Dear Colleagues

This kind 33 year old lady , fit and well, visited my clinic to improve her smile and function. Please find photos attached

The lack of space in the posterior region and the normal shape and size of the anteriors has made my treatment plan a dilemma.

Should I increase the OVD or not, if yes then what about the shape and occlusual considerations of the final anterior teeth? if no and crown lengthening is not an option then how would you approach this case.

My suggested treatment plan:

1.Extraction of the questionable and hopeless teeth +/ - socket preservation of the following teeth: 1, 13( poor coronal structure, long term progonosis is questionable) 16, 20 ( same reasons as tooth 13) 30, 32.

2. Diagnostic Wax up on the remaining anterior / posterior teeth at an increased OVD to give space for the future implant prosthetic component due to lack of space especially at the extracted left premolar region as well as extracted posterior molar region.

3. Michigan splint for obvious reasons and to help in reprogramming the TMJ for the new OVD

4. Provisional crowns / on the remaining posterior teeth at the proposed increased OVD , what are your thoughts on doing a provisional metal crowns / onlays (e.g nickel - chrome, SS) for the posteriors and acrylic on the anterior teeth ?

5. Afterwards Emax veneers / onlays as the definitive treatment for the upper and lower anteriors premolars at the new OVD.

6. Zirconium / PFM crowns as the definitive treatment for the posterior teeth

7.Implants for the missing teeth.

Finally, would it be safe to start (after a few months of placing the Michigan splint) placing Emax Veneers / Onlays immediately on the anterior, premolar teeth on an increased OVD and support the posterior with temporary GI or composite blobs and the continue the final posterior prosthodontic treatment?

Its also a bit difficult to find good technicians and mentors who handle recon cases as such where I live, I really struggle a lot with laboratories and I have to mount cast and face bows my self every time on my semi adjustable articulator as the labs here only use a simple hinge articulator even for recon cases.

I am so grateful to all your comments and advice.

Many thanks and I hope I hear from you all soon.

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