At The Chair                                                                 W I T H R O S S W. N A S H , D D S           ...
Circle 41 on Reader Service Card
At the Chair continuedallow the lower cuspids to pass       ents in this “recipe” of achieving           (except for ortho...
Circle 43 on Reader Service Card
At The Chair continued                                                                                                    ...
Figure 12—The “lost-wax technique”                Figure 13—Layering the porcelain after      Figure 14—Seeing the “big pi...
At the Chair continued                                                              Figure 17—                            ...
Circle 46 on Reader Service Card
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  1. 1. At The Chair W I T H R O S S W. N A S H , D D S Predictable Reconstruction of a Healthy Smile: A Case Report Ross W. Nash, DDS Dr. Nash is founder of Ross Nash Guest Author Hugh Flax is an accredited member of the Private Practice Seminars and director of The Nash In- Hugh Flax, DDS American Academy of Cosmetic Dentistry. Charlotte, North Carolina Private Practice His training with functional esthetics has Clinical Instructor stitute of Dental Learning in Charlotte, North Carolina. A consultant to numer- Atlanta, Georgia spanned the years with Ronald Goldstein, Medical College of Georgia Phone: 404.255.9080 School of Dentistry ous dental product manufacturers, he Peter Dawson, Ross Nash Seminars, Fax: 404.255.2936 Phone: 704.364.5272 lectures internationally on subjects in Email: greatsmile4u PAC~Live, and the Pankey Institute. He is Email: rosswnashdds@aol.com esthetic dentistry. Dr. Nash is an @mindspring.com co-chair for the 2003 American Academy accredited member of the American Cosmetic Dentistry Scientific Session in Society for Dental Aesthetics and a Orlando, Florida. While he maintains a pri- Fellow in the American Academy of vate practice in Atlanta, Georgia, he also Cosmetic Dentistry. writes and lectures about esthetic dentistry. ow good is a new smile basis of bioesthetics), as well as review,4 he noted that Dahl and muscle activity by this methodH if it doesn’t last? In Lee’s chapter of the Fundamentals of Es-thetics,1 he points out the the single collective of the mouth (lips, smile, and gums). • Artistically recreating natural beauty with function. Krogstad reported in 1985 that changes in correcting vertical face height (averaging 1.9 mm) were well tolerated.5 Mack’s allows for the condyles to reach their most superior bone braced position and stabilize the con- dyle-disc complex, harmonizingdichotomy between dentists that • Interdisciplinary approach be- study in 19916 found that “the the bellies of the lateral ptery-focus primarily on function, sta- tween the dentist and laboratory occlusal plane is ultimately the goid muscles and making thebility, and comfort, and those technician/artist.3 determining factor in restoring patient more comfortable.8,9whose priority is esthetic rejuve- When people lose ideal func- necessary facial height.” McAn- Full-mouth rejuvenation is anation. Why not try giving tional masticatory relationships, drews7 agreed with the above “methodical step-by-step proce-patients the benefits of both—a the mouth loses its ability to while going further to say that dure”2 taking into account all thebeautiful smile designed to last a chew efficiently. The teeth, mus- corrected arch alignments and parameters above. Form andlong time? function are intimately inter- During the past 20 years, twined. To accomplish the goals orcelain veneers have evolved from aporcelain veneers have evolvedfrom a color masking/space clos-ing tool to a restorative lengthen- P color masking/space closing tool to a restorative lengthening medium for teeth. of functional, esthetic dentistry in full-mouth care, dentists must maximize anterior guidance whileing medium for teeth as well. Of staying comfortably in the enve-course, the ceramic materials lope of function and avoidinghave become much stronger. eccentric occlusal interferences.Haupt2 correctly points out that cles, and/or gums become over- interauspal relationships were According to Lee,1 nature’s mostdentists should be focusing on loaded/damaged, especially in stable. The key to this positive successful unworn stable, esthet-the “cause” of accelerated wear the anterior dentition and verti- response is detailed attention “to ic, class I dentitions incorporatedon tooth structures, not just the cal dimension of the lower face. achieving holding contacts for all the following characteristics“solution.” The posterior teeth eventually teeth in centric relation.” As- (along with the aforementioned): Predictable results are achiev- lose the natural sharpness of the suming the alveolar bone is capa- • Central incisor vertical over-able by synergistic relationships cusps for chewing food. The goal ble of remodeling (sclerotic bone lap of 4 mm.between: in treating this is to reestablish and exostoses are contraindicat- • Central incisor horizontal• The anterior and posterior this harmony while revitalizing ed in this situation), muscle overjet of 2 to 3 mm.dentition, supporting periodon- the patient’s appearance. activity will be better managed • Maxillary incisor length of 12tium, the temporomandibular The clinical evidence sup- when posterior disclusion is mm (average).joints (TMJ), and the neuromus- porting Lee’s theory is widely obtained with harmonious ante- • Mandibular incisor length ofcular system (the functional documented. In Hunt’s literature rior guidance. Decreased elevator 10 mm (average)—shorter to70 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
  2. 2. Circle 41 on Reader Service Card
  3. 3. At the Chair continuedallow the lower cuspids to pass ents in this “recipe” of achieving (except for orthodontics and wis- Figure 1—through during protrusion. multistructural and multidisci- dom tooth removal in the past 5 Full face and smile• Approximately 18 mm from plinary success will be presented. years). Full evaluation of his demonstratesupper cementoenamel junction mouth included detailed radi- decreased(CEJ) to lower CEJ on the cen- CASE REPORT ographs, models, photographs, youthfulness and health.tral incisors. A 27-year-old man presented and periodontal probings. After• Embrasures progressing in size with severe wear, vertical break- full-mouth periodontal debride-from central incisors to the down, and generalized decay (Fig- ment and nutrition/oral healthbicuspids. ures 1 and 2). He was a very suc- care counseling, the following The purpose of this article is cessful entrepreneur who wanted findings were arrived at using Kois’to demonstrate these ideas in “perfect teeth” and was aware that Diagnostic System.10practice. Several reliable ingredi- he ignored his dental care for years • Periodontal—Generalized gin- Figure 2—Reverse smileline not only ages this patient’s appearance but also function- ally compromises the other dentition. Figure 3—The “Tripod Technique” for getting an accurate centric relation open bite using a composite ball and LuxaBite™. Notice the severity of cervical decay. givitis with localized recession complicated by decay/abrasion. • Biomechanical—Generalized caries and four areas of pulpal pathology demonstrating percus- sion tenderness. • Functional—Severe attrition with group function but a range of motion of 59 mm and no neu- romuscular, TMJ discomfort; the intra-arch CEJ measurement was 13 mm. • Dentofacial—Severe wear and reverse smile line as well as a lack of uniform color and tooth shapes. Although the lip line was low, there were uneven gingival margins. Tooth color was mea- sured at A2/A3 with generalized white decalcifications. At a “codiagnostic visit,” the patient was shown the extent of his problems. More importantly, the “causes” and how to get long-term results by dealing with Circle 42 on Reader Service Card72 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
  4. 4. Circle 43 on Reader Service Card
  5. 5. At The Chair continued Figure 6— The patient gets to pre- view his new smile by creating a Luxatemp® “mock-up”; two colors are tried to help the patientFigure 4—The wax-up establishes a Figure 5—Vertical and CR positioning make a Figure 7—“Transfer bites” using Luxa-“blueprint” of communication and func- can be verified with the “mock-up.” decision. Bite™ helps maintain occlusal relation-tional/esthetic success. ships throughout the preparation visit. Figure 9— Figure 10— Stick-bite The tempo- registration raries add and photo- more youth- graphs allow fulness to the the laboratory patient’s technician to appearance maintain a and create a horizontal prototype for incisal edge the final position. design.Figure 8—Gingival irregularities and Figure 11—Note the accuracy of model toasymmetries are easily modified with registration fit available with Luxa-electrosurgery. Bite™—a prerequisite for full-mouth restoration in the laboratory.them, not just the “curb appeal”/ es- The purpose of the appliance vision for the final result. New the teeth to reverify esthetics asthetic elements were empha- is to create an ideal bite relation- impressions and a Stratos® 200 well as the new vertical using thesized. After showing him a simi- ship without noxious interfer- (Ivoclar Vivadent®, Inc) face-bow molar bite registrations. Withlar patient’s treatment, he agreed ences and allow the condyles to were taken. A new closed reduc- this pre-preparation visit, thisto a comprehensive solution as achieve an ideal position in the tion (CR) bite was taken using author “fine tuned” the commu-long as he was kept sedated dur- glenoid fossa relative to disc and the MAGO as a reference. A small nication with the patient anding his definitive case visits. The muscles. The patient wore the window was cut out in the front laboratory. This saved chair timeplan was to treat the incisors and appliance for approximately 24 of the biteguard to establish an as well as “preframe” expecta-bicuspids with bonded Authen- hours per day for 1 week at the anterior bite reference point. The tions for the patient as he wenttic® porcelain crowns/overlay new vertical dimension of occlu- orthotic was removed and while through treatment (Figures 5veneers (Microstar® Corporation) sion. When he returned with the patient closed into the anteri- and 6).and the molars with cemented some slight discomfort, modifi- or bite registration, a LuxaBite™ Because the goal was toAuthentic® Press-to-Metal™ crowns cations were made that closed index was made in the molar lengthen this patient’s teeth, thebecause of the gingival depth of the vertical dimension from area. The result was a very firm preparation phase became sim-previous decay. upper incisal CEJ to lower vertical bite measurement pre- plified. Little to no incisal or A maxillary guided orthotic incisal CEJ to about 17 mm. dictable for mounting at the lab- occlusal reduction was needed to(MAGO) was constructed to accomplish our goals. On thecentric relation and a vertical other hand, maintaining a con-dimension of 18 mm from upperincisal CEJ to lower incisal CEJ.To add precision to this process, A critical part of the patient-focused philosophy is to allow the clients to “test drive” their new smile and its functionality. stant vertical/CR relationship to match our blueprinted plans was critical to the execution of ouran anterior composite bite was functionally esthetic philosophy.made at a centric relation open Furthermore, because of thebite. The posterior bite was After another 2 weeks, he report- oratory. The laboratory can make esthetic demands, this author“tripoded” using LuxaBite™ (Ze- ed no difficulty with all his oc- an accurate full-mouth wax-up had to treat this patient morenith™/DMG) because of its supe- clusal marks remaining stable. to get all involved parties “on the “macrodentally” to achieve therior handling properties and firm Fortunately for this patient, his same page.” The molar wax-up is goals. In cases such as this, theset (Figure 3). The ability to eas- adaptive capacity was large, and removable to allow verification incisors and bicuspids are pre-ily read and trim the registra- did not require extended adjust- of the new vertical on the wax- pared at the same time for theirtions as well as accurately mount ment time that often can take up up and later on in the mouth new restorations. Through thethe model makes it ideal for cre- to 1 year. (Figure 4). use of serial “transfer bites”11ating throughout this patient’s When this author realized the Before any alterations oc- that began with pre-preparationcase. During MAGO construc- patient’s comfortable vertical curred in the mouth, the patient indices based on the original bitetion, root canals and decay con- position (approximately 17 mm was brought in for a “mock-up registrations, the author was abletrol were done to begin to CEJ to CEJ), it was time to create visit.” At that visit, Luxatemp® to maintain the occlusal/TMJstrengthen tooth structure. a “blueprint” of the patient’s (Zenith™/ DMG) was placed over relationships that he had devel-74 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
  6. 6. Figure 12—The “lost-wax technique” Figure 13—Layering the porcelain after Figure 14—Seeing the “big picture” helps Figure 15—Waxing-in the molar occlu-allows Authentic® restorations to have a “cutting back” enabled the technician to maintain vital esthetic and functional sion “dials in” the posterior restorationvery precise fit marginally and occlusally. create natural incisal translucence. requirements. phase.oped before this visit (Figure 7). The laboratory phase of the well as the engineering guidance two technique.” After removingIt also allowed fine tuning of functional-esthetic journey was for comfort and longevity any excess, occlusion was finesome of the gingival asymmetries critical. Using all the registra- (Figure 14). The molars were tuned with a computer-generat-(and change those landmarks) tions, the models were carefully also waxed-in at this occluso- ed report using the T-Scan™without losing the orientation mounted to a Stratos® articulator esthetic relationship to allow System (Tekscan, Inc) while(Figure 8). This precision was (Figure 11). completion of the posterior checking in CR. Although thefurther enhanced with new stick- Putty matrices of the “tempo- region (Figure 15). The patient molars had not been treated yet,bite and face-bow measurements rary model” allowed the techni- wore the anterior provisionals the patient commented about(the former being done with the cian to precisely recreate the for 4 weeks, the time it took to how comfortable the bite felt.patient in a closed position using contours developed with the complete this laboratory phase. The final phase of the reha-the vertical/CR bite registrations patient. Porcelain restorations The restorations were tried- bilitation was begun 2 weeksin place [Figure 9]). Digital pho- were created using a lost-wax in individually and as a group to later and took an additional 4tographs of the bites as well as technique and ingots of Au- verify fit, color, and occlusion weeks to complete. The occlu-the preparation colors gave the thentic® porcelain (Figure 12). (Figure 16). The patient was able sion was slightly touched up andlaboratory detailed knowledge Characterization of colors with a to give his approval of the esthet- reindexed before anesthesia. The“beyond the stone models.” By cutback modality allowed the ics (Figure 17). All restorations molars were restored at this rela-carefully taking each bite during technician to create natural tex- were placed while using rubber tionship using Authentic® porce-this phase, this author created tures and translucency to give a dam isolation to prevent contam- lain-pressed-to–yellow gold be-continuity of our original game masterful touch to the contours ination and improve the bond cause of the existence of manyplan. and occlusion already estab- strength of the Syntac® system subgingival margins from the Provisionalization with bleach lished (Figure 13). Correct axial (Ivoclar Vivadent®, Inc). Restor- preexisting decay. All sevenshade Luxatemp® was simplified inclinations, embrasure forms, ations were luted and light-cured crowns were luted using Vitremer™when the laboratory created an tooth lengths, and proportions with translucent Variolink® II (3M ESPE) glass ionomer cement.accurate wax-up that was in- created the building blocks to (Ivoclar Vivadent®, Inc) base The patient was also fitted for andexed with Siltec putty. Esthetics facial harmony and beauty as cement employing the “two-by- nighttime upper orthotic to pro-and function needed minorattention when precise recordswere made and used. It alsoallowed this patient, who wassedated with alprazolam, to haveno unpleasant surprises when hesaw his new smile (Figure 10). A critical part of the patient-focused philosophy is to allowthe clients to “test drive” theirnew smile and its functionality. Itallows them (and their significantothers) to “critically evaluatetheir new appearance and theirability to chew, speak, swallow,and kiss.”12 After the patient hada week to do this, this authorfine-tuned the provisionals. Bytaking this extra time to do this,patient participation and satisfac-tion was greatly increased.Communicating these resultswith impressions and photos tothe laboratory technician allowedhim to know three-dimensionallyall the details of the prototypes. Circle 44 on Reader Service CardCONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE May 2003 75
  7. 7. At the Chair continued Figure 17— Figure 19— Final patient A congruent approval with smile line different try-in not only gels creates adds confi- better service dence to an and ensures appearance, agreement but when when the functionally restorations harmonious, are finally it increasesFigure 16—The vertical positioning was bonded. Figure 18—The patient’s smile looks the likeli-verified when trying-in the restorations. brighter and healthier, and the muscula- hood of ture looks more relaxed. comfort and longevity. Figure 20—Unhealthy occlusion often Figure 21—Postoperative view of the nat- leads to gingival irregularity. ural esthetic and biologic harmony created by the synergy of preplanning and action. tect his new restorations from his staff for their shared commit- nocturnal bruxing. All were ment to high quality patient com- checked using the T-Scan™. fort and extraordinary dentistry. Lastly, the author extends his CONCLUSION gratitude to his family for allow- Using the techniques de- ing him to devote the extra time scribed above allowed the res- for continuous improvement and torative team (including the labo- sharing with others. ratory technician/artist) to rejuve- nate this patient’s smile to an REFERENCES 1. Lee RL. Esthetics and its relationship to function. In: appearance that allowed his den- Rufenacht CR, ed. Fundamentals of Esthetics. Carol tal condition to better match his Stream, IL: Quintessence Publishing Co; 1990:chap 5. age (Figures 18 and 19). Using a 2. Haupt J. A team approach to full-mouth rejuvenation. J Cosmet Dent. 2002;18:42-47. series of linked steps, we were 3. Hunt K. Full-mouth multidisciplinary restoration able to match the patient’s esthet- using the biological approach. Pract Proced Aesthet Dent. 2001;13:399-400. ic demands and the bioesthetic 4. Hunt K. Full-mouth rejuvenation using the biologic principles established by Lee.1 approach: an 11-year case report follow up. Biologically, it was gratifying to Contemporary Esthetics and Restorative Practice. 2002;6:26-27. see the harmony improved gingi- 5. Dahl BL, Krogstad O. Long-term observations of an vo-restoratively (Figures 20 and increased occlusal face height obtained by a com- bined orthodontic/prosthetic approach. J Oral 21). By focusing on both esthetics Rehabil. 1985;12:173-176. and function, this patient should 6. Mack M. Vertical dimension: a dynamic concept enjoy many years of health, com- based on facial form and oropharyngeal function. J Prosthet Dent. 1991;66:478-485. fort, and confident esthetics. 7. McAndrews J. Presentation to Florida Prosthodontic There is no doubt that enhancing Seminar; October, 1984; Miami, Fl. 8. Dawson PE. Vertical dimension. In: Dawson PE, ed. his future with this type of care Evaluation, Diagnosis, and Treatment of Occlusal was very rewarding. Controlled Problems. 2nd ed. St. Louis, Mo: CV Mosby Co.; planning and care was definitely 1989:Chap 5. 9. Williamson E, Lundquist DO. Anterior guidance: its the key to our success. ࠗ effect on electromyographic activity of the temporal and masseter muscles. J Prosthet Dent. 1983; 49:816-823. ACKNOWLEDGMENTS 10. Kois J. Diagnostically driven interdisciplinary treat- The author would like to ment planning. Presented to: The Atlanta Dental thank Wayne Payne, CDT, of San Study Group; December 2002; Atlanta, Ga. 11. Montgomery M, Hornbrook D. Records appointment Clemente, California for his men- lecture. Presented at: PAC~Live Advanced Functional torship and dedication to beauti- Course; October 2002; San Francisco, Ca. 12. Flax H. Success by design, not by accident. Oral Circle 45 on Reader Service Card ful and long-lasting smiles. Fur- Health. 2001;91:93-102. thermore, the author appreciates76 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE
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