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Tech-Driven Full-Mouth Rehab by Drs. Jarron Tawzer and Josh Nagao

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Categories: Restorative Dentistry;
Tech-Driven Full-Mouth Rehab 

by Drs. Jarron Tawzer and Josh Nagao

Introduction
Cases in dentistry involving multiple disciplines can often become overwhelming for the general practitioner, especially when they involve more complex treatment planning, modification of multiple biological structures and tissue types, and outlying the actual timeline of the treatment itself.1 Luckily, over the last decade, technology has improved to the point where these cases can become much more predictable, easier to manage and, in the end, more profitable.

Full-mouth rehabilitation cases are some of the most complex of the above-mentioned treatments, as they can involve modifying gingival height, tooth position and vertical dimension of occlusion. The sequence of these cases and timeline of treatment is crucial in the overall success. New technology such as intraoral scanning, 3D printing, CBCT imaging, advancements in biologics and the ability to digitally design cases have made it so these challenging cases, which previously took many months to complete or were referred, can now be predictably completed. In this article, we will overview the treatment of a patient where complex, interdisciplinary treatment was achievable with the use of these technologies.


Patient presentation and history
The patient featured in this case is a 67-year-old-female who presented with a chief complaint of sensitive teeth. She had been using “remineralization liquid” to “help build her enamel back.” Her health history showed a history of Stage 4 cancer and chemotherapy treatment and silent GERD. She found our office online, seeking an additional opinion on her dental needs. She had been to multiple dentists in the area who had given her a wide variety of different recommendations from, in her words, “anywhere from a couple crowns to implant dentures.” Obviously, after hearing such differing treatment options, the patient was confused as to her actual dental needs and even the current condition of her teeth. Unfortunately, similar situations—where wildly differing clinical treatment recommendations are given—are common in dentistry and can make it difficult for a patient to know which treatment option is right for them.2


Initial assessment and treatment plan
A full series of radiographs and set of photos were taken on the patient before a comprehensive examination. This way she was able to see photos of her actual teeth as the recommended treatment was explained to her. The patient had a variety of existing dental problems (Fig. 1). One of the first things noticed was the gingival excess, or a gummy smile. This is likely a result of altered passive eruption3 but creates the look of small, square, undersized teeth (Fig. 2). The second major issue was the cervical abfraction throughout the mouth. This is likely attributed to the patient’s history of both cancer and dry mouth associated with treatment modalities, and functional habits such as clenching and grinding.4 Other factors that were apparent when evaluating the patient’s mouth were the excessive overbite of the upper teeth and lower teeth in occlusion, robust gingival tissue type, acceptable maxillary incisal edge position, and cant in the patient’s lip line (Fig. 3).
Tech-Driven Full-Mouth Rehab
Fig. 1
Tech-Driven Full-Mouth Rehab
Fig. 2
Tech-Driven Full-Mouth Rehab
Fig. 3


After discussing all of the factors present, full-mouth rehabilitation was recommended with maxillary hard- and soft-tissue crown lengthening.5 Because the patient had been made clearly aware of the condition of her teeth and the limitations and risks of other treatment options, she agreed to the full treatment plan presented.


Records appointment
The first appointment following consent to treatment was a records-gathering appointment. This time was used to acquire additional photos and intraoral scans, discuss treatment timeline, discuss shade and appearance of teeth, obtain written consent approval for treatment, and perform presurgical assessment for IV sedation.

It is important to note that the intraoral scans and bite records were taken in the desired vertical (open) position (Figs. 4 and 5). This position was established based on the amount of additional vertical dimension needed. The scans were taken with a leaf gauge placed between the anterior maxillary and mandibular teeth. Taking this “open bite” record is a more predictable way of ensuring proper occlusion in the printed temporaries, as opposed to virtually opening the bite via software, as it maintains the jaw relationship in vivo. It should be noted that one drawback of using a leaf gauge is the potential distalization of the mandible in the recorded position. One way to potentially increase the accuracy when opening the vertical is using a deprogrammer and digital functional tracing via equipment like Modjaw movement tracker or Zebris digital facebow by Amann Girrbach.6
Tech-Driven Full-Mouth Rehab
Fig.4
Tech-Driven Full-Mouth Rehab
Fig.5

Once these records were taken, proposed designs to be used for same-day printed temporaries were designed using Exocad. These preliminary designs can be done by the provider or clinical staff, or they can be outsourced to a lab and serve as a virtual wax-up of the case moving forward. These designs can be 3D printed for patient education or traditional bisacryl temporary fabrication if the provider does not have the ability to fabricate 3D printed temporary crowns in-office.7


Treatment timeline
Once the records were taken and temporary designs completed, the patient was scheduled for treatment of the maxillary arch. The patient was sedated for the procedure using IV Versed, fentanyl, Benadryl and Precedex. Gingivectomy was performed first to establish an appropriate gingival margin aesthetically (Fig. 6). The amount of removal was determined by the amount of gingival height reduction the patient needed in full smile.

Once the appropriate gingival margin was established, the teeth were prepared, leaving the margin of the crowns at the newly established gingival margin. Existing restorations and decay were excavated from the maxillary teeth before placing build-ups where needed (Fig. 7). The preparations were finalized, ensuring a path of draw could be established within sextants, as the provisionals were designed as splinted sextants.
Tech-Driven Full-Mouth Rehab
Fig.6
Tech-Driven Full-Mouth Rehab
Fig.7

A final prep scan was taken at this point for design/adaptation of the pre-design to the prepared teeth. This scan was merged into the previously taken records, where temporary crowns were designed at the planned open vertical (Fig. 8). While design and fabrication of the temporary crowns was being completed (Figs. 9 and 10) (3D printing in resin-ceramic, washing, curing and characterization according to the Sprintray printing workflow),8 a full thickness flap was created to access the maxillary alveolus (Fig. 11). Hard tissue crown lengthening was then completed to ensure proper biologic width from the new margin. Alveolar shaping was also completed to reduce the overall bulkiness of the bone and improve the topography (Fig. 12).9 Vertical sling sutures (6-0 PGCL) were placed to approximate tissues in place and maintain the vertical position of the tissue during healing (Fig. 13).10 At that point, the provisional crowns were complete and placed with temporary cement (Fig. 14). Upon delivery, it was noticed that there was a significant cant in the anterior (Fig. 15). The patient was informed that the anterior temporary crowns (splinted 6-11 as seen in Fig. 16) would be replaced at her next visit (three days later). The design was immediately updated in Exocad and new, uprighted temporaries fabricated to be delivered at her post-op appointment. The authors would note that the ability to quickly and affordably redesign and fabricate provisional restorations is one of the biggest advantages of in-office 3D design and printing.11
Tech-Driven Full-Mouth Rehab
Fig.8
Tech-Driven Full-Mouth Rehab
Fig.9
Tech-Driven Full-Mouth Rehab
Fig.10
Tech-Driven Full-Mouth Rehab
Fig. 11
Tech-Driven Full-Mouth Rehab
Fig. 12
Tech-Driven Full-Mouth Rehab
Fig. 13
Tech-Driven Full-Mouth Rehab
Fig. 14
Tech-Driven Full-Mouth Rehab
Fig.15
Tech-Driven Full-Mouth Rehab
Fig.16

The patient was seen again at two weeks post-surgery for suture removal and new photographs were taken of her updated provisionals (Figs. 17 and 18). A temporary occlusal guard, which had been designed and 3D printed in-office, was also delivered at this time.
Tech-Driven Full-Mouth Rehab
Fig. 17
Tech-Driven Full-Mouth Rehab
Fig.18

The patient was seen two weeks after suture removal for preparation of the lower arch. The same sequence was performed for the lower arch with the exception of hard- and soft-tissue crown lengthening. The patient was allowed to function in the provisional crowns at the new vertical dimension for approximately six weeks to assess comfort and function of the new tooth height and jaw position. Minor occlusal adjustments were made during this time, and once an acceptable occlusal relationship was established, upper and lower scans were taken with corresponding bite so the information could be transmitted to the lab to maintain the current jaw and tooth relationship in the final restorations.

The restorations were fabricated out of high-translucency, multi-layered, milled zirconia. This material was chosen for its combination of strength, wear properties and its higher aesthetic characteristics compared to monochromatic zirconia.12 The restorations were cemented with reinforced glass ionomer cement from GC America and the occlusion was minimally calibrated. Reviewing the patient’s final restorations and result (Figs. 19 and 20) reveal the main goals of treatment were met. The gingival height was adequately improved, decay controlled, vertical dimension appropriately opened and an acceptable aesthetic result achieved.
Tech-Driven Full-Mouth Rehab
Fig. 19
Tech-Driven Full-Mouth Rehab
Fig. 20

This case highlights the transformative impact of integrating advanced dental technologies into complex full-mouth rehabilitation. By leveraging intraoral scanning, 3D printing and advanced imaging, what was once a daunting and lengthy process has been streamlined into a more predictable, efficient and aesthetically pleasing treatment outcome. The patient, previously overwhelmed by conflicting treatment plans, benefited from a clear, technology-driven approach that not only addressed her clinical needs but also enhanced her understanding and acceptance of the treatment process. This case underscores the potential of modern dentistry to not only restore function but also to significantly improve the quality of life for patients with complex dental issues.

As dental technology continues to evolve, the ability to achieve such comprehensive and precise results will undoubtedly become more accessible, setting new standards in dental care excellence.
References
1. Minervini, G. Dentistry: A Multidisciplinary Approach. Medicina 2024, 60, 401. https://doi.org/10.3390/medicina60030401
2. Caplin RL. Dentistry - art or science? Has the clinical freedom of the dental professional been undermined by guidelines, authoritative guidance and expert opinion? Br Dent J. 2021 Mar;230(6):337-343. doi: 10.1038/s41415-021-2726-4. Epub 2021 Mar 26. PMID: 33772186; PMCID: PMC7995380.
3. Alpiste-Illueca F. Altered passive eruption (APE): a little-known clinical situation. Med Oral Patol Oral Cir Bucal. 2011 Jan 1;16(1):e100-4. doi: 10.4317/medoral.16.e100. PMID: 20711147.
4. Nascimento MM, Dilbone DA, Pereira PN, Duarte WR, Geraldeli S, Delgado AJ. Abfraction lesions: etiology, diagnosis, and treatment options. Clin Cosmet Investig Dent. 2016 May 3;8:79-87. doi: 10.2147/CCIDE.S63465. PMID: 27217799; PMCID: PMC4861607.
5. Guzman-Perez, G.; Jurado, C.A.; Azpiazu-Flores, F.X.; Munoz-Luna, H.; Afrashtehfar, K.I.; Nurrohman, H. Soft Tissue Grafting Procedures before Restorations in the Esthetic Zone: A Minimally Invasive Interdisciplinary Case Report. Medicina 2023, 59, 822. https://doi.org/10.3390/medicina59050822
6. Stafeev A, Ryakhovsky A, Petrov P, Chikunov S, Khizhuk A, Bykova M, Vuraki N. Comparative Analysis of the Reproduction Accuracy of Main Methods for Finding the Mandible Position in the Centric Relation Using Digital Research Method. Comparison between Analog-to-Digital and Digital Methods: A Preliminary Report. Int J Environ Res Public Health. 2020 Feb 3;17(3):933. doi: 10.3390/ijerph17030933. PMID: 32028674; PMCID: PMC7037659.
7. Rizzante F, Bueno T, Guimarães G, Moura G, Teich S, Furuse A, Mendonça G. Comparative physical and mechanical properties of a 3D printed temporary crown and bridge restorative material. J Clin Exp Dent. 2023 Jun 1;15(6):e464-e469. doi: 10.4317/jced.60507. PMID: 37388428; PMCID: PMC10306384.
8. https://sprintray.com/oracle/uploads/2023/05/SprintRay-Workflow-Guide-Crown.pdf
9. Souza-Passaroni B, Vieira-Falabella ME, Mendonça-Falabella M. (2024). Aesthetic Crown Lengthening: Case Reports. Int J Odontostomatol. 18(2), 194-199. Retrieved Sept. 20, 2024, from http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-381X2024000200194
10. Ronco V, Dard M. A novel suturing approach for tissue displacement within minimally invasive periodontal plastic surgery. Clin Case Rep. 2016 Jul 23;4(8):831-7. doi: 10.1002/ccr3.582. PMID: 27525096; PMCID: PMC4974440.
11. Jain S, Sayed M, Shetty M, Alqahtani S, Dafer M, Wadei A, Gupta S, Abdulsalam A, Othman A, Alshehri A, Alqarni H, Mobarki A, Motlaq K, Bakmani H, Zain A, Hakami A, Sheayria M. (2022). Physical and Mechanical Properties of 3D-Printed Provisional Crowns and Fixed Dental Prosthesis Resins Compared to CAD/CAM Milled and Conventional Provisional Resins: A Systematic Review and Meta-Analysis. Polymers. 14. 2691. doi: 10.3390/polym14132691
12. Ahmed M, Malallah A, Hasan N, Sulaiman T. (2024). Translucent Zirconia: A Literature Review. Al-Rafidain Dental Journal. 24. 26-36. doi: 10.33899/rdenj.2023.143906.1228
Author Bios
Dr. Jarron Tawzer Dr. Jarron Tawzer earned his undergraduate degree from Utah State University and graduated from Oregon Health and Science University School of Dentistry. He lives and practices in Logan, Utah, focusing on implants and cosmetic dentistry. Tawzer mentors at the Implant Pathway dental implant center in Phoenix, training dentists in complicated atraumatic extractions, bone grafting and dental implants. He has dedicated much of his career to advancements in dentistry, particularly dental implants and cosmetic dentistry.


Dr. Joshua Nagao Dr. Joshua Nagao earned his DDS from The Ohio State University School of Dentistry, graduating first in his class clinically. Nagao is particularly passionate about dental surgery, including implant placements, sedation dentistry and complex reconstructions. He is a faculty member and mentor at Implant Pathway, an associate fellow in the American Academy of Implant Dentistry and a diplomate in the American Board of Oral Implantology. Nagao is also the creator of #implantsanta, a social media page dedicated to digital dental surgery and high-quality photography.

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