Redefining What Is Possible: Treating Function and Enhancing Esthetics Using a Risk Management System
Kris Swanson, DDS; and Leon Hermanides, CDT
Abstract: The case presented involves a patient with a history of extensive dental treatment who had become exasperated with her increasingly uncomfortable bite. She also had concerns about the potential fracture or loss of anterior teeth. In managing her risk profile and esthetic concerns, the clinician utilized a systematic approach to diagnosis and treatment planning. The treatment consisted of addressing her joint pain, restoring the maxillary arch, and then restoring the mandibular arch using a combination of direct and indirect restorations. All treatment was completed without increasing the risk to the patient's overall dental health.
A patient first presented to the practice with concerns of an uncomfortable bite, joint pain, and feeling that she had to squeeze her jaw to bring her teeth together. The patient had a history of dental issues and had grown increasingly frustrated with her oral condition. When faced with a patient describing multiple complex problems, dentists must avoid rushing to complete treatment, as this can lead to inconsistent and unpredictable outcomes as well as frustration for both the clinician and patient. This patient's uncomfortable bite was instead addressed using a systematic approach,1,2 which not only proved beneficial for diagnosing the situation, but also helped increase the patient's trust in the clinician and aided in motivating her to treat her esthetic concerns.
Because treating the patient's constricted chewing pattern (CCP) would involve treating her posterior teeth in an adapted centric position, the uneven visual crown height of the posterior teeth was addressed. The technique utilized involved recontouring the abutments and implant restorations to increase the visual length of the teeth. Collaboration between the clinician and the laboratory technician was vital in creating a clear vision of the desired outcome.
Clinical Case Overview
A 64-year-old female patient who happened to be a former dental assistant was referred by a recently retired dentist who, as a former Kois Center clinical instructor, knew the authors and was familiar with their work. The referral, however, required the patient to travel more than 700 miles from her home; therefore, the treatment phasing was adjusted to accommodate her travel schedule.
Her dental history included orthodontics at age 52, and she reported bite/temporomandibular disorder issues occurring after having additional extensive dental treatment. She had become increasingly unhappy with her smile and was concerned about the black triangles between her mandibular anterior teeth and the uneven gingival margin positions of her maxillary posterior implant restorations. Her maxillary anterior teeth were previously restored with large Class III composites, which had become worn and chipped. She was worried about breaking her front teeth and wanted a more permanent solution than repairing them with direct composite bonding. Her pretreatment clinical condition is depicted in Figure 1 through Figure 4.
Medical and Dental History
The patient's pertinent medical history included an underactive thyroid, acid reflux, and type II diabetes (A1C 5.7), which were all controlled with medication. Due to her medical history and age she was classified as American Society of Anesthesiologists (ASA) class II.
She had received regular dental care and had a family history of periodontal disease. She had a history of broken and/or chipped teethbut no active decay in the previous 3 years.
Diagnosis, Risk Assessment, and Prognosis
Periodontal: Pocket depths of 2 mm to 4 mm were noted with no bleeding present on her natural teeth. Isolated 5 mm to 6 mm pockets were present around her molar implants. She was classified as American Academy of Periodontology (AAP) stage II (2 mm to 4 mm of horizontal bone loss), grade B (due to type II diabetes)(Figure 5).3
Biomechanical: No active caries was noted. The existing implants replacing teeth Nos. 2, 3, 12, 14, 19, 20, 30, and 31, and teeth Nos. 6 and 21 through 28 had a good prognosis. Teeth Nos. 7 through 11 had a fair prognosis due to existing large composite fillings. Teeth Nos. 4 and 5 had a poor prognosis because they were structurally compromised and had previously received root canal treatment.
Functional: The patient reported soreness and bilateral popping of her temporomandibular joint but had no clicking or locking. She avoided many foods because of fear of breaking teeth. Over the previous 5 years, she had noticed that her upper and lower anterior teeth had become shorter and that she now hit harder on her front teeth than the back teeth. She reported having to squeeze her jaw to make her teeth fit together and was aware of daytime and nighttime clenching. She wore a nightguard and had done so regularly for many years. Mobility was noted on teeth Nos. 4, 5, 23 through 27, and 29. The load and immobility tests were negative. Minimal attrition was noted on teeth Nos. 6 through 11 and 21 through 28. The diagnosis was constricted chewing pattern (CCP).4
Dentofacial:The patient had visible gingival display in both her natural and Duchenne smile. She wanted to recreate the smile she used to have.Her maxillary anterior teeth had acceptable gingival symmetry and were in the correct position, which simplified her treatment. Her prognosis, therefore, was elevated from "hopeless" to "poor."
The treatment goals were to achieve the patient's vision of a more comfortable bite and improved esthetics without increasing biomechanical risk, fabricate long-lasting, functional restorations, and create a more harmonious smile. A repeatable mandibular position would be determined using a Kois deprogrammer (KDP) (Kois Center, koiscenter.com),5 and the teeth would then be restored with the mandible in the deprogrammed condylar position. The facial contour of the maxillary posterior implant restorations would be altered to harmonize with the gingival levels of the anterior teeth.
Phase 1: Pretreatment Consult, Delivery of Deprogrammer
At the initial appointment, a complete examination was performed, including a full periodontal charting, a complete series of photographs, and radiographs. Impressions for models, a KDP, and bleach trays were taken.
After the initial examination, the dental laboratory fabricated a 3D-printed KDP, and the patient returned for delivery and to discuss treatment options. The final treatment plan would be confirmed after deprogramming and subsequent bite registration. The treatment would include opening the vertical dimension of occlusion (VDO) by restoring the posterior teeth. This would relieve the CCP and allow the maxillary anterior teeth to be lengthened. Due to the patient's concern about the existing large Class III maxillary anterior composites, she requested indirect restorations for the maxillary anterior teeth. To accommodate the patient's esthetic concerns, the mandibular anterior teeth would be bleached. She was instructed to wear the KDP at all times for 3 weeks, except when eating.
After the 3-week period of wearing the deprogrammer, the patient returned and occlusal records were obtained. She reported joint comfort and being free of pain when wearing the KDP. A Kois Dento-facial Analyzer (Kois Center) was used to mount the casts on a Panadent articulator (Panadent, panadent.com). The point of initial occlusal contact was in the anterior, confirming the diagnosis of CCP.
Phase 2: Finalized Treatment Plan
A diagnostic wax-up would be fabricated using a 10-step treatment approach (Kois Center).1 With lips in repose, the cuspid display was -1 mm; therefore, 1.5 mm was added to the cuspid length, and the upper arch was leveled.6 To harmonize with the anterior teeth, the maxillary posterior teeth would be lengthened approximately 1 mm to 3 mm. The mandibular teeth would be leveled to the length of tooth No. 23.
Indirect restorations would be placed on teeth Nos. 4 through 11 and 29; custom abutment-supported implant crowns would be placed on teeth Nos. 3, 19, 20, 30, and 31; and a custom abutment-supported implant bridge would be inserted on teeth Nos. 12 through 14. Direct composite restorations would be placed on the occlusal surfaces of teeth Nos. 21 and 28 and the incisal edges of teeth Nos. 22 through 27. Additionally, composite would be placed interproximally to remove the black triangles in the gingival third of teeth Nos. 22 through 27.7
The VDO would be opened approximately 1 mm to flatten the chewing pathway and allow longer maxillary anterior teeth.8 The visually inappropriate coronal length in the upper left posterior would be addressed with tissue alteration around implant abutments and an ovate pontic site to allow a more symmetrical and pleasing smile. The patient would receive routine periodontal maintenance care by her local dentist.
Phase 3: Maxillary Arch
Teeth Nos. 4, 5, and 7 through 10 were prepared for conservative full-coverage restorations, while teeth Nos. 6 and 11 were prepared for partial-coverage restorations. The implant restorations on teeth Nos. 2 and 3 and the upper left implant-supported bridge were removed, open-tray impression copings were placed, and a polyvinyl siloxane (PVS) impression was taken.
Upper provisional restorations were fabricated from the diagnostic wax-up using a PVS matrix, with the posteriors retained on temporary abutments.9 The posterior crowns would be fabricated from layered zirconia for strength and opacity to block out underlying metal abutments. The anterior crowns would be lithium disilicate because of this material's enhanced esthetic quality. The visual length of the maxillary implant teeth was determined in the laboratory first (Figure 6 through Figure 8), with the clinical gingival management done at the seat appointment. Slight occlusal adjustment was needed on the mandibular arch to create bilateral equal posterior contact in occlusion. The patient returned the following day for impressions of the provisional restorations and photographs, and to obtain centric occlusion records. The record was taken by creating a small direct composite deprogrammer on the palatal surface of teeth Nos. 8 and 9, opening the bite 0.5 mm.10 The maxillary posterior provisional restorations were removed, tall healing caps were placed on the implants, and a bite registration was taken. Healing caps were removed and sent with the case to the laboratory for mounting.
The patient returned 1 month later for the seating of maxillary restorations. To allow for complete seating of the abutments and restorations, gingival tissue recontouring in the upper left posterior was completed before restoration try-in. After anesthesia was administered, the cover screws were placed. Additional anesthetic was infiltrated around the implant and pontic sites using lidocaine 2% with 1:50,000 epinephrine for pain management and to help control bleeding. After evaluation of the implant and pontic sites on the working model, a KS5 diamond bur (Brasseler USA, brasselerusa.com) was used to alter the tissue to allow passive seating of the custom abutments and implant restorations (Figure 9). Radiographs confirmed complete seating of the implant components prior to cementation.
All restorations were then evaluated for esthetics, complete seating, occlusion, and proximal contacts, and the patient gave approval for permanent seating. Teeth were microetched using 27-micron aluminum oxide, and implant abutments were torqued to 35 Ncm. The lithium-disilicate crowns on teeth Nos. 6 through 11 were cleaned, silanated, and then seated cohesively using a self-adhesive resin cement (RelyX™ Unicem 2, 3M Oral Care, 3m.com). The maxillary posterior zirconia crowns were microetched, cleaned, primed with MDP monomer (Z-Prime™ Plus, BISCO, bisco.com), and seated cohesively on teeth Nos. 4 and 5 and the implant custom abutments. An occlusal adjustment using a printed KDP was completed to refine the occlusion on the mandibular arch.
Phase 4: Mandibular Arch
The mandibular arch was treated the next day. The occlusal and incisal edges of teeth Nos. 21 through 28 were restored with direct bonding, guided by the diagnostic wax-up. An injection molding technique was used to add composite (G-aenial™ Universal Injectable, Bleach White, GC America, gc.dental/america) to the occlusal surfaces of teeth Nos. 21 and 28. A polyvinyl lingual stent was used to add microhybrid composite (Vit-l-escence™, A1, Ultradent, ultradent.com) to the incisal edges of teeth Nos. 22 through 27. The black triangles in the anterior were bonded and closed using a technique the clinician developed,7 utilizing an anterior matrix (Blue View™ VariStrip™, Garrison Dental Solutions, garrisondental.com) with a built-in curvature that facilitates ideal interproximal contours and marginal adaptation. Tooth No. 29 was prepared and a PVS impression was taken for custom abutments and implant crowns on teeth Nos. 19, 20, 30, and 31 and for a crown on tooth No. 29. Mandibular provisionals were fabricated from the diagnostic wax-up using a PVS matrix and temporary abutments. The printed KDP was inserted and a new centric bite taken with the bite opened approximately 0.5 mm. The posterior provisionals were then removed and healing caps placed. The provisional restorations were seated. Healing caps were sent to the laboratory to facilitate mounting the case accurately.
The patient returned 3 weeks later for seating of the mandibular restorations. The same protocols used for the cementation of the maxillary crowns were followed. A KDP was again used to refine the occlusion and achieve equal bilateral simultaneous contact. The patient was seated upright, asked to chew on 220-micron paper, and all interferences were removed in the envelope of function.
Phase 5: Postoperative Check-up and Final Photographs
The patient returned a month after completing treatment for a postoperative check-up and to have final photographs taken. She was thrilled with the comfort of her new bite and overjoyed with her beautiful smile (Figure 10 through Figure 15).
A patient with a history of significant dental treatment sought to address her worsening symptoms due to an uncomfortable bite and jaw pain. The ongoing pain in her jaw joints as well as her concerns for the fracture or loss of anterior teeth were driving the treatment. However, when exposed to the use of the KDP and the associated relief of symptoms she experienced, her trust in the present restorative team to adequately restore her to functional and esthetic harmony was greatly enhanced.
Once the mounted casts were articulated with the deprogrammed occlusal records, it was determined that replacement of the maxillary and mandibular posterior restorations would be required. This would also allow the posterior maxillary implants to be restored to a visible tooth length more harmonious with the gingival levels and length of the maxillary anterior teeth.
From the diagnostic mounting, a blueprint of the final restorations was generated to guide the patient's treatment decisions and create matrices for the provisional restorations. In the dental laboratory a soft-tissue model was poured to replicate the patient's clinical situation. Before designing the custom CAD/CAM abutments, and with the diagnostic cast as a reference, the dental technician was able to alter the soft tissue coronal to the implant fixture. By preparing the tissue prior to 3D scanning for the abutment design it was possible to control the emergence and create more visible tooth structure, harmonizing with the gingival position of the anterior teeth and addressing the patient's concern regarding the visible length of the restorations.11
Although tissue management would have been possible during the provisional phase, consideration was given to the restraints of treating a patient from out of state to reduce chairtime and achieve a more predictable outcome. This choice presented no esthetic or biological compromise to the final treatment outcome.
Addressing the patient's chief concern, which was her joint pain, motivated her to focus more comprehensively on her overall dental treatment goals. Despite having restorations replaced multiple times, her symptoms had continued to worsen and her esthetic expectations had gone unmet. In managing her risk profile and esthetic concerns, the authors utilized a systematic approach in diagnosis and treatment planning, which was vital for creating and implementing new possibilities for the patient.
About the Authors
Kris Swanson, DDS
Mentor, Kois Center, Seattle, Washington; Private Practice, Bellevue, Washington
Leon Hermanides, CDT
Clinical Instructor and Scientific Advisor, Kois Center, Seattle, Washington; Founder, Protea Dental Studio, Redmond, Washington
1. Kois JC. New challenges in treatment planning: incorporating the fundamentals of patient risk assesment - Part 2. J Cosmetic Dent. 2011;21(1):110-121.
2.Kois JC. New challenges in treatment planning: shifting the paradigm toward risk assesment and percieved value - Part 1. J Cosmetic Dent. 2011;26(4):62-69.
3. Tonetti MS, Greenwell H, Kornman KS. Staging and grading of periodontitis: framework and proposal of a new classification and case definition. J Periodontol. 2018;89 suppl 1:S159-S172.
4. Huff C. A systematic method for accurate functional diagnosis. Compend Contin Educ Dent. 2017;38(5):308-316.
5. Revilla-León M, Zeitler JM, Kois DE, Kois JC. Utilizing an additively manufactured Kois deprogrammer to record centric relation: a simplified workflow and delivery technique. J Prosthet Dent. 2022;S0022-3913(22)00364-X. doi: 10.1016/j.prosdent.2022.04.034.
6. Misch CE. Guidelines for maxillary incisal edge position - a pilot study: the key is the canine. J Prosthodont. 2008;17(2):130-134.
7. Swanson KK. Predictable, conservative closure of black triangles. Inside Dentistry. 2018;14(12):32-38.
8.Kois JC, Phillips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent. 1997;18(12):1169-1177.
9. Kois DE, Schmidt KK, Raigrodski AJ. Esthetic templates for complex restorative cases: rationale and management. J Esthet Restor Dent. 2008;20(4):239-250.
10. Solow RA. The anterior acrylic resin platform and centric relation verification: a clinical report. J Prosthet Dent. 1999;81(3):255-257.
11. Phillips K, Kois JC. Aesthetic peri-implant site development. The restorative connection. Dent Clin North Am. 1998;42(1):57-70.