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Restorative: full mouth rehabilitation

THOMAS SEALEY PRESENTS A FULL MOUTH REHABILITATION CASE THAT WAS COMPLETED OVER A

NINE-MONTH PERIOD

CASE PRESENTATIONThis case presentation is of full mouth rehabilitation that was completed over a nine-month period. Treatment planning was restricted by a limited budget. In all instances a minimally invasive approach where possible was considered.

PRESENTING COMPLAINTThis 59-year-old male patient presented showing advanced tooth surface loss (TSL) and loss of occlusal-vertical dimension (OVD) with passive overeruption of his anterior segment.

He was struggling to enjoy the foods he loved and over the last few years had recoiled himself from any form of social engagement as he found public eating very difficult. He was very embarrassed of his smile and only smiled with his mouth closed. He had been in a profession with a lot of stress and had suffered in the past with gastric reflux. Currently he was enjoying a reduced working week and he was calmer and more relaxed.

After candid discussions it became very clear this gentleman’s focus was not on having a full set

of perfect teeth; his objectives were both of function and to restore his confidence, allowing him to once again enjoy social engagements and to eat and smile with friends and family.

DIAGNOSISThe patient was medically fit and well. He was deemed low caries risk at initial assessment as although he demonstrated TSL, his oral hygiene was very good. There were no concerning social habits. His teeth were shaded as A4.

A full clinical examination and radiographic evaluation was completed. Every tooth was tested for vitality using heat and electric pulp tests. With the exception of the upper right first molar tooth, the teeth were all stable and vital with good bone levels and periodontal support. Basic periodontal examination was completed and recorded as 1,1,1/1,2,1. There was no mobility to any teeth.

There was severe tooth surface loss on the incisal/palatal aspects of all canine and incisor teeth and moderate TSL on the upper and lower first premolar teeth. There were no soft tissue or hard tissue anomalies to report.

Panoramic radiograph showed a healthy dentition with normal bone level (Figure 18). There was a submerged retained root mesially to the lower left second molar tooth that showed no signs of pathology. There was an impacted lower right third molar tooth with no pathology associated to this or to the lower right second molar tooth.

The radiograph showed periapical pathology associated with his upper first molar tooth. The root-treated

upper right first molar tooth (UR6) was considered to be of a poor standard, with apparent missing obturation material in the mesial canals and under-filled remaining canals (European Society of Endodontology, 2006). Clinically, there was an advanced area of dental decay undermining the distal aspect of the crown. The tooth was deemed unsalvageable.

His teeth showed tooth surface loss and passive eruption of both the upper and lower anterior segment with excessive upper gum on show during wide smiling. The diagnosis of severe attrition and tooth surface loss was made, as a result of previous acidic reflux and stress-related parafunction, which lead to collapse of the arches and subsequent loss of OVD.

TREATMENT PLANNING All approaches to his rehabilitation were discussed; including implants for replacement of missing teeth, dentures and bridges. The different treatment options for tooth surface loss, as well as all the options regarding the tooth that was unsalvageable and required extracting, were discussed in detail.

Material choices were discussed with the associated costs, treatment processes and expected longevities of each.

Rehabilitation of a patient with severely worn dentition after restoring the vertical dimension is a complex procedure. It is important to monitor these patients and to evaluate their adaptation to a removable occlusal splint to

Educational aims and objectives: To present a full mouth rehabilitation case study that was challenging due to budget limitations.

Clear expected outcomes: Correctly answering the questions on page 56 will show that the reader understands how full mouth rehabilitation can be achieved despite a limited budget.

GDC learning outcome: C

CPD hours: 1 Topics: restorative dentistry

Dr Thomas Sealey is a multiple Award-winning cosmetic dentist based in Essex, UK. He is the co-inventor and co-owner of Smilefast and inventor of the Single-visit Orthodontic Lingual and Invisible Dual (SOLID) retention system. He has a special interest in achieving cosmetic smile makeovers using a minimally invasive approach. He lectures on his techniques internationally and has extensive experience in all aspects of cosmetic dentistry, utilising orthodontics, advanced aesthetic composite restorations and ceramic smile design, to achieve perfectly natural smile transformations. Thomas graduated from Leeds University in 2006 and is currently joint-owner of a private cosmetic dental practice called Start-Smiling in Essex.

BIOGRAPHY

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restore vertical dimension for a period of one month and provisional restorations to determine both the aesthetic and functional outcome for a period of three months (Jain et al, 2013). Confirmation of tolerance to changes in the occlusal-vertical dimension is of paramount importance. Articulated study casts and a diagnostic wax-up can provide important information

for the evaluation of treatment options (Jain et al, 2013).

The upper six anterior teeth would require full-contour restorations to replace the lost palatal tooth surface and the lower teeth would require incisal addition to achieve the correct tooth-shape proportions. This would result in an increase in OVD. We discussed posterior

support and the increase in OVD, which would result from the replacement of the lost tooth surface on the anterior teeth. It was explained that treatment would proceed in a staged approach to allow the patient to accommodate and adjust to the new tooth and jaw relationships and to allow us to refine the OVD until he was functioning comfortable.

It was agreed that the patient would wear a deprogrammer first to allow for a centric relation (CR) registration and cast mounting. This would assist with the treatment planning and would allow for a wax-up to be completed. The wax-up would enable better identification of the final dimensions for the proposed prosthetics and assist in material choice for these, in addition to where no-prep or minimal preparation could be achieved. The patient agreed this stage first and treatment planning continued after this had been completed.

All options were considered for the missing posterior teeth. The deficient bone volume in the upper left region would certainly require augmentation prior to any planned implant placement. The patient felt that he did not want to follow a surgical-

FIGURE 1: Full face

FIGURE 4: Frontal smile view

FIGURE 7: Frontal retracted view, teeth slightly parted

FIGURE 10: Frontal retracted view, teeth in occlusion

FIGURE 12: Left lateral retracted view, teeth in occlusion

FIGURE 2: Full face right

FIGURE 5: Right lateral smile view

FIGURE 8: Right lateral retracted view, teeth slightly parted

FIGURE 11: Right lateral retracted view, teeth in occlusion

FIGURE 13: Anterior close-up view

FIGURE 3: Full face left

FIGURE 6: Left lateral smile view

FIGURE 9: Left lateral retracted view, teeth slightly parted

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restorative pathway due to overall costs involved as well as the process itself for the replacement of the missing upper molar teeth. Alternatives were discussed. The missing posterior teeth were all bounded distally by large molars that were already

FIGURE 14: Right lateral close-up view

FIGURE 17: Lower occlusal view

FIGURE 20: Pre-whitening shade

FIGURE 23: Stent manufacture

FIGURE 26: Stent placement

FIGURE 15: Left lateral close-up view

FIGURE 18: Orthopantomogram full-mouth radiograph

FIGURE 21: Deprogrammer

FIGURE 24: Post-whitening shade

FIGURE 27: Finishing upper composites

FIGURE 16: Upper occlusal view

FIGURE 19: Leaf gauge bite registration

FIGURE 22: Wax-up

FIGURE 25: Upper pre-composite preparation

FIGURE 28: Upper and lower composites immediate post-completion

heavily restored. The teeth adjacent to the spaces anteriorly were all unrestored teeth, however.

Understandably, there is always the sacrifice of some healthy tooth structure in large restorative case for the greater good

of the overall dentition and stability of the planned rehabilitation; but keeping to a minimally invasive protocol where possible still underlines the restorative ethos. There is substantial evidence in the literature supporting a fixed-moveable design of

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posterior bridge (Tipton, 2000). This design accommodates normal

tooth physiological movements that can

allow for a larger pontic-span and more minimal preparation of the abutment teeth as angulation of these teeth is less

important as parallelism is less-necessary that in a fixed-fixed full-coverage design.

Additionally, preparation of the anterior abutment tooth can be kept as minimal as possible by placement of an inlay-design retainer within the body of the anterior tooth that houses the joint of the fixed-moveable bridge design. This allows for the forces to be directed axially down through the anterior tooth, providing occlusal load support for the posterior bridge pontics.

The patient understood that there would be a substantial adjustment period to any of the treatment options we had discussed and that there would be the possibility of an evolving and adapting treatment plan in the following years.

It was reiterated that we cannot predict future events and he must be aware that things may change in the future and we will need to constantly evaluate his occlusal stability and remaining teeth and address any changes that are necessary at that time. It was explained that the success of rehabilitation would not only be due to

FIGURE 29: Lower posterior teeth isolation FIGURE 30: Lower posterior teeth preparation FIGURE 31: Lower posterior teeth pre-impression

FIGURE 32: Lower posterior teeth isolation for cementation

FIGURE 35: Lower posterior teeth immediate post-cementation

FIGURE 38: Fixed-moveable bridge design

FIGURE 40: Assessing smile after six-months

FIGURE 33: Lower right quadrant pre-cementation

FIGURE 36: Lower posterior teeth post-cementation and after finishing

FIGURE 39: Upper left and right posterior quadrant bridge cementation

FIGURE 41: Gürel reduction technique upper preparations

FIGURE 34: Lower right quadrant immediate post-cementation

FIGURE 37: Upper left and right posterior quadrant bridge preparations

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FIGURE 42: Stump shade for final preparations FIGURE 43: Spot etching for temporary restorations

FIGURE 45: Upper preparations after temporary removal

FIGURE 46: Upper teeth isolation for cementation FIGURE 47: Upper teeth etching for cementation

FIGURE 44: Temporary restorations immediate post-placement

the planning and clinical dentistry, but also due to his own determination and lifelong commitment to maintenance of both the restorations and his oral health.

After discussing all of the options, costs, timeframes, ongoing maintenance and repair costs, the patient decided to restore his upper teeth with ceramic crowns/veneers. Due to a restricted budget, he decided against implant placement and opted for upper fixed-movable design bridges. He agreed that the lower teeth would be restored with composite restorations and understood the reduced expected longevity of these compared to ceramic alternatives.

He was aware that these would likely require more servicing and/or replacement earlier than alternative materials. He was aware that monitoring of the stability of his mouth would be completed regularly and there would be the need for additional treatment in the future to maintain his mouth. He agreed that he would wear a nightguard to protect his new restorations from any stress-related parafunctional habits after treatment was completed.

TREATMENT PROCESSTo prepare for the treatment, impressions were taken and a leaf gauge used to approximate the patient into CR (Figure 19). A facebow record was taken. Although fairly inaccurate at this stage, this allowed the laboratory to create a deprogrammer for the patient to wear at an estimated new

OVD (Figure 21). He was reviewed weekly until a stable and repeatable point contact was achieved on the deprogrammer platform, suggesting full decompression of the joint and seating of the condyle. A registration was taken that allowed the laboratory to mount the casts in CR.

While the wax-up was being completed at the laboratory the patient completed a two-week course of home tooth whitening, which improved his shade from A4 to A1 (Figures 20 and 24).

An anterior-only wax-up was completed (Figure 22). It was decided to place temporary composite restorations copied from this wax-up on all the anterior teeth to stabilise the patient at the new OVD and allow for settling and monitoring in this new position. The patient would then be reviewed for four-months to assess stability of the composite restorative work, comfort at the new OVD, aesthetic and phonetics.

This first process was completed by using a stent technique.

A block-out silicone was placed over the waxed teeth and an acrylic suck-down tray made. The block-out was then removed and the acrylic mould filled with a clear silicone putty and impressed over the waxed teeth. Relief holes were drilled through this into the individual teeth (Figure 23).

On the day of preparation all of the old composite restorative material was slowly removed from the teeth using diamond burs and followed by air abrasion with 50µ

• UR8 – missing• UR7 – posterior bridge support full crown• UR6 – bridge pontic• UR5 – anterior bridge support inlay and

ceramic veneer• UR4 – ceramic veneer-onlay• UR3 – full-contour ceramic crown• UR2 – full-contour ceramic crown• UR1 – full-contour ceramic crown• UL1 – full-contour ceramic crown• UL2 – full-contour ceramic crown• UL3 – full-contour ceramic crown • UL4 – ceramic veneer-onlay• UL5 – anterior bridge support inlay and

ceramic veneer• UL6 – bridge pontic• UL7 – posterior bridge support full crown• UL8 – missing• LR8 – missing• LR7 – cuspal coverage zirconia inlay-onlay• LR6 – cuspal coverage zirconia inlay-onlay• LR5 – cuspal coverage composite inlay-

onlay• LR4 – composite direct veneer restoration• LR3 – composite direct veneer restoration • LR2 – composite direct veneer restoration• LR1 – composite direct veneer restoration• LL1 – composite direct veneer restoration• LL2 – composite direct veneer restoration• LL3 – composite direct veneer restoration• LL4 – composite direct veneer restoration • LL5 – cuspal coverage composite inlay-

onlay• LL6 – cantilever bridge pontic• LL7 – cantilever zirconia bridge distal

abutment• LL8 – missing.

TABLE 1: Treatment planned for each tooth

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FIGURE 48: Upper teeth adhesive for cementation FIGURE 50: Upper teeth curing for cementation

FIGURE 52: Upper teeth final cementation

FIGURE 49: Upper teeth restoration cementation

FIGURE 51: Upper teeth finishing after cementation

FIGURE 53: Upper teeth immediate post-cementation

aluminium oxide powder to ensure no additional tooth structure was removed (Figure 25). The teeth were etched and total-etch adhesive bonding protocol followed. Every alternate tooth was separated using Teflon tape and after the adhesive layer was applied and cured, the clear silicone stent compartments were filled with heated composite and then the whole apparatus placed onto the teeth.

Any excess composite flows through the relief channels and then the composite is cured through the stent.

On removal, the upper teeth were then fully-restored to the exact replication of the dimensions from the wax-up. The composite restorations were roughly shaped and polished before the whole process was repeated on the remaining alternate teeth. This process was repeated on the lower teeth and then all the composites were refined, polished and the occlusion and excursions carefully checked (Figures 26-28).

A four-month period passed, allowing the patient to adjust to this new position. He was recalled every four-weeks to assess. Very little occlusal adjustment was necessary and he reported nothing but comfort and happiness with his new smile. As there was no posterior contact during this period, it was decided to complete the lower posterior restorations, leaving them out of occlusion still.

The planned restorations for the lower posterior teeth were to use zirconia

on the molars and composite on the premolars. Composite was chosen for all lower premolar, canine and incisor teeth to keep the overall cost of the treatment plan to within the patient budget. Zirconia was chosen for the molar teeth as it has a considerably higher compressive strength over IPS E.max and also achieves the necessary natural colouring in an aesthetic rehabilitation.

On the day of preparation, the lower teeth were isolated and all of the old restorative materials within these teeth removed (Figure 29). Remaining tooth structure was assessed for cracks and dental caries. The teeth were sandblasted with 50-micron aluminium oxide powder to remove any remaining restorative or liner debris and to increase micro-mechanical retention. Selective enamel etching was completed using 37% orthophosphoric acid. A 2% chlorhexidine scrub was then applied to inhibit the matrix metalloproteinases and to disinfect the dentine. The teeth were then dried, followed by adhesive bonding protocol.

A two-step self-etch adhesive bonding system with selective enamel etching only was employed; this way, there is a short-acting and only mildly acidic component on the exposed dentine during the primer stage, which creates a thin hybrid layer. This is less prone to hydrolysis than using a total-etch technique and less likely to result in dentine sensitisation. Additionally, a more stable and durable bonding

interface is created as there is only partial demineralisation of the dentine and the consequent bonding to the hydroxyapatite crystal that remains (Van Meerbeek et al, 2011).

The removed tooth structure was re-restored with a dual-curing white opaque composite material (Figure 30). This allows for full sealing of the dentine and is easily identifiable during preparation to ensure all restorative margins are on sound tooth structure where possible. The teeth were then prepared for inlay-onlays and impressions taken using a two-stage PVS technique. No retraction of soft tissues was needed as all margins were supra-gingival for easy access to finishing/polishing and for ease of cleansibility (Figure 31).

On the day of cementation, the teeth were once again isolated with rubber dam. The teeth were prepared for bonding following standard protocol of air-abrasion to remove any biofilm and to create enhanced micromechanical retention, followed by total etch protocol. The zirconia surface was treated following the APC zirconia-bonding concept introduced and illustrated by Blatz et al (2016).

This protocol includes three steps: (A) air particle abrasion, (P) zirconia primer, and (C) adhesive composite resin. An abundance of research confirms the strong evidence that air-abrasion at a moderate pressure in combination with using phosphate monomer containing primers and luting resins provide long-term durable

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FIGURE 54: Full face

FIGURE 57: Frontal smile view

FIGURE 60: Left lateral smile view

FIGURE 55: Full face right

FIGURE 58: Relaxed

FIGURE 61: Frontal retracted view, teeth slightly parted

FIGURE 56: Full face left

FIGURE 59: Right lateral smile view

FIGURE 62: Right lateral retracted view, teeth slightly parted

bonding to glass-infiltrated alumina and zirconia ceramic under the humid and stressful oral conditions (Kern, 2015; Mehta and Shetty, 2010). As long as the materials are prepared correctly and strict protocols are maintained then the adhesive bonds to zirconia are comparable to that of other materials (Kern, 2015; Mehta and Shetty, 2010). To optimise the adhesion further, scrubbing with Ivoclar Vivadent Ivoclean removes any remaining phosphate contamination.

Due to the high attraction of the zirconia to phosphate molecules, contamination from local sources can bond to the zirconia surface and render it inert to the zirconia-primer used with resin cements. Saliva and other body fluids contain various forms of phosphate, eg phospholipids; these may react more or less irreversibly with the surface and thus make cleaning difficult. Ivoclean consists of an alkaline suspension of zirconium oxide particles. Due to the size and concentration of the particles in

the medium, phosphate contaminants are much more likely to bond to them than to the surface of the zirconia restoration (Wolfart et al, 2007). Ivoclean, when scrubbed over the zirconia fitting surface, will remove the phosphate molecules, allowing a surface primed for optimum bonding.

The restorations were silanated and loaded with the cement, then placed on the tooth and agitated into positon. After full cure the margins were cleared and refined with a scalpel before being polished with a brownie and greenie before and after rubber dam removal (Figures 33-36).

After four-months both the patient and I were comfortable that the restorations were achieving both functional and aesthetic excellence, and so the final stages of the rehabilitation began. Firstly, the upper posterior bridges were completed. The most posterior abutment teeth were prepared for full-coverage crown restorations and a small box was prepared

into the anterior abutment teeth to house the female-portion of the fixed-movable bridge joint (Figure 37).

Impressions were taken and two fixed-movable bridges were made from metal-ceramic, with a gold cast inlay for the anterior support (Figure 38). Consideration was given during the manufacture of the bridges to allow the correct positioning of the teeth given the planned veneers on the buccal of the anterior abutment teeth (shown as green wax). The gold inlay was cemented into the distal of the anterior abutment teeth and then the bridge unit located and cemented distally (Figure 39). The bridges then brought the posterior teeth back into occlusion and allowed for a defined registration for accurate location and mounting of the models at the anterior preparation stage.

At this stage we discussed the patient’s smile and the positioning of the anterior teeth (Figure 40). What was interesting to note was the reduction of the amount

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FIGURE 67: Anterior close-up view FIGURE 68: Right lateral close-up view

FIGURE 63: Left lateral retracted view, teeth slightly parted

FIGURE 65: Right lateral retracted view, teeth in occlusion

FIGURE 64: Frontal retracted view, teeth in occlusion

FIGURE 66: Left lateral retracted view, teeth in occlusion

of gum on show when he smiled at this four-month stage of treatment; a positive effect of the intrusion of the anterior teeth following those principles explained by Dahl and colleagues (1975).

There was a slight cant in the smile with natural imbrication of the teeth as the composites had been placed directly over the natural position of the upper teeth without any reduction. The patient really liked the ‘wonky’ smile and advised that he felt it fitted his face and really didn’t want things to be perfect at all. We agreed to copy the smile positioning exactly as it was.

Utilising the Gürel (2003) reduction technique, depth-gauged reduction of 0.7mm was completed through the composite circumferentially around the anterior eight teeth with sufficient 2mm incisal and occlusal reduction to allow for the correct thickness and hence strength of the planned IPS E.max restorations (Figure 41). Margins were maintained on enamel where possible, equi-gingivally facially and

supra-gingivally palatally. No preparation was necessary for the planned veneers on the upper second premolar teeth (Figure 42).

The preparations were refined and size 000 retraction cord was placed in to the sulcus to provide the laboratory with the location of the base of the sulcus. This was followed by size one cord for horizontal deformation of the sulcus, which was removed prior to impression-talking. Spot etching was completed and temporary restorations placed (Figure 43). These were made using Luxatemp acrylic from an impression taken over the patients existing teeth pre-preparation (Figure 44).

All appropriate shading photos, facebow record and bite registrations accompanied the impressions to the laboratory. The restorations were returned after three weeks and the patient invited back for fitting of these. The temporary restorations were removed and the tissues assessed. Perfect tissue health was as expected given

the time taking during both the planning and preparation stages of this treatment process (Figure 45). Additionally, the patient was maintaining excellent oral health due to his frequent appointments and continual and ongoing education and good-habit reinforcement.

The teeth were isolated with a rubber dam and the crown/veneers tried-in to assess the fitting. The ceramic work was exceptional and a perfect fit. After try-in, the IPS E.max was conditioned with a 5% hydrofluoric acid etch for 20 seconds as per the manufacturer’s guidelines followed by the cleaning product Ivoclean to remove any salts and phosphate molecule contamination. The E.max was then silanated and pre-loaded with the light-cure Ivoclar Vivadent Variolink Esthetic resin-cement. The restorations were left in a covered restoration tray until ready for use.

The teeth were first isolated with an inverted rubber dam to prevent sulcular fluid contamination and the teeth individually clamped to retract the dam and expose the restorative margins (Figure 46). The neighbouring teeth were protected by placement of a metal matrix strip and then sandblasted first to remove any biofilm to increase micromechanical retention, followed by a short total-etch of only 10-seconds (Figure 47) and then the use of a mild self-etching adhesive bonding system Adhese Universal, which creates a more stable and durable bonding interface as there is only partial demineralisation of any exposed dentine and consequent bonding to the hydroxyapatite crystal that remains (Van Meerbeek et al, 2011) (Figure 48).

The restorations were then individually placed and agitated into positon (Figure 49) and light-cured for only one-second (Figure 50). The quick-cure allows easy clean-up of the cement at the margins (Figure 51) before being fully-cured under an oxygen inhibiting gel. This gentle technique allows very easy clean-up and is much kinder to the gums as you don’t get the cement stuck in-between the teeth etc. The margins were first refined with a scalpel before being polished with a brownie and greenie before and after rubber dam removal (Figures 52-53).

The occlusion was checked and all excursive movements re-created and observed for correctness. Impressions were taken and the patient made an occlusal appliance to wear at night to protect his

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new restorations. I always review my patients after any larger treatments at one-week, one-month and then again at three-months. This allows me to not only check the settling of their restorations but also to reinforce the good hygiene habits and the attendance that we have worked so hard to achieve. The final photographs were taken at the one-week review visit.

REFLECTIONThe review photos were taken at the one-week review visit. The lower composite build-ups are now almost seven-months since placement.

There is some staining on their surface and a slight loss of lustre, which is expected from this Venus Diamond nano-hybrid material. However, there is no chipping and no obvious wear, demonstrating the excellent mechanical qualities of this restorative material. In addition, this demonstrates the well-functioning occlusal scheme with correct guidance and disclusion of the teeth during function.

The patient has adapted to the new OVD very well and has been functioning for more than six-months without complication. By approaching the rehabilitation in a careful and staged approach there was nothing left to chance and no predictions or guess-work employed. Every restoration has been designed to function correctly within the occlusion based on the tried and tested provisional composite restorations.

As far as the aesthetics are concerned,

the integration between the different materials of metal-ceramic, IPS E.max and composite is nigh on undetectable. I am very pleased with the colour-matching between these. I am also confident that the soft tissues will mature nicely into the embrasures of the new restorations over the next six-months and look forward to updating the photos at that time. The pictures of the anterior teeth with transmitted light (Figure 72) show the internal anatomy and translucencies of the ceramic work; particularly the halo effect beautifully replicated and the natural transmission of the light through the tooth, cement and IPS E.max material. If an alternative cement or material had been chosen then this natural effect would have been lost, for example both zirconia and Panevia F cement will block this light transmission and reduce the natural beauty of anterior restorations.

The patient is incredibly happy with the end-result as he can now chew and smile with confidence, which were his two primary objectives. By keeping every restoration as minimally invasive as possible, he is comfortable with zero sensitivity and easily accessible cleansable margins on all restorations. He is aware that, ultimately, the lower composite teeth restorations may need replacing with an alternative material but is very happy with these currently.

This has been a fantastic case to present and I hope I have managed to convey both the emotional and the clinical reasoning behind the choices that both the patient

and I made. I feel that we have anticipated and planned for possible failure and not limited ourselves to only one or two treatment options.

I hope that the planning and design of this rehabilitation means years of success and long-term health, and I am confident that whatever the future holds, this gentleman’s life will be improved for the better. His future options are still open for upscaling his rehabilitation if he ever wishes, and finances permit, and the foundations are now there for good oral health and general physical and emotional wellbeing.

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REFERENCESBlatz MB, Alvarez M, Sawyer K, Brindis M

(2016) How to Bond Zirconia: The APC Concept. Compendium of Continuing Education in Dentistry 37(9): 611-617

Dahl BL, Krogstad O, Karlsen K (1975) An alternative treatment of cases with advanced localised attrition. Journal of Oral Rehabilitation 2: 209-214

ESE (2006) Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. International Endodontic Journal 39: 921-930

Gürel G (2003). The Science and Art of Porcelain Laminate Veneers. Chicago, Illinois, USA: Quintessence Publishing

Jain AR, Nallaswamy D, Ariga P, Philip JM (2013) Full mouth rehabilitation of a patient with reduced vertical dimension using multiple metal ceramic restorations Contemporary Clinical Dentistry 4(4): 531-535

Kern M (2015) Bonding to oxide ceramics – laboratory testing versus clinical outcome. Dental Materials 31(1):8-14

Mehta D, Shetty R (2010) Bonding to Zirconia: elucidating the confusion. International Dentistry South Africa 12(2): 46-53

Tipton P (2000) Bridge design Part 2: Fixed-Movable Bridgework. Restorative and Aesthetic Practice 2(6): 96-103

Van Meerbeek B, Yoshihara K, Yoshida Y, Mine A, De Munck J, Van Landuyt KL (2011) State of the art of self-etch adhesives. Dental Materials 27(1): 17-28

Wolfart M, Lehmann F, Wolfart S, Kern M (2007) Durability of the resin bond strength to zirconia ceramic after using different surface conditioning methods. Dental Materials 23: 45

FIGURE 70: Upper occlusal view

FIGURE 71: Lower occlusal view

FIGURE 69: Left lateral close-up view

FIGURE 72: Transmitted light view