HOPELESS LOWER INCISORS
A VIABLE ATERNATIVE
September 16, 2022
Lower anterior teeth face a particular problem due to the anatomy of the anterior mandible. Often a mismatch between the width of the incisor and the dimension of the mandibular alveolar bone results in very thin or absent bone, particularly on the facial aspect of lower incisors. The thinness of the alveolar support can lead to severe loss of soft tissue and bone. The end result is the challenge of how to treat, retain or replace lower anterior teeth.
I want to share two challenging cases that represent this particular issue.
Patient #1 had a history, well before I met her, of severe recession throughout herdentition.
This recession is genetic due to the wide roots at the CEJ are existing within the narrow confines of the maxillary and mandibular bone.
The patient when I met her was 40 years old and was surprisingly comfortable with the aesthetics that had incurred over her lifetime. Because of the severe facial inclination of the roots, root coverage procedures by advancing soft tissue would have a poor prognosis since the alveolar bone was so far apical and unable to supply support and blood supply for any grafting procedures.
The x-ray of the lower incisors when she presented shows teeth bonded together but as a group showed some mobility even despite their splinting. Moving these lower incisors in the thin alveolus would preclude the possibility of placing implants to replace some since the alveolar bone was so thin. The alternative was to make a fixed anterior bridge, from cuspid to cuspid, which the patient wished to avoid at this point.
With some trepidation it was elected by the orthodontist to gently move these teeth together with Invisalign orthodontics as mobile as they were, and then splint them together with an extra coronal splint and wire that would provide more stability since the teeth would be more proximal. With some trepidation this was done. Now, 12 years later, as current x-rays reveal, she appears to have some mineralization of the bony crests. The teeth do not probe and fortunately the patient's oral hygiene is exceptional and these teeth have surprisingly been maintained in a steady healthy state.
Patient #2 presented with active periodontitis. As you can see with the gutta percha point, one of the teeth had a pocket that goes to the apex. The patient was desirous of retaining her teeth. Surprisingly the lower incisor with severe bone loss was still vital.
In this case the decision was made to treat this periodontally to both correct the issue of the lack of keratinized tissue on the facial leading to recession and further attachment loss, as well as the bony defect.
A connective tissue graft was done on the facial and a bone graft was done interproximally.
13 years later we can see that she has regained a significant amount of crestal bone, most specifically around the incisor that had bone loss to the apex. Again she maintains with an adequate zone of keratinized tissue on the facial as well as enough bone to support these teeth indefinitely.
Both cases required patients that were extremely committed to their maintenance and oral hygiene. In other cases this would not have been the outcome.
As always I appreciate your feedback.
Victor M. Sternberg, D.M.D.
By Westchester Center for Periodontal & Implant Excellence
January 30, 2023