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Anterior aesthetics without dysfunction: a case report. Part 2: the prosthodontic conversion Raj Raja Rayan Aesthetic Update 2025 2:1, 29-33.
Authors
Raj RajaRayan
OBE, MA (ClinEd), MSc, FDSRCS(Ed), FFGDP(UK), MRDRCS(Eng), MGDSRCS(Eng), DRDRCS(Ed), BDS, LDSRCS(Eng), Former Dean, FGDP(UK), RCS (Eng), Former Associate Dean, London Deanery; Recently, Professor and Head of Restorative Dentistry, College of Medicine and Dentistry; Former restorative referral-only practice in Harley Street; Honorary Colonel of The Commonwealth of Kentucky. Now retired
Marketing cosmetic dentistry is financially fashionable. Anterior aesthetic reconstructions are an art form showcasing the dental technician's skill. There is a perceived concern that anterior reconstructions that do not consider the functional features of the mutually protected occlusion may, in susceptible patients, lead to dysfunction with its possible consequences. Part 1 described a case in which severe anterior tooth wear was restored using compomers for the palatal surfaces, and composites anteriorly to provide acceptable aesthetics. The compomers were used so the patient could relatively easily fashion this ‘softer’ material during parafunction. This provided a pattern of anterior guidance within the patient's ability to adapt. Once adequate time was allowed to ensure the guidance was not dysfunctional, it was copied and replicated onto an incisal guidance table for future use. This article deals with the conversion of the guidance to fixed prosthodontic work.
CPD/Clinical Relevance: Transfer of anterior guidance; telescopic crowns and planning for failure.
Article
In the previous article, severe anterior tooth wear was restored using compomers (the material of choice of its time 30 years ago) for the palatal surfaces and composites anteriorly to provide acceptable aesthetics.1 The compomers were used so the patient could relatively easily fashion this ‘softer’ material during parafunction. This provided a pattern of anterior guidance within the patient's ability to adapt. Once adequate time was allowed to ensure the guidance was not dysfunctional, it was copied (Figures 1–3) and replicated onto an incisal guidance table (Figure 4) for future use. This article deals with the conversion of the guidance to fixed prosthodontic work.
The provisional composite work had no signs or symptoms for over 3 months, and the occlusion was stable with posterior stability and anterior disclusion. Once stability was established, and the anterior guidance was within the patient's adaptive capacity, study casts were taken. These were mounted onto an articulator, and the anterior guidance of the provisional aesthetic restorations was transferred to an incisal guidance table.2 This was constructed by sliding articulated upper against lower casts, the envelope of motion of the incisal pin engraving the tooth guidance onto an acrylic mould block placed on the incisal table.3,4 The ensuing photographic illustrations (not the patient being discussed) are of a full mouth reconstruction where the impressions of the final provisional crowns are mounted on a SAM articulator (SAM Präzisionstechnik GmbH, Germany). Because the vertical dimension was changed and the SAM articulator has a straight incisal pin, the incisal pin must be mounted on the mandibular bow and the incisal table on the maxillary bow (upside down in contrast to manufacturer illustrations). If the pin is straight, when the vertical dimension is changed, the centric point of the pin in the acrylic will no longer be centred owing to the closing arc. Hence, it will not be centred in the guidance table. This is not a problem with the Denar articulator (Denar Mark II articulator, WhipMix, KY, USA), where the pin is curved to compensate for the change in height during the closing arc, thus keeping the centre point centred. Hence, in the Denar, the incisal pin remains on the maxillary bow when the vertical dimension changes.
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