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One of the greatest challenges for dental clini-cians is solving esthetic dilemmas that involvewear due to parafunction.1 Not only is there ananterior component, but there is usually a triggeringcontact in the posterior dentition2 causing themandible to assume a more forward position. Whenthis occurs, the envelope of function is restricted and

the masticatory system compensates by excessivelywearing away any anterior interferences. Furthermore,there may be a loss of anterior facial dimension.3 Aswear becomes more severe, the masticatory systemadapts by maintaining its vertical dimension of occlu-sion and tight interproximal contacts,3 resulting in adeteriorated esthetic appearance.4

It is common for patients to seek professional con-sultation because of a displeasing smile.510 During thecomprehensive dental evaluation it is important tofocus on the patients esthetic demands and establisha checklist.1113 This will allow the clinician to gauge thepatients expectations and communicate with the den-tal team during the initial phases of treatment.1419

Although optimal esthetics is important, the ulti-mate goal is to conservatively establish and maintain ahealthy occlusion while satisfying the esthetic de-mands of the patient. This will ensure predictability inthe esthetic alterations. This article describes how tocomprehensively treat esthetic issues due to parafunc-tion in the anterior dentition.

1Private Practice, Baton Rouge, Louisiana, USA; Assistant ClinicalProfessor, Department of Prosthodontics, Louisiana State Univer-sity School of Dentistry, New Orleans, Louisiana, USA; VisitingFaculty, The Pankey Institute, Key Biscayne, Florida, USA.

2Perla Dental Laboratory, Tokyo, Japan.3Hinman Endowed Professor and Director, Esthetic and ImplantCenter, Medical College of Georgia School of Dentistry, Augusta,Georgia, USA.

Correspondence to: Dr Gerard Chiche, Esthetic and ImplantCenter, Medical College of Georgia School of Dentistry,Room AD 3132A, MCG School of Dentistry, 1120 15th Street,Augusta, GA 30912, USA. Email: gchiche@mail.mcg.edu

Anterior Estheticsand Parafunction:A Comprehensive Approach

Tyler Lasseigne, DDS, CDT1

Hitoshi Aoshima, RDT2

Gerard Chiche, DDS3

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ANALYZING WEAR PATTERNSThe first objective when treating a displeasing smile isto determine whether the causative factor is due towear. If so, is it located in the anterior segment, poste-rior segment, or both? In the case shown here, the an-terior wear was isolated to the anterior dentition andincluded both the maxillary and mandibular teeth(Figs 1 to 3). This meant that the condylar guidancewas adequate to disocclude the posterior teeth duringexcursive movements.5,20,21 In addition, since the wearwas only in the anterior segment, the anterior guid-ance did not have to be steepened.3

The anterior guidance must be as flat as possible,allowing only the posterior teeth to contact in centricrelation.2,3,22 As teeth are abraded, the mandibularmovements become more horizontal. The mandibleusually assumes a more anterior position, indicatingthat there may be an unstable position of the man-

dibular condyle.3 To determine the correct condylarposition, splint therapy was needed.

OCCLUSAL APPLIANCE THERAPYA heat-processed centric relation splint was fabricatedand placed on the maxillary arch (Figs 4 and 5). Themain purpose was to ensure that the condyles werefully seated in centric relation. All mandibular support-ing cusps contacted with equal intensity, with the ex-ception of the anterior teeth. Lighter contacts shouldbe maintained on the anterior teeth (Fig 6). All poste-rior teeth were immediately disoccluded in all excur-sive mandibular movements.

Strict instructions were given to the patient to wearthe splint continuously and only remove it duringdaily hygiene procedures. The teeth must not contact

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Figs 1 to 3 Pretreatment views showing maxil-lary and mandibular wear.

Figs 4 and 5 Heat-processed centric relationsplint.

Fig 6 Tooth contact pattern showing light con-tact of the anterior teeth.

1 32

4 5

6

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throughout treatment because this disrupts the stabil-ity of the masticatory system, thus reintroducing theold occlusal system. After 10 weeks of wearing theappliance, a facebow record, centric relation record,and protrusive record were taken to analyze themandibular position. It was determined that or-thodontic therapy was needed to provide freedom inthe envelope of function. Fradeani5 states that boththe overbite and overjet for a dental Class I patientshould be between 2 and 4 mm.

ORTHODONTIC THERAPYThere was constriction in the anterior segment dueto the wear impinging into the interproximal con-tact areas of incisor teeth. Orthodontic therapy wasused to reestablish the correct anteroposterior po-sition of the anterior incisors (Fig 7). This movementincreased the overjet and provided more freedom

between the maxillary and mandibular anterior den-tition.

INCISAL VERIFICATIONIt is of utmost importance that the incisal edge positionbe established prior to proceeding to the wax-up sothat the patient and clinician can mutually agree on thedesired length. This position was confirmed by directlyadding composite resin to the incisal edges of the ante-rior teeth and light curing (Fig 8a). It is best to start withthe central incisors and then progress laterally. Notethat this procedure is not for correcting tooth propor-tions, misalignment, etc, but only for verifying the incisaledge position. Soon after, an alginate impression regis-tering that position is taken and poured by the labora-tory (Fig 8b). The ceramist can now wax up a prototypeof the prospective restorations incorporating ideal con-tours and optimal proportions requested by the dentist.

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Anterior Esthetics and Parafunction: A Comprehensive Approach

Figs 7a to 7c Orthodontic treatment was used to reestablish correct anteroposterior positioning.

Fig 8a Incisal edge position was determined using composite resin.

Fig 8b Alginate impression of the incisal edge position.

7a 7c7b

8a 8b

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ESTHETIC WAX-UPAn esthetic wax-up is a three-dimensional visualiza-tion of the end result23 and should always be guidedby the clinicians prescription to the laboratory. Thisformula will allow the technician to correctly sculpttooth proportions in wax while refining the properanterior guidance. Note that the wax-up only pro-vides a starting point for the clinician. It is not untilthe wax-up is transferred to the mouth that the es-thetics and occlusion can be verified.

In this case, the facial and interproximal surfacesof the involved teeth were reduced. The anticipatedrestorations were veneers, so the cervical toothstone was left intact to maintain the external mar-gins. Next, an additive waxing technique was usedto recreate ideal tooth anatomy and characteristics24

using IQ Sculpturing Wax (Yeti Dentalprodukte,Engen, Germany) (Fig 9). Gingival alterations werecarved into stone using the incisal edge of eachtooth as a guide.

SILICONE MATRIXAfter the esthetic wax-up was completed, it needed tobe transferred to the patients mouth. The wax-up wasduplicated in alginate and a firm matrix was fabricatedby injecting addition reaction silicone (Aquasil Ultra LV,Dentsply Caulk, Milford, DE, USA) into a no. 3 COEImpression Tray (GC America, Alsip, IL, USA) and thenplaced on the duplicated cast. The extension of thesilicone matrix should be approximately 2 mm beyondthe tooths cervical margin facially and lingually (Fig10). Note that the existing occlusal surfaces were suffi-cient to support the matrix. The teeth were spotetched on the midfacial portion using 37% phosphoricacid (Fig 11), and Adper Single Bond Plus Adhesive(3M ESPE, St Paul, MN, USA) was applied to all areasof the tooth. Next, bis-acrylic resin temporary material(Integrity, Dentsply Caulk) was syringed in the facialand incisal areas of the matrix and left to polymerizefor approximately 3 to 5 minutes.

It is important to administer occlusal and facialpressure to ensure proper adaptation. Note the differ-

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9

10 11

Fig 9 Additive wax-up showing ideal toothanatomy.

Fig 10 Silicone matrix.

Fig 11 Spot etching was performed with 37%phosphoric acid.

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ence between a matrix that was fully seated (Fig 12a)and one that was not (Fig 12b). There will be residualtemporary material adjacent to the soft tissue whenthe matrix is not fully seated. When this occurs, it isbest to remove the temporary material and start over.

In this case, the display length and fullness were in-creased and then verified using F and V phonetictests25 and rest position (Fig 12c).26 Next, all excessmaterial was removed and an alginate impression wastaken and poured in Fujirock (GC America). A secondsilicone matrix was fabricated along with reductionguides (Figs 13 and 14), which were used for conser-vative veneer preparation.

TOOTH PREPARATIONThe proposed restorations were veneers on all ante-rior maxillary and mandibular teeth including the firstand second maxillary premolars. Since the shade ofthe prepared teeth was similar in color to that of theunprepared teeth, a type I veneer preparation wasdone using the mock-up, allowing only 0.3 mm of fa-cial reduction from the original tooth contours. Atleast 90% of prepared tooth structure remained inenamel, permitting the technician to use a more es-thetically pleasing porcelain.

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Anterior Esthetics and Parafunction: A Comprehensive Approach

12a 12b

12c

13 14

Figs 12a and 12b Visual difference between a fully seatedmatrix (a) and one that is not fully seated (b).

Fig 12c The silicone matrix was used to verify function andesthetics.

Figs 13 and 14 Second silicone matrix and reductionguides.

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PROVISIONAL RESTORATIONS ANDLABORATORY CONSIDERATIONSAfter the preparation was completed, the provisionalrestorations were fabricated directly in the mouthusing the same technique previously described (Fig15). Since the patients esthetic request was verifiedusing the silicone matrix, most of the time was spentadjusting the anterior guidance. It is important thatthe anterior guidance works in harmony with thecondylar guidance to disocclude all posterior teethduring excursive movements. If posterior disocclusioncan be achieved with an anterior guidance that is inharmony with the envelope of function, the prognosiswill be favorable.3

Alginate impressions of the provisional restorationswere taken and poured in Fujirock for future mount-ing. A facebow recording device (Kois Dento-FacialAnalyzer, Panadent, Colton, CA, USA) was used to re-late the maxillary cast to the same axis position on thearticulator as the condylar axis on the patient. Then,the mandibular cast was related to the maxillary castusing a centric relation record. To further ensure thatthe anterior guidance was followed, a customized an-terior guide table was made (Fig 16). That way theupper bow of the articulator would follow the samepath even if the mandibular cast was removed. Theopening and closing arc for each mandibular toothshould follow the same path on the articulator as itdoes on the patient if the maxillary and mandibularcasts are related correctly. Therefore, strict instructionsregarding anterior guidance must be provided to thelaboratory technician.

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Fig 15 Provisional restorations fabricateddirectly in the mouth.

Figs 16a to 16c Customized anteriorguide table.

15 16a

16c

16b

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FINAL RESTORATIONSThe final restorations included 16 porcelain laminateveneers (EX-3 Super Porcelain, Noritake, Aichi, Japan)(Fig 17). A lower-value dentin powder similar to 1M13-D Vita Shade Tab (Vita Zahnfabrik, Bad Sckingen,Germany) was applied. Internal staining was per-

formed along with the application of bright translu-cent powders. The porcelain thickness applied overthe body layer controlled the value of the restorations.Minute craze lines and hypocalcification spots wereplaced on the distal areas of the central and lateral in-cisors to create a subtler, delicate effect.

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Anterior Esthetics and Parafunction: A Comprehensive Approach

Figs 17a to 17d The defini-tive restorations comprised16 porcelain laminateveneers.

17a

17d

17c

17b

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ESTABLISHING FUNCTIONALHARMONYAll veneer restorations were bonded using clear InsureRegular Viscosity Cement (Cosmedent, Chicago, IL,USA). The excess cement was removed, and estheticswere evaluated and adjusted. Only then was the oc-clusion checked, removing all posterior excursive con-tacts and harmonizing all centric contacts (Figs 18aand 18b). Lighter supporting contacts remained onthe anterior teeth. The anterior guidance was checkedto make sure that equal pressure was exerted on allanterior teeth during protrusive movement and thatthe lateral incisors did not touch during lateral excur-sion and crossover (Figs 18c to 18f).

CONCLUSIONThe best solution for addressing occlusal wearrelatedproblems is prevention.3 Unfortunately, in this case,

the wear process had begun abrading healthy toothstructure beyond the point of acceptance. A com-prehensive exam including all clinical diagnostic in-formation and dental/medical history is valuable todistinguish whether wear patterns are directly causedby parafunctional habits. Treatment should start byverifying and/or stabilizing the condylar position (ie,splint therapy) and then simulating this position withcasts mounted on a semiadjustable articulator. It is notuntil a wax-up of the proposed plan is transferred tothe mouth that the dental team can be assembled fortreatment. The outcome is considered successfulwhen all patient demands are met while using themost conservative treatment option with a stable tem-poromandibular joint.

ACKNOWLEDGMENTThe authors would like to thank Dr Paul Armbruster for providingthe orthodontic treatment.

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Figs 18a to 18f Final result.

18b

18a

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Anterior Esthetics and Parafunction: A Comprehensive Approach

18d

18f

18c

18e

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REFERENCES1. Abrahamsen TC. The worn dentition: Pathognomonic patterns

of abrasion and erosion. Int Dent J 2005;55:268276.2. Ramfjord SP, Ash MM. Occlusion, ed 2. Philadelphia: WB Saun-

ders, 1971.3. Dawson PE. Functional Occlusion from TMJ to Smile Design.

St Louis: Mosby, 2007.4. Okeson JP. Management of Temporomandibular Disorders and

Occlusion, ed 4. St Louis: Mosby, 1998.5. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics, vol

1. Chicago: Quintessence, 2004.6. Goldstein RE, Fritz M. Esthetics in the dental curriculum. J

Dent Educ 1981;45:355357.7. Renner RP. Dental esthetics. In: Renner RP. An Introduction to

Dental Anatomy and Esthetics. Chicago: Quintessence, 1985:241273.

8. Conny DJ, Tedesco LA, Brewer JD, Albino JE. Changes of atti-tude in fixed prosthodontic patients. J Prosthet Dent 1985;53:451454.

9. Dong JK, Jin TH, Cho HW, Oh SC. The esthetics of the smile:A review of some recent studies. Int J Prosthodont 1999;12:919.

10. Rinaldi P. Simplifying anterior esthetics in the general practice.Contemp Esthet Restorative Pract 2001(April):16.

11. Brisman AS. Esthetics: A comparison of dentists and patientsconcepts. J Am Dent Assoc 1980;100:345352.

12. Albino JE, Tedesco LA, Conny DJ. Patient perceptions of den-tal-facial esthetics: Shared concerns in orthodontics andprosthodontics. J Prosthet Dent 1984;52:913.

13. Neumann LM, Christensen C, Cavanaugh C. Dental estheticsatisfaction in adults. J Am Dent Assoc 1989;118:565570.

14. Rivers J, Schmidt G. Improving laboratory performancethrough effective dentist/technician communications.Quintessence Dent Technol 1983;7:5152.

15. Kessler J. Dentist and laboratory: Comunication for success. JAm Dent Assoc 1987;(special issue):97E102E.

16. Nevins M. The periodontist, prosthodontist, and laboratorytechnician: A clinical team. In: Preston JD (ed). Perspectives inDental Ceramics (Proceedings of the Fourth International Sym-posium on Ceramics). Chicago: Quintessence, 1988:407419.

17. Shavell H. Dentist-laboratory relationship in fixed prosthodon-tics. In: Perspectives in Dental Ceramics (Proceedings of theFourth International symposium on Ceramics). Chicago:Quintessence, 1988:429437.

18. Tanaka A. Successful technologist-dentist teamwork. In: Per-spectives in Dental Ceramics (Proceedings of the Fourth Inter-national Symposium on Ceramics). Chicago: Quintessence,1988:443444.

19. Shannon JL, Rogers WA. Communicating Patients estheticneeds to the dental laboratory. J Prosthet Dent 1991;65:526528.

20. Spear F. A patient with severe wear on the anterior teeth andminimal wear on the posterior teeth. J Am Dent Assoc 2008;139:13991403.

21. Spear F. A patient with severe wear on the posterior teeth andminimal wear on the anterior teeth. J Am Dent Assoc 2009;140:99104.

22. Solow RA. Equilibration of a progressive anterior open occlusalrelationship: A clinical report. Cranio 2005;23:229238.

23. Braly BV. A preliminary wax-up as diagnostic aid in occlusal re-habilitation. J Prosthet Dent 1966;16:728730.

24. Morgan DW, Cornella MC, Staffanou RS. A diagnostic wax-uptechnique. J Prosthet Dent 1975;33:16977.

25. Pound E. Personalized Denture Procedures. Dentists Manual.Anaheim: Denar, 1973.

26. Vig RG, Brundo GC. The kinetics of anterior tooth display. JProsthet Dent 1978;39:502504.

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