Treatment with Functional Esthetic Prototypes
Transitional, phased dentistry benefits patients with limited resources
Hugh Flax, DDS
Successfully performing complex restorative dentistry involves minimizing clinical risk factors (eg, bone support, function, biomechanics, esthetics, medical history) and nonclinical fit challenges (eg, finances, time priorities) and requires excellent listening skills, a human touch, and strategic clinical planning that makes the patient healthy and more confident.1-4Oftentimes, a challenging case will necessitate that clinicians stretch treatment out into phases so that multidisciplinary care can be accomplished in a way that fits into patients' budgets and allows them the time to assemble the resources needed to complete treatment.
A 40-year-old, male patient with dental phobia presented to the office and expressed his desire to improve his smile by having all of his teeth removed and immediate prostheses placed with or without implant support (Figure 1). Upon examination, it was determined that many of his teeth had good bone volume and that only tooth No. 3 was catastrophically compromised (Figure 2). The biggest risk factors were biomechanical, including decay and lost vertical dimension from severe wear that occurred as a result of high anxiety from his previous occupation as an undercover police officer.
The treatment plan was focused on saving as many teeth as possible with aggressive generalized periodontal care and decay removal around tooth No. 5. Only tooth No. 3 was immediately at risk, requiring extraction and graft treatment. The ultimate goal was to open the bite to allow for crown and bridge and/or implant therapy. The patient could not immediately afford comprehensive care, so as a transitional strategy to help improve his appearance, as well as to create a functional blueprint for future care, the decision was made to implement a bonded functional esthetic prototype5-6 for the lower lower anterior teeth and a removable version for the upper teeth.
The patient was instructed to wear a Kois deprogrammer to relax the muscles. Using this device in a tripod concept, centric relation was recorded with a fast-setting bite registration material (Futar® Fast, Kettenbach GmbH & Co.) To provide the laboratory with more complete data, a mockup of a tooth was placed on the appliance (Figure 3). The width was determined using a digital application (smarTooth, Augusta University).
The functional wax-up was created by the laboratory, which would be used to develop tissue prosthetically and potentially via grafting when definitive care was ultimately performed. Fortunately, for this case, the bonded functional esthetic prototype could be developed in a minimally invasive fashion with bevels to help improve bonding and margination (Figure 4). The "removable" laboratory was sent a detailed prescription to create an upper overlay prosthesis that was accurately fitting and functionally/esthetically correct.
A critical part of this treatment was the development of an accurate matrix to transfer details to the patient's dentition. A spacer of thin putty (ie, about 2 mm) was placed over the dental anatomy on the preoperative model. After the spacer had hardened and was trimmed 2 mm below the gingival margins, a colorless prosthodontic appliance material (Triad® TranSheet tray, Dentsply Sirona) was shaped and slightly extended to fit over the putty. It was cured in a light curing unit (Triad® 2000, Dentsply Sirona) for 15 minutes and then trimmed and smoothed. A clear vinyl polysiloxane (VPS) impression material (Reveal® Clear Matrix, Bisco) was injected onto the wax-up and into the Triad carrier tray, then held over the blueprint for 5 minutes of setting time. The resulting matrix was inspected for accuracy and the excess was trimmed so that the transitional bonding could be smoothly applied to the existing lower teeth. By design, the tray loosely fit the matrix, and to allow for removal, no adhesive was placed. Following this, the upper prosthesis was adjusted for fit and natural esthetics. Because of the bone loss from the previous anterior extractions, the papilla triangles were deficient and would need correction later.
Next, the lower teeth were isolated using a lip and cheek retractor (OptraGate®, Ivoclar Vivadent), a topical anesthetic was placed, and blockout material was positioned in the gingival embrasures to assist final finishing. A fine diamond bur and an erbium laser were used in any areas that were under suspicion of being decalcified, and microabrasion with 40-micron aluminum oxide was performed on all of the exposed tooth structure and restorations.
After having the patient rinse with an antibacterial solution (Consepsis® 2% Chlor-hexidine, Ultradent Products Inc.), a 35% high viscosity phosphoric acid etchant with benzalkonium chloride (Select HV® Etch, Bisco Inc.) was placed on the exposed teeth for 20 seconds and then rinsed and dried for 15 seconds each. The teeth were slightly moist, so a versatile universal adhesive (All-Bond Universal®, Bisco) could be placed ideally with 10 seconds each of scrubbing, air drying, and light-curing per tooth.
Following application of the adhesive, a high-strength, highly polishable, flowable composite (Reveal® [shade A1], Bisco) was carefully injected onto the intaglio of the silicone matrix to avoid adding bubbles, and the matrix was placed on the teeth (Figure 5). A tack cure was performed over the tray to begin hardening the composite, then the tray was gently removed without disturbing the clear matrix to allow for more intimate curing (ie, 60 seconds per tooth).
To finish, all margins were sculpted with a 12-bladed composite finishing bur to facilitate interproximal cleansing (Figure 6). After the occlusion was carefully balanced, all of the surfaces were polished with discs, points, and cups of various grits and finally with a chamois wheel with aluminum oxide paste. Lastly, to close the upper "black triangles," a pink flowable composite was applied, smoothed, and polished to improve the esthetics (Figure 7). Oral hygiene instructions were emphasized and continuing care visits were scheduled at 3-month intervals.
Although the patient was well aware that the treatment was not a long-term solution, he was ecstatic about the outcome and conservativeness of his care (Figure 8).
About the Author
Hugh Flax, DDS
American Academy of Cosmetic Dentistry
International Congress of Oral Implantologists
For more information, contact:
Bisco Dental Products
1. Kois, JC. New challenges in treatment planning: shifting the paradigm toward risk assessment and perceived value-Part 1. J Cosmetic Dentistry. 2011;26
2. Horvath SD and Seelig JK. Following the "platinum rule" Systematic: treatment planning and patient consultation. J Cosmetic Dentistry. 2015;30(4):
3. Whitehouse J. Dealing with patient feelings. Dent Today. 2004;23(12):99-102.
4. Loxterkamp D. What do you expect from a doctor? Six habits for healthier patient encounters. Ann Fam Med. 2013;11(6):574-576. doi:10.1370/afm.1584.
5. McLaren, EA, Schoenbaum, DDS, FACD. The bonded functional esthetic prototype: part 1. Inside Dentistry. 2013;9(1):70-74.
6. McLaren, EA. The bonded functional esthetic prototype: part 2. Inside Dentistry. 2013;9(5):84-92.