This patient presented with the main complaint that they were concerned with the aesthetics of upper and lower teeth.
On examination it was determined that both upper and lower teeth had tooth loss due to attrition the patient had a history of unsuccessful attempts of bleaching.
There was mild crowding in the 23 area and an existing deep bite.
Concerns of placing upper veneers was creating envelope of function problems.
As always the intention was to be conservative in the treatment and preserve tooth structure.
The choices were to intrude the upper and lower teeth then place ceramic restorations, or open vertical dimension of occlusion and restore anterior teeth this would maintain ideal occlusal relationships.
The concern was opening VDO as this would involve restoration of posterior teeth. As Frank Spear stated, if posterior teeth are unworn and in occlusion then the case must be treated at the existing vertical occlusion and orthodontics would be required. Although there was little wear on the posterior teeth there were sufficient large failing restorations that allowed for partial coverage restorations to open VDO.
The starting point for a case like this is to decide where in the face is the ideal place to put the teeth (facially driven) and then to decide on the functional aspects (VDO, occlusal scheme, speech).
DSD is the perfect starting point. From a 2D design we move to 3D and then to the functional mock up which will eventually drive the treatment.
The concern was to commit the patient to the scale of treatment, but weighing up the clinical situation and the patient’s expectations, it was decided against orthodontics. The treatment would involve minimally invasive protocols, opening VDO creating a facially driven result that would satisfy all functional requirements.
Fig.1
This is a generalised wear case, using the Magne and Belser classification we find indication for treatment
with veneers due to:
1. Type 1b – teeth resistant to bleaching
2. Type 2c – augmentation of incised length
3 Type 3b – extensive loss of enamel due to wear
Fig.2
Lateral view allows us to visualise the affect lengthening incisors will have on the occlusion, clearly it will increase the over-jet and therefore restrict the envelope of function so a decision must be made to either intrude incisors or open the Vertical Dimension of Occlusion (VDO).
Fig.3
An assessment is made on any wear on the occlusal or the extent and condition of existing restorations. Here it is clear that although there is little wear, there are numerous failing restorations some of which are fairly extensive, this might be an influence in deciding to open the VDO rather than orthodontic intrusion.
Fig.4
This might be an influence in deciding to open the VDO rather than orthodontic intrusion.
Fig.5
Facially driven treatment planning should start with facial photos, these a 2 of the most important in the Digital Smile Design protocol, frontal smile and 12 o clock these allow us to make decisions on the correct incised edge position. This is an ideal starting point of any such rehabilitation.
Fig.6
Using the DSDapp we can start the 2D design, this will allow the laboratory to develop the full functional 3D design based on aesthetics and the new occlusal scheme at an increased VDO.
Fig.7
2D simulation from DSDapp showing ideal dento-labial-facial integration.
Fig.8
Full functional mock up.
Here we have the ability to assess all the aesthetic and functional changes necessary to complete the case and highlight the required tooth preparation required. At this stage to case is completely additive allowing an entirely minimally invasive approach and hence an opportunity to preserve the existing enamel.
Fig.9
Full functional mock up.
Fig.10
Full functional mock up. Anterior guidance.
Fig.11
Full functional mock up. Canine guidance.
Fig.12
Guided tooth preparation:
– 0.3 mm on cervical
– 0.5 mm middle and incisal
– 1 mm incisal reduction
Fig.13
Guided soft tissue reduction, diode laser respecting biologic width.
As you can see the case is almost completely additive, but this does not mean it’s prepless. Although aiming to minimal invasiveness preparing the teeth allows to:
1. Hide transition
2. Control emergence profile
3. Manage path of insertion
4. Manage occlusal requirements
5. Control thickness and colour of restorations
Fig.14
Gingival and incisal silicone indices to evaluate buccal reduction and intended embrasures.
Fig.15
Stump shade, the thickness of ceramic and the desired shade will determine the required choice of translucency of e.max (Ivoclar Vivadent) required double cord technique used for impression. In this case I used two #000 cords (Ultradent), the first cord without astringent, and the second one with 15.5% ferric sulphate.
Fig.16
Tooth preparation limited to enamel.
Fig.17
Isolation, split dam with retraction cord, no astringent. One can appreciate the supragingival margins for control on moisture and cementation. Cementation sequence 2 at a time starting with the centrals
Fig.18
This is a common problem with treating just the upper arch and lengthening teeth. It frequently increases the overbite hence creating envelope of function issues, this will result in fractured restorations, myalgia, tooth mobility or tooth movement. In this case the plan is to open the VDO which will correct these problems.
Fig.19
Upper arch completed at existing VDO lower transitional restorations placed at increased VDO purely additive. Monolithic e.max restorations bonded with Variolink aesthetic LC.
Fig.20
Lower transitional restorations.
Fig.21
Guided tooth preparation 1-1.5mm occlusal reduction as per manufacturer recommendation (e.max ivoclar
vivadent).
Fig.22
Just as for the upper arch. Stump shade, the thickness of ceramic and the desired shade will determine the required choice of translucency of e.max (Ivoclar Vivadent) required double cord technique used for impression. In this case I used two #000 cords (Ultradent), the first cord without astringent, and the second one with 15.5% ferric sulphate.
Fig.23
Tooth preparation limited to enamel unless existing restorations present.
Fig.24
CR occlusal relationship recored with leaf gauge and pattern resin.
Fig.25
Bite registration completed in CR using Pattern resin (GC).
Fig.26
Spot etch and then shrink wrap bis-acryl temporisation.
Fig.27
Lower temporaries.
Fig.28
Lower working impression, heavy and light body one stage technique with Aquasil (Dentsply).
Fig.29
Facebow and facial plane relator.
Fig.30
Try in of restorations to confirm fit, choice of value of cement and occlusion before placement of rubber dam.
Fig.31
Isolation, split dam with retraction cord. One can appreciate the supragingival margins for control on moisture and cementation. Cementation sequence for the lowers is to place all 4 incisors together.
Fig.32
Case completed at now correct VDO with favourable envelope of function.
It was discussed with patient that there would be discrepancy in length on upper lateral and canines and the neck of 23 would be warmer due to lack of thickness of ceramic. It was important to keep the preparation in enamel and not have it over contoured.
Monolithic e.max restorations bonded with Variolink aesthetic LC.
Fig.33
Monolithic e.max restorations bonded with Variolink aesthetic LC.
Fig.34
Facially driven functional full mouth rehabilitation using minimally invasive protocols.
Fig.35
Facially driven functional full mouth rehabilitation, notice the detail copied from the 2D Design on the DSD app.
Fig.36
1 year post op.
Conclusions
The case was successful due to meticulous planning focusing on facial aesthetics, function and minimally invasive protocols. Of course other treatment options were available but the patients complaints and expectations were considered as a result a positive result was achieved.
Bibliography
1. Coachman C. Complete digital workflow for facially driven restorative dentistry. Clin Oral Impl Res. 2017;28(Suppl. 14).
2. Ferraris F. Posterior Indirect Adhesive Restorations (PIAR): Preparation designs and adhesthetics clinical protocol. Int J Esthet Dent 2017;12:482–502.
3. Fradeani M, Rademagni M. Porcelain laminate veneers: 6- to 12-year clinical evaluation–a retrospective study. Int J Periodontics Restorative Dent. 2005;25(1):9-17.
4. Spear F. Approaches to vertical dimension of occlusion. J Adv Aesth Multidisc Dent 2006;2(3).
5. Gurel G, Coachman C, Calamita M. Influence of Enamel Preservation on Failure Rates of Porcelain Laminate Veneers. Int J Per Rest Dent. 2013;33.
