Dental Asia March/April 2019

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Behind the Scenes A JOURNEY THROUGH ELEMENTAL REINFORCEMENT OF FUNCTIONAL AND AESTHETIC HARMONY By Dr. Anand Narvekar It did take quite some time for me to understand that dentistry is similar to photography. One has to be at the moment, intervene and implicate the right treatment regimen to provide another’s smile. In order to do all that, I have learned that patience is an important virtue that we must possess through our entire smile journey. This particular case has taught me in all different aspects of dentistry and motivates me to continue contributing smiles, just like how photographers keep on taking more photographs of their work. Case details A 62-year-old female patient came up to my clinic with a chief complaint of fracturing her ceramic crowns in the upper right posterior region and was experiencing mild pain/sensitivity on hot/cold in the upper left molar tooth region. Patient also complained of food lodgement in the upper palatal and gingival areas. Observations Clinical Examination revealed that the upper right fixed prosthesis was devoid of interocclusal spaces with the opposing mandibular natural teeth (Fig.1). The patient had a fixed prosthetic bridge from tooth 13 – 16 with 14 & 15 as pontics, which had leaky margins and the ceramic was predominantly worn off with inner metal exposure especially in the pontic areas.Extensive enamel wear was observed in the lingual aspect of upper central incisors particularly in the cingulum areas and generalised attrition of lower anterior teeth was present. This was a major concern with the bite wherein the lower anteriors occluded with the Lingual marginal areas of the upper anteriors involving the cingulum and gingival areas (Figs. 2-3). Fig. 1 Fig. 2 Fig. 3 Lateral Profile presented with a high overjet and dentofacial analysis revealed an excessive and disproportionate display of teeth structure (Figs. 4-5). However, periodontal examination showed low risks with no signs of inflammation, presented by absence of bleeding on probing and healthy surrounding hard and soft tissues. The study casts were mounted on a semi-adjustable articulator and Supporting photographs revealed a collapsed and traumatic bite with a unilateral scissor bite on the right side. This contributed to the overall extensive generalised enamel loss and high functional risk. The presence of multiple diastemas and malaligned maxillary anteriors were also observed (Fig. 6). The patient had no signs of pain or inflammation in the Temporomandibular (TMJ) region, despite a traumatic bite. Fig. 4 Fig. 5 Fig. 6 Treatment plan Considering the overall observations, clinically, through study models and photographs, the patient’s condition had 68 DENTAL ASIA MARCH / APRIL <strong>2019</strong>
Behind the Scenes to be immediately addressed, which was constituted by a holistic rehabilitative approach in order to best save the remaining natural dentition. A systemic approach and assessment of periodontal, biomechanical, functional and dentofacial risk had to be carried out in order to lay down the most ideal treatment plan which will add to the overall “predictable success” of the treatment which is our top priority. The collapsed/traumatic bite had to be altered by increasing the overall vertical height thus ensuring good occlusal clearance especially in the right side and overall replacement of the degraded enamel had to be carried out. The patient was initially briefed in detail about the clinical observations and the need to commence the treatment without any further delay. Orthodontic Intervention in order to correct the bite and mal aligned teeth was explained but the patient was not willing to undergo the treatment. Replacement of missing tooth nos. 14 and 15 with implants was another option but it was constituted by few retarding factors such as high cost of sinus lift and Guided Bone Regeneration (GBR) procedures, which was a concern for the patient. Furthermore, the possibility of implant failure especially in the tooth 14 region because of reduced bone width and interocclusal clearance was another factor. Another major factor was scissor bite which will received load on implants from different direction. Hence, Treatment plan was laid out with rehabilitation of all the teeth with ceramic crowns. Selection of the type of ceramics would be decided as the treatment progressed with the bite raised to get a clear picture on the clearance and other bite related information. Since it involved overall occlusal collapse/discrepancies, centric occlusion was considered the starting point of treatment. The treatment commenced and was divided into four phases right from preliminary basic treatment procedures followed by raising the bite and stabilising occlusion to overall replacement and rehabilitation with prosthetics. Phase 1 The first phase involved all the preliminary procedures comprising of removal of all faulty/old restorations in both arches, root canal treatment procedures and necessary composite fillings. Then, crown lengthening procedure was carried out on tooth nos. 16, 36 and 37 to increase the overall surface area of the tooth for the prosthetic crown (Figs. 7-8). Fig. 7 Fig. 8 Phase 2 A customised deprogrammer from pattern resin was fabricated in order to deprogram the muscles and destress muscles in order to guide the TMJ and the mandible to an optimum position of comfort (Fig. 9). Centric Record was taken to mount the lower cast to the articulator while the Upper Cast was transferred using the face bow record (Figs. 10-11). The centric pin of the articulator was lowered down and all premature contact points were checked, ensuring that all the teeth were occluding and then the pin was raised by 5mm. (We have decided to raise the bite by 5mm initially, once we loaded the temporaries in patient’s mouth, after checking dentolabial and facial analysis we will increase or decrease VOD). Wax mock-up was done on the cast as per ideal proportions to emulate natural anatomy. An occlusal putty index was made after the mock up. Spot Etching was done over the natural teeth followed by application of bonding agent over the spots (Fig. 12). A temporary bis-acrylic composite( Protemp -4) is injected into putty index and transferred into the patient’s mouth and allowed to set for 3-4 minutes. The index was then removed, the excess luting material was scraped out and finishing was done for the mock up. The white metal acrylic facing fixed prosthesis is placed on 13 to 16 regions because of the high chance of fracturing the temporary material due to clearance (Fig. 13). After careful study of the facial and dentolabial analysis at rest position, display of maxillary anterior teeth (4 mm), we have decided not to increase any VDO to maintain smile design principles (Fig. 14). Fig. 9 Fig. 10 MARCH / APRIL <strong>2019</strong> DENTAL ASIA 69
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CONTENTS MARCH / APRIL 2019 18 24 2
Page 6:
First Words The New Age of Digitali
Page 10 and 11:
Dental Updates New VOCO Prophylaxis
Page 12:
Dental Updates AACD Welcomes 2019 C
Page 15 and 16:
Periodontal Disease Bacteria Linked
Page 18 and 19:
Dental Updates Henry Schein One Acq
Page 20 and 21: Under the Spotlight 18 DENTAL ASIA
Page 22 and 23: Under the Spotlight It is easy for
Page 24 and 25: Word of Mouth by Dr. Christoper Ho
Page 26 and 27: CELEBRATING DIGITAL TRANSFORMATION
Page 28 and 29: Dental Profile achieve very good re
Page 31 and 32: Dental Profile TAKING DIGITAL IMPRE
Page 33 and 34: Dental Profile The high-precision S
Page 35 and 36: Dental Profile MARCH / APRIL 2019 D
Page 37 and 38: Clinical Feature The importance of
Page 39 and 40: Fig. 8: X-ray after extraction show
Page 42 and 43: Clinical Feature Glass Ionomer Seal
Page 44 and 45: Clinical Feature Fig. 1.1: An erupt
Page 46 and 47: Clinical Feature 7 TH GENERATION AD
Page 48 and 49: Clinical Feature 1. Decay is noted
Page 50 and 51: User Report CENTION N: REDEFINING D
Page 53 and 54: User Report Amalgam GIC Cention N P
Page 56: User Report Fig. 15: Teeth 46 and 4
Page 59 and 60: User Report initial drilling channe
Page 61 and 62: User Report Fig. 16: Postoperative
Page 64 and 65: Behind the Scenes REPLACEMENT OF EX
Page 66 and 67: Behind the Scenes angles due to the
Page 68 and 69: Behind the Scenes and silanated for
Page 72 and 73: Behind the Scenes Fig. 11 Fig. 15 r
Page 74 and 75: Behind the Scenes The overall aesth
Page 77 and 78: In Depth With Fig. 1: Primescan - t
Page 79 and 80: In Depth With The blue light used b
Page 81: In Depth With The first set of data
Page 85 and 86: In Depth With Extending Dental Oper
Page 87 and 88: In Depth With combines the cutting-
Page 89 and 90: Product Highlight BRAVIA ® XL Spec
Page 91 and 92: Product Highlight COLTENE Unveils t
Page 93 and 94: Product Highlight 3Shape launches T
Page 96 and 97: Show Preview 9 th -12 th June 2019
Page 98 and 99: Giving Back to Society February is
Page 102: Advertisers’ Index Advertisers Pa
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Dental Asia March/April 2019

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