VITA In-Ceram® Professionals

Restoration with VITABLOCS^® Mark II

The following article describes the restorative treatment of a 31-year-old man with a loss of the vertical dimension (height of bite). After bite elevation the restoration of all 28 teeth was done by VITABLOCS Mark II (from VITA Zahnfabrik, Bad Säckingen) chairside in combination with the CEREC 3D system (from Sirona Dental Systems, Bensheim).
The aim was to restore the appearance as well as the static and dynamic occlusion using a material with properties similar to enamel.

Examination and diagnosis: 

In September 2006 the patient, then 31 years old, presented himself at our practice wishing a beautification of his anteriors. He was in a good overall condition and did not report about any major problems in the preliminary talk.
The upper and lower incisors were characterized by a substantial loss of enamel (attritions) with exposed dentine (dentine exposition). The same impression was given with the canines and molars; partly insufficient fillings were existent. The combination of attrition and insufficient fillings led to the loss in vertical dimension. The tooth status as it was found at the introductory examination is illustrated in the figures 1-6. Moreover, the patient reported about a cracking noise in the right temporomandibular joint. The orthopantomogramm (OPG) Fig. 7 showed no pathological findings. Impression-takings of both the upper and lower jaw using alginate were made.

Treatment plan: 

After studying the situation models and the provisionary wax-up (fig. 8-12) the following treatment plan was set up: 

• Manual structure analysis (MSA) due to the complex of problems in the right temporomandibular joint
• Fabrication of an adjusted bite splint in centric condylar position
• Transition from bite splint to temporary restoration in the final vertical dimension
• Final restoration

MSA:

At the manual structure analysis (MSA), a cracking noise was detected during the closing of the mouth which became more intense through compression and occurred a bit later. With the lateral movement of the lower jaw to the left or right a cracking noise in the right joint could as well be observed. Opening the mouth from the edge-to-edge bite position or mesial occlusion produced a cracking noise. This led to a presumptive diagnosis of a shift of the joint disk to the front including an adjustment towards the normal position in the final bite in the right temporomandibular joint. Since no lower jaw position without cracking noises could be found, neither further diagnostics nor a reposition therapy was done. The compression of the bilaminary zone as well as the pull and lateral displacement of the articular capsules were without pathological findings.

Fabrication of an adjusted bite splint: 

The reconstruction of the vertical dimension and the bilateral canine guidance was done by means of an adjusted bite splint fabricated in centric condylar position. The patient was instructed to wear the splint all day long. The entire wear time until the fabrication of the temporary restoration was 2 months.
During the splint therapy, a far x-ray image was created (fig. 13):

Transition from bite splint to temporary restoration in the final vertical dimension: 

 After the patient had accepted the reconstruction of the vertical dimension as well as the bilateral canine guidance by means of the bite splint, the transition from the splint to the temporary restoration in the final vertical dimension took place. Two more impression-takings were made, filled with a special fast-hardening plaster and mounted into the articulator in centric condylar position. Then the upper jaw model was lowered towards the first premature contact and the position of the other teeth was checked. The premature contact was ground. Since there was only a minimal bite blockage caused by the premature contact, the grinding was not continued. Next, the upper part of the articulator was raised by the value determined during the far x-ray image. In this position the final wax-up (fig. 14-18) with anterior/canine guidance was fabricated, the models were duplicated and deep drawing films (Erkolen from Erkodent) were manufactured. During two sittings the upper jaw was restored by means of the deep-drawing film and adhesively fixed temporaries (ProTemp from 3M Espe). The upper temporaries were adapted to the adjusted bite splint in the lower jaw (fig. 19, 20, 21). In the same way the lower jaw was restored one day later with the result that both jaws are situated in centric condylar position to each other and in final vertical dimension (fig. 22-26). Likewise, the anterior/canine guidance was integrated into the temporaries.  Hereafter, the temporary restoration was transformed into the final restoration step by step.

Final restoration:  

The final restoration was now done step by step using all-ceramic single-tooth restorations from VITABLOCS Mark II blocks in combination with the CEREC 3D system.

The unique fine structure of Mark II ceramics as well as the industrial sintering process at above 1,100°C lay the foundation for substantial advantages as easy polishing and outstanding abrasion properties of the restorations. The restorations made from VITABLOCS are so "soft" that the antagonist polishes the ceramic and is worn out as little as the natural enamel. Thus, adverse abradant effects are avoided.

With the CEREC 3D system, the dentist has the option to use the mouth as articulator since both the static and the dynamic occlusion can be transferred into the system. By means of the correlation mode the dentist is able to integrate existing tooth shapes into the new restoration.

In the present case, e.g. partial crowns were fabricated in the first quadrant from tooth 14 to tooth 17. For the static occlusion a bite by means of MetalBite (from R-dental, Hamburg) was taken and scanned. For the dynamic occlusion FGP wax (FGP wax according to Dr. Griesbeck, from Schuler Dental) was heated in a water bath with water at 52°C for 20 seconds and pressed onto the prepared teeth whereby the antagonists had been isolated with Vaseline beforehand. The patient was now asked to gnaw on the material just like on a usual chewing gum and to move the lower jaw to the left, to the right and forward. The modeled registration tool was then powdered and scanned without removing it from the dies. Thus, all occlusal information for constructing the partial crowns were available.

After the grinding from VITABLOCS Mark II blocks these were adhesively fixed with Syntac (from Ivoclar Vivadent, Schaan/Liechtenstein) and Z100 (from 3M Espe, Seefeld).

The upper front (13-23) was fabricated using the correlation mode. For doing this, the temporary restoration had been powdered and scanned before the preparation. Subsequently, the preparation was scanned. Now the initial situation for the new restoration could be used as an exact match for the new restoration. After grinding from the VITABLOCS Mark II the restorations were glazed in the Vita Vacumat 40T and adhesively cemented as well.

The lower front was fabricated using the indirect procedure. For doing this, the preparation (32-42) was cast with Impregum (from 3M Espe, Seefeld) and filled with a plaster with special scanning properties (esthetic-base Gold, from Dentona). Now the preparation and the wax-up were scanned. The veneers were constructed by means of the correlation mode and ground from VITABLOCS Mark II . These were labially and incisally reduced by the dental technician, individualized using VITA VM9 porcelains and adhesively cemented afterwards. The figures 27-32 display the final restorations at the first check three months after the incorporation.

Discussion:

The present case demonstrates the complex restoration of the entire dentition with all-ceramic restorations. When using the VITABLOCS Mark II blocks and the CEREC 3D system you have the opportunity to manufacture functional and esthetically pleasing restorations directly at the patient. Following the treatment, in the case mentioned above it was planned to use a bite splint for protecting the restorations during nighttime. Since the patient had no problems with the new bite condition, the plan was abandoned after consultation with the patient.  However, such a procedure cannot be recommended as a general rule since the long-term success of such comprehensive therapies has to be awaited first. Furthermore, there have been no clinical studies on this matter so far. Due to the good experience gathered with CEREC restorations from VITABLOCS Mark II block - approx. 500 restorations are fabricated in our practice every year - we took this risk, however.

Contact:

Dres. med. dent. Brunner & Maurer
Dr. med. dent. Thomas Brunner
Hauptstr. 33
D-94258 Frauenau
Phone no. 0049 (0)9926/1755

¹ Diagnostically sound X-ray exposure (panoramic tomography) comprising the entire upper and lower jaw and figuring all teeth including the adjacent jaw areas, both temporomandibular joints as well as the right and left maxillary sinus.

² Forward movement of the lower jaw in the sense of a real progenia

³ Disk ligament at the rear part of the joint disks 

⁴ FGP = Functionally Generated Path

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