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Multidisciplinary treatment plan in the digital era

New technologies may come in very handful when speaking about multidisciplinary cases. Involving orthodontics, restorative and prosthodontics may easily scare a patient away, but digital workflows allow us to help the patient previsualize the result. Moreover, they give the clinician multiple checkpoints that are very useful in complex case rehabilitation.

young patient looking to improve her smile

Fig.1
This patient was complaining about the esthetic appearance of her smile in terms of severe shade dischromia, teeth position and occlusal discomfort too. A complete dataset was fabricated to evaluate the clinical outcome of the dental treatment.

woman before dental makeover

Fig.2
Pre-operative situation.

lateral view of misaligned and stained teeth

Fig.3
Lateral intra-oral view. The crossbite was reported by the patient as one of the main problems in her smile.

intraoral picture of misaligned teeth

Fig.4
Intra-oral front view.

missing and decayed teeth

Fig.5
Intra-oral right view.

missing and stained teeth

Fig.6
Intra-oral left view.

xray for orthodontic skeletal evaluation

Fig.7
Radiographic evaluation aimed to orthodontics analysis.

digital scan of the patient's teeth

Fig.8
The digital alignment of the intra-oral scans with the face picture is the starting point of 3D esthetic and functional analysis.

digital aethestic mock-up

Fig.9
Digital wax up was developed according to orthodontic treatment possibilities and prosthetic as well. The inter-incisal line was positioned within the 4mm “safe space” and was kept straight.

emotional mock-up before smile makeover

Fig.10
The digital wax up was slightly modified in order to obtain an emotional mock-up to give the patient an idea of the possible outcome.

digital wax-up for veneers

Fig.11
The “executional” wax-up showed the exact final position of the teeth. It is a crucial factor in order to evaluate the clinical steps needed to bring the patient to the final goal of the treatment.

occlusal view of digital wax up

Fig.12
Taking into account the orthodontic possibilities, the esthetic and functional aspects to be improved, and the patient requests, a combined ortho/prostho treatment was planned.

Video 1
The orthodontic movement was performed using the Invisalign System, taking into account the final result, and the following prostho-esthetic rehabilitation by ceramic veneers.

digital stages of multidisciplinary treatment plan

Fig.13
At the end of the orthodontic movement, there was a perfect correspondence between the actual and planned outcomes. At this point, it was possible to proceed to the prosthetic treatment through ceramic veneers and crowns where needed.

smile after orthodontic alignment

Fig.14
Smile at the end of the orthodontic treatment.

side view after orthodontic alignment

Fig.15
Tilted view at the end of the orthodontic treatment

intraoral post-ortho situation

Fig.16
Post-orto intra-oral situation.

side post-orthodontic view

Fig.17
Right view.

side post-orthdontic view

Fig.18
Left view.

retraction cord and veneer crown preparations

Fig.19
Central incisors were prepared for crown restorations to replace the old crowns.
The other teeth were prepared according to vertical preparation technique for ceramic veneers.

lower teeth prepared for veneers

Fig.20
Vertical preparation for ceramic veneers.

digital impression

Fig.21
A full digital workflow was used to design and manufacture the ceramic restorations.

zirconia copings

Fig.22
0.3 mm zirconia copings were used to cover the severe dischromia on central incisors and in order to use, as final material, lithium dislicate with the same opacity used for the ceramic veneers.

lithium disilicate crowns on zirconia copings

Fig.23
The lithium disilicate crowns.

digital and real model with veneers and crowns

Fig.24
The initial design was easily transferred to the final .stl file that was used to mill the final restorations.

veneer try in

Fig.25
Try in of the ceramic veneers.

veneers and crowns on upper teeth

Fig.26
Try in of the ceramic veneers, zirconia copings and lithium disilicate crowns.

after cementation of crowns and veneers

Fig.27
Intra-oral view after cementation.

seamless smile restorations

Fig.28
Follow up of the soft tissue integration.

one year after smile veneering

Fig.29
One year follow- up.

happy woman after full smile makeover

Fig.30
Final extra oral view.

style italiano styleitaliano dentistry

Fig.31
Close up of the texture obtained through a full digital workflow.

Conclusions

Digital workflow, esthetic and functional evaluation are aimed to better preview the final outcome of the treatment planning. Digital comparison and super imposition of data (pictures, intra-oral scans, ortho set up, prosthetic set up) allows the clinician to have a better control of the clinical steps reducing variables and increasing predictability even in complex and multidisciplinary clinical cases.

Acknowledgements
The author would like to thank Dr. Federica Semplici that performed the Orthodontic Treatment and Alessandro Giglio for the CAD and Lab work.

Bibliography

1. Mampieri G, Giancotti A. Invisalign technique in the treatment of adults with pre-restorative concerns. Prog Orthod. 2013; 14(1): 40.
2. Imburgia M, Canale A, Cortellini D, Maneschi M, Martucci C, Valenti M. Minimally invasive vertical preparation design for ceramic veneers. International Journal of Esthetic Dentistry 2016 11(4): 2-13.
3. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015 Sep;85(5):881-9.
4. Imburgia M, Cortellini D, Valenti M. Minimally Invasive Minimally invasive vertical preparation design for ceramic veneer:a multi-centre retrospective clinical study on 265 lithium disilicate ceramic veneers. Accepted for publication on International Journal of Esthetic Dentistry

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