Treatment Plan for Two Central Incisors

Dennis Hartlieb

Part 1

This patient has a crazy story - when he was a kid he was just walking home from school one day and was shot by another kid with a BB gun - right into tooth #8! He was incredibly lucky that it was his tooth and not an eye, but how crazy is that?! Anyhow, tooth #8 was crowned, and since that time, he has also had #9 crowned.

My treatment plan is very limited:

  1. Gingivectomy #8, remove crowns #8 and #9, provisional crowns #8 and #9
  2. Patient to be seen by periodontist for osseous reshaping #8 about 2-3 weeks following provisionalization
  3. Healing of crown lengthening 3-6 months
  4. Final crowns #8 and #9

    Now, the patient is very cautious and is not certain that he wants to have the crown lengthening done (he understands that there would be an esthetic improvement, but financially is conservative).

So, we are changing our treatment strategy:

1. Remove crowns #8 and #9, provisional crowns #8 and #9, evaluation of tooth structure for functional considerations (ferrule)
2. Consultation with patient to review findings from appointment 1

Patient will decide between:

1. Have final crowns made at existing gingival margin positions
2. Follow thru with crown lengthening and treatment as outlined above

The patient understands that there will be a separate (additional) fee for me to go back and GV and reprep and retemp if he decides to have crown lengthening.

Part 2

Karl came in a couple of days ago like we had discussed for treatment of the two maxillary central incisors.
After local anesthesia, I removed the existing restorations. I then 'sounded to the bone' on the facial of #8, hoping that there was a deep sulcus, and we could look at potentially just doing a gingivectomy instead of full osseous procedure. No luck...sounding was just over 3 mm (2nd image).

I reprepped the teeth - full coverage restorations (3rd image), and placed the provisionals. I also, very quickly, did some prototype bonding on #10 to bring into alignment. In the smile preview pic, you will notice a cant in the patient's smile, so creating more symmetry in the length of #8 and #9, #10 was going to look to short, or more likely, the patient was going to think that #9 was too long.

So I etched, adhesive and placed composite on #10 to get a better smile blend for the patient.

Karl is returning next week (I think) for discussions about definitive treatment:

1. Leave tissues as they are
2. Crown lengthen for symmetry

Do you have any thoughts on this case before I see Kyle again?

Dennis Hartlieb, DDS, AAACD

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