T
he achievements seen in the fields of esthetics must be followed to optimize the treatment. Thus, suc-
and implant dentistry have attracted the atten- cessful outcomes depend on meticulous treatment
tion of clinicians as well as dental technicians, planning and careful execution of the clinical and labo-
but oftentimes innovations are implemented without ratory procedures planned for each individual case. 1,2
making a global assessment of the patient's restorative Sevralfctosinu emtplanig,cud
needs. In the case of full-mouth rehabilitation, a suitable patient health status, patient motivation, treatment
restorative protocol is crucial, and a logical sequence time, expected costs over treatment phases, profes-
sional skills of the operators for each phase, and ex-
pected long-term results.'
The objective of this article is to describe all clini-
'Director of Spazio Education, Sao Paulo, Brazil.
cal and laboratory steps for a functional and esthetic
'Director of the Advanced Program in Implant and Esthetic
Dentistry, Senac University, Sao Paulo, Brazil. protocol for full-mouth rehabilitation that promotes
'Director of the Oral Rehabilitation Program, Postgraduate School patient understanding and dental team cooperation
of the Argentinian Dental Academy (A.O.A.), Buenos Aires,
Argentina.
to achieve predictable outcomes.
'Director of the Periodontal and Oral Implantology Department, Patients needing oral rehabilitation require a thor-
Spazio Education, Sao Paulo, Brazil. ough initial assessment to determine the options for
treatment as well as the patient's willingness to accept
Correspondence to: Dr Dario Adolfi, Av. Juscelino Kubitschek,
1726, 21st floor, Sao Paulo, SP, Brazil, CEP 04543-000.
recommendations proposed in the treatment plan-
Email: dario.adolfi@spazioeducation.com ning. Thus, caution must be exercised in the first clini-
QDT 2013
ADOLFI/SCOPIN
Fig 1 The four reconstructive steps of a functional and Fig 2 Reconstruction starts on the maxillary segment from
esthetic full-mouth oral rehabilitation protocol: maxillary right to left premolars. The premolars may be included in
anterior segment (blue), mandibular anterior segment (red), this step to achieve better esthetic diagnoses.
mandibular posterior segment (orange), and maxillary pos-
terior segment (magenta).
cal examination. The practitioner should explain the FUNCTIONAL AND ESTHETIC
options in a simple and straightforward way to encour-
age patient understanding. The final treatment plan is
PROTOCOL FOR ORAL
detailed in the second appointment. 4 REHABILITATION
The success of an esthetic rehabilitation depends
on the dental team's knowledge of the biologic con- The functional and esthetic protocol for oral rehabilita-
siderations related to teeth and implants as well as the tion can be divided into four steps (Fig 1):
communication maintained between the prosthodon-
tist, oral surgeon, and dental technician.' 1. Reconstruction of the maxillary anterior segment
When several changes are planned, a diagnostic (from the right second to the left second premolars).
wax-up is fabricated on the study casts to facilitate 2. Reconstruction of the mandibular anterior segment
visualization of the shape, position, and proportions (from canine to canine).
of the planned restorations and to provide the most 3. Reconstruction of the mandibular posterior segment.
functional and esthetic conditions possible. Diagnos- 4. Reconstruction of the maxillary posterior segment.
tic wax-ups can facilitate patient assessment of the
proposed treatment as well as allow technicians and
dentists to predict potential problems that could arise Phase 1: Reconstruction of the Maxillary
during treatment. 67 Anterior Segment
Use of wax-ups facilitates the development of prop-
er contours for provisional restorations and provides This is one of the most important phases, because it
a detailed and accurate guide throughout the restor- defines the patient's overall esthetic appearance (Fig 2).
ative process that can inform other intraoral tools, such When the buccal corridor needs to be realigned, the
as a silicone index for crown lengthening or surgical premolars are included with the anterior segment so
stents used for implant placement.' The creation of a that their overall aspect can be harmonized with the
diagnostic wax-up must follow the functional and es- anterior teeth. Otherwise, premolars are only included
thetic protocol for oral rehabilitation. in phase 4. Phase 1 provides the dental team with a
140 CID
Functional and Esthetic Protocol for Oral Rehabilitation
Esthetic Checklist
9. Lip line
3. Zenith of gingival contours
10. Insical edge configuration
4. Morphology, proportic
11. 3D implant position
and basic shape of natui-
teeth 12. Color
complete overview of the restorative case and ad- for function during excursive mandibular movements.
dresses the patient's esthetic expectations. 9 This should be achieved in accordance with phase 1
When study casts are used in combination with in- to establish adequate anterior guidance that favors
traoral mock-ups to plan the restorations, clinicians the esthetics of the anterior teeth. It is important to
can work with greater predictability and fewer errors, keep the mandibular canine longer than the incisors
even in complex cases that require multiple adjust- for efficient disocclusion patterns (Fig 4). On eccen-
ments. Depending on the clinical scenario and the tric mandibular excursions, freedom of movement and
clinician's skills and knowledge, the intraoral mock-up less muscle energy are essential and are favored by
can be made using composite resin on specific areas the anterior guidance on protrusive and lateral man-
to promote the predictability of the functional and es- dibular paths.
thetic outcomes. The following characteristics must be assessed while
The diagnostic wax-up in phase 1 must include: the mandibular anterior teeth are in occlusion with the
maxillary teeth (Fig 5):
€ Development of the tooth size, shape, and arrange-
ment € Tooth size and form
€ Fabrication of a mock-up for esthetic and phonetic € Vertical dimension of occlusion
evaluation € Centric relation
€ Adherence to the esthetic checklist concepts (Fig 3) € Phonetics
€ Quantity and quality of disocclusion
€ Disocclusion patterns (eg, canine guidance and par-
Phase 2: Reconstruction of the Mandibular tial and total group function)
Anterior Segment
In this phase, the size and position (individual and over-
all) of the mandibular anterior teeth must be evaluated
Fig 4 Reconstruction of the mandibular canines. Fig 5 Reconstruction of maxillary and mandibular teeth in
phases 1 and 2.
Fig 6 The curve of Spee is provided by the mandibular Fig 7 Phase 4 showing reconstruction of the maxillary
posterior teeth. posterior teeth.
Phase 3: Reconstruction of the Mandibular The occlusal contacts determine the occlusal equi-
librium and thus the functional relationships that con-
Posterior Segment
serve tooth integrity and individual positions as well
This phase determines the anteroposterior curvature as provide axial loads at stability at the correct vertical
of the occlusal plane (curve of Spee) achieved through dimension of occlusion (Fig 7).
the positions of the mandibular posterior teeth. The After designing the rehabilitation protocol through
curve of Spee is an imaginary line extending from the development of a diagnostic wax-up, the provisional
tip of the mandibular canine, touching the buccal cusp restorations are fabricated according to the wax-up.
tips of all the mandibular posterior teeth, and continu- The provisionals must protect the teeth and reestab-
ing to the anterior border of the ramus (Fig 6). lish the desired function and esthetics. They must be
a perfect copy of the diagnostic wax-up and are fab-
ricated with the indirect approach, ie, at the dental
Phase 4: Reconstruction of the Maxillary laboratory by the dental technician.
First, the diagnostic wax-up casts are duplicated
Posterior Segment
and new stone casts are poured and related in a semi-
In this phase, the maxillary posterior teeth are recon- adjustable articulator. The provisionals are then made
structed and the occlusal relationships in the posterior using the double-pressing technique for each tooth
quadrants are established. The three occlusal relation- segment to allow better control of occlusal contact
ships are cusp to fossa, cusp to marginal mesial ridge, points as well as of the acrylic resin expansion setting
and cusp to marginal distal ridge. properties.
CASE REPORT
Fig 8 Initial clinical situation showing an Angle Class II, division 2 malocclusion and an accentuated overbite.
Figs 9 and 10 Occlusal views showing porcelain fused to metal crowns and large restorations.
- -
Fig 11 The mandibular anterior teeth are extruded, but the gingival levels were adequate.
Treatment Objectives maxillary central incisors were facially inclined, and the
lateral incisors and canines were inclined more to the
Because the patient was an adult and presented an palatal aspect. On the study casts, the central incisors
adequate facial profile, it was decided to maintain would be moved toward the palatal and the lateral in-
molar-to-molar Class II relationships and to correct the cisors would be slightly inclined to the facial aspects.
exaggerated overjet and overbite of the maxillary cen- Tooth widths were reduced to generate a new anterior
tral incisors. The aim for the mandibular arch was to arch relationship. At phase 2, the canines were reposi-
reestablish the anteroposterior curve (curve of Spee) tioned along with the mandibular anterior teeth.
as well as to level the anterior segment and provide During the fabrication of the provisionals, the clini-
light occlusal contacts on the maxillary anterior teeth cal crowns were removed from the working cast, leav-
to avoid continued mandibular tooth eruption. In ad- ing just the cervical lines as a guide for fabricating the
dition, adequate overbite and overjet along with ad- provisionals from artificial teeth (Premium, Heraeus
equate canine guidance were planned to create an Kulzer, Hanau, Germany) (Fig 12).
esthetic smile. At the same time, indices made from silicone mate-
rial (Zetalabor, Zhermack Badia, Polesine, Italy) were
prepared over the provisionals to ensure correct intra-
Treatment Planning oral transfer (Figs 13 and 14). The index was used to
transfer the correct central incisor position and to re-
Initial impressions of the maxilla and mandible were cord the correct overjet, overbite, midline, and tooth
taken with irreversible hydrocolloid material (alginate) axis.
and poured in orthodontic plaster. It is important that The maxillary right central incisor served as a refer-
accurate casts be kept as part of the patient's records. ence key for placement of all of the provisionals. The
Also, silicone impressions were created for study casts provisional for the right central incisor was positioned
and were related in a semi-adjustable articulator with on the silicone index and secured with cyanoacrylate
the aid of a facebow. glue to assure stability for the intraoral try-in (Fig 15).
The provisional restorations for the maxillary inci- The maxillary right central incisor was prepared for a
sors were fabricated on the study casts using artificial crown restoration, and the silicone index was posi-
acrylic teeth to correct the accentuated overjet. tioned without interfering with the adjacent teeth. A
The patient received a complete outline of the treat- small amount of autopolymerizing acrylic resin (Unifast
ment plan with indications for root canal therapy for Trad powder Ivory, GC America, Alsip, Illinois, USA)
maxillary and mandibular incisors and fiber-reinforced was placed on the palatal aspect of the right central
post and core restorations. Tooth preparation would incisor using the Nealon or brush-dip technique to sta-
be made for all anterior maxillary teeth, and the maxil- bilize the provisional crown (Figs 16 and 17). At this
lary teeth would receive laboratory-made provisionals point, it was possible to verify that the midline and the
based on the diagnostic wax-up. tooth axis were correctly positioned (Figs 18 and 19).
The maxillary left central incisor as well as the maxillary
lateral incisors were then prepared to receive provi-
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
CASE REPORT
Fig 12 Provisional restorations made
on the working cast. The cervical
lines were maintained.
12 13
15
17
19
21
22
23 24
25
Fig 22 The mandibular anterior teeth had overerupted due to the lack of occlusal contact with their maxillary an-
tagonists. However, adequate gingival levels can be seen.
Figs 23 to 25 Acrylic resin veneers were secured with cyanoacrylate glue and flowable resin composite over tooth
preparations to simulate the position of provisional restorations.
Fig 26 The palatal morphology of anterior teeth and their occlusal contact relationships are defined by correct posi-
tioning of acrylic resin veneers.
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
27 28
Phase 2: Reconstruction of the mandibular After the provisionals were placed on the maxillary
anterior segment canines and mandibular anterior teeth, impressions
The mandibular anterior teeth, from right canine to were taken with polyvinyl siloxane material to gener-
left canine, had continued to erupt due to the lack of ate the working casts, which were mounted on a semi-
occlusal contact (Fig 22). The treatment aims were to adjustable articulator with the aid of a facebow.
perform root canal therapy and adequate incisal re-
duction as well as to correct the size and arrangement Diagnostic wax up -
of the teeth. Because no changes were needed in the The wax-up of the maxillary posterior teeth and the
gingival levels and the anatomic crowns presented no mandibular dentition completed the planning of the
wear, they were used as references to create the de- restorative work and the fabrication of the remaining
finitive clinical crowns. provisionals (Figs 27 and 28).
After incisal reduction was completed on the man-
dibular anterior teeth, Premium acrylic resin teeth, Provisional restorations
similar to laminate veneers, were shaped and secured The diagnostic wax-up casts were duplicated and re-
over the anterior teeth with cyanoacrylate glue and lated on a semi-adjustable articulator with the provi-
flowable composite resin to guide the preparation of sional restorations fabricated using the double-pressing
the maxillary canines and the placement of provision- technique. The provisional crowns must be very close
als (Figs 23 to 25). The correct positioning of the acrylic to the diagnostic wax-up to provide a general idea of
laminate veneers on the mandibular incisors was help- the finished case (Figs 29 to 31).
ful in achieving adequate palatal morphology of the The mandibular anterior teeth were prepared to re-
maxillary teeth in the wax-up (Fig 26). ceive fiber posts prior to placement of the provisional
crowns (Fig 32).
QDT 2013
ADOLFI/SCOPIN
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
34
Fig 34 All the provisional restorations are in position according to the functional and esthetic protocol.
Figs 35 and 36 The new occlusal contacts would provide balance to the masticatory system, stability to the tooth
positions, and the correct vertical dimension of occlusion.
ODT 2013
ADOLFI/SCOPIN
37
40 41
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
52
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Figs 60 and 61 The working casts with the zirconia copings related in the semi-adjustable articulator. The maxillary
right first molar would receive an inlay ceramic restoration with lithium disilicate framework.
reduced using the cut-back technique. Incisal and The all-ceramic restorations were luted with univer-
transparent IPS e.max material is built up for adequate sal resin cement Panavia F 2.0 (Kuraray, Tokyo, Japan).
translucence and opalescence. The cut-back was not At this point, the esthetics, vertical dimension of oc-
necessary for the mandibular incisors, which received clusion, central relation, and anterior guidance€de-
only one layer of shade material no.1 for the final scribed in phases 1 and 2€had already been defined
shade Al and were baked at 720—C under vacuum. for this functional and esthetic reconstruction.
The bluish shades, cracks, halo effects, and interproxi- To rehabilitate the posterior teeth, complete impres-
mal stains were painted with IPS e.max Ceram Essence sions of the maxillary and mandibular arches were taken
(Ivoclar -Vivadent) to create a multilayered effect and with Flexitime silicone material, and zirconia copings
obtain optical differentiation between dentin and in- were fabricated. A pick-up transfer was performed to
cisal features. Finally, restorations were glazed twice generate the working casts related in a semi-adjust-
and fired at 770—C under vacuum to preserve all char- able articulator with the aid of a facebow (Figs 60 and
acterizations. 61). A complete esthetic wax-up with the correct oc-
The all-ceramic restorations were then polished clusal morphology was developed over the zirconia
with felt wheels and pumice powder to establish the frameworks, according to the principles already de-
superficial gloss. Superficial gloss is one of the most scribed (Figs 62 to 66).
important factors in the natural integration of restora- The implant-supported provisional restorations on
tions (Figs 57 to 59). the mandibular first molars were used to transfer the
64
Figs 63 and 64 Lateral views showing the high functional and morphologic quality of the posterior wax-ups.
Figs 65 and 66 Occlusal views of posterior wax-ups over the zirconia copings.
necessary information to fabricate customized zirco- because of excellent biocompatibility. Soft tissue re-
nia abutments with the correct emergence profile and sponse to zirconium dioxide is better than soft tissue
cervical contours. The temporary implant restoration response to metals, and less plaque accumulation is
served as a transfer coping. observed; consequently, minimal or no tissue reaction
All-ceramic abutments have started to play a sig- can be expected. 2122
nificant role in achieving esthetically successful results, All waxed-up restorations were injected and pressed
but the material itself is not the exclusive determinant as described and were adjusted in the articulator be-
of esthetic success. It is the use of appropriate design, fore try-in (Figs 69 to 73). The previous verification of
proper handling of the materials, as well as the zirconia the occlusal contacts allowed for only minor adjust-
abutment that enables the clinician to achieve esthetic ments in the oral cavity. At clinical try-in, adjustment
outcomes that were not possible with traditional metal started with the proximal contacts of maxillary and
alloys. 20 Zirconia frameworks must have adequate di- mandibular posterior teeth in the same quadrant. The
mensions, be designed to support ceramic veneering occlusal contacts were developed on a tooth-to-tooth
material, and avoid fracture and/or delamination (chip- basis, maintaining the vertical dimension of occlusion
ping) (Figs 67 and 68). provided by bilateral contact points on the maxillary
The subgingiva I portions of all-ceramic zirconia abut- and mandibular canines; progressive articulating pa-
ments were not veneered; they are designed to be in per foils (Bausch) were used from 200 pm to 12 pm
direct contact with the soft tissue emergence profile (Figs 74 to 76).
QDT 2013 E.
ADOLFI/SCOPIN
rP\1". 7191€
70 71
72 73
Figs 70 and 71 Lateral views of injected ceramic crowns after occlusal adjustments.
ODT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Fig 74 The maxillary and mandibular posterior restorations after the minor occlusal adjustment.
Fig 75 The mandibular posterior restorations tried in before characterization and glazing.
Fig 76 The maxillary posterior restorations tried in before characterization and glazing.
77
81
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
When it is necessary to improve the occlusal morphol- 6. Denehy GE. A direct approach to restore anterior teeth. Am J
Dent 2000;13(special issue):55D-59D.
ogy after all the adjustments, the dental technician can
7. Vanini L, Mangani F, Klimovskaia 0 (eds). Conservative Restora-
use the non-edge technique" for natural reconstruc- tion of Anterior Teeth. Viterbo, Italy: ACME, 2005.
tion of occlusal anatomy and easy reestablishment of 8. Ferencz J, Fanetti P. Enhanced communication. Inside Dent Tech-
proper function. nol 2011;2. http://www.dentalaegis.com/idt/2011/01/enhanced-
communication . Accessed 17 Dec 2012.
All posterior ceramic restorations were character-
9. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of se-
ized and glazed as described for the anterior restora- verely eroded dentition: The three-step technique. Part 1. Eur J
tions and were then luted with a universal resin cement Esthet Dent 2008;3:30-44.
10. Araujo MG, Lindhe J. Ridge preservation with the use of Bio-
(Panavia F 2.0) (Figs 77 to 82).
Oss collagen: A 6-month study in the dog. Clin Oral Implants
Res 2009;20:433-440.
11. Szmukler-Moncler S, Salama H, Reingerwirtz Y, Dubruille JH.
Timing of loading and effect of micromotion on bone-dental
implant interface: Review of experimental literature. J Biomed
CONCLUSION Mater Res 1998;43:192-203.
12. Gapski R, Wang HL, Mascarenhas P, Lang NP. Critical review of
immediate implant loading. Clin Oral Impl Res 2003;15:787-
A functional and esthetic protocol for full-mouth re-
794.
habilitation must have a well-defined diagnosis, prog- 13. Ganeles J, Wismeijer D. Early and immediately restored and
nosis, and treatment plan. This article presented a loaded dental implants for single-tooth and partial-arch appli-
cations. Int J Oral Maxillofac Implants 2004;19(suppl):92-102.
protocol with four phases to treat complex cases with
14. Kupeyan HK, May KB. Implant and provisional crown placement:
the use of diagnostic wax-ups and provisional crowns, A one-stage protocol. Implant Dent 1998;7:213-219.
which provides benefits to patients and practitioners. 15. Wohrle PS. Single-tooth replacement in the aesthetic zone with
The association between CAD/CAM technologies for immediate provisionalization: Fourteen consecutive case re-
ports. Pract Periodontics Aesthet Dent 1998;10:1107-1114.
zirconia frameworks and injection/press techniques for
16. Wang HL, Ormianier Z, Palti A, Perel ML, Trisi P, Sammartino G.
veneering esthetic materials guarantees highly func- Consensus conference on immediate loading: The single tooth
tional and esthetic definitive all-ceramic restorations. and partial edentulous areas. Implant Dent 2006;15:324-333.
17. Tupac RG. When is an implant ready for a tooth? J Calif Dent
Assoc 2003;31:911-915.
18. Morton D, Jaffin R, Weber HR Immediate restoration and load-
ing of dental implants: Clinical considerations and protocols. Int
J Oral Maxilofac Implants 2004;19(suppl):103-108.
REFERENCES 19. Joly JC, Carvalho PFM, da Silva RC. In: Reconstrucao Tecidual
Estetica: Procedimentos Plasticos e Regenerativos Periodontais
1. Stevens FW. The generalist as the coordinator of the dental e Periimplantares. Brazil: Artes Medicas, 2010,253-309.
team. Am J Orthod 1969;56:107-113. 20. Blatz MB, Bergler M, Hoist S, Block MS. Zirconia abutments for
2. Douglass GD. Making a comprehensive diagnosis in a compre- single-tooth implants-Rationale and clinical guidelines. J Oral
hensive care curriculum. J Dent Educ 2002;66:414-420. Maxillofac Surg 2009;67(11 suppl):74-81.
3. Poi WR, Panzarini SR, Pedrini D, Manfrini TM, Zina LG, Hamana- 21. Rimondini L, Cerroni L, Carrassi A, Torricelli R Bacterial coloniza-
ka EF. Plano de tratamento em odontologia: Analise dos pianos tion of zirconia ceramic surfaces: An in vitro and in vivo study. Int
propostos por alunos de graduacao. Pesq Bras Odontoped Clin J Oral Maxillofac Implants 2002;17:793-798.
Integr 2007;7:297-301. 22. Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A. Bacterial
4. Hook CR, Comer RW, Trombly RM, Guinn JW, Shrout MK. Treat- adhesion on commercially pure titanium and zirconium oxid-
ment planning processes in dental schools. J Dent Educ 2002; edisks: An in vivo human study. J Periodontol 2004;75:292-296.
66:68-74. 23. Adolfi D. Natural Esthetics. Chicago: Quintessence, 2003.
5. Adolfi D. Functional, esthetic, and morphologic adjustment of
anterior teeth. Quintessence Dental Technol 2009;32:153-168.