pros tho don tics in clinical practice

PROSTHODONTICS INCLINICAL PRACTICE

PROSTHODONTICS INCLINICAL PRACTICE

Robert S Klugman, DDS

Former Senior Clinical LecturerDepartment of ProsthodonticsHebrew University-Hadassah School of Dental MedicinePrivate practiceJerusalem, Israel

Contributions by

Harold Preiskel, MDS, MSc, FDS RCS

Consultant in Prosthetic DentistryGuy's HospitalPrivate practiceLondon, UK

and

Avinoam Yaffe, DMD

Professor, Department of ProsthodonticsDirector, Graduate Training ProgramHebrew University-Hadassah School of Dental MedicineJerusalem, Israel

MARTIN DUNITZ

2002 Martin Dunitz Ltd, a member of the Taylor & Francis group

First published in the United Kingdom in 2002by Martin Dunitz Ltd, The Livery House, 7-9 Pratt Street, London NW1 OAE

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Patient 15 A new vertical occlusion

163Treatment by Shaul Gelbard

Patient 16 Advanced periodontal disease

173Treatment by Ayal Tagari

IV CONGENITAL DISORDERS

183Patient 17 Severe unilateral cleft lip and palate

185Treatment by Miriam Calev

Patient 18 Unilateral cleft lip and palate andpartial anodontia

197Treatment by Thomas Zahavi

Patient 19 Generalized amelogenesis imperfecta

207Treatment by David Lavi

Patient 20 Bilateral cleft palate and Raynaud's disease

215Treatment by Yael Houri

I ndex 225

CONTENTSvi

FOREWORD

I t has been a pleasure and privilege tomake a contribution to this project. Thebook represents the fruits of a lifetime'sexperience of the principal author; withinit you will find pearls of wisdom and agreat deal of common sense. The workrepresents more than a series of casereports and far more than a technique-oriented clinical manual: it is all about thetreatment of patients and adaptingprosthodontic techniques to the individualsituation, rather than the other way round.So often overlooked is the fact thatpatients who have suffered severe toothloss do not usually arrive for treatmentwith a mouth in pristine condition. Yet DrKlugman and his graduate students takepatients, establish rapport, and motivatethem. This is a book about the real world,and one for all who are interested in

prosthodontics; it illustrates how relativelyinexperienced colleagues can carry outinvolved procedures provided they are setout in a step-by-step logical process.Make no mistake that there is anythingsimple about some of the plans of treat-ment: adult orthodontics, site preparationfor implants and implant prosthodontics,together with complex fixed and remov-able prostheses, all feature within the text.Some of the techniques employed havebeen available for many years, buttechniques, after all, are only means to anend. Dr Klugman has been able to takeadvantage of his clinical experience toadapt these well-tried methods topresent-day prosthodontics, and in thishe has succeeded admirably.

Harold Preiskel

PREFACE

The idea for writing this book came whilesitting in one of the seminars of our gradu-ate program in Prosthodontics.

One of our students was presenting aprogress report of his patient, discussingthe diagnosis, and the possible treatmentplans. Finally, he showed his treatment andexplained its rationale. As I sat there, thethought came to me, what a waste ofinformation this is; the student is present-ing a beautifully documented treatment fora very difficult patient with superb radio-graphs and slides. What a shame that onlythe 12 or so people in the room areviewing it.

The purpose of the book is to share ourtreatment modalities and rationale of treat-ment with as many dentists as possible.

Our seminars provide at least one hourof case presentation time with a continua-tion possible the following week. Duringthe presentation, the instructors and otherstudents question the diagnosis and treat-ment plan, volunteering their opinions andalternative treatment strategies. It's a giveand take situation. It is our conviction, thatthis is one of the best learning processesfor a graduate student.

The Graduate Program i n OralRehabilitation was initiated in 1978 whenthe Israeli Parliament passed a law recog-nizing dental specialties. Until that year, theonly specialization recognized by theMinistry of Health was Oral andMaxillofacial Surgery, which was a 5-yearprogram. In 1979, the Department of OralRehabilitation set up a program to teachGraduate Prosthodontics.

The program is of 3'/ years duration andincludes certain clinical and basic sciencerequirements. Successful completion ofthe program enables the student to beeligible for the specialty licensing examina-tion administered by the Ministry of Healthin order to qualify as a specialist in OralRehabilitation. In the first years, one or twostudents were accepted to the programand, as time went on, the program wasexpanded to include up to four studentsper year. This gave a core group ofbetween 12 and 16 students to participatein seminars and treat patients.

Today the program encompasses fourdays a week, in which the students spend4 hours in seminars each week. Theseconsist of case presentations, literaturereviews, and research on prostheticsubjects, and additional full day seminarsas needed. The students spend 3 days aweek treating clinical patients under thesupervision of board certified instructors.The remainder of their time is spent inclinical or original research. Many of thestudents carry out basic research projectsleading to a Masters degree or Doctorate.

The program is integrated with otherspecialty programs at the Dental School,including Periodontics, Orthodontics, OralSurgery, and Endodontics. The graduatestudents treat implant patients. They planand oversee the surgical phase, but do notperform the surgical procedures. Mostperiodontal surgery, endodontic, oral surgi-cal, and orthodontic procedures arereferred to graduate students or specialistsin the other disciplines.

The philosophy of treatment in theprogram is based on the clinical and learn-ing experiences of the faculty, who havethemselves been trained in Prosthodonticsat The University of Pennsylvania, NewYork University, and The University ofToronto, in the 1960s and 1970s. Thustheir diverse backgrounds mean that thefaculty members bring to the programvaried ideas of treatment. We have tried toincorporate the best aspects of each ofthese programs for our own syllabus.Some of the methods we use have beendeveloped here in Israel.

PREFACE

I would like to personally thank all thegraduate students, former and present,especially those who contributed to thebook, the faculty of the program,Professor Jacob Ehrlich, ProfessorAvinoam Yaffe (Program Director), Dr IsraelTamari, and Dr Erez Mann. Special thanksgo to Professor Harold Preiskel andProfessor Avinoam Yaffe who providededitorial commentaries, who made greatefforts in helping me, and without whoseaid I doubt that the book would have beenwritten.

x

INTRODUCTION

The book is divided into four parts accordingto the primary problem of the patient:Periodontal breakdown, Dysfunctional habitpatterns, Extensive loss of teeth, andCongenital disorders. Naturally, most patientsoverlap and fall into more than one category.

The basis for all our prosthodontic treat-ment, is a healthy periodontium. The maingoal of our treatment is to identify thecausative factors of the patient's dentalproblem, and thus be able to control them.Therefore a prerequisite of all treatment is forus to determine these causative factors and,together with the patient, control them. Thisis done by initiating meticulous oral hygieneand controlling dietary habits and foodconsumption. At the beginning of treatment,the patient undergoes initial preparation untilthey prove that they will cooperate completelyin their own treatment, by executing excellentoral hygiene. Techniques include flossing,correct toothbrushing, use of stimulators andall periodontal aids necessary to maintain ahealthy periodontium. For patients with caries,a dietary analysis is made and the patient iscarefully checked to see that they adhere totheir new diet. The initial therapy permits usto check the individual patient's biologicalresponse and determine whether the diseaseactivity can be controlled. In some cases, dueto genetic factors or the patient's personality,the biological response cannot be controlled,and this will naturally alter the treatment plan.Unless otherwise noted, all patients werenon-smokers.

A speech therapist provides ancillarytreatment, if needed. All past medicalhistories are carefully evaluated and, if

necessary, consultations with the patient'sphysician are conducted prior to anydental procedures.

One of the philosophies of our treatment isto give the anterior teeth the added functionof supporting the vertical dimension of occlu-sion. The anterior teeth are customarily onlyused for incising food, speech, esthetics, andanterior guidance in eccentric movements ofthe mandible. By utilizing the proprioceptiveproperties of the anterior teeth to providebiological feedback, the occlusal forcesapplied to the teeth are reduced. This isespecially important for patients withmutilated dentitions, where the vertical dimen-sion of occlusion has to be changed. It is alsoimportant for patients whose treatmentrequires increasing the vertical dimension forbiomechanical reasons, in order to makespace available for restorations.

It is our experience over many years thatopening vertical dimension using the anteriorteeth, especially the cuspid teeth, will reducebiting force and prevent intrusion of the otherteeth. In fact, in most patients, we are mostprobably restoring vertical dimension that waslost rather than increasing the vertical dimen-sion. These patients now usually close in amore retruded jaw position than their previousacquired one. In patients with a full comple-ment of teeth where change in the verticaldimension of occlusion is required, we preferusing a 'canine platform',1-3a modified methodfor posterior tooth eruption as opposed to aremovable appliance (Hawley). We have foundthat this approach minimizes the need for a fullmouth reconstruction and the necessity ofrestoring otherwise healthy teeth.

I n periodontally involved dentitions, andin patients where the overbite is reducedand the overjet increased due to openingof the vertical dimension, we strive on oneend and are imposed by the other todiminish lateral forces that are applied tothe teeth by decreasing cuspal angles.This then requires flattening of cuspalheight in the posterior teeth.

I n patients where the remaining teeth donot have the ability to support and guidethe occlusion, due to advanced periodon-tal disease and alveolar bone loss,implants are utilized to give additionalocclusal support. Nevertheless, whenusing implants for occlusal support, weprefer that all l ateral and protrusivemovements of the mandible be guided bythe remaining natural teeth.4-6

I n those patients where the vertical dimen-sion is altered, the determining factors areusually biomechanical, to acquire enoughgingival occlusal space for the restorations.I n these cases, we try and limit the amountof change to the minimum that is necessary.Since an increase in vertical dimension ofocclusion in patients with advanced adultperiodontitis worsens the crown-to-rootratio, we utilize orthodontic treatment ofpassive or active eruption of the teeth toimprove this ratio. Using these treatmentmodalities demands meticulous oral hygieneand constant scaling and curettage to attaineruption of the teeth, accompanied byhealthy supporting tissues.

All treatment is fully documented byphotographs and radiographs, thus providingthe source for most of the material for thisbook. The patient follow-up is usually doneby the graduate student in their own privatepractice after completion of the treatment.

Although there are two other systems(the American and the International) in usetoday, the classification system used in this

book to describe tooth position is Palmer's.Palmer's classification divides the mouthinto four quadrants: the upper (maxillary)teeth are noted above a horizontal line; thelower (mandibular) teeth are noted belowthe horizontal line; the right side of themouth is noted to the left of a vertical line,and the left side of the mouth is noted tothe right of the vertical line; teeth arenumbered from 1 to 8 in each quadrant,starting at the center of the mouth.

This gives a grid as follows:

(I n the American classification the toothwould be number 5 and in the Internationalclassification it would be number 14.)

1

2

3

4

5

6

I NTRODUCTION

REFERENCES

Yaffe A, Ehrlich J, The canine platform amodified method for posterior tooth eruption,Compend Cent Education (1985) 6:382-5.Abrams L, Occlusal adjustment by selectivegrinding. In: Goldman HM, Cohen DW, eds,Periodontal Therapy, 6th edn (CV Mosby: StLouis, 1980).Amsterdam M, Peridontal prosthesis. Twenty-five years in retrospect, Alpha Omegan (scientificissue) (1974) December.Hannam AG, Matthews B, Reflex jaw opening inresponse to stimulation of periodontalmechanoreceptors in the cat, Arch Oral Biol(1969) 14:415.Wood WW, Tobias DL, EMG response to alter-ation of tooth contacts on occlusal splints duringmaximal clenching, J Prosthet Dent (1984)51(3):394-6.Storey AT, Neurophysiological aspects of TMD,presented at the American Dental Association,Chicago, 1982.

xi

TECHNICAL INFORMATION

In patients receiving fixed partial prosthe-ses, the graduate students prepare theteeth which will be used as abutments forthe prosthesis. The preparation of choicei n mature and periodontally compromisedpatients is the knife edge preparation. Wefeel that complete shoulder or chamferpreparations are not suitable in these situa-tions since they require too much rootstructure reduction. The students thenusually make either single copper bandelastomeric impressions to impression theprepared teeth or elastomeric completearch impressions. Due to the manyproblems associated with elastomericcomplete arch impressions, such asretraction cord displacement, microhemor-rhage, errant air bubbles (usually at thefinishing line), etc, we have found it to bemore accurate to use single copper bandelastomeric impressions.1 This is especiallytrue in periodontally involved teeth andwhenever a knife edge preparation isi ndicated.

The graduate students prepare all theteeth to be utilized for the prosthesis andtemporize them in as many visits as neces-sary-this will naturally vary with eachpatient. After all the teeth have been fullyprepared for the fixed prosthesis andchecked for proper tooth reduction bymeasuring the thickness of the provisionalrestoration, and proper finishing lines, eachtooth is impressioned individually and, ifincorrect, it can be easily repeated until asatisfactory result is achieved. Again, wewould like to emphasize that in our experi-ence, when we have used full arch

elastomeric impressions, we find that it isvery difficult to get an accurate impressionof all the prepared teeth in one impression,especially in periodontally involved patientswhere there are long clinical crowns andmultiple preparations.1 In the laboratoryphase, it is also difficult to achieve anundistorted wax pattern on withdrawal formultiple abutment cases. One of theadvantages of a full arch elastomericimpression is that it permits a singlecasting with accuracy and eliminates theneed for soldering; however, in periodon-tally involved teeth with long clinical crownsi t is extremely difficult to achieve an undis-torted wax pattern removal for a singlecasting. This usually leads to additionaltreatment, which is both time consumingand traumatic to the patient.

A copper band is measured andtrimmed to fit the prepared tooth, andthen annealed in an ethyl alcohol 70%solution. This produces a softer, morepliable band with a clean polished surfacewhich will not have a rebound effect afterthe acrylic resin is placed. The band isli ned with soft, quick-setting methylmethacrylate resin and allowed to set onthe prepared tooth.

The band is removed, and the resin isinternally relieved to a depth of 0.5 mm. Anescape hole is drilled in the occlusal ori ncisal area to prevent air bubbles and thenthe impression is relined using a blue orgreen Xantropen wash technique. Thei mpressions are cast immediately in diestone; the dies are removed and trimmedafter 1 hour. The dies are hardened with a


drop of cyanoacrylate (Super Glue-5:Loctite International, Welwyn Garden City,UK) to give a very fine protective layer, andcoated with a thin layer of petroleum jelly.

Duralay (Reliance Dental ManufacturingCompany, Worth, IL, USA) or Pattern resincopings (GC Company: Kasugai Aichi,Japan) are then made on the prepareddies using a Neylon paintbrush technique.The Neylon technique is a brush-ontechnique that uses a fine brush dipped inmonomer and then in resin powder to pickup a small ball of resin which is thenplaced on the prepared tooth, starting atthe occlusal or incisal surfaces andworking towards the gingival margins. Ahole is cut in the labial occlusal or incisalcorner of the coping to ensure that thecoping is fully seated on the preparedtooth during try-in. Pattern resin copingsare individually fitted on the prepared teethand checked clinically for fit and theaccuracy of their margins. The copings arealso used for centric relation recording andvertical dimension registration. The resincopings are then picked up with a full archelastomeric impression (Impregum) mat-erial. The individual dies are then placedinto their respective copings in the impres-sion and a master working model is fabri-cated.2,3 A centric relation record is thenrecorded, usually at the vertical dimensionof occlusion, and the models placed in anarticulator and the individual elements ofthe prosthesis are waxed and cast.

Once the metal framework of theprosthesis is returned by the laboratory,the individual metal elements are checkedin the mouth, and joined together usingresin. The metal framework prosthesis isthen sent to the laboratory for soldering.On return, the prosthesis is then checkedin the mouth again and another centricrelation record made. The soldered

copings are then picked up with a full archelastomeric impression (Impregum) mat-erial to capture soft tissue detail.

At this stage, the individual dies are notneeded and the laboratory technicianplaces reinforced resin into the lubricated(petroleum jelly) metal framework in theimpression, and dental stone for theremainder of the model. This is the finalmaster working model. This techniquegives not only fine tissue detail but also areproducible positive seat for the castingswhenever they are removed from themodel, thus avoiding damage to the modelby constant removal and placement.

The master working models are articu-lated to the semi-adjustable articulator(Hanau: Teledyne Hanau, Buffalo, NY USA)by means of a face bow registration andcentric relation records performed at thevertical dimension of occlusion as deter-mined by the provisional restorations.Since the working models are articulatedat the vertical dimension of occlusion, it isfelt that a fully adjustable articulator is notnecessary.4

The porcelain is then baked and fittedin the patient's mouth, with special atten-tion paid to fit and occlusion. If neces-sary, the occlusion is adjusted usingsmall round diamond stones until thearticulating paper shows that there isuniform and even contact in centricrelation (coincident to centric occlusion)between all the posterior teeth and thatthe anterior teeth are in light contact only.The prostheses are then returned to thelaboratory where the final glaze of theporcelain is done.

At the insertion appointment, theprostheses are `cemented' with a paste ofpetroleum jelly and zinc oxide ointment(only) for 24-72 hours. The patient thenreturns and the occlusion is rechecked

XIV


and adjusted if necessary. The restora-tions are then cemented with a mixture ofzinc oxide and eugenol cement (Temp-Bond: Romulus, MI, USA) and petroleumjelly for a further 72 hours. If there is nowashout after 72 hours, the restorationsare cemented with just Temp-Bond for a3-week period. They are then carefullyremoved and checked for wash-out, andadjusted if necessary.

The patient is questioned at each visitafter the initial insertion as to comfort andwhether there is any sensitivity with the newrestorations. Only after everything is to thepatient's and our satisfaction, are therestorations permanently cemented withzincoxyphosphate cement. The preparedteeth are first dried and only then are therestorations cemented. The restorations arecemented in the smallest individual unitspossible, one at a time, with the remainingteeth in occlusion and provide the correctseating forces during cementation. After

cementation, the occlusion is checkedagain to verify its accuracy.

ACKNOWLEDGEMENT

I would like to thank Ardent DentalLaboratory who did most of the laboratorywork pictured in the book.

REFERENCES

1

Gelbard S, Aoskar Y, Zelkind M, Stern N, Effectof impression materials and techniques on themarginal fit of metal castings, J Prosthet Dent(1994) 71(1):1-6.

2

Azizogli MA, Catania EM, Weiner S, Comparisonof the accuracy of working casts made by directand transfer coping procedures, J Prosthet Dent(1999) 81(4):392-8.

3 Lin CC, Ziebert GJ, Donegan SJ, Dhuru VB,Accuracy of impression materials for complete-arch fixed partial dentures, J Prosthet Dent(1988) 59(3):288-91.

4 Weinberg L, Atlas of Crown and BridgeProsthodontics (Mosby: St Louis, 1965).

Ali

logo 2

PATIENT 1

RETROGRADE WEAR

Treatment by Mordehai Katz

THE PATIENT

PAST DENTAL HISTORY

The patient, a 56-year-old self-employedbuilding contractor, came to the clinic fordental treatment. His chief complaints were( Figures 1.1-1.3):

The patient had never visited a dentistregularly. The last visit to a dentist was at

`I can't eat.'' My lower front tooth is shaky.'` Sometimes my side teeth hurt me.'

PAST MEDICAL HISTORY

The patient's medical history was un-remarkable; he had no allergies, and wasnot taking any medication.

Figure 1.2

Posterior teeth-right side.

Figure 1.1

Figure 1.3

Front view of anterior teeth. Posterior teeth-left side.

3

PROSTHODONTICS IN CLINICAL PRACTICE

Figure 1.4

Face-frontal view.

Figure 1.5

Face-side view.

the age of 16 at which time his mandibularmolars were extracted. He claimed that healways had the spaces between his frontteeth, but he felt that they were gettingwider. He brushed his teeth twice a day,morning and evening; he did not use anytoothpaste, only a toothbrush.

EXTRA-ORAL EXAMINATION(Figures 1.4 and 1.5)

Symmetrical faceProfile-straight to convexNormal temporomandibular jointNormal facial musculatureMaximum opening of 40 mmMandibular movements-slight devia-tion to the left upon opening and thereverse upon closingSlight midline discrepancy

I NTRA-ORAL AND FULL-MOUTHPERIAPICAL RADIOGRAPH

EXAMINATION

Maxilla (Figure 1.6):

CariesSpacing between the anterior teethMissing right third molar, and left firstpremolar teethAmalgam restorations on the left andright premolars and molarsRetrograde wearSpacing due to the extraction of the leftfirst premolar and subsequent drifting ofthe left cuspid distallyLeft cuspid-pulp exposureFistulas in the buccal vestibulum of thearea of the right first premolar and leftlateral incisor teeth

•

Very poor oral hygiene• Parabolic arch

Figure 1.6

Maxillary arch-palatal view.

4

RETROGRADE WEAR

Figure 1.7

Mandibular arch.

• Overeruption of the first premolars andmolars on both sides

Mandible (Figure 1.7):

Occlusal examination (Figures 1.1-1.3)revealed that the patient was Angle class IIIwith anterior cross-bite. The interocclusal restspace was 5.0 mm. Overjet was -1.0 mmand overbite was 3.0 mm. The differencebetween centric relation and centric occlusionwas 1.0 mm anterio-posteriorly.

Mobility class 2 on the maxillary left firstmolar, class 1 on the maxillary leftsecond molar, and 1/2 on the maxillaryleft lateral incisor teeth.Mobility class 3 on the mandibular leftcentral incisor, class 2 on the mandibu-lar right central incisor, class 1 on the

mandibular lateral incisor, and class 1/2on the right mandibular cuspid.Fremitus in closing movements onmaxillary right first premolar andi ncisor teeth.Non-working side interferences in leftlateral movements between the maxil-l ary right lateral incisor and themandibular first premolar, and themaxillary right central incisor and themandibular cuspid.Non-working side interferences in rightl ateral movements between the maxil-lary left central incisor and the leftmandibular cuspid and left laterali ncisor.Anterior guidance at the beginning ofprotrusive movements, including themandibular right premolars and at theend of the protrusive movement, the leftfirst premolar also participates.

There was working side contact in rightlateral movements between the right maxil-lary second premolar and the rightmandibular second premolar, and in leftl ateral movements between the maxillaryleft second premolar and the mandibularleft second premolar.

Periodontal examination (Figures 1.8 and1.9) revealed large amounts of calculus andplaque, probing depths of up to 6.0 mm onsome of the mandibular teeth and up to 7.0mm on some of the maxillary teeth. Therewas bleeding on probing (BOP) on most ofthe teeth. There was gingival recessionaround some of the teeth (Figures 1.1-1.3).

The maxillary right first molar had class 2furcation involvement on the buccalsurface, and class 1 furcation on the mesialsurface, and the maxillary left first molarhad class 3 furcation involvement onbuccal, mesial and distal surfaces. The


second left molar had class 1 furcationinvolvement on the buccal and mesialsurfaces.

FULL-MOUTH PERIAPICALSURVEY (Figure 1.10)

Figure 1.8

Periodontal chart-mandible.

Figure 1.9

Figure 1.10

Radiographs of maxilla and mandible-pre-treatment.

6

Periodontal chart-maxilla.

RETROGRADE WEAR

INDIVIDUAL TOOTH PROGNOSIS

Figure 1.11

Cephalometric analysis.

t

CEPHALOMETRIC ANALYSIS

The cephalometric analysis (Figure 1.11) wasdone to evaluate the following relationships:

• Relation of the maxilla to the skull• Relation of the mandible to the skull• Relation of the maxilla to the mandible

Determined values:

Measurement AverageGo-Gn 82 84Co-Gn 125 122.5Palatal plane point A 59 59(Go, gonial; Gin, gnathion; Co, condyle.)

I nterarch relationships:

SNA 85SNB 83ANB 2 2(SNA, seta nasion point A; SNB, selanasion point B; ANB, difference between Aand B.)

DIAGNOSIS

• Pseudo-Angle class III• Advanced adult periodontitis• Reduced posterior occlusal support• Missing teeth accompanied by shifting

of teeth• Extreme wear due to occupational

involvement• Caries• Reduced vertical dimension• Faulty occlusal plane with extrusion and

tipping of teeth• Secondary occlusal trauma with primary

origins• Periapicallesions

ABOUT THE PATIENT

The patient was very pleasant and willing todo what was necessary to have treatment.He was cooperative and had no preferencefor a fixed or removable restoration.

POTENTIAL TREATMENTPROBLEMS

• Many missing teeth accompanied byextensive resorption of the residual

alveolar ridges, extrusion, and shiftingof teeth

•

Extensive loss of tooth structure due tointense wear as well as periodontal andperiapical pathologies

•

Many of the remaining teeth had severeperiodontal problems and their progno-sis was guarded

•

Loss of vertical dimension and extrusioncausing a faulty occlusal plane

TREATMENT PLAN

PHASE 1: INITIAL PREPARATION

•

I nitial periodontal therapy including:oral hygiene instructionscaling and root planing

Extraction of hopeless teethCaries excavation and endodontictreatment where necessaryEvaluation of patient cooperationProvisional fixed prosthesis restoringlost vertical dimension and providingocclusal support in the new verticaldimension

Re-evaluation led to the second phase ofthe treatment plan.

PHASE 2: TREATMENT OPTIONS

Maxilla:

•

Fixed and partial removable prostheses• Fixed prosthesis supported by natural

teeth and implants• Fixed partial prosthesis supported by

natural teeth

Mandible:

•


teeth and implants


TREATMENT

I nitial treatment consisted of oral hygieneinstruction, scaling and root planing (Figures1.12-1.14) The hopeless teeth, maxillaryright first premolar, cuspid, left cuspid andleft first molar, were then extracted.Endodontic therapy was carried out on themaxillary right first molar, left lateral incisor,left second premolar and the left secondand third molars. These teeth were thenrestored with composite resin restorationsto replace the material removed in theendodontic preparation.

After ruling out an abrasive diet, erosivecomponents, and day and night bruxism, itwas concluded that the retrograde wear ofthe patient's remaining teeth was due tothe fact that he had lost many teeth overthe years and the remaining teeth wererequired to take over all masticatoryfunction. I n addition, his professionaloccupation as a builder, where he wasconstantly involved in an environment ofdust, was also a contributing factor to theretrograde wear.

In order to restore the loss of coronaltooth structure over the years, the remain-ing maxillary teeth were then prepared andprovisional restorations placed at a newvertical dimension of occlusion, thusproviding cross-arch splinting. This newvertical dimension was determined by thefunctional and biomechanical requirementsfor treatment.

The provisional restorations in the newvertical dimension and occlusal schemeprovided the following:

Maximum occlusal contactsLateral jaw movements without balanc-ing side prematuritiesSeparation of the teeth during lateralmovement of less than 1.0 mm

RETROGRADE WEAR

Change of vertical dimension to enablemaximum contact in centric relationwith the anterior teethBetter overbite and overjet relationshipsfor protrusive movement disclusion(these can be seen clinically and also onthe cephalometric radiograph doneafter the insertion of the transitionalrestorations)SNB (after treatment with provisonals) 80ANB (after treatment with provisonals)

5

Figure 1.12

After initial preparation-front view.

Figure 1.13

After initial preparation-left side.

Figure 1.14

After initial preparation-right side.

A CT (computerized tomography) radio-graph was then done to determine thepossibility of implant placement in themandible. The radiograph revealed lack ofbone for implants due to the severeresorption of the alveolar ridge over manyyears, most probably due to the early lossof teeth.

Endodontic therapy was also carried outon the mandibular left second premolar. Toimprove its prognosis the tooth was short-ened, changing its poor crown-to-root ratio,and then restored with a coping thusenabling it to be used as an abutment for aremovable partial denture. The mandibularremovable partial denture would replace themissing molar teeth as well as the missingleft central incisor and second premolar.

There was a dramatic improvement inthe patient's periodontal condition due tohis improved oral hygiene and cooperation,and it was decided to complete thepatient's treatment with replacing thetransitional restorations in the permanentprostheses and duplicating both the verti-cal dimension and occlusal scheme of thetransitional restorations.

I n the maxilla, copper band elastomericimpressions were made of all the preparedteeth and pattern resin copings made to fitthe stone dies. A polyether full arch impres-sion was then taken of the maxilla and the

9


Figure 1.15

Mandible, final impression, Mercaptan rubber

master model poured. Mesio-occlusal restpreparations were prepared i n themandible on the left first premolar and rightsecond premolar teeth.

A mercaptan rubber base impressionwas then made using a border moldedcustom tray (Figure 1.15). The mandibu-l ar metal framework was fitted andadjusted in the mouth. An acrylic resinbite tray was constructed on the metalframework. This tray and the patternresin copings of the maxillary teeth wereused to record the centric relation at thesame vertical dimension of occlusion as

the transitional restorations. A facebowregistration was taken and the modelsmounted on a Hanau articulator. Themaxillary metal copings were fitted andconnected with pattern resin for solder-i ng. The soldered prosthesis was thenchecked in the mouth, and a polyetherimpression (Figure 1.16) was then madefor tissue detail and a pick-up of the fixedprosthesis in order to make a final mastermodel.

This was mounted on a Hanau articula-tor by means of a facebow registrationand the pattern resin registration on thesoldered metal prosthesis. The shadewas chosen and porcelain baked to themetal. The bisque bake maxillary prosthe-sis was fitted in the mouth and the occlu-sion checked and adjusted with themissing mandibular teeth that had beenset up on the partial denture. The porce-l ain was glazed and the mandibularprosthesis processed. The denture teethwere made of porcelain in order to matchthe material in the fixed prosthesis in themaxilla.

The maxillary prosthesis was cementedtemporarily and the mandibular prosthesisinserted and adjusted. After 2 weeks, the

Figure 1.16

Treatment completed-fixed prosthesis, anterior view

Figure 1.17

Treatment completed-restorations, maxilla.

1 0

RETROGRADE WEAR

11

Figure 1.20

Treatment completed-restorations, right side.

Figure 1.21

Treatment completed-restorations, anterior teeth, close-up.

maxillary prosthesis was cemented with apermanent cement (zinc oxyphosphate)(Figures 1.17-1.21).

SUMMARY

The patient came to the clinic for dentaltreatment complaining of pain, a loosetooth, and difficulty in eating. He had notvisited a dentist for 40 years and thoughtthat by brushing his teeth twice daily, itwas sufficient. He suffered from very poororal hygiene, and advanced periodontal

disease. He had many missing teeth andsome of the remaining teeth were mobilewith fremitus and periapical pathology.There was extensive wear, severe extru-sion of teeth, midline discrepancy, poorocclusal relationships, anterior cross-bite,spacing in the maxilla, and caries.Radiographs ruled out the use of implantsi n the mandible without pre-prostheticsurgery. Through increased awareness ofthe importance of oral hygiene, extensiveperiodontal, endodontic and prosthetictreatment, a functional and esthetic resultwas attained.


CASE DISCUSSIONAVINOAM YAFFE

CASE DISCUSSIONHAROLD PREISKEL

This 56-year-old person presented to thegraduate clinic with the complaint of diffi-culty in eating, pain, and mobile teeth. Itwas the purpose of our treatment to includethe anterior teeth in occlusal support forseveral reasons: many posterior teeth weremissing, thus occlusal support was lacking;secondly it was intended to achieve anteriorguidance in order to disocclude whateverposterior teeth were left, and to allowfreedom in lateral excursions. In order toaccomplish this, we took advantage of theI C-RC (intercuspal position-retruded cuspalposition) discrepancy; and made a slightchange in vertical dimension along withminor adjunctive orthodontics to close theanterior diastema. These three factorsenabled us to change a pathologic,malfunctioning, unesthetic occlusion into aphysiologic, esthetic, long-lasting occlusalscheme, that included the anterior teeth insupport, along with all the other functions ofanterior teeth, to the patient's satisfaction.

This sensible plan of treatment involvedextensive reconstruction of both jaws,establishing a new occlusal plane andtable. Whether or not there was an erosivecomponent to the loss of tooth substanceis largely irrevelant. There was almostcertainly a significant forward mandibularposture.

The decision to use porcelain artificialteeth on the removable prosthesis is under-standable, although this requires verticalspace to allow for the diatoric design toretain the porcelain. In fact, what reallymatters is not so much the hardness of theocclusal surface, but the coefficient offriction between the upper and lowersurfaces. Provided the glaze of the oppos-ing porcelain is not disturbed, moderncross-linked resin teeth will function perfectlywell, and if they should need to be changedafter 5 to 8 years, it is not such a disaster.Furthermore, if an incorrect assessment ofthe maxillo/mandibular relations had beenmade at the outset, which is quite likely inlong-term cases of forward mandibularposture, then resetting or replacing, or evenadjusting resin teeth would be considerablyeasier. I would expect this restoration tofunction well for many years.

12

14 PROSTHODONTICS IN CLINICAL PRACTICE

Figure 2.1

Figure 2.2

Face-frontal view.

Face-profile view.

Figure 2.3

Figure 2.4

Mandibular arch-lingual view.

Anterior maxillary teeth-palatal view, showing extensivewear.

BRUXISM

Figure 2.5

Anterior teeth-labial view, showing deep overbite.

Figure 2.6


Figure 2.7

Occlusion-left side.

Figure 2.8

Occlusion-right side.

premolar, as well as that between themaxillary right cuspid and first premolar.According to the patient, these spacesalways existed and did not bother her

• Mandibular right third molar wasmissing (Figure 2.10).

Occlusal analysis (Figures 2.7 and 2.8)revealed that the patient was Angle class 1with a vertical overbite of 6.0 mm and ahorizontal overjet of 3.0 mm.

I n addition, she has Fremitus class 1 onthe maxillary right cuspid, right central

incisor, left central incisor, and left cuspidand fremitus class 2 on the maxillary leftlateral incisor. The maximum opening was42.0 mm and the interocclusal rest spacewas 3.0 mm. There was palatal impinge-ment of the anterior mandibular teethonto the gingiva of the right maxillarycentral incisor and both lateral incisorteeth.

Periodontal examination revealed moderatewith localized advanced periodontitis withprobing depths up to 5-6 mm on the

1 5

1 6


mandibular molars and bleeding on • Adequate endodontic therapy withprobing on some teeth (Figure 2.9).

some

l ocalized

periapical

rarefyingosteitis (mandibular right first molar)

Radiographic examination (Figure 2.10)

• Remnants of an old amalgam restora-revealed:

tion around the mandibular secondpremolar and first molar

• Shortened roots

• Widened periodontal ligament around•

Secondary caries

maxillary right first premolar•

Overhanging margins on mandibular leftfirst premolar and left second molar

• Minimal generalized horizontal boneloss

I NDIVIDUAL TOOTH PROGNOSIS

Figure 2.9

Periodontal chart-maxilla and mandible.

The prognosis for all the remaining teethwas good.

DIAGNOSIS

Bruxism and severe wear of the anteriorteethPossible loss of vertical dimensionDeep overbitePrimary occlusal traumaModerate with localized advanced adultperiodontitis

Figure 2.10


BRUXISM

•

Secondary caries• Chronic periapical area•

Faulty restoration (secondary caries)• Spaced dentition• High blood pressure• Hormonal imbalance

ABOUT THE PATIENT

The patient was punctual for her appoint-ments, cooperated in her treatment, andunderstood the reasons for her treatmenteven though she had no subjectivecomplaints.

PHASE 1

Scaling, root planing and oral hygieneinstructionConservative dentistry to replace faultyrestoration and restore carious teethExplanation of the bruxing problem tothe patient and making her aware of theharm that it causes in order to convinceher that she should stop bruxing of herown volition

• Changing the vertical dimension ofocclusion by the use of a canineplatform to allow eruption of the poste-ri or teeth

TREATMENT PLAN

POTENTIAL DIFFICULTIESINVOLVED IN THE TREATMENT PHASE Z

The traumatic deep overbite, coupled withthe great amount of tooth structure lost,jeopardized the maxillary anterior teeth,thus requiring a quick solution. Anotherdifficulty would be the adaptation of thepatient to the required changes in herdaytime habit patterns (avoiding bruxism)which, at the age of 57, is not easy. Anypossible restoration would require changein the vertical dimension of occlusion inorder to restore the anterior teeth andadaptation of the patient to this procedurecould not be forecast. Another possibleproblem with multiple restorations might bethe unfavorable change in the crown-to-root ratio and the possibility that tootheruption would not succeed. After discus-sion with the patient, it was concluded thatthe patient was not a `night grinder' butrather, bruxed her teeth during the daywhile working in the laboratory and peeringthrough a microscope, concentrating onher work.

Conservative dentistry to restore the teethin the new vertical dimension, after passiveeruption.

PHASE 3

If passive eruption did not take place,restoration of the teeth with fixedprosthodontics to the new vertical dimen-sion.

TREATMENT

PHASE 1

The treatment included scaling, rootplaning, oral hygiene instruction, andrestoration of teeth with faulty restora-tions and caries. The daytime bruxingproblem and the resultant harm that itcauses was stressed in discussions with

1 7

1 8 PROSTHODONTICS IN CLINICAL PRACTICE

Figure 2.11

Anterior maxillary teeth-palatal view, showing canineplatform.

the patient. The patient on her ownvolition, by concentrating on not bruxingduring her working hours, was able tocease bruxing. A new vertical dimensionof occlusion was established by the useof a canine platform to enable passiveeruption of the posterior teeth (Figure2.11). The canine platform increased thevertical dimension by about 3.0 mm, asmeasured at the maxillary and mandibularcentral incisors, and 1.0 mm in the molarareas.

Figure 2.12

Anterior maxillary teeth-palatal view, showing compositebuildup.

PHASE 2

After one month when the patientappeared to have adapted to this newvertical dimension of occlusion without anyproblems, the maxillary central and lateralincisor teeth were bonded with compositeresin to contact the mandibular incisorteeth (Figures 2.12 and 2.13).

After three more months, when theposterior teeth failed to erupt into occlusion,it was thought that the tongue occupied theopened existing space and prevented theeruption of the posterior teeth (Figures 2.14and 2.15). At that time, the lingual surfacesof the mandibular premolar and molar teethwere built up by bonding composite resinmaterial to create an overbite between themandibular lingual cusps and the maxillaryli ngual cusps, in order to prevent the tonguefrom entering the space between the teeth,and interfering with the passive eruptionprocess (Figures 2.16 and 2.17).

One month later, the posterior maxillaryand mandibular teeth erupted into occlusalcontact and the lingual additions to themandibular teeth were removed and thesurfaces polished (Figures 2.18 and 2.19).

Figure 2.13

Anterior mandibular teeth-lingual view, showing compositebuildup.

BRUXISM

Figure 2.14

Figure 2.15

Right side, showing failure of teeth to passively erupt.

Left side, showing failure of teeth to passively erupt.

Figure 2.16

Figure 2.17

Mandibular left posterior segment, showing lingual cusp

Mandibular right posterior segment, showing lingual cuspcomposite buildup.

composite buildup.

Figure 2.18

Figure 2.19

Right side, showing teeth passively erupted to contact.

Left side, showing teeth passively erupted to contact.

19


A hard night guard to be worn only atnight was made for the patient as a protec-tive device to prevent continuing toothstructure loss. This was done to preventwear of the composite material that hadbeen placed on the anterior teeth.

The patient has been followed for oneand a half years and there has been noabnormal lose of tooth structure in thistime.

PHASE 3

This was not required.

SUMMARY

The patient, a 57-year-old female labora-tory technician, presented with a severeproblem of abnormal tooth wear due tobruxism. After scaling, curettage and oralhygiene instruction, and restoration ofteeth with faulty restorations and caries, aconservative method of treatment wasattempted that involved the use of acanine platform to increase the verticaldimension of occlusion. The anterior teethwere then restored to occlusal contactwith bonding and composite resinrestorations.

When the posterior teeth failed to eruptpassively into occlusion as anticipated, dueto tongue interference, an attempt to elimi-nate this interference by building up theli ngual cusps of the mandibular posteriorteeth (through bonding and compositeresin) was made. This succeeded, andwithin 3 months the posterior teeth were incontact. The patient has maintained thisnew vertical dimension of occlusion forover 18 months.


A 57-year-old woman presented herself tothe graduate program with traumatic deepoverbite accompanied by severe wear withloss of tooth structure aggravated byimpingement and laceration of the inter-dental papillae in the anterior maxilla. Atthat stage no restoration could be donedue to the deep overbite. An increase invertical dimension was mandatory in orderto solve the problem. The change in verti-cal dimension could be accomplished bycomplete mouth restoration of at least twoquadrants, either i n the maxilla ormandible.

A conservative approach was taken tosolve the problem. Instead of increasing thevertical dimension by the use of restora-tions, thus increasing the crown-to-rootratio, a platform was added to the maxillarycuspid teeth using composite resin material.This created a space between the maxillaryand mandibular teeth, enabling these teethto erupt towards each other until contactwas established. At that new vertical dimen-sion, composite resin was added to theseverely worn anterior teeth, thus restoringthe teeth with minimal expense, andkeeping the crown-to-root ratio the same asthat before the increase in vertical dimen-sion. Thus a complicated situation wassolved by a simple, cost-effective andesthetic restoration.


This patient's treatment represents anexample of sensible planning. Instead ofleading with the air turbine, a mistake thatis so easily made in these circumstances,

2 0

BRUXISM

the operators chose to make occlusalstops on the canines to allow the molarteeth to erupt. Once this had beenachieved, it was a relatively straightforwardprocess to rebuild the dentition. It is inter-esting to note that the original problem

worried the patient's dentist more than thepatient herself, yet the team were able tomotivate their patient to undergo a time-consuming, if not invasive, course of treat-ment. Equally important in this case is themaintenance therapy.

21

PATIENT 3 EXTENSIVE TOOTH WEAR

Treatment by Yehuda Shahal

THE PATIENT PAST DENTAL HISTORY

A 43-year-old retired army officer presentedhimself for examination and consultationwith the following complaints:

His dental history was uneventful. He onlywent to the dentist when he had pain.

` I have small and worn teeth and they areugly' (Figure 3.1).`If I don't have them treated now, I amafraid that I will lose my teeth.'

During his military service, he served as atank mechanic and at the time of his treat-ment had his own garage.


His medical history was negative with nounusual findings.


Normal facial symmetrySlightly square facial outlineStraight profile with competent lipsLower third of the face was slightlysmaller than the other two thirdsAccentuated labio-mental foldMaximum opening was 46 mmNo deviation in either opening or closingmovementsNo muscle sensitivity was notedJaw movements were normal

Figure 3.1

Front view of anterior teeth.

I NTRA-ORAL AND FULL-MOUTHPERIAPICAL EXAMINATION

Maxilla (Figures 3.4 and 3.5):

23

24


Figure 3.2

Figure 3.3

Frontal facial view.

Side face view.

Figure 3.4

Figure 3.5

Maxillary arch.

Lingual view of maxillary anterior teeth.

• Veneer crowns and amalgam restora-tions on some of the teeth

•

Large amounts of wear on the anteriorteeth accompanied by chipping of. Extrusion of the right second molar

EXTENSIVE TOOTH WEAR

the enamel and cupping of thedentineWear facets on the left maxillary premo-l ars were noted, but not on the leftmaxillary molarsAbsence of wear facets on the leftmaxillary second molar toothThere were wear facets on the surfacesof the guiding cusps of the fixed maxil-lary prosthesis on the right side and theveneer crown on the left first premolartooth (Figures 3.4 and 3.6): Figure 3.6

Maxillary right posterior quadrant.

The first left maxillary premolar had a1 0-year-old veneer crown with inflamedsoft tissue around it.


Missing teeth:

Ovoid jaw shapeHigh floor of the mouth withbroad muscle attachmentsShallow vestibulumEdentulous areas of the jaw showedresorption in the both the vertical andbucco-lingual dimensionsRight first molar had a broken amalgamrestoration with overhangRight second premolar had a faultydisto-occlusal amalgam restoration withmarginal overhang and wear facetsVeneer crowns on the left premolar teethwith slight inflammation around the crownsLeft premolars had gingival class Vamalgam restorationsSevere wear patterns on the anteriorteeth with open contact points due tothe wear (Figure 3.8)

Lingual view of mandibular anterior teeth.

wide andFigure 3.7

Mandibular arch.

Figure 3.8

25


Figure 3.9

Right lateral jaw movement.

Figure 3.10

Left lateral jaw movement.

An occlusal examination revealed that thepatient was Angle class 1 classification,with 0.0 mm overbite and an overjet of2.0 mm (Figure 3.1). The interocclusal restspace was 4.0 mm and the maximumopening was 46 mm, without deviation inopening or closing movements. Themandibular midline was slightly left of thecenter of the face.

There

was

a

1.0 mm

discrepancybetween centric occlusion (IC) and centricrelation (CR). Lateral jaw movements weregroup function on both sides-this in spiteof the amount of wear of the anterior teeth

(Figures 3.9 and 3.10). There were nobalancing side contacts. In protrusivemovements, there was disarticulation bythe anterior teeth and the premolars on theright side, and on the left side the posteriorteeth were in contact. There was no fremi-tus or mobility of any of the teeth. Thepatient had a removable partial mandibulardenture, which he felt was unsatisfactoryand did not use.

The periodontal examination (Figures 3.11and 3.12) revealed probing depths of up to3.0 mm on the maxillary teeth and up to

Figure 3.11 Figure 3.12

Maxillary periodontal chart. Mandibular periodontal chart.

2 6


Figure 3.13

Radiographs of right maxillary posterior quadrant.

Figure 3.14

Radiographs of left maxillary posterior quadrant.

3.0 mm on most of the mandibular teeth,with slight bleeding on probing (BOP) onsome of the teeth with restorations. Therewas inflammation around the fixed bridge inthe right posterior maxilla. The rightmandibular molars had probing depths of5.0-8.0 mm, and furcation involvementclass I was found on the right secondmolar, both in the buccal as well as thelingual furcas. There was a boney defect onthe mesial surface of the right secondmolar.


• Hopeless: none• Poor:

4 47

Good: the remaining teeth

RADIOGRAPH EXAMINATION(Figures 3.13 and 3.14)

The right first maxillary premolar hadnarrow roots, an old root canal restora-tion, a dentatus type post, and an asymp-tomatic periapical lesion. The left maxillaryfirst premolar had narrow roots, an oldroot canal filling, a dentatus type post, andan asymptomatic periapical lesion. Therewas extended root trunk in the left maxil-lary first and second molars. The rightmandibular second molar had a tempo-rary restoration following root canaltherapy.

Note: The first maxillary premolar teethhad existing root canals with periapicallesions that, although asymptomatic,would require removal of the posts andrenewal of the root canal therapy shouldnew restorations be required. The rootswere also very thin, making the removalof the existing posts very difficult withoutfracturing the teeth. Therefore theseteeth were considered to have a poorprognosis. The second right mandibularmolar tooth had an infraboney pocket onthe mesial and also a furcation involve-ment and a very broken down coronalportion, leaving a very doubtful prognosisfor the long term for this tooth.

2 7


DIAGNOSIS

•

Gingivitis with localized periodontitis•

Excessive tooth wear•

Missing teeth•

Faulty restorations•

Poor esthetics•

Decreased vertical dimension• Periapicallesions

PATIENT DISPOSITION ANDEXPECTATION

The patient was introverted, hardly everspeaking or smiling, but with a strong motiva-tion for dental treatment. In spite of thedistances involved for him to get to the clinic,he was prepared to come at any time for treat-ment. He wanted to save as many teeth aspossible and to improve the esthetic appear-ance of his mouth. He also preferred to havea fixed rather than a removable restoration.

POTENTIAL TREATMENT PROBLEMS

The patient was a relatively young manwith extensive tooth wearThe many existing restorations werevery large and faultySome of the teeth had old endodontictreatments with periapical lesionsMany of the teeth had calcification of thepulp chambers and some of the canalsThe patient expressed his desire not tohave a removable mandibular partialdenture

DISCUSSION OF THE CAUSES OFWEAR IN THIS PATIENT

that before proceeding with treatment, itwould be wise to discern the cause of theextreme wear. The dental literature refers tothe causative agents in extreme wear as thatof multiple factors. Mohl describes the causesof dental tooth wear as 'contributing factors'rather than 'etiologic factors'.1 The factorsgenerally mentioned in the literature are:parafunction, diet, salivary secretions, exces-sive biting force, and occupational hazards.As for parafunction, the patient informed usthat he had never bruxed his teeth, and wasaware what bruxism meant. He also lackedany of the other symptoms of bruxism, had anormal maximum jaw opening and free lateralexcursions without tenderness in hismuscles. In order to examine whether dietwas a contributory factor, the patient wasasked to record in writing all food and bever-ages that he consumed during the day for aperiod of 2 weeks. This revealed that he didnot have an abrasive or erosive diet. Withregard to salivary function, the patient wasexamined for three different factors: the rateof excretion, the pH of the saliva, and thebuffer capacity of the saliva. The resultsshowed that there were no contributingfactors in his saliva to cause the extreme wearthat was evidenced on his anterior teeth.

All these findings led to the conclusionthat the wear of the patient's teeth wasprobably a result of the fact that he was atank driver and mechanic for 20 years in anarmy field unit that involved testing anddriving tanks many hours a day in a dustyenvironment. This was in the era when tankswere not air-conditioned and the mixture ofdust and vibration encountered during hismany hours in the open tank thus causedthe excessive wear of his front teeth. Thecontributing facts for this theory were that in

Considering that this patient exhibitedextreme wear in some of his teeth, it was felt

Mohl ND, Zarb GA, Carlsson GE, Rugh JD, Textbook ofOcclusion (Quintessence: London, 1988).

2 8


the posterior maxillary teeth, there was nowear of the teeth. This was due to the factthat the opposing mandibular posterior teethwere extracted early in his army career andtherefore could not cause wear of theopposing maxillary teeth. These teethshowed no signs of wear, even though theywere present for 26 years prior to the periodwhen he worked as a mechanic on tanks.Further proof of this theory could be foundin the fact that the greatest amount of wearwas found mostly in the anterior teeth. Thiswas due to the fact that the amplitude of jawmovements during vibrations of the bodyencountered while driving the tank is greaterin the anterior region than in the posteriorregion. Therefore, it was felt that as thepatient had retired from the army, and wasnot involved in testing and repairing heavytanks any more, the wear would not be afactor. This was also proven by the fact thatduring the transitional phase of treatment,the restorations did not undergo any wear.

TREATMENT ALTERNATIVES

Maxilla:

•

Fixed anterior partial prosthesis

Mandible:

• Fixed partial prosthesis with a short-ened arch form

• Fixed partial prosthesis with implantsupport

•

Fixed partial prosthesis with cantilever•

Fixed and removable partial prostheses

TREATMENT

I nitial preparation included scaling, curet-tage, root planing, and oral hygiene instruc-tion. At the end of this stage, an obviousimprovement in the periodontal supportingtissue could be seen and at the periodon-tal recharting it was observed that thepocket depths had diminished greatly andthat the bleeding on probing had disap-peared.

Existing restorations that contributed to theperiodontal problems were removed early intreatment. The crown on the maxillary left firstpremolar was removed, and since there wasa periapical lesion on the tooth, the root canaltherapy was redone after removal of the twodentatus type posts (Figures 3.15 and 3.16).The tooth was followed up for 1 year, duringwhich the periapical lesion remained the

Figure 3.15

Clinical view of left maxillary first premolar, pre-treatment.

Figure 3.16

Radiograph of post-treatment left maxillary first premolar.

2 9

Figure 3.17

Radiograph of right maxillary first premolar, pre-treatment.

same size and there was no evidence ofhealing, and since the walls of the roots of thetooth were very thin, it was decided to extractthe tooth. The root canal filling was redone onthe maxillary right first premolar and the toothwas followed up for 1 year (Figures 3.17 and3.18). Caries was excavated on the mandibu-lar left premolars and, due to the extensivecaries into the pulp chamber, these teethwere also treated endodontically (Figure3.19). The mandibular right second premolarand first molar were also treated endodonti-cally due to the extensive caries extendinginto the pulp chamber (Figures 3.20 and3.21). These teeth then received transitionalrestorations. Upon excavation, the mandibu-lar right second molar was found to have acracked mesial root and the root wasremoved.

I n order to satisfy the patient's desire forimproved esthetics, the vertical dimensionof occlusion was increased and esthetictransitional restorations were done on theanterior maxillary and mandibular teeth(Figures 3.22 and 3.23). Due to the shortclinical crown in the mandibular incisorteeth, and the mandibular left first premo-l ar, crown lengthening procedures weredone on those teeth.


Figure 3.18

Radiograph of right maxillary first premolar, post-treatment.

Figure 3.19

Radiograph post-treatment of left mandibular premolars.

The orthodontic phase of treatment wasstarted using a coil spring to separate theright mandibular first molar in order to elimi-nate root proximity and ensure maximumembrasure space for periodontal mainte-nance.Upon completion of the orthodontictreatment, followed by periodontal re-evaluation (Figures 3.24 and 3.25), castposts were placed in the endodonticallytreated teeth. As the patient had noproblems with the increased vertical dimen-sion, and the periodontal tissues reactedfavorably to the treatment, and the patientwas very satisfied with his new esthetic

30


Figure 3.20

Figure 3.21

Clinical view of right mandibular premolars and molar area.

Radiograph post-treatment of right mandibular premolarpre-treatment.

and molar area.

Figure 3.22

Figure 3.23

Transitional restorations right side.

Transitional restorations left side.

Figure 3.24

Figure 3.25

Periodontal chart at re-evaluation-maxilla.

Periodontal chart at re-evaluation-mandible.

31

appearance, the final treatment plan wasthen carried out.

I t was decided to restore the mandiblewith a premolar occlusion on the left sidefor the following reasons:

Since implants could not be done withthe amount of remaining bone-toplace implants would require additionalsurgical procedures to add boneThe lack of posterior teeth in themandibular left quadrant did not botherthe patientHe very much desired a fixed prosthe-sisThe removable partial denture wouldonly replace two teeth, and the patientwould most probably not use itI t would then require splinting the maxil-lary molars on that side in order toprevent overeruption

Due to the extensive period of timeinvolved in the initial treatment phasesand the periodontal surgery andorthodontic treatment, the transitionalrestorations were then replaced by newprostheses. These were built to the new

Figure 3.26

New transitional restorations-maxilla.


established vertical dimension dictated bythe plane of occlusion and the estheticdemands of the patient as well as thebiomechanical considerations (Figures3.26 and 3.27).

After a period of time it was clear thatthe patient adapted very well to his newrestorations. Copper band impressionswere then taken of all the prepared teethand Duralay resin copings were made.These copings were used to record centricrelation at the vertical dimension of thetemporary restorations and for the finalimpression for the master model (Figures3.28-3.32). The metal copings were thenfitted (Figures 3.33 and 3.34) andsoldered, and after try-in of the solderedmetal framework another elastomericimpression was done for tissue detail.These models were mounted on a semi-adjustable Hanau articulator utilizing afacebow registration and centric recordstaken at the vertical dimension of occlu-sion utilizing Duralay with a Neylontechnique.

At this point the porcelain was bakedand the occlusion checked in the mouth atthe biscuit bake stage and all adjustments

Figure 3.27

New transitional restorations-mandible.

32


Figure 3.28

Figure 3.29

Duralay copings fitted-maxilla.

Duralay copings fitted-mandible.

Figure 3.30

Centric relation record-left side.

Figure 3.31

Figure 3.32

Centric relation record-completed.

Flastomeric pick-up impressions of Duralay copings-maxilla and mandible.

33

Figure 3.33

Metal copings fitted-maxilla.

Figure 3.35

Incisal platform incorporated into anterior maxillary teeth.

needed were then made. The anteriormaxillary teeth incorporated an incisalplatform (Figure 3.35) to enable continuouscontact during jaw movement and to bringthe incisal forces as close as possible tothe long axis of the teeth. The crowns andbridges were cemented with Temp-Bondfor a period of 1 month. The crowns andbridges were then cemented with zincoxyphosphate cement for permanentcementation (Figures 3.36-3.38).

The patient has been returning for follow-up and maintenance twice a year for threeyears and has had no problems.


Figure 3.34

Metal copings fitted-mandible.

Figure 3.36

Case cemented, post-treatment.

SUMMARY

The patient presented with a severe problemof extreme wear on many of his teeth and areduced vertical dimension of occlusion. Healso had furcation involvements and periapicallesions. The wear was correctly diagnosed asdue to occupational hazards, which were nolonger a factor in deciding his treatment. Withendodontic, orthodontic and periodontaltreatment accompanied by occlusal therapy,the patient received a physiological occlusionat the optimum vertical dimension of occlu-sion.

34


Figure 3.37

Radiographs of case, post-treatment.

Figure 3.38

Frontal face view of patient, post-treatment.


This patient represented a severe case oftooth wear accompanied by reduced verti-cal dimension and a faulty occlusal plane,further aggravated by missing teeth, caries,and faulty endodontic treatment. Thesevere wear required periodontal surgeryfor crown lengthening procedures, thusjeopardizing the crown-to-root ratio. Theexistence of a free end saddle in themandible further reduced occlusal support.The case was handled with caution byincreasing the vertical dimension and thecrown lengthening procedures to theminimum required. In order to make up forthe missing posterior support, the anteriorteeth were restored and the incisal areaswere modified to participate in support inaddition to their role in esthetics, speech,and disarticulation of the posterior teeth injaw movements. The cuspal guiding planes

35

were built to a minimum to reduce lateralforces in order to improve the overallprognosis of the case.


While patients who have spent many yearsdriving tanks in dusty environments must bea rare breed, those who are suffering exten-sive tooth wear are abundant. Indeed, withthe increasing life span of our population andthe reduced incidence of caries, the treat-ment of worn down dentitions may be one ofthe most difficult situations to confront us in


the early part of the new century. In thisparticular instance, the operators havepresented tooth substance loss, but this willnot apply to many other patients.

The sensibly chosen staged approachproduced the occasional surprise that all of usfind in a long course of treatment. A split rootcan be difficult to detect at the outset. Whileincreasing the vertical dimension of occlusionseemed reasonable, it is not clear whether theoperators deliberately increased this measure-ment beyond the level they estimated hadexisted before the tooth wear occurred. Therewas little alternative to making a change if agood looking outcome was to be achieved.An excellent result was obtained.

3 6

PATIENT 4 NEGLECTED DENTITION

Treatment by Tzachi Lehr

THE PATIENT PAST DENTAL HISTORY

A 50-year-old woman, employed as a seniorsecretary, came to the clinic for dental treat-ment. Her chief complaints were (Figures 4.1and 4.2):

The patient had never gone regularly to adentist. The last visit to a dentist was 10years ago, and she could not recall whattreatment she received then. Recently shefound it difficult to chew her food. She had

` My teeth look awful.'` My front tooth is loose.'` My front teeth stick out.'

` Lately, my speech seems to be changing.'`I know that I have no choice and needlots of work done on my teeth.'


The patient's medical history was unremark-able.

Figure 4.1

Anterior teeth-labial view.

Figure 4.2

Face-frontal view.

39

Figure 4.3

Face-frontal view (from 27 years ago).

no habits that she was aware of, but wasvery conscious of her poor appearance. Shecompared her current appearance with thatof herself almost 30 years ago, showing alarge smile and healthy teeth (Figure 4.3).


Symmetrical faceProfile-slight tendency to bi-maxillaryprotrusionTemporomandibular joint was normalNormal facial musculatureMaximum opening of 50 mmMandibular movements were withinnormal limitsTrapped lower lip

Figure 4.4

Face-side view.


EXAMINATION


•

Parabolic arch• Caries

Spacing between the anterior teeth (seeFigure 4.1)Missing right and left third molar, andleft second molar teethRight and left first molars-residual rootsExudate around right central incisorLarge amalgam restorations on the leftand right premolarsLeft cuspid with large caries in the

PROSTHODONTICS IN CLINICAL PRACTICE40

coronal section, extending into the root


•

Parabolic arch• Amalgam restorations on the posterior

teeth•

Right second premolar-residual root

NEGLECTED DENTITION

Figure 4.5


Figure 4.6


Figure 4.7


Figure 4.8


•

Missing teeth: right and left second andthird molars, and left second premolar

•

Exudate around right cuspid• Caries:

Occlusal examination (Figures 4.7 and 4.8)revealed that the patient was Angle class I.The interocclusal rest space was 4.0 mm.Overjet was 7.0 mm and overbite was 2.0mm. There was a difference betweencentric relation and centric occlusion ofless than 1.0 mm. There was a midline

discrepancy. There was spacing betweenthe maxillary incisor teeth and the leftlateral incisor and left cuspid, and driftingof teeth.

Fremitus:

Maxillary right central incisor-grade IIIin closing and protrusive movementsMaxillary right lateral incisor-grade II inclosing and protrusive movementsMaxillary right first premolar-grade I inclosing movementsMaxillary left central and lateral incisors-grade 11 in protrusive movement

41

Figure 4.9

Periodontal chart-pre-treatment, maxilla.

Periodontal examination (Figures 4.9 and4.10) revealed calculus and plaque, probingdepths of up to 8.0 mm on most of the maxil-lary teeth and up to 7.0 mm on some of themandibular teeth. There was bleeding of thegingiva on probing (BOP) on most of theteeth. There was slight gingival recessionaround some of the teeth. Class 1 and 2


Figure 4.10

Periodontal chart-pre-treatment, mandible.

Figure 4.11

Radiographs of maxilla andmandible-pre-treatment.

mobility was observed on many of the maxil-lary teeth and class 3 on the maxillary rightcentral incisor and the maxillary right firstpremolar. The mandibular molars had class 1furcation involvement on the buccal andlingual surfaces. The maxillary right secondmolar had class 1 furcation involvement onthe buccal surfaces.

42

NEGLECTED DENTITION


•

Endodontic treatment:

5

5

65 6

Perio-endo lesion around the rightmaxillary central incisorPeriapical lesions around the left maxil-lary cuspid and residual roots of the firstmaxillary molars, and mandibular rightsecond premolarRampant caries and secondary cariesExtensive horizontal and vertical boneloss around most of the remaining teeth


and mobility of a front tooth. She had poororal hygiene, plaque and calculus, andsevere inflammation accompanied by deepprobing depths, reduced alveolar bonesupport and furcation involvements. Someof the teeth were mobile and had under-gone shifting. There was anterior flaringand spacing in the maxilla and mandible,residual roots, and deep caries in manyteeth.

DIAGNOSIS

Advanced adult periodontitisMissing teeth accompanied by shiftingand drifting of teethReduced posterior occlusal supportReduced vertical dimensionSecondary occlusal traumaTrapped lower lipFaulty estheticsFaulty restorationsRampant cariesPeriapical lesionsFaulty occlusal plane

ABOUT THE PATIENT

The patient was highly motivated for treat-ment. She was aware of her condition. Sherequested a fixed rather than a removablerestoration and would be willing to haveimplants if they were necessary for a fixedprosthesis.

SUMMARY OF FINDINGS

A 50-year-old patient, in good health, cameto the clinic complaining of poor esthetics,


Many missing teethThe distribution of the remaining teethwas unfavorable

4 3


•

Many of the remaining teeth had severeperiodontal problems and their progno-sis was guarded

• Treatment would possibly includeopening the vertical dimension of occlu-sion in order to retract the maxillaryanterior teeth, which would cause anunfavorable crown-to-root ratio onperiodontally involved teeth

•

Fixed and partial removable prostheses• Overdenture

Mandible:

• Fixed prosthesis supported by naturalteeth

•


teeth and implants

TREATMENT PLAN

PHASE 1: INITIAL PREPARATIONTREATMENT

•

I nitial periodontal therapy including:oral hygiene instructionscaling and root planing

•

Extraction of the hopeless teeth exceptfor the maxillary right central incisorEndodontic treatment for the maxillaryleft lateral incisor tooth

• Provisional restoration for the maxillaryleft lateral incisor tooth

•

Caries excavation•

Evaluation of patient cooperation• Retraction of the mandibular anterior

teeth and temporary fixation• Retraction of the maxillary anterior

teeth, extraction of the right centralincisor, and fixation by means of a provi-sional fixed prosthesis

Re-evaluation of the first phase of the treat-ment plan.

PHASE 2: TREATMENT OPTIONS

Maxilla:

• Fixed prosthesis, with premolar occlu-sion in maxilla on left side

• Fixed prosthesis supported by teethand implants

Initial treatment consisted of oral hygieneinstruction, scaling and root planing. Themaxillary left lateral incisor was reprepared,the caries excavated, and a provisionalcrown made. Provisional crown restorationswere made on the mandibular right firstmolar and left first molar. Due to the patient'simproved oral hygiene and cooperationthere was a dramatic improvement in herperiodontal condition (Figure 4.12).

These teeth as well as the mandibularright first and mandibular left first premolarswere utilized as anchorage for orthodonticretraction of the mandibular anterior teethby means of elastics (Figures 4.13 and4.14). The maxillary premolars wereprepared for full coverage and transitionalcrowns were placed. Then, with lingualbuttons used on these teeth for retention,the maxillary anterior teeth were retracted toclose the spaces (Figures 4.15 and 4.16).The retracted mandibular teeth weresplinted with orthodontic wiring, and theremaining maxillary teeth were prepared forfull coverage and provisionally restored(Figure 4.17). At this time the maxillarycentral incisor was extracted.

I n the mandible it was decided to make afixed prosthesis, and thus a computerizedtomography (CT) radiograph was made to

44

NEGLECTED DENTITION

Figure 4.12

Figure 4.13

Anterior teeth-labial view, after initial preparation.

Anterior teeth-orthodontic treatment to close spaces andretract teeth: mandible, start.

Figure 4.14

Figure 4.15

Orthodontic treatment, mandible, finish.

Orthodontic treatment, retraction of anterior maxillary teeth,ri ght side.

Figure 4.16

Figure 4.17

Orthodontic treatment, retraction of anterior maxillary teeth,

Maxillary teeth showing provisional splints.l eft side.

45

46


Figure 4.18

CT radiograph of mandible.

Figure 4.19

Figure 4.20

CT radiograph of mandible, left side.

CT radiograph of mandible, right side.

Figure 4.21

Figure 4.22

I mplant placement, right side.

I mplant placement, left side.

NEGLECTED DENTITION

Figure 4.23

Mandible with provisional restorations on implants.

Figure 4.24

Mounting of maxillary model on Hanau articulator withfacebow registration.

check the quality and quantity of bone andthe possibility of implant therapy. The radio-graph showed that it would be possible toplace three implants on the right side, distalto the first premolar, and a single implant onthe left side in the area of the secondpremolar (Figures 4.18-4.20). An acrylicresin surgical stent was prepared and usedduring the implant placement, and threeBranemark implants were placed in the rightposterior region of the mandible and onebetween the left first premolar and the leftfirst molar (Figures 4.21 and 4.22). After 3months, the implants were exposed andabutments placed. New provisional restora-tions were made for the implants (Figure4.23).

Copper band elastomeric impressionswere made of all the prepared teeth andpattern resin copings made to fit the stonedies. These copings and transfer copingsfor the implants were fitted in the mouthand used to record centric relation at thevertical dimension of occlusion of the provi-sional restorations. A polyether full archimpression was then taken of the maxillaand the master model poured andmounted to the mandibular model of the

transitional removable partial denture bymeans of the Pattern resin centric record.

Metal copings for the natural teeth andgold copings were then cast and fitted in themouth and connected by Pattern resin forsoldering. These were soldered together,refitted and a new centric relation recordmade. A polyether impression was thentaken for tissue detail and a pick-up of thefixed prosthesis in the maxilla in order tomake a final master model. This wasmounted on a Hanau articulator by meansof a facebow registration (Figure 4.24) andthe Pattern resin registration on the solderedmetal prosthesis. The shade was chosenand porcelain baked to the metal. This wasfitted in the mouth and the occlusionadjusted to the lower jaw. The porcelain wasthen glazed and the prostheses on thenatural teeth cemented with Temp-Bond for2 weeks. The implant supported prostheseswere screw retained (Figures 4.25-4.29).

SUMMARY

This patient presented with a very severecase of adult periodontitis. She also had

Figure 4.25

Figure 4.26

Mandible-polyether impression for coping pick-up.

Maxilla-polyether impression for coping pick-up.

Figure 4.27

Treatment completed-permanent restorations, anteriorview.

Figure 4.28

Treatment completed-permanent restorations, maxilla.


rampant caries and several hopeless teeth,many missing teeth, and severe bone loss.There were tipped, malpositioned, andextruded teeth. The patient wanted fixedprostheses and was willing to change heroral hygiene habits and cooperate in hertreatment. However, one of the potentialproblems with the treatment plan was thatby increasing vertical dimension, thecrown-to-root ratio would increase thelever forces on the teeth. This was avoidedby first retracting the mandibular anteriorteeth, and then the maxillary anterior teeth,and then leveling the mandibular anterior

48

NEGLECTED DENTITION

Figure 4.29

Treatment completed-permanent restorations, mandible.

Figure 4.30

Treatment completed-face, frontal view

teeth, thus bringing the patient from inter-cuspal position (IC) to retruded cuspalposition (RC): this enabled retraction ofthese without a change in vertical dimen-sion. It was thus possible to restore themaxilla with a fixed prosthesis in spite ofthe poor prognosis of the teeth when thepatient initially presented, by means of thebiomechanical changes that occurredduring treatment. These included improve-ment of the patient's periodontal conditionnot only due to her improved oral hygiene,but also by the new position of the teeth inthe alveolar bone, which directed theocclusal forces in the long axis of the tooth.All the teeth, including the anterior teeth,were now utilized for occlusal support andalso reducing lateral forces to a minimum.With periodontal, endodontic, orthodontic,implant therapy, an esthetic and functionalresult was achieved.


In the case presented above, we haveimproved the remaining teeth prognosis byperiodontal and orthodontic treatment, alongwith a carefully planned occlusal scheme.

49


The orthodontic retraction of the loweranterior teeth improved the periodontalcondition of the teeth, redirected theocclusal forces in a more favorable direc-tion, and the leveling of the teeth thatfollowed their retraction improved thecrown-to-root ratio. The same can beclaimed for the upper remaining anteriorteeth. Additional support was gained byimplants that are carefully protected fromlateral forces by the occlusal scheme thatwas applied in this case. It can beconcluded that by utilizing a multidisci-plinary approach, we maximized toothpotential and provided a functional,physiologic and esthetic restoration tothe patient with minimal surgical inter-vention.


Many prosthodontists dread a patient with aneglected dentition who presents with aphotograph taken three decades previouslyand expects the clock turned back with amagic wand. Although no such device wasavailable to the operators, they have achievedan excellent result with sensibly plannedperiodontal and orthodontic treatment.Retracting the mandibular anterior teeth at anearly stage avoided the hazards of increasingthe crown-to-root ratio of the maxillary teeththat had such poor bone support. The timingand the placement of the mandibulari mplants was sensible and allowed therestoration of a full arcade of teeth.

50

PATIENT 5 UNNOTICED PERIODONTALDETERIORATION

Treatment by Tzachi Lehr

THE PATIENT

The patient, a 47-year-old woman, em-ployed as a secretary, came to the clinic fordental treatment. Her chief complaintswere (Figures 5.1 and 5.2):

` My teeth are moving.'`I am getting spaces between my teethwhich I didn't have when I was younger.'(see Figure 5.3)` My mouth has an odor.'`When I chew, it hurts.'


Figure 5.2

Face-frontal view (forced smile).

The patient suffered from pulmonary valveregurgitation and an allergy to penicillin,

Figure 5.1


Figure 5.3

Face-frontal view (from 23 years ago).

51

The patient underwent periodontal surgery2 years ago. She also disclosed that shehad a habit of cracking nuts.


EXAMINATION

• Symmetrical face, although the rightmasseter muscle was more developedthan the left one

• In profile, she had a tendency to bi-maxillary protrusion



•

Parabolic arch• High palate•

Spacing between the anterior teeth•

Missing third molar teeth•

Porcelain fused to metal crowns on theright premolar teeth

• Amalgam restorations on the rightmolars and left first premolar andsecond molar


•

Parabolic arch•

Missing left third molar tooth•

Amalgam restorations on the molar teeth

Figure 5.4

Face-side view.

Occlusal examination (Figures 5.7 and 5.8)revealed that the patient was Angle class I.The interocclusal rest space was 2-3 mm,overjet was 7 mm and overbite was 4 mm( Figure 5.9). There was a 1.0 mm discrep-ancy between centric relation and centricocclusion with both anterior and verticalcomponents. There was a midline discrep-ancy. The maxillary right central incisor wasextruded (see Figure 5.1). There wasspacing between the maxillary incisor teethand they were also slightly rotated (seeFigure 5.1). Lateral jaw movements wereguided by the canine and premolar teeth


thus, would require prophylaxsis with ERIC(erythromycin capsules) prior to dentaltreatment.

PAST DENTAL HISTORY

• High lip line• Temporomandibular joint was normal,

mandibular motions were within normall imits

• Maximum opening of 50 mm• Incompetent lips-habitually apart

UNNOTICED PERIODONTAL DETERIORATION

Figure 5.5

Figure 5.6



Figure 5.7

Figure 5.8



on the left side, and by group functionfollowed by the canine teeth with incisalcontacts on the right side. Protrusivemovements were guided by the caninesand incisors. No non-working side interfer-ences were noted.

Fremitus:

• Maxillary right central incisor-gradeI I-III both in centric occlusion andprotrusive jaw movements

Figure 5.9

•

Maxillary left central incisor, left lateralOcclusion-anterior view of overbite and overjet.

incisor, and right lateral incisor-grade I

53

both in centric (occlusion) and protru-sive jaw movements

Periodontal examination (Figures 5.10 and5.11) revealed calculus and plaque, probingdepths of up to 8.0 mm on the maxillary

Figure 5.12


teeth and up to 9.0 mm on the mandibularteeth with bleeding on probing on almost allof the teeth. There was slight gingival reces-sion around most of the teeth. The maxillaryleft first premolar and left first molar hadclass I furcation involvement on the mesial.

54


Figure 5.10

Periodontal chart-pre-treatment, maxilla.

Figure 5.11

Periodontal chart-pre-treatment, mandible.

DIAGNOSIS

Advanced adult periodontitisSecondary occlusal trauma withprimary origin of occlusal trauma fromchewing on nutsLoss of posterior support, reducedocclusal supportDeep biteDecreased vertical dimension of occlu-sionAcute dentoalveolar periodontal ab-scess-maxillary right central incisortoothFaultv esthetics

ABOUT THE PATIENT

The patient was highly motivated for dentaltreatment due to the poor esthetic conditionof her teeth. However, the poor oral hygieneshe presented with, just 2 years followingperiodontal treatment and surgery, attestedto the fact that she was unaware of theimportance of good dental hygiene, and thedirect relationship that it had to the successor failure of her dental treatment.

SUMMARY OF FINDINGS

The 47-year-old patient, who suffered frompulmonary valve regurgitation, came to theclinic complaining of recent spacingbetween her front teeth, a foul odor in hermouth, and pain when chewing on the leftside of her mouth. She presented with poororal hygiene, plaque and calculus, andsevere inflammation accompanied by deepprobing depths, furcation involvements,and bleeding upon probing. The teeth weremobile and had fremitus in closing and jawmovements. The maxillary right centralincisor was extruded and had a suppurat-ing periodontal abscess.

TREATMENT PLAN


•

I nitial periodontal therapy including:oral hygiene instructionscaling and root planingcaries excavation

• Occlusal adjustment of the (maxillaryright central incisor) by selective grind-ing to reduce occlusal trauma

The first re-evaluation led to the secondphase of the treatment plan.


55UNNOTICED PERIODONTAL DETERIORATION

•

•


• Endodontic treatment-maxillary rightpremolars slightly short of apex

* Horizontal and vertical bone lossaround most (of the) molar teeth

56


Figure 5.16

Figure 5.14

Figure 5.17

Periodontal chart-first re-evaluation.

Anterior teeth, orthodontic treatment completed.

Anterior teeth, orthodontic treatment to close spaces andretract teeth.

Figure 5.13

Anterior teeth after initial preparation, labial view.

Figure 5.15

Anterior teeth, lingual view, canine platform.


PHASE 2

Eruption of the posterior teethRetraction of the maxillary anterior teethTemporary fixed maxillary prosthesisRe-establishment of an acceptablevertical dimension of occlusion, and aphysiologic occlusal plane

TREATMENT

Initial treatment consisted of scaling, rootplaning, curettage, oral hygiene instruction,and extraction of the mandibular right thirdmolar. At re-evaluation, after initial prepara-tion, bleeding on probing had diminished toa great extent. However, the probingdepths remained deep and showed almostno improvement (Figures 5.13 and 5.14).

I n order to increase vertical dimension toenable posterior tooth eruption along withtheir supporting bone and provide spacefor maxillary anterior tooth retraction, acanine platform was constructed on themaxillary cuspid teeth (Figure 5.15). Aseruption of posterior teeth took place,orthodontic treatment was then started toretract the maxillary anterior teeth andclose the spaces (Figure 5.16). Lingualbuttons were placed on the first premolarsand elastics were then used to close thespacing between the teeth (Figure 5.17). Toprevent drifting of the elastics gingivally,composite stops were placed on the labialsurfaces of the anterior teeth. This treat-ment was accompanied by constantscaling, root planing, and curettage. Sincethe patient had a pulmonary valve regurgi-tation problem, this necessitated the use ofprophylactic antibiotics ( ERIC: coatederythromycin 1 g an hour before treatment,and 500 mg 6 hours after treatment) foreach visit.

Figure 5.18

Maxillary teeth showing provisional restoration.

When the orthodontic treatment wascompleted and the anterior spacing elimi-nated, the maxillary teeth from the secondright premolar to the left cuspid wereprepared for full coverage, and a provi-sional fixed restoration was inserted. At thesame time, the hopeless maxillary rightcentral incisor was extracted (Figure 5.18).

At the second re-evaluation, therecorded probing depths were greater than5 mm and the decision was made toundertake periodontal surgery (Figure5.19). The goal of the periodontal surgerywas to achieve an open clean-up andpocket elimination. During the periodontalsurgery, the decision was made to resectthe disto-buccal roots of both secondmolars in order to eliminate the trifurcationinvolvements of these teeth and improvetheir prognosis (Figures 5.20 and 5.21).Selective grinding and reshaping of thebuccal cusps of the maxillary molar andpremolar teeth was performed to diminishthe strong lateral forces upon them.

At the following re-evaluation, it wasnoted that the maxillary right first premolarstill showed unacceptable probing depths.Orthodontic treatment was then started to

5 7

Figure 5.19

Periodontal chart: maxilla and mandible, re-evaluation.

extrude the tooth and, it was hoped, thesupporting bone with it as a future implantsite development (Figure 5.22). After theorthodontic treatment, charting revealedthat the probing depths were stillunchanged and it was then decided toextract the tooth. Upon extraction, a crackin the buccal root was seen along thepalatal side, which explained why the toothdid not respond to all the treatment.

Periodontal surgery (soft tissue augmen-tation) was then carried out in the maxillarycentral incisor area to reshape the area,

Figure 5.20

Periodontal surgery, maxillary left posterior quadrant.

Figure 5.21

Periodontal surgery-maxillary left posterior quadrant,suturing.

taking tissue from the palate (`pouchtechnique') (Figure 5.23).

Since the vertical dimension had beenincreased during treatment, a minimalocclusal adjustment was made to returnthe patient to her original vertical dimensionof occlusion.

At the final re-evaluation, it was deter-mined that probing depths and mobilityhad been greatly diminished, and the finaltreatment was carried out. This includedfi nalizing the teeth preparations. Copperband elastomeric impressions were made

PROSTHODONTICS IN CLINICAL PRACTICE58


Figure 5.22

Orthodontic treatment to extrude maxillary first premolar.

Figure 5.23

Maxillary right central incisor area-soft tissue graft, suturing.

of the prepared teeth, and stone dies andpattern resin copings produced. Thesecopings were fitted in the mouth andused to record centric occlusion, and apolyether impression was taken for theworking model. A master model was castfrom this impression with the stone dies inplace. This model was articulated to themodel of the mandibular teeth made withan alginate impression. Metal copingswere then cast and fitted on the individualprepared teeth with the pontics attachedto the adjacent tooth. These wereconnected with pattern resin andsoldered, and the soldered prosthesisfitted in the mouth. A centric record inDuralay at the vertical dimension of occlu-sion was made in the mouth and anotherpolyether full arch impression done for thetissue details. This impression was castand mounted to the lower model and thearticulator by means of a facebow trans-fer and the Duralay centric record. Theshade was chosen and the porcelainbaked. The bridge was then fitted andfinal adjustments were done in the mouthin the biscque bake stage. The prosthesiswas then glazed and temporarily

cemented in the mouth with Temp-Bondfor a period of 2 weeks. The prosthesiswas then cemented permanently withzinc oxyphosphate cement (Figures5.24-5.27).

SUMMARY

The patient presented with what shethought was a simple problem of a loosefront tooth and the start of spacing in hermaxillary anterior teeth. Even though shehad periodontal surgery 2 years previ-ously, she was not aware of the impor-tance of good oral hygiene and herperiodontal condition had thus deterio-rated. The initial treatment consisted oforal hygiene instruction and scaling andcurettage. When the probing depths didnot improve, orthodontic treatment wasinitiated as well as periodontal surgery inorder to eliminate the deep pocketsaround the teeth. Even after this treat-ment, the maxillary first premolar did notrespond and had to be extracted. Onlythen, it was discovered that the root wascracked and thus had been untreatable.

5 9

Figure 5.24

Treatment completed-permanent restorations, left side.

Figure 5.25

Treatment completed-permanent restorations, right side.

Figure 5.26

Treatment completed-permanent restorations, anteriorview.


Figure 5.27

Treatment completed-face, frontal view.

What appeared to be a relatively easytreatment turned out to be rather involved,with orthodontic therapy and periodontalsurgery needed in order to achieve anesthetic and functional result.


This case presentation describes a ratherbizarre situation of a 47-year-old womanwith a `tiny' chief complaint that led to acomprehensive treatment plan in order torestore esthetics and regain long-lastingphysiologic occlusion. In order to achieve

60


the goal of physiologic and esthetic occlu-sion with the periodontal condition that thepatient presented with, we utilized thepotential of tooth eruption both to reduceperiodontal defects and minimize thedamage of increasing the crown-to-rootratio. I n order to compensate for thereduced posterior support both byperiodontal involvement and missing teeth,the anterior teeth were incorporated intosupport by retracting them lingually, thusimproving their position over the alveolarridge and redirecting the occlusal forces ina more favorable position. By improving theoverall periodontal condition, improving oralhygiene habits, and compensating forreduced posterior support by including theanterior group of teeth in vertical support,we have accomplished an esthetic longlasting physiologic occlusion.


Patients requiring antibiotic prophylaxispose particular problems due to the needto reduce the number of courses of antibi-otic therapy to a minimum. While thepatient was understandably concernedabout her appearance, she appeared tohave no idea of the severity of the problemsin her mouth, or of what would be requiredto correct them. This is another example ofwhat skilled operators can achieve withpatient motivation, and with success onthat front everything else falls into place.The combination of periodontal therapyand orthodontic treatment with skilledprosthodontics has produced not only ahappy patient but also an esthetic andfunctioning dentition. Long may it last!

61

PATIENT 6 COMPLICATED ADVANCEDADULT PERIODONTITIS

Treatment by Miriam Oppenheimer

THE PATIENT

The patient, a male 49-year-old clerk,presented for dental treatment. His maincomplaints were the following:

`I have difficulty eating.'` My front tooth is loose and hurts when Ichew.'` The spaces between my teeth appear tobe getting bigger.' (Figures 6.1 and 6.2)`Due to the spaces between my frontteeth, I have problems speaking clearly.'

HABITS

The patient clenches his teeth.

DIET

The patient drinks about five mugs ofcoffee and tea per day, with threeteaspoons of sugar.

PAST DENTAL HISTORY


The patient had mitral valve prolapse withmitral valve regurgitation requiring antibioticprophylaxsis before any dental procedures.

The patient was referred to the GraduateProsthodontics Dental Clinic by a privatedentist who felt that the case was too difficultfor him to treat. The patient had recently losttwo molar teeth and thought that most of histeeth had been extracted due to caries.

Figure 6.1

Frontal facial view of patient (on right) 20 years previously.

Figure 6.2

Anterior teeth showing spacing.

63

Figure 6.3


EXTRA-ORAL EXAMINATION( Figures 6.3 and 6.4)

•

Slight facial asymmetry•

Normally functioning muscles of masti-cation

• Temporomandibular joints were normalwith freedom of eccentric movements

•

Maximum opening between the incisorswas 56.0 mm


Figure 6.4

Side face view.

Figure 6.5

Maxillary arch.

• Flaring of the anterior teeth• Palatal surfaces show wear facets• Crown and root caries• Resorbed alveolar ridges especially on

the left side (Figure 6.6)• Flat hard palate


EXAMINATION


COMPLICATED ADVANCED ADULT PERIODONTITIS

Figure 6.6

Maxillary arch-left posterior quadrant.

Figure 6.7

Mandibular arch.

Figure 6.8

Mandibular arch-anterior teeth.

FULL MOUTH PERIAPICAL SURVEY(Figure 6.9)

Failing endodontic therapy accompa-nied by periapical lesionsRidge resorption in the edentulousareas

Occlusal examination revealed that thepatient was Angle class II division I, withan overbite of 9.0 mm and an overjet of4.0 mm The interocclusal rest space was3.0 mm and, as noted, the maximumopening between the incisors was56.0 mm, which if added to the 9.0 mmoverbite would mean that the maximumopening movement was actually65.0 mm. There was no discrepancybetween centric occlusion (IC) andcentric relation (CR). Fremitus and mobil-i ty were evident on the anterior maxillaryteeth. There were two planes of occlu-sion in the mandible and a marked stepi n the occlusal plane distal to the cuspidteeth. There was loss of posteriorocclusal support.

65

66


Figure 6.9


Figure 6.10

Figure 6.11

Maxillary periodontal chart.

Mandibular periodontal chart.

Periodontal examination (Figures 6.10 and

infraboney pockets, furcation involvement6.11) revealed poor oral hygiene accom-

and gingival recession.panied by large amounts of plaque andcalculus. Probing depths of up to 11.0 mm

INDIVIDUAL TOOTH PROGNOSESwere noted on the maxillary teeth and upto 7.0 mm on the mandibular teeth, with

The prognoses for the remaining teethbleeding on probing on most of the teeth.

were the following:There was 60% bone loss around someteeth. The condition was more severe inthe maxilla than the mandible. There wasreduced periodontal support due to


• Fair:

DIAGNOSIS

with infraboney pockets, mobility, andfremitus. There were many missing teethand the remaining residual ridges wereresorbed, he had extensive caries andfaulty restorations, all of which contributedto the difficulty of the treatment.

• Advanced adult periodontitis•

Missing teeth accompanied by edentu-lous ridge resorptionLoss of posterior supportLoss of vertical dimensionSecondary occlusal trauma withprimary origins

•


I rregular occlusal plane• Caries• Periapicallesions

TREATMENT PLAN ALTERNATIVES

Maxilla:

Fixed and removable prostheses if therewas a marked improvement in theperiodontal condition and the transi-tional restorations were maintainableA complete maxillary overdentureAn implant supported fixed or remov-able prosthesis-rejected by the patientdue to cost

ABOUT THE PATIENT Mandible:

The patient was of a philosophical nature; hewas interested in his dental treatment,followed instructions, but not always, andwas generally cooperative. He wanted tokeep as many of his remaining teeth as possi-ble, and specifically requested not to have acomplete maxillary denture. He was not inter-ested in implants because his finances werelimited. He also had never worn a removableprosthesis and was concerned as to how hewould adjust to one.


Fixed prosthesis supported by implantsand natural teeth-rejected by patientdue to costCrowns on

copings on

and a removable partial denture.Telescopic removable denture-rejecteddue to the costComplete overdenture supported bycopings

The patient had never worn a removableprosthesis, had limited finances for dentaltreatment, had poor eating habits, andclenched his teeth. He also was completelyunaware of the severity of his problem. Hesuffered from advanced adult periodontitis

FINAL TREATMENT PLAN

A final treatment plan was chosen whichconsisted, in the first phase, of oral hygieneinstruction, changing dietary habits, andfluoride rinses. This was followed by scaling

67

68


and curettage, root planing, extraction ofthe left maxillary incisor tooth and immedi-ate replacement with an orthodontic appli-ance, removal of caries, and provisionalrestorations. This would be followed by re-evaluation. The second phase of treatmentwould depend upon improvement in thepatient's periodontal condition and hisdetermination to change his dietary habitsand oral hygiene. To improve the periodon-tal condition and change the force directionof the maxillary anterior teeth, to be paral-lel to the long axis of the tooth, the maxil-lary anterior teeth would be orthodonticallymoved in a palatal direction. Then, aftermaking a transitional fixed anterior prosthe-sis with an incisal platform, provisionalpartial removable dentures would beconstructed for both the maxilla andmandible to restore lost occlusal support.Another re-evaluation would then be madeto determine whether periodontal surgerywould be necessary. The prognosis of themandibular anterior teeth and the mandibu-lar left third molar would be assessedtogether with the condition of the maxillaryremaining teeth to support a permanentfixed and removable prosthesis.

TREATMENT

The initial phase of treatment wascompleted with oral hygiene instruction, theintroduction of new dietary habits, fluoriderinses, scaling and curettage, root planing,extraction of the left maxillary incisor toothand immediate replacement with anorthodontic appliance (Figures 6.12 and6.13). Caries was removed and provisionalrestorations were then fabricated for bothjaws (Figures 6.14 and 6.15). The patientexhibited increased dental hygiene awareness and the soft tissues showed great

provisional crowns.

Figure 6.14

Maxillary anterior teeth after orthodontic treatment with

Figure 6.12

Maxillary anterior teeth after extraction of left central incisor.

Figure 6.13

Clinical view of Hawley appliance-pre-treatment.

Figure 6.19

Figure 6.20

Provisional removable partial mandibular denture.

Treatment completed-maxilla.

Figure 6.21

Figure 6.22

Treatment completed-mandible.

Treatment completed-right side.

Figure 6.23

Treatment completed-left side.

restorations. The metal copings were fittedin the mouth, connected with Duralay,soldered and rechecked in the mouth aftersoldering. Elastomeric master impressionswere then made of each jaw in order tofabricate the removable frameworks for theprostheses. The frameworks were fitted,and a facebow index together with a centricrelation record at the vertical dimension ofocclusion was made. The models weremounted on a Hanau articulator. Thedenture teeth were set up on the acrylicresin denture bases and checked clinically

PROSTHODONTICS IN CLINICAL PRACTICE7 0


Figure 6.24

Radiographs of patient-post-treatment.

for function and esthetics. The removablemaxillary partial denture and mandibularcomplete overdenture were processed. Therestorations were then inserted and havebeen followed up since then with no deteri-oration (Figures 6.20-6.24).

SUMMARY

The patient presented with a severe caseof advanced adult periodontitis, manymissing teeth, crowding, mobility andfremitus of teeth, faulty restorations, andpoor dietary habits. He was a clencher.He had difficulty in eating and was inpain. A compromise solution had to befound in this case because of the limitedfinancial means available to the patientfor his dental treatment. He also wantedto retain as many of his remaining teethas possible. The solution consisted ofeliminating the infection, orthodontictreatment to improve tooth position,changing his dietary pattern, andconstruction of a partial maxillary

removable denture supported by a fixedanterior bridge and a complete mandibu-lar overdenture on gold copings on theremaining teeth.


This was a challenging patient, beingeffected both by caries and advancedperiodontal disease complicated by lossof posterior support, aggravated by drift-ing and flaring of teeth. This case wastreated by stretching the biologicalresponse of the patient to its maximum,allowing it to benefit from mechanicalimprovement by redirection of the forcesto improve the crown-to-root ratio andcreating a flat occlusion to minimize lateralforces. The continued success of thistreatment will be dependent on thecooperation of the patient, by controllinghis oral hygiene as well as his diet. Thusthe overall prognosis of this case isguarded.

71



Patients who seek professional help onlywhen their dentition is in a terminal state

pose particular difficulties. These problemsare accentuated if the patient is unaware ofthe severity of the dental problem, eats a

cariogenic diet, and has medical complica-tions. In this instance, the need for antibi-

otic prophylaxsis dictated that as muchwork as possible be undertaken duringeach period of antibiotic cover to avoidunnecessary administration of the agent.

Very sensibly, disease control procedureswere undertaken to begin with. Additionalmeasures included changing dietary habits

and fluoride rinses followed by a re-evalua-tion. Once the patient exhibited increaseddental awareness, demonstrated coopera-tion, and the soft tissue showed a corre-sponding improvement, the stage could beset for planning the definitive treatment. Thistherapy included periodontal surgery, andthe extrusion of a maxillary root to providemore tooth substance for the permanentrestoration. The definitive treatment planalso included construction of an upper

partial denture and a mandibular overden-ture covering precious metal copings.

A mandibular overdenture opposingnatural teeth could be vulnerable to thedestabilizing influences of an irregularocclusal plane. Indeed, the planning andorientation of the occlusal plane is animportant part of the therapy and this

seems to have been undertaken. The

planning of the treatment appears to havebeen thought out in depth and wellexecuted. It is the long term that gives risefor concern, although the overdentureapproach provides considerable versatilityof treatment options should the patient'shome care become less enthusiastic. The

patient, like many who present with a denti-tion in a terminal state, would not usuallyhave been in such a situation if their home

care had been meticulous and they hadalways sought regular professional help.The prospect of losing all the teeth certainly

concentrates the mind, but once thedanger has passed the danger of old habitsreverting is never far away. The overden-ture, by its very nature, covers rootsurfaces and gingivae as well as themucosa, so that plaque control is essentialfor long-term success. I was therefore

happy to read of the outcome of thistherapy, particularly the follow-ups thatwere taken.

7 2

PAST DENTAL HISTORY

The existing prostheses were completedabout 7 years previously, but the patientcould not remember the exact dates.

EXTRA-ORAL EXAMINATION( Figure 7.2)

• Facial asymmetry•

Slightly convex profile•

Normally functioning muscles of masti-cation

•

Normal temporomandibular joints•

Maximum opening 48 mm•

I ncompetent lips

Figure 7.3


Figure 7.4

Left side-pre-treatment.



EXAMINATION (Figures 7.1, 7.3-7.5)

• Angle class I•

Open bite minus 4.0 mm (Figure 7.1)•

Overjet minus 4.0 mm•

I nterocclusal rest space 3.0 mm•

Maximum opening between the incisors48 mm

• Mobility class 1-2 on the maxillaryanterior teeth

• Class 2 mobility of the mandibularanterior teeth

• Discrepancy between centric occlusion(IC) and centric relation (CR) 0.5 mm

Figure 7.5

Right side-pre-treatment.

7 4

ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG

Figure 7.7


Periodontal examination (Figures 7.6 and7.7) revealed probing depths of up to7.0 mm on most of the remaining teeth, withbleeding of the gingiva on probing on mostof the teeth, with the condition being moresevere in the maxilla than the mandible:

•

Missing teeth:


Reduced posterior occlusal supportFlaring of anterior teethCariesFaulty restorationsPoor estheticsOpen biteNeurofibromatosis type 2

ABOUT THE PATIENT

The patient understood the severity of hisdental condition but was highly motivatedas he thought that the dental treatmentwould enable him to be able to close hismouth. However, he absolutely refused toconsider a removable prosthesis.

Hopeless: nonePoor:

DIAGNOSIS

•

Advanced adult type periodontitis•

Missing teeth


Advanced periodontitis and poor oralhygiene, accompanied by many missingteethExisting restorations were faultyOpen anterior biteDue to facial nerve damage, the patientcould not close his lips or eyelids. Duringswallowing, his tongue moved anteriorlyto close the space, putting pressure on

75

Figure 7.6


CariesLow maxillary sinuses60% bone loss around some teethAnterior spacing

Fair: the remaining teethGood: none

the anterior teeth and causing the foodbolus to go down into the esophagusbefore it had been triturated completely.Consequently, the patient wasconstantly dripping liquids from thesides of his mouth

• His difficulty in hearing (left side) andseeing (right side) made it more difficultto teach him proper oral hygiene


Maxilla:

Fixed anterior partial prosthesis and aremovable posterior partial prosthesis,supported by implantsFixed anterior partial prosthesis and aremovable posterior partial prosthesis,supported by the anterior fixed prosthe-sis with either clasps and rests, orattachmentsFixed maxillary restoration as a short-ened arch with only a premolar occlu-sion on the left sideFixed maxillary restoration with a weakterminal abutment on the right side

Mandible:

Fixed anterior partial prosthesis withremovable tooth supported posteriorpartial prosthesisFixed tooth and implant supportedpartial prosthesisFixed partial prosthesis with the cuspidas the terminal abutment on the left sideFixed mandibular restoration with aweak terminal abutment on the left side

Following initial preparation, including oralhygiene instruction, scaling and root

TREATMENT PLAN


planing, and a periodontal re-evaluation, afinal treatment plan was then chosen whichconsisted of selective grinding andorthodontic treatment to improve theocclusal relationship and close the existingspaces between the anterior teeth. Thiswould improve the anterior tooth positionand enable these teeth to participate invertical dimension support. Following theorthodontic treatment a provisional full archfixed maxillary and mandibular prostheseswould be done and carefully followed overa period of at least 6 months to ascertainthe ability of the abutment teeth to supportthe fixed prostheses. If this phase wassuccessful, complete arch maxillary andmandibular fixed prostheses would beconstructed.

TREATMENT

I nitial preparation included scaling, curet-tage, root planing, and oral hygiene instruc-tion. At the end of this stage, an obviousimprovement in the soft tissue could bediscerned. At this time a periodontal re-evaluation was done and it was observedthat the pockets depths had greatly dimin-ished and that the bleeding on probing haddisappeared.

The orthodontic phase of treatment wasthen started using elastics to retract themandibular and maxillary anterior teeth(Figure 7.8) and close the spaces. This wasdone in order to achieve better estheticsand move the teeth into a better position inthe alveolar bone for occlusal support andwith the intent to prepare the site for futuredevelopment should implants be needed.

When the orthodontic stage wassuccessfully completed (Figure 7.9), thesupporting teeth were prepared andtemporary restorations were placed (Figure7.10). Periodontal evaluation was again

76


Figure 7.8

Figure 7.9

Teeth before orthodontic treatment.

Teeth after orthodontic treatment.

Figure 7.10

Transitional crowns.

Figure 7.11

Fitting of Duralay copings.

Figure 7.12

Working models.

performed and disclosed that the probingdepths were less than 3.0 mm in all areas.

Copper band elastomeric impressionswere then taken of all the prepared teethand Duralay copings were made. Thesecopings were used to record centric relationat the vertical dimension of the temporaryrestorations (Figure 7.11), and for the finali mpression for the working die model(Figure 7.12). These models were mountedon a semi-adjustable articulator (Hanau)utilizing a facebow registration, and centricrecords were taken at the vertical dimension

77

7 8

Figure 7.13

Figure 7.14

Working models mounted on Hanau articulator.

I mpression of soldered castings for tissue detail-mandible.

Figure 7.15

Figure 7.16

Treatment completed-right side.

Treatment completed-left side.

Figure 7.17

Treatment completed-anterior view.


of occlusion utilizing Duralay with a Neylontechnique (Figure 7.13). The metal copingswere then fitted and soldered and, after try-in of the soldered metal framework andcentric records had been made, anotherelastomeric impression was done for thefinal tissue detail model (Figure 7.14). Theporcelain was baked and the occlusionchecked at the biscuit bake stage in themouth and all adjustments needed werethen made. The porcelain was then glazedand the crowns and bridges werecemented with Temp-Bond. The crownsand bridges were then cemented with zinc


oxyphosphate cement for permanentcementation in 1995 (Figures 7.15-7.17).

The patient has been returning for follow-up and maintenance twice a year since then.

SUMMARY

The patient, a 36-year-old computer engineer,came to the Graduate Prosthodontics Clinic ofthe Hebrew University Dental School ofMedicine for treatment. He presented with asevere problem of advanced adult periodonti-tis. He had many missing teeth, much alveo-l ar bone loss around the remaining teeth, andfaulty restorations in both jaws. There wasconsiderable bone resorption and probing ofup to 7.0 mm His fixed restorations wereinadequate. There was mobility and fremitus inthe maxillary anterior teeth and mobility of themandibular anterior teeth. His dental conditionwas further complicated by his medical condi-tion (neurofibromatosis type 2), whichrendered him unable to close his mouthproperly, and caused trauma to the anteriorteeth during swallowing. With orthodontic andperiodontal treatment accompanied byocclusal therapy, the patient received fixedpartial prostheses that provided him with aphysiological occlusion at the optimum verticaldimension of occlusion for his periodontalcondition.


The patient presented himself for treatmentsuffering from advanced periodontitis aggra-vated by the loss of many teeth and compli-cated by an anterior open bite. The treatmentgoals were to restore esthetic function andgive the patient a long-lasting physiologic

occlusion. By meticulous oral hygiene,scaling and root planing, his periodontalcondition was greatly improved. Then bymeans of orthodontic treatment that movedthe teeth lingually, and selective grinding toreduce the open bite, the esthetic andfunctional goals were achieved. In reducingthe vertical dimension, the crown-to-rootratio of the posterior teeth (which wereperiodontally involved) was improved.Reasonable overjet and overbite were alsoachieved, gaining mutual protection of theanterior teeth during jaw movements. Theseprocedures enabled us to achieve anesthetic and physiological occlusal schemethat will last for many years.


Relatively young patients with advancedperiodontal disease present challengingproblems. Very sensibly, the initial treatmentwas not side tracked from attention todisease control procedures until a satisfac-tory outcome of this aspect of the treat-ment had been assured. Whether or not anactive tongue thrust was contributing to thei nitial breakdown of the arcade is notmentioned, but it appears that there wereno speech difficulties when the teeth wereretracted into a more ideal relationship. Iassume that the rebuilt occlusion providedthe patient with a competent lip seal, whichwas lacking when he first attended fortherapy. Providing some anterior guidancewas an added bonus. However, themaintenance of the restorations, particu-larly the lower anterior fixed prosthesis, willrequire particular care on the part of thepatient. An excellent result appears to havebeen obtained.

79

PATIENT 8 ADVANCED ADULTPERIODONTITIS

Treatment by Eyal Tarazi

THE PATIENT

The patient, a 64-year-old radiologist anda recent immigrant, came to theGraduate Prosthodontics Clinic for dentaltreatment (Figure 8.1). His chiefcomplaints were:

`I am extremely sensitive to hot and coldfoods on the lower left side.'` Due to my missing teeth, I have difficultyeating on the right side.'` Usually I only eat soft food.'` Food packs underneath my bridge.'

allergy to food or medications. About 40years ago, he suffered from hepatitis A.

PAST DENTAL HISTORY

His last dental treatment was 7 years previ-ously. His upper anterior teeth wererestored 15 years previously. The mandiblewas treated about 18 years previously. Asfor his esthetic appearance, he stated, `It'shard to explain, but because it's been likethis for a long time, I feel that it's natural.'


EXTRA-ORAL EXAMINATION(Figure 8.2)

The patient was healthy, and did not take anymedication. He had no known sensitivity or

Asymmetrical face, with lower thirdbeing greater than the middle third

Figure 8.1


Figure 8.2

Face-frontal view.

81

• Long chin and prominent nose, inprofileHe `smiled' with his lips closedTenderness of the left masseter muscleduring palpation

•

Maximum opening of 52 mm, withdeviation to the left on openingMandibular motions within normal limits

INTRA-ORAL AND FULL-MOUTHPERIAPICAL RADIOGRAPH

EXAMINATION

Maxilla (Figures 8.3, 8.5 and 8.6):

Wide parabolic archDeviation of the mid-palatal suture tothe right sideNarrowed space for the right centralincisorLeft first premolar pontic restored bytwo unitsRight first premolar tilted mesially and inclose proximity to the canineFlat palate and residual ridgesRestorations: fixed all metal partialprosthesis:

Figure 8.3



Mandible (Figures 8.4-8.6):

Wide parabolic archCrowding on the left sideSpacing in the right side because ofmissing teethDistal tilting of the right canine andl ateralRotations, overlapping and toothabrasionHigh floor of the mouthRetained deciduous root instead of rightsecond premolarCaries:

Occlusal examination revealed that thepatient was Angle classification class IIocclusion on the right side and class Iocclusion on the left side. The interocclusalrest space was 3-4 mm. Overjet was3-5 mm and overbite was 4-6 mm. Therewas a 1.0 mm hit and slide from centricrelation to centric occlusion anteriorly andvertically. The mandibular anterior segmentshowed overeruption.

Figure 8.4


Restorations: fixed all metal (gold)partial prosthesis:

82

ADVANCED ADULT PERIODONTITIS

Figure 8.5

Radiographs of maxillaand mandible, pre-treatment.

Figure 8.6

Panoramic radiograph-pre-treatment.

Lateral jaw movements were guided bythe canine and premolar on the left side,and by the canine with incisal contacts onthe right side. Protrusive movements wereguided by the canines and the incisors. Nonon-working side interference was noted.

Fremitus:

•

Maxillary cuspids-grade II•

Maxillary left central incisor-grade III•

Left second premolar-grade III•

Left third molar-grade III

Periodontal examination ( Figures8.7-8.12) revealed large amounts ofcalculus and plaque, probing depths ofup to 10.0 mm on the maxillary teeth andup to 8.0 mm on the mandibular teeth,with bleeding of the gingival tissues onprobing on most of the teeth. There wasgingival recession around almost all of theteeth.

The maxillary left third molar had class 2furcation on the mesial and distal. Themandibular left second and third molars,and the right first molar all had class 1furcation involvements.

83

84


Figure 8.7

Figure 8.8

Mandibular anterior teeth-lingual view, showing calculus

Maxillary anterior teeth showing periodontal inflammation.accumulation.

Figure 8.9

Figure 8.10

Mandibular right posterior teeth showing calculus accumulation.

Mandibular anterior teeth-labial view, showing calculusaccumulation.

Figure 8.11

Figure 8.12

Periodontal chart-maxilla, re-evaluation. Periodontal chart-mandible, re-evaluation.


DIAGNOSIS

Advanced adult type periodontitisMultiple defective restorationsCarious lesions and secondary cariesAbrasion and abfractionMissing teeth-partially edentulous archesDeep biteCompromised posterior occlusionDecreased vertical dimension of occlu-sionPoor occlusal planeSecondary occlusal traumaAcute pulpitis-lower left third molarChronic apical period ontitis-upper leftmolarEsthetic impairment (although it did notappear to effect the patient)

ABOUT THE PATIENT

Scaling and root planingCaries excavationOcclusal adjustment by selective grind-ing to reduce occlusal trauma

RE-EVALUATION I

PHASE Z: TREATMENT PLAN

Replacement of inadequate restorationsby provisional restorationsFurther elimination of occlusal traumaby splinting and stabilization with provi-sional restorationsRe-establishment of an acceptablevertical dimension of occlusion, and aphysiologic occlusal planeCreation of anterior contacts by the useof a lingual platform

He was a highly motivated immigrant whowanted to improve his oral condition, andwas highly disciplined and very patient. Hisexpectations were to improve his oralcondition by all means, and despite hispoor financial condition, he insisted on afixed oral rehabilitation. He had a verysensitive gag reflex. Initial languageproblems were later surmounted.

RE-EVALUATION II

PHASE 3: TREATMENT PLAN

Adjunctive orthodontics-forced eruptionof the upper right premolar, to eliminatethe deep osseous deformityInsertion of two implants on each sideof the maxilla

EMERGENCY TREATMENT PLAN PHASE 4: TREATMENT PLAN

•

Control of acute conditions•

Endodontic therapy-lower third molar•

Extraction of the upper left third molar

TREATMENT PLAN

Provisional restorations.


Prosthetic phase.


•

I nitial periodontal therapy•

Oral hygiene instruction


Recall and maintenance.

85

8 6


I nitial treatment consisted of scaling, curet-tage, oral hygiene instruction, and extractionof the third left maxillary molar. This phase oftreatment took almost 6 months due tocommunication problems, until the patientwas able to improve his oral hygiene to theextent that the treatment could continue(Figure 8.13). The left second mandibularpremolar was also extracted. Root canaltherapy was carried out on the second andthird left mandibular molars, and the right

TREATMENT

Figure 8.13

Anterior teeth after transitional restorations.

Figure 8.14

Figure 8.15

Maxillary canine and first premolar after minor orthodontic

Orthodontic treatment to extrude maxillary left secondtooth movement.

premolar.

Figure 8.16

Figure 8.17

Radiograph

before

extrusion

of

maxillary

left

second

Radiograph after extrusion of maxillary left second premolar,premolar.

showing accompanying bone.


Figure 8.18

CT radiograph of maxilla for implant placement.

Figure 8.19

I mplants-mandible left posterior region.

first maxillary premolar. When that stage wascompleted, minor orthodontic treatmentwas undertaken to open up root proximitybetween the right first maxillary premolarand the right canine (Figure 8.14). At thatstage all the remaining maxillary teeth andthe mandibular teeth from the left third molarto the right cuspid were prepared for provi-sional restorations. On the left side, thesecond maxillary premolar was forced toerupt. This was achieved by first separatingthe first and second premolars (Figure 8.15),and then by use of a coil spring. The secondpremolar was extruded along with theaccompanying bone into position. Thisprocedure eliminated the deep infrabonypocket around the second premolar (Figures8.16 and 8.17).

Due to the severe gag reflex, and in spite ofgreat effort on his part, the patient could notadapt to the provisional maxillary partialremovable prosthesis that was made for him,and it was discarded. At that point it wasdecided that a maxillary removable prosthesiswas not viable, and the treatment plan of fixedmaxillary posterior prostheses on implantswas chosen.

Computerized tomographic (CT) radio-graphs were made of the maxilla utilizing

an acrylic stent with gutta percha pointsin the areas that required implants (Figure8.18). The CT radiographs indicated thatthe bone type was class IV, and on theleft side, the width of the bone wasi nadequate for implant placement. Anautogenous bone graft from the chin wasplaced on the left side 6 months beforethe implant insertion. Two Branmarkimplants (Nobel Biocare USA, Inc: YorbaLinda, CA) were then placed on eachside in the maxilla in the premolar andmolar areas (Figure 8.19). In the rightside, self-tapping 15 and 13 mm long,3.75 mm diameter implants were used,and on the left side self-tapping 12 mmlong and 5.0 mm diameter implants werei nserted.

New provisional transitional prostheseswere then constructed after the uncoveringof the implants. At that point, copper bandelastomeric impressions were taken of all theprepared teeth and Duralay copings weremade. These copings were used to recordcentric relation at the vertical dimension ofthe temporary restorations, together with theteeth position in the arch for the final impres-sion for the working model. A polyethercomplete arch impression in a custom tray

87


was made to pick up the Duralay andimplant impression copings. The metalcopings were then cast, fitted and soldered.After try-in of the soldered metal framework,another polyether impression was made fortissue detail for the final master model. Thesemodels were mounted on a semi-adjustablearticulator (Hanau) utilizing a facebow regis-tration and centric records were taken at thevertical dimension of occlusion utilizingDuralay with a Neylon technique. The porce-lain was baked and the occlusion checked atthe biscuit bake stage in the mouth and alladjustments needed were then made. Theporcelain was then glazed and the crownsand bridges were cemented with Temp-Bond on the prepared teeth for a period of 3weeks. The implant-supported bridges werescrewed in to the implants and were notattached to the natural teeth supportedbridges. The crowns and bridges were thenpermanently cemented with zinc oxyphos-phate cement for permanent cementation(Figures 8.20-8.29).

SUMMARY

The patient presented with various problems.Due to a language problem, communication

was very difficult. Even though at the begin-ning the patient was very satisfied with hisappearance, as the treatment continued, hebecame more and more involved in his treat-ment. The treatment was long and extensive,encompassing a long initial treatment due tothe language barrier. Once the patient under-stood the importance of good oral hygiene,he collaborated and became an importantaccessory to his care. The treatmentextended over more than a 2-year period, butboth the patient and the dentist thought that

This 64-year-old-patient presented fortreatment in the Graduate Prosthodonticsclinic. He had advanced adult periodonti-tis which was complicated by missingteeth, decreased vertical dimensionaggravated by deep bite and faultyrestorations with midline deviation. Allthese findings demanded comprehensiveintegrated treatment planning thatincluded orthodontic treatment for bothperiodontal and teeth alignment problems,

Figure 8.20

Treatment completed-permanent restorations, anterior view.

Figure 8.21

Treatment completed-permanent restorations, right side.

88


Figure 8.23

Post-treatment radiographs, anterior mandibular area.

Figure 8.25

Maxillary right posterior area, clinical view.

Figure 8.26

Maxillary left posterior area, clinical view.

89

Figure 8.22

Figure 8.24

Treatment completed-permanent restorations, left side.

Post-treatment radiographs, maxillary right posterior area.

90


a new occlusal scheme to reduce lateralforces on remaining teeth, and reducingocclusal forces by including the anteriorgroup of teeth in support. At the comple-tion of treatment these objectives weremet. The occlusal support was restored, aphysiologic occlusal scheme was placed,and functional and esthetic demands weremet, to both the patient's and the dentist'ssatisfaction.

Figure 8.27

Post-treatment radiograph, maxillary left posterior area. CASE DISCUSSIONHAROLD PREISKEL

This highly educated patient receivedtreatment involving a combination of skillsand techniques that would stretch thecapabilities of an experienced specialist,let alone a graduate working under super-vision. A pronounced gag reflex and alanguage barrier that initially preventeddirect communication were yet furtherobstacles to be overcome. The saga ofthis patient's therapy makes interesting

Figure 8.28

reading, with the patient himself becoming

Patient's smile after treatment.

ever increasingly involved in his own treat-ment and appreciating the impressiveskills and care that he was receiving.

The gag reflex ruled out the use of aremovable prosthesis that would havesimplified the restoration of the maxillaryarcade. Another, simpler, alternative mighthave been to have left a shortened arch inthe new right posterior maxillary area.Instead I am sure that the patientbenefited from the more complex butcomprehensive restoration that wasconstructed and I trust that his ongoingmaintenance will be continued with the

Figure 8.29

same enthusiasm with which he partici-Patient's forced smile before treatment.

pated in the initial treatment.


and replaced by an implant. She wasseeking a fixed restoration on the implant.

EXTRA-ORAL EXAMINATION(Figure 9.3)

Smiling revealed spacing between theincisor teethDue to slight drooping of the left upperlip, the patient exposed more of herteeth on the right side than the left side

Slight facial asymmetrySlightly convex profileMuscles and temporomandibular jointsnormalMaximum opening 46.0 mm with a3.0 mm deviation to the left side onopening.

Figure 9.3



EXAMINATION ( Figures 9.4-9.8)

Missing teeth (the maxillary missingpremolars were congenitally missing):

Caries60% bone loss around the maxillary leftfirst molarSpacing between the anterior teethMaxillary right first premolar rotated 90°8.0 mm

implant

i n

the

first

rightmandibular areaMid-line discrepancy of the maxillaryincisors

Occlusal examination revealed that thepatient was Angle class 1, with anoverbite of 2.0 mm and overjet of3.0 mm. The interocclusal rest space was3.0. Mobility class 1 and fremitus classI -II were found on the maxillary anteriorteeth. A 0.5 mm discrepancy existedbetween centric occlusion (CO) andcentric relation (CR). There was distaldrifting of the maxillary canine teeth, withthe left canine in the left first premolarposition. In lateral movements there wascuspid protection and in protrusivemovements there was anterior disclusion.

Periodontal examination (Figures 9.6 and9.7) showed probing depths of up to 9.0 mmon the maxillary teeth and up to 4.0 mm on

92

MODERATE TO ADVANCED ADULT PERIODONTITS

Figure 9.4

Figure 9.5

Maxillary arch.

Mandibular arch.

Figure 9.6

Figure 9.7



Figure 9.8

Radiographs of maxilla and mandible.

93


the mandibular teeth; bleeding on probingwas more severe in the maxilla than in themandible. The maxillary left first molar hadclass 2 furcation involvement on the buccaland mesial surfaces, and the left secondmolar had class 2 furcation involvement onthe mesial and buccal surfaces.

a comprehensive treatment plan wasnecessary. After explanation and consulta-tion, she accepted the suggested treat-ment plan. She was very cooperative inher dental treatment and was ready to doeverything necessary in order to save herteeth.

I NDIVIDUAL TOOTH PROGNOSIS POTENTIAL TREATMENTPROBLEMS

Advanced periodontitis complicated byloss of teeth, aggravated by faultyrestoration and flaring of anterior teethThere were large spaces between themaxillary anterior teeth due to thecongenitally missing teeth and thesubsequent drifting of her other teethThe existing restorations were inadequateThe maxillary left first molar had asevere perio-endo lesion

TREATMENT GOALS

In order to attain a more favorable toothposition, orthodontic treatment would berequired. Orthodontic treatment goals were:

Close the anterior spacesExtrude teethLevel gingival marginsCorrect the misaligned center line of themaxillary teethOpen space posteriorly for fixed partialprostheses

A computerized digital picture was made,and different treatment options were thenpresented to the patient. The treatmentplan chosen was to orthodontically closethe anterior spaces, and leave the maxillaryleft cuspid in the premolar position. On the

The patient had come to the cliniccomplaining of difficulty in chewing andconcern with her appearance. However,her main request was for a restoration of asingle crown on the implant placedrecently in her mandible. In order toaddress her complaints she was told that

DIAGNOSIS

Moderate with localized advanced adultperiodontitisCongenital partial anodontiaMissing teeth accompanied by loss ofposterior occlusal supportFaulty restorationsCariesReduced vertical dimensionFlaring of maxillary anterior teethCompromised estheticsSecondary occlusal traumaPerio-endo lesion on the maxillary firstmolar accompanied by probing depthsof 9.0 mm

ABOUT THE PATIENT

9 4


right side of the maxilla, it was decided torotate the maxillary premolar in order toopen space for an additional tooth to beplaced.


Maxilla:

Fixed posterior partial prosthesesFixed anterior partial prosthesis and aremovable posterior partial prosthesis

Mandible:

Fixed partial posterior prosthesisFixed tooth and implant supportedpartial prosthesis

I nitial preparation included scaling, curet-tage, root planing and oral hygieneinstruction. At the end of this stage,an obvious improvement in the softtissue could be discerned. A periodontal

TREATMENT

re-evaluation was made and it wasobserved that the pocket depths hadgreatly diminished, while bleeding onprobing had disappeared.

Endodontic therapy was undertaken onthe palatal root of the maxillary left firstmolar; the mesial and disto-buccal toothroots were resected. The maxillary secondmolar was also prepared and a transitionalfixed acrylic resin restoration was made(Figure 9.9). In the mandible, the rightsecond premolar and the right second molarwere prepared for fixed restorations and afixed transitional acrylic resin prosthesis wasmade (Figure 9.10). The implant in the rightmandibular first molar area was leftunexposed, in the bone.

Before the orthodontic phase of treat-ment started, a diagnostic set-up wasmade, and the anterior maxillary teeth wererepositioned on a study model as a guidefor the treatment goal (Figure 9.11).

Using fixed brackets and a labial archwire, the maxillary incisor teeth wererepositioned to their correct position (Figure9.12) They were then retained in thisposition utilizing a modified Hawley appli-ance (Figures 9.13 and 9.14).

Figure 9.9

Maxilla showing transitional restorations.

Figure 9.10

Mandible showing transitional restorations.

95

9 6


Figure 9.11

Figure 9.12

Palatal view of maxillary anterior teeth repositioned on

Orthodontic treatment-spaces closed.model.

Figure 9.13

Figure 9.14

Modified Hawley appliance.

Modified Hawley appliance in mouth.

At completion of the orthodontic stage(Figure 9.15), two alternative treatmentplans were considered. The first was tosplint the anterior teeth with porcelain fusedto metal crowns with precision attachmentsin the distal of the canines. This wouldenable the posterior splints to be fixed tothe anterior splints. The second option wasto use a lingual wire to splint the maxillaryanterior teeth and have a free-standingposterior restoration.

Figure 9.15

The second option for retention of theseMaxilla-after closing of anterior spaces.

teeth was chosen. The lingual surfaces of


Figure 9.16

Wire splint for maxillary teeth retention (on model).

Figure 9.17

Transitional restorations-anterior view.

Figure 9.18

Duralay copings fitted in maxilla.

the anterior maxillary teeth were pumiced,etched, bonded, and built to occlusalcontact with mandibular anterior teeth byadding microfil composite resin (Durafilvs). A groove was then made in thecomposite platform and a nitinolorthodontic wire was fitted and bonded inplace (Figure 9.16).

The remaining maxillary teeth wereprepared and a transitional acrylic resinrestoration was prepared for fixed prosthe-ses and transitional acrylic resin restora-tions were placed (Figure 9.17).

Copper band elastomeric impressionswere then taken of all the prepared teethand Duralay copings were made. Thesecopings (Figure 9.18) were used to recordthe teeth position in the arch for the finalimpression for the working model andalso centric relation at the vertical dimen-sion of the temporary restorations. Apolyether complete arch impression wasmade to pick up the copings and theirrelationship to the remaining teeth(Figures 9.19 and 9.20). The metalcopings were then cast, fitted andsoldered, and after try-in of the solderedmetal framework another polyetherimpression was made for the final mastermodel. These models were mounted on asemi-adjustable articulator (Hanau) utiliz-i ng a facebow registration. Centricrecords were made at the vertical dimen-sion of occlusion utilizing Duralay with aNeylon technique. The porcelain wasbaked and the occlusion checked at thebiscuit bake stage in the mouth and alladjustments needed were then made.The porcelain was then glazed and thecrowns and bridges were cemented withTemp-Bond for a period of 3 weeks. The

Figure 9.19

Polyether maxillary impression of metal copings.

Figure 9.21

Maxillary restorations-right side.

crowns and bridges were then perma-nently cemented with zinc oxyphosphatecement for cementation (Figures9.21-9.23).

The patient has been returning for follow-up and maintenance twice a year.


Figure 9.20

Polyether mandibular impression of metal copings.

Figure 9.22

Maxillary restorations-left side.

SUMMARY

The 40-year-old female patient came to theGraduate Prosthodontics Clinic of theHebrew University Dental School ofMedicine for a simple restoration of a

98


Figure 9.23

Frontal facial view of patient after treatment completion.

crown on a recently placed implant. Thepatient presented with moderate toadvanced adult periodontitis. She hadmany missing teeth, advanced alveolarbone loss around some teeth, and faultyrestorations in both jaws. There was mobil-ity and fremitus in the maxillary anteriorteeth.

After a complete examination, diagnosis,and consultation, the patient agreed to acomprehensive treatment plan, and not justa single crown for her implant.

With orthodontic and periodontal treat-ment accompanied by occlusal therapy, thepatient received a physiologic occlusion atthe optimum vertical dimension of occlusion.


The patient presented herself to theGraduate Prosthodontics Program, seekingtreatment for various complaints. She hadbeen treated earlier by a periodontist who

replaced a missing lower first right molar byan 8.0 mm implant, even though theadjacent teeth had been previously treated.The patient's advanced periodontal disease,accompanied by flaring of anterior teethalong with several missing teeth, was quitechallenging. The orthodontic treatmentaddressed the patient's esthetic complaintsand improved the periodontal condition.This facilitated participation of the anteriorteeth in occlusal support in their new favor-able position. The occlusal scheme wastailor made to address the periodontalsituation. A functional physiologic occlusionwas established.


The treatment received by this patientunderscores the importance of establishinga comprehensive program of therapy at theoutset, together with achievable goals. Thehazards of treating a patient on a quadrantor tooth-by-tooth basis is clearly evidencedby earlier attempts at treatment.

Computer simulation has been employedto augment the more standardized radio-graphic and diagnostic case investigationtechniques. Modifying an existent diagnos-tic cast is a relatively straightforward andextremely effective way of assessing theresults of therapy and was used to goodeffect. The patient's treatment has trans-formed her mouth from an unsightly,diseased and rapidly deteriorating situationinto one of health, function, and good looks.

9 9

PATIENT 10

SEVERE ADVANCED ADULTPERIODONTITIS

Treatment by Erez Mann

THE PATIENT

best, if some roots could be saved,complete overdentures.

The patient, a 58-year-old engineer,presented herself for examination andconsultation at the Hadassah Hebrew

PAST MEDICAL HISTORYUniversity School of Dental MedicineGraduate Prosthodontics Clinic with the

Past medical history was non-contributory.

following complaint:

` My upper and lower front teeth areloose.'

She had been to several dentists, all ofwhom had told her that she would mostprobably need complete dentures or, at


Normal facial symmetrySlightly convex profile

Figure 10.1

Figure 10.2


Side face view.

1 01

1 0 2


Normally functioning muscles of masti-cationThe temporomandibular joints werenormalThe maximum opening was 48 mmwith a 2.0 mm deviation to the left sideon opening and a 2.0 mm deviation tothe right side in the closing movement


EXAMINATION (Figures 10.3-10.11)

• Caries•

Low maxillary sinuses•

60% bone loss around some teeth•

Spacing between the anterior teeth

Occlusal examination revealed that thepatient was Angle class 1, with an overbiteof 2.0 mm and overjet of 3.0 mm (Figure1 0.5). The interocclusal rest space was3.0 mm and the maximum openingbetween the incisors was 48 mm. Fremitusclass I-II was found on the maxillaryanterior teeth and there was mobility of themandibular anterior teeth. There was a0.5 mm

discrepancy

between

centricocclusion (IC) and centric relation (CR). Thepatient had a removable partial mandibulardenture which was unsatisfactory and wasnot used (Figure 10.6).

Figure 10.3

Maxillary arch.

Figure 10.4

Mandibular arch.

Periodontal examination (Figures 10.7 and1 0.8) revealed probing depths of up to5.0 mm on the maxillary teeth and up to5.0 mm on the mandibular teeth, with slightbleeding of the gingiva on probing (BOP)on some of the teeth, with the condition

Figure 10.5

Anterior overjet and overbite.

SEVERE ADVANCED ADULT PERIODONTITIS

Figure 10.6

Figure 10.7

Patient's removable mandibular partial denture.

Maxillary periodontal chart.

Figure 10.8

Mandibular periodontal chart.

Figure 10.9

Radiographs of maxillary and mandibular anterior quadrant.

Figure 10.10

Figure 10.11

Radiographs of right posterior quadrant.

Radiographs of left posterior quadrant.

1 03


being more severe in the maxilla than themandible.


• The existing restorations were inade-quate

• The patient refused to wear a remov-able mandibular partial denture

ABOUT THE PATIENT

The patient understood the severity of herdental condition and came to the clinichoping to avoid construction of completemaxillary and mandibular dentures, becausethat was what other dentists had told herwas the only possible treatment. She wasvery cooperative in her dental treatment, andwas prepared for any financial outlay neces-sary in order to save her remaining teeth.


• The advanced periodontitis wasaccompanied by many missing teeth

TREATMENT POSSIBILITIES

Fixed anterior partial prosthesis and aremovable posterior partial prosthesissupported by implantsFixed anterior partial prosthesis and aremovable posterior partial prosthesissupported by the anterior fixed prosthe-sis with either clasps and rests, orattachmentsFixed maxillary restoration as a short-ened arch with only a premolar occlu-sion on the left side

Mandible:

Fixed anterior partial prosthesis withremovable tooth supported posteriorpartial prosthesisFixed tooth and implant supportedpartial prosthesisFixed partial prosthesis with the cuspidas the terminal abutment on the left side

Following initial preparation including oralhygiene instruction, scaling and rootplaning, and periodontal re-evaluation afinal treatment plan was then chosen whichconsisted of orthodontic treatment toimprove the occlusal relationship and closethe existing spaces between the anteriorteeth. This would improve the anteriortooth position to facilitate participation in

104

Maxilla:

DIAGNOSIS

Advanced adult periodontitisMissing teeth accompanied by loss ofposterior occlusal support, and flaringof maxillary anterior teethCariesFaulty restorationsPoor estheticsReduced vertical dimension


vertical dimension support and to reducethe root proximity between the mandibularright cuspid and the first premolar.Following the orthodontic treatment, aprovisional fixed maxillary prosthesis termi-nating with a premolar occlusion on the leftside would be done. The mandible wouldbe treated with a provisional fixed prosthe-sis on the remaining teeth, which extendedfrom the right third molar to the left cuspid.At the time the treatment plan was chosenthe patient still refused to consider aremovable mandibular prosthesis.

Figure 10.12

Elastic retraction of mandibular anterior teeth.

TREATMENT

I nitial preparation included scaling, curettage,root planing and oral hygiene instruction. Atthe end of this stage, an obvious improve-ment in the soft tissue could be discerned. Atthis time a periodontal re-evaluation wasdone and it was observed that the pocketdepth had greatly diminished and that thebleeding on probing had disappeared.

The orthodontic phase of treatment wasthen started using elastics to retract themandibular anterior teeth (Figure 10.12).The maxillary incisor teeth were also treatedorthodontically with a modified Hawleyappliance (Figure 10.13). This retracted themaxillary anterior teeth and closed thespaces. This was done in order to achievebetter esthetics and move the teeth intobetter position in the alveolar bone forocclusal support, and with the intent toprepare the site for future developmentshould implants be needed (Figure 10.14).

When the orthodontic stage was success-fully completed, (Figures 10.15 and 10.16)the supporting teeth were prepared andtemporary restorations were placed (Figures10.17-10.19). A coil spring was then insertedto separate the right mandibular cuspid from

Figure 10.13

Hawley orthodontic appliance.

Figure 10.14

Clinical view of Hawley appliance-pre-treatment.

10 5


Figure 10.15

Figure 10.16

Maxillary anterior teeth after orthodontic treatment.

Anterior teeth after orthodontic treatment.

Figure 10.17

Figure 10.18

Final tooth preparation-mandible.

Final tooth preparation-maxilla.

Figure 10.19

Transitional restorations-maxilla and mandible.

the right first premolar (Figure 10.20).Radiographs (Figure 10.21) and periodontalevaluation were again performed anddisclosed that the probing depth were lessthan 3.0 mm in all areas. A transitional remov-able mandibular partial denture was alsosuggested to the patient, and again rejected.

Copper band elastomeric impressions werethen taken of all the prepared teeth andDuralay copings were made. These copings(Figure 10.22) were used to record centricrelation at the vertical dimension of the tempo-rary restorations and for the final impressionfor the master model. The metal copings were

106



Coil spring to separate the right mandibular cuspid andpremolar teeth.

Completed teeth preparations-maxilla and mandible,radiographs.


Duralay copings fitted-maxilla and mandible. Removable partial mandibular denture.

then fitted and soldered and, after try-in of thesoldered metal framework, anotherelastomeric impression was done for tissuedetail and for the final master model. Thesemodels were mounted on a semi-adjustablearticulator (Hanau) utilizing a facebow registra-tion and centric records were taken at thevertical dimension of occlusion utilizingDuralay with a Neylon technique. At this pointthe patient was finally convinced of the impor-tance of a partial removable mandibulardenture and agreed to try and adjust to one.The porcelain was baked and the occlusionchecked at the biscuit bake stage in the

mouth and all adjustments needed were thenmade. Rest preparations were then milled intothe fixed prosthesis in the lingual of the rightmolar area pontic as well as the distal surfaceof the left cuspid. The porcelain was thenglazed and the final elastomeric impression forthe removable mandibular partial denture wasdone. The framework for the partial denturewas then cast and fitted and a bite trayconstructed on it for centric registrationrecord. This was done and the denture teethwere set up and checked in the mouth foresthetics and occlusion. The denture wasthen processed (Figure 10.23). The crowns

1 0 7

1 08

and bridges were cemented with Temp-Bond and the partial removable mandibulardenture inserted. The crowns and bridgeswere then cemented with zinc oxyphosphatecement for permanent cementation (Figures10.24-10.29).

The patient has been returning for follow-up and maintenance twice a year since thenand adjusted to her removable mandibularpartial denture (Figures 10.30 and 10.31).

SUMMARY

The 58-year-old patient came to theGraduate Prosthodontics Clinic of the


Hebrew University Dental School ofMedicine as a last resort. She had been tothree dentists who had all told her that itwould be impossible to save any of herremaining teeth and that she would needcomplete dentures. She was told that theremight be a chance to save some of herteeth to support an overdenture, but only ifshe went to the Dental Clinic at Hadassah.The patient presented with a severeproblem of advanced adult periodontitis.She had many missing teeth, considerablealveolar bone loss around the remainingteeth, and faulty restorations in both jaws.There was much bone resorption but the

Figure 10.25

Figure 10.26

Case cemented-mandible.

Case cemented-post-treatment, anterior view. Case cemented-maxilla.

Figure 10.27

Case cemented-right side.


Figure 10.28

Case cemented-left side.

Figure 10.29

Radiographs of case-post-treatment.

Figure 10.30

Patient clinically-five years post-cementation.

Figure 10.31

Patient radiographs-five years post-cementation.

probing depth around the remaining teethwas not excessive, mostly 4.0 mm or less,except for the right mandibular premolarand the right maxillary second premolarand third molar. Her fixed and removablerestorations were inadequate and shehardly ever wore her removable partialmandibular denture. There was mobilityand fremitus in the maxillary anterior teethand mobility of the mandibular anteriorteeth.

With orthodontic and periodontal treat-ment accompanied by occlusal therapy,the patient received a physiologic occlusion

at the optimum vertical dimension of occlu-sion for this periodontal condition. Thepatient was adamant about not having aremovable prosthesis and refused to useone during the course of treatment. Onlywhen she was told that the case could notbe completed ending in a cuspid occlusionon the left side, did she agree to try to usea removable partial mandibular denture.She successfully overcame her aversion tothe removable denture and today, 10 yearspost-treatment, functions very well with herpartial removable denture. As a compro-mise solution, the missing posterior

109

PROSTILODONTICS IN CLINICAL PRACTICE

mandibular teeth were replaced as ponticson a fixed prosthesis as opposed to theremovable mandibular partial denture, aswe felt that the patient might not wear thepartial denture. If that did occur, at leastshe would have full occlusion on the rightside.

prognosis of the treatment and serving thepatient for the past 10 years with no signsof breakdown.



This patient represents a complicated casewith advanced periodontal disease andmissing teeth accompanied by driftingand flaring of anterior teeth with mobilityand fremitus. The patient was treated withthe intent to address both the occlusal andperiodontal problem that affected herperiodontal condition. Once the occlusionwas stabilized and with successful oralhygiene instruction, scaling and curettage,the periodontal condition improved consid-erably-to such an extent that there wasno need for any surgical periodontal proce-dures. The new position of the anteriorteeth enabled them to participate inocclusal support, thus improving the

Commenting on a treatment plan with thebenefit of the successful 10-year follow-upis relatively simple as it is hard to argue witha good result. The treatment, however, wasfar from straightforward. In addition to theproblems of advanced periodontitis, lack ofposterior support, flaring of the maxillaryteeth, and caries, the operators were facedwith a patient who adamantly refused towear a removable prosthesis. The fact thatthey were able to undertake a comprehen-sive plan of treatment and motivate thepatient to the extent of wearing a remov-able prosthesis, is eloquent testimony totheir communication skills as well as theirclinical expertise. Bearing in mind that thepatient was treated in the early 1990s, theuse of orthodontics to improve a potentialimplant site must be considered well aheadof its time.

11 0

112


Straight profile with accentuated labio-mental fold, and trapped lower lipNormally functioning muscles of masti-cationTemporomandibular joints were normalThe patient also exhibited solar kerato-sis in the lower lip


EXAMINATION (Figures 11.1-11.9)

Extensive caries and loss of crownstructureLow maxillary sinusesWidened periodontal ligament aroundthe mandibular third molars60% bone loss around some teethFurcation involvement of the mandibularright second molar toothRadio-opacity in the maxillary left sinusarea

Occlusal examination revealed that thepatient was Angle class II division I, with anoverbite of 1 0.0 mm and overjet of7.0 mm. The interocclusal rest space was5.0 mm and the maximum opening was52.0 mm.

Fremitus and mobility were found on themaxillary incisor teeth as well as the leftmaxillary first premolar. In the intercuspalposition

(IC)

a

` scissors

bite'

existed

i n

Maxillary periodontal chart

Figure 11.6

Figure 11.4

Scissor bite right side

Figure 11.5

Mandibular periodontal chart


which the buccal outer line angle of themandibular supporting cusp was lingual tothe functional outer aspect (FOA) of themaxillary supporting cusp (Figures 11.3and 11.4). There was no discrepancybetween centric occlusion (IC) and centricrelation (CR). Fremitus and mobility werefound on several teeth.

The periodontal examination (Figures11.5 and 11.6) revealed probing depths ofup to 5.0 mm on the maxillary teeth and upto 10.0 mm on the mandibular teeth, withbleeding of the gingiva on probing (BOP)on most of teeth, with the condition beingmore severe in the mandible than themaxilla (Figures 11.7-11.9).

Figure 11.7

Radiographs of maxilla andmandible-pre-treatment

Figure 11.8

Maxillary arch

Figure 11.9

Mandibular arch

11 3


DIAGNOSIS

ABOUT THE PATIENT

The patient was young and optimistic andunderstood the severity of his dental condi-tion and came to the clinic hoping to avoidconstruction of complete maxillary andmandibular dentures because otherdentists had told him that was the onlypossible treatment. His expectationsregarding his treatment were functional andesthetic improvement to his mouth.


• The advanced periodontitis wasaccompanied by missing teeth

Note: from old radiographs we concludedthat the existing radio-opacity in the maxil-lary left sinus area was due to a molar tooththat had endodontic therapy which wasoverfilled with cement entering the sinus.The tooth had subsequently been extracted.

Maxilla:

Mandible:

• Fixed partial prosthesis• Removable tooth-supported partial

prosthesis• Fixed tooth and implant-supported

partial prosthesisFixed and removable partial prosthesis

The disparity of jaw size caused thescissors bite and lack of occlusalsupportThe deep overbite would cause biome-chanical problems for the restorationsand increasing the vertical dimension ofocclusion would accentuate theunfavorable bucco-lingual relationshipbetween the jaws and also worsen thecrown-root ratio of the teeth, puttingmore stress on the periodontiumBecause of the primary and secondaryocclusal trauma, a complete mouthrehabilitation would be difficult to do.



Fixed anterior partial prosthesis and afixed posterior partial prosthesis sup-ported by implantsFixed anterior partial prosthesis and aremovable posterior partial prosthesissupported by the anterior fixed prosthe-sis with either clasps and rests orattachmentsA fixed maxillary restoration as a short-ened arch with only a premolar occlusion.

Advanced adult periodontitisMissing teethLoss of occlusal supportScissors bite - jaw size disparityDecreased vertical dimensionSecondary occlusal trauma withprimary originsCariesFaulty restorationsPoor estheticsPeriapical changes

114


TREATMENT PREREQUISITES

• In order to achieve a tooth-supportedprosthesis, orthodontic treatment tochange the bucco-lingual relationship ofthe maxillary and mandibular teeth wasmandatory

• In order to do an implant-supportedmaxillary fixed prosthesis, maxillarysinus augmentation would be required

anterior maxillary prosthesis and a removableposterior maxillary prosthesis with semi-precision attachments, and a fixed partialprosthesis in the mandible.

The maxillary second molars that wereconsidered hopeless would be restoredwith temporary restorations to augmentposterior occlusal support during theorthodontic treatment.

FINAL TREATMENT PLAN

A final treatment plan was then chosenwhich consisted of orthodontic treatment toimprove the occlusal relationship, a fixed

TREATMENT

I nitial preparation included scaling, curet-tage, root planing and oral hygiene instruc-tion. At the end of this stage, an obviousimprovement of the soft tissue could bediscerned (Figure 11.10). At this time aperiodontal recharting and evaluation wasdone and it was observed that the pocketsdepths had greatly diminished and that thebleeding on probing had disappeared(Figures 11.11 and 11.12).

The orthodontic phase of treatment wasthen started using a Hawley bite plane

Figure 11.10

Maxillary anterior teeth after initial treatment

Figure 11.11

Periodontal chart at re-evaluation-maxilla

Figure 11.12

Periodontal chart at re-evaluation-mandible

115

Figure 11.13

Clinical view of Hawley appliance-pre-treatment

Figure 11.15

Maxillary teeth-radiograph, extrusion of central incisor teeth

retainer (Figure 11.13), the goals of whichwere to increase the vertical dimension ofocclusion, add occlusal support, inducemuscular relaxation, and make sure thatretruded cuspal position (RC) and intercus-pal position (IC) were co-incidental.

The maxillary incisor teeth, despite theirhopeless prognosis, were also treatedorthodontically to extrude them in order toachieve better esthetics and prepare the sitefor future development if implants were to beused in the future (Figures 11.14 and 11.15).

When the orthodontic stage was success-fully completed, the supporting teeth were


Figure 11.14

Maxillary teeth-orthodontic treatment, extrusion of centralincisor teeth

Figure 11.16

Transitional crowns and removable partial denture

prepared and transitional (provisional) res-torations were placed (Figure 11.16).

Radiographs and periodontal evaluationwere again performed and disclosed thatthe probing depth were less than 3.0 mmin all areas except the mandibular secondright molar. A transitional removable maxil-lary partial denture was also fabricated toget the patient acclimated to a removableprosthesis (Figure 11.17).

Periodontal surgery was performed onthe mandibular right second molar forpocket elimination; it was decided that thetooth was hopeless and it was thus

11 6


Figure 11.17

Transitional crowns and removable partial denture-maxilla

Figure 11.18

Periodontal surgery-right mandibular second molar

Figure 11.19

Duralay copings fitted-maxilla and mandible and centricrelation record

extracted at the time of the periodontalsurgery (Figure 11.18).

Following healing, the teeth were repre-pared and copper band elastomericimpressions were then taken of all theprepared teeth and Duralay copings weremade. These copings were used for thefinal impression for the master model. Theywere also used to record centric relation atthe vertical dimension of the temporaryrestorations (Figure 11.19). The metalcopings were then fitted and soldered andafter try-in of the soldered metal framework(Figures 11.20 and 11.21), another elas-tomeric impression was done for tissuetransfer for the final master model.

These models were mounted on a semi-adjustable articulator (Hanau) utilizing afacebow registration and centric recordstaken at the vertical dimension of occlusionutilizing Duralay with a Neylon technique(Figures 11.22 and 11.23).

The porcelain was baked and the occlu-sion checked at the biscuit bake stage inthe mouth and all adjustments neededwere then made. The porcelain was thenglazed. An elastomeric impression in aclose-fitting individual tray was made onthe non-cemented fixed prosthesis and theedentulous areas, so that the removablemaxillary partial denture framework couldbe fabricated on the crowns and bridges,as opposed to a stone model of them(Figure 11.24).

The framework for the partial denturewas then cast and fitted and a bite trayconstructed on it for centric record regis-tration (Figure 11.25). This registration wasdone in Duralay using the Neylon technique(Figure 11.26) and the denture teeth wereset up and checked in the mouth foresthetics and occlusion.

The denture was then processed andinserted into the mouth. The crowns and

117

118


Figure 11.20

Figure 11.21

Metal copings try-in-maxilla

Metal copings try-in-mandible

Figure 11.22

Figure 11.23

Centric relation record on Hanau articulator-right side

Centric relation record on Hanau articulator-left side

Figure 11.24

Figure 11.25

Elastomeric impression for maxillary removable partial

Fitting of maxillary removable partial denture frameworkdenture framework


Figure 11.26

Centric relation record on occlusal tray on removable partialdenture

Figure 11.27

Case completed-anterior view

Figure 11.28

Case completed-left side

Figure 11.29

Case completed-right side

bridges were cemented with Temp-Bondand the partial removable maxillary dentureinserted. The crowns and bridges werethen cemented with zinc oxyphosphatecement for permanent cementation(Figures 11.27-11.30).

The patient has been returning for follow-up and maintenance twice a year.

SUMMARY

The patient presented with a severeproblem of advanced adult periodontitis,

missing teeth, scissors bite, and loss ofposterior occlusal support. With orthodon-tic and periodontal treatment accompaniedby occlusal therapy, the patient received aphysiological occlusion at the optimumvertical dimension of occlusion.


This patient was a relatively young individ-ual, 46 years old, with a complicated dentalsituation due to many missing teeth, and

119


Figure 11.30

Post-treatment radiographs

loss of support, accompanied by a deepoverbite and aggravated by a scissors bitethat along with a severe periodontitiscaused a total loss of vertical support.

There were several alternative methodsof treatment possible for this patient:

An overlay partial dentureA removable partial denture afterextraction of the maxillary anterior teethOrthognathic surgery

The solution that was utilized in this caseencompassed biomechanical considera-tions and the patient's well-being as well assatisfaction with the final result. Theorthodontic treatment achieved supportfrom the teeth in scissors bite as well asminimal bite opening (needed for theprosthetic treatment) and thus minimizedthe increased crown-root ratio caused by

the periodontal disease which would havebeen aggravated by the increased verticaldimension. The orthodontic treatment alsoincluded future site development before theextraction of the maxillary central incisorteeth. All this, along with the estheticconsiderations, contributed to thesuccessful treatment of the patient.

The patient's treatment represents morethan a complex plan of dental therapy. Itmarks the transition from a patient who hadno motivation into one who was preparedto undertake multiple visits to a dentaloffice involving an impressive amount oftreatment over an extended period of time.The clinicians are to be congratulated on

1 20


the patient motivation achieved and uponthe successful outcome. It is always impor-tant to have a fallback position in case thepatient's interest wanes and a simpler plancan be substituted. The step-by-stepapproach employed has considerableadvantage in this respect.

Another laudable aspect of the therapywas an appreciation of the three-dimensionalproblems associated with a marked discrep-ancy of arch size. At an early stage it wasimportant to establish how much of thederanged occlusion was as a result of loss ofposterior occlusal support and how much asa result of the decrease of vertical dimensionof occlusion. Of course the two are inter-related, with a decrease of vertical dimensionaccentuating the effect of a forwardmandibular posture. The use of transitionalrestorations to determine maxillo-mandibularrelationships is an important aspect of thetreatment. Forward thinking has also beendemonstrated with the extrusion of anteriorteeth to be subsequently extracted toencourage bone growth for possible implantplacement at a later date.

Alternative avenues of approach werediscussed at the very outset. Havingselected root-supported fixed prosthodon-tics as the primary support, a difficult

decision involves the missing maxillarymolars. Is it necessary to replace them orcould a shortened arch be accepted? Theshortened arch would be far simpler from theprosthodontic point of view, for no-oneshould underestimate the complications ofproducing a removable prosthesis. Themaxillo-mandibular relations of this patienthelped make the decision to replace themissing maxillary molars, leaving open thepossibility of employing a distal cantileverpontic on each side to produce some molarsupport without the need for a denture.However, it can be seen that the upper leftsecond pre-molar is root filled and we knowfrom the work of Glantz and others that theprognosis of a restoration with a distalcantilever pontic is not good when the distalabutment is root filled. The clinicians there-fore elected to construct a partial denturewith all the difficulties involved, to say nothingof the maintenance requirements. Theyensured that the patient understood therationale of the treatment from the outset.

I ndividual techniques are simply tools ofour trade; it is the planning and results thatmatter. This patient's treatment representsboth a success in patient education and inclinical dentistry. I hope that the patientreturns for routine maintenance.

121

PATIENT 12 REFUSAL OFORTHOGNATHIC SURGERY

Treatment by Miriam Calev

The medical history was non-contributory.

Figure 12.1

Anterior teeth-labial view

Figure 12.2

Face-frontal view

1 25

THE PATIENT

The patient, a 26-year-old housewife, cameto the clinic for consultation. Her com-plaints were as follows:

' Everything related to my mouth bothersme.' (Figure 12.1)`I am missing lots of teeth.'' My front teeth stick out.'' My palate hurts.'' Due to my fear of dentists, I haveneglected my teeth for many years.'

PAST DENTAL HISTORY

Past dental history was non-contributory.


Symmetrical faceCompetent lipsSlightly convex profileAccentuated labio-mental foldNormally functioning temporomandibu-larjointsMaximum

opening

42 mm

withoutdeviation

126 PROSTHODONTICS IN CLINICAL PRACTICE

Figure 12.3

Face-side view

I NTRA-ORAL EXAMINATION


• Discrepancy between dental and facialmidlines

•

Parabolic asymmetric arch form• Evidence of previous sores in the

anterior palate•

Maxillary right premolars lacking coronalelements due to severe caries

• Caries• Porcelain fused to metal crowns on

the right central and both left incisorteeth

Figure 12.4

Maxillary arch-palatal view


Figure 12.5

Mandibular arch-lingual view

REFUSAL OF ORTHOGNATHIC SURGERY

Figure 12.6

Occlusion-right side

Figure 12.7

Occlusion-left side

Figure 12.8

Periodontal chart-pre-treatment, maxilla

Figure 12.9

Periodontal chart-pre-treatment, mandible

An occlusal examination revealed thatthe patient was Angle class II division I, withdeep impinging bite (Figures 12.1, 12.6and 12.7). There was an overbite of8.0 mm with tissue impingement and anoverjet of 6.0 mm. The interocclusal restspace was 1.0 mm. Centric occlusion (CO)was concentric to centric relation (CR).Fremitus in centric occlusion:

plaque and calculus. Probing depths of upto 4.0 mm on the maxillary teeth and up to4.0 mm on the mandibular teeth werefound, with bleeding on probing on someof the mandibular teeth. Inflamed tissuewas noted.

FULL MOUTH PERIAPICALRADIOGRAPHIC EXAMINATION

(Figures 12.10 and 12.11)

Periodontal examination (Figures 12.8 and12.9) revealed poor oral hygiene with

•

Defective root canal therapy•

Periapical radiolucent areas

127

1 28


FIGURE 12.1U

Radiographs of maxilla andmandible-pre-treatment,periapical

Figure 12.11

Radiographs of maxilla andmandible-pre-treatment,panoramic

• Good bone support on all remaining

ESTHETIC EVALUATION ANDteeth

PROBLEMS (Figure 12.12)•

Rampant caries• Destroyed coronal structure

•

High lip line•

Low maxillary sinus floor on both sides

• Anterior maxillary gingival margins noof maxilla

continuous


Figure 12.12

Anterior teeth-labial view, esthetic problem

• Faulty occlusal relationship, and faultyocclusal planeRampant carious lesionsDefective restorations and endodontictreatment (periapical lesions)Missing teethPoor estheticsGingivitisReduced posterior supportReduced vertical dimensionPrimary occlusal traumaLoss of tooth structure

ABOUT THE PATIENT

• The maxillary incisor teeth were largeand stuck out

• Discrepancy between maxillary andmandibular midlines

• The maxillary incisors did not contactthe lower lip

• A wide smile exposed the gingivaltissues in the maxilla


• Angle class II division I, with deepimpinging bite

DIAGNOSIS

The patient was a young woman with alarge amount of coronal tooth structureloss due to rampant caries. She was veryapprehensive but had finally overcome herfear of dentists and, after visiting manydental clinics, decided on having her dentaltreatment as soon as possible. She hadhigh expectations from her dental treat-ment. She wanted to improve her estheticappearance and would have preferred fixedrestorations, but understood the difficultyinvolved.


A deep bite accompanied by loss of verti-cal dimension and an increased overjet,along with the great difference in jaw sizeand tooth position, made it very difficult toachieve good occlusal relationships whichenabled the inclusion of the anteriorsegments in occlusal support. By restoringlost vertical dimension, needed for therehabilitation, the jaw relations would bemade worse. To utilize implants for poste-ri or support would improve the situation,

129

but would require pre-implant surgery. Theproblem of the rampant caries had to beovercome before any permanent restora-tions were undertaken.


Maxilla:

Fixed and removable partial prosthesesFixed partial prosthesis supported byremaining teeth and implants (wouldnecessitate pre-implant surgery)Fixed prosthesisOrthognathic surgery, orthodontic treat-ment and fixed prosthesis

Mandible:

Fixed partial prosthesisFixed partial prosthesis supported byremaining teeth and implant

I NITIAL PREPARATION

•

Dietary changes•

Oral hygiene instruction•

Fluoride rinses and gel application• Changing the vertical dimension to

relieve the palatal tissue impingement•

Caries removal•

Referral for endodontic therapy•

Evaluation of patient cooperation• Referral for computerized tomography

( CT) radiographs to determine implantpossibility

• Restorative treatment with restorationsand provisional fixed acrylic restorationsfor the teeth with a sizeable loss oftooth structure

TREATMENT PLAN


• Orthodontic treatment for uprightingand realigning teeth

• Re-evaluation and planning of pre-prosthetic periodontal surgeryNew provisional fixed acrylic restora-tions at the new vertical dimension ofocclusion in order to check patientadaptationRe-evaluationFixed partial prostheses for both themaxilla and the mandible

TREATMENT

I nitial preparation included oral hygieneinstruction, scaling, and curettage. Canineplatforms were then built on the lingualsurfaces of the maxillary cuspid teethopening the vertical dimension of occlusionby approximately 2.5 mm (Figure 12.13).This allowed healing of the palatal gingivaby preventing impingement of themandibular anterior teeth on the palate(Figure 12.14).

Endodontic treatment was performed onthe maxillary left third molar and themandibular left second molar. Cariesremoval and provisional restorations weredone where indicated. At this time theanterior maxillary splint was sectioned andremoved (Figure 12.15). Transitional acryliccrowns were then made for these teeth( Figure 12.16). CT radiographs were thentaken of the maxilla to determine theamount and quality of bone available forimplant placement (Figures 12.17 and12.18). After extraction of the maxillary rightpremolars, the remaining maxillary teethwere then prepared for full crowns andtransitional fixed partial prosthesesconstructed (Figures 12.19 and 12.20).

Re-evaluation at this time showed thatthe bucco-lingual jaw relationships on the

130


Figure 12.13

Figure 12.14

Canine platform to open vertical dimension

Healing of the palatal gingiva

1 31

Figure 12.15

Figure 12.16

Removing existing crowns

Transitional prosthesis-maxilla

Figure 12.17

Figure 12.18

CT scan, maxilla-right side

CT scan, maxilla-left side

Figure 12.19

New transitional prosthesis-maxilla, right side

Figure 12.21

Orthodontic treatment-uprighting right mandibular thirdmolar

right side had worsened with the opening ofthe vertical dimension. Therefore thereremained two options for restoring themandible on the right side. The first optionwas orthodontic uprighting of the mandibu-lar third molar and then a fixed partialprosthesis from the second premolar to thethird molar to replace the missing molarteeth. The second option would be toimplant a single wide body implant in thearea of the mandibular right first molar andthen do a fixed restoration on it, thus notinvolving the third molar in posterior support.


Figure 12.20

New transitional prosthesis-maxilla left side

Figure 12.22

Periodontal surgery-anterior maxilla, after healing

The first option was chosen andorthodontic treatment was instituted toupright the mandibular third molar (Figure12.21). At this time, a further re-evaluationwas done. It was decided that due to therelatively young age of the patient (26), thefact that she did not want implants, andthat there was only a relatively small spanto be restored on the mandibular rightside, a fixed partial prosthesis waschosen.

Periodontal surgery was performed inthe anterior segment of the maxilla in order

1 32


Figure 12.23

Final preparation of maxillary teeth

Figure 12.24

Final transitional prosthesis-maxilla

Figure 12.25

Final transitional prosthesis-mandible

to even up the gingival margins and provideadditional tooth structure for retention ofthe fixed prosthesis (Figure 12.22).

At completion of orthodontic andperiodontal treatment the teeth were repre-pared and new provisional restorationswere made to maintain the new verticaldimension and to stabilize the teeth afterthe orthodontic treatment. These transi-tional restorations also enabled the dentistto evaluate the patient's adaptation to thenew occlusal jaw relations (Figures12.23-12.25).

During a period of 3 months with theprovisional restorations at the new verticaldimension of occlusion, the patient exhib-i ted no temporomandibular joint or muscu-l ar problems. Copper band elastomericimpressions were taken and stone dieswere fabricated from the individual impres-sions. On these dies, Pattern resin copingswere made and fitted in the mouth.Polyether pick-up impressions were donefor the working models. The individual dieswere placed into the impression and themodel was made. Centric relation wasrecorded at the new proven vertical dimen-sion using Pattern resin (Figures 12.26 and1 2.27). This was done by leaving the provi-sional restorations in place on the left sidewhile fitting the Pattern resin copings andrecording the centric relation record on thecopings on the right side. The provisionalrestorations were then removed on the leftside and the Pattern resin copings placedon the supporting teeth (Figure 12.28).

Metal copings were then cast and fittedi n the mouth, and the copings connectedfor soldering. The copings were solderedand checked again for proper fit in themouth and a new centric registrationrecord was done in Pattern resin material.

1 33

Figure 12.26

Pattern resin coping try-in-maxilla

Figure 12.28

Centric relation record on pattern resin copings at newvertical dimension

Full arch polyether impressions weremade for tissue detail. The models werethen mounted on a Hanau articulator withthe aid of a face bow registration, and theporcelain was baked.

The final and minute adjustments of thebiscuit bake porcelain were carried out inthe mouth. The final glaze was applied tothe prostheses, and the prostheses werecemented with Temp-Bond for a period of2 weeks. They were then cemented withzinc oxyphosphate cement for permanentcementation (Figures 12.29-12.32).


Figure 12.27

Pattern resin coping try-in-mandible

SUMMARY

The patient presented with a severeproblem of Angle class II deep bite withimpingement of the palatal tissues by themandibular anterior teeth. She had missingand malpositioned teeth. There was a lossof vertical dimension and malocclusioncomplicated by rampant caries. All thesefactors made it mandatory to open thevertical dimension in order to restore thepatient to a healthy and physiologicalocclusion. This would worsen the occlusalrelationship and prevent anterior occlusalsupport. By means of limited orthodontictreatment and modification of the occlusalrelationships, we were able to give thepatient a fixed restoration that included thesupport of many of the remaining teeth,thus giving the patient a functional andesthetic solution to her dental problems.


The patient presented to our clinic with acomplicated situation of missing teeth,rampant caries, loss of the coronal tooth

1 3 4


Figure 12.29

Figure 12.30

Treatment completed-permanent treatment completed,

Treatment completed-patient smilinganterior view

Figure 12.31

Treatment completed-radiographs, maxilla

Figure 12.32

Treatment completed-radiographs, mandible

1 35


structure in most of the remaining teeth,loss of vertical dimension and soft tissueimpingement causing suppuration. Thetreatment of choice should have beenorthognathic surgery, but the patientrefused to undergo this. This situationpresented us with a challenge, whichwould be difficult to cope with. By using thecanine platform as a tool, and guide, wechanged the vertical dimension to aworkable situation and worked out theocclusal relationships and occlusal schemeto this pre-determined scheme. We aimedat including as many teeth as possible toparticipate in occlusal support usingadjunctive orthodontics and including thecanine teeth in support and guidance bythe placement of platforms on both themaxillary and mandibular canine teeth.

The periodontal surgery performed toreach both sound tooth structure and apleasant appearing smile in the anteriorregion was successful. In this patient, thealmost impossible has been achievedwithout orthognathic surgery and implantsthat would have required pre-prosthetic

surgery, to which the patient objected. Shereceived a functional physiologic andesthetic solution to an almost impossibleproblem.


The management of this patient's treatmentdemonstrates what can be achieved usingconventional periodontal and prosthodon-tic therapy when orthognathic surgery iscontraindicated or unwanted by thepatient. The key to rebuilding the occlusalscheme appeared to rest with the cleveruse of the upper canines as a platform. Ofcourse without the patient's motivation, theendodontic therapy, and the periodontaltherapy, nothing would have been of avail.The combination of motivation, cleverplanning, and meticulous execution ofrelatively conventional techniques appearsto have produced a good-looking andfunctional occlusion that I hope will last foryears.

1 36


•

Temporomandibular joint was normal•

Mandibular motions were within normall imitsNormal facial musculatureMaximum opening of 45 mmI ncompetent lipsTrapped lower lip


EXAMINATION

Figure 13.3

Face-frontal view (from 23 years ago)

He showed pictures of himself when hewas younger, showing a large smile andhealthy teeth (Figure 13.3).


•

Symmetrical face• Straight profile


Parabolic archCariesSpacing between the anterior teethMissing left third molar toothRight lateral incisor and right firstpremolar prepared for full coverage butwithout provisional restorationsLarge amalgam restorations on the leftpremolars and molarsLeft second molar and right third molarwith large caries in the crown section,extending into the rootMissing right first molar with anteriordrifting of the second and third molars

Figure 13.4

Face-side view

Figure 13.5


1 38

TREATMENT WITH LIMITED FINANCIAL RESOURCES

Figure 13.6


Figure 13.7



Parabolic archMesial inclination of the left second andthird molarsAmalgam restorations on the posteriorteethMissing teeth:

7643 56

Provisional acrylic crowns on the centralincisorsDeep caries:

Figure 13.8

Occlusion-left side

Occlusal examination (Figures 13.7 and13.8) revealed that the patient was Angleclass I. The interocclusal rest space was3.0-4.0 mm. Overjet was 2.0 mm andoverbite was 3.0 mm. There was no differ-ence between centric relation and centricocclusion. There was a midline discrep-ancy. There was spacing between themaxillary incisor teeth and the left lateralincisor and left cuspid were slightlyrotated. Non-working side interferenceswere noted between the mandibular rightthird molar and the maxillary right secondmolar.

Fremitus:

Maxillary right central incisor-grade I inclosing and right working jawmovementsMaxillary left central incisor, left lateralincisor, and right lateral incisor-grade Iin centric occlusion and protrusive jawmovements

The periodontal examination (Figures13.9 and 13.10) revealed calculus andplaque, probing depths of up to 10.0 mmon most of the maxillary teeth and up to

139

Figure 13.9


8.0 mm on many of the mandibular teeth.There was bleeding of the gingiva onprobing on all the teeth. There was slightgingival recession around some of theteeth. Class 1 mobility was found on themandibular incisor teeth. The maxillary


Figure 13.10


Figure 13.11


molars had class I-II furcation involvementon the mesial and distal surfaces. Themaxillary first premolar had both class IIImesial and lingual furcation involvement.The mandibular molars had class I furcationinvolvement on the buccal surfaces.

1 4 0



Endodontic treatment:

packing between his teeth and a bad tastein his mouth. He had poor oral hygiene,plaque and calculus, and severe inflamma-tion accompanied by deep probing depthsand furcation involvements. Some of theteeth were mobile.

Perio-endo lesion on left maxillary firstmolarPeriapical lesion on left maxillary secondmolarRecent extraction site-mandibular leftsecond premolarRampant caries and secondary cariesaround cast post in maxillary rightcentral incisorExtensive horizontal and vertical boneloss around most of the remaining teeth


DIAGNOSIS

Advanced adult periodontitisMissing teethLoss of posterior supportDecreased vertical dimension of occlusionRampant primary and secondary cariesFaulty restorationsPeriapical lesionsFaulty occlusal planesShifting of teethPrimary occlusal trauma (due totrapped lower lip)Secondary occlusal trauma with primaryorigin of trauma (due to trapped lower lip)

• Deep bite•

Poor esthetics

ABOUT THE PATIENT

The patient was highly motivated for treat-ment. He requested a fixed rather than aremovable restoration, but his financialcapabilities were limited.

TREATMENT PLAN

SUMMARY OF FINDINGS

The patient, a 40-year-old male in goodhealth, came to the clinic complaining ofdifficulty in eating, poor esthetics, food


I nitial treatment including:

•

Oral hygiene instruction•

Scaling and root planing• Diet counseling regarding cariogenic

food

141

Topical fluoride treatment with Elmexgel (GABA Ltd; Basel, Switzerland)

•

Caries excavation• Maxillary left second molar-distal

buccal root resection•

Mandibular right third molar-distal rootresectionExtractions:

PHASE 2: POSSIBILITIES

Maxilla:

Fixed prosthesisFixed and partial removable prosthesesif maxillary left first premolar and molarcould not be saved

Mandible:

•

Complete overdenture•

Fixed and partial removable prostheses

Figure 13.12

Anterior teeth-labial view, after initial preparation

• Fixed prosthesis supported by naturalteeth and implants (rejected by thepatient due to cost)


TREATMENT

Initial treatment consisted of oral hygieneinstruction, scaling and root planing. Themaxillary right lateral incisor was repre-pared, the caries excavated, and a provi-sional crown made. Endodontic treatmentwas done on the maxillary lateral incisorsand the maxillary left second premolar, andleft first molar. At this point, a re-evaluationwas done and even though the patient'soral hygiene had greatly improved, bleedingon probing and the probing depths hadonly been slightly reduced (Figures 13.12and 13.13).

I n the mandible where pocket depths andmobility also had not been significantlyreduced, and considering the limited finan-cial means of the patient, and the poorprognosis of the remaining teeth, it wasdecided to make a removable prosthesisrather than a fixed one. The mandibular leftsecond molar, central incisors, and leftlateral incisor were extracted and the

Figure 13.13

Periodontal chart-first re-evaluation

1 42


Figure 13.14 a

Mandibular anterior teeth-occlusal view after extractionsand endodontic treatment

Figure 13.14 b

Periodontal chart-re-evaluation of mandible

Figure 13.15

Anterior teeth-orthodontic treatment to close spaces andretract teeth

Figure 13.16

Anterior teeth-orthodontic treatment completed

remaining teeth were endodontically treated(Figure 13.14). Due to crown proximity,orthodontic treatment was performed toseparate the left cuspid from the firstpremolar (Figures 13.15 and 13.16). Theremaining teeth were then prepared, provi-sional acrylic copings were made and atransitional removable partial overdenturewas made (Figures 13.17 and 13.18).

Periodontal surgery (open flap curettage)in order to reduce pocket depths as well asto determine the prognosis of the left firstpremolar was then performed in the

maxilla. During the surgery, it was decidedto extract the maxillary left first premolardue to the extensive furcation involvement(class III).

The second re-evaluation was now doneand revealed that the probing depths hadgreatly diminished and the bleeding onprobing had disappeared. Except for themandibular right lateral incisor (class Imobility), there was no mobility of the teeth(Figures 13.19 and 13.20).

The disto-buccal roots of the maxillaryfirst molars were amputated and the

1 43

Figure 13.17

Mandibular removable partial denture

Figure 13.19

Periodontal chart-maxilla, re-evaluation

Periodontal chart-mandible, re-evaluation


Figure 13.18

Mandible-provisional acrylic copings for overdenture

Figure 13.20

remaining maxillary teeth were prepared forfull coverage and a provisional acrylicrestoration was made (Figure 13.21):

In the maxilla, copper band elastomericimpressions were made of all the preparedteeth and Pattern resin copings made to fitthe stone dies. These copings were fitted inthe mouth and a polyether full arch impres-sion was then taken of the maxilla and the

Transitional restorations-maxilla and mandible

master model

made. The copings wereFigure 13.21

1 44



Mandible-magnetic copings for overdenture Maxillary bisc-bake and mandibular overdenture set up onHanau articulator

also then used for a centric relation recordat the vertical dimension of occlusion of theprovisional restorations. This was done bycutting the provisional bridge between thecentral incisors and leaving one side inplace, while recording the centric relation inPattern resin on the copings on the otherside. The provisional remaining bridge wasthen removed and the vertical dimensionrecorded on the Pattern resin copings whileon the contralateral side, the Pattern resincopings maintained the vertical dimensionof occlusion. A polyether full arch impres-sion was then taken of the maxilla, themaster model was poured and mounted tothe mandibular model of the transitionalremovable partial denture by means of thePattern resin centric record.

Metal copings were then cast and fittedin the mouth and connected by Patternresin for soldering. These were solderedtogether, refitted and a new centric relationrecord made. A polyether impression wasthen undertaken for tissue detail and apick-up of the fixed prosthesis in order tomake a final master model. This wasmounted on a Hanau articulator by meansof a facebow registration and the Pattern

resin registration on the soldered metalprosthesis. The shade was chosen andporcelain baked to the metal. This wasfitted in the mouth and the occlusionadjusted to the lower jaw.

At this point, impressions were done tomake magnetic copings for the remaininglower teeth. These were fitted andcemented into place (Figure 13.22). A finalimpression in a custom tray was taken ofthe mandible and cast in albastone. Achrome cobalt metal framework was thencast and fitted in the mouth.

An acrylic and wax bite tray was thenmade on this model over the metal frame-work and fitted in the mouth. The centricrelation record was then taken at the estab-l ished vertical dimension of occlusion. Thismodel was then mounted on the articulatorby means of the bite tray with the centricrecord. The mandibular teeth were then setup (Figure 13.23) and checked in themouth. The denture teeth were made ofporcelain in order to match the material inthe fixed prosthesis in the maxilla.

The mandibular removable partialdenture was processed and inserted. Themaxillary fixed prosthesis was glazed and

1 4 5

Figure 13.24

Completed mandibular partial denture-tissue view

Figure 13.25

Radiographs of completed treatment, maxilla

Figure 13.26

Radiographs of completed treatment, mandible


cemented, with Temp-bond cement. Afterone week, the magnets were cold curedwith acrylic into the denture and the maxil-lary prosthesis permanently cemented.Magnets were not used in all the areas,only opposite the right third molar, secondpremolar, lateral incisor, and left firstpremolar. The left cuspid area did not havea magnet (Figures 13.24-13.27).

SUMMARY

This patient presented with a very deteri-orating situation in his mouth. In spite of

1 4 6


restoration with the greatest possibleprognosis. For obvious esthetic reasonsthe maxillary fixed restoration was made ofporcelain fused to metal restoration. Inorder to cope with the attrition that wouldtake place, porcelain teeth were installed inthe removable, magnet-supported, fixedpartial denture. It can be concluded thatwith the economic restriction we faced theyoung patient received an esthetic andfunctional solution.

Figure 13.27

Treatment completed-permanent resorations, anterior view


his general good health, he had rampantcaries and severe advanced periodontitis,many missing teeth, the majority in themandible, and severe bone loss. Therewere tipped, malposed, and extrudedteeth. There were many hopeless andquestionable teeth among his few remain-ing teeth, yet the patient wanted a fixedprosthesis. Due to the patient's financialcondition, this could not be achieved.However, an esthetic and functionalsolution was found for his dentalproblems.


This case presentation describes a youngpatient with a severe caries problem aggra-vated by neglect, and complicated byperiodontal condition and a poor economicsituation. The patient was treated with theidea of supplying the best cost-efficient

I f the implant option is to be excluded, thenthe amount of dental support available effec-tively dictates a removable lower prosthesisopposing an upper fixed restoration. Suchan approach dictates meticulous planning ofthe occlusal surfaces and, naturally,assumes that the supporting structures arenot only healthy but that the patient canmaintain them in this state. It might beargued that as a telescopic approach wasused on most of the lower abutments thena telescopic retainer could have beenincluded on the left molar rather thanemploying a conventional clasp. Using morethan two magnets and porcelain teeth forthe denture involves a possibility that duringchewing the leverages may disengage oneof the magnets from its keeper and producea clicking sensation. The other problem issimply finding room for the underlyingsubstructure while providing retention for theartificial teeth. The operator appears to haveproduced a functional and good-lookingrestoration.

14 7

PATIENT 14 TRAUMATIC SEQUELAE

Treatment by Irit Kupershmidt

THE PATIENT

The patient, a 44-year-old man, had beenassaulted with an ax about 6 monthsbefore visiting the Hadassah School ofDental Medicine Graduate ProsthodonticClinic. His injuries included scalp wounds,fracture of the right side of his skull, fractureof the left mandible, left maxillary sinushemorrhage, lacerations of the cheek, andmany broken teeth (Figure 14.1). His maincomplaints were the following:

' I have no sensations in my upper andlower lips on the left side and it gives mea bad feeling.''It hurts when I eat on my left side.'' The missing teeth bother me whenchewing, but not so much during speech.'

'The esthetics doesn't bother me thatmuch.' (Figure 14.2)


A year and a half prior to his coming for treat-ment, the patient had a myocardial infarct,and after undergoing an angiogram, wastreated with angioplasty. He suffered fromhigh blood pressure and was being treatedwith Cartia (aspirin 100 mg), Normiten(altenolol), and Cordil (isosorbide dinitrate).

PAST DENTAL HISTORY

For 10 years previous to his assault, hehad not seen a dentist and could not recall

Figure 14.1

Maxillary teeth-palatal view

Figure 14.2


1 49


the condition of his teeth before theassault, but thought that some of themhad crowns. Following his assault, hismandible was fixated with a titanium meshand intra-arch wiring for one month at theDepartment of Oral and MaxillofacialSurgery at Hadassah. After removal of thewiring, he was not able to open his mouthmore than 26 mm as measured at themaxillary and mandibular central incisorteeth. Physiotherapy brought aboutgradual improvement of the condition.

The temporomandibular joints wereasymptomatic but the patient hadlimited mandibular movementsThere was a deviation to the left at theend of the jaw opening movementThe maximum opening between theincisors was 50 mm, measured fromthe mandibular incisal edge to theincisal papillaeStraight profile



EXAMINATION(Figures 14.1,14.2,14.5-14.9)

• Facial asymmetry, with a large scar onthe left sideNormally functioning muscles of masti-cation

Missing teethAll the maxillary teeth were fractured,most of them beneath the gum line,except for the right molars, the right

Figure 14.3

Face-frontal view

Figure 14.4

Face-left profile view

1 50

TRAUMATIC SEQUELAE

Figure 14.5

Anterior maxillary teeth-palatal view, close-up

Figure 14.6

Mandibular arch

Figure 14.7

Anterior mandibular teeth-lingual view, close-up

second premolar, and the left secondand third molarsThe large scar on the inner left side ofthe cheek severely limited the openingof his mouthHigh palate and loss of soft tissue andbone in the anterior part of the maxilla(Figure 14.5)Mandibular left second and third molar,right first molar, and the right centralincisor teeth were missingThe anterior teeth were rotated andcrowded. The lower left third molar wascovered by soft tissue (Figure 14.6)

CariesExtensive bone loss around someteethTitanium mesh in the left mandibleTipping and rotation of some teethNasopalatine duct cystPeriapical abscesses around somemaxillary teeth

• The interocclusal rest space was3.0 mmRestricted mandibular movementsDiscrepancy between centric occlusion(CO) and centric relation (CR) of0.5 mm, with an anterior slideI n all lateral excursions, contact was onthe right side, on the maxillary andmandibular premolars and molars

• I n protrusive movements, contactswere between the maxillary andmandibular right molars

Periodontal examination revealed poor oralhygiene accompanied by large amounts ofplaque and calculus (Figure 14.7), probingdepths of up to 4.0 mm on the maxillaryteeth and up to 5.0 mm on the mandibularteeth (mandibular left third molar), withbleeding of the gingiva on probing on someof the teeth (Figure 14.8).

1 5 1

Figure 14.8a

Periodontal chart

Periodontal chart


Figure 14.8b

Figure 14.9

Radiographs of maxillaand mandible-pre-treatment

Figure 14.10

Radiographs of maxilla-anterior teeth, pre-treatment

TRAUMATIC SEQUELAE


The prognosis for the remaining teeth wasthe following:

DIAGNOSIS

• Multiple fractured teeth, status post-trauma

•

Loss of bony and soft tissue support inthe maxilla status post-trauma

•

Reduced occlusal support•

Shallow vestibulum space•

Loss of sensation in the lips on the leftside

•

Status post-mandibular fracture•

Caries and faulty restorations•

Poor esthetics•

Periapical changes•

Decreased vertical dimension•

Nasopalatine duct cyst• Gingivitis

ABOUT THE PATIENT

a removable prosthesis as a temporarysolution to his problems.


Widespread fractured maxillary teethdue to trauma, accompanied by loss ofbone and soft tissue support, compli-cating a full mouth rehabilitationReduced vestibulum space due to thescarring, limiting movementA nasopalatine duct cyst that mightjeopardize implant placement forprosthetic support


Removable partial dentureRemovable partial denture supportedby natural teeth and implantsFixed partial prosthesis or prosthesessupported by implants and remainingteeth

Removable tooth-supported partialprosthesisFixed partial prosthesis, each eithertooth- or implant-supported

The patient, who suffered from poor health,had had a severe traumatic experience that,due to his injuries, would still requireadditional extensive medical treatment. In aninstant, he went from a full dentition to acondition where he felt that most of his maxil-lary teeth were missing. The patient wanteda fixed prosthesis, but was willing to accept

TREATMENT PLAN

The final treatment plan was then chosenwhich consisted of pre-prosthetic surgery toprepare the site in the maxilla for implants, afixed anterior maxillary prosthesis supportedby the maxillary right second premolar, themaxillary right cuspid and the maxillary right

1 53


Figure 14.11

Mandibular arch-lingual view, after initial treatment

Figure 14.12

Anterior teeth after initial treatment

Figure 14.13

Transitional crowns and maxillary removable partial denture

Figure 14.14

Mandibular left third molar after periodontal surgery

lateral incisor, and a maxillary fixed partialprosthesis supported by implants from theright maxillary central incisor to the left maxil-lary second premolar. A crown was also tobe fabricated for maxillary left first molartooth. The missing mandibular right firstmolar would not be replaced.

TREATMENT

I nitial preparation included scaling, curettage,root planing and oral hygiene instruction. At

the end of this stage, significant improve-ment of the soft tissue could be discerned(Figures 14.11 and 14.12). At this time,periodontal re-charting and evaluationdemonstrated that the pockets depths haddiminished greatly and that the bleeding onprobing had disappeared.

Endodontic therapy was performed onthe maxillary right cuspid and maxillary leftfirst molar. The mandibular left first premo-lar and right third molar and left secondmolar were restored with amalgam restora-tions. The maxillary right lateral incisor,

15 4

TRAUMATIC SEQUELAE

Figure 14.15

CT scan-maxilla

Figure 14.16

CT scan-mandible

Figure 14.17

I mplant insertion-left mandibular molar area

which was fractured and buried under thegingival tissue, was exposed with a crownlengthening procedure, followed byendodontic therapy.

A transitional removable maxillary partialdenture was then made to replace themissing anterior teeth (even though theroots were not yet extracted) to stabilize theocclusion and push back the vestibulum asmuch as possible in the scarred area (Figure1 4.13). Crown lengthening was thenperformed on the mandibular third molar toexpose it in order to perform endodontic

therapy (Figure 14.14). The prognosis wasnot favorable, but it was decided to keepthe tooth as it was the only tooth in themandible maintaining occlusal support onthe left side.

A CT radiograph of the maxilla (Figure1 4.15) revealed a large radiolucent areawhich, at surgery, was confirmed as anasopalatine cyst. It was then decided toplace an autogenous bone implant on thepre-maxilla to provide bone support forfuture implant placement. The bone wastaken from the chin area and checked forintegration after 6 months.

A CT radiograph of the mandible (Figure14.16) showed that there was room for twoimplants in the left mandibular molar area,but this required removal of the mesial rootof the mandibular third molar. The mesialroot was extracted and two implants wereplaced (Figure 14.17). The distal root wasleft in place, temporarily, to maintainocclusal support for a transitional fixedpartial prosthesis during implant placementand healing.

The treatment for the maxilla was thencommenced. It was planned to consist offixed partial prostheses supported by bothnatural teeth and implants. A fixed partial

155

Figure 14.18

Wax-up of maxillary anterior crowns-frontal view

Figure 14.20

I mplant insertion-maxillary anterior area

prosthesis would extend from the maxillaryright second premolar to the right laterali ncisor, replacing the missing right firstpremolar. A single crown for the maxillaryleft first molar and a six-unit fixed partialprosthesis supported by five implants fromthe maxillary right central incisor area to themaxillary left second premolar area were tobe constructed.

In the mandible, an implant-supportedfixed partial prosthesis was proposed toreplace the missing left molars. The missingright first molar tooth was not to be


Figure 14.19

Wax-up of maxillary anterior crowns-left side

replaced as the occlusion had been stablein the area despite the tooth being missingfor many years. There were no gingival orcaries problems in the area, and to replacethe missing tooth with an implant-supported fixed partial prosthesis wouldrequire orthodontic therapy to upright thesecond and third molar teeth. To replacethe tooth with a fixed prosthesis wouldnecessitate preparing the second premolar,which had no restorations or caries.

Following successful bone implantationin the area of the nasopalatine cyst, a Wax-up was done to determine the ideallocation of the maxillary and mandibularteeth that were to be replaced by theimplant supported fixed prosthesis (Figures14.18 and 14.19). Five implants werei nserted in the maxilla (Figure 14.20). In themandible two implants were inserted.When the implants were uncovered, it wasdiscovered that the implant in the maxillarycentral incisor area had failed and, due tothe extensive bone loss, it would be impos-sible to replace it with a wide-body typeimplant (Figure 14.21).

Following a re-evaluation, it was decidedto make an anterior maxillary fixed prosthe-sis supported by only four implants, with

1 56

TRAUMATIC SEQUELAE

Figure 1 4.21

Stage two surgery-exposure of maxillary implants

Figure 14.22

Maxillary implants after healing after second stage surgery

Figure 14.23

Duralay and abutment impression copings fitted-maxilla

Figure 14.24

Duralay copings fitted-centric relation record

the central incisor as a cantilever (Figure1 4.22). The implants had been placed in acurve and thus provided resistance tomultidirectional forces.

During the course of treatment, it wasdiscovered that the maxillary right cuspidhad a periapical lesion. The tooth wasasymptomatic, was not sensitive to percus-sion, and did not have deep probingdepths. An exploratory surgical procedurerevealed granulation tissue around the rootapex, which was enucleated. It wasthought at that time that the periapical area

was an extension of granulation tissue fromthe failed implant in the maxillary rightcentral incisor area.

Copper band elastomeric impressions weremade of all the prepared teeth and Duralaycopings were constructed. These copingswere used for the final impression for themaster model and to record centric relation atthe vertical dimension of the temporaryrestorations (Figures 14.23 and 14.24).

Unfortunately, at the metal coping fittingstage, a fistula was noticed round themaxillary right cuspid and a 10 mm probing

1 57

Figure 14.25

Maxilla after extraction of right cuspid

Figure 14.27

Metal copings try-in maxilla-after soldering and showingsemi-precision attachment connecting tooth- and implant-supported prostheses

depth was found on the palatal aspect ofthe tooth. A second exploratory surgicalprocedure was then performed, whichrevealed massive bone loss on the palatalaspect of the tooth (Figure 14.25). Thetooth was extracted and a longitudinalfracture of the root was discovered (Figure

1 4.26).The treatment plan was again modified,

to a fixed partial prosthesis from the rightmaxillary second premolar to the rightmaxillary lateral incisor. These teeth had


Figure 14.26

Extracted right cuspid-showing fracture

excellent bone support. A semi-precisionattachment was made to connect thisprosthesis and the anterior and left poste-rior prosthesis supported by the fourimplants. The implants would help supportthe fixed prosthesis i n l ateral j awmovements, and the attachment wouldalso allow the teeth to move apically withinthe limits of the periodontal membrane incentric occlusion.

The metal copings were soldered and,after try-in of the soldered metal framework(Figure 14.27), another elastomeric impres-sion was made for the tissue reproductionmodel. These models were mounted on asemi-adjustable articulator (Hanau) using afacebow registration, and centric recordswere taken at the vertical dimension ofocclusion using Duralay with a Neylontechnique.

The porcelain was baked and the occlu-sion checked at the biscuit bake stage inthe mouth and all adjustments neededwere then made. The porcelain was thenglazed. The crowns and bridges werecemented with Temp-Bond. After onemonth the crowns and bridges werecemented with zinc oxyphosphate cementfor permanent cementation (Figures

158

TRAUMATIC SEQUELAE

Figure 14.28

Treatment completed-anterior view

Figure 14.29

Treatment completed-left side

Figure 14.30

Treatment completed-right side

14.28-14.30). A complete series of radio-graphs was taken after completion of treat-ment (Figure 14.31).

many broken teeth. Though he had largeamounts of calculus and plaque, he wasperiodontally resistant. The attack left himwith scarred tissue, and also limited abilityto open his mouth. He had many brokenteeth and was also missing hard and softtissue in the maxilla. A year previous to theattack, he had a myocardial infarct and wasstill being treated with assorted medication.The patient requested a fixed prosthesiseven though he was prepared to accept aremovable prosthesis during treatment, butonly on a temporary basis. During treat-ment many unsuspected problems aroseand the treatment had to be constantlyadjusted to the new circumstances. In spiteof all these problems, an excellent resultwas achieved using a combination ofnatural teeth and implant-supported fixedprostheses.

SUMMARY

The patient presented with a variety ofproblems. Due to his unfortunate accident,he had been left with scalp wounds,fractures of the right side of his skull andthe left mandible, left maxillary sinushemorrhage, lacerations of the cheek, and


The patient, a 44-year-old male, wasreferred for treatment at the Graduate Clinicfollowing a traumatic injury that changedovernight his general well-being and

15 9


Figure 14.31


primarily affected his masticatory system.He was a very pleasant and accommodat-ing patient who adjusted easily to theconstant changes in his treatment plan. Hedid, however, insist on having a fixedrestoration, and was willing to go throughwhatever procedures were needed toachieve this goal. The treatment plan hadto be modified during treatment and evenat a final stage, due to unexpected compli-cations. In the final treatment, a fixedprosthesis was fabricated and specialemphasis was placed on the occlusalscheme to protect both the natural teethand the implants. A non-working contactthat existed on the right side during lateralj aw movements was adjusted to a situationthat maintained contact there, while at thesame time kept working contacts on theimplants on the left side. The semi-precision attachment between the implantand tooth-supported bridges was intended

to provide some fixation for the bridgeduring lateral movements.

The restorations were monitored verycarefully during the last 2 years and it is ourhope that the customized restoration,along with meticulous planning of theocclusion, will provide many years of lastingservice. It was also planned that, in thefuture, if the teeth supporting the maxillaryprosthesis on the right side were to fail,additional implants would be implanted andtheir prosthesis would be connected to theexisting implant-supported prosthesis.


A particularly interesting facet of thispatient's treatment represents his reactionto the appalling physical injuries hereceived. It is apparent that before the

1 60

TRAUMATIC SEQUELAE

attack the state of his dentition was not ofparticular interest to him. One might haveexpected the inevitable psychologicalreaction to his experience to have madehim even less interested in looking after histeeth. Quite the reverse happened, and Iam confident that the team treating himhad a significant influence upon hisattitude: they are to be congratulated.

I t is also intriguing to note that the patientinsisted on a fixed maxillary prosthesisdespite the fact that such an approachboth complicated and lengthened thetreatment, compromised the esthetics(although not by very much), and mademaintenance far more difficult. The step-by-step approach employed providedversatility that was put to good use toovercome a few unexpected events. In along and complex course of treatment, weall receive the occasional surprise.

I quite understand why a premature onlaygraft was not employed, since this wouldhave complicated the treatment still further

and obliged the patient to be without hisremovable prosthesis for some time. Thenet result was that the implants werepositioned slightly palatal to the idealposition, but in a perfectly acceptablerelationship. The price to pay was the needto construct the facial surfaces of therestorations considerably labial to theimplant which, in turn, leads to a mainte-nance problem. It is encouraging that so farthe patient has maintained a good level ofplaque control and his motivation has notwaned.

Connecting the maxillary-implant-supported section to the tooth-supportedprosthesis by means of a semi-precisionretainer is not universally accepted. Therehave been suggestions that there is aserious risk of intrusion of the tooth-supported section. Only time will tell and Ilook forward to an update. From everypoint of view, the operators are to becongratulated on the outcome of thispatient's treatment.

1 61

Figure 15.4

Figure 15.5

Face-frontal view

Face-profile

EXTRA-ORAL EXAMINATION(Figures 1 5.4 and 15.5)

Asymmetric and wide faceDrooping eyesNarrow lipsEnlarged lower third of the faceStraight profileProtruding chin with a wide mandibleWide smile, without showing any teethMaximum opening was 38.0 cm

INTRA-ORAL EXAMINATION(Figures 15.6 and 15.7)

Anterior cross bite (see Figure 15.1)

Distorted occlusal planeExtrusion of the maxillary left posteriorand mandibular anterior teeth (Figures15.8 and 15.9)

Amalgam restoration on maxillary rightsecond molar


Extreme wear of the teeth accompaniedby chipping of the enamel and cuppingof the dentineRounded arch form, with broadridges

Figure 15.6


Figure 15.7


1 64

A NEW VERTICAL OCCLUSION

Figure 15.8

Occlusion-right sideFigure 15.9

Occlusion-left side

Figure 15.10

Periodontal chart-maxillaFigure 15.11

Periodontal chart-mandible

•

Scarring of the tissue from the surgeryto decrease the size of the chin

An occlusal examination revealed thatthe patient was Angle class III modification2 according to Ross (Figures 15.8 and1 5.9). There was a reversed overbite of1.0 mm and an overjet of 1.0 mm. Theinterocclusal rest space was 8.0 mm andthe maximum opening between theincisors was 46 mm, with an `S' deviationin opening or closing movements. Therewas a 2.0 mm discrepancy betweencentric occlusion (CO) and centric relation

(CR). The lateral jaw movements were ingroup function. In protrusive movements,there was complete balance. There werebalancing side interferences in lateralmovements. There was fremitus class I onthe maxillary incisor teeth, and a faultyocclusal plane.

The periodontal examination revealed plaque,calculus, inflammation around most of theteeth, probing depths of up to 9.0 mm on themaxillary teeth and up to 7.0 mm on themandibular teeth, with bleeding on probingon some teeth (Figures 15.10 and 15.11).

1 65

Figure 15.12

Panoramic radiograph-pre-treatment


A complete series of X-rays revealed thefollowing findings:

SUMMARY OF FINDINGS

The 43-year-old patient with Angle class IIImodification 2 occlusion, status post-surgery,and suffering from hyperostosis corticalisgeneralista, came to the clinic complaining ofextreme wear of her teeth and the fear that herteeth would soon disappear. She also noticedthat her gums bled when she brushed herteeth. She exhibited extreme wear of herteeth, extrusion of many teeth, plaque, calcu-lus, missing teeth, and faulty restorations.

• Small caries lesion in the mandibularright first molar toothThickening and condensation of thebone to such an extent that it was verydifficult to differentiate between theroots of the teeth and the surroundingbone

•

Hyperostosis corticalis generalista


• Hopeless: none

DIAGNOSIS

Hyperostosis corticalis generalistaModerate with localized advanced adulttype periodontitisExcessive tooth wearOcclusal disharmony with reducedocclusal support

•

Missing teeth•


Poor esthetics•

Reduced vertical dimension• Caries

ABOUT THE PATIENT

The patient was very cooperative; her maindesire was to have an esthetic and fixedrestoration. Within a short period of time,she improved her oral hygiene, and herperiodontal condition improved.

1 6 6

•



The patient presented with a variety ofproblems:

•

Poor occlusal relationships•

Loss of vertical dimension•

Lack of occlusal posterior support•

Extreme wear•

Moderate with localized advanced perio-dontitis

For the loss of vertical dimension:

After the occlusal equilibration, theoptimum vertical dimension for anesthetic result would be determinedand, according to that, the verticaldimension would be opened by meansof an occlusal appliance.

For the extreme wear:

• The teeth that were very worn wouldreceive crown restorations to replacethe lost tooth structure.

For the moderate to advanced periodontitis:

POSSIBLE TREATMENTSOLUTIONS

For the poor occlusal relationships:

A sliding surgical osteotomy procedurein which a block of bone including theteeth is removed and reset in a morefavorable position. This was rejectedbecause the patient refused to undergoany extensive surgical procedure.

• Orthodontic treatment to intrude theteeth to acquire a physiological occlusion.This option was also rejected because ofthe fear of root resorption due to thepatient's unique bone condition.Crown lengthening periodontal surgery toenable the teeth to be reduced in occlusalheight in order to achieve a physiologicalocclusion and expose sound tooth struc-ture for the margins of the restorations.This option was also rejected as it was feltthat the surgery would cause bifurcationand trifurcation involvement of the premo-lar and molar teeth.Gradual selective equilibration of theteeth and the addition of acrylic to thetransitional restorations in the opposingjaws in order to improve the occlusalplane.

Most of the probing depths were due to` pseudo pockets', and it was felt thatafter initial preparation, these woulddiminish in size. If not, the problem wouldbe solved with periodontal surgery.

TREATMENT PLAN

Before treatment was started, a diagnosticwax-up was done on study modelsmounted on a Hanau articulator with afacebow registration and a centric relationrecord in order to evaluate the esthetic andocclusal solutions (Figure 15.13).

Figure 15.13

Diagnostic wax-up on Hanau articulator

1 6 7



Maxilla:

• Fixed partial prosthesis•

Fixed and removable partial prosthesis

Mandible:

• Fixed partial prosthesis•

Fixed and removable partial prosthesis• Fixed partial prosthesis with implants

support

I nitial preparation included scaling, rootplaning, curettage, and oral hygieneinstruction (Figures 15.14 and 15.15),caries removal, and a mandibular diagnos-tic appliance due to the class III occlusionto evaluate the change in vertical dimen-sion, followed by transitional restorations.At the completion of this stage, a clinicalre-evaluation was done to determinewhether there had been periodontal,esthetic and occlusal improvement. Theocclusal appliance was observed for 8

TREATMENT

weeks. At that time, an obvious improve-ment in the periodontal supporting tissuecould be seen, pockets depths had dimin-ished greatly and bleeding on probing haddisappeared. It also was evident that thepatient had completely adjusted to thenew vertical dimension (Figures 15.16 and1 5.17).

At this time, transitional restorations weremade at the new vertical dimension (Figure15.18). Implants were also done in the leftmandibular posterior quadrant as it was feltthat the mandibular left first premolar andsecond molar did not provide enoughsupport for a fixed partial prosthesis (Figure15.19).

Due to the faulty plane of occlusion onthe left side, the maxillary premolars andmolars were gradually selectively equili-brated and acrylic was added to the transi-tional mandibular restorations to preventovereruption of the equilibrated teeth. Inthis manner, an optimal plane of occlusionwas achieved.

Once the transitional restorations fulfilledall the esthetic, physiological and functionalexpectations of the patient and the dentist,the teeth were reprepared and individual

Figure 15.14

Teeth-right side, after initial preparation

Figure 15.15

Teeth-left side, after initial preparation

168


Figure 15.16

Figure 15.17

Periodontal chart-maxilla, re-evaluation

Periodontal chart-mandible, re-evaluation

Figure 15.18

Transitional restorations

Figure 15.19

Implants-mandible, left posterior region

Figure 15.20

Centric relation record in Duralay

copper band impressions were made of allthe prepared teeth. Duralay copings werethen made and the vertical dimension ofocclusion was recorded with these copings( Figure 15.20). An elastomeric impression(Impergum) was then done to provide aworking model which included the dies andthe implant analogues (Figure 15.21). Afacebow registration was taken to facilitatemounting the maxillary cast on a semi-adjustable articulator (Hanau). The metalcopings were cast and fitted. They wereconnected with Duralay for soldering.

16 9


Figure 15.21

Elastomeric impressions

Figure 15.22

Soldered coping try-in and centric relation registration

Figure 15.23

Temp-Bond for a period of 2 weeks. Theywere then cemented with zinc oxyphos-phate cement for permanent cementation(Figure 15.23).

The patient has been returning for follow-up and maintenance twice a year sincethen and has not had any problems (Figure15.24).

SUMMARY

Treatment completed-permanent restorations

Centric relation was recorded in Duralay(Figure 15.22), and another elastomericimpression was made for tissue detail. Themodels were then mounted on a Hanauarticulator, again with the aid of a facebowregistration, and the porcelain was baked.Models of the transitional restorationsprovided a buccal key for the position andshape of the porcelain, thus copying thetransitional restorations. The biscuit bakeporcelain was checked and adjusted in themouth. After the occlusion was finalized,the final glaze was applied to the prosthe-ses. The prostheses were cemented with

The patient presented with a severeproblem of extreme wear on many teethand a reduced vertical dimension of occlu-sion. She also had a pathologic occlusionwith serious balancing side and protrusivepremature contacts during mandibularmovements. In addition to these problems,she suffered from a severe periodontalproblem and was very concerned abouther esthetics. The treatment consisted ofchanging the vertical dimension of occlu-sion by selective grinding and addition ofrestorative material, where needed, in orderto provide a physiological occlusion. Thefinal restorations thus provided a physio-logical, functional and esthetic solution forher problems.

1 70


Figure 15.24



The patient presented in the clinic with acomplicated situation: missing teeth,severe wear, overeruption of posteriorteeth, combined with advanced periodon-tal disease aggravated by a class III maloc-clusion with occlusal interferences. Thesituation necessitated a dramatic change inthe vertical dimension that had a negativeas well as a positive effect. The positiveeffect was in the relationship between theanterior teeth, changing a class III relationto an almost class I relation, thus facilitatinginvolvement of the anterior teeth inguidance and support. It also facilitatedrestoration of the posterior quadrants thathad undergone severe overeruption. Thenegative effect was the change in thecrown-to-root ratio. This, however, wasminimal due to the compensatory eruptionof the teeth during the retrograde wear. Insummary, a 43-year-old patient wastreated successfully and the pathological

occlusion that was on a course of selfdestruction was changed to a long-lastingtherapeutic, physiological occlusion.


This patient presented an interesting treatmentplanning problem. Apart from the unusualmedical complication, the operator had toassess a new vertical dimension of occlusion.A combination of tooth loss and tooth wear,possibly accentuated by a forward mandibu-lar posture, have all led to a class III incisorrelationship. By how much was it safe toincrease the vertical dimension of occlusion?His treatment appears to have followed alogical pattern with alternative avenuesconsidered at the outset. Apart from the allimportant periodontal and endodontictherapy, the use of transitional restorations ismandatory with problems like these. Theplanning of the occlusal scheme is to becommended and the overall result is gratifying.

1 71

Figure 16.2

Frontal facial view


EXAMINATION(Figures 16.1-16.9)


• The left cuspid and first molar werefractured beneath the gingival tissue;the left central incisor had a provisionalrestorationThere was class 1 mobility on the leftcentral incisor, the left premolars, andthe left second molar teeth


The right cuspid was fractured beneaththe gingival tissueThere was class 3 mobility on all theincisor teeth and class 2 mobility on theleft second premolarThe left cuspid had class 1 mobilityThere were faulty restorations andextensive caries on most of the remain-ing teeth


Figure 16.3

Mandibular arch

Figure 16.4

Maxillary arch

• Extensive caries and loss of crownstructure50% bone loss around the mandibularanterior teeth

• Periapical abscess maxillary centralincisor tooth

• Radio-opacity in the periapical area ofthe left mandibular first premolar

174

ADVANCED PERIODONTAL DISEASE

Figure 16.5

Occlusion-left side

Figure 16.6


Figure 16.7

Radiographs of maxillary andmandibular teeth

An occlusal examination revealed extru-sion of many teeth, a faulty plane of occlu-sion, vertical overbite of 8.0 mm, andhorizontal overjet of 4.0 mm (Figures 16.5and 16.6). The patient had difficultyexecuting lateral and protrusivemovements of the mandible. The onlyocclusal contacts were between the left

second premolars. The mandibularanterior teeth occluded with the palatalgingival tissue (see Figure 16.5).

The periodontal examination revealedgingival recession, but with minimal probingdepths-up to 3.0 mm at the maximum(Figures 16.8 and 16.9).

17 5


Figure 16.8

Mandibular periodontal chart


The prognosis for the remaining teeth wasthe following:

Periapical lesionsResorbed alveolar ridgesAnterior traumatic overbiteAdult type periodontitisPeripheral seventh cranial nerve damage

ABOUT THE PATIENT

Fair: the rest of the teeth

I n the past, the patient had difficulty adjust-ing to a removable partial denture and haddiscarded it.

The patient understood that his dental treat-ment would be complex and extend over along period of time. He agreed to the needto try and save as many teeth as possible.He also voiced his preference for a fixedprosthesis rather than a removable one.

DIAGNOSISPOTENTIAL TREATMENT

PROBLEMS

Missing teethExtruded teethReduced occlusal supportLoss of vertical dimensionOcclusal traumaMobile teethRampant cariesFaulty restorations

The patient had many missing teethDue to rampant caries, some of theremaining teeth were almost totallydestroyedThere was reduced alveolar bonesupport in the anterior part of themandible and increased mobility in themandibular incisor teeth

Figure 16.9

Maxillary periodontal chart

176


•

The patient was in occlusal trauma andbiting on the maxillary palatal tissuesduring chewingDue to the fact that the patient objectedto a removable prosthesis, the treat-ment might have to be compromised

TREATMENT PLAN ALTERNATIVES

Maxilla:

Fixed partial prosthesisFixed and removable partial prosthesesFixed telescopic prosthesis

Mandible:

•

Fixed and removable partial prostheses•

Removable telescopic prosthesis• Overdenture

The treatment was divided into fivephases:

PHASE 1

After initial treatment consisting of oralhygiene instruction, scaling and root planing,the patient showed a marked improvementin his home care and the periodontal tissuesexhibited great improvement. It was thendecided to splint the anterior mandibularteeth with orthodontic ligature for stabiliza-tion. Following re-evaluation, a final treat-ment plan was discussed. This would thenbe a fixed partial prosthesis in the maxilla,and a fixed anterior partial prosthesis with aremovable clasp retained posterior partialprosthesis in the mandible.

TREATMENT

PHASE 2

I n the second phase, the priority was treat-ment of pain and infection, stabilizing theocclusion, and obtaining occlusal support.After completion of the initial preparation. Theright mandibular cuspid and the left maxillarycentral incisor were treated endodontically.The left maxillary second molar wasextracted. The faulty crown on the maxillaryleft second premolar was removed and thetooth was treated endodontically. Excavationof caries and restoration of the left maxillarycuspid and premolars was then done. Themandibular anterior teeth were shortened inheight and splinted with orthodontic wire(Figures 16.10 and 16.11).

At this time a transitional fixed prosthe-sis was made, extending from the maxil-lary right lateral incisor to the left firstpremolar tooth. The mandibular rightcuspid was then orthodontically separatedfrom the mandibular right lateral incisor,and this was added to the anteriormandibular splint. A transitional crownwas made for the maxillary left secondpremolar tooth and a transitional fixedprosthesis was made from the mandibularl eft cuspid to the left second premolar(Figure 16.11). The periodontal re-evalua-tion revealed that the pockets depths haddiminished greatly and that bleeding onprobing had disappeared.

PHASE 3

At this point, after the periodontal evalua-tion, additional occlusal support wasestablished by means of a transitional,mandibular, removable partial prosthesis(Figure 16.12). Periodontal surgery on themaxillary left first molar revealed a perfora-tion. The disto-buccal root was removed.

17 7

178


Figure 16.10

Figure 16.11Lingual view of anterior mandibular teeth

Frontal view of teeth

Figure 16.12

Figure 16.13Lingual view of mandibular temporized teeth

Forced eruption of maxillary cuspid

Figure 16.14

Figure 16.15Crown lengthening procedure-maxillary cuspid

Maxillary transitional prosthesis


During caries excavation, additional nec-essary endodontic treatments were done.Orthodontic treatment, which consisted offorced eruption of the maxillary left cuspid,was then performed (Figure 16.13). In prepa-ration for the crown, a crown lengtheningperiodontal surgical procedure (CLP) wasdone to gain sound tooth structure (Figure16.14).

PHASE 4

models were mounted on a semi-adjustable articulator (Hanau) using afacebow registration and centric recordstaken at the vertical dimension of occlusionin Pattern resin using the Neylon technique.I n the mandible, the porcelain was baked,and the occlusion checked in the mouth atthe biscuit bake stage; all adjustmentsneeded were then made (Figure 16.17).

The removable partial denture frameworkwas constructed. It was fitted and an alteredcast impression was then made for soft

At the completion of orthodontic andperiodontal treatment, a transitional fixedpartial prosthesis was made, extending fromthe maxillary right first molar to the maxillaryl eft second premolar (Figure 1 6.15).Endodontic treatment on the mandibular rightcuspid and the mandibular left second premo-lar was then done. Due to continual infection,and pocketing, the two remaining roots of themaxillary left first molar were extracted. Due tosevere pain, the mandibular left cuspid wasthen endodontically treated.

PHASE J

Figure 16.16

Soldered metal copings being fitted-mandible

At completion of initial preparation and re-evaluation, the final phase of treatment wascarried out. Copper band elastomericimpressions were taken of all the preparedteeth and Duralay copings were made.These copings were used for the finalimpression for the master model and torecord centric relation at the vertical dimen-sion of the temporary restorations. Themetal copings were then fitted andsoldered. After try-in of the soldered metalframework (Figure 1 6.16), anotherelastomeric impression was done to repro-duce an accurate tissue transfer. These

Figure 16.17

Biscuit bake try-in

1 79

1 80


Figure 16.18

Figure 16.19

Altered cast impression

Centric occlusion recording in wax

Figure 16.20

Figure 16.21

Treatment completed-post-treatment anterior view

Treatment completed-maxilla

Figure 16.22

Figure 16.23

Treatment completed-mandible

Treatment completed-radiographs, anterior teeth


tissue duplication (Figure 16.18). At thesame time, a soft wax occlusal record wastaken to mount the model on the articula-tor (Figure 16.19). Teeth were set up on thepartial denture and fitted in the mouth. Theporcelain was then glazed. The crowns andbridges were cemented with Temp-Bondand the removable mandibular partialprosthesis inserted. The crowns andbridges were then cemented with zincoxyphosphate cement for permanentcementation (Figures 16.20-16.22). Acomplete series of radiographs was doneafter completion of treatment (Figures1 6.23-16.25).

SUMMARY

parotid gland. His face drooped, and wasasymmetrical. The mandibular anterior teethexhibited class 3 mobility, which gave apoor prognosis for their long-term retention.He had rampant caries, related to hismedical history, and many broken teeth. Hisvertical dimension of occlusion wasoverclosed and he was traumatizing theanterior palatal tissue when closing hismouth. The patient requested a fixedprosthesis, even though during treatmenthe agreed to accept a removable prosthe-sis. In the course of treatment manyproblems arose, and his treatment had tobe adjusted to the new circumstances. Inspite of all these problems, an excellentresult was achieved using a combination offixed and removable prostheses.

The patient, a 70-year-old retired schoolprincipal, presented with many variedproblems. He had undergone a number ofsurgical procedures to remove a pleomor-phic adenoma, which left him with perma-nent facial nerve damage and loss of the left


The patient, a 70-year-old male,presented to the clinic for treatment. He

1 81


had many missing teeth, loss of occlusalsupport, and anterior traumatic overbiteaggravated by advanced periodontaldisease. His condition was complicatedby status post- pleomorphic adenoma ofthe left parotid gland, that left him withfacial asymmetry and paralysis of theseventh cranial nerve. The treatment wasstarted in 1989, when the use of dentalimplants was just beginning in Israel, andthey were mainly placed in the anteriorregion of the mandible. At that time, agreat effort was made to save thepatient's remaining teeth. His verticaldimension was changed, and hismandibular anterior teeth were shortenedto improve the crown-to-root ratio, whilecreating an incisal platform for the maxil-lary transitional restoration. The aim of histreatment was to join tooth support forvertical dimension to posterior occlusalsupport by means of the removablepartial denture. In order to cope with hisproblem of severe caries, fluoride rinseswere administered as well as the use ofartificial saliva. The restorations that weremade restored function, esthetics, andocclusal support to the complete satis-faction of both the patient and the treat-ment team.


The treatment team demonstrated theirability to take the failing dentition of a 70-year-old patient with a compromised medicalhistory and to transform it into healthy,functional, and good-looking units. Toachieve this, most of the specialities withindentistry were involved. Forced eruption andother orthodontic treatment, endodontictreatment, and, naturally, periodontal therapyare all involved in this well thought out plan. Iwas pleased to note that the mandibularbilateral distal extension removal prosthesiswas made with an altered cast technique.Since the anterior teeth were splintedcrowns, a better looking restoration mighthave been achieved using attachments,albeit at the cost of increased complexity tomanufacture and to maintain. This treatmentwas commenced well over a decade ago.

Professor Yaffe has intimated that today it isjust possible that the use of implants mightrealize the patient's dream of fixed prosthesesin both jaws. Naturally, this may be feasible.However, what is for sure is that the principleof treatment carried out in the previous decadeis just as sound today as it was then, and willprobably be good for many years to come.

1 82

PATIENT 17 SEVERE UNILATERAL CLEFTLIP AND PALATE

Treatment by Miriam Calev

THE PATIENT

The patient, a 27-year-old builder,presented himself for examination andconsultation. His complaints were asfollows:

and palate. He only had one kidney, havingdonated a kidney to his father for transplan-tation.

PAST DENTAL HISTORY

`I have difficulties in eating and breathingbecause of the hole in my palate.' (Figure17.1)` Sometimes my teeth hurt.'` My scar is ugly but it will be fixed soon.'

I n the past, a general dentist had treated himin his village and had referred him fororthodontic treatment at Hadassah DentalSchool.

PAST MEDICAL HISTORYEXTRA-ORAL EXAMINATION


The patient suffered from a peptic ulcer forwhich he was taking medication (Gastro40 mg daily) and congenital unilateral cleft lip

• Asymmetrical face on right side due tounilateral cleft lip and palatal scar, andnose deformity

Figure 17.1


Figure 17.2

Face-frontalview

185


Figure 17.3

Face-side view

Figure 17.4


Figure 17.5


Competent lipsStraight profile with slight concavity anddepression of the noseNormally functioning temporomandibu-lar joint, with bilateral clicking onopeningMaximum opening 38 mm, with a slightdeviation to the left upon openingNegative overbite of 8.0 mmEnlarged lower third of the face

186

SEVERE UNILATERAL CLEFT LIP AND PALATE

Figure 17.6


Figure 17.7

Occlusion-left side

Figure 17.8


Figure 17.9


Occlusal examination revealed that thepatient was Angle class III (Figures17.5-17.7), with a reverse overbite of 8.0mm and a reverse overjet of 3.0 mm.There were wear facets on the rightsecond premolar and second molars.The interocclusal rest space was3.0 mm, measured between the incisors.There was a slight discrepancy betweencentric occlusion (CO) and centricrelation (CR). Anterior and bilateral poste-rior cross-bite was found. Centricocclusal contacts were found on the rightsecond molars, right maxillary cuspid toright mandibular first premolar, left

cuspids, and left second molars.Occlusal balancing side and protrusivepremature contacts during lateral andprotrusive mandibular movements werenoted.

Periodontal examination (Figures 17.8and 17.9) revealed unsatisfactory oralhygiene with plaque and calculus.Probing depths were found of up to4.0 mm on the maxillary teeth and up to3.0 mm on the mandibular teeth, withbleeding on probing on some teeth. Therewas inflammation around most of theteeth.

1 87


Figure 17.10


FULL MOUTH PERIAPICALRADIOGRAPHIC EXAMINATION

(Figure 17.10)

Endodontic treatment-mandibular rightlateral incisor with poor condensationPeriapical radiolucent areas around theright mandibular third molar and lateralincisor, and the left lateral incisor andthird molarGood bone support of all remainingteethCariesLateral maxillary right alveolar andpalatal cleftShort roots of the maxillary anterior teethResidual roots-maxillary right first molar

SUMMARY OF FINDINGS

The patient, a 27-year-old man, sufferingfrom a peptic ulcer and status post-surgeryfor congenitally unilateral cleft lip andpalate, and complaining of difficulty ineating, bleeding gums, and estheticproblems, came to the clinic for treatment.

I NDIVIDUAL TOOTH PROGNOSISTeeth 8 8 are listed in the periodontal chart as 7 7. As

determined by radiographic evaluation, they really are thirdmolar teeth that have shifted mesially to the second molarposition.

1 88


He presented with poor oral hygiene,plaque, gingival inflammation, and shallowand intermediate probing depths. He haddeep caries, residual roots, crowdedanterior mandibular teeth, defectiveendodontic treatment and restorations.There were periapical lesions around fourmandibular teeth and occlusal interfer-ences during l ateral and protrusivemandibular movements.

significance of proper oral hygiene and itsimportance in his treatment.


Cleft lip and palate:• Scarred lip• Esthetic problems• Limited opening

DIAGNOSIS

• Cleft lip and palate (oronasal fistula)(status post surgery)

•

Angle class III with anterior and bilateralposterior cross-bite accompanied bysevere interarch discrepancy

• Faulty occlusal relationship, and faultyocclusal plane

• Carious lesions• Defective restorations and endodontic

treatment (periapical lesions)•

Crowded anterior mandibular teeth•

Poor esthetics• Gingivitis• Reduced anterior and posterior

support•

Reduced vertical dimension• Residual root

Oronasal fistula:• Breathing problems• Eating problems•

Phonetic problems

Underdevelopment of the maxilla:•

Missing teeth•

Jaw discrepancy•

Failure of osseous union

Arch levelMaxilla:

• Few remaining teeth with unfavorabledistribution and malposition of the rightcuspid

•

Open oronasal fistula

Mandible:

• Remaining teeth had poor prognosisdue to caries and defective restorations.

I nter-arch levelCross-bite and Angle class III jaw relation-ship

•

Large interarch discrepancy• Limited mouth opening and limited

mandibular movements•

The need to change the vertical dimen-sion in order to restore the mouth

• The small difference between centricrelation and centric occlusion

ABOUT THE PATIENT

The patient was very conscientious, andwilling to cooperate in spite of his physicalhandicaps (scar, limited mouth opening). Hehad high expectations from his dental treat-ment and even more so from the plannedplastic surgery procedures. He wanted toimprove his appearance but did not haveany preferences for fixed versus removablerestorations. He did not appreciate the

1 89



Maxilla:

occlusion in order to check patientadaptation

• Re-evaluation

Telescopic, removable partial dentureFixed partial prosthesis and smallobturatorFixed and removable partial prostheses

Mandible:

PHASE 4

• Fixed partial prostheses for both themaxilla and the mandible

• Fixed partial prosthesisTREATMENT


Oral hygiene instructionScaling and curettageDietary changesFluoride rinses and gel applicationExtraction of residual rootsCaries removalEvaluation of patient cooperation

PHASE Z

•

Orthodontic and surgical consultations•

Endodontic therapy where indicated• Restorative treatment with restorations

and provisional fixed acrylic restorationsfor the teeth with ample loss of toothstructure

PHASE 3

• Orthodontic treatment for uprightingand realigning teethRe-evaluation and planning of pre-prosthetic periodontal surgeryNew provisional fixed acrylic restora-tions at the new vertical dimension of

TREATMENT PLANI nitial preparation included oral hygieneinstruction, scaling, and curettage. Cariesremoval and provisional restorations weredone where indicated. The maxillary rightfirst molar roots were extracted. Endo-dontic therapy was performed on themandibular right premolars, the mandibularright third molar, the maxillary left centraland lateral incisors, and all the mandibularincisors.

At this point, it was determined that thepatient was actively participating in histreatment, as his oral hygiene was greatlyi mproved (Figures 17.11-17.14).

Upon completion of the endodontictreatment, the right mandibular third molarwas restored with an amalgam post andcore, and the other endodontically treatedteeth were prepared for cast post andcores and provisional restorations.

After consultation with the plastic surgeryand oral and maxillofacial surgery depart-ments, the decision was made by allconcerned that additional surgery wouldnot contribute to the success of the treat-ment, and would probably only traumatizethe patient. Periodontal surgery (vestibulumdeepening), due to the lack of attachedgingiva, was performed upon the maxillaryright cuspid, including a soft tissue graftfrom a donor site in the palate, and the

1 90


Figure 17.11

Figure 17.12

Anterior maxillary teeth-palatal view, after initial preparation

Anterior mandibular teeth-lingual view, after initial prepa-ration

Figure 17.13

Figure 17.14

Periodontal chart-mandible, first re-evaluation

Periodontal chart-maxilla, first re-evaluation

Figure 17.15

Provisional restorations-anterior view

remaining endodontically treated mandibu-lar teeth (crown lengthening procedures).The anterior maxillary teeth were preparedfor full crown restorations and temporizedwith provisional restorations at anincreased vertical dimension (Figure 17.15).

Orthodontic treatment was planned andexecuted to expand the maxillary arch inorder to attain an incisal tip-to-tip relation-ship, rather than the class III Angle thatexisted. The maxillary right cuspid was alsotreated orthodontically to bring it to a morelabial position (Figure 17.16).

191

Figure 17.16

Orthodontic treatment, mandible

Figure 17.18

Periodontal chart-mandible, second re-evaluation

At completion of orthodontic andperiodontal treatment, the cast posts andcores were finished and cemented intoplace on the endodontically treated teeth.A re-evaluation regarding the final treat-ment plan was then carried out. Newprovisional restorations were made tomaintain the new vertical dimension and tostabilize the teeth after the orthodontictreatment. These provisional restorationsalso enabled us to evaluate patient'sadaptation to the new occlusal jawrelations (Figures 17.17-17.19).


Figure 17.17

Provisional acrylic resin restorations

Figure 17.19

Periodontal chart-maxilla, second re-evaluation

After a period of 6 months with the provi-sional restorations at the new verticaldimension of occlusion, the patient exhib-ited no temporomandibular joint or muscu-lar problems. The teeth were re-prepared(Figure 17.20), copper band elastomerici mpressions were taken and the treatmentwas continued as outlined in the TechnicalI nformation chapter.

The treatment for the oronasal fistulawas to incorporate a precision attachmenton the lingual aspect of the anterior fixedprosthesis opposite the oronasal fistula. A

192


Figure 1 7.20 Figure 17.21

Final tooth preparation-mandible Facebow registration

removable gold foil prosthesis was thenmade to seal the oronasal fistula by attach-ing it to the fixed prosthesis by means ofthe precision attachment.

Full arch polyether impressions weremade for tissue detail. The models werethen mounted on a Hanau articulator withthe aid of a facebow registration (Figure17.21) and the porcelain was baked. Thefinal and minute adjustments of the biscuit-bake porcelain were carried out in themouth. The final glaze was applied to theprostheses, and they were cemented withTemp-Bond for a period of 2 weeks. Theywere then cemented with zinc oxyphos-phate cement for permanent cementation(Figures 17.22-17.26).

SUMMARY

The patient presented with a severeproblem of unilateral cleft lip and palate,remaining residual roots, caries, andmalpositioned teeth. There was a patho-logic occlusion with serious balancing sideand protrusive premature contacts duringmandibular movements. He was very

concerned about esthetics. The treatmentwas further complicated by the severeAngle class III jaw relationships and thenegative overbite and overjet. Anotherproblem was that the patient had no under-standing of good oral hygiene. Due thedecision after consultation with the plasticsurgery and oral and maxillofacial surgerydepartments, that additional surgery wouldnot contribute to the success of the treat-ment and would only cause more traumato the patient, surgery was not performed.

Figure 17.22

Gold foil obturator to close palatal cleft

1 93

1 94


Figure 17.23

Figure 17.24


Treatment completed-anterior view, close up

Figure 17.25

Radiographs-post-treatment, maxilla

Figure 17.26

Radiographs-post-treatment, mandible


Treatment consisted of oral hygieneinstruction, periodontal surgery, endodontictherapy, oral surgery, removal of caries,orthodontic treatment, and altering thevertical dimension of occlusion in order toprovide a physiological occlusion andchange the jaw relationship from Angleclass III to that of edge-to-edge. The finalrestorations accomplished all of thesegoals as well as providing an estheticsolution to the patient's problems.

oronasal fistula. A gold foil was fabricated toseal the oronasal fistula by attaching to thefixed prosthesis by means of the precisionattachment, thus providing a fixed prosthe-sis along with a seal of the oronasal fistulaand potential access for cleaning whenneeded. In the execution of this treatmentplan, this young patient was provided with asolution to his functional and estheticdemands, providing him with a much betterquality of life.



This treatment represents a prosthodonticsolution to a severe unilateral cleft lip andpalate, with pathologic occlusion along withi nterarch discrepancy. Further problemsincluded esthetic complaints that could notbe otherwise solved, due to an unsuccess-ful previous attempt for orthodontic treat-ment and limited surgical success toremedy the situation of the oronasal fistulaalong with the unilateral cleft lip and palate.

By using the existing small amount ofintercuspal/retruded cuspal discrepancyalong with optimal increase of the verticaldimension and utilizing adjunctive orthodon-tics, the pathologic occlusion of Angle classI II was converted to an esthetically satisfac-tory functional physiologic occlusion withminute anterior guidance. In order to sealthe oronasal fistula, and avoid a removableappliance, a precision attachment wasincorporated on the lingual aspect of theanterior fixed prosthesis opposite the

This patient appeared to combine achallenging cocktail of prosthodonticdifficulties. Naturally, surgical closure ofthe naso-palatine fistula would have beenpreferable, but in this case had notproved feasible. The need to constructan obturator added yet one moreprosthodontic difficulty. The degree ofpatient cooperation achieved was quiteremarkable in view of the past history,and orthodontic treatment for botharches following periodontal therapy wasa requirement if a good-looking outcomewas to be achieved. Indeed, the maxillaryorthodontic treatment involved crossingthe cleft, but the subsequent construc-tion of a fixed prosthesis should preventany relapse. The use of transitionalrestorations in the evaluation of changesof a dimension of occlusion is to berecommended and the result achievedeminently satisfactory.

195


• Speech difficulty•

His front teeth are sensitive to hot andcold


• Asymmetrical face: non-alignment oflips, nose and eyes

• Normal profile with a sharp naso-labialangle and full lipsTemporomandibular joint had a recipro-cal click in the right joint

Maximum opening of 46 mm withoutdeviation (measured from the maxillaryright central incisor to the mandibularanterior edentulous ridge)Scarred left lip

I NTRA-ORAL AND FULL-MOUTHPERIAPICAL RADIOGRAPHIC

EXAMINATION (Figures 18.4 and 18.5)


•

Narrow ridges

Figure 18.2

Face-frontal view

Figure 18.3

Face-side view

Figure 18.4


Figure 18.5


1 9 8

UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA

Triangular archHigh palateUnilateral closed cleft palateDeciduous teeth:

Amalgam restorations on the rightdeciduous second molarMaxillary central incisors in labio-versionSharp conical-shaped cuspidsSpacing between the right lateral incisorand right cuspid


•

Sharp conical-shaped cuspids•

Narrow V-shaped residual ridges

Occlusal examination (Figures 18.6 and18.7) revealed that the patient was Angleclass III. The interocclusal rest space was5.0 mm. Overjet and overbite could not bemeasured due to the missing anterior teeth( Figure 18.1). There was no discrepancybetween centric relation and centric occlu-sion. Lateral jaw movements were guidedonly on the non-working side of the maxil-lary lateral incisor and the mandibularcuspid teeth on the right side, and by themaxillary central incisor and first molar andthe mandibular left central incisor and firstmolar on the l eft side. Protrusivemovements were guided by the left firstmolar maxillary and mandibular teeth.

Figure 18.6


Figure 18.7

Occlusion-left side

Fremitus class 1 was noted on the maxil-lary right lateral incisor and the mandibularright cuspid (due to the cross-bite).

The periodontal examination (Figures1 8.8 and 18.9) revealed some plaque,probing depths of up to 3.0 mm on themaxillary and mandibular teeth andbleeding (of the gingiva) on probing.There was slight gingival recessionaround most of the teeth and severevertical recession on the lingual surfacesof the mandibular right second and leftfirst molar teeth.

199

200


Figure 18.8

Figure 18.9



Figure 18.10

Radiographs of maxilla andmandible-pre-treatment,periapical

FULL-MOUTH PERIAPICALSURVEY

(Figure 18.10)

• Severe bone loss around the distalsurface of the maxillary left central incisor

• Vertical bone loss approximate to theareas of missing teeth



SUMMARY OF FINDINGS

The 24-year-old patient, status post surgeryof unilateral cleft lip and palate, came to theclinic complaining of missing teeth, difficultywhen chewing food, difficulties in speaking,and esthetic problems. He presented withpoor oral hygiene, plaque and calculus, andbleeding upon probing. The jaws wereundeveloped in the areas where there weremissing teeth. There was a discrepancy injaw size, a significant amount of missingalveolar bone in the area of the cleft, andpartial anodontia. The occlusion was Cross-bite, with a scissors bite between the remain-ing teeth. The only teeth in occlusal contactwere the left first molars and the right maxil-l ary cuspid with the mandibular lateral incisor.There were retained deciduous teeth andsharp-pointed conical cuspids.

importance of good oral hygiene, inparticular in relation to his dental treat-ment. He wanted a fixed restoration, ifpossible.


Maxilla:

Telescopic removable partial dentureOverdentureFixed partial prosthesis-tooth-supported

Mandible:

Fixed prosthesis-tooth-supportedFixed prosthesis-tooth- and implant-supported

DIAGNOSIS

• Status post closed unilateral cleft lipand palate (left side) with scarring thatresulted in a small maxilla, both antero-posteriorly and bucco-lingually

•

Poor occlusal plane•

Cross-bite and scissors bite•

Partial anodontia• Reduced occlusal support•

Primary occlusal trauma•

Decreased vertical dimension of occlu-sion (questionable)Retained deciduous teethGingivitisFaulty esthetics


Cross-bite and missing teethDifference in jaw sizeCongenital lack of many teethLack of bone support in the area of themissing teethDevelopmental defects in the jawI nability to incorporate orthodontic andsurgical treatmentSome of the supporting teeth weredeciduous and their long-term progno-sis was unknown

TREATMENT PLAN

ABOUT THE PATIENT PHASE 1: INITIAL PREPARATION

The patient was motivated for dentaltreatment in spite of his years of unsuc-cessful treatment. He was unaware of the

I nitial periodontal therapy including oralhygiene instruction, scaling and rootplaning

201


Figure 18.11

Patient after initial preparation

Figure 18.12

Wax-up

Figure 18.13

Wax-up

Figure 18.14

Wax-up

•

Diagnostic wax-up• Transitional restorations

PHASE 2

• Fixed restorations

TREATMENT

After a short period of initial treatmentconsisting of scaling, root planing, curet-tage, and oral hygiene instruction (Figure18.11), study models were taken and

mounted on an articulator to determine thepossibility of fixed prostheses at the exist-ing bucco-lingual jaw relationship. This wasfound to be impossible and a wax-up wasmade in which the vertical dimension wasopened 5.0 mm in the incisor area (Figures18.12-18.14).

After the wax-up on the articulator hadbeen examined, and the amount of waxneeded to build up the teeth to occlusiondetermined, it was decided to undertakeminimal crown preparation of the teethwhich were to be restored and normalcrown preparation of the remaining teeth.

20 2


Figure 18.15

Transitional prosthesis I-anterior view

The decision to make a fixed restorationwas taken with the understanding thatthere would be minimal tooth preparationand thus conservation of tooth structureand vitality of the teeth, thus minimizing theneed for endodontic therapy.

The teeth were then prepared and thefirst transitional restorations were made atthis new vertical dimension (Figure 18.15).At this time, endodontic treatment wasundertaken on the maxillary central incisorswhich had pulp tested non-vital.Endodontic treatment was also carried outon the mandibular cuspids in order to

improve their bucco-lingual relationships.The problem of crowding between themaxillary incisor teeth was then treated byseparating them using wedges. Due to thefact that the mandibular incisors neverformed, the vertical level of the soft tissuewas lower than normal, thus necessitatingperiodontal surgery to add papillae to themesial of the mandibular cuspid teeth. Thevertical dimension of the transitionalrestorations was then duplicated in asecond set of transitional restorations. Inorder to be sure that the patient adapted tothe new increased vertical dimension, andthat the occlusion was stable, as well as tocheck the vitality of the prepared teeth, thepatient was maintained in these restora-tions for one year.

At re-evaluation one year later, the clinicalsituation was stable and there were noproblems (Figures 18.16-18.18). The finalphase of treatment was then carried out.The teeth were reprepared (slightly), andindividual copper band elastomeric impres-sions were taken, and stone dies andPattern resin copings made as described inthe Technical Information chapter. Theprostheses were then glazed and temporar-ily cemented in the mouth with Temp-Bond

Figure 18.16

Transitional prosthesis II-right side

Figure 18.17

Transitional prosthesis II-left side

203


Figure 18.18

Transitional prosthesis II-patient smile

Figure 18.19


Figure 18.20

Treatment completed-radiographs

for a period of 2 weeks. The prostheseswere then cemented permanently with zincoxyphosphate cement (Figures 18.19 and18.20). Due to the difficulty in obtaining aparallel path of insertion in the mandible, thelower prosthesis was built in two sections.

The first bridge extended from the leftmandibular first molar to the left first premo-l ar, and the second, from the left mandibu-lar cuspid to the right mandibular secondmolar. The maxillary restoration wasconstructed in one unit.

20 4


SUMMARY

This patient presented with severe

problems. He was status post (S/P)surgery for unilateral cleft lip and palate,which left him with scarring that negatedany orthodontic or surgical treatment. Hehad many missing teeth, mostly congeni-tal. He had a severe cross-bite andscissor bite with a very difficult anterio-

posterior and bucco-lingual jaw relation-ships to deal with. He wanted a fixedrestoration yet was ignorant of good oralhygiene. A careful evaluation was made

using mounted study models on an artic-ulator and a tentative wax-up was done todetermine whether fixed treatment was

possible. The patient was then treatedwith transitional restorations for over one

year, in order to make sure that he couldadapt to the increased vertical dimension.Only then were permanent restorationsmade. The maxillary anterior teeth wererestored esthetically in spite of the severel i mitations that the patient presented. The

anterior teeth were restored in a class Irelationship although in the posteriorregion, a slight cross-bite was built inorder to improve function. The cuspids

guided lateral movements without anynon-balancing side contacts. The maxil-l ary left central incisor tooth was restoredwith supra-gingival margins in order toachieve a better path of insertion. Thiscould be done as the patient had a highli p line and esthetics was not a problem.Total treatment time was 2 years and allthe teeth remained vital, except for thefour teeth that were treated endodonticallyat the beginning of the treatment. Thetreatment gave the patient esthetics andfunction that he had never had previously,

due to his pre-existing congenital difficul-ties.


This case represents a rather controversialtreatment plan. On one hand, retained decid-

uous teeth served as abutment teeth forfixed partial restoration, and at the same time

the vertical dimension of occlusion wasincreased by 5 mm. This further jeopardized

the survival of the deciduous teeth. All thatwith the intention to facilitate, from a biome-chanical aspect, fabrication of a fixed partialrestoration. This case was executed with

caution at each step. The team was aware ofthe risk, therefore the diagnostic wax-uptook into account existing tooth position, andthe food table was thus designed tominimize the off-center loading on the teeth.The occlusal scheme was performed withminimum rise on lateral excursions tominimize load and trauma to the teeth. At the

completion of this restoration, it can beclaimed that the solution provided in thiscase is esthetic, satisfactory from a functionalstandpoint, and provides the patient with a

physiologic therapeutic occlusion.


Treating a patient with a cleft palate and

collapse of the maxillary dentition togetherwith the associated derangement of occlu-sion is never straightforward. The decisionto increase the vertical dimension by some

5 mm was probably correct, although the

preparing of teeth at an early stage of treat-ment must be considered brave. A morecautious approach would have been toincrease the vertical dimension usingremovable prostheses until the correctvertical dimension had been established,and only at this stage to undertake

20 5


i rreversible procedures such as toothpreparation. It is not simply the inter-archspace that poses the problem, it is theinter-abutment space and the cleansabilityof the resultant prosthesis that is likely to

pose maintenance problems in the longerterm. One can only hope that the patient'smotivation is preserved, along with all thehard work that went into construction ofthe restoration.

206

PATIENT 19 GENERALIZEDAMELOGENESISI MPERFECTA

Treatment by David Lavi

THE PATIENT PAST MEDICAL HISTORY

The patient, a 25-year-old woman (Figure19.1), presented herself for examinationand consultation. Her complaints were asfollows:

The patient had suffered some illnesses inchildhood, but was currently in goodhealth.

` My teeth are ugly.''The color of my teeth is awful.'` My gums bleed and hurt when I brushthem.'`I feel that my mouth is one big mess.'` Food sticks between my teeth afterevery meal.''My teeth are sensitive to anything hot orcold.'

PAST DENTAL HISTORY

Treatment at a local dental clinic includedtwo root canal treatments, two posts, andsome amalgam restorations. Previously,because of an accident, some of heranterior maxillary teeth were extracted anda provisional fixed acrylic restoration wasplaced (Figure 19.2).

Figure 19.1

Face-frontal view

Figure 19.2


207


EXTRA-ORAL EXAMINATION(Figures 19.1 and 1 9.3)

Symmetrical faceCompetent lipsStraight profileNormal temporomandibular jointMaximum opening 60 mm, with a slightdeviation to the left upon opening

Figure 19.3

Face-profile view

I NTRA-ORAL EXAMINATION(Figures 19.4 and 1 9.5)

Figure 19.4

Mandibular arch

Figure 19.5

Maxillary arch

Exposed dentinExtensive cariesRounded arch formWear of teeth accompanied by chippingof the enamel and cupping of thedentineMissing teeth:

Fixed provisional acrylic partial prosthe-sis:

I rregular occlusal plane (Figures 1 9.6

and 19.7)

An occlusal examination revealed thatthe patient was Angle class III (Figures19.6 and 1 9.7), with an overbite of0.0 mm and an overjet of -1.0 to -1.5 mm.The interocclusal rest space was 2.0 mm,measured between the incisors. Therewas no discrepancy between centricocclusion (CO) and centric relation (CR).Balanced occlusion and anterior and bilat-eral posterior cross-bite were noted.There was edge to edge occlusionbetween the left maxillary central incisor

208

GENERALIZED AMELOGENESIS IMPERFECTA

Figure 19.6


Figure 19.7

Occlusion-left side

Figure 19.8

Periodontal chart-mandible

Figure 19.9

Periodontal chart-maxilla

and the left mandibular central and lateralincisor teeth (as restored by the provi-sional restoration).

FULL-MOUTH PERIAPICAL ANDCEPHALOMETRIC SURVEY


The periodontal examination (Figures 19.8and 19.9) showed unsatisfactory oralhygiene with large amounts of plaque andcalculus. Probing depths were found of upto 5.0 mm on the maxillary teeth and up to4.0 mm on the mandibular teeth, withbleeding on probing on some teeth. Therewas inflammation around most of theteeth.

209

Figure 19.10

Radiographs of maxilla and mandible

Figure 19.11

Cephalometric radiograph



SUMMARY OF FINDINGS

The 25-year-old patient complained of pooresthetics, sensitivity in her teeth and gums,and bleeding gums on brushing. She sufferedfrom exposed dentine, short clinical crowns,noticeable changes in the shape and color ofher teeth, and root and crown proximity. Shehad poor oral hygiene, caries, missinganterior maxillary teeth, and faulty restora-tions. Probing depth was average, and therewas a radiolucent area in the right maxilla.

DIAGNOSIS

Angle class III with bilateral posteriorcross-biteAmelogenesis imperfectaMultiple carious lesionsRoot and crown proximityFaulty restorationsOcclusal disharmony and faulty occlusalplaneMissing maxillary teethPoor estheticsGingivitisRadiolucent area in the right maxillaI mpacted maxillary left cuspid

21 0


ABOUT THE PATIENT

The patient was very cooperative, and withina short period of time, her oral hygiene andher periodontal condition improved. Shewanted an esthetic, fixed restoration andhad high expectations of how much it wouldimprove her appearance.


• Amelogenesis imperfecta complicatedby root and crown proximity

• Poor occlusal relationships-Angleclass III with bilateral cross-bite

•

Short clinical crowns that would requirecrown-lengthening procedures, therebyincreasing the crown-to-root ratio, whichmight worsen the overall prognosis

TREATMENT PLAN

• Oral hygiene instruction• Scaling and curettage•

Caries removal and endodontic therapy,where indicatedEvaluation of patient cooperationI mmediate provisional fixed acrylicrestorations for the teeth with consider-able loss of coronal tooth structureOrthodontic treatment to alleviate rootand crown proximityCrown-lengthening surgery, where indi-catedRe-evaluationFixed partial prostheses for both themaxilla and the mandible

TREATMENT

removal and endodontic therapy wereperformed on the mandibular left firstmolar, second right mandibular premolar,and the right mandibular first and secondmolars, as indicated. The endodonticallytreated teeth were restored with amalgampost and cores. Full coverage provisionalrestorations were made serially in order torestore extensive lost tooth structure(Figure 19.12).

Orthodontic treatment was performed toalleviate root and crown proximity (Figure19.13). At this point, after re-evaluation,

Figure 19.12

Transitional restorations

I nitial preparation included oral hygieneinstruction, scaling, and curettage. Caries

Figure 19.13

Orthodontic treatment-to alleviate root and crown proximity

211


Figure 19.14

Periodontal surgery-crown lengthening procedure

localized crown lengthening was under-taken on the left maxillary and mandibularsecond molars. Periodontal surgery to alignthe gingival margins of the maxillary anteriorteeth was carried out (Figure 19.14).Additional orthodontic treatment was thenperformed to realign the maxillary left centralincisor tooth, correcting the existing midlinediscrepancy (Figure 19.15). At completionof orthodontic and periodontal treatment,new provisional restorations were made tomaintain the newly acquired interproximalspace and tissue health (Figure 19.16).

Figure 19.15

Figure 19.16

Orthodontic treatment to re-align anterior maxillary teeth

New transitional restorations after periodontal surgery

Figure 19.17

Biscuit bake porcelain try-in

Figure 19.18

Finished restorations on Quick articulator

21 2


Figure 19.19

Facial view of patient's smile after treatment completion

Figure 19.20

Finished restorations in mouth

Once the esthetic, physiological andfunctional expectations of the patient andthe dentist had been attained in the transi-tional restorations, the teeth were repre-pared, individual copper band elastomericimpressions were taken, and stone dies andPattern resin copings made as described inthe Technical Information chapter. Themetal copings were fitted, connected,soldered and refitted as previouslydescribed and the porcelain biscuit bakeapplied. The final and minute adjustmentsof the biscuit bake porcelain were carried

out in the mouth (Figure 19.17). The finalglaze was applied to the prostheses (Figure19.18), and the prostheses were cementedwith Temp-Bond for a period of 2 weeks.They were then cemented with zincoxyphosphate cement for permanentcementation in 1999 (Figures 19.19-19.21).

SUMMARY

The patient presented with a severeproblem of enamel hypoplasia on all of her

Figure 19.21

Radiographs after treatment completed

21 3


teeth, multiple carious lesions, massive lossof tooth structure, and root and crownproximity. There was a pathologic occlusionwith serious non-working side and protrusivepremature contacts during mandibularmovements. She was very concerned abouther esthetics. The treatment consisted ofchanging the vertical dimension of occlusion,orthodontic treatment, in order to provide aphysiological occlusion and decrease theroot proximity, and provide a proper founda-tion for the future fixed restorations.Periodontal surgery was also undertaken forcrown lengthening as well as gingival align-ment. The final restorations provided her witha functional, physiological, and estheticsolution.


The 25-year-old patient presented to theclinic with generalized amelogenesis imper-fecta complicated by multiple cariouslesions with massive loss of tooth structure,and aggravated by close proximity of rootsand crowns. The solution provided tookinto consideration all of these factors. Inorder to solve the problem of short crowns(retention for a fixed prosthesis) due to theloss of enamel (Amelogenesis imperfecta)the vertical dimension of occlusion wasincreased so that there was minimalocclusal reduction. This reduced the needfor crown-lengthening procedures onone hand, and also improved the

anterior-posterior occlusal relationship,gaining 1.5 mm of overjet and 1.0 mm ofoverbite, thus enabling a physiologic occlu-sion and minimally jeopardizing long-termtooth survival. At completion of the rehabil-itation, all the esthetic, functional, andphysiologic criteria were accomplished.


This patient's treatment represents anotherexample of what can be achieved withdedicated and skilled operators and amotivated patient. The daunting problem ofamelogenesis imperfecta, malpositionedroots, caries, and active periodontal disease,were overcome in a sensible manner. It ishard to believe that little more than onepracticing generation ago such a combina-tion of problems would have been treated bythe removal of the roots and the construc-tion of complete upper and lower dentures.Nowadays, the combination of difficult rootposition, short clinical crowns, and caries,might have tempted operators to considerthe implant approach. Indeed, this may havebeen a viable option, but I feel that Dr Lavimade the right decision and in the unlikelyevent that the restoration should not survivea reasonable period of time the implantoption still remains. The periodontal care,orthodontic therapy, and restorative treat-ment have produced an excellent result, butone that will require unwavering enthusiasmif it is to be maintained.

21 4


Figure 20.3

Frontal view of teeth showing orthodontic retainers

Figure 20.4

Face in profile

Figure 20.5

View of lips showing PITS

•

Lower lip exhibited two PITS, indicativeof the Raynaud's disease (Figure 20.5)

•

Bridge of the nose was very wide andthe nostrils were without bone supportand were enlarged (Figure 20.1)Maximum opening was 53 mm, andthere was no deviation in either openingor closing movementsNo muscle sensitivity was noted andthe jaw movements were normalCompromised esthetics due to thebilateral lip clefts and the missing maxil-lary lateral incisor teeth

compromised and sometimes difficult tounderstand. At age 14, he underwentorthopedic surgery to build up his nose andalso to close the boney hard palate clefts.There was a family history of sensitivity toOptalgin (glucose-6-phosphate dehydroge-nase deficiency).

EXTRA-ORAL EXAMINATION

• Straight profile with incompetent lips(Figures 20.1 and 20.4)

INTRA-ORAL EXAMINATION


Jaw-normal size, asymmetrical, trian-gular, with a class 3 soft palate andshallow vestibulumAmalgam restorations on some of themolar teethCaries on the left maxillary molars andthe right maxillary first molarVery poor oral hygiene with inflamedgingivae accompanied by calculus andplaque

BILATERAL CLEFT PALATE AND RAYNAUD'S DISEASE

Figure 20.6

Maxillary arch

Figure 20.7

Mandibular arch

• Congenital absence of the maxillarylateral incisor teeth, an oral nasal fistulaon the right side between the hardpalate and the premaxilla; the pre-maxilla was slightly mobilePalatal scar above the left molar teethThird molar teeth impacted


Ovoid jaw shapeHigh floor of the mouth with wide andbroad muscle attachments and shallowvestibulumAmalgam restorations on some of themolar teeth

An occlusal examination revealed thatthe patient was Angle class III, with anopen anterior cross-bite (Figure 20.3). Theinterocclusal rest space was 2.0 mm.There was no midline deviation. The poste-rior teeth were in an edge to edge relation-ship bucco-lingually. The plane of occlusionwas faulty, with incomplete contactsbetween the maxillary and mandibularteeth (Figure 20.8). The only working sidecontacts in lateral jaw movements were onthe second molars. There were balancing

Figure 20.8

Open bite right side

side contacts between the maxillarysecond molars and the mandibular thirdmolars. In protrusive movements, therewas no anterior disclusion and the onlycontacts were on the second molars.

The periodontal examination revealedprobing depths of up to 5.0 mm on themaxillary teeth and up to 4.0 mm on mostof the mandibular teeth, with bleeding onprobing on some teeth (Figures 20.9 and20.10). There was slight inflammationaround the maxillary and mandibularmolars.

217

218


Figure 20.9

Figure 20.10

Maxillary periodontal chart Mandibular periodontal chart

Figure 20.11

Radiographs of maxillaryand mandibular anteriorquadrant



• Maxillary left first molar had an mesio-occlusal amalgam restoration withmesial caries

• Small distal caries in the maxillary leftcuspidDistal caries in the right maxillary centralincisorOcclusal amalgam restorations in thesecond molar teeth

missing and the maxillary third molars wereimpacted. Some of the existing restorationswere faulty and there was extrusion of themandibular right third molar. There wascaries on many teeth. He was Angle classI I I with an anterior cross-bite as well as ananterior open bite, with a faulty plane ofocclusion.


All the teeth had a good prognosis.

SUMMARY OF FINDINGS

The patient, a 17-year-old high schoolstudent, came to the clinic complaining ofpoor esthetics and missing front teeth. Hewas very concerned about his appearanceand wanted to have a fixed prosthesis toreplace his removable one.

His previous medical history consisted ofcongenital bilateral cleft palate and lip withmany unsuccessful attempts at surgicalrepair, and he remained with muchscarring. He suffered from Raynaud'sdisease. There was a lack of bone betweenthe premaxilla and the maxilla on the leftside, and on the right side there was anarrow bridge of bone connecting thepremaxilla and maxilla. He had undergoneorthodontic treatment and had removablemaxillary and mandibular orthodonticmaintainers, which also replaced themissing maxillary lateral incisor teeth. Therewas an oral-nasal fistula between his hardpalate and premaxilla on the right side.

His oral hygiene was poor. He had largeamounts of plaque and calculus causinggingivitis, but with good bone support. Themaxillary lateral incisors were congenitally

DIAGNOSIS

• Bilateral cleft lip and palate s/p (statuspost) surgeryOral-nasal fistulaCongenitally missing teethPoor estheticsAnterior cross-biteAnterior open biteGingivitisCariesRaynaud's diseaseI mpacted maxillary third molars

ABOUT THE PATIENT

The young patient seemed to have nounderstanding of the importance of theneed for his cooperation in his dental treat-ment. He was strongly motivated to havedental treatment for esthetic reasons, andwanted his teeth fixed before he wasinducted into army service.


The patient was a young man who hadundergone multiple, extensive, but unsuc-cessful surgical procedures to repair acongenital condition, and was thereforewary of extensive dental treatment.

21 9

220


Maxilla:

•

Maxillofacial surgery to add needed bonei n the cleft areas in order to close the oral-nasal fistula and stabilize the premaxilla,and to provide bone support for implants

• Fixed partial prosthesis to replace themissing lateral incisor teeth with a remov-able prosthesis to seal the oral-nasal fistula

• Removable partial dentureFigure 20.12•

Restoration of carious teethCT radiographs of the maxilla

Mandible:

TREATMENT PLAN

•

Restoration of carious teeth

TREATMENT

I nitial preparation included oral hygieneinstruction, scaling, curettage, and rootplaning. The carious teeth were thenrestored. At the end of this stage, anobvious improvement in the periodontalsupporting tissue could be seen, and it wasobserved that the pocket depths haddiminished

and

that

the

bleeding

on

Figure 20.13

probing had disappeared.

Anterior view of teeth

Occlusal equilibration was performed toreduce the anterior open bite and obtainstable intercuspal position. The patient wasalso referred for speech therapy. Following aCT radiograph (Figure 20.12), consultationwith the oral and maxillofacial surgery depart-ment revealed that the chance for success-ful augmentation of the cleft on the left sideand closure of the fistula was almost negligi-ble. The possibilities of treatment of themaxilla were then limited to a removablepartial denture to replace the missing maxil-lary lateral incisor teeth and to cover theopening of the fistula,

or to

restore the

Figure 20.14

missing lateral incisors with a fixed partial

Palatal view of maxillary anterior teeth



Dies and Duralay copings Soldered metal copings being fitted

prosthesis from the right cuspid to the leftcuspid, with provision for a removable palatalattachment to cover the palatal fistula. A veryaccurately fitting gold palatal leaf (denture)that would seal the fistula was chosen. Itwould be retained by a precision attachmentfitting into the maxillary right lateral incisorpontic (split lingual attachment).

The maxillary central incisor and cuspidteeth were prepared and temporized with atransitional fixed prosthesis, which alsocorrected the cross-bite and gave anteriorcontact in centric relation and anteriorguidance in lateral and protrusive movementsof the mandible (Figures 20.13 and 20.14). Inaddition, `guided' passive eruption allowedthe molars on the right side to erupt intocontact. This was accomplished by buildingup the mandibular lingual cusps withcomposite resin in order to prevent lateraltongue thrust, which was preventing the teethfrom erupting to contact. The composite wasremoved after occlusal contact had beenachieved and the surfaces finely polished.

After the patient adapted to his new rest-orations, copper band impressions of methyl-methacrylate and elastomeric impressionmaterial (Xantropen) were taken of the maxil-

lary prepared teeth, and Duralay copingswere made (Figure 20.15). These copingswere used to record centric relation at thevertical dimension of occlusion as determinedby the posterior teeth, and for the impressionfor the model to make the metal copings. Themetal copings were built with a semi-preci-sion attachment in the maxillary right lateralincisor pontic. These were then fitted andsoldered and, after try-in of the solderedmetal framework, a centric registration recordwas made in Duralay (Figure 20.16) and anelastomeric impression was made for thetissue pick-up for the master model.

The models were mounted on a semi-adjustable articulator (Hanau) utilizing afacebow registration and centric recordswere taken at the vertical dimension of occlu-sion utilizing Duralay with a Neylontechnique. At this point the porcelain wasbaked and the occlusion checked at thebiscuit bake stage in the mouth and alladjustments needed were then made. ADuralay palatal attachment was fitted andrelined in the mouth with Duralay (Figure20.17). This palatal attachment was thencast in gold, with a male attachment to fit thefemale attachment in the right maxillary

221


Figure 20.17

Palatal seal in Duralay

Figure 20.18

Palatal seal in gold

Figure 20.19

Case cemented-post-treatment anterior palatal view

l ateral incisor pontic (Figure 20.18). The goldremovable palatal attachment was fitted andchecked in the mouth. The maxillary fixedprosthesis was glazed and polished, as wasthe gold palatal attachment. The prosthesiswas cemented with Temp-Bond for a periodof 2 weeks and the palatal attachmentinserted (Figures 20.19 and 20.20). Thepatient was taught how to insert and removethe palatal attachment for cleaning purposes.The crowns and bridges were thencemented with zinc oxyphosphate cementfor permanent cementation.

Figure 20.20

Frontal facial view of patient after treatment completion

SUMMARY

The patient presented after many unsuc-cessful surgical attempts to close a bilateralcongenital palate and lip cleft. He had poororal hygiene, difficulties with speech and avery poor self-image due to severelycompromised esthetics. The patient wasrestored to form and function with the

222


minimal treatment necessary, whichincluded a fixed partial prosthesis toreplace the congenitally missing maxillarylateral incisor teeth, and a semi-precisiongold palatal attachment to cover the exist-ing oral-nasal fistula, thus preventing foodand liquids from entering the nasal cavity.

anterior fixed prosthesis. Additionalocclusal support was also obtained bypassive eruption of posterior teeth thatformerly were not in contact.



The patient, a 17-year-old high schoolstudent, presented to the clinic seekingtreatment to solve esthetic and functionalproblems. He was anxious to get rid of hisremovable partial orthodontic retainer,which also restored his missing lateralincisor teeth. Once the possibility for asurgical correction of the fistula wasnegated, the patient, in order to preventhaving a removable prosthesis, claimedthat the fistula really did not bother him.However, as the fistula did create aproblem, a solution was found that couldsatisfy the patient's wishes as well as sealthe fistula. This was a fixed partial prosthe-sis with a small removable partial dentureto cover the oral-ateral fistula. Prior to fabri-cating the provisional prosthesis, selectivegrinding was performed, with the intentionof obtaining a stable occlusion andfreedom in mandibular movements for the

The successful outcome of this youngman's treatment appears to have beenachieved as a result of a team approachwith successful patient motivation. As aresult, the tongue thrust that was causingmolar separation on the right hand sidewas overcome with the aid of transitionalcomposite additions to the lower teeth andocclusal stability obtained. Missing laterali ncisors were restored with fixed prosthe-ses-something the patient had wantedfrom the outset-while the obturation of anoro-nasal defect was obtained by meansof a very small removable device incorpo-rating an attachment within the ponticreplacing the lateral incisor. In order toobtain a perfect seal, the path of insertionof the obturator had to be carefullyplanned and this, in turn, was decided bythe alignment of the attachment in thepontic. This highlights the importance ofan overall plan of treatment, that includedthe path of insertion for the removableprosthesis.

223

I NDEX

congenital cleft lip/ palate 185, 215-23congenital partial anodontia 92, 94contacts, premature 187, 193, 214copings 106

abutment impression 157Duralay xiv, 107, 169

after trauma 157cleft lip /palate 221extensive wear patient 32, 33periodontal disease 179periodontitis 77, 87, 88, 97, 117

gold 47i mpression 88magnetic 145metal 10, 32, 34

cleft lip/palate 221neglected dentition 47, 59new vertical occlusion 169patient with limited finances 145periodontitis 70, 97, 106-7, 117and refusal of surgery 133

Pattern resin xivamelogenesis imperfecta 213cleft lip/palate 203neglected dentition 47, 59patient with limited finances 144, 145and refusal of surgery 133retrograde wear patient 9

provisional acrylic 144transfer 47, 69try-in 118, 134, 158, 170

coronal structure loss 8, 112, 126, 128, 174cross-arch splinting 8cross-bite 164, 187, 189, 219, 211

cleft lip/palate 199, 201, 205bilateral 217, 221

crowding of teeth 65, 71, 82, 126, 151crown lengthening 30, 35, 69

after trauma 155amelogenesis imperfecta 211, 212, 214cleft lip/palate 191new vertical occlusion 167periodontal disease 178, 179

crowns 167fabrication of prostheses on 117preparation 130, 202provisional 142short clinical 211, 214splinted 182transitional 44, 130, 154

periodontal disease 177periodontitis 77, 116

crown-to-root ratios 9, 17, 20, 114, 211change 171i mprovement xii, 50, 61, 71, 79, 182minimizing increase 120potential problems 44, 48

curettage scc root planing/scaling/curettage

deciduous teeth, retained 199, 201dentine exposure 25, 208dentures

existing 102, 103, 137partial 107, 146

overlay 120removable 9, 26, 117, 118, 120, 144

removable 179attitude to 28, 67, 75

severe periodontitis 104, 105, 107, 108, 109teeth 117, 145transitional 116, 154, 155

diagnosisadvanced periodontal disease 176after trauma 153amelogenesis imperfecta 210i n bruxism 16-17cleft lip/palate 189, 201, 219with deterioration 55excessive wear patient 7, 28new vertical occlusion 166periodontitis 67, 85, 94, 104, 113and refusal of surgery 129

diagnostic set-ups 95, 99dietary factors xi, 28, 63, 130, 137, 141

cleft lip/palate 190i mprovement 67, 68periodontitis 71, 72

disarticulation 26, 35Durafil vs 97Duralay 32, 78, 88, 97

after trauma 158cleft lip/palate 221with deterioration 59new vertical occlusion 169, 170periodontitis 107, 117see also under copings

dust in tooth wear 18, 28-9

elastics 44, 57, 76, 105Elmex gel 142enamel chipping 24-5enamel hypoplasia 213-14endodontic therapy 114

after trauma 154, 155

226

I NDEX

amelogenesis imperfecta 211cleft lip/palate 190, 195, 203patient with limited finances 142, 143periodontal disease 177, 179periodontitis 95

and refusal of surgery 130retrograde wear patient 8, 9

eruption xii

compensatory 171forced 85, 178, 182passive 20, 21

in bruxism 17, 18, 19with deterioration 57, 61guided 221, 223

esthetics 35, 79, 128-9amelogenesis imperfecta 214cleft lip/palate 193, 197, 216, 222neglected dentition 43patient with limited finances 141patient's attitude to 28, 30-1

periodontitis 76, 99, 104, 105, 114and refusal of surgery 129

extractions 86, 142, 143, 158extra-oral examinations

after trauma 150amelogenesis imperfecta 208in bruxism 13

cleft lip/palate 185-6, 198, 216excessive wear patients 4, 23limited finances 138neglected dentition 40, 52new vertical occlusion 164

periodontal disease 173periodontitis 74, 81-2, 92, 92-4

complicated 64severe 101-2, 111-12

and refusal of surgery 125extrusion

cleft lip/palate 218

deliberate 58, 59, 86, 116, 121with deterioration 52, 55new vertical occlusion 164periodontal disease 175, 176periodontitis 65retrograde wear patient 7, 11roots 69

exudate 40, 41, 186

facebow registrations 10, 32, 59after trauma 158cleft lip/palate 193, 221neglected dentition 47

new vertical occlusion 167, 169, 170patient with limited finances 145periodontal disease 179periodontitis 70, 77, 88, 97. 107, 117and refusal of surgery 134

financial factors 67, 71, 85financial resources, limited 137-47fistulas 157, 215

covering attachments 193, 221oro-antral 197, 223oronasal 189, 193, 195, 217, 219, 223oronasal-palatal 186retrograde wear patient 4

flaring of teeth l10neglected dentition 43periodontitis 64, 75, 94, 99, 104

fluoride gel 142, 190fluoride rinses 67, 68, 130, 182, 190fremitus

in bruxism 15cleft lip /palate 199neglected dentition 41, 53-4, 55new vertical occlusion 165patient with limited finances 139periodontitis 65, 71, 79, 99

severe 102, 109, 110, 112, 113retrograde wear patient 5, 11

friction coefficient 12furcation involvements

extensive wear patient 27limited finances 140neglected dentition 42, 43, 55periodontitis 66, 83, 94, 112

gag reflex 85, 87, 90gingival disorders 15, 20, 73, 127, 136gingival margins 128, 132-3, 212, 214gingival recession

cleft lip/palate 199limited finances 140neglected dentition 42, 54periodontal disease 175periodontitis 66, 83retrograde wear patient 5

gingivitis 129, 153, 186, 201, 210, 219grafts 87, 155, 190

see also augmentationgrinding/ reshaping of teeth 57, 76, 79, 170,

223

Hawley appliance xi, 68, 95, 96, 105bite plane retainer 115-16

22 7

heart disorders 51, 55, 57, 63, 159hormonal therapy 13hyperostosis corticalis generalista 163, 166

impacted teeth 209, 218implant placement 156i mplants 47, 85, 87, 153, 169

existing 92, 99failed 156i nsertion/ exposure 155, 157placement 46, 87, 130

i mplant-supported prostheses 47, 156Impregum xivi mpressions xiii

alginate 59altered cast 179, 180copper band elastomeric xiii-xiv, 33, 69, 77, 169,

221advanced periodontal disease 179after trauma 157amelogenesis imperfecta 213cleft lip/palate 193, 203excessive wear patients 9, 32neglected dentition 47, 58patient with limited finances 144periodontitis 70, 87, 106, 107, 117and refusal of surgery 133

elastomeric 117, 118, 158, 170, 179mercaptan rubber base 10polyether full-arch 59, 87, 145

cleft lip/palate 193neglected dentition 47, 59periodontitis 97, 98and refusal of surgery 134retrograde wear patient 9

of soldered castings 78inflammation 84, 127, 165, 209

cleft lip/palate 187, 216, 217severe 43, 55, 141

infraboney pockets 66intra-oral examinations 82-4

advanced periodontal disease 174-5after trauma 150-2amelogenesis imperfecta 208-9in bruxism 13, 15-16cleft lip/palate 186-7, 198-9, 216-17excessive wear patients 4-6, 23-7neglected dentition 40-2, 52-5new vertical occlusion 164-5patient with limited finances 138-40periodontitis 64-5, 74-5, 102-4, 112-13and refusal of surgery 126-7

j aw relationshipsin cleft lip/palate 187, 193, 195, 205occlusal 133

j aw size disparity 114, 121, 201

labiomental fold, accentuated 23, 112language barrier 85, 88, 90l ateral force reduction xii, 90lesions 43

apical 28, 29periapical 29-30, 141, 156, 189perio-endo 94

l eveling of teeth 49, 50lingual additions/ buttons 18, 44, 57lingual cusp buildup 19, 20lip line, high 128, 205lip seal 73, 79lips

i ncompetent 138trapped lower 40, 112, 138

magnets 146, 147maintenance 21, 206, 214methyl-methacrylate 221midline discrepancy 52, 92, 126, 129, 139, 212mid-palatal suture deviation 82missing teeth 104

after trauma 150, 151amelogenesis imperfecta 208cleft lip/palate 186, 199congenital 92, 217neglected dentition 40, 43new vertical occlusion 166, 171patient with limited finances 138, 139periodontal disease 174, 176periodontitis 64, 65, 73, 108, 114and refusal of surgery 126, 129retrograde wear 4, 5

mobility of teeth 110neglected dentition 42, 43, 55, 58patient with limited finances 140, 141, 142,

143periodontal disease 174, 181periodontitis 74, 79, 99

complicated 65, 71severe 102, 109, 112, 113

retrograde wear patient 5, 11models xiv, 10, 144, 145, 157, 179

periodontitis 77, 117study 95, 96, 202working 77, 78

mouth, inability to close 73, 79

I NDEX228

I NDEX

periapical full-mouth examinations (coat.)extensive wear patient 23-7new vertical occlusion 166patient with limited finances 141radiographic 82-4, 92-4, 174-5

after trauma 150-2i n bruxism 13, 15-16cleft lip/palate 188, 198-9neglected dentition 40-2, 52-5periodontitis 64-5, 74-5, 102-4, 112-13and refusal of surgery 127retrograde wear patient 4-6

survey 6, 42, 55, 65-6periodontal charts

after trauma 152amelogenesis imperfecta 209i n bruxism 16cleft lip/palate 187, 190, 192, 200, 218excessive wear patients 6, 26, 31neglected dentition 42, 54, 56, 58new vertical occlusion 165, 169patient with limited finances 140, 142, 143, 144periodontal disease 176periodontitis 66, 75, 84, 92

severe 103, 112, 115and refusal of surgery 126

periodontal deterioration 51-61periodontal disease, advanced 173-82periodontal examinations 116

amelogenesis imperfecta 209in bruxism 15-16cleft lip/palate 187, 199, 217excessive wear patients 5-6, 26-7limited finances 139-40neglected dentition 42, 54new vertical occlusion 165periodontal disease 175periodontitis 75, 83, 92-3

complicated 66severe 102-4, 113

periodontal surgery 69, 132-3, 203advanced periodontal disease 177amelogenesis imperfecta 212cleft lip/palate 190, 195patient with limited finances 143periodontitis 116-17

periodontitis 7, 16, 47, 55, 176advanced 73-9, 81-90, 167

complicated 63-79severe 101-10, 111-21

moderate to advanced 91-9phenytoin 73

pick-up impressions 33, 47, 48, 97, 133

platforms 97canine xi

in bruxism 17-18, 20with deterioration 56, 57and refusal of surgery 130, 131, 136

incisal 34

lingual 85see also rests

pleomorphic adenoma 173, 181, 182pocket elimination 69' pouch technique' 58probing/ pocket depth

after trauma 151, 154, 157-8amelogenesis imperfecta 209in bruxism 15-16cleft lip/palate 187, 199, 217, 220excessive wear patients 5, 26-7improvement 76, 95

neglected dentition 42-3, 54, 57-8, 59new vertical occlusion 165, 168patient with limited finances 139-40, 142-3periodontal disease 175, 177periodontitis 75, 83, 92, 94

complicated 66, 69improvement 76-7severe 102, 105-6, 109, 113, 115-16

and refusal of surgery 127prophylaxis 52, 57, 61, 63prostheses

fixed 44, 48, 76, 79, 95, 203

insistence on 153, 159, 160, 161partial 69, 79, 130, 177permanent 222, 223provisional 130six-unit 156transitional 177, 179, 221

fixed vs removable 109-10, 141, 142implant-supported 156insertion difficulties 204, 223provisional 87removable 67, 69, 87, 177, 223tooth-supported 201transitional 178

see also bridges; crowns; restorationsproximity 132, 209, 211, 214

pseudo pockets 167pulpitis, acute 85

radiographic examinations 16, 27see also under periapical full-mouth examinations

230

I NDEX

speech problems 35, 79, 220cleft lip/palate 197, 198, 215, 222

splinting 85, 96, 97, 130, 177cross-arch 8of retracted teeth 44, 45

stents 47, 87stone dies xiii-xiv

amelogenesis imperfecta 213cleft lip/palate 203with deterioration 59

patient with limited finances 144periodontitis 69and refusal of surgery 133

stops see platforms; rests

support, posterior 129-34, 141suppuration 136

swallowing problems 75-6, 79

technical information xiii-xvtelescopic prostheses 147, 190, 201Temp-Bond see cementation of prosthesestilting/tipping 65, 82, 151titanium mesh 150tongue

interference from 18, 221, 223lack of control 73pressure from 75-6, 79

tooth material, choice of 10, 12, 145tooth position classification xiitooth preparation 105, 205-6tooth structure loss 8, 112, 126, 128, 174,

214transfer copings 47, 69traumatic sequelae 149-61trays, bite 10, 107, 145

custom 10, 87, 117treatment 85, 114-19

after trauma 153-9in bruxism 17-20

cleft lip/palate 189, 189-93, 201-4, 219-22excessive wear patients 7-11, 29-34neglected dentition 44-7, 55-60new vertical occlusion 167-70patient with limited finances 141-6periodontal disease 176-81

periodontitis 76-9, 85-8, 94-8, 104-8complicated 67-71

and refusal of surgery 129-34trifurcation involvements 57, 167

valproic acid 73vertical dimension of occlusion xi, 17, 30, 58, 192

adaptation to new 205alteration of xii, 8, 12, 18, 20, 214

cleft lip/palate 195, 203centric relation record 145, 157, 158

advanced periodontal disease 179cleft lip/palate 221periodontitis 77-8, 88, 97

severe 106, 107, 117and refusal of surgery 133, 134

increase of 48, 130extensive wear patient 35, 36, 116neglected dentition 44, 57

loss of 16, 134, 135, 167, 176reduced 121, 153

neglected dentition 55new vertical occlusion 170patient with limited finances 141periodontitis 88, 94, 104, 114and refusal of surgery 129

vertical occlusion, new 163-71vestibulum, shallow 153, 190, 216, 217vibration in tooth wear 28-9

wax-ups 156, 167, 202wear

anterior teeth 24, 25excessive 20, 28-9, 36extensive 23-36extreme 13, 14, 16, 164, 170

new vertical occlusion 166, 167, 171retrograde 3-12

wear facets 25, 64, 187

wire/ wiring 44, 95, 97, 150Worth's disease 163

Xantropen xiii, 221

zinc oxyphosphate cement see cementation

232

pros tho don tics in clinical practice

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