Clinical Cases in Restorative and Reconstructive Dentistry

Author xi

Contributors to Appendices xi

Acknowledgments xiii

Introduction xv

Part 1 Didactics 3

Chapter 1 Fundamental Principles of the Comprehensive Approach 5

The Case for the Four-Part Comprehensive Evaluation 5

The Details of the Four-Part Comprehensive Evaluation 5

The Initial Conversation 6

The Clinical System–Based Masticatory System Examination 8

Imaging 22

Articulated Diagnostic Casts 25

Chapter 2 The People Side of Dentistry 27

The Importance of Behavioral and Communication Skills 27

The All-Important 5 Questions 27

The Codiscovery Process 29

Which Approach Is Best—The 4 Quadrants 33

Dentistry: A Blend of Technical, Emotional, and Intellectual Skills 33

Chapter 3 The 4 Essential Skills of the Comprehensive Dentist 37

Section A Bite Splint Therapy 38

Section B Definitive Occlusal Therapy: Equilibration 45

Section C The Diagnostic Blueprint—Wax-Up 50

Section D Provisionalization55

Chapter 4 The 10 Decisions 63

Section A TMJ Diagnosis and Condylar Position 64

Section B Vertical Dimension 66

Section C Lower Incisal Edge Position 74

Section D Upper Incisal Edge Position 77

Section E Centric Stop Design 86

Section F Anterior Guidance 91

Section G Curve of Spee 98

Section H Curve of Wilson 101

Section I Cusp to Fossa Angle 102

Section J The Aesthetic Occlusal Plane 105

Part 2 Case Studies 109

Chapter 5 Nonremovable Implant Restoration with Natural Teeth 111

Case 1 Nonremovable maxillary implant restorations with natural teeth restorations including crowns, veneers, and fixed partial dentures 112

Case 2 Transitioning a maxillary tooth-supported fixed partial denture to an implant-supported fixed partial denture along with other single crowns and tooth-supported fixed partial dentures 121

Case 3 Lower reconstruction with lower left being implant-supported, important neutral zone consideration affecting design; upper reconstruction landmarks acceptable; temporomandibular disorder managed 129

Case 4 Maxillary fixed partial denture supported by both teeth and implants along with other maxillary and mandibular implant-supported crowns and tooth-supported crowns and fixed partial dentures 133

Case 5 Maxillary extractions, periodontal surgery, orthodontics, veneers, and fixed partial dentures on teeth; mandibular extractions, implants, fixed partial dentures on teeth and implants 139

Case 6 Multiple congenitally missing teeth, past orthognathics/orthodontics, tooth position inconsistencies handled restoratively, multiple implants, tooth-supported crowns and fixed partial dentures, implant-supported crowns and fixed partial dentures 143

See also: Chapter 6 Case 1 148

Chapter 7 Case 7 216

Chapter 14 Case 4 342

Chapter 6 TM Disorders Followed by Reconstruction 147

Case 1 Osteoarthritis of the left TMJ managed with bite splint therapy followed by implant-supported restorations and tooth-supported restorations 148

Case 2 Intracapsular and muscular components of a temporomandibular disorder managed with bite splint therapy followed by occlusal therapy and a full reconstruction 152

Case 3 Intracapsular and muscle disorder resolved with bite splint therapy followed by occlusal reconstruction with maxillary lingual porcelain veneers 157

Case 4 Intracapsular and muscle disorder with resultant occlusal plane asymmetry resolved with bite splint therapy and followed by occlusal therapy with restoration only on the lower left 162

Case 5 Past condylar replacement due to avascular necrosis followed by posterior occlusal reconstruction 166

Case 6 Temporomandibular disorder resolved with bite splint therapy followed by definitive occlusal therapy including a maxillary reconstruction and mandibular functional changes with composite 171

Case 7 Past mandibular orthognathic surgery to correct maxillary to mandibular malrelationship caused by condylar degeneration; intracapsular and muscle pain resolved with bite splint therapy followed by definitive occlusal therapy with posterior reconstruction and anterior composites 178

See also: Chapter 15 case 1 350

Chapter 16 case 1 360

Chapter 7 Restorations to Achieve Aesthetic and Functional Changes 183

Case 1 Restoration of anterior aesthetics and anterior guidance in a deep overbite damaged by bruxism with upper and lower anterior reconstruction 184

Case 2 Posterior reconstruction with severe interferences to the centric arc of closure 189

Case 3 Restoration of aesthetics and anterior guidance damaged by wear by increasing overbite with upper and lower anterior crowns 195

Case 4 Maxillary reconstruction at open vertical dimension to improve aesthetics, length, buccal profiles, and functional landmarks; mandibular restorations only recontoured 199

Case 5 Maxillary and mandibular aesthetic and functional reconstruction with lab-processed composite restorations to treat amelogenesis imperfecta 204

Case 6 Restorations maxillary bicuspid-to-bicuspid done first as part of a comprehensive plan; maxillary left central incisor implant and other functional discrepancies corrected with reshaping and equilibration 210

Case 7 Maxillary and mandibular dental reconstruction including 4 dental implants replacing unrestorable teeth; impaired aesthetics due to recession handled with grafts and all porcelain restorations 216

See also: Chapter 16 case 1 360

Chapter 8 Complete Implant-Supported Restorations 221

Case 1 Complete implant-supported maxillary reconstruction— transitioning the anterior teeth from tooth-supported to implant-supported 222

Case 2 Complete maxillary nonremovable restoration supported by 6 implants converted from a completed removable restoration on 4 implants 226

Case 3 Complete implant-supported nonremovable maxillary and mmandibular reconstructions; transitioning from natural teeth that were not predictably restorable 231

Case 4 Maxillary extractions, immediate implant placement, immediate loading, and complete nonremovable zirconia restoration with pink porcelain 237

Case 5 Mandibular implant bar–supported full removable denture converted to a nonremovable restoration to improve comfort of the neutral zone and phonetics 240

Chapter 9 Orthognathics 245

Case 1 Severe anterior open bite corrected with maxillary-only orthognathics and occlusal therapy with upper incisor restorations 246

Case 2 Mandibular orthognathic surgery and chin implant; managing a temporomandibular disorder during treatment; posterior restorative dentistry including implants 250

Case 3 Maxillary and mandibular orthognathic surgery with chin advancement; prerestorative occlusal therapy with equilibration and composite additions 256

See also: Chapter 16 Case 1 360

Chapter 10 Bruxism and Wear Reconstruction 261

Case 1 Restoration of worn lower anterior teeth in a deep bite without changing other restorations 262

Case 2 Severe wear from parafunctional habits restored with a complete reconstruction at an increased vertical dimension of occlusion 266

See also: Chapter 16 Case 2 366

Chapter 11 Perioprosthesis 275

Case 1 Full maxillary periodontal-restorative reconstruction improving aesthetics and function; lower posterior reconstruction following conventional surgery, bone and soft tissue grafts, covering recession 276

Case 2 Posterior reconstruction in conjunction with conventional periodontal surgery; root resection, pocket elimination 282

Chapter 12 Implants in the Aesthetic Zone 289

Case 1 Hopeless maxillary central incisor transitioned to an implant-supported restoration (delayed placement and delayed loading) with crowns on the remaining incisors along with occlusal therapy 290

Case 2 Extraction and immediate implant placement, delayed loading, and restoration maxillary central incisors; pink porcelain to simulate papilla 296

Case 3 Congenitally missing maxillary lateral incisors, orthodontics to open lateral incisor space, dental implants, and other aesthetic improvements 302

Case 4 Congenitally missing upper right cuspid; upper right lateral incisor lost in an accident; implant placed in cuspid position with 2-unit cantilever restoration, pink porcelain to simulate gingival 307

Case 5 Maxillary central incisor extracted and replaced with a dental implant, delayed placement, and delayed loading 311

See also Chapter 7 case 6 210

Chapter 13 Removable Implant-Supported Restoration with Natural Teeth 313

Case 1 Maxillary implant-supported bar-retained removable partial denture along with tooth-supported restorations to reconstruct occlusion and vertical dimension 314

Case 2 Combination mandibular fixed anterior–removable posterior reconstruction with Locator attachments 319

See also: Chapter 14 Case 4 342

Chapter 14 Combination Fixed-Removable Restoration on Natural Teeth 323

Case 1 Maxillary bar–supported removable partial denture; lower crowns with semiprecision removable partial denture 324

Case 2 Maxillary fixed partial dentures with precision removable partial denture; mandibular bar–supported complete denture 331

Case 3 Maxillary telescope case: alumina copings on natural teeth and removable overstructure; mandibular telescope case: Galvano copings on natural teeth and nonremovable overstructures 337

Case 4 Mandibular anterior fixed partial denture and posterior removable partial denture with implants and Locator attachments for added support and retention; maxillary reconstruction, telescope case with 1 dental implant included along with 6 teeth 342

Chapter 15 Implant-Supported Complete Dentures 349

Case 1 Maxillary extensive bone graft followed by implant-supported bars and bar-supported overdenture after managing a temporomandibular disorder; flange needed for lip support necessitating a removable rather than a nonremovable approach 350

Case 2 Severe maxillary and mandibular resorption; maxillary bone grafting; maxillary and mandibular implant-supported bar and bar-supported dentures; flange needed for lip and cheek support necessitating a removable rather than a nonremovable approach 355

Chapter 16 Reconstructions on All Natural Teeth 359

Case 1 Severe anterior overjet handled with occlusal/restorative treatment in lieu of orthognathics; muscular component of a temporomandibular disorder also managed 360

Case 2 Failed multiple reconstructions; original deep overbite with current condition in provisionals with an opened vertical dimension and anterior overjet; managed with a new reconstruction harmonizing a physiologic deep overbite 366

Case 3 Maxillary reconstruction combined with extractions and periodontal surgery to improve periodontal architecture; landmarks of lower acceptable with minor modification 373

Case 4 Full mouth reconstruction utilizing crown-lengthening surgery, extractions, single crowns, veneers, and a fixed partial denture sequenced over 2 years 379

Case 5 Maxillary complete fixed partial denture on 9 Galvano telescopic copings; mandibular anterior fixed partial denture on 4 Galvano copings 385

See also: Chapter 6 Case 6 171

Chapter 14 Case 3 337

Chapter 14 Case 4 342

Appendix 1 Definitive Occlusal Therapy Using the T-Scan III, by Robert BKerstein, D.M.D391

Appendix 2 What Your Laboratory Technician Needs to Provide Excellence, by Jerry Ulaszek, C.D.T433

Index 449