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| The image on the left above shows the appearance of a
patient's front teeth two weeks after I had attempted to
repair the right central incisor for the third time in three
years. The tooth was repaired in composite, using a
pin in order to help stabilize the restoration. The
reason that this patient kept breaking it was the tooth's
rather prominent position, since in addition to being tilted
severely to the patient's right, it projected considerably
in front of the adjacent teeth. |
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This made it very prone to traumatic injury. The patient
plays contact sports, and even though he wore a sports mouth guard,
the lack of support from adjacent teeth made this tooth especially
prone to breakage, right through the flexible silicone rubber of the
guard.
This incisal image shows just how crowded the dentition was.
It also shows how prominent the broken tooth was when the patient presented
in my office.
The dark spot is the remains
of the now broken pin that was originally used to stabilize the restoration.
Also, please note the severe crookedness of the teeth adjacent to
the broken tooth.
I had been seeing this person since he was a child, and had
originally urged
the parents to consider orthodontics (braces), but at that time the
family was unable to afford it. By the time of this accident
the patient was reaching adulthood, and he did not want to go
through the years in braces that orthodontics would entail at this
time of life. Therefore, a decision was made to simply extract
the offending tooth and repair the smile using a prosthetic
device,
which means a false tooth.
As you can see from the incisal view
above, simply extracting the
most crooked tooth without altering the shape of the adjacent teeth
would leave very little room for a false tooth. Putting a tiny
false tooth in the space vacated by the original would have created
a very poor result. Thus the treatment plan included
placing crowns on both adjacent teeth to make them smaller.
This would allow for more room which can be divided up more
equitably.
In addition, this option has the added benefit of creating retainers
for a three unit fixed (non removable) bridge which can be built to
straighten the adjacent teeth as well as adding a false tooth to
replace the broken one.
The right lateral incisor and the left central incisor were prepared
as abutments for a three unit bridge. Note that the teeth were
prepared prior to the extraction of the crooked central incisor.
The reason for this was to avoid water and air spray from
contaminating a fresh extraction site causing a possible infection.
After the preparation of the abutment teeth, the right central
incisor was extracted, and a lab processed temporary three unit
bridge was placed over the abutments and the extraction site.
The above image was taken immediately upon placement of the
prefabricated
laboratory processed plastic temporary
three unit bridge. The notch between the patient's right
canine and right lateral incisor is there to allow space for the
crooked lower canine on that side. Closing that notch
would have caused the lower canine to hit the plastic of the
temporary bridge, and would not allow the patient to fully close his
mouth. The irregular appearance of the gums around the
temporary is due to the fact that the crooked natural tooth was just
extracted from this site. The temporary will be worn for about
six weeks to allow the extraction site to heal and the gum tissue to
remodel.
About six weeks after the temporary bridge was placed, the patient
returned to the clinic, the temporary was removed, and the
preparations were refined. The six weeks represents the time
needed to allow the socket to heal and the gums to remodel.
Refining the preparations means essentially cutting the preparation
margins back beneath the gum line so that they will be hidden when
the final appliance is inserted. At this time, an impression
was taken and sent to the laboratory for fabrication of the final
restoration.
Three weeks later, the lab sent back the finished bridge. This
restoration is made of Lava, the 3M-ESPE version of a
zirconium ceramic framework
overlain with esthetic porcelain. The zirconium framework
provides tremendous strength without compromising the translucent
esthetics necessary to approximate the appearance of natural teeth.
The finished case, pictured above was cemented in place with a resin
modified glass ionomer cement. The result is quite good, even
though some compromises have been made in the final shape of each
individual unit to allow for proper sizing of the individual teeth.
The above image shows a patient who was missing his right lateral
incisor with the two central incisors bucked in. As a result,
the right canine and left lateral incisor look like fangs.
This, along with the serious discoloration of the natural teeth kept
the patient from smiling. The solution in this case was to do
five crowns to include the four anterior teeth, but also the
patient's right first premolar (the one with the visible amalgam
filling). The trick in this case was to create the illusion
that the premolar was actually the patient's right canine. The
canine was built to look like a slightly enlarged lateral incisor,
the left lateral was built to be more prominent, and the central
incisors were rebuilt to be straight. The left first bicuspid
remains in its natural condition and now becomes the patient's left
canine. The result is seen in the image below. This
gives the patient a much wider and brighter smile in addition to
straight teeth.
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