Treating Severe Attrition - Help Gerald!!!!

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Posted on By R. Terry Councill In Esthetic Therapy (General)

80 year old healthy male desires cosmetic dentistry at the urging of his spouse. DSD, wax up and mock up were done. Guide created to assist in clinical crown lengthening. esthetic provisionals let in place for 2 months to allow healing and verification of esthetics and phonetics. Crown and Bridge using translucent Zirconia (no layering due to bruxism habit) and Panavia with 10-MDP bonding agent. Immediate implants in positions 14,15,30. Retained implants in positions 3,18,19 and re-restored. Followed with centric relation night-guard.

Thanks to:
Marcelo Silva, DDS
Gerald Benjamin, DDS
Esthetics Dental Studio, Cypress, Texas


Pre Op

Wax up Mock up
Crown Lengthening

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Nice case Gerald!
I think your patient does not have bruxizm. I think chemical erosion is a primary source and occlusion is secondary. Since it is chemical I usually try to do less crown lengthening since it will expose more root surface causing more sensitivity. I would do Ortho and small crown lengthening. Thank you for sharing your case. Gregory


Terry; This is an amazing case management and technical skills by ALL involved. You should be very proud and your patient extremely pleased. How did you manage VDO? What is post op for patient? Any material selection criterai that you utilize? Thnx Dr. S


Thank you for your comments and questions Dr. Salama. I chose Panavia F 2.0 as my bonding agent in this case because of its consistent high bond strengths to dentin. Panavia F 2.0 effectively bonds to dentin regardless of which technique is used, i.e., etch and rinse, self-etch with or without primer.
(J Adv Prosthodont 2013, Volkan et al). Granted, etch-rinse technique yileds greater boind strenghts, however, I chose to use Panavia with self-etch primer, eliminating the acid etch and rinse step due to risk of pulpal damage. Translucent zirconia was chosen for the anterior and bicuspids crowns while monolithic zirconia was chosen for the molar regions because of the combined advantages of fracture strength, in extremely thin restorations, and acceptable esthetics. I chose to use custom titanium abutments because of the combined advantages of strength and cleansability.

The VDO considerations included:
1. Prosthetic space required, especially posteriorly
2. DSD and incisal edge position ā€“ esthetics
3. Phonetics, especially the ā€œSā€ sound and freeway space
We opened the anterior vertical 4 mm and fabricated PMMA provisionals. The provisionals were relined with self-cure acrylic at prep date. Dots, placed on the nose and chin, were used to confirm the increase in VDO. The PMMA provisionals were left in place for 2 months to allow patient evaluation of phonetics, esthetics and function. Luckily, the patient was very tolerant of the increase and was without complaints. Another important factor was normal TM joints. Had there been TMJ pathology, I would have extended the trial period of the PMMA.

Follow-up care recommendations include nightly use of a balanced CR splint and 4 month recare appointments.

Implant Restorative


Great explanation and fantastic case, Terry!
I like your implant choice.
Thank you for sharing your inspiring work


Thank you Snjezana. I used Astra in this case. I have recently switched to Thommen Medical because of the options with a polished collar. It's well noted, as you know, that with PET (socket shield) there is non-infiltrated connective tissue at the coronal 1/3 of the implant. I feel the polished collar in these types of cases is an advantage. Are you experiencing the same thing? I hope to see you again soon.


Lot of work Terry. Great result.


Thank you very much for commenting.


Terry congratulations on a wonderful case. Huge amount of work, very nice team work. Increasing the VDO is a lot of work. Did you placed the provitionals the day of surgery I suppose? Did you use a night-guard during this time? Do you normally wait 2 months with provitionals or in some cases you do different times? I ask you since in some cases we have observed a slight change in the gingival margins after 3 months, specially on patients with thin Biotypes.
My high complements for you and your team, beautiful case management and wonderful work. I really like your result.
Thanks for sharing.
Warm regards my friend


Food for thought Manuel. I would normally wait 3 months for full maturation of the gingival margin, as you said. This case presented with thick bio-type and a slightly impatient patient, so risk was mitigated at least some. We placed the provisionals at the time of surgery. It was an 11 hour day. Crown lengthening, Prepping, Provisionalization, immediate Implant Placement. No night-guard was used in the provisional phase, but next time may be a consideration. Thanks for you comment. Hugs my friend. see you in Brazil.


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