One-on-One An Interview with Dr. Paul Homoly Simply Beautiful A ...

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porcelain products. Its manufacturer reports that the uniform leucite structure seen in Venus porcelain allows a smoother surface, with the clinical advantages of easier adjustment and intraoral polishing to a consistently high luster. A multiple fitting process during manufacturing allows consistent shading, bottle-to-bottle, which is an important feature, whether fabricating full-mouth restorations, restoring a few teeth, or a quadrant or arch at a time. The following case report features Venus porcelain and Venus stacked on zirconium in the functional and esthetic ceramic rehabilitation of a Class II postorthodontically treated patient. Figure 1: Preoperative full-smile view of a post-orthodontically treated Class II malocclusion. Note how the roots of the maxillary central incisors had to be inclined distally to create proximal contact. As a result, there is a “black triangle” that can never be filled with gingival papillae, because the contact is too far incisally to the interproximal crestal bone. Diagnosis and Treatment Planning The patient presented for a comprehensive examination after more than two years of orthodontic treatment to correct a Class II malocclusion (Figure 1). The limitations of orthodontic tooth repositioning are evident, based on the final treatment positions (Figures 2–5). This case was an orthodontic retreatment—the first premolar extractions and the first-time orthodontics had been performed several years previously. Without corrective skeletal surgery, the patient was left with the following conditions: • A deep overbite and the inability to retract the maxillary anterior segment sufficiently enough to close the diastemata (interproximal spaces) without inclining the incisors palatally. Figure 2: A preoperative oblique view of the patient’s smile reveals other esthetic problems. The maxillary central incisors are inclined too far in the palatal direction, and there is still a diastema present distal to the maxillary canine. • A Bolton’s discrepancy, due to the extracted first premolar teeth, leaving the orthodontist unable to close the spaces distal to the maxillary cuspids, due to inadequate mesialdistal widths of the remaining teeth and the excessive arch length. From a dental perspective, most of the posterior teeth had received large restorations that were breaking down and were in need of repair and/or replacement. The short cervico-incisal heights of the posterior teeth and the limited inter-arch space created a problem in reducing the posterior dentition enough occlusally (1.5 mm to 2.0 mm) to create adequate space for restorative materials. Based on the need for posterior dental rehabilitation, the deep overbite, and the anterior spacing, it was decided that the patient would need a porcelain rehabilitation to conservatively “resurface” anterior teeth and close the interproximal spaces. At the same time, the vertical dimension of occlusion would be opened, or recaptured (approximately 3 mm), to gain occlusal space for the posterior reconstruction and correction of the deep overbite (100 percent overbite). The patient also desired to have a more youthful, whiter smile. Because the platinum foil remains in the feldspathic restora- Figure 3: View of a retracted full preoperative smile. Note the 100 percent overbite in the CO position. Figure 4: A maxillary full-arch preoperative occlusal view shows that most of the maxillary posterior teeth have large restorations and short clinical crowns. 42 www.chairsidemagazine.com
tions, it is not possible to assess marginal integrity, proximal contact, or color of the anterior teeth. To accomplish these goals, it was decided to use a feldspathic porcelain on the anterior teeth, so that the preparation could be performed in a more conservative manner, with zirconium crowns on the posterior dentition for esthetics and strength. 1,2 Figure 5: A mandibular full-arch preoperative view. Prosthetic restoration of vertical dimension will require full-coverage restoration of anterior and posterior teeth. Figure 6 : A Diagnostic Wax-Up was created by the laboratory technician to act as a template for the provisional reconstruction. Treatment Methodology Diagnostic Wax-up At the first visit, preoperative photographs, maxillary and mandibular impressions for a Diagnostic Wax-Up, a facebow with interocclusal records, and full-mouth digital X-rays were taken. The dental technician poured up the models and mounted the case on a semi-adjustable articulator (Denar ® , Teledyne Water Pik; Fort Collins, CO). The completed Diagnostic Wax-Up is shown in Figure 6. To create sufficient posterior space to develop normal cervico-incisal heights for the clinical crowns, the dental technician had to open the pin on the articulator by 3 mm. This procedure allows the height of the posterior teeth to be corrected, decreases the overbite of the maxillary anterior teeth, and allows the mandibular anterior teeth to be visible during maximum intercuspation. Figure 7: A silicone matrix is used as a preparation guide in the reduction of the maxillary teeth during the preparation phase of treatment. Figure 8: The maxillary arch provisional restorations are shown in place as a plastic matrix filled with a bisacrylic provisional material placed over the mandibular preparations, and the patient is instructed to close into light occlusal contact. Provisional Stent A silicone matrix was made from the maxillary wax-up, to be used as a provisional stent. Another matrix was made and the facial portion was cut away, allowing the palatal outlines of the corrected tooth forms to remain. When placed in position, this stent can be used as a preparation guide to aid in the reduction of teeth during the preparation process (Figure 7). 3 Once the tooth preparation was completed, a bisque acrylic provisional material (LuxaTemp ® , Zenith DMG; Englewood, NJ), was dispensed into the maxillary stent and then placed over the maxillary preparations for approximately two minutes. When the provisional material is set, it can be removed from the matrix, carved, and polished. It is then placed upon the maxillary preparations, while the mandibular teeth are prepared. A clear plastic provisional stent is made from a plaster duplicate of the mandibular wax-up, filled with bisque acrylic, and placed over the mandibular preparations (Figure 8). The clear plastic stent was used rather than a silicone matrix, so that the patient could close into centric occlusion (CO), while the provisional material polymerized. Figures 9 through 11 are views of the completed provisional restorations. Simply Beautiful: A Venus Reconstruction of a Class II Malocclusion43
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Page 6 and 7: Letters to the Editor “Dear Dr. D
Page 8 and 9: Contributors Michael C. DiTolla, DD
Page 11 and 12: Dr. DiTolla’s CLINICAL TIPS - ART
Page 13: Dr. DiTolla’s CLINICAL TIPS PRODU
Page 16 and 17: 14 www.chairsidemagazine.com
Page 18: If you have seen the marketing prop
Page 21 and 22: Interview with Dr.Paul Homoly - INT
Page 23 and 24: eplacing old crowns on 7 through 10
Page 25 and 26: ing the dentist quoting the fee. Wh
Page 27 and 28: the time, my grandfather, my mom’
Page 29 and 30: Now, when I teach this choice dialo
Page 31 and 32: But I understand Kevin has two boys
Page 33: PH: Right. After a while it just fe
Page 38 and 39: In the normal osseous crest, the
Page 40 and 41: 6. Facially, extend the preparation
Page 42: Low and high osseous crests can be
Page 47 and 48: smoothed, using a rotary diamond in
Page 49 and 50: completion of the cure. This “two
Page 51 and 52: Creative Uses for Topical Anestheti
Page 53 and 54: ❚❙❘ Abstract Low-level laser
Page 55 and 56: peared to be completely coated with
Page 58 and 59: ■ The Economics of a Dental Websi
Page 60 and 61: Michael DiTolla: Glenn, we know tha
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