Same-Day Full-Arch Reconstruction to Increase Vertical Dimension

Miguel A. Ortiz, DMD | Carlos A. Ortiz, CDT

By actively engaging patients during the mock-up and trial phases, restorations can be refined within the oral cavity itself, leveraging real-time patient feedback to attain exceptional precision. This interactive process not only streamlines the clinical pathway but also substantially enriches the patient experience by eliminating the need to wait for permanent prostheses.

A 74-year-old male patient presented with a severely broken-down dentition. Contributing factors included bruxism and the historical presence of an acidic environment, which could have resulted from gastroesophageal reflux or dietary sources. The damage was extensive and affected most of the natural tooth surfaces-lingual, incisal, and buccal. As a result of these conditions, the patient experienced significant loss of dental hard tissue and a reduction in his vertical dimension of occlusion. The presence of several posterior crowns further complicated the case. After discussing treatment options, the decision was made to remove the patient's existing restorations and increase his vertical dimension by restoring each arch with same-day indirect restorations milled from a monochromatic feldspar ceramic material.

The first clinical appointment began with the acquisition of comprehensive diagnostic data, including a full-mouth series of radiographs, intraoral scans (Primescan^®, Dentsply Sirona), and detailed photographs (Figure 1 through Figure 5). Next, the ideal length of the maxillary central incisors was established through direct composite restorations (Figure 6), and the centric relationship was captured with a leaf gauge, which enabled the new vertical dimension of occlusion to be determined.

During the second clinical appointment, a full-mouth digital wax-up was rendered, and a series of putty matrices was fabricated. A full mock-up was then created in situ using a bis-acryl material (Figure 7 through Figure 9). This allowed for immediate modification and fine-tuning, including changes related to occlusal adjustments, speech testing, and patient input. The patient's mock-up was completed in 45 minutes, creating the blueprint for the final restorations.

To begin the treatment of the maxillary arch, the posterior sectors were prepared first, which took approximately 1 hour. All of the preparations were carried out under local anesthesia, methodically removing the existing crowns and old composite restorations. The preparation designs were conservative and nonretentive to favor the use of adhesive techniques for all of the final restorations. Scanning, designing, and milling were then completed in an additional hour. While the maxillary posterior restorations were being milled from monochromatic feldspar ceramic blocks (VITABLOCS^® Mark II [1M1C], VITA North America), the maxillary anterior teeth were prepared and scanned. The posterior try-in and adjustments were then conducted while the anterior restorations were being milled, and the anterior try-in coincided with the staining and glazing (VITA AKZENT^® Plus, VITA North America) of the posterior restorations, which were then fired in a furnace.

Once the posterior restorations were finalized, they were delivered while the anterior restorations were being finalized, and then the anterior restorations were delivered. All bonding steps were performed under isolation. To begin the bonding protocol, a selective etch technique was performed with 35% phosphoric acid (K-ETCHANT syringe, Kuraray Noritake) before rinsing with chlorhexidine. A desensitizer (Gluma^® Desensitizer, Kulzer) was then applied followed by a primer and bonding agent (CLEARFIL^™ SE Protect, Kuraray Noritake) to ensure an ideal environment for the adhesive process. For final cementation, a universal cleaner with MDP (KATANA^™ Cleaner, Kuraray Noritake) was applied to both the tooth surfaces and the restorations, followed by a clear adhesive resin cement (Panavia^™ V5, Kuraray Noritake). Curing with an LED curing light (VALO^™, Ultradent) and meticulous occlusal adjustments completed this phase. With the maxillary arch complete, the patient was appointed for the mandibular arch treatment and dismissed.

The patient returned for the third clinical appointment, which mirrored the protocols of the previous one but for the mandibular arch, which was restored with the same attention to detail and adherence to conservative principles (Figure 10 through Figure 14). Following delivery of the mandibular restorations, a temporary heat-formed occlusal guard was provided to the patient, who was also scanned for a final night guard.

The fourth and final clinical appointment involved fitting the maxillary thermoplastic nightguard and conducting a thorough inspection of the restorations and occlusion, confirming the harmonious integration of the prostheses.

At the patient's 1-month follow-up appointment, he reported that he was very pleased with his new smile and improved dental function, which he said had resulted in a profound improvement in his quality of life (Figure 15 through Figure 17).

During the treatment phase, all of the restorations were designed, milled, stained, and glazed with the patient's full involvement, and they were all tried-in and modified until finished using the patient's mouth. This immediate and intimate involvement with the patient during the creation and adjustment of the restorations helped to ensure optimal form, fit, and function, marking a significant improvement over more protracted traditional protocols.

This case demonstrates how contemporary restorative protocols can deliver full arches of restorations within condensed timeframes, maintaining the patient's anatomic integrity and comfort without the need for traditional temporary restorations.

Miguel A. Ortiz, DMD
Private Practice
Wayland, Massachusetts

Carlos A. Ortiz, CDT
Ibiza Dental Lab
Ibiza, Spain

Figures and Images

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Fig. 1

(1.) Pretreatment full face patient portrait.

Fig. 2

(2.) Pretreatment smile photograph showing the patient’s broken-down dentition and reduced vertical dimension.

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(3.) Pretreatment retracted photograph showing the patient’s occlusion and reduced vertical dimension.

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(4.) Pretreatment maxillary and mandibular occlusal views, respectively. Note the extreme wear caused by bruxism and erosion.

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(5.) Pretreatment maxillary and mandibular occlusal views, respectively. Note the extreme wear caused by bruxism and erosion.

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(6.) View of the direct composite restorations that were placed at the initial appointment to establish the ideal length of the maxillary central incisors so that the new vertical dimension of occlusion could be determined.

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(7.) Retracted view of the bis-acryl mock-up with the teeth apart.

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(8.) Retracted views of the mock-up in left lateral and right lateral excursion, respectively.

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(8. AND 9.) Retracted views of the mock-up in left lateral and right lateral excursion, respectively.

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(10.) Immediate posttreatment occlusal views of the of the final maxillary and mandibular restorations, respectively.

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(11.) Immediate posttreatment occlusal views of the of the final maxillary and mandibular restorations, respectively.

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(12.) Immediate posttreatment retracted view of the final restorations with the teeth apart.

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(13.) Immediate posttreatment retracted views of the final restorations in left lateral and right lateral excursion, respectively.

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(14.) Immediate posttreatment retracted views of the final restorations in left lateral and right lateral excursion, respectively.

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16.) One-month posttreatment smile photograph.

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(17.) One-month posttreatment full face patient portrait.

Miguel A. Ortiz, DMD

Carlos A. Ortiz, CDT