Tag Archives: gingival margin

Ankylosis Part III: Treating Children with Ankylosed Permanent Teeth

ankylosisAs was mentioned in Ankylosis Part I and Part II, several factors need to be taken into consideration when deciding on the appropriate treatment option for an ankylosed tooth. When ankylosis is diagnosed in a child, these factors are even more important to evaluate prior to making the treatment decision.

These factors include:

  • Whether the ankylosed tooth is deciduous or permanent;
  • The time/age of the onset of ankylosis;
  • The time/age at diagnosis;
  • Patient gender;
  • The location of the affected tooth;
  • The patient’s smile line.

Here we have a female patient that presented to the office at the age of 15 with tooth #8 ankylosed. (Fig 1.)

This tooth was avulsed when she was 11-years-old and re-implanted after being out of the mouth for approximately one hour. The desire of the patient and her family was to improve the esthetics. As you can see, the incisal edge and gingival margin are more apically positioned compared to the adjacent teeth.

What do we know about this young ankylosis patient?

  • The tooth most likely ankylosed at the age of 11-12
  • The patient is now 15
  • The patient is female

ankylosisPrior to figuring out what we should do, there are still a few questions that we need to address:

How fast is the resorption occurring? As can be seen from the radiographs that the patient brought, the rate of resorption seems to be progressing very slowly. (Fig 2)

Fig threeWhere is the smile line? The patient has a very low smile line and does not show the FGM. (Fig 3.)

Where is she in relationship to her growth? Females generally are done growing at the age of 17. Given that she is 15 years of age now, it is anticipated that she is near the end of her growth phase.

So, what are the treatment options and treatment concerns in this ankylosis patient?

The treatment options are:

  • Extract the tooth and prepare for implant placement;
  • Subluxate the tooth and orthodontically reposition;
  • Use a segmental osteotomy to orthodontically reposition to the desired area;
  • Leave the tooth in its current position and restore the esthetics.

If the tooth is extracted, she will need hard tissue augmentation, will have to wait until she is 17-years-old to have an implant placed, and we will need to provide an interim tooth replacement option throughout this time period. The downside of this option, as far as the ankylosis patient and her family are concerned, is that this is a very formidable time in her life – managing appointments, schedules and interim tooth replacement would be difficult.

Subluxating the tooth and orthodontically repositioning it into the desired position will have limited success depending on how much of the tooth is ankylosed. This option typically works better on teeth that only have partial or spot ankylosis.

Using a segmental osteotomy to reposition the desired tooth can be successful depending on the surgical approach, but could be very problematic if necrosis of the segment were to occur.

What about leaving the ankylosed tooth for now and improving the esthetics by adding to the incisal edge? Will this create more problems? What we know already know is:

  • The replacement resorption is occurring slowly (so it could possibly be maintained for another 5-10 years;
  • The patient is 15 and near the end of her growth phase (so the defect created by the ankylosis shouldn’t appreciably increase);
  • The patient has a low smile (so you don’t see the gingival margin discrepancy).

ankylosisAlthough the tooth could be extracted now in preparation for a single tooth implant, the decision was made to leave the tooth and restore the incisal edge length with composite. (Fig 4.)

ankylosisThe ankylosis patient and her family knew that the composite was an interim restoration and that the tooth would require extraction and implant placement in the future. The question of when depends on the rate that the resorption progresses. In this patient, the tooth lasted another 10 years before it required extraction. (Fig 5)

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Ankylosis Part II: Treating Adults with an Ankylosed Tooth

ankylosed toothSeveral factors need to be taken into consideration when deciding on the appropriate treatment option for an ankylosed tooth. These factors include:

  • Whether the ankylosed tooth is deciduous or permanent;
  • The time/age of the onset of ankylosis;
  • The time/age at diagnosis;
  • Patient gender;
  • The location of the affected tooth;
  • The patient’s smile line.

It is known that the root of the ankylosed tooth will typically undergo continual resorption and subsequent replacement with bone. In addition, depending on when the tooth ankylosed, a hard/soft tissue defect in the area of the ankylosed tooth will be present if the tooth became ankylosed prior to the completion of growth and development. If, however, the tooth became ankylosed after growth was complete, there may be no impact on the hard and soft tissue positions.

This patient is in her late 50s and has tooth #9 ankylosed. Given the position of the gingival margin and incisal edge of this tooth compared to other teeth in the arch, it is apparent that it became an ankylosed tooth at some time prior to the completion of growth. (Fig. 1)

ankylosed toothIn contrast, this patient in his mid-30s also has tooth #9 ankylosed, but the gingival margin is level with the adjacent central incisor, leading us to conclude that it became an ankylosed tooth after growth was completed. (Fig 2.)

When treatment planning an ankylosed tooth in an adult, it must be stated that the ankylosed tooth does not need to be extracted just because it is ankylosed. If you think about it, an ankylosed tooth is not that dissimilar from an osseointegrated implant. The treatment decision on whether to keep the ankylosed tooth – and possibly restore it – or remove it, will depend on the esthetic impact of any hard/soft tissue defect and the rate at which the resorption is occurring.

ankylosed tooth

If the treatment chosen is to keep the ankylosed tooth, many options exist:

  • Keep the tooth and restore in its current position;
  • Subluxate the tooth and orthodontically reposition into the desired location;
  • Move the ankylosed tooth into the correct position using a segmental osteotomy containing the ankylosed tooth.

If the patient has a low smile line – or the gingival margin position is still correct – and the rate of resorption is slow, keeping and restoring the ankylosed tooth in its current position is a simple way to improve the esthetics. The unknown of this treatment option, though, is how long with the tooth will last before the resorption advances to the point that the tooth structurally needs to be extracted. Even though there is a significant gingival margin discrepancy on the ankylosed tooth #9, the impact on the overall esthetics is low because of the patient’s low smile. (Fig 3)

ankylosed toothGiven that the resorption is occurring at slow rate – the tooth became ankylosed prior to the completion of growth and the patient is now in her late-50s – the treatment plan was just to restore the incisal edges of #8, #9 and #10 with composite. The composite restorations were in place approximately 10 years before the resorption advanced to the point that #9 required extraction. (Fig. 4)

ankylosed tooth

ankylosed toothIf the ankylosed tooth is an esthetic issue and the rate of the resorption is advancing quickly, extraction of the tooth is recommended. The area will typically require augmentation with either hard or soft tissue depending if the final restoration is a single tooth implant or a tooth supported FPD. (Fig. 5-6)

To see Part I of this series covering etiologies and considerations for ankylosis, click here.

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Eggshell Provisionals: Full Arch Cases [Part II]

As discussed in Part I of this series, an easy way to transfer the esthetics and occlusion from the diagnostic wax-up to the mouth is to use the “eggshell” provisional technique. As I explained, rather than lightly prepping the model, I inject the provisional material into the putty itself. Once the material that has been injected into the putty is set, the next step is to trim and hollow the shell. This is done in two distinct steps and can take a little bit of time to do.

Step 1: Trim the provisional shell to the free gingival margin. In this step you’re essentially trimming back to the gingival margin, or more accurately, back to where the bulk-out wax ended on the gingival margin. If the wax margin is not well delineated it will be very difficult to determine how much needs to be trimmed off the shell. This first step in the trimming process should be done by orienting the acrylic bur perpendicularly to he axial wall along all the buccal and palatal surfaces.

Step 2: “Hollow” out the internal of the shell to allow it to freely seat over the preparations without binding. Once your first step is completed you can use a rounded acrylic burr or a #6 round burr to hollow out the internal of the shell. Upon completion, the provisional should be very thin once the internal is thinned out – which is exactly why this technique is called an “eggshell” provisional. The palatal and buccal walls of the provisionals usually measure around .5mm thick.

On the incisal edges and occlusal table, the walls can be ~1mm thick, since more preparation depth is anticipated in these areas. At this point, you will also want to verify that you aren’t leaving too much material interproximally which could impinge on the interproximal soft tissue and prevent complete seating. Lastly, a disc is used to open up the facial and palatal gingival embrasures to help ensure that the shell doesn’t impinge on the papillae.

At this point, the shell is ready to take to the mouth. After prepping the teeth, you’ll want to try the shell in the mouth. It should be noted that when trying the shell over the preps, it should not bind on the teeth at all. It’s will actually be the soft tissue that helps determine the seating of the shell. This trying in and fitting the shell properly is the most important step when using the shell technique. Rushing this step can affect the seating of the provisional and cause problems both with the occlusion and esthetics.

The best way to know if the shell is seated correctly (not over-seated or under-seated) is to use calipers to measure from incisal edge to gingival margin on the diagnostic wax-up, and verify the measurement in the mouth when fitting the shell. This verification can be done on multiple teeth to ensure that it isn’t binding somewhere or being over seated. This is typically done after the prep is essentially completed, but before cords are packed on the anterior teeth and the margins dropped.

The reason is that once cord is placed, your reference position for the gingival margin is no longer accurate. To make the sure the shell will be repositioned accurately after packing cord, place some Triad material in the incisal 1/3 of the centrals, seat and manipulate the shell until its seated correctly (using measurements and the opposing occlusion) and cure the Triad. Now you can pack your cords and refine the preparation without losing the ability to re-seat the provisional accurately.


Eggshell Provisionals: Full Arch Cases [Part I]

If you happen to be creating provisionals for an exceptionally large case, such as a full arch, an easy way to transfer the esthetics and occlusion from the diagnostic wax-up to the mouth is to use the “eggshell” provisional technique. This concept utilizes a prefabricated shell in the desired tooth form (made from the diagnostic wax-up).

Although this technique is typically used with larger cases, it is versatile enough that it can be used in any situation, all the way from a single unit to a three-unit bridge, or even a quadrant. This series will concentrate on using the “shell” provisional in a full arch situation.

To make provisionals in a full arch case while using a matrix (putty or clear matrix) requires the presence of hard tissue stops. If you are leaving parts of teeth untouched (ie. anterior veneer preparations or posterior partial coverage restorations) using a matrix is easy and predictable. If you don’t have enough hard tissue stops remaining to secure the matrix, the matrix will then have to rely on the soft tissue to determine the proper “seating” position. The problem when using soft tissue only to seat the matrix is that it is movable/resilient and pressing too hard can compress the soft tissue and hence produce a distorted provisional with regard to esthetics and occlusion. If you don’t have enough tooth structure to key the matrix because everything will be full coverage, or if you are opening the VDO, using the eggshell provisional technique can efficiently help transfer the esthetics, occlusion and vertical dimension from the diagnostic wax-up back to the patient in a very efficient and predictable manner.

Create Diagnostic Wax-Up
The first step is to create a diagnostic wax-up on the mounted models. Once this is complete, you have two options to fabricate the shell. The first option is to have the lab fabricate the shell for you. These days this would be done with a CAD/CAM approach. Scan the wax-up, create a very light prep on the model, scan the prepped model, and then have the shell “milled” via a CAD/CAM technique. This can be a very quick and efficient way to have a shell fabricated. The only downside with this approach is that there will be a lab fee for milling the shell that could be quite significant.

Another way to fabricate the shell is to have the technician complete the diagnostic wax-up and then fabricate the shell using more traditional techniques: using your hands! With this, you will first need to duplicate the diagnostic wax-up, so as to leave the original wax-up undisturbed. The easiest way to duplicate a wax-up is to soak the model in very soapy water until it is saturated, then make a traditional alginate impression of the model and pour the impression in stone. This stone model of the diagnostic wax-up will be used to add “bulk-out” wax to help account for the shrinkage of the provisional material.

When working with provisional materials, it’s important to remember that virtually all of them shrink. I typically make my shells out of a BisAcryl type of provisional material, although any material can be used. If we don’t account for the shrinkage of the material, the shell may shrink to such a point that it won’t fit around the margins of the preparation. In order to overcome any shrinkage, a small layer of wax is applied over the cervical 1/3 on both the facial and palatal surfaces of the teeth on the duplicated model of the wax-up. The thickest portion of the wax (~1/2 mm) is started on the gingival margin and then feathers down to nothing in the junction of the cervical and middle 1/3s.

End on the Gingival Margin
It should be noted that the gingival portion must not end on the tooth but rather on the gingival margin itself. This will enable the cervical 1/3 to be over-contoured compared to the original wax-up and in the process, help accommodate any shrinkage of the material. Doing this on a stone model of the wax-up better allows you to visualize where the bulk out wax is applied and how much is placed. Once completed, a putty impression of the “bulked out” model can be taken.

At this point, rather than lightly prepping the model and using the putty as a matrix carrying the material back to the model, I will inject the provisional material into the putty itself.  Essentially, the provisional shell will start out in more of a “block form” and then have to be trimmed and hollowed into “shell form” after it sets. Why do I choose to do this rather than lightly prep the model and seat the matrix over the preps? Because BisAcryl tends be a rather brittle when it is very thin and will typically end up breaking when you first try to remove it from the model.

In the next article in this series I discuss trimming the eggshell provisional.

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Creating Gingival Harmony

Many patients who have changed their smiles by restoring their teeth are quick to notice a discrepancy in the tooth length/gingival margin on even a single tooth. In the absence of a soft tissue grafting procedure, they would have had to tolerate a longer looking tooth.

When we restored with PFM restorations, we could build pink porcelain onto the metal framework and create gingival harmony; however, I've recently been informed that this can be done on lithium disilicate restorations also.

My patient was thrilled that despite all the implants, grafting procedures and pink ceramic on her bridgework in the posterior quadrant, that she wouldn't have that “long" eye tooth by having an all-ceramic crown with pink at the margin.

This is an excellent option when treating a gingival recession case. A smile improves dramatically when we don't have to seat long restorations apically.

Mary Anne Salcetti, DDS, PC, Spear Education Visiting Faculty. [ www.maryannesalcettidds.com ]

Placing Composite in Large Non-Carious Cervical Class V Lesions

We all have had large non-carious cervical lesions to restore on the facial or buccal surfaces of teeth. The challenge in finishing them is usually over adjusting when removing the excess in two directions (cervical 1/3 and facial 1/3). This often results in a less than desirable root form when finished.

I have always used this end (see photo) of the composite instrument to place composite and condense it when restoring posterior Class II preparations. I have discovered that it is the perfect shape for smoothing down the last application of composite on large Class V lesions.

When held against the cavosurface margin to the gingival margin it shapes the composite so nicely that there remains almost no other finishing to be completed.

Restorative Treatment Option for Ankylosis in Young Patients

Limited treatment options are available for young patients that have ankylosis of teeth after traumatic avulsion and re-implantation. Generally, we choose to treat these patients by extracting the ankylosed tooth prior to the patient entering their growth phases so as to minimize the potential bony defect. However, since many variables exist each situation must be evaluated individually to determine the most appropriate treatment option.

Take for instance the 14-year-old female in the photograph; she had a traumatic injury at the age of nine that caused her right central to be avulsed. What the literature reveals is that the longer the tooth is kept out of the mouth, the incidence of ankylosis increases dramatically. Ideally, the tooth should be re-implanted within 15-18 minutes to help decrease the chances of ankylosis. In this situation, the tooth was found and re-implanted within an hour.

Now, at age 14 it can be verified radiographically that the tooth has ankylosed as well as esthetically by comparing the discrepancies in the gingival margin and the incisal edge positions. The good news is the ankylosis is occurring at a very slow rate (this was verified by comparing radiographs and clinical images taken from the age of nine through the age of 14). What treatment options do we have for this patient?

What this patient currently has is an esthetic problem because of the discrepancies in the incisal edge and gingival margins. What we know is that at the age of 14, she is near the completion of her growth phase, meaning that most of the damage from the ankylosis and eruption during growth has already taken place. We’ve also established that although replacement resorption is occurring, it is occurring at a very slow rate.

In evaluating her smile line, it was noticed that she has a low smile line with less than average lip mobility. Her lip mobility was such that she didn’t show the gingival margin of the teeth during either a posed or spontaneous smile. Given this information, the treatment option chosen was not to extract the tooth, but rather keep the tooth and add length to the incisal edge. Simply bonding composite or placing a veneer on the tooth will address the esthetic component in this case. The tooth can later be extracted and the ridge grafted for implant placement at any time (either after growth is complete or at a later date when the progression of the replacement resorption necessitates treatment)

What I hope you’re realizing is that rather than just “extracting” the ankylosed tooth, many factors need to be taken into consideration when treating young patients that have undergone traumatic avulsion. We not only have to manage the site at the time of the trauma, but also continue to manage the area until the patient has reached an age suitable for implant placement whether the tooth has been extracted or maintained. However, it must be noted that depending on the age of the patient and the potential for growth, it is typically advisable to extract the tooth (or decoronate the tooth) before the patient enters their growth phase so as to minimize the potential bony defect.

Ridge Evaluation of Ovate Pontics

The goal of an ovate pontic is to create the illusion that the tooth is emerging from the gingiva with a cuff of tissue surrounding it on the facial. In order to achieve this, it’s necessary to identify when an ovate pontic is possible and when it is not.

In fact, the ridge the patient has and whether it is adequate or can be grafted determines the feasibility of an ovate pontic. There are three things we look at in order to decide whether the ridge is adequate, or if it would need augmentation to accommodate the pontic.

1. Interproximal height: If we drew lines on this patient’s photograph between the natural teeth and the height of the papillae in the pontic area, it shows what appears to be a vertically deficient ridge.

The condition of the ridge can be very deceiving however because this particular pontic is sitting on top of the ridge casting a very dark shadow interproximally. To actually evaluate the interproximal height of the ridges, this patient’s bridge needed to be removed to expose the real tissue height. After doing that, the tissue was revealed to be adequate in height vertically towards the palatal aspect of the ridge, but deficient in height towards the facial.

2. Free gingival margin: If we compare the tooth that is present (right central incisor) with the tooth that’s missing (left central incisor) it’s revealed that the pontic is shorter than the natural tooth. However, the only reason it is shorter is because it’s rolled in with an extreme convexity. If this particular pontic had the correct contour, it would be significantly longer than the adjacent tooth.

3. Facial prominence: The most important view to look at is down from the incisal. Because the tissue has to be facial to the pontic to make it seem like the pontic is emerging out of tissue instead of resting on top of it. The cervical portion of the tooth is where the white line is; the right central and left lateral have at least another 1-1.5mm of gingiva facial to that line. In the pontic area the tissue is lingual to that line, which is causing that dark shadow. This ridge needed to be augmented significantly on the facial to allow an ovate pontic to be created and make the pontic appear like a natural tooth growing out of that tissue.

The augmentation for this patient was done with a connective tissue graft to make the ridge prominent enough to embed the pontic and produce a natural appearance.