Full-mouth restoration is a process requiring attention to detail from preoperative impressions to cementation and bonding to final occlusal adjustment. Once we as clinicians master the techniques of preparation and bonding, we may be anxious to treat large cases. But often, in our excitement to perform this high-level service, we overlook the physiological readiness of the patient to receive our care successfully.
Chart. Patient Categories.
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Patient selection for high-level care such as full-mouth restoration is more complex than the most commonly used criteria of simple need, readiness, willingness, and financial ability. Of course, willingness and financial ability are ultimate determining factors, but the patient has the sole responsibility for those criteria. Need, on the other hand, is a combination of both clinician and patient input. But readiness can be more complicated. In regard to readiness, I divide my patients into 4 categories. These categories are based on a combination of clinical signs and symptoms (Chart). By using these combinations, I can assess the patient’s physiological readiness for care, a critical aspect when determining the potential success, or prognosis, of that care.
PATIENT TYPES
Type I patients present with no clinical occlusal, aesthetic, or TMJ signs, and have no symptoms. Certainly, this type of patient has no need for care.
Type II patients present with one or more occlusal, aesthetic, or TMJ signs but have no symptoms. Their stomatognathic system is resilient enough to withstand the observed conditions of dysfunction without a display of symptoms. Because of this resilience and natural resistance to pain, type II patients are often good candidates for comprehensive care.
Type III patients not only present with clinical signs of dysfunction, but they are symptomatic as well. These individuals require us to step back to evaluate and associate the symptoms with the signs of dysfunction. In that way, we can treat the dysfunction, which in turn can provide symptomatic resolution. Only then should the clinician proceed to restorative care.
Type IV patients are symptomatic but lack demonstration of clinical signs that can be associated with those symptoms. This most difficult group can require comprehensive, interdisciplinary evaluation and should be approached with guarded optimism.
From this categorization, it becomes apparent that only type II and type III patients are those to be treated, as they are the ones presenting with clinical occlusal, aesthetic, and/or TMJ signs. Further, type II patients are preferred, as they present with the need for care and a resistance to symptoms.
CASE REPORT
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| Figure 1. Preoperative view, full face. | Figure 2. Preoperative view, unretracted smile. Note the reverse smile curve. |
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| Figure 3. Preoperative view, retracted smile. | Figure 4. Preoperative view, maxillary arch. |
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| Figure 5. Preoperative view, mandibular arch. |
The case presented is a patient who was referred to my practice by an existing patient who had just completed his own smile enhancement. The patient was a healthy 53-year-old who presented with a request to fix his 6 front teeth. He was concerned that he could not see his front teeth when he smiled. He also related that he did not like the variations in his tooth color (Figures 1 to 5).
Dental History
The patient’s dental history consisted of traditional dentistry with several large amalgam restorations and porcelain-fused-to-metal crowns. He was under the care of a periodontist for treatment of localized adult periodontitis. On examination of the periodontium, slightly elevated bleeding indexes were confined to the lower left molars. Residual pocketing was noted in other areas in absence of bleeding. It was therefore deemed that the periodontal condition would support any planned restorative care.
Comprehensive Evaluation
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| Figure 6. Resting electromyography demonstrates low microvolt level of temporalis, masseter, SCM, and digastrics. | Figure 7. Computerized mandibular scanning demonstrates normal range of motion. |
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| Figures 8a and 8b. Waveform and spectral analysis of TMJ vibrations reveal low-frequency vibrations indicative of joint laxity, a very early form of disk displacement. | |
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| Figures 9a and 9b. Left and right tomographic TMJ views in the closed position. |
The patient was asked to complete a symptomatic history fashioned after the Kinnie-Funt-Stack Visual Index. No symptoms were reported. The existing occlusal disease, including occlusal wear, anterior chipping, and abfractions raised my level of concern for the condition of the TMJ complex. In order to evaluate TMJ health, bioelectric instrumentation from BioResearch was utilized (Figures 6 to 8b) in conjunction with corrected, bilateral, multipositional, para-sagittal tomograms (Figures 9a and 9b). The information from these diagnostic tests demonstrated the patient’s resistance to systemic breakdown, and the decision was made that the TMJ complex did not need to be treated prior to restoration. The information also helped to establish a prognosis: the patient’s high resistance to systemic breakdown, even withstanding his occlusal disease, should make his acceptance of a new occlusal environment much easier. In summary, he was a type II patient.
Case Planning
In order to increase the length of the central incisors, the 3-D relationship of the mand-ible to the maxilla had to be modified. The vertical, anteroposterior, and lateral position of the mandible was determined by finding physiologic rest through neuromuscular techniques. From physiologic rest position, isotonic closure through freeway was recorded using computer-enhanced jaw tracking. Closure along physiologic trajectory was noted, and the centric occlusal position was on that trajectory with a freeway space of 1.0 mm. This position was recorded with Blue Sapphire (Bosworth). To determine incisal length, the phonetic determination of the
F-point and V-point was utilized.
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| Figure 10. Maxillary wax-up on stage of Accu-Liner articulator. Note the level occlusal plane. | Figure 11. Completed wax-up on Accu-Liner articulator. |
The maxillary and mandi-bular casts with the occlusal registration were then sent to the lab (Arrowhead Dental Laboratory) for mounting on the Accu-Liner articulator (Accu-Liner Products). The maxillary cast was mounted to the upper member of the articulator using the HIP (hamular notch—incisive papilla) plane. Dr. Harry Cooperman introduced this plane to dentistry in 1960, and it has been shown to be a very reliable horizontal reference plane of the skull.1,2 The mandibular cast was mounted relative to the maxillary cast utilizing the occlusal registration provided. The mandibular cast was removed from the articulator, and the provided stage was set in place. The central incisor length, as determined by the f-point and v-point, was duplicated on the central incisors of the cast, and the maxillary cast was lowered so the central incisors’ intended incisal edge contacted the stage of the articular. The maxillary wax-up was then completed to ideal plane against the stage (Figures 10 and 11).
Preparations
Once the wax-ups were completed, the laboratory made temporary stints and reduction guides. The case was now ready for preparations. Laser-assisted tissue recontouring was performed first. This contouring was done to place gingival zeniths in the appropriate position for each tooth independently as well as in relation to one another. I opted to prepare all 28 teeth in one visit. Teeth Nos. 3 through 7 and Nos. 10 through 14 were prepared. The Blue Sapphire registration was reintroduced, and the registration was relined in the prepared areas with LuxaBite (Zenith/DMG) to maintain the integrity of the occlusal registration. The unprepared teeth would allow for proper orientation of the registration. The 4 remaining maxillary teeth were then prepared. All preparations were prepared with shoulder margins for IPS Empress restorations (Ivoclar Vivadent).
The mandibular teeth were then prepared. The 4 molars would be prepared to receive porcelain-fused-to-high-noble gold crowns. This was dictated by the need to cement versus bond these crowns, as determined by the margins of the previously placed dentistry. All other teeth were prepared for IPS Empress. The arch was prepared in the same manner as the maxillary teeth, maintaining the bite registration through closed segmental reline.
The color mapping, smile selection, and preparation (stump) shades with necessary photographs were obtained. A stick bite related to horizontal was taken. This allows the laboratory to compare horizontal to the stage of the Accu-Liner articulator and remove the potential for canting in the final restorations.
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| Figures 12a and 12b. Provisionals in place. |
Provisionals were fabricated by loading Integrity (DENTS-PLY/Caulk) into the Sil-Tech stints (Ivoclar Vivadent) fabricated from the wax-ups. The maxillary stint was loaded, vibrated to reduce bubbles, and seated against the maxillary preparations. An attempt was made to place even pressure throughout the stint using the palate and tuberosities as positive stops. Rubbing the anterior portion of the stint with a finger helps to thin excess, making removal easier. The Sil-Tech stint was removed 2 minutes after placement, and the excess material was removed with a No. 12 scalpel and fine carbide burs. The lower provisionals were fabricated in similar fashion. Once finished, the provisionals were very aesthetic (Figures 12a and 12b).
Maintaining tissue health to minimize gingival bleeding at the seat appointment is vital to the bonding process. In this regard, removal of excess material in the gingival embrasures is required for proper cleansing. This contouring was accomplished with a Brassler 8392-016 carbide interproximal finishing bur. Carefully passing this bur through the gingival embrasure will allow for Super-floss (Oral-B) to be used daily. In addition, daily Water Pik (Water Pik) irrigation with a solution of water, Listerine (Pfizer), and antibacterial hand soap promotes healing and reduces bacterial activity.3
The patient was asked to return to the office 3 days post-preparation. At this appointment the occlusion, aesthetics of the provisionals, and home care were evaluated. Any changes to the provisionals were noted and related to the laboratory so the final restorations could be produced to the patient’s satisfaction.
Cementation
At the cementation/bonding appointment, following lingual anesthetization, the maxillary provisionals were sectioned and removed. The preparations were cleaned with Consepsis scrub (Ultradent) and an intracoronal brush (Ultradent), followed by Consepsis liquid. Each unit was tried independently for fit and as a group for proximal contact determination. Once confirmation of each unit was accomplished, the anterior segment was placed and viewed for midline, length, and canting. Use of try-in paste may be required for color observation.
Once the patient accepted the restorations, they were removed, thoroughly rinsed, and etched with 37% phosphoric acid. Silane primer (Kerr) was applied to the restorations followed by the appropriate shade of Variolink bonding resin (Ivoclar Vivadent). They were placed in the Crown and Bridge Organizer (C & B Organizer) to maintain a light-free environment and log their respective position in the arch.
The rubber dam was placed in a trough format, and the palate was sealed with bite registration material to prevent saliva contamination. The teeth were etched for 12 seconds and washed. Excess water was removed, and Ultracid (Ultra-dent) was placed as a wetting agent. OptiBond Solo Plus (Kerr) was applied in the manner the manufacturer recommended.
The units were then placed, starting with the 2 central incisors. Reasonable attempts were made to remove excess bonding resin without dislodging the restoration. Tacking the gingival area maintains the position of the unit while others are placed. Next, the lateral and cuspid were placed, one side then the other, and tacked to place. The process of front-to-back placement was continued until all units were tacked.
At this time, all interproximal areas were flossed, using care not to dislodge the units and yet remove excess interproximal bonding resin. Final curing was performed with multiple light units to expedite the curing process.
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| Figure 13. Unretracted postcementation view of the smile. | Figure 14. Retracted postcementation view of the smile. |
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| Figure 15. Full-face postcementation view. | Figure 16. Two-dimensional contour view of the T-Scan II system demonstrates near 50-50 balance of occlusal force summation. |
Remaining bonding resin was removed with a 12 bladed scalpel, fine finishing burs, and diamond-impregnated finishing strips. The rubber dam was removed. The mandibular arch was seated in the same manner. Once the mandibular arch was seated, preliminary occlusal adjustments were performed. Since the patient’s occlusal awareness was reduced by the effects of the anesthesia, adjustments were done only to remove obvious centric occlusion prematurities (Figures 13 to 15).
Final Adjustments
Forty-eight hours later the patient returned to the office for residual bonding resin removal and initiation of occlusal balancing. Balancing was accomplished by utilizing the T-Scan II System (TekScan). This system accurately records the timing of occlusal contacts and the forces they generate. The T-Scan II occlusal analysis system measures occlusal contact in real time and has the ability to disclose time and force data. Occlusal data is recorded by instructing the patient to occlude on an intraoral sensor that is connected to a computer. This time and force measurement capability allows the clinician to optimize occlusal contact patterns precisely, thereby attaining measurable verification of what has been theorized as ideal occlusal parameters in many classical occlusal principles.4-7
The data displayed on the monitor represents the maxillary arch (Figure 16). Data can be displayed in various formats, including the 2-D contour view and the 3-D columnar view. The 2-D view resembles articulation paper marks, and the 3-D view makes force viewing easy when compared to the color-coded force legend. The force-versus-time graph allows the clinician to view time between initial tooth contact and last tooth contact, ideally less than 0.2 seconds.8
CONCLUSION
This type II patient presented with several occlusal signs of dysfunction as well as aesthetic concerns, but no symptoms. Through comprehensive evaluation, a diagnosis, treatment plan, and prognosis were developed, all prior to initiation of restorative care. The patient’s stomatognathic system, as predicted, maintained a resilience and natural resistance to pain before, during, and following his restorative care.
Acknowledgment
The author would like to thank Arrowhead Dental Laboratory for the fabrication of the rest-orations used in this article.
References
1. Cooperman HN, Willard SB. Studies of the Louchheim Collection of Skulls. New York, NY: American Museum of Natural History, 1960.
2. Cooperman HN. HIP plane of occlusion in oral diagnosis. Dent Surv. 1975;51;60-62.
3. Venneri AJ. A new approach to at-home oral irrigation. J Am Dent Assoc. 1997;128:755.
4. Kerstein RB. Current applications of computerized occlusal analysis in dental medicine. Gen Dent. 2001;49:521-530.
5. Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd ed. St Louis, Mo: Mosby Year Book: 1989.
6. Schuyler CH. Fundamental principles in the correction of occlusal disharmony, natural and artificial. J Am Dent Assoc. 1935;22:1193-1202.
7. Glickman L. Clinical Periodontology. 4th ed. Philadelphia, Pa: WB Saunders: 1972.
8. Kerstein RB, Grundset K. Obtaining bilateral simultaneous occlusal contacts and a straight line path of closure with computer analyzed and guided occlusal adjustments. Quintessence Int. 2001;32:7-18.
Dr. Stevens is an international speaker on the subjects of smile enhancement, principles of occlusion, full-mouth restoration, and diagnosis and treatment of temporomandibular disorders (TMJ). An active lecturer since 1989, Dr. Stevens has spoken to thousands of care providers including dentists, physicians, chiropractors, and physical therapists. His focus continues to be instructing doctors and their staff on the use of computer-enhanced electro-diagnostic equipment in dentistry. Dr. Stevens is also a founding member of the Dr. Dick Barnes Group. He can be reached at (608) 837-4880, at cjs@thebestsmiles.net, or by visiting thebestsmiles.net.
Disclosure: Dr. Stevens is a member of the Dr. Dick Barnes Group and also lectures for BioResearch. He does not receive financial remuneration for any product mentioned in this article.
