Written by Jay J. Jensen, DDS Friday, 31 March 2006 19:00
A 24-year-old woman who was unhappy with her smile came to my office asking for veneers on her maxillary anterior teeth (Figures 1a to 1c). Although she had a general complaint of jaw pain and headaches, she had not given much thought to the rest of her mouth. Upon examination, we discovered underlying TMD issues, an over-closed bite (Figure 2), some wear from parafunction, and most conspicuously, many large and defective old restorations associated with her posterior teeth (Figures 3a and 3b).
Digital photographs displayed on a large monitor helped us to explain the problems and their possible negative consequences, both for her oral health and for the simple smile makeover that she had envisioned. She was not surprised and agreed that the situation would only deteriorate. After a thorough discussion of treatment options, she chose to address all of the issues with a full-mouth reconstruction.
|Figures 1a to 1c. A patient unhappy with her smile requested veneers on her maxillary anterior teeth.|
Figure 2. There were underlying TMD issues and an over-closed bite.
Figures 3a and 3b. Some wear from parafunction, and many large and defective old restorations associated with her posterior teeth.
Our diagnostic workup included a comprehensive exam, periodontal exam, full-mouth series of x-rays, panoramic x-ray, transcranial x-rays, diagnostic photographs, and diagnostic impressions. The most important element of the diagnosis and treatment planning was to locate the optimal bite for the full-mouth reconstruction. We knew that she was over-closed and elicited some signs and symptoms of TMD. Therefore, it was imperative to use specialized instrumentation. The K7 instrumentation from Myotronics allowed us to establish a baseline to determine the location of her current bite and to indicate where her new bite needed to be according to the proper path of closure and the EMGs.
|Figure 4. After establishing the baseline, a Myomonitor TENS unit was used to pulse the muscles into a more natural down-and-forward, untorqued position to establish the proper resting position of the mandible.||Figure 5. EMGs in the new mandibular position show a difference from the initial muscle readings.|
After establishing the baseline, a Myomonitor TENS unit (Myotronics; Figure 4) was used to pulse her muscles into a more natural down-and-forward, untorqued position to establish the proper resting position of the mandible. EMGs in the new mandibular position (Figure 5) show a difference from her initial muscle readings. The former shows hypertonic muscles, while the latter shows calm, relaxed muscles as the result of the TENS.
|Figure 6. The proper path of closure was established using a jaw tracking device or CMS. (Photo courtesy of Myotronics.)||Figure 7. The new ideal bite registration. After the bite registration was complete, the case was mounted according to the new bite.|
Figure 8. A diagnostic wax-up of the patient’s full mouth set to the new mandibular position.
At this point, the proper path of closure was established using a jaw-tracking device or CMS (Myotronics; Figure 6). The CMS and EMGs helped establish the new ideal bite, which we registered using Aquasil Rigid (DENTSPLY Caulk). After the bite registration was complete, the case was mounted according to the new bite (Figure 7), and we then asked MicroDental Laboratories to prepare a diagnostic wax-up of the patient’s full mouth set to the new mandibular position (Figure 8).
|Figure 9. A fabricated mandibular repositioning appliance, or orthotic, for the patient to wear in the new, relaxed, down-and-forward mandibular position for a minimum of 3 months.|
For the Phase I treatment, we fabricated a mandibular repositioning appliance, or orthotic, for the patient to wear in the new, relaxed, down-and-forward mandibular position (Figure 9) for a minimum of 3 months—a critical step to stabilize the patient and ensure she is symptom-free before moving on to Phase II definitive treatment.
Our plan called for removing all of the old, defective restorations and replacing the teeth with 28 units of MAC Veneers and crowns (MicroDental Laboratories). We selected MAC pressed porcelain because of its strength, durability, and lifelike color and beauty.
After anesthetizing the patient, our first step was to remove the old restorations, which is always a challenging process in full-mouth reconstructions and particularly difficult in this one. Much to the patient’s regret, her dietary habits and general indifference to oral hygiene during adolescence, perhaps magnified by hormonal changes and genetics, had left her mouth in a compromised condition. She had large, deep amalgam fillings with recurrent decay and fractures undermining the cusps, which were ready to shear. We removed 15 old restorations, removed significant decay, extracted 2 teeth, and referred the patient to an endodontist for 2 root canals. We also used a laser to correct discrepancies in the gingival zenith, to perform a frenectomy, and to gain subgingival access to eliminate decay at that level. We completed the clean-up process from first molar to first molar, leaving the second molars untouched.
Next, we prepared the upper arch, which required core buildups on several teeth. We used Ultradent’s Ultra-Etch for etching, Phoenix Dental’s Super Seal for wetting, Kerr’s OptiBond Solo Plus for bonding, and Centrix’s SuperCure as resin. Once the buildups were finished, we prepared the posterior teeth, excluding the second molars, for crowns. With the second molars still intact, we knew where the bite was supposed to be, and took a bite registration. We then gutted, built up, and prepared the second molars, and took another bite registration, all while properly managing and maintaining the bite with the Sil-Tech (Ivoclar Vivadent) bite stint fabricated by Micro-Dental Laboratories. After completing exactly the same process on the lower arch, all teeth were prepared, and we took PVS impressions using Aquasil XLV wash material and Aquasil Heavy Body tray material (DENTSPLY Caulk) in full-arch trays.
Figure 10. Temporary restorations were fabricated
After cleaning and disinfecting all of the preparations with Consepsis (Ultradent), we used Integrity Bleach Shade (DENTSPLY Caulk) to create temporaries, with the aid of a Sil-Tech putty stent prepared by MicroDental from an impression of the wax-up. The stent expedited the temporization process. We seated the Sil-Tech matrix with the temporary material, let it sit for 2.5 minutes, and peeled off the matrix, leaving beautiful temporaries locked into place (Figure 10). We did this to both arches, trimmed off a small amount of flash, checked and grossly adjusted the bite, and then sent the patient home for 3 weeks.
SEATING THE RESTORATIONS
When the patient returned, she was again anesthetized. We then cut off the temporaries with a large diamond bur and proceeded to seat the restorations, starting with the second molars on the upper arch. We used the same materials as before—Ultra-Etch, Super Seal, and OptiBond Solo Plus—as well as Calibra Translucent Esthetic Resin Cement (DENTSPLY Caulk). After seating the second molars, we placed a rubber dam and dry-seated the additional restorations to check for fit, appearance, etc. When satisfied, we cleaned, silanated, and dried the interiors of the restorations, and then used the seating materials to place the restorations on the upper arch using a rapid cementation technique. We repeated the process for the lower arch.
Once the seating was finished, we completed gross clean-up of excess cement, flossing, and rinsing. We then performed only gross occlusal adjustments to allow her mandible to autorotate, and sent the patient home. The next day, we refined her bite with a coronoplasty using a TENS unit. A week later, we used K7 instrumentation to ensure that there was no bite interference we did not detect previously. This step is a necessary precaution, because often times a bite looks perfect, but something “just feels wrong” to the patient. The K7 equipment enabled us to observe exactly where the teeth were hitting and then make final adjustments to complete the treatment.
|Figures 11a to 11f. Veneers enhanced the patient's appearance with a striking smile. She completed the treatment with a healthy mouth and no more pain.|
|Figure 12. This case turned out so beautifully that the patient is used in all of our television and print ads.|
This case was complex and difficult, but the treatment was trouble-free, thanks to excellent materials, expeditious and extremely reliable lab work, and a supportive and enthusiastic patient. Although she was already beautiful when she arrived, the MAC Veneers enhanced her appearance with a striking smile. She completed the treatment with a healthy mouth and no more pain (Figures 11a through 11f). Her case turned out so beautifully that she is used in all of our television and print ads (Figure 12). She was thrilled with the results, and especially happy that we took a comprehensive approach that went beyond just aesthetics.
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