Figure 1: I happened to see a case from a doctor who’s doing a full-mouth rehabilitation, and he did a really good job of maintaining the vertical dimension. When we want to maintain the vertical dimension on a case like this, we find that one of the easiest ways to do it is with BioTemps^® Provisionals (Glidewell Laboratories; Newport Beach, Calif.). Not only can you maintain (or open) the vertical, but you can also have a very nice, esthetic result and have some strong temporaries that are going to look pretty good, especially if you’re going to have the temporaries on longer than the usual two weeks.

Figure 2: When we make the temporaries, we suggest to the doctor that we do it in three segments. One segment will have a temporary that spans from teeth #12–15, another from teeth #2–5, and the third temporary will take care of the canines and the incisors. You can see all the wear on the patient’s teeth. This patient broke some PFMs before, so the doctor is doing this as a full-mouth BruxZir zirconia rehabilitation, assuming that’s the only material this patient won’t be able to break. Considering these are all single-unit crowns, I feel pretty strongly that I would have also chosen BruxZir Solid Zirconia for this case. You’ve seen us take a hammer and smash a BruxZir crown into a two-by-four, but bridges are not quite the same. We need to follow the Rule of 27 when we get those extended spans, but for single units like this, I’m highly confident that if the doctor reduces enough, we will in fact have crowns that will be able to withstand this patient’s biting forces.

Figure 3: When prepping these, you can start wherever you want. Sometimes it’s fun to start in the anterior if you’re not opening the bite, just to be able to get some esthetic change there. You can certainly start in the posterior as well, if you wanted. Let’s pretend we’re going to prep these four posterior teeth, too. We’re going to start by prepping the two bicuspids and the two molars on one side of the arch. When we’re done, before we take the impression, we’re just going to reline those BioTemps. Because only these four teeth are prepped and the rest of the teeth in the arch are unprepped, it’s very easy to maintain the vertical dimension on those temporaries by just having the patient bite them into place while the reline material is on the inside of the temporary.

Figure 4: After teeth #12–15 are prepped and have temporaries, we can prep the four teeth on the other side of the arch. And when these four preps (#2–5) are complete and we’re ready for an impression, we’ll put the BioTemps for #12–15 back in place. You can set them in or cement them in, depending on how far you’re going to go today. Then, we’re going to reline the BioTemps for #2–5 at that same dimension. If the BioTemps for #12–15 were out, or we had to prep both sides at the same time, we would just be hitting on the anterior teeth, which is a little sketchy for holding vertical dimension. Now, after all the molars and bicuspids have been prepped and have temporaries, we then prep the six anteriors and reline those with the posterior temporaries in place. If you finish those all in one appointment, now that you’ve relined all three segments at the correct vertical dimension, you’re free to take a master impression and then put these temporaries back into place. But typically, that’s a lot of work for the patient and you’re going to end up maybe just prepping the whole arch, getting the temps on, and having the patient back next time to pack cord and take the impression.

Figure 5: Here are the impressions we got in from the doctor. Full-arch trays, of course, because they’re full-arch preparations — that’s absolutely necessary. Plastic trays; we can certainly work with that. We like metal a little better, but we know we’re splitting hairs sometimes. These types of impressions are the most difficult thing to do in dentistry. I mean, come on. You have to prep 14 teeth and then have to control the tissue and pack cord around all of them. This is more difficult than surgically placing an implant, more difficult than taking out an impacted wisdom tooth; this is as tough as it gets. That’s why I like this to be its own appointment. And I also like to see what the BioTemps are going to do to the tissue in case we have to drop some margins.

Figure 6: So the doctor takes two acceptable impressions, and then we pour them up to get our uppers and lowers. Of course, the issue here is going to be: How do we maintain the vertical between these if we’re not going to open the bite? If we’re going to have enough room to put these BruxZir crowns in place, if we don’t need to add to the incisal edge length of, say, the central incisors, or need more room — essentially, if the doctor’s reduced enough — then we want to maintain that same vertical.