Rishi Bhimani1* and Avishkar Mokal2
1Freelance Consultant Periodontist and Private Practitioner and Proprietor at Dr. Rishi’s Dental Clinic, Navi Mumbai, India
2Orthodontist, Zellene Dental Care, Kharghar and Consultant Orthodontist, Shurusha Citizen’s Hospital, Mumbai, India
*Corresponding Author: Rishi Bhimani, Freelance Consultant Periodontist and Private Practitioner and Proprietor at Dr. Rishi’s Dental Clinic, Navi Mumbai, India.
Received: April 08, 2021; Published: : May 11, 2021
Citation: Rishi Bhimani and Avishkar Mokal. “Comprehensive Treatment of a Discolored, Endodontically and Periodontally Compromised Upper Central Incisor through Interdisciplinary Approach: A 2-Year Follow Up". Acta Scientific Dental Sciences 5.6 (2021): 35-39.
Dentistry has evolved leaps and bounds in the past few decades, from simple treatment procedures to more complex, full-mouth life-changing treatment plans. Complex clinical situations necessitate the expertise of various disciplines of dentistry, which must be communicated and co-ordinated, leading to a holistic treatment approach known as Interdisciplinary dentistry.
This case report describes one such clinical situation in which various disciplines of Dentistry- namely Orthodontics, Periodontics, Prosthodontics and Dental Implantology have been integrated to transform the smile of young individual, suffering from dental problems.
To achieve ideal aesthetics of a single maxillary incisor is still the most difficult problem to tackle in Dentistry. This case describes a discoloured, endodontically and periodontally compromised upper central incisor which is complicated by mal-alignment and dental crowding. This case has been successfully treated by an interdisciplinary approach, providing satisfactory and stable results, followed-up over a 2-year period.
Keywords: Interdisciplinary Orthodontics; Dental Implant; Endo-Perio Lesion; Interdisciplinary Dentistry; Discolouration; Socket Preservation
Implant therapy has become a viable option for the rehabilitation of partial and single edentulism [1]. In the anterior maxilla, a successful implant procedure requires not only well-anchored implants, but also natural looking result especially when a single incisor needs to be replaced. The only way to gain this result is to correctly place implants in all the three dimensions of bone (i.e. apicocoronal, faciolingual, and mesiodistal) [2]. However, pre-existing endo-periodontal lesions can lead to considerable horizontal hard and soft tissues defects, affecting bone volume and contour. Additionally, the pathologic migration of anterior teeth and pre-existing orthodontic problems like crowding and proclination of other anterior teeth may jeopardize the final esthetic outcome.
Several clinical and histologic studies have shown the dynamic resorptive process that unfolds after tooth extraction [3]. When the alveolar site presents deficiencies, many techniques can be used for its development, one of them being preservation of the alveolar socket at the time of tooth extraction. While ridge augmentation has proven to be effective and predictable, supra-alveolar periodontal regeneration has not yet been demonstrated. Therefore, in clinical practice, periodontal regeneration should precede alveolar augmentation and implant placement.
The complete healing of such grafted alveolar ridges may take up to 6 - 12 months after tooth extraction and prior to implant placement. During this period, a provisional tooth prosthesis is necessary to restore esthetics, phonetics, mastication and maintain or preserve the gingival architecture post-extraction.
The current case report describes a complete smile make-over of a patient by replacing a discolored maxillary central incisor with significant bone loss by a dental implant prosthesis at a regenerated bone site along with fixed orthodontic therapy to completely transform the smile using an interdisciplinary approach. This case has a follow-up duration of 2 years.
A 36-year-old male reported to Zellene Plastic, Cosmetic and Dental Care, Kharghar, Navi Mumbai presenting a discolored and mobile upper left central incisor (21) with extrusion and severe proclination due to history of trauma (Figure 1). The patient also presented with mal-aligned and proclined upper lateral incisors. The upper left central incisor was endodontically treated, but the tooth presented with a reinfection resulting in severe bone loss extending up to the root apex (Figure 2). The following treatment protocol was finalized- (1) Fixed orthodontic therapy for the correction of mal-aligned teeth. (2) extraction of failing 21 and socket preservation, followed by a delayed implant placement after 3 months (3) internal bleaching of the natural crown of 21 and temporization with orthodontic wire (4) Implant placement after 3 months (5) Final Prosthesis after 3 months.
Figure 1: Pre-treatment discoloured, proclined upper left central incisor.
Figure 2: Radiograph showing total bone loss.
Fixed orthodontic therapy with ceramic brackets was started. 21 was extracted with minimal trauma and the socket was curetted to remove all the infected granulation tissue (Figure 3). The remaining alveolar bone was inspected, partial buccal plate dehiscence was present. Socket grafting was done with a combination of Freeze-dried bone allograft (FDBA) bone block as well as FDBA particulate graft (Figure 4) procured from Tata Tissue Bank, Tata Memorial Hospital, Parel, Mumbai. This was covered later by a chorion membrane and sutured.
Figure 3: Tooth socket after extraction.
Figure 4: Socket grafted with FDBA particles.
During the same appointment, the extracted 21 was decoronated. The discolored crown was internally bleached with 3% Hydrogen peroxide to lighten the shade and then filled up with a composite resin. An incisor bracket was bonded to the temporary crown, which was later placed at the extraction site, retained by orthodontic wire (Figure 5). Orthodontic treatment continued every month as per the plan. The grafted site was evaluated every month for bone healing and maturation.
Figure 5: Extracted tooth crown used as temporary pontic.
3- months after the extraction, CBCT scanning for implant site evaluation was done. CBCT evaluation showed some supra-alveolar bone regeneration with loss of the labial cortical plate. A 4.0 x 11.5 mm TSIII OSSTEM implant was placed. Due to the labial cortical plate dehiscence, there was exposure of 2 implant threads labially at the crest, whereas the implant was surrounded by bone palatally, mesially and distally (Figure 6). FDBA particulate bone graft was placed labially, covered by a collagen membrane and sutured. The temporary crown was placed back. Orthodontic tooth movement continued. After 3 months, stage 2 implant surgery was performed and slight palatal connective tissue was extracted and transplanted labially, followed by gingival former placement and suturing. 15 days after healing (Figure 7), the impression procedure for implant was carried out. As 11 was fractured, a veneer was planned to correct its shape and aesthetics. After a bisque trial, the final veneer with 11 was bonded and a cement-retained FP3 type metal-free Zirconia prosthesis with cervical pink porcelain was fixed. Simultaneously, debonding of orthodontic brackets was done and a fixed lingual retainer was placed. The patient was extremely overwhelmed and satisfied with the new smile (Figure 8). 6-monthly follow-ups have been carried out since then.
Figure 6: Radiograph showing implant placed.
Figure 7: Healed site after implant placement, prior to final prosthesis.
Figure 8: Post treatment with final prosthesis.
Figure 9: 2-year follow-up showing gingival tissue cuff around the cervical porcelain.
Copyright: © 2021 Rishi Bhimani and Avishkar Mokal. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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