“If I am going to have a denture, what can be done to change my smile?”

Donna M. Hecker, DDS, MS Diplomate, American Board of Prosthodontics

Prosthodontist, The Dental Specialists-Maple Grove

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Navigating the Esthetic Zone

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Changing the Smile Line

• Conventional dentures • Fixed Implant Denture- one arch • Fixed Implant Denture- both arches • Full Mouth Reconstruction on • Natural Teeth/ Implants

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THE HIGH SMILE LINEDENTURES

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CLASS II MALOCCLUSION WITH STEEP VERTICAL

OVERLAP

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EXCESSIVE GINGIVAL DISPLAY

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CHANGING THE OCCLUSAL PLANE

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TEMPORARY DENTURES

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The Retrusive MaxillaDentures

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Class III Malocclusion

No maxillary anterior tooth display

at rest

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Temporary Dentures

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THE HIGH SMILE LINEFIXED IMPLANT DENTURE

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TEMPORARY DENTURE

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TEMPORARY DENTURE

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VERIFICATION JIG

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FRAME TRY-IN

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1ST WAX FRAME TRY-IN

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1ST INSERT APPT.

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2ND WAX/ FRAME TRY-IN

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3RD WAX FRAME TRY-IN

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2ND INSERT APPT.

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1ST LAB VISIT

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2ND LAB VISIT

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FINAL FIXED IMPLANT DENTURE

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PROMINENT LOWER TOOTH DISPLAY

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WHAT CHANGED ?

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LAB CORRELATION TO CLINICAL

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FULL MOUTH RECONSTRUCTION ON TEETH AND IMPLANTS

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WHAT THE PATIENT DOES NOT

WANT!

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SURGICAL PLAN #1

Same Day Surgery Center Surgeon: • Removal of lower anterior teeth and placement of 5 implants • Removal of upper teeth and implant #11

• (leave #3, 4 and implant #7) • Sinus lift/ bone graft on upper left side • Placement of implants # 12, 13, 14 Prosthodontist: • Insertion of upper removable partial denture • Insertion of lower fixed round-house bridge, cemented on pre-molars and

molars.

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SURGICAL PLAN #2

Surgeon’s Office Surgeon • Placement of implants in sites #5,6,10,11 • Uncovering of lower implants Prosthodontist: • Insertion of new upper removable partial denture • Modification of lower fixed round-house bridge, cemented on pre-

molars and molars.

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SURGICAL TEMPORARY PROSTHESES

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WANTS A BIT MORE UPPER

TOOTH DISPLAY

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HEAT-CURED TEMPORARY FIXED RESTORATIONS

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PORCELAIN TRY-IN

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PORCELAIN TRY-IN

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FINAL FIXED RESTORATIONS

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FINAL FIXED RESTORATIONS

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WHY DOES MY CHILD HAVE AN EXTRA TOOTH?

Adam Ridgeway, DDS Diplomate, American Board of Pediatric Dentistry Pediatric Dentist, The Dental Specialists-Roseville

May 19, 2015

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Supernumerary-HyperdontiaDefinition:

• A developmental abnormality that can affect Both the Primary and Permanent dentition

• Occurs when the tooth number Exceeds the normal dental formula

• Can occur Singular or Multiples, Maxillary or Mandibular, Unilateral or Bilateral

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Supernumerary-Hyperdontia

Etiology:

Evidence points to a Genetic Predisposition that hyperdontia might follow autosomal dominant inheritance with a lack of penetrance

Multifactorial- Genetic and Environmental

“The Curse of the Family Mesiodens”

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Supernumerary-HyperdontiaEtiology: 3 predominate mechanisms

Atavism: A reversion back to extinct primate dental tissue

- largely discounted - only accounts for individual occurrences

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Dichotomy: An equal or unequal split of the tooth bud/germ cells resulting in supplemental or rudimentary supernumeraries

Independent Hyperactivity Dental Lamina: Most Accepted Theory Lamina is responsible for dental formation Permanent dental lamina buds off of Primary Dental Lamina Formation from Remnants of dental lamina

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Hyperdontia Associated Developmental Disorders

Most with Multiples Apert Cleft Lip and Palate Cleidocranial Dysplasia Crouzon Downs Syndrome Gardener Syndrome Hallermann-Streiff Noonan Syndrome Oral-Facial-Digital Sturge-Weber Zimerman-Laby Syndrome

Less commonly: Ehlers-Danlos Syndrome, Fabry Anderson's Syndrome, Chondroectodermal Dysplasia, Incontinentia Pigmenti and Tricho Rhino-Phalangeal Syndrome, Zimerman-Laby/Noonan Syndrome

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Supernumerary-Hyperdontia

Prevalence of .3-3% in Primary and Permanent dentition - Compared to 3-7% Hypodontia

5x more common in Permanent dentition

Primary Supernumeraries .3-.6% prevalence Primary supernumeraries (most supplemental laterals) almost

always erupt due to excess primary space

1/3 of cases with a Primary Supernumerary will Also have Permanent Supernumerary

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Supernumerary-Hyperdontia

Favors Males over Females 2:1

Rule of 90s: - 90% Occur in the Maxilla - 90% of those in the Premaxilla - 90% Located Palatal/Lingual

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ClassificationPrimary/Permanent, Location, Orientation and Morphology

Location: Mesiodens Most Common Midline Anterior Maxilla

Paramolar Distomolar Bilateral 13% Multiple: Less than 1% of all cases

Orientation: Inverted reported as high as 48% Transverse Vertical

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Classification• Morphology:

Supplemental, normal shape and size also called incisiform

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Rudimentary, abnormal shape and smaller size, 4 subtypes

• Conical-most common subtype, single or paired mesiodens, inversion is common

• Tuberculate-width equals length with tubercles, stunted roots or lack of root and rarely erupts

• Molariform-very rare, similar to tubercle type but occurs in pairs and has complete root formation/eruption

• Compound Odontoma - may be used for classification of collection of enamel, dentin and cementum

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Diagnosis • Clinical and Radiographic

• Asymmetry or Disruption in Sequence

• Anterior is size 2 occlusal film, large occlusal film if possible

– Localize Parallelism/SLOB rule; 90 degree cross-section or lateral may be used

• PANO: Most commonly used

• CBCT/3D

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Complications• 7-20% cases will have no complications

• Nasal Eruption

• Cystic degeneration/Dentigerist Cyst

• Impaction

• Delayed or Ectopic Eruption: most common

• Spacing or Crowding Issues

• Adjacent Tooth Impaction or Displacement; they have not been shown to cause resorption or devitalization without trauma

• 79-91% are unerupted in early mixed dentition and 42-51% remain unerupted during adolescents

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Management• Removal and Treatment:

– Early (before 6) or Delayed (after 7) intervention needs to take several factors into account from the diagnosis

– Due to the high probability of developing complications, removal should occur after diagnosis Except when: • 1: A midline non-inverted conical tooth with a good prognosis for early

eruption • 2: Lacking any Complications AND any of the following:

– close proximity to permanent root apex, – vessels, – nerves, – sinus, – pterygomaxillary space or – orbit

CBCT if in Doubt

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Management-Delayed • 75% of incisors will erupt fully within 1.5 to 3 years after the

supernumerary is removed; however, most will be short (~1mm) of the occlusal plane due to previously matured gingival fibers

• Surgical exposure unerupted incisor only after no evidence of movement after ~6 months from the extraction of the supernumerary

• 85% of teeth that require surgical exposure will spontaneously erupt after the procedure

• Ortho eruption should be implemented only after failed spontaneous eruption following previous surgical exposure

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Case 1

• Initial radiographs

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• My fist look at this case

• No Pano • Talon? • Dysplastic?

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• Large Occlusal • Molariform

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Case 2

Note Early Displacement Normal Eruption

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Thank YouAAPD, Pediatric Dentistry:, V 36/ No 6, (2014/15): 255, 278-79.

Pinkham, Casamassimo, Fields, McTigue, and Nowak. Pediatric Dentistry: Infancy through adolescence, 4th edition. St. Louis: Elsevier Sanders, 2005.

Nowak and Casamassimo. The Handbook of Pediatric Dentitry. 3rd Ed. AAPD, 2007.

Primosch, RE. Anterior supernumerary teeth - assessment and surgical intervention in children. Pediatric Dentistry (1981) 3(2):204-215.

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THIRD MOLAR WISDOMTO EXTRACT, OR NOT TO EXTRACT?

THAT IS THE QUESTION.

Matthew Karban, DMD, MD Oral & Maxillofacial Surgery

The Dental Specialists

May 19, 2015

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What Patients Think• Causes crowding

• Hard to clean

• Cavities

• Pain

• *Trust their dentist*

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But What if They Have No Symptoms?

• Remove?

• Observe?

• Refer?

• Is risk worth benefit?????

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AAOMS White Papers• 2007, task force to review current literature

• Ovid Medline, Pubmed, Google Scholar, Cochrane

• Addressed 10 major topics

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Topics AddressedNatural hx of wisdom teeth

Periodontal concernsMicroflora/bacteria

Effects of ageOrthodontic considerations

ImagingRole of Coronectomy

Lingual nerve/flapSocket management

Nerve damage

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Natural History• Unerupted teeth can change position beyond

3rd decade of life

• Adequate osseous space does not mean adequate physiological space

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Perio Concerns• Presence of 3rd molars is assoc. with elevated

levels of periodontitis

• Impacted molars are related to root resorption and perio attachment loss

• Ext. beyond age 26 can cause perio defects or lead to progression if defect already present

• GTR in these high risk patients may be beneficial

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Microflora• Pathogenic bacteria exist around a symptomatic

3rds in clinically significant numbers

• Perio disease progresses in absence of symptoms

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Age Risk

• 40% of caries on erupted 3rds before age 40

• Post op morbidity higher in pts > 26yrs of age

• Perio defects deteriorate with age

• Germectomy has lower morbidity

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Ortho Concerns

• Dental crowding complex and multi-factorial

• Does play some role in crowding but may not be clinically significant

• No study isolates effect of 3rd molars

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Imaging

• Panoramic imaging is standard imaging technique for evaluation

• Exact role of CBCT is evolving and unclear

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Coronectomy• Should be considered if

nerve proximity is a concern

• Minimal literature, should be considered as alternative only

• No standard of care with regard to technique

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Lingual Flap

• Lingual flap and retractor is acceptable

• Must stay subperiosteal, be broad and without sharp edges

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Socket Management

• Grafting sites for high risk perio patients shows predictable benefit

• High risk = >26yrs, horizontal/MA impaction, pre-existing perio defect

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Nerve Damage• IAN: temp 1-7%, perm 0-0.9%

• Lingual: temp 0.4-1.5%, perm 0-0.5%

• Nerve repair is effective and should be considered in timely manner

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Risks of Observation• Decay

• Perio

• Cysts/Tumors

• *Increased morbidity with late removal

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Risks of Extraction• Lingual/IAN damage

• Jaw fracture

• Sinus complications

• Alveolar Osteitis

• Perio defects

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A Worst Case Scenario!

• 52 yr M presents with tenderness over #17

• Referred by his DDS

• Obtained Panoramic film

• Exam: palpable swelling, trismus

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• Obtained CT

• Multiloculated cyst, impacted #17

• Obtained biopsy and extracted #17, 18

• Concern of dentigerous cyst, OKC or ameloblastoma

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• Squamous cell carcinoma arising within an odontogenic cyst

• Referred to colleague at Mayo Clinic

• Mandibular resection with microvascular fibular free flap reconstruction

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Preventable????

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Take Home Message• All wisdom teeth should be properly evaluated

from an early age

• Observation vs extraction is multifactorial and dynamic

• Understand and be aware or risks with observation and extraction

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Thanks!

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I AM ALLERGIC TO EPINEPHRINE & LATEX. CAN I STILL GET

A ROOT CANAL TREATMENT?

Matthew J. Royal, DDS

May 19, 2015

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Questions Your Patients Are Asking

“I am allergic to epinephrine and latex. Can I still get a root canal treatment?”

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Yes, you can still have root canal treatment.

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Local Anesthetics

➢ Introduced injectable LA to dentistry ➢ Cocaine with 1:50,000 epinephrine ➢ 1885 administered IAN block for the “surgical

removal of the nerve” ➢ By early 1900s reports of adverse rxn’s ➢ Halsted became addicted to cocaine

Dr. William Halsted (1852-1922)

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Evolution of Local Anesthetics

➢ 1904 Alfred Einhorn (Germany): Procaine (Novocaine)

➢ 1943 Nils Lofgren (Sweden): Lidocaine ➢ 1965 Carbocaine introduced ➢ 1970s Marcaine ➢ 1970s Articaine (Germany), 1983 (Canada) ➢ 2000 (US)

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Epinephrine

1. Prolongs duration/effective anesthesia 2. Hemostasis 3. Prevent toxic reaction to LA

Why do we use it? Vasoconstrictor

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Allergy to Epinephrine?

➢ True allergic rxn is very rare ➢ A few case reports of allergic reaction or

hypersensitivity demonstrated by skin tests

Allergy vs. Adverse Reaction

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Endogenous Epinephrine

➢ Naturally occurring ➢ Circulates in a nonpolymerized state ➢ Produces no epinephrine antibody

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Exogenous Epinephrine

➢ Composed of artificial chemical products ➢ Case reports showing hypersensitivity to

epinephrine hydrochloride and epinephrine bitartrate

➢ Polymerized epi has been demonstrated to cause antibodies in humans and animals

Kohase, H., Umino, M., Anesth Prog 51:134-137 2004

Used in dental LA preparations

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Communication

➢ Allergic vs. adverse reaction

“What happened when epinephrine was used?”

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3% Carbocaine w/o epi

1. Discuss w/ patients that it might be more difficult to get and keep them numb

2. May want to consider an intraosseous injection (for lower molar RCT)

3. Intrapulpal injection might be necessary (especially for RCT on a “hot tooth”)- warn patient prior to IP injection

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Diphenhydramine HCl

1. Two 5ml syringes w/ needle 2. Diphenhydramine supplied in 1ml ampules

(50mg/ml) 3. Diluent (saline)

Dr. Stanley Malamed

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Preparation

1. Load contents of 1ml ampule into syringe 2. Dilute to a total of 5ml of fluid by adding 4ml

of saline 3. “diphenhydramine HCL 10mg/ml”

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Technique

➢ Administer in same manner and volume as any traditional LA

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Duration of Action:

➢ 60 min most likely contains epinephrine ➢ Soft tissues: 2-4 hours

Pulpal anesthesia: 30-60 min

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Side Effects:

➢ Drowsiness: patient needs a driver ➢ Soreness at injection site: warn patient and

inject slowly ➢ Consider using supplemental N2O

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Latex Allergy

➢ Proteins found in natural rubber and/or chemicals used to manufacture commercial latex can cause allergic reactions

➢ www.aae.org (under Clinical Resources/guidelines and position statements)

AAE Position Statement

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3 Types of Reactions

1. Irritant contact dermatitis: • Most common reaction • Mainly caused by added chemicals or powder • Directly injures skin – redness, swelling, dryness,

itching, burning • Not a true allergy • Symptoms disappear w/in hours of removal

Natural Rubber Latex (NRL)

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3 Types of Reactions

2. Allergic contact dermatitis: • Cell mediated, type IV (delayed hypersensitivity) • Chemicals used in manufacturing • Penetrate skin – allergic reaction • Swelling and redness w/in 24 – 48 hours after

exposure (can last for several days) • Account for 80% of true allergic reactions

Natural Rubber Latex (NRL)

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3 Types of Reactions

3. Latex allergy: • Immediate, type I hypersensitivity response to

proteins found in NRL • Response occurs w/in minutes of exposure • Hives (skin exposure) • Respiratory (inhaled): wheezing, runny nose,

sneezing

Natural Rubber Latex (NRL)

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Latex Allergy Continued

➢ Facial swelling, difficulty in breathing, severe drop in blood pressure

➢ Protein introduced directly into blood ➢ Patients w/ multiple allergies and frequently

exposed to NRL products ➢ Maybe sensitive to chestnuts, bananas, kiwi

fruits, avocados

Anaphylactic Reaction

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Latex Allergy Stats

➢ Incidence of hypersensitivity reactions up significantly since late 1980s (why?)

➢ 1-6% of general population is allergic ➢ 5-10% of health care workers ➢ Children and adolescents w/ spina bifida

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Is Gutta-Percha safe?

➢ To date (2012) only 2 case reports of possible type I immediate hypersensitivity reaction during RCT

➢ No definitive proof reactions occurred from gutta-percha, more likely from rubber dam and/or gloves

➢ Several studies showing no cross-reactivity

Cross reactivity between gutta-percha and NRL?

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Precautions

➢ Thorough medical and dental history ➢ Nitrile gloves and dental dam ➢ Remove rubber stoppers from endodontic

instruments (use indelible ink to mark WL) ➢ 1st morning appointment to minimize airborne

latex particles ➢ Special latex-free rooms (hospital setting?)

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Alternative Materials

➢ Resilon (RealSeal – SybronEndo) • Handles like gutta-percha • Cost relatively similar to gutta-percha • Retreatment similar to gutta-percha

Obturation

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Resilon

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Alternative Materials

➢ MTA (Mineral Trioxide Aggregate) • Medical grade Portland cement • Technique sensitive/difficult to handle • Expensive (often end up wasting material) • Difficult, if not impossible to retreat • Staining of teeth and/or gingival tissues

Obturation

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Alternative Materials

➢ EndoSequence Bioceramic root repair material (BC-RRM) by Brassler • Easier to handle than MTA and less waste • Doesn’t stain • Superior results? (recent study saw better healing

vs MTA for root-end filling) • Retreatment?

Obturation

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BC-RRM

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Questions?

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