08 January 2019

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Prosthetic and Conservative Rehabilitation with 3 step technique: a clinical case

Franco De Chiesa

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The patient M. D. (years 52) comes to our observation showing the need to improve in a less invasive way his dental situation that has deteriorated over the years, alarmed by the pigmentation and wear of the front group (fig 1,2,3).
The general anamnesis is negative, while the dental history presents: grinding and nocturnal lock, chewing problems, cigarette smoke (30 a day), frequent use of mate grass (infusion). These habits have generated over the years a problem of abrasion and reduction of the upper and lower incisal length and slight collapse of the perilabial soft tissues with consequent functional problems (reduced masticatory capacity) and aesthetic problems (dyschromia, reduced incisor length). 

The intraoral visit we see numerous incongruous restorations (old composites and amalgams, implants and Richmond on natural teeth) in the lateral sectors and the periodontal survey shows a slight horizontal reabsorption.  Considering the patient's expectations, and the precise request to adopt the least invasive treatment possible, and after a careful evaluation of the clinical photos, study models and digital waxing (digital smile system), the dental technician performs the waxing of the 2nd sextant and creates a silicone mask for direct molding of the mock-up (fig 4-6).

This test is carried out with the necessary modifications then transferred through an impression in the laboratory, in order to respect the correct incisal length of the frontal group from the phonetic point of view and the correct aesthetic plan. During the second appointment the waxing of the lateral sectors is transferred into the oral cavity, with the use of rigid transparent silicone keys (fig 4,5). Then the lower incisal group is temporarily reconstructed with the aid of a lingual support template (fig 6). Once the occlusal contacts have been adjusted, the patient is discharged in order to test the new vertical dimension. 
At the next follow-up visit, the patient does not report any muscular or articular problems, so we decide to proceed with the definitive restoration with palatal composite facets of the 2nd sextant, using a plaster model CAD / CAM technique, trying to be the most conservatives possible (Fig 7-14). 

The next phase of the treatment consists in rehabilitating the posterior sectors by means of indirect restorations of CAD / CAM in lithium disilicate (onlays, crowns, inlays) both on the residual dental elements and on the implants (Fig 15-26).

Finally, the vestibular composite faces CAD / CAM on the lower incisors were applied in order to restore the correct aesthetics and function.It is important to specify that the buccal veneers (as in the sandwich technique) were not applied on the 2nd sextant because the patient was largely satisfied with the result achieved. To complete the rehabilitation performed, a night-time protective bite was delivered to the patient to limit the damages due to his parafunctions (Fig 27-31).