Need Help Treatment Planning

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1 Need Help Treatment Planning Dentists discuss their priorities when it comes to aesthetics cases, and give their two cents on whether they believe this particular case requires orthodontic treatment. Rizzla Posted: 12/25/2010 Post: 1 of 48 Hi guys, I know it s Christmas day but I need your help on this case. Middleaged lady wanting to improve the appearance of her teeth. Can this case be done without orthodontic treatment? Or will I be compromising the results? Any help would be appreciated. Thanks in advance. Fig. 1 Fig. 2 Fig. 3 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 12 Fig. 11 Fig. 13 Fig. 14 continued on page 40 38

2 continued from page 38 cudmd Post: 2 of 48 How many teeth can she afford to treat? Not even addressing occlusion (which does need to be addressed, as I d be very concerned at her lack of posterior support), if I were purely planning the aesthetic issues of this case, I d consider an Inman aligner to move 8 and 9 back into the archform prior to prepping. This could likely be accomplished in a very short amount of time (six to 10 weeks) and would correct the anterior open bite without having incisal edges that are 3mm thick or overly prepped teeth if you were to attempt to correct this in porcelain. I still think you need to address the soft tissue issues of 8 and 9 as well, but this should not be done until the provisional stage prior to the final impressions anyways. Before I d even tackle this case, and the functional side, what does she want to accomplish? Is it realistic given her financial resources, willingness to go through ortho/perio? Is she concerned about the missing teeth and spaces? If so, is she ready to fix her issues or does she want a quick fix? Answer those and you re already on your way. mattyboy Post: 3 of 48 The gingival zenith of #8 is way higher than the others. Without orthodontics to move the tooth palatally, you will not be pleased with the outcome and there s a good chance that your patient won t be either, because one of her front teeth will look 3mm longer than the other. As mentioned above, posterior support is going to be critical for long-term success. Out of curiosity, how s her perio? Is she a smoker? Her papilla definitely looks blunted. Post: 4 of 48 Just working up some possibilities in my head, I would say that this case could easily be done without ortho... if we don t need to gain anterior coupling. Which I don t necessarily see a need for. Looks like a fun one. Rizzla Post: 5 of 48 Hi guys, thanks for your responses. Michael, can you jog my memory what is anterior coupling? Posts: 6 & 7 of 48 One eye closed rule... if you have it before, you better have it after. If you don t have it before, you can get it after, but the patient might or might not tolerate it... really broad rule. [] OK Riz... with the above comments first figure out where you want to get, what she wants and then figure out how to get there. The patient talked about improving her smile so let s walk through it. Lip at rest... What do you think about the display based on this picture? Do you like either of the 1s? In this picture, think about 11 or 21 and tell us which 40

3 cosmetic you like or think about one and say more display or less display and then we can work from there. My concept of anterior coupling, not to in any way imply dr_dex correction of Melkers s concept, Post: 8 of 48 is the full range of interaction between all of the anteriors from CR out to crossover contact in all directions possible. My personal preference is no contact in CR/CO (me likey some long centric ) and even contact and alignment of four lower incisors with two upper incisors in end-to-end (unless Class III) while equal rub on lingual both upper incisors in protrusion and of course cuspid rise, all features of anterior coupling. Visit us at the Hinman Dental Meeting March 24-26, 2011 Booth #712 MyPerioPath & MyPerioID PST salivary diagnostic tests Fair enough. P.S. CR is a joint position independent of any teeth con- Post: 9 of 48 tact. CO is the first tooth that touches while maintaining CR. MIP is teeth all the way together... formerly called CO. Back to the case. I would treatment plan this case with incisal-edge-driven Post: 11 of 48 treatment planning. Find aesthetic A and B point first. Worrying about ortho, gingival zeniths and other very important items will come in time, but first find A and B point. Michael, I am relatively happy with the incisal edge position. I think she has good tooth display both at rest and when smiling. It is the gingival zeniths that I would like to change. Rizzla Post: 12 of 48 Advancing Patient Wellness Through Salivary Diagnostics MyPerioPath Salivary DNA test that determines the cause of periodontal infections The MyPerioPath test will reveal what pathogenic bacteria are responsible for the infection, which is valuable information you need to treat patients more effectively and with more predictable outcomes. MyPerioPath test results also serve to establish a baseline reading, so you can monitor treatment effectiveness over time. MyPerioID PST Salivary DNA test that determines who is at increased risk for severe periodontal infections The MyPerioID PST test identifies individual genetic susceptibility to periodontal disease and enables you to establish which patients are at increased risk for more severe periodontal infections due to an exaggerated immune response. To order MyPerioPath & MyPerioID PST testing supplies, contact your Henry Schein representative at For more information, Which edge and which zenith do you like? Post: 13 of 48 continued on page 42 Exclusively Distributed by 2011 OralDNA Labs Inc. All Rights Reserved. OralDNA Labs is a subsidiary of Quest Diagnostics Inc. FREE FACTS, circle 41 on card dentaltown.com «March

4 continued from page 41 Fig. 16 Fig. 17 Fig. 18 Fig. 16: Here is your pre-op mostly outlined. Fig. 17: Which looks about like this and 21 incisal edges are a bit different. Figs : So if we work with say 11, which zenith level do you like? Or does 11 work on both edge and zenith for you? Do you have a personal preference between the two? Fig. 19 Posts: 14 & 15 of 48 Mentioned earlier was a thought of bringing the labial contour of #8 and 9 palatal prior to restoring. When you say you are happy with the incisal edge position, does that mean labio-lingual also? Once you determine that they measure up from your corrected incisal edge position. If she has 11mm of central, then start to blend in proportion the other anterior teeth. Make a virtual denture set up. If you have an 11mm long denture tooth and the incisal edge is correct, what do you do if there is still excessive gingival display? You either move the tooth incisally or move the incisal edge up. This might make the incisal edge position too short. So, you crown lengthen the wax and expose more CEJ of tooth or custom add composite to the cervical of the tooth. The point is, find out at the correct incisal edge position where 11mm apically puts you. Then make a diagnosis about excessive gingival display. Can it be corrected by intrusion and incisal edge restoration? Can it be corrected by crown lengthening or is it an OGN case? That is why incisal edge position is so important. Not just the length, but the A Point. The three-dimensional point that speaks to bucco/lingual and mesio/ distal position. [] Miguel beat me to it. Proves a picture is worth 1,000 words and the same holds true to your patients. What he just showed you is what a patient will get in a second versus what I just took 10 minutes to type. Post: 16 of 48 Fig. 20 Fig. 21 Figs : So based on those two, you might end up with either of these. Of course the 3s zeniths could be changed as well... so where do you want to end up? Post: 18 of 48 The trend today is to discuss the transition line or the area where restorative meets hard and soft tissue. The trend is also to eliminate it! I don t agree with that. I heard Garber talk recently about eliminating this transition by crown lengthening apically until you don t see the transition in a hard smile reveal. Coachman (his former tech) presents beautiful work on pink aesthetics. However, it is important to not lose sight of mechanics and biology. To have a restorative margin 20mm from 42

5 cosmetic the incisal edge just to eliminate the visible transition line can compromise C/R ratio, challenge the limits of restorative materials, etc. Regardless, the A point or the gingival zenith, this case is still deficient in the placement of the cuspids relative to the buccal corridor and will require orthodontic resolution. velogeek Post: 20 of 48 Visit us at the Hinman Dental Meeting March 24-26, 2011 OraRisk Booth #712 HPV salivary diagnostic test The OraRisk HPV test determines who is at increased risk for oral HPV-related oral cancers. Require? Nah... it might improve the buccal corridor aesthetics, but required? I see it as Post: 21 of 48 an option that has benefits if pursued and consequences or effects if not. Still figuring out where we want to get to and balancing the maxillary occlusal aesthetic plane. P.S. If you look at filling the buccal corridor... really filling it, wouldn t you be looking at an OMFS? How far you want to fill it? Let me put it this way... without knowing A point, I have a difficult time determining if ortho will be necessary. Post: 23 of 48 No disagreement Howard, velogeek we all have our own algorithms, but the original poster asked if Post: 26 of 48 ortho would be necessary, and the cuspid position just bothers me aesthetically. I don t see just a restorative solution. You very well might be right. So if we need to move the cuspid distal, where does that leave the Post: 27 of 48 width proportions of the resulting tooth positions? And by the way, I am a big advocate of filling buccal corridor space. It is one of the things I spend much time discussing when I talk about implant reconstruction of continued on page 44 Advancing Patient Wellness Through Salivary Diagnostics Studies reveal that the human papillomavirus, particularly HPV-16, has been definitively implicated in oral cancers. 1,2 In fact, over 50% of oropharyngeal tumors contain the HPV genome (DNA). 2 Early detection of oral HPV is a fundamental element of a patient s overall wellness plan. The OraRisk HPV salivary diagnostic test is a non-invasive, easy-to-use screening tool to identify the type(s) of oral HPV, a mucosal viral infection that could potentially lead to oral cancer. The test enables clinicians to establish increased risk for oral cancer and determine appropriate referral and monitoring conditions. To order OraRisk HPV testing supplies, contact your Henry Schein representative at References: 1. Ragin CC, Modugno F, Gollin SM. The epidemiology and risk factors of head and neck cancer: a focus on human papillomavirus. J Dent Res Feb;86(2): Fakhry C, Gillison ML. Clinical implications of human papillomavirus in head and neck cancers. J Clin Oncol Jun 10;24(17): For more information, Exclusively Distributed by 2011 OralDNA Labs Inc. All Rights Reserved. OralDNA Labs is a subsidiary of Quest Diagnostics Inc. FREE FACTS, circle 42 on card dentaltown.com «March

6 continued from page 43 the posterior maxilla. Too often, due to the medial pattern of resorption, the sinus graft rebuilds in a superior direction to allow adequate height of implants, but the transverse position of the implant leaves a crossbite dynamic and doesn t fulfill the aesthetic requirement of a full buccal corridor. So we cantilever in a facial direction creating ridge laps, challenged hygiene and unfavorable biomechanics. velogeek Post: 28 of 48 My sense of anterior aesthetics is biased toward how my own teeth look. I find that the golden proportion for the teeth and the buccal corridor tends to be too strong and just looks unnatural to me. My anterior arrangement (if I m given the OK from the patient to do so) is to develop the A point and make ideal proportioned centrals. Then I like to position the cuspids in the proper place to transition into the buccal corridor. Then whatever space is left for the laterals, I fit them in, and usually this requires a slight rotation to do so. Obviously we need to complete model work, wax up and flashing on a prototype to make sure that everyone is on the same page. Find it online at Need Help Treatment Planning A New Standard For Dental Isolation Now with Two Solutions! Both the original Isolite with 5 levels of brilliant intra-oral lighting and the new lightless IsodryTi systems provide continuous adjustable suction, tongue and cheek retraction, throat protection, and a comfort bite block. Professionals using this award-winning isolation technology are experiencing: Superior intra-oral lighting 30% Faster Procedures Improved Patient Comfort Reduced Ergonomic Strain Lightless but brilliant! To Learn More about Isolite, Call OR VISIT ISOLITESYSTEMS. COM DT FREE FACTS, circle 47 on card