Best Rate (Guwahati ) Call Girls Guwahati ⟟ 8617370543 ⟟ High Class Call Girl...
Rebuilding anterior dental aesthetics
1. Rebuilding Anterior Dental Esthetics:
Interdisciplinary Treatment of an Iatrogenically
Induced Marginal Tissue Recession
Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015
B. Arzu Alkan, A. Erdem Yagan, and Kerem Kilic
DR GAURI KAPILA
MDS STUDENT
2. Clinical Presentation
In July 2010, a 45-year-old female was referred to the Department of Endodontics, Faculty of
Dentistry, Erciyes University, Kayseri, Turkey, with the complaint of severe pain in the maxillary
right central incisor and poor esthetic appearance attributable to a fractured incisal edge of
the neighboring left central incisor.
3. Clinical Presentation
On clinical and radiographic examination, the tooth was diagnosed as having irreversible pulpitis, and
endodontic therapy was initiated by an undergraduate student.
During the preparation of the access cavity searching for the pulp chamber, the coronal root third was
accidentally perforated at the labial surface of the tooth, resulting in an acute marginal tissue
recession.
4. Clinical Presentation
Root canal treatment was completed over 1 week in two sessions, and the
perforation site was sealed with a temporary filling material (Fig. 1).
The patient was referred to the the Periodontology Department for consultation 7
days after root perforation and completion of root canal therapy.
Clinical periodontal examination revealed a 5-mm-deep and 3-mm-wide
marginal tissue recession measured at the level of the cemento-enamel
junction (CEJ) and 1 mm of enamel loss at the maxillary right central incisor.
5. Clinical Presentation
Measurements of
mid-labial probing depth (PD) = 1mm
amount of keratinized gingiva = 5mm
attached gingiva = 4 mm, respectively, at the maxillary right central incisor.
There was no radiographic or clinical evidence of bone loss and soft tissue existed in
the adjacent interproximal regions.
6. Case Management
Oral informed consent was obtained from the patient prior to
treatment. The Miller Class I marginal tissue recession (Fig. 2)
was treated with subepithelial CT graft (SCTG) preceded by the
simultaneous root surface restoration using a glass ionomer
cement on the day of consultation.
After local anesthesia, a split-thickness flap was
reflected by using a no. 15C blade to create a
pouch-like recipient bed to expose the root surface
and the bony margins (Fig. 3).
7. Case Management
No vertical incisions were made.
A rubber dam was placed for isolation of the operative field.
Minimal root preparation was performed to flatten the margins of the perforation.
A resin ionomer restoration was placed following the manufacturer’s instructions to cover the entire
defect.
8. Case Management
The SCTG was harvested from the inner surface of a
mucoperiosteal flap raised at the palatal premolar-molar region.
Mattress and sling sutures crossing over the SCTG were used
for the immobilization and tight adaptation of the soft-tissue
graft to the root surface (Fig. 4).
9. Case Management
A 5-0 polyglactin suture was used for this purpose, and the donor area was closed with 4-0 silk suture
material. The patient was advised not to brush the treated site for 21 days.
The patient was placed on 15 ml 0.12% clorhexidine gluconate twice daily for 3 weeks, and an
analgesic (275 mg naproxen sodium, one tablet three times daily) and an antibiotic (625 mg amoxicillin,
one tablet twice daily) were prescribed for 2 and 7 days, respectively.
10. Clinical Outcomes
The sutures at the recipient and donor sites were removed 10
days after surgery. Follow-up visits were performed at 2, 4, 6,
8, and 12weeks and at 5 months after surgery.
Total root coverage was obtained, but 1 mm of glass ionomer
cement at the mid-labial enamel surface was evident.
11. Clinical Outcomes
The mid-labial PD was the same as that of the baseline at final examination, and the width of keratinized
tissue (KT) reached 10 mm (Table 1).
12. Clinical Outcomes
Five months after surgery, the patient was referred to the
Prosthodontics Department for the restoration of the maxillary
central incisors using porcelain veneers (Figs. 6 and 7).
13. Discussion
Endodontic claims are the most frequently filed malpractice claims in dentistry, and it is reported that
errors frequently occur during instrumentation and root canal filling. Root perforation mostly occurs
during access opening, as seen in this case report.
The location of the perforation is the overriding factor in the decision-making process. Although
perforations coronal to the crestal bone can frequently be managed non-surgically, apical third and
critical crestal zone perforations may necessitate a surgical intervention.
The root perforation in the present patient starts on the enamel 1mmcoronal to the CEJ and extended
5mmalong the root surface, resulting in an acute marginal tissue recession.
14. Discussion
Regardless of the surgical technique performed to cover the exposed root surface, the restoration
material of choice is important and should meet some criteria.
In this context, GIC is insoluble in oral fluids and biocompatible with soft and hard tissues.
Additionally, it releases fluoride, which may positively affect bacterial plaque chemistry.
Successful treatment outcomes in terms of root coverage were reported in some cases. Although a
histologic examination could not be performed for ethical reasons in the present case, it was reported
that epithelium and connective tissue adhere to the resin ionomer when placed in a subgingival
environment.
15. Discussion
To the best of the authors’ knowledge, no study exists on the long-term stability of either the veneer
adaptation over the glass ionomer or the glass ionomer subgingivally over time. The use of glass
ionomer cement in combination with root coverage procedures appear in the literature in some case
reports.
For the management of soft tissue esthetics before any restorative treatment, an SCTG procedure was
considered as a treatment option. A width of 5 mm of KT was present mid-labially apical to the gingival
margin.
16. Discussion
Indeed, this amount of KT was quite enough to cover the SCTG completely by a double papilla pedicle
or coronally positioned flap.
However, a high frenum attachment extending corono-apically just in the proximity of recession
borders could have jeopardized the immobilization of any pedicle flap used to cover the graft.
Therefore, the SCTG was placed into the pouch-like recipient bed prepared by split-thickness flap.
No problem occurred with the survival of the CT graft. Total root coverage was maintained at 5 months
after surgery.
Excellent color match of the veneers with the neighboring teeth satisfied both the patient and the
clinicians and restored anterior esthetics.
17. Conclusion
In conclusion, dental practitioners will continue to be faced with endodontic perforations as a result of
anatomic variations, technical deficiency, or simply a clinician’s insufficient knowledge, skill, and
experience performing the procedure.
Whatever the cause is, saving the tooth is the first mission of the clinician.
In the case of the deterioration of anterior dental esthetics, an interdisciplinary approach can
successfully restore both esthetics and function, as described this case report.
18. Strengths of the article
Excellent esthetic clinical outcomes achieved following a multidisciplinary treatment
approach.
Clearly mentions the treatment steps involved in a complex malpractice case.
Encourages communication among dental professionals from different specialties.
19. Limitations of the article
Technique of harvesting the SCTG was not mentioned clearly.
Not all sizes and different locations of the root perforation can be treated with this
approach.
A great quality of clinician’s skill is required.
