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Multidiscipline Restoration of the

June 26, 2019 by AACD Executive Office

Written by AACD Sustaining Member, John C. Calamia, DMD

As you know, modern-day esthetic dentistry is constantly changing. Understanding the extent of what goes into cosmetic cases in the modern day is an important part of executing procedures to the highest degree.  Along with this, the idea of multidisciplinary restorations, specifically utilizing orthodontics, is massively important in helping perfect the smiles of patients. The design of the smile is one of the most important parts of determining how the final product will turn out. Let’s look at the components of the smile design.

Smile Evaluation

The multi-disciplined restoration of the esthetic zone looks at the full gamut of what makes up the smile and the problems the patient has with their smile in order to make the result as esthetically pleasing and functional as possible. The piece that makes this all possible is the smile evaluation that looks at all aspects of the smile on the macro and micro level.

First Steps

For the initial consultation of the patient, the first steps are to:

  • Compile a comprehensive history of any dental work that the patient has had
  • Perform an examination of the oral cavity,
  • Note any pulpal sensitivity,
  • Take intra-oral and extra-oral photographs

From here, the diagnostic cast will be made, and, if necessary, a diagnostic wax-up will be created. Then, oral hygiene instruction will be given to ensure the longevity of the restoration, as well as specialty consults in terms of other disciplines like orthodontics or periodontics.
A thorough general medical history will be taken along with a social history of the patient, which could include smoking, drinking, etc. The intra-oral examination will take place alongside an extra-oral examination to evaluate the skin, head, face & neck, muscles, and TMJ. All these components provide information that results in a final diagnosis.

“All these components provide information that results in a final diagnosis.”

Case 1

When looking at the facial and maxillary midline of the patient, the problem is presented. The dental (Max.) midline and the facial midline do not coincide. The facial midline is set up on the mesial of tooth #9, where there is a large gap (diastema) between #8 and #9. Most of the discrepancy is to the right side of the patient. If the final restoration was lined up on the facial midline, #8 would end up very wide in comparison to the mesial-distal width of #9. The smile line is also looked at and compared with the lower lip. The Maxillary Axial Inclinations are then evaluated, as well as the gingival zeniths.

After the completion of the smile evaluation, a list of problems is organized. These periodontics, endodontics and orthodontics problems will be the ones addressed during the restoration. There will also be a list of preventative measures to be taken in order to make sure the same problems don’t happen after the restoration has been completed.

The treatment plan for this case will be completed in phases:


Phase 1

Phase one will involve resolving periodontics issues, including prophy and oral hygiene instruction. In this case, phase one will also involve a laser reduction of the Buccal Frenum, which may have been the leading factor of the diastema in the first place.

 

Phase 2

Phase two will require the use of orthodontics in order to get the teeth into the proper position. The movement of the teeth will allow for ideal spacing or the “Golden Proportion”. This makes for less preparation of the tooth and will allow for mimicking the facial midline.

 



Phase 3

Phase three will involve a surgical diode laser for the re-contouring of the uneven Gingival Zenith’s.



 


Phase 4

Phase four will entail restorative treatment of #8 and #9, with porcelain crowns being placed on both teeth. Alongside these, #5-7 & 10-12 will receive porcelain veneers as a more conservative approach to give the color the patient wants, as well as closing the spaces.

 

Follow Up

Lastly, the patient will receive maintenance protocols as well as preventative tools to prevent relapse of any past issues. Watching the restorations as time goes on to make sure the quality is being maintained. In this case, a retainer was fabricated to protect the restoration and keep them in the correct position.
 

To take a more detailed look at the surgical phase and orthodontics that went into restoring this patient’s smile, view the full course in the AACD Virtual Campus.
 



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