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The loss of teeth results in the resorption of the residual alveolar ridges. This case report describes the successful maintenance of the alveolar ridge contour in the maxillary anterior region under a fixed prosthesis by the mucosal coverage and submersion of an endodontically retreated root, including a 6-year follow-up.
INTRODUCTION: Birmingham Children's Hospital (BCH) is the centre for a regional comprehensive cleft service attempting to implement the national guidelines for minimum standards of care. A national audit of cleft management (CSAG) found that 58% of alveolar bone grafts were successful; published series suggest that success rates can be of the order of 95%. We present the results of an audit of alveolar bone grafting over a 33-month period, after implementation. PATIENTS AND METHODS: A retrospective clinical process audit was taken from the hospital notes and an analysis of radiological outcome by Bergland score was obtained by two independent assessors. RESULTS: The audit highlighted the difficulties of integrating the increased clinical workload. Other difficulties included poorly standardised pre- and postoperative occlusal radiography, inconsistent orthodontic management and a lack of prospective data collection. An 81% success rate for alveolar bone grafting compares favourably to the CSAG study. Of 82 patients, 68 had sufficient data for a retrospective review; 21 were our own patients and 47 were referred into the centralised service. The success of bone grafting as defined by CSAG (including Bergland scores) is based on only two-thirds of the patients as many have their orthodontic treatment managed in more distant units and radiographs are much harder to obtain. Bone grafting later than age 11 years, was true for 28% (6/21) of our BCH patients and 46% (22/47) for those referred to our service. CONCLUSIONS: This audit demonstrates what has been achieved in a re-organised service in the context of Real Politik in the NHS and suggests the areas that require improvement.
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Supraeruption of the right maxillary molars and concomitant drop of the alveolar ridge resulted in loss of intermaxillary space. With the patient under local anesthesia and intravenous sedation, a posterior segmental osteotomy was performed, on an outpatient basis, to reposition this segment superiorly into the maxillary sinus. Stabilization was accomplished with a prefabricated acrylic splint. The patient quickly resumed her daily routine with normal postoperative healing and satisfactory intermaxillary space.
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Although different opinions exist about surgical repair of cleft lip and cleft palate, cooperation between a number of specialities is essential to a successful result and final rehabilitation of the patient.
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A review of a new plastic surgical procedure using autogenous grafts of dense connective tissue placed submucosally in anterior areas of collapsed, deformed edentulous ridges has been presented. This technique allows augmentation of an anterior, deformed edentulous ridge to a proper form, color, and texture before placement of a fixed prosthesis. Previous solutions to this problem have resulted in an esthetic compromise at best. Long-term follow-up shows good dimensional stability offering an acceptable solution to a difficult prosthetic problem.
The preprosthetic management of individuals with denture instability caused by severe alveolar ridge atrophy is discussed with respect to augmentation by bone grafting or implantation of denture retention devices. Specific indications were made for the use of each surgical procedure and the clinical effectiveness of each was illustrated with a case presentation. In the maxilla and mandible, there is a range of functional alveolar ridge heights that results in unsatisfactory denture retention. If the alveolar morphology lends itself to a soft tissue procedure, a vestibuloplasty will often provide satisfactory improvement in stability. However, if the alveolar height is severely diminished, denture retention can be satisfactorily enhanced only by ridge augmentation procedures such as bone grafting or the placement of metal implants. Implantation of denture retention devices can improve denture stability on certain severely atrophic mandibular alveolar ridges. The staple is a precision appliance that must be placed during a surgical procedure under general anesthesia, requires close attention by patient and prosthodontist following placement, and is expensive. The ramus frame is a less expensive alternative that can be placed on an extremely atrophic mandible under local anesthesia with conscious sedation. The morbidity associated with harvesting autogenous iliac crest or rib for bone grafting, though it requires a general anesthetic, is relatively minimal in the healthy patient. Vigilant postoperative care and aggressive physical therapy lead to rapid rehabilitation of the individuals who must recover from the additional surgery.
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These investigations were undertaken to evaluate durapatite, a particulate, ceramic, nonresorbable bone-grafting material for augmentation of deficient alveolar ridges. A total of 207 augmentations were reported among 198 patients over 24 months. Subjective and objective data showed that durapatite alone was successful for all classes of ridges augmented; height, bulk, contour, and ridge form generally improved and soft tissue overlying the augmented ridges was firm and immobile. Impressions for dentures usually began 4 to 6 weeks after surgery and these dentures remained stable, retentive, and esthetically pleasing throughout the study. Other than transiently altered sensations resulting from mental nerve manipulation during surgery, no other important procedural complications were noted. No infection or bone resorption beneath the implant was observed throughout these studies. Durapatite used in an outpatient setting provides a less costly and more permanent method for alveolar ridge augmentation than do augmentation procedures using autogenous or banked bone.
Evaluation of the nonresorbable particulate form of hydroxylapatite for localized ridge augmentation has been described. The surgical technique using this material is simple and effective, and produces an improved ridge base for pontic function. Six-month postoperative examination showed the area to be clinically stable with significant improvement of cosmetic appearance. The augmented area of the ridge was convex and had improved contour in width and height.
Only by controlling plaque early and consistently, before periodontal and restorative problems require intervention in the form of a full prosthetic and periodontal reconstruction, the continued maintenance of a full dentition is assured. Plaque control is not merely continued prophylaxes, but a striving for a healthy biologic situation with the placement of every restoration. This is attainable only through ensuring a normal attachment apparatus and establishing that all restorative margins be accessible to plaque control measures. Deep, subgingival restorations are not only difficult to place and finish correctly, but, by providing an environment conducive to microbial plaque retention and proliferation, also lead to inflammatory periodontal destruction and recurrent carious lesions. Early detection, although difficult, is essential to avoid excessive destruction of the tooth and its supporting structures. A deterrent to early detection may be the response of the patient's tissue. Paradoxically, if the patient's periodontal tissues respond in a fibrotic manner to early gingival inflammation, rather than in a dramatic, edematous manner, the situation may appear clinically healthy. Waerhaug discussed "submarginal gingivitis," a situation in which the tissue will appear pink and firm, elicit to exudate or bleeding on probing, and mimic healthy to the casual examiner. When this is coupled with the difficulty inherent in detecting early recurrent carious lesions, resulting from the radiographic superimposition of the existing restoration or the deep subgingival extent of the restoration, the situation becomes all the more demanding of the practitioner's efforts.
Periodontal surgery and biologic principles can be used to treat a variety of restorative and endodontic complications. Four cases illustrated the application of orthodontic therapy and periodontal surgery in the treatment of these difficulties.
Treatment planning for dental implants presents special challenges to the dentist. The authors review the conventional radiographic and non-radiographic methods for the assessment of the implant site. A new dental interactive treatment planning program under development at the University of Alabama School of Dentistry Department of Periodontics is described.