11B. Combined Periodontal and Orthodontic Therapies Flashcards
(41 cards)
Fracture/caries
- …So not only when we have a pocket depth but what if I have a fracture? Subgingivally? What if I have a caries subgingivally? How do I treat that?
- I cannot go and put a crown all the way up to the bone level because I will be invading biologic width. Thats unacceptable.
- If that is the situation then we must do a ____ of that. To apically relocate the biologic width. BUT we know what happen when do the crown lengthening here because we don’t do one tooth crown lengthening, we need to level the two adjacent (????) area we know the consequence of that.
- So we are going to utilize exactly same idea for different purpose – not for the purpose of eliminating the bony defect periodontal lesion– but as a ____ procedure we are going to go and do exactly the same thing.
• So from before where we have the bone is completely level (lower blue line) and normal and free of pathology we are going to go and put the brackets the way I want for the purpose that I’m thinking…
crown lengthening
pre-prosthetic
Post orthodontic
- Osseous crest level
• …and we are going to erupt this tooth as you can appreciate on leveling of the apical apex of the root equal amount of a coronal part that we erupted.
- And intentionally now we create abnormality of ____, which we don’t want, but intentionally we create anomaly here. Why? Because now I can go do ____ tooth crown lengthening, eliminating excessive bone around this tooth, eliminating excessive soft tissue around it (circled).
- By doing that I go back to level bone and soft tissue I can afford the luxury of…
low HIGH low
one
Localized tooth lengthening surgery
Post multi discipline approach treatment
- …Luxury of doing single tooth crown lengthening. So I can do single tooth crown lengthening we are doing orthodontic in preparation to that. Otherwise I couldn’t do it.
- So often you get to here this a simple situation (????) I just need one tooth crown lengthening – but those are the most difficult ones! Because you know what I need to do. To do crown lengthening of that one tooth I need to remove the ____ here and here (he points to a bunch of areas in the immediate surrounding teeth).
- When 2,3,4 teeth are problem those are ____.
bone
easy
- …But so we can create a favorable environment clinically for the restoration of this tooth we are going to do the orthodontics.
- As you see pre-op where gingival margin is level (top left pic) – of course as we saw on the radiograph bone was level – we are going to position the bracket at a ____ level (top right pic).
- We are going to erupt this tooth. As the eruption happens what happens to the soft tissue? Soft tissue will follow? Why? It belongs to the ____.
- Free of inflammation I move the tooth up and soft tissue and bone will follow. Move to left or right the same thing will happen, attachment apparatus will follow the tooth.
• So we create an unleveling of the gingival margin so I can do one tooth crown lengthening now and pulpal flap elevation (bottom left).
• What I see? This is what we see (circled, bottom right). This bone moved from here to there (orange).
• Equal amount of the eruption of the tooth that we did.
• Does orthodontics create new bone? NO! Orthodontics does NOT create new ____.
Orthodontics does NOT create ____. Orthodontics ____ attachment.
• When we pull the tooth up the attachment followed the tooth. He again emphasizes that ortho does not create new bone or soft tissue.
different
tooth
bone
soft tissue
relocated
- So that relocated attachment level we are going to do a localized ____ and put the margin back where it was (bottom left picture).
- So we did the entire surgery there and removed the soft tissue and removed the bone but did not affect the adjacent teeth. Did not affect adjacent attachment level.
- Thats post surgery free gingival margin.
crown lengthening
Patient was referred for replacement of tooth #8 with implant
- Here is a case where the patient was referred to us because there was a crown in here and she cracked the crown so this tooth is not ____.
- Can you extract this tooth and put an implant in there? Of course we can do that.
restorable
• So here is the initial presentation. Number 8 is fractured subgingivally.
• Tooth is not restorable as it is. What do I need to do? I need to do a ____
here. What is going to happen when I do the crown lengthening here?
• I need to remove the bone here, I need to remove the bone there (points to green spots).
As I remove the bone, the interdental papilla is going to ____ and I”ll create adequate tooth structure so I can put a crown in there but I’ll create other problems. Esthetic problems.
• Thats why the referring dentist don’t do the crown lengthening. Extract this tooth and put an ____ there so it doesn’t affect the esthetics of the adjacent teeth. Thats one way of doing it.
crown lengthening
recede
implant
• We do the endo. We put a cast, post, and core.
Forced eruption of tooth #8 with temporary crown in place
- We are going to do the orthodontics. So why orthodontics? Why don’t we extract the tooth and put an implant there? Well that’s a template/terrible (????) way of doing it. We don’t do that. WE save the teeth in here.
- So we go and we do the endo. Cast, post, and core. Put a temporary there. We are going to ____ this tooth.
- You see the reason why it is into the slot. You see where the wire is? Tooth is erupting. And you are going to erupt this tooth as much as you need to.
- We put the bracket, rebound the bracket, bring the tooth down. Now what do I have? Look at the soft tissue where it is. (green line). Compared to before.
- Did orthodontics create more soft tissue? It did not! It ____ soft tissue to the coronal level…
erupt
relocated
Adequate inter occlusal space for the eruption of tooth is required to prevent uncontrolled trauma from the occlusion
• Intentionally unleveling it… always making sure that you control the occlusion because orthodontics is a ____ trauma.
• And we are going to do the ____ limited to that one tooth. Leveling the
osseous crest the way it should be (blue line).
• So change of a gingival margin because attachment is following the tooth and crown lengthening is done. From pre-op we unleveled ____ intentionally ____ the bone so that we can do one tooth crown lengthening.
controlled
crown lengthening
high, low, high
unleveled
• And that’s before the surgery (left picture).
• That’s after the surgery (right picture). ____ has been done without affecting
the adjacent teeth or without removing healthy attachment apparatus of an adjacent area.
Level the gingival margin.
crown lengthening
Post orthodontics and pre prosthetic crown lengthening surgery
- Now I can go and if you look at preorthodontics where the margin of the post was and post orthodontic where the margin of the post stays.
- Why the post go from gold to white?It’s a cast post and core and metal post under the porcelean crown it modify the shade and esthetics, so we cut back the gold and we masked that with ____. That’s why.
- Its not only periodontics. Not only restorative, not only prosthodontics, not only perio, not only orthodontics. It’s a combo of everything. You use everything you know to maximize the outcome of it. That is going to make you different from john smith at the corner over there.
composite
Normal condition w/ Crown tooth #8
- In a situation where you have a crown restoration on the adjacent tooth and something happened to the tooth next to it. What happened?
- If you have an existing crown here and something happens to the adjacent tooth you do the surgery — you already know what the outcome will be. You don’t need to do it to find out. We know that. You need to be able to ____ what the outcome is going to be so that you can properly plan and select what type of therapy you will be implementing or recommending. You don’t do it – oops, maybe this is not the best way. You need to be able to visualize what the outcome of the treatment is going to be.
- So you properly select what the best is for you and the patient.
- He clicks through the next few slides as an animation.
visualize
Other than for that prosthetic purpose-restorative purpose—what other situations we do orthodontics is to modify the environment. There is situations where ____ proximity is present and because of the root proximity you have bone loss, you have a pocket depth, you have inflammation in all – and there is no perio treatment that is going to give you satisfactory outcome here.
Because what is the etiology? Is the root to root relationship is etiology unless you modify that nothing is going to work. How do you modify this root to root relationship? You only have two options.
Either you take one ____ out, or you move them ____.
We are going to move them apart. That root proximity over there. And we are going to do the orthodontics, and we are going to separate those roots. From that relationship, to that relationship. We have a little over there to move this tooth over there, move this tooth – we augment, we enlarge edentulous space in here, and we make a ____ with a pontic there. This serves as a prosthetic replacement of tooth, serving as a periodontal splint. To reduce the mobility of it. That is the only way that we can solve this problem, reducing that ____ to a healthy situation. Modifying the environment of it.
root to root tooth apart lingual splint environment
Same thing over here. Root proximity issue there (green circle, bottom left) – we are going to do anatomy of anterior teeth triangular toward the incisal edge we have a thicker enamel layer.
We are going to do what we call ____. We are going to reduce the width and align them. Going from there to there (green arrows, bottom right pictures)– from that proximity– to that much of a cervical embrasure opening over there. There is no other periodontal or any other therapy that can solve that because the problem there is not a plaque or hygiene or nothing. Problem is a ____ proximity and you gotta modify the ____.
interproximal stripping
root
environment
Mesially drifted molar w/ osseous defect
Utilizing the orthodontics as a pre-prosthetics. In the posterior for example where the molar is mesially tilted, it should result in what? ____. Not vertical defect but angular crest.
IN that angular crest where plaque and calculus and all other local and etiologic factors is super-imposed now you have further bone loss– that healthy angular crest now became what? ____. It’s a very different you need to analyze (?????) many different aspects of the tooth and the defect before defining or diagnosing that as a pathology or not because angular crest is a state of health. That’s a physiology of it.
____ is a pathology that needs to be treated. So, situation like this if I wanna do a bridge it cannot be done because you don’t have a path of ____. It cannot be done because you have a ____ periodontal pocket there.
angular crest infrabony defect infrabony defect draw deep
Orthodontic molar uprighting
Or, we can utilize orthodontics. So now, just look at the drawing going back to discussion we had. Why suddenly I’m using wire like this? Because from here to there (arrow, green) is too close, wire is too ____ too ____ too much force. We are going to lengthen the wire length to increase the ____ and you incorporate any type of mechanics that you want to in a design that you want to– to achieve the purpose of the lengthening and increase the flexibility. For what purpose we are going to upright this molar? ….\
short
stiff
flexibility
Post orthodontics
Eruption during uprighting
….That way. Depending on the mechanics that you used. Amount of eruption doing orthodontics as a molar uprighting for example – amount of eruption you get can be controlled, but certain amount of eruption is always a possibility.
You can reduce the eruption but the eruption is super eruption above the occlusal plane is always a possibility. And if orthodontic itself is a trauma, and you don’t control the occlusion, you put that tooth under ____ – you are going to lose that tooth.
So, its not only the ____ of the periodontium but controlling the ____ is a key factor. Not only in periodontal tooth movement but in periodontal therapy in general. Because occlusion is a part of perio. So, we will erupt that tooth as the eruption come as you see super uprighting, super eruption of the molar there (circled) and that occlusion has to be always ____ and adjusted as needed….
hyperocclusion
inflammation
occlusion
controlled
Once restored -> single crown, bridge or implant
….or we are going to put an implant that restores that. Now, when molar uprighting is done. Every orthodontics at the end of the orthodontic movement comes what? ____. That’s why you wear a retainer after braces. Your retention has to be there and if the retention is there – its going to collapse in front of your eyes.
You upright this tooth – you get the brackets on, you keep looking at it, you see that tooth going back. It moves that fast. When we consider retention post orthodontics is a mandatory that the retention is means of a ____ appliance. Never removable.
Meaning, case like this once you upright it this molar (as he did a couple slides back) – once the uprighting is done, if your final prosthetic plan is to give it ____ partial. Its not going to work. Because by the time you took the impression and framework came back. Its not going to fit. That tooth has moved already.
retention
fixed
removeable
Post orthodontics and single tooth implant
If you are lucky you made the partial that, that patient take the partial out in the night time. Try to put back in in the morning. That partial is not going to go in. So your retention has to be a means of a ____ appliance, never removable. If it’s a removable. Your retainer must be worn ____ hours a day. Otherwise its not going to fit. That’s why the option of restoring this tooth as a single crown and that’s it– is not ____. Because this tooth will move back. Its going to relapse. So either you need to have a fixed ____ (last slide), or you have an ____ in there because that’s going to serve as a fixed splint.
fixed 24 acceptable fixed bridge implant
As an example, here. CEJ is right here. And your bone follows a drop (top right picture, green). It’s a angular crest or infrabony defect? Now it became an ____. If this bone was coming straight this way, parallel to CEJ, there would be an angular crest and you don’t treat that, which is not the case (blue line, top right pic).
infrabony defect
This is a very old case that today probably we would treat this very differently. But, first molar decay down and how are we going to treat this tooth? Don’t forget we are talking about orthodontics we do ortho. Whats the problem we have here besides inadequate tooth structure? The furcation. We section the root, we put a single crown on each root. But we have a ____ proximity! Look at the anatomy of the root. These are converging. We don’t have enough of an embrasure there (in between the roots). Prosthetically it does not work….
MANAGEMENT OF INTER RADICULAR DISTANCE
So we split that. Separate the ____. Much more favorable prosthetically speaking now. We are going to restore them as individual premolars. Today probably we are not going to treat this case this way. Probably we are going to extract and put an implant in here because the bone is perfect size for an implant. The point is how you think – you look at it, analyze it. Just DON’T assume that this tooth is hopeless. That an implant HAS to be put in there.
root
root
So we analyze this and what is the problem why this is breaking? Why the anteriors breaking (circled)? Because of trauma. Why the anteriors is under trauma? Because ____ is not effective. Posterior support is not working. But you just got this bridge done! I’m sorry. Whoever put the bridge there was not thinking or was thinking only about the bridge. Nothing about something else. So what is the solution here? You are going to solve this problem here (the posterior bridges). The posterior support has to (????).
posterior
So we go and as you see anterior teeth are frayed out. Under trauma. That’s why teeth breaking. The chief complaint is right here. How do you solve this chief complaint over here. I’m going to do something on the back first so I can solve this problem. Remember way back hour and half ago you don’t do orthodontics and anterior retraction —- without properly establishing ____ support.
We are going to open the ____ dimension.
functional posterior
vertical
Increased ____
Increased ____
Decreased ____
Restore the posterior support proper way. Provisional (circled). Because we open the vertical now and have anterior open bite. Now I can retract this the way I want. To the proper position. You see the excessive.
Remember the vertical dimension I talk about it. You open the vertical what are the consequence of that? You modify the ____, the ____. It’s a triad. You always these three factors always follow together. You cannot modify the vertical dimension without modifying the overjet or overbite, or vise versa.
VDO overjet overbite overjet overbite
