Case Report
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Utilization of minimally invasive principles in restoring congenitally malformed teeth | ||||||
Julia J. Ma1, Ram M. Vaderhobli2 | ||||||
1Health Sciences Assistant Clinical Professor, Department of Preventive and Restorative Dental Sciences, Advanced Education in General Dentistry Resident 2016-17, NYU Langone Medical Center at UCSF School of Dentistry, UCSF School of Dentistry, San Francisco, California, USA 2Health Sciences Associate Clinical Professor, Department of Preventive and Restorative Dental Sciences, Dental Director of Advanced Education in General Dentistry Residency 2016-17, NYU Langone Medical Center at UCSF School of Dentistry, UCSF School of Dentistry, San Francisco, California, USA | ||||||
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Ma JJ, Vaderhobli RM. Utilization of minimally invasive principles in restoring congenitally malformed teeth. Edorium J Dent 2018;5:100030D01JM2018. |
ABSTRACT
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Introduction: Congenital agenesis of incisors often results in compromised dental and facial esthetics that require clinical application of minimally invasive dental procedures. Case Report: The aim of this clinical case report is to discuss a combination of treatment approaches to esthetically restore congenitally malformed maxillary lateral teeth, also known as peg-shaped lateral incisors. A 24-year-old female patient presents with a chief complaint of “sharp-looking and small” bilateral maxillary lateral teeth. The case began with diagnostic models and wax-ups, followed by soft and hard tissue crown lengthening, veneer preparations with ultra-fine finish lines, and final restorations with indirect porcelain ceramic veneers. Conclusion: Esthetic results were achieved with a comprehensive approach utilizing principles of minimally invasive dental procedures. Patient satisfaction in clinical outcomes was achieved by addressing patient’s opinions and concerns at all stages of the treatment. Keywords: Anodontia therapy, Dental veneers, Esthetics | ||||||
INTRODUCTION
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The high demand for an esthetic smile has propelled the use of minimally invasive dental procedures and advanced technology. This leads to creating a smile that can closely mimic that of natural teeth. This article presents a case report where both function and esthetics of peg shaped maxillary lateral teeth were restored by recontouring the gingival zenith using both soft and hard tissue crown lengthening procedures and restoring with conservative indirect porcelain veneers. | ||||||
CASE REPORT
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Subject
Diagnostic approach and treatment planning
Diagnostic models and wax-ups
Periodontal treatment
The ideal clinical crown length for #7 was marked on the cast and an Essix of the marked cast was fabricated to use as a guide during the crown lengthening procedure. During the surgical procedure a full thickness envelope flap with no vertical-releasing incisions was reflected. The Essix was used to mark the desired clinical crown height of tooth #7, as indicated by the yellow line in Figure 5. To reestablish the patient’s biologic width on tooth #7, 4 mm of alveolar crestal bone around the facial aspect of #7 had to be removed apical to the yellow line, as indicated by the green line in Figure 5. With the removal of 4 mm of bone, the most apical portion of the buccal crestal bone happens to be at the level of the buccal cemento-enamel junctions of teeth #6 and #8. A periodontal probe was placed horizontally from #6 to #8 and the depicted green line shows that this was used as a reference for the removal of bone at #7 site. Utilizing this reference technique, the bone around #7 was recontoured and scalloped to maintain the positive boney architecture. Patient returned after six-week post op and second stage gingivectomy was completed with the same diode laser using similar settings as done previously. This was then followed by a scalpel to scallop and recontour tooth #7 facial gingiva at the same visit as preparing the teeth for veneers, as shown in Figure 6.
Veneer preparation
Final impressions
Evaluation of the veneers
Veneer cementation
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DISCUSSION | ||||||
A functional and successful restorative treatment was achieved by matching patient’s expectations with clinical outcomes. This began with understanding patients’ perspectives on facial evaluation. A systematic review by Del Monte et al., found that the face is the most important anatomic region that determines a person’s attractiveness; and following the role of the eyes, dental appearance is the second most important feature for facial attractiveness [1]. From a patient’s perspective, the esthetic smile probably stems initially from the nature of teeth [2]. However, from a dental provider’s perspective, there is both a facial and a dental component consisting of not only the golden proportions of teeth, but also the gingiva and the lip support [3], [4] . In this case, patient was not concerned about establishing an ideal dental smile with golden proportions in dentistry, but rather, having two maxillary lateral teeth recontoured so that the teeth filled the spaces naturally with no sharp cusps. This was also consistent with a study by Pini et al., where they found that when recreating smiles for patients with lateral incisor agenesis, many of the smiles are pleasing but not necessarily exhibiting the golden proportions [5]. There are many factors that can come into play when patients evaluate their own facial attractiveness, especially maxillary anterior teeth [6]. A study by Žagar investigated how a few esthetic dental and facial measurements may correlate with the variability of patients’ ratings of their satisfaction with maxillary anterior teeth appearance [7]. Some of the dental factors that can be an important aspect of facial attractiveness include tooth color, position, shape, size, gingival morphology, upper lip height, maxillary incisal display at rest and at smile, and intercommissural width at rest and at smile [8]. Thus, with a multitude of factors that can contribute to an esthetic smile, it is always challenging in creating the ideal smile as perceived by the dental patient. When evaluating the maxillary lateral teeth, studies have shown that these are one of the two groups of teeth that have the highest variability in its size and shape [9] . It has been reported that macrodontia occur more often in men and microdontia occur more often in women, both of which are genetically predetermined [10]. Another study examined pediatric patients and revealed that about 1.7% of the population has peg-shaped lateral incisors [11]. Thus, the peg shape of lateral teeth could present as an esthetic challenge for many patients. The gingival architecture may also be affected with peg laterals. The gingival zeniths in maxillary central incisors are typically distally displaced, while more centralized in maxillary lateral incisors and canines [12]. When examining solely on maxillary lateral teeth, the average gingival zenith displacement from the bisecting line of the long axis of the tooth is approximately 0.44 mm for women and 0.66 mm for men [7] . Thus, when shaping gingival architecture for peg lateral teeth, the location of the gingival zenith could vary depending on gender and patient’s preferences. When treating patients with peg lateral teeth, these additional factors must also be evaluated along with the size, shape, and appearance of the teeth themselves. Changing the gingival architecture requires either soft or hard tissue periodontal procedures of the gingiva. During the periodontal phase of treatment it would be imperative to maintain the biologic width of teeth to allow for proper healing and gingival health after restorative procedures. Thus, with any crown lengthening procedure, biologic width must be taken into planning when establishing the new clinical crown [13]. | ||||||
CONCLUSION
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Treatment planning with an approach to restore not only esthetics, but also function, and biologic health of both hard and soft tissues involved multidisciplinary fields of dentistry. In this case report, in addition to clinical considerations, the patient’s opinions and concerns were addressed at all stages of the treatment. This allowed the patient to recognize any limitations, given the timeline and financial allowances, and led to achieving patient satisfaction in clinical outcomes. | ||||||
REFERENCES
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Author Contributions
Julia J. Ma – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published Ram M. Vaderhobli – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published |
Guarantor of Submission
The corresponding author is the guarantor of submission. |
Source of Support
None |
Consent Statement
Written informed consent was obtained from the patient for publication of this case report. |
Conflict of Interest
Author declares no conflict of interest. |
Copyright
© 2018 Julia J. Ma et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information. |
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