Records for full mouth rehabilitations

Below is a general outline of the steps required to rehabilitate an arch or two in ceramic. Records are essential in these cases both for the success of the case and for medicolegal reasons. The more records we provide the technician the more chance we have of a successful case and less adjustments in the final. Supplemental procedures such as orthodontics, root canal treatment, implant placement and crown lengthening will fit in in certain stages of this protocol.

Consultation appointment

1. Case discussion, treatment and financial consent
2. Radiographs: OPG/CBCT for screening supplemented with bitewings or PAs as needed
3. Extraoral photographic records:
• Full face: Rest and full smile
• Lateral face photograph
• Smile close up
4. Intraoral photographs:
• Retracted full anterior 
• Retracted 45 degrees left and right
• Buccal segments mirror
• Occlusal mirror maxilla and mandible
• Contrasted maxillary and mandibular arch
5. Upper and lower impression in Medium body and PVS light body wash for waxup
6. Smile design on photos to guide tooth shape and length for waxup with technician

Laboratory steps

1. Construct models in stone
2. Construct AMPSA if deprogramming is desired to rebuild arches in centric relation
3. Waxup based off smile design
4. Mock up transfer putty with PVS putty and a light body wash after putty set
5. Labial reduction putty for veneer preparations
6. Shell temporaries if desired

First treatment appointment

1. Mock up in bisacryl
2. Full extraoral and intraoral photographs of mockup
3. Profound local anaesthesia
4. Occlusal reduction through mock up
5. Rough preparations of teeth 
6. Construct and cement temporary crowns 
7. Adjust bite, phonetics and aesthetics

Second treatment appointment

1. Replace any broken or fractured temporary crowns
2. Refine bite phonetics and aesthetics, before local anaesthesia
3. Full set of Photographs before la as the patient will still be able to smile
4. Use digital calipers to measure the length of temporaries from gingival margin to incisal edge. Take 3 measurements and if there are any outliers retake the measurement until you have a reproducible result. This measurement will guide the technician to verify they have made the crowns the right length. If you do not do this they will tend to lengthen the teeth even when provided an impression of the temporary crowns. Poorly fitting temps will cause inaccuracies in these measurements as there will be a gap at the margin or poor quality gingiva that may confuse the technician. It is important to get these measurements before removing the crowns as you will lose your vertical position and final preparations can damage and inflame the gingival margin. This is also why verifying your bite registration is at the right vertical dimension is difficult after all the crowns have been removed and the gingiva traumatised.
5. Use digital calipers measure the distance between the upper and lower gingival margins in a few locations. e.g 15-45, 25-35, 11-41. The technician will measure this after mounting the casts to verify they have mounted it correctly. If there is a large discrepancy there may have been an issue with the bite record or impressions. 
6. Profound local anaesthesia as impression of the temporary crowns is likely to dislodge the crowns and cause sensitivity.
7. Upper and lower PVS impressions of temporary crowns to communicate shape and length to the technician
8. Final tooth preparations
9. Full set of intraoral photographs of preparations
10. Upper and lower PVS impressions for preparations with double cord technique
11. Bite registration: Static or in centric relation to mount models
12. Protrusive bite 4-5mm from static bite to program condylar angle on the articulator 
13. Facebow record 
14. Stick bite to confirm correct mounting of the maxillary model
15. Recement temporaries
16. Final shade and stump shade photographs

Laboratory steps

1. Construct models
2. Mount maxillary case with facebow
3. Mount mandibular cast with bite registration. You can mount the upper temporary crown model in relation to the mounted lower cast. This will allow you to verify correct mounting with gingiva-gingiva measurements or alternatively you can try in the stick bite to see if the stick is parallel with the condyles on the articulator. You can make a putty index of the incisal edges temporary crown model against the lower to guide the buildup of porcelain.
4. Construct crowns on models according to the specifications provided
5. Prepare the crowns for bonding

Third treatment appointment

1. Verify the fit of the crowns against the model. Verify the length of the crowns matches your specifications. If you have to jiggle or force the crowns onto the model it will never fit in the mouth. Stone is softer than tooth structure and repeated insertion will wear down the interferences to seating. There should be a passive fit to all your prostheses. Similarly, if the marginal fit is poor on the model it will be very poor in the mouth
2. Local anaesthesia
3. Remove temporary crowns and clean temporary cement off teeth
4. Try in crowns, check bite, phonetics and aesthetics. Consent to proceed. The patient needs to know that if they say they are happy with the aesthetics but change their mind after cementation they must pay for all the remakes. Also, make sure that you are happy with the work before you proceed. Don't think about your hourly rate going down to rebook the appointments for another try in. Think about the hourly rate lost cutting all the newly cemented crowns off and remaking them for free.
5. Gingival retraction
6. Rubber dam isolation
7. Clean surface of crowns
8. Clean tooth surfaces verified with plaque disclosing dye
9. Prepare the intaglio surfaces of the crowns
10. Boding procedures
11. Cement crowns
12. Clean up cement
13. Take bitewing radiographs to verify all cement has been cleared
14. Check occlusion, phonetics and aesthetics
15. Full photographs