Cases

Cracked Teeth

A 72-year-old male presented for a comprehensive exam with a chief complaint that the tooth on the upper right side had had a root canal done twice, but he was still in pain. He was wondering if there was a possible sinus infection. Health history included a pacemaker, Warfarin, and thyroid cancer. Testing of the upper right side was, for the most part, inconclusive, aside from some 6 mm pockets in the upper right quadrant. Radiograph was WNL . A potential sinus infection was discussed, along with the possibility of a periodontal abscess. The patient was placed on antibiotics, referred to an ENT, and had scaling and root planing done on the upper right quadrant. The report from the ENT was negative. The symptoms persisted and, in fact, started to worsen. The likelihood of a vertical root fracture was then discussed with the patient. He was referred to an endodontist who took a CBCT scan. Evaluation by the endodontist showed a very small direct, vertical 9 mm drop on the lingual with radiolucency on the lingual root in the scan about halfway down . Given the history of the double root canal, symptoms, and radiographic evidence, it was concluded that the patient had sustained a vertical root fracture on the lingual root of tooth No. 4. Prognosis was poor, and the tooth was removed with discussion regarding replacement options. This case is a classic example of how elusive diagnosing these types of teeth can be and how critical a comprehensive assessment is to produce the most accurate diagnosis.

Conservative Dentistry Endodontics

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Diagnosing what it's cracked up to be: A lesson in endodontics

There’s no one-size-fits-all approach for diagnosis/treatment of cracked or fractured teeth. Dr. Stacey Gividen presents two clinical cases to help you sort things out. Is the tooth cracked or fractured? Does it need a root canal? You’ll want to keep the decision matrix in this article as a reference tool for your endo cases. Resource for your patients >>> Cracked tooth: Types, causes, and treatments Patient: “My tooth hurts, especially when I bite down.” You: “Does the pain linger? Is it sensitive to hot and/or cold? How long has the pain been going on?” Meanwhile … tests begin and clues to the puzzle begin to come together. Diagnosis: Cracked tooth? Fractured tooth? Split tooth? Extent—unknown (or … you may have an idea, but it is subjective). So how do you decide which one it is? Now what? Root canal? Crown? What is the prognosis for treatment versus alternative replacement options? These are all questions that run through my mind when a patient presents with a cracked or fractured tooth. Sure, the test results will dictate a subsequent recommended treatment plan; however, what I’ve learned is that there is not a one-size-fits-all diagnosis and treatment for teeth such as these. Why is that? Additionally, one must consider patients who present with completely asymptomatic craze and crack lines all over their teeth. You cringe just looking at these teeth and know that there’s likely going to be a problem at some point down the road. What is the dialogue that you have with these patients? “Watch” these teeth? Recommend crowns (and often get accused of trying to bamboozle money from the patient for expensive dental work because a second opinion from another dentist suddenly renders you incompetent)? The conundrum is real. Treatment and outcome for a cracked or fractured tooth is dependent on location, direction, type, and size of the crack. Being able distinguish the difference can aid in a diagnosis that will ultimately lead to proper care and treatment. The American Association of Endodontists has classified five types of cracks in teeth: 1. Craze lines 2. Fractured cusp 3. Cracked tooth 4. Split tooth 5. Vertical fracture Refer link: https://www.dentistryiq.com/dentistry/endodontics/article/16366420/diagnosing-what-its-cracked-up-to-be-a-lesson-in-endodontics

Conservative Dentistry Endodontics

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Clinical question: What would you do—internal bleaching or crowns?

A young patient presented for a consult to consider endo/internal bleaching on nos. 9–11. An endodontist would like your perspective on the various treatment options. Here’s a question from an endodontic colleague, asking for insight from our various perspectives regarding this scenario. Take a read... Is endo/internal bleaching considered aggressive or conservative compared to full-crown coverage? How about when multiple teeth are involved? I recently had a young lady come in with multiple teeth darkened from trauma that happened years ago. It was for a consult to consider endo/internal bleaching. The patient was given the alternative for full-crown coverage on teeth nos. 9–11, with no. 9 being slightly darkened, no. 10 more so, and no. 11 in the initial stages (as compared to the normative opposing incisors). The lesion on no. 10 (which one can guess is from trauma due to the very limited restoratives; figure 1) was the main reason for being referred. Of course, there is the esthetic issue as well. So, which do you think? 1. Endodontic treatment of no. 9, 10, and 11 (with conservative accesses) with internal bleaching and lingual restorations posttreatment? Or… 2. Treat no. 10 and then do full porcelain coverage on all incisors since the shading is light enough for coverage and no show-through. Is taking a bur to the teeth too aggressive? Is it practical? Internal bleaching has its drawbacks and may not be the best definitive long-term solution the patient is looking for. Time is money; perspective is everything. State your case and why you feel that way, and I’ll post the responses for everyone to reflect on. Looking forward to the discussion! Keeping dentistry real, raw, and day-to-day... Cheers, my friends! Refer link: https://www.dentistryiq.com/dentistry/restorative-cosmetic-and-whitening/video/14203210/clinical-question-what-would-you-dointernal-bleaching-or-crowns

All Specialities Dental Materials + 1 more

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Flip-flop pathology: Same or different lesions?

Numerous radiolucent lesions in the same patient were biopsied five years apart. Based on the clinical findings, are these lesions the same or different? Case presentation and medical history A 60-year-old female presents for a new patent exam to “get established.” She had no concerns. Medical history, other than occasional social smoking and acetaminophen allergy, was insignificant. Dental history, however, was not so vanilla. Approximately five years ago, at one of her general dental appointments, she had informed her dentist that she had some tenderness in the proximity of her lower front jaw. Radiographic assessment had apparently revealed numerous radiolucent lesions in the anterior mandibular area. The patient was referred to an oral surgeon, who removed the lesions and sent them off for biopsy. The definitive diagnosis was glandular odontogenic cyst. Postsurgery, it was recommended that the patient be diligent with her recare exams, specifically radiographic follow-up as the lesions tend to recur. Clinical exam At her visit with me, the updated radiographs showed the presence of multilocular radiolucencies in the lower anterior area. Some tenderness was present but vague and very sporadic. Since there was a history to the area, it warranted another assessment and biopsy. As a side note, teeth nos. 25 and 26 had root canals on them, which I suspect were done because of the radiolucencies in the area. All other lower anterior teeth tested vital. Diagnosis and discussion The patient was referred to an oral surgeon who performed curettage on the lesions and sent the tissue off to pathology. This was the attending pathologist’s report: “…based on the morphology, I favor lateral periodontal cyst, although recurrences are more typical of the polycystic variant termed botryoid odontogenic cyst. I note that there is a reported ‘history of glandular odontogenic cyst in the same location,’ highlighting the well-known challenge differentiating lateral periodontal cyst from glandular odontogenic cyst…both lateral periodontal cyst and odontogenic keratocyst are believed to be derived from dental lamina. Clinical follow-up is recommended to ensure resolution of the radiographic abnormality.” So, there’s a flip-flop diagnosis between the patient’s original lesion and the current lesion, both of which have a similar origin. Here is some basic information about lateral periodontal cysts and glandular odontogenic cysts. Refer link: https://www.dentistryiq.com/dentistry/pathology/article/14202339/flipflop-pathology-same-or-different-lesions

Oral Medicine and Radiology Cyst and Tumors + 2 more

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An extreme case of oral herpes

A patient with a long and varied medical history presents for an extraction. Dr. Stacey Gividen discovers numerous lesions and gives her diagnosis. A 70-year-old male presents for an extraction of tooth no. 5 due to gingival-level fracture. The patient was seen two weeks prior for a limited exam to assess the break. At that time, he had received his first dose of the COVID-19 vaccination. At this dental visit, he’d had the second round of the vaccine. Medical history Over the course of the last year, the patient reported extreme stress, grinding, and subsequent breaking of teeth, of which no. 6 was extracted not nine months earlier. He received an interim partial denture/acrylic flipper to replace missing nos. 6 and 7. His blood pressure had been noted to increase over the last year, to which he had been turned away at one dental visit and advised to see his general practitioner to get his blood pressure lowered before treatment was rendered. Furthermore, this patient was recently diagnosed with type 2 diabetes. Chronic back and neck injuries, with prescriptions written for pain medications and muscle relaxants, have been his constant companion for numerous years. In addition to these issues, the patient had a history of drug abuse in the 1970s, the extent of which he claims is one of the reasons his overall health is poor. Clinical examination When we sat the patient back in the chair for delivery of local anesthetic, numerous large, irregular-bordered ulcerated lesions were noted throughout the mouth as well as the perioral area (figures 1–3). The lesions appeared crusted over and yellowish in color. Their size ranged from 5 mm to more than 15 mm. Upon inquiring, the patient stated that since his tooth broke, his tongue perpetually rubbed against the flipper, eventually causing those lesions, as well as others, throughout his mouth. He said the lesions appeared about one week prior. Given the location and duration of the lesions and the patient’s health history, it was clear that the partial was not the genesis for this pathology; stress and poor health were indeed the culprits. The diagnosis Canker sores. Fever blisters. Aphthous ulcers. Herpes type 1 (HSV-1). Yes, all of these as they are one in the same lesion. The cause Well, the ramifications of COVID-19 once again have reared their ugly head. Stress, grinding, increased blood pressure, nervous habits, poor diet, diagnosis of type 2 diabetes...put all of these into a melting pot of challenges that place strain on the body’s systems, and something has to give. In this particular scenario—due to the size and conglomerated nature of the lesions—the patient had herpetiform/aphthous major ulcers. Treatment and discussion Treatment for this patient was a prescription for acyclovir 400 mg, four to five times a day for a week. He was given instructions for care, which were primarily palliative, for the next seven to 10 days. A prescription for topical cream was denied. Here is an informative, research-based LINK that will give you a quick guide/reference/refresher on HSV-1. While the existence of canker sores has always been part of many of our patients’ lives, recent environmental stressors have played a role in an increased outbreak across the general population. This has created a need for us, as health-care providers, to up our game in prompt diagnosis, treatment, and encouragement of patient overall self-wellness. Refer link: https://www.dentistryiq.com/dentistry/pathology/article/14201524/oral-pathology-case-an-extreme-case-of-oral-herpes

Oral Medicine and Radiology Oral Mucosal Lesions + 1 more

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A 62-year-old female presented complaining of periodic symptoms from right mandibular molar area

A 62-year-old female presented complaining of periodic symptoms from right mandibular molar area Dr. Hassem Geha ([email protected]) – MS Oral and Maxillofacial Radiology University of Connecticut, School of Dental Medicine, Farmington, CT Symptoms haven’t been severe in recent times. She was previously seen by a dentist approximately 12-18 months ago due to swelling and infection in that area. At that time, she was treated with antibiotics and was told that the mandibular right wisdom tooth needs removal by a surgeon. The patient reported that she has had anesthesia of her lower right lip during flare up episodes, but this has resolved completely with no further paresthesia or anesthesia after antibiotherapy. Current clinical examination showed moderate gingival inflammation surrounding 48, and 48 was slightly tender to percussion. Caries were noted on teeth 48 and 18. Radiographic findings A panoramic radiograph and a Cone beam CT of the right mandible showing 48 and 47 and part of the mandibular ramus were available for radiographic interpretation. The viewed images show that Tooth 48 is impacted with an enlarged follicular sac. There is a well-defined, non-corticated low density extending from the level of the buccal CEJ of this tooth and extends inferiorly to the level of the apex of this tooth and loops around the apex into the lingual aspect of the tooth. This low density extends to the lingual cortical plate causing thinning and mild expansion and likely a perforation. Additional Findings • Endodontically treated 36 with widened PDL space were noted suggestive a periapical pathosis. • Missing teeth 28. Radiographic differential diagnosis Findings in the area of 48 are suggestive of an enlarged pericoronal sac that got infected and invaded the buccal PDL space of 48 and spread into the lingual area of this tooth. This is highly supported by the history of inflammation and infection as reported by the patient and the current clinical observation of tender swelling and moderate inflammation. In addition, there appears to be some occlusal trauma on 48 by 18 causing an additional stress on the PDL space of the tooth leading to a wider PDL space. Although an infected cyst can cause resorption, it is unlikely that it loops around the roots and causes resorption lingually and thinning and perforation of the lingual cortical plate with no expansion or subperiostal new bone formation. Usually, such cysts expand in a balloon-like fashion beyond the CEJ. This feature is not present in the current lesion. We clearly see a different path of expansion on the distal aspect of 48 that is not in continuity with the follicular sac. Also, while an infected cyst can cause erosion of the cortical outline of the mandibular canal, there is likelihood that the origin of the lesion is neurogenic tumour that extends from the mandibular canal and causes the resorption on the lingual aspect of 48. Such a lesion can cause thinning and perforation of the lingual cortical plate with no expansion. Also the patient has had episodes of anesthesia that can fit a neurogenic tumour. However, as these symptoms resolved, such tumour becomes an unlikely candidate. Another unlikely lesion can be a low grade muco-epidermoid carcinoma. Usually such malignant tumours tend to cause anesthesia or paresthesia that does not subside with treatment. Our differential included the following in a preferential order: 1. High likelihood for infected follicular cyst. 2. Low likelihood of Neurogenic tumour with or without superimposed infection. 3. Least likelihood of a low grade malignant tumour. Course of action Since the patient was asymptomatic, she was referred to an Oral and Maxillofacial surgeon for tooth extraction and biopsy. Surgical planning of extraction of 48 and associated requested biopsy should take into consideration the position of the mandibular canal within the lesion and the fact that the cortical outline is lost. Also, the surgical treatment should take into consideration the possible lingual perforation and the risk of injury of the lingual nerve in this area. Refer link: https://www.dentalnews.com/2019/09/26/62-year-old-female-right-mandibular-molar/

Oral Medicine and Radiology Cyst and Tumors + 2 more

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Case report of soft tissue crown lengthening

The case report that will be presented below was realized with a 980 nm diode laser. Diode laser is one of the most popular lasers because of its compact size, light weight, portable unit and relatively reduced cost while remaining efficient with beneficial effects. Its active medium is a solid state, composed from semi-conductor crystal combining Indium, Gallium and Arsenide (InGaAs) that transform the electric current into light energy. It is a modern device with the foundation of modern electronics. Depending on the clinical situation, the diode laser can be used in contact mode or non-contact mode (PBM, bleaching, desensitizing.). Cutting tissue by diode lasers occurs through photothermolysis: Chromophores in the target tissue absorb the light energy rapidly, immediate rise in temperature with subsequent denaturation of tissue protein, as well as fragmentation and vaporization of the melanin, followed by vaporization of water content. So, it is temperature rise that causes soft tissue disruption. Depending on the temperature level reached at the surgical site, soft tissue are subjected to warming, welding, coagulation, protein denaturation, drying, ablation then vaporization or carbonization10. Power settings of the diode laser device are adjustable, and the laser beam may be delivered in a constant continuous mode or in gated mode: A) With continuous mode, there is a gradual increase in the temperature then heat generation gets much faster; there is tremendous risk to get uncontrolled damage (the amount of heat generated is translated directly into the amount of collateral damage) B) With gated continuous mode, when using gated mode, there is still a rise in temperature, but the tissue has time to cool down during the thermal relaxation time, which leads to controlled collateral damage & lower thermal rise. This explains the general recommendation for laser use at low power and in gated mode for soft tissue procedures Before surgery with the diode laser, the ultra-thin lasing fiber could be initiated. This process allows capturing most of the energy (60% of the energy or more) at the end of the laser fiber and the incision is faster. This is done by tapping the laser fiber on articulating paper while the laser is energized. Usually a 300µm tip is selected for surgical gingival cutting rather than a 200µm tip, because this latter is more fragile and breakable Before cutting gingival tissue, the depth of the sulcus should be measured with a periodontal probe. The bone level should be sounded and a biological width of 2-3mm should be respected in order to avoid any further periodontal damage. During surgery, the 300µm fiber tip is placed in contact with the tissue. This gives the clinician the essential tactile feedback which is absent with some other lasers such as CO2 lasers. Excision is performed with gentle sweeping brush motions. It is important to emphasize that the laser tip does not cut like a blade, but it vaporizes tissue layer by layer at the fiber end and not on the sides, since these latter areas are protected by the collimation cladding so the energy cannot be transmitted through the sides. The correct technique is to avoid pressing on the fiber, but to simply guide it along the precise route desired, using light brush stroke to “paint away“ the amount of tissue to cut, and to let the highly directed laser energy do the work. Water irrigation with a syringe is helpful to reduce the charred layers and to cool down the tissue; high aspiration removes the dangerous laser plume.

Aesthetic Dentistry Bleaching + 1 more

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Erosion infiltration technique for enamel white discoloration

Abstract Early stage caries (White spots), fluorosis, traumatic hypomineralizations and molar incisor hypomineralization (MIH) all present to differing degree, clinical symptoms involving white marks on the enamel. It can impact patients’ quality of life. The most conservative treatment in such cases is erosion-infiltration. This treatment using Icon® (DMG, Hamburg, Germany) is one of the most conservative and efficient protocols. The Icon® treatment was initially proposed as a simple and minimally invasive alternative for caries treatment of initial proximal lesions, but surprisingly the technique proved a high ability to mask the white spots by modifying the refractive index of the lesion. The proposed strategy is not based on the elimination of dysplastic enamel, but on masking the lesion by infiltrating the porous subsurface enamel with a hydrophobic resin that has a refraction index closer to that of sound enamel, after permeating the non-porous surface enamel through hydrophobic acid erosion. This article provides an overview of different indications suitable for treatment with the technique of resin infiltration (Icon®, DMG), such as white-spot lesions (WSL), enamel fluorosis, and molar-incisor hypomineralisation (MIH) in different patients. Key words: Infiltration, White spot lesion, Fluorosis, MIH Introduction Clinically, early carious lesions in enamel is initially seen as a white opaque spot and is characterized by being softer than the adjacent sound enamel. It becomes even whiter when dried with air. These lesions may present a serious aesthetic problem along with the progression of demineralization 1. These white spots can be the result of different factors: early stage caries (due to plaque accumulation and bad oral hygiene) near the gingival line or around orthodontic brackets, fluorosis, medicine intake, molar incisal hypomineralization (MIH) and traumatic hypomineralization 2. Management of this type of white spot lesion is generally by means of topical application of Fluoride therapy, Casein-Phospho Peptide-Amorphous Calcium Phosphate pastes, Novamin (calcium sodium phosphosilicate) 3. All these treatment modalities end up in surface remineralization, but the subsurface is still porous. To overcome the drawback of retaining a porous subsurface caries, resin infiltration seems to be a promising and less invasive treatment modality. In this method, the subsurface porosities are occluded by a clear hydrophobic resin applied on the surface of the conditioned lesion 5. The resin infiltration technique prevents further progression of the lesion using a low-viscosity resin with a high penetration coefficient, filling the enamel intercrystalline spaces 6. A reduced visibility of infiltrated WS-lesions is an additional positive side-effect, which is due to the similar refractive index of the infiltrated and sound enamel areas. This technique has been reported to remove the whitish opaque color therapy changing the color and translucency of the white lesion 7. The purpose of this clinical report was to describe and illustrate a minimally invasive technique that improves the esthetic aspect of the white spot lesion. Clinical Cases report This article presents a series of three cases of patients aged between 20 and 26 years who exhibited enamel white discolorations in esthetically compromised tooth areas. Anamnesis and clinical assessment were performed to determine the etiology of discolorations. All patients signed an informed consent authorizing the treatments and use of images. The treatment decision was based on minimal intervention dentistry, using the resin infiltration technique with low-viscosity resin (Icon®, DMG, Hamburg, Germany) as an attempt to mask these lesions. Case 1 (Figure 1) were diagnosed as postorthodontic white spot lesion. Case 2 very mild fluorosis (Figure 2) Case 3 (Figure 3) was classified as hypomineralized spots resulting from molar incisor hypomineralization. When lesions were close to the gingival margin, a conventional rubber dam with ligatures was used to protect the oral soft tissues, deflect the gingival tissue, expose the cervical portion of the tooth, and provide a clean and dry working field. On the other hand, when no deflection of the gingival tissue was necessary, a resinous gingival barrier (liquid rubber dam) was used. After cleaning with prophylaxis pumice, the affected areas were etched with 15% hydrochloric acid (Icon-etch) for two minutes and then washed with water spray for at least 30 seconds. At this time, the lesions were assessed for color alteration, and if no visual color change was obtained with water, the etchant was applied again for an additional two minutes, until some color alteration could be observed at the wet eroded surface. The surface was then air dried, and ethanol (Icon-dry) was applied for 30 seconds to maximize the water removal inside the lesions. The lesions were air dried again, and the surfaces exhibited a chalky white appearance. The resin infiltrant (Icon®) was then applied on the lesion surface, and it was allowed to penetrate for three minutes. Excess resin was removed using a blow of air, and light curing was performed for 40 seconds. The resin infiltrant application was repeated for one minute, followed by light curing for 40 seconds. The surfaces were polished using fine-grained abrasive flexible discs, rubber points, and finishing strips, depending on the treated area. An immediate esthetic improvement, with partial or total color masking, could be observed after treatment. The final pictures were obtained one week after the end of the treatment, allowing rehydration of the teeth and gingival tissue repair. Case Report 1 A 24-year-old female patient reported to our department of restorative dentistry and endodontics with a chief complaint of white patches in the lower tooth. After oral examination, she presented with mild to moderate postorthodontic WSLs at the right lower canine and premolar (Figure 1a) following treatment with a fixed orthodontic appliance for two years at the Department of Orthodontics. Informed consent was obtained from the patient and treatment plan was established as Caries Infiltration with ICON® (DMG, Germany) (Figure 1b, c, d) Case Report 2 A 26-year-old female patient who did not have any problems in her medical history was referred to the department of conservative dentistry and endodontics, with a chief complain of white lines on her maxillary incisors and brown and yellow discolorations on the other maxillary teeth. Informed consent was obtained from the patient and treatment plan was established as Caries Infiltration with Icon® (DMG, Germany) and dental whitening with 16% carbamide peroxide. (Figure 2) Case Report 3 A 23-year-old female patient presented with white spot lesions on her upper teeth. The spots are easily visible in the frontal view of the anterior teeth: a big white spot on tooth number 21 and 11. This patient was looking for an esthetic solution for these defects in her smile (Fig. 3). After the clinical and radiographic examination, the occurrence of hypomineralization of the upper and all the first permanent molars characterizing MIH was diagnosed. In our first case describing superficial infiltration we limited application of the erosion/infiltration technique to cases which required no dental preparation, such as early stage caries, most types of mild fluorosis and hypomineralization resulting from superficial traumatic lesions. But the technique as presented resulted in failures in many cases such as where lesions originate at the dentino-enamel junction and extend into the enamel, as in MIH. This is why treatments of MIH lesions by erosion/infiltration were never, or almost never, successful. In view of the high level of prevalence of such cases, it was essential to find solutions to overcome these failures. The concept of deep infiltration involves paying a price in the form of mild mutilation of the enamel through preparation by sandblasting or milling so as to ensure that the infiltration can indeed reach the “ceiling” of the lesion in the case of MIH or spread through almost the whole of the lesion if the latter is deep (fluorosis or deep traumatic hypomineralization. Discussion White marks and white lesions on anterior teeth can be unsightly. Patients often seek treatment to have these marks eradicated. Whilst there is a wide array of treatments available, which includes whitening as a first choice7 and bonding over the mark as a last option, a new technique using resin infiltration has been introduced 8. Tooth-whitening techniques have been employed, with the aim of bleaching regular enamel, camouflaging the white-involved areas, and making the tooth color more uniform. Nevertheless, the results are not always satisfactory, and in many cases, microabrasion with pumice and hydrochloric acid needs to be performed. Enamel microabrasion can produce acceptable esthetic improvement in shallow lesions, 11 and although the amount of enamel loss is related to the acid type and concentration, abrasive particles, duration and number of applications. Refer link: https://www.dentalnews.com/2019/05/22/erosion-infiltration-technique-for-enamel-white-discoloration/

Aesthetic Dentistry Smile Designing + 1 more

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Dental implant bridge supported by four or more implants

For many patients missing all their teeth can have a devastating impact on quality of life. For replacement of all teeth, we have 2 main options: A removable prosthetic denture secured on two or more implants using mechanical anchors or a bar. A fixed prosthesis consists of a dental implant bridge supported by four or more implants. Implant retained bridgework allow patients to function normally without restrictions, these are easily maintained by good home care. Case Overview This pleasant gentleman was referred in 2007 for the possibility of implant therapy as he did not wish to have a removable denture in the lower jaw. as he had suffered from severe gum disease, this is a high-risk factor for future implant complications…… A diagnosis of severe chronic periodontitis was made along with cosmetic concerns. Unfortunately, due to the severe bone loss present, the natural teeth could not be saved. The decision was made in conjunction with the patient to make a new complete upper removable denture and a fixed implant bridgework in the lower. Procedure STAGE 1 The radiograph shows extreme bone loss around all the remaining natural teeth. Unfortunately, none of these teeth had a good long-term prognosis. STAGE 2 The natural teeth were extracted and 6 dental implants were placed at the same time. The final fixed bridge was made from acrylic wrapped onto a cad/cam titanium frame. The upper jaw was restored with a removable complete denture. Clinical Prognosis Prior to starting the treatment, the patient was made well aware of his role during and post-treatment. As he had suffered from severe gum disease, this is a high-risk factor for future implant complications. He has been attending regular hygiene appointments on a twice-yearly basis and an annual review with the dentist. After 9 years in function there have been no complications and with his excellent home maintenance, we hope to get several more years without any issues. “The result has been I now have a full set of implanted teeth, which has helped me return to a normal life, I can eat, speak and drink normally.

Aesthetic Dentistry Dental Materials + 3 more

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One of my favorite orthodontic cases

Here, he covers the extraction of a supernumerary tooth, as well as wires, brackets, X-rays, bleaching, and a retainer. First off I'm not an orthodontist nor do I play one on TV, but I was at least partially trained at a Holiday Inn Express. I have taken several comprehensive orthodontic training courses including Dr. Robert Gerety's course, Progressive Orthodontics, and a hands-on tip edge course in Austin with Dr. Jeff Gerhardt. This is a case that I took on early in my career as a wannabe orthodontist. She came to me for an orthodontic consultation. She was 24 years old and hoping to marry her then-boyfriend at some point, but she didn't like her smile; she felt it was unattractive. So we gathered her orthodontic records and pointed out to her that it appeared she had either a supernumerary tooth or over-retained primary tooth between her upper centrals. Along with this, she also had some minor crowding on her lower teeth. She had a Class I molar relationship that I hoped to maintain. After getting her cleaned up, we presented her with a treatment plan of extracting the upper supernumerary tooth, closing the space between her upper centrals, an in-office bleaching treatment, and later restoring them by removing the caries and bonding composite. Treatment progression Extraction of supernumerary tooth — Month 0-3 I like to start all my orthodontic cases off with a light round nickel titanium wire such as an 014N or 012N. While in this wire, I used some elastomeric chain to help align and rotate the teeth. Month 4-10 I continued to level the teeth and begin to reposition brackets on a 18X25 heat-activated NiTi wire based on a panoramic X-ray that I like to take to help me with root positioning. Month 11-16 Progress to a stainless steel 19x25 wire for more tooth torque and better bracket engagement. Month 16-18 Finishing on a 018SS. I don’t have much wire-bending skills, so I mostly move brackets and am capable of only some simple step bends. Bleaching: We debanded the upper and performed a Zoom bleaching up top. At that time we also impressed to make a lower bonded lab-fabricated retainer. (I know we should do this in-office.) When the patient returned, we delivered the retainer and removed the last of the brackets. The patient was more than thrilled with the final outcome of the case. That was one of our first cases, and I'm sure at this point we could manage the case more efficiently. I call this one of our best cases not because of the orthodontic challenges. Most dentists out there could do a better job. Today we may have offered her a lovely set of veneers to really knock it out of the park. But the reward was great, because I feel we possibly changed someone's life. The positive change in her smile and appearance gave her a newfound confidence.

Aesthetic Dentistry Orthodontics and Dentofacial Orthopaedics + 4 more

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