Full Mouth Rehabilitation of a complex wear case, the digital approach

Modern smile rehabilitation has become increasingly predictable thanks to digital workflows. The primary goal is to achieve results that are harmonious with the patient’s facial features while being minimally invasive. Understanding function is crucial for ensuring the longevity of each case. The new digital approach enables precise planning, facilitating fully guided dentistry. Furthermore, a new generation of monolithic materials for both direct and indirect restorations exhibit remarkable physical and optical properties. Coupled with libraries of natural teeth, dentists can attain superior results that prioritize aesthetics, function, and biology.

styleitaliano style italiano initial status of tooth wear

Fig.1
The patient sought a second opinion after being advised to undergo complex orthodontic treatment, orthognathic surgery, followed by restorative rehabilitation.

The patient’s primary complaints were:

1. Poor aesthetics
2. General sensitivity of teeth
3. Teeth appearing to disappear

Upon clinical examination, the following diagnoses were made:

1. Generalized erosion in the upper anterior and lower posterior regions (likely due to reflux)
2. Decay
3. Stable periodontal and temporomandibular joint (TMJ) conditions
4. Class 3 skeletal and dental relationship
5. Reverse smile curve
6. Incorrect anterior tooth proportion

styleitaliano style italiano smile analysis

Fig.2
When analyzing the face, it’s crucial to recognize that the smile is dynamic. Therefore, a series of photos or even a video is necessary to make accurate decisions regarding various aspects such as the position of the central incisor edge, tooth proportion, and most importantly, the required smile curve. An ideal smile curve should align with the curvature of the lower lip while this patient exhibits a negative smile curve.

styleitaliano style italiano digital smile design

Fig.3
Digital Smile Design (DSD) should serve as the foundational step in all smile rehabilitations. While the orofacial analysis typically relies on mathematical rules and straight lines, it’s important to acknowledge the presence of facial asymmetries in many cases. Understanding how to develop smiles that are in harmony with the face rather than purely symmetrical is crucial.
The facial flow concept, pioneered by Bruno Perera and Christian Coachman, emphasizes the use of landmarks such as the glabella, the tip of the nose, the philtrum, and the center of the chin. In our patient’s case, there is a slight deviation or flow to the right. Recognizing and comprehending this asymmetry is essential to achieve organic and balanced aesthetic results, as the teeth, gums, and face must work together seamlessly.
The smile frame, determined by these considerations, dictates the central incisal edge position, ideal tooth proportions, and the smile curve. Leveraging libraries of natural teeth and artificial intelligence enables us to select teeth that promote ideal facial harmony. In this instance, we utilized the natural teeth of Dr. Kyle Stanley, a respected colleague and renowned dentist, as our smile donor.

styleitaliano style italiano digital wax up

Fig.4
Visualizing the three-dimensional changes necessary to restore this case is essential. Full mouth rehabilitation (FMR) is a comprehensive dental treatment aimed at addressing various oral health issues throughout the entire mouth. It involves rebuilding, restoring, and rejuvenating the teeth, gums, and jaw to achieve both functional and aesthetic improvements. The objective of FMR is to restore oral health and function, correct bite alignment, and enhance the smile’s appearance. Importantly, the concept of full mouth rehabilitation doesn’t mandate the treatment of every tooth.

styleitaliano style italiano digital full mouth rehabilitation project

Fig.5
Utilizing 3D design enables a comprehensive understanding of the patient’s treatment. The objective was to address only the affected teeth, leading to a decision to increase the Vertical Dimension of Occlusion (VDO) for several reasons:

1. To create space for restorations while conserving tooth structure.
2. To enhance facial integration by lengthening the upper anterior teeth.
3. To improve occlusal relationships, including axial load, overjet/overbite, and the steepness of guidance.

The treatment plan unfolds as follows:

Visit 1: Preparation of upper teeth 14-24 for ceramic (e.max) restorations, along with lower posterior teeth 34-36 and 44-46 for Tetric CAD milled composite restorations.

Visit 2: Fitting of upper ceramic restorations and lower posterior restorations at an increased VDO, followed by scanning for no-prep Tetric CAD restorations on teeth 33-43.

Visit 3: Fitting of lower anterior Tetric restorations.

Given that the upper and lower second molars were unaffected by wear, they were excluded from the plan. The Dahl concept will be applied, allowing these teeth to naturally erupt into occlusion over a short period.

styleitaliano style italiano from design to mock up

Fig.6
The 3D (digital design) STL file serves as the basis for printing a 3D model, which is then utilized for the mock-up process. This mock-up, often referred to as a “test drive,” serves multiple purposes. It confirms both the aesthetics and function of the proposed treatment while providing essential information regarding tooth preparation, color, and ceramic selection for the CAM restorations.

In this case, a functional mock-up was done, involving designs for both the maxillary and mandibular regions. This comprehensive approach allows for the analysis of not only aesthetics but also changes in occlusion, including adjustments to the vertical dimension and the establishment of new guidance for the patient. Additionally, phonetics are evaluated during this process to ensure optimal function and patient comfort.

styleitaliano style italiano preparation through the mock up

Fig.7
Guided tooth preparation is crucial for minimally invasive restorative dentistry. Opting for an additive approach with indirect restorations allows for conservative tooth preparation, preserving enamel whenever possible. The mock-up serves as the starting point for this process.

Through guided tooth preparation, precise space is created for ceramic restorations, controlled by specific depth-cut burs. Gingival cuts are typically 0.3mm, while facial cuts range from 0.5mm to 0.7mm, and incisal cuts from 1mm to 1.5mm.

After depth cuts, the mock-up is removed to identify areas needing tooth reduction. This ensures optimal space for CAD CAM ceramic restorations, faithfully replicating the 3D design/mock-up.

styleitaliano style italiano intraoral scan taken with anterior jig based on new VDO

Fig.8
Centric Relation is considered the optimal occlusal relationship for full-mouth rehabilitation due to its reproducibility and muscular stability. Achieving an accurate bite scan is best facilitated by using an acrylic (Pattern resin) jig.

In this case, it was determined to separate contact between the upper teeth. This decision was influenced by early interproximal decay and the need for treatment of both buccal and palatal surfaces affected by erosion. Importantly, only margins were placed on both buccal and palatal surfaces, without any preparation.

styleitaliano style italiano before and after preparation

Fig.9
For the lower preparation of Tetric CAD (composite), the procedure included removing old composite restorations or decay, followed by the application of a flowable composite for immediate dentin sealing.
Teeth without existing restorations or decay were simply smoothed using a Soflex disc, constituting a non-prep protocol. The necessary space for the restorations would be achieved by increasing the Vertical Dimension of Occlusion (VDO).
It should be noted that the lower anterior teeth were aligned using clear aligner therapy.

styleitaliano style italiano minimal preparation

Fig.10
Here, we present a cross-section overlay of tooth 11. The blue scan represents the pretreatment condition, while the brown scan depicts the preparation stage. Notably, on the buccal surface, no preparation was necessary as the case was entirely additive. Similarly, on the palatal side, no preparation was done as the required space for ceramic was attained through an increase in the Vertical Dimension of Occlusion (VDO).
The only modification made was the rounding of the incisal edge, ensuring a smooth and rounded internal surface conducive to achieving optimal results for CAD CAM restorations.

styleitaliano style italiano emax and tetric cad restorations

Fig.11
The upper e.max ceramic restorations and lower Tetric CAD restorations were milled from copies of the 3D design, a process often colloquially termed “copy-paste dentistry.”

styleitaliano style italiano cementing indirect restorations

Fig.12
For the isolation during the cementation of e.max restorations, both a full dam and split dam were utilized, along with a chord to retract the gingiva, ensuring superior moisture control and efficient removal of residual cement. As part of standard adhesive dentistry practices, the substrate surface was pre-cleaned using 29-micron aluminum oxide sandblasting (Aquacare).

In the final step, I employed Ari-Fol forceps from Bausch to check for tight contacts, enabling precise adjustment. The e.max restorations were bonded using a full adhesive protocol, starting with Monobond etch and prime applied to both the ceramic and tooth surfaces. The tooth was prepared with a total etch approach, considering the minimal amount of exposed dentine. Subsequently, a universal bonding agent (Adhese Universal by Ivoclar) was applied and cured. Finally, Variolink Esthetic (light cure) resin cement was used to bond the restorations in place.

styleitaliano style italiano cementing posterior overlays

Fig.13
The Tetric CAD restorations are milled from composite blocks, which boast a flexural strength of 272 MPa. These restorations are ideally cemented using heated highly filled composite, enabling precise margin polishing.

styleitaliano style italiano scan if lower arch preparation

Fig.14
During the second visit, the upper anterior ceramic restorations and lower posterior composite restorations were fitted at the increased Vertical Dimension of Occlusion (VDO).
Additionally, a new intraoral scan (IOS) was taken to fabricate the lower anterior Tetric CAD non-prep restorations.

styleitaliano style italiano cad model of lower veneers

Fig.15
With the CAD process, we incorporated a cutback technique for micro-layering, creating small spaces to add incisal composite. This addition served to enhance translucency and enable precise control over occlusal contacts and guidance.

styleitaliano style italiano tetric veneers

Fig.16
Composite offers the advantage of finer margins compared to ceramic, making it well-suited for a non-preparation approach. The surface of these restorations requires sandblasting at 53 microns and 1-1.5 bar pressure, followed by the application of a universal bonding agent.
Subsequently, the restorations are cemented using the same highly filled heated composite shade as the block, such as A1 Tetric. This ensures that the restorations can be polished without concerns of exposing weak, unfilled cement.

styleitaliano style italiano after full mouth rehabilitation

Fig.17
The beautiful tissue integration of both upper and lower restorations highlights the success of the full mouth rehabilitation (FMR). The longevity of FMR hinges on preserving tooth structure and achieving the ideal occlusal scheme, including correct anterior and canine guidance.

styleitaliano style italiano esthetics of composite and emax veneers

Fig.18
This full mouth rehabilitation (FMR) was entirely additive, allowing the patient to bypass comprehensive orthodontics and orthognathic surgery. In just three visits, we successfully restored both function and aesthetics, thanks to the precise control afforded by a fully digital workflow.

styleitaliano style italiano scan of the final restorations checking thickness

Fig.19
After completing the treatment, we take an intraoral scan (IOS) of the final restorations and occlusion. This allows us to overlay the prep IOS with the final IOS, enabling evaluation of whether we achieved the ideal thickness of the ceramic restorations, as recommended by the manufacturer.
Furthermore, the final IOS can be superimposed with the initial 3D design to assess how accurately our guided tooth preparation followed the design. One of the significant challenges in indirect restorations is ensuring adequate space for the ceramic. Alternatively, over-preparation of the teeth can compromise any residual enamel, especially in cases where an additive approach is employed.

styleitaliano style italiano smile after full mouth rehabilitation

Fig.20
Achieving ideal facial integration, correcting the upper central incisal edge position, optimizing tooth proportion, and establishing the ideal smile curve are paramount in smile rehabilitation. These factors, combined with the use of natural shapes and appropriate value, form the essence of a successful smile transformation.

Conclusions

The success of this procedure can be attributed to precise planning through Digital Smile Design (DSD) and a digital workflow, which facilitates guided dentistry, ensuring accurate replication of the 3D plan. Controlled tooth preparation enabled us to preserve all bonding substrates to the enamel, which positively impacts the longevity of the restorations.
Moreover, opening the Vertical Dimension of Occlusion (VDO) allowed for correction of the smile curve, creation of space for the restorations, and improvement of occlusal relationships, including axial load, overjet/overbite, and steepness of guidance.

Bibliography

  1. Coachman C, Sesma N, Blatz MB. The complete digital workflow in interdisciplinary dentistry. The International Journal of Esthetic Dentistry. 2021 Spring;16(1).
  2. Coachman C, Calamita Ma, Sesma N. Dynamic documentation of the smile and the 2D/3D Digital Smile Design process. Int J Periodontics Restorative Dent. 2017;37:183–193.
  3. Mahn E, Sampaio CS, da Silva BP, Stanley K, Valdés AM, Gutierrez J, Coachman C. Comparing the use of static versus dynamic images to evaluate a smile. J Prosthetic Dent. 2020 May;123(5):739-746.
  4. Silva BP, Mahn E, Stanley K, Coachman C. The facial flow concept: An organic orofacial analysis of the vertical component.
  5. Edelhoff D, Prandtner O, Saeidi Pour R, Liebermann A, Stimmelmayr M, Güth JF. Anterior restorations: The performance of ceramic veneers. Quintessence Int. 2018;49(2):89-101.
  6. Gurel G. The science and art of porcelain laminate veneer. Chicago: Quintessence publishing; 2003.
  7. Azarbal A, Azarbal M, Engelmeier RL, Kunkel TC. Marginal Fit Comparison of CAD/CAM Crowns Milled from Two Different Materials. J Prosthodont. 2018 Jun;27(5):421-428.
  8. Calamita M, Coachman C, Sesma N, Kois J. Occlusal vertical dimension: treatment planning decisions and management considerations. The International Journal of Esthetic Dentistry. 2019 Jan;14(2):166-181.
  9. Gurel G, Morimoto S, Calamita MA, Coachman C, Sesma N. Clinical Performance of Porcelain Laminate Veneers: Outcomes of the Aesthetic Pre-evaluative Temporary (APT) Technique. The International journal of periodontics & restorative dentistry. 2012 Dec;32(6):625-35.
  10. Poyser NJ, Porter RWJ, Briggs PFA, Chana HS, Kelleher MGD. The Dahl Concept: past, present and future. British Dental Journal. 2005 Jun 11;198(11):669-76.
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