Treatment options for fused anterior maxillary teeth number 8, 9

581 Rating(s).


Posted on By Abtin Shahriari In Implants

Patient is a 37 year old female with no known past medical history.

CC- I have been dealing with my front two teeth for ever and now I want it fixed and want to look normal when I smile

Exam- High smile line, Gingival recession, 2-3 mm of gingival show; narrow palate, roots of the teeth number 7, and 10 medially positioned.

please refer to the xrays

Clinical photo front
Clinical photo front 2

Pan
CT


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28 Comments

FUSION of the 2 Maxillary Central incisors!! Extremely challenging case here. Lack of space, roots of lateral mesially positioned, gingival recession already present at the midline and a patient with a HIGH LIPLINE!! Can't wait to see what our members have to say about possible options here. Thanks for sharing such an interesting case. Dr. Salama


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Dr. Salama, with all due respect, I would like to ask: if the fused teeth were extracted /grafting of the socket (DBBM - improved long term stability of the bone replacement graft?) and soft tissue augmentation were to be performed, what would be your opinion regarding the use of a Maryland bridge on this case? (6mm pontic-pontic and 6.5mm tooth-pontic inter proximal soft tissue height, would translate into an improved esthetic outcome / less invasive, less complications / high predictability if correctly fabricated). Thank you


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Abfin. I would consider preparing the mid facial as if it were a molar with furcation involvement ( barrel prep / creeping attachment). Perhaps may be able the cultivate the appearance of a papilla. Then restore as 2 splinted central incisors. Just a thought. Tough case. Good luck.


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wow wow. the patient with high smile line and this appearance and seeking for esthetic is tough.ortho extrusion to bring tissue more coronally and then replace those fused centrals with one implant and a pontic due to lack of enough space between lateral roots is one option that can be predictable. i also like the idea by Chuck but i think if so we need ortho extrusion prior to that but i am not sure if in this patient with high smile line it gives us the best result possible.
tnx Abtin for sharing this case. looking forward to see the oucome.
Dr Moghaddas


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How about:
Extract 8-9, bone and tissue graft. Let heal and evaluate.
Ortho move 7&10 to central incisor positions .
Implants in lateral incisor positions.
Crowns on implants, veneers on centrals.


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Thank you Dr. Kozy.

The issue is that the patient wants to do this ASAP and the shortest time period which is not ideal.


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tough case!
mother nature made mistake, so, to correct that we have to redesign it .one the options can be extraction of three anterior teeth and place two dental implants on #7(#12) and #10(#22) area and make four units dental implant supported bridge. During the surgery the gum line can be corrected as well.


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I like Dr. Kozy's suggestion. Very Creative. Move laterals into Central positions will bring bone and tissue to midline NON-SURGICALLY!! You can then restore the laterals to look like centrals. Then place implants where the lateral were originally. This would allow for single implants rather than consecutive implants. BUT the patient must accept an extended ortho phase. If not, then.........


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How about bringing down the tissue and bone by ortho- extrusion, cut the crowns of 8 and 9, submerge the roots, and fabricating a bridge from lateral to lateral, just a thought.


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Ashok; Now that is creative as well.....it would require preparation of laterals as full crowns which we prefer to avoid. Dr. S


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Yes, Tough situation. Lets go back to the patients CC and desire for an attractive Smile.
Using Facial Aesthetics as a starting point, lets distract the eye from the obvious, 8/9 then let the eye be focused on an attractive smile rather than focusing on Centralized problem.

I would build out the buccal corridors, fill out the arch form and enhance/idealize teeth contours. Starting with a Functional Dx wax Up. #5-12.
Plan:
-Ext 8/9, graft hard soft tissues needed, Implant single
-Prep Temp#5-12, #7-10 Provisional Bridge allowing soft tissue to mature and for implant integration
Finals
-Veneer #5,6,11,12
-Cantilever Implant Bridge #8/9


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Thank you Dr. Heimke.

One thing I have to add to the CC or HPI is that pt has gone to multiple specialists and the patient is convinced that implant and Ortho is the only way.

I appreciates all the member's comments and trying to give the patient as many options possible.


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Abtin,

I like the idea of moving laterals- we utilize all the time in mandible- but my concern is can you show pic of cone beam that shows bone around 8-9 in buccal-palatal aspect- what are we working with before considering moving medially-

Thx

Richard


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Richard. My thoughts as well. Removal of that tooth may leave a large defect without facial/palatal bone. In addition, this may be complicated by incisive canal anatomy. Chuck.


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I think I would like to first be conservative: The main problem is recession and lack of papilla, hence try Ortho extrusion, Recontour the Buccal bone crest and marginal gingiva to the scallop of 8, 9, maybe even adding the mid facial barrel prep/creeping attachment that Dr. Schwimer suggested and place an Emax crown seeming like 2 crowns as was done earlier on the fused tooth itself. I would like to see if, the root being fused, still remains firm despite being shorter by about 5-7mm. If this is not successful, we could still try Dr. Kozy's idea.


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Richard and Chuck; There is relative bone buccal and palatal to the Fused tooth. Abtin has shown me the case and will try to add those images later in the week. I am curious as to how and if that would change your treatment design. I really liked Chuck's idea of barreling into the fused area and prepping them allowing for some "creeping attachment". In then end, can we make that tooth look like 2 centrals? Dr. Salama


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Endo, would be a good consideration in this approach so that the barrel prep can be maximized to create room for Ceramic to create the two tooth look.


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Great option John. thank you


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John....good addition here....Mo


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Please see the additional photo from the Ct. There is adequate bone buccal to the fused tooth.


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Please see the attached picture from the Ct. there is adequate buccal bone


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Abtin, orthodontic tooth extrusion is the key for successful aesthetic treatment. doing that, you will coronolly position the free gingival margin as well the facial bone crest. During orthodontic extrusion, lateral incisors root position could be adjusted.Then extraction with ridge preservation and CTG would be a good alternative before implant placement. thanks


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Thank you Fahed. Great input


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Dr. Kozy's suggestion is wonderful and really biological. Moving laterals into central positions will bring BONE & SOFT TISSUE tothe midline, transform laterals into centrals and implants where the lateral were originally. This would allow for SINGLE implants rather than consecutive implants. Orthodontic tooth extrusion of the fused teeth will coronally position the free gingival margin as well the facial bone crest, HOWEVER THERE WILL BE A PROBLEM IN TRYING TO RECREATE THE PAPILLA BETWEEN THE CENTRALS. So... sometimes if we´re not able to make patients understand that longer treatments are really shorter than shorter one´s... they can actually become much longer...
Thx for sharing and good luck. Filipe Lopes


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Dr. Kozy's suggestion is wonderful and really biological. Moving laterals into central positions will bring BONE & SOFT TISSUE tothe midline, transform laterals into centrals and implants where the lateral were originally. This would allow for SINGLE implants rather than consecutive implants. Orthodontic tooth extrusion of the fused teeth will coronally position the free gingival margin as well the facial bone crest, HOWEVER THERE WILL BE A PROBLEM IN TRYING TO RECREATE THE PAPILLA BETWEEN THE CENTRALS. So... sometimes if we´re not able to make patients understand that longer treatments are really shorter than shorter one´s... they can actually become much longer...
Thx for sharing and good luck. Filipe Lopes


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Filipe Lopes; Well said and Dr. Kozy made a good suggestion. We have a case just like this that I did with David Garber...moved laterals into central position after trauma to the 2 central incisors from a Horse accident. It worked very well. The laterals will require restoration after tooth movement and likely splinting for stabilization purposes. Dr. Salama


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Forced eruption #8, 9 Tip roots #7, 10 distally Extraction #8, 9 One implant #8 or 9 with a pontic or 4 unit bridge #7-10


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Mikhail; Very creative solution....


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