December 1, 2005
by Elliot Mechanic, DDS, BSc
There are times when a patient presents in our practices with dental problems that may initially confuse us. How can a dentist restore a compromised dentition without disappointing the aesthetic aspirations of our patient?
Creative treatment planning using dental technologies from different dental specialties often leads to results that we wouldn’t think possible just several years ago and make us proud of our restoration and what we have done to change someone’s smile and self-confidence.
Our patient presented with generalized moderate periodontal bone loss, significant gingival recession on the upper right canine and a severe gingival recession on the upper left canine (Figs. 1A-C).
Although she accepted the fact that her dental state was a result of her own neglect, at 50 years of age, she was mentally discouraged because the treatment plans she had been previously presented ranged from full mouth periodontal surgery and crown and bridge of the “piano key variety” to the extraction of all her upper teeth and a full upper denture.
Rather than do something she believed she would regret, she elected to do nothing up until this point. The breakdown of the interdental papilla and the beginning of the appearance of what is frequently referred to as the “black triangle” between the anterior incisors is an indication of underlying bone loss. A composite restoration was placed on the root surface of the upper left canine to further complicate the ability to achieve root coverage with gingival grafting.
Visually, the central incisors were short with a crown to root ratio of 1:1 (7.75mm x 7.75mm). We know a ratio of 70-75 percent to be ideal so if we use periodontal surgery creatively to raise our gingival level, we begin to diminish the discrepancy between the anterior and cuspid gingival level. To reposition the gingival margins of the canines, we choose to initially place free gingival grafts and then use orthodontic extrusion to create gingival level harmony.
After four months of periodontal healing, final impressions were taken of our preparations and provisonals. The patient has now had several months to preview her new look and make any changes if needed. The laboratory will fabricate templates of the model of our provisional restoration so that the final all porcelain restoration will duplicate the aesthetics, incisal embrasures, thickness and contours of the temporary. This will help to ensure that the patient will like the final restoration. They will just be a higher quality version of the provisionals.
Dr. Elliot Mechanic practices aesthetic dentistry in Montreal, Canada. He received his Bachelor of Science (1975) and Doctor of Dental Surgery (1979) degrees from McGill University. Dr Mechanic is the Cosmetic/Aesthetic Editor for Oral Health Journal.