DTUS1410

COSMETIC TRIBUNE The World’s Cosmetic Dentistry Newspaper · U.S. Edition Fig. 1: Smile photograph showing asymmetry in smile, maxillary cant, slant- ed midline, negative buccal corridor and poor axial inclinations. Fig. 2: Retracted frontal photograph. g CT page 2C May 2010 www.dental-tribune.com Vol. 3, No. 6 By Christopher C.K. Ho, BDS. Hons., Grad. Dip. Clin. Dent., M. Clin. Dent. Esthetic rehabilitationUsing provisional restorations to improve results in complex restorative cases The esthetic rehabilitation of patients with a functionally compro- mised dentition frequently involves a multidisciplinary approach incorporat- ing several different treatment modali- ties. A correct esthetic and functional diagnosis with an appropriate treat- ment plan as well as careful material selection and application are critical factors in the successful restoration. The following case presentation demonstrates a multi-disciplinary approach to re-create an esthetic smile in a female patient with a functionally and esthetically compromised denti- tion. Patients requiring prosthodontic rehabilitation often have multiple con- cerns (esthetic, functional and health) and have left rehabilitation for some time due to fear, cost and time con- straints. It is the goal of treatment to provide an esthetic and functional dentition with minimal maintenance over the long term. Treatment planning & procedures The primary objective was to re-cre- ate an esthetic smile and to establish a functional occlusion. This would involve orthodontic, periodontal and restorative modalities. Periodontal treatment. The patient underwent a preliminary treatment plan that included professional oral hygiene and reinforcement of oral hygiene practices. Orthodontic treatment. In order to correct the tipped and drifted man- dibular teeth that were a consequence of missing teeth. Diagnostic wax-up. This allows the team to preview the desired esthetic appearance. The diagnostic wax-up provides guidelines of the desired treatment and a blueprint for the final restorations. This wax-up also allows the manufacture of putty keys for pro- visionalization and reduction guides for the preparation process. Gingival recontouring. A 940 nm diode laser (Biolase EZlase) was uti- lized to improve soft-tissue esthetics. Periodontal bone sounding was per- formed to ensure that biologic width was not invaded and then gingival tissues were lased to improve the gin- gival contour, symmetry and gingival zeniths. Preparation. For all-ceramic crowns it is recommended that an axial reduc- tion of 0.8 mm to 1 mm and an occlusal reduction of 2 mm be made as these materials need a certain thickness to withstand masticatory and parafunc- tional stresses. Finish lines are recommended to be chamfers or 90-degree rounded shoulders to provide sufficient bulk at the margins and allow the transfer- ence of stresses adequately around the margins. To minimize stress concentration within the restoration, all line angles should be rounded, all sharp edges smoothed, and boxes and grooves and “butt’” type shoulders are contra-indi- cated. Impression procedure. The use of a double zero retraction cord (Ultrapack #00, Ultradent) was placed into the gingival sulcus as a first cord and then a retraction paste, Expasyl (Kerr), was then placed over the first cord. The correct use of this retraction paste should see blanching of the gin- gival tissues as the paste is extruded into the gingival sulcus. An impression was made with a polyvinyl siloxane material (3M Imprint 3). Maxillo-mandibular relations. The Kois Dento-Facial Analyzer System registers and transfers the patient’s occlusal plane as well as tilts in the occlusal plane in three planes of space to the articulator related to an aver- age 100 mm axis-incisal distance. This allows orientation for esthetic position- ing of the anterior teeth in relation to the midline of the face and ensures correct orientation of the incisal plane. Provisionalization. The provisional restorations are duplicated from the diagnostic wax-up that incorporates the proposed changes. It allows the patient a “test run” of the final result by allowing her to see a preview of the planned result. This is an essential step in the planning process. The aims of provisionalization are as follows. Health: pulpal protection and peri- odontal health and gingival stability. Function: the provisional restora- tions can be used to assess and alert if there are any occlusal and phonetic problems with the proposed chang- es. The pronouncing of “V” and “F” sounds should create a light contact between the central incisor and the “wet-dry” line of the lower lip. Esthetics: the provisional restora- tions can be used to assess the basic shade to be chosen, incisal edge dis- AD