Achieve Positive Outcomes in Full Mouth Esthetic and Functional Rehabilitation

Many factors go into how dentists decide which treatment options to present to patients. What are the best results that can be achieved with the technical abilities and tools we have? Can the patient tolerate the procedures, and are they willing to go on the treatment journey to get the desired result? Does the patient understand the possible consequences of no treatment?

Patients must maintain ownership of the chosen treatment. Co-diagnosis is key in this approach. Working together with patients to discern their dental goals upfront will establish expectations and create a better working relationship. Ensuring patients are fully committed and understanding their part in the process — both short- and long-term — presents the best chance for success.

This case report looks at a patient who desired full mouth esthetic and functional rehabilitation.

Case Report

At a prophylaxis appointment, an established patient expressed interest in replacing some of his old fractured crowns, eliminating the dark lines showing at his gumline, making his front teeth not look so “thin,” and preventing further wear (Figure 1 and 2).¹ After discussing his concerns, he agreed to a separate appointment to take photos and further discuss options for how to best accomplish his treatment goals.

At the evaluation, it was clear that if anything was to be added to his front teeth, room was needed by either shortening his mandibular anterior teeth or increasing the vertical dimension.²

Also discussed was the crowding of his lower mandibular teeth, the retroclination of the maxillary anterior teeth, and the perfectly matching wear patterns of the anterior teeth. All of this was most likely caused by his constricted envelope of function.³

The patient denied having any of the typical risk factors: disrupted sleep patterns, snoring, and acid reflux. Positioning his teeth in a more favorable position would improve the final outcome and, ultimately, result in less tooth structure being removed.

The planned treatment included clear aligner therapy, bleaching mandibular anterior teeth, building up mandibular anteriors with composite resin, preparing maxillary anterior teeth for conservative crowns, and replacing and preparing maxillary and mandibular posterior teeth for crowns, all while opening his vertical dimension to restore the worn and eroded tooth structure.

Clear Aligner Therapy. The goals of clear aligner therapy were to straighten, level, and align mandibular anterior teeth. In addition, proclination of the patient’s maxillary and mandibular anterior teeth was desired, since each degree of change in the steepness results in a decrease in force applied.

The mandibular anterior incisal edges would be lengthened with composite to make a level plane and increase the vertical dimension of occlusion, so gingival levels needed to be as even as possible. The patient wore his clear aligners for about 12 months, and the alignment goals were successfully achieved. A whitening tray for the mandibular anteriors was fabricated since they would dictate the shade for his final restorations.

Fine tuning the sequence of treatment. The next phase was restorative and, most important, fine tuning the sequence of treatment. The first step was to establish the new maxillary incisal edge position using tooth show at repose.⁴ Normally, a man of this age would show 0 to 0.5 mm of tooth at rest and possibly a little more for a youthful look.

Facial esthetics and lip mobility should be considered in addition to how the added length would appear with a natural smile.⁵ The patient was deficient 4 mm from showing tooth at rest (Figure 3). However, in considering his smile line and measuring his lip mobility, adding 4 mm would probably be too much.⁶ Ultimately, about 1.5 to 2 mm were added, measuring from his current incisal edge position in the diagnostic wax up.⁷

Clear communication with the ceramist completing the diagnostic wax up is imperative, so the most incisal portion of the edge of tooth #8 was referenced for the starting point (Figure 4).⁸ The new vertical dimension position was determined by using a leaf gauge to open the bite and record the very repeatable, comfortable, and fully seated condylar position (Figure 5).

The patient was instructed to close on the leaf gauge, slide forward, slide back, and lightly squeeze. Leaves were added and subtracted until the desired amount of increased vertical was achieved. In addition, the amount of overjet increased slightly as the mandible rotated down and back.⁹

The wax addition to the lower anteriors was only additive to the incisal edges to make them somewhat level to aid in the anterior guidance through excursive movements and improve esthetics.¹⁰

Study models were mounted on an articulator via facebow transfer with the pin set at 0. This enabled the lab to simply use the magnetic mounts to attach the models to the articulator because it is split cast accurate. Once the wax up was completed and returned, several copyplast and putty matrices were fabricated to be used for both reference for reduction and fabrication of the provisionals (Figure 6, page 14).

Preparation Day one

The entire full-mouth procedure was to be completed over three days. Day one involved doing the lower anterior composites on teeth #s 22 to 27.¹¹ The every-other-tooth technique was used by etching #s 23, 25, and 27.

A tofflemeyer band was used between each tooth to prevent etching and bonding the adjacent teeth (Figure 7, page 14). A lingual putty matrix was used to add composite to #s 23, 25, and 27. Several composite shades were used to create the full contour, multilayered restorations (Figure 8).

Full finishing and polishing were completed so the adjacent composites could be easily separated.¹² Mylar strips were placed interproximally and the same steps completed for teeth #s 22, 24, and 26. The only difference was that each mylar strip was quickly pulled in a facial or lingual direction prior to curing the composite.

Once the mylar strip was removed, the uncured composite was “pushed” gently into the interproximal area to touch the adjacent, fully polished surface. To remove or break this junction, simply insert a paddle instrument interproximally and slightly twist. A click will be audible, which creates enough space to allow floss to pass through but with a tight contact. The patient went home with anterior-only contact, much like an anterior bite plane.

Preparation Day Two

The following day focused on preparing, impressing, and provisionalizing the entire maxillary arch. Old restorations were removed and bis-acryl material was placed into a putty matrix and seated intraorally. The putty was gently removed leaving the bis-acryl on the unprepped teeth. This provided a preview of the final result while the patient had full lip mobility before anesthesia, as well as guidance for an ideal preparation.

The preparation was completed through the provisionals, thus ensuring uniform reduction and material thickness (Figure 9). In some areas, no further tooth reduction was needed (Figure 10). All of the teeth were prepared except for #s 8 and 9.^13,14 The leaf gauge was reinserted and the vertical dimension checked. A bite registration in centric relation was recorded.

The preparation of #s 8 and 9 was finalized, and the two posterior bite registrations were connected. So now, there is one solid bite registration at the final desired vertical dimension that has recorded upper preps against the mandibular teeth. Retraction cord was placed, and a full arch polyvinyl siloxane final impression was recorded. The bis-acryl provisional restoration was then fabricated and made in three segments: #s 2-5, 6-11, and 12-15.

Sometimes the number of splinted units varies based on the draw of the preparations and the connector thickness and strength. The provisionals were polished and a final glaze was cured onto the surface. However, the provisionals were not cemented since they would be removed the next day to complete the bite registration of maxillary preps to mandibular preps.

Preparation Day three

The final day of prep was similar to day two. Old crowns were removed and bis-acryl temporaries made with a putty matrix following the wax up design. Preparations were done through those provisionals in similar fashion as with the maxillary arch.

Two bite registrations were taken:

1. With the upper provisionals against the lower preps
2. With the maxillary preps against mandibular preps

The second bite registration involved the bite from the day before that recorded maxillary preps against the mandibular unprepared teeth. At today’s appointment, the upper provisionals were removed, the bite registration previously taken was inserted into the patient’s mouth, and the mandibular posterior aspect of the bite registration was relined with bite registration material.

The final impression with polyvinyl siloxane was taken and provisionals were fabricated. Prior to cementation of the provisionals, the stump shade was chosen. The patient wanted white, but natural final restorations. He was open to having slight imperfections, natural wear facets, translucency, some very faint craze lines, and other subtleties that would help make the new porcelain look like they were his teeth. More chroma on the gingival aspects, a gradient of color running from gingival up to the incisal, and canines to be a half shade darker to mimic a natural dentition were all desired.

A facebow transfer was recorded with the maxillary provisionals to mount on the articulator. The mandibular working model can then be mounted against the maxillary provisionals using the bite registration and then cross mount the maxillary working model against the mandibular working model using the second bite registration. All of this was done with the articulator pin set at 0. Now the desired vertical dimension was set on the articulator with both working models accurately mounted.

The patient returned the following week to make any changes to the provisionals, fine tune his occlusion, and relay the detailed communication to the ceramist. The incisal edge position, facial-lingual inclinations, lip support, occlusal plane cants, midline position and any cants, and the occlusal design were all evaluated. The occlusion needed to be designed to minimize muscle contraction and maximize joint health. This can be accomplished with precise, simultaneous posterior contacts with cusp tips contacting flat receiving areas and having front teeth lightly touching.

When the mandible moves in any eccentric movement, the anterior teeth should disclude the posterior teeth.¹⁵ This could be in a canine-guided set up or with a progressive release where there is group function, but the force moves in an anterior direction.

When the patient moves in lateral excursion further out into a crossover pattern, the anterior teeth (preferably the maxillary central incisor) should take the force in a very smooth hand off from the canine.

In protrusive, the movement should be smooth riding up the cingulum of the incisors with freedom and ease as the steeper the guidance, the more force is applied. This is controlled by the relationship between the mandibular incisal edge and, most important, by the contour of the cingulum of the maxillary incisors.

In summary, a mutually protected occlusion is desired where the back teeth protect the front teeth in centric occlusion and maximum intercuspation positions, and the front teeth protect the back teeth in all excursive movements. The long axis of the teeth plays a part in some of the design of the occlusal scheme. With this information conveyed to the ceramist, final restorations were ready to be fabricated. Layered lithium disilicate was chosen for the maxillary anterior eight teeth and monolithic lithium disilicate for the maxillary posterior teeth and all mandibular posterior teeth.

Delivery

The patient returned approximately 4 weeks later to try in the final restorations. Provisionals were removed and preps cleaned with hydrogen peroxide. The maxillary restorations were tried in and checked for marginal integrity and flossed to ensure there was adequate interproximal contacts.

The midline was verified as being centered and having no cant. The occlusal plane was verified and deemed to be appropriate relative to the patient’s interpupillary line and his facial proportions. The mandibular posterior units were tried in and margins and contacts verified. The occlusion was lightly checked to be very accurate knowing that some small adjustments might need to be made.

Resin-reinforced glass ionomer cement was chosen due to its strength and simplicity. It was decided to cement the maxillary anterior six crowns at one time, with the sequence of placement as #s 8 and 9, followed by #s 7 and 6, and lastly #s 10 and 11.

The posterior right maxillary quadrant was tried in again to ensure complete seating and adequate interproximal contact. Learning from past experiences, I have found that cemented crowns do not have the slight amount of movement that only tried-in crowns have, and the interproximal contacts have caused the crowns not to fully seat. Trying in the crowns and going the extra step to ensure complete seating are extremely beneficial.

Remaining in control of the cementation process, in any case, is key to long-term success. Crowns # 2, 3 , 4, and 5 were cemented at one time and the cement cleaned. The same process for crowns # 12, 13, 14, and 15 was completed. Each lower posterior segment was cemented in similar fashion. Slight occlusal adjustments were made. Smooth transitions, simultaneous and even contacts, and freedom for the patient to have his teeth glide over each other were all attained. A maxillary nightguard was fabricated after a one-week follow-up with the patient (Figure 11 and 12, page 16).

In Summary

The goals of the case were achieved, and the patient was extremely happy with the results (Figure 13 and 14). The case did present some challenges throughout the treatment. Porcelain veneers were considered on the maxillary anterior teeth, but the vertical dimension would not have been able to open unless the ceramic was placed far down the lingual surface.

Another observation is that the contact lengths on the maxillary anterior teeth are slightly longer than desired. Ideally a 40% to 50% length of the papilla in relation to the entire tooth length would be achieved. To be able to close the gingival embrasures and prevent the presence of dark triangles, it was necessary to make the contact lengths longer than ideal. The ceramist did an excellent job with shading and characterizations in the interproximal areas to help create line angles in an appropriate proportion to the tooth but also shading to help hide the shortened papilla.

Papilla fill directly relates to the distance between the height of interproximal bone to the most gingival extent of the contact point.¹⁶ That distance had been determined to be from 4 to 5 mm for complete papilla fill. Additionally, after going through the patient’s desires to fix the fractured porcelain and replace his gold restoration, which had a hole in the occlusal surface, there was a tooth or two that didn’t necessarily need any treatment but would have prevented our goals from being achieved had they not been included in the treatment.

Partial coverage overlays were certainly an option to preserve more gingival enamel. An important aspect to this case was the patient’s attention to detail and ability to have optimal oral hygiene (Figure 15). That cannot be overstated. He had healthy tissue, excellent oral hygiene, strong bone support, and a good understanding of his dental goals and what it would take to achieve them. He was involved and took ownership of the process. With a patient like this and a superb ceramist, positive results can be achieved (Figure 16 and 17).

Key Takeaways

• A mutually protected occlusion is desired where the back teeth protect the front teeth in centric occlusion and maximum intercuspation positions, and the front teeth protect the back teeth in all excursive movements.
• Trying in the crowns and going the extra step to ensure complete seating are extremely beneficial.
• Remaining in control of the cementation process is key to long-term success.
• Papilla fill directly relates to the distance between the height of interproximal bone to the most gingival extent of the contact point.
• Treating a highly motivated, healthy patient with excellent oral hygiene is a strong factor in achieving positive outcomes.

References

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13. Spear F. Using margin placement to achieve the best anterior restorative esthetics. J Am Dent Assoc. 2009;140:920–926.
14. Robbins JW. Tissue management in restorative dentistry. Functional Esthetics and Restorative Dentistry. 2007;1(3):2–5.
15. Cranham J. Anterior Guidance: Myth or Mandatory. Available at: aegisdentalnetwork.com/​id/떏/葎/​anterior-guidance-myth-or-mandatory. Accessed July 17, 2023.
16. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992;63:995-996.

From Decisions in Dentistry. July/August 2023;9(7/8):13-19.