Dental Tribune U.S. Edition

Clinical DENTAL TRIBUNE | OctOber 20114A Obvious to her as well, her lower anteriors were worn and shortened, making us cognizant of occlusal relation discrepancies. Due to abra- sive grinding, the teeth on her lower anteriors were shortened, exposing the different yellowish tan color of the dentin inside her teeth. Her vertical relationship needed correc- tion. However, the color of her teeth needed to be corrected as well as their shape and size. Also obvious was the shape of the maxillary incisors. The square shape is unnatural. The normal shape of maxillary incisors is usu- ally one that is longer than they are wide. This is also a more youth- ful appearance than the square, “older” look she had at her initial visit. Her gingival horizontal lateral line was uneven and asymmetrical. There was, however, an adequate zone of pinkish, keratinized gingi- val tissue, which could be utilized and manipulated for our final goal of a symmetrically appearing peri- odontal background of esthetics, health and its maintenance in the future. Correcting her vertical rela- tion required support in her pos- terior areas to support the correct prosthesis and its newly corrected occlusal height. The patient also requested that a “non-removable prosthesis” be prominent in our treatment plan goal. The radiographs indicated adequate osseous support in her mandible posteriors such that peri- odontal therapy, including surgical intervention, would be of a posi- tive result, the latter of which will support the changes to be made to restore the vertical dimension. The maxillary posterior, how- ever, is a different entity altogether. This patient is utilizing prescribed oral bisphosphonates for her osteo- protic condition. By avoiding osteo- porosis and its effects, she will be able to support and maintain oral endosseous implants and their functioning. Sinus-lift techniques to regenerate support for the maxil- lary posterior implants would need to be accomplished. Would the fact that she is osteo- porotic and utilized oral bisphos- phonates hinder the acquisition of new regenerative support? All these factors are considered and dis- cussed with the patient before com- mencing. If the patient desires, as this one does, non-removable pros- thesis replacements, then implants and sinus lifts must be considered. The maxillary right posterior had two prognostically poor teeth that were extracted. We recommended use of implants to support the new crowns with the corrected occlusal height restored. Yet, Mrs. G had inadequate bone support to support the implants in the posterior max- illa. Thus, we elected to initially us the sinus-lift technique to provide adequate support for the needed implants. The patient has osteoporosis, and as previously stated, has taken oral bisphosphonates for more than 10 years. Questions that were discussed included the regenera- tion of osseous support be healthy enough or adequate to support the implants and their needed func- tion. Will such dental procedures be tolerated without being susceptible to osseous necrosis? Yes, because she has been on oral bisphospho- nates all these years. Augmenta- tion procedures were selected to acquire the adequate bone needed to support the implants. Mrs. G’s upper left side had two teeth, #12 and #15, that were to be kept. Yet the area that initially had pontics above them, also needed a new bone to support forthcoming added implants, which will support the future restored crowns and the occlusal changes. A sinus augmen- tation procedure was done in the upper left to facilitate the fabrica- tion of new osseous support. The existing UL bridge was kept as a provisional splint while the sinus-lift technique was accom- plished even around and apical to the preserved molar. After six months of uneventful healing, a provisional splint was placed in the UL, replacing the existing perma- nent bridge. Endosseous implants were then inserted and integrated in the #12 and #13 edentulous area. After six months, we began the restorative phase. Both the UR posterior sinus lift and the UL sinus-lift surgeries were accomplished during the same sur- gical appointment. However, the UR #3 and #5 had a very poor prognosis and were extracted during the same treatment with osseous grafts added to the voided sockets. The restorative phase for the posteriors was accomplished at the same time and after the use of pro- visionals. Then they were adjusted to achieve the proper occlusal rela- tionship, especially in the poste- riors initially. After the posteriors were restoratively corrected in pro- visionals, the anterior teeth were then treated. The maxillary ante- riors were changed from the ini- tial square appearance to a bright, more streamlined and youthful appearance. With the posteriors restor- ing the vertical height, there was enough space and room for the return of correctly shaped lower anteriors. The chance to see her worn down stubs of older appear- ing teeth appear vibrantly youthful and regenerated in length, appear- ance and color was encouraging to Mrs. G. All of this was made possible by restoring the correct vertical dimension by correcting the pos- terior teeth height. To achieve this, implants and sinus lifts with bone regeneration techniques were utilized. The restorative crowns allowed the stabilization and main- f DT page 1A Fig. 2: X-ray pre-treatment UR. Fig. 3: X-ray UR post sinus-lift treatment and extraction of #3 and #5. Fig. 4: X-ray UR of inserted implants and prosthetics. Fig. 5: X-ray UL, pre-treatment. Fig. 6: X-ray UL with maintained splint and completed sinus lift. Fig. 7: X-ray UL of inserted implants and prosthesis.