CATEGORY AUSTRALASIAN DENTIST 69 CLINICAL Case Study A 33-year-old woman presented wanting an improvement of her existing crowns on her central incisors. Her main concerns were the short appearance of her central incisors, her gummy smile and the gingival margin discolouration. However, her main motivation for treatment was her crowns had become loose. Medical and Dental History Her medical history was unremarkable. The existing endodontic treatment and crowns were placed when she was 10-years-old after trauma. She felt that one of the crowns was mobile and would like a second opinion. She had been previously recommended extraction of the central incisors and placement of dental implants as there was limited tooth structure present. She was strongly against having orthodontics and implant treatment. Clinical findings The patient had an unremarkable extra-oral examination except minor asymptomatic clicking in her TMJ. During a normal smile and a high smile, she had 4.0mm and 6.0mm of gingival display respectively. At repose she had a central incisal display of 3mm. 21 had a periapical area had a slight swelling that was slightly tender to palpation. General periodontal condition was sound. She had bleeding on probing and gingival discolouration around 11 and 21. Neither 11 and 21 were tender to percussion. Both 11 and 21 crowns were mobile. The crowns were easily removed and 11 had an absence of ferrule and 21 preparation was extremely tapered (Figure 2). Radiographic findings 11 and 21 was previously endodontically treated and had been restored with a post, core and crown. 21 had a periapical radiolucency present (Fig 3). orthodontic extrusion as the primary option. However, given the patient’s reluctance to undergo orthodontics, an alternative approach was pursued – functional crown lengthening surgery. Functional crown lengthening not only facilitated the enhancement of the gummy smile but also addressed concerns related to the width/length ratio of the central incisors and encroachment on biologic width. Upon conducting an aesthetic examination and analysing the ideal width/length ratio, it was determined that the optimal gingival margin should be positioned 2mm apical to the current location, considering the constraint that the width of teeth 11 and 21 cannot be altered (see Fig 5). Fig 3. CBCT show the extent of the periapical radiolucency present on 21. persistent inflammation likely due to invasion of biologic width and misfitting crowns. The width/length ratio of 11 and 21 was 94% and 98% respectively indicating short teeth (Figure 4). Fig 4. Analysis of width/length ratio of the central incisors helps us determine that they are short. Treatment Options Simplifying the treatment plan for this case involved breaking it down into smaller objectives aligned with the patient’s expectations. Following a collaborative discussion, it was evident that the patient’s primary goal was to defer implant treatment and maintain her central incisors as long as possible. The ultimate objective was to achieve resolution to the aesthetic concerns linked with a gummy smile and ensure the stability of the final restorations. A case could be made for extraction and implant therapy to replace the central incisors, particularly due to the insufficient coronal tooth structure for a sufficeint ferrule effect. The evidence strongly suggests that without adequate ferrule effect that a poor clinical outcome is very likely (Juloski et al 2012). Nevertheless, taking into account the patient’s age, the high smile line and high patient expectations, she opted to attempt to keep the central incisors acknowledging the risks, limitations and the potential for eventual failure. The initial step in the treatment process involved assessing the potential resolution of the endodontic lesion associated with tooth 21. To address this, a referral was made to an Endodontist for potential retreatment of both 21 and 11. Simultaneously, a crucial concern emerged regarding insufficient tooth structure, specifically the absence of a ferrule effect. As per Juloski et al.’s recommendations in 2012, the absence of coronal tooth structure suggests considering Fig 5. Determination of the future gingival margin position. Botox treatment was also discussed to improve her overall gummy smile but was declined. TREATMENT SEQUENCE Functional Crown Lengthening Prior to the completion of retreatment by the endodontist, functional crown lengthening was necessary to provide additional coronal tooth structure for isolation. This involved ostectomy and osteoplasty. Bone was removed 3.0mm from the future crown margin position respecting biologic width. (see Fig 6). The healing process progressed uneventfully, and sutures were removed after a two-week period (see Fig 7). Clinical summary From the findings it was concluded that she had a gummy smile. 21 had apical periodontitis and loss of retention of 11 and 21 post, core and crown restorations. The findings highlighted multiple issues such as compromised endodontic treatment, absence of ferrule effect and Fig 6. Functional crown lengthening surgery with circumferential osseous surgery. The flap apically repositioned. Fig 7. Uneventful healing after 2 weeks.
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