How to correct a Recesson defect associated with interproximal bone loss and a diastema.

118 Rating(s).


Posted on By Manuel De LA ROSA In Anterior/Esthetic

30 y/o female came with a Chief Complain : "I want to save my tooth and cover the root exposed with gingiva"
Patient underwent Orthodontic therapy a year ago, she mentions they moved her teeth in 3 months. She had a lot of pain on all her teeth. She noticed then her gingiva started to shrink on # 9. Now she has a class III Miller recession defect, as well as a class I mobility on tooth # 9. She comes to me seeking for a chance on saving her tooth.
The treatment option that comes to my mind is:
With orthodontics close the diastema between # 9 and 10. Have endodontic treatment performed and then move # 9 towards the lingual in a body movement, so as to enhance the osseous width on the buccal, then extrude it so as to reduce the distance between the contact point and the osseous crest. Then I could do a CTG to cover the recession. Finally crown # 9 and do a fix retainer on the lingual of all 6 maxillary anteriors so as to improve the support on # 9.
Do you have any other alternatives?? Comments and opinions are more than welcome.

Frontal view
panoramic xray

periapical x ray
Add to Favorites
Add a comment to the discussion on How to correct a Recesson defect associated with interproximal bone loss and a diastema.


Upload photos
1.  Photo Title:

2.  Photo Title:

Would you like to follow this post?
Case has been added to your favorites.
Case has been removed from your favorites.
Thank you for your input. Your comment has been posted.
You are now following this member. You will get notified on any new topics posted by this member.
You are no longer following this member. You will not get notified on any new topics posted by this member.
Edit Comment
1.  Photo Title:
Current Image:   Delete Image
2.  Photo Title:
Current Image:   Delete Image
Comment has been updated.

23 Comments

Manuel;
This is an absolutely GREAT post. Looks simple because it is a small area and not a large segment of teeth. But the decision tree here is critical to good treatment planning.
Mobility of teeth, IHB (Interproximal Heights of Bone), Tissue Thickness, Gingival Margin positions, long term stability and esthetics of teeth retention or implant placement and strategies to correct the Type 3 Vertical defect that is present. Can't wait to see the responses to this post.
thanks Dr. Salama


Reply


Reply

THis is a tough one... the thing that concerns me is the amount of root resorbtion on #9 and the apparent loss of bone on mesial of 10... if you erupt #9 by 5mm to correct ression than you probably will need to remove it... with the bone discrepancy on 10 this might be a better indication for a fixed bridge rather than implant... could always erupt 10 depending on the soundings on m10.... i do not forsee #9 making it for the long term.....


Reply

Wow, it reminds me to a almost case I had 4 years ago. I guess I would do ortho to retrude, close gaps and fit retainer and whitening. Then wait to see improvement in mobility and tissue gain. Maybe schedule surgical to place some soft tissue graft.

According to my short expereince, I would not do root canal, and extrusion and crown in this situation. If so, Manuel, how long do you think this new aesthetic situation would last?

If I was to extrude 21, it would be in order to place an implant. I would avoid doing the root canal and straightaway do root submersion technique to gain more tissue, do provisional using same tooth with fiber-glass impregnated with composite, etc. I have used this technique with some good results over the last years. I learnt this in Brazil. They even sell what I think is the best commercial fiber glass impregnated with composite. So useful.

Btw, have you found any other vertical defects like this?
I'm thrilled to see the evolution.

Regards Manuelito

Manu.


Reply

Manuel. Thanks for your opinion.
I understand trying to save the tooth is complex and the new aesthetic scenario would have a limited longevity. The end of the line is that 21 will be lost, but we are trying to give a last shot due to the patients great interest in saving her tooth.
On the other question, I have seen quite often 1-wall osseous defects associated with a patient undergoing ortho and a reduced periodontium.
Regards Manu


Reply

Dr Manuel vi su tecnica en el congreso de la ALAO en Bs As me parecio increible los resultados obtenidos, a cuantos años son los estudios en casos de defectos tipo 3 y como siguen en la actualidad en terminos esteticos y conservacion de hueso.-


Reply

Manuel, I would love to know more in depth about this new technique. If you have any pictures and x-rays to share. Thank you Robin


Reply

Treatment of this case requires an understanding, first, of etiology. There is a huge open contact in this case. No corrective surgery will regenerate tissue until the contact is first closed (composite, porcelain restoration, orthodontic closure). When the contact is closed, I would then reshape the facial root with fine finishing diamonds to allow some incisal migration of the gingival margin. After achieving as much migration of tissue as possible, a connective tissue graft would increase the biotype of the tissue. ONLY then could we contemplate osseous grafts with L-PRF to restore crestal form. This is not only possible, but in a very carefully planned sequence of procedures can be HIGHLY predictable. But you have to get the biology of the site on your side before each subsequent procedure.
Robert J. Miller


Reply

Robert; How would you manage the vertical loss of Bone?
What procdures woulf you utilize?
BTW, welcome to the Forum.
Maurice


Reply

This case has several steps.
a-orthodontics to close the diastema and bring the contact point as high as possible.
b-A conciste surgery in:
- An incision mesial distal 21 and 22 and held high crescent centered at the papilla
- Tunnel from an incision at another
- Put this cavity formed within a tissue expander to dilate and expand the tissues
- Then put a filler.

I have just one case for more than 10 years that could conpartirlo.
regards


Reply

Mo; I like to use a graft with a higher proportion of cortical chips to extend the resorption time as this is a one-walled defect. We had previously used emdogain, but now use plasma from PRF to hydrate graft. But the key to our success is to use lambone on the facial and palatal, tacked to the ridge and sutured high in the interproximal with a resorbable suture (3-0 PGA or 4-0 vicryl). This will help to keep migration of the particulate graft at a minimum and prevent periosteal cells from infiltrating the outer layers. We then use PRF membranes on the outer component of the graft with the flap coronally repositioned and the PRF membrane extending 1-2 mm suprgingival. I then fabricate a modified ESSEX retainer with complete relief over the grafted area. Growth factors, lambone membranes, and complete protection from microtrauma gives us very impressive results in these cases.
Robert


Reply

Thank you all for your input on this case. All opinions have a positive and interesting complement to the case. I think the key issue here is, like Robert Miller says: Understanting the etiology of the case and then the biology of combining the periodontic and orthodontic treatments. We can make different combination of treatments as far as we understand this both concepts, then either way we go we will succeed.
Thanks. M de la Rosa


Reply

Dr. Robert Miller;
Thank you for sharing in details your techniqual approach of such a hardly managed case. So useful and interesting.


Reply

i may be too late to respond to the post.. my opinion...the prognosis of the tooth seems questionable considering the amount of bone loss that is close to 2/3. in such case by orthodontically repositioning the tooth we would by no means be able to achieve the desired result as atleast 2/3 of bone support is necessary for the tooth to be stabilised. Even if the anteriors are all splinted lingually it would be of no real use and the mobility will remain! endodontically treating the tooth would be a good option as it could prevent future possible perio-endo problems. however the use of growth factors and bone regenerating procedures may be helpful if the defect can contain the material. I am vastly inexperienced and i thought could learn a lot by participating in the discussions here. kindly educate me if am wrong :)


Reply

Looks like rapid ortho resulted in severe loss of the labial plate which I think would be difficult to regenerate in the presence of tooth #9.I think extraction and regeneration with over grafting followed
Later with CTG.I would also trim the extracted tooth and use as a temp. Bonded to teeth #8 and 10 to help shape soft tissue during healing.


Reply

Major problem is the request of the patient to retain the natural teeth. It seems that mesio-distal axial inclination of tooth # 9 is not ideal (root is inclined distally and, apparently, buccally as well). I would suggest to start with orthodontic treatment to correct axial inclination of tooth # 9. By doing this, some bone may be gained at the distal and buccal aspect of tooth # 9 (tension side). This may be followed by (1) space closure and (2) slow, limited, vertical extrusion of teeth # 9 and 10 to partially correct residual interproximal vertical soft tissue discrepancies. Then, splinted crowns on both teeth or an all-ceramic bridge from #8 to 11 for better stability.


Reply

My question is: How much capacity does the PDL have to grow bone as it is being stretched while a Hyalinization process is taking over after the Ortho treatment?
Because if the tooth is out of the Bony Housing and an open contact is present, that is one of the reasons for not having Interprox papillae, by moving it palatally I don't know if that is predictable in terms of gaining bone, even though many literature supports it. But by forcing erupt both teeth in order to loose the central and keeping the lateral, would we be predictable? Thanks. Nicolas


Reply

That was a real tough case that you have discussed here. The only concern for the patients is to the post dental pains that might affect the patient a lot.


Reply

A CBCT would be interesting and necessary to evaluate the chances for ortho but it could be definitely worth a try. Alternative would be to go with GBR/autogenous block & GTG and later implant placement but especially given the compliance and wishes of this patient I too would opt for ortho here. Not sure I would do the RCT though. Why do you think the RCT is necessary at this stage? Thanks for sharing this great case! Hana


Reply

Type III defect here.
I would have a long discussion with pt. RBA's
I would sacrifice 9 for sure and probably 10 (need more info CBCT, probes, ect..)
Phase I- endo and orthodontic extrusion 9+10 to change defect to type II
Phase II- GBR
Phase III- Implant placement #9, with cantilever pontic #10


Reply

perfect


Reply

Tye, nice treatment plan. Dr. Salama


Reply

I think it is great. Many information gathered together. Different people having different ideas and experience. It is a great platform to understand everything about dentistry. Thanks a lot guys for sharing your knowledge.


Reply

Related Posts


3Shape
Omnia
Ritter