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ePaper created 2016-11-22, 11:57:56 | version 1.38.0
14 Dental Tribune Asia Pacific Edition | 11/2016 TRENDS & APPLICATIONS Paring down a complex case Extensive all-ceramic restoration for the upper and lower jaws By Dr Tetsuya Uchiyama and Michiro Manaka, Japan This awarded entry in the Asia- Pacific category of the IPS e.max Smile Award 2016 describes the case of a patient who was treated with tooth-supported and im- plant-borne restorations. This ini- tially complex case was expertly solved by using a straightforward treatment approach and establish- ing a uniform colour base for the all-ceramic restorations. The abundant variety of solu- tions offered by contemporary dentistry—diverse materials, dif- ferent technologies, customised approaches—is very much appre- ciated by patients and clinicians alike. Nevertheless, complex cases continue to present many chal- lenges. In prosthetic dentistry in particular, extensive restorations in the upper and lower jaws are often necessary. In these cases, it is important to obtain a full view of the situation and to analyse it in detail and then to develop a treatment plan. The main aim is to pare down the complex situation to a simple and sound base for the fabrication of the restorations. Well-grounded planning is the key element in this process. Clinical case The 66-year-old patient com- plained about her inability to chew properly, as well as the unattrac- tive appearance of her teeth. In the upper jaw, she had various defec- tive metal–ceramic restorations, of which some had already become loose (Figs. 1a–c). In the lower jaw, a free-end gap extended from tooth #35 to #37. The crown on tooth #34 was also loose. The gingival margin of tooth #13 had clearly shifted to- wards the apical aspect. The curve of Wilson (transversal curvature) deviated, which added to the gen- eral disharmony. The shade of the different restorations varied quite considerably. Furthermore, the op- tical properties of the individual restorations did not match prop- erly. The patient requested restora- tions that would look and function like natural healthy teeth. The main goal was to establish a stable occlusal situation that would enable natural masticatory functions and a harmonious aes- thetic maxillofacial situation. For this purpose, the existing crowns and bridges had to be replaced and the gingival contour had to be adjusted. Tooth #24 had to be replaced with an implant, which would function as an additional abutment. Further treatment with implants was planned for the mandibular posterior region. From wax-up to provisional The diagnostic wax-up is gen- erally considered to be an indis- pensable part of complex treat- ment planning. The loss of tooth substance, which is the vertical di- mension of occlusion, is verified in wax. The teeth are then ad- justed on the model using addi- tive (in some cases subtractive) means to achieve the desired situ- ation. The treatment plan was dis- cussed with the patient and modi- fied as necessary. In this case, the diagnostic wax-up served as the foundation for all the subsequent working steps. The horizontal and vertical aesthetic lines and planes were determined and the upper and lower facial heights were eval- uated by means of a radiographic image (Fig. 2). In addition to the clinical and aesthetic diagnosis, a manual functional and structural analysis provided important ref- erence points for the treatment plan. For the wax-up procedure, the incisal plane was lowered in the articulator. The incisal edges were slightly reduced (1 mm) to obtain an ideal lower face height. In ad- dition, the angle of the occlusal plane was tilted (6°) anticlockwise. The chewing surface was succes- sively modelled until optimum occlusal conditions were achieved (Fig.3).Thecross-mountingmethod —articulating the upper wax-up against the lower jaw and vice versa—was used to fabricate the provisional composite restora- tions (Figs. 4a–f). Once the old restorations has been removed, we were faced with an additional challenge (Fig. 6). Metal build-ups and vari- ous fillings in the abutment teeth created a rather patchy overall impression. As a result, the ap- pearance of the abutment teeth Figs. 1a–c: Pre-op situation with various defective restorations, impaired aesthetics and an untreated gap in the lower jaw.—Fig. 2: Evaluation of the aesthetic facial parameters.—Fig. 3: The diagnostic wax-up.—Figs. 4a–f: Transfer of the wax-up details to the provisional restoration using the cross-mounting method.—Figs.5a & b: The long-term temporary comprising three segments. Fig. 6: Situation after the removal of the old restorations.—Fig. 7:Teeth being prepared for the placement of the all-ceramic restorations.—Figs. 8a & b: Impression of the emergence profile of tooth #14.—Fig. 9: Situation in the upper jaw after tissue control was completed. 1a 1b 1c 2 3 4a 4b 4c 4d 4e 4f 5a 5b 6 7 8a 8b 9 67