Surgical and Orthodontic Management of the Ectopic, Labially Impacted, Maxillary Canines: A Case Series.

Maxillary canines are the second most commonly impacted teeth. Two thirds of these impacted canines are palatal, and one third are labially impacted. Maxillary labial impactions comprise approximately 0.33% to 0.75% of the general population. Like palatal impactions, preventive and interceptive methods can be employed to help the impacted tooth erupt and avoid surgical uncovering. Early extraction of appropriate primary teeth and palatal expansion has helped some of these impactions erupt spontaneously. Most labially impacted canines are positioned "in the slot," in a midalveolar location between the lateral incisor and first premolar. If they do not erupt after preventive or interceptive means, they can be managed with simple closed-eruption uncovering techniques. The most difficult labial impactions are ectopically positioned. These are usually horizontally positioned, mesial to the lateral incisor. They can be very apically positioned, near the base of the nose and near the midline. The rarest labial impaction occurs between the central and lateral incisors or between the premolars. These are extremely rare and require special orthodontic and uncovering techniques. All of these ectopic impactions require a technique that leaves the impacted tooth uncovered so the orthodontist can employ the proper mechanics to move these teeth without damage to adjacent structures. This article elucidates the surgical uncovering techniques and the orthodontic mechanics to successfully move these teeth and minimize root resorption, bone loss, and recession.

The Palatally Impacted Canine, Preorthodontic Uncovering Technique, and Spontaneous Eruption: A Case Series.

Maxillary canines are the second most commonly impacted teeth, with mandibular third molars being the most commonly impacted teeth. One-third of the impacted maxillary canines are labially impacted, and the remaining two-thirds are palatally impacted. Palatally impacted canines (PICs) comprise approximately 1% to 2.5% of the general population. These impactions can be managed with preventive, interceptive techniques or surgical uncovering. If preventive or interceptive measures are unsuccessful in allowing the canine to erupt, there are many techniques that can be employed to uncover the PIC. Canines that are very superficially impacted can be uncovered with a simple gingivectomy. Canines that are more deeply impacted will require flap reflection, bone removal, and the placement of some type of orthodontic bracket. Most often, the surgeon will attach a chain to the impacted tooth so the orthodontist can immediately begin movement with some form of traction device. The preorthodontic uncovering technique (POUT) allows spontaneous eruption of the impacted tooth without active orthodontic force. When this technique is employed early (approximately 6 months before orthodontic treatment is initiated), it will save considerable time and trauma in erupting these teeth. Research has shown that this technique decreases orthodontic treatment time to properly position these teeth. In addition, this technique has been shown to be healthier for the bone and root structure of the impacted tooth and surrounding teeth. This article elucidates the benefits of the POUT when uncovering simple and very complicated PICs.

Soft Tissue Reconstruction of a Class III Ridge Deformity: Case Report with a 9-Year Follow-up.

A healthy, 45-year-old woman requested that her general dentist whiten her two front teeth. Internal bleaching was performed on the teeth at sites 11 and 12 (FDI tooth-numbering system). An internal barrier was not placed, and tooth 11 developed external root resorption. The patient was referred to an oral surgeon to extract the tooth and place an implant. Tooth 12 was salvageable, but the surgeon recommended extraction of both teeth. Implants were immediately placed in the sockets. The implant at site 12 failed and was removed, resulting in a severe ridge defect. Multiple hard and soft tissue surgeries were unsuccessful and the defect worsened, resulting in a Class III ridge defect. The patient was referred to a prosthodontist for consultation, and he recommended referral to a periodontist to reconstruct the badly damaged ridge prior to prosthetic restoration. The periodontist successfully reconstructed the damaged ridge, and a restoration was placed on the implant at site 11 with a cantilevered pontic for site 12. This case elucidates the difficulty in reconstructing a damaged ridge and returning it to its preextraction contour when two adjacent teeth are extracted.

Social Norms and Engagement in Protective Health Behaviors Among Rural Health Providers.

The COVID-19 pandemic has had far-reaching effects for individuals and healthcare systems in the United States. Increasing and sustaining behavioral changes to reduce transmission of disease among medical providers is essential for the protection of the community at large. Using a social norms perspective, this study aimed to (a) examine the accuracy of perceptions of engagement in protective health behaviors among a sample of rural health providers, and (b) determine whether greater self-other discrepancies were associated with engagement in these behaviors. Electronic surveys were completed by 214 rural medical providers. Findings suggested that rural healthcare providers had exaggerated perceptions of peer engagement in several COVID-19-related protective health behaviors. As expected, positive self-other differences were positively associated with providers' own behaviors, and perceived descriptive norms were associated with providers' engagement in these behaviors. Future studies using normative interventions might examine how positive self-other differences increase the use of protective health behaviors over time.

A Novel Solution to Treat Unesthetic Implant Restorations in the Esthetic Zone: A Case Report.

INTRODUCTION: Soft tissue dehiscences and deficiencies can occur around implants especially when they are malpositioned. There is a dearth of information on burying these fixtures and bridging over them to improve the prosthetic result. The patient presented with a very functional fixed dental prosthesis (FDP) from #7 to #10 which had been in place for 20 years. The patient requested replacement of the restoration for a better esthetic outcome. CASE PRESENTATION: The FDP was intact and did not need replacement other than for esthetic improvement. Implants were placed in the #8,9 sites and complications developed. After multiple hard and soft tissue surgeries, the case worsened. It was referred to a periodontist who reconstructed the site to ideal tissue levels. The patient had a very high smile line showing all of the soft tissue framework around the missing teeth. The prosthodontist and periodontist decided to leave the implants buried and bridged over them which resulted in an excellent esthetic outcome. CONCLUSION: This case points out the importance of considering all possible treatment plans and involving the patient in the final decision. The seemingly apparent obvious plan would have been to restore the implants and try to achieve an esthetic result. However, after the implants were placed and developed complications, the decision to bury them improved the probability of a better esthetic outcome. The gingival levels and height of papillae were esthetically more acceptable with an FDP than what would have resulted if the fixtures were re-uncovered and restored.

Technology-Assisted Supplemental Work Among Rural Medical Providers: Impact on Burnout, Stress, and Job Satisfaction.

EXECUTIVE SUMMARY: Burnout among healthcare providers has been identified as a national public health concern. The purpose of this study was to (a) examine technology usage outside the workplace among rural medical providers, (b) examine whether technology usage is associated with perceived stress and burnout, and (c) examine the impact of technology usage and perceived usefulness of technology on job satisfaction. Results indicated that supplemental technology usage was associated with perceived stress and burnout. Years in practice, supplemental technology usage, and perceived usefulness of technology were all correlated with whether providers would recommend their organization to those considering working there. Findings expand upon past research on physician burnout and indicate that perception of the usefulness of technology is correlated with job satisfaction and whether one would recommend that others work at one's organization. Finding ways to increase positive perceptions of technology usage in a technology-driven medical system may increase the likelihood of retaining or recruiting staff.

Interdisciplinary management of a maxillary central incisor with a palato-radicular groove: A case report with 27 years follow-up.

OBJECTIVE: The palato-radicular groove (PRG) is caused by a developmental anomaly, genetically determined, whereby an in-folding of the enamel organ and Hertwig's epithelial root sheath occurs. The depth and length of the groove determine the prognosis for the tooth. The interdisciplinary team formulated a treatment plan to save this tooth for this 8-year-old patient. The goal was to prolong the life of the tooth until his growth was completed and a more permanent tooth replacement could be considered if the tooth failed. CLINICAL CONSIDERATIONS: This patient had #8 with a very deep palatal groove extending from the CEJ to the apex of the tooth, causing a 12 mm periodontal pocket with suppuration. Endodontic treatment, periodontal regeneration, and orthodontics were done to prolong the life of the tooth and preserve the bone for future tooth replacement if the tooth failed and needed to be extracted. The tooth survived for 11 years before the pocketing recurred due to the deep groove. The tooth was extracted and replaced with an implant. CONCLUSION: Teeth with a PRG present multiple challenges depending on the depth and length of the groove. An accurate diagnosis of the endodontic and periodontal status of the tooth is critical. Teeth with very long and deep grooves make the case more difficult to treat endodontically and periodontally. The tooth had a very poor prognosis; however, it was saved for an extended period of time with a well thought out interdisciplinary treatment plan. The advantages of maintaining this tooth, in lieu of extraction at age 8, will be elucidated. CLINICAL SIGNIFICANCE: Retaining guarded teeth in the maxillary esthetic zone for an 8-year-old patient, has many advantages. It can simplify and enhance future treatment results. The patient retained this central incisor through the formative years. It simplified the orthodontic treatment and implant treatment. The importance of keeping "roots in the bone" to preserve the alveolar bone has many advantages for future treatment options.

Interdisciplinary treatment of a patient with amelogenesis imperfecta: Case report with a 35-year follow-up.

OBJECTIVE: This case will illustrate the interdisciplinary management of an adolescent female patient with amelogenesis imperfecta (AI). It will contrast this approach and compare it to the previous "multidisciplinary" treatment rendered before the patient was referred for a second opinion. CLINICAL CONSIDERATIONS: The patient had a family history of AI affecting all of her permanent teeth. There were many impacted teeth. The majority of her family and relatives afflicted by this opted for dentures. The patient had undergone 2 years of treatment and was told that her "braces would be removed next week." Her new dentist was concerned because the case was not ready to restore. CONCLUSION: He recommended referral to another orthodontist for a second opinion and formulation of an interdisciplinary treatment plan that would include a periodontist, endodontist, and restorative dentist. The patient's family accepted the second opinion referral and restarted treatment with an interdisciplinary team. The restorative dentist was the quarterback for this integrated and sequenced approach. The case was ultimately restored. A 35 year follow-up shows stability with a caries free, periodontally healthy, esthetic result.

Interdisciplinary Management of a Complex Esthetic Dilemma.

Esthetic dilemmas often require an interdisciplinary approach to achieve an optimal result. This article describes such a case in which the patient presented with unesthetic porcelain crowns on structurally compromised maxillary anterior teeth. The maxillary incisors had failing root canals, advanced mobility, and deep periodontal pockets. In addition, there was a congenitally missing maxillary lateral incisor. The canine substitution created a severely canted appearance exacerbated by the patient's high smile line. A coordinated interdisciplinary treatment plan was put into action to satisfy the patient's chief complaints and achieve a successful outcome. In this instance, this approach involved a periodontist, orthodontist, and prosthodontist, as well as initial input from an endodontist.

The long-term stability of soft tissue augmentation in treatment of localized severe maxillary anterior ridge deformities.

The long-term stability of soft tissue augmentation in treatment of localized severe maxillary anterior ridge deformities. OBJECTIVE: Severely deformed edentulous ridges in the esthetic zone (EZ) are very difficult to restore with an esthetic fixed dental prosthesis (FDP). Soft tissue augmentation of these deformed ridges can dramatically improve the esthetics of the restoration. The long-term stability of soft tissue grafting used alone to treat severe localized alveolar ridge deformities will be reported. CLINICAL CONSIDERATIONS: Three different soft tissue augmentation techniques, connective tissue graft (CTG), keratinized gingival graft (KGG), and pediculated connective tissue graft (PCTG) used to treat severe ridge deformities in the maxillary anterior region in five patients will be described. The stability of the augmentation will be shown at follow-up periods ranging from 5-30 years. CONCLUSIONS: All three soft tissue grafting techniques demonstrated long-term stability following the six-month post-treatment result. CLINICAL SIGNIFICANCE: Edentulous ridges in the esthetic zone, with severe hard and soft tissue deformities, are very difficult to restore esthetically. The development of soft tissue augmentation techniques has allowed clinicians to enhance the esthetics of their fixed dental prostheses (FDP). Restorative clinicians need to be assured that soft tissue shrinkage under the pontics will not occur after the final prosthesis is seated. The stability of these soft tissue augmentations over an extended period of time, will be demonstrated in the presented cases.

Long-term management of avulsed "hopeless" teeth in the adult dentition.

OBJECTIVE: This case will demonstrate a thoughtful approach to the management of avulsed/replanted teeth in the adult dentition and their long-term maintenance. Often times these teeth are either not replanted, or extracted soon after replantation when resorptive lesions appear and the teeth are deemed "hopeless". The term "hopeless tooth" (HT) has become more popular since the advent of implants. Implants allowed for a simple solution to the HT by extraction and immediate replacement with a fixture and a restoration. However, now that we are realizing that implants do not last forever and also have attendant problems, saving the HT takes on a new light. CLINICAL CONSIDERATIONS: Prolonging the life of the HT can preserve bone and give the patient a functional, esthetic tooth for many years. With each additional year, clinicians garner new skills, and technology improves our future treatment outcomes. This will allow clinicians to improve and extend the life of future replacements. CONCLUSIONS: If there is minimal risk to adjacent structures, retaining the HT has many advantages for the patient and clinician. Clinicians should adopt a policy of thinking ahead and asking "What's Next"? when their prospective treatment fails or needs to be replaced. By prolonging the life of the HT, the "best ultimate treatment" has a greater chance to outlive the patient. CLINICAL SIGNIFICANCE: With the advent of single tooth implants, the term "hopeless tooth" has become more popular. It is easier to justify extraction of a tooth when it is deemed "hopeless". Many of these teeth could be saved. The advantages of this philosophy will be elucidated.

Treatment of the amalgam tattoo in the esthetic zone.

OBJECTIVE: When pigmentations appeared in the esthetic zone and were visible during the patient's smile, they were very disconcerting. There are multiple techniques to eradicate or ameliorate these discolorations. This article will address those pigmentations caused by amalgam particles. CLINICAL CONSIDERATIONS: Keratinized gingival grafts were used to cover and mask these pigmentations. In addition, connective tissue grafts were used to aid in the elimination of the external pigmentation. CONCLUSIONS: Both techniques were shown to be very effective in masking or eliminating these unesthetic pigmentations. Long-term follow-up has shown these results to be stable with no recurrence of the pigmentation. CLINICAL SIGNIFICANCE: Unesthetic pigmentations in the esthetic zone that are visible during a patient's smile are very disconcerting. Elimination of these unesthetic discolorations can make a dramatic improvement in the patient's smile.

Ridge Preservation Strategies in Children Following Anterior Tooth Trauma.

The sequelae associated with anterior oral trauma during childhood growth may require a protracted period of clinical management to achieve an optimal foundation for future prosthetic therapy. This article presents two case examples of long-term ridge development and preservation in children after anterior dental and alveolar trauma. These two patients were managed for periods of 11 years, one from age 8 to 19 and the other from age 9 to 20, until they were old enough to receive implantsupported restorations. Two different treatment plans were prescribed based on whether or not the teeth in question were ankylosed. In one case, fractured roots that were not ankylosed were retained; in the other, decoronation of an ankylosed tooth was performed.

Interdisciplinary management of anterior dental esthetics.

BACKGROUND: Dental esthetics has become a popular topic among all disciplines in dentistry. When a makeover is planned for the esthetic appearance of a patient's teeth, the clinician must have a logical diagnostic approach that results in the appropriate treatment plan. With some patients, the restorative dentist cannot accomplish the correction alone but may require the assistance of other dental disciplines. APPROACH: This article describes an interdisciplinary approach to the diagnosis and management of anterior dental esthetics. The authors practice different disciplines in dentistry: restorative care, orthodontics and periodontics. However, for more than 20 years, this team has participated in an interdisciplinary dental study group that focuses on a wide variety of dental problems. One such area has been the analysis of anterior dental esthetic problems requiring interdisciplinary correction. This article will describe a unique approach to interdisciplinary dental diagnosis, beginning with esthetics but encompassing structure, function and biology to achieve an optimal result. CLINICAL IMPLICATIONS: If a clinician uses an esthetically based approach to the diagnosis of anterior dental problems, then the outcome of the esthetic treatment plan will be enhanced without sacrificing the structural, functional and biological aspects of the patient's dentition.

The pediculated connective tissue graft: a technique for improving unaesthetic implant restorations.

Clinicians are often faced with the treatment of complex aesthetic dilemmas around implants, which can be caused by improper fixture placement and inadequate soft tissue management. Even the most aesthetic porcelain crown restoration will have an undesirable appearance if the soft tissue architecture is deficient. Although some implant fixtures may need to be trephined and the site grafted and retreated, this is a long process and may have an unpredictable outcome. One alternative is to attempt soft tissue augmentation around the unaesthetic restoration. Cases will be used to demonstrate the use of the pediculated connective tissue graft to augment deficiencies in soft tissue around previously restored implants in the maxillary aesthetic zone.