Atlanta Aesthetic dentistry, Atlanta Dental Implants

ow good is a new smile if it doesn’t last? In Lee’s chapter of the Fundamentals of Es- thetics, 1 he points out the dichotomy between dentists that focus primarily on function, sta- bility, and comfort, and those whose priority is esthetic rejuve- nation. Why not try giving patients the benefits of both—a beautiful smile designed to last a long time? During the past 20 years, porcelain veneers have evolved from a color masking/space clos- ing tool to a restorative lengthen- ing medium for teeth as well. Of course, the ceramic materials have become much stronger. Haupt 2 correctly points out that dentists should be focusing on the “cause” of accelerated wear on tooth structures, not just the “solution.” Predictable results are achiev- able by synergistic relationships between: The anterior and posterior dentition, supporting periodon- tium, the temporomandibular joints (TMJ), and the neuromus- cular system (the functional basis of bioesthetics), as well as the single collective of the mouth (lips, smile, and gums). Artistically recreating natural beauty with function. Interdisciplinary approach be- tween the dentist and laboratory technician/artist. 3 When people lose ideal func- tional masticatory relationships, the mouth loses its ability to chew efficiently. The teeth, mus- cles, and/or gums become over- loaded/damaged, especially in the anterior dentition and verti- cal dimension of the lower face. The posterior teeth eventually lose the natural sharpness of the cusps for chewing food. The goal in treating this is to reestablish this harmony while revitalizing the patient’s appearance. The clinical evidence sup- porting Lee’s theory is widely documented. In Hunt’s literature review, 4 he noted that Dahl and Krogstad reported in 1985 that changes in correcting vertical face height (averaging 1.9 mm) were well tolerated. 5 Mack’s study in 1991 6 found that “the occlusal plane is ultimately the determining factor in restoring necessary facial height.” McAn- drews 7 agreed with the above while going further to say that corrected arch alignments and interauspal relationships were stable. The key to this positive response is detailed attention “to achieving holding contacts for all teeth in centric relation.” As- suming the alveolar bone is capa- ble of remodeling (sclerotic bone and exostoses are contraindicat- ed in this situation), muscle activity will be better managed when posterior disclusion is obtained with harmonious ante- rior guidance. Decreased elevator muscle activity by this method allows for the condyles to reach their most superior bone braced position and stabilize the con- dyle-disc complex, harmonizing the bellies of the lateral ptery- goid muscles and making the patient more comfortable. 8,9 Full-mouth rejuvenation is a “methodical step-by-step proce- dure” 2 taking into account all the parameters above. Form and function are intimately inter- twined. To accomplish the goals of functional, esthetic dentistry in full-mouth care, dentists must maximize anterior guidance while staying comfortably in the enve- lope of function and avoiding eccentric occlusal interferences. According to Lee, 1 nature’s most successful unworn stable, esthet- ic, class I dentitions incorporated the following characteristics (along with the aforementioned): Central incisor vertical over- lap of 4 mm. Central incisor horizontal overjet of 2 to 3 mm. Maxillary incisor length of 12 mm (average). Mandibular incisor length of 10 mm (average)—shorter to 70 May 2003 CONTEMPORARY ESTHETICS AND RESTORATIVE PRACTICE At The Chair At The Chair W ITH R OSS W. N ASH , DDS Predictable Reconstruction of a Healthy Smile: A Case Report P P orcelain veneers have evolved from a color masking/space closing tool to a restorative lengthening medium for teeth. Ross W. Nash, DDS Private Practice Charlotte, North Carolina Clinical Instructor Medical College of Georgia School of Dentistry Phone: 704.364.5272 Email: [email protected] Dr. Nash is founder of Ross Nash Seminars and director of The Nash In- stitute of Dental Learning in Charlotte, North Carolina. A consultant to numer- ous dental product manufacturers, he lectures internationally on subjects in esthetic dentistry. Dr. Nash is an accredited member of the American Society for Dental Aesthetics and a Fellow in the American Academy of Cosmetic Dentistry. Guest Author Hugh Flax, DDS Private Practice Atlanta, Georgia Phone: 404.255.9080 Fax: 404.255.2936 Email: greatsmile4u Hugh Flax is an accredited member of the American Academy of Cosmetic Dentistry. His training with functional esthetics has spanned the years with Ronald Goldstein, Peter Dawson, Ross Nash Seminars, PAC~Live, and the Pankey Institute. He is co-chair for the 2003 American Academy Cosmetic Dentistry Scientific Session in Orlando, Florida. While he maintains a pri- vate practice in Atlanta, Georgia, he also writes and lectures about esthetic dentistry. H


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Transcript of Atlanta Aesthetic dentistry, Atlanta Dental Implants

Page 1: Atlanta Aesthetic dentistry, Atlanta Dental Implants

ow good is a new smileif it doesn’t last? InLee’s chapter of theFundamentals of Es-

thetics,1 he points out thedichotomy between dentists thatfocus primarily on function, sta-bility, and comfort, and thosewhose priority is esthetic rejuve-nation. Why not try givingpatients the benefits of both—abeautiful smile designed to last along time?

During the past 20 years,porcelain veneers have evolvedfrom a color masking/space clos-ing tool to a restorative lengthen-ing medium for teeth as well. Ofcourse, the ceramic materialshave become much stronger.Haupt2 correctly points out thatdentists should be focusing onthe “cause” of accelerated wearon tooth structures, not just the“solution.”

Predictable results are achiev-able by synergistic relationshipsbetween:• The anterior and posteriordentition, supporting periodon-tium, the temporomandibularjoints (TMJ), and the neuromus-cular system (the functional

basis of bioesthetics), as well asthe single collective of the mouth(lips, smile, and gums).• Artistically recreating naturalbeauty with function.• Interdisciplinary approach be-tween the dentist and laboratorytechnician/artist.3

When people lose ideal func-tional masticatory relationships,the mouth loses its ability tochew efficiently. The teeth, mus-

cles, and/or gums become over-loaded/damaged, especially inthe anterior dentition and verti-cal dimension of the lower face.The posterior teeth eventuallylose the natural sharpness of thecusps for chewing food. The goalin treating this is to reestablishthis harmony while revitalizingthe patient’s appearance.

The clinical evidence sup-porting Lee’s theory is widelydocumented. In Hunt’s literature

review,4 he noted that Dahl andKrogstad reported in 1985 thatchanges in correcting verticalface height (averaging 1.9 mm)were well tolerated.5 Mack’sstudy in 19916 found that “theocclusal plane is ultimately thedetermining factor in restoringnecessary facial height.” McAn-drews7 agreed with the abovewhile going further to say thatcorrected arch alignments and

interauspal relationships werestable. The key to this positiveresponse is detailed attention “toachieving holding contacts for allteeth in centric relation.” As-suming the alveolar bone is capa-ble of remodeling (sclerotic boneand exostoses are contraindicat-ed in this situation), muscleactivity will be better managedwhen posterior disclusion isobtained with harmonious ante-rior guidance. Decreased elevator

muscle activity by this methodallows for the condyles to reachtheir most superior bone bracedposition and stabilize the con-dyle-disc complex, harmonizingthe bellies of the lateral ptery-goid muscles and making thepatient more comfortable.8,9

Full-mouth rejuvenation is a“methodical step-by-step proce-dure”2 taking into account all theparameters above. Form andfunction are intimately inter-twined. To accomplish the goalsof functional, esthetic dentistryin full-mouth care, dentists mustmaximize anterior guidance whilestaying comfortably in the enve-lope of function and avoidingeccentric occlusal interferences.According to Lee,1 nature’s mostsuccessful unworn stable, esthet-ic, class I dentitions incorporatedthe following characteristics(along with the aforementioned):• Central incisor vertical over-lap of 4 mm.• Central incisor horizontaloverjet of 2 to 3 mm.• Maxillary incisor length of 12mm (average).• Mandibular incisor length of10 mm (average)—shorter to


At The ChairAt The ChairWITH ROSS W. NASH, DDS

Predictable Reconstruction of a Healthy Smile: A Case Report

PP orcelain veneers have evolved from a color masking/space closing tool to a

restorative lengthening medium for teeth.

Ross W. Nash, DDSPrivate PracticeCharlotte, North CarolinaClinical Instructor Medical College of Georgia

School of DentistryPhone: 704.364.5272Email: [email protected]

Dr. Nash is founder of Ross NashSeminars and director of The Nash In-stitute of Dental Learning in Charlotte,North Carolina. A consultant to numer-ous dental product manufacturers, helectures internationally on subjects inesthetic dentistry. Dr. Nash is anaccredited member of the AmericanSociety for Dental Aesthetics and aFellow in the American Academy ofCosmetic Dentistry.

Guest AuthorHugh Flax, DDSPrivate PracticeAtlanta, GeorgiaPhone: 404.255.9080Fax: 404.255.2936Email: greatsmile4u

Hugh Flax is an accredited member of theAmerican Academy of Cosmetic Dentistry.His training with functional esthetics hasspanned the years with Ronald Goldstein,Peter Dawson, Ross Nash Seminars,PAC~Live, and the Pankey Institute. He isco-chair for the 2003 American AcademyCosmetic Dentistry Scientific Session inOrlando, Florida. While he maintains a pri-vate practice in Atlanta, Georgia, he alsowrites and lectures about esthetic dentistry.


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allow the lower cuspids to passthrough during protrusion.• Approximately 18 mm fromupper cementoenamel junction(CEJ) to lower CEJ on the cen-tral incisors.• Embrasures progressing in sizefrom central incisors to thebicuspids.

The purpose of this article isto demonstrate these ideas inpractice. Several reliable ingredi-

ents in this “recipe” of achievingmultistructural and multidisci-plinary success will be presented.

CASE REPORTA 27-year-old man presented

with severe wear, vertical break-down, and generalized decay (Fig-ures 1 and 2). He was a very suc-cessful entrepreneur who wanted“perfect teeth” and was aware thathe ignored his dental care for years

(except for orthodontics and wis-dom tooth removal in the past 5years). Full evaluation of hismouth included detailed radi-ographs, models, photographs,and periodontal probings. Afterfull-mouth periodontal debride-ment and nutrition/oral healthcare counseling, the followingfindings were arrived at using Kois’Diagnostic System.10

• Periodontal—Generalized gin-

givitis with localized recessioncomplicated by decay/abrasion.• Biomechanical—Generalizedcaries and four areas of pulpalpathology demonstrating percus-sion tenderness.• Functional—Severe attritionwith group function but a rangeof motion of 59 mm and no neu-romuscular, TMJ discomfort; theintra-arch CEJ measurement was13 mm.• Dentofacial—Severe wear andreverse smile line as well as alack of uniform color and toothshapes. Although the lip line waslow, there were uneven gingivalmargins. Tooth color was mea-sured at A2/A3 with generalizedwhite decalcifications.

At a “codiagnostic visit,” thepatient was shown the extent ofhis problems. More importantly,the “causes” and how to getlong-term results by dealing with

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Figure 2—Reverse smileline not only agesthis patient’s appearance but also function-ally compromises the other dentition.

Figure 3—The “Tripod Technique” forgetting an accurate centric relation openbite using a composite ball and LuxaBite™.Notice the severity of cervical decay.

Figure 1—Full face and smiledemonstratesdecreasedyouthfulnessand health.

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them, not just the “curb appeal”/ es-thetic elements were empha-sized. After showing him a simi-lar patient’s treatment, he agreedto a comprehensive solution aslong as he was kept sedated dur-ing his definitive case visits. Theplan was to treat the incisors andbicuspids with bonded Authen-tic® porcelain crowns/overlayveneers (Microstar® Corporation)and the molars with cementedAuthentic® Press-to-Metal™ crownsbecause of the gingival depth ofprevious decay.

A maxillary guided orthotic(MAGO) was constructed tocentric relation and a verticaldimension of 18 mm from upperincisal CEJ to lower incisal CEJ.To add precision to this process,an anterior composite bite wasmade at a centric relation openbite. The posterior bite was“tripoded” using LuxaBite™ (Ze-nith™/DMG) because of its supe-rior handling properties and firmset (Figure 3). The ability to eas-ily read and trim the registra-tions as well as accurately mountthe model makes it ideal for cre-ating throughout this patient’scase. During MAGO construc-tion, root canals and decay con-trol were done to begin tostrengthen tooth structure.

The purpose of the applianceis to create an ideal bite relation-ship without noxious interfer-ences and allow the condyles toachieve an ideal position in theglenoid fossa relative to disc andmuscles. The patient wore theappliance for approximately 24hours per day for 1 week at thenew vertical dimension of occlu-sion. When he returned withsome slight discomfort, modifi-cations were made that closedthe vertical dimension fromupper incisal CEJ to lowerincisal CEJ to about 17 mm.

After another 2 weeks, he report-ed no difficulty with all his oc-clusal marks remaining stable.Fortunately for this patient, hisadaptive capacity was large, anddid not require extended adjust-ment time that often can take upto 1 year.

When this author realized thepatient’s comfortable verticalposition (approximately 17 mmCEJ to CEJ), it was time to createa “blueprint” of the patient’s

vision for the final result. Newimpressions and a Stratos® 200(Ivoclar Vivadent®, Inc) face-bowwere taken. A new closed reduc-tion (CR) bite was taken usingthe MAGO as a reference. A smallwindow was cut out in the frontof the biteguard to establish ananterior bite reference point. Theorthotic was removed and whilethe patient closed into the anteri-or bite registration, a LuxaBite™

index was made in the molararea. The result was a very firmvertical bite measurement pre-dictable for mounting at the lab-

oratory. The laboratory can makean accurate full-mouth wax-upto get all involved parties “on thesame page.” The molar wax-up isremovable to allow verificationof the new vertical on the wax-up and later on in the mouth(Figure 4).

Before any alterations oc-curred in the mouth, the patientwas brought in for a “mock-upvisit.” At that visit, Luxatemp®

(Zenith™/ DMG) was placed over

the teeth to reverify esthetics aswell as the new vertical using themolar bite registrations. Withthis pre-preparation visit, thisauthor “fine tuned” the commu-nication with the patient andlaboratory. This saved chair timeas well as “preframe” expecta-tions for the patient as he wentthrough treatment (Figures 5and 6).

Because the goal was tolengthen this patient’s teeth, thepreparation phase became sim-plified. Little to no incisal orocclusal reduction was needed toaccomplish our goals. On theother hand, maintaining a con-stant vertical/CR relationship tomatch our blueprinted plans wascritical to the execution of ourfunctionally esthetic philosophy.Furthermore, because of theesthetic demands, this authorhad to treat this patient more“macrodentally” to achieve thegoals. In cases such as this, theincisors and bicuspids are pre-pared at the same time for theirnew restorations. Through theuse of serial “transfer bites”11

that began with pre-preparationindices based on the original biteregistrations, the author was ableto maintain the occlusal/TMJrelationships that he had devel-

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Figure 4—The wax-up establishes a“blueprint” of communication and func-tional/esthetic success.

Figure 5—Vertical and CR positioningcan be verified with the “mock-up.”

Figure 6—The patientgets to pre-view his newsmile by creating aLuxatemp®

“mock-up”;two colors aretried to helpthe patientmake a decision.

Figure 7—“Transfer bites” using Luxa-Bite™ helps maintain occlusal relation-ships throughout the preparation visit.

Figure 8—Gingival irregularities andasymmetries are easily modified with electrosurgery.

Figure 11—Note the accuracy of model toregistration fit available with Luxa-Bite™—a prerequisite for full-mouthrestoration in the laboratory.

Figure 9—Stick-biteregistrationand photo-graphs allowthe laboratorytechnician tomaintain ahorizontalincisal edgeposition.

Figure 10—The tempo-raries addmore youth-fulness to thepatient’sappearanceand create aprototype forthe finaldesign.

AA critical part of the patient-focused philosophy is to allow the clients to “test

drive” their new smile and its functionality.

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oped before this visit (Figure 7).It also allowed fine tuning ofsome of the gingival asymmetries(and change those landmarks)without losing the orientation(Figure 8). This precision wasfurther enhanced with new stick-bite and face-bow measurements(the former being done with thepatient in a closed position usingthe vertical/CR bite registrationsin place [Figure 9]). Digital pho-tographs of the bites as well asthe preparation colors gave thelaboratory detailed knowledge“beyond the stone models.” Bycarefully taking each bite duringthis phase, this author createdcontinuity of our original gameplan.

Provisionalization with bleachshade Luxatemp® was simplifiedwhen the laboratory created anaccurate wax-up that was in-dexed with Siltec putty. Estheticsand function needed minorattention when precise recordswere made and used. It alsoallowed this patient, who wassedated with alprazolam, to haveno unpleasant surprises when hesaw his new smile (Figure 10).

A critical part of the patient-focused philosophy is to allowthe clients to “test drive” theirnew smile and its functionality. Itallows them (and their significantothers) to “critically evaluatetheir new appearance and theirability to chew, speak, swallow,and kiss.”12 After the patient hada week to do this, this authorfine-tuned the provisionals. Bytaking this extra time to do this,patient participation and satisfac-tion was greatly increased.Communicating these resultswith impressions and photos tothe laboratory technician allowedhim to know three-dimensionallyall the details of the prototypes.

The laboratory phase of thefunctional-esthetic journey wascritical. Using all the registra-tions, the models were carefullymounted to a Stratos® articulator(Figure 11).

Putty matrices of the “tempo-rary model” allowed the techni-cian to precisely recreate thecontours developed with thepatient. Porcelain restorationswere created using a lost-waxtechnique and ingots of Au-thentic® porcelain (Figure 12).Characterization of colors with acutback modality allowed thetechnician to create natural tex-tures and translucency to give amasterful touch to the contoursand occlusion already estab-lished (Figure 13). Correct axialinclinations, embrasure forms,tooth lengths, and proportionscreated the building blocks tofacial harmony and beauty as

well as the engineering guidancefor comfort and longevity(Figure 14). The molars werealso waxed-in at this occluso-esthetic relationship to allowcompletion of the posteriorregion (Figure 15). The patientwore the anterior provisionalsfor 4 weeks, the time it took tocomplete this laboratory phase.

The restorations were tried-in individually and as a group toverify fit, color, and occlusion(Figure 16). The patient was ableto give his approval of the esthet-ics (Figure 17). All restorationswere placed while using rubberdam isolation to prevent contam-ination and improve the bondstrength of the Syntac® system(Ivoclar Vivadent®, Inc). Restor-ations were luted and light-curedwith translucent Variolink® II(Ivoclar Vivadent®, Inc) basecement employing the “two-by-

two technique.” After removingany excess, occlusion was finetuned with a computer-generat-ed report using the T-Scan™

System (Tekscan, Inc) whilechecking in CR. Although themolars had not been treated yet,the patient commented abouthow comfortable the bite felt.

The final phase of the reha-bilitation was begun 2 weekslater and took an additional 4weeks to complete. The occlu-sion was slightly touched up andreindexed before anesthesia. Themolars were restored at this rela-tionship using Authentic® porce-lain-pressed-to–yellow gold be-cause of the existence of manysubgingival margins from thepreexisting decay. All sevencrowns were luted using Vitremer™

(3M ESPE) glass ionomer cement.The patient was also fitted for annighttime upper orthotic to pro-


Figure 13—Layering the porcelain after“cutting back” enabled the technician tocreate natural incisal translucence.

Figure 14—Seeing the “big picture” helpsmaintain vital esthetic and functionalrequirements.

Figure 15—Waxing-in the molar occlu-sion “dials in” the posterior restorationphase.

Figure 12—The “lost-wax technique”allows Authentic® restorations to have avery precise fit marginally and occlusally.

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tect his new restorations fromnocturnal bruxing. All werechecked using the T-Scan™.

CONCLUSIONUsing the techniques de-

scribed above allowed the res-torative team (including the labo-ratory technician/artist) to rejuve-nate this patient’s smile to anappearance that allowed his den-tal condition to better match hisage (Figures 18 and 19). Using aseries of linked steps, we wereable to match the patient’s esthet-ic demands and the bioestheticprinciples established by Lee.1

Biologically, it was gratifying tosee the harmony improved gingi-vo-restoratively (Figures 20 and21). By focusing on both estheticsand function, this patient shouldenjoy many years of health, com-fort, and confident esthetics.There is no doubt that enhancinghis future with this type of carewas very rewarding. Controlledplanning and care was definitelythe key to our success. �

ACKNOWLEDGMENTSThe author would like to

thank Wayne Payne, CDT, of SanClemente, California for his men-torship and dedication to beauti-ful and long-lasting smiles. Fur-thermore, the author appreciates

his staff for their shared commit-ment to high quality patient com-fort and extraordinary dentistry.Lastly, the author extends hisgratitude to his family for allow-ing him to devote the extra timefor continuous improvement andsharing with others.

REFERENCES1. Lee RL. Esthetics and its relationship to function. In:

Rufenacht CR, ed. Fundamentals of Esthetics. CarolStream, IL: Quintessence Publishing Co; 1990:chap 5.

2. Haupt J. A team approach to full-mouth rejuvenation.J Cosmet Dent. 2002;18:42-47.

3. Hunt K. Full-mouth multidisciplinary restorationusing the biological approach. Pract Proced AesthetDent. 2001;13:399-400.

4. Hunt K. Full-mouth rejuvenation using the biologicapproach: an 11-year case report follow up.Contemporary Esthetics and Restorative Practice.2002;6:26-27.

5. Dahl BL, Krogstad O. Long-term observations of anincreased occlusal face height obtained by a com-bined orthodontic/prosthetic approach. J OralRehabil. 1985;12:173-176.

6. Mack M. Vertical dimension: a dynamic conceptbased on facial form and oropharyngeal function.J Prosthet Dent. 1991;66:478-485.

7. McAndrews J. Presentation to Florida ProsthodonticSeminar; October, 1984; Miami, Fl.

8. Dawson PE. Vertical dimension. In: Dawson PE, ed.Evaluation, Diagnosis, and Treatment of OcclusalProblems. 2nd ed. St. Louis, Mo: CV Mosby Co.;1989:Chap 5.

9. Williamson E, Lundquist DO. Anterior guidance: itseffect on electromyographic activity of the temporaland masseter muscles. J Prosthet Dent. 1983;49:816-823.

10. Kois J. Diagnostically driven interdisciplinary treat-ment planning. Presented to: The Atlanta DentalStudy Group; December 2002; Atlanta, Ga.

11. Montgomery M, Hornbrook D. Records appointmentlecture. Presented at: PAC~Live Advanced FunctionalCourse; October 2002; San Francisco, Ca.

12. Flax H. Success by design, not by accident. OralHealth. 2001;91:93-102.

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Figure 18—The patient’s smile looksbrighter and healthier, and the muscula-ture looks more relaxed.

Figure 19—A congruentsmile linenot onlyadds confi-dence to anappearance,but whenfunctionallyharmonious,it increasesthe likeli-hood ofcomfort andlongevity.

Figure 17—Final patientapproval withdifferent try-ingels createsbetter serviceand ensuresagreementwhen therestorationsare finallybonded.Figure 16—The vertical positioning was

verified when trying-in the restorations.

Figure 21—Postoperative view of the nat-ural esthetic and biologic harmony createdby the synergy of preplanning and action.

Figure 20—Unhealthy occlusion oftenleads to gingival irregularity.

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