An Efficient Approach to Full-Mouth Reconstruction of the Apprehensive Patient

One of the most gratifying accomplishments in dentistry is restoring an entire mouth to proper form, function, and health. Doing so using aesthetic materials that mimic tooth structure is even more gratifying, and with today’s modern materials, it’s entirely possible.

From removing decay and replacing old restorations, to restoring proper vertical dimension, there are many reasons for reconstructing an entire mouth. However, knowing how to proceed and what materials to select are most significant. Additionally, exercising skill when dealing with a patient’s apprehension and dental anxiety is another integral part of the treatment process¹ that may be overlooked.

This article presents a case requiring full mouth reconstruction as well as management of patient anxiety.

CASE PRESENTATION

Figure 1. Preoperative full-face view of patient.	Figure 2. Preoperative retracted view.

A 59-year-old man presented to the practice dissatisfied with the appearance of his smile and profile (Figure 1). He commented that he felt his teeth were unattractive because of wear, decay, and negligence on his part for not seeking routine professional dental care² (Figure 2). In fact, the patient stated that he had not been to a dentist in about 25 years because of his extreme apprehension about dental procedures. Because of the condition of the patient’s mouth and his desire for a more attractive and functional smile, full-mouth reconstruction was required.

DIAGNOSIS AND TREATMENT PLANNING

Figure 3. Preoperative occlusal view of the maxillary teeth.	Figure 4. Preoperative occusal view of the mandibular teeth.
Figure 5. Preoperative retracted right side view.	Figure 6. Preoperative retracted left side view.

The patient exhibited an array of problems ranging from severely decayed teeth to broken root tips (Figures 3 and 4). His periodontal condition was not very stable, and he exhibited a malocclusion (Figures 5 and 6).

Figure 7. Maxillary diagnostic wax-up.	Figure 8. Mandibular diagnostic wax-up.

Initial diagnostic evaluation consisted of a series of 35-mm slides with study casts, a centric-relation bite record, and a facebow transfer. A diagnostic wax-up was completed (Figures 7 and 8), taking into account gingival recontouring, restoration of maxillary incisal length, lingual contour, mandibular incisal edge placement, anterior guidance, and cuspid rise.

Following a review of the wax-up and the extent of the preparations needed to attain treatment goals, a restorative plan was developed that consisted of full-coverage restorations on all his existing teeth, extraction of nonrestorable teeth, endodontic therapy, and periodontal therapy. To enhance aesthetics and simultaneously restore the occlusion to a more favorable anterior and lateral scheme,³ as well as to replace edentulous areas, a combination of restorative materials was selected.

Lithium disilicate all-ceramic crowns (IPS Eris, Ivoclar Vivadent) were selected for the anterior region. The combination of this system’s lithium-disilicate framework layered with a fluorapatite ceramic produces exceptionally strong,^4,5 vital, and aesthetic restorations with the desired optical properties, natural translucency, opalescence, and fluorescence. Furthermore, because the preparations would probably be subgingival, leading to a concern of gingival contamination, this system’s ease of cementation using conventional methods was very advantageous. In the posterior region, a metal-ceramic system (IPS d.SIGN, Ivoclar Vivadent) was selected for strength, because long edentulous areas would require bridgework, and occlusal forces from bruxism would need to be addressed.

CONSIDERATIONS FOR DEALING WITH DENTAL ANXIETY

Based on specific instructions and detailed communication, the laboratory technician created an ideal aesthetic wax-up of the proposed treatment plan for the patient to view and evaluate. A matrix (Sil-Tec, Ivoclar Vivadent) of the wax-up was created in order to fabricate provisional restorations that would mimic the form, function, and aesthetics of the proposed final results.

Because the patient was very apprehensive from the beginning, he was reassured that his comfort was the dental team’s first concern. Caring staff addressed all of his questions and inquiries professionally.

Once the patient had an understanding of the dental treatment proposed, anesthesia options were then discussed in detail.⁶ It was very important to discuss all the anesthetic options with the patient, including regional anesthesia, conscious sedation, and hospital anesthesia or deep sedation. Often, when patients learn about all of these options, they choose a less-invasive mode than originally requested. The majority of high-fear patients choose conscious sedation or oral premedication with nitrous oxide, even though they originally wanted to be “put out.” In this particular situation, the patient chose to have oral premedication with nitrous oxide.

Because many apprehensive patients require at least initial periodontal treatment with anesthesia, it is beneficial to schedule combined restorative/hygiene appointments.

By accomplishing treatment stages in longer, well-planned sessions, the patient can receive high-quality comprehensive care in a comfortable atmosphere.⁷

In this case, the patient’s treatment was divided into 3 sessions, as follows: (1) preparation of teeth, endodontic therapy, periodontal therapy, extraction of nonrestorable teeth, fabrication of provisional restorations; (2) removal of temporaries, evaluation of preparations and periodontal tissue, impressions for final restorations; and (3) placement of final restorations.

By accomplishing the majority of the procedures and placing aesthetic temporaries in the first appointment, the patient gained the confidence and excitement necessary to motivate him to complete the treatment process without hesitation.

PREPARATION

Once informed consent was obtained from the patient, treatment was initiated. Prior to tooth preparation, the patient was anesthetized with 2% lidocaine (1;100,000). Using a No. 5847KR-016 bur (Brasseler USA) for gross reduction and a No. 8847KR-016 bur for finishing, a 1-mm shoulder with a rounded line angle was created for axial reduction. A 2-mm reduction from the occlusal and incisal surfaces was also created.⁸

Following sequential preparation of the maxillary and mandibular teeth, a stick-bite registration was taken. This stick-bite registration would aid the technician in preparing the model and mounting the case. It also communicated to the ceramist the orientation of the interpupillary line so that the incisal edges of the final restorations would not appear canted.

At this time, any teeth requiring endodontic therapy were treated and cores placed. Additionally, nonrestorable teeth were extracted prior to fabrication of the provisional restorations. Extraction sites were filled with Bioplant HTR (Bioplant Inc) and sealed with Biofoil.

The Sil-tec matrix was then used to fabricate the provisional restorations using shade A-1 of the provisional material (Systemp, Ivoclar Vivadent) (Figure 9). Once the provisionals were placed, the hygienist performed periodontal charting, scaling, and curettage while the patient was still in a comfortable and relaxed state.

Figure 9. Retracted view of the provisional Systemp restorations.	Figure 10. Full-face view of the Systemp provisional restorations.

The patient was instructed to return to the office in a few days to re-evaluate the occlusion, aesthetics, and phonetics of the provisional restorations (Figure 10). When these parameters were judged satisfactory and the patient was pleased, an alginate impression was taken of the temporaries. This information was then forwarded to the laboratory for interpretation and fabrication of an incisal matrix to correctly position the edges of the final restorations.

During the second treatment appointment, the patient was anesthetized and the temporaries removed. Preparations and gingival tissue were evaluated for adequate reduction and health. Because an oral rinse (Tooth and Gum Tonic, Dental Herb Company) was prescribed for use after the initial scaling and root planing appointment, the gingival tissue exhibited a healthy response. The advantages of using this rinse were that it would not stain the temporaries and felt very soothing to the patient.

Final impressions were taken using a polyvinyl impression material (Virtual, Ivoclar Vivadent). The provisional restorations were again placed until the final restorations were fabricated.

LABORATORY FABRICATION

Figure 11. Maxillary restorations on the model.	Figure 12. Mandibular restorations on the model.

At the laboratory, the full-arch polyvinylsiloxane impressions were used to pour a master model on which the restorations were based (Figures 11 and 12). The master model was segmented into individual dies that were trimmed and pinned to determine the manner in which the final restorations would integrate with the soft tissue.

Figure 13. Internal aspect of the maxillary restorations.	Figure 14. Internal aspect of the mandibular restorations.

A silicone incisal matrix of the provisional restorations was created to guide the placement of the incisal effects and edge positioning for subsequent porcelain buildup. The internal aspect of the final restorations indicated which material would be used in each section for the upper and lower arches (Figures 13 and 14).

CEMENTATION

When returned from the laboratory, the restorations were evaluated for marginal fit on the working die-trimmed and solid models. The patient was then anesthetized and the provisional restorations were removed.

The teeth were cleaned with 2% chlorhexidine and the restorations were tried in with glycerin to verify fit. A water-soluble try-in gel (Variolink II, Ivoclar Vivadent) was used to try in the restorations to evaluate shade and aesthetics.

When fit and aesthetic factors were satisfied, the restorations were cleaned and placed with Vivaglass cement (Ivoclar Vivadent). Using this cement eliminated the need to adhere to strict bonding protocols and addressed concerns regarding subgingival margins that would have diminished the patient’s comfort level.

CONCLUSION

Figure 15. Postoperative retracted view.	Figure 16. Postoperative full-face view.
Figure 17. Preoperative smile view.	Figure 18. Postoperative smile view.
Figure 19. Preoperative side-smile view.	Figure 20. Postoperative side-smile view.

If the challenges of cases such as this are carefully diagnosed and analyzed, and a treatment plan is designed, they can be addressed successfully, even when the patient experiences severe dental anxiety. Key to the process is understanding the patient’s psychological and emotional state, but also knowing the most appropriate, durable, and predictable restorative materials to facilitate the case and contribute to a comfortable experience for the patient. Figures 15 through 20 demonstrate how the patient’s aesthetic desires were achieved.

References

1. Johnsen BH, Thayer JF, Laberg JC, et al. Attentional and physiological characteristics of patients with dental anxiety. J Anxiety Disord. 2003;17:75-87.

2. Stetson BA. Influence of behavioral science research on oral health promotion. Compend Contin Educ Dent Suppl. 2000;30:24-30.

3. Cranham JC. Centric relation: an anatomical and physiological treatment position. Contemp Esthet Restor Pract. 2001;5:56-61.

4. Chitmongkolsuk S, Heydecke G, Stappert C, et al. Fracture strength of all-ceramic lithium disilicate and porcelain-fused-to-metal bridges for molar replacement after dynamic loading. Eur J Prosthodont Restor Dent. 2002;10:15-22.

5. van Dijken JW. All-ceramic restorations: classification and clinical evaluations. Compend Contin Educ Dent. 1999;2:1115-1134.

6. Dailey YM, Humphris GM, Lennon MA. Reducing patients’ state anxiety in general dental practice: a randomized controlled trial. J Dent Res. 2002;81:319-322.

7. Maggirias J, Locker D. Psychological factors and perceptions of pain associated with dental treatment. Community Dent Oral Epidemiol. 2002;30:151-159.

8. Nash RW. Treatment planning with modern materials. Compend Contin Educ Dent. 1997;18:1064-1071.

Dr. Nazarian maintains a private practice in Troy, Mich, with an emphasis on comprehensive and restorative care. In 2002, he received the Excellence in Dentistry Award. He is a member of the Academy of General Dentistry and the American Academy of Cosmetic Dentistry. He can be reached at ara20002@comcast.net.