Treatment planning began with a 2D functional-esthetic analysis checklist, looking at the articulated models, photographs, and a summary report of the exam findings. The case was examined for the requirements of occlusal stability4: equal intensity stops; anterior guidance in harmony with the envelope of function; and immediate disclusion of posterior teeth in excursive movements. None of these functional criteria were met. The posterior interferences, in particular, offered an explanation for the patient’s bruxism. While implants will restore the posterior teeth, they lack the proprioreception of the natural dentition. The sensory feedback from the patient’s retained anterior teeth can be used to create anterior guidance and reduce or eliminate parafunctional muscle activity.5
Global and macro esthetics were considered. It was found that the mandibular plane required correction to establish an acceptable curve of Spee. In addition, the position of the maxillary anteriors violated the parameters of golden proportion (Figure 3).
Corrections to the shape, size, and position of the teeth were visualized while working through a 3D checklist on the Diagnostic Wizard and articulated models. After considering surgical, restorative, equilibrative, and orthodontic options, a treatment plan was developed and accepted by the patient.
Edward Hilton, DMD:
Achieving Occlusal Goals with Virtual Orthodontics
Bringing a wealth of experience to the study club, orthodontist Ed Hilton has consistently produced case results meeting the requirements of occlusal stability. The patient was referred to Hilton for orthodontic treatment to reposition the teeth to achieve golden proportion and anterior guidance, allowing for minimally invasive restoration.
Using the virtual CAD tools available with the Invisalign® system (Align Technology Inc., www.invisalign.com), the team was able to design outcomes to meet the parameters set by their 2D and 3D checklists. Spaces were left to accommodate planned tooth size and contours that would be created with the addition of restorative material. The Invisalign treatment was scheduled to proceed.
Becky Fox, DMD:
When it was determined that the patient lacked the necessary anchorage to orthodontically position the anterior teeth, the team turned to Becky Fox, an advanced CEREC® (Dentsply Sirona, www.cereconline.com) user and trainer with expertise in digital impressioning, digital design, and in-office milling, for a solution. By placing scan bodies on the implant analogs in the pretreatment diagnostic models, she was able to digitally impress and articulate the dentition. Using IPS e.max® CAD lithium-disilicate blocks (Ivoclar Vivadent, www.ivoclarvivadent.us), she milled screw-retained crowns to serve as anchorage devices (Figure 4). The crowns were designed out of occlusion and with open contact to allow for the anticipated tooth movement.
Robert Myers, DMD:
Bone, Implants, and Cloud-Based Communication
Oral and maxillofacial surgeon and implant specialist Robert Myers provided initial treatment for the patient that included ridge augmentation and bilateral sinus lifts with platelet-rich plasma. Six maxillary and two mandibular posterior implants were later placed and exposed using a two-stage protocol. A final implant was eventually added in the No. 31 position.
To help streamline and share information among doctors, technicians, and staff and advance standards of care, Myers has developed a cloud-based application to allow providers to upload and access files to and from a patient history. PatientWeb (www.patientweb.com) also allows doctors to message, create referrals, provide treatment updates, and draft lab prescriptions.
Through the course of this case, at least two dozen instances of online communication took place. Photographs, x-rays, treatment prescriptions, reports, and Diagnostic Wizard data were electronically managed by connecting the entire team to a single HIPAA-compliant platform.