Patient 4 is a 55-year-old female seeking improvement of the aesthetics of her upper teeth. A facial analysis found excessive soft tissue display, loss of anatomical form due to tooth wear and restorations, and a deep bite. X-rays showed crowding, malpositioned teeth, and a malpositioned implant. The treatment plan involves hard and soft tissue grafts, provisional restorations, and ceramic restorations to restore anatomy and satisfy aesthetic concerns with a long-term strategy.

1. Patient 4

2. Patient 4
* female
* 55 years
* medical condition: none
* patient’s request
- improvement of the aesthetics
of her upper teeth

3. Facial Analysis
Digital Facebow

4. Facial Analysis
long upper lip

5. Facial Analysis
excessive
soft tissue display
wnl/gummy
smile (posterior)
facial/dental
midline
WNL
(slight to the left)

6. Facial /dental Analysis
facial/dental
midline
WNL
(slight to the left)

7. Facial Analysis
Straight profile

8. Facial Analysis Lips in Repose
+/- 4 mm tooth structure

9. Facial Analysis Full Smile
Lip Dynamics High lip dynamics

10. Dental Analysis
15 mm frialit implant
Seibert class III
Seibert class I
11.5 mm
overbite: 5 mm CRO = MIP

11. Dental Analysis Loss of anatomical form
wear anterior teeth (deep bite)
wear posterior teeth/flat restorations

12. Dental Analysis Loss of anatomical form
(dento-alveolar eruption)
wear anterior teeth (deep bite)
deep curve of spee

13. Dental Analysis dento-alveolar compensation
( premolars)
slight angle classs II
overbite: 5 mm
angle classs II
overjet: 4 mm

14. Intra-Oral Examination

15. X-ray Examination

17. patient visits a oral
hygienist 2-3 times a year
and oral hygiene is at a
good level, no abnormal
probing depths

18. deep bite due to dento alveolar eruption of
lower anterior teeth due to restorations of the
anterior teeth
diagnosis
crowding lower anterior teeth and malposition
23 and 24 (25 not present)
mal-positioned implant 22
soft tissue deficiency siebert class III 22 and
siebert class I 12
dento-alveaolar eruption premolars upper jaw
los of anatomical form due to restorations:
16,15,14,26,27 34-37 and 44-47
wear lower anterior teeth (attrittion)

19. what are the patient’s financial constraints?
how could we satisfy the patient’s aesthetic?
how to treat the hard and soft tissue
deficiencies in the aesthetic zone
Is the patient willing to go through orthodontic
and surgical procedures surgery
can we restore this patient predictably with
long-term strategy?
primary concerns
what to do with the implant at the 22

20. improve hard and soft tissue
volume at the 12 and 22
restore anatomy of the teeth
satisfy aesthetic concerns
develop long term-strategy
treatment objectives
create a stable occlusion with
anterior guidance

21. treatment plan
wax-up
hard and soft tissue graft 22
provisional restoration 21=22=23
connective tissue graft pontic site 22
copy provisionals to ceramic restoration
soft tissue healing and maturation
contouring soft tissue through
provisional restoration
prep teeth for restorations (16-27 and 33-37,43-47)
and open vdo in provisional restoration phase and
recontour lower anterior
(patients doesn’t want ortho)
evaluate biology, function and aesthetics
3 months

22. Treatment options Increasing the VDO
lower anterior rotate back, more
ClassII

23. Treatment options
Change Angle of
Restorations
With or without surgical crown lengthening

24. Initial Wax-Up

25. Initial Wax-Up

28. provisional bridge

29. surgical
procedure

30. 3 months healing

31. aesthetic/functional wax-up
vacuum shell (duran)
prep guide for sufficient reduction
if necessary adjust preparation
measure provisional restoration thickness

32. Communication to laboratory
VDO registration impression

33. 6

34. try inn zirconia
frame work

35. pick-up soft
tissue details

42. 2 Year Result