Complex reconstruction changes a patient’s life

Carmen had seen examples of our work on our website, so she felt confident that she was coming to the right place for her care.

Despite her confidence in us, however, she was still nervous about having major dental work done.

We did everything we could to relieve her anxiety and make the process as easy and comfortable as possible.

Patient history

Several teeth had been broken because of abuse from a former boyfriend, and she had severe dental pain due to the trauma and resulting malocclusion. Carmen had been a model as a teenager, but she had rarely smiled since the teeth had been broken (Fig. 1a).

In fact, she was so self-conscious that she rarely opened her mouth in public, and she never showed her teeth in photographs.

After eight years of living with little hope, she hoped to regain her smile, self-confidence and faith in people because of her experience with us.

She cried with gratitude when I told her that we could help her to regain the confidence, chewing function and comfort that she had lost many years ago.

Clinical examination findings

Our comprehensive evaluation included a full series of radiographs, digital photographs, clinical examination of the teeth and periodontium, diagnostic models and patient interview. Carmen’s teeth were also severely affected by tetracycline staining.

Heavy attrition, deteriorating restorations and extensive decay added to the complexity of her restorative situation.

A lack of regular dental care and many years of smoking helped lead to moderate periodontal disease and the loss of several posterior teeth. Carmen’s measurement from the cemento-enamel junction (CEJ) of the maxillary central incisors to the CEJ of the mandibular central incisors (Shimbashi measurement) was only 11 mm.

This was a result of the heavy wear on her remaining teeth (Figs. 2–4). A Shimbashi measurement of about 16 to 18 mm is typical for patients exhibiting Class I occlusion.

Initial periodontal protocol

We began Carmen’s treatment by addressing her periodontal disease. Thorough oral hygiene instructions were given, scaling and root-planing appointments were scheduled immediately and she began rinsing with chlorhexidine twice daily. My hygienist thoroughly cleaned her teeth under local anesthesia in two visits. Then we reevaluated her periodontal health four weeks later at the follow-up cleaning.

She had already improved dramatically. Pocket depths decreased significantly (from 4 to 5 mm down to 2 to 4 mm), bleeding upon probing was eliminated and her plaque score improved significantly. For the first time in many years, the gingival apparatus appeared to be pink and healthy. Now convinced of her commitment to maintaining her oral health, we proceeded with additional records to finalize our restorative treatment plan.

Diagnostic records and the restorative plan

Carmen’s needs were extensive, so we opted to perform full-mouth rehabilitation to restore her natural form, function and esthetics. New diagnostic models were made in order to facilitate creation of a full diagnostic wax-up.

We made an NTI appliance for her to wear for several nights in order to deprogram (or relax) her tense masticatory muscles. This allowed us to obtain a more accurate centric relation (CR) measurement. Facebow and stick-bite records were also made, and photographs were taken to aid our ceramist (Marv Staggs, Precision Dental Restorations [PDR]; Salem, Ore.). These records allowed him to accurately mount Carmen’s models for a full-mouth wax-up.

We reviewed photographs from several smile guides with Carmen to decide how to design her new smile. We determined what she wanted her new teeth to look like, selecting shapes, embrasures, line angles and texture. We also decided on the desired colors and incisal translucency to be utilized.

Local anesthetic was administered so we could “sound” the bone to see how much gingival recontouring we could do. We were able to improve gingival symmetry with our laser, and we made new PVS impressions.

After reviewing restorative options with our ceramist, we decided to restore Carmen’s upper and lower arches with crowns and a bridge. Because strength and maximizing esthetics were both high priorities, we decided to use Empress (Ivoclar Vivadent; Amherst, N.Y.) crowns for teeth #4–#11 and #21–#29, and a Lava (3M ESPE) bridge for #12–#14. Her missing posterior teeth would be restored later with implants or removable partials.

First restorative appointment

At the preparation appointment, we evaluated the wax-up with Carmen, and we were all very pleased. We therefore proceeded with her restorative treatment.

We modified several teeth with reduction models provided by PDR so that we could preoperatively transfer the wax-up to the mouth with Luxatemp (Zenith/DMG; Englewood, N.J.). This gave us a tool for verification of our records, desired lengths of teeth, CEJ-to-CEJ measurements, proper canine and anterior guidance and occlusion.

The full-mouth Luxatemp mock-up also served as an ideal intraoral preparation guide so that depth cuts could be made into the Luxatemp and tooth structure. This allowed us to maintain even reduction and ideal orientation within the arch form. We segmentally prepared all maxillary teeth, making bite registrations (LuxaBite, Zenith/DMG) for the anterior, right side and left side, allowing us to maintain the new vertical dimension that had been established with the mock-up.

After the maxillary preparations were completed, we checked the preparation shades, took photographs and made a maxillary final impression.

We used the Sil-Tech stint to make ideal temporaries, and the CEJ-to-CEJ measurements and tooth lengths were again verified.

Sequential bite registration records were again used while prepping the lower arch for the anterior and both posterior sections.

We systematically recorded the relationship from the lower to upper preparations and the lower preparations to the upper temporaries. This helped to ensure that all models could be easily cross-mounted by the laboratory and that the new vertical dimension was maintained.

We made the mandibular impression and temporized #21–#29 with Luxatemp. We then recorded the bite relationship between the maxillary preparations and the mandibular temporaries. After temporarily cementing the maxillary temps, we recorded the bite relationship between the upper and lower temps.

Facebow record and stick bites were also made, and photographs of each were taken. We completed the preparation appointment with photographs and PVS impressions of the temporaries (Fig. 5).

All of the relevant photos were sent to PDR on a disc, along with the laboratory prescription, impressions, bite registrations and models. We provided detailed instructions for completing her case.

Trial period with temporaries

Our goal was to restore Carmen to a Shimbashi measurement of 17 mm to allow for ideal function, comfort and maximum esthetics. Her occlusion was restored to CR in the temporary stage, and she adapted to the temporaries very well.

If she had any issues with the increased vertical dimension, we could have adjusted her temporaries to a position of greater comfort while maintaining proper function.

Her self-confidence increased dramatically with her temporary restorations, and she found herself smiling more than ever. Carmen was looking forward to a new future filled with hope and happiness, and her inner joy was reflected on the surface.

Seating the case

Evaluation of her new restorations on the articulator confirmed that the fit, lengths, esthetics, occlusion and color were all exactly as prescribed (Fig. 6).

When she arrived for her seat appointment, she was still very comfortable, so a little more than three months after our first consultation we were ready to deliver her beautiful porcelain restorations (Figs. 7–9).

We removed the maxillary temporaries and cleaned up the prepared teeth after administering local anesthesia. We tried in each restoration individually and collectively, and everything fit very well. The maxillary restorations also occluded well with the mandibular temporaries. After determining that we both preferred the translucent shade of RelyX (3M ESPE), the maxillary restorations were bonded utilizing standard bonding protocol and the “tack-and-wave” technique.

The maxillary restorations were fully seated at the same time and were individually “tacked” in with the Bluephase (Ivoclar Vivadent) curing light with tacking tip for one second each.

The standard tip was then used in order to “wave” across the arch for a few seconds on the facial and lingual sides, hardening the cement to the point where the gross excess could be simply removed.

Liquid Strip (Ivoclar Vivadent) was placed around all of the margins (to ensure that the oxygen-inhibition layer cured completely), we flossed carefully and final curing was completed. The lower arch was anesthetized, and maxillary cleanup was completed.

We removed the mandibular temporaries and utilized the same try-in and seating techniques that we used in the maxillary arch.

Occlusion was adjusted slightly, photographs were taken and postoperative instructions were given. Seeing her new smile in the mirror elicited tears of joy for Carmen (Fig. 10).

About the author

Dr. Jim Arnold serves on the advisory board for the Academy of Comprehensive Esthetics while balancing his time between three busy dental practices, his four children and triathlon training. In 2008, the American Academy of Cosmetic Dentistry awarded Arnold with the Partners in Peace Award for his extensive work with the Give Back a Smile program. Contact Arnold at drarnold@smilesbyarnold.com or visit www.SmilesByArnold.com.