Protocolo Rehabilitacion Oral

Dario Adolfi, DDS, CDT' Oswaldo Scopin de Andrade, DDS, MS, PhD 2

Gustavo Javier Vernazza, DDS3 Mauricio Contar Adolfi, DDS 4

The 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, Argentina.

'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. Email: [email protected]

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-

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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.

FUNCTIONAL AND ESTHETIC 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

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1. Midline, symmetry axis, and

tooth axis

3. Zenith of gingival contours

4. Morphology, proportic and basic shape of natui-

teeth

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-ment

Fabrication of a mock-up for esthetic and phonetic evaluation

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 overall) 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)

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ADOLFUSCOPIN

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 properties.

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CASE REPORT

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.


CASE PRESENTATION 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.

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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 axis.

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-sionals.

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).

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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.

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Fig 20 Provisional restorations po-sitioned before reconstruction with fiber posts.

Fig 21 Fiber posts placed within the coronal reconstructions.

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CASE REPORT 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-acrylate.

Figs 16 and 17 The silicone index with the esthetic veneer in position.

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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.

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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).

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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.

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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).

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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.

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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 matured 1718

(Fig 37). Flapless crown lengthening 19 was performed on the

maxillary central incisors to improve the gingival levels (Figs 38 and 39).

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Figs 40 and 41 The maxillary and mandibular teeth prepared to receive all-ceramic crowns.

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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).

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Figs 46 and 47 The zirconium dioxide copings on the working casts.

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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

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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.

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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.

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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-acterizations.

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 guidancede-scribed in phases 1 and 2had 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

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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.

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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.2122

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).

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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.

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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.

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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 plane.

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 restorations.

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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).

CONCLUSION 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.

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Protocolo Rehabilitacion Oral

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