In two previous posts I discussed a patient I suspected of having a restricted envelope of function due to his symptoms and repeatedly breaking his provisonals. At the last appointment when we remade the anterior provisonals we also captured full arch impressions a facebow and a protrusive record so I could mount the case and work out a new occlusal scheme. My goal on the mounted models is to increase his freedom in the anterior. There are two ways to approach this, decrease overbite and increase overjet. Decreasing overbite is also an esthetic decision. In this case we already had minimal tooth display at rest so shortening the upper anterior teeth to decrease the overbite was out of the question. That leaves me with the options of shortening lower anteriors. We definitely had room to level the lower anteriors and shorten them a small amount. The only other way to decrease overbite requires opening the vertical dimension and therefore restoring many additional teeth. Had this been determined at the front end of the treatment plan it would have been a viable option. With orhto and implant placement complete and inheriting this case at the last phase of restoration opening VDO will be my last resort.
Increasing overjet was my go to option, and fit as looking in profile the upper anterior teeth were retroclined, or tipping to the lingual. Proclining the laterals and centrals would allow me to increase overjet, and could increase tooth display as it impacts lip rise and help the final esthetic result. I waxed the centrals and laterals to the facial and used a handpiece to remove the lingual stone and move the lingual contour to the facial as well. I added wax to the mesial lingual incline of the maxillary canines and worked the articulator through protrusive to gain guidance on these teeth. Having the condylar elements set using a protrusive record so as to mimic the patients condylar guidance is required for this to be transferable to the mouth. I was able to use the canines for protrusive and not pick up the centrals until right at end to end. Canine guidance in right and left excursive was maintained and the anterior teeth were not uncoupled in ICP.
The patient immediately commented on the “feel” when we placed his new provisionals. It has been several days since we delivered them and he reports no headaches and so far no damage or loosening to the temps, so I will keep you posted.