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High-Risk Esthetically Driven Restoration:
Begin With the End in Mind
Michael T. Ricciardi, DDS; and Peter Pizzi, CDT, MDT
Abstract
A high-risk esthetically driven restorative case requires the dental team, along with the patient, to
have a clear vision of the final outcome. In this case of a 33-year-old woman who wanted to
improve her smile, esthetic problems stemmed from a retained deciduous maxillary left canine
along with an impacted tooth No. 11. Among a number of concerns was the shape and color ofthe deciduous canine and the uneven length of the maxillary central incisors. A treatment plan
that included orthodontics with removable aligners, occlusal adjustment, composite restorations,
extraction and implant placement, indirect porcelain veneers, and a custom abutment and PFM
crown was successfully executed in four phases over the course of more than 4 years.
When beginning a high-risk esthetically driven restorative case, it is important for the patient andthe dental team to have a clear vision of the final outcome. It is often difficult for patients to
articulate what they find esthetically undesirable. Sometimes, they are simply “unhappy” with
their appearance. Part of the role of dentists is to gain an understanding of their patients’ esthetic
concerns and discuss with them the solutions that are available. These solutions may involve prolonged treatment plans that span many years before the desired outcome is acheived.
1
Clinical Case Overview
Patient History and Chief Complaint: A 33-year-old woman presented for treatment in March
2007 desiring to improve her smile. She was developing a career in art sales and her smilehindered her confidence (Figure 1). She was aware that her front teeth had become shorter in
recent years. She was also unhappy with the way the teeth on her right side “dipped in” and her
canine (on the same side) “stuck out.” The left side had a retained deciduous canine (tooth H)
with an impacted maxillary left canine (tooth No. 11). The shape and color of the deciduouscanine was objectionable (Figure 2 and Figure 3).
The patient’s medical history was unremarkable. She had a past history of tobacco use but had been a nonsmoker for many years. Her dental history was limited to recall appointments and
simple restorative procedures.
Diagnostic Findings, Risk Assessment, and Prognosis
Prognosis was established by taking the risk assessment into consideration as well as the age of
the patient, the presence or absence of the contributing factors of disease, the expected lifespanof the patient, diet, and what the patient did with and to her teeth. Prognosis was determined
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without considering intervention so the patient could understand the potential outcomes if the
disease process was left untreated.
Periodontal: Radiographs showed localized mild horizontal bone loss. Periodontal probe
readings were generally 2 mm to 4 mm in depth, with slight bleeding on probing. The patient
was placed on a 6-month periodontal recall. Based on existing bone levels, the periodontaldiagnosis was deemed AAP type II.
Risk: LowPrognosis: Good
Biomechanical: The patient’s biomechanical risk was determined based on her current and past
history. The patient presented with no new carious lesions, no structurally compromised teeth,
and minimal erosion. She reported no new carious lesions in the past 4 to 5 years. She had some
conservative posterior composite restorations and one amalgam restoration.
Risk: LowPrognosis: Good
Functional: The patient showed mild to moderate attrition on her maxillary and mandibular
anterior teeth with the most notable being on teeth Nos. 8 and 9. She had mild attrition on her bicuspids. The right and left temporomandibular joints were comfortable under load. The patient
had no history of abnormal neuromuscular habits or bruxism, but felt as though she had more
than one bite. A preliminary functional diagnosis of occlusal dysfunction was made, and laterconfirmed using the Kois deprogrammer.
2
Risk: Moderate
Prognosis: Fair
Dentofacial: An accurate evaluation of the overall esthetics was challenging because of the patient’s guarded smile. Once relaxed, the patient laughed and it became apparent that she
exhibited high lip dynamics. Since both the teeth and the tissue contours were visible in a full
smile, the following esthetic deficiencies were noted: incisal edge position 0.5 mm short ofideal,3 asymmetrical gingival architecture, intra-arch tooth position constricted in the maxillary
bicuspid region, and dissatisfaction with the tooth shade.
Risk: High
Prognosis: Poor
Treatment Goals
The treatment goals were to:
• orthodontically position the teeth into a more ideal vertical and horizontal intra-arch position• respect the patient’s desire to avoid the use of fixed orthodontic brackets
• create room for the placement of an implant in the No. 11 position
• create equal, simultaneous posterior occlusal contacts
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• replace tooth No. 11 with an implant-supported restoration
• improve the horizontal symmetry of the gingiva
• improve the tooth shapes and color without incr easing the biomechanical risk• sequence the treatment over time for affordability
Treatment Plan
The proposed treatment plan included:
• orthodontic treatment with the aid of removable aligners
• occlusal adjustment • composite restorations on teeth Nos. 8 and 9 to help establish ideal tooth length
• extraction of impacted canine No. 11 and deciduous canine H with site preparation for implant
placement
• crown lengthening of teeth Nos. 7 through 9 • indirect porcelain veneers on teeth Nos. 6 through 10
• a custom abutment and porcelain-fused-to-metal (PFM) crown on tooth No. 11
Treatment Phases
Phase 1: Orthodontics
Removable orthodontic aligners (Invisalign®, Align Technology, Inc., www.invisalign.com)
were offered as a treatment and accepted, with the explanation that the use of aligners would provide limited orthodontic intervention. Using the diagnostic wax-up as a guide, the arch was
expanded in the bicuspid region on the right side, reducing the arch constriction. The anterior
region was expanded slightly to create more space around the deciduous canine to facilitate
future implant placement. Correcting the crossbite in the right posterior region was not a predictable move and, therefore, was not attempted. Approximately 1 mm of overjet was left in
the maxillary anterior region in anticipation of future occlusal adjustment. Upon completion of
the orthodontics, composite was placed on teeth Nos. 8 and 9 to lengthen the incisal edge position by 0.5 mm. With a more harmonized arch and adequate space around the deciduous
canine, the teeth were in position to successfully complete implant placement and conservative
restorative treatment.
Phase 2: Functional
Six months after completion of the orthodontic treatment, the patient was placed in a Kois
deprogrammer to evaluate the occlusion.2 The patient’s first point of contact, with the
temporomandibular joints in centric relation, was on the buccal incline of tooth No. 5. A centric
relation bite record was made and the models mounted. Evaluation of the models confirmed theinitial point of contact on tooth No. 5. A trial equilibration was done on the models to verify that
even, simultaneous contacts could be achieved.
The patient returned for occlusal equilibration. Bilateral simultaneous posterior point contacts
and canine guidance were achieved intraorally. The patient was functionally stable for 3 years, at
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length, and color (Figure 13 through Figure 15). Treatment goals were met by satisfying the
patient’s desire for improved esthetics while respecting risk management, thereby increasing the
probability and predictability of long-term success (Figure 16 through Figure 18).
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
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Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
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Figure 11
Figure 12
Figure 13
Figure 14
Figure 15
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Figure 16
Figure 17
Figure 18