The image on the left above shows the appearance of a patient’s front teeth two weeks after I had attempted to repair the right central incisor for the third time in three years. The tooth was repaired in composite, using a pin in order to help stabilize the restoration. The reason that this patient kept breaking it was the tooth’s rather prominent position, since in addition to being tilted severely to the patient’s right, it projected considerably in front of the adjacent teeth.
This made it very prone to traumatic injury. The patient plays contact sports, and even though he wore a sports mouth guard, the lack of support from adjacent teeth made this tooth especially prone to breakage, right through the flexible silicone rubber of the guard.
This incisal image shows just how crowded the dentition was. It also shows how prominent the broken tooth was when the patient presented in my office. The dark spot is the remains of the now broken pin that was originally used to stabilize the restoration. Also, please note the severe crookedness of the teeth adjacent to the broken tooth.
I had been seeing this person since he was a child, and had originally urged the parents to consider orthodontics (braces), but at that time the family was unable to afford it. By the time of this accident the patient was reaching adulthood, and he did not want to go through the years in braces that orthodontics would entail at this time of life. Therefore, a decision was made to simply extract the offending tooth and repair the smile using a prosthetic device, which means a false tooth.
As you can see from the incisal view above, simply extracting the most crooked tooth without altering the shape of the adjacent teeth would leave very little room for a false tooth. Putting a tiny false tooth in the space vacated by the original would have created a very poor result. Thus the treatment plan included placing crowns on both adjacent teeth to make them smaller. This would allow for more room which can be divided up more equitably. In addition, this option has the added benefit of creating retainers for a three unit fixed (non removable) bridge which can be built to straighten the adjacent teeth as well as adding a false tooth to replace the broken one.
The right lateral incisor and the left central incisor were prepared as abutments for a three unit bridge. Note that the teeth were prepared prior to the extraction of the crooked central incisor. The reason for this was to avoid water and air spray from contaminating a fresh extraction site causing a possible infection. After the preparation of the abutment teeth, the right central incisor was extracted, and a lab processed temporary three unit bridge was placed over the abutments and the extraction site.
The above image was taken immediately upon placement of the prefabricated laboratory processed plastic temporary three unit bridge. The notch between the patient’s right canine and right lateral incisor is there to allow space for the crooked lower canine on that side. Closing that notch would have caused the lower canine to hit the plastic of the temporary bridge, and would not allow the patient to fully close his mouth. The irregular appearance of the gums around the temporary is due to the fact that the crooked natural tooth was just extracted from this site. The temporary will be worn for about six weeks to allow the extraction site to heal and the gum tissue to remodel.
About six weeks after the temporary bridge was placed, the patient returned to the clinic, the temporary was removed, and the preparations were refined. The six weeks represents the time needed to allow the socket to heal and the gums to remodel. Refining the preparations means essentially cutting the preparation margins back beneath the gum line so that they will be hidden when the final appliance is inserted. At this time, an impression was taken and sent to the laboratory for fabrication of the final restoration.
Three weeks later, the lab sent back the finished bridge. This restoration is made of Lava, the 3M-ESPE version of a zirconium ceramic framework overlain with esthetic porcelain. The zirconium framework provides tremendous strength without compromising the translucent esthetics necessary to approximate the appearance of natural teeth.
The finished case, pictured above was cemented in place with a resin modified glass ionomer cement. The result is quite good, even though some compromises have been made in the final shape of each individual unit to allow for proper sizing of the individual teeth.
The above image shows a patient who was missing his right lateral incisor with the two central incisors bucked in. As a result, the right canine and left lateral incisor look like fangs. This, along with the serious discoloration of the natural teeth kept the patient from smiling. The solution in this case was to do five crowns to include the four anterior teeth, but also the patient’s right first premolar (the one with the visible amalgam filling). The trick in this case was to create the illusion that the premolar was actually the patient’s right canine. The canine was built to look like a slightly enlarged lateral incisor, the left lateral was built to be more prominent, and the central incisors were rebuilt to be straight. The left first bicuspid remains in its natural condition and now becomes the patient’s left canine. The result is seen in the image below. This gives the patient a much wider and brighter smile in addition to straight teeth.