The crown preparation was done without the administration of local anesthesia. A supragingival shoulder margin was made. Patient was informed about the supragingival shoulder margin, as this being the back tooth, supragingival margin does not compromise the esthetics and the patient can also maintain good oral hygiene. As the tooth had a short clinical crown, two grooves on buccal and lingual surfaces were made for extra retention. The tooth has a very small mesial fracture line. The fracture line was eliminated completely. Temporary crown was fabricated, final impression was taken and the temporary crown was cemented. The patient felt very comfortable and was fully satisfied and happy with the treatment.

S.S., NYU College of Dentistry<–>

Drug-induced Gingival Hyperplasia (DIGH)

My exercise today was to look over a patients record and figure out what the possible treatment options are for the next phase of dentistry.

Chief Complaint: Patient wants to explore treatment options regarding possibility of restoration of anterior dentition. He is open to dentures, implants and any other options. Patient is very phobic, repeated past history of failed dentistry. No dental visits in the past several years.

Relative medical history: Patient has HTN and is taking a calcium channel blocker
Drug-induced gingival hyperplasia (DIGH):
Inflammation of the gingival tissue from bacterial plaque and the subsequent development of gingival crevicular fluid may allow sequestration of the calcium channel blocker, thus predisposing the tissue to a localized toxic effect and the development of gingival hyperplasia. All of the available calcium channel blockers have been reported to cause gingival hyperplasia.

Treatment options include meticulous plaque control, and in severe cases, gingivectomy. Drug-induced gingival hyperplasia (DIGH) is an iatrogenic dental disorder that is characterized by gums that are enlarged and inflamed, and bleed readily upon probing. The gums appear lobulated from papillary enlargement, and the tooth crowns may be partially covered by hyperplastic tissue. Drug-induced gingival hyperplasia is usually only cosmetically disfiguring; however, the formation of tissue pockets can interfere with proper oral hygiene, contributing to periodontal disease and dental caries. Patients who develop DIGH are at risk of treatment failure because of noncompliance. Those who develop severe DIGH may eventually require invasive oral surgery, such as a gingivectomy. (D.B. Lawrence et alJ Fam Pract 1994; 39:483-488)

Initial therapy consisted of scaling and root planing, extraction of four lower incisors that had severe bone loss, and provisional restorations in the edentulous space. After scaling and root planing was completed, and four lower incisors were extracted, provisional restorations were fabricated using Luxatemp. Luxatemp is the temporary crown and bridge material - internationally successful for more than 10 years and Number 1 in the USA since 1997. Luxatemp was the first bis-acrylic composite that was offered in the advantageous 10:1 mixing ratio for automatic mixing. Other advantages are Luxatemp’s outstanding biocompatibility and the safety cartridge developed by DMG. (http://www.dmg-dental.com/produkt.php?lan=en&produkt=58. ) A provisional bridge was fabricated using teeth #22 and #27 as abutments.

Stage two of the treatment will involve permanent restorations in place of extracted teeth to restore esthetics, phonetics and function. The following is what was proposed by me as possible treatment options:

To properly evaluate possible treatment options, the first step would be to conduct radiographic examination using cone beam CT scan which gives dentists a 3D evaluation of the remaining bone. Given the severity of periodontal involvement, a regular 2D image may not be sufficient evaluation tool. If the remaining bone in the mandibular anterior region is sufficient to accept implants then several treatment options are available:

First treatment option:
Placement of four single-unit implants and restore them with four Zirconia abutments and Alumina-porcelain single-unit crowns. Use of the non-metal abutments and crowns will give more natural looking results than conventional porcelain fused to metal crowns and metal abutments.

Second treatment option:
Placement of four single unit implants and restoring them with conventional metal abutments and four porcelain, fused to gold, crowns.

Third treatment option:
Four single unit implants and restoring them with a four-unit bridge. This option will give additional stability to the final restoration but will compromise the ability to thoroughly clean the area. For the patient with already compromised gingival health, this may not be the best solution. Porcelain fused to metal or Zirconia can be used to as the bridge material.
One of the obstacles to overcome with the above mentioned treatment options is the difficulty of achieving a good emergence profile and good esthetics in the region of the central incisors.

Fourth treatment option:
Placement of two implants in place of the lateral incisors and fabricating two two-unit bridges with central pontics having ovate gingival contact area; this will give an illusion of pontic coming out of gingiva. This approach will give a more predictable central papilla and emergence profile in the central incisor area. This option will also be the least expensive treatment involving implants for the patient. As far as the choice of the materials for this treatment option, we can use ether conventional metal pontics and porcelain fused to metal bridge or Zirconia pontics and Zirconia fused to porcelain bridges. Even though Alumina gives better esthetic results, use of alumina for the frame of the bridge is not recommended.

Fifth treatment option:
Placement of two single unit implants and restoring them with a four-unit bridge. Advantage of this method is additional stability and disadvantage is limited cleansibility. If the width of the bone in the anterior region of the mandible is inadequate, a procedure called “ridge augmentation” can be performed to add bone to the region. This procedure will increase time of the treatment by approximately nine months, which is necessary for proper bone healing. In a case of inadequate bone height, other options that do not involve implants must be considered.

Options that do not involve implant dentistry:

Option one:
Eight unit porcelain fused to metal or porcelain fused to Zirconia bridge spanning from #21 to #28 using #’s 21, 22, 27, 28 as an abutments and # 23, 24, 25 ,26 as pontics.

Option two:
Six unit porcelain fused to metal or porcelain fused to Zirconia bridge. This treatment choice however has the poorest prognosis of any other treatment option mentioned above due to the fact that the canines have less than 70% of the bone remaining, compromising support of the bridge. According to Ante’s law, the sum of all root surfaces of the teeth to be replaced by pontics should be less or equal than the sum of the root surfaces of all abutment teeth. Since there is great bone loss in the canine area the sum of the root surfaces of the abutments will be less than the pontics. Additionally, cleansibility of the area will be impaired facilitating gum disease.

Finally, there is a last option that patient was originally inquiring about: a removable partial denture.

Final thoughts:
As with any fixed treatment in patients with severe periodontal disease, any treatment outcome will depend on the level of patients’ involvement in his oral health. Meticulous oral hygiene has to be implemented to reduce the effect of periodontal disease: brushing at least twice a day but preferably after each meal, flossing at least twice a day, use of a Peridex mouth wash once a day one week out of a month for life. Repeated visits with a periodontist for perio maintenance and/or any other active therapy. The patient needs consultation with his physician to explore an option of switching to a different class of medications that will not result in gingival hyperplasia. Only with this kind of involvement can we expect any relatively predictable outcome, without it any treatment will result in premature failure.

I.E., New York University College of Dentistry

Case C
A 40 year old male patient presents with fractured incisal edges and anterior maxillary spacing. The patient is concerned about his appearance and hence presented to explore possible treatment options to address his chief complaint.

Past Medical History: None Contributory. The patient is not on any medication nor does he have any known drug allergies.  A radiograph was taken to evaluate periodontal health which was within normal limits.

Possible treatment options to address this issue include:

• • Veneers from Teeth # 7-10
  • Anterior ceramic crowns from teeth #7-10

It was agreed upon that veneers, rather than ceramic crowns, would be used to treat his condition. This is usually a more conservative option since very little tooth structure is actually removed.  Additionally, it is usually more aesthetically pleasing.

In the preparation, a 0.5 mm reduction is performed on the facial surface while a 1-1.5 mm reduction is performed on the incisal surface. The finishing margin is usually a 0.5 mm supragingival chamfer. The preparation is done under local anesthetic infiltration. It is recommended a matrix is fabricated prior to the preparation which will be used for making the temporary veneers.

Final impressions were taken using impregum and a counter model impression taken in alginate. This was sent to the laboratory for the veneer fabrication. The temporary veneers were made with Luxatemp using the impression matrix originally taken. Following their return from the dental lab, the veneers were ready to be cemented.

The temporary veneers were removed from the preparations and the teeth were polished using pumice without fluoride and rinsed with water. The veneers were tried-in to evaluate their fit. They were etched using hydrofluoric acid for about a minute and silane coupling agent painted on them and allowed to air dry. The prepared teeth were also etched using phosphoric acid for 15-20 seconds, rinsed with water and air dried. Bonding agent was applied to the etched surface and cured. The veneers were then cemented permanently and excess cement was removed from the margins and finished using finishing strips and finishing burs. The patient’s occlusion was checked and slight adjustments were made. Post-operative instructions were provided and the patient was delighted with the result.

Maintenance of good oral hygiene is of great value for any restoration.
This would involve frequent flossing and brushing using the correct technique.  The patient should therefore be aware of this in order to have a long lasting restoration.

Miscellaneous
One very challenging aspect of using composite restorative material in restoring class II lesions is establishing contact with this material. This elective program has helped me learn techniques to avoid this problem. This will be discussed as follows:

• • The preparation of a class II lesion is made
  • The matrix band is put in place and secured
  • The tooth is pre-wedged to cause slight separation between teeth
  • Cavity is etched with phosphoric acid, rinsed and dried
  • A bonding agent is applied to cavity walls and cured for 15 seconds
  • Matrix band is slightly loosened and burnished against the adjacent tooth.
  • Bisfil (an unfilled resin) is injected into the proximal box and left uncured
  • Composite beads (small round composites that have been pre-cured) are placed into the proximal box with the uncured bisfil
  • Using a plastic instrument, the composite bead is pushed into the proximal box and against the adjacent tooth.  This is then cured using the curing light.
  • Then, the remainder of the preparation is filled incrementally, curing after each increment. The final restoration is adjusted and polished

Such restorations restored in this manner usually have a very tight contact. This helps prevent food packing into the interproximal space that may give rise to recurrent decay.

A 32 year old Caucasian male presented with the chief complaint, “I want to fix my smile.” The patient complained of hot and cold sensitivity as well as swollen, bleeding gums after brushing.

Past Medical History: The patient is not on any medication and has no known allergies to food or medications. The patient also denied using any illicit drugs.

This patient had very limited funds to have his mouth fully rehabilitated. However, several treatment options were discussed with the patient which include:

# Extraction of the non restorable teeth
# Root canal therapy, cast gold post and core with final crown restoration of restorable teeth
# Composite restorations
# Crowns and bridges

However, the patient could not afford the treatment options provided. Based on this, a maxillary round-house provisional restoration was agreed upon. This was treatment planned; however the poor prognosis of some teeth was largely noted. The patient was solely concerned about his esthetic look, hence requested that only the maxillary arch be treated. Appropriate consent forms and treatment plans were signed prior to any rendered treatment.

Treatment Procedure
A maxillary local infiltration with Carbocaine was performed. Extraction of teeth #s 2, 5, 12 and 15 was also performed and hemostasis was achieved through the placement of sutures.

Peripheral wax was adapted over the maxillary arch area where the patient had worn-out teeth. An upper alginate impression was taken to serve as a matrix for the provisional restorations. Gross crown preparation reductions were done on all existing maxillary teeth with the exception of tooth #4 and #13 which were used to achieve occlusal stops to maintain the patient’s vertical dimension of occlusion.

With the use of the previously taken alginate impression matrix, Luxatemp was used as the temporary restorative material. This was injected into the alginate matrix and then re-seated on top of the prepared teeth. The temporary round-house restoration was taken out of the patient’s mouth and was trimmed and recontoured to proper shapes and sizes. It was then tried-in and final adjustments were made for the margins and contour. The occlusion was checked and then cemented temporarily into patient’s mouth. The patient was pleased with the work completed. From start to finish, the entire treatment procedure took approximately two hours.

Although, this was not the most beneficiary dental procedure that could have been rendered, considering the patient’s limited finances and his desire to look esthetically presentable, this was the best treatment that could have been provided at that moment. The patient was well informed about possible sensitivity following this treatment as well poor long term prognosis of some existing teeth.

Another option for treatment could have been extraction of all maxillary teeth and subsequent fabrication of an upper maxillary complete denture. The denture could have been implant supported to enhance stability and function of the denture. But this would have cost much more money that the patient could not afford.

Apart from rendering quality care to patients like this, a thorough dental and social history should be elicited from patients so that the etiology or possible risk factors causing such rampant nature of the disease be identified and addressed. This constitutes part of the treatment options. If this is not addressed, no matter the treatment rendered, it will surely fail. Good oral hygiene instructions should be given and frequent recall appointments given to such patients.

O.O., New York University College of Dentistry