September 2013
Volume 34, Issue 8


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An Esthetic Concern Leads the Way to Improved Oral Health

Salvatore Guarnieri, DDS


In order to make appropriate treatment decisions, clinicians must consider a patient’s needs in total. As such, a systematic risk assessment is essential for developing a treatment plan that will both satisfy the patient’s esthetic concerns and lower his or her risk for future problems. In this case, the patient’s immediate concern was his smile, but he was unaware of the need for additional treatment, which included addressing occlusal dysfunction, extracting hopeless teeth and replacing them with an implant-retained prosthesis, and placement of indirect porcelain restorations. A comprehensive interdisciplinary approach between the clinician, implant surgeon, and laboratory was crucial for a successful outcome.

The treating clinician’s insight into all of a patient’s needs is important in order to make appropriate treatment decisions. In the case presented, a systematic risk assessment was performed1 that included a detailed medical and dental history, as well as a thorough diagnosis of all the presenting concerns. These findings enabled an understanding of the patient’s wants while evaluating his needs to develop a treatment plan that satisfied the patient’s esthetic concerns and lowered his risk for future problems. The patient’s quality of life and oral health both were improved as a result of the treatment provided.

Clinical Case Overview

A 43-year-old male construction company owner presented with a primary concern that his quality of life and confidence were affected by two dark front teeth, which were malaligned (Figure 1). He reported pain in the apical region of the upper right central and lateral incisors and experienced intermittent pain on both sides of his mouth during chewing, and occasionally when drinking or eating hot and cold foods.

His medical history was noncontributory. Teeth Nos. 7 and 8 had received endodontic therapy several years prior due to a sports injury. The patient reported that the root canals had failed and apical surgery was necessary to treat an infection. He received routine preventive care every 6 months. At the initial examination, it was noted that tooth No. 7 was in linguoversion and tooth No. 8 had dropped down incisally relative to Nos. 9 and 10, and were significantly darker than the rest of his dentition (Figure 2). He reported that the change in tooth position had occurred during the previous year.

Diagnostic Findings, Risk Assessment, and Prognosis

Periodontal: The examination revealed mild chronic periodontitis, American Academy of Periodontology (AAP) Class II,2 with probing depths within normal limits. No radiographic bone loss greater than 2 mm was noted.

Risk: Low

Prognosis: Good

Biomechanical: Teeth Nos. 3 and 14 were carious, and teeth Nos. 3, 14, 30, and 31 had defective restorations. Teeth Nos. 3, 7, 8, 14, 18, 30, and 31 were structurally compromised due to the size of the existing restorations. Radiographic evidence of periapical pathosis and apical resorption was noted on teeth Nos. 7 and 8 (Figure 3). While the patient was concerned about his esthetically compromised smile, he was unaware that his high biomechanical risk posed the greatest threat to a predictably successful outcome. Treatment was necessary to decrease this risk if his mouth was to be predictably restored with a positive prognosis.

Risk: Moderate

Prognosis: Fair; hopeless for teeth Nos. 7 and 8

Functional: The patient could comfortably open 52 mm, with no deviation or joint noise. The load and immobilization tests were also normal, with no pain or discomfort reported in either the muscles or the temporomandibular joint. Moderate attrition from normal force was present on teeth Nos. 2, 3, 14, 15, and 22 through 27. Neurologic disorders and sleep bruxism histories were negative. The patient reported some difficulty chewing such items as bagels and gum as well as other hard foods. The wear patterns noted and the difficulty with chewing because of muscle fatigue were consistent with an inefficient use of the masticatory muscles. These symptoms likely indicated a diagnosis of occlusal dysfunction. After wearing a Kois deprogrammer3 for a period of 3 weeks, the patient’s jaw moved posteriorly, confirming the initial diagnosis of occlusal dysfunction.4

Risk: Moderate

Prognosis: Fair

Dentofacial: The patient’s low lip dynamics decreased the esthetic risk (Figure 4); however, the position of the incisal edges of teeth Nos. 7 and 8 needed to be modified, and would be positioned approximately 1 mm to 2 mm apically to align with the adjacent anterior teeth (Figure 5). Gingival asymmetry was noted on tooth No. 11. This was not a concern to the patient due to the lack of gingival display, and he elected to not have the asymmetry corrected. His primary concern was the discoloration and position of the teeth.

Risk: Moderate

Prognosis: Fair

Treatment Goals

The patient’s primary treatment goal was to improve the esthetics via modification of the color, shape, and position of the maxillary anterior teeth, recreating the smile that he had prior to the damage sustained from the sports accident. The biomechanical concerns would be addressed by the eradication of the periapical infections present on teeth Nos. 7 and 8, replacement of the defective restorations, and the treatment of the carious lesions. Additionally, instituting a caries management program would be critical to long-term treatment success. The final treatment goal was to reduce the functional risk by correcting the occlusal dysfunction.

Treatment Plan

Following a thorough discussion with the patient regarding the risk and prognosis in all categories, it was decided to treat the occlusal dysfunction and extract the hopeless teeth Nos. 7 and 8, which would be replaced with an implant-retained prosthesis. Once the patient realized what esthetic improvements were possible, it was decided to place indirect porcelain restorations on teeth Nos. 6 and 9 through 11. A comprehensive interdisciplinary approach with the implant surgeon and laboratory was crucial for a successful outcome.

Treatment Phases

Phase 1

Teeth Nos. 7 and 8 were extracted, with a socket preservation bone graft utilized in the position of tooth No. 8 for future implant placement.5 The patient was given a transitional removable partial denture to be worn during the first phase of treatment. During surgery, a vertical root fracture was discovered on tooth No. 8. Tooth No. 7 was removed due to the hopeless prognosis resulting from multiple endodontic procedures, significant apical infection, and the presence of apical resorption. After 3 months of healing, a Zimmer root form implant ( was placed in the position of No. 8 and allowed to osseointegrate for 4 months.

During osseointegration, a second transitional removable denture was fabricated and modified to be used as a Kois deprogrammer (Figure 6 and Figure 7). After deprogramming, a functional analysis mounting and laboratory equilibration was performed. The information from the functional analysis was transferred to the mouth, and a full-mouth subtractive equilibration was performed to correct the occlusal dysfunction. Bilateral equal simultaneous contacts with equal intensity were established on the posterior teeth. Restoring teeth Nos. 6 and 11 not only improved the esthetics, but created contact on the lingual of the cuspids.6

Caries management protocols consisted of at-home daily use of an alkaline pH fluoride rinse (CTx3, CariFree, and in-office fluoride varnish at recare.7

Phase 2

After an assessment of the mounted models and the creation of a diagnostic wax-up, it was apparent that the esthetic outcome would be maximized with the treatment of all six upper anterior teeth. Teeth Nos. 6 and 9 through 11 would receive all-porcelain (e.max®, Ivoclar Vivadent, restorations, and teeth Nos. 7 and 8 would be replaced with an implant screw-retained prosthesis. A transitional screw-retained prosthesis (No. 7 pontic, No. 8 retainer) was utilized to develop the ovate pontic site prior to the final prosthesis fabrication8 (Figure 8 through Figure 10). Teeth Nos. 6 and 9 through 11 were prepared for the final restorations following the diagnostic wax-up. These restorations were inserted before the implant-retained prosthesis was finalized.

Following the completion of the anterior dentistry, both the maxillary and mandibular first and second molars were restored with the indirect restorations. All indirect restorations were luted with RelyX™ Unicem (3M ESPE, after the tooth surface was treated with microabrasion with 27-micron aluminous oxide at 40 psi (PrepStart, Danville, Inc., The intaglio surface of the restorations was treated with 35% phosphoric acid for 1 minute followed by rinsing, drying, and applying silane primer for 1 minute prior to cementing the restorations. Re-evaluation of esthetics, gingival health, and refinement of the occlusion occurred 4 weeks later (Figure 11 and Figure 12).


In this case, the patient’s immediate concern was his smile and he was unaware of needing additional treatment. Through the use of systematic and thorough diagnostic and prognostic protocols, he gained an understanding of all necessary treatment. This allowed him to accept care that significantly improved both his oral health and the longevity of the restorative care delivered, as well as providing him with the smile he wanted (Figure 13 and Figure 14).


The author would like to thank Suresh Goel, DDS, Pittsford, New York, for surgical support, and Adina Chambers, Adina’s Dental Lab, Inc., Seneca Falls, New York, for her laboratory support.


Salvatore Guarnieri, DDS
Private Practice, Pittsford, New York


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