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Inside Dentistry
September 2022
Volume 18, Issue 9
Peer-Reviewed

Interdisciplinary Treatment Can Improve Health While Addressing Esthetics

Combining surgical and orthodontic procedures to correct skeletal discrepancies optimizes restorative outcomes

Rebecca Bockow, DDS, MS | Gregg Kinzer, DDS, MSD | Sam Bobek, DMD, MD

When managing interdisciplinary cases, arriving at a correct and complete diagnosis is key to developing an ideal treatment plan, especially when skeletal discrepancies are involved. A 48-year-old female patient presented with a desire to replace her unesthetic maxillary anterior restorations. A comprehensive examination was performed, which revealed an unhealthy skeletal diagnosis. Vertical maxillary excess (ie, excessive maxillary development in the vertical plane) generally coincides with mandibular retrognathia. The occurrence of a downward and backward growth trajectory early in life is often secondary to early childhood mouth breathing. In this case, the patient presented with vertical maxillary excess, mandibular retrognathia, a double posterior crossbite, gingival asymmetry, and unesthetic anterior crowns. Simply replacing the crowns, with or without clinical crown lengthening, would have only addressed the esthetics of the front teeth but would not necessarily have made her healthier. Once the patient understood that a comprehensive treatment plan would not only address her esthetic concerns, but also have the potential to improve her breathing, sleep, and overall health, she was committed to moving forward.

The orthodontic treatment plan included aligning the gingival margins and decompensating the dentition orthodontically. Orthognathic surgery was completed to widen and impact the maxilla and also bring the mandible forward. The surgical treatment plan improved her ability to breathe nasally, created more space for her tongue, opened her airway, and facilitated the development of a healthy occlusal scheme with the teeth loaded on their long axes. After the orthodontic/surgical treatment was completed, the existing full coverage restorations were removed, and provisional restorations were fabricated (Protemp™ Plus, 3M) and placed (Temp-Bond™, Kerr Dental) to act as an esthetic and functional blueprint for the definitive restorations. The definitive all-ceramic restorations were fabricated from lithium disilicate (IPS e.max®, Ivoclar Vivadent).

Upon completion of the treatment, the patient reported experiencing a significant improvement in breathing, sleeping, and overall quality of life. When clinicians work as an interdisciplinary team and understand how to diagnose and treat skeletal discrepancies, they can not only improve esthetics and function but also make patients healthier as well.

About the Author

Rebecca Bockow, DDS, MS
Instructor
Spear Education
Scottsdale, Arizona
Private Practice
Seattle, Washington

Gregg Kinzer, DDS, MSD
Director of Curriculum and Campus Education
Spear Education
Scottsdale, Arizona
Private Practice
Seattle, Washington

Sam Bobek, DMD, MD
Fellow
American College of Surgeons
Private Practice
Seattle Washington

Rebecca Bockow, DDS, MS

Gregg Kinzer, DDS, MSD

Sam Bobek, DMD, MD

Pretreatment full-face and profile photographs of an adult female patient who presented with the chief concern of unesthetic anterior restorations. A comprehensive exam revealed vertical maxillary excess, mandibular retrognathia, and three-dimensional facial and skeletal malocclusion.

Fig. 1

Pretreatment full-face and profile photographs of an adult female patient who presented with the chief concern of unesthetic anterior restorations. A comprehensive exam revealed vertical maxillary excess, mandibular retrognathia, and three-dimensional facial and skeletal malocclusion.

Fig. 2

The pretreatment smile photograph demonstrating uneven gingival margins, visible crown margins, vertical maxillary excess, and narrow buccal corridors.

Fig. 3

Pretreatment retracted and right and left lateral photographs showing bilateral posterior crossbites, a Class II occlusal relationship, and gingival asymmetry.

Fig. 4

Pretreatment retracted and right and left lateral photographs showing bilateral posterior crossbites, a Class II occlusal relationship, and gingival asymmetry.

Fig. 5

Pretreatment retracted and right and left lateral photographs showing bilateral posterior crossbites, a Class II occlusal relationship, and gingival asymmetry.

Fig. 6

The pretreatment maxillary and mandibular occlusal photographs revealed a narrow upper arch and a crowded lower arch.

Fig. 7

The pretreatment maxillary and mandibular occlusal photographs revealed a narrow upper arch and a crowded lower arch.

Fig. 8

Post-orthodontic/orthognathic treatment retracted and right and left lateral photographs displaying the successful surgical correction of the posterior crossbites, the correction from Class II to Class I with the mandibular advancement, and the orthodontic alignment of the maxillary gingival margins. Note: the porcelain on the restorations required adjustment as the gingival margins were aligned.

Fig. 9

Post-orthodontic/orthognathic treatment retracted and right and left lateral photographs displaying the successful surgical correction of the posterior crossbites, the correction from Class II to Class I with the mandibular advancement, and the orthodontic alignment of the maxillary gingival margins. Note: the porcelain on the restorations required adjustment as the gingival margins were aligned.

Fig. 10

Post-orthodontic/orthognathic treatment retracted and right and left lateral photographs displaying the successful surgical correction of the posterior crossbites, the correction from Class II to Class I with the mandibular advancement, and the orthodontic alignment of the maxillary gingival margins. Note: the porcelain on the restorations required adjustment as the gingival margins were aligned.

Fig. 11

The existing restorations were removed, and the preparations were refined. After final impressions were taken with silicone, provisional restorations were fabricated and cemented with temporary cement.

Fig. 12

The existing restorations were removed, and the preparations were refined. After final impressions were taken with silicone, provisional restorations were fabricated and cemented with temporary cement.

Fig. 13

The existing restorations were removed, and the preparations were refined. After final impressions were taken with silicone, provisional restorations were fabricated and cemented with temporary cement.

Fig. 14

The existing restorations were removed, and the preparations were refined. After final impressions were taken with silicone, provisional restorations were fabricated and cemented with temporary cement.

Fig. 15

Posttreatment smile photograph taken after delivery of the definitive lithium disilicate restorations. Note that the smile better filled the buccal corridors and less gingival display was present upon smiling.

Fig. 16

Posttreatment retracted, close-up, and maxillary/mandibular occlusal photographs demonstrating the improved occlusal scheme, including wider arches, mandibular advancement from Class II to Class I, and improved gingival architecture.

Fig. 17

Posttreatment retracted, close-up, and maxillary/mandibular occlusal photographs demonstrating the improved occlusal scheme, including wider arches, mandibular advancement from Class II to Class I, and improved gingival architecture.

Fig. 18

Posttreatment retracted, close-up, and maxillary/mandibular occlusal photographs demonstrating the improved occlusal scheme, including wider arches, mandibular advancement from Class II to Class I, and improved gingival architecture.

Fig. 19

Posttreatment retracted, close-up, and maxillary/mandibular occlusal photographs demonstrating the improved occlusal scheme, including wider arches, mandibular advancement from Class II to Class I, and improved gingival architecture.

Fig. 20

Posttreatment full-face and profile photographs showing a less gummy and wider smile. Note how the chin has come forward with the mandibular advancement, elongating the neck and bringing the lips closer to one another at rest.

Fig. 21

Posttreatment full-face and profile photographs showing a less gummy and wider smile. Note how the chin has come forward with the mandibular advancement, elongating the neck and bringing the lips closer to one another at rest.

Fig. 22

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