Same Day Full-Arch Reconstruction to Increase Vertical Dimension

By actively engaging patients during the mock-up and trial phases, restorations can be refined within the oral cavity itself, leveraging real-time patient feedback
to attain exceptional precision. This interactive process not only streamlines the clinical pathway, but also substantially enriches the patient experience by avoiding the challenge of waiting for permanent prostheses.

A 74-year-old male patient presented with a complex case of severely broken-down dentition. Contributing factors included bruxism and a historical presence of an acidic environment, potentially from esophageal reflux or dietary sources. The damage was extensive across most dental surfaces-lingual, incisal, and buccal. The presence of several posterior crowns further complicated the case. As a result of these conditions, the patient experienced significant loss of dental hard tissue and a reduction in his vertical dimension. The decision was made to increase the patient's vertical dimension using a monochromatic feldspar ceramic block.

Consultation and Records

The first meeting involved acquiring comprehensive diagnostic data, including a full-mouth series of radiographs, detailed photographs, and intraoral scans (Figure 1 through Figure 3). The key to this step was establishing the ideal length of the maxillary central incisors through direct composite restorations. The centric relationship was captured utilizing a leaf gauge, allowing the new vertical dimension of occlusion to be determined (Figure 4 through Figure 6).

Restoration of the Maxillary Arch

A full-mouth digital wax-up was rendered, and a series of putty matrices was fabricated. Using bis-acrylic material, a full mock-up was created in situ during the second appointment. This allowed for immediate modification and fine-tuning, including occlusal adjustments, speech testing, and patient input (Figure 7 through Figure 9).

The patient's mock-up was completed in 45 minutes using an intraoral scanner (CEREC Primescan, Dentsply Sirona), creating the blueprint for the final restorations. The posterior sectors were prepared in 1 hour. Scanning, designing, and milling was then completed in an additional hour. While the posterior restorations were milled, the maxillary anterior teeth were prepped. The posterior try-in and adjustments were then conducted while the anterior restorations were being milled, and the anterior try-in coincided with the glazing of the posterior restorations. Finally, the posterior restorations were cemented during the milling of the anterior restorations, and the anterior restorations were delivered.

All preparations were carried out under local anesthesia, methodically replacing existing crowns and removing old composite restorations. Non-retentive, conservative preparations were performed to favor adhesive techniques for all final restorations.

Selective etching was performed with 35% phosphoric acid (K-ETCHANT, Kuraray Noritake) before rinsing with chlorhexidine. A desensitizer was then applied (Gluma^® Desensitizer, Kulzer) along with a primer and bonding agent (CLEARFIL^™ SE Protect, Kuraray Noritake) to ensure an ideal environment for the adhesive process. All bonding steps were performed under isolation.

All restorations were milled onsite using monochromatic feldspar ceramic blocks (VITABLOCS^® Mark II [1M1C], VITA Zahnfabrik). The try-in stage preceded the stain and glaze technique (VITA AKZENT^® Plus, VITA Zahnfabrik) and finalization in a furnace.

For final cementation, a universal cleaner with MDP (KATANA^™ Cleaner, Kuraray Noritake) was applied to both the tooth surfaces and the restorations, followed by the use of a clear cement (Panavia^™ V5, Kuraray Noritake). Meticulous occlusal adjustments and curing with an LED curing light (VALO^™, Ultradent) completed this phase.

During the treatment phase, all restorations were designed, milled, stained, and glazed with the patient's full involvement. All restorations were tried in and modified to finish in the patient's mouth. This immediate and intimate involvement with the patient during the creation and adjustment of restorations ensured optimal fit, function, and form, marking a significant improvement over the previous and protracted protocols.

Restoration of the Mandibular Arch

The subsequent appointment mirrored the previous protocol for the mandibular arch, with the same attention to detail and adherence to conservative principles. Postrestoration, a temporary heat-formed occlusal guard was provided, with immediate scanning for a final nightguard (Figure 10 through Figure 14).

The last appointment involved fitting the maxillary thermoplastic nightguard with a thorough inspection of the occlusion and restorations, confirming the harmonious integration of the prostheses.

The patient was very pleased with his new smile and improved dental function, and during his 1-month follow-up appointment, reported a profound improvement in his quality of life (Figure 15 through Figure 17).

This protocol demonstrates the opportunity for contemporary dentistry to deliver full-arch restorations within condensed timeframes, embracing the patient's anatomic integrity and comfort without the need for traditional temporary stages.

Embodying the innovative spirit of twenty-first century dental practice, this approach illustrates a seamless blend of technology and technique, setting a new benchmark for efficiency and effectiveness in dental restorative services.

Miguel A. Ortiz, DMD
Private Practice

Wayland, Massachusetts

Carlos A. Ortiz, CDT
Ibiza Dental Lab
Ibiza, Spain