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Special Issues
July/August 2018
Volume 39, Issue 3

Minimizing the Difficulty of Complex Cases Through Teamwork

Jeff Trembley, DDS

Complex restorative cases can be successfully managed with proper support. First, accurate records are needed, such as impressions, radiographs, facebow and bite records, and high-resolution photographs. Next, good “allies” are necessary, such as an experienced laboratory technician/ceramist whose interest in success aligns with the clinician’s and local specialists who can help manage the plan and treatment. In the present case, with proper records in hand, the author relied on his lab tech/ceramist “ally” (Macstudio By MicroDental Laboratories, macstudio.com) to supply materials to manage the entire case, including reduction guides, temporary stints, and a maxillary wax-up to increase the patient’s vertical dimension of occlusion (VDO). An initial minimal preparation day to remove old fillings and restorations and seat new temporaries served two purposes: a test drive for the patient’s new VDO and a guide for crown lengthening. Crown lengthening of teeth Nos. 9 through 11 to balance the tissue was performed by a periodontist “ally” (Robert Pulliam, DMD, MS, Nashville, Tennessee). After that, all that was needed was an afternoon of refining preparations, recording the VDO accurately, and replacing the temporaries.

Key Takeaways

Accurate records and photographs serve as the foundation upon which a restorative case is built.

A dependable laboratory partner in whom a clinician trusts with his or her records is indispensable.

Consultation with specialists on the front end of a case will help clinicians avoid missteps and often stimulates ideas not previously considered.

About the Author

Jeff Trembley, DDS
Private Practice
Nashville, Tennessee

Fig 1. Patient’s pre-treatment smile.

Figure 1

Fig 2. Occlusal view showing fractured cusps and severe acid erosion of the maxillary dentition. Note that the canal chamber was visible on teeth Nos. 6 through 11.

Figure 2

Fig 3. The mandibular arch presented in fine shape, except for cervical decay and the need for endodontic therapy on tooth No. 31.

Figure 3

Fig 4. Measurements of tooth No. 8 from the cementoenamel junction; incisal edge and gingival margin to incisal edge were recorded to determine the proposed length of anteriors and new VDO.

Figure 4

Fig 5. Retracted extraoral image helped aid in communication with the laboratory and periodontist. It was determined that crown lengthening of teeth Nos. 9 through 11 to match the levels of teeth Nos. 6 through 8 would allow for balanced zenith levels of the right and left.

Figure 5

Fig 6. Diagnostic casts were mounted using a facebow, and the pin was opened from the point of initial contact to allow for restorative space for full-coverage lithium-disilicate crowns. The proposed wax-up was built from the increased vertical position to ensure no further reductions of the anterior dentition would be needed. The proposed length of the central incisors from the gingival margin of No. 8 to the new incisal edge was planned for 11 mm.

Figure 6

Fig 7. After initial preparation in which decay and old restorations were removed, teeth were sealed using a three-step bonding system (Surpass®, Apex Dental Materials, Inc., apexdentalmaterials.com) followed by composite placement (SureFil®, Dentsply Sirona, dentsplysirona.com and Filtek™ Z250, 3M ESPE, 3m.com) for build-ups. Minor marginal preparations were made to break proximal contacts. Occlusal reductions were needed only to allow for seating of the bis-acryl temporaries (Integrity®, Dentsply Sirona). The temporaries were adjusted to balance the bite and polished. The patient experienced no discomfort in the new vertical dimension for 2 weeks. She was then scheduled for periodontal surgery.

Figure 7

Fig 8. Following the crown lengthening procedure, the patient returned for preparation refinement and master impressions of the upper arch. A critical three-part step of the treatment was to “tripod” the existing vertical dimension by removing the temporaries in thirds. Step 1: The temporaries were sectioned from the distal of tooth No. 11 and removed. The preparations for teeth Nos. 12 through 15 were refined. A rigid polyether material (Impregum™, 3M ESPE) was placed to record the bite record of Nos. 12 through 15 while the temporaries on Nos. 2 through 11 remained. Step 2: The temporaries were removed from teeth Nos. 2 through 5, and the preparations were refined. Impregum bite record material for Nos. 2 through 5 was placed, and the patient closed to establish the second leg of the Impregum tripod. Step 3: The remaining temporaries were removed from Nos. 6 through 11, the preparations refined, and the two Impregum bite records placed in the posterior. A third and final anterior bite record was captured. A master impression was then captured and new temporaries placed for 2 weeks while the definitive restorations were fabricated. With the new master impression and the tripod of Impregum, the periodontist replicated the exact position the patient would be comfortable with, leaving enough restorative space for the restorations and anterior esthetics.

Figure 8

Fig 9. For the delivery appointment, the temporaries were carefully removed and the teeth treated with desensitizer (MicroPrime™, Zest Dental Solutions, zestdent.com). With healthy tissue and a comfortable vertical dimension established, the front six restorations were placed first, followed by the posterior. The laboratory team crafted the occlusion such that very little adjustment was necessary for stability and functionality.

Figure 9

Fig 10. For the delivery appointment, the temporaries were carefully removed and the teeth treated with desensitizer (MicroPrime™, Zest Dental Solutions, zestdent.com). With healthy tissue and a comfortable vertical dimension established, the front six restorations were placed first, followed by the posterior. The laboratory team crafted the occlusion such that very little adjustment was necessary for stability and functionality.

Figure 10

Fig 11. Nearly 3 months after the initial appointment, the patient’s smile featured beautiful and functional teeth. Note the healthy tissue and exceptional healing due to proper planning, crown lengthening, and crown fabrication by the MicroDental lab team. The shade and shape of the restorations fit the smile.

Figure 11

Fig 12. Nearly 3 months after the initial appointment, the patient’s smile featured beautiful and functional teeth. Note the healthy tissue and exceptional healing due to proper planning, crown lengthening, and crown fabrication by the MicroDental lab team. The shade and shape of the restorations fit the smile.

Figure 12

Fig 13. Transformation of the patient’s smile was complete, displaying functional restorations that renewed her confidence and beauty.

Figure 13

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