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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 method
H 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, harmonizing
dichotomy 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 the
bility, and comfort, and those technician/artist.3 determining factor in restoring patient more comfortable.8,9
whose priority is esthetic rejuve- When people lose ideal func- necessary facial height.” McAn- Full-mouth rejuvenation is a
nation. 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 the
beautiful smile designed to last a chew efficiently. The teeth, mus- corrected arch alignments and parameters above. Form and
long time? function are intimately inter-
During the past 20 years, twined. To accomplish the goals
orcelain veneers have evolved from a
porcelain veneers have evolved
from 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 while
ing medium for teeth as well. Of staying comfortably in the enve-
course, the ceramic materials lope of function and avoiding
have 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 most
dentists 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 incorporated
on 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 12
tium, 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 of
cular system (the functional documented. In Hunt’s literature rior guidance. Decreased elevator 10 mm (average)—shorter to
70 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

2. Circle 41 on Reader Service Card

3. At the Chair continued
allow 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 demonstrates
upper 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 health
bicuspids. 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.10
practice. 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 Card
72 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

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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 patient
Figure 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 to
asymmetries 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 as
thetic elements were empha- is to create an ideal bite relation- impressions and a Stratos® 200 well as the new vertical using the
sized. After showing him a simi- ship without noxious interfer- (Ivoclar Vivadent®, Inc) face-bow molar bite registrations. With
lar patient’s treatment, he agreed ences and allow the condyles to were taken. A new closed reduc- this pre-preparation visit, this
to 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 and
ing his definitive case visits. The muscles. The patient wore the window was cut out in the front laboratory. This saved chair time
plan 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 went
tic® porcelain crowns/overlay new vertical dimension of occlu- orthotic was removed and while through treatment (Figures 5
veneers (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 to
Authentic® Press-to-Metal™ crowns cations were made that closed index was made in the molar lengthen this patient’s teeth, the
because 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 the
centric relation and a vertical other hand, maintaining a con-
dimension of 18 mm from upper
incisal 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 our
an anterior composite bite was functionally esthetic philosophy.
made at a centric relation open Furthermore, because of the
bite. 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 more
nith™/DMG) because of its supe- clusal marks remaining stable. to get all involved parties “on the “macrodentally” to achieve the
rior handling properties and firm Fortunately for this patient, his same page.” The molar wax-up is goals. In cases such as this, the
set (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 their
tions as well as accurately mount ment time that often can take up up and later on in the mouth new restorations. Through the
the model makes it ideal for cre- to 1 year. (Figure 4). use of serial “transfer bites”11
ating throughout this patient’s When this author realized the Before any alterations oc- that began with pre-preparation
case. During MAGO construc- patient’s comfortable vertical curred in the mouth, the patient indices based on the original bite
tion, root canals and decay con- position (approximately 17 mm was brought in for a “mock-up registrations, the author was able
trol were done to begin to CEJ to CEJ), it was time to create visit.” At that visit, Luxatemp® to maintain the occlusal/TMJ
strengthen 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. 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 restoration
very 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 removing
It also allowed fine tuning of functional-esthetic journey was for comfort and longevity any excess, occlusion was fine
some 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 the
further 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 weeks
in place [Figure 9]). Digital pho- were created using a lost-wax in individually and as a group to later and took an additional 4
tographs 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 and
laboratory 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 many
plan. 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 seven
shade 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 an
dexed with Siltec putty. Esthetics facial harmony and beauty as cement employing the “two-by- nighttime upper orthotic to pro-
and function needed minor
attention when precise records
were made and used. It also
allowed this patient, who was
sedated with alprazolam, to have
no unpleasant surprises when he
saw his new smile (Figure 10).
A critical part of the patient-
focused philosophy is to allow
the clients to “test drive” their
new smile and its functionality. It
allows them (and their significant
others) to “critically evaluate
their new appearance and their
ability to chew, speak, swallow,
and kiss.”12 After the patient had
a week to do this, this author
fine-tuned the provisionals. By
taking this extra time to do this,
patient participation and satisfac-
tion was greatly increased.
Communicating these results
with impressions and photos to
the laboratory technician allowed
him to know three-dimensionally
all the details of the prototypes.
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CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE May 2003 75

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 increases
Figure 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 appreciates
76 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

8. Circle 46 on Reader Service Card