CHIEF COMPLAINT:
Patient desired an aesthetic improvement on his front teeth, which suffered recurring damage.
DIAGNOSIS:
Male patient, 36 years old, non-smoker. Had performed orthodontic treatment and aesthetically rehabilitation of the anterior sector with composite resin restorations. The restorations presented an average vertical increase of 2 mm in relation to the incisal edge. They looked aesthetically satisfactory but with a few incisal fractures. Tooth 1.5 presented an apical process and tooth 2.6 presented endodontic treatment and an endo-periodontal lesion. In the lower jaw, at the site of tooth 3.5, was an implant with a screwed crown, and tooth 8.5 was still present in the mouth with agenesis of tooth 4.5. The patient presented a slight loss of vertical dimension of occlusion probably associated with visible wear of the occlusal surfaces. The periodontium was thick and had excellent oral hygiene.
TREATMENT PLAN:
After clinical and imaging analysis, the patient was proposed to recover the vertical dimension of occlusion essentially at the cost of inferior occlusal increments using overlays in the posterior sector and veneers in the anterior sector. The screwed crown on the 3.5 implant would be replaced to accompany this increase. In the maxilla, tooth 2.6 would have extraction indicated and would later be rehabilitated with an implant and respective crown. To aesthetically rehabilitate the patient in a minimally invasive manner, the placement of feldspathic veneers in the antero-superior sector was proposed. The objective of slightly increasing the V.D.O would have the function of effectively “protecting" the upper-sector.
TREATMENT NOTES:
After the diagnosis and decision on the treatment to be performed, it became important to define the sequence of work to be undertaken in order to achieve the rehabilitation of the V.D.O, in a progressive and balanced manner. In the first phase a pre-impression was made of the lower dental arch, using silicone putty, and then dental preparation of the entire posterior sector. Preparation for overlays was done coronally to the cementoenamel junction in the sense of being as conservative as possible. The impression was made with wash technique impression, after gingival retraction performed with Kaolin paste. The provisional one was made with dual cure composite resin. In the laboratory, the overlays were performed after having slightly opened (1.5mm) the V.D.O. in the mounted master casts on semi-adjustable articulator. At the same time, the anterior-inferior sector was waxed to follow this increase in V.D.O. A transparent silicone index key was also made for later confection of the anterior-inferior provisionals. In the mouth, temporization of the anterior teeth was first performed using pre-heated composite resin after preparation of the dental surfaces for bonding. The rubber dam was placed to promote absolute insulation and later the overlays were glued. In the laboratory, a new silicone index was made to prepare the anterior-superior provisionals. The six anterior-superior teeth were then placed in the mouth after the gingival retraction cord was placed. After adequate preparation of the dental surfaces, a wash technique impression and corresponding provisional were done. In the laboratory, 6 feldspathic veneers were made in a Geller model cast. The provisional one was removed and the veneers were bonded in the mouth using competent relative isolation. This option was chosen because the patient had a negative experience with the placement of the rubber dam on the jaw. After bonding antero-superior veneers, 12 weeks were given to evaluate the patient’s adaptation to the new situation, before beginning confection of anterior-inferior facets. After placing the gingival retraction cord, the appropriate dental preparations were performed and then the impression was made. Preparation of tooth 3.4 was also done, which, however, had suffered a fracture of the overlay. The veneers and restoration of 3.4 were performed in a Geller model cast. After removal of the provisional, the facets were glued in the mouth using relative isolation for the previously mentioned reasons. After placement of the work, the patient was rehabilitated by other colleagues with an implant in the 2.6 zone and replacement of the screwed crown on the implant placed in the 3.5. Later fractures occurred in the overlays of teeth 4.7 and 3.7 which were rehabilitated with Zr overlays.