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14 Dental Tribune Asia Pacific Edition | 1+2/2017 TRENDS & APPLICATIONS Aesthetics and function A systematic approach to full-mouth rehabilitation with all-ceramics By Dr Anna Giorgadze & Ilias Psarris, Greece This awarded entry in the Europe, Middle East and Africa category of the IPS e.max Smile Award 2016 describes the complex full-mouth rehabilitation of a female patient who consulted our practice be- cause she was dissatisfied with the appearance of her smile. A reliable and efficient approach made the most of the interplay of aesthetics and function and all-ceramic ma- terials. Aesthetics and function— these two requirements are in- separable in restorative dentistry. The case outlined in this ar- ticle highlights just how closely these two aspects are connected. The patient primarily wanted the treatment to enhance her appear- ance. The dental team, however, could not fulfil these aesthetic demands without taking into ac- count the functional considera- tions. Our aim from the time of the treatment planning stage was to achieve a harmonious result. The extensive prosthetic work required a systematic treatment approach. Case presentation The young female patient con- sulted our dental practice about a smile enhancement. Her max- illary and mandibular anterior teeth were severely abraded and stained (Fig. 1). Moreover, she had received inadequate restorations in the past. The metal-reinforced bridges in the posterior region did not provide suitable function and aesthetics, and the patient was dissatisfied with the entire sit- uation (Fig. 2). The unattractive appearance of her teeth was an embarrassment to her, especially when she smiled. Diagnosis and planning The first general diagnosis was based on the needs of the patient. Furthermore, specific aspects of the situation were assessed. A cor- responding diagnosis was made and the patient was presented with a preliminary treatment plan. In accordance with our pro- tocol, the plan focused on attain- ing a satisfactory balance between the functional and aesthetic re- quirements. Furthermore, mainly additive measures were planned, which would make the treatment minimally invasive. The clinical diagnosis revealed the extent of the damage. Severe abrasion had considerably shortened the an- terior teeth, which showed well- defined wear facets. The vertical dimension of occlusion was clearly too low. The patient’s smile line was not ideal and therefore nega- tively affected her facial expres- sion. The patient was in good gen- eral health. She did not complain of any temporomandibular joint pain or of tense jaw muscles. In the development of the final treatment plan, we first con- centrated on the functional re- quirements. In the process, we established that the vertical di- mension of occlusion needed to be raised by 1 mm and a new oc- clusal scheme created. Therefore, we proposed the following steps: stabilise the situation with the help of long-term temporaries be- fore starting the prosthetic treat- ment; place two implants to close the gaps left by the loss of teeth #46 and #36; restore the dentition with all-ceramic crowns, bridges and veneers (IPS e.max Press, Ivoclar Vivadent); and provide the patient with a bite guard to pro- tect the teeth after the treatment. The patient agreed to this plan. Prosthetic pretreatment Portrait photographs and video clips showing the patient when speaking and smiling constituted important diagnostic tools in the treatment process. They provided us with valuable information for the design of the diagnostic wax-up. Impressions were taken for the fabrication of the models. A face-bow record was taken for the skull-related transfer of the situation to the articulator. Fur- thermore, the new vertical dimen- sion was verified in the mouth and it was raised by about 1 mm compared with the original situ- ation. From wax-up to mock-up The models were articulated and then a diagnostic wax-up (Figs. 3–5) was created. The teeth were built up according to the new vertical dimension of occlusion. The anterior teeth were designed in such a way that their shape and length would suit the face of the patient. The aesthetic parameters, such as the smile line, midline and buccal corridor, were given as much attention as the functional requirements of the occlusion. Since we wanted to check the planned tooth length and shape in the patient’s mouth, we fabricated an acrylic mock-up on the basis of the wax-up (Fig. 6). The try-in of the mock-up allowed the dental team to obtain indispensable in- sight into the aesthetics and func- tion of the restoration. It also pro- vided the patient with a preview of the restoration and helped her to become accustomed to her new “The all-ceramic restorations looked completely natural in the patient’s face.” Figs.1 & 2: Severely abraded maxillary anterior teeth and compromised aesthetics.—Fig.3: The master cast clearly showed the functional and aesthetic shortcomings.— Fig. 4: Additive build-up of the anterior teeth for the diagnostic wax-up.—Fig. 5: The wax-up with approximately 1 mm higher vertical occlusion.—Fig. 6: The mock-up fabricated on the basis of the wax-up on the model.—Fig. 7: Try-in of the mock-up and validation of the functional and aesthetic parameters.—Fig. 8: Prepared teeth ready for the permanent restorations.—Fig. 9: Grinding in of functional abrasion facets on the veneers in the lower jaw.—Fig. 10: The finished all-ceramic restorations on the model of the lower jaw.—Fig. 11: Harmonious photograph of the all-ceramic restoration in situ.—Fig. 12: Examination of the functional parameters. 4 5 6 7 8 9 10 11 12 1 2 3 456 789 101112 123