Help with Treatment Planning?

162 Rating(s).


Posted on By Charles Payet In Soft Tissue Enhancement

So I took the Soft Tissue Augmentation course with Dr. Maurice Salama a couple weekends ago (loved it BTW) and have gotten my Salvin microsurgery kit in, and I have a patient who is very interested in proceeding. He has teeth with recession in all 4 quadrants of varying degrees of severity, so I'm thinking of using a couple different techniques and would like feedback on my tentative treatment plans. Also, I want to make sure that I use the correct ADA codes.

Overall periodontal health is excellent, with PDs of 1-3mm on the facials of all teeth. Little to no inflammation, pt. is pretty obsessive about oral health.

BWX do show some posterior horizontal bone loss, and he's obviously a bruxer and does not current wear a nightguard. He's probably apneic but has not been diagnosed.

The patient is in excellent health, no meds, no allergies, he's good to go on that front.

RIGHT SIDE, BOTH ARCHES: Semi-lunar incisions and coronal repositioning.

Because he already has significant AG, 2-3mm of recession, and minimal cervical abfractions, I am thinking of doing some slight buccal contouring to reduce the abfractions further (a la Danny Melker and Biologic Shaping), then doing Semi-lunar incisions to pull that great AG over the recession without adding additional tissue. Why add more when he already has so much?

LEFT SIDE, BOTH ARCHES: Alloderm/tunneling technique

Again, first do some recontouring of the buccals to reduce the height of contour. Geristore in the #14 and #20 abfractions as they're closer to 1.5mm deep. Because the amount of AG present on #13 and on the mandibular teeth are noticeably less, I am thinking a tunneling technique with Alloderm (the patient would prefer to avoid a palatal donor site if possible)

Thoughts, critique of the plan and my rationale for each, alternate suggestions?

I believe the correct ADA code for the Alloderm is D4275, but I do not know what the ADA code for a semilunar flap and coronal repositioning is.

Lastly, any suggestions for insurance narratives?

Right side
Left side

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9 Comments

I'm thinking this is not a great case to start with.
There is a lot of attached mucosa below and I feel the recession is minor, rather there is significant abrasion/?abfraction -looking at occlusal wear
Once you have rebuilt normal tooth structure to cej there is not a lot of recession


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So you think that this would be a better restorative case than grafting?


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Hi Charles,
Can we see occlusal views of both the Maxillary and Mandibular arches?

He is not 'obviously a grinder' Someone took out his bicuspids and retracted and constricted the maxillary arch (note the palatal inclination of the maxillary arch.
gerald


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I would, but I didn't take any. Sorry about that.

Perhaps it's not obvious, but he is absolutely a bruxer. No doubt about it.


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Charles, Thank you for posting this interesting case. I would be cautious with this one. It has been shown that coronally repositioned flaps do not hold up long term, especially without adding additional tissue. Autologous tissue is the gold standard and has been shown to hold up long term in both the vertical and horizontal dimensions. I would favor reshaping the root over restoration with glass ionomer, however glass ionomer may be necessary for deep abfractions. Any graft with coronal re-positioning will not get closer than 3 mm apical to the papillae at best. Because of the amount of grafting necessary, allograft could be considered with the correct informed consent. I think that the damage is done and staging the grafting over a period of time, planning to use autologous tissue will get your patient the best result. Root prep is critical as I'm sure Dr. Salama stressed. Good Luck!!!


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Thank you for those points, Terry. My thought on the repositioning (and yes, I definitely remember Maurice talking about the relapse with repositioning, usually 50% or more within 2 years?) was simply that he has so much AG already, why add more? But if adding more is more likely to get the success that he wants, I'm sure he'll be fine with that.

I'll certainly talk to him about the advantages of the CTG if that will make that much more of a difference vs. the alloderm, too.


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Keep us posted.


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During treatment the effects of what has been done should be periodically reviewed. This allows either the dentist or patient to retire honourably from active treatment if that seems appropriate. For example, the patient's plaque control may not reach an appropriate standard. This is clearly important in its own right but is also a useful barometer of a patient's level of interest and commitment. Efficacy of plaque control should be measured by bleeding scores not by plaque scores. Plaque scores inform only about performance on the day while bleeding scores give a longer term view.

Sometimes it becomes apparent that the patient may not wish to continue with treatment or the need for the planned work has diminished. Organisation of treatment into stages allows convenient points to be reached when the dentition is relatively stable. If the dentist or patient agree, the patient can enter a maintenance programme and be reviewed periodically. The other phases of treatment are organised to allow a logical progression toward completion of the treatment plan.


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Control occlusal trauma with NG, restore severe abfractions with Glass ionomer with flat contour, clean and condition roots, and then ACDM and alternating papilla tunnel techniques would be my standard on this case. Good luck Dr. Salama


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Hu-Friedy
BTI