Abstract: This case details a single-arch rehabilitation incorporating digital tools and traditional methods. The systematic approach taken was aimed at balancing functional, esthetic, and financial concerns of the 45-year-old patient, who presented with severely damaged dentition and occlusal issues. Digital scans with intraoral mock-ups enhanced communication with the dental laboratory. A second set of provisionals was also incorporated into the workflow to refine the restoration. The final outcome provided the patient with a beautifully restored dentition that accommodated his treatment preference without increasing periodontal, functional, biomechanical, or periodontal risks.
Large dental rehabilitations require careful consideration of treatment options, patient goals, and financial barriers. Clinicians can enhance their communication with patients regarding the benefits and limitations of various alternative treatments by combining digital and analog techniques. These digital and traditional methods can also be used during the planning and execution phases to ensure patient and clinician expectations are met.1
In the present case, the patient's desire for a functional and esthetic smile demanded consideration for both his budget and his request to avoid orthodontics. The clinical assessment identified a constricted bite that required either orthodontic therapy or restorations to increase his vertical dimension of occlusion (VDO) to meet his esthetic goals and correct his functional issues.2 A detailed medical and dental history, along with a thorough interview process, helped provide a plan that met the patient's goals while also lowering the risk of future problems. Long-term provisional restorations were used to allow time to further refine the esthetics and evaluate the function.3 Digital scans of the provisionals were recorded once the patient was satisfied, facilitating precise communication with the dental laboratory on the final design.
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Clinical Case Overview
A 45-year-old man presented with the chief concern of embarrassment when smiling due to his short, misshapen, and discolored teeth. The examination revealed gingivitis with corresponding attachment loss, multiple carious lesions, and worn teeth and restorations (Figure 1 through Figure 3). His constricted chewing pattern (CCP) placed him at moderate functional risk, requiring the occlusion to be considered in the treatment plan.
Treatment goals were to create a smile the patient could be proud to display without increasing his risks for future problems. His treatment preferences included a desire to avoid orthodontics and a treatment plan that would accommodate his financial limitations. By closely following a comprehensive systematic approach,4 a single-arch solution was developed that both opened the VDO and provided a highly esthetic and stable result.
Medical and Dental History
The patient's medical history was noncontributory. He was in good health and required no prescription medications; therefore, he was classified as American Society of Anesthesiologists (ASA) I.5
The dental history revealed past caries, including a tooth extraction (No. 31) due to resulting infection. The patient also was aware of pulling his jaw back and clenching his teeth both during the day and at night. Additionally, he noted that his front teeth were becoming shorter.
Diagnosis, Risk Assessment, and Prognosis
Periodontal:The patient reported that he had not been to the dentist in at least 10 years. All the patient's teeth had at least one 4 mm probing depth. Probing depths of 5 mm were found on teeth Nos. 2 through 6, 11 through 15, 18, 19, 22, 23, 26, 29, and 30. Probing depths of 6 mm were recorded on teeth Nos. 3, 13, and 18. Tooth No. 18 also had an 8 mm probing depth recorded on the distobuccal aspect, which was most likely an isolated defect that resulted from the removal of tooth No. 17. The posterior teeth had recession of 1 mm to 2 mm, and the cementoenamel junctions were visible on the buccal surfaces.
Clinical attachment loss was calculated to be 3 mm to 4 mm generally and up to 5 mm to 6 mm in select locations. Teeth Nos. 19 and 30 had grade 2 furcation involvement. The patient had 20 different sites of bleeding on probing that were generalized throughout the mouth. He was classified as American Academy of Periodontology (AAP) stage III, grade B (Figure 4).6,7
Risk:High
Prognosis: Fair
Biomechanical: Carious lesions were present on teeth Nos. 3 through 6, 12, 13, 18, 20, 21, and 28. The patient had large existing restorations on teeth Nos. 2 through 6, 13 through 15, 18 through 20, 29, and 30. Three teeth had existing crowns, and teeth Nos.19 and 20 had previous root canal treatment. Tooth No. 18 was missing a significant amount of tooth structure. Moderate to severe attrition and erosion were noted on the anterior teeth. Multiple restorations on teeth Nos. 2 through 5, 11,12, and 18 were poor or failing (Figure 5 and Figure 6).
Risk:High
Prognosis:Hopeless for the teeth with carious lesions; poor for those with problematic restorations, wear, and fractures
Functional: The patient's maximum opening was 51 mm, with lateral movements of 10 mm. The patient stated that his jaw clicked, however no joint sounds were detected during the examination. He said he had no pain in the muscles, and the load and immobilization tests were negative. He noted that he felt he was pulling his jaw back and squeezing his teeth together during the day. He also noticed that his front teeth were becoming shorter. Based on these clinical findings and the patient's feedback, CCP was determined as the preliminary diagnosis, which was later confirmed using a Lucia jig and a Kois deprogrammer (Kois Center, koiscenter.com).2
Risk:Moderate
Prognosis: Fair
Dentofacial: A full smile (ie, Duchenne smile) revealed all the tooth and gingival tissue at the apical portions of the teeth.8 The gingival architecture was uneven, especially on teeth Nos. 8 and 9. The patient was unhappy with the color and shape of his anterior teeth.
Risk: High
Prognosis:Fair
Treatment Goals
The treatment goals were to stabilize the periodontal disease, decrease the patient's biomechanical and functional risks, and create an esthetic and natural-looking smile. His new restorations at the increased VDO would decrease the functional risk by opening the functional envelope in an adapted centric relation (CR) position.9 A natural-looking, more esthetic smile would also be created by improving the color and shape of the teeth.
Treatment Plan
The treatment plan comprised six elements: (1) establish gingival health to reduce bleeding and inflammation; (2) establish a repeatable reference position (adaptive CR) to allow increasing of the VDO in the wax-up design; (3) perform transulcular (flapless) crown lengthening on tooth No. 9 to create symmetrical gingival margins; (4) restore the maxillary teeth with full-coverage lithium-disilicate restorations to repair decay and open the VDO to correct the CCP; (5) remove decay and restore mandibular teeth with direct and indirect restorations; and (6) provide post-treatment care to ensure the caries and periodontal risks remain managed.
Treatment Phases
Phase 1: Periodontal Treatment
The patient received full-mouth scaling and was provided detailed oral hygiene instructions, including proper brushing and water flossing use. He was placed on a treatment rinse (CTX-4 Treatment Rinse, CariFree, carifree.com) and a 3-month recare interval. After 4 months, the patient's tissue health was improved and he was appointed for the next phase of treatment.
Phase 2: Diagnostic Records, Kois Deprogrammer, Analysis, Smile Mock-up
Complete diagnostic records were taken, including radiographs, photographs, and digital scans. A bite recorded with a Lucia jig was used for an initial mounting. The patient's initial contact with this bite record was on teeth Nos. 9 and 24. A Kois deprogrammer was then ordered to allow the patient's muscles to fully relax and obtain a more accurate bite record. Photographs with the patient wearing facial reference glasses (Kois Facial Reference Glasses, Kois Center), including the patient in full smile (Figure 7), retraction view (Figure 8), and repose, were used to capture the patient's natural head posture and analyze his tooth position and wear.
Using the initial records, multiple treatment options were developed. A photograph mock-up created from a digital hub (Evident Hub, Kois Center, kois.evidentdigital.com) demonstrated the proposed restorative solution. The photograph mock-up also helped determine the patient's ideal tooth length and shape and provided the patient with confidence in the result before the more expensive full laboratory wax-up was initiated. The patient was given the option of orthodontics to address the functional issues and gingival asymmetries, which he declined.
The diagnostic wax-up was completed from the STL files and digital mounting captured in the records appointment. A digital model of the wax-up was printed and a polyvinyl siloxane impression of it was taken, allowing a bis-acryl transfer to the patient's mouth for a smile mock-up (Figure 9). Half of the smile mock-up was then removed to demonstrate the length added to the patient's teeth (Figure 10). The patient approved of the mock-up and agreed to proceed with treatment.
Phase 3: Transulcular Crown Lengthening Tooth No. 9
Flapless crown lengthening was completed on tooth No. 9 to create gingival symmetry with tooth No. 8 (Figure 11). With the use of a scalpel, 1 mm of tissue was removed followed by the use of a KB-1 chisel (Brasseler USA, brasselerusa.com) to remove enough bone from line angle to line angle to establish a 3 mm distance from the free gingival margin to the bone crest.
Phase 4: Tooth Preparation, Provisional Restorations, Bite Registrations
The patient was instructed to wear the Kois deprogrammer for 1 week prior to the preparation appointment. Teeth Nos. 2 through 6 and 11 through 15 were prepared for lithium-disilicate crowns (IPS® e.max, Ivoclar, ivoclar.com), the deprogrammer was inserted, and an analog bite (Futar®, Kettenbach, kettenbachusa.com) and digital scans were taken to record the adapted CR bite at the increased VDO. Providing the lab with both an analog and digital bite would allow the lab to compare them to check accuracy.
Next, teeth Nos. 7 through 10 were prepared for lithium-disilicate crowns. Retraction cords were placed and a digital scan taken. Bis-acryl provisional restorations (Luxatemp®, shade B1, DMG America, dmg-america.com) (Figure 12) were made chairside at the new VDO from a silicon matrix taken on the printed model of the diagnostic wax-up and then cemented with a resin-based temporary cement (Temp-Bond™ Clear, Kerr, kerrdental.com).
Phase 5: Evaluation of Esthetics, Modification of Provisionals
The patient desired several minor changes to teeth Nos. 7 through 11, including smaller incisal embrasures, less facial anatomy, and slightly squarer shape; therefore, a new digital scan was taken to create a new set of polymethyl methacrylate (PMMA) provisionals. The new provisionals were delivered (Figure 13), and the occlusion was refined to ensure bilateral simultaneous contacts with no chewing envelope interferences.
The patient returned 4 weeks later stating that he approved of the esthetics and that his bite felt comfortable. A new digital scan was taken and sent to the laboratory to replicate the provisionals and fabricate the final restorations. Lithium-disilicate crowns (IPS e.max) were chosen due to their conservative preparation requirements and superior esthetics.
Phase 6: Delivery of Final Restorations
The teeth were cleaned using micro-abrasion with 27-µm aluminum oxide (PrepStart™, Zest Dental Solutions, zestdent.com). The restorations were prepared by the lab using hydrochloric acid and a silane-based primer (RelyX™ Ceramic Primer Silane, 3M Oral Care, 3m.com). After try-in and approval by the patient, the definitive restorations were cleaned with 37% phosphoric acid and re-silanated. The restorations were cemented with a self-adhesive resin cement (Rely X™ Unicem 2, 3M Oral Care) (Figure 14). The occlusion, which had already been refined in the provisionals, was re-evaluated in maximum intercuspation (MIP) for bilateral, simultaneous contacts while the patient was reclined 45 degrees. The functional envelope was then checked with the patient sitting upright and chewing on blue 200-µm articulating paper. All blue streaks were removed to ensure there was no friction in the chewing envelope.
Phase 7: Restoration of the Mandibular Arch
After the maxillary arch was restored to the proper vertical dimension, the mandibular arch was treated. Teeth Nos. 18 and 19 were restored with lithium-disilicate crowns following the same protocol described above. Teeth Nos. 21, 23 through 26, and 28 were restored with direct resin restorations.
Phase 8: Post-Treatment Caries Control and Periodontal Management
Because of the patient's susceptibility to periodontal disease, proper home care and a close recare interval would be needed to maintain his improved periodontal status. Hygiene instructions were reviewed with the patient, and a 4-month hygiene recare interval was recommended. Daily use of a 5,000 ppm fluoride toothpaste (CTX-4, CariFree) and a fluoride varnish treatment bi-annually were also recommended to decrease his caries risk.10,11
Discussion
In a large dental rehabilitation such as a single-arch restoration, an accurate diagnosis and a clear understanding of the patient's desires are both critical in the development of a treatment plan. In the present case, once a diagnosis of CCP was made, the occlusion also needed to be addressed to ensure the longevity of the final restorations.The patient could have chosen orthodontic treatment to increase his VDO by extrusion of the posterior teeth on either arch, intrusion of teeth Nos. 23 through 26, and/or proclination of teeth Nos. 7 through 10. However, he was adamantly opposed to orthodontics. Because his maxillary teeth had large defective restorations and were structurally compromised, placement of full-coverage restorations on the entire arch was a reasonable option. Full-coverage restorations would provide support for the structurally compromised teeth, lowering his biomechanical risk, increasing the VDO to address the CCP, and giving the patient the smile he desired (Figure 15 through Figure 18).12
Conclusion
When dealing with a severely damaged dentition and occlusal issues, careful diagnosis and risk assessment helps clinicians determine the best treatment options for their patients. Using both traditional and digital methods to convey these options prior to delivery of the final restorations is an excellent way to ensure that the patient's esthetic goals are achieved. In the present case, refining the occlusion and esthetics with a second set of provisionals clarified communication with the dental laboratory. This case demonstrates how a systematic approach to treatment planning combined with detailed communication with the lab can result in not only a beautiful outcome, but one that reduces the patient's risk for future problems.
Acknowledgment
The author thanks David Haley, principal owner of Prolab Esthetics, for his collaboration and beautiful dental laboratory work; John C. Kois, DMD, MSD, for his training and mentorship; and Susan Sheets, DDS, and Matt West, DMD, for their editing assistance.
About the Author
Wade Kifer, DDS
Clinical Instructor and Course Facilitator, Kois Center, Seattle, Washington; Private Practice, Fayetteville, Arkansas
References
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10. Koch G, Petersson LG, Rydén H. Effect of fluoride varnish (Duraphat) treatment every six months compared with weekly mouthrinses with 0.2 per cent NaF solution on dental caries. Swed Dent J. 1979;3(2):39-44.
11. Staun Larsen L, Nyvad B, Baelum V. Salivary fluoride levels after daily brushing with 5000 ppm fluoride toothpaste: a randomised, controlled clinical trial. Eur J Oral Sci.2023;131(3):e12934.
12. Seay A. Achieving esthetic and functional objectives with additive equilibration. Compend Contin Educ Dent. 2014;35(9):688-692.
Figures and Images
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