Last month, we discussed the importance of the diagnostic phase of treatment. The goal of this phase is to develop a 3-dimensional plan that would incorporate any aesthetic change the patient may desire, with a proper dental evaluation that would isolate any factor that could cause breakdown of the dentition or its supporting structures.
This month will focus on the treatment phase of optimum dental care. It requires the restorative team to organize the data collected in the diagnostic phase, visualize a proper course of treatment, and then efficiently deliver the care. If the case is to be successful, then 5 requirements need to be fulfilled. They are…
(1) Aesthetic Expectations. Nothing is more fun than delivering dental care that thrills a patient with the end aesthetic results, and nothing is more frustrating than falling short. Predictable aesthetics are obtained by using photographs of the preoperative condition combined with photographs of finished cases, and if necessary, computer imaging to clearly understand the patient’s desires prior to treatment.1 This information is incorporated into the diagnostic wax-up and then tested in the provisional restorations. The bottom line is that aesthetic success is determined by the patient.
(2) Functional Requirements. An important tenet of optimum dental care is developing harmony within the gnathostomatic system. This should include healthy TMJs, muscles that are not tight, sore, or tense, and teeth that are not worn, mobile, or migrating.2 This requires that all parts of the system are working together.
(3) Periodontal Health. The periodontal structures provide the all-important frame as well as the foundation for restorative dentistry. The tissue should lack inflammation and have a maximum probing depth of 3 mm.2 This will provide gingival structures that are maintainable by the patient. Additionally, a minimum of 2 mm of attached gingiva should be present on the facial and lingual of each tooth. This will ensure long-term tissue stability.
(4) Cleansability. Immediate value for the patient is determined by the aesthetic outcome, the comfort of the rehabilitation, and the manner in which the care was delivered by the team. Long-term value is directly related to longevity. Longevity is related to the control of occlusal forces and bacteria that could lead to caries or periodontal breakdown. Optimum oral health should allow the patient to easily clean all the surfaces of every tooth.2
(5) Structurally Sound. The last factor to consider is to choose a restorative material that will best meet the patient’s goals from an aesthetic, functional, tooth structure conservation, and longevity standpoint. In other words, the restorative team wants to choose the material that will conserve the most tooth structure, provide the best aesthetic result, and give the patient the longest life span possible. This also considers any pre-prosthetic procedures such as crown lengthening, posts and cores, and buildups that will be necessary during the restorative process.
CASE STUDY
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| Figure 1. Full-face preoperative view. | Figure 2. Smile preoperative view: the patient wants a fuller, larger, whiter smile. |
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| Figure 3. Retracted preoperative view. |
A healthy 54-year-old woman was referred from a local periodontist (Figures 1 through 3). She had a long dental history, with a great deal of effort to enhance her smile as well as save her teeth for a lifetime. She had undergone numerous restorative procedures, as well as porcelain veneer restorations on her maxillary anterior teeth. After a short conversation, it became clear that this patient was ready to do whatever it took to get the smile she had always dreamed of, as well as stabilize her dentition.
Recently, she had problems keeping the porcelain veneers in place, and repairs were required because of fracture. She was also concerned about the 5-tooth bridge on her lower left side, as the periodontist had indicated that the pier abutment (tooth No. 20) might be fractured and hopeless.
Additionally, she was unhappy with her appearance. She wanted longer, whiter teeth that appear more natural, but also could be seen when she smiled. Currently, she felt that her lower teeth showed more than her upper teeth. She also wanted to be sure that whatever she did, she would not have the problem with breakage she had in the past. She wanted this care (except for re-care) to represent the majority of procedures she would need for the rest of her life.
VISUALIZE OPTIMUM AESTHETICS
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| Figure 4. Rest position: note that no maxillary tooth structure is displayed at rest. One treatment goal was to increase the length of her maxillary teeth. | Figure 5. E position: Ideally the maxillary incisal edges should be half the distance between the upper and lower lip. Her maxillary teeth are short by 2 mm. |
The utilization of digital photographs in conjunction with before-and-after photos of other patients is a wonderful way to begin a conversation regarding the specific changes the patient would like to make. The first thing to visualize is the length of the central incisors by looking at the smile (Figure 2), the Rest position (Figure 4), and the “E” position (Figure 5).
We utilize the patient’s preoperative photograph to discuss with them their general feelings about the “look.” Comparing this to before-and-after photos of other similar cases is very helpful to gain an insight into how much tooth structure the patient views as “aesthetic.” It never ceases to amaze our practice how significant the variation is from one patient to another.
Studies tell us that at age 30, 1 to 3 mm of maxillary tooth structure is displayed at rest, and the mandibular teeth cannot be seen.3 This reverses by age 70. To make a smile more youthful, adding length can be very beneficial. This patient preferred longer, whiter teeth. Figure 4 indicates that no maxillary tooth structure could be seen in this view, indicating a length addition of 1 to 2 mm.
Having the patient say the letter “E” can also be a good determinant of ideal length (Figure 5). As the patient enunciates this sound, the maxillary incisal edge should be seen halfway between the upper and lower lips. This again indicates the teeth could be lengthened from an aesthetic standpoint approximately 2 mm.4
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| Figure 6. Diagnostic casts mounted in centric relation on a SAM III articulator. | Figure 7. The Boley gauge is set at 10 mm. Increasing the incisal length by 2 mm as previously determined allows for optimum placement of the gingival tissues. |
With this information, mounted casts are fabricated, mounting on a Sam III articulator (Great Lakes Prosthodontics) in centric relation (Figure 6). This will allow optimum study from an aesthetic and functional standpoint. In this case, the patient was attracted by teeth that were in the 10 mm length range. Her preoperative length was 6.5 mm. Figure 7 illustrates how we can set the Boley gauge at 10 mm, add the 2 mm of length incisally, and then also see that this will require approximately 1.5 mm of gingival recontouring to establish ideal length and width-to-length ratio. This information will be recorded and sent to the laboratory with the pertinent functional information to guide the diagnostic wax-up.5
TREATMENT PLAN FOR OPTIMUM FUNCTION
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| Figure 8. Mounted diagnostic casts: note extreme wear and severe occlusal plane problem. |
A thorough evaluation of the TMJs through patient history, range of motion tests, palpation, load testing, doppler auscultation, and joint vibration analysis6,7 was performed. This patient had extremely healthy TMJs. The muscles of mastication were also evaluated through palpation and EMG studies. These muscles were tight, mildly sore, and hyperactive. Lastly, the teeth were examined and found to have extreme wear and evidence of some migration on the upper left side. Her occlusal evaluation revealed interferences to centric relation as well as a complete lack of anterior guidance. This was caused primarily by her short, worn anterior teeth, as well as a significant occlusal plane problem on the left side (Figure 8).
The occlusal treatment plan involved restoring her occlusal plane and building an occlusion with equal intensity contact on all her teeth in centric relation, with an anterior guidance in harmony with the envelope of function. In order to correct these problems, opening the vertical dimension of occlusion (VDO) 2 mm would be necessary. Aesthetically, this would also improve her lower face height, which appeared over closed. Additionally, by opening the VDO, the patient’s overbite could be kept the same, which would prevent a steeper guidance angle (which could be detrimental to the horizontally bruxing patient8). This plan would create a mechanical disadvantage by building the damaging lateral forces as far away from the fulcrum as possible.9 Additionally, eliminating the proprioception from the posterior teeth in lateral excursions would decrease the muscle activity, which is desirable with this type of patient.2
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| Figure 9. Diagnostic wax-up: the 3-dimensional guide that will guide the restorative team to solving all aesthetic and functional problems. |
With these aesthetic and functional goals in mind, duplicate mounted diagnostic casts were sent to the laboratory for a diagnostic wax-up. The restorative team specified the changes to the incisal edge position and marginal gingiva. These included the changes to the vertical dimension of occlusion and the changes to the occlusal plane, with the ideal functional goals. The diagnostic wax-up illustrated in Figure 9 is the 3-dimensional plan that will drive the treatment phase.5
START WITH A HEALTHY FOUNDATION
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| Figure 10. Full smile with provisional restorations. Note ideal length and lip support. | Figure 11. Full-smile lateral view. |
The patient was brought into the office on 2 successive mornings. Both arches were prepped, and processed acrylic provisionals were fabricated from matrices of the diagnostic wax-up. Every tooth was built up and prepared to contemporary restorative standards. The provisionals were then customized to meet the aesthetic expectations of the patient, as well as the long-term functional goals. Figures 10 and 11 illustrate the properly contoured provisional restorations.
With provisional restorations in place, the patient was sent back to the periodontist for the necessary surgical therapy. Aesthetic crown lengthening was performed in the anterior maxilla and mandible, as well as crown lengthening in the mandibular posterior segments to expose enough tooth structure to allow for a minimum of 3 mm distance from the final crown margin to the top of the preparation. The periodontist also removed tooth No. 20 and placed three 3i implants in the areas of teeth Nos. 19 through 21.
After 90 days of healing, the patient returned for final preparation of the maxillary arch and final impressions. It was decided that Captek restorations would be placed on teeth Nos. 3 through 14, with full gold crowns on the second molars. The final impressions were made with Take One (Kerr), and an impression of the provisionals was also made at this time. The master casts were mounted on a SAM III articulator (Great Lakes Prosthodontics), interchangeably with the model of the provisionals. A shade was discussed and taken, as well as photographs with the shade tab in place. This information was sent to the laboratory.
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| Figure 12. Maxillary laboratory work. Captek crowns teeth Nos. 3 through 14, gold crowns teeth Nos. 2 and 15. This is opposing a new diagnostic wax-up for fabrication of a new processed acrylic provisional restoration. | Figure 13. Maxillary laboratory work. Captek crowns teeth Nos. 3 through 14, gold crowns teeth Nos. 2 and 15. |
Figures 12 and 13 illustrate the laboratory work. The restorations were contoured to follow the aesthetic and functional goals determined in the provisional restorations. A final wax-up of the mandibular restorations was completed, as well as fabrication of a final provisional restoration as the implants completed osseointegration. At the next appointment, the maxillary restorations were adjusted and cemented with Rely X luting cement (3M ESPE), and a new mandibular provisional was fabricated and placed.
Sixty days later, the patient returned for final preparation of the mandibular teeth and final impressions. The tissue was retracted and the final impression was made of the mandibular arch, including an implant pick-up impression, using Take One (Kerr). Bite registrations were made at the correct vertical, and all master casts were mounted on a SAM III articulator (Great Lakes Prosthodontics) in centric relation. Additionally, a model of the mandibular provisional was sent to the lab to use as a guide.
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| Figure 14. Mandibular laboratory work over model of completed maxillary. Note implants in positions Nos. 19 through 21. As in the maxilla, Captek crowns first molar to first molar, with gold crowns on second molars. | Figure 15. Mandibular laboratory work. Captek crowns teeth Nos. 19 through 30, gold crowns on teeth Nos.18 and 31. |
As with the maxillary arch, Captek restorations were chosen for their strength, beauty, and their ability to be cemented conventionally. Gold would be placed on the second molars, while Captek restorations would be placed on teeth Nos. 19 through 30. Figures 14 and 15 illustrate the case as returned from the lab.
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| Figure 16. Full-face postoperative view. | Figure 17. Full-smile postoperative view. |
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| Figure 18. Full-smile right lateral postoperative view. | Figure 19. Retracted postoperative view. |
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| Figure 20. Left lateral retracted postoperative view. |
The crowns were cemented as 14 single units with Rely X Luting Cement (3M ESPE). Minimal adjustments were required. Figures 16 through 20 illustrate the finished result. After careful planning, all aesthetic, functional, periodontal, and restorative goals were realized.
PREDICTABLE RESTORATIVE EXCELLENCE
Dentistry is traveling through an incredible time. As the baby boomer generation ages, they are presenting many aesthetic and functional challenges as they are driven to look their best and want to keep their teeth for a lifetime. This case illustrates how careful planning, combined with a multidisciplinary approach to optimum care, can predictably solve some very complex functional as well as aesthetic problems.
References
1. Cranham J. Optimum dental care, part I: the diagnostic phase. Dent Today. 2003;22:56-61.
2. Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems. 2nd Ed. St Louis, Mo: C.V. Mosby; 1989.
3. Vig, R. G. and Brundo, G. C. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39:502-504.
4. Refenenacht CR. Fundamentals of Esthetics. Chicago, Ill: Quintessence Publishing Co; 1990:186.
5. Lerner JM, Rosenthal L, Kim JJ. The diagnostic wax-up: a blueprint for predictable success. Contemp Esthet Restor Pract. 2002;5:46-56.
6. Christensen LV, Donegan SJ, McKay DC. Temporomandibular joint vibration analysis in a sample of nonpatients. J Craniomandib Pract. 1992;10:35-41.
7. Ishigaki S, Bessette R, Maruyama T. A clinical study of TMJ vibrations in TMJ dysfunction patients. J Craniomandib Pract. 1993;11:7-13.
8. Williamson E, Navarro E, Zwemer J. A comparison of the EMF activity between anterior reposition splint therapy and a centric relation splint. J Craniomandib Pract. 1993;11:178-183.
9. Okeson J. Fundamentals of Occlusion and Temporomandibular Disorders. St Louis, Mo: C.V. Mosby; 1985.
Dr. Cranham is an internationally recognized speaker on the aesthetic principles of smile design, contemporary occlusal concepts,
laboratory communication, and happiness and fulfillment in dentistry. He is the founder of Cranham Dental Seminars that provide a combination of lecture, mobile hands-on programs, and intensive 2- to 3-day hands-on experiences. Additionally, he provides occlusionlectures for Dr. Larry Rosenthal’s Aesthetic Advantage in New York, NY, and West Palm Beach, Fla. He can be reached
at smildoc@aol.com or at cranhamdentalseminars.com.
Note: Special thanks to Dr. Albert Konikoff of Virginia Beach, Va, who placed the implants and provided the periodontal therapy. Also to Dental Arts Laboratory for the fabrication of the beautiful restorations.
