Full Mouth Rehabilitation With All-Ceramic Restorations

A 41-year-old female patient presented for a consultation appointment. She expressed concern about the discoloration and chipping affecting the composite-restored teeth in the anterior region of her maxillary arch and the appearance of worn and chipped restorations in the right side of her mandibular arch—all of which were impacting the overall esthetics of her smile as well as her functionality (Figure 1 and Figure 2). Due to the extensive wear on the restorations in the posterior regions of both arches, the patient had lost posterior vertical dimension of occlusion and reported difficulty chewing. In addition, she revealed that she experienced lingering pain in tooth No. 5 when it was exposed to heat or cold, and it was determined that root canal treatment would be needed to relieve her discomfort. The patient stated that she now had the financial resources needed to address the totality of her concerns and was looking to undergo definitive treatment.

The treatment plan presented and accepted by the patient was a full mouth rehabilitation. The proposed plan would increase the vertical dimension of teeth Nos. 8 through 25 from 13 mm to 17 mm to balance the symmetry of her smile and restore her Curve of Spee. All of the teeth in both arches would be restored with all-ceramic crowns, except for teeth Nos. 23 through 27, which would receive veneers. To create gingival symmetry, crown lengthening would be performed on teeth Nos. 5 and 12. The patient declined to undergo orthodontic treatment to reduce the need for preparation.

Radiographs were taken to assess the extent of the caries under the patient's existing composite and full crown restorations as well as her unrestored teeth. A complete smile design analysis (3Shape Smile Design, 3Shape) was performed using facial reference glasses (Kois Facial Reference Glasses, Kois Center), and a series of preoperative photographs was completed for communication with the laboratory (Figure 3 through Figure 8). In addition, preoperative intraoral scans (iTero^®, Align Technology) of both arches and bite scans were acquired and sent to the laboratory along with the preoperative photographs for the digital design of the proposed final outcome. The patient was then referred to an endodontist to complete the root canal therapy.

At the patient's next appointment, she underwent routine prophylaxis and reviewed the digital design that was created by the laboratory. After she approved the digital wax-up of the proposed final outcome, her upper arch was prepared, and a shade tab photograph was acquired for communication with the laboratory (Figure 9). The preparations were then cleaned and spot-etched, and temporary restorations that were created using a putty matrix supplied by the laboratory were placed.

The next day, the patient returned to the office, and the teeth in her mandibular arch were prepared and photographed with a shade tab for communication with the laboratory (Figure 10). The temporization protocol that was performed on the maxillary arch was then repeated for the mandibular arch. Photographs of the temporized patient were acquired along with postoperative intraoral scans, and these were sent to the laboratory to inform the fabrication of the final restorations.

The patient was asked to wear the temporary restorations for 6 weeks to assess the function and esthetics, and she confirmed that she was pleased with both. Upon delivery of the final restorations to the office, the maxillary crowns were tried in using a neutral try-in paste (Variolink^® Esthetic DC [neutral], Ivoclar). Photographs were then taken with reference glasses to assess the esthetics of her smile line and verify the midline (Figure 11). After the mandibular restorations were tried in and approved, all of the final restorations in both arches were bonded. The patient stated that she was amazed and thrilled with the final outcome (Figure 12 through Figure 15).

Acknowledgement

The author would like to thank Juan Rego, CDT, FAACD, of Smile Designs by Rego, Santa Fe Springs, California, for his work on this case.

Dimple Desai, DDS
Accredited Member
American Academy of Cosmetic Dentistry
Luminous Smiles
Newport Beach, California