With A Little Help From My Friends A Case Report

I am envious of those of you that practice with other practitioners – generalists and/or specialists. Why? Because you can easily discuss your challenging treatment plans with someone to gain another perspective. Fortunately, I practice in the midtown of a large metropolitan centre, where there are ample brilliant minds to reach out to for help and guidance.

Examination
A 45-year-old patient (Fig. 1) was referred for upper and lower anterior veneers. One of her first comments was “I don’t like my smile!” Further discussion elicited the following concerns: 1. Lower teeth are worn and short; 2. Upper front teeth are small and 3. The space between her upper front teeth. Of interest was that there was no mention of a “gummy smile” (Fig. 2).
Intra and extra – oral examination revealed the following:

1. Well balanced facial proportions (Fig. 3), 2. 5-6 mms of gingival display during a moderate smile (Fig. 4), 3. 100
percent overbite and minimal overjet with a class I molar relationship (Fig. 5), 4. Moderate upper anterior cingulum wear and moderate lower incisal edge wear (Fig. 6) and 5.
Radiographic evaluation revealed a moderately restored dentition with the presence of four lower posterior implants (Fig. 7).

FIGURE 1.

FIGURE 2.

FIGURE 3.

FIGURE 4.

FIGURE 5.

FIGURE 6.

FIGURE 7.

Consultations
In order to restore this patient and address her aesthetic concerns my “wish list” was as follows: 1. Intrusion of the maxillary anterior segment to reduce gingival display and provide clearance for the restorations, 2. Shallower (less steep) anterior guidance in protrusive and lateral excursions, and 3. Reduction of gingival display by 3 – 4 mms.
A consultation/discussion was set up between myself, the Orthodontist (Dr. Angelos Metaxas) and the Periodontist (Dr. Alan Hiltz). During this meeting treatment goals and a sequence of treatment were established.

Treatment Sequence
Orthodontic Phase – maxillary anterior intrusion was accomplished using a stepped arch wire (Ricketts intrusion arch) followed by the use of a secondary intrusion arch wire (piggy-back intrusion arch wire) (Fig. 8).

FIGURE 8.

Initial Prosthodontic Phase – immediately after upper orthodontic debond (Fig. 9) #12, 11, 21, 22 were prepared and temporized (Fig. 10).

FIGURE 9.

FIGURE 10.

Periodontal Phase – maxillary anterior crown lengthening was performed with osseous contouring (Figs. 11 & 12).

FIGURE 11.

FIGURE 12.

FIGURE 13.

Secondary Prosthodontic Phase – at three weeks after crown lengthening the tooth preparations were refined to the level of the gingival margins (equi-gingival) and the temporary crowns relined (
Fig. 14).

FIGURE 14.

The same sequence was repeated for the lower anterior teeth.

Final Prosthodontic Phase – after healing and tissue maturation the gingivae were retracted with a single wrap of “000” retraction cord and a ferric sulphate hemostatic agent (Fig. 15). The margins were refined equi – gingival and a polyvinylsiloxane impression was made. The master cast was fabricated and mounted on a semi-adjustable articulator (Fig. 16). A model of the temporary crowns will serve as a template for the lab to follow during the fabrication of the final crowns (Fig. 17). The final restorations were fabricated using Cerec Inlab and were made from layered Vita MK II (a feldspathic porcelain) (Fig. 18). The crowns were bonded using Variolink II translucent luting cement.

FIGURE 15.

FIGURE 16.

FIGURE 17.

FIGURE 18.

Conclusion
When getting involved in a multi-disciplinary treatment plan involving other specialists it is important to have pre-set common treatment objectives, to have open and frequent lines of communication and to meet periodically as treatment is progressing.
Two unsung heros of the multi-disciplinary team that deserve mention are the ceramist, Kris Piotrowicz, RDT of Select Dental Laboratory, and the patient who had the patience and fortitude to let us do what we had to do (Figs. 19 and 20).