Smile Design in All-On-4 : A Sneak Preview (Part 2)
November 15, 2012
In this article, we show a female patient with a failing dentition (Figure 1). Con- ventional implants, crowns and bridges would be difficult, very costly, time consuming and have no guarantee of long-term success due to the medium to poor prognosis of abutment teeth and the positions of the teeth relative to an ideal aesthetic outcome.
It was decided, instead, to extract the remaining teeth, perform an alveolectomy and then place four implants using the All- on-4TM concept developed by Prof. Paulo Malo and Nobel Biocare.
Composite overlays (mock-ups) were used to reposition teeth and a black pen used to give the illusion of shortening the teeth to design an ideal smile within the patient’s dynamic lip position (Figure 2).
The completed mock-up is shown to the patient to gain acceptance of a final tooth position. These mock-ups are removed from the mouth and sent to the laboratory with instructions, photos and a study model of the existing teeth (Figure 3).
These are used in the laboratory by the technician who then places the mock-ups on the study model to begin to develop a plan for the Final Tooth Position (Figure 4). Using these photos of the mock-ups in the mouth, the dental technician has an oral record of smile design and can create the desired outcome accurately (Figure 5).
In the case of a full arch implant sup- ported reconstruction (All-on-4), these composite mock-ups are used to guide the technician in the placement of the prosthetic teeth to be used in the final prosthesis. The teeth with mock-ups in place are then removed from the model one tooth at a time and replaced with the final prosthetic teeth (Figure 6).
This set-up is then used to create the wax try-in (Figure 7). Once the try-in has been finalised, the definitive All- on-4 prosthesis (Figure 8) is produced by the dental laboratory and returned to the dentist for insertion (Figure 9).
The Final Tooth Position or Smile Design can be planned from the original consult visit (Figure 10); accepted by the patient using composite overlays (Mock- up); and communicated to the dental technician with photos and the overlays (Mock-ups) (Figure 11).
The definitive prosthesis that results is thus an accurate reproduction of the smile design agreed to by the patient (Figure 12).
The initial vision or plan has been achieved in a predictable and efficient manner. The use of composite overlays or mock-ups to develop a realistic and viable plan has ena- bled the dental team to produce an accurate and beautiful prosthesis in harmony with the initial vision. The patient’s vision of a beautiful smile has also been fulfilled.
Just as an architect draws sketches and then details the plans for the builder, so MUST the dentist develop a plan for the dental technician/dental artist to execute in harmony with the patient’ s desires.
This plan eliminates misunderstand- ings and limits the artistic license that can occur when clear goals are not articulated.
Removable composite overlays or mock-ups are sketches that detail the plan agreed to by dentist and patient for the “smile design”. When an experienced and competent dental technician knows where to go, the outcome is predictable and in harmony with everyone’s vision.
About the author
Russell Young is a prosthetist and master ceramist at Omega Ceramics Dental Lab- oratory in Melbourne and a key member of All-on-4 Lab Team Australia. He can be contacted on (03) 9826-6877.