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Completion of parts one and two of this article left the patient ready for final restoration fabrication and seating.
The following have been accomplished for the patient:
1. A DATA Appliance has been utilized to create a Stable Biomechanical Platform.
2. Ideal functional and esthetic restorative treatment objectives have been determined and designed on this platform.
3. Tooth preparations and crown lengthening procedures consistent with this design have been performed.
4. Provisional restorations matching this design have been fabricated and seated.
This, the final part of this article, will illustrate a process for creating and seating final restorations mimicking the esthetic and functional qualities developed in these provisional restorations. Key functional and esthetic qualities requiring communication will be listed and methods of communicating them detailed. In conclusion, techniques for utilizing the DATA Appliance to perfect and protect these restorations will be described.
Every technician knows that a single anterior tooth is the hardest to match when taking a patient’s custom shade. In the first case study below, a minimum veneer preparation revealed a very dark stump shade that would need to be masked with porcelain and translucency. Under this category come several other issues, such as: Will a platinum foil technique produce the best restoration? How will we control opacity? What about the adjacent teeth – what is their color? Is there any white calcification? Is the white color subtle, medium, or solid?
These questions, or something similar, seemed to come up over and over again when I reviewed the various cases sent into the lab for fabrication. And I came to realize that we didn’t really have a very good method of communicating shade with each other-the dentist, the patient and the technician- especially if there was anything unusual about the case.
The imitation and manufacture of incisors has always been a particularly hard task for dental technicians. When called to rehabilitate an individual incisor, the operator needs to cope with several problems, sometimes insuperable, especially when there are no chances to see the patient in the laboratory. In order to achieve acceptable results, a perfect layering technique, much expertise, familiarity with the tricks of the trade and a close cooperation with the clinician are fundamental. In the following article, the author presents 3 clinical cases.
Part I of this article primarily focused on biomechanical issues in our patient’s care. It described the use and advantages of the DATA Appliance, the Integrated Classification System, and development of a Stable Biomechanical Platform. It concluded with development of a Stable Biomechanical Platform on a patient requiring extensive restorative treatment. It is important to recall that initially, esthetic improvement was not a high priority for our patient. However, once development of a Stable Biomechanical Platform made him comfortable, he indicated that improved esthetics was very important. The patient now indicated that there were no restrictions on treatment options he would accept to achieve ideal function and esthetics - except that he did not want treatment of any type for his remaining second molars.
The achievement of ideal esthetics and function should be the goal of every dentist choosing to restore a dentition. In addition, long-term durability of our restorations is mandatory if we are to consider our treatments successful. These objectives are most predictably realized if careful attention is given to all factors impacting each part of the Masticatory System, including both microbial and biomechanical issues.
The purpose of this article is to describe a system that manages these biomechanical factors and also assists in developing ideal esthetics. This system consists of three elements: the Integrated Classification System (ICS), the DATA Appliance (Diagnosis And Treatment Assisting Appliance), and a Stable Biomechanical Platform. In this article, the ICS, DATA Appliance, and Stable Biomechanical Platform will be utilized to guide the evaluation and treatment of a patient with complex esthetic and functional problems1,3,10. It is divided into three parts:
1. This, part one, focuses on utilization of the DATA Appliance and ICS to evaluate the patient and guide development of a Stable Biomechanical Platform.
2. Part two demonstrates the techniques and advantages of designing an ideal esthetic and functional restorative plan on this platform. Provisional restorations are then fabricated to represent this design.
3. Part three describes a process for creating and seating final restorations mimicking the esthetic and functional qualities developed in the provisional restorations. It then describes utilization of the DATA Appliance to perfect and protect these restorations.
The mounting of dental casts in a TMJ articulator requires the use of a facebow. The facebow transfers distances and the alignment of the mandible relative to the TMJ onto the articulator, which is why it is often referred to as a transfer bow. Two methods can be used for this process: determination of the position of the arbitrary axis either in relation to the mandible or in relation to the maxilla. Michael Kluck explains why he prefers the second method.
Recording Jaw Relations
The position of the arbitrary axis is determined either in relation to the mandible or in relation to the maxilla. In the first method, the dental technician uses a bite index to mount the maxilla on the mandible in centric relation; in the second method, this process is reversed. The results are objectively the same and differ only in their philosophy. The maxilla forms an integral part of the skull.
Determining the position of the hinge axis relative to the maxilla is the simpler and safer procedure. It also makes it easier to find a place to attach the facebow to, especially if the patient is to be provided with complete dentures. For these reasons, I prefer determining the jaw relations relative to the maxilla.
Reproducing each detail and trying to faithfully imitate the teeth’s natural look has always been the most rewarding aspect in building an esthetic restoration. The shape, color, shine and all the details that make up the tooth esthetics can be clearly seen only through a detailed photographic image. It is useful to constantly use pictures in our daily practice in order to decode the tooth natural features that are to be transferred to a prosthetic restoration.
One-element restorations, even if unchallenging from a technical viewpoint, can be really difficult as far as esthetics is concerned. They need to perfectly blend in the patient’s natural dentition without being easily recognizable. The first of the following cases was particularly gratifying for us because both the clinical and technical steps were carried out during a course with the patient participation.
Introductory Thoughts on Restorations The variety of natural teeth is as inexhaustible as human individuality. The job of the dental restoration team is to retain this variety and individuality by seeking to create authentic restorations.
Notable successes have already been achieved in many prosthetic disciplines. Contrastingly not much progress has been made in other areas such as implants and total prosthetics.
Restorations are chiefly wanted for the sake of an attractive personal cosmetic or aesthetic appearance; however incorporating oral rehabilitations should have a positive therapeutic effect on the entire patient’s body (Figures 1 and 2). It is insufficient to merely fill gaps in the oral cavity (Figures 3 and 4).
The incorporated restoration becomes part of a highly complex neuromuscular system. Research has revealed that more than 70% of internal problems and diseases have a reference to the oral cavity and teeth. This makes it all the more important to generate a new dental awareness.
Dental awareness should be understood holistically, seek to retain oral structures and include the quality of life affected by oral health.
Only when “all gears smoothly mesh” in oral rehabilitation (this includes all related biological, functional, psychosocial material, and technological considerations) will the patient accept the price of a restoration.
This may sound a bit extravagant, but it is true. The patient always pays two prices: a financial and biological one.
With regard to esthetics, the single central incisor poses the greatest restorative challenge for the clinician; not surprisingly, it can also be the most difficult tooth for the dental technician to match. Selecting the shade of the restoration depends in part on the material used for the understructure, and there is a wide assortment available from which to choose. The following are among the most common: An experienced technician can mask the underlying dark tooth color using porcelains with detailed colormasking techniques.
• Zirconia (e.g., Procera® [Nobel Biocare; Yorba Linda, CA], Lava™ [3M ESPE, St. Paul, MN], Cercon® [Dentsply Int., York, PA], Everest™ [KaVo America Corp.; Lake Zurich, IL], In-Ceram® [Vident; Brea, CA])
• Flexural strength: approximately 1,200 Mpa
• Translucency: very low
• Opacity: high
• Alumina core or glass-infiltrated alumina (e.g., Procera, In-Ceram)
• Flexural strength: 450 to 700 MPa
• Translucency: low
• Opacity: moderate
• Pressed Ceramics (leucite-reinforced or lithiumdisilicate and apatite glass ceramics, e.g., Empress® [Ivoclar Vivadent; Amherst, NY], OPC® [Pentron; Wallingford, CT], Authentic® [Jensen Industries; North Haven, CT], GC Initial [GC America; Alsip, IL])
• Flexural strength: 120 to 450 MPa
• Translucency: high
• Opacity: low
• Nonoxidizing metal (e.g., Captek™ [Captek; Altamonte Springs, FL], Bio 2000® [Argen; San Diego, CA], Sinterkor™ [Pentron])
• Similar to porcelain-fused-tometal (PFM)
• Flexural strength: equal to porcelain to metal
• Translucency: low—equal to porcelain to metal
• Opacity: high—equal to porcelain to metal
Healthy natural teeth are precious property. Just how precious is something we and our patients usually recognize only in hindsight. Beauty, individuality, function, and a harmonious total picture are the key features to be kept in mind by the Denturist. A person’s facial beauty is heavily influenced by the form, shade, and position of the teeth, but we must never leave function out of the equation when striving to get the esthetics right. Just ask a patient struggling daily with a denture poorly designed in any of these areas about how difficult it can be to bite a roll or eat a meal. Phonetics too are affected and changed by dental prosthetics. Small changes in tooth position or poorly fitting prostheses can significantly disrupt personal communication, even make it intolerable.
Keywords: age-appropriate contouring and shading, individual surface development, harmonious gingival development
In article III (Spectrum dialogue, June/July 2008) I presented an overview of the vertical dimension and its basic association to dental 3D space. I defined tooth length, axis rotation and tooth intercuspal curvatures that relate to how dentition will act accordingly within the vertical component. In article IV, I will analyze the horizontal dimension, x,z-the horizontal plane that makes up the other component in any dental 3D universe. At this point, we will not be discussing canine disclusion or component interaction, as that is a subject that we will come to later when we put both planes together as 3D dental space. Fig.0 illustrates the plane we are now discussing and its association to the geometry. What will be of importance in this examination is that the horizontal plane plays an important role in the determination of posterior tooth morphology, width, longitudinal length, cusp positioning and the arcs that the cusps will ultimately pass through. The anterior component in the horizontal plane, again like the anterior input in the vertical component, is also the subject of arcs but plays another role. Without the horizontal protection of the anteriors and how they work in the horizontal plane, dentition affected by the interaction of both planes would face rapid wear or deterioration. Therefore, the horizontal plane contributes to the masticatory system as an element that can work effectively in a dynamic way to complete any 3D dental universe.
Reconstruction is not just about sitting down and waxing teeth, bowing to patients’ wish lists nor is canine disclusion the most important requisition to reconstruction. There is a lot more to it. Each element involved plays a significant role in how other elements will interact. This method of defining the planes separately, explaining each as a separate entity with its own calibrations and geometry, opens one’s eyes to what is actually going on instead of looking at the system as a simple mechanism that can be ignored or treated with a basic approach.
Reflect back on the previous articles as refreshers so you can keep track and build up a picture of what this will all eventually unfold into. Look at these preliminary articles as 2 dimensional plans and then when we come to the 3D geometry it will come together with a far better logical and meaningful understanding.
This report evaluates various studies and published literature on mouth guard protection, evaluation of different types and a review of detailed injuries. There are new patented developments in design and fabrication which offer whole head protection with the focus on concussion prevention.
Keywords: mouth guard, injury prevention, concussion, trauma, air cushioned, and shock absorption.
Introduction:For the people who engage in sporting activities, a mouth guard is essential because the single most serious tragedy is not losing the competition, but receiving a serious injury that could have been prevented. Anyone who is active in sports should wear protective equipment, especially mouth guards. By doing so, this simple safety appliance will reduce more oral injuries in athletes in all sports every year. Accidents in full contact or non-contact sports can cause harm to lips, teeth, tongues, jaws, and can even produce concussions. This is why dentists see more injuries to the mouth as a consequence of participating in sports activities, than from any other types of damage. Research literature has pointed out that mouth guards definitely aid in averting broken teeth, fractured jaws and traumatic injuries to the bone that hold the roots of the teeth in place.