PMC5994272_01
Preoperative lateral views with teeth in centric occlusion.
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TMJ's, and class III incisor relation (Figure 1) on a skeletal class 3 base.
Preoperative upper occlusal view.
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Tooth 13 was missing and 12 had drifted to the 13 position (Figure 2).
Preoperative frontal view with teeth apart.
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This gave rise to a reduced visible crown height and a reverse smile line (Figure 3). The gingival level of the upper central incisors was level with the lateral incisors and below that of the canine teeth.
Preoperative lower occlusal view.
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A crack line was detected at 46 distoocclusal area (Figure 4) with no periapical radiolucency (Figure 5), and a diagnosis of crack tooth syndrome was suspected.
Preoperative periapical of 46 and upper anterior teeth showing no periapical radiolucency with good alveolar bone level.
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A crack line was detected at 46 distoocclusal area (Figure 4) with no periapical radiolucency (Figure 5), and a diagnosis of crack tooth syndrome was suspected.
Lingual view of the bite platform on working model.
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This was then cast in cobalt-chromium (CoCr) (Remanium  GM 800+, DENTAURUM GmbH & Co., Ispringen, Germany) (Figure 6).
Stable occlusion of numbers 11 and 21 on the lingual bite platform.
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At the same visit, composite resin (Aeliteflo , Bisco Inc., Schaumburg, IL, U.S.A) was directly added to restore the incisal edges of 11 and 21 and facilitate occlusion on the opposing bite platform at the increased OVD of 1.5 mm (Figures 7 and 8) using a silicone putty jaw record as a jig.
The appliance in situ with composite build-up in supraocclusion on numbers 11 and 21 incisal to separate all other teeth by 1.5 mm. The design of using incisal hooks on the lower teeth helps improve the resistance to dislodgement of the appliance.
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fig8
At the same visit, composite resin (Aeliteflo , Bisco Inc., Schaumburg, IL, U.S.A) was directly added to restore the incisal edges of 11 and 21 and facilitate occlusion on the opposing bite platform at the increased OVD of 1.5 mm (Figures 7 and 8) using a silicone putty jaw record as a jig.
Complete reestablishment of the occlusal contacts 2 months after appliance cementation.
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After 2 months, the posterior teeth were found to be in occlusion (Figure 9).
Further composite build-up on numbers 11, 21, and 22 incisal to separate all other teeth by 1.5 mm.
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Therefore, further composite build-up was performed on the incisal edges of 11, 21, and 22 to again create supraoccluding restorations on the lower appliance (Figure 10).
The occlusion reestablished full arch contacts over 9 months after appliance insertion, with crown heights of numbers 11 and 21 increased from 5 to 8 mm and number 22 from 5 to 7 mm.
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Complete reestablishment of all occlusal contacts was achieved after another seven months (Figure 11).
Diagnostic wax-up on number 13 to number 23 new study casts.
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Teeth 12 to 23 were prepared and provisional restorations made according to the diagnostic wax-up of the study casts which were taken at the new OVD and after complete reestablishment of occlusal contacts (Figure 12).
Temporary crowns in situ, which were designed to provide positive overjet. However, the crown height of numbers 11 and 21 looked short, and the tooth number 12 at 13 region did not look like a canine.
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With the temporary restorations in the mouth, the aesthetic outcome as well as patient's expectations were assessed (Figure 13).
Surgical crown lengthening.
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Surgical crown lengthening was performed (Figure 14) with alveolar bone being removed by approximately 1.5 mm limited to the midlabial of 12, 11, and 21.
Temporary restorations numbers 13-23 in situ 1 month after crown lengthening on numbers 12, 11, and 21.
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Tooth preparation margins were refined, and new temporary restorations using Protemp were made chairside using an index of the diagnostic wax-up of the expected final restorations (Figure 15).