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Dental TribuneAsia Pacific Edition | 10/201516 the basis of a functional analysis. The anticipated final situation was waxed up according to the diag- nostic set-up (Fig. 3). The waxed-up restorations were recreated with composite and the help of a clear silicone matrix (Fig. 4). The occlusal veneerswerethencompleted.Inthe process,wepaidparticularattention to functional and morphological principles. Next, the veneers were adhesivelycementedinthepatient’s mouth and the functional parame- ters were checked. This temporary restoration represented a decisive stepinthetreatmentprocedureand a significant component in achiev- ingalastingresult.Thepatientcould not be expected to wear the occlusal appliancecontinuouslyfor24hours. The long-term temporaries, how- ever, enabled the movement pat- terns to be optimally established, since they were cemented in place (Fig.5). The situation stabilised over the next three months and the patient indicated that he felt very comfort- able. The temporaries did not show any signs of wear and the patient was pain-free. The time had come for the final treatment phase to begin. We had carefully assembled all the strategic pieces up to this point. At this stage, the success of the per- manent restoration would depend completely on the preparation tech- nique. Neither the horizontal nor the vertical maxillomandibular re- lationship could be disturbed. The sequential preparation phase started withtheocclusalveneers.Inthefirst step, teeth #36, 46 and 43 were pre- pared (Fig. 6), and three-point sup- port was established. Subsequently, themaxillomandibularjawrelation- ship was recorded (Fig. 7), and teeth #33to37,aswellas#44to47,werepre- pared according to minimally inva- sive principles. This is currently the acceptablestandardinaestheticand functional restorative treatment, as it corresponds to the requirements of patient-oriented and responsible dentistry.Thepatient’steethshowed a number of cervical lesions (dam- aged fillings and untreated wedge- shaped lesions). As a result, the preparationstrategywasadjustedto taketheselesionsintoaccount.First, the damaged fillings were replaced with composite (Tetric EvoFlow, Ivoclar Vivadent), then the now in- tact fillings and the wedge-shaped lesions were included in the enamel preparation and sealed with the oc- clusal veneers. We ensured that the preparationmarginswerelocatedin theenamelandwerefreeofcompos- ite(Fig.8).Wedecidednottoprepare orbuilduptheteethwithcomposite intheloweranteriorjaw. After the impressions had been taken, the study models were fabri- cated and mounted in the articulator in relation to the horizontal plane. Before the final mandibular restora- tionwascompleted,wediscussedthe aesthetic and functional reconstruc- tion of the maxillary anterior teeth (veneers for teeth #13 to 23) with the patient. We helped the client to visu- alisetheanticipatedresultbybuilding up the teeth in wax. The teeth ac- quired a distinctive shape and a suit- able length. The wax-up was used to fabricate a mock-up, which was tried in by the patient. He was extremely pleased with what he saw and was completely satisfied with the veneer solution.Nevertheless,hewantedour assurancethatwewouldnotgrindany healthy tooth structure unnecessar- ily.State-of-the-artmaterialsthatcan be cemented with adhesive methods enabled us to fulfil his wish. In this case, we used ultrathin lithium di- silicate veneers, which we bonded to the healthy tooth structure for long- lastingresults. Fabrication of the final restorations High strength was a priority in the posterior dentition. Therefore, full- contour restorations (monolithic) were fabricated with IPS e.max Press (Figs. 9 & 10). The occlusal veneers were produced in wax according to customarymethods.Therestorations were created in ceramic using the press technique and then prepared for adhesive cementation. The teeth were conventionally prepared accord- ing to the requirements of the ad- hesive technique. For the permanent cementation of the restorations, we used a dual-curing luting composite (VariolinkII,IvoclarVivadent). The teeth in the lower jaw were built up with a highly aesthetic com- posite resin (Tetric EvoCeram, Ivoclar Vivadent; Figs. 11 & 12). The maxillary anterior teeth (#13 to 23) were pre- pared by removing a minimal amount of tooth structure. A model was produced and then the veneers were fabricated with IPS e.max Press HT ingots (high translucency). The pressed veneers were cut back and customisedwithaveneeringceramic (IPS e.max Ceram, Ivoclar Vivadent; Figs.13&14).Inthelayeringprocess,we strovetoachievealifelikeappearance and therefore paid a considerable amount of attention to this step. With the help of gold powder, we wereabletoproducealifelikesurface texture. We polished the restorations manually. All the parties involved were impressed with the result after the adhesive cementation of the restorations. The inclined all-ceramic restorations showed excellent fit and physiological function. As a result, a very natural-looking appearance was achieved (Figs. 15 & 16). A lifelike in- terplayofcolourwasobservedwithin theveneers. Conclusion A well-coordinated treatment plan composed of many pieces, like a mo- saic, is required in situations where complex restorative treatment, in- cluding bite elevation, is necessary. In the process, it is important to treat patients responsibly and inspire them with the required confidence. Careful deliberation is particularly important in the establishment of thephysiologicalbiteelevation.Inthe casedescribed,anon-invasivestrategy was devised to re-establish a stable vertical dimension. The teeth were groundforthepreparationofthefinal restoration only after a suitably long temporary phase (occlusal veneers madeofcomposite)andstabilisation ofthebiteelevation. TRENDS&APPLICATIONS Dr Jan Kersting is a dentist at Dr Roland Ritter dental practice in Nuremberg in Germany.Hecan be contacted at jankersting@ t-online.de. Alexander Mi- ranskij is a den- tal technician at dentalmanufaktur nürnberg in Nurem- berg in Germany. He can be con- tacted at mail@ dentalmanufaktur- nuernberg.de. Dr. Biju Krishnan ,UK AD Fig.14: The ultrathin anterior veneers were applied to pressed frameworks (cut back).—Figs.15 & 16: The restorations in situ showed a lifelike interplay of colour.A well-structured treatment plan and high-strength ceramic restorations enabled the dental team to adjust the vertical dimension of occlusion of the patient and improve his appearance quite dramatically. 14 15 16 DTAP1015_14_16_Kersting 14.10.15 09:13 Seite 2 141516 DTAP1015_14_16_Kersting 14.10.1509:13 Seite 2