INTRODUCTION
It has become all too commonplace in the author’s practice to be faced with the challenges of treating victims of iatrogenic dentistry. Inappropriate and negligent procedures performed by prior treaters can promote inflammation and periodontal disease. In this all-too-familiar scenario, the damage caused by the dentist is referred to as iatrogenic damage.1 Restorations can become iatrogenic to the periodontium when not executed properly. Awareness needs to be raised amongst dental clinicians of the significant impact iatrogenic factors play in predicting the long-term success of restorations and periodontal health.2
To understand the impact of restorations on the periodontium, clinicians need to comprehend the important role of the biologic width in maintaining healthy gingiva surrounding the restorations.1 Biologic width is defined as the distance between the base of the gingival sulcus and the crest of the alveolar bone. It consists, on average, of 1.07 mm of connective tissue and 0.97 mm of junctional epithelium.1 Restorations that violate this zone can result in inflammation, bone resorption, and the development of periodontitis. It has been demonstrated that 3.0 mm between the preparation margin and the alveolar bone will maintain periodontal health. This measurement accounts for 1.0 mm of supracrestal connective tissue attachment, 1.0 mm of junctional epithelium, and 1.0 mm for the gingival sulcus in general. Therefore, it is recommended not to place a margin deeper than 0.5 mm to 1.0 mm below the gingival sulcus to avoid invasion of the biologic width.3 Restorations that violate the principles of biologic width have a negative and deleterious effect upon periodontal health. The close association between iatrogenic restorations and chronic periodontitis has been recognized for more than 20 years.2 Despite this well-documented history, violations of the biologic width still exist and are prevalent amongst the new patient population in the author’s private practice.
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| Figure 1. Periodontal issues were noted on the right maxillary lateral and central incisors that were related to poor restoration margins and invasion of the biologic width. |
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| Figure 2. A periapical radiograph demonstrated very poor marginal fit of the crown on the lateral incisor. | Figure 3. A periapical radiograph demonstrated poor-fitting crown margins on teeth Nos. 7 and 8, as well as an overhanging margin on the central incisor. |
CASE REPORT
Diagnosis and Treatment Planning
A 42-year-old healthy male presented for an initial exam without any complaints. Clinical and radiographic examination revealed ill-fitting all-ceramic crowns present on teeth Nos. 7 and 8. The gingival margins of these restorations presented with erythema, chronic progressive gingival inflammation, and bleeding upon probing (Figure 1). Radiographic findings regarding these teeth included open margins, overhangs, and alveolar bone loss (Figures 2 and 3). A diagnosis of iatrogenic restorations was determined based on these findings. The iatrogenic violations were numerous, including violation of the biologic width. Treatment plan goals were to recreate nature and to restore the periodontal health with proper form, fit, and function on the 2 previously crowned teeth. This included crown lengthening to re-establish biologic width and replacing the ceramic crowns with new all-ceramic restorations.
The challenges of the treatment plan were many. The aim was to restore periodontal health while rendering the least amount of treatment to achieve that goal. Treatment would include crown lengthening of the previously crowned teeth to first re-establish proper biologic width. Then, new properly fitting/contoured and aesthetic all-ceramic crowns would be done. The challenges include matching gingival symmetry, tooth shape, size, and the color of the adjacent virgin dentition. To achieve these goals, a collaborative team approach was employed to include a periodontist, Joseph Aronoff, DDS, MS, and a ceramist, Bill Marais, CDT.
Preliminary Planning and Diagnostic Wax-Up
Preliminary vinyl polysiloxane (VPS) putty and light-body wash (Splash [DenMat]) maxillary and mandibular full-arch impressions were taken with disposable, closed plastic trays using a 2-step technique. The trays were painted with a VPS tray adhesive (3M). Two “putty paks” were hand mixed and loaded into the maxillary tray and seated intraorally. The tray was left in intraorally for one minute and then removed and dried with an air/water syringe. Next, the impressed areas of the teeth were loaded with a light-body wash. The impression was reseated intraorally and allowed to fully set before removal. The same process was then repeated for the lower arch. A full-arch VPS bite registration (Blu-Mousse [Parkell]) was taken in the patient’s habitual maximum intercuspation position. A Kois Dental Facial Analyzer (Panadent) was then used with bite registration material to record the patient’s midline and incisal planes. Last, a series of extraoral and intraoral photos were taken to document the patient’s lips at rest, the full smile, the gingival display, and the shade of teeth. The records and photos were sent to the dental ceramist to pour the impressions and mount the models. The laboratory team was instructed to fabricate a diagnostic wax-up of the teeth to be restored, a putty index (GCLT Laboratory Putty [GC America]) of the diagnostic wax-up, a duplicate white epoxy model of the wax-up, and a clear vacuum-formed matrix to be used as a preparation guide.
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| Figure 4. A slot was created in the crowns being replaced to aid in their removal. | Figure 5. The preparations following crown removal. |
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| Figure 6. Repreparation of the teeth and the placement of a retraction cord (SilTrax [Pascal International]) for hemostasis. | Figure 7. Lab putty index, inserted intraorally. |
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| Figure 8. Provisionals were created using a silicone index that was fabricated by the lab team using the diagnostic wax-up. | Figure 9. Crestal bone was moved apically during osseous crown lengthening. |
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| Figure 10. Osseous crown lengthening had been performed and the soft tissue sutured prior to recementation of the provisional restorations. | Figure 11. Preparations following refinement, prior to the final impression. |
Clinical Protocol Preparation and Provisionalization
A local anesthetic (Septocaine [Septodont]) was carefully administered via the Wand (Milestone Scientific) to locally infiltrate the maxillary anterior in the most comfortable way possible. A pear-shaped coarse diamond bur #820-012M (Henry Schein) was used in a high-speed handpiece (KaVo) to make a vertical slice in the middle of the facial across the incisal and onto the palatal of the current crowns (Figure 4). A crown separator instrument (B134 [Brasseler USA]) was placed into the slot created with the bur and gently torqued to split the mesial and distal halves of the crowns apart. Both crowns were successfully removed in 2 segments each (Figure 5). The gingival tissues were inflamed, and heavy bleeding was noted. The previous crown preparations extended 2.0 mm subgingivally and invaded the biologic width on both teeth. A size 00 gingival retraction cord (SilTrax [Pascal International]) was placed with a hemostatic agent to control the bleeding (ViscoStat Clear [Ultradent Products]) (Figure 6). The teeth were prepared using a course diamond chamfer (#856.018 [Brasseler USA]), followed by a fine grit chamfer diamond (#8856.018 [Brasseler USA]). The chamfer margins were finished and smoothed with hand chisels (DM1 and DM2 [Deppeler]).
Splinted provisional crowns were then fabricated by injecting the lab-fabricated silicone putty index using a bisacryl provisional material (Luxatemp [DMG America]). The loaded index was seated in the mouth and allowed to set (Figure 7). The provisional crowns were then finished and margins trimmed with a fine grit diamond flame-shaped bur (#8862.014 [Brasseler USA]). The fit of the provisional restorations was checked and the margins were verified to be closed. The contacts and occlusion were checked. The splinted prototype crowns were then cemented with a polycarboxylate luting cement (Durelon [3M]) (Figure 8). The patient was referred to the periodontist for osseous crown lengthening.
Crown Lengthening Procedure
Osseous crown lengthening was performed by the periodontist to re-establish biologic width (Figures 9 and 10).
Final Impression
Following a 4-month healing period after the crown lengthening was completed, the gingival health was restored. In the author’s experience, a waiting period of 4 months after crown lengthening in the anterior aesthetic zone allows for predictable gingival marginal stability. The localized gingival erythema had completely resolved, and gingival tissues were healthy and pink.
Local anesthetic (Septocaine) was administered using the Wand. The provisionals were removed with crown removal pliers (GC Pliers [GC America]). A Cavitron (Dentsply Sirona) was used to remove any remaining cement on the preparations (Figure 11). The preparation margins were refined with a fine grit diamond chamfer bur (#8856.018 [Brasseler USA]) and then finished with hand chisels DM1 and DM2. A single piece of size 00 retraction cord (SilTrax) was placed around each prep. A full-arch VPS impression was taken using a light-body VPS (Imprint 3 [3M]) syringed around the preps and a heavy-body VPS (Imprint 3) in the tray. Upon setting, the impression was removed and carefully checked (Figure 12).
For additional communication and guidance, photos were taken to illustrate the stump shades as well as the adjacent tooth shades for the ceramist. Both preps and the adjacent teeth were scanned (VITA EasyShade [VITA North America]). Photographs were taken with VITA Classic shade tabs (VITA North America) (Figure 13).
The splinted provisional crowns were relined using a bisacryl provisional material (Luxatemp). The provisionals were extraorally trimmed with a flame-shaped fine grit diamond bur (Brasseler USA) and recemented with Durelon.
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| Figure 12. The final impression demonstrated capture of the marginal details. | Figure 13. A photograph with shade tabs to aid in shade communication with the ceramist. |
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| Figure 14. Lithium disilicate (GC Initial LiSi Press [GC America]) crowns on the master model. | Figure 15. A post-insertion radiograph was taken to document marginal fit and to verify complete removal of any excess cement. |
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| Figure 16. The completed all-ceramic restorations, showing excellent aesthetics and restored gingival health. |
Laboratory Work
To achieve the ultimate balance between strength and natural-looking aesthetics, the author’s material of choice for the final restorations was lithium disilicate (GC Initial LiSi Press [GC America]). This all-ceramic material is highly aesthetic, with a flexural strength greater than 500 MPa. It features low abrasion of opposing natural tooth structure, is wear resistant, and also demonstrates excellent fluorescence (Figure 14).
Delivery of Final Restorations
Local anesthetic (Septocaine) was administered with the Wand. Next, the provisional restorations were removed with crown removal pliers (GC Pliers). The preparations were cleaned (Cavitron) and then scrubbed with 4% pure chlorhexidine. The final lithium disilicate crowns were tried in, and margins, contacts, and occlusion were verified.
Next, in preparation for bonding, the intaglio surfaces of the crowns were cleaned for 20 seconds using a universal cleaning gel (Ivoclean [Ivoclar Vivadent]), then rinsed and dried. OptiBond XTR (Kerr Dental) adhesive was applied to the intaglio surfaces of both restorations and then air-dried for 20 seconds. The preparations were treated with an application of a glutaraldehyde desensitizer (GLUMA [Kulzer]). A coat of OptiBond (Kerr Dental) primer was applied to the preparations and then air-thinned. Then a coat of Optibond XTR adhesive was applied on the tooth preparations and air-dried.
The crowns were loaded with a translucent resin cement (NX3 Nexus [Kerr Dental]) and seated. The cement was tack cured for 5 seconds using a curing light (Bluephase [Ivoclar Vivadent]). With the cement in the gel state, excess resin cement was removed using an explorer. In addition, interproximal contacts were flossed to remove excess cement. Once clean, both restorations were light cured on high for 40 seconds each. A postoperative radiograph was taken to confirm that all of the excess cement was removed (Figure 15). Finally, photos were taken of the completed case (Figure 16).
The patient was very pleased with the aesthetic results. The lithium disilicate restorations had a natural appearance and blended seamlessly with the adjacent teeth.
CLOSING COMMENTS
When clinicians fail to adhere to biologic principles that they were trained to know and respect, the impact on the health of the teeth and gums can be catastrophic. It is unacceptable to ignore these principles and place inferior, ill-fitting restorations in our patients’ mouths that can do more harm than good. Although challenging, clinicians must do their best to diagnose and treat these victims of iatrogenic dentistry. With proper treatment planning, team collaboration, attention to detail, and the proper use of high-quality dental materials, cases such as this one can have a positive outcome in achieving optimal aesthetics while restoring gingival health.
Acknowledgment
The author would like to thank ceramist Bill Marais, CDT, co-owner of Disa Dental Studio in Portland, Ore, and Joseph Aronoff, DDS, MS, periodontist at Port Jefferson Smiles in Port Jefferson Station, NY, for their assistance with the case presented.
References
- Shenoy VK, Rodrigues S. Iatrogenic dentistry and the periodontium. J Indian Prosthodont Soc. 2007;7:17-20.
- Joshipura V. Do we care about iatrogenic damage? A wake-up call for periodontists. International Journal of Contemporary Dentistry. 2010;1:32-38.
- Rosenberg ES, Cho SC, Garber DA. Crown lengthening revisited. Compend Contin Educ Dent. 1999;20:527-542.
Dr. Halpern graduated with a dual degree from the University of Pennsylvania in 2002, earning both a DMD and a master’s degree in higher education. She then completed a general practice residency in 2003 at New York Presbyterian/Cornell Weill Medical Center in New York. As a general dentist, Dr. Halpern maintains a private practice in Port Jefferson Station, NY. She has lectured on the topic of fixed prosthetics, ceramic materials, and dental photography. Dr. Halpern can be reached at (631) 928-1300, via the email address portjeffsmiles@gmail.com, or via the website portjeffersonsmiles.com.
Disclosure: Dr. Halpern is a paid consultant for GC America and receives compensation for lectures and articles.
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