Complex cases, lesson 1: think as an architect, act like a dentist

22 Dec 2017 - 19492

Recording the “starting point”, the “time zero” of a patient’s oral situation is one of the biggest issues when a practitioner is facing a full mouth rehabilitation.

The purpose of this simple article is to highlight the main spirit of a rehabilitation: having the vision of the case, in other words “thinking out of the box”, then drawing the final esthetic outcome with functional impact (many times rising the vertical dimension), and use the contemporary materials to visualize the future in 2 minutes.

 

Fig. 1

This patient has been affected by anorexia and bulimia during fifteen years of her life and now that she’s been completely recovered for more than ten years she is seeking for an aesthetic aspect of her smile. The smile line is of course affected and the central incisors have been broken and worn. All the teeth are vital.

 

Fig. 2

The palatal view shows the complete enamel destruction which accelerates the wear process. This is why the treatment planning is based on the reconstruction of the loss of volume around the tooth (palatally and buccally). For this reason, if the main interest is biological preservation, an increase of the vertical dimension will offer the needed space for the new anatomy.

Fig. 3

After providing all the data (pictures, impressions, free hand composite on the two centrals incisors for the incisal edge and the palatal anatomy, bite registration in centric relation with the new space created by our JIG) Technician Gerald Ubassy performed the full mouth wax up in order to recreate the outcome of the smile following the data we sent him.

Fig. 4

One of the issues then, is to transfer the full wax up into a full mock up in the mouth. Many options have been proposed (Koubi.S/Gurel.G, Tirlet G, Vailati.F)

The digital workflow can be a reliable option instead of the silicone index. For this we have to follow certain steps:

1 – scanning the full wax up 

2 – creating STL files

3 – using a suitable software (exocad for example) to get the automatic proposal of a template able to cover the existing model

4 – 3D printing of the model of the wax-up and the template to get the rigidity. (DMG 3Deluxe printer)

5 – Place adhesive inside the template to bond with the light body silicone we will use to reline this template and offer a very good friction during the insertion in the mouth. 

Fig. 5

A Bis-acryl resin  (Luxatemp star DMG) is injected in the 3D printed template and inserted in the mouth with a very high stability without pumping effect and offer a very precise transfer. Same protocol is performed for the lower. In 4 minutes patient and dentist are able to validate the treatment planning and more other the esthetic and functional change.

Fig. 6

Facial view of the full mock up with a good esthetic integration

Fig. 7

Smile line and lateral corridor have to be controlled to check the good integration of the project.

Fig. 8

Once the project is validated we split the treatment in two parts:

1- Preparation of the upper arch and bonding protocol of the Emax crowns and veneers. (Emax press LT B1) (Ivoclar Vivadent Schaan)

2 – Preparation of the lower arch and bonding protocol of the Emax crowns and veneers. (Emax press LT B1).

Fig. 9

Once the full mock up has been validated, the dentist is guided during the preparation steps, and the technician is driven by the design in order to precisely copy, thanks to the silicone index, the shape of the teeth. Then the dentist is able to offer a very soft transition without discontinuity between the initial situation, the full mock up, temporaries and final restoration.

Fig. 10

Final appearance with a nice integration of the smile in the face harmony.

 

Conclusions

Again a complex topic has to be split in simple part.

Remember to think out of the box at the first step to see where the dentist wants to place the white part ideally

Once the project is edited and transferred in the mouth we have validate it and only at this step select the ideal tool (crown, veneer, implant…..) to reach the final design

1 – think as an architect and then…

2 – act as a dentist

Bibliography

Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Le projet esthétique et fonctionnel: nouveau “GPS” de la dentisterie moderne. Rev Int de Proth Dent 2014, n°4 : 257-272.

Vailati F, Belser U: full month adhesive rehabilitation of  a severely eroded dentition: 3 step technique part 1 .Eur J Esthet Dent. 2008 Spring;3(1):30-44.

Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Le projet esthétique et fonctionnel: nouveau “GPS” de la dentisterie moderne. Rev Int de Proth Dent 2014, n°4 : 257-272.

Fradeani M, Barducci G, Bacherini L, Brennan M.:Esthetic rehabilitation of a severely worn dentition with minimally invasive prosthetic procedures (MIPP).Int J Periodontics Restorative Dent. 2012 Apr;32(2):135-47.