This bridge is 32 years old and pretty darn good if you ask me. It is by no means a failure. However, the time has come for it to be replaced; the patient doesn't like the way it looks and she would like a new one. She does not want implants because she doesn't want the required bone grafts needed to place an implant. She is congenitally missing her lower centrals.

She is willing to have soft tissue grafting procedures to create some attached tissue and gain some root coverage.

Now the question is, can I just replace the bridge? Notice how the opaque is showing through the incisal edges of all three of the PFM restorations. While that could be a restorative design issue, in this case it is wear. All six of her upper anterior teeth have Class 1 or 2 mobility and severe wear facets on the palatal surfaces.

These two findings are symptomatic of a restricted pathway or lack of overjet and perhaps a steep anterior guidance.

If I only replace the bridge and do nothing about the inadequate overjet, the problem remains. Inadequate overjet can be eliminated by:

  1. Orthodontic treatment to procline the upper anteriors or retrocline the lower anteriors
  2. Restorative treatment to reshape the teeth
  3. Opening vertical dimension of occlusion

Option 2 is a poor choice in this case. By creating more room on the palatal of the uppers or cutting the lower preps so the facial of the lower anteriors could be more retroclined the uppers will end up in dentin and the lowers will have compromised preps.

In this case, because of other restorative needs and the significant wear on the palatal of the uppers, we will open her bite. Opening the VDO effectively moves the facial of the lower anteriors in a posterior direction, making room for restorations and increased overjet.


Commenter's Profile Image Stephen Lawrence
December 19th, 2013
Hey Steve, In reading this piece, I was wondering, how old is the patient? If in the 70's or older then doing the soft tissue graft seems superfluous; this is one of those "clinical judgement" cases that my instructors would badger us about in dental school. The previous bridge was 32 years old. Unless the patient wanted a full reconstruction I do not see the reason to do additional work unless the patient requested it after discussing the options.
Commenter's Profile Image Steve Ratcliff
December 19th, 2013
Hi Steve, I agree this is a clinical judgement call. We are choosing to graft her because of the toothpaste abuse and cervical wear as well as her esthetic concerns. Simply trying to protect the root surfaces and I would prefer not to have to prep that far down the root. Just easier if I don't have to. Steve