Case 1

A 27-year-old man attended for review following previous treatment for severe localized periodontitis that had particularly affected the incisor teeth. He reported no problems with his gums, but he was deeply upset about the appearance of his upper anterior teeth, which had always been imbricated, but this appearance was now exacerbated by recent additional drifting and by gingival recession.

On examination, it was noted that he had responded extremely well to the previous periodontal treatment and there were no persisting pockets greater than 4 mm, no gingival bleeding, and plaque control was good. The upper anterior teeth showed marked crowding and imbrication, with UR2 retroclined and UL2 proclined, together with unevenness of the central incisors. The patient had an anterior open bite, and none of the teeth exhibited any increased mobility (Figure 15.1).

Fig 15.1 Case 1 (A) at presentation and (B) at extractions and fitting of immediate acrylic partial denture. (C) Teeth replaced with resin-bonded bridge with abutments at UL3 and UR3.

The teeth were carefully assessed, and although it was considered that following periodontal treatment their prognosis was good, the options for improving the aesthetics were limited. Because of the imbrication, there was loss of space overall for the upper incisors. Orthodontic treatment was not considered a suitable option in this case because of lack of space and the severely compromised periodontium of the teeth. Therefore, it was agreed that the only suitable solution would involve extraction of some or all of the teeth.

To assess further, study models were made and a range of options explored by diagnostic wax-ups, including extraction of upper lateral incisors and replacement with single pontic cantilevered resin-bonded bridges. However, because of the lack of space and the irregularity of the central incisors, it was agreed with the patient that extraction of all four incisors would give by far the best aesthetic result, recognizing that the central incisors would be made slightly narrower mesiodistally to allow for an even matching of the teeth. Consequently, the incisors were extracted and initially replaced with an immediate acrylic partial denture and finally replaced by a resin-bonded bridge using the UR3 and UL3 as abutments (Figure 15.1).

Extraction of the incisors was a major issue for the patient, but ultimately he was delighted with the outcome. Sometimes extraction of teeth is the right treatment not because they have existing disease but, rather, for overall aesthetics. In this case, the use of the upper canine teeth as abutments for the bridge was readily considered because these teeth were largely unaffected by the severe periodontal disease seen on the incisors and also because the occlusal loading on the bridge was relatively low, given the anterior open bite.

More generally, the decision regarding the use of periodontally compromised teeth as abutments for fixed or removable prostheses requires careful assessment. First, it is imperative that such teeth have been successfully treated for periodontal disease, but in these circumstances studies convincingly show that increasing occlusal load on teeth by using them as abutments will not result in renewed attachment loss provided that they are well maintained in a plaque-free state. However, the increased occlusal load on an already compromised tooth can further increase tooth mobility. Thus, when determining whether to use a periodontally compromised tooth as an abutment, consideration has to be made regarding the magnitude of the likely increased occlusal load to which it will be subjected, if it is possible to spread the load over a number of abutment teeth, and in the most extreme cases, whether to incorporate “cross-arch bracing” to prevent mobility of prostheses.

Case 2

A 46-year-old woman with generalized severe chronic periodontitis that had been successfully treated complained of marked mobility, particularly of UL1, and some spacing of the upper incisors. She has good plaque control but is a smoker of approximately 10 cigarettes a day. She is committed to trying (again) to quit smoking.

On examination, the UL1 showed grade 2 mobility and the UR1 grade 1 mobility. The patient reports the UL1 is uncomfortable, particularly on eating, and thus affects her masticatory function. She is always concerned about “catching” the UL1 during function and making it even more mobile.

The mobility was managed by the use of a fibreglass-reinforced composite splint applied to the incisors, and the contour and spacing of the teeth improved by composite buildups (Figure 15.2). She was given careful instruction in how to keep the area clean using interdental brushes, and further maintenance visits were arranged.

Fig 15.2 Case 2. (A) Radiograph of upper central incisors showing severe bone loss, particularly at UL1. (B) Fibreglass-reinforced splint placed on incisors. The splint has had to be placed quite apically to avoid occlusal interferences, and it requires very careful maintenance because of the increased risk of plaque accumulation. (C and D) Labial view of splinted teeth. Composite buildups have been placed as part of the splint to improve contours of teeth, particularly at UR1 distal and UL1 mesial.

Acid-etch bonded composite materials are very useful in managing some spacing and dri/>