Cosmetic crown lengthening with new prosthetic restorations

The patient was referred in our clinic by the GP for aesthetic crown lengthening of the maxillary anterior teeth, in order to improve the teeth proportions and re-establish bilateral symmetry.
Post crown lengthening composite resin was placed over the newly exposed root surfaces in order to support the gingival in there new position.
12 weeks post-op a new set of temporary prostheses were placed and the tissue was allowed to mature for an additional month before final restorations were placed.

Surgery: Ioannis Vergoullis, DDS, MS
Prosthetics: Claudia Stamatidou, DDS
Lab: TDK

Esthetic rehabilitation of the maxillary anterior teeth

The patient was referred to our clinic for esthetic evaluation of the maxillary anterior teeth. 

The teeth were in malposition in the arch. They also had uneven gingival margins as well as inadequate crown proportions. 

We recommended orthodontic treatment for proper teeth alignment. Followed by cosmetic crown lengthening for establishment of adequate crown proportions. Finally, prosthetic rehabilitation with full ceramic veneers and crowns.

The patient declined ortho treatment. Patient understood that esthetic results may be compromised without ortho treatment and more invasive teeth preparation might be needed.

Diagnostic wax-up was performed and a direct mock-up was done in the patient mouth. 

Based on the mock-up, cosmetic crown lengthening was performed. 

Final restorations were cemented 3 months later.

At 6 months follow up, stable results are appreciated.

Surgery: Ioannis Vergoullis, DDS, MS

Restorative treatment: Marieta Kalogirou, DDS

Immediate replacement of a primary canine with an implant

Patient presented to our clinic for removal of a long standing primary upper right canine (#53) and to be replaced with a dental implant. Clinically, the tooth to be extracted presents with class 3 mobility. 

Patient is a mild smoker (<10 cig/day) without any other contributing factors in the medical history.

We proceeded with the extraction of the primary tooth. The socket was thoroughly derided and difinfected with diamond burs and rinsing with a mixture of TTC solution and saline. 

A Legacy3 3.7x11 implant was immediately placed following the appropriate position within the existent socket.  A high insertion torque was obtained. An impression was taken and a 2 stage protocol was utilized due to the smoking habit of the patient. 

Uncovery of the implant was performed 3 months later.  A temporary crown was placed at this time in order to guide soft tissue profile during healing. 

1 month later, a final screw retained crown was placed by the GP. 

At 1 year post-implant placement, soft and hard tissues seem favorable. However, patient's interproximal oral hygiene was fair and thus mild gingival inflammation is evident on the mesial papillae. 

Oral hygiene was reinforced and an appropiate maintenance schedule was discussed with the patient to ensure gingival health around the implant.

SOCKET GRAFT WITH CYTOPLAST MEMBRANE

Patient presented in our clinic for extraction of tooth # 36 and dental implant replacement after it was diagnosed non-restorable by the patient's dentist.

Treatment plan:

- Extraction of #36 and socket graft

- Dental implant placement 3-4 months later

- Restoration of the dental implant 2-3 months later.

Upon extraction and thorough disinfection of the socket, a facial dehiscence ranging from 8-11mm was identified. Also, a 4mm deep 4-wall defect was found on mesial of tooth #37.

The #36 socket and the periodontal defect on #37 were grafted with a mixture of FDBA and tetracycline and covered with a cytoplast membrane. The membrane was left exposed. Oral hygiene instructions to the patient involved chlorhexidine gel 0.2% application 3 times per day for 7 weeks until the membrane was removed.

A Legacy3 5.2x10mm dental implant was then placed 4 months later presenting high initial stability. After 1 year post-op, good bone stability around the implant can be observed. Also, the defect on medial of #37 responded favorably as it can be observed clinically and radiographically. 

The technique used in this particular case could be utilized in posterior sites with a thick soft tissue and where large amount of bone augmentation is required. Patients medical history should be clear so proper healing could be expected. It is not recommended for patients with potentially impaired healing like diabetics and smokers.

Sinus graft complications & management

The following clinical case shows several minor complications and management during different dental implant surgical stages. 

This is the case of a  28 years old healthy male who came to our clinic for dental implant rehabilitation of the posterior left maxillary area. After clinical and radiographic evaluation, the need for vertical and horizontal ridge bone augmentation was determined. Vertical augmentation was treatment planned to be obtained through lateral window sinus lift surgery accompanied by horizontal ridge augmentation using particulate bone grafting material and membrane. 

Two dental implants were placed 8 months post sinus lift surgery. During the osteotomy for the molar site implant, a small membrane perforation was identified, managed and controlled through the osteotomy site. Dental implants were placed and primary stability was obtained for both. 

Upon dental implant uncovery, 3 months after surgical placement,  bone loss was found on the molar site implant. We reduced the exposed implant threads with Implant-plasty using a fine diamond bur and a layer of HA xenograft bone grafting material was used to graft the facial aspect of the implant. 

The 3 year follow up X-ray shows good bone stability around the implants.

Ioannis

Gingival recession treatment with connective tissue graft

Patient presented to our clinic with the chief complaint of: "Increased and persistent sensitivity on upper left central, lateral, canine and first premolar teeth (21, 22, 23, 24)"

After clinical and radiographic evaluation our Diagnosis given to those teeth was: Class I Miller recession on 21, 22, 23, 24

Etiology: Traumatic forces (applied with a hard toothbrush) over a thin tissue biotype.

Treatment plan: Connective tissue graft with a coronally positioned flap

Prognosis: Excellent (90-100% root coverage is anticipated in class I miller recessions)

Some post operative instructions given to the patient included but were not limited to: 

- Oral hygiene modification: modified Bass toothbrusing technique was instructed

- Recommended the use of a soft toothbrush 

Ioannis

Excision of a Fibroma with the use of a Nd-Yag Laser

Clinical diagnosis:
- Trauma induced Fibroma

Treatment protocol:
1. Occlusal adjustment of the uneven cusps of the teeth involved
2. Complete excision of the lesion for histologic evaluation

The excision of the lesion was performed using a Nd-Yag Laser.
Settings used: 4W, 200mJ, 20Hz

GBR at the time of Immediate Implant Placement

Factors to consider after reviewing a similar case to the one presented in this video:

1. In the presence of an edentulous space next to a tooth that is treatment planned to be extracted, you should evaluate the width of the crest at the edentulous site. This might give you an idea of how much resorption the extraction socket would have if not grafted or immediately place an implant.

2- If not planning on horizontally graft the edentulous site, place your dental implant in the extraction site 2mm lingually to the facial wall of the edentulous site. This is irrespective of the gap between the implant body and the facial wall of the socket. This way you will have a predictable result. If this case scenario would compromise the prosthetic rehabilitation of the implant, then perform GBR and place the implant at second stage.

3. Place the immediate dental implant 2mm sub-crestally to the lingual wall of the extraction socket to accommodate for height resorption, to provide space for establishment of proper emergence profile of the restoration and to establish adequate thickness/height of soft tissue around your implant for the uncovery stage.

Ioannis

Replacement of a broken dental implant

This patient was referred in our clinic for evaluation of an implant that was previously placed by another dentist.

Upon clinical and radiographic evaluation, our diagnosis was:

- Broken dental implant collar associated with occlusal parafunctional habits (bruxism)

Our treatment plan was as follow:

- Dental Implant removal & guided bone regeneration
- Placement of a new dental implant 4-6 months later
- Restoration + delivery of a biteguard for night use: 2-3 months later

Tips: A wider diameter dental implant would be preferable but the limited space mesio-distal and the triangular shape of the desired final restoration would not allow for the use of it. In order to overcome the above, the final prosthesis was kept out of contacts on lateral excursions and protrusion movements.

Ioannis

Dental implant uncovery with simultaneous free gingival graft procedure to augment keratinized gingiva

Diagnosis:
- Movable muccosal tissue around dental implant

Treatment plan for this case:
- Free gingival graft upon uncovery of the implant

Why is stable keratinized tissue important?

1. Keratinized attached tissue around a dental implant minimizes the chance of future recession and possible bone loss on the facial surface of the implant

2. Oral hygiene practices could be performed with minimal discomfort on the area and plaque removal is more predictable if done correctly.

3. Reduction on discomfort related to mastication of hard foods on that site.