You are on page 1of 25

Dario Adolfi, DDS, CDT'

Oswaldo Scopin de Andrade, DDS, MS, PhD2

Gustavo Javier Vernazza, DDS 3
Mauricio Contar Adolfi, DDS4
he achievements seen in the fields of esthetics
and implant dentistry have attracted the atten-
tion of clinicians as well as dental technicians,
but oftentimes innovations are implemented without
making a global assessment of the patient's restorative
needs. In the case of full-mouth rehabilitation, a suitable
restorative protocol is crucial, and a logical sequence
'Director of Spazio Education, Sao Paulo, Brazil.
'Director of the Advanced Program in Implant and Esthetic
Dentistry, Senac University, Sao Paulo, Brazil.
'Director of the Oral Rehabilitation Program, Postgraduate School
of the Argentinian Dental Academy (A.O.A.), Buenos Aires,
'Director of the Periodontal and Oral Implantology Department,
Spazio Education, Sao Paulo, Brazil.
Correspondence to: Dr Dario Adolfi, Av. Juscelino Kubitschek,
1726, 21st floor, Sao Paulo, SP, Brazil, CEP 04543-000.
must be followed to optimize the treatment. Thus, suc-
cessful outcomes depend on meticulous treatment
planning and careful execution of the clinical and labo-
ratory procedures planned for each individual case. 1,2
Several factors influence treatment planning, including
patient health status, patient motivation, treatment
time, expected costs over treatment phases, profes-
sional skills of the operators for each phase, and ex-
pected long-term results.'
The objective of this article is to describe all clini-
cal and laboratory steps for a functional and esthetic
protocol for full-mouth rehabilitation that promotes
patient understanding and dental team cooperation
to achieve predictable outcomes.
Patients needing oral rehabilitation require a thor-
ough initial assessment to determine the options for
treatment as well as the patient's willingness to accept
recommendations proposed in the treatment plan-
ning. Thus, caution must be exercised in the first clini-
QDT 2013
Fig 1 The four reconstructive steps of a functional and
esthetic full-mouth oral rehabilitation protocol: maxillary
anterior segment (blue), mandibular anterior segment (red),
mandibular posterior segment (orange), and maxillary pos-
terior segment (magenta).
Fig 2 Reconstruction starts on the maxillary segment from
right to left premolars. The premolars may be included in
this step to achieve better esthetic diagnoses.
cal examination. The practitioner should explain the
options in a simple and straightforward way to encour-
age patient understanding. The final treatment plan is
detailed in the second appointment. 4
The success of an esthetic rehabilitation depends
on the dental team's knowledge of the biologic con-
siderations related to teeth and implants as well as the
communication maintained between the prosthodon-
tist, oral surgeon, and dental technician.'
When several changes are planned, a diagnostic
wax-up is fabricated on the study casts to facilitate
visualization of the shape, position, and proportions
of the planned restorations and to provide the most
functional and esthetic conditions possible. Diagnos-
tic wax-ups can facilitate patient assessment of the
proposed treatment as well as allow technicians and
dentists to predict potential problems that could arise
during treatment. 67
Use of wax-ups facilitates the development of prop-
er contours for provisional restorations and provides
a detailed and accurate guide throughout the restor-
ative process that can inform other intraoral tools, such
as a silicone index for crown lengthening or surgical
stents used for implant placement.' The creation of a
diagnostic wax-up must follow the functional and es-
thetic protocol for oral rehabilitation.
The functional and esthetic protocol for oral rehabilita-
tion can be divided into four steps (Fig 1):
1. Reconstruction of the maxillary anterior segment
(from the right second to the left second premolars).
2. Reconstruction of the mandibular anterior segment
(from canine to canine).
3. Reconstruction of the mandibular posterior segment.
4. Reconstruction of the maxillary posterior segment.
Phase 1: Reconstruction of the Maxillary
Anterior Segment
This is one of the most important phases, because it
defines the patient's overall esthetic appearance (Fig 2).
When the buccal corridor needs to be realigned, the
premolars are included with the anterior segment so
that their overall aspect can be harmonized with the
anterior teeth. Otherwise, premolars are only included
in phase 4. Phase 1 provides the dental team with a
CID 140
1. Midline, symmetry axis, and
tooth axis
3. Zenith of gingival contours
4. Morphology, proportic
and basic shape of natui-
6. Interproximal contacts
1.1nterincisal angle
8. Incisal edge position
9. Lip line
10. Insical edge configuration
11. 3D implant position
12. Color
13. Surface textures and
superficial gloss
Esthetic Checklist
Functional and Esthetic Protocol for Oral Rehabilitation
Fig 3 The esthetic checklist.
complete overview of the restorative case and ad-
dresses the patient's esthetic expectations. 9
When study casts are used in combination with in-
traoral mock-ups to plan the restorations, clinicians
can work with greater predictability and fewer errors,
even in complex cases that require multiple adjust-
ments. Depending on the clinical scenario and the
clinician's skills and knowledge, the intraoral mock-up
can be made using composite resin on specific areas
to promote the predictability of the functional and es-
thetic outcomes.
The diagnostic wax-up in phase 1 must include:
! Development of the tooth size, shape, and arrange-
! Fabrication of a mock-up for esthetic and phonetic
! Adherence to the esthetic checklist concepts (Fig 3)
Phase 2: Reconstruction of the Mandibular
Anterior Segment
In this phase, the size and position (individual and over-
all) of the mandibular anterior teeth must be evaluated
for function during excursive mandibular movements.
This should be achieved in accordance with phase 1
to establish adequate anterior guidance that favors
the esthetics of the anterior teeth. It is important to
keep the mandibular canine longer than the incisors
for efficient disocclusion patterns (Fig 4). On eccen-
tric mandibular excursions, freedom of movement and
less muscle energy are essential and are favored by
the anterior guidance on protrusive and lateral man-
dibular paths.
The following characteristics must be assessed while
the mandibular anterior teeth are in occlusion with the
maxillary teeth (Fig 5):
! Tooth size and form
! Vertical dimension of occlusion
! Centric relation
! Phonetics
! Quantity and quality of disocclusion
! Disocclusion patterns (eg, canine guidance and par-
tial and total group function)
QDT 2013 141
Fig 4 Reconstruction of the mandibular canines. Fig 5 Reconstruction of maxillary and mandibular teeth in
phases 1 and 2.
Fig 6 The curve of Spee is provided by the mandibular
posterior teeth.
Fig 7 Phase 4 showing reconstruction of the maxillary
posterior teeth.
Phase 3: Reconstruction of the Mandibular
Posterior Segment
This phase determines the anteroposterior curvature
of the occlusal plane (curve of Spee) achieved through
the positions of the mandibular posterior teeth. The
curve of Spee is an imaginary line extending from the
tip of the mandibular canine, touching the buccal cusp
tips of all the mandibular posterior teeth, and continu-
ing to the anterior border of the ramus (Fig 6).
Phase 4: Reconstruction of the Maxillary
Posterior Segment
In this phase, the maxillary posterior teeth are recon-
structed and the occlusal relationships in the posterior
quadrants are established. The three occlusal relation-
ships are cusp to fossa, cusp to marginal mesial ridge,
and cusp to marginal distal ridge.
The occlusal contacts determine the occlusal equi-
librium and thus the functional relationships that con-
serve tooth integrity and individual positions as well
as provide axial loads at stability at the correct vertical
dimension of occlusion (Fig 7).
After designing the rehabilitation protocol through
development of a diagnostic wax-up, the provisional
restorations are fabricated according to the wax-up.
The provisionals must protect the teeth and reestab-
lish the desired function and esthetics. They must be
a perfect copy of the diagnostic wax-up and are fab-
ricated with the indirect approach, ie, at the dental
laboratory by the dental technician.
First, the diagnostic wax-up casts are duplicated
and new stone casts are poured and related in a semi-
adjustable articulator. The provisionals are then made
using the double-pressing technique for each tooth
segment to allow better control of occlusal contact
points as well as of the acrylic resin expansion setting
QDT 2013 142
Fig 8 Initial clinical situation showing an Angle Class II, division 2 malocclusion and an accentuated overbite.
Figs 9 and 10 Occlusal views showing porcelain-fused-to metal crowns and large restorations.
Fig 11 The mandibular anterior teeth are extruded, but the gingival levels were adequate.
Functional and Esthetic Protocol for Oral Rehabilitation
A 64-year-old Caucasian woman with an Angle Class II,
division 2 malocclusion and accentuated overbite pre-
sented for treatment (Fig 8). The first clinical examina-
tion revealed several porcelain-fused-to-metal crowns,
large restorations, tooth rotations, and some gingival
recession (Figs 9 and 10). Also, the mandibular incisors
were extruded because of the lack of occlusal contact
with the maxillary anterior teeth (Fig 11). No issues with
the vertical dimension of occlusion or temporoman-
dibular disorders were observed.
QDT 2013

Treatment Objectives
Because the patient was an adult and presented an
adequate facial profile, it was decided to maintain
molar-to-molar Class II relationships and to correct the
exaggerated overjet and overbite of the maxillary cen-
tral incisors. The aim for the mandibular arch was to
reestablish the anteroposterior curve (curve of Spee)
as well as to level the anterior segment and provide
light occlusal contacts on the maxillary anterior teeth
to avoid continued mandibular tooth eruption. In ad-
dition, adequate overbite and overjet along with ad-
equate canine guidance were planned to create an
esthetic smile.
Treatment Planning
Initial impressions of the maxilla and mandible were
taken with irreversible hydrocolloid material (alginate)
and poured in orthodontic plaster. It is important that
accurate casts be kept as part of the patient's records.
Also, silicone impressions were created for study casts
and were related in a semi-adjustable articulator with
the aid of a facebow.
The provisional restorations for the maxillary inci-
sors were fabricated on the study casts using artificial
acrylic teeth to correct the accentuated overjet.
The patient received a complete outline of the treat-
ment plan with indications for root canal therapy for
maxillary and mandibular incisors and fiber-reinforced
post and core restorations. Tooth preparation would
be made for all anterior maxillary teeth, and the maxil-
lary teeth would receive laboratory-made provisionals
based on the diagnostic wax-up.
Functional and Esthetic Protocol
Phase 1: Reconstruction of the maxillary segment
It is important to bear in mind that any modifications
of tooth arrangement not achieved by orthodontic
movement must preserve the correct cervical tooth
levels for proper planning of new tooth positions. The
maxillary central incisors were facially inclined, and the
lateral incisors and canines were inclined more to the
palatal aspect. On the study casts, the central incisors
would be moved toward the palatal and the lateral in-
cisors would be slightly inclined to the facial aspects.
Tooth widths were reduced to generate a new anterior
arch relationship. At phase 2, the canines were reposi-
tioned along with the mandibular anterior teeth.
During the fabrication of the provisionals, the clini-
cal crowns were removed from the working cast, leav-
ing just the cervical lines as a guide for fabricating the
provisionals from artificial teeth (Premium, Heraeus
Kulzer, Hanau, Germany) (Fig 12).
At the same time, indices made from silicone mate-
rial (Zetalabor, Zhermack Badia, Polesine, Italy) were
prepared over the provisionals to ensure correct intra-
oral transfer (Figs 13 and 14). The index was used to
transfer the correct central incisor position and to re-
cord the correct overjet, overbite, midline, and tooth
The maxillary right central incisor served as a refer-
ence key for placement of all of the provisionals. The
provisional for the right central incisor was positioned
on the silicone index and secured with cyanoacrylate
glue to assure stability for the intraoral try-in (Fig 15).
The maxillary right central incisor was prepared for a
crown restoration, and the silicone index was posi-
tioned without interfering with the adjacent teeth. A
small amount of autopolymerizing acrylic resin (Unifast
Trad powder Ivory, GC America, Alsip, Illinois, USA)
was placed on the palatal aspect of the right central
incisor using the Nealon or brush-dip technique to sta-
bilize the provisional crown (Figs 16 and 17). At this
point, it was possible to verify that the midline and the
tooth axis were correctly positioned (Figs 18 and 19).
The maxillary left central incisor as well as the maxillary
lateral incisors were then prepared to receive provi-
All provisional crowns were placed prior to coronal
build-up to help guide the positioning of fiber posts
to the root (Fig 20). The fiber posts must remain within
the reconstruction material (Luxacore, DMG, Hamburg,
Germany) to strengthen the coronal build-ups after
tooth preparation (Fig 21).
QDT 2013
12 13
145 QDT 2013
Figs 18 and 19 The esthetic acrylic
veneer is in position over maxillary
right central incisor. The median line
and axial inclinations are now correct.
Fig 20 Provisional restorations po-
sitioned before reconstruction with
fiber posts.
Fig 21 Fiber posts placed within the
coronal reconstructions.
Functional and Esthetic Protocol for Oral Rehabilitation
Fig 12 Provisional restorations made
on the working cast. The cervical
lines were maintained.

Fig 13 Silicone indices over the
provisional restorations on the work-
ing cast.

Fig 14 The silicone index is trimmed
to accommodate the position of the
central incisor.
Fig 15 The provisional acrylic es-
thetic veneer for the maxillary right
central incisor is positioned on the
silicone key and secured with cyano-
Figs 16 and 17 The silicone index
with the esthetic veneer in position.

Fig 22 The mandibular anterior teeth had overerupted due to the lack of occlusal contact with their maxillary an-
tagonists. However, adequate gingival levels can be seen.
Figs 23 to 25 Acrylic resin veneers were secured with cyanoacrylate glue and flowable resin composite over tooth
preparations to simulate the position of provisional restorations.
Fig 26 The palatal morphology of anterior teeth and their occlusal contact relationships are defined by correct posi-
tioning of acrylic resin veneers.
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation

Fig 27 Frontal aspect of the diagnostic wax-up.
Fig 28 Correct development of occlusal contacts and anterior guidance pathways.
Phase 2: Reconstruction of the mandibular
anterior segment
The mandibular anterior teeth, from right canine to
left canine, had continued to erupt due to the lack of
occlusal contact (Fig 22). The treatment aims were to
perform root canal therapy and adequate incisal re-
duction as well as to correct the size and arrangement
of the teeth. Because no changes were needed in the
gingival levels and the anatomic crowns presented no
wear, they were used as references to create the de-
finitive clinical crowns.
After incisal reduction was completed on the man-
dibular anterior teeth, Premium acrylic resin teeth,
similar to laminate veneers, were shaped and secured
over the anterior teeth with cyanoacrylate glue and
flowable composite resin to guide the preparation of
the maxillary canines and the placement of provision-
als (Figs 23 to 25). The correct positioning of the acrylic
laminate veneers on the mandibular incisors was help-
ful in achieving adequate palatal morphology of the
maxillary teeth in the wax-up (Fig 26).
After the provisionals were placed on the maxillary
canines and mandibular anterior teeth, impressions
were taken with polyvinyl siloxane material to gener-
ate the working casts, which were mounted on a semi-
adjustable articulator with the aid of a facebow.
Diagnostic wax- up
The wax-up of the maxillary posterior teeth and the
mandibular dentition completed the planning of the
restorative work and the fabrication of the remaining
provisionals (Figs 27 and 28).
Provisional restorations
The diagnostic wax-up casts were duplicated and re-
lated on a semi-adjustable articulator with the provi-
sional restorations fabricated using the double-pressing
technique. The provisional crowns must be very close
to the diagnostic wax-up to provide a general idea of
the finished case (Figs 29 to 31).
The mandibular anterior teeth were prepared to re-
ceive fiber posts prior to placement of the provisional
crowns (Fig 32).
QDT 2013
Figs 29 and 30 Occlusal aspect of the provisional crowns.
Fig 31 Perfect occlusal relationships were developed on the provisionals.
Fig 32 Placement of provisional crowns from the mandibular left canine to
the mandibular right lateral incisor. Because the mandibular right canine
would be restored with minimal tooth preparation and a ceramic laminate
veneer, it is not necessary to perform this specific step in this phase.
Fig 33 Reconstruction of the mandibular posterior teeth with the correct
anteroposterior occlusal plane.
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Fig 34 All the provisional restorations are in position according to the functional and esthetic protocol.
Figs 35 and 36 The new occlusal contacts would provide balance to the masticatory system, stability to the tooth
positions, and the correct vertical dimension of occlusion.
Phase 3: Reconstruction of the mandibular
posterior segment
The overall position of the mandibular posterior teeth
had been altered, particularly on the left side, with dia-
stema and rotation between the canine and first pre-
molar (see Fig 10). After necessary corrections, it was
possible to improve the anteroposterior curve (curve
of Spee). The left canine and first premolar were pre-
pared for complete crowns and received provisional res-
torations. Any interference with the antagonist arch on
mandibular closure must be adjusted on the maxillary
teeth while maintaining an adequate vertical dimension
of occlusion. It is important to avoid altering the position
and morphology of the mandibular provisional crowns
and thus the anteroposterior curve that had been estab-
lished on the diagnostic wax-up (Fig 33).
Phase 4: Reconstruction of the maxillary
posterior segment
The maxillary left first premolar was prepared for a
provisional in good occlusal contact with its mandibu-
lar antagonist. It is very important to make individual
crown adjustments at this time, because it is still pos-
sible to make minor modifications on the mandibular
provisional restorations for the anteroposterior curve
or at the buccal corridor. If repositioning of a man-
dibular provisional crown was deemed necessary, a
new relining was made before preparing the remain-
ing maxillary posterior teeth. The planned objectives
were achieved over several clinical appointments (Figs
34 to 36).
ODT 2013
Fig 37 A screw-retained provisional with ad-
equate cervical contours following 6 months
of healing. The provisional crown restores
the implant placed in the position of the
mandibular left first molar.
Figs 38 and 39 Lateral views of the gingival
levels after crown lengthening.
Implant placement
The mandibular left first molar presented with sig-
nificant distal coronal destruction and up to 4 mm of
subgingival involvement that compromised the entire
structure. Conventional methods of treatment would
include crown lengthening and extensive osteotomy
along with root canal treatment and post insertion to
rebuild the lost coronal structure. Thus, it was decided
to extract the tooth and replace it with an implant to
preserve bone structure and encourage a more favor-
able prognosis.
A minimally traumatic tooth extraction was per-
formed to avoid compromising soft and hard tissue
architecture, and a 5.0 mm x 8.0 mm implant (No-
belReplace, Nobel Biocare) was placed through the
root septum to assure that adequate anatomy was
preserved after tooth extraction.
The extraction alveoli were filled with demineralized
bovine bone matrix (Bio-Oss, Geistlich, Princeton, New
Jersey, USA) to preserve the alveolar process. 1 Be-
cause of high initial implant stability, the provisional
crown was placed at the time of surgery." -13 A pre-
fabricated abutment (Easy Abutment, Nobel Biocare,
Zurich, Switzerland), originally designed for cemented
crowns, was selected to fabricate a screw-retained,
implant-supported restoration. All contacts during cen-
tric and eccentric mandibular positions were removed
to avoid excessive loading during healing.
14-16 The
provisional crown was maintained throughout the heal-
ing period while the soft and hard tissues matured1718
(Fig 37).
Flapless crown lengthening 19 was performed on the
maxillary central incisors to improve the gingival levels
(Figs 38 and 39).
QDT 2013 150
Functional and Esthetic Protocol for Oral Rehabilitation
Figs 40 and 41 The maxillary and
mandibular teeth prepared to receive
all-ceramic crowns.



Fig 42 The working casts on a semi-
adjustable articulator.

Fig 43 The stone casts made from
the provisional restorations to be
related with the working casts.

Fig 44 Silicone index obtained from
the provisional restorations
Fig 45 The silicone index is used on
the working casts to control overbite
and overjet relationships.

Impression procedures
After achieving adequate balance among the provi-
sional restorations during the oral rehabilitation pro-
cess, it was possible to provide definitive ceramic res-
torations in phases. It is recommended to start in the
anterior maxilla and mandible to verify the functional
and esthetic checklists (see Fig 3) that determine si-
multaneous and bilateral contacts, centric relation oc-
clusion, adequate phonetics, vertical dimension of oc-
clusion, and anterior guidance pathways.
The maxillary and the mandibular anterior teeth
were restored with all-ceramic crowns using the press-
to-zirconia technique, with the exception of the man-
dibular right canine that was prepared for a partial ce-
ramic restoration (Figs 40 and 41).
Thus, new impressions were taken with addition sili-
cone material (Flexitime, Heraeus Kulzer) to generate
the definitive working casts related on a semi-adjust-
able articulator (Fig 42). The stone casts obtained from
the maxillary and mandibular provisional restorations
must be related with the working casts to provide in-
formation for the definitive ceramic crowns with the
aid of the silicone indices (Figs 43 to 45).
QDT 2013 151
Figs 46 and 47 The zirconium dioxide copings on the working casts.
Press-to-zirconia technology
With the incorporation of computer-aided design and
computer-assisted manufacture (CAD/CAM) technol-
ogy to fabricate zirconium dioxide frameworks, the
demand for metal-free restorations, primarily in the
esthetic zone, has increased considerably by both pa-
tients and practitioners. The benefits of zirconia frame-
works include biocompatibility, esthetics, excellent
marginal fit, and strength. Also, it is possible to benefit
from an injection molding procedure to "press" the
esthetic veneering over the zirconia framework. This
technique not only provides stable and predictable
quality but also excellent development of anatomical
and morphologic features at the occlusal surface with
correct contact points.
Lava zirconia (3M ESPE, St Paul, Minnesota, USA) in
shade no. 2 was used for the frameworks for the maxil-
lary and mandibular teeth (Figs 46 and 47). The man-
dibular right canine received a lithium disilicate lami-
nate core with ceramic veneering material (IPS e.max,
Ivoclar-Vivadent, Schaan, Liechtenstein). Before the
esthetic wax-up of the maxillary and mandibular an-
terior teeth, a liner material (IPS e.max Ceram ZirLiner,
Ivoclar-Vivadent) was applied over the zirconia copings
to improve bond strength at the interface of the ce-
ramic veneer and zirconia core.
The completed waxed-up restorations must follow
the functional and esthetic requirements set out in
phases 1 and 2 (Figs 48 to 50). The high translucency
ingot (IPS e.max ZirPress, Ivoclar-Vivadent) in value Al
was selected to provide excellent optical characteris-
tics including fluorescence. All restorations were ad-
justed on the working cast before the intraoral try-in
(Figs 51 to 53).
After the provisional restorations were removed, the
tooth preparations were cleaned with pumice paste to
remove any remnant of provisional cement and to as-
sure perfect crown fit. Ceramic crowns were adjusted
by checking the interproximal contacts of the maxillary
and mandibular teeth on each side and then by adjust-
ing occlusal contacts, tooth by tooth, with the antago-
nists. This procedure was done with care to maintain
the vertical dimension of occlusion.
The vertical dimension of occlusion was achieved
through bilateral contact of the maxillary and mandib-
ular dentition, including the canines, using articulating
paper (Bausch, Nashua, New Hampshire, USA) with
progressive thickness of 200 pm to 12 pm.
The aim of these functional adjustments was to de-
termine the occlusal patterns established by the pro-
visional restorations with canine guidance and partial
and/or total anterior group function. In this clinical sit-
uation, canine guidance and disocclusion of the poste-
rior teeth were created (Figs 54 to 56).
After all functional, esthetic, and morphologic ad-
justments were performed, the maxillary incisors were
QDT 2013
Figs 48 and 49 Full-contour wax-ups over the
zirconia copings.
Fig 50 The completed wax-ups for the definitive
ceramic restorations in full occlusion.
Figs 51 and 52 Definitive maxillary and mandibu-
lar crowns made using the injection molding and
press technology.
Fig 53 The adjustment of occlusal contacts and
anterior guidance is completed on the semi-
adjustable articulator.
Functional and Esthetic Protocol for Oral Rehabilitation
QDT 2013 153
Fig 54 Adjustment of the definitive maxillary and man-
dibular anterior restorations in the mouth.
Figs 55 and 56 The canine guidance and disocclusion
patterns of posterior teeth are visible.
Figs 57 and 58 The definitive maxillary anterior restora-
tions after bonding.
Fig 59 The definitive mandibular anterior restorations
after bonding.
QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Figs 60 and 61 The working casts with the zirconia copings related in the semi-adjustable articulator. The maxillary
right first molar would receive an inlay ceramic restoration with lithium disilicate framework.
reduced using the cut-back technique. Incisal and
transparent IPS e.max material is built up for adequate
translucence and opalescence. The cut-back was not
necessary for the mandibular incisors, which received
only one layer of shade material no.1 for the final
shade Al and were baked at 720C under vacuum.
The bluish shades, cracks, halo effects, and interproxi-
mal stains were painted with IPS e.max Ceram Essence
(Ivoclar -Vivadent) to create a multilayered effect and
obtain optical differentiation between dentin and in-
cisal features. Finally, restorations were glazed twice
and fired at 770C under vacuum to preserve all char-
The all-ceramic restorations were then polished
with felt wheels and pumice powder to establish the
superficial gloss. Superficial gloss is one of the most
important factors in the natural integration of restora-
tions (Figs 57 to 59).
The all-ceramic restorations were luted with univer-
sal resin cement Panavia F 2.0 (Kuraray, Tokyo, Japan).
At this point, the esthetics, vertical dimension of oc-
clusion, central relation, and anterior guidance!de-
scribed in phases 1 and 2!had already been defined
for this functional and esthetic reconstruction.
To rehabilitate the posterior teeth, complete impres-
sions of the maxillary and mandibular arches were taken
with Flexitime silicone material, and zirconia copings
were fabricated. A pick-up transfer was performed to
generate the working casts related in a semi-adjust-
able articulator with the aid of a facebow (Figs 60 and
61). A complete esthetic wax-up with the correct oc-
clusal morphology was developed over the zirconia
frameworks, according to the principles already de-
scribed (Figs 62 to 66).
The implant-supported provisional restorations on
the mandibular first molars were used to transfer the
QDT 2013 155
Fig 62 Frontal view of all wax-ups in position on the semi-adjustable articulator.
Figs 63 and 64 Lateral views showing the high functional and morphologic quality of the posterior wax-ups.
Figs 65 and 66 Occlusal views of posterior wax-ups over the zirconia copings.

QDT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Figs 67 and 68 The framework wax-up
of the dental implant for the mandibular
left first molar is made with adequate size
for ceramic support before scanning of
the prosthetic component.
necessary information to fabricate customized zirco-
nia abutments with the correct emergence profile and
cervical contours. The temporary implant restoration
served as a transfer coping.
All-ceramic abutments have started to play a sig-
nificant role in achieving esthetically successful results,
but the material itself is not the exclusive determinant
of esthetic success. It is the use of appropriate design,
proper handling of the materials, as well as the zirconia
abutment that enables the clinician to achieve esthetic
outcomes that were not possible with traditional metal
alloys. 20 Zirconia frameworks must have adequate di-
mensions, be designed to support ceramic veneering
material, and avoid fracture and/or delamination (chip-
ping) (Figs 67 and 68).
The subgingiva I portions of all-ceramic zirconia abut-
ments were not veneered; they are designed to be in
direct contact with the soft tissue emergence profile
because of excellent biocompatibility. Soft tissue re-
sponse to zirconium dioxide is better than soft tissue
response to metals, and less plaque accumulation is
observed; consequently, minimal or no tissue reaction
can be expected.
All waxed-up restorations were injected and pressed
as described and were adjusted in the articulator be-
fore try-in (Figs 69 to 73). The previous verification of
the occlusal contacts allowed for only minor adjust-
ments in the oral cavity. At clinical try-in, adjustment
started with the proximal contacts of maxillary and
mandibular posterior teeth in the same quadrant. The
occlusal contacts were developed on a tooth-to-tooth
basis, maintaining the vertical dimension of occlusion
provided by bilateral contact points on the maxillary
and mandibular canines; progressive articulating pa-
per foils (Bausch) were used from 200 pm to 12 pm
(Figs 74 to 76).
E. QDT 2013
rP\"."7191! 1
72 73
Fig 69 Injected ceramic crowns on the working cast.
Figs 70 and 71 Lateral views of injected ceramic crowns after occlusal adjustments.
Figs 72 and 73 Occlusal views of injection-molded, press-to-zirconia restorations.
ODT 2013
Functional and Esthetic Protocol for Oral Rehabilitation
Fig 74 The maxillary and mandibular posterior restorations after the minor occlusal adjustment.
Fig 75 The mandibular posterior restorations tried in before characterization and glazing.
Fig 76 The maxillary posterior restorations tried in before characterization and glazing.
DDT 2013

QDT 2013
Fig 77 Frontal view of the completed case.
Fig 78 The maxillary arch with ceramic bonded restora-
tions in position.
Fig 79 Correct development of the mandibular occlusal
Fig 80 The definitive maxillary and mandibular restora-
tions achieved light occlusal contacts.
Fig 81 Occlusal aspect of the definitive maxillary resto-
rations. A lithium dissilicate restoration is bonded to the
maxillary right first molar.
Fig 82 Occlusal aspect of the definitive mandibular
Functional and Esthetic Protocol for Oral Rehabilitation
When it is necessary to improve the occlusal morphol-
ogy after all the adjustments, the dental technician can
use the non-edge technique" for natural reconstruc-
tion of occlusal anatomy and easy reestablishment of
proper function.
All posterior ceramic restorations were character-
ized and glazed as described for the anterior restora-
tions and were then luted with a universal resin cement
(Panavia F 2.0) (Figs 77 to 82).
A functional and esthetic protocol for full-mouth re-
habilitation must have a well-defined diagnosis, prog-
nosis, and treatment plan. This article presented a
protocol with four phases to treat complex cases with
the use of diagnostic wax-ups and provisional crowns,
which provides benefits to patients and practitioners.
The association between CAD/CAM technologies for
zirconia frameworks and injection/press techniques for
veneering esthetic materials guarantees highly func-
tional and esthetic definitive all-ceramic restorations.
1. Stevens FW. The generalist as the coordinator of the dental
team. Am J Orthod 1969;56:107-113.
2. Douglass GD. Making a comprehensive diagnosis in a compre-
hensive care curriculum. J Dent Educ 2002;66:414-420.
3. Poi WR, Panzarini SR, Pedrini D, Manfrini TM, Zina LG, Hamana-
ka EF. Plano de tratamento em odontologia: Analise dos pianos
propostos por alunos de graduacao. Pesq Bras Odontoped Clin
Integr 2007;7:297-301.
4. Hook CR, Comer RW, Trombly RM, Guinn JW, Shrout MK. Treat-
ment planning processes in dental schools. J Dent Educ 2002;
5. Adolfi D. Functional, esthetic, and morphologic adjustment of
anterior teeth. Quintessence Dental Technol 2009;32:153-168.
6. Denehy GE. A direct approach to restore anterior teeth. Am J
Dent 2000;13(special issue):55D-59D.
7. Vanini L, Mangani F, Klimovskaia 0 (eds). Conservative Restora-
tion of Anterior Teeth. Viterbo, Italy: ACME, 2005.
8. Ferencz J, Fanetti P. Enhanced communication. Inside Dent Tech-
nol 2011;2.
communication . Accessed 17 Dec 2012.
9. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of se-
verely eroded dentition: The three-step technique. Part 1. Eur J
Esthet Dent 2008;3:30-44.
10. Araujo MG, Lindhe J. Ridge preservation with the use of Bio-
Oss collagen: A 6-month study in the dog. Clin Oral Implants
Res 2009;20:433-440.
11. Szmukler-Moncler S, Salama H, Reingerwirtz Y, Dubruille JH.
Timing of loading and effect of micromotion on bone-dental
implant interface: Review of experimental literature. J Biomed
Mater Res 1998;43:192-203.
12. Gapski R, Wang HL, Mascarenhas P, Lang NP. Critical review of
immediate implant loading. Clin Oral Impl Res 2003;15:787-
13. Ganeles J, Wismeijer D. Early and immediately restored and
loaded dental implants for single-tooth and partial-arch appli-
cations. Int J Oral Maxillofac Implants 2004;19(suppl):92-102.
14. Kupeyan HK, May KB. Implant and provisional crown placement:
A one-stage protocol. Implant Dent 1998;7:213-219.
15. Wohrle PS. Single-tooth replacement in the aesthetic zone with
immediate provisionalization: Fourteen consecutive case re-
ports. Pract Periodontics Aesthet Dent 1998;10:1107-1114.
16. Wang HL, Ormianier Z, Palti A, Perel ML, Trisi P, Sammartino G.
Consensus conference on immediate loading: The single tooth
and partial edentulous areas. Implant Dent 2006;15:324-333.
17. Tupac RG. When is an implant ready for a tooth? J Calif Dent
Assoc 2003;31:911-915.
18. Morton D, Jaffin R, Weber HR Immediate restoration and load-
ing of dental implants: Clinical considerations and protocols. Int
J Oral Maxilofac Implants 2004;19(suppl):103-108.
19. Joly JC, Carvalho PFM, da Silva RC. In: Reconstrucao Tecidual
Estetica: Procedimentos Plasticos e Regenerativos Periodontais
e Periimplantares. Brazil: Artes Medicas, 2010,253-309.
20. Blatz MB, Bergler M, Hoist S, Block MS. Zirconia abutments for
single-tooth implants-Rationale and clinical guidelines. J Oral
Maxillofac Surg 2009;67(11 suppl):74-81.
21. Rimondini L, Cerroni L, Carrassi A, Torricelli R Bacterial coloniza-
tion of zirconia ceramic surfaces: An in vitro and in vivo study. Int
J Oral Maxillofac Implants 2002;17:793-798.
22. Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A. Bacterial
adhesion on commercially pure titanium and zirconium oxid-
edisks: An in vivo human study. J Periodontol 2004;75:292-296.
23. Adolfi D. Natural Esthetics. Chicago: Quintessence, 2003.
QDT 2013

Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.
Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.