CERP

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, companiesthat 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 bythe 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 patient’s overall dentalcare. Many general dentists andprosthodontists 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 presenta-tion details the manner in whicha collaborative approach amongdental specialists and the labora-tory, as well as the selection ofthe most appropriately indicatedrestorative materials, can pro-duce a comprehensive andinvolved full-mouth rehabilita-tion for a patient with a severelycompromised smile.

CASE PRESENTATIONA 40-year-old woman pre-

sented with one request: a morepleasing smile (Figure 1). Shestated that she had undergoneorthodontic treatment but hadsince completely relapsed. Shewas also unhappy with the grayhue throughout her dentitionfrom light tetracycline stain-ing. After a complete examina-tion, it was determined thatideal treatment would involveorthognathic surgery and ortho-dontic treatment.

Eight-Handed Dentistry: An InterdisciplinaryApproach to Full-Mouth Rehabilitation

Christopher Ramsey,DMD

Private PracticeThe Studio of Esthetic DentistryPalm Beach Gardens, FloridaPhone: 561.626.6667Fax: 561.627.7211Email: [email protected]

36 December 2001 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE

SA S EC T U D Y

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

Figure 2—Smile exhibiting vertical maxil-lary excess.

Figure 3—Teeth exhibiting Class II, DivisionII malocclusion.

Figure 4—Maxillary crown lengtheningand gingivectomy provided ideal tissueheight.

Robert G. Ritter, DMDClinical DirectorInstitute for Oral Art and

DesignSarasota, Florida

Private PracticeThe Studio of Esthetic DentistryPalm Beach Gardens, FloridaPhone: 561.626.6667Fax: 561.627.7211Email:

[email protected]

Karina F. Leal, DMDPalm Beach

Gardens, Florida

Lee Culp, CDTOwner Mosaic Studios, Inc.Bradenton, Florida

Founder/DirectorInstitute for Oral Art and

DesignSarasota, FloridaPhone: 941.907.6084Fax: 941.907.6984

TT he dental experience is now more rewarding for both the dentist and

the patient.

Circle 20 on Reader Service Card

C1K02992.EPS

Interdisciplinary PerspectiveThe patient consulted spe-

cialists in both areas and foundthat, while surgery and 1 to 2years of orthodontic braceswould correct occlusal dishar-monies, she would still have an

unattractive smile. Therefore, itwas incumbent upon all dentalprofessionals involved to identifya solution that would provide theesthetics the patient desired andan occlusal pattern that wouldfunction successfully, long-term.

The first concern was thepatient’s high smile line. Hershort clinical crowns left herwith the appearance of a“gummy” smile (Figure 2). Afterperiodontal probing of the entiredentition, it was determined thatperiodontal crown lengtheningwas required in the maxillaryarch (Figure 3). The periodontistfirst performed a gingivectomyto achieve the correct height-to-length ratios (Figure 4). Oncethese were verified, the tissuewas raised to remove the neces-sary osseous structure, so thefinal restorations would notinvade the biologic width(Figure 5). The patient healedfor approximately 4 to 6 weeks(Figure 6). The final result was a


Case Study continued

Figure 5—A full-thickness flap was raised toexpose osseous structure for recontouring.

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

II t was incumbent uponall dental profession-

als involved to identifya solution that would

provide esthetics and anocclusal pattern that

would function success-fully, long-term.


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 measurefrom 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 patient’s 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 betteresthetics, rather than leaving thepatient with a slightly overclosedlook. The patient was bimanual-ly manipulated, and a centricrelation bite registration wasobtained. Models were mountedand evaluated for occlusal dis-crepancies. During the patient’snext 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 ESTHETICS AND RESTORATIVE PRACTICE December 2001 39

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

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

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



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 a vanilla bite reg-istration material (DiscusDental) to help the ceramistplace the incisal edges in space inthe 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 theunderlying 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 dimen-sion for 4 to 6 weeks.

Pressed ceramic crownrestorations (IPS Empress®) wereselected to restore the entire den-tition. All units were placed withExcite® adhesive and transparentbase Variolink® II (IvoclarVivadent). When all 20 unitswere placed and the occlusionverified, the remaining 8 teeth(Nos. 2, 3, 14, 15, 18, 19, 30, and31) were prepared and tempo-rized. The patient left the officewith a new, completely stabilizedvertical dimension of occlusion.Three weeks later, she returnedfor placement of the 8 remainingunits and, for the first time in herlife, had the smile she alwayswanted (Figures 14 and 15).

CONCLUSIONThe esthetic demands of the

general public grow strongereach day and, we owe it to ourpatients to constantly stay abreastof the latest techniques and mate-rials available. In addition, weowe it to ourselves to collaborateand remain associated with den-tal specialists and laboratoriesthat strive to deliver the bestquality and service available forour patients. �

REFERENCES1. Becker CM, Kaiser DA, Schwalm C: Mandibular cen-

tricity: centric relation. J Prosthet Dent 83(2):158-160, 2000.

2. Dawson PE: Evaluation, Diagnosis, and Treatment ofOcclusal Problems. St. Louis: Mosby Books, pp 41-55, 1989.

3. Dahl BL: The face height in adult dentate humans. Adiscussion of physiological and prosthodontic prin-ciples illustrated through a case report. J OralRehabil 22(8):565-569, 1995.


Case Study continued

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

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

Figure 15—Final 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 Pineview Drive, Amherst,

NY 14228Phone: 800.533.6825

Fax: 716.691.2285

Product: Vanilla bite registration material Manufacturer: Discus Dental

Address: 8550 Higuera Street, Culver City, CA 90232

Phone: 800.422.9448Fax: 310.845.1537

Product: Luxatemp®

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

07631Phone: 800.662.6383

Fax: 201.894.0213

Product References

WW e owe it to ourselves to

collaborate and remainassociated with dental

specialists and laboratories.



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