Full-Mouth Reconstruction: The Importance of Treatment Planning in Restoring Aesthetics and Function

BACKGROUND
Many times, we are faced with patients who have neglected their teeth and gums. They are often not sure what their options are when it comes to restoring their mouths. As clinicians, we are sometimes guilty of not telling the patients what they really need for fear of rejection. It might also be true that most general dentists will shy away from the more complex cases for fear of failure. Patients rarely understand the complexity of these cases and will also tend to shy away from having the work done. The cost of the treatment, the time involved, and the potential discomfort associated with the process can all act as barriers to treatment plan acceptance.

This article presents a full-mouth reconstruction case which showcases the use of 2 modern restorative all-ceramic materials (leucite-reinforced porcelain and lithium disilicate) to provide a highly aesthetic, functional, and durable result.

CASE REPORT
Diagnosis and Treatment Planning
A 45-year-old male patient presented to the office, with excessive wear and a reduced vertical dimension of occlusion (VDO), requesting a “new smile.” The patient stated that he was a heavy “grinder.” The health history revealed prolonged (20 years-plus) obesity and gastric reflux. Multiple attempts to get control of the patient’s weight problems by other health professionals had been less than successful. The patient admitted to weighing close to 400 pounds at more than one time in his life. Through positive reinforcement from his family, proper diet, and the help of a personal trainer, the patient had been able to reduce his weight by more than 100 pounds.

During the initial visit, comprehensive clinical and radiographic examinations were performed (Figures 1a to 1e). The patient presented with extreme wear and multiple faulty restorations. Caries was visible clinically and in the radiographs. During the initial visit, visual, periodontal, and occlusal assessments were also performed. Mounted study models and photographs were used to document the patient’s current condition. Cemento-enamel junction (CEJ) to CEJ measurements (teeth Nos. 9 to 24) were confirmed at 14.5 mm. It was determined that open bite registration records would be performed, allowing a new VDO to be chosen. This would allow proper guidance and function to be re-established.

It was also determined that digital imaging and a “trial smile” would be used to help the patient visualize the outcome in advance of any nonreversible treatment. Using both digital imaging and the trial smile would allow the patient to see the potential outcome prior to treatment. Allowing patients to test drive the trial smile gives them the ability to become an active participant in the procedure. The trial smile will allow patients to visualize and feel the aesthetic and functional changes prior to proceeding with the case. Often times, this is all that is needed to motivate the patient to accept the treatment plan.

Figure 2. Composite mock-up of both central incisors.	Figure 3. Lab-fabricated diagnostic wax-up.

Proper treatment planning in advance of any nonreversible treatment is paramount when dealing with cases as complex as this. During the aesthetic treatment planning phase, it is important to visualize the maxillary central incisors relative to the upper lip.¹ In an effort to create a more youthful appearance, it was determined that the centrals and cuspids were to be made approximately the same length. The laterals would be slightly shorter.² This would be accomplished by doing a direct composite resin (Venus Diamond [Heraeus Kulzer]) mock-up of the 6 anterior teeth. Typically this information can be gathered by mocking up the 2 central incisors only (Figure 2); however, most clinicians would be better served letting the dental laboratory team fabricate a diagnostic wax-up to use as a guide to help determine the proper length and position of the centrals. The diagnostic wax-up would also be used to help the patient visualize the projected outcome of his full-mouth reconstruction.³ A silicone putty (Flexitime [Heraeus Kulzer]) matrix, fabricated using the wax-up to create a trial smile, would be used to help accomplish this.

FIRST PHASE OF CLINICAL AND LABORATORY PROCEDURES
Once the patient accepted the treatment plan, a release appliance was fabricated and delivered in preparation for open bite apex of force registrations to be taken. Wearing the appliance for 24 hours prior to the records appointment helped deprogram the muscles that control the mandible during closure. Apex of force bite registrations were taken using a fast-setting vinyl polysiloxane (VPS) bite registration material (Futar D [Kettenbach]) and sent to the laboratory team for mounting on a fully-adjustable articulator (Stratos [Ivoclar Vivadent]). Using the impressions taken at the initial visit, a full-mouth diagnostic wax-up was created by our dental laboratory team, opening the VDO by approximately 2.5 mm⁴ (Figure 3).

At the patient’s next visit, the lab-fabricated diagnostic wax-up was used to determine those areas that would require gingival recontouring, and to assist in creating the proper shape and tooth form of the new smile design. It was also used to help in developing a more stable occlusion and proper, aesthetic gingival contours. A matrix made from the wax-up would be used to fabricate provisional restorations. Using this same matrix to place the temps over the existing tooth structure prior to preparation of the teeth, the patient was able to view his trial smile. Using the mock-up of the new smile, we were able to confirm that the length and position of the teeth were correct (Figures 4a and 4b). Phonetics were checked using the E and S sounds. Visible confirmation that the incisal edges were in the proper position and contacting the inner vermillion border of the lower lip, when pronouncing the letters F and V, was obtained. The correct position would allow the air to flow naturally between the upper and lower incisors when creating an S sound. During this appointment, gingival recontouring was accomplished using a diode laser (NV Microlaser [Zila Pharma]) at the 1.0 setting. Sounding to bone was performed and removal of one to 2 mm of tissue (where possible) was accomplished to create more aesthetic gingival contours. Care was taken so that there was no violation of the biologic width during the contouring process.

Preparation of teeth Nos. 4 to 13 and Nos. 20 to 29 was achieved using calibrated diamond burs (Brasseler USA) (Figures 5a to 5c), and featured butt joint margins and rounded internal line angles. Reduction stents, created at the laboratory, were used to guide tooth reduction. The diagnostic wax-up, preparation model, and preparation guides were used to help verify aesthetic design, phonetics in the temporaries, and the adequate tooth reduction required to achieve the prescribed restorative needs. Supragingival margins were created where possible, and final VPS impressions using initial contact heavy tray and initial contact light (Panasil [Kettenbach]) were taken (Figures 6a and 6b). During the process, control bites were checked and rechecked to confirm that the new vertical dimension was being maintained correctly. After completing the preparations, a desensitizer (Systemp [Ivoclar Vivadent]) was applied. Bisacryl provisional restorations (Perfectemp [DenMat]) were then made using the lab-fabricated matrix that had been previously created from the diagnostic wax-up. With the temporaries in place, the occlusion was refined, and the anterior and cuspid guidance in lateral and protrusive excursive movements was recorded. The patient was released and given 4 weeks to evaluate both the comfort and function of the new occlusion/VDO (as reflected in the provisional), and his new aesthetics.⁵

Working closely with the dental laboratory team, it was determined that this portion of the case would be completed using leucite-reinforced porcelain crowns (IPS Empress Esthetic [Ivoclar Vivadent]) (Figure 7). Leucite-reinforced all-ceramic has been a gold standard for anterior aesthetic restorations for more than 20 years. Because of this dental material’s inherent ability to closely mimic the optical characteristics of tooth structure, it can provide patients with an extremely aesthetic and natural looking outcome. The laboratory procedures for fabricating the restorations for this case included: creating full-contour wax-ups of the teeth, investing and burning out the wax-ups in the oven, pressing the restorations with appropriately shaded (030) IPS Empress Esthetic ingots, and using a cut-back and layering technique for optimal aesthetics.

Approximately 4 weeks later, the patient returned for delivery of the maxillary and mandibular all-ceramic crowns. After the patient was anesthetized, the maxillary provisionals were carefully removed; slot preparations and a crown splitter were used to help facilitate the removal process. The preparations were then cleaned (Consepsis Scrub [Ultradent Products]). Next, the restorations were tried-in to verify fit, integrity of the margins, and aesthetics; a try-in paste (Choice 2 Try-in Gel [BISCO Dental Products]) was used to help aid in the retention of the restorations during the patient approval process (Figure 8). Verification of the new VDO, with the maxillary restorations opposing the lower provisional, was verified as well.

Figure 7. The all-ceramic leucite-reinforced restorations (IPS Empress Esthetic [Ivoclar Vivadent]) on the die-trimmed models. Note: Monolithic lithium disilicate (e.max [Ivoclar Vivadent]) all-ceramic crowns (not done at this point in the clinical-laboratory process) were used for the molars in phase 2 of this case.	Figure 8. Prior to final placement, try-in paste (Choice 2 Try-in Gel [BISCO Dental Products]) was used to allow patient to see the restorations in place.

Figure 9. A 35% phosphoric acid gel (Ultra Etch [Ultradent Products]) was simultaneously applied by the doctor and assistant.

Prior to isolating the maxillary teeth, the restorations were cleaned and prepared for bonding. Silane (Ultradent Products) was applied and allowed to dry for several minutes, allowing the alcohol component to evaporate out completely. Bonding adhesive (ExciTE F [Ivoclar Vivadent]) was applied to the internal surfaces of the restorations, and then they were placed in a light-shielded environment until it would be time to deliver them.

Next, a rubber dam (Super Dam [Patterson Dental]) was placed to isolate the maxillary teeth. Great care was taken to eliminate any moisture contamination during this process. The teeth were etched with a 35% phosphoric acid gel (Ultra Etch [Ultradent Products]) (Figure 9), then thoroughly rinsed with water and dried, being cautious not to desiccate the teeth. Next, a single coat of Systemp desensitizer was applied and lightly air-dried. Following this step, 2 coats of ExciTE F adhesive were applied (Figures 10a and 10b), and a dry brush was used to eliminate any pooling of excess bonding material at the margins prior to light-curing. Light-curing (FLASHlite Magna LED Dental Curing Light [DenMat]) was then accomplished.

Figure 11. Tacking tip on the curing light (FLASHlite Magna LED Dental Curing Light [DenMat]) was used to begin the curing process of the resin luting cement (Choice 2 Veneer Cement [BISCO Dental Products]).	Figure 12. Light-curing was then completed with 2 curing lights by the doctor and assistant simultaneously.
Figure 13. Lower 6 anterior restorations being tried-in after upper restorations were placed and the final light-curing was completed. Reconfirmation that the new VDO has been maintained.	Figure 14. Restorations in place, immediately following the final cure.

With our assistant’s help, the restorations were then loaded with a light-cured composite resin cement (Choice 2 Veneer Cement [BISCO Dental Products]) and placed in the mouth. The central incisors were placed first, with care being taken to verify proper seating and alignment. Next, the laterals and cuspids were placed, followed by the remaining bicuspids. Excess material was then removed, and the tacking tip on the Magna Light (DenMat) (Figure 11) was used for a preliminary cure. An barrier solution to prevent an oxygen inhibited layer (DeOx Oxygen Barrier Solution [Ultradent Products]) was applied to the margins, and light-curing was completed. Contacts were separated, and then excess bonding material was removed using sharpened hand scalers. The restorations were then fully light-cured (Figure 12).

The process for placement of the lowers was the same as the maxillary arch. Confirmation of the new VDO was confirmed prior to bonding the lower arch in place (Figure 13). After complete curing of all 20 restorations, minor occlusal and adjustments at the margins were made (Esthetic Finishing Kit [Brasseler USA]. A diamond polishing paste (Diashine [VH Technologies]) with a rubber cup was then used to impart a high gloss finish to any areas that had been adjusted (Figure 14).

Figure 16. The completed case.

Second and Final Phase of Clinical and Laboratory Procedures
Once this first phase was completed, the patient returned 2 weeks later to have the posterior 8 molars restored. (Figures 15a to 15c). Due to the higher forces that would be exerted on the posterior teeth during function, the decision was made to use monolithic lithium disilicate (IPS e.max [Ivoclar Vivadent]) instead of layered leucite-reinforced porcelain. When lithium disilicate is fabricated to full contour (using a stain and glaze technique), the monolithic structure provides the higher strength needed for a case like this one. In addition, lithium disilicate also demonstrates opalescence, translucency, and light diffusion properties similar to natural tooth structure, thus allowing the dental laboratory team to create restorations that are not only strong, but very aesthetic (Figure 16).

CLOSING COMMENTS
Treating complex cases without an underlying idea of the outcome prior to treatment can lead to much frustration. Not having a working knowledge of how to deal with changing the VDO can become a daunting task. Proper planning, along with a working knowledge of the desired outcome, will often lead to an extremely happy patient and an even happier, more confident dentist.

Acknowledgment
The authors wish to thank Susie Willies and the dedicated team of dental technicians at Utah Valley Dental Lab (Provo, Utah) for the fabrication of the restorations shown herein. We would also like to thank Dr. Sheldon Seidman for his mentorship throughout the process. Dentistry for this case was done by Dr. Charles C. Cooper, DMD.

References

1. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc. 2006;137:160-169.
2. Goldstein RE. Change Your Smile. Chicago, IL: Quintessence Publishing; 1984:6-30.
3. Garcia LT, Bohnenkamp DM. The use of diagnostic wax-ups in treatment planning. Compend Contin Educ Dent. 2003;24:210-212.
4. McIntyre F. Restoring esthetics and anterior guidance in worn anterior teeth. A conservative multidisciplinary approach. J Am Dent Assoc. 2000;131:1279-1283.
5. Achieving predictable, beautiful smiles using a dento-facial esthetic diagnosis system. Compend Contin Educ Dent. 2007;28:50-55.

Dr. Cooper received a BA with honors in Science Education at Mississippi State University, a Doctor of Medical Dentistry degree at the University of Mississippi School of Dentistry, and participated in the General Practice Residency Program at the Medical College of Georgia School of Dentistry. While furthering his knowledge of dentistry through thousands of hours of continuing education classes, he has lectured in not only the dental field but was selected as a presenter at the coveted Georgia Oglethorpe Awards Session, which is Georgia’s highest level of recognition for organizational performance excellence. Dr. Cooper focuses on functional-appearance related conditions and cosmetic solutions for those patients seeking total oral health. He is a member of the American Academy of Cosmetic Dentistry, the Georgia Academy of Cosmetic Dentistry, AGD, the Georgia Dental Association, and ADA. He is a regular participant in the “Give Back A Smile” program in which he and his office donate their time and skills to help battered women achieve a new smile. Since 2000, Dr. Cooper has been the official dentist of the Atlanta Falcons Cheerleaders. Recently he took part on a humanitarian trip to the Dominican Republic northern coast, to provide dental services to local residents in need of dental care at the Leon/Laroche Medical/Dental Clinic. Dr. Cooper currently practices at the world famous Atlanta Center for Cosmetic Dentistry in Atlanta, Ga. He works very closely with Dr. Debra Gray King. He can be reached at drcooper@georgiasmiles.com or at the Web site atlantacenterforcosmeticdentistry.com.

Disclosure: Dr. Cooper reports no disclosures.

Dr. Sosa graduated from the Universidad de los Andes, in Mérida-Venezuela, in 2004. He is a member of the Venezuelan Dental Association and the Mérida Dental Association. In the past few years he has worked under the mentorship of world-renowned pioneer of cosmetic dentistry, Dr. Ronald A. Feinman at the Atlanta Center for Cosmetic Dentistry, where he also serves as the assistant marketing director. He has numerous continuing education courses. He has worked very closely with the Hispanic community in the State of South Carolina, as well as with the Federal Strategic Health Alliance, providing support to the Nation’s Reserve Forces. Recently he took part on a humanitarian trip to the Dominican Republic northern coast, to provide dental services to local residents in need of dental care at the Leon/Laroche Medical/Dental Clinic. He can be reached at andres@georgiasmiles.com or at atlantacenterforcosmeticdentistry.com.

Disclosure: Dr. Sosa reports no disclosures.