High-Risk Esthetically Driven Restoration Begin With the End in Mind

7/23/2019 High-Risk Esthetically Driven Restoration Begin With the End in Mind

http://slidepdf.com/reader/full/high-risk-esthetically-driven-restoration-begin-with-the-end-in-mind 1/8

High-Risk Esthetically Driven Restoration:

Begin With the End in Mind

Michael T. Ricciardi, DDS; and Peter Pizzi, CDT, MDT

Abstract

A high-risk esthetically driven restorative case requires the dental team, along with the patient, to

have a clear vision of the final outcome. In this case of a 33-year-old woman who wanted to

improve her smile, esthetic problems stemmed from a retained deciduous maxillary left canine

along with an impacted tooth No. 11. Among a number of concerns was the shape and color ofthe deciduous canine and the uneven length of the maxillary central incisors. A treatment plan

that included orthodontics with removable aligners, occlusal adjustment, composite restorations,

extraction and implant placement, indirect porcelain veneers, and a custom abutment and PFM

crown was successfully executed in four phases over the course of more than 4 years.

When beginning a high-risk esthetically driven restorative case, it is important for the patient andthe dental team to have a clear vision of the final outcome. It is often difficult for patients to

articulate what they find esthetically undesirable. Sometimes, they are simply “unhappy” with

their appearance. Part of the role of dentists is to gain an understanding of their patients’ esthetic

concerns and discuss with them the solutions that are available. These solutions may involve prolonged treatment plans that span many years before the desired outcome is acheived.

1

Clinical Case Overview

Patient History and Chief Complaint: A 33-year-old woman presented for treatment in March

2007 desiring to improve her smile. She was developing a career in art sales and her smilehindered her confidence (Figure 1). She was aware that her front teeth had become shorter in

recent years. She was also unhappy with the way the teeth on her right side “dipped in” and her

canine (on the same side) “stuck out.” The left side had a retained deciduous canine (tooth H)

with an impacted maxillary left canine (tooth No. 11). The shape and color of the deciduouscanine was objectionable (Figure 2 and Figure 3).

The patient’s medical history was unremarkable. She had a past history of tobacco use but had been a nonsmoker for many years. Her dental history was limited to recall appointments and

simple restorative procedures.

Diagnostic Findings, Risk Assessment, and Prognosis

Prognosis was established by taking the risk assessment into consideration as well as the age of

the patient, the presence or absence of the contributing factors of disease, the expected lifespanof the patient, diet, and what the patient did with and to her teeth. Prognosis was determined



without considering intervention so the patient could understand the potential outcomes if the

disease process was left untreated.

Periodontal: Radiographs showed localized mild horizontal bone loss. Periodontal probe

readings were generally 2 mm to 4 mm in depth, with slight bleeding on probing. The patient

was placed on a 6-month periodontal recall. Based on existing bone levels, the periodontaldiagnosis was deemed AAP type II.

Risk: LowPrognosis: Good

Biomechanical: The patient’s biomechanical risk was determined based on her current and past

history. The patient presented with no new carious lesions, no structurally compromised teeth,

and minimal erosion. She reported no new carious lesions in the past 4 to 5 years. She had some

conservative posterior composite restorations and one amalgam restoration.

Risk: LowPrognosis: Good

Functional: The patient showed mild to moderate attrition on her maxillary and mandibular

anterior teeth with the most notable being on teeth Nos. 8 and 9. She had mild attrition on her bicuspids. The right and left temporomandibular joints were comfortable under load. The patient

had no history of abnormal neuromuscular habits or bruxism, but felt as though she had more

than one bite. A preliminary functional diagnosis of occlusal dysfunction was made, and laterconfirmed using the Kois deprogrammer.

2

Risk: Moderate

Prognosis: Fair

Dentofacial: An accurate evaluation of the overall esthetics was challenging because of the patient’s guarded smile. Once relaxed, the patient laughed and it became apparent that she

exhibited high lip dynamics. Since both the teeth and the tissue contours were visible in a full

smile, the following esthetic deficiencies were noted: incisal edge position 0.5 mm short ofideal,3 asymmetrical gingival architecture, intra-arch tooth position constricted in the maxillary

bicuspid region, and dissatisfaction with the tooth shade.

Risk: High

Prognosis: Poor

Treatment Goals

The treatment goals were to:

• orthodontically position the teeth into a more ideal vertical and horizontal intra-arch position• respect the patient’s desire to avoid the use of fixed orthodontic brackets

• create room for the placement of an implant in the No. 11 position

• create equal, simultaneous posterior occlusal contacts



• replace tooth No. 11 with an implant-supported restoration

• improve the horizontal symmetry of the gingiva

• improve the tooth shapes and color without incr easing the biomechanical risk• sequence the treatment over time for affordability

Treatment Plan

The proposed treatment plan included:

• orthodontic treatment with the aid of removable aligners

• occlusal adjustment • composite restorations on teeth Nos. 8 and 9 to help establish ideal tooth length

• extraction of impacted canine No. 11 and deciduous canine H with site preparation for implant

placement

• crown lengthening of teeth Nos. 7 through 9 • indirect porcelain veneers on teeth Nos. 6 through 10

• a custom abutment and porcelain-fused-to-metal (PFM) crown on tooth No. 11

Treatment Phases

Phase 1: Orthodontics

Removable orthodontic aligners (Invisalign®, Align Technology, Inc., www.invisalign.com)

were offered as a treatment and accepted, with the explanation that the use of aligners would provide limited orthodontic intervention. Using the diagnostic wax-up as a guide, the arch was

expanded in the bicuspid region on the right side, reducing the arch constriction. The anterior

region was expanded slightly to create more space around the deciduous canine to facilitate

future implant placement. Correcting the crossbite in the right posterior region was not a predictable move and, therefore, was not attempted. Approximately 1 mm of overjet was left in

the maxillary anterior region in anticipation of future occlusal adjustment. Upon completion of

the orthodontics, composite was placed on teeth Nos. 8 and 9 to lengthen the incisal edge position by 0.5 mm. With a more harmonized arch and adequate space around the deciduous

canine, the teeth were in position to successfully complete implant placement and conservative

restorative treatment.

Phase 2: Functional

Six months after completion of the orthodontic treatment, the patient was placed in a Kois

deprogrammer to evaluate the occlusion.2 The patient’s first point of contact, with the

temporomandibular joints in centric relation, was on the buccal incline of tooth No. 5. A centric

relation bite record was made and the models mounted. Evaluation of the models confirmed theinitial point of contact on tooth No. 5. A trial equilibration was done on the models to verify that

even, simultaneous contacts could be achieved.

The patient returned for occlusal equilibration. Bilateral simultaneous posterior point contacts

and canine guidance were achieved intraorally. The patient was functionally stable for 3 years, at

http://www.invisalign.com/






length, and color (Figure 13 through Figure 15). Treatment goals were met by satisfying the

patient’s desire for improved esthetics while respecting risk management, thereby increasing the

probability and predictability of long-term success (Figure 16 through Figure 18).

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

http://www.dentalaegis.com/media/26900/







Figure 6

Figure 7

Figure 8

Figure 9

Figure 10








Figure 11

Figure 12

Figure 13

Figure 14

Figure 15








Figure 16

Figure 17

Figure 18




High-Risk Esthetically Driven Restoration Begin With the End in Mind

Documents

Transcript of High-Risk Esthetically Driven Restoration Begin With the End in Mind