This example case was restored with e.max restorations on 2,3, 6-11, 18-20, 22, 27 and two Lava Bridges 13-15, 29-31 and a screw-retained implant bridge 29-3. There was also some gingival re-contouring.
I remember when this case came to my desk, it was obviously going to be a challenging case. We were beginning a full mouth wax-up and were not sure where to start. I then recalled one of the core principles of facially-generated treatment planning and asked, "Where do we want the central incisors positioned in the face?" I looked at the lip at rest picture, then the smile picture, and determined what had to happen to the central incisors to make the smile line up with the goals of a facially generated treatment plan. Then we were ready to begin the wax-up.
The key that unlocked this case and any future case was defining the first step, which establishes the rest of the case choices. The initial focus is the incisal edge position of the centrals following the guidelines above.
With this information in hand, we began the diagnostic wax-up with the two central incisors. We determined what needed to happen to the central incisors in order to put the incisors in the desired position.
- Looking at the lip at rest photo, there was no display of the maxillary central incisors.
- Evaluating the smile photo, we can see that the incisors are retroclined and up to 3 mm too short.
After evaluation of the current incisal edge position, we decided to lengthen the centrals about 2 mm and procline all of the incisors.
Fig. 3 - Maxillary - Anterior Wax-Up
After the incisors were positioned in the wax up, there was a template to establish the maxillary occlusal plane. The posteriors were waxed to have an idealized occlusal plane in relation to the anterior teeth.
After the maxillary teeth were waxed, the lowers were waxed to the maxillaries. The anterior bite was opened 2 mm in order to have space to level the lower occlusal plane. The lower incisors were slightly retroclined in the incisal 1/3 and lengthened to occlude more ideally with the maxillary anteriors.
The wax-up provided a template for the provisionals created chairside.
The provisionals were worn for several weeks. There were occlusal adjustments made and the anteriors were lengthened 1 mm. Once the patient approved the provisionals, impressions of the temps were taken and sent to the lab along with the final prep impression.
The final restorations were made for the entire case by Burbank Dental Lab. At the 6-month recall, the #10 was chipped and was replaced with additional adjustments to the lower opposing. The whole case has been in with no additional damage for 7.5 years.
Figure 5 - Final restorations
Note: The patient was not willing to undergo orthodontics or surgical options. The full treatment was completed restoratively with some gingival re-contouring and endodontic treatment.