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Now is a great time to be indentistry. Never beforehave patients esthetic

demands been met with suchconsistency; this is due in largepart to materials and techniqueadvancements made in the lastdecade through the collaborativeefforts of dental professionals,laboratories, and material manu-facturers. In this time of highesthetic expectations, companies

that deliver the functional andesthetic products we need enableus to collectively provide restora-tions that offer strength anddurability and, most of all, a life-like appearance.

As a result, the dental experi-ence is now more rewarding forboth the dentist and the patient.Pressed ceramic restorations(IPS Empress, Ivoclar Viva-dent, Inc.), fabricated by thelaboratory according to specificinstructions communicated by

the dentist, can create the smile

and functional enhancementspatients desire. Simultaneously,for dentists who feel unable tomake the plunge into all-ceramic restorations, recentlyintroduced porcelain-fused-to-metal (PFM) alternatives (IPSd.SIGN, Ivoclar Vivadent,Inc.) offer the security and pre-dictability of a PFM restoration

that still meets the high estheticdemands placed upon them bytheir patients.

A great deal of restorativesuccess, however, is dependenton a collaborative team approachto the patients overall dentalcare. Many general dentists and

prosthodontists have been fortu-

nate to align themselves withspecialists in their area whohave taken the time and special-ized training to become morein touch with what materials andtechniques can be used to ulti-mately deliver the desiredrestorative outcome. Unlikebefore, dental professionals nolonger need to adjust their

restorative plans to compensatefor deficiencies in soft andhard tissues. Rather, by comingtogether as a team, clinicians,specialists, and laboratory tech-nicians have minimized thosefactors that compromise thetreatment process and are achiev-

ing far more superior results.

The following case presentation details the manner in whica collaborative approach amondental specialists and the laboratory, as well as the selection othe most appropriately indicaterestorative materials, can produce a comprehensive aninvolved full-mouth rehabilitation for a patient with a severelcompromised smile.

CASE PRESENTATIONA 40-year-old woman pre

sented with one request: a morpleasing smile (Figure 1). Shstated that she had undergonorthodontic treatment but hasince completely relapsed. Shwas also unhappy with the grahue throughout her dentitiofrom light tetracycline staining. After a complete examination, it was determined thaideal treatment would involvorthognathic surgery and ortho

dontic treatment.

Eight-Handed Dentistry: An Interdisciplinary

Approach to Full-Mouth RehabilitationChristopher Ramsey,DMD

PrivatePracticeTheStudio of EstheticDentistryPalmBeach Gardens, FloridaPhone: 561.626.6667Fax: 561.627.7211Email: [email protected]

36 December 2001 CONTEMPORARY ESTHETICSAND RESTORATIVE PRACTI

SA S EC T U D Y

Figure 1Preoperative full-face view.Notice the short appearance of the teeth.

Figure 2Smile exhibiting vertical maxil-lary excess.

Figure 3Teeth exhibiting Class II, DivisionII malocclusion.

Figure 4Maxillary crown lengtheninand gingivectomy provided ideal tissuheight.

Robert G. Ritter, DMDClinical DirectorInstitutefor Oral Art andDesign

Sarasota, Florida

PrivatePracticeTheStudio of EstheticDentistryPalmBeach Gardens, FloridaPhone: 561.626.6667Fax: 561.627.7211Email:[email protected]

Karina F. Leal, DMDPalmBeachGardens, Florida

Lee Culp, CDTOwnerMosaicStudios, Inc.Bradenton, Florida

Founder/DirectorInstitutefor Oral Art andDesign

Sarasota, FloridaPhone: 941.907.6084Fax: 941.907.6984

TThe dental experience is now morerewarding for both the dentist and

the patient.

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Circle 20 on Reader Service Card

C1K02992.EPS

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Interdisciplinary PerspectiveThe patient consulted spe

cialists in both areas and founthat, while surgery and 1 to years of orthodontic bracewould correct occlusal disharmonies, she would still have a

unattractive smile. Therefore,

was incumbent upon all dentaprofessionals involved to identifa solution that would provide thesthetics the patient desired anan occlusal pattern that woulfunction successfully, long-term

The first concern was thpatients high smile line. Heshort clinical crowns left hewith the appearance of gummy smile (Figure 2). Afteperiodontal probing of the entirdentition, it was determined thaperiodontal crown lengthenin

was required in the maxillararch (Figure 3). The periodontisfirst performed a gingivectomto achieve the correct height-tolength ratios (Figure 4). Oncthese were verified, the tissuwas raised to remove the necessary osseous structure, so thfinal restorations would noinvade the biologic widt(Figure 5). The patient healefor approximately 4 to 6 week(Figure 6). The final result was


Case Study continued

Figure 5A full-thickness flap was raised toexposeosseous structurefor recontouring.

Figures 6 and 7Healing of maxilla at 8 weeks. Figure 8Full contour wax-up mounteon a Stratos 200 articulator.

IIt was incumbent upon

all dental profession-

als involved to identify

a solution that would

provide esthetics and an

occlusal pattern that

would function success-

fully, long-term.


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more pleasing architecture onwhich to begin placing therestorations (Figure 7).

Comprehensive RestorativeTechnique

A technique commonly usedin the western part of the UnitedStates to help determine correctfacial esthetics is to measure

from the cemento-enamel junc-tion (CEJ) of the maxillary cen-tral incisors to the CEJ of themandibular central incisors. As astarting point, the ideal measure-ment is 17 mm to 18 mm. In thiscase, the patients measurementwas approximately 15 mm.

Taking this measurement intoconsideration along with thelower third face height, it wasdetermined that opening the ver-tical dimension in the anterior by2 mm would provide better

esthetics, rather than leaving thepatient with a slightly overclosedlook. Thepatient was bimanual-ly manipulated, and a centricrelation bite registration wasobtained. Models were mountedand evaluated for occlusal dis-crepancies. During the patientsnext visit, an occlusal equilibra-tion was performed, to makecentric relation equal with cen-tric occlusion.1,2

To accurately acquire thedesired measurement of 17 mm,

a ball of composite was placed onthe mandibular central incisors.The patient was again manipu-lated and slowly closed onto thecomposite ball. Once the lowerincisors pressed up against themaxillary centrals, the ball andthe CEJs measured 17 mm, andthe ball was cured to lock thedesired vertical dimension. Afterwaiting 5 minutes for thecondyles to fully seat, bite regis-trations were taken. The patient

CONTEMPORARY ESTHETICSAND RESTORATIVE PRACTICE December 2001 39

Figures 9 and 10Occlusal views of the wax-up show proper arch form and occlusalanatomy for full intercuspation.

Figure 11Preparation of the maxillaryand mandibular anterior 20 teeth to idealdepths for pressed ceramic restorations.

Figure 12Stump shades taken of under-lying dentin to communicate to the labora-tory ceramist.


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was returned to an upright posi-tion to evaluate lower faceheight, which was determined tobe acceptable.3 A mock-up usingflowable resin on the anteriorfour maxillary incisors wasrecorded with avanilla bite reg-istration material (DiscusDental) to help the ceramistplace the incisal edges in space in

the wax-up. These registrationswere sent with maxillary andmandibular vinyl polysiloxaneimpressions to the laboratory forfabrication of the diagnosticwax-ups (Figures 8 through 10).

To maintain the original ver-tical dimension as a point of ref-erence, it was decided to preparethe 10 maxillary teeth (Nos. 4through 13) and 10 mandibularteeth (Nos. 20 through 29)(Figure 11). Upon completion ofthe preparations, stump shadeswere taken to determine the

underlying dentin shades(Figure 12). Additionally, a face-bow transfer (Stratos 200,Ivoclar Vivadent, Inc.) and stickbite were also given to the labo-ratory (Figure 13). Using a sil-tech putty matrix fabricated fromthe laboratory wax-ups, thepatient was given temporaries forboth arches (Luxatemp, Zenith/DMG Foremost). After occlusaladjustments were made, thepatient was sent home to func-

tion in the new vertical dimension for 4 to 6 weeks.

Pressed ceramic crowrestorations (IPS Empress) werselected to restore the entire dentition. All units were placed witExciteadhesive and transparenbase Variolink II (Ivocla

Vivadent). When all 20 unitwere placed and the occlusioverified, the remaining 8 teet(Nos. 2, 3, 14, 15, 18, 19, 30, an31) were prepared and temporized. The patient left the officwith a new, completely stabilizevertical dimension of occlusion

Three weeks later, she returnefor placement of the 8 remaininunits and, for the first time in helife, had the smile she alwaywanted (Figures 14 and 15).

CONCLUSIONThe esthetic demands of th

general public grow strongeeach day and, we owe it to oupatients to constantly stay abreasof the latest techniques and materials available. In addition, wowe it to ourselves to collaboratand remain associated with dental specialists and laboratoriethat strive to deliver the besquality and service available foour patients.

REFERENCES1. Becker CM, Kaiser DA, SchwalmC: Mandibular cetricity: centric relation. JProsthet Dent83(2):15

160, 2000.

2. Dawson PE:Evaluation, Diagnosis, and Treatment

Occlusal Problems.St. Louis: Mosby Books, pp 4

55, 1989.

3. Dahl BL: Thefaceheight in adult dentatehumans

discussion of physiological and prosthodonticpri

ciples illustrated through a case report. J O

Rehabil22(8):565-569, 1995.


Case Study continued

Figure 13A stick bite was used to trans-fer the interpupillary line and help facili-tate proper mounting of casts.

Figure 14Final smile, exhibiting natur-al appearance and contours.

Figure 15Final full-face view. Noteincreased lower third of face height.

Product: IPS Empress, IPS d.SIGN,Stratos 200, Excite,Variolink II

Manufacturer: Ivoclar Vivadent, Inc.Address: 175 PineviewDrive, Amherst,

NY14228Phone: 800.533.6825

Fax: 716.691.2285

Product: Vanillabiteregistration materialManufacturer: Discus Dental

Address: 8550 HigueraStreet, CulverCity, CA90232

Phone: 800.422.9448Fax: 310.845.1537

Product: Luxatemp

Manufacturer: Zenith/DMGForemostAddress: 242 S. Dean St., Englewood, NJ

07631Phone: 800.662.6383

Fax: 201.894.0213

Product References

WWeowe it to

ourselves to

collaborate and remain

associated with dental

specialists and

laboratories.


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