Full-Mouth Rehabilitation Using All-Ceramic Restorations

Cosmetic dentistry has benefitted from scientific and technological advancements, leading to greatly improved metal-free ceramic systems for fixed prosthodontics as well as porcelain veneers. As a result, these treatment options have become highly suited for achieving superior cosmetic outcomes. Rehabilitation treatment stages, including careful treatment planning of the case by the dental professional in collaboration with the laboratory technician, the selection of suitable ceramic materials, and proper preparation of the teeth, are essential for assuring the long-term survival of the restorations. Furthermore, rapid advances in materials technology in the area of glass and oxide ceramics, as well as in adhesive technologies, have led to new treatment options for a wide variety of indications, such as the ability to prepare crowns less invasively.¹

The improved mechanical properties of dental ceramics, together with the optical quality of these materials, have afforded clinicians esthetic predictability.² Furthermore, some types of ceramics, such as lithium disilicate, enable mechanical and micromechanical adhesion to tooth structure by means of etching the ceramic with hydrofluoric acid, a silane coupling agent, and subsequent ligation with resin cement.³ This allows the retention of ceramic restorations, even when there is little coronal tooth structure available. Other important characteristics of ceramics are surface smoothness and resistance to degradation.⁴ These features allow color stability and integrity of the restorations over time.⁴ In addition, these features contribute to excellent gingival tissue response, such as providing an environment similar to enamel with little biofilm aggregation.⁵

Thus, this paper aims to present a clinical case of full-mouth rehabilitation using all-ceramic restorations with porcelain metal-free unit crowns in the maxilla and porcelain veneers from the left inferior premolar to the right inferior premolar, achieving an excellent esthetic and functional result for the patient.

The patient, a healthy 64-year-old woman, sought treatment because of her dissatisfaction with the esthetics of her existing dental work, which included numerous metal-ceramic fixed prostheses of different colors, and a large composite resin restoration with different colorations at the upper incisors (Figure 1 and Figure 2). In the lower arch, the right inferior first molar had furcation involvement in the lingual region; she also had crowding of incisors, highly discolored teeth, and some metal-ceramic crowns in the posterior region. However, she was in good general and dental-gingival health and was neither a smoker nor a bruxer.

The pre-treatment radiograph indicated that teeth Nos. 4 through 6, 11, 13, 14, and 30 had satisfactory endodontic treatment without periapical changes; teeth Nos. 4 through 6, 11, 13, 14, 30, and 31 had single metal-ceramic crowns; teeth Nos. 7 through 10, 19 through 22, 25, 26, 28, and 29 had radiopaque restorations; the region of tooth No. 12 had an implant with a crown; and tooth No. 18 was missing (Figure 3). A computer tomography of the left inferior second molar area was performed to evaluate remaining bone height. Due to the furcation involvement in the lingual of the right inferior first molar, the tooth was extracted and alveolar healing time was allowed prior to implant surgery. In addition, tooth No. 19 was endodontically treated due to intense pain reported by the patient.

Three months after tooth extraction, an implant (5 mm x 10 mm, TryOn, external hexagon, S.I.N. Sistema de Implante, www.sinimplante.com.br) was placed in the right inferior first molar, and a short dental implant of 6 mm in height and 5 mm in diameter (Implalife, www.implalife.com.br) was also placed at the site of the left inferior second molar.

Ten days after implant surgery, both arches were molded; study plaster models were mounted on an articulator for occlusal evaluation, diagnostic waxing, and mock-up. In order to fabricate the mock-up, waxing was copied by a transfer guide made with impression material (addition silicone) and placed directly in the patient’s mouth using bis-acrylic resin (Structur 2 SC, VOCO, www.voco.com), which provides both patient and dentist a proof of the new format and color of the future restorations. The all-ceramic restorations with porcelain metal-free unit crowns in the maxilla, the porcelain veneers from the left inferior premolar to the right inferior premolar, and the implant-supported porcelain metal-free crown on the right inferior first molar and on the left inferior second molar were all defined after the diagnosis, treatment planning, and patient’s approval of the mock-up.

At the next appointment, a cast was created in order to perform a transfer of the left superior first premolar to make the acrylic resin provisional crowns of the superior teeth (from the right second premolar to the left first molar), reflecting the shape of the teeth set during diagnostic waxing. Then, superior metaloceramic crowns (teeth Nos. 4 through 6, 11, 13, and 14) were removed and the remaining upper teeth were prepared for placement of the acrylic resin provisional crowns.

Within days of placement of the provisional crowns, the right upper first premolar root had fractured. Immediate root extraction and implant placement surgery was planned and carried out using a Strong SW 4513 internal hexagon implant (S.I.N. Sistema de Implante); a provisional bridge of teeth Nos. 4 through 6 was also placed.

The upper teeth were maintained with provisional crowns during the osseointegration period for the right upper first premolar implant. During this period, inferior rehabilitation was started.

After teeth were prepared, addition silicone (Futura® AD, Nova DFL, www.novadfl.com.br/en) was used to create a transfer mold of the preparations for the implants and the veneers from the left inferior second premolar to the right inferior second premolar. An inferior plaster model, along with a new plaster model of the upper provisional restorations, were mounted on a semi-adjustable articulator for fabrication of the inferior-arch porcelain restorations. Porcelain veneers were cemented with RelyX™ Veneer Cement (3M ESPE, www.3MESPE.com), and implant crowns were screwed in (Figure 4).

After the osseointegration period for the superior implant, transfer molding of the two upper implants together with the upper teeth preparations was performed with the use of retraction cord and vinyl polysiloxane (Futura) (Figure 5). Bite registration using an acrylic resin material (DuraLay, Reliance Dental Mfg. Co., www.reliancedental.net) was conducted. A new plaster model of the lower arch post-installation of the porcelain veneer restoration was made and mounted on a semi-adjustable articulator together with the upper mold. Porcelain metal–free crowns were fabricated and cemented in the upper arch, and metal-free implant crowns were screwed in.

The case report has been followed-up for nearly 3 years (Figure 6 through Figure 8). The patient was satisfied with the treatment, as excellent esthetic and functional results were achieved.

Lower-arch rehabilitation was performed only after provisional crowns of the superior teeth replicating the shape of the future permanent prosthesis had been placed. The use of provisional restorations to mimic future final restorations is important to guide the practitioner and the patient; therefore, permanent treatments should be implemented only after patient consent has been obtained through objective assessment of provisional restorations.⁶ Provisional restorations allow an objective communication between practitioner and patient.⁶ In the clinical case presented here, the only differences between provisional and definitive restorations were the material used and the coloring. Initially, the patient was afraid to whiten her teeth, but just a few months after the installation of the provisional restoration, she opted for whitening. The shape of the provisional crowns was retained in the definitive crowns.

Issues such as fracture of provisional crowns, endodontic treatment needs, non-osseointegration of an implant, and root fractures may occur during major restoration planning and treatment. These types of problems should be explained to the patient during discussion of the treatment plan and fees. In the clinical case presented here, the root of tooth No. 5 fractured after the installation of provisional crowns of the upper teeth. The authors opted to delay placing the implant at the site of the fractured root until after the osseointegration period of the installed implant in order to rehabilitate all upper teeth at the same time for esthetic reasons.

Porcelain veneers are considered advantageous to maintain tooth vitality and preserve hard tissue,⁷ especially if preparation of teeth is based on a diagnosis guide made from a diagnostic waxing.⁸ Preparations for both the porcelain veneer and porcelain crowns should be guided by a diagnosis guide in order to create adequate space for the lab technician to apply the porcelain to achieve the desired anatomy, which is that indicated by the diagnostic waxing previously made. Porcelain veneers were chosen for inferior teeth for better preservation of tooth structure, while metal-free crowns were chosen for the upper incisors because the upper incisors had had large composite restorations in almost all aspects, which impeded the preparation for veneers. During all preparations, a guide made with silicone addition was used to guide preparation.

The clinical case has been followed-up for nearly 3 years. The patient was satisfied with the treatment, as excellent esthetic and functional results have been achieved. Prosthetic planning, along with appropriate patient collaboration, were prerequisites for its success.

As demonstrated in this case, metal-free prostheses and porcelain laminate veneers are excellent treatment options for delivering superior esthetic and functional results.

Eloá R. Luvizuto, DDS, MS, PhD
Assistant Professor
Department of Surgery and Integrated Clinics
Araçatuba Dental School
Universidade Estadual Paulista
São Paulo, Brazil

Thallita P. Queiroz, DDS, MS, PhD
Assistant Professor
Department of Health Sciences
Implantology Postgraduation Course
School of Dentistry
University Center of Araraquara
São Paulo, Brazil

Walter Betoni-Júnior, DDS, MS, PhD
Assistant Professor
Department of Oral Surgery
Dental School
University of Cuiabá
Mato Grosso, Brazil

Celso K. Sonoda, DDS, MS, PhD
Assistant Professor
Department of Surgery and Integrated Clinics
Araçatuba Dental School
Universidade Estadual Paulista
São Paulo, Brazil

Sônia R. Panzarini, DDS, MS, PhD
Assistant Professor
Department of Surgery and Integrated Clinics
Araçatuba Dental School
Universidade Estadual Paulista
São Paulo, Brazil

José Carlos Monteiro de Castro, DDS, MS, PhD
  Assistant Professor
Department of Surgery and Integrated Clinics
Araçatuba Dental School
Universidade Estadual Paulista
São Paulo, Brazil

Eloisa M. Boeck, DDS, MS
Assistant Professor
Department of Orthodontics
School of Dentistry
University Center of Araraquara
São Paulo, Brazil