribution to this case appears in the sidebar of this article.)
|Bone Grafting: A Challenging Case|
|Peter Rosenstein, DMD |
This 42-year-old female patient, referred to us by Dr. Marvin Fier, presented with a missing maxillary left central incisor. The tooth had a long history of periodontal breakdown and was finally extracted within the past year.
The treatment plan was to place an implant in the areas to replace the missing tooth. Clinical and radiographic examination showed extensive vertical and horizontal ridge atrophy, necessitating bone augmentation prior to implant placement. Bone grafting was eventually done on 3 separate procedures: the first 2 procedures were prior to implant placement and the third was done at the same time as implant placement. Several different modes of bone grafting were considered and discussed with the patient. Factors such as financial issues, use of donor sites, success rate, and various risks and possible complications were all used in selecting a bone-grafting method to be used.
The first procedure involved creating a full-thickness flap with vertical incisions at each line angle. A thin "knife-edge" ridge with 6 mm of vertical height of bone loss (measured from the crest of the bone of the adjacent teeth) was revealed. Bone grafting on the labial and palatal sides of the ridge was done using a combination of large-particle PUROS and BIO-OSS synthetic hydroxyapatite. The graft material was covered with resorbable BIO-GUIDE membrane held in place by titanium tacs. The flap was closed with 4-0 vicryl sutures. Primary closure was attempted but not achieved. The graft site was allowed to heal for 6 months before it was flapped open again.
Bone augmentation of one mm in height and 2 mm in thickness had occurred. The increase in the thickness occurred mainly on the labial side. This was deemed insufficient for implant placement, and so additionally bone grafting was done using the same technique and materials as done previously. Healing was uneventful and the area was allowed to heal for another 5 months.
The site was again flapped open, revealing an additional one to 2 mm gain in thickness but less than one mm in height. Bone quality was also poor. A surgical stent was used to place the implant in the correct mesiodistal position; however, because of the poor quality of bone, it was decided to place the implant slightly labial to the surgical stent. This was done in order to place the implant completely within the labiopalatal border of the ridge rather than risk perforating or completely obliterating the palatal wall in trying for ideal location from a prosthetic point of view. Additional bone grafting was placed around the implant using a nonresorbable TEFGEN membrane.
Healing was uneventful and the implant was uncovered 6 months later. The membrane was removed and a healing abutment was placed. The patient was referred back to the restorative dentist a few weeks later.
Treatment Planning Consultation With the Laboratory
When Diane returned after the No. 9 implant was uncovered, I already knew from Dr. Rosenstein that the Nobel Replace Select implant (Nobel Biocare) was not where I wanted it. (You Can't Always Get What You Want.) I was faced with the choice of either restoring the implant or burying it and making a fixed bridge. The second choice would have made Diane feel all the time, money, and effort she spent on rebuilding the ridge was for naught. This is not something we want a patient to feel, if at all possible. On the other hand, could I really create a good result based on the malposition of the implant? I wasn't sure.
Fortunately, Diane had a low lip-line when smiling (Figure 12). This allowed some leeway in making a restoration that would blend in if we could create a custom abutment that "repositioned" the crown. Proper gingival contours and coloring using gingival porcelain would also be essential if we were to achieve an acceptable result.
Before making the decision about how to proceed, I discussed the case in depth via a treatment planning consultation (TPC) with the dental laboratory team who would be doing this case. (The TPC, introduced by Dr. Damon Adams, is defined as a detailed sharing of diagnostic and technical information between the doctor and the dental laboratory team prior to beginning certain definitive clinical treatment.1) I cannot stress strongly enough the importance of good dentist-laboratory communication prior to doing any type of unusual, complex, or large restorative case.
An impression with the healing cap in place using a VPS impression material (Position Penta Quick Step [3M ESPE]) was made. Tooth No. 10 was to receive a new crown that would also require gingival porcelain, so we included this in our TPC. I sent the impression, opposing arch model, bite registration, and photos taken with a Canon point-and-shoot dental setup (PhotoMed International) to Stephen Killian, CDT, and his team at Killian Dental Ceramics. Their belief was that they could create an abutment that would allow us to make a crown for tooth No. 9 in proper alignment with the rest of the arch. There were many technical challenges ahead, but I was confident that together we could meet them. After discussing the case with him, I felt we had a very good chance to make Diane feel that all she must go through would be worth it.
Now confident that we could achieve a good result, final impressions for working models were taken (EXA'lence [GC America]). A counter impression, bite registration, shade photos, facial photos, and shade tabs were sent to the dental laboratory team. Interestingly, no gingival porcelain shade tab resembled exactly what was needed for the pink porcelain required in this case. Several denture acrylic guides were used to try to match the gingiva as closely as possible. Nature-Cryl No. 36 (GC America) (Figure 13) was chosen as the shade for the gingival porcelain. Since there may be slight variations in shade tabs from a manufacturer, it is my belief that for any aesthetically critical area, the shade tabs used in the dental office should be sent to the laboratory team so they can see the actual tabs. A carefully designed custom abutment (Figure 14) and PFM (high noble) crowns for teeth Nos. 9 and 10 were constructed. Great pains were taken to bring the coronal portion of the abutment into proper alignment with the rest of the anterior teeth. This goal was achieved as seen in Figure 14.
The crowns were tried-in. Although they were close to what was needed (Figure 15), there were several problems that, once corrected, would significantly improve our result. It was necessary to increase the pink gingival porcelain in an incisal direction, and to create more lifelike gingival embrasures. In addition, refinement of the coronal shading to better match the adjacent natural teeth was needed. The case was sent back to our laboratory team with images made at the try-in visit and a written prescription for the changes requested.
|Figure 13. Shade matching for gingival porcelain.||Figure 14. Custom abutment.|
|Figure 15. First try-in.||Figure 16. Second try-in: Note gingival porcelain is too bulky.|
When the case was returned, I excitedly tried it in, thinking this might be the day we accomplished what we were after. However, there were still some issues at this second try-in visit. The gingival embrasures were far better than before, but the pink porcelain looked "swollen," imparting a look not unlike gingivitis (Figure 16). I refined these areas until I felt that they were properly contoured (Figure 17). The coronal shading of the crowns was improved and was acceptable to the patient. From a conversational distance, the new crowns blended with Diane's natural dentition. When she looked at the result in a mirror, she was very happy and wanted the crowns "today." However, in my ongoing pursuit of excellence, I asked Diane's indulgence for just a few minutes. I called the laboratory and spoke with Steve Killian again. After describing the lack of maverick coloring, he said, "Just e-mail me what you're looking at." Within a few minutes, he and I were looking at our computer screens, and he said, "I can do better than that." That was all I needed to hear.
I told Diane about the conversation with my dental technician and asked her for permission to return the crowns to the laboratory for some final adjustments in the shade. Why ask her permission? She had been through a lot to get to this day and was happy with what she saw in a mirror. She would have walked out with the restorations that day, so of course she was a bit reluctant to let me send the case back again. However, she did agree to it. She was rescheduled for another visit just a few days later, knowing the adjustments would not take long to accomplish.
|Figure 17. Gingival porcelain recontoured.||Figure 18. Immediate post-op after insertion.|
In a few days the case came back and our patient returned for the third try-in. This time, not only was Diane very happy, but I was also ecstatic because the result was now excellent. We had achieved what I considered the best possible result under the challenging circumstances with which we had to deal. The abutment was torqued to 35 Ncm (Screwdriver Machine Multi-Unit Torque Wrench [Nobel Biocare]). The insides of both crowns were cleaned with gentle sandblasting (Microetcher IIA [Danville Materials]) using a sandblasting containment system (Micro-Cab [Danville Materials]). The crown on tooth No. 9 was luted in place with a noneugenol temporary resin cement (Premier Implant Cement [Premier Dental Products]). A permanent composite resin cement (Clearfil SA [Kuraray]) was used to cement the crown on tooth No. 10. The final result on insertion day is seen in Figure 18. Since the gingival porcelain areas required small amounts of cantilevered porcelain in order to achieve an aesthetic result, we showed Diane how to insert dental floss between the restorations and clean above the gingival porcelain.
At a one-week follow-up visit, Diane said that everything "feels and looks great." She reported that cleaning around her new crowns was easy and she was "so happy" she did it. We scheduled examination and prophylaxis visits at 3-month intervals.
Since the work was completed, Diane has been maintaining the tissues around her restorations very well and told us no one ever noticed that she had anything done to her teeth. The After Image shows the one-year postoperative results.
Clinical dentistry requires us to diagnose and plan treatment for every situation we face, whether a small carious lesion or the most involved rehabilitation before picking up an instrument. We should know what a patient's goals are for his or her health and appearance. Then, we render care to the very best of our ability.
While on the journey to our final result, we must remember that sometimes things don't always work out as we planned. Perhaps we made a crown and could not foresee RCT being necessary prior to final cementation. In Diane's case, we planned for multiple surgeries to rebuild bone so an implant could be placed in a certain position, and it didn't go as planned. In addition, I surely didn't get exactly what I wanted as her restorative dentist. However, by working hard as a team to find a solution, we got a result that was very pleasing to the patient.
I hope this article will motivate you to seek solutions to what sometimes might seem like impossible situations. By looking for answers, we can satisfy our patients and continually grow as professionals.
The author extends his heartfelt thanks to Stephen Killian, CDT, and his entire team at Killian Dental Ceramics Irvine, Calif, and Dr. Peter Rosenstein, periodontist, NY, for their contributions to Diane's case.
1. Adams DC. The treatment planning consultation: the doctor/technician partnership. Dent Today. 2004;23:92-95.
Disclosure: Dr. Fier receives materials, honoraria, and lecture support from many of the companies mentioned herein, including KaVo, SS White, Ultradent Products, Kuraray, Premier, 3M ESPE, GC America, DMG America, and Danville Materials.
Disclosure: Dr. Rosenstein reports no disclosures.