This case illustrates how orthodontics and dental implants were used in a multidisciplinary approach to provide a patient with proper esthetics and function based on her desires. Orthodontics aligned the patient's teeth into the correct position. Implants were then placed to stabilize the teeth and provide a foundation for restorations. Over two and a half years, orthodontics, implant placement, and restorations transformed the patient's smile from undersized and misaligned teeth to an esthetically pleasing result that met her expectations.

1. Christopher D. Ramsey, DDS, AAACD
Nelson A. Rego, CDT, AAACD
Karina F. Leal, DMD
Scott F. Meier, DDS

2. AbstractMeeting or exceeding a patient’s expectations for exceptional dentistry can be very rewarding. Utilizing a multidisciplinary
approach to comprehensive care can be delivered very predictably. This case illustrates the collaboration of several
specialties to provide proper esthetics and function based upon the patient’s desires. The utilization of orthodontics
allowed teeth to properly align in the correct position. Following up with dental implants provided the groundwork for the
restoration to be predictable and successful. Based upon the patient’s desires and finances, the maxillary arch was
stabilized to ideal, with the intention to complete the mandibular arch in the future.
Key Words: implants, orthodontics, screw-retained, comprehensive care, undersized teeth
Adapted from the full article, which originally appeared in the AACD’s
Journal of Cosmetic Dentistry, Summer 2015 issue.
For more information, visit www.AACD.com.

3. View of the patient’s natural smile with the
provisional bridge in place on her left side.
The patient presented with a previously placed
provisional bridge restoration after another
dentist had tried in an esthetically unsatisfactory
PFM restoration.

4. Right lateral preoperative view. Left lateral preoperative view of the patient’s
smile showing the provisional bridge placed
by the previous dentist.

5. Full-mouth retracted close-up view illustrating the extent of the patient’s undersized and misaligned teeth.

6. Close-up retracted left lateral view of the
provisional bridge restoration.
Occlusal view with provisional bridge in
place showing current tooth positioning.

7. The patient committed to 16 months of orthodontics following extraction of the retained primary canines,
which were only in soft tissue. Teeth ##9-14 were individually provisionalized.

8. Following orthodontic treatment, the brackets
and denture teeth pontics at #6 and #11 were
removed.
Close-up post-orthodontic view of the patient’s
smile without the denture teeth at #6 and #11.

9. A surgical stent was utilized for implant
placement.
4.1 mm x 11 mm implants were placed at #6 and
#11, and crown lengthening was performed on
##7-10.

10. The patient wore a retainer for six months while
the implants healed.
Temporary cylinders were utilized to create
screw-retained provisionals for #6 and #11 to
begin to correctly shape the gingival contours.

11. Occlusal view of the screw-retained provisional
at #6.
The provisional restorations demonstrated the
corrected vertical dimension, a reproducible
orthopedic position of the mandible, corrected
tissue contours around implants #6 and #11, and
approved esthetics and function.

12. A digital full-contour wax-up was created from a
scan of the approved provisional impression.
The laboratory split the file to differentiate
between the zirconia coping design and wax-up
to enable their simultaneous milling, saving the
laboratory technician time.

13. Zirconia copings and modeling blue wax were milled from the same design file.

14. The restorations were pressed over zirconia and then cut back, after which multiple
ceramic layers were applied.

15. Silver die colorant was applied to the restorations to evaluate the contours.

16. The restorations were glazed once and then
hand-polished with polishing paste to avoid an
over-glazed appearance.
The restorations were seated and the occlusion
verified.

17. Postoperative right lateral view of the patient’s
smile at a 45-degree angle.
Close-up postoperative view of the patient’s
completed comprehensive maxillary cosmetic
dental treatment.

18. Proper function-based esthetics completed in final restoration.

19. The patient’s final smile.

20. Summary
Although this maxillary and initial mandibular rehabilitation required approximately two-and-a-half
years to complete, its interdisciplinary nature was based upon the type of comprehensive evaluation
and coordinated treatment planning that establishes a foundation for long-term oral health,
functional stability, and predictable esthetics. Unfortunately, many dental professionals remain
unaware of how to incorporate comprehensive esthetic evaluations and interdisciplinary
collaboration into their practices. As a result, patients with high esthetic expectations but little
understanding of the true scope of their needs can fall victim to inappropriate and/or substandard
care, leaving them disappointed and upset. Fortunately, in this case, a combination of dentist/patient
interaction, detailed evaluation and planning, interdisciplinary team communication, and ideal
material selection enabled a previously wary patient to achieve the smile of her dreams.

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23. Dr. Ramsey is an AACD Accredited
Member. He maintains a private
practice in Jupiter, Florida.
Dr. Leal is a Diplomate of the
American Board of Periodontology.
She maintains private practices in
West Palm Beach and Jupiter,
Florida.
Mr. Rego is an AACD Accredited
Member and Accreditation
Examiner. He maintains a private
laboratory in Santa Fe Springs,
California.
Dr. Meier maintains a private
practice in Jupiter, Florida.

24. To receive the quarterly, peer-reviewed Journal of Cosmetic Dentistry,
available to members only, enroll as an AACD member at
www.AACD.com/join