INTRODUCTION
Either you see it, or you don’t! Some people never see it, while others see it immediately. It will drive you absolutely crazy if what you see does not match your aesthetic vision. Over the past several decades, we have witnessed a revolution in the fields of facial and dental aesthetics. A dentist’s key to success is to have a totally clear vision of the desired final result. A sequential treatment plan can then be made to predictably satisfy the patient.

If you watch television, you have undoubtedly seen commercials for orthodontic aligners delivered directly to your home for 60% less than the fees of a conventional orthodontist. The patients in the infomercials all express their total delight without any reservations. In my opinion, these advertisements imply superior high-tech treatment and quality equal to or beyond the capabilities of the average dentist. Everything seems so simple—but is it? In Greek mythology, Procrustes was a villain who either cut the legs off of or stretched his victims so that they would fit exactly into his iron bed. Everyone had to conform to be exactly one size. Procrustean treatment planning places everyone in the identical situation. There is no account for individual differences. Human beings, however, come in different sizes, shapes, and colors and have different personalities.

Having practiced and taught dentistry for more than 40 years, I am constantly asked if I have a set formula for treatment planning. Many educators have attempted to break down treatment planning into rules, steps, and sequences for the sake of teaching. Their aim is to provide their students with repeatable steps. Looking back in time, early orthodontic pioneers based their treatment objectives solely on art and aesthetics. Norman Kingsley (1829-1939) was an artist, sculptor, and orthodontist who published the first orthodontic paper (1853) and textbook (1880). He based his entire diagnosis and treatment objectives on facial proportions and his vision of beauty. When Edward Angle established the first orthodontic school, he set out to find a formula for beauty that could be repeatedly taught. He hired an artist, Edmund Wuerlpel, to help him. However, together, they failed to find a formula for beauty. Instead, they settled on the Angle Class 1/2/3 classification, which is still in use today based on its ability to be repeatable and taught to students. Angle needed set rules in order to be able to teach. However, his classifications are based on static factors, such as molar relationships, and do not always produce aesthetically pleasing results. Orthodontic diagnosis changed from evaluating facial aesthetics to relying on absolute measurements. Visual examination was superseded by information from a cephalometric radiograph and plaster study models. These do not consider patients’ facial features and soft tissue and how they will change over the patients’ lifetimes.

Aesthetic Vision
In my own practice, I have always based my treatment planning on the premise that “people want to look like people,” keeping in mind the ideal vision of the skeletal, soft-tissue, and muscular anatomy of the head and face. I never lose sight of the ideal tooth position, as seen in the typodont study model that I was given in my first year of dental school. This is my initial vision and the goal of my treatment planning. Dr. Irwin Smigel, a pioneer in the arena of aesthetic dental procedures, used to say, “Who owns the face? We do!” Dentists are capable of creating spectacular facial changes! We always begin with a visual assessment of the patient’s face and features. What is the face shape, width, and chin position? How much tooth is displayed at rest and when smiling? The relationship of the smile to the eyes, nose, and facial musculature must be considered. There is not a procrustean method of treatment planning where one size fits all. In aesthetics, there is a great deal of human variation, and a dentist’s experience, artistic ability, and ability to see with aesthetic vision are essential.

The Importance of Orthodontics in Restorative Dentistry
Historically, orthodontists were not accustomed to dealing with patients requiring restorations. A patient with ideally shaped teeth may fit into the “procrustean bed.” However, some patients do not conform to the ideal and require tooth positioning in order to accommodate a change in tooth size. The orthodontic objectives are different for these patients compared to the patient not requiring restorative changes. The teeth may have to be positioned by the orthodontist to accommodate a change in tooth shape, and sometimes we may choose to restore or place a provisional before starting orthodontics. The orthodontist is often the one making a decision that can affect a patient’s appearance for the rest of his or her life. By solely basing an orthodontic treatment plan on the Angle classification, we run the risk of poor facial results and unhappy patients. Orthodontic therapy should establish a functional occlusion, enhance the heath of the periodontium, and improve dental-facial aesthetics. We must approach each patient from an artistic perspective and do facial analysis using dentofacial proportions not solely based on a cephalometric film. We must consider the vertical placement of the anterior teeth at rest and when smiling, the smile arc characteristics, and the vertical relationship of the gingival margins to each other. Above all, we must consider the effect of aging of the patient’s facial features. Time is the “dental twilight zone.”

In order to establish a comprehensive treatment plan, it is essential for the dental team to be able to visualize the final result before commencing any treatment. Meticulous planning is essential. It is paramount for the dental health professional to not limit his or her vision to his or her own specialty. With a coordinated treatment plan and a multidisciplinary team approach, we can achieve predictable and pleasing results that will satisfy our patients for a lifetime.

The face should dictate the treatment. Every case begins with an aesthetic analysis of the facial shape and soft tissue. We must then reference the maxillary anterior tooth position and gingival levels relative to the face and determine if the upper anterior teeth are in an ideal position or if their position must be altered. We cannot establish the occlusal pattern until we determine our final vision of the maxillary anterior teeth. Aesthetics will dictate the final position of the entire dentition and the pathways of guidance.

CASE REPORT
Diagnosis and Treatment Planning
The parents of the 14-year-old boy presented in this case report article believed that he required orthodontics to close the gaps between his front teeth (Figure 1). Beginning with a visual examination, we felt that he had a handsome, oval-shaped face in pleasing proportion with his eyes, lips, and chin. His dental arch displayed full buccal corridors, and the posterior teeth were in occlusion. Upon comparing the patient’s dental models with the ideal typodont, we concluded that the spaces existed between his teeth because the teeth were too narrow and not in proportion with the arch width (Figure 2). To eliminate the spacing, either the arches would have to be constricted to pull the teeth together or the teeth would have to be made larger to fit the existing form.

Figure 1. Upper anterior teeth, showing spacing.	Figure 2. Occlusal view of the upper dental arch.

We discussed the boy’s current aesthetics and, in addition, the future effect of what may happen to his facial features and aesthetics over time. The patient and his parents did not want to risk changing his appearance and chose to restore his teeth to the proportion necessary to close the spaces maintaining the existing arch form. If they would have chosen to bring the existing narrow teeth together and constrict the arches, occlusal and airway problems could result for his lifetime. These issues would be challenging to resolve. By explaining the problem and presenting the facts and all the possible solutions, a patient can then make an informed decision in his or her best interest.

There are different approaches to this situation. Some orthodontists prefer to finish the orthodontics and then have the teeth restored. If meticulously measured, the case can be done in this manner. In our experience, however, we do not like to leave anything up to chance, so we restore the tooth proportion first and then proceed with the orthodontic alignment. In my experience, closing the interdental spaces with composite bonding is a challenging task requiring 2 adjacent interproximal restorations with ideal dimensions in order for each space to be closed properly. This can consume a great deal of time, patience, and skill, even for a very talented dentist. In order to restore the gaps simply and predictably, we elected to use lab-fabricated micro-veneer additions. These would be conventionally bonded to the interproximal surfaces without any tooth preparations. Since they are composed of composite resin, we would be able to adjust, repair, and polish them.

Clinical Protocol
Each smile design begins by assessing the size of the maxillary central incisors. Ideally, they should respect the golden proportions with a 70% to 75% width-to-length ratio. As the centrals to be widened were 10.0 mm long, we calculated that an 11.0-mm central was necessary to respect the proportion with the additions. Visually, our patient’s teeth were long enough incisally; therefore, we chose to elongate the teeth gingivally by 1.0 mm using a diode soft-tissue laser, without infringing upon the biologic width of the attached gingiva (Figure 3). The lateral incisors were given a new length of 9.5 mm, and the canines were 11.0 mm, which was in proportion with the central incisors (Figure 4). The interproximal tissue was troughed with the laser (Gemini 810+980 diode laser [Ultradent Products]) allowing us to establish a natural emergence profile. We wanted the composite micro-veneer additions to follow the interproximal tooth surface so that overhanging food traps were not created.

Figure 5. Retraction paste (Expasyl [Kerr]) shown in place.	Figure 6. Interproximal emergence profile.
Figure 7. An intraoral scan (TRIOS [3Shape]) was taken.	Figure 8. Final VPS impression (Honigum Pro-Putty and light-body Honigum wash impression materials [DMG]).
Figure 9. An accurate acrylic bite registration (LuxaBite [DMG]) was taken.	Figure 10. Mounted stone models.
Figure 11. Wax-up of the restorations.	Figure 12. Individually boxed composite micro-veneer additions.

A gingival retraction paste (Expasyl [Kerr]) was placed for 2 minutes (Figure 5) and then thoroughly rinsed with water (Figure 6), providing clean exposed prep margins. A TRIOS (3Shape) digital scan (Figure 7) registered the impression, bite registration, and shade. While the latest digital technology certainly has its advantages, it is not essential to have a digital intraoral scanner, as identical results can be achieved with conventional impressions and bite registrations. When using a physical impression technique, I prefer to use a quality vinyl polysiloxane (VPS) (such as Honigum Pro Putty [DMG]) to take putty-wash impressions with Rim-Lock trays (Dentsply Sirona). Honigum Pro-Putty is used because it is extremely firm and displaces a light body wash impression material (Honigum) subgingivally into the sulcus, yielding a highly detailed and accurate impression (Figure 8). Subgingival detail is critical, as the microadditions must have ultrafine margins. The rigid metal Rim-Lock trays do not distort upon placing, removing, and pouring the impression. The lower opposing model was taken with a polyvinyl siloxane alginate substitute (StatusBlue [DMG]). The bite registration was taken using an acrylic material (LuxaBite [DMG]), which does not flex, allowing for extremely accurate mounting of the models, which will decrease the number of adjustments and remakes. LuxaBite should be applied sparingly to just the incisal and occlusal surfaces of the teeth so as not to engage in any undercuts (Figure 9).

Dental Lab Protocol
At the dental laboratory, stone models sealed with Tanaka Stone Surface Sealer (Tanaka Dental Products) were mounted on an Artex Articulator (Jensen) (Figure 10). Iso-Stift Separator (Renfert USA) was applied to prevent the new composite micro-veneer restorations from adhering to the model. A diagnostic wax-up from canine to canine was created on a duplicate model, providing a guide for the proportions of the composite restorations (Figure 11). GRADIA composite (GC America) micro-veneer additions were created by applying incremental layers (shade B1), each light cured for 10 seconds (Steplight SL1 [GC America]). Gradia Air Barrier (GC America) was then applied, and final curing was done with a Labolight LV4 (GC America). Diamonds, carbides, rubber wheels, and points were used to adjust the contours. A diamond polishing paste (Legabril Diamond Polish [Cendres & Metamucil]) then imparted a final high-luster polish. Then the inner surfaces of the restorations were cleaned and sandblasted to prepare them for bonding. Each composite restoration was individually packaged for identification and returned to the dental office (Figure 12).

Delivery of the Lab-Fabricated Micro-Veneer Restorations
The installation of the composite micro-veneer additions required an exacting protocol. First, the teeth were acid-etched (Uni-Etch [BISCO Dental Products]) for 15 seconds and then thoroughly rinsed with water. A universal adhesive (All-Bond Universal [BISCO Dental Products]) was applied (exactly per the manufacturer’s instructions) (Figure 13). A thin coating of a flowable micro-filled composite resin (Renamel Flowable Microfill [Cosmedent]) was applied to the internal surface of the composite micro-veneers, and then they were individually placed to each interproximal tooth surface and light cured (Figure 14). Polishing carbides, strips, and the use of the Top Finisher System (Cosmedent) (Figure 15) finalized the restorations.

Figure 15. Creation of a new tooth dimension.	Figure 16. The iTero (Align Technology) orthodontic scan.

Orthodontic Phase Begins
A new dimension in our patient’s maxillary incisors had now been established, and the orthodontist can now view them as the natural teeth. An iTero (Align Technology) scan was taken (Figure 16), and Insignia orthodontic software (Ormco) was used to determine the orthodontic movements that would be required. Insignia personalized brackets with built-in custom torque (Ormco) were created. The arch wires were prefabricated with first- and second-order bends that were designed specifically for this case (Figures 17 and 18).

CLOSING COMMENTS
Predictability is the key to success for a successful dental practice. The ability to see with aesthetic vision, meticulously plan, and know which treatment modality to use will often allow a simple solution for complex challenges. Either you see it, or you don’t!

Acknowledgments:
The author would like to thank Dr. Brita Nadeau, orthodontist, for being a key player in our interdisciplinary team and for her continuous inspiration. He also wishes to express his sincere appreciation to Chuck Maragos and the entire dental laboratory team at Valley Dental Arts (Stillwater, Minn) for their excellent work.

Dr. Mechanic has been practicing multi-disciplinary restorative aesthetic dentistry in Montreal since 1979. He received his Bachelor of Science (1975) and Doctor of Dental Surgery (1979) degrees from McGill University. He is a Diplomate of the American Board of Aesthetic Dentistry and a Fellow of the European Society of Cosmetic Dentistry and the International Academy of Dental Facial Aesthetics. He is the author of more than 40 dental publications and the book Aesthetic Dentistry/Smile Design: The Patient Guide, which has been published in 9 languages. He can be reached via email at elliotmechanic@gmail.com.

Disclosure: Dr. Mechanic reports no disclosures.

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Treatment of Severe Oligodontia in Identical Twins

Interdisciplinary Treatment Planning: What Would You Do If She Were Your Daughter?

The Interdisciplinary Treatment Planning: The Restorative Quarterback

INTRODUCTION
Young patients with complex developmental problems that impact the skeletal and dental systems require well-coordinated interdisciplinary management to restore functional, aesthetic, and psychological deficits. The following case report describes the management of a young female with hypohidrotic ectodermal dysplasia (HED) (also known as “anhidrotic ectodermal dysplasia” and “Christ-Siemens-Touraine syndrome”) by an interdisciplinary team comprising prosthodontists, an orthodontist, 2 oral-maxillofacial surgeons, and a team of dental technologists. In addition, this patient’s unique dental needs were well suited for use of a newly available restorative material in the course of her treatment. One of the many advantages of coordinated interdisciplinary treatment is the ability to sequence treatment to achieve short-term and long-term goals that help enhance the patient’s quality of life in logical, sequential steps.^1,2

Teeth in proper alignment and interarch relationship are required for phonetics, mastication, deglutition, and sound nutritional support, as well as psychological well-being.³ Yet the medical condition of ectodermal dysplasia has significant dental complications: primarily oligodontia or anodontia and hypoplastic teeth.^4,5 The featured patient exhibited all these manifestations, which impacted her ability to chew, speak, and function normally.

The diverse group of hereditary disorders that constitute ectodermal dysplasia mainly affect ectodermal structures such as hair, skin, nails, and teeth.^3,4 Patients usually present with onychodysplasia (nail dystrophy), hypotrichosis or alopecia (scant or lacking hair), hypohidrosis (lack of sweat glands), and oligodontia or anodontia involving the primary and/or permanent dentition. This patient reflected her HED as predominately craniofacial malformations and had not developed some of the other systemic signs of HED. HED is thought to be an X-linked inheritance affecting males more severely and only partially in heterozygous female carriers with an incidence of 1:10,000 to 1:100,000 births, which coincides with the findings in this young female patient. Implant-supported crowns are a common treatment modality to replace congenitally missing teeth in the ectodermal dysplasia patient and will be utilized in this case after the skeletal defect and teeth malalignment are corrected.^6-9 This article will focus solely on the patient’s phase I treatment to prepare her for the orthodontic and surgical phases that are to follow.

CASE REPORT
Clinical Examination Findings
An 18-year-old woman was referred to our practice from her oral-maxillofacial surgeon (Dr. Michael Gunson, Santa Barbara, Calif) for a prosthodontic evaluation prior to complex orthognathic surgery. She presented with a form of HED that involved oligodontia of 15 teeth. The patient had only 2 areas of occlusal contact for mastication; anteriorly, teeth Nos. 8 and 9 occluded with teeth Nos. 24 to 26, and, posteriorly, teeth Nos. 14 and 15 occluded with teeth Nos. 18 and 19. The deciduous molars were ankylosed/partially resorbed, and the remaining deciduous teeth had severe wear and were not viable for the long term. The oral maxillofacial surgeon (Dr. Gunson) and treating orthodontist (Dr. Todd Walkow, Newport Beach, Calif) requested the deciduous teeth be extracted prior to the commencement of orthodontic alignment to allow consolidation of the spacing for future prosthodontic rehabilitation. Aesthetic and functional improvements could be achieved on an interim basis utilizing the limited deciduous and permanent teeth that were present (Figure 1).

Figure 1a. Pretreatment photo showing the effects of hypohidrotic ectodermal dysplasia-related dental compromises. She presented with an unaesthetically pleasing smile due to numerous missing maxillary anterior teeth.

Figure 1b. Pretreatment photo demonstrating a complete lack of posterior occlusion on the patient’s right side.	Figure 1c. Pretreatment photo demonstrating some posterior occlusion with permanent molars on the patient’s left side.

The lateral cephalometric radiograph revealed that the patient exhibited a concave facial profile with a maxillary anterior-posterior hypoplasia, a moderate asymmetric skeletal and dental Class III occlusion, an occlusal cant, a midline discrepancy in both jaws, and a severe posterior lateral open bite of 6.0 mm on the right side. These issues would be addressed in later phases of her interdisciplinary treatment.

The patient’s oligodontia involved 15 permanent teeth: Nos. 1, 4 to 7, 10 to 13, 16, 17, 20, 28, 29, and 31. The deciduous teeth that were present at her initial presentation were A to D, G to J, M, R, and T. Her periodontal health was good, but she had high biofilm levels and required focused oral health instruction to improve her cleaning habits to better prepare her for the many years of treatment that were ahead.

Treatment Planning and Sequencing
Phase 1 treatment objectives were to provide the patient with improved occlusal stability, extract non-functional deciduous teeth, and prepare her dentition for orthodontic treatment. By maintaining the 4 deciduous teeth C, D, G, and H, it was possible to maintain an anterior centric stop, aid in mastication, provide anchorage for orthodontic treatment, and establish a natural, aesthetic appearance. The maxillary deciduous teeth were restored to ideal permanent tooth contours to assist the orthodontist in establishing the correct spacing of the remaining dentition. The deciduous teeth A, B, I, J, M, R, and T were also extracted in phase 1 to allow the alveolar ridge to be grafted for future implant surgery (Figures 2 and 3).

Figure 2. Teeth marked with an X depict deciduous teeth to be extracted in the maxillary arch. Deciduous teeth C, D, G, and H were to be prepared for provisional crowns to establish appropriate tooth dimensions.	Figure 3. Teeth marked with an X denote deciduous teeth to be extracted in the mandibular arch.

A long-term, composite-based provisional crown material (LuxaCrown [DMG America]) was selected to build up the fragile, remaining deciduous anterior teeth (C, D, G, and H) to ideal dimensions for presurgical orthodontic anchorage and provide guidance for the orthodontist to align the permanent teeth (Nos. 2, 3, 14, 15, 18, 19, 21, and 30). LuxaCrown was chosen because it would provide the required color stability, polishability, durability, and strength that would be required during the orthodontic and surgical phases of her care. Those 4 teeth (C, D, G, and H) needed to be stable for the long term without significant maintenance, as they would be critical to many aspects of her future care. Additionally, the anterior restorations would provide her with more self-confidence in social interactions, as she was entering college the following year; it would be the first time the patient would have a more “normal” smile.

The planning phase included interdisciplinary consultations; the creation of a diagnostic wax-up; and treatment coordination between the patient, her parents, and the multiple specialists’ offices. This preliminary phase was also utilized to train the patient in the technique of careful biofilm removal, including correct tooth brushing, flossing, and use of the water irrigation device. She mastered the new techniques and understood the significance of this new behavioral change that was reinforced at every hygiene and clinical visit. The diagnostic wax-up and the proposed treatment plan were thoroughly discussed with the patient and her parents. They gave approval for the treatment plan, and the restorative/surgical phase 1 appointment was made. For comparison, the diagnostic casts showing the preliminary and post wax-ups are shown in Figure 4.

Figure 5. Photo showing the conservative crown preparation and preservation of enamel for deciduous teeth C, D, G, and H.

Figure 6. Gypsum model of tooth preparation for fabrication of the provisional crowns.	Figure 7. LuxaCrown (DMG America) resin material was selected for long-term aesthetic provisionalization of the maxillary anterior teeth.

Clinical Phase
The patient was sedated by an anesthesiologist for the extended appointment to complete the restorative and preliminary surgical procedures.

The primary teeth to be restored had partially resorbed roots and were severely worn, with approximately only half of the clinical crowns remaining. Conservation of enamel was paramount to provide sufficient enamel surface area for bonding during phase 1 of her treatment. The preparation design preserved as much tooth enamel as possible, only removing sharp corners/angles created by the wear. Conservative full-coverage micro-preparations were completed on the 4 teeth as demonstrated in Figure 5. The mesial aspect of teeth Nos. 8 and 9 were bonded chairside to close the diastema that was present and provide more aesthetic contours.

Figure 9. Provisional restorations on the model, ready for trimming and refinement.

Laboratory Phase
In the dental laboratory, an immediate plaster model was made from the vinyl polysiloxane (VPS) impression taken of the tooth preparations. The model was trimmed to allow the putty (Precision Putty [Denmat]) guide made from the diagnostic wax-up to fit over the tooth preparations. The teeth on the model were lubricated to prevent the composite material from sticking to the plaster. The LuxaCrown material was placed into the VPS putty stint and then seated over the plaster model and placed in a pressure cooker for a denser and more rapid set of the material. The putty mold was removed, the restorations were trimmed, the occlusion was adjusted, and the restoration was polished. The restorations were then returned to the operatory for delivery to the patient following the tooth extractions (Figures 6 to 9).

Figure 10. Bonded LuxaCrown provisional restorations provided enhanced aesthetics and orthodontic guidance and stability.

Figure 11. A more favorable arch form and tooth/space distribution were achieved after the deciduous posterior teeth were extracted and the incisors were restored to ideal dimensions.	Figure 12. Orthodontic presurgical treatment with deciduous teeth extracted. Anterior spacing was left for stabilization wires post-surgery.

The oral maxillofacial surgeon (Dr. Larry Lorenzi, Newport Beach, Calif) extracted all the ankylosed teeth without complications while the laboratory team completed the indirect restorations. The restorations were tried in to evaluate the fit, aesthetic display, and occlusion. All clinical goals were accomplished, patient approval was obtained pre-sedation, and the restorations were bonded individually for greater control and precision. Each preparation was cleaned, etched, and bonded with a resin-modified glass ionomer cement (RelyX Luting Plus Cement [3M]). The excess resin was removed with a resin-moistened microbrush (Scotchbond Single Bond Universal Adhesive [3M]) prior to final curing. Teeth Nos. 8 and 9 were restored using direct composite resin (Filtek Supreme Ultra Universal Restorative, shade A1 [3M]) to eliminate the diastema (Figure 10).

Follow-up
The patient was evaluated one week postoperatively and demonstrated excellent healing. She was very pleased with the aesthetic improvement that the anterior restorations had created for her. She stated that she was smiling much more. She was referred back to her orthodontist to commence her presurgical orthodontic therapy. The patient was maintained on a 3-month hygiene and oral health review schedule that continues to the present time. Her orthodontic treatment has been completed (Figures 11 to 13), and she has been scheduled for the orthognathic surgery in the summer of 2019.

CLOSING COMMENTS
Newly available restorative materials provide excellent alternatives when longer-term provisional stabilization and restoration of dental patients who are undergoing long-term multi-phase prosthodontic rehabilitation are required. This cost-effective, long-term approach is beneficial from a mechanical, a functional, an aesthetic, and an economic perspective. In this ectodermal dysplasia patient, the

LuxaCrown material proved perfectly suited to provide strong, aesthetic, and functional restorations until she is ready to proceed with her final restorative phase.

References

1. Pigno MA, Blackman RB, Cronin RJ Jr, et al. Prosthodontic management of ectodermal dysplasia: a review of the literature. J Prosthet Dent. 1996;76:541-545.
2. Van Sickels JE, Raybould TP, Hicks EP. Interdisciplinary management of patients with ectodermal dysplasia. J Oral Implantol. 2010;36:239-245.
3. Kaul S, Reddy R. Prosthetic rehabilitation of an adolescent with hypohidrotic ectodermal dysplasia with partial anodontia: case report. J Indian Soc Pedod Prev Dent. 2008;26:177-181.
4. Clarke A. Hypohidrotic ectodermal dysplasia. J Med Genet. 1987;24:659-663.
5. Crawford PJ, Aldred MJ, Clarke A. Clinical and radiographic dental findings in X linked hypohidrotic ectodermal dysplasia. J Med Genet. 1991;28:181-185.
6. Koyuncuoglu CZ, Metin S, Saylan I, et al. Full-mouth rehabilitation of a patient with ectodermal dysplasia with dental implants. J Oral Implantol. 2014;40:714-721.
7. Knobloch LA, Larsen PE, Saponaro PC, et al. Early implant placement for a patient with ectodermal dysplasia: thirteen years of clinical care. J Prosthet Dent. 2018;119:702-709.
8. Mascolo A, Boschetti E, Flanagan D. An ectodermal dysplasia patient treated with a small diameter implant supporting a single crown. Clin Cosmet Investig Dent. 2018;10:171-177.
9. Alsayed HD, Alqahtani NM, Alzayer YM, et al. Prosthodontic rehabilitation with monolithic, multichromatic, CAD-CAM complete overdentures in an adolescent patient with ectodermal dysplasia: a clinical report. J Prosthet Dent. 2018;119:873-878.

Dr. Sheets maintains a full-time private practice in Newport Beach, Calif, for aesthetic rehabilitative dentistry. She is an international educator, a clinician, an author, and a researcher. She is a Fellow of the AGD, the American College of Dentists (ACD), the International College of Dentists (ICD), the Pierre Fauchard Academy (PFA), and the Academy of Dentistry International. Dr. Sheets is founder and co-executive director of the Newport Coast Oral Facial Institute (NCOFI), a non-profit international teaching and research center for dentists and dental technicians, in Newport Beach, Calif. She and James C. Earthman, PhD, professor of material science and bioengineering at the University of California Irvine School of Engineering, are leading research on energy dissipation in teeth and implants. They hold numerous US and international patents on the technology for quantitative percussion diagnostics. Dr. Sheets can be reached at cgsheets@ncofi.org.

Dr. Paquette is a past president of the American Academy of Esthetic Dentistry and the Pacific Coast Society of Prosthodontics (PCSP) and serves on the editorial board of the Journal of Prosthetic Dentistry. She is recognized nationally and internationally as a leader in aesthetic dentistry, prosthodontics, and implant dentistry. She is a Diplomate of the American Board of Prosthodontics and a Fellow of the American College of Prosthodontists. She holds fellowships in the ICD, the ACD, and the PFA. She is also a member of the American Academy of Restorative Dentistry and the Academy of Osseointegration. Dr. Paquette has authored numerous research and clinical articles on her areas of expertise and co-authored several textbook chapters. She is co-executive director of the NCOFI. Dr. Paquette can be reached at jmpaquette@ncofi.org.

Dr. Wu is on the executive council for the PCSP and a past president of the Academy of Microscope Enhanced Dentistry. She is also a member of the ADA, the California Dental Association, and the Orange County Dental Society (OCDS). She was a board member of the OCDS in 2011 and a senior delegate in 2012. Currently, Dr. Wu is a partner in the Sheets, Paquette & Wu Dental Practice and on the faculty at the NCOFI. She is also actively involved with several research projects on dental implants and materials and has published articles in several dental journals. Dr. Wu can be reached at jcwu@ncofi.org.

Disclosure: The authors report no disclosures.

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INTRODUCTION
Our dental school educations definitely encompassed a multitude of oral presentations, both hard- and soft-tissue, to identify, study, and treat. During a clinic rotation, you may have had the opportunity to view cases that combined real-time symptoms and classroom knowledge. Those patients’ cases were unique in how they came alive and would imbed in your memory for future professional practice. Other presentations remained remote and were never identified other than in a pathology or restorative textbook. As a student throughout this learning process, you would ask yourself, “Will I ever see that in my practice? Does it always look like this? Are there variations? What is the best approach? When do I refer the case? What are the steps in treating a multifactorial case?”

What Your Practice Uncovers
As you settle into practicing dentistry, the answers to those early learning questions become more noteworthy, especially as you encounter patients’ conditions and health histories. Your experience grows, and, with more clinical expertise, your ability to understand a patient’s journey and discover other imposing factors on their dental health increases. Regardless, it is imperative, more than ever, for dental professionals to take complete histories not only of the medical and dental components but also to uncover behavioral aspects. The clinician must gather all the needed information that is required to make a solid diagnosis that will result in the proper treatment.

The Effect of Acid on the Oral Environment
Dental erosion is the irreversible loss or wear of hard tissue by acids not caused by bacteria (Figure 1). The oral environment is in a constant battle for pH balance against chemicals and bacteria. Enamel’s carbonated calcium structure has been estimated to dissolve at a pH of 5.5. The hydroxyapatite composition balance relies on saliva that contains various phosphate and calcium ions for defense and buffering.¹

Figure 1. Dental erosion.	Figure 2. A pH chart.

Dental erosion may be caused extrinsically from diet and/or intrinsically from acid reflux or excessive vomiting. In particular, carbonated soft drinks, sports drinks, and other acidic beverages—especially those with added citrus—are prominent offenders. Many of these beverages range from a level 2 to 3 pH, so it is easy to understand the damage that can ensue. The result of these drinks is a chemically induced invasion, causing erosion2 (Figure 2).

Structurally, the enamel suffers from permanent weakening as the acid washes relentlessly over the enamel rods. The erosion also exposes dentin and teeth to further damages, such as decay caused by bacteria and chipping or cracking caused by biting or chewing. The exposure of dentin can be particularly challenging due to aesthetics, sensitivity, and potential caries.^2,3

Lifestyle
Extrinsic factors appear to be a modern-day phenomenon, especially with the introduction and consumption of diet sodas in our diet today. Beverages are, in fact, largely responsible for dental erosion.^4,5 Besides carbonated beverage consumption, other contributing factors to consider are dietary habits, work schedules, and environmental stressors.^5-8 Over time, patients are often unaware of the additive deterioration of the enamel until spontaneous pain or sensitivity develops and/or significant portions of tooth shapes change and the patient is prompted to seek care. Typically, thinning enamel with no sensitivity is a telltale clinical presentation.

CASE REPORT
Diagnosis and Treatment Planning
An adult female patient came to our office with the following presentation for a consult for cosmetic treatment (Figure 3). Initial photographs were taken and put on an operatory monitor for the patient to best explain what changes she wanted to make to her smile. Her chief complaint: “I am embarrassed to smile and want my teeth to look natural.”

Figure 3. Initial case presentation.

A comprehensive examination was performed that included periodontal charting, a full-mouth radiographic series, and a panoramic radiograph (Panorex). Normal periodontal values were recorded, and no caries were found. A soft-tissue and cancer screening did not yield any findings. However, erosive facial lesions were evident on multiple teeth: maxillary teeth Nos. 3 to 14 and mandibular teeth Nos. 23 to 26. Also noteworthy was a general loss of all canine cusps and maxillary anterior incisal edge chipping and thinning. Further clinical evaluation revealed a deep bite, with the lingually inclined maxillary anterior teeth almost enclosing the mandibular anterior teeth. Her right maxillary lateral overlapped the adjacent canine. Bilateral canine protection of the anterior teeth was absent in lateral excursions. No clicking was found in her temporomandibular joints, and no parafunctional habits were noted. Her midline had shifted approximately 3.0 mm to the right. She presented with a Class II, Division 2 malocclusion.

Figure 4. Invisalign (Align Technology) template.

After much discussion, the patient revealed she had lived abroad (France) much of her adult life and, several years ago, began drinking hot water laced with fresh lemon juice every morning. This habit continued for at least 3 years, by her recollection. She discontinued this habit after her front teeth began to discolor and became more sensitive to air and water. She also could not recall the use of any toothpaste brand, fluoride rinse, or other preventive measures.

The patient’s malocclusion was of primary concern. Dental erosion was clearly evident and exacerbated the anterior malocclusion. If the occlusion was not corrected, more exposed dentin would be lost, and restorative recovery would be much more difficult.

These findings were shared with the patient. Clear explanations of treatment choices, a timeline, and aesthetic expectations were given to her. Also, preventive maintenance was emphasized. We used patient photographs, drawings, and models to ensure equal expectations between clinician and patient were met. The patient agreed to an orthodontic consultation to start treatment.

Pre-restorative Orthodontic Phase
An initial orthodontic discovery was completed with photographs and impressions (Figure 4). The treatment plan included a series of clear aligner therapy (Invisalign [Align Technology]) for 14 months. During this phase, the patient was very compliant, wearing her aligners and diligently changing them every 10 to 12 days. Because the aligner plastic would be covering the teeth for 22 hours per day, a preventive maintenance roadmap was created and presented by a hygienist. This regimen included daily application of RECALDENT (GC America), which is contained in MI Paste Plus (GC America). RECALDENT is a milk-derived protein (CPP-ACP) that offers a bio-available release of calcium and phosphate into the tooth surfaces (Figure 5). The goal was to lessen any potential sensitivity and provide oral buffering. The patient was advised to brush her teeth before bedtime in a traditional manner. She was advised to place a pea-sized amount of MI Paste Plus on her tongue and then use that to coat all the surfaces of her teeth and was instructed not to rinse. This coating was to remain undisturbed for 20 minutes. After that time, she was allowed to insert her aligner for bedtime wear.

Figure 5. The patient applied MI Paste Plus (GC America).

After 14 months, the final arch alignment and orthodontic result was achieved. Note the regained anterior space and posterior support (Figure 6). Both arches were maintained with an Essix ACE clear aligner for 6 months before restorative treatment would commence.

Restorative Phase 1
The restorative phase was ready to begin after 6 months of retention. Due to the loss of canine anatomy and guidance, the mandibular anterior teeth were initially restored with direct composites.

Figure 6. The final alignment, post-orthodontic treatment.

Teeth Nos. 22 to 27 were isolated, pumiced, rinsed, and shade matched. Two-ml bevels were placed on the enamel framework edges to enhance adhesion. Each tooth was interproximally isolated with a clear matrix. A selective-etch method was done using a phosphoric acid etchant that was applied to the enamel for 15 seconds, then rinsed thoroughly with water for 5 to 10 seconds, and then excess water was removed while allowing for a moist surface to remain. A fresh drop of universal bonding agent (Prime&Bond elect [Dentsply Sirona]) was scrubbed into the enamel and dentin surfaces equally for 20 seconds, followed by syringing a clean air stream for 5 seconds to thin the bonding agent. Each surface was light cured for 20 seconds. A universal composite (TPH Spectra ST [Dentsply Sirona]) in shade BW (bleach white) was applied and sculpted to restore the missing tooth surfaces, then appropriately light cured (SmartLite Focus [Dentsply Sirona]). The patient’s restored occlusion would guide the height of the canines. Each restoration was finished, occlusion verified, and then polished using discs and cups (Enhance [Dentsply Sirona]) to achieve a nice luster. The patient was very pleased with the mandibular restorative phase (Figure 7).

A mandibular impression was taken to create a new retention aligner. The patient was scheduled to return in 2 months for her final restorative phase.

Restorative Phase 2
The final phase of the treatment plan called for the 6 maxillary anterior teeth to be protected and restored with pressed all-ceramic veneers (IPS e.max Press [Ivoclar Vivadent]). Per the patient, care was taken to restore the original shade and shape of her teeth with respect to the missing incisal line angles and edges. This was an opportunity to create a chairside mock-up for the patient to best visualize and approve her new aesthetic look. This “new look” was used to create a template for the upcoming transitional restorations.

Figure 8. Maxillary veneer transitionals.	Figure 9. The completed maxillary veneers.

The patient was given a local anesthetic, and, using a minimally invasive approach as much as possible, veneer preparations were created. Then impressions and a bite registration were taken, and provisional restorations were fabricated (Figure 8).

After 2 weeks, the patient returned for her insertion appointment. Again, local anesthetic was given, and the temporaries were removed. The preparations were pumiced and rinsed, and the veneers were tried in using a translucent try-in paste (Calibra Veneer Esthetic Resin Cement [Dentsply Sirona]) to confirm the fit. At this point, the aesthetics were also evaluated and approved by the doctor and the patient. Each veneer was thoroughly rinsed and dried. Next, the intaglio surface of each veneer was coated with universal primer (Silane coupling agent [Dentsply Sirona]) and allowed to air dry. A thin coat of bonding agent (Prime&Bond elect) was applied and then air dried for 5 seconds. Each veneer was set aside and covered to prevent any premature adhesive curing from the ambient operatory lights. A total-etch method was used, acid etchant was applied on each preparation for 15 seconds and then rinsed with water for 10 seconds, and then the excess water was removed to the extent that the tooth remained moist. The bonding agent was then scrubbed into each preparation for 20 seconds, and then each preparation was air-thinned for 5 seconds to prevent any pooling. Each prep was then light cured for 10 seconds, beginning with the maxillary centrals. During this time, an aesthetic veneer cement (Calibra Veneer Esthetic Resin Cement, Light shade) was loaded into the restorations. As the restorations were seated, care was taken to ensure proper placement. The gingival portion was briefly light cured for no more than 10 seconds, and excess cement was carefully removed. A final, 20-second light curing of all surfaces was completed. Margins were finished using a fine, flame-shaped diamond and then lightly polished, as needed, using a composite polishing point. Finally, all the restorations were flossed, and the occlusion was reverified (Figure 9).

Postoperative Care
The patient’s anterior tooth enamel that was once threatened by erosion on the buccal surfaces was now fully protected with bonded all-ceramics. A final clear aligner retainer was delivered that the patient would continue to wear for 6 months, then alternate nightwear thereafter. She was advised to follow the home care instructions given to her for the rest of her life.

CLOSING COMMENTS
I had never before encountered dental erosion to this extent in my practice. This condition presented as a significant, multifactorial treatment challenge. Through the work required to treat this patient, I have learned that dentists and hygienists need to create strategies for a cohesive message when diagnosing and staging a case of this magnitude. Our dual role is to not only restore patients’ oral health but also to encourage and support them along the transformation process.

Acknowledgments:
The author would like to thank Dan Becker at Becker Dental Lab in Herculaneum, Mo, for the beautiful ceramic work.

References

1. American Dental Association. Oral health topics. Dental erosion. https://www.ada.org/en/member-center/oral-health-topics/dental-erosion. Accessed February 21, 2019.
2. Scheutzel P. Etiology of dental erosion—intrinsic factors. Eur J Oral Sci. 1996;104(2 pt 2):178-190.
3. Twetman S. The evidence base for professional and self-care prevention—caries, erosion and sensitivity. BMC Oral Health. 2015;15(suppl 1):S4.
4. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996;104(2 pt 2):151-155.
5. Shlossman M, Montana M. Preventing damage to oral hard and soft tissues. In: Spolarich AE, Panagakos FS, eds. Prevention Across the Lifespan: A Review of Evidence-Based Interventions for Common Oral Conditions. Charlotte, NC: Professional Audience Communications; 2017:97-120.
6. Zero DT. Etiology of dental erosion—extrinsic factors. Eur J Oral Sci. 1996;104(2 pt 2):162-177.
7. Huysmans MC, Chew HP, Ellwood RP. Clinical studies of dental erosion and erosive wear. Caries Res. 2011;45(suppl 1):60-68.
8. Meurman JH, ten Cate JM. Pathogenesis and modifying factors of dental erosion. Eur J Oral Sci. 1996;104(2 pt 2):199-206.

Dr. Trost received her dental degree from the Southern Illinois University School of Dental Medicine. She maintains a private practice in the Greater St. Louis area. Dr. Trost offers postgraduate courses to dentists and their team members that draw from her extensive private practice experience and focus on restorative dentistry, digital technology, dental materials, orthodontics, business management, and patient communication. She is an author, clinical evaluator, and editorial board member and is listed as one of Dentistry Today’s Leaders in Continuing Education. She can be reached at loritrost.com or via email at trost@htc.net.

Disclosure: Dr. Trost reports no disclosures.

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With the plethora of options available, it is incumbent on each practitioner to educate the patient as to the prognosis of each treatment option, as well as the limitations of treatment, and to satisfy requisite patient goals.

This case study will highlight an evidence-based treatment solution to an aesthetically challenging external resorptive defect.

CASE REPORT
A 56-year-old woman presented with a Class II, Division 2, orthodontic classification. She had diastemas distal to her canines and a retroclined anterior maxillary segment (Figure 1). She had been bleaching weekly for more than 20 years. She reported feeling a ledge on the lingual surfaces of her maxillary anterior teeth, and then one day the ledge was gone and she felt “something weird” at the gumline. The etiology of her resorption could have been due to the long-term bleaching activity, as she reported no history of trauma, orthodontics, or any other incident involving her anterior teeth.

Figure 1. A full-face, preoperative photo of the patient (Class II, Division 2).	Figure 2. The pre-op retracted view.
Figure 3. A pre-op photo of tooth No. 9, showing internal resorption.	Figure 4. A profile view of the smile, displaying retro-inclined incisors.

Figure 5. The right profile view, highlighting a large diastema distal to tooth No. 6.

She presented with an external resorptive lesion on the lingual of tooth No. 9, which was assessed as having a fair-to-poor long-term prognosis (see Inset on page 108). A work-up was done to assess her available bone for an implant, abutment, and crown restoration. The patient’s retroclined incisors—coupled with a thin gingival biotype and gummy smile, along with a near translucent enamel shade—necessitated evaluating orthodontics with (or without) a cosmetic rehabilitation of the anterior teeth to restore her teeth and smile to a more ideal level of aesthetics while protecting a severely compromised tooth No. 9 (Figures 2 to 5).

This patient had an orthodontic and orthopedic discrepancy as well as a failing anterior tooth secondary to external resorption. Orthodontic correction would have taken at least 1.5 years, and the forces placed on the teeth could have led to further resorptive changes and the loss of an anterior tooth.²

Figure 7. A clear pull-down matrix was made from the diagnostic wax-up and is shown here over the teeth.

Extract the Anterior Tooth, or Not?
Complications from the Acute Implant/Abutment Angle
Implant replacement of tooth No. 9, with the resulting abutment/implant angle due to a Class II, Division 2 orthodontic classification, would have made implant placement and prosthetic rehabilitation difficult. Furthermore, if implant placement was to be considered, the thin gingival biotype, quality and quantity of bone, and high smile line would have made this aesthetic rehabilitation challenging. Lastly, the patient’s frequent bleaching and the difficulty in shade matching made the comprehensive aesthetic rehabilitation a more predictable solution to these myriad problems. The use of multiple shade guides could not approximate a close match if a one-tooth solution was chosen (Figure 6).

Figure 8a. The stick bite (Blu-Mousse [Parkell]).	Figure 8b. The sequential bite registration (Blu-Mousse).
Figure 9. The stumpf (stump) shade of preparations.	Figure 10. A tissue retractor guard is used to protect the margination of the preparations.

An endodontic consultation was sought, external resorption was diagnosed, and the patient decided to attempt to save the tooth with endodontic therapy and cosmetic rehabilitation. At the conclusion of the aforementioned treatments, a nocturnal splint would then be made and delivered to help prevent any damage from bruxism or parafunction. Selection of the enamel shades, as a part of the preoperative workup, was completed prior to preparation so the enamel would not be dehydrated. Several shade guides were used to assess a natural hue, chroma, and value for the whitened teeth she presented with. After taking photos with the standard shade guide tabs and reviewing them (Figure 6), the laboratory team fabricated several custom shade tabs that were also used for assessing and finalizing the final tooth shades and translucency.

After a facebow transfer and alginate impressions were taken, a diagnostic wax-up (Glidewell Laboratories) was fabricated. A clear pull-down matrix was made over a stone model of the wax-up and was used to assess the teeth and to create a preparation guide prior to initial tooth reduction (Figure 7). This clear template was filled with bis-acryl temporary material (Integrity Multi-Cure [Dentsply Sirona Restorative]) and seated gently on the teeth. A stick bite, utilizing bite registration material (Blu-Mousse [Parkell]), ensured that the incisal plane would be parallel to the floor and parallel to the interpupillary lines, as well as marking the midlines to provide a means to begin our check-bite process. This was accomplished by squirting Blu-Mousse on the occlusal surfaces and placing an extra bolus anterior to the front teeth. Then, a cotton tip applicator was twirled into the Blu-Mousse and leveled while the patient stared directly at the doctor so it could be parallel to the interpupillary line. A secondary master bite was also made that was altered after every 2 to 3 preparations.

The preparations were completed on the patient’s right side, leaving teeth Nos. 8 and 9 unprepared to ensure a positive anterior stop. Then the master bite was trimmed, Blu-Mousse was injected, and the bite was seated to record the newly prepared teeth. The Blu-Mousse bite registration was carefully trimmed, and the procedure was repeated on the patient’s left side. Next, teeth Nos. 8 and 9 were prepared and (again) the bite was relined so that there was a segmental bite as well as an untouched stick-bite for the lab team to use for verification of the bite registration (Figure 8). The dentin shades were then captured with photos that included the shade guide tabs (Figure 9). Note the respect that has been paid to the tissues by careful retraction via the use of gingival retraction instruments. Not only were gingival zeniths preserved, but the interproximal anatomy of the papillae was maintained with gingival retracta-guards (Tanaka Dental) (Figure 10).

The provisionals were made by injecting a bis-acryl provisional material (Integrity Multi-Cure) into a putty matrix (Sil-Tech [Ivoclar Vivadent]) (Figure 11) made from the approved diagnostic wax-up.

The ability to perform predictable aesthetic rehabilitation requires that the soft tissues be given time to heal and mature. Giving provisional restorations a “test drive” allows patients to evaluate aesthetics, phonetics, and function prior to seating the definitive restorations and, in addition, allows for an intraorally confirmed template for the prototypic restoration (Figure 12). This light-cured or dual-cured bis-acryl material is strong, taking on a high shine once polished. Figure 13 shows the contouring of the restorations prior to glazing and polishing.

Figure 11. The Sil-Tech Putty Matrix (Ivoclar Vivadent) with Integrity Multi-Cure provisional material (Dentsply Sirona Restorative).	Figure 12. Healed tissue, after one month in the provisionals.
Figure 13. The provisionals, prior to staining and glazing.	Figure 14. A vinyl polysiloxane (VPS) impression (Aquasil Ultra Xtra [Dentsply Sirona Restorative]) was taken of the preparations.
Figure 15. Lithium disilicate (IPS e.max [Ivoclar Vivadent]) crowns on the day of cementation.	Figure 16. A 3-year postoperative photo of the lithium disilicate (IPS e.max) restorations.

Figure 17. The occlusal view of the 3-year-old restorations.

Carefully fabricated provisionals allowed for custom anterior guide tables to recreate proper lingual contours in the approved provisionals and the final restorations. The use of a double-cord technique, a quality vinyl polysiloxane (VPS) material (Aquasil Ultra Xtra [Dentsply Sirona Restorative]) that exhibits hydrophilicity and high tear strength, and a working time that gives the operator a full 5 minutes to carefully inject the material in a wash/tray application provided an excellent master impression (Figure 14). In addition, a stick bite, a master bite, and stumpf (stump) and enamel shade photos provided the dental laboratory team with everything needed to create the ideal restorations.

Immediately after cementation, the layered lithium disilicate (IPS e.max [Ivoclar Vivadent]) restorations displayed symmetry of form and function with no bleeding and well-healed gingival tissues (Figures 15 to 18). However, since this case cannot be stated as a successful resolution of this patient’s problem without demonstrating longevity of the work accomplished, the 3-year postoperative photos are shared here to document the morphologic balance, bilateral canine guidance (as designed and tested in provisional restoration), and anterior guidance achieved for the patient (Figures 19 and 20). The patient’s soft-tissue contours have remained stable, and the occlusal view displays normalized contours and maintenance of cuspal integrity. The patient was as pleased with the aesthetics of her rehabilitation at 3 years post-op as she was when it was first cemented (Figures 16 to 20). The periapical radiograph and CBCT, taken 3 years post-op, demonstrate the lack of spread of the ECR as well as intimate coverage by the all-ceramic (IPS e.max) crowns (Figures 21 to 22). The 3-year post-op photos shared here demonstrate the well-maintained cosmetic rehabilitation of this complex and aesthetically compromised case (Figure 23).

Figure 18. The smile view at 3 years post-op.	Figure 19. The canine guidance right at 3 years post-op.

Figure 20. The canine guidance left at 3 years post-op.

Figure 21. The 3-year post-op periapical radiograph, taken after repair of resorption and restoration.	Figure 22. A CBCT showing the extent of the Class II external cervical resorption.

CLOSING COMMENTS
Some patients have aesthetic problems that are not easily amenable to implant therapy due to unfavorable tooth position. Creative mindsets can often offer solutions that will mask orthodontic or orthopedic malpositions while facilitating desired aesthetic outcomes.

Whether this case would have been restored with a single tooth implant or the way it was restored with endodontic treatment, an external cervical resorption (ECR) restoration and traditional crowns depend on training, skill, philosophy, and judgment. However, when also considering the patient’s aesthetic desires, the solutions become more patient centered. Now, if the central incisor fails, the shade of the teeth has already been documented and recorded, and a custom porcelain shade tab was fabricated and preserved to mimic her most difficult porcelain shade. The emergence angle and profile of tooth No. 9 is a positive emergence angle and profile, so it will make implant rehabilitation easier without having to create an acute angle between the implant and the abutment in the future.

Lastly, and perhaps most importantly, protective canine guidance has been created that will pave the way for a successful implant restoration without traumatic occlusion or parafunction as she had presented with initially. So the stage has been set for success, and, in the event of future failure, we are still set up for success should an implant rehabilitation be required. Remember, if one fails to plan, a case may fail. This article demonstrates how upgradeable dentistry¹⁵ can be built into a current treatment plan to help the patient achieve predictable results now and into the future, should the initial design fail.

The evaluation of the literature on ECR provided a cogent etiology of this patient’s lesion as well as an evidence-based analysis of prosthetic treatment options. This patient was instructed to stop bleaching her teeth and to wear her mouthguard to prevent parafunction that could compromise the success of her aesthetic and functional rehabilitation.

References

1. Hamilton RS, Gutmann JL. Endodontic-orthodontic relationships: a review of integrated treatment planning challenges. Int Endod J. 1999;32:343-360.
2. Heithersay GS. Clinical, radiologic, and histopathologic features of invasive cervical resorption. Quintessence Int. 1999;30:27-37.
3. Heithersay GS. Invasive cervical resorption: an analysis of potential predisposing factors. Quintessence Int. 1999;30:83-95.
4. Heithersay GS. Invasive cervical resorption following trauma. Aust Endod J. 1999;25:79-85.
5. Heithersay GS. Treatment of invasive cervical resorption: an analysis of results using topical application of trichloroacetic acid, curettage, and restoration. Quintessence Int. 1999;30:96-110.
6. Tronstad L. Endodontic aspects of root resorption. In: Tronstad L. Clinical Endodontics: A Textbook. 2nd ed. Stuttgart, Germany: Thieme; 2002:146-156.
7. Rotstein I, Torek Y, Misgav R. Effect of cementum defects on radicular penetration of 30% H₂O₂ during intracoronal bleaching. J Endod. 1991;17:230-233.
8. Andreasen FM, Sewerin I, Mandel U, et al. Radiographic assessment of simulated root resorption cavities. Endod Dent Traumatol. 1987;3:21-27.
9. Gulabivala K, Searson LJ. Clinical diagnosis of internal resorption: an exception to the rule. Int Endod J. 1995;28:255-260.
10. Gartner AH, Mack T, Somerlott RG, et al. Differential diagnosis of internal and external root resorption. J Endod. 1976;2:329-334. 
11. Schwartz RS, Robbins JW, Rindler E. Management of invasive cervical resorption: observations from three private practices and a report of three cases. J Endod. 2010;36:1721-1730.
12. Heithersay GS. Invasive cervical resorption. Endod Topics. 2004;7:73-92.
13. Patel S, Dawood A. The use of cone beam computed tomography in the management of external cervical resorption lesions. Int Endod J. 2007;40:730-737.
14. Patel S, Ford TP. Is the resorption external or internal? Dent Update. 2007;34:218-229.
15. Winter R. Upgradeable dentistry: part 1. Dent Today. 2009;28:82-87.

Suggested Reading
Brosh T, Pilo R, Sudai D. The influence of abutment angulation on strains and stresses along the implant/bone interface: comparison between two experimental techniques. J Prosthet Dent. 1998;79:328-334.

Lewis S, Avera S, Engleman M, et al. The restoration of improperly inclined osseointegrated implants. Int J Oral Maxillofac Implants. 1989;4:147-152.

Cavallaro J Jr, Greenstein G. Angled implant abutments: a practical application of available knowledge. J Am Dent Assoc. 2011;142:150-158.

Clelland NL, Gilat A, McGlumphy EA, et al. A photoelastic and strain gauge analysis of angled abutments for an implant system. Int J Oral Maxillofac Implants. 1993;8:541-548.

Eger DE, Gunsolley JC, Feldman S. Comparison of angled and standard abutments and their effect on clinical outcomes: a preliminary report. Int J Oral Maxillofac Implants. 2000;15:819-823.

Dr. Winter, a 1988 graduate of the University of Minnesota School of Dentistry, maintains a private practice in Milwaukee. He is a Master in the AGD, a Diplomate in the American Board of Oral Implantology/Implant Dentistry and the International Congress of Oral Implantologists, and a Fellow in the American Academy of Implant Dentistry. He lectures on the topics of upgradeable dentistry, advanced treatment planning, and general dentistry as a specialty. He can be reached by visiting hamptondentalassociates.com or via email at rick@winterdental.com.

Ms. Winter is a third-year dental student at Marquette University School of Dentistry in Milwaukee. She can be reached via email at ariel.winter@marquette.edu.

Disclosure: The authors report no disclosures.

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Excessive gingival display (EGD), often referred to as a “gummy smile,” would be an example of negative visual tension created by normal proportions being out of balance. Ideally, in an attractive smile, 2.0 mm or less of gingival tissue would be displayed. In fact, a study conducted by Kokich Jr et al² compared the perceptions of dentists and lay people to altered dental aesthetics and found that a gingival display of 3.0 mm or greater was considered to be unattractive and not visually appealing.

EGD is actually a descriptive term and not a diagnosis. Since multiple factors may be responsible for the condition, it is always important to determine the etiology (or etiologies) before developing a treatment plan.³ Etiologies may be both dentoalveolar and non-dentoalveolar in nature.⁴ Dentoalveolar etiologies include altered passive eruptions, wear and compensatory eruptions, and anterior dentoalveolar extrusions. Non-dentoalveolar etiologies include short upper lips, hypermobile lips, and vertical maxillary excess.

Due to the complexity of cases involving excessive gingival display and the possibility of having more than one etiology, an interdisciplinary treatment approach is often indicated that may involve periodontists, orthodontists, oral surgeons, plastic surgeons, and the restorative dentist.⁵ The following case report will illustrate the importance of determining the etiology and then the utilization of a coordinated interdisciplinary approach to achieve a successful result for a patient with short teeth and EGD.

CASE REPORT
Diagnosis and Treatment Plan
A 31-year-old female presented for a consultation because she was unhappy with the appearance of her smile. Specifically, she felt that she showed a lot of gum tissue when smiling and that her front teeth were short (Figures 1 to 3). Two of the most common etiologies of short teeth and excessive gingival display are altered passive eruption (APE) and wear with compensatory eruption.

Figure 1. Preoperative full-face smile.

Figure 2. Pre-op close-up smile.	Figure 3. Pre-op occlusal view. Note wear on the incisal edges.

In cases of APE, the teeth appear short because gingival tissues do not recede to a normal position and actually cover part of the clinical crown. However, the incisal edges would not exhibit any signs of wear.⁶ APE can usually be successfully treated with simple gingivectomies or periodontal crown lengthening procedures with osseous resection. Compensatory eruption cases may also be treated with a combination of crown lengthening and restorative dentistry, though this combination treatment can result in a less than ideal crown-to-root ratio and emergence profile due to the necessity of having to place a restoration on the root.⁷ Therefore, when treating excessive gingival display due to compensatory eruption and incisal wear, it might be more beneficial to consider a treatment plan that combines orthodontic intrusion and all-ceramic restorations.⁸

The clinical exam revealed short teeth (7.5 mm) with evidence of incisal edge wear and compensatory eruption that contributed to the increased gingival display. In addition, the patient exhibited some hypermobility of the upper lip, further enhancing the excessive gingival display when smiling. A thorough discussion of treatment options included the pros and cons of crown lengthening and orthodontic intrusion, as well as soft-tissue procedures to limit lip elevation. Because of the diagnosis of wear and compensatory eruption, orthodontic intrusion (in lieu of the option of crown lengthening) was recommended. The patient agreed to an orthodontic evaluation to discuss intrusion, but declined a consultation to discuss possible soft-tissue procedures to limit lip elevation.⁹ In addition to the orthodontic consultation, the treatment plan included all-ceramic veneers on teeth Nos. 4 to 13.

Clinical Protocol: Orthodontics and Restorative Phases
After accepting and completing orthodontic treatment (Figures 4 to 6), the patient returned to begin the restorative phase. The orthodontist had successfully intruded the incisors, decreasing the amount of gingival display and creating the space necessary for ideal length all-ceramic veneers (Figures 7 to 10).

The first step of the restorative phase was to determine incisal edge position. This is a critical step when increasing incisal length, and, although arbitrary to some degree, the case can be evaluated aesthetically, functionally, and phonetically with the provisionals before the definitive restorations are fabricated.¹⁰ Initially, composite was added to the central incisors to increase the length to 11.0 mm and to display about 3.0 to 4.0 mm of tooth with the lips at rest. Although this incisal edge position and the length of the centrals were arbitrarily chosen based upon proven smile design principles, they can be evaluated with a fair degree of certainty while the patient is wearing provisional restorations.

Figure 4. Orthodontic intrusion phase, full-face view.

Figure 5. Orthodontic intrusion phase, close-up smile view.	Figure 6. Orthodontic intrusion phase, occlusal view.

Figure 7. Post-orthodontic intrusion, pre-restorative full-face smile.

Figure 8. Post-orthodontic intrusion, pre-restorative close-up smile.	Figure 9. Post-orthodontic intrusion, pre-restorative retracted view.

Normally, the central incisor mockup is sufficient to convey the necessary information to the dental laboratory team to fabricate a diagnostic wax-up and a putty matrix that will be used to make the provisionals. However, in this particular case due to time constraints, a lab-fabricated diagnostic wax-up and putty matrix was not possible. Instead, all 10 teeth (Nos. 4 to 13) were mocked up using composite resin without acid-etching the teeth. No local anesthetic was used for this mockup step so that the smile, speech, and function could be evaluated preoperatively for ideal length, shape, and facial contours. An impression of the completed mockup was taken and set aside to be used later as a matrix for the provisionals.

Next, depth cuts were made in the mockup to allow the most conservative and minimally invasive preparation possible (Figure 11). After removing the mockup composite, a diode laser (Picasso Lite Plus [AMD LASERS]) was used for minor recontouring to create ideal gingival height symmetry. Then, using the depth cuts as a guide, the teeth were conservatively prepared using a single-use round-ended tapered coarse diamond (1116.10 NeoDiamond [Microcopy]) (Figure 12). After completing the preparations, a full-arch polyether impression (Impregum Soft [3M]), an occlusal record, and a stick bite were taken. The shade of the prepared teeth (stump shades) along with a written lab prescription detailing the goals of treatment, material selection, and desired shade (BL2/BL3, taken before preparation of the teeth had begun) were forwarded to the laboratory team. Using the impression of the pre-op mockup, the provisionals were fabricated (Tuff-Temp Plus [Pulpdent]).

After 2 days, the patient returned to evaluate the provisional restorations for aesthetics, phonetics, and function. After minimal adjustments, photos (Figure 13) and an impression were taken of the (patient- and doctor-approved) provisionals. These were also forwarded to the laboratory team to serve as communication tools, providing a blueprint to follow while fabricating the definitive restorations.

The patient returned in 3 weeks to have the lithium disilicate (IPS e.max Press [Ivoclar Vivadent]) all-ceramic veneers, that had been cut back and layered to optimize aesthetics, delivered. The patient had experienced no postoperative problems. The provisionals were removed, and the veneers were tried in with water to evaluate fit, color, and interproximal contacts.

Next, the teeth were isolated using a rubber dam (Non-Latex Dental Dam [COLTENE]) in preparation for cementation using a resin cement. The intaglio surfaces of the restorations were easily cleaned using a universal cleaner (Ivoclean [Ivoclar Vivadent]), then rinsed and dried with oil-free air and treated with silane. The restorations were set aside (organized by tooth number). The isolated teeth were etched with phosphoric acid gel (Select HV Etch, containing the antimicrobial ingredient BAC [BISCO Dental Products]) using the total etch technique for 15 seconds each, rinsed, and lightly air dried.

Figure 10. Post-orthodontic intrusion, pre-restorative 1:1 close-up view.	Figure 11. Depth cuts were made in the composite resin mockup to ensure minimally invasive preparations.

Figure 12. Diode laser recontouring was done around the finished all-ceramic preparations.

A universal adhesive (ALL-BOND UNIVERSAL [BISCO Dental Products]) was applied, the solvent was evaporated, and then the adhesive was light cured. The translucent shade, which was a light-cured resin cement (Choice 2 [BISCO Dental Products]), was placed on all 10 teeth, and the veneers were seated simultaneously. Excess cement was cleaned off with cotton rolls and brushes. The veneers were tack cured at the gingival margin, allowing the cement to be removed interproximally by flossing the contacts. All the restorations were light cured (Bluephase 20i [Ivoclar Vivadent]) from the facial and lingual directions for 40 seconds.

The rubber dam was removed. The occlusion was checked using articulating paper and a T-Scan Novus (Tekscan) and then adjusted where needed. The restorations, where adjusted, were polished with fine and super-fine grit rubber cups and points (CeraMiste [Shofu Dental]). Finally, the patient was appointed for a post-op evaluation and photographs (Figures 14 to 18).

Figure 13. The patient and doctor approved the provisional restorations, seen here after careful evaluation and any needed adjustments.	Figure 14. Postoperative full-face view.
Figure 15. Post-op close-up smile.	Figure 16. Post-op retracted view.
Figure 17. Post-op 1:1 close-up view.	Figure 18. Post-op occlusal view.

IN SUMMARY
Excessive gingival display (gummy smile) is not a diagnosis. It is a descriptive term. When the amount of gingival tissue displayed while smiling is 3.0 mm or greater, it is widely considered to be unattractive and can often be a source of embarrassment or accompanied by a loss of self-esteem. Gummy smiles can be both dentoalveolar and non-dentoalveolar and may have more than one etiology. That is why determining the etiology is important before formulating a treatment plan and deciding on a course of action. More than one treatment option may exist to reach the desired result, and this should always be explained and thoroughly discussed with the patient.

In the case presented in this article, a diagnosis of incisal wear with compensatory eruption and mild hypermobility of the upper lip was determined to be the cause of the patient’s gummy smile and short teeth. Treatment options were explained and discussed, and, although she elected not to pursue any procedures to limit lip elevation, a successful outcome was achieved for this patient using orthodontic intrusion and all-ceramic lithium disilicate veneers. 

Acknowledgement
The author would like to recognize the contribution of the orthodontist in the case presented, Dr. David Sarver (Birmingham, Ala), and for the artistry demonstrated in the all-ceramic veneers skillfully created by Mr. Gary Vaughn, CDT (Corr Dental Designs, Roseville, Calif).

References

1. Gürel G. The Science and Art of Porcelain Laminate Veneers. Chicago, IL: Quintessence Publishing; 2003.
2. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311-324.
3. Robbins JW. Differential diagnosis and treatment of excess gingival display. Pract Periodontics Aesthet Dent. 1999;11:265-272.
4. Gottesman E. Excessive gingival display: addressing multiple etiologies for optimal esthetics outcomes. Perio-Implant Advisory. September 12, 2012. http://www.perioimplantadvisory.com/articles/2012/09/excessive-gingival-display-addressing-multiple-etiologies-for-optimal-esthetic-outcomes.html. Accessed November 5, 2017.
5. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc. 2006;137:160-169.
6. Dolt AH III, Robbins JW. Altered passive eruption: an etiology of short clinical crowns. Quintessence Int. 1997;28:363-372.
7. Kois JC. Altering gingival levels: The restorative connection part 1: biologic variables. J Esthet Dent. 1994;6:3-9.
8. Kois JC. Anterior wear: orthodontic and restorative management. In: Cohen M, ed. Interdisciplinary Treatment Planning, Volume II: Comprehensive Case Studies. Chicago, IL: Quintessence Publishing; 2012:189-210.
9. Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am. 1988;32:307-330.
10. Cranham J. The horizontal position of the maxillary incisal edge: the key to optimum esthetics, phonetics, and function. Contemporary Esthetics and Restorative Practice. 2006;10:22-24.

Dr. Dudney is a 1977 graduate of the University of Alabama, Birmingham School of Dentistry. He is an active member of the Alabama Dental Association, the AGD, the ADA, and the Birmingham District Dental Society. He is an accredited member of the American Society for Dental Aesthetics and is a Diplomate of the American Board of Aesthetic Dentistry. He is clinical director for the California Center for Advanced Dental Studies’ live-patient, hands-on continuum. Formerly, he was the clinical director for the Rosenthal Group’s Aesthetic Advantage hands-on continuum and taught at the New York University College of Dentistry and the Eastman Dental Clinic in London, UK. Dr. Dudney has been a speaker at several major dental meetings and has authored several articles on aesthetic and restorative dentistry. He can be reached via the email address tedudneydmd@aol.com or via the website thomasdudney.com.

Disclosure: Dr. Dudney reports no disclosures.

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Creating a More Youthful Appearance: Multidisciplinary Treatment Planning

Interdisciplinary Treatment Expanded

Full-Mouth Black Triangle Treatment Protocol

This case study will serve to highlight issues clinicians face daily that involve when to extract teeth and place implants, how long to treat periodontally challenged teeth, and how to improve aesthetic difficulties in a patient with severe occlusal disharmonies.

CASE REPORT
Diagnosis and Treatment Planning
This patient presented with chief complaints of pain when chewing and dissatisfaction with her smile. In examining her dentition, it was noted that she had a blocked lateral incisor in linguoversion; a Class II malocclusion with a deep bite that resulted in her biting her incisive papillae during normal chewing; a severely canted occlusal plane; and severe fremitus with localized, severe type IV periodontitis, according to the ADA and American Academy of Periodontology (AAP) classification of periodontal disease. In discussing her treatment wishes, she expressed the desire to have us “pull her teeth and give her implants.” There was Class III mobility of teeth Nos. 6, 10, 12, and 23 to 26, along with several posterior molars.

Figure 1. Preoperative full-face photo.

Her full-face smile photo revealed a large 3.0-mm diastema with a rotated canine and a slight grimace in maximum intercuspation position (Figure 1). In relaxed smile position, it was noted that the lower anteriors were in contact with her incisive papillae (Figure 2). Upon slight opening of her dentition and in the occlusal photograph, a canted occlusal plane with super eruption of tooth No. 22 into the missing tooth No. 11 site was noted, highlighting the reasons for her occlusal traumatism and fremitus (Figures 3 and 4). There was a stippled appearance to her gingiva, but a loss of interdental papillae in the mandibular anterior was representative of her bone loss. The patient had undergone periodontal surgery 4 years prior. The left lateral view showed a super-eruption of tooth No. 22 to the crestal ridge where tooth No. 11 had been removed, and the “step” between teeth Nos. 21 and 22 was significant and was the etiology for mobility of teeth Nos. 10 and 12 (Figure 5). The right lateral view revealed that tooth No. 10 was angled and tooth No. 6 had super-erupted (Figure 6).

Periodontal therapy was instituted with scaling and root planing, and a periodontal consultation was done. The patient had stable periodontium but understood that, even though there was not active bleeding upon probing and her oral hygiene was adequate, several teeth would be lost due to severe mobility from chronic periodontal disease and concomitant occlusal disease. Her participation in ongoing periodontal therapy and maintenance was required prior to initiating orthodontics and restorative prosthetics.

Figure 2. Pre-op relaxed-smile photo.	Figure 3. Pre-op retracted photo with patient in slight disclusion.
Figure 4. Pre-op occlusal view, showing missing tooth No. 11 and tooth No. 7 in linguoversion.	Figure 5. Pre-op left lateral view, showing super-eruption of tooth No. 22.
Figure 6. Pre-op right lateral view.	Figure 7. Interim orthodontic photo.
Figure 8. Left lateral view in braces.	Figure 9. Frontal view near the end of orthodontic treatment.

Figure 10. Smile display at the completion of orthodontic treatment.

To plan a comprehensive solution, while allowing for restoratively driven implant placement, a diagnostic wax-up would be required. Even with the most thoughtful planning, placing implants to replace her mobile teeth would require proper mesial-distal and occlusal vertical space. It would also require canine guidance, which would be protective for implant placement and the stability of her remaining dentition.

If teeth Nos. 7 to 10 and 22 to 26 required extraction with implant replacement, would there be enough space for all of her teeth to be placed in the available arch form? How much osteoplasty would be required in the areas of teeth Nos. 22 to 26 to level the bone and, thus, to level her curves of Spee and Wilson?

The complicated nature of anticipating the final occlusal construct necessitated orthodontic intervention to “set the stage” for proper implant placement.² But how could orthodontics be treatment planned where there was ADA AAP type IV localized severe periodontal disease? Is that irresponsible? Would participating dentists get sued for tooth loss caused by orthodontic intervention?

To answer these questions, the following scenario can be evaluated: If a tooth is broken and extraction is inevitable, is it OK to use orthodontics to erupt this tooth to bring the bone down with the root prior to extraction? Can we use terminal teeth to help us achieve our goals? Of course, the answer is yes, and—if informed consent is discussed and documented and the patient understands that teeth will be lost either during or post orthodontic care to achieve idealized results—then the use of compromised dentition as anchorage units to achieve goals is warranted.^3,4

Figure 11a. Full-face photo near the end of orthodontics.	Figure 11b. Full-face photo after removal of orthodontic appliances.

The Use of Orthodontics
The use of orthodontics to facilitate a stable, aesthetic, implant-protected occlusion with idealized space creation and bone leveling is not only responsible, it is justifiable.

Orthodontics was prescribed by the general practitioner with specific instruction to align and correct rotated teeth, distalize the upper left quadrant of teeth, level the occlusal plane, intrude tooth No. 22, harmonize both arches, level the CEJs, bring tooth No. 7 into the arch in harmony with tooth No. 10, and achieve canine protected occlusion by using tooth No. 12 to mimic tooth No. 11 by placing it strategically into the No. 11 site and tipping it to look and act like a canine.

It is imperative that all treating doctors can communicate and offer insights to appreciate optimal multidisciplinary care. In this case, the dictates of future prosthetic rehabilitation required skilled orthodontic movement to ensure proper foundational support for implants, with minimal bone grafting needs post orthodontics. Without using orthodontic movement of teeth, bone grafting may have been required for the bony cleft present over tooth No. 7, the loss of bone width in the No. 11 site, and in areas of anticipated extraction due to bone loss and mobility.

Orthodontic treatment took 18 months and successfully achieved the outlined goals as delineated (Figures 7 to 10).

Upon the removal of brackets, there was a noted cosmetic improvement in smile display, the occlusal plane was normalized, buccal corridor symmetry was improved, and canine guidance was established.

Figure 12. Retracted view at 8 years postoperatively.	Figure 13. Smile view at 8 years post-op, with no implant placed to date.

Optimal Results!
Debonding revealed occlusal stability, lack of mobility, lack of fremitus, lack of pain on closure in maximum intercuspation, and no pain in protrusive or excursive border movements. The resolution of occlusal disharmony and optimization of occlusal vertical dental positioning led to resolution of the symptoms for which she had sought treatment. Simply put, no pain, no mobility, and no implants.

While this patient understands that perhaps some of the bone loss on posterior molars may require further treatment in the future, the use of a Talon appliance (Space Maintainers Laboratory [Van Nuys, Calif]) to optimize her occlusion and treat her nocturnal bruxism, along with a conscientious periodontal maintenance program, is all that may be needed to maintain long-term stability.

The postoperative photos taken at an 8-year recall appointment demonstrate this stability and periodontal health (Figures 11 to 13).

References

1. Winter R. Upgradeable dentistry: Part 1. Dent Today. 2009;28:82-87. 

2. Kois DE, Kois JC. Comprehensive risk-based diagnostically driven treatment planning: developing sequentially generated treatment. Dent Clin North Am. 2015;59:593-608.
3. Feu D, Menezes FC, Augusto Mendes Miguel J, et al. Orthodontic treatment in the severely compromised periodontal patient. J Orthod. 2012;39:303-313.
4. Cho YD, Kim S, Koo KT, et al. Rescue of a periodontally compromised tooth by non-surgical treatment: a case report. J Periodontal Implant Sci. 2016;46:128-134.

Additional Reading
Johal A, Ide M. Orthodontics in the adult patient, with special reference to the periodontally compromised patient. Dent Update. 1999;26:101-108.
Kokich VG. Managing complex orthodontic problems: the use of implants for anchorage. Semin Orthod. 1996;2:153-160.
Mankoo T, Frost L. Rehabilitation of esthetics in advanced periodontal cases using orthodontics for vertical hard and soft tissue regeneration prior to implants—a report of 2 challenging cases treated with an interdisciplinary approach. Eur J Esthet Dent. 2011;6:376-404.
Nemcovsky CE, Beny L, Shanberger S, et al. Bone apposition in surgical bony defects following orthodontic movement: a comparative histomorphometric study between root- and periodontal ligament-damaged and periodontally intact rat molars. J Periodontol. 2004;75:1013-1019.
Ong MA, Wang HL, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Periodontol. 1998;25;271-277.
Panwar M, Jayan B, Arora V, et al. Orthodontic management of dentition in patients with periodontally compromised dentition. J Indian Soc Periodontol. 2014;18:200-204.

Dr. Winter, a 1988 graduate of the University of Minnesota School of Dentistry, maintains a private practice in Milwaukee, Wis. He is a Master in the Academy of General Dentistry, a Diplomate in the American Board of Oral Implantology/Implant Dentistry, a Fellow in the American Academy of Implant Dentistry, and a Diplomate in the International Congress of Oral Implantologists. He lectures on the topics of upgradeable dentistry, advanced treatment planning, and general dentistry as a specialty. He can be reached vai email at rick@winterdental.com.

Disclosure: Dr. Winter reports no disclosures.

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Upgradeable Dentistry, Part 2

Upgradeable Dentistry, Part 3

Maxillo-Mandibular Atrophy: Success Through Interdisciplinary Planning

This article will be focused on 2 of 4 brothers who presented with varying numbers (3 to 18) of congenitally missing teeth. Having 4 brothers present with this many congenitally missing teeth is certainly not a common everyday occurrence in a dental practice!

CONGENTIALLY MISSING TEETH: CLASSIFICATIONS AND ETIOLOGY
There are various terms used in the classification of congenitally missing teeth. Hypodontia is the term used when fewer than 5 teeth are missing. Oligodontia is when a patient is missing 6 or more permanent teeth. Someone born without any deciduous or permanent teeth is said to have anodontia.

Hypodontia is highly prevalent in the population. Early recognition is essential for diagnosis, treatment planning, and restoration.² However, oligodontia is rare, affecting 0.09% of the population, usually occurring in conjunction with other genetic disorders such as ectodermal dysplasia, Van der Woude syndrome, Down syndrome, or Rieger syndrome. Oligodontia has seldom been observed to occur as an isolated entity. Thirty percent of oligodontia patients have a reduced secretion of saliva, and 10% have a reduction in function of their sweat glands. Syndromic and nonsyndromic forms of oligodontia can be differentiated by a thorough examination of hair, nails, sweat glands, eyes, etc.

Figure 1. Vincent (age 21 years), missing 3 teeth.	Figure 2. Louis (age 24 years), missing 9 teeth.
Figure 3. Thomas (age 16 years), missing 15 teeth.	Figure 4. Alex (age 16 years), missing 18 teeth.

Missing teeth have been reported with an increase in maternal age, low birthweight, and multiple births.^3,4 A wisdom tooth is the most commonly missing tooth, occurring in 25% to 35% of the population. Upper lateral incisors are missing as frequently as 2%, and when only one lateral is missing, the other is usually misshaped or a microdont. Often, the central incisors and canines may also be misshaped. The incidence of missing second premolars has been reported to be as high as 3%.⁵

Missing teeth not only affect appearance but can also contribute to situations involving dental breakdown. Moderate to severe malocclusion, impaired chewing ability, periodontal problems, insufficient alveolar bone growth, and difficulties in pronunciation can create complicating consequences. Treating these situations can be time-consuming, costly, and painful.

The precise etiology of congenitally missing teeth is believed to originate from environmental or genetic factors during dental development. There is an increased frequency in twins, leading one to believe that the condition is programmed from the time of conception. Although research has shown that genetics play a dominant role, the exact genetic mechanism is unknown. It is believed that mutations of divergent genes coding for transcription factors, such as MSX1 and PAX9, are responsible.^6-8

Figure 6. The VDO was re-established with a positive overjet and a pleasing profile for one of the twins. (The same result was achieved with his twin brother.)	Figure 7. A LuxaBite registration (DMG America) captured the desired VDO.

Figure 8. The completed bite registration.

Oral Rehabilitation Considerations
The oral rehabilitation of a patient with congenitally missing teeth begins with early recognition. It is usually both an orthodontic and a restorative issue with the restorative dentist typically acting as the team leader for the multidisciplinary treatment of the patient’s care. Procedures and materials available in the various dental disciplines should be evaluated, and realistic treatment objectives should be established based upon the patient’s needs and expectations. A clinical protocol is determined that often involves periodontal, orthodontic, and implant treatments. Misshapen and malformed teeth are sometimes built to ideal proportions before orthodontics begins. The restorative dentist must interact with the participating specialists throughout the treatment, while also checking and taking radiographs to visualize root proximity, angulations, and if adequate space is available for the proposed restoration (implants, fixed bridgework, or removable dentures).⁹ Missing teeth are a dental anomaly that is debilitating, time-consuming, and a financial burden for the patient.

CASE REPORT
For this family, every sibling was affected by missing teeth. Their mother is a dental hygienist, which made communication and her understanding of the problem much easier.

Figure 9. Mounted study models.

Figure 10. The maxillary diagnostic wax-up.	Figure 11. The completed upper full-arch and lower full-arch diagnostic wax-ups.
Figure 12. A stereolitho­graphy file was created from an optical scan of the diagnostic wax-up.	Figure 13. Snap-On Smile appliances (DenMat).

Vincent, age 21 years, was missing 3 premolars and had already completed orthodontics (Figure 1). Louis, age 24 years, had 9 missing teeth and was left with a deep bite after orthodontics (Figure 2). It was decided to retreat him with orthognathic surgery to correct the shift in his mandible. Then he would be retreated orthodontically to be able to establish an ideal vertical dimension, leaving precise spacing to eventually replace all his missing teeth with implants and to reconstruct his misshapen teeth to ideal proportions.

The focus of this case report article will be on a pair of 16-year-old twin brothers: Thomas, who was missing 15 teeth (Figure 3), and Alex, who was missing 18 teeth (Figure 4). They required what I refer to as disaster relief dentistry.

The twins had nearly identical severe bite collapses with the mandibular teeth completely overlapping the uppers. Since early childhood, the boys had been followed by the dental department of a pediatric hospital. The supervising orthodontist had informed their parents that there was nothing that could be done until the boys were older and finished growing. They would then have an “operation” to move their lower jaws “into the proper position” so that restoration could be possible. The parents were told that it was impossible to improve upon what their sons had at this time in their lives. I believe that the orthodontist in that busy hospital clinic probably assumed that they were Angle Class 3 and would require mandibular orthognathic surgery. This diagnosis was based solely by looking at the teeth without placing the patients in the appropriate vertical dimension.

From the conversations that we had, I believed that the psychological effect on the twins was just as important as their dental condition. Although both brothers easily accommodated to chewing and speech, they felt that they were constantly perceived as being “different.” Having understanding friends, strong family values, confidence, and inner strength are what led them into adolescence. With high school graduation approaching, the boys and their family really hoped that something could be done aesthetically, even if it was only temporary. I believed that, if the existing permanent teeth could be placed in their appropriate positions, a removable prosthesis (Snap-On Smile [DenMat]) could be fabricated over the existing teeth, recreating vertical dimension, function, aesthetics, and phonetics. This noninvasive prosthesis could be used for restorative assessment and, in addition, as a template for the eventual placement of implants and fixed restorations.

Figure 14. Post-op photo of Alex.	Figure 15. Post-op photo of Thomas.

Figure 16. Post-op profile view of one of the twins. (The same result was achieved with his twin brother.)

I introduced myself to the treating orthodontist via telephone and, unfortunately, I was immediately met with aggressive resistance. She was insulted that I questioned her diagnosis and said that what I proposed would cause irreversible temporomandibular joint (TMJ) problems and result in the twins losing all their teeth. I explained that they were currently at the wrong vertical dimension of occlusion (VDO) and, if opened with cotton rolls, they displayed normal profiles. I also clarified that I would be opening their bite to the centric relation (CR) position, and that current research has shown that opening the vertical dimension is safe and predictable. Furthermore, it does not create problems in the TMJ and any negative effects are self-limiting.¹⁰ I was then told that I did not know what I was talking about, was not an orthodontist, and should not interfere.

I believe in the concept of health professionals working together for the benefit of the patient.¹¹ Egos should be left at the door. I believed that a Snap-On Smile was a simple solution to help Alex and Thomas feel and immediately appear like other teenagers their age. I explained the situation to the parents. They tried to approach their orthodontist and were again told that there was nothing that could be done until the boys were older. Understanding that what I was proposing was completely reversible, and knowing how important aesthetics were to their sons, the parents chose to abandon their orthodontist and continue care with us, under our treatment plan.

A full set of radiographs and a digital intraoral iTero scan were taken. The vertical dimension would be opened based on ideal aesthetic dimensions. The stomatognathic system can adapt rapidly to a change in the vertical dimension. There is no indication in the current research that a permanent alteration of occlusal dimension will produce long-lasting TMJ symptoms. Transient discomfort can occur, usually not lasting longer than 2 to 3 months.¹² In many instances, opening the vertical dimension is beneficial in the following ways: (1) to create adequate space for the restoration, (2) to enhance aesthetic tooth display, (3) to reestablish a physiologic occlusion, (4) to avoid crown lengthening, and (5) to avoid cutting teeth (thus maintaining tooth structure).

Every dental treatment plan begins by first evaluating the facial aesthetics referencing the patient’s lips, cheeks, skin, etc. We always begin the dental evaluation by looking at the position of the maxillary central incisors and their gingival levels relative to the face to evaluate if and how they must be changed. The occlusal scheme cannot be established until we determine the desired position of the upper anterior teeth. The position of the maxillary 6 anterior teeth will dictate the vertical display as well as establish the pathways of guidance. Ideally, if orthodontics is indicated, the final position of the existing permanent teeth should be centered within the proposed restoration. Once we have the parameters of the position of the upper arch, we can then set the position of the mandibular teeth accordingly.

An upper Hawley retainer was fabricated with posterior occlusal acrylic coverage, which allowed sufficient bite opening for the correction of the anterior crossbite. Anterior springs were used to bring teeth Nos. 7 and 8 slightly more buccal. Hooks were soldered onto the molar Adams clasps to allow placement of CL III elastics. Caplan hooks were bonded to the deciduous mandibular canines to support the CL III traction and, to increase anchorage, an Essix appliance was placed, covering the entire lower arch (Figure 5). Upon initial observation, the bite was extremely closed and the maxilla appeared to be retrognathic. By opening the bite, it was observed that we would achieve a positive overjet. If this position could be maintained, it may stabilize whatever is remaining of the residual growth. If surgery would be necessary in the future, it would most likely be a maxillary advancement (Figure 6).

The twins wore CL III Ormco 5/16 light (3 oz) elastics (Ormco) on this setup for 4 months. The VDO was comfortable and the profile was pleasing. We felt that we were ready for impressions and a bite registration. A digital optical scanning system is ideal for this situation as there are no tooth preparations necessary, and all the information that needs to be captured is supragingival, which greatly simplifies the process. For the sake of this article, I chose to take traditional impressions and bite registration. The impressions were taken with StatusBlue (DMG America), a vinyl polysiloxane with a firm consistency that remains dimensionally stable and can be poured multiple times.

The bite registration was taken with a bis-acryl material (LuxaBite [DMG America]) with glass filler in a matrix of multifunctional methacrylates. I prefer to register the LuxaBite with cheek retraction so that the patient bites passively into the material with minimal resistance and no interference from the patient’s cheeks that could disturb the material. The use of cheek retractors also allows me to be able to visually ascertain that the patient is biting properly, as there is an unobstructed field of vision. The secret to using LuxaBite is to use it sparingly, placing it as a ribbon and being sure not to allow it to flow and engage in any undercuts. The material is easy to trim and does not compress for mounting, as do polyvinyl materials. LuxaBite is conveniently dispensed from a 10:1 gun and sets to a Barcol hardness of 20.

Leaving the orthodontic bite appliance in place to maintain the VDO and to open the patient’s bite in the CR position, we initially placed LuxaBite on the anterior section and allowed it to set for 2 minutes (Figure 7). The material set to a rigid consistency, locking the desired anterior bite into place. We then did a second-stage technique, removing the bite appliance and adding the LuxaBite to the posterior sections, then joining it to the previously taken anterior section (Figure 8). LuxaBite is a highly accurate bite registration, allowing us to capture the CR bite at the appropriate/desired VDO.

The study models were then poured with Silky-Rock low-expansion stone (Whip Mix) and mounted on an Artex Articulator (Jensen) (Figure 9). A conventional wax-up was created for the upper arch, based upon the parameters established by our orthodontic setup, allowing for a maxillary central incisor length of approximately 11.0 mm. The rest of the tooth dimensions can be easily extrapolated based on the size of the centrals (Figure 10). Once the shape and form of the upper arch was complete, the lower arch was added, establishing anterior guidance, midline, and overbite overjet parameters (Figure 11).

As previously stated, these procedures are ideal for a digital scan, smile design, and the wax-up. For the sake of this article, the presentation is conventional. Having a diagnostic wax-up in hand gives us the benefit of being able to physically visualize it and thus make modifications before fabricating the restoration. However, with current advancements in 3-dimensional printing, this step is not essential.

The diagnostic wax-up was optically scanned by the lab (DenMat) (Figure 12) and a stereolithography digital file was created. Proprietary CAD software was then used to design the Snap-On Smile. Specialized pucks of acetal resin were then milled to the prescribed parameters (Figure 13). The pucks come in a variety of shades. Once milled, the appliances were trimmed, finished, and polished.

The Snap-On Smile appliances snapped into place exactly as claimed. Made of crystalized acetal resin, they display unique flex characteristics. The material expands over the heights of the contours of the teeth, creating the snap effect. What a thrill it was to see the twins look at their new smiles for the first time (Figures 14 and 15). Neither appliance required any adjustment whatsoever. The CR position prescribed vertical dimension and bite registration, and the working models proved to be extremely accurate and created a pleasing profile (Figure 16). Speech and comfort were easily adapted to by the patients within a few days. The twins wear these appliances all the time, removing them only for cleaning, with no negative effects. Entirely tooth-borne, the appliances do not impinge on the gingival tissue.

Once the twins stop growing and are ready for phase 2, the next step is to plan the placement of implants according to the positions set forth in the Snap-On Smile appliances. Restoration at that point should be straightforward with the ultimate goal being to restore their dentitions with individual implants and ceramic restorations.

CLOSING COMMENTS
What appeared to be a crisis situation turned into simple case management. Although the final restoration is far from complete, the first phase’s outcome was life changing and satisfied the twins and their family. The intermediate Snap-On Smile appliances not only gave them noninvasive immediate gratification but also set the parameters for their future implant restoration by establishing an appropriate and tested vertical dimension with the ability to judge if the existing permanent teeth are in appropriate position to accommodate the final restoration. Until the actual Snap-On Smile appliances were placed in their mouths, there was no way to be completely sure.

As exemplified herein, the Snap-On Smile appliances, when used as diagnostic devices, can be an invaluable tool. And, from a psychological perspective of the patient, they can be life changing! Sometimes, simple solutions are all that is really needed. Knowing about them is the secret.

Acknowledgment
The author would like to thank Brita Nadeau, DMD, Cert Ortho (Montreal, QC, Canada).

References

1. Mechanic E. Interdisciplinary treatment planning: the restorative quarterback. Dent Today. 2015;34:72-77.
2. Larmour CJ, Mossey PA, Thind BS, et al. Hypodontia—a retrospective review of prevalence and etiology. Part I. Quintessence Int. 2005;36:263-270.
3. AlShahrani I, Togoo RA, AlQarni MA. A review of hypodontia: classification, prevalence, etiology, associated anomalies, clinical implications and treatment options. World Journal of Dentistry. 2013;4:117-125.
4. Schalk van der Weide Y, Prahl-Andersen B, Bosman F. Tooth formation in patients with oligodontia. Angle Orthod. 1993;63:31-37.
5. Kokich VG, Kokich VO. Congenitally missing mandibular second premolars: clinical options. Am J Orthod Dentofacial Orthop. 2006;130:437-444.
6. De Coster PJ, Marks LA, Martens LC, et al. Dental agenesis: genetic and clinical perspectives. J Oral Pathol Med. 2009;38:1-17.
7. Lyngstadaas SP, Nordbo H, Gedde-Dahl T Jr, et al. On the genetics of hypodontia and microdontia: synergism or allelism of major genes in a family with six affected members. J Med Genet. 1996;33:137-142.
8. Vastardis H. The genetics of human tooth agenesis: new discoveries for understanding dental anomalies. Am J Orthod Dentofacial Orthop. 2000;117:650-656.
9. Forgie AH, Thind BS, Larmour CJ, et al. Management of hypodontia: restorative considerations. Part III. Quintessence Int. 2005;36:437-445.
10. Abduo J. Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int. 2012;43:369-380.
11. Mechanic E. Focus on: interdisciplinary dentistry. Dent Today. 2014;33:18.
12. Moreno-Hay I, Okeson JP. Does altering the occlusal vertical dimension produce temporomandibular disorders? A literature review. J Oral Rehabil. 2015;42:875-882.

Dr. Mechanic received his bachelor of science (1975) and doctor of dental surgery (1979) degrees from McGill University, and practices aesthetic dentistry in Montreal, Canada. He maintains membership in numerous professional organizations, including the American Academy of Cosmetic Dentistry, the Academy for Dental Facial Esthetics, the American Society for Dental Aesthetics, and the European Society of Cosmetic Dentistry. Dr. Mechanic is the co-founder of the Canadian Academy for Esthetic Dentistry. For Dentistry Today, he is a member of the advisory board of and is also listed as one of its leaders in continuing education. He can be reached via the email address: info@drmechanic.com.

Disclosure: Dr. Mechanic reports no disclosures.

Related Articles

Interdisciplinary Treatment Planning: What Would You Do If She Were Your Daughter?

Reversing Genetic Mutations Can Restore Smiles

We all want the dentistry that we deliver to have an excellent long-term prognosis, especially when the care involves costly treatment plans. If a patient is investing thousands of dollars for an aesthetic and functional smile, neither patient nor dentist is pleased when things go wrong in a short period of time. This usually means that you will be “married” to this patient for a long time, redoing complicated dentistry that results in an unhappy patient and an even unhappier dentist. Before embarking on the dental implant journey with patients, it is important for every clinician to accomplish proper examinations and diagnostics to insure the highest rate of treatment success for a good long-term prognosis.

Evaluating Bruxism
One of the most important areas in which clinicians fail to do a proper evaluation is when care involves the treatment of bruxism. With one out of 3 patients having some level of bruxism, it is vitally important to get this under control with proper recognition and bruxism treatment before placing any implants or for that matter any dentistry.

There are 2 ways to evaluate a patient for destructive bruxism. One way is the physical examination of the patient. Most dentists are trained to detect the signs of tooth wear that are symptoms of bruxism. What we would like to focus on is what the American Academy of Facial Esthetics (AAFE) refers to as reading faces for bruxism and occlusal disease. You are probably wondering what a patient’s face has to do with bruxism in the mouth. In the experience of thousands of AAFE members who are dental professionals, we would all tell you that reading faces is much more important than seeing what is happening in the mouth.

Let’s look at a face together and it will be clear as to what the authors mean. Figure 1 shows the patient, who is the focus of the case report in this article, at rest. What do you see? If you learn to read her face, you will see very big masseter muscles with her left masseter being significantly larger than her right masseter. At rest, these muscles are unusually large, which means they are getting quite the workout to achieve that size. Indeed, they are the same as any other muscle in the body—the more you work it, the larger it gets. Would it surprise you that this patient has significant destructive bruxism? I don’t even have to look in her mouth to know it. She didn’t even have to tell me how the 8 bruxism appliances she had during the last few years—which she chewed through—didn’t help her at all. Most certainly, before we performed any restorative dentistry in her mouth, we would need to address these masseter muscles which provide all the power to her bruxism. This is what we refer to as reading faces.

If we want to confirm objectively how much bruxism this patient has, we can have her take an overnight bruxism/sleep monitor test (STATDDS). We in fact did administer this test and found that her bruxism episodes index (BEI) was 6.2, which gave us a baseline of the destructive bruxism that she had (a BEI greater than 5 is clinically destructive bruxism). It would be foolish to attempt any restorative dentistry, especially implant dentistry, without addressing her bruxism issues concretely. It is for this reason that Dr. Gordon Christensen¹ has said, “Bruxism monitoring is one of the most important concepts in dentistry today.”

Using Botulinum Toxin in the Treatment of Bruxism
Botulinum toxin (Botox [Allergan] or Xeomin [STATDDS]) can be an excellent treatment option for bruxism. Botox reduces the intensity of contraction of the muscle through its mechanism of action of interrupting the neurotransmission of acetylcholine to the muscle. With proper training in the anatomy, physiology, pharmacology, and botulinum toxin delivery, a simple injection in each masseter would eliminate this patient’s bruxism and give her face a more aesthetic appearance. This was confirmed by a post-test with the STATDDS bruxism/sleep monitor, which now showed her BEI to be 0.6, effectively eliminating her bruxism. Even more so, this is clear by reading her face in the postoperative photo. In Figure 2, you can see for yourself that her bruxism is eliminated even without testing.

The advantages of using botulinum toxin for bruxism over any kind of appliance are that there are no compliance issues to deal with, and it is safe and effective. In this patient’s case, none of the bruxism appliances she had made were successful (she reported how each successive dentist told her the previous appliance wasn’t going to work, but the new one definitely would). Her bruxism and 12-year history of orofacial pain was completely resolved with a treatment plan consisting of botulinum toxin injections and trigger point therapy. It is important to let patients know that it takes botulinum toxin 2 to 10 days to begin to work after treatment and will last for 3 months, at which time the patient will need retreatment.

Once a patient’s bruxism is under control, then it is time to go inside the mouth, and implant treatment can begin and the clinician can feel confident of the long-term prognosis. Another way to deal with the results of bruxism is to use high-strength restorative materials that can withstand the impact of excessive bruxism.

CASE REPORT
Diagnosis and Treatment Planning
A 43-year-old female presented with a chief complaint of missing maxillary right and mandibular left dentition, broken-down bicuspid teeth, and unaesthetic and worn-down maxillary anterior teeth (Figures 3 to 5). Her maxillary right first bicuspid (tooth No. 5) was fractured, and she reported having pain in her second bicuspid (tooth No. 4) (Figure 6). She was unhappy with her smile and had several concerns, including pain in the upper right quadrant, fractured teeth, and loss of occlusion due to the missing maxillary right teeth and mandibular left teeth. It was determined that her mandibular teeth were in good repair and maintained aesthetic contours.

Figure 1. Reading this patient’s face tells the clinician that she has been suffering from destructive bruxism and TMJ/orofacial pain.	Figure 2. After treatment with Botox (Allergan), her bruxism issues were resolved, allowing restorative treatment to begin.
Figure 3. This patient was a bruxer with worn maxillary teeth and some missing posterior teeth.	Figure 4. Digital periapical radiographs demonstrated large broken restorations along with caries.
Figure 5. This radiograph showed more of the same, including a significant loss of tooth structure on the cuspid due to bruxism.	Figure 6. Tooth No. 4 was deemed nonrestorable and endodontic therapy treatment was done on tooth No. 5.

Figure 7. Postoperative radiograph of the Hahn Tapered Implant System (Glidewell Laboratories) implants were ideally placed.

When patients present with missing posterior occlusal stops, function then rests on the anterior teeth. This may result in excessive wear and un-aesthetic flattening of incisal edges due to her occlusion and bruxism.

She was also being treated for Crohn’s disease with Asacol and was previously diagnosed with micoadenoma pituitary gland.

We discussed the possibility of retaining teeth Nos. 4 and 5 and consulted with an endondontist who found tooth No. 4 unrestorable. A conventional post-and-core and crown would be completed on tooth No. 5.

The decision was made to restore the maxillary arch with implants and strong aesthetic crowns. This would increase the vertical dimension of occlusion, improve the length of the teeth to a younger appearance, and provide stability to the occlusion due to restoration of the posterior regions.

Figure 8. Postoperative CBCT images (Vatech America) of implant in No. 3 position in proper orientation.

Figure 9. Postoperative CBCT images (Vatech America) of implant in No. 4 position in proper orientation.

Implant Treatment Protocol
For this case, the Hahn Tapered Implant System (Glidewell Laboratories) was to be used due to its innovative design and initial stability following surgical placement. The system allows the practitioner to angle and position the implant into available bone due to the pronounced threads that bore firmly to maximize bone adaptation. There is a buttress thread pattern that allows this stability and reduces bone resorption at the crest, which is often seen with other implant systems. Coronal microthreads help to preserve the crestal bone. The Hahn implant is processed with a resorbable blast media, which promotes osseointegration.^2,3 There is also an intentional machined collar on the implant, which helps with soft-tissue health. The internal design of the implant is a conical hex connection. This connection ensures a firm and proper prosthetic seal. Note that the prosthetic design is one of platform switching, with all abutment connection on the inside of the body of the implant.

The surgical protocol for the Hahn Tapered Implant System is precise. First, a 2.2-mm diameter pilot drill is used to create the initial osteotomy. This establishes proper depth around any vital anatomy and the mesial-distal angulation of the implant. Dr. Kosinski prefers to parallel multiple implants to the natural tooth roots. Proper depth is determined radiographically. Next, 3.5-mm and 4.3-mm diameter osteotomy burs of established depth are used to create the final osteotomy. The Hahn implant is threaded into the prepared site and torque is established. Here, 40 Ncm of torque was achieved upon initial placement. Cover screws are inserted into the implants. The beveled surface of the implant is positioned slightly subcrestal in the immediate extraction socket, but at the crestal ridge of the edentulous molar site.

Using CAD/CAM designed and milled custom abutments allow for proper emergence profile and smile design. The margins are created at or just slightly subgingival to maintain tissue health and eliminate the possibility of cement staying in the gingival sulcus. Screw-retained crowns are used when the vertical occlusal space is compromised or where milled abutments would be too short to maintain a cement on crown. In this case, high translucency monolithic zirconia crowns would be used. This high-strength all-ceramic material is designed for long-term durability and yet to exhibit a more natural translucency than seen with the originally introduced zirconia materials. The implant-retained crowns are virtually designed and milled using the most innovative CAD/CAM technology.

Figure 10. After a period of 4 months for osseointegration, the clinical work continued. Impression copings were placed into the internal design of the Hahn implants.	Figure 11. A radiograph was taken to ensure the complete seating of the impression copings.
Figure 12. The Glidewell Laboratories team fabricated an abutment for a screw-retained zirconia crown (BruxZir) for the No. 3 implant abutment. A custom abutment was fabricated for the No. 4 implant.	Figure 13. Occlusal view of the 2 implant crowns (Nos. 3 and 4) in place.

Figure 13. Occlusal view of the 2 implant crowns (Nos. 3 and 4) in place.

The treatment plan called for dental implants to be strategically placed in the maxillary right second bicuspid (No. 4 position) and first molar (No. 3 position) area, following atraumatic extraction of the nonrestorable second bicuspid tooth. The maxillary right first bicuspid (tooth No. 5) was treated with a post-and-core assembly and a new functional crown.

Clinical Treatment
Tooth No. 4 was atraumatically removed and the site grafted with Cerasorb Tri-Calcium Phosphate 250 to 1,000 μm (Curasan). Next, a 4.3-mm x 13-mm implant (Hahn Tapered Implant System) was immediately inserted and torqued to 40 Ncm. Then, a second 4.3-mm x 8-mm implant (Hahn Tapered Implant System) was also placed in the edentulous maxillary right first molar site using a flapless technique. The implant engaged bone anterior to the maxillary sinus (Figure 7). The implant placement was prepared and then verified for proper orientation and position with CBCT images (Vatech America) (Figures 8 and 9). Note that the immediate implant placement was about 1.0 mm subcrestal, allowing for proper physiologic reorganization of the bone.

The implants (Figures 10 and 11) were allowed to integrate for approximately 4 months prior to impressions and the fabrication of custom abutments and implant crowns.

The Glidewell Laboratories team fabricated a custom abutment for the maxillary right second bicuspid (No. 4) implant. Note that the margins were prepared at or just slightly subgingival to ensure that cement removal was simple and complete. A cement-retained zirconia crown (BruxZir [Glidewell Laboratories]) was placed (Improv [Salvin Dental Specialties]) on the No. 4 implant abutment. An abutment and screw-retained zirconia crown (BruxZir) for the No. 3 implant abutment was fabricated and placed. (The access opening would be easily concealed later using composite resin [Figures 11 to 13].)

The mandibular left posterior site was also restored with Hahn implants. The plane of occlusion was established using the mandibular arch, which was in better repair.

Due to the excessive wear of the maxillary anterior teeth, durable and aesthetic zirconia crowns (BruxZir Anterior [Glidewell Laboratories]) were prescribed and placed for teeth Nos. 6 to 12. This restorative choice gave the patient teeth with the desired aesthetics, while increasing the incisal opening to improve function and the patient’s overall facial aesthetics (Figure 14).

CLOSING COMMENTS
The days are over when a dentist simply gives a patient a bruxism appliance while thinking that the bruxism is adequately under control prior to any restorative and implant treatment. Clinicians have different options to deal with bruxism, and the treatment of this disease should be addressed before any restorative dentistry is accomplished. This article has presented the concepts and a case demonstrating the need for bruxism monitoring, treatment using Botox for the bruxism, and the use of high primary stability implants along with strong restorative materials.

Every dentist should seek and receive appropriate training in these diagnosis and treatment arenas. This will help clinicians ensure better therapeutic outcomes for their patients. Both of the authors are heavily involved with training general dentists in these areas, and every general dentist is capable of placing implants and using Botox treatment for bruxism. Get trained today!

References

1. Malcmacher L, Christensen G. Botox and Dermal Fillers in Dentistry . Utah, Nev: PCC Dental; 2015.
2. Piattelli M, Scarano A, Paolantonio M, et al. Bone response to machined and resorbable blast material titanium implants: an experimental study in rabbits. J Oral Implantol. 2002;28:2-8.
3. Nishimoto SK, Nishimoto M, Park SW, et al. The effect of titanium surface roughening on protein absorption, cell attachment, and cell spreading. Int J Oral Maxillofac Implants. 2008;23:675-680.

Dr. Malcmacher is a practicing general dentist and an internationally known lecturer and author. He is the president of the American Academy of Facial Esthetics, and he can be reached at (800) 952-0521 or via email at drlouis@facialesthetics.org.

Disclosure: Dr. Louis Malcmacher is an unpaid consultant for STATDDS.

Dr. Kosinski is an affiliate adjunct clinical professor at the University of Detroit Mercy School of Dentistry and is in private practice in Bingham Farms, Mich. He is currently the associate editor of the AGD journals. He is a Diplomate of the American Board of Oral Implantology/Implant Dentistry and the ICOI, and he is a Fellow of the AAID, ACD, ICD, and the ADI. He can be reached at drkosin@aol.com.

Disclosure: Dr. Kosinski reports no disclosures.

Authors’ Note
Visit facialesthetics.org for information about live-patient Botox and dermal filler training, frontline TMJ/orofacial pain trigger point therapy, dental implant training, frontline dental sleep medicine, bruxism therapy and medical insurance, download Dr. Malcmacher’s resource list, and sign up for a free monthly e-newsletter.

Also By These Authors

The Occlusion Myth

The Dental Decision Maker: Reducing or Eliminating Failed Dentistry

A few years ago, I discovered the Inman Aligner. This ingenious device was invented by Don Inman, CDT, of Coral Springs, Fla. It is a removable appliance that consists of an inner bow that pushes teeth labially and an outer bow that pulls teeth lingually (Figure 1). The appliance encompasses nickel titanium coil springs powering 2 opposing aligner bows to guide the teeth into their new positions. The Inman Aligner works quickly because the gentle forces are active over a very large range of movements. Most cases can be completed in 6 to 12 weeks, and sometimes one or 2 clear aligners are needed for refinement. It is useful only for the anterior 6 teeth that have crowding of 3.0 mm or less. I have used the Inman Aligner to align mandibular anterior teeth prior to restoration of opposing maxillary teeth to provide better functional contact. I have also used it for maxillary crowded teeth or to close spaces caused by flared teeth.

My patients have embraced the appliance because it can be removed according their lifestyle. It must be worn for 16 to 20 hours a day and removed for at least 4 hours a day. The relaxation of the bone upon removal allows for the absence of bone loss.

The appliance itself needs no adjustments as the total action is built in. Sometimes, I have added a small amount of composite resin on distal to the spring to tighten it when the bow has lost the “ping” due to tooth movement; however, this is rare. Interproximal reduction (IPR) with diamond-coated strips is all that is usually required. After the aligner is delivered, the patient is seen every 2 weeks to make slight adjustments to proximal contacts using the IPR technique. Sometimes, tooth contouring with discs or burs to reshape proximal surfaces is desired. Lifetime retention is recommended and can be accomplished with a bonded lingual wire or removable Essix retainers.

CASE REPORT
Diagnosis and Treatment Planning
Our patient presented desiring porcelain veneers to align and restore her maxillary anterior teeth (Figure 2). Upon evaluation, it was obvious that part of the problem was the uneven incisal contact with the crowded mandibular anterior teeth. In Figure 3, you can see her contact position. The facial view in Figure 4 illustrates crowding of the mandibular 4 anterior teeth, uneven and worn incisal edges, and an uneven tissue line. The incisal view before treatment is shown in Figure 5. It was explained to the patient that the uneven contact with the mandibular teeth was, in part, the cause of wear of the incisal edges of her maxillary centrals. She was thrilled to hear that the mandibular teeth could be straightened in only a matter of weeks with a removable appliance. This would be done prior to the placement of veneers on her maxillary anterior teeth so that the occlusal contacts between the teeth in the anterior segment could be idealized for optimal restorative longevity.

Figure 1. Diagram showing forces on Inman Aligner.	Figure 2. Pre-op photo of the patient’s anterior teeth.
Figure 3. Pre-op closed bite incisal view of the patient’s anterior teeth.	Figure 4. Pre-op close-up facial view of mandibular anterior teeth.
Figure 5. Incisal view of mandibular anterior teeth before treatment.	Figure 6. Facial view of Inman Aligner at delivery.
Figure 7. Incisal view of Inman Aligner at delivery.	Figure 8. Incisal view after 8 weeks of treatment.
Figure 9. Facial view of mandibular anterior teeth after alignment.	Figure 10. Incisal view of mandibular anterior teeth after alignment.
Figure 11. Close-up view after composite resin (NANOCERAM BRIGHT [DMP Dental]) was bonded to the incisal edges.	Figure 12. Bonded retainer wire in place.
Figure 13. Facial view of maxillary veneer (IPS e.max [Ivoclar Vivadent]) in place and mandibular incisors aligned and bonded.	Figure 14. New crystal clear wire-free labial bow (Inman Aligner).

An accurate impression of her mandibular arch using an A-silicone impression material (Panasil [Kettenbach LP]) and an opposing alginate substitute impression (Salginat [Kettenbach LP]) was also taken along with an A-silicone occlusal registration (Futar [Kettenbach LP]). These were sent to the Inman Ortho Lab where models were poured and trimmed, then scanned and digitized. Using sophisticated software, the laboratory team digitally corrected the misaligned teeth and a report was created giving IPR location and amount, a tooth movement summary, and before and after screen shots. The corrected digital model was then sent to a 3-D printer where a corrected physical model was printed. The appliance was then designed and fabricated on the corrected physical model so that all the corrective forces were built into it. The Inman Aligner appliance was then returned to our office and was ready for delivery.

At the patient delivery appointment, the interproximal stripping (IPR) was accomplished and the appliance delivered. The patient was shown how to place and remove the appliance. She was instructed to leave it in place for at least 16 hours a day, and to remove it for at least 4 hours a day. The patient was to return in 2 weeks for an aligner check and adjustments to proximal contacts. The Inman Aligner is shown in place from the facial view at delivery in Figure 6 and from the lingual view in Figure 7.

The patient returned in 2 weeks and slight additional IPR was done. This was repeated at 4 weeks and again after 4 more weeks. The alignment achieved in 8 weeks can be seen from the incisal view in Figure 8 with the Inman Aligner in place. Figure 9 shows the aligner removed from the facial view and the incisal view in Figure 10. Note the improvement in the tissue levels.

At the 8-week appointment, composite resin bonding using a nano-hybrid composite (NANOCERAM BRIGHT [DMP Dental]) at the incisal edges was accomplished (Figure 11) and a bonded lingual wire was attached for retention (Figure 12). The maxillary incisors (teeth Nos. 7 to 10) were prepared for porcelain veneers. Impressions were taken, sent to our restorative dental laboratory team, and lithium disilicate (IPS e.max [Ivoclar Vivadent]) veneers were fabricated and returned for delivery using an adhesive bonding technique with a light-cured resin cement (Choice 2 [BISCO Dental Products]). The completed prerestorative ortho/restorative-aesthetic interdisciplinary case can be seen in Figure 13.

CLOSING COMMENTS
By utilizing the Inman Aligner, the expectations for this patient’s desired aesthetics and improved function were more easily achieved. Using this conservative and affordable approach is a choice that your patients will also appreciate.

The appliance is regularly being improved, and recently a more aesthetic crystal clear wire-free labial bow has been introduced (Figure 14).

Dr. Nash maintains a private practice in Huntersville, NC, where he focuses on aesthetic and cosmetic dental treatment. An accredited Fellow in the American Academy of Cosmetic Dentistry and a Diplomate for the American Board of Dental Aesthetics, he lectures internationally on subjects in aesthetic dentistry and has authored chapters in 2 dental textbooks. He is co-founder of the Nash Institute for Dental Learning in Huntersville and is a consultant for numerous dental product manufacturers. He can be reached at (704) 895-7660, via email at rosswnashdds@aol.com, or at the website thenashinstitute.com.

Disclosure: Dr. Nash reports no disclosures.

Author’s Note
For CE opportunities, certification is voluntary in the United States but highly suggested and can be done online at inmanalignertraining.com and using the code “Inmanortho.” Dr. Nash also teaches a full-day Inman Aligner hands-on course at The Nash Institute, covering everything from case selection to final retention.

Also By Dr. Nash

Marrying Clinical Techniques and Teamwork

Minimally Invasive Preps for Thin Porcelain Veneers

Ceramic Crown for an Implant Abutment

Until the late 1970s, the public looked at dentists with fear and associated dentists with pain. In their minds, dentists just “drilled, filled, and billed.” A group of dentists, at that time, began to perform elective dental services on their patients for purely aesthetic reasons. These inventive aesthetic pioneers changed the public’s perception of dentistry, and people began to appreciate and desire elective aesthetic procedures. However, a large number of dentists looked upon these services as being unnecessary and even detrimental to the patient’s oral health. The demanded that these “aesthetic quacks” be stopped and their right to practice revoked.

How times have changed! All the dental specialties have now gotten into the act. Orthodontists today do not just treat “crooked” teeth but align tissue levels, repair periodontal defects, and align teeth to exacting positions to accommodate a proposed restoration. Periodontists do not merely treat disease but electively aim to place tissue levels with proper aesthetics.

The aesthetic dental pioneers and rapid changes in techniques and dental materials opened a dental revolution and inspired a revolution in dental education. We are no longer living in G. V. Black’s and Edward Angle’s world of conventional rules and standards. Dentists are now thinking outside the box, allowing the patient’s face to dictate the treatment, and patients are benefitting enormously.

The restorative dentist should be the team leader, like a quarterback executing the plays to achieve the desired treatment outcome. The clinician is expected to deliver an excellent final outcome, and that is a big obligation! To begin with, the restorative dentist must have a clear vision of the desired outcome in order to plan and sequence the necessary steps to achieve it. In addition, one must also be familiar with the procedures available in the various dental disciplines and guide the patient accordingly.

First and foremost, the clinician, as quarterback, should listen to the patient and establish realistic treatment objectives based on the patient’s needs and expectations, while taking into account any budgetary considerations. The restorative dentist should create the vision of the desired result and establish a blueprint (treatment plan) on how to execute the plan. A treatment sequence is determined that often involves periodontics, orthodontics, and implantology. Misshapen and malformed teeth are usually first built to ideal proportion and are positioned to facilitate restorative treatment. The quarterback (clinician) must interact with the various players (specialists) throughout treatment, checking and taking radiographs during finishing to visualize root proximity, angulations, and if there is adequate space available for implants. Sometimes, the restorative dentist may even choose to temporize teeth before specialty treatment is completed to help visualize proposed tooth positions and to verify if any treatment changes might be needed. Once everything is in place, the final restorative work is fabricated and delivered.

THE ROLE OF THE ORTHODONTIST
Historically, orthodontists were treating teenagers and not accustomed to dealing with patients requiring restorative intervention. Adolescents generally require little or no restoration. However, in the 21st century, orthodontists are often treating adults who have not benefited from preventive dentistry, and have serious restorative and/or periodontal needs. The objectives of orthodontic treatment may be totally different for the restorative patient as compared to a nonrestorative patient. For example, (1) the teeth may have to be moved by the orthodontist to place them in an ideal position to be restored and, sometimes, it may be beneficial to temporize these teeth before or during orthodontics to achieve a better vision and perspective of the final result; (2) orthodontics may be required to correct tooth malposition that is compromising to the patient’s oral hygiene; and (3) orthodontics may be performed for elective or nonelective periodontal reasons.

The restorative patient may require tooth positioning that may be totally different from the nonrestored adolescent patient with all of his or her natural teeth. The teeth may be worn, resulting in discrepancies in the incisal and occlusal planes. There may be fractured, misshapen, or malformed teeth, such as peg laterals or narrow anteriors lacking anatomical form. Missing teeth may have led to midline asymmetry and edentulous areas lacking the require space to accommodate the desired tooth replacement. The patient may have periodontal bone loss, missing papilla, and uneven gingival margins. Therefore, current orthodontic objectives include (1) establishing a stable and functional occlusion, (2) enhancing the health of the periodontium, and (3) improving dental facial aesthetics.

THE ROLE OF THE PERIODONTIST
There are times when orthodontics provides the best benefit for the periodontal patient:^1,2 (1) by aligning crowded or malposed teeth, periodontal maintenance is easier; (2) vertical orthodontics can be utilized to improve osseous defects; (3) orthodontics can improve the position of the gingival margins; (4) high-intensity orthodontic extrusion can create forced eruption of fractured teeth; (5) orthodontics can be used to regenerate lost papilla; and (6) orthodontic care is often necessary to optimize the position of implant placement.
Various periodontal procedures exist, and are being developed, to alter gingival position for health and aesthetics^3-7 (Tables 1 and 2).

Facially Generated Treatment Planning
In a world where dental standards are being rewritten, and the dentist has been recognized as an oral plastic surgeon, the dental paradigm has shifted to what is known as facially generated treatment planning. In other words, “the face dictates the treatment.” Every dental treatment plan begins by evaluating the facial aesthetics first by referencing the patient’s lips, cheeks, skin, etc. We always begin by evaluating the maxillary tooth position and gingival levels relative to the face to evaluate if and how things must be changed. We cannot establish the occlusal scheme until we determine the final desired position of the anterior teeth; this information will then dictate the vertical and edge-to-edge position as well as the pathways of guidance.

When establishing a treatment plan, the restorative quarterback should always begin by establishing a final aesthetic vision. If we don’t know what we are trying to achieve, how can we expect to predictably get there? Once we have determined the aesthetic goal, the health of the teeth and periodontium must be evaluated to create a dental result that is easily maintainable, with a stable and functional occlusion that is in in facial harmony and muscle balance.

The orthodontist is often the first in line in a decision process that can affect the patient’s appearance for the rest of that individual’s life.⁸ Traditionally, orthodontists evaluated a patient’s facial appearance both resting and during movement in 3 dimensions: vertical, horizontal, and sagittal. It is most important to consider a “fourth dimension” too: time! Time is the “dental twilight zone,”⁹ as it is difficult to predict how the patient’s facial appearance will change with age. We must do everything we can dentally to help protect our patients’ faces from the ravages of time.

As previously stated, the first thing we evaluate in the treatment planning protocol is the maxillary anterior tooth position.^10-12 It is important to observe how much of the anterior teeth are showing at rest and when the patient smiles. As people age, their maxillary anterior tooth display decreases, and their mandibular tooth display increases.¹³ We must evaluate if their lips are full, thin, or hypermobile. Then, one can compensate for many of these factors in any treatment plan.

Once the desired position for the maxillary anterior teeth has been established, the position and form of the lower arch is evaluated.¹¹ Lower arch discrepancies affect the position of the upper arch as they must fit together. Lower arch discrepancies result in deviations in the incisal and occlusal planes. Just as architects design structures from the ground up, dentists must do the same. We must ask ourselves if the lower arch is in proper alignment to accommodate the proposed changes to the upper arch. If not, we must begin by redesigning and placing the lower arch in ideal position using restorative techniques, orthodontics, and/or surgery.

We begin by evaluating the position and form of the mandibular incisors for midline, arrangement, overbite, overjet, wear, mobility, fractures, signs of disharmony, and pathways of guidance. We then observe the posterior teeth looking for position, plunger cusps, wear, microfractures, abfraction, supereruption, etc. We ask ourselves if we can simply reshape or restore the teeth, or whether we need to move them orthodontically.

Once we have determined the desired aesthetic result and the corresponding position of the teeth, we must establish the arrangement, contour, and shade the patient desires. Personality and age must be taken in account and, in addition, the length, shape, width, and surface texture. There are many different restorative options available: composite resins, ceramic veneers, all-ceramic crowns, metal ceramics, implants, and removable prostheses. We must consider the biological, spatial, and logistical issues when choosing what type of restoration and which material to use:

1. How much resistance and retention is there on the prep? We need adequate prep length and retentive ferrule.
2. Is the tooth biologically strong, or has it been weakened by endodontics or extensive restoration?
3. Are there light or heavy mechanical forces on the dentition? We must evaluate bruxism, clenching, attrition, abrasion, etc.
4. Do we have adequate space for our ideal restorative material, or do we need to change our material choice or create more available space?
5. What are the chemical influences on the proposed restoration (acidity, erosion, perimolysis)?
6. What material does our lab prefer? As with everything else, certain people prefer one product to another.

CASE REPORT
Diagnosis and Treatment Planning
Our patient first presented to obtain a second price quote for upper implants to replace teeth Nos. 10 to 12 (Figure 1). He explained that his problems began when he fractured tooth No. 10 off at the gumline. It was replaced with a cantilever pontic that utilized the canine (No. 11) as an abutment. He was told that the canine was a very strong tooth and would be able to support the missing lateral indefinitely. However, the canine soon fractured off also, followed by the first bicuspid. An acrylic partial denture was then fabricated to replace the 3 missing teeth. The dentist also recommended implants to permanently replace the missing teeth, but the patient found the proposed cost to be excessive and he wanted a second opinion and price quote.

Figure 1. Preoperative photo. Patient missing teeth Nos. 10 to 12.	Figure 2. Several years later, more teeth have been lost.
Figure 3. Lower arch collapse did not allow adequate space for a restoration.	Figure 4. The surgical implant stent.

Evaluation of the position and shape of the upper anterior teeth found them to be acceptable. The midline was not totally centered, and the teeth were slightly canted, but this did not bother the patient.^14,15 However, the lower teeth were not aligned, resulting in posterior bite collapse and an excessively deep bite, creating excessive forces to the upper anterior teeth. It was thoroughly explained to the patient that his problem included his lower teeth, and that lower orthodontic treatment was needed before placing the upper implants and fixed prosthesis. He looked at me as if I was crazy and exclaimed that dentists just try to “rip off patients for as much money as possible.” All he wanted was “3 #&$%! upper teeth.” What did the “lower teeth have to do with replacing 3 upper teeth?” None of his previous dentists ever said he had problems with his lower teeth. He left without saying thank you or goodbye.

Interestingly, a few years later, he reappeared for another consultation. He had subsequently snapped off his crown on tooth No. 9 and had yet another partial denture made (Figure 2). Tooth No. 13 was now extremely mobile and painful. His dentist told him that his teeth were weak and that it was best for him to remain in a partial, as other teeth would probably break as well. The patient did not want to continue losing his teeth, and was now open to really listen to what I had tried to explain to him several years earlier.

The lower arch had now collapsed to a point where there was not adequate space to create an upper fixed restoration (Figure 3). The lower left canine was rotating and sliding buccally over the bicuspid distal to it. I explained that this canine was the probable culprit that caused the loss of the lateral, canine, and first bicuspid. This time, the patient had an open mind and seemed to understand and accept his predicament. We decided to simultaneously begin lower orthodontic treatment to align the lower arch to ideal and to place implants in order to have a fixed porcelain restoration replacing the missing upper teeth. Total treatment time of 8 to 10 months was anticipated.

Clinical Protocol
A diagnostic setup and surgical implant stent were created in order to place the implants in their specified position (Figure 4). The stent not only showed us the position of the teeth, but also allowed us to align the correct vertical angulation and depth, permitting us to visualize the position of the proposed tooth in full form and contour. Implants (ANKYLOS [DENTSPLY Implants]) were placed in position Nos. 9, 11, and 12; tooth No. 13 was extracted and was replaced with an immediate implant (Figure 5). ANKYLOS implants were chosen because they are placed subcrestally, and the conical, 6° Morse taper abutment places no load on the abutment screw. By having no micromovement, there is little to antagonize the hard and soft tissues resulting in papilla preservation, with no subsequent bone loss and a natural looking emergence profile.

Figure 5. ANKYLOS (DENTSPLY Implants) implant placement using the surgical stent.

Figure 6. ANKYLOS transfer copings.

Figure 7. Verification using a panoramic radiograph of the ANKYLOS transfer copings.

Figure 8. Bite registration using an acrylic baseplate and wax rim.

Figure 9. Lab made provisional bridge (Telio Lab [Ivoclar Vivadent]), using ANKYLOS temporary abutments.	Figure 10. The provisional bridge in place.

Figure 11. Teeth Nos. 7 and 8 were prepared, and dentin and porcelain shades taken.

Figure 12. Teeth Nos. 7 and 8 receive the provisional (Luxatemp Ultra [DMG America]).	Figure 13. Parallel metal ANKYLOS abutments.

Six months passed, the upper implants were integrated, and the orthodontics had advanced to the point where the lower arch was nearly aligned. It was decided that it was time to fabricate a fixed upper temporary prosthesis. ANKYLOS transfer copings were placed and a Panorex radiograph was taken to verify position and alignment (Figures 6 and 7). The author prefers to take open-tray implant impressions and still use the “old school” method of joining the implant transfers with dental floss and pattern resin. This technique prevents movement of the transfers and virtually guarantees an accurate impression and perfectly fitting implant abutments. A vinyl polysiloxane putty (Honigum MixStar Putty [DMG America]) and light-body wash (Kopy [Dental Savings Club]) were used for the final impression. The Kopy light body is extremely flowable, and the Honigum Putty is an extremely firm material ideally suited to implant impressions as it firmly locks the transfers in place, preventing any micromovement that could result in inaccuracies when pouring the stone model. A wax rim on an acrylic baseplate was used to register the bite (Figure 8).

An acrylic (Telio Lab [Ivoclar Vivadent]) provisional bridge was fabricated by the laboratory team using ANKYLOS temporary abutments (Figure 9) and placed in the patient’s mouth (Figure 10). This allowed the patient to experience fixed teeth for the first time in years. In addition, aesthetics were evaluated and, most importantly, the accuracy of the master impression was verified, assuring us that the permanent restoration would fit accurately. The lower orthodontic brackets were removed and a lingual retention wire placed on the lower anterior teeth.

Upon seeing and feeling the fixed provisional restoration in his mouth, our patient began to feel excited and started to appreciate his treatment plan. Although he had previously and emphatically made it clear that he had no interest in restoring more than the missing teeth, he was now interested in enhancing the look of his other front teeth. Teeth Nos. 7 and 8 were prepared, dentin and porcelain shades with shade photos taken (Figure 11), and then the teeth were provisionalized (Luxatemp Ultra [DMG America]) (Figure 12). Our treatment plan called for a 5-tooth porcelain-to-zirconia fixed restoration, attached to metal implant abutments by lingually placed Dentatus set screws. The lingual set screws allow the bridge to be retrieved should a future repair be needed. They also are not influenced by implant position, nor do they weaken the porcelain, as often occurs with larger screws placed through the occlusal surfaces. By eliminating the use of cement, the risk of peri-implantitis is also reduced.^16,17

Our lab team fabricated parallel individual metal implant abutments (Figure 13) with occlusal screw access to the ANKYLOS implants and lingual screw taps for the tiny Dentatus screws to secure the zirconia prosthesis (Figure 14). An acrylic jig was supplied to be able to easily place the abutments in the patient’s mouth (Figure 15).

When the metal abutments and zirconia frame (Prettau [Zirkonzahn]) were placed in the patient’s mouth, the fit was precise (Figure 16). Utilizing an open-tray impression technique with the fabrication of a temporary bridge using temporary abutments ensures the predictability of fit of the final restoration. An acrylic bite registration material (LuxaBite [DMG America]) was placed over the zirconia frame, and then a new bite registration was taken. This material eliminates any movement and inaccuracies that would otherwise be associated with the use of vinyl polysiloxane bite registration materials. The zirconia frame and abutments were then removed and replaced with the acrylic provisional bridge.

Lithium disilicate (IPS e.max [Ivoclar Vivadent)] was layered over the zirconia frame (Figure 17). An appointment was made to place the bridge and take the final impression for teeth Nos. 7 and 8 that had previously been prepared and temporized. To our complete surprise, the patient asked if we could restore his upper right arch as well. Had he ever come around! This was most definitely not the same man who we had first met!

Figure 14. The lingually placed Dentatus set screws attach the zirconia frame.	Figure 15. An acrylic jig enables easy placement of the abutments in the patient’s mouth.
Figure 16. The zirconia frame (Prettau [Zirkonzahn]) with Dentatus set screws in place.	Figure 17. The zirconia frame was layered with lithium disilicate (IPS e.max [Ivoclar Vivadent]).
Figure 18. The restored dentition.	Figure 19. Lingually placed Dentatus screws secure the bridge and a thin coating of TempBond Clear (Kerr) was used to seal the margins.

Figure 20. A very happy patient.

The upper right quadrant was prepared, impressed, and a Luxabite registration taken. Lithium disilicate (e.max) restorations were fabricated and cemented with a glass ionomer cement (Fuji II [GC America]) (Figure 18). A small amount of TempBond Clear (Kerr) was placed at the margins of the zirconia bridge, which was then secured with the lingually engaging Dentatus screws (Figure 19). The restoration was then checked in protrusive, and right and left excursive movements, and adjusted as required to correct any occlusal discrepancies. After many years of dealing with less than satisfactory results and ongoing problems, our patient was finally one happy camper (Figure 20)!

CLOSING COMMENTS
The importance of a complete treatment plan, with a clear vision of the final outcome, cannot be over emphasized. The clinician must always realize that patients did not go to dental school and can often be misinformed by being told what a previous dentist assumed that they wanted to hear. In our office, every one of our treatment plans follows the same protocol of first establishing the position of the upper anterior teeth and then determining if the lower teeth are in the correct position to support and maintain them in health.

If we take the time to thoroughly educate our patients by telling them what we know, it is the author’s belief that many more patients would opt for ideal treatment. It is this author’s opinion that people do not want to intentionally hurt themselves. Oftentimes, they just are not adequately prepared to make an educated and fully informed decision. Just as there are no shortcuts in medical surgical procedures, the same standards should apply in dentistry.

Acknowledgement
The author would like to thank the following people: Eric Chatelain, DMD, for implantology; George Pappas, DMD, MSc, for orthodontics; and Bassam Haddad, MDT, for oral design (Vivaclair dental lab, Quebec, Canada).

References

1. Kokich VG, Spear FM. Guidelines for managing the orthodontic-restorative patient. Semin Orthod. 1997;3:3-20.
2. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod. 1996;2:21-30.
3. Kois JC. Altering gingival levels: the restorative connection. Part I: biologic variables. J Esthet Restor Dent. 1994;6:3-9.
4. Miller PD Jr. Reconstructive periodontal plastic surgery. J Tenn Dent Assoc. 1991;71:14-18.
5. Heithersay GS. Combined endodontic-orthodontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg Oral Med Oral Pathol. 1973;36:404-415.
6. Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects—rationale and case report. J Periodontol. 1974;45:199-206.
7. Brindis MA, Block MS. Orthodontic tooth extrusion to enhance soft tissue implant esthetics. J Oral Maxillofac Surg. 2009;67(suppl 11):49-59.
8. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2. Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop. 2003;124:116-127.
9. Mechanic E. Anterior tooth challenges, part 4: Canines in the lateral position. Dent Today. 2014;33:84-89.
10. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111.
11. Kokich V. Esthetics and anterior tooth position: an orthodontic perspective. Part II: vertical position. J Esthet Dent. 1993;5:174-178.
12. Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004;16:769-778.
13. Kokich VG. Esthetics and vertical tooth position: orthodontic possibilities. Compend Contin Educ Dent. 1997;18:1225-1231.
14. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39:502-504.
15. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311-324.
16. Wadhwani CP. Peri-implant disease and cemented implant restorations: a multifactorial etiology. Compend Contin Educ Dent. 2013;34(special issue 7):32-37.
17. Wilson TG Jr. The positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontol. 2009;80:1388-1392.

Dr. Mechanic received his bachelor of science (1975) and doctor of dental surgery (1979) degrees from McGill University. He maintains membership in numerous professional organizations, including the American Academy of Cosmetic Dentistry, the Academy for Dental Facial Esthetics, the American Society for Dental Aesthetics, and the European Society of Cosmetic Dentistry. He practices aesthetic dentistry in Montreal, Canada, and he is the aesthetic editor of Canada’s Oral Health dental journal, and is on the editorial board of Dentistry Today. He also is the co-founder of the Canadian Academy for Esthetic Dentistry, program coordinator of the University of Toronto Advanced Restorative Continuum, and is recognized as a leader in continuing dental education. His work has been profiled in magazines, television, and radio. He can be reached at info@drmechanic.com.

Disclosure: Dr. Mechanic reports no disclosures.