Dr Sarah Chin periodontist Dr Zainab Hamudi prosthodontist Dr Vivian Liu endodontist

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Susanna Hampton
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1 Dr Sarah Chin periodontist Dr Zainab Hamudi prosthodontist Dr Vivian Liu endodontist

2 Multi-discipline nature of dentistry Diagnosis Treatment planning Referral where appropriate A story of teamwork

3 Presenting complaint Poor aesthetics, localised throbbing associated with tooth 11 History Endodontic treatment, composite resin stained

4 September 2013 November 2013

5 Orthodontic intrusion Gingival margin discrepancy Management options Crown lengthening

9 Considerations and contraindications for crown lengthening May alter the symmetry across the midline in anterior region Contraindications Importance of tooth is incompatible with extent of procedures required Where there is compromise functionally or aesthetically Unfavourable crown:root ratio Patient expectations Allen 1993; Ingber et al. 1977; Rosenberg et al. 1980, Lindhe 2008

11 May 2013

12 Diagnostic challenges Multiple teeth involved History of trauma Previous treatment What has caused the persistent symptoms? Which factors can affect the prognosis of the teeth? How can we manage this differently?

13 Tooth 11 - May 2013

14 Some questions What has happened here? What has caused the resorption? Will it resolve with treatment? What is the appropriate treatment? What is the prognosis of this tooth? Will the patient be better off replacing this tooth?

15 Requirements for resorption Injury Loss of cementum or pre-dentine Stimulation Inflammation associated with the unprotected root surface Destruction of root surface by clastic cells Healing of affected surface by cementoblasts or osteoblasts

16 Replacement resorption Progressive replacement of root structure by alveolar bone Part of normal bony metabolism Common after avulsion and severe intrusive luxation injuries Significant areas of damaged periodontal ligament and cementum allow osteoclasts to contact dentine and initiate resorptive process

17 Infection-induced resorption Inflammation around infected root leads to resorption of root structure Exposed dentinal tubules allow egress of bacteria/bacterial toxins into periradicular tissues Result of root canal infection, may be superimposed on a tooth which has suffered a dental injury May lead to communication between root canal space and periodontium

18 November 2013

19 Some more questions What has caused the persistent pain on chewing? How could this be managed differently? May 2013

20 Persistent root canal infection Coronal leakage Temporary restorations for post-retained restorations fail within 30 days Balto et al Poor restoration and/or root filling Chugal et al. 2007; Gillen et al Inadequate or incomplete instrumentation Infected dentinal tubules Vieira et al Biofilm in inaccessible areas Ricucci & Siqueira 2011; Vieira et al. 2012

21 July 2013 September 2013

22 September 2014 January 2015

25 Age indications for treatment Zitzmann 2015

26 Submerging teeth Initially suggested by Malmgren (1994). RCT filling removed to prevent foreign body reaction.

27 Submerging teeth Width of the alveolar process is preserved at 8.7mm (9 months after submerging) compared with the contralateral central incisor which was 4.2mm after decoronation. Tooth fragment still not fully replaced at this stage ( Filippi 2001) Decoronation of the tooth may allow for bone to grow over the root, however over months, loss of bucco-palatal dimension was present ranging from +0.5mm to 2.8mm and was correlated with followup time. (Shaul 2013) Age of decoronation is an important factor for ridge development- decoronations performed at a mean age of 14.6 years in boys and 13 years in girls yielded a considerable increase in bone levels (Malmgren 2015)

28 Infraposition of teeth Malmgren 2002

contact with the implant with newly formed bone ( Cardoso 2014) Implants placed in subjects with ankylosed roots

30 Can you leave ankylosed tooth fragments? Implants were placed in retained ankylosed roots in animal model dentine was resorbed and other areas were in contact with the implant with newly formed bone ( Cardoso 2014) Implants placed in subjects with ankylosed roots showed no problems with osseointegration ( Malmgren 2015) There was less bone formation and smaller bone to implant interface which may have been due to presence of gutta percha (Cardoso 2014)

31 Can you leave ankylosed tooth fragments? Implants were placed in retained ankylosed roots in animal model dentine was resobred and other areas were in contact with the implant with newly formed bone ( Cardoso 2014) There was less bone formation and smaller bone to implant interface which may have been due to presence of gutta percha

32 Bridge failure Clinical presentation Possible causative factors Immediate and long-term temporization

34 OCCLUSION!!! Lack of coronal structure Edentulous for 10 years Temporization Removable partial denture Fixed conventional bridge!!! Implant retained prosthesis Clinical considerations Options

40 How do we know what s right for each case?

41 Missing lateral incisors The 2 nd most common congenitally missing tooth What is the most ideal treatment? Management options: Canine substitution Tooth supported restoration Single implant retained prosthesis Treatment decision depends on: Patient age Malocclusion Specific space requirements Tooth-size relationship Size and shape of the canine Condition of adjacent teeth Always consider: Conservation Restorative in conjunction with orthodontic plan

42 Missing lateral incisor Treatment options Canine substitution OCCLUSION Possible with the following malocclusions: -Angle Class II malocclusion with no crowding in the mandibular arch. In this occlusal pattern, the molar relationship remains Class II and the first premolars are located in the traditional canine position. -Angle Class I malocclusion with sufficient crowding to necessitate mandibular extractions.

43 Missing lateral incisor Treatment options Canine substitution TOOTH SIZE Determine if satisfactory aesthetic result is achievable Diagnostic wax up pre-orthodontics Measure canine mesio-distal width compared to adjacent teeth Determine amount of canine reduction required

44 Missing lateral incisor Treatment options Canine substitution SHAPE AND COLOR OF THE CANINE Canine is naturally larger and darker Convexity of proximal and labial surfaces Gingival margins convexity

Missing lateral incisor Treatment options Canine substitution LIP LEVEL The gingival margin of the natural canine should be positioned slightly incisal to the central incisor gingival margin.

45 Missing lateral incisor Treatment options Canine substitution LIP LEVEL The gingival margin of the natural canine should be positioned slightly incisal to the central incisor gingival margin. This helps camouflage the substituted canine. Occasionally, gingivectomy may need to be performed to properly position the marginal gingiva. High smile lines and a prominent canine root eminence may also be an easthetic concern.

46 Missing lateral incisor Replacement options How much space do we need? Methods to determine the space necessary 1-Golden proportion 2-Use the contralateral lateral incisor 3-Bolton analysis 4-Diagnostic wax up

47 Missing lateral incisor Treatment options Canine substitution Size and contour considerations

48 Missing lateral incisor Canine substitution

49 Missing lateral incisor Canine substitution

50 Missing lateral incisor Replacement options OPTION FOR REPLACEMENT Tooth supported restorations -Conventional 3 units bridge -Cantilever 3 units bridge -Resin bonded bridge -Cantilever resin bonded bridge Implant retained crown Not for young and patients not willing to go through surgical procedures

51 Missing lateral incisor Replacement Maryland bridge Conservative Traditionally relies on adhesion Success rate varies 10-54% over 11 years

52 Missing lateral incisor Replacement Maryland bridge Criteria to consider Tooth position- overbite Tooth position- inclination Mobility of the abutment teeth Abutment teeth translucency Parafunction

53 Missing lateral incisor Replacement Maryland bridge Criteria to consider Tooth position- overbite Tooth position- inclination Mobility of the abutment teeth Abutment teeth translucency Parafunction

54 Missing lateral incisor Replacement Maryland bridge Criteria to consider Tooth position- overbite Tooth position- inclination Mobility of the abutment teeth Abutment teeth translucency Parafunction

55 Missing lateral incisor Replacement Maryland bridge Criteria to consider Tooth position- overbite Tooth position- inclination Mobility of the abutment teeth Abutment teeth translucency Parafunction

56 Missing lateral incisor Replacement Maryland bridge Criteria to consider Tooth position- overbite Tooth position- inclination Mobility of the abutment teeth Abutment teeth translucency Parafunction

57 Missing lateral incisor Replacement Maryland bridge Ideal candidates -Abutment teeth are nonmobile -Abutment teeth are moderately thick -Abutment teeth translucency localized in the incisal onethird -A shallow overbite -Shallow anterior relationship

58 Missing lateral incisor Replacement Cantilever resin bonded bridge Degree of mobility is not a critical issue Canine as abutment Grooves and pins Pulpal size is a concern in young patients Abutment color and translucency

59 Missing lateral incisor Replacement Cantilever resin bonded bridge THE KEY TO SUCCESS? Pontic occlusion

60 Missing lateral incisor Replacement Cantilever resin bonded bridge

Missing lateral incisor Replacement CONVENSIONAL

Abutment tooth requires a crown or need to alter

angulation-pre-orthodontic planning Palatal tooth

61 Missing lateral incisor Replacement CONVENSIONAL FIXED PARTIAL DENTURE Least conservative-least ideal Abutment tooth requires a crown or need to alter facial aesthetics Occlusion Abutment angulation-pre-orthodontic planning Palatal tooth preparation and joint size-maximum joint size for full ceramic restorations

62 Missing Lateral incisor Although each of these restorative treatment options can be used to achieve predictable aesthetics, function, and longevity, they require varying amounts of tooth structure removal.

63 Missing Lateral incisor Replacement Implant retained crown -Predictable Osseointegration -Long-term function and aesthetics -Intact adjacent teeth -Not for young patients

Missing Lateral incisor Replacement Implant retained crown Implant mesidistal

5mm to adjacent teeth to allow proper form and maintenace of papilla 7mm: 1.

5 implant then only 0.75mm to adjacent tooth Radicular Minimum 5mm to allow 0.

64 Missing Lateral incisor Replacement Implant retained crown Implant mesidistal space requirement Coronal 1.5mm to adjacent teeth to allow proper form and maintenace of papilla 7mm: 1.5 bilateral and maximum of 4mm implant platform 5mm: if use 3.5 implant then only 0.75mm to adjacent tooth Radicular Minimum 5mm to allow 0.75mm between root with small implants Preferable 7mm to allow 1.5-2mm between implant and adjacent teeth Roots angulation Parallel if possible

65 Missing Lateral incisor Replacement Implant space requirements Roots angulation

66 Implant placement -Timing -Position Missing Lateral Replacement Space maintenance Removable retained-issues Surgical guide Provisional implant crown

67 Missing lateral incisor Implant retained crown

68 Peg lateral incisor Space requirements

69 Young patients to implant or not to implant?

70 Bone graft and resin bonded bridge

72 Space for implants

73 Ridge/augmentation preservation

74 Ridge augmentation/preservation Avila-ortiz 2014

75 Implant restoration Restorative considerations Restoratively driven implant placement Gingival margin level: Biological width Emergence profile In single implant restorations adjacent to natural teeth, the level of the marginal soft tissues and interproximal papillae is dictated by the attachment level on the adjacent teeth. Salama 1998 Interproximal papilla height: Emergence profile Biological width Lees predictable with two adjacent implants.

76 Implant restoration Restorative considerations Emergence profile Temporization

77 Implant restoration Restorative considerations Ridge lap

78 Implant restoration Restorative considerations Ridge lap

80 Over-eruption of opposing dentition

81 Root resorption Treat, extract or implant?

82 Aetiology & Classification Trauma-induced Surface resorption Transient resorption Replacement resorption Infection-induced (inflammatory) Hyperplastic (invasive) Lindskog et al 2006

83 Transient resorption September 2014 March 2015

84 Replacement resorption September 2007 October 2008

85 Internal inflammatory resorption May 2013 July 2014

86 Combined replacement and inflammatory resorption

87 Invasive cervical resorption

88 Heithersay 1999

89 Prognosis Favourable prognosis: Surface resorption Transient resorption (may require endodontic treatment) Infection-induced resorption if restorable Invasive cervical resorption (class I and II) if restorable Poor prognosis: Replacement resorption Invasive cervical resorption (class III and IV)

91 PA restored

92 Recession Defect- graft or monitor?

93 Causes of localised recession Location of tooth relative to the alveolar process Eruption close to the mucogingival line minimal keratinised tissue Frenal pull Lip piercings Ward 1974, Kapferer 2007, Zucchelli 2015

94 Causes of generalised recession Thin gingival biotype Periodontitis Toothbrush abrasion Orthodontic movement Sagnes 1976, Vassalli 2010

95 Consequences of Recession Poor aesthetics Particularly in the maxillary incisor, canine and premolar region Dentine hypersensitivity Recession leads to dentine exposure. According to Branstromm s hydrodynamic theory, fluid can move within the dentinal tubules causing the sensitivity or pain. Wedge-shaped defects due to tooth brush abrasion (cervical abrasion) Exposed root surfaces are easily abraded as the dentine/cementum is significantly softer than enamel Plaque accumulation Root caries Lindhe 2008, Newman 2015

96 Recession- when to treat

97 When to monitor recession

98 Monitor recession Lang (1972) suggested 2mm minimum was necessary to maintain gingival health A minimum width of keratinised gingiva is not necessary providing good oral hygiene (Wennstrom 1987)

99 Direct comps vs crowns Indications Conservative Affordable Temporary Diagnostic Easy to modify

100 Direct composite resin

101 Direct composite resin

102 Direct composite resin History of periodontitis Black triangles Recession-long clinical crowns

103 Direct composite resin

104 Direct composite resin

105 Direct composite resin

106 Tooth discoloration

107 Causes of tooth discolouration Extrinsic discolouration Intrinsic discolouration during tooth development Intrinsic discolouration after tooth eruption Pulp hemorrhage subsequent to trauma Pulp calcification Pulpal necrosis Endodontic procedures and materials Tooth resorption

108 Causes of tooth discolouration Intrinsic discolouration how do we differentiate? Red/dark pink pulp hemorrhage Yellow pulp calcification or ageing Grey - pulp necrosis or dental materials Pink cervical resorption

109

110 Management of tooth discolouration No treatment Extracoronal bleaching Intracoronal bleaching Veneer Crown

111 Indications for bleaching vs. coverage restoration Bleaching-Vital -Conservative -May not be effective in sever staining cases -May increase sensitivity -Unpredictable result with heavily restored teeth -Aggressive bleaching can alter surface integrity and microstructure of enamel crystals leading to demineralization -Not permanent

112 Extracoronal bleaching An update Light activation offers no benefits for amount of whitening achieved, persistence of the whitening treatment, or avoidance of tooth sensitivity from the whitening treatment. Home-based bleaching results in less tooth sensitivity than in-office bleaching. The optimal regimen to obtain persistence of tooth whitening is to follow an in-office treatment with monthly home-based touch-up treatments using OTC products. Aggressive bleaching with high concentrations of hydrogen peroxide office-based products causes enamel softening, surface roughness, and an increase in the susceptibility of the tooth to demineralization, based upon in vitro findings. Dental restorations are susceptible to unacceptable colour change even when using the home-based OTC systems. In-office bleaching of restored teeth using a 35% hydrogen peroxide product caused tooth sensitivity in all cases. Teeth with restorations have a significantly greater chance of becoming sensitive and result in a greater degree of pain when exposed to whitening regimens. Carey 2014

113 When is endodontic treatment indicated? Grey discolouration Red discolouration with no reversal Signs and symptoms of root canal infection Poor endodontic treatment Signs of coronal leakage if previously treated

114 Transient apical resorption following trauma Mild luxation injuries No treatment Indicative of healing process re-establishment of pulpal blood supply Often associated dark red discolouration

115 Transient apical resorption Heithersay 2007

116 Endodontic treatment and intracoronal bleaching Case 28

117 Treating tooth discoloration Veneer

118 Treating tooth discoloration Crown

119 Interdisciplinary management Chief complaint Tenderness of tooth 23 Bad taste Poor aesthetics Broken tooth getting sharp(referring to site 24)

120 Interdisciplinary management

121

122

123

124

125 Conclusion Discussion & Questions

FRACTURES AND LUXATIONS OF PERMANENT TEETH

FRACTURES AND LUXATIONS OF PERMANENT TEETH 1. Treatment guidelines and alveolar bone Followup Procedures INFRACTION Clinical findings Radiographic findings Treatment Follow-Up Favorable Outcome Unfavorable