Socket Shield with a twist

217 Rating(s).


Posted on By Howard Gluckman In Anterior/Esthetic

This is an interesting case that was referred to me. I have NOT treated this case yet but thought I would throw this case out there and get some opinions for the experts first and then take it from there. She want to have a more esthetic result. She would like new crowns on the front teeth and was told she could not save the teeth and needs them to be removed. One of the crowns came out and is loose and the remaining root has no ferrule.




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22 Comments


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Hi Howard, this case looks similar to a man you already have done. I would go with SS in conjunction with apicoectomies. No doubt.
The only particualrity is that I would cut the shield acording to the new neck position of the crowns. I think it´s possible to improve the smile line with crown enlargment towards apical.
Good luck!
Regards
Jorge


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Howie,

As you know my thoughts would be to orthodontically Align teeth for possibility of "longer" shield vs postion now- also increase the the overjet and open bite a bit for more restorative space- apicoecomtomies to allow bone fill during movement- How many teeth are we looking at 4 for 6 ? Could you use digital wax up to see if new postion of teeth prior to procedure- also ortho could help with postion of mandibular teeth which appear to be lingually positioned- what is postion of joints?



Cheers

Richard


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I must kind of agree with Richard here. The teeth look significantly lingually inclined. Perhaps tooth movement if possible prior to PET extraction and apicoectomies. Or, if ortho is NOT a possibility in maxilla then would get a waxup, perhaps ortho on mandibular incisors and plan positioning of implants in new more labial position using a guide to optimize esthetics.
Yes, as Jorge says, the teeth seem to need some additional crown lengthening to get proper proportions although it does not show up in smile image provided??
In any case, placing implants in current occlusal scheme with or without PET would seem to limit the upside of the therapy.
regards Mo


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Howie,

Also Patient appears ( Yes ) to have a degree of vertical maxillary excess but I do not think that orthognathic ( maxillary impaction) is an option here due to lack of strength of teeth to support even a few weeks of intermaxillary fixation .....


Cheers,

Richard


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I agree with both Richard and Maurice, I don't think that this case can be handled just with SS or PET in any way. My feeling is both ortho and orthographic possibly to put everything in the right position. It looks like the teeth have been completely put back into an S-curve totally crazy. I really feel that ortho is essential in this case that is for sure. The bulbousness of the gingiva is a problem when she smiles as her lips slip over it and get stuck. Rich I don't think this case requires impaction I feel the vertical may be right but a lat. ceph will confirm that. Sh is keen and willing to go the whole way so I have referred her for soncultations and we will see what the team says


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Howie,

I agree with consultations- What I was trying to say no corrective jaw- A video of her during a conversation will show us the true smile and lip position .... food for thought

Cheers,

Richard


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Howie,
more than challenging case, thank you for asking for interaction.
Orthodontics, ortho - surgery, PET - before patient receives too much or not enough therapy I would say that backward planing should be done. 3D digital designing of teeth position based on photography, models and CBCT. You can outsource it. There are specialists combining smile design-dynamic occlusion. I`ll try to get one of them on board. Than you look how it corresponds to the bone and what should be done.
And I believe that bulbousness of the gingiva is going to be much better when incisors are not reclined and gingiva margin higher.
Exciting!
Cheers
Snjezana


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Thanks for the input I agree. Thanks for the offer I would love to have some more input and see where we need to go. In the mean time we will get the consults and see where it takes us. Thanks all for the input


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XP is all about this interaction which enables better options for our patients around the world.....thanks to ALL and especially Howie for involving us. regards Mo


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The best advice a practitioner can get for sure.


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History of trauma to front teeth that pushed the alveolus palatally as well??


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NO the teeth were cut back and then crowned that way patient couldn't afford Ortho and this was UK NHS at its best


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I'm not as experienced as our previous posters but I agree with the possibility of orthodontic tx to facilitate better positioning and the use of DSD to see where you want to be and work backwards. Additionally what can help is if you get an stl file of the final or get a wax up done and scan it to allow you to import it into the cbct software to overlay over the original you can see the final plan over the original bone, roots, and tissues. This may give you a better visual in allowing you to tx plan the ideal interdisciplinary plan. Lip positioning during smiling and speaking should also recorded for planning. Very interesting case. Hope this helps. Regards Naheed


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Thanks Naheed for the valuable info


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I agree that we need more information to make the diagnosis. More photography, lateral ceph, video of patient talking and smiling, mounted study model printed form IOS on an appropriate articulator, face photos with facial analysis, and possible DSD protocol.

Then and only then could I personally make some sense of what we are seeing. On a subjective basis, I would like to know how realistic the patient's expectations are-Ron Goldstein's book would be a starting point to access the patient's cosmetic expectations.

I would want to work with an experienced interdisciplinary team with orthodontist, periodontist, OMS, and possibly a prosthodontist or general dentist would is experienced in these type of case. The lab person and the lab expertise in working with these types of cases is critical also.

The techniques to treat the patient are in my opinion the easiest part of the cases---it is getting a consensus is the difficult and most demanding part of the patient's care.


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Agreed George. We are at the information gathering stage at this point.


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Thanks for sharing your cases, my humble opinion is that we can suspect it is a class II division II oclusion because of the shape and size of the four centrals are very similar besides that it seems that she compensate the discrepancies so she have lost the chance in this point to do it with no ortho, the midline is 3mm to the left and according to Kokich we are in the limite to start seen the midline non esthetic, because of the compensation the extrution you have to deal now is what makes me think ; where we want our smile and where is now and when you do PET you maybe will need to use the bur apically and I do not know if we are getting close to the infection zone, I would take the left canine as an esthetic guide for smile if I have to choose before ortho, my very humble opinion. Try to get central dominance size to achieve esthetics, maybe use a suck down machine with whitenning plastic and use gutapercha in the zenith were you want it to be in the end help me very much and take the CT scan so accurate measurements can be done, thanks for sharing knowledge.


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Great points from all...more info for sure. Dental Detective work.


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Howie I am sure this case initially was a wear case with dentist-alveolar extrusion of the upper anterior teeth hence the classic discrepancy of gingival margins . The proportion of incisors also now incorrect looks more like 100% should be 75-80%. Incisal edge position not too bad could move slightly apically if necessary the gingival margins of incisor need to be moved up this will solve tooth proportionm. This can be done with ortho or during the surgery or both .
This would be a great case to use 3D planning with CBCT where we could decide on all the prostho, aesthetic, ortho and surgical needs
I would send the case to Nemo planning Centre


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Mark that is a great idea lets do that


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Ohh you done a fabulous job. But as you said and we can see one crown came out but surprisingly the remaining root has no ferrule.


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