A 21-year-old male presented to the clinic with the chief complaint, “I would like to have my front teeth fixed.” The history of the present illness revealed that the patient had several fractured anterior teeth; however, there were no symptoms related to temperature or chewing. The patient had no significant medical history or allergies and was not taking any medications at this time. The patient denied the use of tobacco, alcohol, and recreational street drugs. Clinical and radiographic examination revealed the following findings (Figures 1 and 2):
Figure 1. Initial smile.
Figure 2. Initial smile, retracted.
- Tooth No. 7. Previous root canal treatment, large composite restoration with recurrent caries, and periapical radiolucency.
- Tooth No. 8. Previous root canal treatment and large composite restoration with recurrent caries .
- Tooth No. 9. Missing tooth structure, and caries.
- Tooth No. 10. Caries.
Overall, there was uneven gingival architecture and excess overbite on teeth Nos. 7 to 10.
Diagnoses and prognoses for the teeth were as follows:
- Tooth No. 7. Previous root canal treatment with asymptomatic apical periodontitis: hopeless.
- Tooth No. 8. Previous root canal treatment with widened periodontal ligament: poor.
- Tooth No. 9. Recurrent caries with missing restoration: guarded.
- Tooth No. 10. Primary mesial caries: good.
Treatment Plan
A treatment plan was presented to the patient based on the findings, patient finances, and prognoses. The proposed treatment plan consisted of aesthetic crown lengthening, crown retainers (Nos. 6, 10, and 11), crown pontics (Nos. 7 to 9), and extractions with grafting (Nos. 7 to 9) (Figure 3). The goal was to maintain alveolar ridge width in the hopes of placing implants in the future after the patient has stopped growing. Risks, benefits, and alternatives were presented to the patient, and he elected to proceed with the recommended treatment under intravenous sedation (IV sedation).
Figure 3. Planning.
Procedure
On the day of the procedure, the patient came to the office NPO with a driver. Venipuncture was performed in the right antecubital fossa with a 22-ga catheter (BD Insyte Autoguard), and saline (0.9% Sodium Chloride Injection USP 500 mL [Baxter]) was attached to the catheter using an IV line (Solution Set with Duo-vent Spike 105”). The following drugs were given through the IV solution throughout the 4-hour duration of the procedure: 1 gg of Ancef, 4 mg of ondansetron, 8 mg of dexamethasone, 30 µg of toradol, 50 mg of diphenhydramine, 10 mg of versed, and 200 ug of fentanyl. Two red tubes and one white tube of blood (10 mL BD Vacutainer) were obtained using a 21-gauge butterfly needle (BD Vacutainer Safety-Lok Blood Collection Set with Pre-Attached Holder). This was placed in a centrifuge at 4,000 RPM for 14 minutes to obtain platelet-rich fibrin (PRF) clots in the red tubes and concentrated growth factor liquid in the white tube.
Two carpules of 0.5% Marcaine 1:200k epinephrine (Novocol Pharmaceutical of Canada Inc.) were used to achieve local anesthesia via infiltration injections in the maxillary anterior between teeth Nos. 6 to 11. A one-quarter carpule of 2% lidocaine 1:100,000 epinephrine (Patterson Dental) was used to achieve local anesthesia via a nasopalatine block. After achieving profound anesthesia, a 15-blade (Feather Safety Razor) and laser were used to complete a gingivectomy for teeth Nos. 7 to 10 (Figure 4). Teeth Nos. 6, 10, and 11 were then prepared for crowns using a round-end chamfer bur. Caries indicator dye was used while preparing the teeth. As tooth No. 10 was being prepared, caries appeared to extend over the pulp horn, and the decision was made to leave affected dentin as there was greater than 2 mm of clean tooth structure surrounding the area. Immediate dentin sealing was completed on tooth No. 10 by using the primer for 10 seconds, air thinning, and then placing the bonding agent (OptiBond eXTRa [Kerr]) and curing for 10 seconds (VALO Curing light [Ultradent Products]). Missing tooth structure was replaced using flowable composite (SimpliShade Bulk Fill Flowable [Kerr]) and then curing for 10 seconds. The oxygen-inhibited layer was removed by placing KY Jelly over the prep and curing for another 20 seconds. A digital impression of the maxillary, mandibular, and bite were obtained using an intraoral scanner (TRIOS 3 [3Shape]).
Figure 4. Gingivectomy.
A full-thickness sulcular incision was made from the mesio-facial line angle of tooth No. 6 to the mesio-facial line angle of tooth No. 11. An envelope flap was reflected using a molt elevator.
Crown lengthening was completed to ensure bone levels were 3 mm apical to the new gingival tissues and crown margins using a fissured surgical bur (702 FGSURG [Brasseler USA]) (Figure 5).
Figure 5. Crown lengthening after prep.
Teeth Nos. 7 to 9 were then luxated using a spade elevator (Angled Bone Preservation Elevator #60B [A. Titan Instruments]) and delivered with a #1 forcep (AtrauLux [Salvin Dental]). All sites were then curetted and irrigated with saline solution. One PRF clot was torn apart using cotton forceps and mixed with 1.0 cc of MinerOss cortico-cancellous bone size 0.60 to 1.25 mm (MinerOss [Medtronic]) and the liquid CGF to create a sticky bone mixture. The extraction sites were grafted with this sticky bone mixture, and the tissue was re-approximated using a monofilament suture with a reverse cutting needle (4-0 p-12 19 mm PGCL [AD Surgical]) (Figure 6). A digital impression of the maxilla was obtained for for the tissue profile.
Figure 6. Extractions and re-approximation.
Figure 7. Same-day printed provisional.
The scans were used to design a 6-unit fixed partial denture (FPD) using exocad software (exocad). The FPD was then printed on a SprintRay Pro 55s printer (SprintRay) using their Ceramic Crown Resin shade B1. After the print was completed in 26 minutes, the FPD was removed from the build plate, and residual resin was removed using 99% isopropyl alcohol (Florida Laboratories) and compressed air. The printed FPD was then placed in the SprintRay Procure Unit and cured for 6 minutes and 30 seconds, per the manufacturer’s guidelines. Flowable resin shade A3 (Patterson Dental Supply) was used to characterize the facial surfaces, and the FPD was polished using a Scotchbrite and rag wheels. The prosthetic was delivered using temporary cement (Temp-bond Clear [Kerr]) (Figure 7). Excess cement was removed, and the bite was adjusted for light centric contacts.
CONCLUSION
When the patient returned to the clinic for his 3-week follow-up appointment, he reported no discomfort and approved the aesthetics of the restoration (Figures 8 to 10). Local anesthesia was obtained using 4% Septocaine 1:100,000 epinephrine (Septodont Canada) via infiltrations. The sutures were removed, and the printed temporary was replaced with a zirconia restoration (Nautilus Dental Lab) using temporary cement. Temporary cement was used as the retention of the crown retainers was adequate and it would allow for further augmentation in the future if there are any changes to the soft tissue.
Figure 8. Healing at 3 weeks postoperative.
Figure 9. Smile with printed restoration.
Figure 10. Tissue contours at 3 weeks.
The patient returned to the clinic 48 hours later for follow-up photos (Figures 11 and 12). The patient reported he was happy with his new smile. This case report illustrates a workflow that highlights the use of digital technologies for good surgical and restorative outcomes.
Figure 11. Retracted zirconia restoration.
Figure 12. Smile with zirconia restoration.
ABOUT THE AUTHOR
Dr. Yeung graduated from Virginia Commonwealth University School of Dentistry and completed a General Practice Residency at the Dental College of Georgia. He practices general dentistry in Atlanta. He can be reached via email at yeungdds@gmail.com.
Disclosure: Dr. Yeung reports no disclosures.
