Use of forced eruption to enhance the Pontic site in the anterior maxilla - Essay Example

?First Lecture’s Homework Use of forced eruption to enhance the Pontic site in the anterior maxilla Over time, periodontics has metamormphisized in order to provide functional as well as aesthetic results for patients. For any periodontal therapy, the main objective is the restoration of the normal health of the periodontium. In many cases, periodontal therapy starts with an extraction of teeth which demands an implant. Tooth loss is often results in migration of other adjacent teeth and deficit of hard and soft tissues. Implant therapy has over the years become an alternative to replacing missing teeth following an extraction since extraction results in migration of other adjacent teeth as well as defects in both hard and soft tissue causing an unfavourable environment for implant placement the main limitation of placing implants is the lack of adequate bone and soft tissues (Comut, Varun, and Leila pg 74). There are various techniques for bone augmentation including hard and soft tissue augmentation surgeries. Earlier treatment was focused on reconstruction of hard and soft tissues for placement of implants and this involved surgery and a combination of grafting procedures including hard and soft tissue augmentation. Hard and soft tissue augmentation enables recreating a proper height and width for the implantation site. The soft tissue augmentation was performed to correct the gingival architecture after an extraction and the hard tissue was performed to strengthen the alveolar bone which underwent resorption after extraction. After augmentation implant followed. The other alternative solutions involved though not commonly used are the use of ovate pontics. The ovate Pontic is used to create an illusion that the tooth is growing out of the gum using an anatomically shaped crown incorporated with a root form profile. Pink porcelain is also used in restorative dentistry to correct gingival defects as well as gingival molds which involve the use of a provisional crown to mold the gingival tissue into the desired contour and gradia com which is used to make indirect fillings (Comut, Varun, and Leila pg 76). All of the above procedures are surgical and run the risks of excessive bleeding and nerve injury. The increasing demand for highly aesthetic results in dentistry has influenced implant therapy and made it challenging. The main challenge is in creating harmony between the teeth and the surrounding soft tissues. Whereas implant therapy is well accepted, disadvantages like complications arising from surgical procedures, the challenge in obtaining well contoured gingival papillae for the case of gingival molds and the possibilities of bone resorption around the implant which might lead to gingival recession make it not very viable. An aesthetically acceptable result does not only depend on the final restoration but careful consideration of soft and hard tissues adjacent to the implant. In pursuit of improved aesthetic, research has been done on successful maintenance and regeneration of the gingival and alveolar bone which are lost after extraction and the traditional Fixed Dental Prosthesis was found to be the preferred choice of treatment for the Anterior maxilla and creates a natural aesthetic. FDP is cost effective, does not require surgical interventions which makes it to require short treatment time for a guaranteed long-term aesthetic stability. Prosthetic treatment contributes to better soft and hard tissue management which contributes further to achieving an acceptable final result obtained by having a harmonious soft tissue profile, a well and correctly contoured final restoration and re-establishment of normal functions. As an alternative to the conventional hard and soft tissue augmentation surgeries, use of forced eruption was introduced. Forced eruption is a process whereby a tooth is moved intentionally in a coronal direction by applying a small amount of force to effect changes in the bone and soft tissues. Forced eruption Forced Eruption works in a manner that during tooth movement, the gingival fibres are stretched creating tension to the alveolar bone. This tension that is created by the stretching is believed to stimulate bone opposition at the alveolar crest. During the extrusion, the amount of gingival increases as the gingival margin migrates coronally and the mucingival junction remains in a stable state resulting in an increase volume of soft tissue. This process is recommended for the correcting of the gingival margin of the tooth by extruding an additional 2mm coronary to its intended position so as to make up for the bone resorption following extraction. To prevent loss of the buccal plate which is vital for the success of forced eruption and Pontic site enhancement with no additional tissue, this method recommends that the tooth is extracted vertically as opposed to a protrusive direction. Damaging the buccal plate may achieve bone height but compromise bone width and this might warrant for a soft and hard tissue augmentation intervention because the emergence effect of the pontic will not be realized (Comut, Varun, and Leila pg 78). Forced eruption takes place at a very slow rate of 1mm per month to about 1mm per week under a force ranging from between 0.25N to 0.75N. The rate of eruption and force applied depends on the amount of bone, the length of the root as well as the presence of ankylosis which allows for new bone opposition. Forced eruption has been considered as a technique used to erupt impacted teeth extracting teeth that cannot be restored creating a recipient site for implantation in the process. Case Report A 68 year old white woman reported to the Advanced Education program in prosthodontics at the New York University College of dentistry and her chief complaint was poor dental aesthetic and her desire was to restore her maxillary teeth. Clinical examinations revealed amalgam and composite resin restorations, fixed dental Prosthesis, she had metal ceramic crowns, endodontic therapy and casts and cores on multiple teeth. She was also diagnosed with moderate chronic periodontitis which was observed to have affected her maxillary left central incisor and the maxillary left second and third molars. To justify her aesthetic concerns, the dentists observed and established that she had a large diastema between her maxillary left and central right incisors. She also had buccally malpositioned left central and lateral incisors. Her gingival level was very uneven and due to occlusal wear and an extensive composite restoration on the maxillary left lateral incisor, her morphology of teeth was very poor. Treatment The main challenges during planning for her treatment involved correcting her uneven gingival level discrepancies that existed between the left and right anterior maxilla and at the same time preserving the bulk of buccal bone so as to create an illusion of root prominence and subsequent development of an emergence profile for FDP. Treatment options that were considered included implant therapy, and a removable prosthesis. The patient was convinced into undergoing a comprehensive reconstruction of the maxillary teeth which she complained of with the use of the traditional FDP after the extraction of the maxillary left second and third molars which had poor prognosis. Since she had specifically requested for surgery to be avoided, Forced eruption of the maxillary left central and lateral incisors were proposed as the possible alternative to surgery. Subsequent extraction of the maxillary left central incisor was also suggested. To sufficiently restore the functions and aesthetics of the remaining maxillary teeth, the prosthetic treatment employed was the use of metal ceramic crowns and FDPs. The maxillary left incisor was treated using an endodontic treatment after which is when the Forced eruption was introduced. To perform this, Orthodontic brackets were hooked on each tooth between the maxillary right and the first pre- molar on the left. The orthodontic protocol of 1mm per month with a minimal force of 0.25N was applied to achieve the desired outcome. For purposes of maintaining a proper occlusion, every month she had a check up during which the edges of the extruded teeth were shortened for a period of six months. Once the gingival level was achieved, the tooth was stabilized by keeping the bracket in the same position till the end of the forced eruption. On each consecutive month the bracket on the maxillary left central incisor was removed apically to continue the eruption because at the extraction site, bone resorption occurs in an apical and palatal direction leading to asymmetrical levels of supporting tissues as compared to the originally existing incisor. The extrusion process was completed by the fifth month; the tooth was stabilized for another 6weeks before removing all the brackets. The root of the maxillary left central incisor was extracted in an autromatic fashion. An ovate pontic was developed at the extraction site to create an illusion of a natural emergence. In order to adequately replace the core structure of the previously endodontically treated maxillary left lateral incisor, a cast post and core were fabricated .She was made to wear IFDPs for six months to enable maturation of hard and soft tissues at the pontic site. Results The forced eruption procedure resulted in the levelling of the gingival height of the pontic site with that of the contra lateral tooth. This levelling aided in the compensation for the bone resorption that followed extraction. However, the buccopalatal width of the ridge was deficient due to the lack of buccal bone before the forced eruption. Soft and hard tissue augmentation were not deemed necessary because the metal ceramic crowns she had were restored using a semi adjustable articulator and cemented using resin-reinforced glass ionomer luting cement and the patient was satisfied with the results. Discussions The main advantage with the Forced eruption process is that it does not allow for surgical procedures, hard and soft tissue development is influenced by the opposition of the patient’s own bone and in the process it eliminates the need for hard and soft tissue augmentation surgeries and implants therapy and can still affords to give an acceptable aesthetic result. The other advantage in the Forced eruption process is that the treatment period is short due to decreased number of surgical interventions. Because of surgery interventions, potential complications that arise from surgery like barrier membrane exposure and graft failure are also avoided. The disadvantage however with this procedure is that the patient will be required to undergo orthodontic therapy since for the tooth to be extruded, endodontic treatment is needed. Conclusion Many techniques and materials have been applied in an attempt to replace teeth that have been extracted either voluntarily or accidentally. However, it is only appropriate that an evidence-based approach is used in developing a treatment plan including Proper examination and diagnosis and careful planning if success is to be achieved. It is therefore imperative that specialists evaluate each case individually and carefully consider the consequences of the procedure to be employed. From the literature, forced eruption is a viable treatment option for both hard and soft tissue augmentation even when there is not enough bone. More research is yet to be conducted to establish a treatment with optimal functions and aesthetics. Work Cited Comut, Alper, Varun, Acharya, and Leila, Jahangiri. "Use of forced eruption to enhance a pontic site in the Anterior maxilla."Journal of prosthetic dentistry 108.5 (2012): 73-78. Print. Read More