Beyond Single-Tooth Dentistry: A Systematic Approach to Full-Mouth Rehabilitation

This case highlights a patient who had replaced worn and fractured restorations over the course of 20 years without achieving lasting results. Repeated restorative failures can point to underlying issues such as occlusal dysfunction, a problem that can lead to premature wear and failed restorations. In the present case, after a diagnosis of occlusal dysfunction was confirmed with the use of a Kois deprogrammer,¹ it was determined that the vertical dimension of occlusion (VDO) needed to be increased to restore the patient’s worn teeth and create a stable bite.² A full-mouth rehabilitation was necessary to address the occlusal problems and global esthetics.

Clinical Case Overview

A 58-year-old female dental hygienist presented with a history of recurring restorative failures. She was self-conscious about her appearance (Figure 1 through Figure 3) and desired a more harmonious, symmetrical smile with whiter teeth and less gingival display. As a dental professional, she understood the limitations of single-tooth dentistry and after years of frustration sought a comprehensive, long-term solution that would provide stability, improve esthetics, and prevent further breakdown.

The phased approach to her treatment began with occlusal deprogramming using a Kois deprogrammer (Kois Center, koiscenter.com) to confirm a repeatable centric relation position. A diagnostic wax-up was used to guide the establishment of an increased vertical dimension, ensuring predictability in function and esthetics. The treatment was sequenced to prioritize occlusal stability while making the process financially manageable. Final restorations provided improved function, a balanced occlusion, and an esthetically harmonious smile.

Medical and Dental History

The patient presented in good overall health. Her medical history included allergies to nickel and thimerosal. She was diagnosed with breast cancer in 2021 and had chemotherapy and a double mastectomy. Armour® Thyroid was being taken for hypothyroidism. The patient was classified as American Society of Anesthesiologists (ASA) II due to her breast cancer treatment.

She had an extensive dental history with multiple fillings and crowns. She reported clenching and grinding, noting that her teeth had become shorter and increasingly worn in the past 5 years. There was a planned extraction of tooth No. 4 due to a root fracture around the post and core (Figure 4). Six broken restorations that had occurred in the past 5 years had been replaced.

Diagnosis, Risk Assessment, and Prognosis

Periodontal: The posterior teeth had less than 2 mm of horizontal bone loss with probing depths of 3 mm or less with no bleeding. With clinical attachment loss of less than 2 mm, the patient was classified as American Academy of Periodontology (AAP) stage I, grade A (Figure 5).³

Risk: Low

Prognosis: Good

Biomechanical: Porcelain was worn through to the metal on teeth Nos. 18 and 30. The implant provisional on tooth No. 4 was fractured. Erosion was present on teeth Nos. 6, 7, 11, 22, and 27. Tooth No. 2 had a fractured amalgam restoration, and tooth No. 20 had a questionable restoration (Figure 6).

Risk: Moderate

Prognosis: Poor

Functional: Moderate attrition (1 mm to 2 mm) was present on teeth Nos. 6, 7, 10, 11, 13, and 22 through 27. The patient was aware of clenching her teeth day and night and wore an occlusal guard while sleeping. Wear facets consistent with squeezing were present on the lingual surfaces of teeth Nos. 6, 7, and 9 through 11. Joint load and muscle immobilization tests were negative. A diagnosis of constricted chewing pattern was considered, but the patient did not feel that her lower jaw was being pushed back and she had generalized attrition. Due to the multiple broken restorations and wear facets, it was apparent that her maximum intercuspal position needed to be addressed. Deprogramming revealed tooth No. 18 as the initial contact point, and a diagnosis of occlusal dysfunction was confirmed.

Risk: Moderate

Prognosis: Poor

Dentofacial: The patient’s right maxillary canine display was -2 mm in repose. She showed excessive gingival display in the Duchenne smile. She said she felt uncomfortable and self-conscious about the appearance of her teeth because of their mismatched shape and color (Figure 1).

Risk: High

Prognosis: Poor

Treatment Goals

The treatment was aimed at satisfying the patient’s goals to have “a beautiful smile where all the restorations looked like they belonged in the same mouth” and that they would withstand chipping and breaking. She desired whiter, natural-looking teeth with less gingival display. Resolving the patient’s occlusal problems before placing the final restorations would allow for a more predictable outcome.

Treatment Plan

The treatment plan consisted of opening the VDO to allow the patient’s worn anterior teeth to be restored to a more ideal length and establish posterior occlusal contacts that were precise with bilateral equal intensity. The plan was segmented into multiple stages to ease the financial burden, as follows: deprogramming and diagnostic wax up; posterior provisional placement to confirm the new increased VDO; preparation and cementation of posterior restorations; gingivectomy, preparation, and cementation of the maxillary anterior teeth; and, lastly, preparation and cementation of the mandibular anterior teeth. Initially, the treatment plan included composite veneers on teeth Nos. 22 through 27; however, prior to the mandibular anterior treatment phase, the patient decided to restore these teeth with porcelain as well.

Treatment Phases

Phase 1: Deprogramming and Diagnostic Wax-up

Facial reference glasses (Kois Facial Reference Glasses, Kois Center) were used to determine the horizontal plane in the patient’s natural head position (Figure 7). A dentofacial analyzer (Kois Dento-Facial Analyzer, Kois Center) was used in conjunction with the glasses to record this position and allow for transfer of the maxillary arch to an articulator (Panadent, panadent.com). The patient had worn a Kois deprogrammer for 3 weeks, and deprogramming was confirmed when she repeatedly occluded on the same point of contact on the platform. She reported that tooth No. 18 was the first tooth to contact when removing the deprogrammer. Dysfunction was confirmed, and a deprogrammed, centric relation bite was taken using a wax wafer (Denar® Bite Registration Wax, Whip Mix, whipmix.com) and used to mount the mandibular cast. Alginate impressions of both arches were taken.

The dental laboratory was given instructions to add 2 mm of length to the maxillary canines to establish the patient’s canine position at zero in repose. The lab was instructed to level the rest of the teeth in the maxillary arch to the platform. The mandibular arch would have the length restored to the anterior and the anatomy restored to the posterior teeth. After 4 months, the implant on tooth No. 4 had integrated, and the case was sent to the lab to be waxed at the increased VDO (Figure 8).

Phase 2: Provisionalization of Posterior Teeth in the New VDO

The existing crowns on teeth Nos. 3, 5, 12, 14, 18, 19, 29, and 30 were removed and the teeth prepared for full-coverage lithium-disilicate restorations (IPS® e.max, Ivoclar, ivoclar.com), and teeth Nos. 13, 20, 21, and 28 were prepared for e.max onlays. Bis-acryl provisionals (3M™ Protemp™, 3M Oral Care, 3m.com) were fabricated in each quadrant using a putty matrix (Virtual®, Ivoclar) made from the laboratory wax-up. All provisionals were cemented with temporary cement (Temp-Bond™, Kerr, kerrdental.com).

The bite was adjusted to have equal-intensity, simultaneous, and bilateral contacts. Shimstock foil was utilized to verify the intensity of the contacts. The patient wore the provisionals for 2 weeks to allow her to test the new occlusion and esthetic design prior to placement of the definitive restorations.

Phase 3: Final Preparation and Impression of the Posterior Teeth

The provisionals were scanned (Medit i500, Medit, medit.com) to allow the working prototypes to be printed (Max UV, Asiga, asiga.com) and used for reference for the final restorations. The maxillary and mandibular right provisionals were removed, size 00 cord (Ultrapak™, Ultradent, ultradent.com) was packed, and the preparations were refined. An elastomeric bite registration (Futar® D, Kettenbach, kettenbach-dental.com) was taken on the right side. Next, the provisionals were removed from the maxillary and mandibular left sides. Size 00 cord was packed and the preparations were refined.

The implant provisional on tooth No. 4 was removed and placed on an implant analog in plaster. The facial, lingual, mesial, and distal surfaces were clearly marked on the plaster and a transparent A-silicone material (Memosil® 2, Kulzer, kulzer.com) was injected around the bottom half of the provisional. After the material had set, the provisional was removed from the plaster and replaced with an impression coping (BioHorizons, biohorizons.com). Flowable composite (inspiro®, Edelweiss DR, edelweissdr.com) was injected into the clear putty around the coping and light-cured (Valo™, Ultradent) to mimic the emergence profile of the provisional.⁴ The implant impression coping with the composite was placed back in the mouth. Size 1 cord was packed on all maxillary teeth and a full-arch polyvinyl siloxane (PVS) impression (Impressiv, Cosmedent, cosmedent.com) was taken. The same cord and impression technique was repeated for the mandibular teeth. The provisionals were recemented on the right side, and a bite registration of preparations on the left side was taken. The left-side provisionals were then recemented.

Phase 4: Cementation of the Posterior Restorations

The patient returned 5 weeks later for cementation of final restorations. Provisionals on the right side were removed. The custom abutment on tooth No. 4 was placed using a seating jig. All right-side restorations were tried in and checked for marginal integrity, proximal contacts, and proper occlusion. The same technique was repeated for the left side and the occlusion was adjusted.

The abutment screw of tooth No. 4 was torqued to 35 Ncm and retightened 10 minutes later.⁵ Teflon tape was packed into the screw-access channel. All restorations were etched with 5% hydrofluoric acid for 30 seconds and rinsed with water. Restorations were placed in an ultrasonic bath with distilled water for 3 minutes. Silane primer (Kerr) was applied to the intaglio surface and heated in a 210°F oven for 1 minute. The teeth and custom abutment were micro-etched with 2 µm aluminum oxide at 40 psi. All teeth were etched with 30% phosphoric acid (Ultra-Etch™, Ultradent) for 30 seconds and then rinsed with water. Heated adhesive (OptiBond™ FL, Kerr) was applied to both the teeth and the restorations. All restorations were cemented, one quadrant at a time, with a neutral shade resin cement (Variolink® Esthetic LC, Ivoclar). Tooth surfaces were tack-cured for 3 seconds with a curing light. Excess cement was removed and then each tooth light-cured again for 20 seconds. All margins were air-blocked with glycerin gel and light-cured again.

The occlusion was rechecked, adjusted, and polished. Simultaneous, bilateral, and equal-intensity contacts on the posterior teeth were achieved (Figure 9 and Figure 10). The patient was reappointed in 1 month to check the occlusion for both function and comfort.

Phase 5: Preparation of the Maxillary Anterior Teeth

One month later, the restorations on teeth Nos. 8 and 9 were removed. Tooth No. 8 was prepared for a full-coverage lithium-disilicate restoration and the remaining maxillary anterior teeth were prepared for lithium-disilicate laminate restorations.⁶ Utilizing the putty matrix fabricated from the wax-up, a bis-acryl reduction guide was placed on teeth Nos. 6 through 11. Small round burs (Brasseler, brasselerusa.com) were used to reduce the facial for proper reduction.

Sounding to bone revealed a low osseous crest with probing depths of 4 mm facially and 5 mm interproximally; therefore, a gingivectomy would suffice to reduce the patient’s “gummy” smile.⁷ Using a No. 15 blade, 1 mm to 1.5 mm of gingiva was removed on teeth Nos. 7 through 9. Size 00 cord was packed, preparations were smoothed with micro-etching, and stump shade photographs were taken. Size 1 cord was packed and a PVS impression, bite registration, and alginate opposing impressions were taken.⁸ A provisional for the solo crown on tooth No. 8 was made and cemented with temporary cement (Temp-Bond). All other maxillary anterior teeth (Nos. 6, 7, and 9 through 11) were provisionalized using the shrink-wrap technique.

Phase 6: Cementation of the Maxillary Anterior Teeth

Five weeks later, the same protocol that was utilized to cement the posterior quadrant restorations was followed to cement the maxillary anterior restorations (Figure 11). The patient would return 2 months later for preparation of teeth Nos. 22 through 27.

Phase 7: Preparation of the Mandibular Anterior Teeth

After 2 months, the patient returned for preparation of the mandibular anterior teeth.⁹ PVS impressions were taken and the teeth were provisionalized with bis-acryl composite resin using the shrink-wrap technique. A new upper alginate impression was taken and sent to the lab.

Phase 8: Cementation of the Mandibular Anterior Teeth

The patient returned 5 weeks later for try-in and cementation of the remaining six e.max restorations on teeth Nos. 22 through 27. The same protocols were used for try-in and cementation as previously described. Her occlusion was checked with articulating paper and shimstock foil.

Discussion

Phasing the treatment over 18 months allowed this patient to be able to afford a full-mouth rehabilitation by not placing a large financial burden on her at one time. Her expectations were exceeded and she was extremely happy with her new smile (Figure 12 through Figure 16). At her 6-month follow-up visit all restorations were intact with no chipping or breaking, and she reported her bite was comfortable as well.

Conclusion

Identifying the root cause of the patient’s failing restorations as being due to a previously undiagnosed dysfunctional occlusion helped her understand the poor prognosis of any future treatment if her bite was not addressed. This dialogue motivated her to transition from single-tooth dentistry to a full-mouth rehabilitation. Phasing the treatment was beneficial to the patient, as she was able to avoid incurring the entire treatment cost at one time, and her goal of having a beautiful smile that is expected to be long-lasting was achieved. By creating a detailed, systematic, and comprehensive plan prior to treatment, the clinician remained in control of the final outcome despite the treatment being phased.

ACKNOWLEDGMENT

The author thanks Yuichi Komaki, RDT, dental technician at Ultimate Styles Dental Laboratory, Irvine, California, for his exceptional craftsmanship and collaboration throughout this case; John C. Kois, DMD, MSD, for the foundational principles taught at the Kois Center, which provided the theoretical framework for many aspects of this treatment; and Susan A. Sheets, DDS, and Ken E. LeVos, DDS, for their editorial support and encouragement in preparing this article.

ABOUT THE AUTHOR

Nicole D. Watson, DDS
Private Practice, Bakersfield, California

Figures and Images

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Figure 1

Fig 1. Pretreatment full-face smile. Note the excessive gingival display.

Figure 2

Fig 2. Pretreatment close-up smile showing mismatched dental work throughout the mouth.

Figure 3

Fig 3. Pretreatment retracted view. Note the generalized incisal wear and the frictional wear facets on the facial of the mandibular incisors.

Figure 4

Fig 4. Pretreatment maxillary occlusal view displaying the broken implant provisional on tooth No. 4 and lingual frictional wear on teeth Nos. 6 through 11.

Figure 5

Fig 5. Pretreatment full-mouth x-ray series.

Figure 6

Fig 6. Pretreatment mandibular occlusal view showing wear on incisal edges and on existing porcelain-fused-to-metal crowns.

Figure 7

Fig 7. Full-face view of the patient with facial reference glasses to standardize the head position.

Figure 8

Fig 8. Full-mouth wax-up on articulator.

Figure 9

Fig 9. Close-up view with posterior restorations in place. The new VDO was apparent as incisal edges of the maxillary teeth were now above the facial wear facets on the mandibular incisors.

Figure 10

Fig 10. Retracted view of posterior restorations after treatment, showing the expansion of the buccal corridor.

Figure 11

Fig 11. Retracted view with full maxillary arch restored. Note the improved gingival symmetry and proper length-to-width ratio of anterior teeth.

Figure 12

Fig 12. Post-treatment full-face smile showing less gingival display and better framing of the teeth.

Figure 13

Fig 13. Post-treatment close-up smile demonstrating continuity of the restorations, improving the overall smile.

Figure 14

Fig 14. Post-treatment retracted view showing the final mandibular restorations leveling the arch.

Figure 15

Fig 15. Post-treatment maxillary occlusal view showing new occlusal scheme.

Figure 16

Fig 16. Post-treatment mandibular occlusal view showing coverage of previous wear.