Minimally invasive treatment for a beautiful smile

Case by Dr Marko Jakovac, Michele Temperani

Thanks to the work of a well-practiced team of experts, a young man receives a new smile and gains new confidence. The impressive result is achieved through a systematic procedure and carefully coordinated materials. This digital case documentation presents the treatment of a patient with tooth agenesis. 

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About the patient

Name: Krešo
Age: 23
Country: Croatia

Krešo is twenty-three years old and lives in Croatia. He showed hypodontia: seven teeth were missing in both the upper and the lower jaw. The young man was burdened with the non-esthetic appearance of his teeth. 

Krešo's sadness was clearly visible during his first visit: It took some time to convince him to smile for the camera. He kept covering his mouth with his hand when he spoke.

Krešo had a clear aim: He wanted his teeth to be more beautiful. However, since he is afraid of surgeries he wanted to avoid a surgical intervention (treatment with implants). Furthermore, the treatment should not be too expensive because of his financial constraints. A challenging task for the treatment team, Dr Marko Jakovac (dentist) and Michele Temperani (dental technician).

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Clinical examination and treatment planning

The first part of the oral rehabilitation process involved a clinical examination in which the facial and dental conditions were analyzed. Krešo's vertical dimension was substantially reduced. The patient was missing 14 permanent teeth due to dental agenesis (hypodontia). Furthermore, several deciduous teeth were still in place. Tooth 36 had been destroyed by caries, making its extraction inevitable. There was no way around a total prosthetic treatment. The treatment team, together with the patient, decided to do a full mouth reconstruction with conventional fixed prosthodontic therapy due to the patient's financial constraints. The therapy should be minimally invasive.

The tailored solution for Krešo:

  1. All-ceramic bridge in the upper jaw (Zirconium oxide)
  2. Lithium disilicate veneers in the lower jaw
  3. Metal-ceramic restorations in the posterior region

In order to provide the dental technician with the information required for waxing up a restoration, details related to the vertical dimension of occlusion and a facebow record must be supplied in addition to the impressions. If the vertical dimension of occlusion needs to be increased, the correct centric position has to be evaluated first. Dr Jakovac used a muscle relaxation splint together with an anterior Lucia jig of thermoplastic material as registration aid.

The facebow record provides information about the relationship of the maxillary jaw to the horizontal reference plane or the interpupillary line.
In the fabrication of extensive restorations, the protrusive and laterotrusive positions have to be recorded in order to make any necessary adjustments in the articulator. For this purpose, the addition silicone Virtual CADbite was used.

In most cases, the record with Virtual CADbite is faster and more accurate than with wax. 

In most cases, this type of material produces faster and more accurate results than wax. When wax is used for bite taking, the patient has to be shown how move into the protrusive and laterotrusive position. Experience has shown that it is easier to let the patients produce these movements of their own accord and stop them when they arrive at the "right" position. Virtual CADbite is injected while the teeth are in this closed position.
Dr Jakovac in Zagreb sent all the collected data and information to Michele Temperani in Florence.

What is hypodontia?

Hypodontia refers to missing teeth. This means the lack of development of one or more teeth due to dental agenesis. Hypodontia can have negative effects on the masticatory function. In addition, it can affect the esthetic appearance. More information (Source: Wikipedia)

 

Interview

How did Dr Marko Jakovac and Michele Temperani decide on the correct treatment and the materials to be used? 

Treatment

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Wax-up and Mock-up

The following minimum documentation was required for the fabrication of the wax-up: precision impressions of the upper and lower jaw, a facebow transfer record, a centric bite record in thermoplastic material with predetermined vertical dimension of occlusion, portrait pictures of the patient as well as close-ups when the patient is smiling. Based on this information, Michele Temperani built up the restoration in wax. Moreover, he brought the teeth into their ideal functional and esthetic position and adjusted the occlusal plane as well as the Spee's curve. The mock-up of the wax-up was made so that Dr Jakovac would be able to check the laboratory work intraorally. As soon as the wax-up was finished, he sent it to the dentist. 

Dr Jakovac was then able to check all functional and esthetic parameters in the patient's mouth with wax-up. This treatment stage is important for many reasons. Patients are given the opportunity to actively participate in designing their new smile, which is a very motivating experience. In addition, the functional wax-up, the maximum intercuspation, the new vertical dimension and the protrusive and laterotrusive movements can be tested in a realistic situation. Moreover, the wax-up serves as a model for the provisional restoration. Therefore, it should be produced with the highest of accuracy. Once the patient is completely satisfied with the proposed result and the mock-up fulfils all the clinical criteria, the actual treatment can begin.

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Preliminary treatment

At first, Dr Jakovac cleaned the teeth of the patient very thoroughly. Following this, the necessary extractions were performed and an endodontic treatment was done. Subsequently, Dr Jakovac prepared the teeth for the prosthetic treatment.

Meanwhile, dental technician Michele Temperani had finished the long-term temporary for Krešo. Doing so, he took advantage of the CAD/CAM technology: First, he digitalized the wax-up using a laboratory scanner. This information provided a basis for the provisional. The provisional was fabricated with tooth-coloured composite. As soon as the temporaries were finished, the dental technician sent them to the practice of Dr Jakovac, who then seated the long-term temporaries in the patient’s mouth. After the pretreatment, the provisional served as a test object or blueprint during the healing process: This phase enabled the dentist to examine the function and esthetics closely and adjust in detail.

Fabrication of the permanent restorations 1

The final prosthetic phase started after the long-term temporary had been worn for an adequate period of time. Before impression-taking, Dr Jakovac prepared the teeth again and polished them. 
Then the precision impressions for the master cast were taken. Dr Jakovac used a customized tray for this purpose. 

 

It is very important to transfer the vertical dimension of occlusion and the information about the tooth-to-tooth relationship from the provisional to the final restoration with great care. The "cross-mounting" technique is suitable for this purpose. Dr Jakovac sent all this information to his partner Michele Temperani.

 

Fabrication of the permanent restorations 1

What is the cross-mounting technique?

The cross-mounting technique is a technique to transfer the vertical dimension of occlusion and to determine the tooth-to-tooth relationship of the provisional restoration in relation to the final restoration. This method entails first making a bite record of the prepared teeth in the upper and lower jaw. Subsequently, a second bite record of the provisional restoration in the upper jaw and the prepared teeth in the lower jaw is taken. This is followed by a third bite record, capturing the prepared teeth in the upper jaw and the provisional restoration in the lower jaw.

Fabrication of the permanent restorations 2

His task was to "copy" the shape and occlusal plane of the temporaries and to accurately transfer this information to the final restoration. For this purpose, the master casts were placed in the articulator using the "cross-mounting" technique. Since the final situation had been successively attained by means of the temporaries, it was a relatively easy task for Michele Temperani to fabricate the frameworks.

As a result of using the CAD/CAM approach, the final restoration could be visualized, modified and/or duplicated with the assurance that all the design guidelines would be observed.

The Wieland Precision Technology (WPT, Naturns, Italy) milling centre was responsible for fabricating the frameworks for the metal-ceramic restorations in the posterior region as well as the zirconium oxide framework for the upper anterior teeth.

In Zagreb, Dr Jakovac tried in the frameworks to confirm the correct fit of the restoration. Most of the inaccuracies that usually occur are due to errors made during impression taking, casting or model fabrication. In this case, however, there were no inaccuracies. Everything fitted perfectly together!

Everything fitted perfectly together!

Michele Temperani also used the digital technology to fabricate the veneers for the lower jaw. The dental technician used the press technique with the lithium disilicate glass ceramic IPS e.max® to fabricate the veneers. The metal frameworks were veneered with the new metal-ceramic system IPS Style®. It allowed him to achieve the desired natural-looking, translucent shade without having to sacrifice on brightness. The IPS Style ceramic offers a major advantage in that it can be optimally combined with IPS e.max Ceram. As a result, the veneers on the metal frameworks could be optimally adjusted to the bridge in the upper jaw. Then, Michele Temperani sent the first bake to Zagreb so that Dr Jakovac can perform a try-in on the patient.

During the try-in of the first bake, Dr Jakovac checked whether small corrections in the ceramic are necessary before the restoration was completed. Having done this, he sent the first bake back to Michele Temperani. Then, the time had come: In his dental lab in Florence, Michele Temperani finished the restoration through glaze firing and polishing. He also finished the veneers by firing on a thin layer of IPS e.max Ceram A1, followed by a second firing with a thin glaze layer. The restoration was then ready to use and was sent back to the dental practice of Dr Jakovac.

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Seating the final restoration

Before Dr Jakovac seated the final restoration into the patient’s mouth, he thoroughly cleaned Krešos’ teeth. In the next working step, he placed a rubber dam. Then he started to seat the restoration. Suitable for this purpose are luting composites, e.g. Variolink Esthetic. This cement exhibits excellent adhesive properties and clinically beneficent characteristics such as easy removal of excess and outstanding, long-term shade stability.
Dr Jakovac used Monobond Etch & Prime to condition the veneers (adhesive cementation). After gentle sandblasting, the zirconium oxide and metal-ceramic restorations were prepared for placement by applying Monobond Plus. In order to avoid the formation of an inhibition layer, he also applied glycerine gel.

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What does Dr Marko Jakovac say about this case?

The treatment team

Dr Marko Jakovac

Dr Marko Jakovac

Marko Jakovac was born in Zagreb, Croatia, in 1974. He completed his studies at the School of Dental Medicine of the University of Zagreb in 1998 and launched his career as junior scientist and assistant at his alma mater in 2001. Specializing in prosthodontics, he embarked on a PhD program in 2004. Since 2005, he has been working as a specialist in prosthodontics at the University of Zagreb. Three years later he became the owner and manager of Aesthetica dental office in Croatia’s capital and he also completed his PhD in 2008. From 2009 till 2015, Marko Jakovac had been assistant professor and since 2015 he is Associate Professor at the department of Fixed Prosthodontics and Head of Preclinical and laboratory fixed prosthodontics, Microscope in dental medicine for undergraduate students and Esthetic therapy on teeth and implants for postgraduate students at the School of Dental Medicine in Zagreb. He is also head of various study programs and further education courses and has authored and co-authored numerous scientific publications. He is also an active contributor to international meetings.

Michele Temperani

Michele Temperani

After completing his Diploma in Dental Technology, Michele Temperani undertook specialization in fixed denture prosthetics in the USA, where he attended the courses of the Tanaka Dental Technology Institute and the seminars of Masahiro Kuwata at the University of Washington. For three years, he was the head of the ceramic department at Kijosato Okamoto dental lab in Seattle (USA). He regularly participates in the "Continuing Education Project" which is held in Seattle each year.
Since 1990, he has been the co-owner of a dental lab in Florence, Italy, together with his brother, specializing in ceramic restorations. He has been using the press technique for the fabrication of all-ceramic restorations since 1998. 
He conducts courses and holds lectures at international meetings and is the author of numerous publications.

Dr Marko Jakovac
Michele Temperani
Dr Marko Jakovac

Dr Marko Jakovac

See complete profile

Marko Jakovac was born in Zagreb, Croatia, in 1974. He completed his studies at the School of Dental Medicine of the University of Zagreb in 1998 and launched his career as junior scientist and assistant at his alma mater in 2001. Specializing in prosthodontics, he embarked on a PhD program in 2004. Since 2005, he has been working as a specialist in prosthodontics at the University of Zagreb. Three years later he became the owner and manager of Aesthetica dental office in Croatia’s capital and he also completed his PhD in 2008. From 2009 till 2015, Marko Jakovac had been assistant professor and since 2015 he is Associate Professor at the department of Fixed Prosthodontics and Head of Preclinical and laboratory fixed prosthodontics, Microscope in dental medicine for undergraduate students and Esthetic therapy on teeth and implants for postgraduate students at the School of Dental Medicine in Zagreb. He is also head of various study programs and further education courses and has authored and co-authored numerous scientific publications. He is also an active contributor to international meetings.

Michele Temperani

Michele Temperani

See complete profile

After completing his Diploma in Dental Technology, Michele Temperani undertook specialization in fixed denture prosthetics in the USA, where he attended the courses of the Tanaka Dental Technology Institute and the seminars of Masahiro Kuwata at the University of Washington. For three years, he was the head of the ceramic department at Kijosato Okamoto dental lab in Seattle (USA). He regularly participates in the "Continuing Education Project" which is held in Seattle each year.
Since 1990, he has been the co-owner of a dental lab in Florence, Italy, together with his brother, specializing in ceramic restorations. He has been using the press technique for the fabrication of all-ceramic restorations since 1998. 
He conducts courses and holds lectures at international meetings and is the author of numerous publications.

A patient case goes viral

Dr Marko Jakovac and Michele Temperani are not only successful in their practice or lab. The Croatian-Italian duo participates in international congresses and seminars time and again. Find out how they work together seemingly with ease – beyond language boundaries and national frontiers. Watch the two experts presenting this exciting case at the third International Expert Symposium from Ivoclar Vivadent in Madrid (June 2016) in front of an audience of 1,000 people from all over the world!

You can also find the current patient case of Dr Marko Jakovac and Michele Temperani in the issue 2/2016 of the international dental magazine Reflect.

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