Many patients are familiar with clear aligner therapy—it is a common treatment modality in many dental practices. But in some cases, such therapy may not be the best solution. A little while ago, my colleague referred a young gentleman to me for an Invisalign® consultation. The patient’s chief complaints were the diastemas between his front teeth. He had many friends improve their smiles with clear aligner therapy and he was ready to try that treatment as well.
Given the patient’s entrapped bite and anterior implant, I determined that Invisalign® therapy may not fully achieve his goals.
When discussing treatment with my patient, I discovered that he is a third shift (late-night) nurse and a beta-tester of table games. He had developed poor sleep and diet habits due to his professional lifestyle, and he reported persistent acid reflux, grinding, and fatigue. We discussed the limitations of Invisalign® and also alternative treatment options. During this visit, I performed a comprehensive exam and reviewed digital photos and X-rays.
THE PROBLEMS
After studying the patient’s case, I observed significant mandibular occlusal and buccal posterior attrition and erosion. This resulted in decreased vertical dimension, reverse Curve of Spee, and deep anterior overbite. To further complicate the case, the patient had a congenitally missing tooth number 7, and in 2007, he had an implant placed at that site. I noted asymmetrical tissue formation of the implant restoration. The patient had 1 to 2 mm diastemas between all teeth, from canine to canine.
Given the patient’s entrapped bite and anterior implant, I determined that Invisalign® therapy may not fully achieve his goals. With that treatment, spaces would result somewhere in the upper arch given the constricted bite, and the anterior implant would limit the movement possibilities and aesthetic symmetry. Furthermore, Invisalign® could not correct his deep, entrapped bite, or rebuild the lost enamel that resulted in the loss of vertical dimension.
The patient returned to the practice for his diagnostic review. We discussed his desire to improve his smile by closing the spaces between his front teeth. I displayed his photos and discussed the extensive enamel loss to his lower posterior teeth, and I explained the significance of the erosion at such a young age. The patient understood that his bite was collapsing and shrinking his airway space. We talked about how his lower teeth were “trapped inside the garage” of the upper teeth and would cause forces that would contribute to further breakdown over time.
Although the patient had presented for an Invisalign® consultation, we talked about the limit-ations of that treatment in his case. I gave him multiple options to achieve his aesthetic and oral health goals. The patient chose to restore his entire lower arch and his upper teeth from premolar to premolar. He was absolutely determined to keep his teeth for a lifetime. The patient secured financing for treatment through personal funds and a loan from a family member, so he accepted treatment on the same day that it was presented.
GETTING READY
The most important factor in setting this case up for success was capturing the patient’s bite in the desired raised vertical dimension. I used a swallow-bite technique for this record—the patient swallowed and slowly closed on wax cubes until he achieved the desired Shimbashi measurement.
I used a laser to mold the facial tissue around the implant . . . so the emergence of the crowns would mimic natural teeth.
Communication with Arrowhead Dental Lab, our chosen lab, was also crucial to a successful outcome. We planned the case so that height was added to the lower teeth only, for a few reasons. First, the lower teeth had shortened over time from acid erosion and grinding. Adding porcelain to the worn teeth would rebuild them to their natural shape and correct the reverse Curve of Spee, allowing for proper occlusion and function. Second, the patient’s maxillary tooth lengths were pleasing within his smile, so we did not want to lengthen them.
PREPPING AND SEATING
At the first appointment, I prepped tooth numbers 4 through 13. I spent extra time recontouring the patient’s gingiva to improve symmetry. I used a laser to mold the facial tissue around the implant at site number 7 and by all the diastemas, so the emergence of the crowns would mimic natural teeth.
I then made the provisionals using a putty matrix. Arrowhead fabricated the matrix off the diagnostic wax-up. I love delivering temporaries in the desired shape and position to really allow patients to “test-drive” their smiles. I then overlayed the provisionals on the patient’s lower teeth. By doing this, I confirmed a balanced occlusion and protective eccentric function. We used a combination of Elite e.max® press veneers and crowns for this case.
At the seat appointment, I tried in all the restorations dry to confirm marginal fit and interproximal contact tightness. I then placed the Elite e.max® restorations with a try-in gel so the patient could stand and look at his teeth in a mirror for consent to the permanent cementation. I cleaned the Elite e.max® with Ivoclean Monobond® Primer and then bonded with the Adhese® Universal VivaPen® by Ivoclar.
Next, I isolated the patient’s upper teeth with a rubber dam. We then pumiced the prepped teeth, cleaned with Consepsis™, etched and bonded again with Adhese®. I seated the e.max® restorations with Variolink® Esthetic LC.
The patient returned to the practice 48 hours later, when we checked his phonetics, occlusion, and eccentric contacts. Because minimal changes were needed, we proceeded with treatment on the lower arch.
Three weeks after placing the maxillary e.max® veneers, I prepped the patient’s full lower arch. For this process, the blueprint was laid by the diagnostic wax-up and provisionals, so the final restorations required minimal occlusal adjustments, and the patient reported that they felt natural immediately.
AN UNEXPECTED SURPRISE
One complication arose in the middle of the case. After the lower final impression was sent to the lab for the restorations, a possible distortion was discovered. I discussed how to remedy the situation with a lab technician, and we collaboratively decided to take a new final impression. This was somewhat frustrating and inconvenient for both the patient and me. Our patient was very understanding, however, and everyone wanted the best final outcome. So the patient returned to my office to fully remove his lower provisionals and get a new final lower impression.
In general, bonding a full arch of porcelain in one sitting is challenging. Moisture, bleeding, and multiple tiny restorations are some of the factors that make it tricky. My preferred technique is to use an Isodry® device to isolate and seat only the molars, so the restorations can be bonded in a dry field. Once those are fully cured, I place a rubber dam to isolate the teeth from the second premolar forward. The same materials and process were used to bond the lower teeth as I used for the upper teeth.
A SUCCESSFUL OUTCOME
I attribute the success of this case to two things—first is an education in full arch dentistry. Through the Dr. Dick Barnes Group and other continuing education (CE) courses, not only did I learn how to physically complete this case, but I also learned what to look for so I could properly diagnose and treatment-plan for a successful, long-lasting result.
Initially, this patient came to my practice with spacing concerns and requested Invisalign®, which we could have given to him. But by digging deeper into the patient’s lifestyle and oral changes, we agreed that Invisalign® would not accomplish the patient’s goals. Instead, porcelain restorations were a better treatment option for his health and smile.
Second, Arrowhead Dental Lab has extensive experience with complex cases, including full arch dentistry. I provided them a detailed prescription and digital photos, and Arrowhead fabricated the tools I needed to complete the case successfully. With an experienced lab, I know the product I’m delivering to my patients will have minimal adjustments and my seat appointments will be stress-free. Arrowhead is truly elite.
This patient’s health and life have changed due to the treatment we delivered. He is a raving fan and a fervent referral source for our practice. His new smile has helped him in many areas in his life—he’s mentioned that he’s sleeping and breathing better. The patient is taking better care of his overall health, his eyes are brighter, and he’s more vivacious. He absolutely loves his smile and feels much more confident. It is so gratifying as a dentist to see such a positive result. While I love providing Invisalign® treatment, I am thankful for the CE training I’ve completed so that I can recognize when it will not be the best treatment modality.
