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  1. 1. CONTINUING 32 eDucaTion INSIDE DENTISTRY—FEBRUARY 2007 CONTINUING THIS CE LESSON IS MADE POSSIBLE THROUGH AN eDucaTion EDUCATIONAL GRANT FROM LEARNING OBJECTIVES Is Occlusion and Comprehensive After reading this article, the reader should be able to: I describe the benefits of Dentistry Really That Important? approaching restorative/ prosthetic cases in a Gary Alex, DMD comprehensive fashion. I recognize when an alteration ABSTRACT in the existing occlusal scheme might be beneficial prior to case treatment. Patient demand for cosmetic dentistry has never been greater. This has led many dentists to invest considerable time, effort, and money mastering various cosmetic procedures and techniques. While this is commendable, it should be recognized that I possess a better under- it is one thing to be able to make beautiful teeth, and an entirely different thing to make beautiful teeth that actually last standing of centric relation, and function in harmony with the rest of the masticatory system. An acceptable cosmetic result, without regard for function how to use it, and ways to and/or parafunction, will often result in premature case failure. What the truly successful clinician of today requires is a logical and find and record it. systematic methodology in approaching cosmetic/restorative cases that will lead to a reasonably predictable and durable end result. The following case presentation describes how a comprehensive approach to dentistry, one that integrates both I discuss the value of function and esthetics, can be used to successfully diagnose, treatment plan, and restore a cosmetic/restorative case. earbow transfers and properly mounted models for case diagnosis. A true understanding of occlusion and harmony without addressing esthet- relationship, causing a problem, or prob- become apparent, the existing occlusal and comprehensive dentistry is only im- ics often leads to patient disappointment. lems, somewhere in the masticatory system. scheme was altered prior to performing portant if you want to become the best Conversely, esthetics without regard for These problems can manifest as muscular the prosthetic dentistry. A detailed ration- dentist you can possibly be. The fact is, the function (or parafunction) often leads to pain, joint problems, wear and/or chip- ale and methodology is described. The predictability and longevity of all the case failure and/or masticatory dishar- ping of teeth, tooth mobility, tooth sen- case demonstrates just how the science of beautiful dentistry that dentists create, mony. The dentist who wants to practice sitivity, an uncomfortable bite, and a variety occlusion and comprehensive dentistry can and the overall comfort and functioning truly excellent dentistry must be able to of other symptoms. By using the existing actually be applied to clinical dentistry. of their patients, is predicated on just how think comprehensively and address both bite relationship in such a situation, den- well they understand and apply these function and esthetics.3-5 tists are in fact placing restorations into CASE PRESENTATION two principles. An understanding of occlusion is essen- an occlusal scheme that is not working The patient was a 37-year-old woman who A primary tenet of comprehensive tial to practicing comprehensive dentistry. well for that patient. It would seem logi- was referred for a consultation regarding dentistry is that all of the components of There are at least five occlusal philosophies cal to try and improve the occlusal/mastic- the replacement of congenitally missing the masticatory system (teeth, soft tissues, in use today (Classic Gnathology, Bioes- atory relationships in such a patient prior maxillary lateral incisors and improving skeletal structures, muscles, and joints) thetics, Dawson/Pankey, Neuromuscu- to, or in conjunction with, doing the re- the appearance of her teeth and smile are intimately related and dependent on lar, and Maximum Intercuspation [MIP]). storative dentistry. 6 The questions to (Figure 1 and Figure 2). She had previous- one another for ideal function.1-2 This While an in-depth discussion of each of ask are, when does the patient’s existing ly consulted with a number of other den- interrelationship is mediated by the cen- these philosophies is well beyond the scope occlusal scheme need to be altered prior to tists and had explored restorative options tral nervous system via the exquisite pro- of this article, it is probably safe to say performing restorative/prosthetic proce- including implants, orthodontics, and prioceptive nerve network that permeates the vast majority of dentists use MIP (hab- dures and when is it acceptable to work fixed bridgework. At the age of 20 she the entire gnathic system. Comprehensive itual closure) as a starting and ending point with the occlusal scheme as it exists? underwent 15 months of orthodontic dentistry is really about seeing, and un- when developing an occlusal scheme. The The following case presentation, in treatment to reposition the upper ante- derstanding, the “big picture.” This is a far reason for this is probably because it re- which both functional and esthetic issues rior teeth and to create space between different approach than the “see the hole, quires the least thought, time, knowledge, are addressed, demonstrates a compre- the central incisors and canines. Over the fill the hole,” mentality often employed in and effort. The dentist simply works with hensive approach to restorative dentistry. past 15 years she had worn three different restorative dentistry. Addressing esthetic the occlusal relationship as it exists. The In this particular case, for reasons that will Maryland-type fixed bridges to replace concerns is also an integral component of problem is that in many cases the patient’s comprehensive dentistry. Creating “ideal” existing MIP and occlusal scheme is far functional and masticatory relationships from ideal. In fact, it may be a destructive Gary Alex, DMD Private Practice Huntington, NY Figure 1 Preoperative full smile. Figure 2 Preoperative MIP retracted view with teeth apart. Note the lingual thinning of the upper anterior teeth, chipping and wear of the lower anterior teeth, and abfraction-type lesions on teeth Nos. 8, 11, 24, and 25. All of these are potential signs of potential occlusal instability. Log on now to to take the FREE CE quiz!
  2. 2. CONTINUING 34 eDucaTion INSIDE DENTISTRY—FEBRUARY 2007 the lateral incisors; at least one of those fixed bridges had composite or ceramic wings. She stated she was never happy with how any of them looked and that they would fall out occasionally. She had been evaluated for dental implants but there was insufficient space for restora- tions of this nature (Figure 3 and Figure 4). At the time of her initial visit she was wear- ing a flipper-type removable partial den- Figure 3 Occlusal view of the upper anterior Figure 4 Radiographic appearance of the Figure 5 Photograph of the removable partial ture that she was very dissatisfied with, teeth showing lack of sufficient interproximal anterior teeth showing insufficient space for den- denture (“flipper”) that the patient was wearing both because of the esthetics and because space for implants. tal implants. on her initial visit. it caused her discomfort (Figure 5). She stated that she was very self-conscious ab- out her teeth and smile, and often avoided smiling in photographs. Quite significant- ly, she also mentioned that she was not comfortable with her teeth touching and that her bite “felt off ” and that some- times it felt like she had “two bites.” She was not aware of any grinding or clench- ing habits. Her periodontal status was excellent. The medical history was non- remarkable. When she was asked what Figure 6 and Figure 7 The earbow is used to record the relationship of the maxilla relative to the Figure 8 Try-in of a denture with a canted she would like as far as her teeth and smile TMJs. The data is then transferred to an articulator. The correct hinge axis starting position (or close esthetic plane. An earbow transfer was taken and were concerned, her reply was: “a whiter/ approximation) is essential when taking an open bite record. the denture was mounted on a semi-adjustable brighter smile, something that looks really articulator (also see Figure 9). nice and I feel good about, something that will last, nothing I can take in and out, and I would like my bite to feel com- fortable because it has never felt right.” TREATMENT PLANNING The concept of comprehensive dentistry and the comprehensive exam was ex- plained and discussed with the patient at her initial visit. It is often helpful to show the patient another case that has already been worked up comprehensively to help Figure 9 A properly taken earbow and upper Figure 10 Denture with the corrected esthetic Figure 11 The author prefers to use a level to them better understand what is involved cast mounting will enable the technician to visu- plane after adjustment on the articulator. align the earbow parallel to the horizon to deter- and the advantages of such an approach. alize the cant as it actually appears in the patient’s mine the esthetic plane. In this example, it is easy A typical comprehensive exam requires mouth, with the head straight and erect, allowing to see that if the interpupilary line was used to about 60 to 90 minutes and includes a for easy correction (also see Figure 10). determine the esthetic plane, the final restorations full set of radiographs, full maxillary and would be canted relative to the horizon once they mandibular alginate impressions, diag- were placed in the patient’s mouth. This is because nostic digital photographs, an earbow one eye is significantly higher than the other. transfer, and centric relation (CR) and/ or MIP bite records. In addition to this, a temporomandibular joint (TMJ), range legal protection; and documentation of the recorded via an earbow or hinge axis re- taken earbow transfer is more accurate of motion, and muscle screening exami- case before and after treatment. Dentists cording when taking an open bite record, than “stick bite” type registrations for eval- nation is performed. Stable and comfort- should also know how to use a basic edit- then the casts will not meet properly when uating horizontal and vertical planes. The able joints are essential prior to definitive ing program for cropping and editing as the models are closed together. In addition, author also prefers to use a level to help treatment. Input from other dental spe- required. This author will typically take a the starting hinge axis position will have determine the esthetic plane. This is achie- cialists and/or other diagnostic imaging series of digital photographs, including an effect on excursive pathways. An incor- ved by having the patient sit in a chair (eg, CAT scan, MRI, tomogram, etc) in various smile, occlusal, lips in repose, full rect hinge axis position during fabrica- and orienting the head so it appears level addition to conventional dental x-rays face, and retracted views. These are then tion of the restorations will often result and straight relative to the horizon. The may also be required. The information stored in individual patient folders that in considerably more time spent adjust- anterior bow is then moved in the hori- from the comprehensive exam is used to can be recalled at any time. ing the case once it is placed. zontal plane until the bubble in the level formulate a concise written narrative de- It is also essential that dentists under- Even if the dentist chooses to take a is centered (Figure 11). One of the treat- scribing, among other things, just what it stand how to take an earbow transfer closed MIP bite record, it is advantage- ment goals is to create an esthetic plane is the patient is looking to do, clinical find- and just why it is so important. The ear- ous to take an earbow transfer and mount of occlusion that is parallel to the horizon, ings, one or more treatment options, ad- bow is used to record the relationship of the case on an articulator. For one thing, with the head straight and erect, regard- vantages and disadvantages of each option, the patient’s maxillary arch relative to the a properly taken earbow transfer and up- less of any facial discrepancies.7 Although time frames involved, and anticipated TMJ, and then transfer this relationship per cast mounting will enable the dentist many dentists use the interpupilary line fees for treatment. to an articulator (Figure 6 and Figure 7). and technician to visualize any cant of to orient the bow to determine the esthe- Diagnostic photographs are an integral An earbow transfer is absolutely essential the maxillary teeth as they relate to the tic plane, this is often incorrect because part of any comprehensive exam and the whenever an open bite record is taken, as facial midline and horizon. In other words, one eye is frequently higher or lower than author believes it is imperative that den- is the case with most CR bite records. the earbow transfer relates the “esthetic the other (Figure 11). tists be adept with digital photography. The correct axis of condylar rotation plane” (line from upper canine to cani- A TMJ and muscle-screening exam Quality digital photographs are essential (actually a close approximation) is record- ne) to the articulator just as it appears in should be part of any comprehensive exam. for a number of reasons, including com- ed by the earbow, which is then used to the patient’s mouth with the head held The simple fact is that any change in con- munication with the patient, laboratory, mount the upper cast to this hinge axis straight and erect (Figure 8 through Figure dylar position and/or morphology will and the patient’s insurance company; position. If the correct hinge axis is not 10). In the author’s opinion, a properly affect the way the teeth come together. It
  3. 3. CONTINUING INSIDE DENTISTRY—FEBRUARY 2007 eDucaTion 35 simply makes sense that we ascertain the Figure 12 and Figure 13 for examples) but are in their proper position and orienta- proven to be a very repeatable, reliable, and condition of the joints prior to definitive a very significant “hit and slide” from CR tion on the heads of the condyles. Peter useful position for case diagnosis and de- treatment. The author uses a simple and to MIP was noted. A “hit and slide” is the Dawson defines CR as “the relationship of sign, as well as in the management of many concise TMJ- and muscle-screening exam terminology used to describe the slide the mandible to the maxilla when the pro- occlusal-muscular disharmonies. form as a guide during this aspect of the seen as patients squeeze their teeth to- perly aligned condyle/disc assemblies are Because there was clear evidence of comprehensive exam. It is important to es- gether from the first point of tooth con- in the most anterior superior position of occlusal disharmony in this case, the tablish baseline parameters in terms of tact, with the joints in CR, to an MIP the glenoid fossa.”1 What clinicians need author felt a CR bite record and mount- joint and muscle health prior to treatment. position (Figure 14 and Figure 15). to understand is that CR is a repeatable ing was essential to properly diagnose If significant problems are suspected then Centric relation (CR) is a joint-based joint-based axial position found inde- the existing occlusal relationships. In the other diagnostic information, such as an position where the condyles (medial poles) pendently of the teeth.8-11 In fact, CR bite author’s experience, CR can be found MRI, may be required. Stable and comfor- are fully seated in their most superior po- records are typically taken with the teeth fairly easily in the vast majority of pa- table joints are vital to overall case com- sition in the glenoid fossa and the disks apart. In the author’s experience, CR has tients without prolonged splint therapy fort, stability, and predictability. In this particular case several “red flags” were evident regarding the stability of the patient’s existing occlusal scheme. The patient had stated that she was “not comfortable with her teeth touching” and her bite “felt off.” She had also men- tioned that it felt like she had “two bites.” During the TMJ screening exam, consis- tent reciprocal clicking (clicking on open- ing and closing) of the left joint was noted. In addition, the patient reported discom- fort to direct palpation of the left TMJ. Lingual thinning of the upper anterior teeth and chipping and wear of the lo- wer anterior teeth also was evident (re- fer back to Figure 2). Both joints could be loaded comfortably with light and firm pressure via bilateral manipulation (see Figure 12 Frontal view of proper finger posi- tion for bilateral manipulation. Bilateral manipu- lation uses a gentle, unforced hinging movement of the mandible to seat the condyles upward into the glenoid fossa. Figure 13 Sagittal diagrammatic view of bilat- eral manipulation demonstrating proper finger positioning and how the mandible is rotated to fully seat the condyles in their respective sock- ets. (Illustration courtesy of Dr. Peter Dawson.) (Circle XX on Reader Service Card)
  4. 4. INSIDE DENTISTRY—FEBRUARY 2007 Figure 14 TMJ illustrator demonstrating the Figure 15 As the “teeth” close/slide together first point of tooth contact (arrow) with the into MIP the condyles are no longer in CR but are condyles in CR. down and forward from that position. This move- ment, from the first point of tooth contact with the condyles in CR (see Figure 14) to an MIP tooth-based position, is called a “hit and slide” from CR to MIP. Figure 16 View of a Pankey deprogrammer Figure 17 Bilateral manipulation is used to that has been filled and seated over the upper hinge the mandible in CR until the lower incisal anterior teeth. The surface of the deprogrammer edges penetrate the soft composite and contact has been roughened and coated with a Bis-GMA the hard surface of the deprogrammer. The com- resin that facilitates adhesion to a subsequently posite is then light-polymerized, resulting in a placed thin layer of composite. very precise incisal index. A very firm-setting PVS is injected between the separated posterior teeth while the patient is closed into the index to take the CR bite record. often by the author is to use BLM in con- junction with a modified Pankey depro- grammer. The Pankey deprogrammer is filled with a very firm and quick setting polyvinyl siloxane (Futar® D Occlusion, Kettenbach GmbH & Co, KG) and placed over the upper anterior teeth. The sur- face of the deprogrammer should be kept parallel to the occlusal plane. The patient is reclined to a horizontal position, with the deprogrammer in place, for 5 to 15 minutes. The idea is to keep the teeth apart for a time to assist in muscle relax- ation (deprogramming). Some patients can be deprogrammed very quickly while others require more time. Muscle relax- ation, especially of the lateral pterygoids, is Figure 18 After the upper cast is mounted one of the keys to locating a correct CR with the earbow transfer, the lower model is position.17 To paraphrase Frank Spear, mounted to the upper cast using the CR bite DDS, MSD (various lectures): “CR is not record and incisal index. a position you have to put people in, it is a position the condyles go when the lat- (as is advocated by some). CR can be de- eral pterygoids relax.” termined in any number of ways, in- After deprogramming, BLM is used cluding bilateral manipulation (BLM), to gently hinge the mandible while hold- leaf gauge, central bearing point and ing the condyles up in the glenoid fossa Gothic arch tracing, and various types (CR). Using this hinging motion, the low- of anterior deprogrammers such as a er anterior teeth are guided through a thin Lucia jig.12-16 The technique used most layer of composite that has been placed on (Circle XX on Reader Service Card)
  5. 5. CONTINUING INSIDE DENTISTRY—FEBRUARY 2007 eDucaTion 37 the surface of the Pankey deprogrammer (Figure 16). As the incisal edges of the low- er anterior teeth penetrate the soft com- posite, they contact the hard surface of the deprogrammer. At this point the compo- site is light-polymerized, creating a very precise incisal index of the lower anterior teeth on the surface of the deprogrammer (Figure 17). It is important to roughen the smooth surface of the deprogrammer and brush on an unfilled resin prior to placing the thin layer of composite (to en- Figure 19 Properly trimmed and polished CR- Figure 20 and Figure 21 When the models are closed together with the hinges locked in CR, the sure it sticks). If CR has been properly de- mounted models on a semi-adjustable articulator. only point of tooth contact is the mesio-lingual cusp of tooth No. 16 (compare with Figure 23). termined, then each and every time the mandible is hinged using BLM, the lower incisal edges will fit precisely into the incisal index. In fact, once the patient is de- programmed no external manipulation is required as the patient, on command, will consistently close into the index with- out any external guidance. If everything was done correctly, the condyles will be in CR when the patient is closed into the index. All that remains to be done is to Figure 22 In CR, the teeth on the right side Figure 23 The fact that the same (and only) Figure 24 Tooth No. 16 is “extracted” on the inject a very firm-setting PVS between the are completely out of occlusion, as are all the point of contact we see in the mouth using bilat- model with a heatless stone. separated posterior teeth while the patient teeth on the left side with the exception of tooth eral manipulation is exactly the same as what we is closed into the index. The resulting bite No. 16. see on the articulator confirms the accuracy of record and index is then used to mount the mounting. the case in CR on a semi-adjustable ar- ticulator (Figure 18 and Figure 19). Hav- ing taught this technique to hundreds of dentists, the author finds that most will pick up the technique relatively quick- ly. For those not comfortable with bilater- al manipulation, the use of a leaf gauge or Lucia Jig offers a viable alternative for finding CR; however, one loses a certain degree of “tactile” information obtain- ed from a more hands-on technique like bilateral manipulation. In this CR-mounted case, the only point of tooth contact when the models were Figure 25 and Figure 26 Removing tooth No. 16 eliminated almost all of the “hit and slide” from Figure 27 Anterior coupling (tooth contact) closed together was the mesiolingual cusp CR to MIP and bilateral posterior contacts are now evident from the premolars back. , was achieved by minor equilibration of the mod- of tooth No. 16 (Figure 20 through Figure els after tooth No. 16 was removed. 22). This was the same first and only point of contact seen in the patient’s mouth when bilateral manipulation was used to hinge the mandible in CR (Figure 23). The fact that what we see in the mouth is duplicated precisely on the articula- tor confirms the accuracy of the mount- ing. The patient’s hit and slide from CR to MIP can be easily demonstrated by unlocking the articulator hinges and sliding the models together into an MIP position. Basically, the same thing is oc- Figure 28 The TMJ illustrator is used to demon- Figure 29 Diagnostic wax-up of teeth Nos. 4 Figure 30 As was done on the models, tooth curring in the patient’s mouth. In order strate the occlusal scheme created on the mod- through 13. The diagnostic wax-up should be No. 16 was extracted in the patient’s mouth, and for the patient to bring his or her teeth els that resulted in a new MIP position that is viewed as our “best guess” as to what the case the teeth equilibrated to CR. The patient’s “hit and together into MIP, one or both of the now coincident with CR. should look like in its final form. It must be test- slide” from CR to MIP was completely eliminated. condyles must translate out of CR, and ed in provisionals. A matrix for provisionals, facial move down the eminence to some de- reduction guide, and incisal reduction guide are gree. It should be pointed out that this all fabricated from the diagnostic wax-up. may not be a clinical problem and that it is often acceptable to place restorations into an occlusal scheme such as this. Spe- very often, or brings them together with well for them, and dentists need to con- One of the goals in a CR-based occlu- cifically, if no signs or symptoms of oc- little intensity, or just has a high adaptive sider a change before placing definitive sion is the harmonization of MIP with clusal disharmony exist, and the patient capacity. In the author’s opinion, it is a restorations. The trick is to know when CR. In other words, when the patient clo- is comfortable and has no difficulty chew- mistake to alter an existing occlusal scheme a change is required and when it is not.18 ses into MIP the condyles are also in CR. In ing, then a change in the existing occlusal that is already working solely to satisfy The clinical findings and history in this case this case, the only point of tooth contact, relationship may be unwarranted. Even the philosophical occlusal “ideal” of a par- clearly indicated a problem with the exist- with the condyles in CR, was the ML cusp a seriously flawed occlusion may not ticular occlusal philosophy. Having said ing occlusal scheme and the decision was of tooth No. 16. This was essentially a cause clinical problems if the patient that, there are many patients that have made to modify the occlusion prior to do- nonfunctional tooth that also had mes- does not bring his or her teeth together an occlusal scheme that is NOT working ing the clinical dentistry. ial caries. It was decided to “extract” this
  6. 6. CONTINUING 38 eDucaTion INSIDE DENTISTRY—FEBRUARY 2007 Figure 31 through Figure 33 The incisal edges of the lower anterior teeth were evened out to create a more esthetic profile. Great care should be taken Figure 34 Photograph of the facial reduction whenever lower incisal edges are altered. It is very important to preserve the proper incisal inclination and maintain a sharp buccal-incisal line angle. guide in place. It is evident that more facial reduction is required on teeth Nos. 8 and 9. Figure 35 Matrix fabricated from diagnostic Figure 36 and Figure 37 The patient was seen 1 day after the preparation appointment so that Figure 38 Model showing preparations for the Lava wax-up being filled with Luxatemp (DMG). the provisionals could be evaluated for comfort, esthetics, phonetics, and function. bridges on teeth Nos. 6 through 8 and 9 though 11. eliminated. The following week, the pa- “THIS IS THE FIRST TIME SINCE I CAN REMEMBER tient was re-evaluated and she reported that she was very comfortable with her THAT MY BITE HAS FELT COMFORTABLE AND new bite. In her own words: “This is the first time since I can remember that my I KNOW HOW MY TEETH SHOULD FIT TOGETHER.” bite has felt comfortable and I know how my teeth should fit together.” Once the occlusion had been addressed, the teeth tooth on the upper model to ascertain what 1. Perform a diagnostic wax-up of teeth provisionals are deemed acceptable, an were prepared as treatment planned. First, effect this would have on the occlusion Nos. 4 through 13 on CR-equilibrated alginate will be taken of the provisionals the incisal edges of the lower anterior (Figure 24). The tooth was removed with a models (tooth No. 16 was removed). and a solid model will be fabricated. The teeth were evened out to create a more es- heatless stone and the models closed to- The wax-up would be used to fabri- solid model will be sent to the labora- thetic profile (Figure 31 and Figure 32). gether with the hinges locked in a CR cate a matrix for provisionals and also tory along with various photographs of Great care should be taken whenever low- position. Just removing this one tooth to fabricate reduction guides that would the patient in the provisionals to assist er incisal edges are altered. It is very im- eliminated almost all the hit and slide be used during tooth preparation. The the ceramist in the fabrication of the portant to preserve the proper incisal from CR to MIP and bilateral posterior plan would call for porcelain veneers final restorations. inclination and maintain a sharp buccal- contacts were now evident (Figure 25 and on teeth Nos. 4, 5, 12, and 13 along with 6. At the fourth appointment, try in incisal line angle (Figure 33). In this case, Figure 26). Anterior coupling (anterior two three-unit Lava™ (3M ESPE, St. and evaluate the final restorations. Once there was a degree of latitude in reshap- tooth contact) was subsequently achieved Paul, MN) bridges from teeth Nos. 6 the case is approved, the veneers will ing the lower incisal edges because the by minor equilibration of the models (Fi- through 8 and Nos. 9 through 11, with be bonded in and the bridges cement- lingual contours of the upper anterior gure 27). The occlusal scheme created on pontics at teeth No. 7 and No. 10. ed in place. Lava bridges could be designed as required the models resulted in a new MIP position 2. At the first appointment, extract 7. Fabricate and insert a Durasoft to ensure proper occlusion with the alter- that was now coincident with CR (Figure tooth No. 16. Equilibrate patient to CR. nightguard/retainer at case comple- ed lowers. After the lower incisal edges 28). By doing the occlusal correction on 3. Before the preparation appoint- tion (Great Lakes Orthodontics, Ton- were reshaped, the upper canines and cen- the models first, it was determined that ment, the lower teeth are whitened awanda, NY). trals were prepared for Lava bridges and the same process could easily be repeat- with a take-home system (Nite White®, The patient accepted the treatment the premolars for porcelain veneers. The ed in the patient’s mouth without exces- Discus Dental, Culver City, CA). This plan as presented and was anxious to begin. reduction guides, fabricated from the di- sive removal of tooth structure. could be done at any time in the treat- The equilibrated models were sent to the agnostic wax-up, were used to ensure ad- In addition to the aforementioned oc- ment plan, but usually it is done be- laboratory and a diagnostic wax-up was equate removal of tooth structure (Figure clusal issues, a number of other factors were fore the preparation appointment. returned along with a matrix for provi- 34). Final impressions were taken with a considered in developing a treatment plan 4. At the second appointment, adjust sional restorations and reduction guides polyether impression material (Impreg- for this patient. She was not a candidate for and even out the lower incisal edges. to be used during the preparation phase um™ Penta™ Soft Quick Step heavy body dental implants. She would not accept a re- Prepare teeth Nos. 6, 8, 9, and 11 for of treatment (Figure 29). The diagnostic and light body, 3M ESPE) along with a movable appliance of any type. She had two all-ceramic Lava bridges. Prepare wax-up should be viewed as a “best guess” closed bite record. It should be pointed out negative experiences with three different teeth Nos. 4, 5, 12, and 13 for porcelain as to what the case should look like in its that the closed MIP bite record was now fixed Maryland-type bridge replacements. veneers. Take final impressions and final form. The only way to ascertain that also a CR bite record because the patient She had very high esthetic expectations, and fabricate provisional restorations us- this “guess” is correct is to actually try the had been equilibrated to an MIP posi- space management was a significant con- ing the matrix fabricated from the di- case out in provisionals that mimic the tion that was now coincident with CR. cern because of the insufficient room in the agnostic wax-up. wax-up. Provisional restorations were fabri- lateral incisor areas for replacement with 5. At the third appointment, evaluate The treatment began by essentially du- cated using the matrix fabricated from teeth of appropriate width. After con- the patient in provisionals 1 to 2 days plicating what was done on the mounted the diagnostic wax-up in conjunction with sidering all of these factors and carefully after the preparation appointment and models. As on the models, tooth No. 16 Zenith/DMG Luxatemp® Fluorescence evaluating the information obtained from make changes as required. Evaluate was extracted and the teeth equilibrated (Zenith/DMG Brand Division Foremost the comprehensive exam, the following the provisionals for esthetics, phone- to CR (Figure 30). The patient’s hit and Dental LLC, Englewood, NJ) B-1 shade. treatment plan was presented to the patient: tics, occlusion, and function. Once the slide from CR to MIP was completely The matrix was filled with the Luxatemp
  7. 7. CONTINUING 40 eDucaTion INSIDE DENTISTRY—FEBRUARY 2007 Figure 39 Definitive restorations (veneers on Figure 40 The porcelain veneers on the premo- Figure 41 Cementation of Lava bridges with a teeth Nos. 4, 5, 12, and 13 and two Lava bridges). lars have all been bonded in using a total-etch adhe- RMGI cement (Rely X Plus, 3M ESPE). sive system protocol (One-Step Plus, BISCO). Figure 42 through Figure 44 Finished case 2 weeks after placement. Figure 45 Patient at 14-month recall. The patient is “delighted” with her new smile and has a comfortable and stable bite relationship. and seated over the prepared teeth (Fig- system One-Step® Plus (BISCO, Inc, Sch- ACKNOWLEDGMENTS 14. Long JH. Locating centric relation with a leaf ure 35). Once the material was set, the aumburg, IL) in conjunction with a wet- The author would like to thank Frontier gauge. J Prosthet Dent. 1973;29(6):608-610. provisionals were removed in three sec- bonding protocol.21-24 The veneers were Dental Lab in San Francisco, CA, for their 15. Carroll WJ, Woelfel JB, Huffman RW. Simple tions (the veneers on teeth Nos. 4 and 5, sandblasted, etched with hydrofluoric acid, contributions to the success of this case. application of anterior jig or leaf gauge in rou- the veneers on teeth Nos. 12 and 13, and and treated with hydrolyzed silane be- tine clinical practice. J Prosthet Dent. 1988; the bridge on teeth Nos. 6 through 11) so fore placement. There are many good res- REFERENCES 59(5):611-617. that they could be smoothed and polished in cements that can be used for placement. 1. Dawson P Evaluation, Diagnosis, and Treatment . 16. Dawson PE. Centric relation: Its effect on outside of the mouth. The occlusion was Once the veneers had been placed, the of Occlusal Problems. 2nd ed, C.V. Mosby; 1989. occluso-muscle harmony. Dental Clinics of adjusted and the provisionals were pla- Lava bridges were sandblasted with 50-µm 2. Dawson PE. Want a thriving practice? Con- North America. 1979;23(2):169-179. ced by spot-bonding in the veneers and aluminum oxide and cemented with a centrate on clinical excellence. Dent Econ. 17. Spear FM, Kokich VG. Interdisciplinary man- cementing the anterior bridge of teeth resin-modified glass ionomer cement 1992;82(10):78-79. agement of anterior dental esthetics. J Am Nos. 6 through 11 with TempBond® (Kerr (RelyX™ Plus, 3M ESPE).25-26 After all the 3. Alex G, Polimeni A. Comprehensive dentistry: Dent Assoc. 2006;137(2):160-169. Corporation, Orange, CA). The patient re- restorations were placed, final finishing the key to predictable smile design. AACD 18. Yaffe A, Hochman N, Ehrlich J. Physiologic oc- turned the day after the preparation ap- and polishing was performed under high Monograph. 2006;15-20. clusion vs pathologic occlusion and ration- pointment so that the provisionals could magnification. The occlusion was checked 4. Spear FM. The business of occlusion. J Am al for treatment. Compend Contin Educ Dent. be evaluated for comfort, esthetics, pho- in centric closure and excursive move- Dent Assoc. 2006;137(5):666-667. 1996;17(11):1093-1098. netics, and function (Figure 36 and Fig- ments, and the patient was given written 5. Miller L. Symbiosis of esthetics and occlusion: 19. Fondriest JF. Using provisional restorations ure 37). Once the case had been worked and oral instructions on proper home care thoughts and opinions of a master of esthetic to improve results in complex aesthetic re- out in provisionals, an incisal index was and maintenance. The lower teeth had dentistry. J Esthet Dent. 1999;11(3):155-165. storative cases. Pract Proced Aesthet Dent. fabricated to precisely record the incisal been whitened prior to tooth preparation 6. Tarantola GJ, Becker IM, Gremillion H, Pink 2006;18(4):217-224. edge position. In addition to this, various with the Nite White® Excel 3 system. The F. The effectiveness of equilibration in the 20. Terry DA, Moreno C, Geller W, Roberts M. The digital photographs were taken along with patient returned 1 week after the case was improvement of signs and symptoms in importance of laboratory communication in an alginate of the provisional restora- placed for final adjustments, photographs, the stomatognathic system. Int J Periodontics modern dental practice: stone models with- tions. A solid model of the alginate im- and the insertion of a flat-plane Durasoft Restorative Dent. 1998;18(6):594-603. out faces. Pract Periodontics Aesthet Dent. pression was fabricated and sent to the acrylic upper night guard. The author rou- 7. Lee RL. Standardized head position and ref- 1999;11(9):1125-1132. laboratory along with the photographs tinely provides nightguards in cases such erence planes for dento-facial aesthetics. 21. Kanca J III. Improving bond strength through and incisal index. With this information, as this, both for protection of the porcelain Dent Today. 2000;19(2)82-87. acid etching of dentin and bonding to wet a good laboratory can duplicate every- and opposing natural teeth and to act as a 8. Tarantola GJ, Becker IM, Gremillion H. The dentin surfaces. J Am Dent Assoc. 1992;123 thing that was right with the provisionals retainer maintaining tooth position. The reproducibility of centric relation: A clinical (9):35-43. in the final restorations and/or make mod- patient was delighted with the final results approach. J Am Dent Assoc. 1997;128(9): 22. Alex G. Adhesive dentistry: where are we ifications as required. Using the provi- (Figure 42 through Figure 45). 1245-1251. today? Compend Contin Educ Dent. 2005; sionals as a guide19-20 is a much more What is needed when approaching a 9. McKee JR. Comparing condylar position re- 26(2):150-155. predictable approach then simply having cosmetic/restorative case such as the one peatability for standardized versus nonstan- 23. Tay FR, Gwinnett AJ, Pang KM, Wei SH. Res- finished restorations returned and “hop- presented here is a logical and systematic dardized methods of achieving centric relation. in permeation into acid-conditioned, moist, ing” the case looks good, feels good, and methodology that will lead to a reason- J Prosthet Dent. 1997;77(3):280-284. and dry dentin: a paradigm using water-free functions well. ably predictable final result. The place to 10. The glossary of prosthodontic terms. J adhesive primers. J Dent Res. 1996;75(4): The master models and finished re- start should always be the comprehen- Prosthet Dent. 2005;94(1):10-92. 1034-1044. storations were inspected after they were sive exam. It is up to clinicians, through 11. Spear FM. Occlusion in the new millenni- 24. Gwinnett AJ. Moist versus dry dentin: its received from the laboratory (Figure 38 comprehensive diagnostic examination um: the controversy continues. Signature. effect on shear bond strength. Am J Dent. and Figure 39). The restorations were sub- and evaluation, to develop a treatment 2000;7(2):18-21. 1992;5(3):127-129. sequently evaluated in the patient’s mouth plan that fulfills not just the esthetic 12. McKee JR. Comparing condylar positions a- 25. Raigrodski AJ, Chiche GJ, Potiket N, et al. to ensure proper fit, occlusion, and esthe- but the functional requirements of a chieved through bilateral manipulation to The efficacy of posterior three-unit zirconium- tics. Once approved by the patient, the case. While an excellent cosmetic result condylar positions achieved through mastica- oxide-based ceramic fixed partial dental restorations were placed by first bonding is always a desirable goal, it was the re- tory muscle contraction against an anterior prostheses: A prospective clinical pilot study. in the porcelain veneers (Figure 40) follow- cognition and treatment of the occlusal deprogrammer: a pilot study. J Prosthet Dent. J Prosthet Dent. 2006;96(4):237-244. ed by cementation of the anterior Lava issues prior to doing the definitive re- 2005:94(4):389-393. 26. Palacios RP Retention of zirconium oxide . bridges (Figure 41). The veneers were storative dentistry that made this case a 13. Lucia VO. A technique for recording centric ceramic crowns with three types of cement. bonded in using the total-etch adhesive true success. relation: J Prosthet Dent. 1964;14:492-505. J Prosthet Dent. 2006;96(2):104-114.
  8. 8. 42 INSIDE DENTISTRY—FEBRUARY 2007 THIS CE LESSON IS MADE POSSIBLE THROUGH AN EDUCATIONAL GRANT FROM GlaxoSmithKline , MAKERS OF SENSODYNE, SUPER POLIGRIP, POLIDENT, AND OASIS. CONTINUING QUIZ eDucaTion Log on to to take this FREE CE quiz. Is Occlusion and Comprehensive Dentistry Really That Important? Gary Alex, DMD Tufts University School of Dental Medicine provides 2 hours of FREE Continuing Education credit for this article for those who wish to document their continuing education efforts. To participate in this CE lesson, please log on to, where you may further review this lesson and test online. Log on now, take the CE quiz and, upon successful completion, print your certificate immediately! It’s that easy! For more information, please call 877-4-AEGIS-1. 1. A primary tenet of comprehensive dentistry is that: 6. A “hit and slide” is the terminology used to describe: a. all cases should be built in centric relation. a. the movement of the condyles when using bi- b. all components of the masticatory system lateral manipulation. are intimately related and dependent on one b. the movement seen from the first point of tooth another for ideal function. contact, with the joints in CR, to an MIP position. c. it is only applicable in a Dawson/Pankey c. the mandibular movement when using a leaf occlusal philosophy gauge. d. it is never applicable in a Dawson/Pankey d. the force used to put the patient into CR. occlusal philosophy. 7. Centric relation: 2. A destructive occlusal relationship can cause a. is a joint-based position where the condyles problems somewhere in the masticatory sys- are fully seated in their most superior posi- tem, such as: tion in the glenoid fossa and the disks are in a. joint pain. their proper position and orientation on the b. muscular pain. heads of the condyles. c. tooth sensitivity. b. can be found by pushing the condyles back. d. all of the above c. cannot be found without prolonged splint therapy. d. can be identified by the clicking of the TMJ. 3. An earbow transfer is used to: a. transfer the “esthetic plane” to the articulator. 8. An anterior deprogrammer can be used to: b. record the correct axis (or a close approxima- a. assist in muscle relaxation. tion) of condylar rotation. b. keep the teeth apart. c. record the relationship of the maxillary arch c. locate the correct CR position. relative to the TMJ. d. all of the above d. all of the above 9. In the case presented in this article, the patient's "hit 4. Any change in condylar position and/or morphology: and slide" was demonstrated by: a. should be closely watched for 6 months. a. taking radiographs. b. will affect the patient’s sense of taste. b. manipulating the jaw. c. will affect the way the teeth come together. c. unlocking the articulator hinges and sliding d. is potentially dangerous and should be the models together. aggressively treated. d. taking an impression with a high-viscosity PVS material. 5. Stable and comfortable joints are vital to: a. case comfort. 10. When adjusting lower incisal edges: b. stability. a. there is no need to maintain centric stops. c. predictability. b. great care should be taken to maintain a d. all of the above sharp buccal-lingual line angle. c. the jaw should be forced into centric relation. d. first determine the curve of Spee. Tufts University School of Dental Medicine is an Association for Continuing ADA CERP and ACDE recognized provider. Dental Education