Case 47 | Prosthodontic Award 2015 | Italy
Dr. Marco Veneziani
Full mouth adhesive rehabilitation
48-year-old male patient. He came to me with the request of improving the aesthetics of the upper anterior teeth.
The patient showed severe wears caused by friction and mechanical abrasion on the occlusal surfaces and incisal margins with loss of vertical dimension.
A clinical and radiographic analysis highlighted several inadequate pre-existing restorations on the posterior upper and lower teeth.
There was widespread and recurrent tooth decay, marginal infiltrations, endodontic lesions and violation of the biological width of elements 16-24-25. An initial aesthetic analysis showed significant asymmetry of the smile with inclination of the occlusal plane, deep bite, severe discolorations of all teeth. An old horizontal asymptomatic root fracture of element 21 was also found with minor mobility. Implant-prosthetic restorations were found on tooth 26 and 36; the fixtures were in proper condition.
The treatment plan included a first phase of periodontal ,endodontic and restorative rehabilitation, then a digital study of the case ,the full mouth adhesive mock-up with clinical pre-visualization of aesthetics and function, finalized with complete rehabilitation of the arches with lithium silicate indirect adhesive restorations.
More in detail, the first phase involved: direct restorations and adhesive build-up. I worked on the four posterior quadrants in order to remove the previous restorations, thoroughly cleaned the carious lesions and carried out direct adhesive restorations , build-up and pre-prosthetic restorations depending on the degree of loss of dental substance. Root canal re-treatment of elements 14 ,24 ,25 ,37 was performed. Surgical crown lengthening was carried out on the subgingival cervical lesions in order to restore the biological width (el. 16, 24 – 25).
Second phase: Analysis of face and smile by means of Digital Smile Design and virtual aesthetic treatment plan .Based on the digital information obtained, a first wax-up for aesthetic evaluation was made, followed by a full mouth wax-up with an increased vertical dimension . Based on wax-up, silicon indices were made which were used for mock-up and provisionals. So I performed adhesive direct resin mock-up of both arches .The patient was then evaluated from a functional and aesthetic point of view and the project was validated.
Third phase: Restorative finalization of the posterior teeth with heat-pressed monolithic Lithium Disilicate adhesive restorations . The preparations were minimally invasive (1-1.5mm thickness), driven by mock-up, with depth cutter. First the lower posterior sectors (Quadrant 3-4) were rehabilitated then the upper posterior sectors (Q1-2). A rigorous procedure of adhesive cementation was performed with a rubber dam. The elements restored with crowns provided a simplified adhesive cementation with self-adhesive resin cement . The crowns were then screwed on implants and the access hole was filled with direct composite.
Fourth phase: Restorative finalization of anterior teeth with Lithium Disilicate Layered Veneers . Traditional ceramic laminate veneers were carried out onto the lower anterior teeth . This minimally invasive preparation technique was driven by mock-up with buccal and incisal depth cutter and immediate check with silicone indeces.
Full Lithium Disilicate Veneers layered in the buccal side on the upper anterior teeth were adhesively cemented. As I had to increase the vertical dimension, I nedeed a complete preparation which was however minimallly invasive and entirely in enamel.
All the full veneers were cemented with strict adhesive procedures in a field isolated with rubber dam.
Element 21, which displayed a completely asymptomatic horizontal root fracture, was periodontally stable and was kept in the arch, with the consent of the patient, for a minimally invasive approach, thus avoiding an implant-prosthetic replacement.
The final rehabilitation shows excellent occlusal stability, proper protrusive and lateral guides, a good periodontal health and a good aesthetic result that meets the needs of the patient
Laboratory procedures have been carried out by DT F.Pozzi and A . Quintavalla (Parma,Italy)