Table of Contents

Practice Building
Restorative

Inside Dentistry

April 2009, Volume 5, Issue 4
Published by AEGIS Communications

Turning the Clock Back for Baby Boomers

Jacinthe Paquette, DDS

There is no doubt that the dental industry is in the midst of transformation. The crux of this reform is caused by, in part, advanced dental technologies and materials offered by dental manufacturers, which make esthetic rehabilitative dentistry a natural component in treatment plans for patients today.1 The media also has drawn attention to greater esthetics and benefits associated with a healthier life through dental care. More importantly, though, the push toward esthetic rehabilitative dentistry has come from the average American baby boomer, now between 44 and 62 years of age, who takes his or her health and beauty more seriously than his or her ancestors had before. Patients in this age category often have dated restorations and other dental esthetic compromises from a long and varied history of dental treatments. Esthetic rehabilitative dentistry provides patients with an opportunity to “turn the clock back” by restoring their dentitions to a healthier, more youthful state.

This increase in patients requesting complex treatments has created the need for clinicians to have a good understanding of three key elements to rehabilitative treatments. Much the way grammar school students must learn the three basic subjects, dentists must learn the three basic elements to complex rehabilitative dentistry:

  1. Vertical Dimension of Occlusion (VDO)
  2. Centric Relation (CR) of Occlusion
  3. Occlusal Plane Orientation

These fundamentals are critical to creating successful esthetic treatments. Following these three key gnathological concepts offers a structured methodology for the prosthodontic procedures of the esthetic rehabilitation.2 From this foundation, further esthetic refinements, such as smile design, tooth alignment, gingival display, gingival symmetries, etc, also can be achieved.

The Presentation of Today’s Patient

With the varied presenting concerns that patients have today, the proficient clinician must first recognize the deficiencies to appropriately and ideally address the patient’s orofacial make-up for the most esthetic result possible. Treatment planning must begin with well-defined esthetic objectives. From a comprehensive dental examination and an esthetic evaluation, the clinician can assess the impact a dental rehabilitation will have on the patient’s esthetics, function, and biologic health. Very often the aged dentition requires an interdisciplinary approach to establish a stable foundation to best idealize the end result.3,4 After all, aged dentitions often will present with a number of possible compromises, which can include:

  1. Aged, broken preexisting restorations
  2. Missing teeth
  3. Discolored, stained, or ill-matching teeth or restorations
  4. Drifted and misaligned teeth
  5. Lack of tooth display at rest
  6. Lack of support of the facial soft tissues and lips
  7. Slight loss of VDO

A patient presented at a point in his life where he eagerly sought to change his dentition to one that he had always dreamed about. Because of years of varied restorative treatment, he presented with numerous dental and orofacial compromises. The clinical examination revealed numerous discolored, stained teeth, and ill-matching porcelain shades (Figure 1 and Figure 2). Some of the preexisting restorations had defective and/or overcontoured margins. Some of these restorative compromises could be seen radiographically (Figure 3).

The majority of his dental esthetic compromises stemmed from congenitally missing lateral incisors. This condition resulted in retention of the deciduous cuspids, which were too small, worn, and esthetically disproportionate. His permanent cuspid teeth had erupted into the lateral incisor positions and been veneered many years earlier (Figure 4 and Figure 5).

The patient had a low lip line and his overall tooth display was minimal even with a full smile. Therefore, any attempts to smile appeared forced and exaggerated, creating a strained and unnatural appearance (Figure 6 and Figure 7).

Treatment plan recommendations included orthodontic treatment to correct the existing vertical and horizontal limitations to restoring the anterior teeth. The patient was not receptive to this treatment option and preferred to have his treatment accomplished through restorative means only. The VDO needed to be restored to accomplish three goals5:

  1. Provide for more tooth display at rest and with a full smile
  2. Create room for the restoration of the anterior teeth where a deep overbite existed
  3. Redefine symmetry in the occlusal plane

The patient’s periodontal health was good. He was referred to an oral surgeon for the placement of endosseous implants in the retained deciduous cuspid sites. Additionally, the restorative treatment plan included porcelain-bonded restorations and full-coverage porcelain-fused-to-gold crowns for a complete esthetic rehabilitation (Figure 8 and Figure 9).

The Three Key Elements of Esthetic Rehabilitative Dentistry

Vertical Dimension of Occlusion
A preliminary evaluation of the patient’s existing VDO can be accomplished in a number of ways and can be further cross-checked at various times as the patient’s treatment progresses. The interarch freeway space can be assessed clinically by measuring the difference between VDO in the intercuspal position and the postural vertical dimension. VDO is a highly adaptable position and there is no single correct vertical dimension.6 These assessments act as guides to identify patient toleration and provide a valuable preview of the potential space available for increasing the VDO in the rehabilitation.7 Other commonly used techniques for the assessment of interocclusal space are after swallowing or at the relaxed postural mandibular position.

The preliminary models of this patient were mounted at the prescribed VDO (Figure 10 and Figure 11). An effective measurement of the degree of change to determine VDO is to measure from the cementoenamel junction (CEJ), or the gingival margins of the maxillary central incisors to the CEJ or gingival margin of the mandibular central incisors.8 In this patient, a significant increase was planned to create an esthetic tooth display and sufficient available space for the future restorations.

In addition, the patient’s facial profile offers an initial external guide to identify the need and/or possibility of an adjustment to the existing VDO. Yet, the profile can only serve as a guide, because typically in most of life’s activities the teeth are apart and, thereby, not affecting the facial profile.9 Loss of VDO is typically most pronounced in patients with the loss of numerous teeth, resulting in a drifting of the dentition and an overall collapse of the occlusion and lower face height. In more extreme cases of a loss in VDO, these conditions also can be coincident with angular chelosis. These more extreme losses of VDO should have a thorough assessment of the temporomandibular joint assemblies. This initial assessment only serves as a guide in the initial evaluation process and is to be used in addition to other clinical clues. Patients with a pronounced history of parafunctional activity may some-times display no difference in these two positions because the hypertrophied musculature sometimes can prevent a relaxed/rest position from occurring. Generalized and exaggerated occlusal wear serves as another intraoral clue to assess the need and possibility for an increase in the VDO.

Centric Relation of Occlusion
The proper function and stability of the esthetic rehabilitation relies, in a great part, on the precision executed during treatment. Accurate interarch records are important and need to be remounted and crosschecked through the course of the patient’s treatment. The CR of occlusion provides a reliable and repeatable position for the reconstruction. This level of accuracy helps ensure the accuracy and stability of the occlusion developed in the end10 (Figure 12; Figure 13; Figure 14; Figure 15).

Accurate record models and mountings translate to a diagnostic wax-up that is also precise and effective for the course of the restorative process. The diagnostic wax-up can serve predictably as the template for the indirect provisional restorations. The fabrication of precise provisional restorations is a key component to success in complex rehabilitative dentistry.11,12 It allows for the diagnostic assessment of the restorative plan in the early stages of the reconstructive treatment.

The primary diagnostic information established with the use of the provisional restorations is an integral part for the successful course of treatment in the interim phase of care, including13,14:

  1. Comfort and stability of the occlusion
  2. Appropriateness of the corrected VDO
  3. Suitability in the phonetic and esthetic design

Occlusal Plane Orientation
The occlusal plane orientation is a critical part of the esthetic rehabilitation not only for the functional parameters it dictates but also for the overall esthetic outcome of the completed treatment. This orientation is especially important in patients with dentitions that have drifted over a lifetime and sometimes is overlooked by clinicians during the treatment process. The degree of severity of tooth drifting may be slight, involving only a few teeth, to very pronounced, whereby entire quadrants of the dentition are out of alignment. Extreme tooth drifting significantly compromises the esthetic appearance of the patient if the plane’s orientation does not compliment the patient’s orofacial symmetries.15 For this reason, the relation of the occlusal plane to the patient’s face should be evaluated closely for need of correction throughout the evolving phases of care, including:

  1. Examination
  2. Diagnostic wax-up
  3. Provisionalization phase
  4. Delivery of the final restorations

Extraoral guides, such as the patient’s face and lips, are the best sources to assess the occlusal plane’s orientation relative to the patient’s facial symmetry. The horizontal plane of the patient’s eyes, ears, and lips during smiling helps to guide the proper orientation. These guides are very familiar to clinicians involved in comprehensive esthetic treatments.16 This assessment needs to be made from two perspectives: (1) the anterior-to-posterior orientation (sagittal plane); and (2) the side-to-side orientation (frontal plane). Additionally, the levels of the buccal cusps of the bicuspids and molars bilaterally serve to evaluate this aspect of the plane (Figure 16; Figure 17; Figure 18; Figure 19). Camper’s plane is especially useful in evaluating the lateral views of the patient with a unilateral or bilateral loss of the posterior teeth resulting in exaggerated drifting or supra-eruption of the posterior occlusion.

The intraoral guides to the occlusal plane have been well described in removable prosthodontics and can be applied to the dentate patient as well. The retromolar pads, for example, are a useful source for determining the proper occlusal height of the posterior teeth. The tongue position at rest can help to determine the correct occlusal height of the posterior teeth. Esthetic and phonetic assessments help to guide the proper orientation of the incisal height and position of the anterior teeth (Figure 20; Figure 21; Figure 22; Figure 23). All of these clinical clues are checked and cross-checked during the finalization of treatment from the provisional phase to the final phases of treatment.

Conclusion

Our aging population and its members’ desires to maintain a youthful, healthy dentition will increase the need for a sophisticated approach to complex rehabilitative dentistry. This trend and the fact that between 2000 and 2010 there will be more patients between 44 and 62 years of age indicate that esthetic rehabilitative dentistry is here to stay. The patient treatment example in this article illustrated the many benefits available to the baby boomer population. A well thought out and systematic approach to this type of dental care helps to ensure predictable, esthetic, and successful treatment outcomes. This evolving patient population presents today’s clinician with a need for a deeper understanding and sophistication to approach the esthetic dental rehabilitation. The key elements of a proper occlusal plane orientation, an idealized VDO, and an accurate CR of occlusion are an integral part of creating a successful treatment outcome in these patients. In addition, today’s baby boomers’ needs may involve other cosmetic procedures, such as dental veneers or dental implants. To address the growing needs of this population, clinicians are encouraged to become involved with well-respected continuing education programs to improve their diagnostic skills and comfort level in these more challenging treatment cases.

References

1. Christensen GJ, Ruiz JL. Restorative dentistry: current developments and a look to the future. Dent Today. 2008;27(2):98-102.

2. Pokorny PH, Wiens JP, Litvak H. Occlusion for fixed prosthodontics: A historical perspective of the gnathological influence. J Prosthetic Dent. 2008;99(4): 299-313.

3. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent Clin North Am. 2007;51(2):487-505.

4. Small BW. Interdisciplinary treatment for esthetic restorative dentistry. Gen Dent. 2002;50(3):230-236.

5. McLaren EA, Rifkin R. Macroesthetics: facial and dentofacial analysis. J Calif Dent Assoc. 2002;30(11):839-846.

6. Spear FM. Approaches to vertical dimension. Advanced Esthetics and Interdisciplinary Dentistry. 2006;2(3):2-12.

7. Miralles R, Dodds C, Palazzi C, et al. Vertical dimension. Part 1: comparison of clinical freeway space. Cranio. 2001;19(4):230-236.

8. Lee RL. Esthetics and its relationship to function. In: Refenauct CR, ed. Fundamentals of Esthetics. Chicago, IL: Quintessence Publishing; 1990.

9. Gross MD, Nissan J, Ormianer Z, et al. The effect of increasing occlusal vertical dimension on face height. Int J Prosthodont. 2002;15(4):353-357.

10. Small BW. Centric relation bite registration. Gen Dent. 2006;54(1):10-11.

11. McIntyre FM, Jureyda O. Occlusal function. Beyond centric relation. Dent Clin North Am. 2001;45(1):173-180.

12. Rinchuse DJ, Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective. J Am Dent Assoc. 2006;137(4): 494-501.

13. Strupp WC Jr. Simplifying complex full-arch cases by using an indirect provisional technique. Functional Esthetics and Restorative Dentistry. 2008;24-28.

14. Doan PD, Goldstein GR. The use of a diagnostic matrix in the management of the severely worn dentition. J Prosthodont. 2007;16(4):277-281.

15. Sesemann MR. Enhancing facial appearance with aesthetic dentistry, centric relation, and proper occlusal management. Pract Proced Aesthet Dent. 2005;17(9):615-620.

16. Bloom DR, Padayachy JN. Increasing occlusal vertical dimension—why, when and how [comment]. Br Dent J. 2006;200(10):542.

Figure 1 An occlusal view of the maxillary arch displayed numerous preexisting alloys and overcontoured restorations. Figure 2 An occlusal view of the mandibular arch depicted a collection of varied restorative designs of the teeth treated through the years.
Figure 3 A complete set of full-mouth radiographs illustrated numerous areas of existing restorative compromises that would benefit from replacements.
Figure 4 The most prominent of the patient's concerns were the esthetic compromises that had been propagated through the years without any definitive improvement in the overall esthetic appearance to his smile. Figure 5 The veneered cuspid teeth in the lateral incisor positions and the retained deciduous cuspids further compromised his esthetic appearance.
Figure 6 A right lateral view of the patient's smile appeared strained and unnatural as he forced a smile because of the deep overbite. Figure 7 The reduced VDO created a limited tooth display.
Figure 8 A right lateral view of the patient in complete intercuspation. Figure 9 A left lateral view of the patient in complete intercuspation.
Figure 10 A right lateral view of the patient's mounted models illustrating the extent to which the VDO was to be increased. Figure 11 A left lateral view of the patient's mounted models of the planned increase in VDO. Clinical examination of the patient at rest also depicted this level of vertical opening.
Figure 12 The right lateral view of the diagnostic wax-up. This elaborate wax-up can serve as the template to create the provisional restorations. Figure 13 The left lateral view of the diagnostic wax-up. The newly prescribed VDO will allow for the correction of occlusal plane, esthetic, and functional discrepancies, which existed before the rehabilitation.
Figure 14 A view of the maxillary anterior tooth preparations. Porcelain veneer preparations for the cuspid teeth in the lateral incisor positions needed to be of a more aggressive nature to create a more slender lateral incisor form. Figure 15 An occlusal view of the maxillary anterior region. The implants were restored with the use of custom-milled abutments.
Figure 16 The final restorative outcome for the maxillary arch created an esthetic and balanced tooth symmetry and tooth length. Figure 17 The right lateral view of the completed treatment illustrates a level plane of occlusion.
Figure 18 Facial view of the final restorative outcome, which created an esthetic and balanced tooth symmetry and tooth length. Figure 19 The left lateral view of the completed treatment.
Figure 20 The right lateral view of the patient's smile shows a relaxed smile with appropriate tooth display. Figure 21 The facial view of the patient's smile shows an esthetic outcome to the buccal corridor.
Figure 22 The left lateral view of the patient’s smile. Figure 23 A pleased and confident patient with an esthetic dental rehabilitation.
About the Author
Jacinthe Paquette, DDS
Co-Executive Director
Newport Coast Oral Facial Institute
Newport Beach, California

Private Prosthodontic Practice
Newport Beach, California