The Award contest 2017/ 23 February 2017/

Case 82 | The Award 2017 | Germany

Dr. Wolfgang Seuser / DT: Dominik Steindor

Prosthodontic rehabilitation in a case of extended erosive lesions

In that case of an 29 year old women bulimia nervosa starting in the age of 16. Meanwhile after a psychological treatment, BMI =17, Main concern of the patient: esthetic treatment of her front teeth.
Tooth wear 14-24 Scale 3; 17,16,26,27,36 and 46 Scale 2 ( Lussi- Classification) . Reduced vertical dimension and increased steepness of the upper frontteeth and canines causing manibular/condylar avoidance mechanism with high muscular strengh.
In 2012 we start this case with functional diagnostics , pretreatment and wax-up following the concept of Prof. Slavicek and develop a treatment paln including a functional and esthetic rehabilitation, minimal invasiv and in steps considering the still underweighted patient with poor condition for extensiv treatments. We also like to have a „test-drive“ of our therapeutic position and realized that with our mock-up in the upper jaw in combination with provisional s in the lower jaw.
We did the whole work in Emax – Lithium-disilicat-ceramics as table-tops modified by covering the eroded palatinal/lingual surfaces. The upper frontteeth and canins were done in a 360°veneer technique.
Our goal was a safe and minimal invasiv functional reconstruction with a controlled and predictable result , especially in the esthetics of the upper front theeth.
The last photos show the follow up in 2014. Another follow up 2016 was documented with video-files (so that it can not be presented here) and shows a stable and satisfying result.

Finished reconstruction. Palatinal view

Finished reconstruction. Recall 2 years later

Finished reconstruction. Frontal view

Finished reconstruction. Before and after

Finished reconstruction. Lower Jaw

Finished reconstruction. Recall 2 years later

Finished reconstruction. Functional guidance

This picture from the initial situation show the severe tooth wear by influence of Bulimia nervosa. Even the buccal surface structur is affeccted and looks tarnished.

The frontal view of the situation . The lenghts of zhe lower front teeth is more than that of the upper front theeth.

Some views from the palatinal side. Especially in the upper front area massive wear of tooth structure. The very thin border of remained enamel is interupted on some areas near the gum.

This effect of interupted enamel border line is also seen in the x-rays.This influenced our disicion to do 360° veneers in the upper front and canine region.

The severe erosion on the palatinal side has also fuctional consequences. The measurement of the guidances ( Reference SL ) shows an increased steepness of front – teeth and canines . Too steep canine guidance induces mandibular / condylar avoidance mechanisms with high muscular strength. For that we have to consider functional aspects

This is a look fromm palatinal side. Casts mounted in RP (Reference Position)

According the concept of Prof. Slavicek condylografie, lateral ceph analysis and mountening the casts in RP- situation was done ( Cadiax, Cadias . Gamma Dental). Patient had an orthodontic treatmant in her childhood. 4 premolars are extracted at that time. The skeletal disposition is a Class II with an rethrognatic aspect. The lower facial high is not increased, but on upper limit of the normal range. So we had only 2 mm to increase the vertical dimension.

Casts in TRP ( therapeutic reference position) with an increased vertical dimension of 2 mm.

Wax-up starting points

Diagnostic Wax-up following Prof. Slavicek concept of sequentiell guidance.

Concluding the find outs of our functional analysis and diagnostic wax-up we developed the treatmaent plan. First goal was to start in one step to increase vertical high. Done by a fixed Mock-up in the upper jaw and provisionals in the lower. After finishing the definite work the lower jaw and functional test-drive of the situation , transfer the posterior Mock –up to definite ceramic overlays. At least veneers on the upper front teeth and canines . So we had two test-drive situations to create a functional stable system, we had small steps in treatment with care of the health situation of our patient and we can concentrate in the last step of estetic aspects – the main concern of our patient.