Case Study: Increasing Vertical Dimension
By Samuel L. Corey, DDS, Fort Wayne, IN
Fabricating successful restorations requires detailed and accurate communication between the dentist and the dental laboratory. When increasing the VDO or any full mouth rehabilitation considerable diagnostic tools are required such as; preoperative photographs and radiographs, study models, centric relation bite registration (CRBR) and accurate measurements of the existing and desired length of the anterior teeth. The lab will then fabricate a diagnostic wax-up to the proper VDO along with a two stage putty wash matrix. Photographs of the prepared teeth and provisionals, stump shades, a detailed diagram of the blending of shades for the permanent restorations, master impressions and accurate occlusal records are sent to the lab. This level of collaboration between the dentist and laboratory is absolutely necessary to achieve consistently successful results.
Patient presented with severe occlusal wear and lost vertical dimension. He desired improved esthetics and function by increasing verical dimension.
IPS e.max was the ideal material for the anterior due to it’s translucency and esthetics. BruxZir Solid Zirconia blended well esthetically in the posterior without scacrificing strength. IPS e.max #5 -12 BruxZir Solid Zirconia #2- 4, #13- 15.
55-year-old man with severe wear on all of his teeth, which loped over years due to a combination of age and bruxism.After the initial consultation, the patient agreed to re-establish a new VDO with a two-phase treatment plan that will rehabilitate his appearance, speech and function by treating the maxillary and mandibular arches with metal free restorations comprised of IPS e.max™ lithium disilicate and BruxZir™ Solid Zirconia.
Phase I: Restore the maxillary arch.
Phase II: Restoring the mandibular arch will be planned later date due to financial reasons.
IPS e.max™ Press Monolithic crowns were chosen for the anterior teeth due to the lack of tooth structure to support veneers. The posteriors were to be restored with BruxZir™ Solid Zirconia for the greater strength and fracture toughness that the solid zirconia provides. The treatment will finish with the fabrication of a night guard.
Periodontal charting and a complete series of pre-operative photographs and radiographs were taken. Alginate impressions were taken to fabricate the diagnostic models and duplicated. A centric relation bite registration (CRBR) was taken and measurements were made of the existing teeth. This information allowed the laboratory to produce a precise diagnostic wax-up of the patients new VDO.
This treatment involved more of an additive technique due to the bruxism, therefore minimal tooth structure was removed. Duplicating the wax-up and fabricating a vacuform clear template (Ivisacryl C® Great Lakes, Orthodontics,LTD) assisted with the the preparation. Impressions were taken using full arch impression trays (COE® disposable spacer trays), and Vinyl PolyEther Silicone (VPES) Heavy tray and light body material (Exa’lence™ GC America). Stump shades and shade selection (Chromascop shade guide by: Ivoclar Vivadent) were chosen along with digital photography to assist the laboratory. A stump shade is needed when using IPS e.max due to it’s translucency and dark stumps will need to be compensated for by the laboratory during ceramic ingot selection. Provisioals (Integrity® DENTSPLY) were sectioned into right posterior, left posterior and anterior segments. The segments were used to create a CRBR that matched the diagnostic wax-up and maintained the VDO that was created. Provisionals were then cemented, (GC TEMP ADVANTAGE®) cleaned, and polished.
The provisionals were removed and the preparations were cleaned using a chlorohexadine rinse (Oris® chlorohexadine oral rinse 0.12%) and a toothbrush. The patient was isolated with cotton rolls and the final restorations were placed to confirm marginal integrity, occlusal contacts, shading and patient approval. Cementation protocols were followed (GC FujiCEM Automix) and post-op photographs were taken. Alginate impressions were made of the cemented final restorations to fabricate an occlusal night guard.
Monolithic restorations such as IPS e.max and BruxZir are becoming extremely popular due to their reliability and esthetics. Unlike PFM’s or porcelain fused to zirconia restorations, monolithic restorations are one solid material throughout. This significant difference nearly eliminates the risk of porcelain chips and fractures that are common when using PFM’s and porcelain fused to zirconia restorations. The combination of these two monolithic materials covers nearly every indication that is needed in the fixed restorative arena while providing improved reliability and esthetics.