CLINICAL RESEARCH

Modern treatment planning

approach facing a failure
of conventional treatment.
Part II: Case report and discussion
Giovanni Garavaglia, DMD
Department of Fixed Prosthodontics and Occlusion, Department of Gerodontology
and Removable Prosthodontics, School of Dental Medicine, University of Geneva,
Switzerland

Philippe Mojon, DMD

Director Postgraduate Program in Prosthodontics, Department of Fixed Prosthodontics
and Occlusion, Department of Gerodontology and Removable Prosthodontics,
School of Dental Medicine, University of Geneva, Switzerland

U r s B e l s e r , D M D , Prof. Dr med dent

Professor of Fixed Prosthodontics and Occlusion, School of Dental Medicine,
University of Geneva, Switzerland

Correspondence to: Giovanni Garavaglia

Department of Fixed Prosthodontics and Oooiusion. Department of Gerodontology and Removabie Prosthodontics,

Schooi of Dentai Medioine. University of Geneva. 19, rue Barthéiemy-Menn; CiH-1205 Genève, Switzeriand;

Tei: +41 22 379 4088/60 Fax +41 22 379 4052; E-maii: giovanni.garavagiia@unige,ch

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Abstract
In this two-part case presentation, the
benchmarks of our treatment planning
principles are briefly exposed and their
application is discussed with regards to
a 35-year-old female patient with multi-
ple failing restorations and an esthetic
complaint regarding the maxillary anter-
ior teeth.
In the first part, our four treatment princi-
ples were proposed, the patient's main
GARAVAGLIA ET AL
problems were presented and three
treatment options were disoussed.
In the second part, the treatment choice
is disclosed along with the decision-
making process, the respective diag-
nostic procedures involved, and finally
the sequential treatment.
The aim of these articles is to stimulate
a debate and to promote therapeutic
choices that take into account the evo-
lution of contemporary dental medicine.
(Eur J Esthet Dent 2O13;8:68-87)
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 CLINICAL RESEARCH
Introduotion
In the previous article the benchmarks
of our treatmient planning were briefly
exposed and their application was dis-
cussed through the presentation of three
treatment options for a given patient.
The advantages and disadvantages
of the different treatments were evalu-
ated according to our point of view.
The four principles discussed below
are the cornerstones of treatmient plan-
ning at the University of Geneva and are
the result of our experience based on
current scientific literature:
• First principle: improve tooth (abut-
ment) prognoses.
• Second principle: trust in adhesion.
• Third principle: keep a conservative
attitude.
• Fourth principle: segmentation of
prosthetio restorations to single unit
and short span bridges.
In this article, the final choice is revealed
and discussed. Furthermiore, the plan-
ning process and the treatment se-
quence are presented. Since the proce-
dures realized at the mandible were of
minor interest, they will be presented to
complete the treatment, but the debate
will focus on the nnaxilla. Obviously the
two arches have to be considered as a
whole.
Patient presentation
A 35-year-old woman with multiple fail-
ing restorations, consulted the dental
clinic of the University of Geneva.
An extensive description was given in
the previous article.
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The miedical history revealed a gener-
ally healthy patient. Her chief complaint
was the nonesthetic appearance of the
maxillary anterior teeth.
The patient suffered from congenital-
ly missing lateral incisors; a debonded
Maryland type fixed dental prosthesis
(FDP); unaesthetic anterior composite
veneers; and a defectous maxillary pos-
terior 5-unit bridge. The interocclusal
space of the long span posterior bridge
was severely reduced. Multiple caries
lesions and failing restorations were
present. Periodontal charting revealed
a generally healthy status, whereas the
radiographs confirmed multiple caries
lesions and revealed two periapical in-
volvements on endodontically treated
teeth 14 and 15.
Treatment options
In the first part of this article, three treat-
ment options were proposed and their
advantages and disadvantages dis-
cussed.
The first treatment option proposed
a conventional full arch rehabilitation:
a treatment that may seduce dentists
seeking an easy and practical solution
with little provisional problems and re-
duced healing delays.
The second treatment option pro-
posed the correction of occlusal and
esthetic problems with orthodontic treat-
ment, followed by replacing the lateral
incisors and posterior missing teeth with
implants.
The third treatment option proposed
the correction of esthetic and gingival
problems with crown lengthening sur-
gery, the restorative correction of oc-

clusal parameters, the replacement of
posterior teeth by implants and an adhe-
sive approach to the anterior teeth.
Decision process
The patient's main problems concerned
an excessive gingival display, the gen-
eral esthetics, the reduced overbite, the
inclined occlusal plane, the failing Mary-
land type FDP and failing posterior long-
span FDR
The gingival exposure during smil-
ing was excessive from tooth 16 to tooth
24. Teeth 11 and 21, instead, are infra
erupted and the gingival zenith level is
widely altered. The central incisors are
quite large and long and cannot be fur-
ther lengthened to correct the smile line
and the overbite.
All anterior teeth, besides the right ca-
nine, have lost a lot of dental structure
due to decay and previous restorations.
The posterior 5-unit FDP appears mark-
edly reduced in height due to the wear
of the cosmetic resin veneering or due to
plastic yielding of the metal framework.
The occlusal plane is inclined and the
mandibular over-erupted teeth are so in this patient.
olose to the alveolar ridge that any type
of restoration in the maxilla would be too
thin. Furthermore, the actual abutments
are so short that their retention/resist-
anoe form is compromised.
Orthodontic treatment could have
been a po\A/erful tool but the patient re-
fused categorically and a compromise
to correct all the above-mentioned prob-
lems was needed.
The treatment option finally chosen
was the third proposed, which aimed at
the improvemient of the esthetic and gin-
GARAVAGLIA ET AL
gival problems by surgery and the cor-
recticn of the occlusal plane with cverlay
restorations.
In the anterior maxilla it was not pos-
sible to insert an implant due to a lack of
space and therefore it was necessary to
cope with the existing abutments.
The Maryland type FDP was replaced
by a single-abutment cantilever bonded
bridge and the vestibular composites
were replaced by porcelain veneers.
This solution was preferred to a con-
ventional 3-unit FPD because it is much
more conservative. Since the teeth \A/ere
already restored, almost no further tooth
structure was lost.
The equiginglval location of the finish-
ing line of the preparation would main-
tain gingival health and improve esthetic
integration of the soft tissue.i-3
Undoubtedly, a bonded bridge is
more conservative than a conventional
one, but it can still be considered as a
long-term provisional solution because
of its limited survival rate compared to
conventional bridges (85% at 5 years)^
(65% at 1 O years).5 The survival rate of
bonded bridges may be improved by lo-
cal factors, some of which were present
Resin-bonded bridges in the anter-
ior maxilla have a better performance
compared to posterior and mandibular
ones.öS /\ deep bite occlusal relation-
ship is contraindicated for such a restor-
ation, but it has been demonstrated that
a reduced overbite represents a more
favorable situation. Furthermore, a fa-
vorable prognostic element consisted in
the fact that the old resin-bonded pros-
thesis had been realized with a conven-
tional technique and used for several
years without failing. The introduction of
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 CLINICAL RESEARCH
an adhesive luting method would further
improve the long-term prognosis.
Recenf sfudies from Kern showed
that the survival rate of bonded bridges
on jusf one abutment rises to 92.3% at
5 years and it could represent a reliable
solution.9-11 This was finally the proced-
ure selected.
Material selection also plays a rele-
vant role. Full ceramic resin-bonded
cantilever bridges often fail because of
mechanical fracture without de-bonding
of the retainer 11 For this reason, a zirco-
nia core was used.12
Concerning the failing posterior 5-unit
bridge, it was preferred to replace it with
two single crowns on distal abutments,
and a 3-unit implant supported FDP in
the edentulous area. This solution allows
a better segmentation of fhe restoration,
which will be easier to fabricate, and will
have a better prognosis and mechanical
performance.
Since an exfensive anterior crown
lengthening procedure was pro-
grammed to reduce the gingival dis-
play, it was also necessary to treat the
second quadrant to create a harmoni-
ous gingival line in the maxillary upper
arch. Therefore, the crown lengthening
was extended to the leff maxilla and the
implant positioning could benefit from
an osfeofomy to result in a more apical
implant position.
Furthermore, the occlusal plane need-
ed to be lowered on the leff side and the
over-eruption of the mandibular teeth had
to be compensated by an overlay of fhe
tooth 36 follo\A/ing crown lengthening sur-
gery. The missing tooth 46 was replaced
with an implant. The exposed dentin of
the unrestored preparation on the tooth 45
was protected with a full ceramic crown.
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Tooth 14 was extracted because the
caries lesion involved the root surface.
For its replacennent, an implant-sup-
ported crown was programmed. In the
mandible, the patient decided, for eco-
nomical reasons, to keep the gaps distal
to the first molars and to conserve the
wisdom teeth.
Planning procedure
After removal of the old restorations and
caries lesions, impressions were taken
for study models, which were used for
treatment planning (Fig 1a). The models
of the patient were mounted on the artic-
ulator with a facial bow transfer to assure
correct three-dimensional positioning.
Tooth axes were traced and the future
gingival margins were marked accord-
ing to esthetic parameters and parallel
to the desired occlusal plane (Fig 1 b).
The models were modified by raising
apically fhe gingival margins to antici-
pate the level following surgery (Figs 1 b
to 1d). A complete wax-up was then re-
alized on the modified casts (Figs 1 e to
1j) and the anterior teeth were \A/axed
according to the standard height/length
ratio of 3/5 (Figs 1e and 1f).i3
A silicon index from this cast was then
produced and a resin mock-up was car-
ried out in the patient's mouth (Fig 3).'^'^-
16 The excess of resin above the gingival
margin creates the illusion of the fufure
outcome after crown lengthening.
Once the project was validated and
accepted, the study casts with the wax-
up represented the aim of the treatment
and were used as the model of refer-
ence.
 GARAVAGLIA ET AL

Fig 1 The planning of the

treatment has been real-
ized on plaster casts. Atten-
tion was paid to mount the
casts with a face bow. Fu-
ture gingival margins were
drawn and then carved to
anticipate oro\A/n lengthen-
ing and osteotomy (a t o d).
The wax-up was performed
to respeot tooth proportions
and height/length ratio f e
and f). The occlusal plane
was corrected Cg and h).

73
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Fig 2 The Maryland type bridge was debonded on the mesial abutment and a seoondary decay had
developed (a and b). After removal of cement and caries (c and d), teeth were restored with direot
composites. The Maryland bridge was transformed in a resin-bonded prosthesis and kept as provisional
restoration f e and f ) .

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 GARAVAGLIA ET AL

Fig 3 The project realized on the cast needed to be validated with a mock-up. The resin was pressed
directly in the mouth with a silicon key of the wax-up. Gingival margins are overlapped by the resin to give
the illusion of the planned crown lengthening. Note the significantly reduced gingival display, the occlusal
plane correction, and the harmonious integration of the teeth in the patient's smiie.

Treatment sequence The crown lengthening was per-

In the initial phase of treatment, caries
and endodontic lesions were treated.
The prognosis of tooth 14 was consid-
ered poor due to the extent of the caries
lesion, which involved the root and thus
it \A/as extracted. The Maryland type FDP
was debonded on the mesial abutnnent
(Fig 2) where a secondary decay had
developed.
After cement and caries rennoval,
teeth were restored with direct comipos-
ite resins. The Maryland type FDP was
modified and subsequently kept as a Additional
provisional restoration. The mesial re-
tainer was removed and a perforation
was performed in the distal retainer to
permiit easy placennent and removal via
composite tags (Figs 2e and 2f).
formed on the base of the mock-up to
obtain a distance of 3 mm from the bone
to the margin of the future restorations. ^^
Implants where inserted at the same
time. To fit the project and get sufficient
space for the subsequent restorations,
the placement was performed more ap-
ical than the actual bone level by means
of an osteotomy.
After the healing of soft and hard tis-
sues a new miock-up was performed to
validate the gingival level and confirm
esthetics and the occlusal plane (Fig 4).
minor gingival corrections
were needed prior to the prosthetic pro-
cedure (Fig 5).
Posterior teeth were prepared for
complete coverage according to the
initial wax-up, using a silicone index.

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 CLINICAL RESEARCH

Fig 4 After the orown lengthening and implant placement, a seoond set of mook-ups was oarried out to
validate the procedures and guide the prosthetic phase.

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Fig 5 Based on the mock-up, a secondary surgical correction was performed to reposition gingival
zeniths.

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Fig 6 Veneer prepara-

tions, impression and provi-
sionals. After removing the
old restorations, almost no
further dental preparation
was needed, but teeth re-
vealed to be dischromic
fa and b|. The provisional
restoration was realized in
one piece with a composite
resin ( e t o g).

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 GARAVAGLIA ET AL

F i g 7 Luting of the veneers. All the procedures were carried out with rubber dam isolation to ensure the
best adhesive performance. Tooth 12 is still a provisional element fi). The bonded bridge was completed
later on.

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 CLINICAL RESEARCH

Fig 8 The bonded bridge

was fabricated independent-
ly from the veneers to avoid
overlap of the preparations
and to avoid luting problems.
The ovate lodgment was
formed with the provisional
(a). Then, a minimal prepar-
ation in the enamel was per-
formed Cc} to ensure correct
placement {d and e).

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 GARAVAGLIA ET AL

Fig 9 Close-up view of teeth preparations and impression. After initiai caries removal f a t o
c l , the posterior right teeth were prepared for overlays | d t o f). The ooolusal plan has been
prosthetioally corrected (g and h i .

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Fig 10 f a t o f ) Close-up view of the luting adhesive procedure.

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Fig 11 The posterior 5-unit bridge has been separated into a combination of two single crowns and a
short-span, implant-supported FDP.
The next step was to insert provisional
crowns on implants at the same time as
the overlays on the posterior right teeth.
The aim was to get a good posterior sup-
port before the finalization of the case
(Figs 9—11). The rest of the treatment
was split in two.
GARAVAGLIA ET AL
Anterior veneers were finalized first
and then the posteriors cro\A/ns com-
pleted the treatment. Preparations of the
anterior teeth were minimal. After remov-
ing the old restorations, almost no fur-
ther dental reduction was needed even
though tooth 1 1 revealed a rather dark
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Fig 1 2 Post treatment intraoral views.

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Fig 1 3 Post treatment extraoral views and anterior details.

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Fig 14 Post treatrTient radiographs.

color previously hidden by the compos- correct placement of the bridge but
ite veneer (Figs 6—8). attention was paid not to exceed the
The bonded cantilever bridge for enamel thickness. The treatment was
the tooth 12 was realized after the ve- then easily completed with the place-
neers were completed (Fig 8). This ment of the posterior crowns and the
choice was taken to avoid overlap of bridge (Figs 9-1 1 ).
the preparations and interference dur-
ing luting procedures. A composite
resin provisional restoration allowed Acknowledgnnent
the ovate lodgement to form before the
The authors wish to acknowledge Dr Marjan Ghas-
final impression. Tooth 1 3 was minimal- semian for the kind human and linguistic support
ly prepared in the palatal side to insure and the technician Etienne Martini.

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