Maurizio De Stefano
COMPLEX INTERDISCIPLINARY
CASE.
Maurizio De Stefano DDS-CDT
and Mario D’Orlando CDT, Marco Pappacena CDT, Giancarlo Cozzolino
CDT, Leonardo Castaldo CDT.
Case displaying
The patient, male, aged 27, presented in our office in December
2012. With aesthetic and functional problems, he reported to suffer of awake
and sleep bruxism, and severe headaches, from a long time, increased last year by an annoying tinnitus in both
ears.
Smoker, 10 cigarettes a day, He had not undergone any surgery over
the years.
Moreover, he never had any trauma to the head and neck regions.
He had noticed a dramatic reduction in his teeth size.
In fact, both the upper and lower incisors are worn.
Furthermore, he noted a change in his facial appearance.
The request was to regain an optimal aesthetic, whiter and more
natural teeth.
He was aware that the reduction of headaches and annoying tinnitus
would not be certain.
Furthermore, the patient’s request was to avoid orthodontic
treatment.
Case Analysis:
Occlusal
Analysis:
- Dental Angle class II left and right
- wear of front upper and lower incisors;
- presence of right and left canine guidances (only in part, then
accompanied with the front group, with evident functional wear facets);
- anterior guidance;
- no wear or alteration of centric holding cusps;
- alteration of Wilson and Spee compensation curves;
- tooth profile is lingually tipped in the upper and lower front
group;
- deep bite with an over bite of 6 mm, over jet of 4.5 mm;
- interincisal line sup. VS Inf 0.5 mm deflected on the right;
- intermascellar position of maximum
- intercuspation.
Cephalometric
based Diagnosis:
–
First class in skeletal Normomaxillia .;
–
Mild mandibular retrusion with mandibular post-rotation;
- lingual tipping of upper and
lower incisors;
TMJ analysis
The
problems, associated with bruxism and the spatial angle of the jaw, has given
rise to a symptomatology at various stomatognathic apparatus districts.
TMJ
constantly stressed by overloading of the levator muscles, have undergone a
remarkable job, forcing the disk to slide forward, slowly, over time, it has
completely changed in form. The Ptg. lateral sup. muscles. contracted, have
consistently kept the articular disc forward, leaving, chronically, an
incoordination without reduction.
Critical
clinical situation analysis:
The
malocclusion, has further encouraged a pre-maxillary rotation.
In
fact, the jaw, forced by the upper arch, constantly strains to push forward
with a respective wear of the lower incisors and to push up and back the
condyles.
This
situation accentuates the lingual tip, generating a malposition
condyle/articular cavity (in patient with anterior bruxism and tinnitus).
The
patient, has about 6 mm of free
interarch space.
Upper
incisors are about 1 mm behind the lower lip vermilion.
Wear
of front upper and lower incisors about 6 mm.
The
patient does not accept orthodontic treatment to restore his clinical
situation.
Goals of
the therapy
- found a new asymptomatic orthopedic
position of the jaw;
- improve the aesthetic appearance of the face
and the dento-gingival composition, in proportion and dental size;
- Prosthetic restoration by minimally invasive
prosthetic procedures.
History of therapy
– In the first phase, a Kois device was used to achieve a new
mandibular position with no symptomatology.
– A Farrar anterior repositioning plaque was used to obtain a new
mandibular closure pattern in a more anterior position.
With the Jankelson’s orthotic and an adhesive mock up in the upper
jaw, we have defined the occlusal function and set the mandibular final
stable orthopedic position with the interincisal point in advance of 3
mm and a OVD increased by 6 mm.
– To ensure both optimal aesthetics and structural strenght we
have choosen the Litium Disilicate as rehabilitation material.
The whole stomatognathic system has been successfully treated,
tested with enamel bonded mock up, with a reduction of masseter hypertrophy.
– Aesthetically the patient has noted an overall streamling of the
face due to the reduced muscolar tone with his facial profile improvement.
– After this first phase of physiotherapy, mandibular and condyle
repositioning, he noted immediately benefits, with migraine disappeareance and
a tinnitus reduction in terms of 70 % – 80 %.
– With the new occlusion, achieved by the Jankelson orthotic, the
patient noted, moreover, the orizzontal bruxism disappareance.
– The final movement patterns have been well defined and the
occlusion, both in static and dynamic, has well supported the overall kinetics.
– 28 Litium Disilicate single restorations were performed:
– monolithic in the posterior areas, in order to
copy the functionalized
temporary crowns,
– layered ceramics in
anterior regions to obtain the best aesthetic results .
To ensure durability to the entire rehabilitation a protective
retainer was performed .
The patient full
satisfaction was achieved in terms of aesthetics, function and greater
self-confidence .
Tak On T, Kois JC.
Digital Smile Design Meets the Dento-Facial Analyzer: Optimizing Esthetics While Preserving Tooth Structure.
Compend Contin Educ Dent. 2016 Jan;37(1):46-50.Occlusal Analysis:
Dental Angle class II left and right
wear of front upper and lower incisors;
presence of right and left canine guidances (only in part, then accompanied with the front group, with evident functional wear facets);
anterior guidance;
no wear or alteration of centric holding cusps;
alteration of Wilson and Spee compensation curves;
tooth profile is lingually tipped in the upper and lower front group;
deep bite with an over bite of 6 mm, over jet of 4.5 mm;
interincisal line sup. VS Inf 0.5 mm deflected on the right;
maximum intercuspation. wear of the upper incisal edge
Extrusion and wear of the lower incisal group.
Mandibula is worner than maxilla
Dental aspect at rest, displays the lack of visibility of the upper incisal edge, while, for a boy of 27, it should be 1.5 mm visible at least.
L’esposizione dentale a riposo, mette in evidenza l’assenza di visibilità del margine incisale superiore, che al contrario, in un ragazzo di 27 anni, avrebbe dovuto essere visibile almeno 1,5 mm
Initial XRays
bite wings carie of 1.4
Lower wisdom teeth included;
no evindence of other injuries.
Gelb’s Grid of temporomandibular joint position. allows to evaluate the correct position of the condyle over the glenoid cavity. To be precise the 4/7 position is the correct one.
Griglia di Gelb di posizione articolazione temporo mandibolare, permette di valutare la posizione spaziale corretta del condilo rispetto la cavità glenoide. In particolare la posizione 4/7 rappresenta la posizione corretta di riferimento.
Cephalometric based Diagnosis:
– First class in skeletal Normomaxillia .;
– Mild mandibular retrusion with mandibular post-rotation;
– lingual tipping of upper and lower incisors;
Critic analysis:
The malocclusion, has further encouraged a pre-maxillary rotation.
In fact, the jaw, forced by the upper arch, constantly strains to push forward with a respective wear of the lower incisors and to push up and back the condyles.
This situation accentuates the lingual tip, generating a malposition condyle/articular cavity (in patient with anterior bruxism and tinnitus). In addition, bruxism, could be occurred, just like the protection mechanism of an anatomical constriction.
The patient, has about 6 mm of free interarch space.
Upper incisors are about 1 mm behind the lower lip vermilion.
Phonetic tests, through the use of the device of Kois highlight a VD loss of about 6 mm.
Treatment Plan
1 Causal therapy: motivation, hygiene, charting;
2 Physiotherapy for ATM and masticatory muscles (the patient has a spinal sensitization
C2 with dysfunction of levator muscles of the jaw, presence of trigger points in
masseter muscles and painfulness to palpation of all suprahyoid ones);
3 Aesthetic and functional analysis
Rx orthopanoramic, ATM and Lateral teleradiographic projection, cephalometric analysis,
silicone impressions for study models, set the prosthetic plane,
ultrasonic pantography, kinematic face bow, initial individual data.
4 Kois’ deprogrammer
Required an appointment 4 hours, to evaluate the vertical dimension of occlusion and
ideal spatial position of the jaw and of the TMJ, in order to identify in which sagittal
position he had a reduction of symptoms.
5 Farrar’s plaque of anterior repositioning splint (ARS – Farrar WB 1977)
applicated 23 hours a day.
6 Waxing diagnostics and mask to press the first upper mock-up.
after detecting the relationship determined to the ARS, we used Jankelson’s Orthotic
7 Diagnostic wax up with Spee and Wilson Curves, construction of silicone keys to press.
8 16 posterior restorations in monolithic lithium pressed disilicate,
12 anterior restorations in layered lithium pressed disilicate.
9 Retainer
Lina-Granade G, Truy E, Ionescu E, Garnier P, Thai Van H.
Tinnitus and temporomandibular joint: State of the art
Rev Stomatol Chir Maxillofac Chir Orale. 2016 Dec;117(6):458-462.
Physiotherapy
The problems, associated with bruxism and the spatial angle of the jaw, has given rise to a symptomatology at various stomatognathic apparatus districts.
TMJ constantly stressed by overloading of the levator muscles, have undergone a remarkable job, forcing the disk to slide forward, slowly, over time, it has completely changed in form. The Ptg. lateral sup. muscles. contracted, have consistently kept the articular disc forward, leaving, chronically, an incoordination without reduction.
The specific physiotherapy, reduced the contracture of the elevators, decreased joint pressure, elongated temporal muscles, responsible for headaches, eliminating back discitis and capsulitis. In addition, trigger point were eliminated by dry needling techniques.
A Kois’ deprogrammer was built , in order to evaluate both the vertical dimension and a new orthopedic mandibular position, reducing problems to the ATM and tinnitus.
After choosing a mandibular position, and locked with a silicone (Occlufast, Zhermack), it has controlled the condylar displacement using a radiographic examination of the TMJ.
Note the mandibular displacement from A to B.
The B position, has been maintained, thanks to a mandibular advancement splint (Farrar).
Mazzone N, Matteini C, Incisivo V, Belli E.
Temporomandibular joint disorders and maxillomandibular malformations:
role of condylar “repositionin” plate.
J Craniofac Surg. 2009 May;20(3):909-15.
(ARS) Anterior Repositioning Splint
of Farrar, to keep the new relationship inter-arch and rewrite new patterns of movement.
The patient provided the use of the plate with a daily application of about 23 hours.
The Farrar plaque was used for 12 months.
Clinical recording of the prosthetic plane, parallelized to the Camper plane,
Sang YH, Hu HC, Lu SH, Wu YW, Li WR, Tang ZH.
Accuracy Assessment of Three-dimensional Surface Reconstructions of In vivo Teeth from Cone-beam Computed Tomography.
Chin Med J (Engl). 2016 Jun 20;129(12):1464-70.
Importing the prosthetic plane on the Cone Beam CT
identification of the Camper’s plane and prosthetic table in digital;
Comparison of the analog measured data with the digital data;
Export data from digital to analog.Digital models, imported from analogue, oriented in space, according to analog recording.
Ceck of the prosthetic plane and possible asymmetries.
Waxing in plane.
Anterior Repositioning Splint, put on for 12 months, rewrites a new mandibular movement pattern, in a more advanced position reestablishing a normal anatomic relationship between condyles and Glenoid cavities.
After 12 months, the plaque has been broken to detect the new orthopedic position, thanks to a silicone bite (OCCLUFAST, Zhermack). The request to the laboratory, has been to make a first wax up, in plane, according to the above mentioned data.
Clinician’s request:
wax up in plane
wax up duplication
silicone keySimon H, Magne P.
Clinically based diagnostic wax-up for optimal esthetics: the diagnostic mock-up.
J Calif Dent Assoc. 2008 May;36(5):355-62.
Mock up
the first mock-up is intraorally pressed adhesively, with a silicone key, like a bite, with bis-acrylate (3M Protemp4) and layred with transparent hybrid composite (Ivoclar), in order to improve the occlusion, also with the next Jankelson’s plaque.
Note the parallelism of horizontal reference lines.In the same session, after pressing the upper mock-up, it was taken an arbitrary facebow, impressions and silicone bite, in order to build the Jankelson’s orthotic with the aim to define the occlusal movements.
Meanwhile, the patient has brought a jig position.
Baker PJ, Setchell DJ, Tredwin CJ.
Reproduction of articulator settings and movements with an
ultrasonic jaw movement recorder.
Eur J Prosthodont Restor Dent. 2006 Jun;14(2):55-62.
After 5 months of Jankelson’s orthotic,availment we transferred to laboratory all the informations about dental movements.
Individual data were collected by ultrasonic pantograph;
spatial position of the upper model was transferred with KTS System (KaVo).
Silicone impressions and silicone bite inter-arch were obtained by fracturing Jankelson’s orthotic.
Gelb’s grid
According to the author the right condyles position, in Glenoid cavity, is the 4/7 one.
Both the condyles, after the treatment are in the correct position (4/7), and in an asymptomatic orthopedic position.
Tinnitus have been reduced by 80%.
Headache is gone just applying a Farrar’s plaque.
Articulation of the upper model
with the first mock-up by KTS System (kavo) and lower arch still untouched.
The articulator was set to individual values.
The request was to waxing both models, with a slight modification of the upper situation, increasing by 0.3 mm incisal edge and the full wax-up of the lower arch.
Waxing, must follow Wilson and Spee’ compensation curves.
Celenza’s occlusion,
analogically realized and digitally optimized.
After duplicating dental wax up, masks have been created. A Composit Intraorally pressed system, allowed us to teste aesthetics and occlusion in the new mock-up.
The control of eccentric movements, has been achieved through the construction of a grouped lateral occlusion and an anterior guidance.
Gürel G, Bichacho N.
Permanent diagnostic provisional restorations for predictable results when redesigning the smile.
Pract Proced Aesthet Dent. 2006 Jun;18(5):281-6; quiz 288, 316-7.
The patient who lives 500 kilometers from dental practice, should have led the temporary restaurations, on partial preparations, for a long time.
In order to improve patient compliance, it was decided to press with a silicone key the second mock-up, adhesively and without touching teeth.
II° mock-up has been pressed with bis-acrylate and then, after the cut back, with Micro-Hybrid transparent composite. While the upper jaw was pressed over the first mock-up.
The aim was to test the aesthetics and function, such as a second provisional and let it
functionalizing for 3 months.
After this period the patient was in total confort.
Cortellini D, Canale A.
Bonding lithium disilicate ceramic to feather-edge tooth preparations: a minimally invasive treatment concept.
J Adhes Dent. 2012 Feb;14(1):7-10.
Schlichting LH, Resende TH, Reis KR, Magne P.
Simplified treatment of severe dental erosion with ultrathin CAD-CAM composite occlusal veneers and anterior bilaminar veneers.
J Prosthet Dent. 2016 Oct;116(4):474-482.
Imburgia M, Canale A, Cortellini D, Maneschi M, Martucci C, Valenti M.
Minimally invasive vertical preparation design for ceramic veneers.
Int J Esthet Dent. 2016;11(4):460-471.
Fradeani M, Barducci G, Bacherini L.
Esthetic rehabilitation of a worn dentition with a minimally invasive prosthetic procedure (MIPP).
Int J Esthet Dent. 2016 Spring;11(1):16-35.
Transfer of informations from the provisional functionalized
it has been realized by cross mounting.
Dental preparation began by milling the provisional (mock up). To not lose VD and spatial position of the jaw, a composite articular key was built with a front stop on 1.1 and 2.1 and two posterior on 1.7 – 2.7.
Laboratory needs:
2 silicone impressions, to repress provisionals;
2 silicone impressions for cross mounting;
silicone bite(Occlufast, Zhermack) between functionalized provisionals;
Kinematic facebow;
resin recordings, for cross mounting;
Final impressions.
Schmidt KK, Chiayabutr Y, Phillips KM, Kois JC.
Influence of preparation design and existing condition of tooth structure
on load to failure of ceramic laminate veneers.
J Prosthet Dent. 2011 Jun;105(6):374-82.
Bakeman EM, Rego N, Chaiyabutr Y, Kois JC.
Influence of ceramic thickness and ceramic materials on fracture resistance of
posterior partial coverage restorations.
Oper Dent. 2015 Mar-Apr;40(2):211-7.
Dental milling was performed using the concept of minimal invasiveness.
Posterior teeth were prepared for occlusal-buccal veneers.
Front teeth were prepared for veneers, according to wrap preparation technique.
(Schmidt KK e coll. 2011)
Impressions and developed master models
AFTER DENTAL PREPARATION a new provisional was pressed with bis-acrylate
(Protemp 4 3M). using the silicone impressions of the mock-up.
Provisional Details
Cross mounting
and individualization of anterior guidance.
During the construction of the final products, you want to have continuous control of the reconstructions, in relation to the provisional functionalized, thanks to a possible model exchange. It then makes the Crusading assembly, initially blocking the top model of the provisional functionalized (kinematic face bow), comparing successively, the lower the stumps model. Then, to the latter, the upper model is coupled with the stumps and finally, the lower model to the upper of the provisional consideration.
This procedure allows us to build a incisal individualized guidance, designed by the journeys of the models with the provisional functionalized, thus obtaining softer excursions and curvilinear.
Zhang Z.
Iterative point matching for registration of free-form curves and surfaces.
Int J Comput Vis. 1994;13:119–52.
Sang YH, Hu HC, Lu SH, Wu YW, Li WR, Tang ZH.
Accuracy Assessment of Three-dimensional Surface Reconstructions of In vivo Teeth from Cone-beam Computed Tomography.
Chin Med J (Engl). 2016 Jun 20;129(12):1464-70.
Mischkowski RA1, Pulsfort R, Ritter L, Neugebauer J, Brochhagen HG, Keeve E, Zöller JE. Geometric accuracy of a newly developed cone-beam device for maxillofacial imaging.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Oct;104(4):551-9.
Digital Convertion of analogic data about curvature planes, allows us to optimize virtual modeling of occlusal contacts. This has resulted in an overall improvement of the desired occlusion.The inter-incisisal angle is an important factor of the position of the incisors from the cephalometric and gnathological point of view.
In Deep bite cases the angle is reduced, while it is increased in cases of open bite.
In this case we have pursuit a right interincisal angle 125°.
Clinician’s request
Posterior monolithic restorations (occlusal-vestibular veneers Emax Ivoclar), in order to not lose the information received by the functionalized provisional.
Anterior stratified veneers, to optimize the aesthetics ( Emax Ivoclar).
The images, want to show coherence between digital design project, analogical project and plastic prototypes.
Two anterior prototypes were produced, with different shapes and different incisal edge, to evaluate which would integrate aesthetically better.
Once tested the prototypes, the forms were chosen together with the patient.
Crowns in lithium silicate and thickness control for veneering
Final dental restorations on models mounted, on the articulator.
Magne P, Perroud R, Hodges JS, Belser UC.
Clinical performance of novel-design porcelain veneers for the recovery of coronal volume and length.
Int J Periodontics Restorative Dent. 2000 Oct;20(5):440-57.
Cementation
All restorations were tried individually, checking the fit and the contact points.
Guess PC1, Selz CF, Steinhart YN, Stampf S, Strub JR.
Prospective clinical split-mouth study of pressed and CAD/CAM all-ceramic
partial-coverage restorations: 7-year resultInt
J Prosthodont. 2013 Jan-Feb;26(1):21-5
Guess PC1, Selz CF, Steinhart YN, Stampf S, Strub JR.
Prospective clinical split-mouth study of pressed and CAD/CAM all-ceramic
partial-coverage restorations: 7-year resultInt
J Prosthodont. 2013 Jan-Feb;26(1):21-5
Partial preparation design to all teeth. Anterior guidance and group function.
No problems highlighted
Greater self-confidence
5 years follow-upThe patient’s request was to improve function and to have aesthetically pleasing aspect. After a few weeks by cementation, the patient, reported to the clinician to feel more confident, to relate to others in a different way, less shy, more outgoing and prone to dialogue. Finally he feels himself, with a new approach to life.
After five years he feels very well. No problems with his headache, although he still has bruxism.
The most important thing is that every night he inserts his dental protection bite. He is very happy and tells us every time he would do it again.In ogni lavoro ultimato c’è il sudore della passione, della voglia di fare, facendolo al meglio. C’e’ la speranza di aver reso felice un paziente, una persona che ha avuto fiducia in noi. Quante sono le responsabilità che noi medici abbiamo: nella diagnosi, nella scelta del piano di trattamento più adeguato, nelle scelte dei materiali, nell’atteggiamento sempre deontologico!
Non bisogna mai dimenticarlo!
L’odontoiatria per me è una passione!!
Ringrazio Dio che ha fatto in modo che il mio Hobby fosse anche il mio lavoro.
Maurizio De Stefano
