bridge over troubled waters
This case was one of the most challenging esthetic and structural situations I've ever been faced with. We knew going into this case that it was going to fall far short of ideal because of the poor position surrounding the existing implant #9. It was an old Calcitek implant that was placed far too deep and much too far buccally. We made the easy decision to bury the implant in favor of a FPD #8-9-10 and have the periodontist perform hard and soft tissue grafting to gain as much bulk as possible in the ovate pontic #9 site. Here's what he was able to accomplish:
As you can see, even after extensive grafting there was still a considerable vertical defect remaining. So I made a mid-crestal incision and used pressure from the ovate pontic to push the tissue as far facially as I could. We were still quite deficient, so I then injected Juvederm hyaluronic acid filler into the papillae and facial tissue to shape it around the provisional bridge contours. Next, I had to deal with the very dark stump (ND9 prep shade) on endo-treated #8, so internal bleaching was performed using sodium perborate. This took the stump shade from ND9 to ND3, making the difficult block-out much more manageable...
The next challenge was to match the very translucent enamel on her natural teeth with the e.max LT bridge block. To attempt to accomplish this, I milled an LT BL2 block and layered lavender stains first, followed by some brown chroma, and finished with a white-wash to match her striated enamel. After several layers of stain/glaze characterization, we ended up with approximately B1 as a final ceramic shade. It's not perfect, but here are the before and after shots:
After struggling with every aspect of this restoration, the biggest take-home message I learned was: once the soft tissue becomes deficient, it's very hard to recover and create a truly natural look. The papillae loss meant we would never have a biomimetic result, but we pulled out all the tricks to make it as natural-looking as we could. I'm honestly just very happy to have this one finally completed, even with it's shortcomings.
really nice plan and result. The tissue is always the issue, but you came up with a great way to resolve. The patient must be ecstatic with the result.
I have never seen or done this, nor have I worked with facial fillers extraorally. How long do you expect the filler to hold up? Is there a plan for ongoing maintenance?exciting stuff.
Dude, give yourself some extra credit on this one. This patient has no idea how lucky she was to have YOU as her restorative dentist. None. If she would have visited any other dentist in our nation, she had a 1 in 100,000 chance of finding anyone who would have even had the ability to even plan this case, let alone carry it out. I know I would have screwed it up so badly I'd be in front of the Board fighting for my license. You did an awesome job. Beyond awesome. Thanks for sharing and making us all jealous and envious! You rock!
Shortcomings??? Did you say shortcomings?
Compare the before and after photos, it is insanity to think this result has any shortcomings! If you just posted the final photos and said which one is a crown I think we'd all have a tough time finding it and it is a bridge no less. Your work is absolutely amazing!!!
It's only February, but I think this has CDOCs case of the year sealed up.
Don
Very nice, we all have cases like this in our practice. Usually touching them is like quicksand, you just make it worse. Really nice result in a difficult situation. I would love to see more about the surgery.
On 2/8/2017 at 10:25 pm, Marc Thomas said...
really nice plan and result. The tissue is always the issue, but you came up with a great way to resolve. The patient must be ecstatic with the result.
I have never seen or done this, nor have I worked with facial fillers extraorally. How long do you expect the filler to hold up? Is there a plan for ongoing maintenance?exciting stuff.
Juvederm Plus (crosslinked hyaluronic acid) lasts around 6-12 months in highly mobile areas like the lips and perioral region. In less mobile areas of the face, like the jawline and cheeks, we can get 12-18 months. Since the gingiva doesn't move at all, I've read anecdotal reports of a 2-3 year lifespan. I have a fair amount of experience using facial fillers and that seems like a reasonable guess to me, but this is my first time using it in the gingival tissues. The patient is aware that we will need to reinject every couple years and, since we only use a portion of a 2cc syringe of the material, I just keep her leftover filler here in my medical refrigerator. The material cost is about $400 for a 2cc syringe of Juvederm Plus and she should get 2-3 treatments out of one syringe.
This is going above and beyond for the patient! I expected nothing less from you Ross. Truly amazing result after starting with such an up hill battle. Documentation is stellar as always.
Thanks for sharing,
JG
Hey Ross. This is an incredible case. I can't imagine how ecstatic the patient was after seeing her completed smile! I want to see you and Skrammy go 1v1 in a live patient duel.
On 2/10/2017 at 7:55 am, John Yu said...Hey Ross. This is an incredible case. I can't imagine how ecstatic the patient was after seeing her completed smile! I want to see you and Skrammy go 1v1 in a live patient duel.
Umm, no. I don't have a death wish. But you're welcome to challenge him!
Great case Ross. Love how you handled the Pontic. Can you elaborate on the lavender stains(what you were trying to accomplish using that color) and what stains and glazes you used? How many fires?
Thanks
Tom
Fantastic case Ross. I was thinking of posting something by someone with lesser skills--me--but now I'm intimidated. 
On 2/9/2017 at 9:50 am, Thad Vincent said... Ross, where did you learn to administer facial fillers?
I took my Botox and dermal fillers certification course from Aesthetic Facial Dimensions in Florida, taught by a couple dentists and a nurse. Since then, I've done several technique update courses through PALETTE, which is affiliated with (but not sponsored by) Allergan, who makes Botox and Juvederm. I've also been trained to use a filler called Radiesse, by Merz. They actually send a trainer to your office to certify you before they will sell you the product. This was all years ago before it was mainstream and taught by everyone. Now there's no shortage of people teaching these techniques.
Ross,
This is absolutely amazing! I needed to end my week viewing this case. Wow! Thank you so much for sharing this cool case. Just wow!
Ross, you should take minute to feel really good about yourself. All of us envy your skills and are continually wowed by your results. I know your techniques and results come from an enormous amount of continuing education and the constant drive to get better. That sometimes creates a sense of nothing is ever good enough. Please know that your hard work is worth it and it is ok to feel like this is "good enough"
Great job. Some of us are working to get to your level, but it is a steep and long hill to climb. Thanks for sharing.
Ross,
I have a case that is WAY over everyone's head. Number 8 removed, 7&9 perio compromised Would you like to take a look? I will see if he is willing to travel to Florida. His dad is an oral surgeon, retired. But wants his hands in/on the case. He came to me with a failed implant, exudate. Referred to OS finally removed implant and bone graft failed. I placed a Maryland bridge on the facial, recommended by this site, so no pressure on the site but still failed. He had an appointment with someone his dad found today. But I am sure he does not have the skills you do. It has been discussed to extrude 7&9 to attempt to regain bone, orthodonically. He is in such a terrible situation, I need a talented dentist to figure this out. If you want to take a look I will ask him if he is willing to fly to Florida. And I will post his case. He is young too! But fortunately low smile line.
Carrie
obviously, I think you are awesome! I think a Ross V Skrammy should take place! Live TV! Maybe beat Ross show! Like Bobby Flay's.
