After reviewing many different cosmetic cases in journals and seeing cases presented at the podium, it is evident that there is a lot of great dentistry happening in dental offices around the world. Yet astute clinicians should keep in mind that for every amazing “perfect” case that they read about in the journals or hear about in a lecture, there are a good number of cases in which problems and challenges can arise that are unique to each individual clinical situation. However large or small, these real-world problems are rarely included or discussed in published articles or in the conference halls.
The purpose of this article is to showcase a smile transformation from beginning to end and to show the steps involved, including the management of problems that were encountered in the insertion and try-in phase of the final restorations. This is being done in a way so the clinicians who read this article, regardless of their skill level in cosmetic rehabilitation, will better appreciate that a successful and long-lasting result depends upon the consistent management of patients, smile design, and excellent teamwork with our dental laboratory technicians.
CASE REPORT
Diagnosis and Treatment Plan
A 59-year-old female patient presented for rehabilitation of her upper arch (Figures 1 to 3). There was existing recurrent decay associated with 4 posterior left amalgam restorations. An upper right posterior PFM restoration demonstrated porcelain fatigue due to wear and fracture. The patient also had 4 anterior porcelain crowns that had been placed 13 years previously. The patient’s bite was unbalanced and over-closed, measuring 13.0 mm from the cementoenamel junction (CEJ) of tooth No. 9 to the CEJ of tooth No. 23. She complained of neck pain, temple headaches, and pain when turning her head to look over her shoulder.
Although the patient considered these symptoms to be minor, as a practicing dentist she was concerned that her bite was a contributing factor to her pain symptoms and long-term health. The patient’s cosmetic concerns were not related to shade but improvement (leveling) of the bilateral buccal corridor symmetry from the canines and extending posteriorly.
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| Figure 1. Preoperative photo: upper arch. | Figure 2. Pre-op photo: retracted, in occlusion. |
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| Figure 3. Pre-op photo: smiling. |
Our treatment goal was to increase the patient’s vertical dimension of occlusion (VDO) and to balance and stabilize the bite. This would be done by establishing a new VDO and testing it with a fixed functional orthotic during a period of 3 months. Simultaneously with increasing the VDO, the smile design would address the symmetry of the smile and teeth size. Any stated patient desires related to shade and overall cosmetic satisfaction would also be considered throughout the restorative process.
Vertical Dimension of Occlusion
It should be noted that there are many viable schools of thought and techniques to increase the VDO and to improve the bite. The mode of treatment depicted in this article represents just one technique. Prior to attempting to increase the VDO, it is recommended that the clinician be well versed in a proven technique and have knowledge and experience in treating the joints/musculature and the occlusion. In this case, since the existing VDO was measured to be 13.09 mm, a 3.0- to 4.0-mm increase of down and forward movement of the lower jaw was desired.
A new VDO was established using a low-frequency transcutaneous electrical nerve stimulation (TENS) unit with electrodes placed in front of the patient’s ears and at the midline of her neck. The utilization of TENS helps relax the muscles bilaterally so a physiologic resting position of the jaw can be recorded. In this case, a new VDO of 17.0 mm was established and built into the new fixed orthotic.
Smile Design
Along with the desired VDO measurement, the dental lab team must be given explicit instructions related to the proportionality of the anterior teeth so harmony can be achieved between the facial features and tooth shape, shade, and proportion. This is accomplished by evaluating the amount of space that is available to work with from the mesial of the left canine to the mesial of the right canine.
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| Figure 4. The fixed orthotic in place. | Figure 5. Removing the fixed orthotic on one side. |
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| Figure 6. The right side bite registration was taken. | Figure 7. Documentation of the dentin and enamel shade. |
The Golden Proportion of the central incisors was then determined. The proportion of teeth Nos. 8 and 9 was 0.618 times the width of teeth Nos. 7 to 10. The width of teeth Nos. 7 to 10, in this case, was 30.0 mm. We multiplied 30.0 mm by 0.618 and divided the result by 2. This number approximated the width of teeth Nos. 8 and 9 individually. In this case, the approximate width of Nos. 8 and 9 would be 9.0 mm. The length, therefore, was proportionally determined to be between 75% and 80% of the width, so the starting point for the length of the centrals would be 10.5 mm.
Orthotic Phase
After determining the VDO and the size and shape of the anterior teeth, the lab team was given instructions to create an upper fixed orthotic. This orthotic is utilized to test and change the VDO (if needed) and to determine if the bite established will be comfortable to the patient prior to permanently restoring the arch. Head and neck pain symptoms are considered throughout the fixed orthotic stage to determine that the symptoms are improving, not worsening. In this case, a secondary use for the orthotic was to sample the smile design being built into the final smile restorations. Prior to orthotic fabrication, the lab team was given explicit instructions of proportionality of the anterior teeth’s width and length (as determined previously when considering smile design).
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| Figure 8. A bite relator was used to record details for mounting the models. | Figure 9. The prepared teeth, prior to taking the master impression. |
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| Figure 10. Inspecting the all-ceramic restorations on the master model. | Figure 11. Systematically removing the fixed orthotic. |
The orthotic was placed using a bis-acryl provisional material (Integrity [Dentsply Sirona]) (Figure 4). Next, the bite was evaluated. The patient liked the cosmetic and symmetrical aspects. The patient would be left to function normally with the orthotic in place for 3 months. She was asked to visit the office periodically to check the bite and for any changes in her head and neck symptoms. During that 3-month period, the head and neck symptoms were eliminated, and very little change to the orthotic was needed. The patient was eager to move on to the restorative phase of treatment.
Restorative Phase
To maintain the bite (VDO) that had been established during the orthotic phase, and to transfer the established bite to the temporary and then the final restorations, it was important to methodically remove the temporary and to prepare the teeth in a stepwise fashion (Figure 5).
The first step in removing the orthotic is to remove it on one side. In this case, it was removed from teeth Nos. 4 to 8 first, leaving a posterior stop that consisted of part of the orthotic on one to 2 contacting posterior teeth. Then teeth Nos. 4 to 8 were prepped, and a bite was taken using a vinyl polysiloxane (VPS) bite impression material (Darby Dental) (Figure 6). Next, the remaining posterior orthotic was removed, and the posterior teeth were prepared. The previously taken bite was relined in the posterior area only, and the VPS bite material was reseated. The same preparation and bite registration protocol was then used for teeth Nos. 9 to 12 (as described above). Next, in finalizing the preparations for the final impression, a diode soft-tissue laser (Picasso [AMD LASERS]) was used to trough the soft tissue around the prepared teeth. This allows for excellent visualization of the margins circumferentially, ensuring an optimal impression.
Prior to preparation, it was decided that this case would be fabricated in a combination of high-strength all-ceramic materials: lithium disilicate (IPS e.max [Ivoclar Vivadent]) in the anterior region and zirconia (BioZX [Dental Direkt]) in the posterior region. The enamel shade was selected (Chromascop Shade Guides [Ivoclar Vivadent]) at the time of orthotic placement by the patient. She selected a more natural shade, opting out of the more popular bleach white shades. After the preparations were finalized, a final dentin (stumpf) shade was chosen (Figure 7). This was photographed along with all preoperative photos and preparation/shade photos and sent to our dental lab team on a digital USB memory stick.
A symmetry bite (Symmetry Facial Plane Relator [CLINICIAN’S CHOICE Dental Products]) was taken for accurate mounting of the case by the lab team (Figure 8). (Note: An important part of taking the symmetry bite is the vertical component lining up in the midline of the face. The lab uses the horizontal component when mounting the case.)
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| Figure 12. Trying in the all-ceramic restorations. | Figure 13. The try-in of the restoration for tooth No. 7 showed that it did not seat properly. |
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| Figure 14. The restoration for tooth No. 10 did not seat properly. | Figure 15. The restorations for tooth No. 11 did not seat properly. |
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| Figure 16. Re-temporization of teeth Nos. 7, 9, 10, and 11. | Figure 17. The completed restorations on the maxillary arch. |
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| Figure 18. The restored smile. |
Prior to taking the final impression, one last check was made to ensure that there was no bleeding and that there was positive visualization of the margins circumferentially around all the preparations (Figure 9). A heavy-body/light-body impression technique was utilized (Aquasil Ultra Plus [Dentsply Sirona]). The impression was inspected under loupe magnification to ensure that all margins were clearly visible. The orthotic stent was reinserted to fabricate new provisionals and to maintain the bite. The case was then sent to the laboratory team for fabrication of the prescribed restorations.
When the case was received back from the dental laboratory (Aurum Ceramic @ LVI in Las Vegas), the restorations were carefully inspected on the model. Proper contact and marginal integrity was verified (Figure 10). The patient arrived for the delivery appointment, and the provisional restorations were carefully removed (Figure 11). The preparations were then cleaned and the restorations tried in, using water to wet the intaglio surfaces (Figure 12). Marginal integrity and contacts were checked. It should be noted that the order in which the restorations were tried in was the same order that we would later use to bond them into place. The patient was given a chance to see the restorations in place to evaluate their shape and shade and her smile. Our patient loved the look of her new smile and signed off on the final placement of the restorations.
An Unexpected Problem
When inserting the restorations in the case photographed, everything fit very well, except for 4 teeth (the restorations for teeth Nos. 7, 9, 10, and 11). The restorations did not seat fully onto the preparations (Figures 13 to 15). After carefully observing the intaglio surfaces of the restorations and rechecking the restorations on the master dies and the surface of the preps, it was determined that either there had been a problem in the laboratory fabrication process of the restorations or a problem (distortion) in the master impression. Regardless, it was determined that the other restorations fit properly and that the smile design goals initially set had been met. The matter at hand now became how to proceed given this unexpected problem.
When this situation happens, it should be noted that alteration of the restoration or the preparation should only be attempted if there is an obvious minor and immediate solution. While there are rare instances where minor alterations might be permissible to make, no alterations were made to either the crowns or the preparations in this case.
The patient was immediately in-formed of the situation, and a decision had to be made with regard to the next step(s). One option was to refabricate the provisionals and to send the entire case back to the lab team to remake the restorations. The other option was to seat all the restorations delivered, except for the restorations for teeth Nos. 7, 9, 10, and 11, and to then re-temporize teeth Nos. 7, 9, 10, and 11. With either option, a new impression would be required.
It was decided that bonding the restorations except for the 4 restorations that did not fit would be the best option. Afterward, a new full-arch impression would be taken to capture teeth Nos. 7, 9, 10, and 11. A temporary was fabricated for the 4 teeth that were not bonded (Figure 16). Kolor + Plus (Kerr) stains were applied to the bis-acyl temporary to match the color of the final restorations. A compatible resin glaze material (PermaSeal [Ultradent Products]) was then applied over the surfaces of the provisional restorations to give them the luster of the enamel and to protect them for the time that the temps would be in use.
Following their return from our dental laboratory team, the 4 new all-ceramic crowns that had been remade were successfully bonded into place (Calibra Esthetic Resin Cement [Dentsply Sirona]) to complete the case (Figure 17). Figure 18 shows our very pleased patient with her beautiful new smile!
CLOSING COMMENTS
Regardless of the degree of difficulty of any dental procedure, there exists the potential for problems that can arise. The clinician should expect challenges and potential problems and communicate to patients that problems and challenges can arise in a complicated case prior to initiating the procedure. This advance information should be included as part of a proper informed-consent process so that the patient will understand that unexpected problems should really be thought of as an expected part of the treatment process. When issues do arise in the process of any case, the clinician should take charge and develop a solution that results in a successful outcome.
Acknowledgement
The author wishes to thank Aurum Ceramic @ LVI (Las Vegas) for the laboratory work performed on this case.
Dr. Simos maintains private practices in Bolingbrook and Ottawa, Ill. He received his DDS degree at Chicago’s Loyola University and is the founder and president of the Allstar Smiles Learning Center and client facility (Bolingbrook), where he teaches postgraduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry. He is an internationally recognized lecturer and leader in cosmetic and restorative dentistry. He can be reached via email at cmesmile50@gmail.com, via the website allstarsmiles.com, or via the Twitter handle@allstarlc1.
Disclosure: Dr. Simos reports no disclosures.
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