A Segmented Approach to Full Arch Reconstruction.
Val has been my neighbor for about 18 years, and our families have a close relationship. Our kids have grown up together, and she’s been my patient as well as a friend. I knew that Val thought about her smile often. Many times, she would ask me about bleaching and express her frustration with over-the-counter products. Although Val didn’t express dissatisfaction with her smile, I knew she was not aware of how it could be improved with techniques in today’s dentistry.
Whenever Val inquired about whitening, I used the opportunity to discuss different aspects of her smile. When Val came in for recall appointments, I showed her photographs of other cases that I had restored.
I answered all of her questions and planted seeds of knowledge so that she would realize something could be done if she wanted. I never put any pressure on her for treatment. Ultimately, comprehensive treatment had to be her decision. Val eventually chose to seriously examine her smile and investigate what could be done to improve it. At that point, I treated Val as a new patient and scheduled her for a full comprehensive exam. It had been several years since her initial exam and I wanted to make sure that everything was up to date.
Initial Work-Ups
In mid-2017, we performed a comprehensive exam that included an oral cancer screening, a periodontal and temporal mandibular joint screening, a series of full mouth X-rays, digital photographs, study models, a facebow transfer, and a centric relation bite record. I took notes about the aspects of Val’s smile that she wanted to improve.
Val had several diastemas on her upper arch. Her teeth were of various widths and were asymmetrical in relation to the gingival levels. She also had a history of fractured enamel, fractured restorations, and fractured porcelain-fused-to-metal (PFM) crowns. She obviously experienced problems with clenching, grinding, and malocclusion. I knew such issues had to be addressed prior to the placement of new crowns, otherwise the new crowns would succumb to the same fate as her natural teeth.
After showing Val the results from some of my other patients, I turned my attention to her smile. I showed Val the digital images we had taken and explained the similarities she had to some previous patients. In particular, I wanted her to see the issues she had with clinical crown length and gingival asymmetry. Val did not need much convincing—the proof was in the photographs. Val understood the problems in her own smile from the pre-operative photographs and models. She was very eager to move forward.
A Segmented Approach
Although dental technology and techniques have advanced to allow dentists to do incredible same-day comprehensive treatment, the multi-appointment approach continues to be an option. Ultimately, this was the best approach for Val’s case because it provided more predictability, and it allowed me to achieve the desired aesthetics and occlusion.
I referred Val to William B. Farrar, D.D.S., at Columbia Periodontal Associates in Columbia, SC. Dr. Farrar completed crown lengthening on tooth numbers 4, 5, 6, 11,12, and 13, and gingivectomies on tooth numbers 7, 8, 9, and 10. Val noticed a dramatic difference in the aesthetics of the gingival tissue created by Dr. Farrar. After this treatment, and prior to the first prepping appointment, we had a final consultation.
During the final consultation, we revisited the models, X-rays, and digital photographs. I also reviewed the diagnostic wax-up. Arrowhead Dental Laboratory’s White Wax-Up was a blueprint for how Val’s final full arch restorations were planned. I recommend using one in every comprehensive case. The wax-up allowed me to see the final result and work backward from there. It also allowed Val to see the goal and provide feedback on any changes she might want to make to the plan before the actual procedure.
At this appointment, I answered all of Val’s questions so that she would feel comfortable with the procedure. We discussed everything, from the type of preparations I would do to the type of material that would be used. (Her crowns would be fabricated using Arrowhead’s Elite ZirMax restorations.) She also allowed me to do an initial pre-prep equilibration.
Although Val’s vertical dimension was not compromised, an important and challenging part of the case was to maintain the occlusion and transfer that relationship to the lab.
APPOINTMENT 1
During this visit, we addressed Val’s posterior teeth.
1. I sectioned and removed the old PFM crowns on tooth numbers 3, 4, 12, and 14.
2. The old restorations were removed on tooth numbers 5 and 13.
3. Composite resin was used where needed for core buildups and fillers.
4. Tooth numbers 3, 4, 5, 12, 13, and 14 were prepped.
5. To fabricate temporaries, I used a Sil-Tech® matrix from the diagnostic wax-up. This allowed me to have the exact shape and size of teeth as presented in the wax-up.
6. I cemented the temporaries and adjusted the occlusion.
7. Val scheduled her next appointment for a few days later.
APPOINTMENT 2
When Val returned for this appointment, I evaluated her occlusion and equilibrated as needed.
1. I leveled and aligned the lower incisors and eliminated any sharp enamel edges and discrepancies.
2. A pre-prep bite registration was taken.
3. The previous restorations were removed on tooth numbers 8 and 9.
4. Crown preparations were accomplished on tooth numbers 6, 7, 8, 9, 10, and 11 using the stent sent by Arrowhead Dental Lab as a reduction guide.
5. After prepping, I relined the previous bite registration and obtained a facebow registration.
6. A final impression using a custom tray was taken of anterior tooth numbers 6, 7, 8, 9, 10, and 11.
7. The temporaries were fabricated using Sil-Tech® from the diagnostic wax-up, just as was done for the posterior teeth.
8. I made Val a soft brux guard (orthotic) to wear at night to protect her temporaries.
48-HOUR FOLLOW-UP
Two days later, Val returned for a follow-up appointment. I wanted to check the occlusion and the temporaries to see how they held up during the previous 48 hours of function. If Val felt like a tooth was too long or too prominent, or if her speech was interrupted or she had any other issues, I could adjust the temporaries as needed. Fortunately, all aspects of the temporaries were satisfactory, including the aesthetics, phonetics, and function.
An alginate impression was made of the temporaries. This allowed Arrowhead to make an index of the temporaries using the corresponding model. At this point, the lab had everything they needed.
APPOINTMENT 3
When the anterior crowns arrived from Arrowhead, we scheduled Val’s delivery appointment. At that visit, Val had been wearing the temporary restorations for about three weeks.
1. I removed the temporary restorations on tooth numbers 6, 7, 8, 9, 10, and 11.
2. I tried each permanent crown on individually and then all together to check the margins and contacts.
3. I verified proper occlusion. The shape, size, and symmetry looked great and Val approved of everything.
4. I cemented the crowns in the following order: tooth numbers 8 and 9, followed by tooth numbers 6 and 7, and finally tooth numbers 10 and 11.
24-HOUR FOLLOW-UP
Val returned to the office for a short visit a day after seating so that I could confirm proper anterior guidance, verify that all cement was removed, and evaluate her overall comfort. At that appointment, Val expressed that she was extremely pleased with the anterior crowns. She remarked that they looked and felt great.
APPOINTMENT 4
1. The temporary restorations were removed on tooth numbers 3, 4, 5, 12, 13, and 14.
2. The tooth preparations were refined as needed.
3. We took a final impression, a bite registration of the posterior teeth, and another facebow transfer.
4. All temporaries were re-cemented and the case was sent to the lab for fabrication of the posterior crowns.
APPOINTMENT 5
After we received the posterior crowns from the lab, Val presented for delivery.
1. Again, the temporary restorations were removed.
2. I tried in the crowns on tooth numbers 3, 4, 5, 12, 13, and 14.
3. As with the anterior crowns, I tried them in individually and then together to confirm contacts, marginal integrity, and proper occlusion.
4. I cemented the crowns for tooth numbers 3, 4, and 5, followed by tooth numbers 12, 13, and 14.
5. Only minimal occlusal adjustment was required.
6. Finally, all 12 crowns were seated and the maxillary arch reconstruction was complete.
7. I made Val an occlusal guard (orthotic) to protect the new crowns and instructed her to wear it nightly.
RESULTS
Val returned for a follow-up appointment after one week, and then again after a month. I checked the occlusion to make sure it was still on target. Overall, I was very pleased with Val’s case. I was happy to resolve her issues with occlusion, crown length, gingival symmetry, and the gaps between her teeth.
Although somewhat inconvenient for the patient, I was glad we followed a multi-appointment approach to treatment. It was important to address the occlusion issues using a slow, methodical process prior to seating her permanent crowns. This process helped us create and ensure long-term success for the patient.
Most importantly, Val was pleased with the results. Every time I see her, she has a big smile on her face. She loves the look of her new smile and is already making plans for work on her lower arch. I’m glad that I was able to work on a case that has had such a positive impact.
