In this case, we have a 43 year old female patient with aggressive periodontitis. Unlike chronic periodontitis, which is an extension of gum disease and a manifestation of years of poor hygiene, this condition affects certain patients starting at a young age, and has a family predilection. Despite excellent hygiene, this patient has severe localized bone loss around the upper centrals. The tissue does not bleed, there is no infection, but the upper centrals were mobile, had a poor prognosis, and mainly, the patient did not like her appearance. After discussing her options, she preferred a bridge over bone grafting and implants, because it would be quicker and more affordable for her. (Insurances will often cover bridges, but not implants… so this can drive the decision making quite a bit.)
You can see the overall healthy tissues and that most upper teeth (besides #8 and 9) are in good alignment. Bone grafting would require a block graft, it would be highly unpredictable, costly and time consuming. There is also a tight frenum attachment contributing to the problem, so she would need a frenectomy. Yes, these things could be done in an ideal world, but bridges are covered by insurance.
On day 1, I took an impression, trimmed #8 and 9 from the stone, and ordered lab fabricated provisionals.
Never extract front teeth unless you have some new ones in your hand. I prepped #7 and 10 prior to doing the extractions to keep the sockets clean. Here is the site after placing sutures and the provisional, here is the patient on the same day of her extractions. Yes, there are empty sockets under there:
I love this because so much of a difference was made in a single day. The provisionals will guide the tissue healing. There are 2 schools of thought on that. One is, push the pontics into the tissue to create an emergence profile resembling natural teeth and roots, the other is, let the tissue grow and thicken a little, since the maxilla has a notoriously thick layer of keratinized soft tissue covering the bone. I chose the former. The former option creates gingival papillae and a scalloped appearance, while the latter may show a flat, horizontal tissue profile. (I’ll take your comments on that.) This patient has a low smile line, so either option would suffice. This is a temporary bridge, so it is designed to be relined, trimmed, and critiqued by the patient before the final restoration is made over the mature tissue. Check it out again:
SAME DAY OF EXTRACTIONS: LAB-FABRICATED PROVISIONALS
And here’s the finished case, porcelain fused to zirconia, after complete tissue healing. I was really happy with the shade match, since in most cases, people usually include the canines. I was able to nearly match the natural canines and save the patient some money.
AFTER TISSUE HEALING: FINAL PORCELAIN/ZIRCONIA JACKET
I was glad that the shade and incisal translucency matched her natural teeth so well.