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A Dynamic Duo by Dr. John Heimke

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Categories: Prosthodontics; Restorative Dentistry;
A Dynamic Duo 

A team approach with Oral Design specialists for full-mouth rehab and bite management

by Dr. John Heimke

Today’s cultural and social norms greatly influence the universal perception of a beautiful, aesthetically pleasing smile.1 A bright, white, defect-free smile is considered an indication of good health and youth, while a smile that exhibits discolored, chipped, worn or missing teeth reflects aging and neglect. Over a lifetime, teeth are naturally exposed to numerous corrosive and physical influences as well as parafunctional habits that negatively not only affect the color and shape of the teeth but also can lead to various forms of tooth wear that can adversely affect the patient’s general health and quality of life.2

Often, patients exhibiting tooth wear are asymptomatic because of the slow pace of the disease and a lack of symptoms such as tooth sensitivity, headaches or other related indicators. Consequently, these patients most often present for treatment because of aesthetic or functionality concerns.3 They have become very aware of physical changes affecting the nature of their smile, such as shortened anterior teeth, tooth discoloration or a general dissatisfaction or change in their ability to chew efficiently. For adults in the workforce, deterioration of dental aesthetics has a significant social impact on how they perceive themselves and are perceived by others.

The case reported here involves a prominent dental professional who was concerned about the wear on his maxillary anterior teeth and the aesthetic effects of his shortened teeth on his smile. After a thorough examination, it was determined that his worn anterior teeth were an indicator of a more serious problem.

Case report
A healthy 54-year-old patient presented to the practice concerned with the aesthetics of his smile. His major concern was the lack of tooth display when smiling (Fig. 1) and general lackluster appearance of his teeth. Because he interacted with patients on a daily basis, it was important to him that the youthfulness and aesthetics of his smile be restored.
Prostho Full Mouth Rehab Case
Fig. 1

The patient reported no pain, tooth sensitivity or other symptoms. Upon initial examination, occlusal wear was noted on all teeth, along with multiple areas of abfraction and tooth wear at the necks of the teeth in both arches (Fig. 2).4–6 Tooth #14 was missing, with the appearance of significant bone loss, and Teeth #30 and #19 exhibited mobility as well as signs of occlusal stress and needed to be extracted. There was also moderate crowding in the anterior lower arch.
Prostho Full Mouth Rehab Case
Fig. 2

With the patient exhibiting occlusal signs of dysfunction, a comprehensive diagnostic screening was undertaken to determine if the loss of anterior guidance and cuspid rise was the causative factor. X-rays confirmed severe bone loss at the sites of missing/ extracted Teeth #14, #19 and #30. A series of preoperative photos (Figs. 3–7) were taken, along with full-face and retracted videos of the patient going through dynamic border movements to assess dynamic motion and function. In this case, the canines had lost their protective cusp, allowing the back teeth to occlude during all the chewing phases.
Prostho Full Mouth Rehab Case
Fig. 3
Prostho Full Mouth Rehab Case
Fig. 4
Prostho Full Mouth Rehab Case
Fig. 5
Prostho Full Mouth Rehab Case
Fig. 6
Prostho Full Mouth Rehab Case
Fig. 7


A key point in restoring vertical dimension is to take preoperative distance measurements using calipers—in this case from Tooth #7 to #26 to guide the postoperative goal of opening vertical dimension of occlusion (VDO) by 2 mm, restoring the occlusal relationship and the aesthetics of his smile.7–11 The preoperative findings were shared with the patient to demonstrate the need for a full-mouth rehabilitation using the “smile artist” approach of an Oral Design dentist and master ceramist to restore normal function and meet his demand for an aesthetic smile.12

Treatment plan and diagnostic wax-up
The treatment plan presented was to extract Teeth #30 and #19 and place zirconia three-unit bridges on #13–#15, #18–#20 and #29–#31, all-ceramic crowns on Teeth #6–#12 and #28, and zirconia crowns on #3–#5. All-ceramic veneers were prescribed for teeth #21–#27. The digital photos were uploaded into smile design software (SmileFy) to create a 3D smile design to share with the patient for case acceptance and with the laboratory as a blueprint for the final case outcome (Figs. 8–9).
Prostho Full Mouth Rehab Case
Fig. 8
Prostho Full Mouth Rehab Case
Fig. 9

Silicone impressions (Silginat, Kettenbach Dental) were taken of both arches and sent to the laboratory, along with all diagnostic records including X-rays, preoperative photos, videos and 3D smile design, as well as bite registration (Futar D, Kettenbach) and facebow photographs.

The laboratory created an analog diagnostic waxup of the final case outcome for clinical approval.

Note: Although the patient expressed a desire for implants to replace the three missing teeth and was referred to an oral surgeon for treatment, bone grafting did not achieve the bone height needed for implant placement. It was decided to instead move forward with preparing and provisionalizing the case during this phase, with placement of the bridges delayed until a decision on the possibility of implants was finalized.

Preparation and provisionalization
To control the final aesthetics and establish the occlusal plane, it was decided to begin restorative treatment on the anterior teeth of the lower arch.13 To provide the patient with the desired strength and aesthetics needed, as well as a material that could be pressed to minimal thickness that some teeth in this case required, we decided to use lithium disilicate (IPS E.max Press, Ivoclar) and zirconia (IPS E.max ZirCad Prime, Ivoclar).

The patient was anesthetized and retracted (Optragate, Ivoclar). The lower anterior arch was prepared for veneers on Teeth #21–#27 and an all-ceramic crown on #28. A stump-shade photo of the preparations (Fig. 10) was taken for communication with the laboratory. The prepared teeth were then spot-etched (Total Etch, Ivoclar), a bonding material applied (Adhese, Ivoclar) and the putty matrix filled with self-curing provisional material shade BL (LuxaTemp, Ivoclar). After four minutes, the putty matrix (Lab Putty, Kettenbach) was removed, excess material trimmed, tooth shapes refined and margins adjusted. The provisonals were shaped and finalized (Fig. 11).
Prostho Full Mouth Rehab Case
Fig. 10
Prostho Full Mouth Rehab Case
Fig. 11

One week later, the patient returned to the practice for a postoperative appointment to evaluate the function and aesthetics of the provisionals and make any necessary adjustments.

In collaboration with Oral Design master ceramist Peter Kouvaris, it was determined that shade OM3 Natural (Vita 3D Master, Vita) would be used for the final restorations. Three weeks later, the final veneers for Teeth #21–#27 and the crown for #28 were delivered and seated. At the same appointment, the upper maxillary teeth were prepared; bites were taken and the new VDO verified with calipers. Retraction cord and pellets (Retrax Hemostatic Pellets, Pascal Dental) were placed, then removed, and the preparations rinsed and dried. Final impressions (Identium Heavy and Light, Kettenbach) were made of the prepared teeth and photos taken of the stump shade (Fig. 12) for communication with the laboratory. The maxillary teeth were temporized using the same provisional protocol (Figs. 13 and 14).
Prostho Full Mouth Rehab Case
Fig. 12
Prostho Full Mouth Rehab Case
Fig. 13
Prostho Full Mouth Rehab Case
Fig. 14

Teeth #13–#15, #18–#20 and #29–#31 were then prepared for fixed bridges and provisionalized. The overall aesthetics of the smile was then evaluated, phonetics verified and occlusal contacts checked (Fig. 15). The patient was advised to wear the provisionals for two weeks. At the end of two weeks, the patient reported back to the practice, pleased with the aesthetics and functionality of the provisional restorations. Photographs, a video and final impressions of the provisionalized patient were taken for communication with the laboratory for delivery of the final restorations.
Prostho Full Mouth Rehab Case
Fig. 15


Delivery
The patient returned four weeks later for seating of the final restorations. The patient was retracted (Optragate) and the temporaries were gently removed. Before final bonding, an aesthetic try-in paste (Variolink Esthetic, Ivoclar) was applied to select final restorations to verify shade, then cleaned and dried. Then, the prepared teeth were acid-etched and an adhesive was applied (Adhese) and light-cured for 20 seconds. Each restoration was cleaned (Ivoclean) and a primer applied (Monobond Etch and Prime, Ivoclar). Luting composite shade Light (Variolink Esthetic) was applied to each restoration and seated. A brush was used to remove any excess material, and then each restoration was tacked and cured (FlashLite Magna 4.0, Denmat). An ultra-fine ET diamond (Komet, Brasseler) was used to clean the margins and a separating strip (Komet) used to clean the proximals of any material and adjust occlusion. Rubber porcelain polishing points (OptraFine, Ivoclar) were used to final-polish each restoration.

The patient was pleased with the highly aesthetic outcome (Figs. 16–20) and was provided a lower-arch nightguard.
Prostho Full Mouth Rehab Case
Fig. 16
Prostho Full Mouth Rehab Case
Fig. 17
Prostho Full Mouth Rehab Case
Fig. 18
Prostho Full Mouth Rehab Case
Fig. 19
Prostho Full Mouth Rehab Case
Fig. 20

Conclusion
This complex full-mouth rehabilitation resulted in a successful outcome using an Oral Design team protocol. The dentist and master ceramist team work in a predictable workflow protocol using the “Face to Teeth” 2D digital smile design, then 3D-prototyping the smile with the patient test-driving the aesthetics and function of the proposed design before a master ceramist uses his or her specific skill sets to fabricate the final porcelain restorations.

Today the workflow for this type of dentistry is rapidly evolving into using layered digital files, such as 3D face scans, intraoral scans and digital face bows, and meshing those files with lab design software to generate 3D-printed prototypes for milled wax copings for pressing or milling lithium disilicate and zirconia final restorations. Combined with the human touch of an analog “smile artist,” the final restorations come alive with a skilled master ceramist shaping, microlayering, staining and glazing the restorations to a final result.
 

References
1. Ruefnacht C. Fundamentals of Esthetics. Hanover Park, IL: Quintessence Pub. 1990.
2. Farzin M, Giti R, Heidari E. “Age-related changes in tooth dimensions in adults in Shiraz, Iran.” J Int Oral Health [serial online] 2020 [cited 2023 Nov 12]; 12, Suppl S1:24–29.
3. Bartlett D, O’Toole S. “Tooth wear: Best evidence consensus statement.” J Prosthodont. 2020 Dec 17. doi: 10.1111/jopr.13312. Epub ahead of print.
4. Tunkiwala A. “The worn and eroded dentition: Etiology, risk assessment and treatment considerations.” Journal of Cosmetic Dentistry, 2020; 36(1):50.
5. Wazani B, Dodd M, Milosevic A. “The signs and symptoms of tooth wear in a referred group of patients.”Br Dent J. 2012 Sep; 213(6):E10.
6. Gkantidis N, Dritsas K, Gebistorf M, Halazonetis D, Ren Y, Katsaros C. “Longitudinal 3D study of anterior tooth wear from adolescence to adulthood in modern humans.” Biology (Basel). 2021 Jul 13; 10(7):660.
7. Abduo J, Lyons K. “Clinical considerations for increasing occlusal vertical dimension: a review.” Australian Dental Journal, 2012 57: 2–10.
8. Muts E-J, van Pelt H, Edelho D, Krejci I. “Tooth wear: A systematic review of treatment options.” Journal of Prosthetic Dentistry (2014), 112(4):752–759.
9. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. “Current concepts on the management of tooth wear: Part 4. An overview of the restorative techniques and dental materials commonly applied for the management of tooth wear.” Br Dent J. 2012 Feb 24; 212(4):169–177.
10. Banerji, S., Mehta, S. “Clinical management of pathological tooth wear in general dental practice.” Br Dent J 220, 209–210 (2016).
11. Turner KA, Missirlian DM. “Restoration of the extremely worn dentition.” J Prosthet Dent. 1984 Oct; 52(4):467–74.
12. Ruiz, J-L., “Diagnosing and educating patients about occlusal disease.” Inside Dentistry, 2014. 10(1).
13. “Sequencing a Full Mouth Rehab: Anterior or Posteriors First?,” The Dawson Academy Blog.

Author Bio
Dr. John Heimke Dr. John Heimke, who has more than 30 years of experience in cosmetic and implant dentistry, now practices in Cleveland. Heimke earned a DMD at Case Western Reserve University School of Dental Medicine in Cleveland and an MPH from Emory University in Atlanta, and completed an advanced education program in general dentistry at Fort Benning, Georgia, while serving as a captain in the U.S. Army medical department.

Heimke is a fellow of the Academy of General Dentistry and the Pierre Fauchard Academy, and a member of the Oral Design International Foundation. A Digital Smile Design master and instructor, he also lectures on cosmetic dentistry, digital/analog dentistry workflows, full-arch implants, marketing, and consults and case acceptance.

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