full mouth restorationthe total mouth reconstruction (fig. 61, 62, 63), provided by the dentist....

14 Spectrum dialogue – Vol. 13 No. 8 – October 2014

Full Mouth RestorationLuke S. Kahng, CDT

Spectrum dialogue – Vol. 13 No. 8 – October 2014 15

Fig. 2

Fig. 3 Fig. 4

Fig. 1

Fig.1: CT Scan

Fig.2: Bone reduction stereolithographic stent

Fig.3: Various stents

Fig.4: Four BioHorizon implants

Fig.5: Copings in the mouth

Introduction

In his entire career as a technician, the author hasvery seldom been privileged to work on a case of thistype. It involves a lot of commitment on the part ofall the dental professionals involved: thePeriodontist, Oral Surgeon, the Prosthodontist andthe Lab Technician as well as the patient. Thetechnician needs to have enormous knowledge ofthe process before the implants are placed and begiven all the information gained from the CTanalysis scanning. Size of implants and distancebetween the implants is crucial information becausethe Periodontist will place the implants based on hisanalysis of the patient’s scan - which will have animpact on the esthetic outcome of the case.Ultimately, this question is not going to be ofconcern to the specialist – he is there to perform thesurgery. The technician, along with the dentist, has

to decide what will be best for the patient in thelong-run. Our article will deal with the behind-the-scenes work the author put into helping achieve thebest possible results for the patient.

Case Study

In (Fig 1), the mandibular CT scan planning fromthe Prosthodontist was provided for the author as helooked into case development. One bone reductionguidance stereolithographic stent was created for thecase (Fig. 2) along with several other types of stents(Fig. 3). During surgery, four BioHorizon implantswere placed (Fig. 4). Size of teeth, shape, toothprotrusion – all these factors were measured andanalyzed when implants were placed based on theTreatment Plan Wax-up. Before impression, note theview of copings in the mouth (Fig. 5). Duringlaboratory processing, temporary abutment

Fig. 5

Fig. 6 Fig. 7

Fig.6: Lab processing.

Fig.7: Verify fit

Figs.8, 9, 10: Putty Matrix.

Fig. 11: primopattern LC paste

Fig. 8

Fig. 10 Fig. 11

Fig. 9

placement was verified using primotec gel (Fig. 6).Fit was verified (Fig. 7). In (Figs. 8, 9, 10) puttymatrix was placed on top of the model to note thedifferences between the size of teeth and aid inadding, cutting and placing the UCLA abutments.The author used primopattern LC Paste duringfabrication of this case (Fig. 11) after abutmentswere cut back and primotec gel placed over the top(Figs. 12, 13). Primotec gel was cured (Fig. 14) andthen ground down by the author to define theshape based on the full contour wax-up (Fig. 15).

Sprue was placed (Fig. 16) and then put inside themetal ring, the traditional technique since resin isinvolved, with burn out (Fig. 17). Investmentfollowed (Fig. 18), then casting and finishing withwhite precious metal from Argen Corporation - 52HN (Figs. 19, 20). A variety of porcelains were usedin this case (Fig. 21) as the first build up was begun(Fig. 22). After the first bake was completed, therestoration was fired (Figs. 23, 24). Depth of dentin,enamel overlay demonstration (Figs. 25, 26) usingTN, EN59, EOP 4 and TMO2, follows. Build - up



Fig. 12

Fig. 15

Fig. 13

Fig. 14

Figs. 12, 13: Cut back abutments, place gel

Fig. 14: Cure primopattern LC paste

Fig. 15: Shape definition

Fig. 16: Sprue

Fig. 17: Metal ring

Fig. 18: Investment

Fig. 18

Fig. 16 Fig. 17


Fig. 19

Fig. 21 Fig. 22

Fig. 20

Figs. 19 and 20: Casting, finish white precious metal

Fig. 21: Variety of GC Initial porcelains

Fig. 22: Build-up

Figs. 23 and 24: ) After first bake

Figs. 25 and 26: Second bake

Fig. 25 Fig. 26

Fig. 23 Fig. 24


Fig. 27

Fig. 29 Fig. 30

Fig. 28

Fig. 33

Fig. 31 Fig. 32

Fig. 27: Build-up with TO, GU

Fig. 28: After second bake

Fig. 29: Post-firing

Fig. 30: Final contour and build-up

Fig. 31: Lustre Paste layer

Fig. 32: L3 application

Fig. 33: L3 applied to distal incisal 1/3

was applied with TO as well as gum color (GU)(Fig. 27) and baked for the second time (Fig. 28).Post firing (Fig. 29), final contour and build-up wasapplied (Fig. 30).

After contouring, Lustre Paste was layered on (Fig.31), L3 in this case (Fig. 32) applied to the distal andincisal 1/3 area (Fig. 33). L2 was used on thegingival/horizontal line area (Figs. 34) with L5 (light


Fig. 34

Fig. 36 Fig. 37

Fig. 35

Fig. 38 Fig. 39

Fig. 40

blue) over the incisal 1/3 area (Figs. 35, 36, 37).After firing at 800°C, note appearance (Fig. 38).Finished side view illustrates in/out/in/out line tomimic nature (Fig. 39). Note convexity, created forbetter cleaning ability for the patient (Fig. 40).

Fig. 34: L2 gingival, horizontal application Figs. 35, 36, 37: Incisal 1/3 Light Blue

Fig. 38: After firing at 800°C

Fig. 39: Side view

Fig. 40: Convexity


Figs. 41, 42, 43: Tissue contour

Fig. 44: Pre-molars

Fig. 45: Curve of Spee and Wilson

Figs. 46, 47, 48: Mirrored image

Fig. 41 Fig. 42

Fig. 43 Fig. 44

Fig. 45 Fig. 46

Fig. 47 Fig. 48

Tissue contour (Fig. 41), transparency color depth(Figs. 42, 43) and pre-molar double-check (Fig. 44).Next, lingual horizontal Curve of Spee and Wilsoncheck (Fig. 45). Mirrored view closely illustrates eachcolor, contour and shape (Figs. 46, 47, 48). Healingcaps on the lowers and old denture on the maxillary,


Fig. 49: Healing caps

Fig. 50: Torque lowers

Figs. 51 and 52: Intraoral occlusion check

Fig. 53: Occlusion and movement check

Fig. 54: Facial view

Fig. 55: Left side view

Fig. 56: Right side view

Fig. 49 Fig. 50

pre-operatively shown (Fig. 49) before torquing lowerteeth (Fig. 50). Intraoral occlusion check follows(Figs. 51, 52). Occlusion and movement from old tonew dentures (Fig. 53) and a facial view (Fig. 54)noted, followed by a left side view (Fig. 55). Desiredeffect was achieved: right side view and the naturalappearance of the teeth – irregular, not too bright,with low opacity (Fig. 56) follows. Custom

Fig. 51 Fig. 52

Fig. 53 Fig. 54

Fig. 55 Fig. 56

restoration - with shape, tissue contour and lobedesign are all accounted for. Details andcharacteristics were checked next (Fig. 57) and thedenture was then cleaned underneath with dentalfloss (Figs. 58, 59). Implant holes were filled in withcomposite by the clinician (Fig. 60).

A maxillary CT scan plan led to the next step ofthe total mouth reconstruction (Fig. 61, 62, 63),provided by the dentist. Healing caps in place, thepatient was back to be checked after one year (Fig.64). Bio Horizon implants are in, healing caps outand we can see the beautiful work of the dentist.The thickness of the gingival neck and height makes

Fig. 59

Fig. 60 Fig. 61

Fig. 63 Fig. 62

Fig. 58


Fig. 57

Fig. 57: Detail and characteristics check

Figs. 58 and 59: Clean and floss

Fig. 60: Fill in with composite

Figs. 61, 62, 63: Maxillary CT scan


Fig. 66 Fig. 67

Fig. 68 Fig. 69

Fig. 64: Healing caps in place

Fig. 65: Bio Horizon implants

Fig. 66: Take impression

Fig. 67: Provisional denture

Fig. 68: Two piece metal framework

Fig. 69: Fire

Fig. 70: Build-up

Fig. 71: Symmetry check on model

Fig. 71 Fig.70

Fig. 64 Fig. 65

the case easy to work with (Fig. 65). An impression was taken next(Fig. 66). Patient will wore a preliminary, provisional denture (Fig.67) to check for fit and size, etc. Argen 52 HN two piece metalframes (Fig. 68), with UCLA abutments, created because the pathof insertion issue made one piece restoration impossible to do.Firing – opaque with inside color (Fig. 69). Build-up stage is next,(Fig. 70) then placement on the model to check symmetrybetween 8 and 9, 7 and 10 and 6 and 11 (Fig. 71). A mirrored


image follows (Fig. 72) and then a side view (Fig.73). The author checked gum contour and tissue(Fig. 74) and the denture teeth, final match up –change contour (Fig. 75).

Mirrored 2 piece restoration – check fortranslucency (Fig. 76) and then a close-up check for

texture (Fig. 77). A mirrored side view (Fig. 78) andreminder to the reader that because of occlusion, wedid not need to place an implant at #14 - note thatthere is framework only (Fig. 79). Also, readers,please note tissue color, harmony of color (Fig. 80)and after an immediate try-in (Fig. 81) a pleasedpatient (Fig. 82).

Fig. 76

Fig.78

Fig. 77

Fig. 72: Mirrored image

Fig. 73: Side view

Fig. 74: Gum and tissue contour

Fig. 75: Match up/occlusion check

Fig. 76: Two piece restoration

Fig. 77: Close up texture check

Fig. 78: Mirrored side view

Fig. 74 Fig. 75

Fig. 72 Fig. 73


Fig. 81 Fig. 82

Conclusion

This case was a long journey for everyone involved. Ifwe do not have a plan for a case such as this one, wecannot reach our final destination. The dentist andthe technician had to work together on this case inorder to achieve the best results for the patient. Thepatient had no dentition which therefore meantimplants would hold his restoration in place, butwhat about planning? Without tooth morphologyunderstanding, after extractions, we would not havehad a true strategy for the patient. The technicianhad to measure size of teeth, contour, andunderstand how to apply color internally to create a3 dimensional, natural effect.

The author extends great thanks to Dr. JosephCaruso for the opportunity to work on this case andhopes that in another six months’ time the patientwill provide us with a new photographic image tocompare with what we currently have. This is a largescale case with many steps along the way, andfantastic results due to planning and patience!

About the author

Luke S. Kahng is one of the world’s finestand most accomplished lab technicians,specializing in high-end ceramicrestorations. Luke has served on severalmajor dental journal boards as a

contributing member.Luke invented the Chairside Shade Guide

– Volumes 1 and 2 and then expanded thebreakthrough to a unique ceramic shadeguide system named the Seasons of LifeSelection. These valuable tools are useddaily on a world-wide basis.

Luke is owner and President of his ownlab, LSK121 Oral Prosthetics, one of thelargest dental laboratories in the country,located in Naperville, IL.

He has published over 100 articles inmajor national dental publications.Additionally, Luke has authored severalbooks, including Anatomy from Nature, TheAesthetic Guide Book, Smile Selection PlusCS3 Clinical Cases, and The KaleidoscopeWax-Up Book. These books have beendistributed throughout the world as must-haves for Dentists eager to gain moreknowledge in their industry.

In 2014, Luke will publish anotherimportant milestone book, The Secret ofShade Guide Matching.

Fig. 79: No implant needed for tooth #14

Fig. 80: Tissue contour, harmony

Fig. 81: Try-in

Fig. 82: Pleased patient

Fig. 79 Fig. 80

full mouth restorationthe total mouth reconstruction (fig. 61, 62, 63), provided by the dentist....

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