Giuseppe Marchetti
Interdisciplinary treatment plan and execution of a complex case, with orthodontics (Dr. Renato Cocconi ), maxillo surgery ( prof. Mirco Raffaini ), periosurgery and implantology ( Dr. Paolo Marchetti ), restorative and prosthodontics ( Dr. Giuseppe Marchetti ), lab work ( CDT Vincenzo Musella).
The patient, male 38 years old, came in 2012 to the attention of the orthodontist complaining about esthetic and occlusal issues and about the perception of his asymmetry. In a second time the orhodontist sent the patient to my attention for a prosthetic evaluation and to the attention of my brother for a periodontal evalution too. Then we brainstormed as a team for an interdisciplinary treatment plan to fix his problems.
Diagnosis
Orthodontic Diagnosis:
Due to a condilar hyperplasia ,on the right, there was an excessive growth of the lower jaw on the right with consequent deviation of the lower jaw on the left, with a chin that was deviated on the left too. That leaded to a compensation in the growth with a consequent canting of the occlusal plane, and backing of the left canines as a consequence of the compensation of the asimmetry. There was also an antero-posterior hypoplasia of the upper jaw with a trasversal deficit. Moreover there was an asimmetry of the nose and of the nasal septum. So it was a class III asimmetric, with conditions of hyper-divergence. Both the TMJ had no symptoms, despite they seemed remodeled looking at the cone beam, and no other symptoms were told by the patient. There was also a bilateral posterior cross- bite.
Periodontal diagnosis:
patient had perio issues, and after the evaluation of the periodontist it was defined a localized periodontitis Stage II Grade A ( following the new classification of periodontal desesase ) with missing teeth 3.6 and 4.4 ( included ).
Endodontic and restorative diagnosis:
incongruous endodontic treatments of 1.6-1.7 with apical lesions and incongruos restorations with primary and secondary caries on 1.4 1.5 1.6 1.7 2.4 2.5 2.6 2.7 3.7 3.8 4.6 4.7 4.8
Prosthetic diagnosis:
Malocclusion and wear. Lack of the anterior guidance both in protrusion due to the reduced orverbite and overjet, lack of a canine guidance in left and right laterality and presence of a group function. At the functional analysis of the plaster models there was no coincidence of maximum intecuspidation and centric relation ( centric occlusion ).
Prognosis:
Good for all teeth except for 3.8, 4.4 (impacted) and 4.8 that had been extracted.
Goals of the therapy:
1) resolution of the ortho-surgical issues
2) resolution of the periodontal issue
3) fixing of the functional and esthetic issues with a low invasive prosthetic rehabilitation
Treatment plan:
1) Periodontal initial causal therapy with scaling and rootplanning
2) Pre-prostetic restorative with build up of the teeth affected by caries and endo retreatments
3) Surgical extraction of 4.4 impacted and ankylotic and mini-implant in 3.6 to support the orthodontics
4) Applications of acrylic provisional crowns on the molars with orthodontic attachments inside, bonded with a composite cement
5) Evaluation of the TMJs before the ortho procedures
6) Pre-surgical orthodontics to achieve a symmetry of the lower arch, trying to get a pre-surgical decompensation. There was also the need to get space on the lower right arch to substitute with an implant the 4.4 that was impacted and ankylotic, . Alignment of the upper arch with corticotomies to ease the alignment and decompensation of the upper arch without the induction of excessive periodontal stresses. Opening of the space in the lower right arch,for positioning the implant in 4.4, uprighting of the lower right,with the help of a distal TAD in the lower right, uprighting of the lower left with the help of a mini implant.
7) Maxillo surgery to fix the trasversal deficit, to get a bi-maxillary advancement and to reach a correction of the asimmetry.
8) Post-surgical orthodontics to reach a correct canine class on the left and further distalization of 3.7 to reach the correct space for positiong the implant in position 3.6. Alignment of the six upper front teeth to get a proper gingival emengence profile and proprortions of the six upper front teeth to have mini-invasive prosthetic preparations
9) Removal of the previous bonded provisional crowns and adjustment of the old build up done before the ortho procedures.
10) Preliminary impressions and face bow and taking over of the Centric Relation position with leaf gauge for the analytic wax up.
11) Resective and regenerative perio-surgery to fix the residue pockets that last after the orthodontic therapy. Impant positioning in 3.6 and in 4.4( with GBR and connective graft in a second surgery).
12) Application of the provisionals on implants ( screw retained ones)
13) Prosthetic rehabilitation with partial preps on the front teeth and on the premolars and crowns on the molars, to get functional results first ( recreating the anterior guidance in protrusion and laterality with disclusion in posteriors with absence of precontacts). Starting from the ortho- surgical result there was the need to open the VDO in Centric relation to increase the overjet and get a proper front guide. To counteract the negative overbite as a result of the opening of the VDO, there had been the need to increase the incisal length of the lower front teeth too ( no possibility to add on the palatal of the superiors front teeth that were only partially prepared ). The patient asked for an esthetic improvement too, so the prosthetic rehabilitation was also for esthetic reasons. All was done with pressed and painted lithium disilicate veneers, veneerlays and crowns, to copy the wax up and to reproduce the result that i got with the provisionals done directly with silicon stamps inside the mouth. All was done with a vertical cervical finishing line (except for the crowns that had a modified chamfer finishing line ), changing also the kind of partial preparations. In fact for the very first time the veneerlays have no mesial or distal boxes and are prepared almost like a feather edge crown except for the lingual-palatal surface that was not touched by the burs, to be as much conservative as possible.
14) Michigan bite to protect the restorations from non functional movements during the night
15) Follow up and perio manteinance with professional hygiene every 4 months.
Conclusions:
This complex interdisciplinary treatment plan started in 2012 and ended 5 years later in 2017 with full satisfaction of the Team and of the patient both for the functional and esthetic outcome, all the problems were fixed, despite we could have reached probably a better amount of keratinized tissue and surgical root covering and esthetic outcome in 4.3 position ( after the graft surgery ) that probably for its vestibular position at the end of the orthodontics and for the multiple surgeries became with a longer clinical crown, but the patient refused one more surgical intervention, and we agreed to end the proshtetic case with this little compromise.
Initial situation: pictures of the face of the patient that show the asymmetry of the face
Initial picture of the smile and intraoral situation, contraction of the upper arch, posterior bilateral cross- bite
Initial Rx ortopantomography and tele radiography
Initial x ray endodontic status
Evaluation of the TMJs before the ortho procedures
Preliminary periodontal chart
Initial evaluation of the preliminary plaster models on the articulator ( artex CR )
Orthodontic digital set up
Bonding of the provisional crowns with orthodontic attachment using the rubber dam and initial phase of the orthodontics with the provisional crowns with orthodontic attachment included
Initial phase of the orthodontics, after the surgical estraction of 4.4 included and ankylotic and the positioning of the mini implant in 3.6
Details of the face of the patient before the maxillo surgery
Details of the face of the patient after the maxillo surgery
Details of the final fase of the orthodontics and of the face and of the smile after the post surgical orthodontics
Functional evaluation after ortho and maxillo surgery to focus on the prosthetic treatment plan and goals
Intraoral details before the prosthetic therapy
New build ups after the removal of the provisional crowns previously bonded
Impressions of the second provisionals, taken with a VPS, and details of the wax up and of the provisionals on the plaster model
Centric relation position taken over with a leaf gauge, face bow and new preliminary impressions taken for the analytic wax up
Details of of the mounting of the face bow and of the mounting of the models in Centric Relation, and of the digital project too
Analytic wax up of the full mouth rehabilitation and functional trials
Resective periosurgery of the 1st quadrant
Regenerative perio surgery of the second quadrant with emdogain and x rays before and after
Corrective resective perio surgery of the second quadrant and implant placement in 3.6 positition with GBR too
Implant placement in 4.4 position with split crest and GBR in a first surgery and connective tissue graft in a second surgery
Details of the provisionals on implants and on natural abutments in place
Partial preparations guided by th silicon guides done on the wax up
Details of the preps and of the checking of the vertical dimension with the provisional posterior crowns in place
Details of the preps, of the impressions taken both with a polyether and a VPS and of the face bow ( Artex system )
The provisionals ( and the mock up ) are stamped with a flowable high charged composite and a transparent silicon index
Details of the preparations on the plaster models. I introduce a new concept: the changing of the kind of the preparation of the overlay-veneerlay in patients with previous perio-issues now fixed, and long clinical crown, using a feather edge finishing line as for crowns and removing the presence of the interproximal boxes. This leads to a very conservative partial preparation. Details of the lithium disilicate pressed and painted restorations.
Try in of the restorations before the painting and glazing with fit checker
Details of the preps with healed tissues and of the try in, intra-oral details and details of the smile
Bonding procedures using the rubber dam
Details at the end of the bonding procedures and at one week check
The preparations of the lowers using the silicon guides as for the uppers
Registration of the vertical dimension with the provisionals in place and impressions of the upper arch
Precision impressions of the lower preps taken also this time with a polyether and a VPS and face bow ( artex )
Details of the cross mounting of the low and of the lab work
Esthetic and functional try in of the lower arch too before painting and glazing
Details of the lithium disilicate restorations of the lower arch after the painting and the glazing
Details of the bonding procedures of the lowers with the rubber dam
final xray status
Final x-ray ortopantomography and tele radiography
The perio chart at the beginning and at the end of the whole work
The face of the patient at the end of the prosthstic treatment plan at one year check
Intra oral details at one year check
Details of the new smile at one year check
Functional aspects at one year check, details of the maximum intercuspidation of the protrusion and laterality restored properly with posterior disclusion with absence of precontacts.
Details of the Michigan bite used to protect the restorations during the night
Intra-oral details and details of the face before and after the therapy.