Twelve-year stabilizers
clinical
James D. Lytle, Cincinnati, Ohio
report
on multiple
A--
Trivate practice, Cincinnati, 10/l/34867
THE
1. Patient
JOURNAL
grafting of the marginal areas that exhibited inadequate gingivae (Fig. 4). Fig. 5 illustrates the free gingival graft of 360 degrees placed over the prepared tooth with the provisional splint removed.
PLAN-EXECUTION
The caries were removed and the remaining dentition was stabilized with an acrylic resin complete coverage splint. This provisional restoration of the mandibular anterior teeth allowed time for evaluation before a final treatment plan was implemented. The endodontic therapy, including endodontic implant stabilization in five of the teeth, was performed. Several teeth exhibited 2 plus mobility before this phase. The periodontal treatment phase included free gingival
Fig.
implant
DDS*
45 year old woman patient was examined in December 1976 because she had been involved in a minor automobile accident that affected her dentition. The patient’s restorative dentistry before the accident had consisted of two mandibular anterior pin splints, combined with complete artificial crowns on the distal abutments (Fig. 1) and a mandibular removable partial denture (RPD) opposing a complete maxillary denture. Gold occlusal onlays had been placed posteriorly in the prosthesis to establish the occlusal scheme and ensure efficient mastication. The dentistry had been completed about 3 years before the accident. Radiographs were made at the initial examination (Fig. 2). A new treatment plan was then devised because of the dislodged splint (Fig. 3), recurrent caries, and the compromised supporting abutments.
TREATMENT
endodontic
after initial
OF PROSTHETIC
Ohio.
examination,
DENTISTRY
December
1976.
Fig. 2. Radiograph at initial examination, December 1976. Widened periodontal ligament space demonstrates occlusal trauma.
Fig. 3. Loosened December 1976.
mandibular
splint
and recurrent
caries,
LYTLE
Fig. 4. Gingival tached gingivae,
recession December
and inadequate 1976.
band
of at-
Fig. 5. Facial and lingual views of single circumferential free gingival graft over prepared mandibular left canine, January 1977.
Fig.
6. Completed
restoration,
December
1977.
Fig. 7. Mandibular RPD with internal attachments, occlusal onlays, and gold retromolar pad coverage.
gold
A cast fixed complete coverage splint with internal attachments and an RPD were constructed (Fig. 6). The mandibular RPD (Fig. 7) was fabricated opposing a complete maxillary denture, using the cast gold occlusal posterior onlay surfaces from the original prostheses. The occlusion had been comfortable and functioning well. Therefore a concerted effort was made to duplicate the original vertical dimension of occlusion of the patient.
TREATMENT
MANAGEMENT
To stabilize the remaining natural teeth, the artificial crowns were splinted and endodontic stabilizers were inserted to improve the crown-to-root ratio. This splint would function as the abutment retainer for the RPD. Since the teeth were essentially “in line” rather than in a curved arrangement, their pretreatment fixed position with the abbreviated root form was less than ideal. Crown marginal maintenance, including interproximal oral hygiene, have been carefully performed by the patient, and she has been placed on a 6-month maintenance program (Fig. 8). The gingival crevice depths were 2 mm or less, ex750
Fig. 8. Twelve years after treatment of splinted restoration, January 1990. Note embrasure spaces, gingival margin placement, and survival of gingival graft. Metal collars were placed in gingival crevice for optimal thinness because esthetics was not a factor.
cept for the mandibular right central incisor that was 3 mm on the distal surface. Fig. 8 demonstrates the status of the patient after 12 years. Fig. 9 verified that the attached gingivae was present after 12 years following the grafting proJUNE
1992
VOLUME
67
NUMBER
6
EXTENDED
TREATMENT
PLAN
9. Lingual view of retained attached gingivae from circumferential graft with mandibular left canine 12 years postoperatively, January 1990.
Fig.
cedure noted in Fig. 5. The posttreatment radiographs at 12 years also confirmed the health of the periodontium and particularly of the crestal bone, dentition, and endodontic stabilizers (Fig. 10).
TREATMENT
RATIONALE
Osseointegrated implants have been reported to have an average loss of 0.1 mm of bone per year. Although gridded radiographs were not recorded for this patient, the proximity of healthy crestal bone to the crown margins was visible. This demonstrated that it was practical to use these compromised mandibular incisors as abutments and that they can be maintained in health without deterioration for more than a decade. This clinical report was presented to describe an imaginative, flexible interdisciplinary treatment plan for the retention of the patient’s natural teeth. The combined interspecialty treatment of the endodontist, periodontist, and prosthodontist was favorable. It was not the intention of this report to suggest this approach was the only, or even
THE
JOURNAL
10. Radiograph at 12 years, December 1989. Return of normal periodontal ligament space and extension of endodontic stabilizers can be seen. Fig.
OF PROSTHETIC
DENTISTRY
the most desirable treatment plan, but to emphasize that this treatment
did not jeopardize
the dentition.
Longitu-
dinal studies confirming the patient’s periodontal health, innocuous function, and the retention of her natural dentition
are the criteria
for success.
The author acknowledges the periodontal treatment of Dr. William J. Morgan and the endodontic treatment of Dr. Laurence Lazarus. Reprint requests to: DR. JAMES D. LYTLE 121 WILLIAM HOWARD TAFT RD. CINCINNATI, OH 45219
751
clinical
James D. Lytle, Cincinnati, Ohio
report
on multiple
A--
Trivate practice, Cincinnati, 10/l/34867
THE
1. Patient
JOURNAL
grafting of the marginal areas that exhibited inadequate gingivae (Fig. 4). Fig. 5 illustrates the free gingival graft of 360 degrees placed over the prepared tooth with the provisional splint removed.
PLAN-EXECUTION
The caries were removed and the remaining dentition was stabilized with an acrylic resin complete coverage splint. This provisional restoration of the mandibular anterior teeth allowed time for evaluation before a final treatment plan was implemented. The endodontic therapy, including endodontic implant stabilization in five of the teeth, was performed. Several teeth exhibited 2 plus mobility before this phase. The periodontal treatment phase included free gingival
Fig.
implant
DDS*
45 year old woman patient was examined in December 1976 because she had been involved in a minor automobile accident that affected her dentition. The patient’s restorative dentistry before the accident had consisted of two mandibular anterior pin splints, combined with complete artificial crowns on the distal abutments (Fig. 1) and a mandibular removable partial denture (RPD) opposing a complete maxillary denture. Gold occlusal onlays had been placed posteriorly in the prosthesis to establish the occlusal scheme and ensure efficient mastication. The dentistry had been completed about 3 years before the accident. Radiographs were made at the initial examination (Fig. 2). A new treatment plan was then devised because of the dislodged splint (Fig. 3), recurrent caries, and the compromised supporting abutments.
TREATMENT
endodontic
after initial
OF PROSTHETIC
Ohio.
examination,
DENTISTRY
December
1976.
Fig. 2. Radiograph at initial examination, December 1976. Widened periodontal ligament space demonstrates occlusal trauma.
Fig. 3. Loosened December 1976.
mandibular
splint
and recurrent
caries,
LYTLE
Fig. 4. Gingival tached gingivae,
recession December
and inadequate 1976.
band
of at-
Fig. 5. Facial and lingual views of single circumferential free gingival graft over prepared mandibular left canine, January 1977.
Fig.
6. Completed
restoration,
December
1977.
Fig. 7. Mandibular RPD with internal attachments, occlusal onlays, and gold retromolar pad coverage.
gold
A cast fixed complete coverage splint with internal attachments and an RPD were constructed (Fig. 6). The mandibular RPD (Fig. 7) was fabricated opposing a complete maxillary denture, using the cast gold occlusal posterior onlay surfaces from the original prostheses. The occlusion had been comfortable and functioning well. Therefore a concerted effort was made to duplicate the original vertical dimension of occlusion of the patient.
TREATMENT
MANAGEMENT
To stabilize the remaining natural teeth, the artificial crowns were splinted and endodontic stabilizers were inserted to improve the crown-to-root ratio. This splint would function as the abutment retainer for the RPD. Since the teeth were essentially “in line” rather than in a curved arrangement, their pretreatment fixed position with the abbreviated root form was less than ideal. Crown marginal maintenance, including interproximal oral hygiene, have been carefully performed by the patient, and she has been placed on a 6-month maintenance program (Fig. 8). The gingival crevice depths were 2 mm or less, ex750
Fig. 8. Twelve years after treatment of splinted restoration, January 1990. Note embrasure spaces, gingival margin placement, and survival of gingival graft. Metal collars were placed in gingival crevice for optimal thinness because esthetics was not a factor.
cept for the mandibular right central incisor that was 3 mm on the distal surface. Fig. 8 demonstrates the status of the patient after 12 years. Fig. 9 verified that the attached gingivae was present after 12 years following the grafting proJUNE
1992
VOLUME
67
NUMBER
6
EXTENDED
TREATMENT
PLAN
9. Lingual view of retained attached gingivae from circumferential graft with mandibular left canine 12 years postoperatively, January 1990.
Fig.
cedure noted in Fig. 5. The posttreatment radiographs at 12 years also confirmed the health of the periodontium and particularly of the crestal bone, dentition, and endodontic stabilizers (Fig. 10).
TREATMENT
RATIONALE
Osseointegrated implants have been reported to have an average loss of 0.1 mm of bone per year. Although gridded radiographs were not recorded for this patient, the proximity of healthy crestal bone to the crown margins was visible. This demonstrated that it was practical to use these compromised mandibular incisors as abutments and that they can be maintained in health without deterioration for more than a decade. This clinical report was presented to describe an imaginative, flexible interdisciplinary treatment plan for the retention of the patient’s natural teeth. The combined interspecialty treatment of the endodontist, periodontist, and prosthodontist was favorable. It was not the intention of this report to suggest this approach was the only, or even
THE
JOURNAL
10. Radiograph at 12 years, December 1989. Return of normal periodontal ligament space and extension of endodontic stabilizers can be seen. Fig.
OF PROSTHETIC
DENTISTRY
the most desirable treatment plan, but to emphasize that this treatment
did not jeopardize
the dentition.
Longitu-
dinal studies confirming the patient’s periodontal health, innocuous function, and the retention of her natural dentition
are the criteria
for success.
The author acknowledges the periodontal treatment of Dr. William J. Morgan and the endodontic treatment of Dr. Laurence Lazarus. Reprint requests to: DR. JAMES D. LYTLE 121 WILLIAM HOWARD TAFT RD. CINCINNATI, OH 45219
751
