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.

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.

Fig.2

Pre-operative situation.

Fig.3

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

Fig.4

Intra-oral front view.

Fig.5

Intra-oral right view.

Fig.6

Intra-oral left view.

Fig.7

Radiographic evaluation aimed to orthodontics analysis.

Fig.8

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

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.

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.

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.

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.

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.

Fig.14

Smile at the end of the orthodontic treatment.

Fig.15

Tilted view at the end of the orthodontic treatment

Fig.16

Post-orto intra-oral situation.

Fig.17

Right view.

Fig.18

Left view.

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.

Fig.20

Vertical preparation for ceramic veneers.

Fig.21

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

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.

Fig.23

The lithium disilicate crowns.

Fig.24

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

Fig.25

Try in of the ceramic veneers.

Fig.26

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

Fig.27

Intra-oral view after cementation.

Fig.28

Follow up of the soft tissue integration.

Fig.29

One year follow- up.

Fig.30

Final extra oral view.

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

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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.
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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