April 3, 2019
by Amanda Seay
Patients often present with the desire to maintain or improve their overall dental health and may state that their only goal is to have their teeth outlive them. They don’t desire a smile makeover or esthetic enhancement, but instead seek treatment that will allow them to eat, speak and enjoy life normally without the worries of catastrophic dental events. Their circumstances differ vastly from the patients that seek esthetic improvement as their primary goal. Those that choose cosmetic dentistry as the goal often want treatment that is fast and simple while not impacting their lifestyle. Patients who seek improved function and long-term oral health are often more willing to commit to the complex and arduous journey necessary to achieve a stable, healthy oral system.
Treatment that achieves the patient’s main goal of better function and health often comes with an unexpected benefit of a significant improvement to esthetics. Even when esthetics were not the initial chief concern, patients are still thrilled with the improvements to their smile that result from the treatment.
A 58-year-old patient presented with a chief concern that she had struggled her whole life with maintaining a healthy mouth. She had been a regular dental patient, and always accepted the treatment that was recommended to her. She had been diagnosed with periodontal disease in the past, and experienced decades of replacing previous dental work when recurrent decay was noted. As she approached retirement, she particularly wanted to avoid future problems, and avoid further tooth loss. She was unaware of what treatment would be necessary, but wanted to explore all her options.
Her oral health and risk of future breakdown was evaluated in four areas.
Periodontal: She had been diagnosed with periodontal disease 30 years ago, and had received periodic scaling and root planning as part of her periodontal treatment. Our examination revealed probing depths of 2-3 mm generalized with localized pocket depths in the posterior areas of 3-5 mm. The was 1-2 mm of generalized bone loss and 3mm of bone loss noted in localized posterior areas. She struggled with oral hygiene especially around the areas of crowding and open embrasure spaces. She complained of constantly getting food stuck in between her teeth. She was diagnosed with AAP Type 2 periodontal disease, with a good prognosis after treatment.
Biomechanical: Recurrent decay was noted on all the existing restorations with no decay found on unrestored tooth surfaces. Some composites were discolored and had open margins with recurrent decay present. Many teeth were structurally compromised. Due to her past history of decay and restoration placement, intervention would be necessary to lower her risk of future biomechanical breakdown.
Functional: A TMJ exam revealed no joint noise or pain. She had moderate wear on the upper and lower anterior teeth due to the deep bite and constricted chewing pattern. She did note that the wear had worsened over the last three years. In order to decrease her risk of continued wear, the position of the anterior teeth would need to be treated.
Dentofacial: The patient reported no concerns with how her smile looked, but was unhappy that she could feel her upper teeth dig into her lower lip. She wanted her teeth to be shorter so this would not happen.
A treatment planning discussion was held with the patient, focusing on her priority of longevity and health. Orthodontics would place the teeth in a more ideal location, which would decrease her risk of future disease in several ways. It would eliminate the crowding and overlap of teeth thus making good oral hygiene more achievable. The teeth would be placed in a more favorable plane of occlusion and eliminate the upper teeth impinging on her lip. Due to the triangular shape of her teeth and the current overlapped alignment, she was informed that she might notice larger cervical embrasure spaces after the orthodontic treatment was completed. This would improve the ability to clean in those areas, and if they were esthetically a concern, could be addressed in the restorative phase of treatment. A combination of composite, veneers and crowns would be placed to restore all the teeth with defective restorations. Two implant crowns were indicated on the upper right to replace missing teeth. A comprehensive treatment plan of Invisalign orthodontics and porcelain restorations for teeth No. 3-13 were made. The lower teeth would be managed with composites and replacement of a few failing crowns (Figs. 1-4).
Right side pre-op.
Left side pre-op.
The patient received a full mouth deep cleaning and a homecare protocol was established. Any composite restorations with active decay near the tissue were restored prior to the start of orthodontic treatment.
The desired post-orthodontic tooth position was created through Keynote software presentation. After the photos were imported to the smile design software, a digital facebow and plane of occlusion were used to identify where the teeth belonged in the face, which became the ideal post-treatment tooth position after all phases of treatment were completed. Since teeth No. 3-13 were planned for restorative treatment after orthodontics, the teeth would be moved into the position that would accommodate the restorative treatment and minimize the removal of tooth structure when the teeth were prepared.
After one-year of Invisalign treatment, the teeth were in a more harmonious position with her face and the framework of her lips. The maxillary incisal edges no longer impinged on the lower lip and the deep bite was eliminated. There were some areas with excess spacing, which would be corrected with the final restorations.
The patient presented for the records appointment, where upper and lower VPS impressions, a CR bite, stick-bite and facebow were taken. A known measurement was taken to calibrate and verify the accuracy with the lab technician and the final restorative design. The length of tooth No. 8 from the cervical margin to the incisal edge was used.
To accurately communicate the facial aspects of the case to the lab technician, the following photo and video protocol was performed:
1. These photos at a 1:10 magnification ratios of full-face series (Figs. 5-14).
2) Full smile
3) Full smile teeth apart
4) Smile 45 degree right
5) 45 degree left
6) Straight profile
9) Full-face retracted
10) 12 o’clock
1:10 magnification repose.
1:10 magnification full smile.
1:10 magnification full smile teeth apart.
1:10 magnification 45-degree right side.
1:10 magnification 45-degree left side.
1:10 magnification straight profile.
1:10 magnification facebow.
1:10 magnification stickbite.
1:10 magnification full face retracted.
1:10 magnification 12 o’clock.
2. A short video was taken to best capture lip movement dynamics. The two extremes of lip movement can also be captured by two photos instead of video. The Duchenne smile will show the cervical limit of the upper lip, and the “shush” movement can capture the cervical limit of the lower lip.
3. These photos are taken at a 1:2 magnification (Figs. 15-22)
2) Full smile
3) Full smile teeth apart
4) Smile 45 degree right
5) Smile 45 degree left
6) Retracted teeth apart front
7) Retracted teeth apart right
8) Retracted teeth apart left
1:2 magnification in repose.
1:2 magnification with full smile.
1:2 magnification with full smile, teeth apart.
1:2 magnification 45-degree right.
1:2 magnification 45-degree left.
1:2 magnification, retracted teeth apart front.
1:2 magnification, retracted teeth apart right.
1:2 magnification, retracted teeth apart left.
After the records appointment data was gathered, the lab prescription was written. The smile design had been completed prior to the start of orthodontics, so the initial plan could now be revisited and refined to accommodate any variation in actual tooth position from what was predicted.
The photos and video were placed into a keynote presentation. Horizontal and perpendicular reference lines were drawn to orient photos to the plane of the horizon. The photos can be easily rotated until a selected reference such as the pupils, sides of face, or commissures of the mouth are lined up with the reference lines. This step also allows the clinician to check the accuracy of the facebow as it is seen in the photograph. The lab technician who designs the cases digitally can do this step, however when the clinician does it as well, they may note something not easily visible without using the smile design process. In this case, it was noted that the midline was slightly canted and not centered. In weighing the decision to straighten and correct the midline, this process allowed the dentist to determine if too much tooth structure would be removed to make that midline change.
Once these photos were rotated to be level with the horizon, the facially determined tooth position could be re-evaluated in fine detail. This included an esthetic evaluation of the soft tissue and tooth structure interface. Though the orthodontics created more favorable tooth alignment, it was noted that minor soft tissue recontouring would be necessary to raise the tissue height of tooth No. 9 to match tooth No. 8. This was noted on the lab prescription, as the crown lengthening for tooth No. 9 would be completed at the prep appointment.
The lab technician used all the information from the records appointment and the prescription to create an initial smile design. They sent a screenshot of that smile design integrated with the photos to the dentist. The clinician could then visualize the smile design in the patient’s face to determine if any changes needed to be made prior to the prep appointment. These modifications to design are easily made prior to the prep appointment as digital design allows fast and efficient communication (Fig. 23).
The smile design integrated with the clinical photos.
After final approval of the smile design, the lab delivered a model that showed the clinician where any tooth reduction was necessary to allow complete seating of the provisional template. Those areas were marked in red on the model. The lab also delivered a provisional template that was filled with bis-acryl, then seated over the teeth prior to preparation for the restorations (Fig. 24).
Template in place for preparation guidance.
Once the bis-acryl had set, the template was removed, leaving the bis-acryl in place over the teeth. Depth cuts were made through the provisional material to guide tooth preparation so only the minimal amount of tooth structure was removed. Once the proper reduction was obtained, the bis-acryl was removed, all existing composite restorations were removed and buildups were completed. Tooth preparation was finished, retraction cord packed and final impressions taken with VPS material. To fabricate the provisionals, bis-acryl was injected into a putty matrix made from a printed model of the approved smile design. This was placed over the teeth and allowed to cure for one minute, then removed and allowed to fully cure outside of the mouth. The provisional was carefully teased out of the matrix and trimmed extra-orally. Optibond Fl Part 2 was placed in the provisional, then the provisional placed over the teeth and cured. The margins were cleaned and refined with #12 blade and fine carbide finishing bur. The posterior contact points were refined with TrollFoil articulating paper and verified with shimstock. The final occlusal check was made with the patient sitting up at 45 degrees and chewing on 200 micron articulating paper.
Provisional Approval for Final Fabrication
The patient returned two days later for post-operative bite check. It is recommended that the patient remain in provisionals long enough to ensure no modifications need to be made for function, speech or esthetics. She returned three weeks later for final approval of the provisional. The same photo and video protocol that was done at the records appointment was repeated as well as facebow, stickbite, MIP bite and VPS impression of provisionals (Figs. 25-35).
Photos of provisional restoration at 1:10 magnification (Figs. 25-32).
Photos of provisional restorations at 1:2 magnification (Figs. 33-35).
Once again, the lab prescription was sent to confirm any modifications that may have been made to the provisional after the smile design was originally created. The technician can overlay the provisionals with the digital design to evaluate the fine esthetic details (Figs. 36-38).
Two points of reference help orient the maxillary arch with the face.
Visualing minor modifications from original digital design with the provisionals.
Final digital design.
The patient was anesthetized and the provisionals removed. The teeth were micro-abraded with 27-micron aluminous oxide at 40 psi (PrepStart, Zest Dental Solution), then thoroughly rinsed and dried. To verify fit, the restorations were tried in with a drop of water one at a time to evaluate individual fit, then tried in two at a time to evaluate contacts.
For final delivery, the restorations were seated in pairs using the same sequence as the try-in. The internal surfaces of porcelain were treated with phosphoric acid gel and silane, then set aside. The teeth were treated with phosphoric acid, rinsed and lightly air dried. Unfilled adhesive resin was applied to the teeth with a brush, then thinned with air and cured. A dual-cured resin cement was used to lute the restorations. Excess cement was removed with a microbrush and rubber tip stimulator interproximally, then fully cured. An upper occlusal splint was made for orthodontic retention and protection of final restorations (Figs. 39-40).
Post-op both arches.
As clinicians, we see a variety of patients with differing goals. While some seek esthetics as the chief endpoint, there are others who desire improved function and health as their goal. Whether the primary goal be form or function, both must be coupled to deliver a favorable outcome for the patient. The length of time for multi-disciplinary treatment can be daunting but patients are willing to proceed when they understand the importance of thorough treatment to address their concerns. The reward is magnified when a patient who is expecting practical outcomes receives one that is exceeds their esthetic expectations as well.
Oral Health welcomes this original article.
About The Author
Dr. Amanda Seay maintains a full-time private practice in Charleston, South Carolina focusing on comprehensive restorative dentistry. She holds a Clinical Instructor position at the Kois Center in Seattle, Washington. Dr. Seay is a member of the American Academy of Restorative Dentistry and an Accredited Member of the American Academy of Cosmetic Dentistry and Fellow in the Academy of General Dentistry. She was named Top 25 Women in Dentistry in 2012 by Dental Products Report. Dr. Seay was the recipient of the Lucy Hobbs 2015 award for The Woman to Watch in Dentistry. She is the restorative section editor for Inside Dentistry. She publishes and lectures on the art and techniques of aesthetic dentistry.
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