Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2016-04-15, 11:52:27 | version 1.38.0
Dental TribuneAsia Pacific Edition | 10/201514 TRENDS&APPLICATIONS Many different therapeutic compo- nents combine to produce a treat- ment solution that focuses on both functional and aesthetic parameters. However, the different pieces have to becarefullymatchedinordertoobtain asatisfying,long-lastingresult.Awell- structuredtreatmentplanisrequisite, particularly in extensive restorative procedures. Continuous interaction and communication between the practitionerandthedentaltechnician throughoutthetreatmentandthepa- tient’s confidence in these specialists represent important components in theprocessofrestoringtheaesthetics andfunctionofthepatient’sdentition. In addition, materials play a piv- otal role. In this regard, the high- strength lithium disilicate glass- ceramic IPS e.max Press (Ivoclar Vivadent) offers excellent physical and aesthetic characteristics, making it the ideal choice for many indica- tions. Apart from its high strength, the material has a very attractive appearance, allowing exceptionally aestheticresultstobeachieved,even ifspaceislimited. When the patient consulted our practice for the first time, he had severely worn anterior and posterior teeth.Hewasofastrongbuildandhad been participating in competitive sportsformanyyears.Hisfacialmus- cles were exceptionally pronounced (Fig. 1). Dental professionals are in- creasingly faced with cases demon- strating this type of pathological loss of tooth structure today. Causes in- clude erosion (demineralisation of the teeth without the involvement of micro-organisms), attrition (phys- iological or pathological occlusal contacts) or abrasion (mechanical processesandbruxism). Preoperative considerations Thepatientoriginallypresentedto the dental practice to have a carious lesion in tooth #46 repaired. Owing totheobviousdysfunctionofhisjaw, we explained to him the medical im- portanceofundergoingasuitabletreat- ment. In order to achieve the long- termsuccessofthetreatment,wefirst hadtorealignthephysiologicalverti- calocclusion.Therefore,weneededto establishthecauseofthedestruction, as this significantly influences the treatmentplanningandthechoiceof thematerialstobeusedintheprocess. In many cases, wear is caused by a number of different factors. Here, the strenuous physical activity of the patient appeared to be the main con- tributortothelossoftoothstructure. Wedevisedaminimallyinvasivetreat- ment plan, which was discussed with him. All the necessary patient details wererecorded.Owingtotheextensive lossofverticalocclusion,thepatient’s physiognomy had changed dramati- cally. His facial features were asym- metrical and his smile was crooked. The corners of his mouth were not properly aligned. Contrary to aes- thetic guidelines, the curve of the lowerlipwasnotparalleltotheupper incisal edge. The incisors had been so severely abraded that they no longer formed an upward curve. Further- more, the lower lip drooped on the rightside.Thepatientreportedthathe often clenched his teeth, especially during physical exertion. He also complained of tenseness of his jaw muscles. Planning phase The initial diagnosis involved the evaluation of intra-oral and extra- oral photographs and a clinical func- tional analysis. In addition, study models were assessed. A diagnostic wax-up based on a digital aesthetic analysis(DigitalSmileDesignaccord- ing to Dr Christian Coachman) gave us essential information about aes- theticaspects,theverticaldimension of occlusion, the occlusal design and biteelevation.Theexistingstructures were rebuilt in wax using an additive method, and the physiological state was restored. In this case, the wax-up was used not simply to evaluate the initial situation and guide the treat- ment process, but also as a commu- nication device. The wax-up allowed thepatienttovisualisethetreatment result. Furthermore, the model gave him the motivation to persevere in pursuing the challenging and time- consumingtreatmentgoals. In the first part of the treatment, the patient was fitted with a cus- tomised occlusal appliance. The aim of the splint therapy was to restore the physiological bite of the patient. Before the appliance was fabricated, a comfortable physiological rest po- sition was evaluated. Furthermore, a 2.5 mm increase in the vertical di- mensionwasrequired(Fig.2).Several daysafterthesplinthadbeenplaced, thepatientreportedthathefeltcom- fortable with the old-but-new verti- cal dimension of occlusion. He wore theapplianceforthreemonths,dur- ingwhichtimehedidnotexperience any functional problems. The mus- clesrelaxedquitevisibly. The occlusal situation that could be established with the appliance wasstabilisedbytreatingthepatient with long-term temporary restora- tions. We decided to provide him with non-invasive occlusal veneers made of composite, which would be adhesively cemented in the lower jaw.Forthispurpose,thestudymod- els were set up in the articulator in the arbitrary hinge axis position on Amosaicofnumerousindividualpieces Treatment plan for restoring a badly abraded dentition By Dr Jan Kersting & Alexander Miranskij,Germany 11 Fig.1: Reduced vertical dimension of occlusion.The photograph shows the well-developed masseter muscle on both sides of the face.—Fig.2: Customised occlusal appliance raising the vertical dimension by approxi- mately2.5mm(splint therapy).—Fig.3:Wax-upincorporating theverticaldimensionevaluatedvia theocclusalappliance.—Fig.4:Wax-uprenderedincompositebymeansofasiliconematrix.—Fig.5:Compositeoc- clusalveneersadhesivelycementedtothetoothstructurewithoutanypriorpreparation.—Fig.6:Sequentialpreparationforthepermanentrestorationbymaintainingtheverticaldimensionofocclusion.—Fig.7:Bite taking after the preparation of teeth #36,46 and 43.—Fig.8: Prepared mandibular teeth. 5 6 7 8 Fig.9: Occlusal veneers modelled in wax according to conventional wax-up principles.—Fig.10:The successively waxed-up restorations were recreated exactly in ceramic (IPS e.max Press).—Figs.11 & 12:The occlusal veneers were placed with the adhesive technique, and the mandibular anterior teeth were built up with composite. The restorations blended in smoothly with the remaining dentition. Owing to its strength, lithium disilicate can withstand high masticatory forces.—Fig.13:The ultrathin anterior veneers were applied to pressed frameworks (cut back).(see next page) 1 2 3 4 9 10 12 13 DTAP1015_14_16_Kersting 14.10.15 09:49 Seite 1 5678 1234 910 1213 DTAP1015_14_16_Kersting 14.10.1509:49 Seite 1