Dental Tribune Middle East & Africa Edition

Media CME DENTALTRIBUNE Middle East & Africa Edition6 2 Hours (mCME articles in Dental Tribune (always page 6) has been approved by HAAD as having educational content acceptable for (Cate- gory 1) CME credit hours. Term of approval covers issues published within one year from the distribution date (September, 2010). This (Volume/Issue) has been approved by HAAD for 2 CME credit hours. A smile that is perceived as un- attractive mars confidence, so- ciability and self-regard. For somepatients,thelackofvisual appeal stems in large part from a “gummy smile,” which a layperson begins to consider disharmonious when there is 3 to 4 mm of gingiva displayed.1 Management of such a com- plaint often entails both peri- odon-talandrestorativetherapy, if not also orthognathic surgery and facial plastic procedures. The following report show- cases two-stage esthetic crown length- ening and prosthetic re- habilita- tion for the treatment of a gummy smile. Patient history A medically and periodon- tally sta- ble 40-year-old female presented with excessive, asym- metric gin- gival display of 5 to 7 mm upon smiling, short clinical crowns and incisal wear from tooth #4 to #13 (Figs. 1, 2). Due to attrition and the rela- tionship between the dentition and periodontal drape, the ante- rior teeth appear square-shaped and “masculine.” Diagnoses included (1) Coslet Type IA altered passive eruption, evidenced by a wider- than-cus- tomary dimension of keratinized gingiva and an alve- olar crest at least 1.5 apical to the cementoe- namel junction (CEJ); and (2) vertical maxillary excess.2,3 The patient also shows a thick tissue biotype. Treatment plan Consult with oral and maxil-• lofacial surgeon regarding orthognathic surgery Consult with facial plastic• sur- geon regarding lip low- ering therapy Consult with restorative• dentist regarding ideal tooth shapeset-upandfabrication of surgical guide Two-stage esthetic crown• lengthening from tooth #4 to #13• First stage: osseous recon-• tour- ing 6-week healing period• Second stage: gingivectomy• 3-month healing period• Final porcelain veneer• restorations for teeth #4 through #13 Delivery of maxillary oc-• clusal bite guard Treatment plan rationale Ideal treatment for the pa- tient with vertical maxil- lary ex- cess embraces a host of dental and medical specialties. Insuchacaseasthis,inwhich thepatientdem-onstratesupto7 mm of gingival display, LeFort I maxillary impaction may further refine results if con- ventional crownlengtheninginsufficiently elevates the peri- odontal margin, cre- atesanunacceptable crown-to-root ratio or precludes achievement of a natural-seeming emergence profile due to exposure of excessive radicular structure.3 Likewise, neuro- muscular relaxation of the upper lip by botulinum toxin type A (BTX-A) depresses the lip, and thus masks any mucosal surplus left after pe- riodontal surgery.4 As the patient de- clined orthognathic and facial plastic therapy, the treat- ment rendered to al- leviate her gummy smile and reestab- lish tissue and dental symmetry included a two-stage crown lengthen- ing proce- dure followed by de- livery of porcelain veneers from tooth #4 to #13. A biphasic crown lengthening ap- proach mini- mizes the1to3mmcoronal gingival shifts com- mon after one-stage procedures detected especial- ly in pa- tients with thick soft- tissue biotypes (such as the patient fea- tured in this re- port).5 Byfirstreshaping only the osseous crest and letting healing commence, it is possible to cor- rect any coronal re- bound of the soft tis- sue seen after heal- ing at the second, gingivectomy-only, sur- gery. Once the attachment appara- tus fully remod- els post-gingivectomy, which takes roughly three months, final restorations may be cemented. Restorative consult From the diagnostic models, thepatient’sprosth-odontistcre- ated an ideal dental wax-up, upon which a vacuform matrix was applied to generate a surgi- cal guide (Figs. 3, 4). osseous recontouring (first stage) The first stage of biphasic crown lengthening of teeth #4 through #13 involved only os- seous resec- tion. The patient took 0.25 mg oral triazolam and 600 mg ibuprofen one hour before surgery. Anesthesia with 2 percent lidocaine with 1:100,000 epi- nephrine and 0.5 percent bupivi- caine with 1:200,000 epineph- rine was given via local infiltra- tion. A buccal sulcular incison was made extending from tooth #4 to #13, and vertical incisions were dropped at the mesio-buccal and disto-buccal line angles of teeth #4 and #13. A full-thickness flap was elevated (Fig. 5). Ostectomy was performed using an Ochsenbein chisel, car- bidefinishingburandNeumeyer bur to position the alveolar crest at least 3 mm from the antici- pated restorative margin at each site, as veri- fied by the surgical guide (Fig. 6). The bone was gradualized such that no sharp edges or bul- bous areas existed, and positive archi- tecture was preserved. The flaps were replaced and su- turedinslingfashionwith4-0ex- panded polytetrafluoroethylene (ePTFE) (Fig. 7). The gin- gival height and shape post-surgery appeared simi- lar to that found beforesurgery,even10daysafter intervention (Fig. 8). Gingivectomy (second stage) Once the soft tissue resettled six weeks post-ostec- tomy (Fig. 9), the second stage of biphasic crown lengthening of teeth #4 through #13 was executed. The patient was sedated and anes- thetized as above. A definitive external bevel gingivectomy of teeth #4 through #13 was per- formed with a #15 scalpel utiliz- Two-stage esthetic crown lengthening By Michael Sonick, DMD, Stephen Rothenberg, DMD and Debby Hwang, DMD Fig. 1a: Initial facial pre- sentation of patient, who exhibits a gummy smile (up to 7 mm of soft-tissue dis- play) and vertical maxillary excess. Fig. 1b: Initial view of maxillary ante- rior teeth upon smiling. The clinical crowns appear short and demon- strate attrition. Fig. 2: Excessive kera- tinized gingiva, a thick soft- tissue biotype and asymmetric gingival con- tours exist. Fig. 3a: The maxillary diagnostic model. Fig. 3b: Ideal wax-up created on the diagnostic model. AfterBefore Fig. 14: Facial view six years post-treatment. Fig. 4: Surgical guide in place in the mouth. The ideal tooth contours are shaded in white. Fig. 5: Initial full-thickness flap reflec- tion at first stage surgery. Note the api- cal level of the alveolar crest compared to the cemento-enamel junction. Fig. 6a: Final bone contours after ostec- tomy. Fig. 6b: The final osseous contour lies at least 3 mm from the anticipated restor- ative margins, as outlined by the surgi- cal guide. Fig. 3a Fig. 3b