Our patient presents with hopeless # 9 She is also beginning orthodontic treatment to level and align her teeth, so there is plenty of time to phase treatment of this area. How would you approach the deficiency? How would you go about extraction and preparation for implant placement?
This is an extremely complex case. Tooth #8 was restored with an extra wide M-D contour so this
needs to be remedied. As for tooth #9 I would suggest removal with GBR and a CT graft to augment
the hard and soft tissue. Pending the result, it may be necessary to do a secondary augmentation procedure before considering implant therapy.
This tooth could be replaced using a bridge or an implant. If an implant is the patient’s preference, I would suggest the tooth be orthodontically erupted moving the gingiva and bone coronally partially eliminating the poor crestal bone and gingival profile. When extracting the tooth and if needed I would provide any bone augmentation and subepithelial grafting to give the best chance of a successful implant that is esthetically the best possible.
If a bridge is the patient preference and if esthetics is important I would again erupt the tooth and would place a subepithelial tissue graft for ridge augmentation when extracting the tooth.
I agree with the statement that 8 needs to be corrected. However, if the patient is going to undergo orthodontic therapy, I would be more in favor of having the orthodontist extrude the tooth so that the bone levels will rise to be equal with the adjacent teeth. The orthodontist will be seeing the patient on a monthly basis and continued extrusion can be easily maintained in his office. This would give better underlying soft and hard tissue contour if the patient wanted a bridge or an implant.
Extremely complex and lots of issues to deal with such as bruxism,gingival issue #21,occlusion, etc etc
She’s not a youngster , that’s for sure!
A battered dentition.
Consider keeping it simple.3 unit bridge with pink porcelain on #21
You can aslo consider a full mouth reconstruction is she has a spare $50,000
If the pt is already going to be in the hands of an orthodontist forced eruption is the way to go- bring the bone down as you extrude tooth, cutting the tth down as it extrudes. Provided there is no ankylosis (didnt get a good view of the periodontal ligament looks missing in spots on the 2D image) and provided the rest on the mouth is reasonably restorable.
Thank you for sharing this challenging case. Since it is in esthetic zone, the Tx can be affected with smile line, from exo #9 simply if she has a low smile line and no gum show to something more complex if smilling shows her ging margin.
@drtoast151 Thanks for your input. I like your approach but I would be concerned that with a traditional augmentation and CT graft there would be a major coronal displacement of the MGJ. I chose to treat this case a little differently.
@period @Page_Barden Orthodontic eruption could be good choice although in this case bc it is missing so much buccal plate I don’t think its predictable. Also, in this case, the patient was opting for Invisalign, not brackets.
@alan keeping it simple is definitely simple but not sure how esthetic. But pink porcelain can be a lifesaver at times.
@pedram you make a great point. I intentionally left out the smile line picture so that we could have a discussion assuming the smile line is high so we can try to work out the best esthetic result.
Thank you all for your insightful comments. This particular case if coming to a close soon and I am excited to post the pictures.
Ortho extrusion is ideal but keep in mind it is not consistent. Many factors including operator ability. Might be prudent to start with it and advise the patient that revisions in the treatment plan may be necessary.
