Ali Tunkiwala
Personal History: 57 year old, male Patient
Medical History: Not Clinically Significant.
Immediate Concern:
- Old Broken Restoration with food lodgement
- Inability to eat
- Upper front teeth have become shorter in past few years and
- Noticed some damage by wear on posterior teeth too
Clinical Findings:
- TMJ healthy. Load test negative
- No muscular pain
- Faulty bridge in upper right quadrant. On removal of bridge, upper right first premolar structurally poor and over prepared
- Broken lower left second molar (#37)
- Moderate to severe generalized wear
- No tooth exposure when lips are in repose and minimal tooth display in maximum smile
Risk Assessment:
Periodontal Risk: Low.
The overall periodontal condition of teeth is good and no bleeding on probing except in area of the faulty bridge. No mobility of any teeth. Gingival Recession seen in upper left Canine.
Biomechanical Risk: Moderate
Overall structure of teeth was good inspite of the wear. Sufficient enamel was present on axial surfaces of most teeth for bonding. Risk of biomechanical failure was high for #14 and #37
Functional Risk: Moderate
The inability to chew well along with the loss of tooth morphology contributed to the moderate risk.
Dentofacial Risk: Low
The low lip line with no display of the gingival architecture led to a low risk from aesthetic standpoint. The recession on #23 was not treated with any soft tissue procedure as it was not visible in the smile and thus additional procedures were not needed to aesthetically correct it.
Diagnosis: Occlusal Dysfunction
Treatment Plan:
- Remove all old restorations and evaluate underlying teeth
- Recalibrate vertical dimension of occlusion to restore it
- Remake all restorations in CR and
- Achieve anterior guidance that respects the chewing envelope of the patient
#23 Gingival Recession not treated as Lip Line was low with no gingival display
#37 Crown Lengthening was done to get ferrule
Treatment Sequence:
Deprogram with Lucia jig and scan the preoperative status of the teeth with an intraoral scanner with joints in seated condylar position. (CR). The scan was performed at desired increased vertical dimension of occlusion. 3 D Printed models were made at this position on which analogue wax up was done for full coverage on all teeth to replace the lost occlusal anatomy. Onlay’s on posteriors were avoided as there wasn’t sufficient enamel to bond to on the occlusal surfaces and the bite forces were high. A putty index was made from the wax up to make bonded provisional restorations on all unprepared teeth. This enables us to test drive function and aesthetics.
The patient was given 3 weeks time to adapt to the new provisionals and in that much time the endodontics for #14 was redone and some more teeth needed the same. Crown lengthening was done for #37.
At 6 weeks, anterior preparations were done for Lithium disilcate restorations and digital impressions taken. A scan of approved provisional was used in the lab to merge the morphology of the final upper anteriors similar to the approved provisionals.
After 2 weeks, upper anterior’s were bonded and then all the remaining teeth were prepared and digital impressions done. Molars received translucent zirconia crowns and the upper right bridged was made in layered high strength zirconia.
Final occlusion was adjusted to achieve shim stock contacts from canine backwards on all posterior teeth, Anterior teeth will not hold the shim stock. The patient was then asked to chew on 200 micron paper to mark out all chewing interferences that were removed to have a friction free chewing pathway.
The case has been followed up for 15 months so far.
Lab work: Adaro Dental lab, Mumbai
REFERENCES:
- Mauro Fradeani. 1: Esthetic Rehabilitation In Fixed Prosthodontics: Esthetic Analysis: A Systematic Approach To Prosthetic Treatment. 1st ed. Quintessence Publishing USA;2004
- Mauro Fradeani,Giancarlo Barducci.2: Esthetic Rehabilitation in Fixed Prosthodontics: Prosthetic Treatment: A Systematic Approach to Esthetic, Biologic, and Functional Integration 1st ed.Quintessence Publishing USA;2004
- Kois JC.New Challenges in treatment planning-Shifting the Paradigm Toward Risk Assessment and Perceived Value—Part 1. Journal Cosmetic Dentistry; Winter 2011; 26( 4): 63-69
- Kois JC.New Challenges in treatment planning Part 2 Incorporating the Fundamentals of Patient Risk Assessment. Journal Cosmetic Dentistry Spring 2011; 27( 1):110-117
- Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems. 2nd ed. St. Louis, MO: Mosby; 1989
- Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago, IL: Quintessence Publishing; 2002.
- Edelhoff D, Sorensen JA. Tooth structure removal associated with various preparation designs for posterior teeth. Int J Periodontics Restorative Dent. 2002;22(3):241-249.
