Page 20 - GP Fall Final 2017

An Interdisciplinary Approach:
Solving A Complex Mandibular Anterior Reconstruction

By John G. Albert, DMD, Robert Schaefer, Jr., DDS, and Vincent Smith, MS, DDS

In the field of dentistry, we are problem cial aspect of #23. A comprehensive peri- • Regeneration of the extraction socket
solvers. Everyday our technical skills are odontal examination revealed this defect defect.
challenged by patients who present unique to be an isolated problem with all adjacent • Cortical stimulation with bone grafting
clinical situations that must be addressed. teeth displaying a high degree of periodon- of the alveolar ridge (Regionally Ac-
Our approach to tackling complex tasks, tal health. The examination located vertical tivated Phenomena) to permit bodily
while making them appear routine, often support loss on the mesial, facial and distal tooth movement during corresponding
starts with a detailed, individualized treat- root surfaces of #23, approximating 270 of labial plate expansion. This Accelerat-
˚
ment plan. Seldom do patients appreciate exposed root surface from the alveolar ed Osteogenic Orthodontic Procedure®
the gravity of their particular problem. Is- ridge. The tooth occupied a labial version (AOO) minimizes the risk of addition-
sues of adequate support, acceptable aes- with #22 and #24 drifting proximally in an al root exposures of the adjacent teeth
thetics with predictably functional results attempt to close the space. These lingual during the expansion process.
must be packaged into a restorable solu- forces from the movement of #22 and #24 • Orthodontic expansion of the mandib-
tion that maintains oral health. Frequently, were suspect in assisting the movement of ular anterior sextant to recapture space
that is not an easy task. at the #23 position while developing an
#23 toward the labial. The normal incisive anterior Class I relationship.
The following case report evolved into one forces of routine mastication may also be • Single dental implant placement at #23.
of those cases. What initially brought this contributing to the labial repositioning of • Crown fabrication over the dental im-
attractive female patient into our offices for #23. Any soft tissue grafting procedure plant fixture.
dental care was an irritated and unsightly will not completely address the problem
area of gingival recession. In the age of nor will it replenish the missing supporting Case Report
aesthetic dentistry, the patient sought only structures. A lack of supporting bone with Prior to the initial surgical visit, ortho-
an aesthetic solution. What we found was a prominent labial root would further in- dontic brackets were placed (Figures 3,4).
an advanced periodontal support problem crease the chances of donor tissue necrosis However, orthodontic forces were not in-
with occlusal and spatial relationship com- due to compromised blood supply to the troduced for two weeks following the ex-
plexities that had no easy or readily avail- donor tissue. traction/regeneration procedure.
able aesthetic answer.
Teeth #24, 25, 26 and #27 shared approx- Tooth #23 was extracted, resulting in the
The treatment plan that developed ad- imately a 6mm overjet (Figures 1,2), pro- development of a tapering walled ridge
dressed all of the patient’s needs while sat- viding space for orthodontic correction that defect (Figure 5). Corticotomies were com-
isfying the requirements to deliver predict- would lead to improvement of the existing pleted (Figure 6), preceding the introduc-

able restorative dental care. Class II relationship. The following treat- tion of composite graft materials (Figure

ment plan was developed and enacted: 7). Primary closure with ePTFE suture is Immediate and in treatment provisionalization is
extraction/regeneration procedure. Tooth #23 is
Immediate and in treatment provisionalization is
extraction/regeneration procedure. Tooth #23 is
Introduction extracted resulting in the development of a tapering predominantly completed by first using the natural
important to prevent loss of the graft or ex-
predominantly completed by first using the natural
extracted resulting in the development of a tapering
A 40-year-old female presented to the of- • Extraction of the poorly supported, labi- posure of the thin, fragile labial and lingual enamel crown then applying prosthetic acrylic pontics,
enamel crown then applying prosthetic acrylic pontics,
fice with a mucogingival defect on the fa- ally positioned #23. plates of bone (Figure 8). During the first figs. 9 and 10.
figs. 9 and 10.

Fig. 5 Fig. 6
Fig. 5 Fig. 6

led ridge defect, fig. 5. Corticotomies are
1-3 wald ridge defect, fig. 5. Corticotomies are
1-3 walle
Immediate and in treatment provisionalization is is
Fig. 9 Fig. 10
extraction/regeneration procedure. Tooth #23 is completed, fig. 6, preceding the introduction of Fig. 9 Fig. 10
extraction/regeneration procedure. Tooth #23 is
Immediate and in treatment provisionalization
completed, fig. 6, preceding the introduction of
Figure 3. Figure 4.
Figure 1. Figure 2.
predominantly completed by first using the natural
predominantly completed by first using the natural
extracted resulting in the development of a tapering composite graft materials fig. 7. Primary closure with For short periods of time during care, removable
For short periods of time during care, removable
composite graft materials fig. 7. Primary closure with
extracted resulting in the development of a tapering
temporization may be necessary in some cases.
enamel crown then applying prosthetic acrylic pontics,
enamel crown then applying prosthetic acrylic pontics, temporization may be necessary in some cases.
figs. 9 and 10.
figs. 9 and 10.

Fig. 5 Fig. 6
Figure 7. Figure 8.
Figure 5. Figure 6. Fig. 7 Fig. 8
Fig. 5 Fig. 6
Fig. 7 Fig. 8
1-3 walled ridge defect, fig. 5. Corticotomies are
1-3 walled ridge defect, fig. 5. Corticotomies are ePTFE suture is important to prevent loss of the graft
ePTFE suture is important to prevent loss of the graft

www.nysagd.org l Fall 2017 l GP 17
Fig. 9 Fig. 10
completed, fig. 6, preceding the introduction of
or exposure of the thin, fragile labial and lingual pla
completed, fig. 6, preceding the introduction of or exposure of the thin, fragile labial and lingual plates Fig. 11 Fig. 12
Fig. 9 Fig. 10 tes
Fig. 11 Fig. 12
composite graft materials fig. 7. Primary closure with
For short periods of time during care, removable
For short periods of time during care, removable
composite graft materials fig. 7. Primary closure with of bone, fig. 8. During the first two weeks following Within 6 weeks following the regeneration/activation
of bone, fig. 8. During the first two weeks following
Within 6 weeks following the regeneration/activation
temporization may be necessary in some cases.
temporization may be necessary in some cases.
the AOO® procedure, a focal osteopenia is developing procedures positive results are apparent, fig. 11 and
the AOO® procedure, a focal osteopenia is developing
procedures positive results are apparent, fig. 11 and
throughout the bone activated at the surgical site. fig. 12. Space development and ridge regeneration
throughout the bone activated at the surgical site.

fig. 12. Space development and ridge regeneration
Once the Regionally Activated Phenomena has are noted in the fore mentioned digital images.
Once the Regionally Activated Phenomena has
are noted in the fore mentioned digital images.
occurred, accelerated osteogenic turnover can be However, the Orthodontic forces expand only the ridge
However, the Orthodontic forces expand only the ridge
occurred, accelerated osteogenic turnover can be
expected. During any treatment whose intent is to plates housing the adjacent teeth. There is no
expected. During any treatment whose intent is to
plates housing the adjacent teeth. There is no
stimulate a rapid osteogenic process, patients should expansion at the edentulous space. The edentulous
stimulate a rapid osteogenic process, patients should
expansion at the edentulous space. The edentulous
be strongly advised that use of any Non-Steroidal space lacks the applied labial force to a vital cortical
be strongly advised that use of any Non-Steroidal
space lacks the applied labial force to a vital cortical
Anti-Inflammatory Drugs (Nsaids) will rapidly and

plate. Some particulate graft compression and

Anti-Inflammatory Drugs (Nsaids) will rapidly and plate. Some particulate graft compression and
Fig. 7 Fig. 8
Fig. 7 Fig. 8 irreversibly shut down the desired biologic process. resorption can be expected at the edentulous site.
irreversibly shut down the desired biologic process.
resorption can be expected at the edentulous site.
ePTFE suture is important to prevent loss of the graft
ePTFE suture is important to prevent loss of the graft

or exposure of the thin, fragile labial and lingual plates
Fig. 11 Fig. 12
ORTHODONTIC TREATMENT
or exposure of the thin, fragile labial and lingual plates ORTHODONTIC TREATMENT In 4 months and 1 week the Orthodontic care is
Fig. 11 Fig. 12
In 4 months and 1 week the Orthodontic care is
of bone, fig. 8. During the first two weeks following
of bone, fig. 8. During the first two weeks following Within 6 weeks following the regeneration/activation complete. The space is achieved at #23. Doses of
complete. The space is achieved at #23. Doses of
Within 6 weeks following the regeneration/activation
the AOO® procedure, a focal osteopenia is developing
procedures positive results are apparent, fig. 11 and
the AOO® procedure, a focal osteopenia is developing Orthodontics initiated with the placement of Dentsply Nsaids are initiated to arrest the osteogenic process,
Orthodontics initiated with the placement of Dentsply
procedures positive results are apparent, fig. 11 and
Nsaids are initiated to arrest the osteogenic process,
throughout the bone activated at the surgical site.
fig. 12. Space development and ridge regeneration
GAC In-Ovation R and C .002 brackets with a -6°
throughout the bone activated at the surgical site. GAC In-Ovation R and C .002 brackets with a -6° enhancing the long-term retention of the case. Re-
fig. 12. Space development and ridge regeneration
enhancing the long-term retention of the case. Re-
Once the Regionally Activated Phenomena has
are noted in the fore mentioned digital images.
Once the Regionally Activated Phenomena has lingual crown torque for the mandibular incisors. evaluation of the case reveals two concerns. There is
lingual crown torque for the mandibular incisors.
are noted in the fore mentioned digital images.
evaluation of the case reveals two concerns. There is
occurred, accelerated osteogenic turnover can be
However, the Orthodontic forces expand only the ridge
Brackets are placed on the entire mandibular arch as
However, the Orthodontic forces expand only the ridge an expected ridge deficit at the edentulous #23. And,
occurred, accelerated osteogenic turnover can be Brackets are placed on the entire mandibular arch as an expected ridge deficit at the edentulous #23. And,
plates housing the adjacent teeth. There is no
expected. During any treatment whose intent is to
expected. During any treatment whose intent is to anchorage preventing over expansion of the the attached gingiva is stressing throughout the labial
plates housing the adjacent teeth. There is no
anchorage preventing over expansion of the
the attached gingiva is stressing throughout the labial
stimulate a rapid osteogenic process, patients should
expansion at the edentulous space. The edentulous
stimulate a rapid osteogenic process, patients should mandibular anterior sextant, while continuing to retain aspect of the expanded anterior sextant. Six weeks
expansion at the edentulous space. The edentulous
mandibular anterior sextant, while continuing to retain
aspect of the expanded anterior sextant. Six weeks
be strongly advised that use of any Non-Steroidal
space lacks the applied labial force to a vital cortical
be strongly advised that use of any Non-Steroidal the buccal occlusal relationship. The patient declined following removal of the Orthodontic appliances, the
the buccal occlusal relationship. The patient declined
space lacks the applied labial force to a vital cortical
following removal of the Orthodontic appliances, the
Anti-Inflammatory Drugs (Nsaids) will rapidly and
plate. Some particulate graft compression and
Anti-Inflammatory Drugs (Nsaids) will rapidly and maxillary arch orthodontic care. ridge at #23 is grafted for a second time. Figure 13
maxillary arch orthodontic care.
plate. Some particulate graft compression and
ridge at #23 is grafted for a second time. Figure 13
irreversibly shut down the desired biologic process.
irreversibly shut down the desired biologic process. resorption can be expected at the edentulous site.
resorption can be expected at the edentulous site.

A passive .016 stainless steel archwire is applied while
A passive .016 stainless steel archwire is applied while

ORTHODONTIC TREATMENT
In 4 months and 1 week the Orthodontic care is
ORTHODONTIC TREATMENT the bone graft and corticotomies are completed. The
In 4 months and 1 week the Orthodontic care is
the bone graft and corticotomies are completed. The
complete. The space is achieved at #23. Doses of
enamel crown is affixed to the archwire, fig. 9, as an
complete. The space is achieved at #23. Doses of
enamel crown is affixed to the archwire, fig. 9, as an
Nsaids are initiated to arrest the osteogenic process,
Orthodontics initiated with the placement of Dentsply
Nsaids are initiated to arrest the osteogenic process,
Orthodontics initiated with the placement of Dentsply aesthetic transitional solution. Following a slight
aesthetic transitional solution. Following a slight
GAC In-Ovation R and C .002 brackets with a -6°
enhancing the long-term retention of the case. Re-
GAC In-Ovation R and C .002 brackets with a -6° interproximal reduction of the mandibular incisors, a
enhancing the long-term retention of the case. Re-
interproximal reduction of the mandibular incisors, a
lingual crown torque for the mandibular incisors.
evaluation of the case reveals two concerns. There is
lingual crown torque for the mandibular incisors. .014 Sentinol archwire is placed for three weeks. At
evaluation of the case reveals two concerns. There is
.014 Sentinol archwire is placed for three weeks. At
Brackets are placed on the entire mandibular arch as
an expected ridge deficit at the edentulous #23. And,
Brackets are placed on the entire mandibular arch as that point, a .020 X .020 archwire with active coil
an expected ridge deficit at the edentulous #23. And,
that point, a .020 X .020 archwire with active coil

anchorage preventing over expansion of the
the attached gingiva is stressing throughout the labial

the attached gingiva is stressing throughout the labial
anchorage preventing over expansion of the spring is introduced for 6 weeks followed by 7 weeks of Fig. 13 Fig. 14
spring is introduced for 6 weeks followed by 7 weeks of
Fig. 13 Fig. 14
mandibular anterior sextant, while continuing to retain
aspect of the expanded anterior sextant. Six weeks
aspect of the expanded anterior sextant. Six weeks
mandibular anterior sextant, while continuing to retain .017 X .025 TMA archwire to coordinate and detail the clearly displays the body’s inability to regenerate new
.017 X .025 TMA archwire to coordinate and detail the
clearly displays the body’s inability to regenerate new
the buccal occlusal relationship. The patient declined
following removal of the Orthodontic appliances, the
the buccal occlusal relationship. The patient declined occlusion. A three week orthodontic appointment bone to fill extraction socket voids with the same rate
following removal of the Orthodontic appliances, the
occlusion. A three week orthodontic appointment
bone to fill extraction socket voids with the same rate
maxillary arch orthodontic care.
ridge at #23 is grafted for a second time. Figure 13
maxillary arch orthodontic care. schedule is maintained during active care. Fixed and efficiency that existing vital labial plates can be
ridge at #23 is grafted for a second time. Figure 13
schedule is maintained during active care. Fixed

and efficiency that existing vital labial plates can be
A passive .016 stainless steel archwire is applied while retention with a Hawley appliance is used to initiate expanded and remodeled. For this reason, a second
retention with a Hawley appliance is used to initiate
expanded and remodeled. For this reason, a second
A passive .016 stainless steel archwire is applied while the retention phase of the case. An Essix retainer is regeneration procedure is needed to complete an
the retention phase of the case. An Essix retainer is
the bone graft and corticotomies are completed. The
regeneration procedure is needed to complete an
the bone graft and corticotomies are completed. The recommended for long term retention. acceptable ridge augmentation, fig. 14.
recommended for long term retention.
enamel crown is affixed to the archwire, fig. 9, as an
acceptable ridge augmentation, fig. 14.
enamel crown is affixed to the archwire, fig. 9, as an
aesthetic transitional solution. Following a slight
aesthetic transitional solution. Following a slight
interproximal reduction of the mandibular incisors, a
interproximal reduction of the mandibular incisors, a
.014 Sentinol archwire is placed for three weeks. At
.014 Sentinol archwire is placed for three weeks. At
that point, a .020 X .020 archwire with active coil
that point, a .020 X .020 archwire with active coil
spring is introduced for 6 weeks followed by 7 weeks of

spring is introduced for 6 weeks followed by 7 weeks of Fig. 13 Fig. 14
Fig. 13 Fig. 14
.017 X .025 TMA archwire to coordinate and detail the
.017 X .025 TMA archwire to coordinate and detail the clearly displays the body’s inability to regenerate new
clearly displays the body’s inability to regenerate new
occlusion. A three week orthodontic appointment
occlusion. A three week orthodontic appointment bone to fill extraction socket voids with the same rate
bone to fill extraction socket voids with the same rate
schedule is maintained during active care. Fixed
schedule is maintained during active care. Fixed and efficiency that existing vital labial plates can be
and efficiency that existing vital labial plates can be
retention with a Hawley appliance is used to initiate
retention with a Hawley appliance is used to initiate expanded and remodeled. For this reason, a second
expanded and remodeled. For this reason, a second
the retention phase of the case. An Essix retainer is
the retention phase of the case. An Essix retainer is regeneration procedure is needed to complete an
regeneration procedure is needed to complete an
recommended for long term retention.
recommended for long term retention. acceptable ridge augmentation, fig. 14.
acceptable ridge augmentation, fig. 14.