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| Figure 1. Before and after photos. |
Many patients and doctors can find it challenging when multiple disciplines of dentistry are needed in the course of treating a patient. We know that a comprehensive general dentist and/or a comprehensive team can best handle more complex treatment plans. Patients simply want to have a positive outcome, and most people believe that we were put on this earth to help one another. If we can assure them of that, and if we work together to have a treatment plan and timeline for care that is within our patients’ financial abilities, they will accept the proposed treatment(s).
CASE REPORT
A 44-year-old patient presented to our office via a referral from an existing patient (Figure 1). She was not happy with her smile and facial appearance. She thought her lower jaw was moving progressively forward, and her front teeth were wearing and fracturing. The patient commented that she has a large nose and, as her jaw moved forward, it was making her upper lip look smaller. She also thought that this was making her nose look even bigger. Her comments served to really emphasize her concerns related to the aesthetics of her teeth and face.
Previously, she had gone to an orthodontist who, in turn, referred her to an oral surgeon. After consultation with one another, the specialists believed that she would need upper and lower jaw surgery as well as orthodontic treatment. In the course of their proposed treatment, her upper jaw would be moved forward and her lower jaw back. Successfully accomplishing both of these procedures would take a significant amount of time and money (Figure 2). She had a consultation with the orthodontist and oral surgeon, though she did not accept their treatment plans or the costs involved.
In a comprehensive examination of the patient in our office, it was first noted that she had joint and muscle issues. Her centric relation (CR) position was more end-to-end, but her centric occlusion (CO) position was an even more acquired Class III relationship. The more her anterior teeth were progressively wearing and breaking, the more she had to position her bite forward to achieve maximal intercuspation. There were 2 previously placed posterior composite resin restorations. During the examination process, it was observed that her muscles were sore to palpation, but the joints were not sore upon loading. The first step in her treatment would be to ensure that her muscles could be made comfortable. So, a hard (on the bite side) and soft (on the tooth side for comfort) bite guard (Kombiplast [Dentsply Sirona Orthodontics]) was fabricated and delivered, which brought her immediate relief.
It should be noted that the patient had stated that even if she had possessed the financial ability, she did not want any surgical procedures to be done. In thinking through the needs of this patient, knowing her chief complaint and desire for treatment without surgery, and given my 38 years of experience and training, there were some interesting possibilities for a viable treatment plan. We rechecked CR and recorded that bite position and slide to CO, which was about a 3.0- to 4.0-mm anterior slide. What if her bite (OVD) could be opened up and she was restored to the first point of contact between her anterior teeth? That could likely be done as an additive procedure. Now, what if her case was mounted on an articulator and then diagnostically waxed up with the goal of improving anterior function along with a fuller and more open smile, giving us a blueprint for an additive treatment solution (Figure 3)?
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| Figure 2. The orthodontic photo series for this case. |
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| Figure 3. Diagnostic waxup and photos of the bis-acryl provisionals (Luxatemp Automix Plus Bleach Light [DMG America]) that were placed for aesthetic and functional evaluation by the clinician and the patient. |
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| Figure 4. The completed case. The patient was extremely happy with a minimally invasive restorative approach that did not involve surgery. |
Well, this is exactly what was done! The patient was asked if she would she like to see what this restorative outcome would look like in her mouth. We told her that this would be possible, and she was excited to be able to have that opportunity in this stage of the treatment planning process.
We took a vinyl polysiloxane (VPS) putty index (Splash! Putty [DenMat]) of the diagnostic waxup. A strong and aesthetic bis-acryl resin provisional material (Luxatemp Automix Plus Bleach Light [DMG America]) was injected into the stint, then seated. After setting, the stint was removed and the excess material cleaned away, and then the patient was given a hand mirror to see and evaluate the result of this temporary additive mock-up. It made an immediate difference in her appearance that she would have to adjust to, but she did like it. It locked on well enough that we decided to let her wear it home for further evaluation.
She wore it for 2 weeks, during which we saw her 3 times for adjustments of size, shape, and function. Her jaw felt better, and she continued to report that the aesthetics were pleasing to her. Now, having been an actual part of the process of fully evaluating the aesthetics and function of the additive restorative treatment proposed, she said, “Let’s do this!”
Clinical Protocol
The first step was to remove the occlusal bis-acryl temporaries from teeth Nos. 2 to 5 and Nos. 12 to 15. Due to her budget concerns, we placed occlusal buccal direct composite resin onlays in lieu of porcelain onlays. This was carried out by doing one side at a time to maintain the 1.5-mm bite opening (OVD). We took off the left-side provisionals first and built up and created a balanced occlusion. Next, we removed the right-side provisionals and, once again, built up and developed a balanced occlusion. We then leveled and aligned the lower anterior teeth by doing selective odontoplasty.
The patient was then ready for preparation and fabrication of 6 porcelain veneers (teeth Nos. 6 to 11). An incisal matrix was fabricated (Jet Blue [COLTENE]) to use as a guide for length and fullness. Now the anterior temporaries would be removed. Everything that was done to this point was added to the upper teeth. The maxillary anterior teeth being treated with porcelain veneers would be minimally prepared, doing only what was absolutely necessary to remove or block out any undercuts. After this was accomplished, a final VPS impression (Honigum [DMG America]) was taken. Next, a new anterior provisional restoration was fabricated at the chair using the incisal edge matrix and VPS putty index with bis-acryl provisional material (Luxatemp Automix Plus Bleach Light). The provisional restoration was removed, trimmed, and then temporarily cemented with Prime One dentin enamel primer (Mirage) and Temp-Bond Clear (Kerr Dental).
The dental laboratory team fabricated feldspathic porcelain veneers with custom shading (half lMlPlus and half OM3) to allow for natural vitality in the final restorations. After the completed veneers were received back from the laboratory, the patient returned to have them delivered. The teeth (Nos. 6 to 11) were cleaned and total-etched using a 38% phosphoric acid gel (Etch-Rite [Pulpdent]). The teeth were then rinsed and air-dried, and an adhesive (CLEARFIL LINER BOND 2V Primer A&B [Kuraray America]) was applied and light cured per manufacturer’s instructions. The intaglio surfaces of the veneers were conditioned (Silane Porcelain Bond Enhancer [Pulpdent]), and the restorations were bonded into place using a light-cured resin cement (daVinci Resin Cement; Bright [Cosmedent]).
For our patients, oral hygiene and tissue management are maintained by following a recommended professional patient recall appointment protocol, along with an at-home hygiene regimen that includes a line of botanical debriding rinses and serums (TRI-OLOGY Professional Oral Cleansing & Care [NOWsystem; triologycare.com]). These products (with 3 US patents) contain a proprietary blend of botanical ingredients and carbamide peroxide. The formulations, according to the manufacturer, have been found to integrate and to work with saliva supra- and subgingivally for the removal of debris, fungi, bacteria, and other irritants.
CLOSING COMMENTS
Everyone involved in this case was pleased with the outcome of the minimally invasive treatment plan. The patient absolutely loved her new smile and facial makeover (Figure 4). One of my mentors, Dr. Irwin Smigel, always said, “As dentists, we own the face!”
During so much of the time in life, our outlook tends to follow the old saying, “If all we have is a hammer, everything looks like a nail!” The more tools we are aware of and learn how to use, the more ways we can help patients get what they want. As GPs, we need to have a better awareness of all the tools and material options that are currently available in dentistry for the benefit of our patients and our practices.
Acknowledgment:
The author wishes to express his sincere thanks for the excellent laboratory work provided for this case by the wonderful team at Myron’s Dental Laboratory (Kansas City, Kan).
Special note from the author:
My references do not come from articles, but from hands-on courses with doctors; a camaraderie of participants; and more than 38 years of practice, teaching, and helping patients get what they want. The following individuals and organizations have made a dramatic and positive impact in my life, in the professional journeys of many others, and on the health and well-being of countless patients:
1. Total Dentistry: Dr. Pete Dawson, the Pankey Institute, Dr. John Kois, and Dr. Frank Spear
2. Functional Orthodontics: Drs. John Witzig and Meryl Bean
3. Orthodontics: Drs. James Osborne, Vince Kokich, and Bob Garrity
4. Periodontics: Drs. Dennis Tarnow, John Moralis, Nancy Newhouse, Dave Mathews, and Bill Robbins
5. Endodontics: Dr. L. Stephen Buchanan
6. Aesthetics: The late Drs. Irwin Smigel and Bob Nixon, Dr. Buddy Mopper, Dr. Jack Turbyfil, and the American Academy of Cosmetic Dentistry (AACD) and the American Society for Dental Aesthetics (ASDA).
Dr. Elias is a 1979 graduate, with honors, of the University of Missouri-Kansas City. He practices in Independence, Mo. Dr. Elias is a Fellow of the American Society for Dental Aesthetics (ASDA), an accredited member of the American Academy of Cosmetic Dentistry (AACD), and a past mentor with Dr. John Kois and CRE (Creative Restorative Excellence). He is a life member of the ADA, Omicron Kappa Upsilon, Phi Kappa Phi, and the Missouri Dental Association. Dr. Elias can be reached via the email address jameselias448@msn.com.
Disclosure: Dr. Elias reports no disclosures.
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