The Crucial Role of Imagery in Dental Lab Collaboration by Dr. Lee Gary
Case Background
Throughout her 20’s and early 30’s, Hannah has fractured multiple posterior teeth requiring fixed restorative, endodontic treatment, and implant placement. Hannah was also unhappy with the esthetics of her smile. She has great oral hygiene but was continuing to fracture teeth. After a comprehensive exam of her hard and soft tissue including a full mouth series of radiographs, we decided that it would be best to balance her bite while also giving her a smile that was amazing. The final treatment plan included crown lengthening #7 and #8 along with full coverage restorations 3-14 opening her vertical dimension of occlusion.
Treatment Journey
The first step in treating Hannah was a referral to the periodontist for crown lengthening #7 and #8 to better match the gingival margins of #9 and #10. Flowable composite was placed at the gingival margin of #7 at the desired new gingival height margin. An alginate impression was made and a clear essix suck down was fabricated. The essix appliance was trimmed to the correct gingival margin and sent to the periodontist for a surgical guide. After 4 weeks of healing, Hannah was given a Quicksplint that would serve as a deprogrammer. Hannah was instructed to wear the Quicksplint 
during nighttime sleep for 2 weeks. After 2 weeks of deprogramming, Hannah returned to the office for a centric relation bite record at her new VDO, Kois earless facebow registration, upper and lower study models, and a series of photos for lab communication. These diagnostics were sent to GoldDust dental lab with instructions to mount her models in centric relation and wax-up 4-13 at the new established VDO. The lab was also given instructions to build in anterior guidance. After restoring 4-13, we will then restore #3 and #14 along with an occlusal night guard to finish the case.
After provisionalizing the case, Hannah returned to the office a few days later for photographs. Full face and close up photographs were taken of the provisionals. The reason we waiting for several days before photographing was to allow all anesthesia to dissipate so that we could get an idea of how the provisionals looked with her natural smile. Our goal is to always make the provisionals as close to the finals as possible so that Hannah is only surprised by how brighter and natural the finals look. When reviewing the photographs, I noticed some issues with the provisionals that I did not notice on prep day. Specifically I noticed a midline cant and I noticed that 4-8 had a flatter smile line while 9-13 had more curvature that followed the curvature of her lower lip. I made some adjustments at the incisal of 4-8 to better mimic 9-13. A scan and earless facebow of the provisionals were recorded after these adjustments to GoldDust along with instructions to closely follow the provisionals when fabricating the finals. GoldDust fabricated full contour e.max restorations for premolars and cut back and layered e.max restorations for 6-11 with light texture, light morphology, and incisal translucency.
Results
As shown in the final photos, GoldDust dental lab did a fantastic job in making the corrections from provisionals to finals. Without quality photos, it wold be impossible for dental technician to see how the incisal edge follows the curvature of the lower lip, the facial midline, the proper axial inclinations, and other features that stone or printed models do not communicate. Photography gave us the ability to make the final outcome exceptional and forever grateful patient.
Case by CMS Faculty Dr. Lee Gary
