Maged Iskaros
From Single Discolored Tooth to a Full-mouth Reconstruction
Abstract
A full
mouth reconstruction and rehabilitation is a reality. Predictability and success can be achieved if
the golden rules of healthy, functional, dynamic occlusion are tested and
implemented in a structured, orderly manner to secure the multiple intricate
phases of treatment.
How do
you address healthy, functional occlusion to a person who doesn’t have any
pain, discomfort, or concern? This is the greatest challenge that facing dentists
who try to achieve and provide optimum dental care for all their patients
Introduction
A
majority of dentists cannot articulate and present the benefits and value of
optimal care to their patients, especially if the patient doesn’t have any
symptom like pain or discomfort. Accordingly, these dentists provide patch-up
dentistry, which doesn’t last and leaves the patient unhappy with the outcome
and the dentist professionally dissatisfied with his/her performance due to
failing to transfer the benefits of achieving their end goals of proper
treatment: health, aesthetic, beauty, function, longevity and stability.
Case report
A 62-year-old male presented to our office
with the chief complaint of a discolored tooth #8: “I don’t like the color of
my front tooth.” What transpired was a journey from a single discolored tooth
to a full mouth reconstruction.
As the
first step, a full comprehensive oral-muscular examination was performed: full
mouth x-rays and full upper and lower diagnostic models were taken. Additionally,
face bow record to mount the upper cast and CR records were taken by the bimanual
manipulation technique with the first point of contact to record any deviation,
deflection or fremitus in occlusion.
Before starting any prosthetic work, as a diagnostic methodology it is of a great importance to make sure the condyles are completely seated in CR position without any pain or tenderness and to remain stable for a few months. In order to achieve this, an orthopedic physiological occlusal splint (deprogrammer) was constructed on the lower jaw on CR records mounted on the articulator, establishing four points of even contact on the left and right side simultaneously. The splint was then utilized to relax the mastication muscles as the first step of occlusal therapy and to differentiate between occlusal muscular disorder or true internal derangement of the joint.
In
1983, it was determined by Williamson and Lundquist, via electromyographic
activity, that the muscles of mastication were shown to be at rest during
canine guidance more than during group function, suggesting that canine
protected occlusion reduces muscle strain.
The
goal is to find and locate the centric relationships (“CR”), regardless of the
teeth’s position—CR is the relationship between the upper and lower jaws which
is the condyles to be seated in the glenoid fossa without strain or force. The
CR is considered a great reference point on how to start and end up with a
healthy and stable bite. A complete charting, periodontal examination revealed
moderate horizontal bone loss. However, occlusal exam revealed attrition,
abrasion, clenching, grinding. Additionally, the teeth were flattened and
significantly worn down, with further occlusal analysis we found the following occlusal
scheme:
- No cuspid protected occlusion was
found
- Slight bilateral group function
and considerable deflection from the third molar in protrusive movement which
predicts the lack of anterior guidance. As it shows in figure one, it’s edge to
edge in class III malocclusion.
Wiens,
et al. provides a discussion on occlusal equilibration. The definition of
occlusal equilibration is, “the elimination of prematurities or deflective
occlusal contacts or [creating] harmonious gliding tooth contacts, which
reduces off-axis loading or atypical wear patterns.” [3] Specifically, on those
patients who are symptomatic or those who will be undergoing. They also argue
for a mutually protected occlusion and that the goal of occlusal therapy is to
create stability and harmony by which ever means is appropriate for the patient
in each specific case. There should not be any balancing interfering contacts
during any movement in all cases in a natural and prosthetic dentition. Wines,
et al. also including support for a canine protected occlusion because of its
effectiveness in eliminating occlusal interferences during laterotrusive,
mediotrusive, and protrusive excursions.
The
master treatment plan and the blueprint was constructed as follows:
- Redo RCT on tooth # 8, cast
post, and all porcelain crowns on teeth #’s 4 à 13 and cast gold on all upper
molars
- The proposed and approved
treatment plan by the patient is to lengthen the clinical crowns of teeth #’s 4
à 13 and teeth #’s 20 à 29
- Removal of lower teeth #s 17 and
32
- Complete perio-osseous surgery
for four quadrants to remove all diseased bone and reducing pocket depth and
establishing a better, healthier perio environment for the more definitive
prosthetic work
- Construction of lower porcelain
veneers on teeth #’s 22 à
27, PFM on premolars #’s 20, 21, 28, 29, and complete cast gold crowns on tooth
#’s 18, 19, 30, 31.
Due to
severe grinding and attrition, the patient lost all his posterior holding
contacts. Therefore, the mandible slide forward and gave a pseudo class III
impression.
A
diagnostic wax-up was made and presented to the patient. Then this was
transferred to a set of acrylic provisionals. By utilizing the models, copying
the diagnostic wax up, and having a plastic tray made on the models, they served
us as a guide during the surgical crown lengthening procedure to determine how
much we needed to remove from the soft and hard tissues to achieve appropriate
length of the upper and lower anterior teeth.
- Lower
anterior teeth #’s 22 à
27 was prepared for veneers. Luxatemp was used as a temporary restoration
- Upper
anterior and bicuspid teeth #’s 4 à 13 were prepared for full porcelain crowns,
acrylic crowns were used as a temporary restoration.
- All
bicuspids were prepared for PFM
- All
molars were prepared for full casted crowns
- It’s
noteworthy that temporary restorations will chip and wreck for 2-3 times during
2-3 months of being temporized by acrylic which is considered normal for
adjusting to a new normal bite. From deprogramming to reprogramming, the
muscles will accept and adopt to the new muscular position
Conclusion
The
patient was very cooperative and receptive to a full mouth rehabilitation
treatment although it took 12 months to finish the entire treatment.
Additionally, the patient continues to wear the occlusal splint to protect the
restorations from possible damage and to provide reasonable guidance during the
night in case of any non-conscious excursive movement.
The
patient reported no muscle pain or discomfort and appreciated the outcome by elevating
the dental IQ of the patient. Moreover, by creating a form of simple steps to a
complete occlusal rehabilitation and breaking it into small procedures, we can
test drive the outcome of every phase of the treatment before getting to the
next phase and making more definitive changes if needed for long-term success.
Very
often manipulation of occlusion can be tough and acceptance is never guaranteed;
however, predictability was achieved and accomplished by providing education to
the patient and creating the proper form and function to assure the cardinal
goals of successful treatment which are:
- Function
- Health
- Beauty
- Longevity
- (and most importantly) Stability
A
significant amount of time was spent educating and demonstrating the benefits
of the therapy to the patient; both risks and rewards were addressed as well
as.
Canine protected
occlusion was the occlusal scheme of choice for restoring the patient’s
dentition due to:
- The canine has a good crown and
root ratio capable of tolerating high occlusal stress and it is the patient’s
strongest tooth to bare the lateral excursion forces
- The upper canine root has a
greater palatal surface area which is suitable for guiding lateral movement
- The canine is the best tooth to
play a pivotal role in crossover movement (extreme lateral – protrusive to
protect the four incisors)
- The canine provides the best
proprioception in the anterior region
Below
are the before and after pictures of this patient’s full-mouth rehabilitation
treatment. Please note the transformation from pseudo-Class III occlusion to
Class I occlusion:
References
- Wiens J., et al. “Occlusal
Stability”. Dental Clinics of North
America 58.1 (2014) 19-43.
- Williamson EH and Lundquist DO.
“Anterior guidance: its effect on electromyographic activity of the temporal
and masseter muscles”. Journal of
Prosthetic Dentistry 49.6 (1983): 813-823.
