Dental emergencies or limited routine treatment can sometimes be the precipitating event to make significant changes in a patient’s oral health. A patient’s visit to the dental office can become an opportunity to educate the patient on the benefits that today’s dentistry can provide, and how dental health promotes overall systemic health. A typical example of this treatment opportunity is a patient illustrated in this article. Sharon initially presented to our office with some very simple desires. She had become dissatisfied with the bonded restorations on her front teeth and needed a full coverage restoration on a recently completed endodontically-treated tooth. Her request, in light of what was ultimately accomplished, was minimal. However, upon a more thorough evaluation, she had additional needs of which she was unaware. A more comprehensive treatment could potentially transform her life and provide years of improved oral health.
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ARE YOU INTERESTED IN VIEWING THE ENTIRE PROGRAM?
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Her initial desires emphasize that patients often present with a particular request based upon partial information. The slow, progressive process of deterioration occurs over many years, and patients often become adaptive to the compromised function, fit, and aesthetics that slowly evolve.
As clinicians, we have an opportunity to offer all possible options to our patients, including staging or delaying treatment so that a more ideal final result is possible.
CASE REPORT
Diagnostic Phase
Sharon initially presented with a history of a car accident that had avulsed her front teeth when she was 21 years old. She had become self-conscious of her compromised smile, and requested several new crowns and replacement of her existing bonded restorations (Figures 1 to 3).
Clinical examination revealed multiple preexisting restorations with numerous problems including: overhanging margins, recurrent decay, deteriorating composites, and stained/ill-matching restorations. The extent of her needs presented an excellent opportunity to accomplish a dramatic aesthetic, functional, and biological change. By spending time educating her on the problems that existed in her mouth, as well as the potential solutions that dentistry could provide, Sharon started to develop an educated vision of what could be accomplished with a systematic treatment plan that would restore her mouth to optimal health. The process helped her realize that she had decades of life ahead of her in which a healthy dentition was an important factor for quality of life and self-esteem.
With the preservation of remaining tooth structure as a goal, the final treatment plan included design variations of porcelain-bonded restorations, porcelain-fused-to-zirconia, and PFM full coverage restorations. We chose zirconia copings (Cercon [DENTSPLY]) for her previously crowned right and left maxillary central incisors, precious metal copings for the PFM restorations on the maxillary left second bicuspid and first molars, and feldspathic porcelain (Venus [Heraeus Kulzer]) for all of the porcelain-bonded restorations. Although there are many excellent porcelain choices, our laboratory and clinical team felt that we could accomplish excellent aesthetic compatibility with the porcelain-bonded technique using the Venus system. The lifelike translucency found in this porcelain would work well with the patient’s tooth preparation shade, thus providing the light, natural-appearing shade that the patient desired. Additionally, this porcelain was compatible with substrates such as zirconia and metal that required the use of opaquing layers.
An aesthetic analysis of her smile revealed good lip symmetry. Unfortunately, her beautiful lip symmetry was not enhanced by the negative aesthetic factors of an uneven occlusal plane, unnatural/aged appearance of older crowns/bonded restorations, uneven spacing, and her mild “gummy smile.” A retracted lip analysis further revealed a midline discrepancy, recurrent decay, 2 missing mandibular central incisors, severe enamel loss related to past eating disorders, and restoration overhangs/overcontours. There was a heavy plaque retention problem with a resultant generalized marginal gingivitis. Additional indications of parafunctional activity and bruxism were evident.
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| Figure 1. The patient’s preoperative smile. She had become self-conscious of the stained and discolored bonded restorations. | Figure 2. Right-lateral preoperative view. |
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Figure 3. Left-lateral preoperative view. |
Phase 1 Treatment
Phase 1 treatment for Sharon was to establish biofilm control (plaque control) in her mouth. Our dental hygienist treatment coordinator started the educational process for Sharon by teaching her about her specific dental needs, while simultaneously creating a healthy foundation for her future dentistry and establishing new habit patterns for disease prevention. Phase 1 treatment included conservative periodontal therapies, fluoride tray treatments, and the elimination of decay areas with composite foundational restorations (buildups). Additionally, study models, computerized jaw recordings, centric relation records, a face-bow, and photographs were taken as a preamble for a diagnostic wax-up of her proposed dental restorations. The dental laboratory team worked with us to establish a prototype that would meet the patient’s biological, aesthetic, mechanical, and functional needs. A review of the diagnostic wax-up (Figure 4) with the patient and the doctor-technician team helped confirm the original treatment plan and allowed us to evaluate the need for any further modifications in the restorative material choices.
Sharon had an ideal balance of hard tissue (teeth and bone) and soft tissue (lips and gums), which allowed us to move into the restorative phase as soon as her tissues were healthy. She had another very positive characteristic—a strong desire for change coupled with realistic expectations of what could be accomplished.
Laboratory Communication
Thorough planning is required before starting the preparation phase of the dental rehabilitation. Communication with the laboratory team is critical for a shared overall treatment objective. The goal is to provide as much quality information as possible to the technical team.
Sharon’s jaw movement recording visit (Denar [Cadiax]) provided the necessary information to customize an articulator to replicate her jaw movements and create a more accurate diagnostic wax-up. The preliminary photos, pretreatment models, written notes of the patient’s aesthetic expectations, instructions on structural limitations, radiographs, and overall treatment objectives (a laboratory prescription with a plan for each tooth) were also provided to the laboratory technologists. A conservative treatment plan was desired that would preserve remaining tooth structure and protect her remaining teeth for hopefully decades to come.
To achieve the proper functional objectives, it would be necessary to increase the vertical dimension of occlusion. The increased vertical dimension would allow us to provide needed space for the restorative materials, allow a more idealized anatomy, provide a natural contour/emergence profile to the restorations and establish a more favorable functional scheme.
From an aesthetic standpoint, Sharon’s presenting anterior arrangement was compromised. She provided us with photographs of her natural teeth prior to an automobile accident years ago. It appeared that her natural central incisor teeth were much wider, dominant, and longer than the older crowns. She said that she had always felt that her natural teeth were “a little too prominent” for her comfort but that the old crowns never looked correct either. The mutual decision was to establish a compromise between the width of her natural teeth and her former crowns.
The Anterior Dentition
In order to achieve a beautiful, natural appearance in the aesthetic rehabilitation, it is critical that restorations project a translucent color that responds to light in a way that mimics nature. For porcelain-bonded restorations, the tooth preparation and the ceramic choice together create the final optical result. The dental technician must understand the properties of all of the available ceramic materials and how color will be affected with the various substructures. Especially interesting with Sharon’s treatment plan from a laboratory perspective, was that the same veneering porcelain was to be used with 3 different “coping” materials—tooth structure, zirconia, and metal.
Since full-coverage restorations were necessary on Sharon’s maxillary central incisors, we decided to utilize porcelain-fused-to-zirconia (Cercon) restorations for strength and aesthetic control. This choice would allow for the strength of the zirconia coping, to be utilized with the same porcelain system (Venus) utilized for the feldspathic veneers on all of the remaining maxillary teeth except for the left second bicuspid and first molar, which would be metal ceramic.
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| Figure 4. A diagnostic wax-up served as a valuable guide to select the best-suited restorative option for each tooth in the maxillary arch. | Figure 5. This occlusal view of the laboratory master model illustrates the varied preparation designs that were selected for this treatment with the objective of meeting the aesthetic needs of the patient and providing conservative treatment to each individual tooth. |
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| Figure 6. This frontal view of the laboratory master model illustrates the completed veneer preparations adjacent to the full coverage preparations for the 2 central incisors. |
Restorative Phase: Full-Coverage and Veneer Preparations
Sharon’s existing crowns were removed with an 880 medium-cut diamond bur (Brasseler USA) and a carbide metal cutting bur (Great White 856 [SS White]). Crown removal revealed that the former preparations were extremely aggressive, perhaps in response to the fractured tooth structure from the automobile accident. Once the metal was removed down to the tooth structure, the crowns were expanded and lifted off without trauma to the underlying teeth.
On one of the central incisor teeth, a large band of composite material was evident between the tooth preparation and the crown margin. Upon removal of the composite, tissue inflammation was evident throughout the entire interproximal area. The increased vascularization resulted in spontaneous heavy bleeding. The former restorations had obviously been an irritant for the surrounding biologic tissues.
The subgingival depth of the preexisting anterior crown margins required a diagnostic decision regarding the depth of an ideal margin for this situation. Additional considerations included crown lengthening and/or orthodontic extrusion as possibilities. While removing the preexisting restorations, a magnified view of cervical defects, bevels, and abnormal root anatomy could be seen. With the goal of respecting the biologic width, and with the extra visibility and illumination from the microscope, it was possible to place the margin in a healthy and biologically sound location.
The root roughness was smoothed with the aid of the clinical microscope and fine diamonds were used to create a more idealized preparation. The goal was to provide a very precise, smooth preparation creating a fine finish line for the porcelain margins.
With the central incisor crowns prepared, it became evident that the maxillary lateral incisors had been artificially broadened to close the contacts interproximally. These dimensions created an unnatural shape and symmetry to these teeth. Following formerly published guidelines for porcelain-bonded preparation designs (Sheets, Paquette, Wu, 2008), the remaining maxillary teeth were prepared according to their tooth-specific needs for either porcelain veneers, porcelain veneer inlays, porcelain veneer onlays, or porcelain inlays. The porcelain veneer preparation margins were placed slightly subgingivally or equagingivally for selective control of tooth symmetries and restorative contours.
Once all of the preparations were completed (Figures 5 and 6), an overall evaluation of the preparations was accomplished with the use of a reduction guide created from the diagnostic wax-up to verify there is sufficient reduction for all the preparations.
The Posterior Dentition
Various preparation designs were planned for the treatment of Sharon’s maxillary posterior teeth. The overlying objectives were to be as conservative as possible while also creating an aesthetic outcome. The maxillary right first molar illustrates how these objectives could be met on a per tooth basis. Tooth No. 3 had been planned to receive an inlay restoration as a replacement for a preexisting alloy. Yet, upon considering the extent of the tooth displayed on full smile and its contralateral partner, it was decided to create a slightly more extensive design by incorporating a porcelain veneer over the mesiobuccal aspect of the tooth. This restorative design thereby created a better match to the corresponding full crown for the tooth on the opposite side while still providing a more conservative treatment option than would have been possible with a full-coverage restoration.
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| Figure 7. The provisional restorations for the posterior teeth. |
Figure 8. The provisional restorations for the anterior teeth. |
One cannot overemphasize the value of accurately fitting and aesthetically precise provisional restorations in an aesthetic dental reconstruction. This becomes especially true in a patient treatment where significant aesthetic changes are to be introduced, as was in Sharon’s treatment.
The importance of the provisional restorations is to provide good marginal adaptation so that the tissues, which were so inflamed at the outset, could heal during the provisionalization stage. This form of treatment also provides an aesthetic and phonetic template for the patient, who can see how the teeth will look and feel in her mouth. This can often prevent miscommunications or misconceptions on aesthetic goals as the final restorations are being fabricated.
In this case, the provisional restorations for the posterior teeth were interconnected to allow for better stability during the duration of the temporary phase of treatment (Figure 7). The provisional restorations for the anterior teeth were also interconnected. The central incisor segment was cemented into place with zincphosphate cement, while the veneer portion of the temporary was bonded into place with unfilled resin liquid (Figure 8).
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| Figure 9. Clinical view of the anterior restorations at the aesthetic try-in visit. Note the tissue health indicative of well-fitting provisional restorations. | Figure 10. Postoperative anterior view. Note symmetry of the overall tooth arrangements, and tooth lengths complimenting the patient’s lower lip. |
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| Figure 11. The healthier and happier patient. |
Delivery of the Final Restorations
An aesthetic/clinical try-in of the final restorations enables the patient to evaluate the aesthetic outcome of the treatment before the delivery visit. This also enables the clinician to assess the overall symmetry of the restorations in the horizontal plane relative to the patient’s facial symmetry and pupillary line. During the clinical try-in visit for Sharon very minor changes were made until everyone—the dentist, the patient, and the laboratory technician—unanimously approved of the aesthetic outcome of the dental rehabilitation (Figure 9).
The patient returned for seating of the final restorations, and was delighted with the appearance of her new smile (Figures 10 and 11). Due to financial concerns, Sharon had decided to postpone the restoration of the mandibular arch. With this in mind, the maxillary arch was designed ideally and the mandibular cast was marked with a few areas for intraoral adjustment. Yet, because the stage has been set for an idealized occlusal and aesthetic framework with the treatment of the maxillary arch, the end result will be uncompromised when she proceeds with treating the mandibular arch.
CONCLUSION
As more studies continue to strengthen the medical health community’s realization of the close linkage between oral health and systemic health, dentistry has an increasing role in the health of the public at large. Recent reports have linked transient bacteremia significant enough to cause subacute bacterial endocarditis following tooth brushing in the mouths of patients with periodontal disease. As we continue to find additional ways that inflammation and infection in the mouth adversely affects the patients in our care, it becomes even more important to strive for the highest levels of oral health for all we treat.
The passion for precision in dentistry is now even more important as we realize the access that is provided to the human body through ill-fitting margins, biofilm accumulation, periodontal inflammation and capillary transference of inflammatory bacteria. Technology that improves the precision that our profession can achieve needs to be a top priority—now and in the future.
Dr. Sheets maintains a full-time private practice in Newport Beach, Calif, with a special emphasis on aesthetic rehabilitative dentistry and implants. She is an educator, clinician, author, and a national and international lecturer. Dr. Sheets is co-executive director of the Newport Coast Oral Facial Institute. She is also a clinical professor of Restorative Dentistry at the USC School of Dentistry and is on their Board of Councilors. She is a past president of the American Academy of Esthetic Dentistry and the American Association of Women Dentists; a member of numerous professional organizations, including the American Academy of Restorative Dentistry, the American Equilibration Society, the Pacific Coast Society of Prosthodontics, and the Academy of Osseointegration; and a Fellow in the Academy of General Dentistry, both American and International Colleges of Dentists, Academy of Dentistry International, and the Pierre Fauchard Academy of Dentistry. She received the 2002 Gordon Christensen Award for Excellence in Lecturing, the 2006 Section Honor Award from the California Section of the Pierre Fauchard International Honor Dental Academy. Dr. Sheets serves on numerous editorial boards of peer-reviewed journals. She is also the Founder and Chairman Emeritus of The Children’s Dental Center in Inglewood, Calif. She is also the Founding Chairman of the National Children’s Oral Health Foundation. She can be reached at cgsheets@ncofi.org.
Dr. Paquette maintains a full-time private prosthodontic practice including an in-house dental laboratory with laboratory dental technicians in Newport Beach, Calif. She received her advanced prosthodontic training at the USC where she now serves as associate clinical professor in the School of Dentistry. She serves on numerous editorial boards, advisory boards, and peer-reviewed journals including Consumer Guide to Dentistry. Dr. Paquette also serves as co-executive director of the Newport Coast Oral Facial Institute, in Newport Beach. Among her professional affiliations, she is a Fellow in both the American and International Colleges of Dentists, the Pierre Fauchard Academy of Dentistry; is a Diplomate of the American Board of Prosthodontics; and is a member of numerous societies including the American Academy of Restorative Dentistry, the American Academy of Esthetic Dentistry, the Academy of Osseointegration, and the Pacific Coast Society for Prosthodontics. She has authored more than 40 research and clinical articles on her areas of expertise and co-authored several textbook chapters. She can be reached at jmpaquette@ncofi.org.
Dr. Wu received a Bachelor of Dental Science degree and a Masters in Prosthodontics from the University of Melbourne, Australia. She completed advanced training in Maxillofacial Prosthetics studying at the University of Pittsburgh, Pa. She maintained a full-time prosthodontic private practice in Australia, and was a Prosthodontist at the Royal Children’s Hospital of Melbourne. She was also a distinguished lecturer and clinical instructor at the University of Melbourne and past president of the Australian Prosthodontic Society. After relocating to the United States, Dr. Wu earned a DDS at the University of Tennessee and was an instructor and lecturer in the Restorative Dentistry Department. Dr. Wu is a member of the American Dental Association, the California Dental Association, the Orange County Dental Society, the American College of Maxillofacial Prosthetics, and the Royal Australasian College of Dental Surgeons. Dr. Wu is on faculty with the Newport Coast Oral Facial Institute. She is also actively involved with several research projects on dental implants and materials, and has published articles in several dental journals. She can be reached at jcwu@ncofi.org.
Disclosure: Drs. Sheets, Paquette, and Wu report no conflict of interest.
