Cassandra came to us with a lot of dental needs. She knew she had a mouth full of cavities and was ready to commit to treatment. On her comprehensive exam we took x-rays, extra-oral pictures, intra-oral pictures and study casts. Our exam revealed positive TMJ (temporomandibular joint) on her left side, but she was not experiencing any pain or discomfort. Her muscle exam was negative; no problems there. But the occlusal (biting surface of the teeth) was positive due to missing teeth. Her lower front teeth nested nicely behind her upper front teeth, which is normal. But due to so many missing teeth, her chewing surfaces in back were not meshing properly. She had retained a baby back tooth from childhood. She said her premolars were missing from birth and had never come in. All of her remaining teeth had cavities and several were abscessed.
We discussed all her options, including constructing removable partials as well as restoring her mouth with fixed crowns and bridges. She chose fixed crown and bridge treatment. We also discussed replacing the missing teeth with implants. Because so many teeth required crowns, we decided that fixed crowns and bridges would save money over single implants and still retain good aesthetics and function.
Her lips and profile look good. Her front teeth come together well, so we will not be recommending changing her bite, nor will we open her vertical dimension.
Here you can see the broken and missing teeth
Several teeth were beyond restoring and had to be removed. We chose to use Eris crowns instead of porcelain-fused-to-metal (PFMs). Eris are all porcelain products which allow us to layer a lot of color and definition. They provide better cosmetics than PFMs. Even though she was not choosing implants, bone grafting was recommended in the extraction sites to allow her the option of going to implants in the future, if she so chose.
Even though she was experiencing a lot of tooth decay, her gums were in excellent health. Very low bleeding index and no pockets greater than 4mm. Her bone support is good. These conditions definitely increase the longevity of the work she is considering.
We discussed the possibility of grafting selected sites to enhance the possibility of implants at some point in the future, if she so chose.
Before committing to treatment, I insisted that we send her study casts to the lab to have them create her new smile in wax. This would allow her to see a mock up of the end result and make changes prior to the final work. Much easier to change wax than to change porcelain.
Here we are taking measurements for the wax up. The wax model will also be used to create her temporary crowns until the new porcelain ones can be constructed.
The big day arrived and Cassandra was prepared to spend the day with us. We recommended IV sedation because of the length of the appointment. We prescribed Valium the night before to make her sleep well. The morning of her appointment she took hydroxyzine hydrochloride and triazolam one hour before she arrived. She was very relaxed when she walked in. We began IV medication and she slept well through the appointment.
Here we are reducing tissue around the front teeth to give the effect of longer and more beautifully proportioned front teeth. The cosmetic effects were dramatic. The appointment lasted about seven hours. She was tender for a few days, but she healed quickly
Here we have completed her new temporary crowns. They are all attached in a single unit to increase stability. She will wear them a month to let her heal. In about 4-5 weeks she will come back for impressions. This will be about a two hour appointment, but she still opted to be sedated.
