Dental Asia Jan/Feb 2019

User Report DENTAL ASIA JANUARY / FEBRUARY 2019 46 Introduction The restorative treatment of anterior teeth often presents a considerable challenge to general dentists. The aim is always to obtain the best possible result. A well-guided approach is necessary if the visualised outcome is to be achieved. Precision planning and a consistent protocol are indispensable. Modern dentistry has simplified the ways and means of attaining aesthetic results. Nevertheless, the success of the treatment, in the anterior region in particular, greatly depends on meticulous planning, which includes a detailed analysis of the patient’s smile as well as the fabrication of a working model. This model is used to plan and reproduce the shapes and contours of the future restoration with utmost precision. This article describes a comparatively simple treatment technique on the basis of a clinical case. The initial aesthetic treatment plan was jointly developed by the dental technician and the dentist. It served as a guide or “GPS” for all the clinical steps which helped the dental team to successfully “navigate” through the treatment. Clinical case presentation A woman in her forties consulted our practice due to extreme mobility of her front teeth, which had caused aesthetic problems (Figs. 1-2). The teeth hadmoved forward and the level of the smile line had dropped. Due to severe periodontitis, the upper front teeth showed considerable gingival recession (Fig. 3). A detailed examination revealed that the four upper front teeth could not be saved and had to be extracted. The treatment plan was to insert two implants in the sockets of tooth 12 and 22 after the extraction process. Subsequently, an implant-supported bridge extending from tooth 12 to 22 would be fabricated and tooth 13 and 23 would be restored with single crowns. The main objective was to restore the harmonious appearance of the smile line and the convex shape of the gingiva. The patient’s smile was analysed by means of a photographic record. Furthermore, impressions of the situation were taken. Based on this information, a provisional bridge spanning from tooth 13 to 23 and incorporating the aesthetic and functional adjustments would be produced with PMMA (polymethyl methacrylate) material (Telio ® CAD). Surgical procedure At the second treatment session, the four upper incisors were extracted. The canines 13 and 23 were prepared to receive the provisional bridge (Fig. 4). During the same appointment, two implants (V3, MIS Implants Technologies) were inserted in the sockets of tooth 12 and 22. The implants would serve as the abutments for the implant-supported bridge. The surgical procedure also included two connective tissue grafts in the area of tooth 11 and 21 in order to increase the horizontal volume of the jaw. The augmentation of the ridge tissue helped to restore the convex shape of the dental arch and established a sound basis for the development of a natural- looking emergence profile. Therefore, the alveolar sockets of tooth 11 and 21 were filled with a bone replacement material (xenograft product, Bio Oss) to prevent the gingival tissue from collapsing after the tooth extraction. Fig. 1: The patient was dissatisfied with her smile Fig. 2: The anterior teeth were damaged due to periodontitis and moved labially and extruded. Fig. 3: Intraoral view: severe periodontitis caused gingival recession for the upper central incisors Fig. 4: After extraction After the surgical procedure, the provisional bridge was placed (Fig. 5). The provisional restoration plays a significant part in this type of treatment and considerably influences its outcome. A flowable composite material was applied to the base of the provisional bridge to condition the gingival tissue and shape the desired emergence profile. Suitable conditioning of the gums helps to preserve the tissue volume. Guided Concept in the Aesthetic Zone By Dr. Stefen Koubi and MDT Gérald Ubassy