When a full mouth rehabilitation is the necessary course of treatment due to severe breakdown of the dentition in its current state, one must keep in mind that as restorative dentists, we still have the ability to do things in a much less invasive way. We can always take out the drill and take away as much tooth structure as necessary to complete our task, but venturing outside the box when possible can give us the same if not better results, doing far less harm to the patient and their dentition. We as dentists have the knowledge to deliver treatment to a patient in many different ways to achieve the same result. This paper will demonstrate the use of orthodontics, laser closed flap crown lengthening and minimally invasive restorative dentistry to achieve a less invasive approach to full mouth rehabilitation.
Case Analysis
This 54-year-old healthy male presented for consultation regarding fixing his “tiny teeth” (Fig. 1).
FIGURE 1./201504081047120bokpr0ygqh04vl55yawpr4ej.jpg)
Upon examination, it was discovered that the patient was a severe bruxer with heavily worn dentition, giving him the tiny teeth that he complained about. As well, he had almost a 100 percent overbite. As well, he had a midline diastema between 11 and 21, which he did not like. He wanted to show more of his teeth when he smiled and was well motivated to consider any treatment that ultimately would give him the smile that he wanted. Figure 2 shows the retracted view of his teeth in maximum occlusion.
FIGURE 2./201504081047131bokpr0ygqh04vl55yawpr4ej.jpg)
It was clear to me that the only way restoratively that we would be able to lengthen his anterior teeth sufficiently would be to open up his occlusion via full mouth reconstruction. I presented this option to him explaining that we would have to work on every tooth in his mouth and change his bite so we could lengthen his teeth. However, was this the only way we could achieve success? No! I also explained to him that in my mind there was a better less invasive way to achieve the same result. I then explained that I would like him to consider orthodontics which would change the way he bites, as well as give us sufficient room in the front to be able to lengthen his teeth (by intrusion of the upper and lower anteriors from cuspid to cuspid). The patient again was well-motivated and agreed to start with orthodontics.
Orthodontic Phase
The patient elected to go with Incognito (3M) lingual braces. The treatment plan was reviewed with the orthodontist to include opening up his vertical dimension of occlusion by approximately 1mm and intrusion of the upper and lower anteriors. As well, we wanted to ensure that the anterior teeth were placed in position to ultimately widen the teeth to allow us to lengthen and widen the teeth to get rid of any excess spacing including the midline diastema. The orthodontic treatment phase lasted roughly 15 months. Figure 3 shows the positioning of his teeth after orthodontics was complete.
FIGURE 3./201504081047132bokpr0ygqh04vl55yawpr4ej.jpg)
Unfortunately, the patient asked us to speed up the timeline because he decided that he was going to move to a new city as soon as treatment was over, and was hoping to move sooner than the treatment times outlined to him. The orthodontist, the patient, and I concluded that we had done enough orthodontics to achieve our goals, and the patient was made aware that, not only would his upper and lower midlines not match if we stopped treatment at that time, but also the 37 would remain slightly tipped because of the absent 36. He was fine with that.
Diagnostic Phase post Orthodontics
Once we determined that our patient was done with the orthodontic phase, we sent study models off to our lab, and instructed them to do a diagnostic waxup of teeth 15-25 and 34-44. These models were accompanied by a complete set of diagnostic photos (post ortho), bite registration and an facebow transfer jig so that the diagnostic waxup would be as accurate as possible and allow us to fabricate a provisional VPS stent to make chairside provisionals the day of his restorative prepping appointment. From the diagnostic waxup, we determined that tooth 25 could have benefitted from slight intrusion and labialization. Figure 4 illustrates the positioning of 25.
FIGURE 4./201504081047133bokpr0ygqh04vl55yawpr4ej.jpg)
Laser Closed Flap Crown Lengthening # 25
In order to achieve the balanced esthetics for 24, 25, and 26, we decided that we would need to crown lengthen 25,so that the gingival margin height would be correct. This was done via laser closed flap crown lengthening with the Waterlase iPlus (Biolase). Figures 5 and 6 illustrate the crown lengthening from start to laser bandage placement at the end of treatment.
FIGURE 5./201504081047134bokpr0ygqh04vl55yawpr4ej.jpg)
Laser crown lengthening via an iPlus hard tissue/soft tissue laser allows the patient to heal remarkably faster compared to the traditional scalpel open flap procedure. As a matter of fact, I could have done this simple crown lengthening procedure at the time of the prepping appointment, and be almost 100 percent certain that at the time of veneer insertion, the margins would have remained exactly in the same position as at the time of crown lengthening and that the tissues would be almost completely healed. Traditional open flap crown lengthening performed with a scalpel and a carbide surgical bur to remove the bone would have necessitated an eight to 12 week healing period before the tooth could be prepped for the final restoration. There is no necrosis of the tissues, and the effect of low-level laser therapy called Biostimulation, ensures that everything will heal extremely fast.
The steps used in closed flap laser crown lengthening are very similar to traditional crown lengthening. We still probe the gingival crevice and then sound to bone to determine the measurement from the crest of the gingival margin to bone. We do this to ensure that after the crown lengthening procedure is complete, we still will have harmony between the tissue and the bone known as Biological Width. Once the first measurement is taken, we know that ou
r final measurement from the new crest of gingiva post-surgery will allow for 3mm to the crest of bone. This figure was determined by Garguilo, Orban, and Wentz in their landmark paper in 1961.1 Once we perform a simple laser gingivectomy, we then sound bone with a periodontal probe and measure how close the bone is to the new gingival margin, then mark the laser tip with a sharpie at the 3mm mark. This 3mm marking will ensure the removal of bone to accommodate the 3mm distance from bone crest to gingival margin. We then smooth the bony ledge and thin it out by “ramping” it apically, and then thin the gingival margin so that the gingiva will now sit tightly against the bone. This simulates the internal bevel incision with the scalpel technique. Once again we probe to ensure biological width and then place a laser bandage using very low power laser energy to impart healing to the area. This is seen in Figure 6.
FIGURE 6./201504081047145bokpr0ygqh04vl55yawpr4ej.jpg)
Restorative phase
At the restorative appointment, we had all our pre-op models, diagnostic waxups and provisional stents present. Prior to prepping, we took a facebow transfer using a Denar facebow. We also took a photo of this to show the lab that it was taken correctly in the event that they had any questions about the facebow (Fig. 7).
FIGURE 7./201504081047146bokpr0ygqh04vl55yawpr4ej.jpg)
We then took a photo of the existing unprepped shade, as well as the future veneer sHade. We want to give the lab the ability to compare our photos for shade accuracy so that they know completely how to correct for any inaccuracies with our camera settings. The full shade tabs are visible in the photos to identify the shade (Fig. 8).
FIGURE 8./201504081047147bokpr0ygqh04vl55yawpr4ej.jpg)
It was determined that we would need to wrap the majority of the veneers to the palatal/lingual aspects of the teeth. This was necessary so that we could fully restore the broken down teeth and be able to achieve golden proportions for the dimensions of the teeth, now that the orthodontics placed the teeth in the correct locations. The final margin location need not extend to the gingival marginal area to be a 360 degree wrapped veneer. Place the margin below any of the worn surfaces, and in an area not where the occlusion will be, for health of the future veneer. Figure 9 shows the maxillary veneer preps.
FIGURE 9./201504081047148bokpr0ygqh04vl55yawpr4ej.jpg)
Temporization was done using a prefabricated VPS stent of our diagnostic wax-up, spot etching of each tooth and resin bond on each of the etched spots. The VPS stent (Fig. 10) was then carried to the mouth with a shade of Bisacryl temporization material (Perfect Temp-Discus) in the stent.
FIGURE 10./201504081047159bokpr0ygqh04vl55yawpr4ej.jpg)
Using the shrink-wrapped technique, the stent is massaged and manipulated for the first two minutes on the patients teeth to force the material interproximally, and then left to fully set on the prepped teeth. This locks the material interproximally which aids in retention of the provisionals. The accuracy of the VPS stent and the diagnostic wax-up makes this a foolproof method of provisionalization, without fear of disturbing the preparations on removal of the temps. The veneers were then trimmed and polished carefully so as not to disturb the underlying tooth preparations.
The same exact steps were performed on the mandibular arch, and then provisionalization was carried out there as well. At this point, occlusion was verified in centric, lateral and protrusive excursive paths ensuring canine guidance, and crossover guidance. Figures 11 and 12 shows temporization completed.
FIGURE 11./201504081056580bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 12./201504081056591bokpr0ygqh04vl55yawpr4ej.jpg)
Occlusion was verified and the patient was dismissed. Figure 12 also shows complete tissue health at the location of the laser crown lengthening after only two weeks.
An uneventful two-week period then passed, and the patient returned for veneer tryin. Figures 13 and 14 show the beautiful eMax layered veneers fabricated by Valley Dental Arts in Minnesota.
FIGURE 13./201504081056592bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 14./201504081056593bokpr0ygqh04vl55yawpr4ej.jpg)
These eMax layered veneers were fabricated to be no greater than 0.5mm thick. Absolute beautiful artistry!
At the try-in appointment, the patient was anesthetized, and the provisionals were removed with extreme caution so as not to disturb the underlying preparations and ensure optimal fit. All debris was removed, and
the maxillary veneers were then tried in using water only on the fitting surface as opposed to translucent try-in paste. This aids in cleanup prior to bonding the veneers in place. Each veneer was tried in one at a time, then in pairs, then all at once to verify fit. At this point, the veneers are still quite fragile, and no attempt was made to verify occlusion. The veneers were removed, and then the same procedure was carried out on the mandibular teeth. Once it was determined that the fit was perfect, and the patient was shown the veneers in the tryin state, the veneers were again removed and the patient gladly approved of the veneers. The teeth were then cleansed with a Chlorhexidine solution, and then thoroughly rinsed. All teeth were then hydrated with water soaked gauze for a period of five minutes, to rehydrate the teeth prior to bonding. This decreases post-op sensitivity. The maxillary veneers were first bonded with Allbond 3 bonding agent and Choice2 veneer luting cement (Bisco). Excess cement was then removed and then the same procedure was carried out on the mandibular teeth. Once all veneers were bonded, trimmed and polished, the occlusion was then verified in centric, lateral canine guidance, and protrusive guidance to ensure that there were no interferences and that the patient felt completely comfortable. One week later, the patient returned for a post–op appointment to verify complete cement removal and to check occlusion again. Once it was concluded that the patient was extremely happy and that we were as well with the tissue response and fit, final photos were taken. Figures 15, 16, 17, 18, and 19 show the final veneers in place.
FIGURE 15./201504081056594bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 16./201504081057005bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 17./201504081057006bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 18./201504081057007bokpr0ygqh04vl55yawpr4ej.jpg)
FIGURE 19./201504081057008bokpr0ygqh04vl55yawpr4ej.jpg)
Conclusion
As cosmetic restorative dentists, we must remain resolved that there is more than one way to perform treatment. In order to satisfy our mantra and remain as conservative in our approach as possible, we must be forever cognizant that just simply restoring every tooth in the mouth may not be the best approach to rehabilitating a patients occlusion and broken down, worn dentition. While not an absolutely perfect result, the final photos show that harmony was achieved and we managed to satisfy all of the patients’ needs while preserving tooth structure in the process. Keep in mind, with this approach, ten additional teeth were not touched at all in this full mouth reconstruction case, rendering the case highly conservative and quite satisfying to both the patient and dentist alike.OH
Dr. Rykiss maintains his private practice in Winnipeg, MB. He is a graduate of the University of Manitoba as well as a graduate and Mentor at the Nash Institute for Dental Learning in Charlotte, N.C. He has his Fellowship with the International Academy for Dental Facial Esthetics, an associate Fellowship from the World Clinical Laser Institute, and is a member of the ASDA and CAED. He teaches, lectures, and writes articles on restorative, cosmetic dentistry, and hard and soft tissue laser use.
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References:
1.Garguilo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J periodontol.1961; 32:261-7
