A Comprehensive Approach for Restoring Esthetics
and Function in Fixed Prosthodontics
Walter Gebhard, MDT*
federn dental reconstructions do not only
aim at restoring the patients mastication,
but rather at improving general well-
being and quality of life, espacially in terms of es-
theties. This is why for many patients today, con-
sulting the dentist does not necessarily mean only
treatment of thoir teeth, but having their outer ap-
pearance improved as well, The madi, the Inter.
net, advertising, and many other facets of society
contribute to an ineveased cosmatic auiareness,
Society today doss not readily perceive accep-
tance of factors that may negatively impact a per-
son's quality of Ife, Therefore, a variety of modem
therapies (erthodontia, bleaching, implart dental
prostheses), as well the unlimited possibilities of-
fored by intograted dental prostheses (ether peri-
“ctr Dental Tecnica, Gebhard AG DantalLabor Zieh,
Reprint request: Wr Wier Gebhard, Gaba AG Dena
(Sto, Wenbargrvaro toe, C1005 Zc, Stanard
Emai:watereohrdahornslcom
‘odontal or implant allow the dentist to satisfy the
patient's wishes as superior as they may be.
To provide for biologie acceptance, optimum
chewing function, and individual esthetics, a sys-
tematic procedure in clinical treatment and a stan-
dardized method in dental technology are indi-
cated. Any restoration should be based on
scientifically based result, biologic knowledge,
and clasreut technical concepts, including mater:
als and applied methods
During treatment planning, the following
methodology should be obsorved
1. Establish treatment objectives and goals
2. Approach the problems
3. Visualize final results.
4, Determine sequence of treatment.
5. Determine costs
To do this, the patients wishes are incorporated
and the clinicians, dental hygienists, technician,
and patient cooperate in an interdisciplinary way
to achieve the optimum result. Ary step leading
10.2 high-quality result should be discussed and
or ai cconaro
Figs 1 and 2 Because of the achesive technique
conservative to tooth stucture, Veneer prepara
cartied out in accordance with the ideal concept
applicable in the respective case, even ifin individ
ual cases compromises cannot he prevented,
There are numerous parameters that are 1
sponsible fora high-quality result, including
+= Biocompatible materiale
‘Non-invasive, reversible procedures; conserva-
‘ive preparations (Figs 1 t0 4)
* Intimate ft on abutment, passive fit in implantol-
ogy (Figs 5 to 12)
+ Individual function, madern occlusal concepts
* Accessibilty for oral hygiene procedures
* Longevity
+ Proper phonetics
+ Predictability
+ Comfort for the patient
* Individualized reconstructions (Figs 13 to 23)
is possible to minimally propare taath,
‘of mandibular anterior teeth in 1991
E
Figs 3 and 4 Micropreparation today on maxillary lft central inizor and after bonding,
[ff PREOPERATIVE CLINICAL AND TECHNICAL
PROCEDURES.
Diagnostic Waxup
‘The first step in fabricating the dental prosthesis
in a functional, unobtrusive way should be per
formed preoperatively after completion of the
clinical examination, diagnosis, and treatment
planning. This should include the exact descrip-
tion of goals to be achieved by the treating den-
tist and a diagnostic waxup or setup, To accom.
plish this, the diagnestic (duplicate) models (Figs
24 to 33}, facebow mounted on the articulator, are
completed with wax or the plaster teeth. In turn,
the occlusal surfaces are equilibrated such that
the teeth will be in an ideal contact relation to
each other. Also, centric and eccentric paths
should allow canine and/or anterior guidance toFig 5 Finvossimpresion vee exact reproduction of
the preparation, The presi should teach beyond
‘he preparation mt fo beter conte emer
pores pole
Fig 6 Secioned and sold dupeato model are made
for faite comectons ond ail ue
Figs 710-11 Each chosen reconstuction sytem
‘hed bo ble tobe processed problem feo, 9 that
gh pecon inthe margin canbe achive. Light
{wansision ar wel er the colgeshape and ght optic
{uolies can be conralled and improved thanks tothe
Ghreme margin
Fig 12 Implantcupported meta ceramic ved pari
denture daring the Selfel test ater posststion
‘hough the sparc erosan technique: the ang orm
Siecas of enplon-auppoded estore den an
‘gement alsa depends onthe past f/secracyHicesiaro
Fig 13 Modern dental rconswucions often requite a Figs 15 t0.17 Acceptable calor transtionbetaoon the
Combination of tetmiques systems on the model and inst
Fig 14 On the tieue model: refractory ls for ve- Figs 18 and 19 Preparations anata completion,
eer, Spine cores for lseralncears neta ceramic
Couns ard beds forthe canines and posteioreeth, Figs 200.23 Before and ater westment
Klos:Restoring Esthotics and Function in Fited Prosthodontics
Figs 24 and 25 Study model A
Fig 26 Study medal mounted on articulator
Fig 27 Duplicated model Bas mounted on ecu
Tet, with teeth prepared and complemented iealy
Fig 28 Diagnostic wane,
Figa 29 o 33 From duplicated model B (wasp,
tmadelC i obtained whic also mounted on at
lator The new stuaton cane ber assessed in
form Ailend anol mac ch
{ere resin is pressed onthe prepared model Wih
thea fcrgue orale
ual characterzed: Alec polishing the cron ae
thinned! ae much a posse fom the intra
cor on ElHi ceonaro
Figg 24 and 25 Disonostc plan
‘ings expec iportant for
Implontstpported reoratons,
ttthis show hygiene access,
Shes anc implant space, amon:
ther fact can be dterminod
Figs 36 to 43 An apparant easy
tase Replacement atthe maxillary
letecentra incisor Patiant nd
dontst suggestions, which are re
alisic and predictable, lead tothe
‘best possible esthetic result. With
tha analysis of the model, the fel:
lowing points become apparent:
+ Problems in function
{ Diteren aval of nisl soe
1 Unpleasne anstton of marsinal
iterone ses of ed
+ Diterent ses of gaps compa
tothe contalatecl sooth (ght
conta
1 Detectin sheolar side
SMichshe diagnose now, sev
‘cl options tome aross vl
mpantsuppented single.
—Inplane supported single
crown; vente on te Ie
iste
—Implertsupporte single
ietconval
Cronin onthe sight cons
‘ar extension semen onthe
Toft contal (posal incosing
the ef oer
From this analysis, the best possi-
ble esthetic result ean bs deter-
mined and the necessity of ilge
ugmentation, eon elongation,
‘nd laminate veneers can be con-
StoredFigg 46 and 45 Diagnortc and finshed work Wit shape and arangement given, one
Closely on he nine shading and carame buldup,
bbe produced, n applying this method, functional
problems will be recognized in an eory stage and
2 formal treatment plan con be discussed. A the
‘same time it ie possible to correcta disharmonic
‘gingival lie or ridge defects and to show this
method ina descriptive way. the dentist plans to
any out an implart prosthetic reconstuction, the
diagnostic waxup constitutes the subsequent
technically ideal implant pesition and orientation
‘ofthe implant long axis (Figs 24 to 45),
As the patient wil likely not be available, the
dental technician should be provided with the d=
agnostic madels and standardized photo dacu:
mentation. This is expecially cequire in cases of
Anterior tooth ceconstruction. However, i the
technician isin the position to meet the patient
personally, he has the advantage of getting to
know the pationt’s personality, facial physiog
omy, a well as dental and periodantal statin,
To a certain extent, the missing patient contact
may be replaced by modem means of digital
photography, digital video, and transmission via
Invemet
‘The diagnostic waxup allows this information to
bee transferred in provisional restorations that al-
ready contain the intial corrections (auch as oc-
lusal plane, anterior tocth position, etc). In this
‘way, 2 basis of discussion is ertablshed for both
the dentist and the patient
Computer Imaging
Imaging can prove 2 valuable addition to diagnos.
tics in patient management, The great ackantage
is that the patient can be made aware of esthetic
shortcomings in a graphic and accessible manner
luring intial conuhations. Virtual idealization of
the conditions in the patients mouth allows both
the patient and the dentist to splay, assess, and,
were necessary modify the desired changes di-
rectly on screen. The disadvantage isthe expecta-
tions this method occasionally creates ia the pa
tient, An unfavorable abutment position or the
patient's general dental condition may impose
technical mations and thereby prevent the real
[ste goal rom being achieved (Figs 46 to 50),
oor a0Khor ns
Fig 49 The mason right fist premelar wae
femocaled oa canno nth s veneer The
Fig 46 Preoperative suai, Fig 47 Gingival canarmories at wal as
‘herasng maul ight otra nar
‘canbe corected by strate analyele
Sing ake color lary asa
ole
feed Aneel
Figs a ond 48 Computer mniplatd “ideal
Fig 50 Postoperative shone inprvement of the
SiebnaodeLeccweet Iaumiee eeRestoring Esthetics ond Function in Fixed Prosthodontics
Provisional Restorations
The provisional restorations primarily serve to pro-
tect and stabilize the prepared tact, 28 well 0
contal the dagnostcally Specified funcional pa-
rameters. Furthermore, they make ie posible to
ty out new vertical dimensions and to condition
the sof tissue in the pantic design proces
In general, when producing the provisional
shell, dimension, form, and position should be ac-
cessed so that the eating dentist can easly ac-
ses5 the length of the crown, centerline, incial
‘edge line, lip support, and phonetics. Adltion-
ail itis possible to make the calor of the prow
Sonal metch the existing dentiion. At this treat
ment stage a beauttully created sot of provisional
restorations net only contibutes tothe patient's
wellbeing, it also allows consideration of the
final reconstruction and possible modifications
ede
‘for granting the patient time to acclimate,
the provisional restorations should be newly as:
sossed by the treating team together with the pa-
tient and, if necessary, be modified. Depending
fn the scope of modification, tis may be carried
cut by the dentist inthe patents mouth or inthe
laboratory At this time, the thickness ofthe prov
sional shell should be measured to assess the
space available and to cary out @ subsequent
preparation
The Metal-Supported Long-Term Provisional
Unit
Comprehensive reconstructions requiring o%:
tended preparation time will need 10 include
secondary meta-supported provisional unit inthe
tneatment concept which wll be applied after the
fist eatment using provisional shes, The metal
‘supported long-term provisional unit flills bas
cally the same objectives as provisional restora-
tions. However, it has to withstand a higher load
resulting fom the pariociontal, surgical, ancio-