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Excellent Communication Benefits: A Full-mouth Rehabilitation Case by Joseph L. Caruso, DDS, MS, and Luke Kahng, CDT

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Introduction

The dentist and patient involved in this particular case were long-time friends. The patient is a world traveler, residing in both California and France. The clinician resides in Illinois but visits California frequently and often sees the patient there. Her personality is artistic, with a love for unique, eclectic things.

It was obvious to him and to her that her teeth were in need of assistance. She was suffering from periodontal disease and caries, which had gone untreated. She was fearful of the work that needed to be done and somewhat indecisive about the procedures she would need to undergo. After meeting with several other dentists as well as her long-time friend and hearing his opinion, she decided to go ahead with his treatment plan. There were challenges involved due to the distance she needed to travel in order to see him. However, she was determined to restore her teeth to a healthy level.

It was decided that treatment would involve the mandibular teeth #29, 30 and 31 with a three-unit bridge, and #18, 19 and 20 with single crowns; #19 and 20 being implants. Proper occlusion was the main goal with this particular phase of the plan. Tooth # 10 was treated with a post/core, and # 7 was to be restored with a zirconia crown. Teeth #4 and 5 were implants. All of the maxillary teeth were to be restored but it was decided that #22- 27 would be taken care of in Phase II.

During her multiple stays in Illinois, the patient visited the lab and spoke at length with the author and dentist about her expectations and her apprehensions. She was not necessarily looking for a dramatic change in color, simply a brighter appearance. Even at her current age, her teeth were darker than she would have liked. The importance of these discussions cannot be overstated because the patient's fears and concerns were addressed during these sessions. This was a significant step toward her moving forward with the treatment.

Case Study

The patient's pre-operative appearance was noted (Fig. 1). Her natural color was warm and dark in tone, but the technician and clinician were concerned with the alignment and general organization of her dentition. She was interested in a natural, healthy smile with a livelier character to her color. From the technician's standpoint, her natural color was very good; it just needed a tone adjustment.

The technician articulated the models and evaluated the patient's occlusion (Fig. 2). He noted that tooth #27 was protrusive and that #6 was short in comparison to #11. In fact, #11 was just too long. To create a three-dimensional and opacious appearance to the model, the technician painted a gold paste onto the models for better evaluation.

A full-mouth treatment plan wax-up was fabricated for evaluation of the proportions of the mid-line and the centrals (Fig. 3). Teeth #6-11 were matched in a horizontal line, as well. From the wax-up, the provisionals were created (Fig. 4) in order to test and evaluate the fit with her natural dentition. She was then later asked to appraise the color and the general feel of the provisionals so that the laboratory could fabricate restorations that were satisfactory to her. Any changes she wanted to incorporate could be considered at that time.

The dark after-prep color was of great concern to the dental professionals (Fig. 5). The restorations were to be metal-free and several of her teeth had a dark shade due to metal or the color of the natural dentition. The Seasons of Life Shading System was very helpful in determining after-prep coloring and whether it would be a detriment to the final restoration color. Especially after cementation, there is sometimes color bleed-through that cannot be masked so it's best to determine whether that is an issue before-hand.

In determining the patient's provisional tooth color, the professionals used the Middle Years 4.0 version of the Seasons of Life shade tabs (Fig. 6). The shade tabs have a moderation of colors with more translucency and different enamel overlays to mimic natural dentition. In this particular instance, the technician was able to use one simple shade tab formula for MY5, and create excellent colorization for the patient while also concentrating on the shape and contour for the aesthetic design of the case.

Before preparation, the mandibular teeth were photographed in order to verify alignment and shape (Fig. 7) and what needed to be corrected in the future. Fabricated with the GC Initial Porcelain System, the posterior mandibular restorations were placed on a mirror for an appearance check (Fig. 8). Insertion of the restorations demonstrated the harmonious appearance the dental professionals were able to create upon cementation (Fig. 9). Excellent height of contour, occlusion table and good cusp alignment were all noted for the maxillary teeth. As has been mentioned, #22-27 were to be restored in Phase II.

After preparation, the author took an occlusion view shot to clearly see indications for the placement of the CAD/CAM implant abutments on teeth #12 and 13 and all other restorations (Fig. 10). Each of the zirconia understructures were fabricated by the GC Advanced Technologies Milling Center in Alsip, Illinois.

On the model, after scanning and milling, the zirconia copings and bridgework were fit to the die cast (Fig. 11). Note that the first dentin frame modifier had been applied prior to the GC Initial Porcelain in order to bring out the most possible life-like color. Thirteen units were displayed on a mirrored surface (Fig. 12).

The final cementation stage was handled using Automix Compatible GC FujiCEM cement (Fig. 13). Finally, a post-cementation shot of the maxillary anterior and mandibular posterior restorations in the mouth (Fig. 14). Tooth size measured well with good harmony from gingival to incisal for #6-11 and proper buccal corridor. During the final phase, a post smile view shot was taken and recorded (Fig. 15).

Conclusion

After Phase I of the case was completed, the patient left for France. Thankfully, communication between the parties had gone well regarding color, shape and size of the restorations. Distance, however, did play a role in the timing of the case and was a big consideration as they moved from one segment of treatment to the next.

Talking to the patient about her particular situation became a big portion of the case. Her fearfulness played a role in all the decisions that were made, and set the pace of the treatment. At the end of the cementation phase, however, she was very happy and satisfied with her results. She will move on to the second phase soon.

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September 2025
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