This patient is a 30-year-old male with an unremarkable medical history. He has neglected dentistry for eight years, and he has a history of drinking 2–3 Red Bulls per day for at least ten years. He has been wearing a retainer to replace a missing #8. He wants to extract all of his teeth with the goal of improving his smile.
The radiographic exam reveals that he has non-restorable #7, 9, and 10, plus restorable caries on many other teeth. The TMJ exam is within normal limits. His perio exam shows generalized 4–6mm pockets. Upon evaluation of his full smile, he has a very high smile line and shows 3+mm of gums in the esthetic zone.
Katherine Dangler, DDS, MAGD
First, educate the patient on his current habits contributing to the carious lesions. The patient’s main concern is improving his smile. Discuss the advantages and disadvantages of removable vs. fixed options for a better aesthetic outcome. Talk to the patient about the possibility of keeping restorable teeth and managing the periodontal disease. If the patient decides to keep the restorable teeth, then proceed with scaling and root planning, as well as restoring the carious lesions. Discuss the option of replacing #7–10 with an implant supported fixed bridge.
In a patient with a high smile line, the biggest challenge is controlling the vertical dimension of bone/soft tissue. Teeth 7,9, and 10 are non-restorable and eventually need to be extracted. When teeth are extracted, 1 mm of vertical soft tissue is lost. Orthodontic extrusion will bring the soft tissue and bone down vertically. Orthodontically extrude teeth #7, 9, and 10 to gain about 2–3 mms of extrusion.
After extrusion, teeth 7,9, and 10 will be extracted and implants placed. Implant placement and position should be considered: Implant should be placed 3–4 mm from the desired gingival margin. Adjacent implants make it more difficult to handle the soft tissue and bone. Because of the bone defect present in site #8, an implant there may increase the need for ridge augmentation. So, implants could be placed at either site #7–10 or #7–9.
If implants can be immediately loaded, a temporary bridge replacing #7–10 can be placed. In that case, remove the lateral and protrusive movements on the temporary bridge. If implants can’t be immediately loaded, use customizable healing collars to support the soft tissue. A removable prosthesis such as a flipper or essex can be placed over the customized healing collars.
Once the implants can be loaded, a temporary bridge replacing #7–10 can be placed to further sculpt the soft tissue. After the implants have finished osteointegration, proceed with the final bridge replacing #7–10.
Tom Petnuch, DMD, MAGD
I find that initially focusing on the patient’s chief concern allows me to establish a relationship of trust that will permit to speak freely about other looming clinical concerns and establishing an ongoing care plan. I want to know what has kept him from seeking care for eight years and what are other factors that will influence his ability to have treatment completed and maintain continued care and maintenance.
The presentation of extensive caries would warrant discussion of risk factors with the patient included but not limited to diet (specifically soda, sports and energy drinks in this case), systemic health risks like acid reflux as well as home care education. I would also kindly suggest he seek some level of care with a physician in the future. Non remarkable medical histories are often non remarkable because patients do not seek routine medical care.
My impression is that the 4–6mm pockets may improve with debridement and prophylaxis. It has been eight years so I might expect some level of inflammation. I am not sure where the pockets are present, but I suspect the 2nd and 3rd molar area may require surgical consultation. Ideally, I would like to see the 3rd molars removed but with calculated risks due to position. I cannot rule out the possibility of the loss of 2nd molars due to 3rd molar position. Ultimately patient’s periodontal condition must be stable, and he will need to understand his commitments to ongoing care and maintenance. Other areas of concern for this patient that I would address are the need for restoration of the generalized caries mentioned in the case presentation.
Now back to the chief complaint. I would advise the patient (based on provided information) that he does not need to extract his teeth to have a nice smile. Upon review of submitted images alone I am not certain that #7,9 and 10 are non-restorable (may consider root canal therapy, posts and crown and bridge) but given the narrative on the case submission I will go with it.
My plan would entail photos and diagnostic models of the patient’s dentition in addition to the radiographs submitted. These are important for patient education, lab communication as well as documentation. The “high smile line” issue is a large concern for me when considering implants versus tooth supported crown and bridge as well as removable options. Soft tissue management/architecture and patient expectations should be reviewed as it relates to each treatment. Remember implants and high smiles can create challenges.
I would inquire and determine his level of interest in fixed versus removable treatments. The patient must have a clear understanding of what will be involved from a “Time, Effort, and Dollars” standpoint regarding each of the options. The patient needs to understand the limits to each treatment from a functional/mechanical standpoint as well cosmetic limits of each. In addition, what are the ongoing maintenance requirements on the home care front as well as future replacement or repair of prosthetic hardware.
The extraction of non-restorable teeth and removable partial denture option may provide the cosmetics he desires at a price point he is comfortable with. Let’s face it he: has been wearing the retainer option for many years and without the wire and an improvement in shade would not be so bad.
If the implant or tooth supported crown and bridge option were considered, the timelines of treatment and costs change. Extractions, socket preservation, and potential use of an interim removable partial denture should be reviewed. I can’t stress enough the understanding of the timelines involved as to avoid patient frustration about length of treatment time before final prosthetics are delivered. We have all heard patients with selective memory inquire “am I getting my teeth today?” at the first appointment or subsequent try-in when in fact it’s months before a definitive prosthesis may be delivered.
A written treatment plan will be provided to the patient to acknowledge and sign. The written plan is presented with specifics on the phases of treatment as well as the financial liabilities at each phase. Once signed and financial commitments solidified, we can proceed on the chosen treatment path. Best of luck!
From Tom Kratzenberg, DMD, MAGD
This is an interesting case and one that illustrates that there are many alternatives to a successful outcome. But how would you define success? Simply give the patient what he says he wants? Or refuse to give in and tell him what he needs? Might I suggest a different option where a conversation takes place between the doctor and the patient so that the patient’s chief complaint can be resolved, but maybe in a way that he did not know was possible. I believe the latter is one of the most rewarding aspects of our job.
I think that we as dentists would agree that removing all the teeth would be a big mistake for the patient, and my guess is that the patient probably realizes this as well. I like to first say to the patient that his teeth are not as bad as I had expected since he stayed away from the dentist for the past eight years. As I am saying this, I like to watch the patient’s reaction. If I see a surprised reaction (which I would expect) I would then say, “If I could improve the appearance of your teeth without needing to remove all of them, would you be interested? And by the way, it may cost less money and it will certainly cause far less pain.” The patient almost always says yes.
I then say to the patient something like, “Before we proceed, we need to determine what is causing these cavities to form, because I do not want to repair your teeth over and over. Is that OK?” Again, the patient almost always says yes. I can then say that we need to find the sugar source. I also tell them that I am not asking them to cut the sugar, only minimize its contact time on the teeth. Most patient’s do not realize that it is not the quantity of sugar consumed, but the frequency that causes the problems. I cannot begin to tell you how many patients have totally transformed their mouth by simply learning this most basic fact. But we, as doctors (and hygienists) must be willing to take the time to educate our patients.
Of course, I am speculating, but I would guess that this patient is sipping on the Red Bull throughout the day instead of just drinking it rapidly. If I was correct, I ask the patient if he thinks that he could stop sipping it and just drink the whole can at once so that the sugar is not constantly in his mouth. Often, when patients realize that they only need to modify their behavior slightly rather than change it completely, they are more likely to comply.
So why did I just spend all this time trying to answer these questions? Well, the obvious answer is that it helps me decide what treatment plan we will now develop.
If, for some reason, the patient still decides that he wants all of his remaining teeth removed; I would simply refuse to treat. Viewing the radiographs and photos, there simply is no way that I could justify extracting most of a patient’s teeth just because he is looking for an easy way out so that he can continue an extremely bad habit. I could not even justify referring him, nor do I even know anyone who would treat the patient in this way (but I would bet they exist.)
“The likely scenario would be that the patient really does not want his teeth removed. He just thinks that his teeth are so bad that they are not worth saving. It is our job to help him past that belief. We need to establish a treatment plan that removes any pain and caries as well as stabilizing the dentition.”
The likely scenario would be that the patient really does not want his teeth removed. He just thinks that his teeth are so bad that they are not worth saving. It is our job to help him past that belief. We need to establish a treatment plan that removes any pain and caries as well as stabilizing the dentition. Let me say that in reviewing the photo and radiograph, there is a reversal of both the image and the radiograph as it appears that #9 was the tooth originally replaced. Also, panoramic radiographs are not ideal for treatment planning and we certainly do not have the ability to examine the patient, but I wonder if the lateral and the central incisors are truly hopeless. I might investigate that a bit further. If those teeth can be saved, I would consider root canals for long-term treatment objectives.
I would next restore any caries along with prophylaxis/periodontal treatment. Behavioral modifications are needed to reduce sugar exposure time on the teeth. I would consider temporary replacement of the partial denture to improve the appearance while the patient is able to change his habits. If the patient can exhibit, through subsequent periodic examination appointments, that he has indeed arrested the decay processes, then I would have him consider a more permanent fixed option. My choice of fixed option would probably be a multi-unit fixed partial denture versus an implant due to gingival esthetics caused by the lack of bone width and the high smile line.
This is a great case with no singular way forward except that the patient must totally buy in to the need for saving his remaining teeth. I would proceed cautiously and deliberately. It took the patient eight years to arrive at this point. It will take some time to remedy the problem.