PROSTHODONTICS INCLINICAL PRACTICERobert S Klugman, DDSFormer Senior Clinical LecturerDepartment of ProsthodonticsHebrew University-Hadassah School of Dental MedicinePrivate practiceJerusalem, IsraelContributions byHarold Preiskel, MDS, MSc, FDS RCSConsultant in Prosthetic DentistryGuys HospitalPrivate practiceLondon, UKandAvinoam Yaffe, DMDProfessor, Department of ProsthodonticsDirector, Graduate Training ProgramHebrew University-Hadassah School of Dental MedicineJerusalem, IsraelMARTIN DUNITZ
2002 Martin Dunitz Ltd, a member of the Taylor & Francis groupFirst published in the United Kingdom in 2002by Martin Dunitz Ltd, The Livery House, 7-9 Pratt Street, London NW1 OAETel.: +44 (0) 20 74822202Fax.: +44 (0) 20 72670159E-mail: email@example.comWebsite: http://www.dunitz,co.ukAll rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance withthe provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any li cence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1 P OLP.A CIP record for this book is available from the British Library.ISBN 1-85317-817-9Distributed in the United States and Canada by:Thieme New York333 Seventh AvenueNew York, NY 10001Composition by Scribe Design, Gillingham, Kent, UKPrinted and bound in Singapore by Kyodo Pte Ltd.
vi CONTENTS Patient 15 A new vertical occlusion 163 Treatment by Shaul Gelbard Patient 16 Advanced periodontal disease 173 Treatment by Ayal Tagari I V CONGENITAL DISORDERS 183 Patient 17 Severe unilateral cleft lip and palate 185 Treatment by Miriam Calev Patient 18 Unilateral cleft lip and palate and partial anodontia 197 Treatment by Thomas Zahavi Patient 19 Generalized amelogenesis imperfecta 207 Treatment by David Lavi Patient 20 Bilateral cleft palate and Raynauds disease 215 Treatment by Yael Houri I ndex 225
FOREWORDI t has been a pleasure and privilege to prosthodontics; it illustrates how relativelymake a contribution to this project. The i nexperienced colleagues can carry outbook represents the fruits of a lifetimes i nvolved procedures provided they are setexperience of the principal author; within out in a step-by-step logical process. it you will find pearls of wisdom and a Make no mistake that there is anythinggreat deal of common sense. The work simple about some of the plans of treat- represents more than a series of case ment: adult orthodontics, site preparation reports and far more than a technique- for implants and implant prosthodontics,oriented clinical manual: it is all about the together with complex fixed and remov-treatment of patients and adapting able prostheses, all feature within the text.prosthodontic techniques to the individual Some of the techniques employed havesituation, rather than the other way round. been available for many years, butSo often overlooked is the fact that techniques, after all, are only means to anpatients who have suffered severe tooth end. Dr Klugman has been able to takel oss do not usually arrive for treatment advantage of his clinical experience towith a mouth in pristine condition. Yet Dr adapt these well-tried methods toKlugman and his graduate students take present-day prosthodontics, and in thispatients, establish rapport, and motivate he has succeeded admirably.them. This is a book about the real world,and one for all who are interested in Harold Preiskel
PREFACEThe idea for writing this book came while The program is of 3/ years duration andsitting in one of the seminars of our gradu- includes certain clinical and basic scienceate program in Prosthodontics. requirements. Successful completion of One of our students was presenting a the program enables the student to beprogress report of his patient, discussing eligible for the specialty licensing examina-the diagnosis, and the possible treatment tion administered by the Ministry of Healthplans. Finally, he showed his treatment and in order to qualify as a specialist in Oralexplained its rationale. As I sat there, the Rehabilitation. In the first years, one or twothought came to me, what a waste of students were accepted to the programinformation this is; the student is present- and, as time went on, the program wasing a beautifully documented treatment for expanded to include up to four studentsa very difficult patient with superb radio- per year. This gave a core group ofgraphs and slides. What a shame that only between 12 and 16 students to participatethe 12 or so people in the room are in seminars and treat patients.viewing it. Today the program encompasses four The purpose of the book is to share our days a week, in which the students spendtreatment modalities and rationale of treat- 4 hours in seminars each week. These ment with as many dentists as possible. consist of case presentations, literature Our seminars provide at least one hour reviews, and research on prosthetic of case presentation time with a continua- subjects, and additional full day seminarstion possible the following week. During as needed. The students spend 3 days athe presentation, the instructors and other week treating clinical patients under the students question the diagnosis and treat- supervision of board certified instructors. ment plan, volunteering their opinions and The remainder of their time is spent inalternative treatment strategies. Its a give clinical or original research. Many of theand take situation. It is our conviction, that students carry out basic research projectsthis is one of the best learning processes leading to a Masters degree or Doctorate.for a graduate student. The program is integrated with other The Graduate Program in Oral specialty programs at the Dental School, Rehabilitation was initiated in 1978 when including Periodontics, Orthodontics, Oralthe Israeli Parliament passed a law recog- Surgery, and Endodontics. The graduate nizing dental specialties. Until that year, the students treat implant patients. They plan only specialization recognized by the and oversee the surgical phase, but do not Ministry of Health was Oral and perform the surgical procedures. Most Maxillofacial Surgery, which was a 5-year periodontal surgery, endodontic, oral surgi- program. In 1979, the Department of Oral cal, and orthodontic procedures are Rehabilitation set up a program to teach referred to graduate students or specialists Graduate Prosthodontics. in the other disciplines.
x PREFACE The philosophy of treatment in the I would like to personally thank all the program is based on the clinical and learn- graduate students, former and present, ing experiences of the faculty, who have especially those who contributed to the themselves been trained in Prosthodontics book, the faculty of the program, at The University of Pennsylvania, New Professor Jacob Ehrlich, Professor York University, and The University of Avinoam Yaffe (Program Director), Dr Israel Toronto, in the 1960s and 1970s. Thus Tamari, and Dr Erez Mann. Special thanks their diverse backgrounds mean that the go to Professor Harold Preiskel and faculty members bring to the program Professor Avinoam Yaffe who provided varied ideas of treatment. We have tried to editorial commentaries, who made great incorporate the best aspects of each of efforts in helping me, and without whose these programs for our own syllabus. aid I doubt that the book would have been Some of the methods we use have been written. developed here in Israel.
INTRODUCTIONThe book is divided into four parts according necessary, consultations with the patientsto the primary problem of the patient: physician are conducted prior to anyPeriodontal breakdown, Dysfunctional habit dental procedures.patterns, Extensive loss of teeth, and One of the philosophies of our treatment isCongenital disorders. Naturally, most patients to give the anterior teeth the added functionoverlap and fall into more than one category. of supporting the vertical dimension of occlu- The basis for all our prosthodontic treat- sion. The anterior teeth are customarily onlyment, is a healthy periodontium. The main used for incising food, speech, esthetics, andgoal of our treatment is to identify the anterior guidance in eccentric movements ofcausative factors of the patients dental the mandible. By utilizing the proprioceptiveproblem, and thus be able to control them. properties of the anterior teeth to provideTherefore a prerequisite of all treatment is for biological feedback, the occlusal forcesus to determine these causative factors and, applied to the teeth are reduced. This istogether with the patient, control them. This especially i mportant for patients withis done by initiating meticulous oral hygiene mutilated dentitions, where the vertical dimen-and controlling dietary habits and food sion of occlusion has to be changed. It is alsoconsumption. At the beginning of treatment, important for patients whose treatmentthe patient undergoes initial preparation until requires increasing the vertical dimension forthey prove that they will cooperate completely biomechanical reasons, in order to makein their own treatment, by executing excellent space available for restorations.oral hygiene. Techniques include flossing, It is our experience over many years thatcorrect toothbrushing, use of stimulators and opening vertical dimension using the anteriorall periodontal aids necessary to maintain a teeth, especially the cuspid teeth, will reducehealthy periodontium. For patients with caries, biting force and prevent intrusion of the othera dietary analysis is made and the patient is teeth. In fact, in most patients, we are mostcarefully checked to see that they adhere to probably restoring vertical dimension that wastheir new diet. The initial therapy permits us lost rather than increasing the vertical dimen-to check the individual patients biological sion. These patients now usually close in a response and determine whether the disease more retruded jaw position than their previous activity can be controlled. In some cases, due acquired one. In patients with a full comple-to genetic factors or the patients personality, ment of teeth where change in the vertical the biological response cannot be controlled, dimension of occlusion is required, we prefer and this will naturally alter the treatment plan. using a canine platform,1-3a modified method Unless otherwise noted, all patients were for posterior tooth eruption as opposed to a non-smokers. removable appliance (Hawley). We have found A speech therapist provides ancillary that this approach minimizes the need for a full treatment, if needed. All past medical mouth reconstruction and the necessity of histories are carefully evaluated and, if restoring otherwise healthy teeth.
xi I NTRODUCTION I n periodontally involved dentitions, and book to describe tooth position is Palmers. i n patients where the overbite is reduced Palmers classification divides the mouth and the overjet increased due to opening i nto four quadrants: the upper (maxillary) of the vertical dimension, we strive on one teeth are noted above a horizontal line; the end and are imposed by the other to l ower (mandibular) teeth are noted below diminish lateral forces that are applied to the horizontal line; the right side of the the teeth by decreasing cuspal angles. mouth is noted to the left of a vertical line, This then requires flattening of cuspal and the left side of the mouth is noted to height in the posterior teeth. the right of the vertical line; teeth are I n patients where the remaining teeth do numbered from 1 to 8 in each quadrant, not have the ability to support and guide starting at the center of the mouth. the occlusion, due to advanced periodon- This gives a grid as follows: tal disease and alveolar bone loss, i mplants are utilized to give additional occlusal support. Nevertheless, when using implants for occlusal support, we prefer that all l ateral and protrusive movements of the mandible be guided by the remaining natural teeth.4-6 I n those patients where the vertical dimen- sion is altered, the determining factors are usually biomechanical, to acquire enough (I n the American classification the tooth gingival occlusal space for the restorations. would be number 5 and in the International I n these cases, we try and limit the amount classification it would be number 14.) of change to the minimum that is necessary. Since an increase in vertical dimension of occlusion in patients with advanced adult REFERENCES periodontitis worsens the crown-to-root 1 Yaffe A, Ehrlich J, The canine platform a ratio, we utilize orthodontic treatment of modified method for posterior tooth eruption, passive or active eruption of the teeth to Compend Cent Education (1985) 6:382-5. i mprove this ratio. Using these treatment 2 Abrams L, Occlusal adjustment by selective modalities demands meticulous oral hygiene grinding. In: Goldman HM, Cohen DW, eds, Periodontal Therapy, 6th edn (CV Mosby: St and constant scaling and curettage to attain Louis, 1980). eruption of the teeth, accompanied by 3 Amsterdam M, Peridontal prosthesis. Twenty- healthy supporting tissues. five years in retrospect, Alpha Omegan (scientific issue) (1974) December. All treatment is fully documented by 4 Hannam AG, Matthews B, Reflex jaw opening in photographs and radiographs, thus providing response to stimulation of periodontal the source for most of the material for this mechanoreceptors in the cat, Arch Oral Biol (1969) 14:415. book. The patient follow-up is usually done 5 Wood WW, Tobias DL, EMG response to alter- by the graduate student in their own private ation of tooth contacts on occlusal splints during practice after completion of the treatment. maximal clenching, J Prosthet Dent (1984) Although there are two other systems 51(3):394-6. 6 Storey AT, Neurophysiological aspects of TMD, (the American and the International) in use presented at the American Dental Association, today, the classification system used in this Chicago, 1982.
TECHNICAL INFORMATIONI n patients receiving fixed partial prosthe- elastomeric impressions, we find that it isses, the graduate students prepare the very difficult to get an accurate impressionteeth which will be used as abutments for of all the prepared teeth in one impression,the prosthesis. The preparation of choice especially in periodontally involved patientsi n mature and periodontally compromised where there are long clinical crowns andpatients is the knife edge preparation. We multiple preparations.1 I n the laboratoryfeel that complete shoulder or chamfer phase, it is also difficult to achieve anpreparations are not suitable in these situa- undistorted wax pattern on withdrawal forti ons since they require too much root multiple abutment cases. One of thestructure reduction. The students then advantages of a full arch elastomericusually make either single copper band i mpression is that it permits a singleelastomeric impressions to impression the casting with accuracy and eliminates theprepared teeth or elastomeric complete need for soldering; however, in periodon-arch impressions. Due to the many tally involved teeth with long clinical crownsproblems associated with elastomeric i t is extremely difficult to achieve an undis-complete arch impressions, such as torted wax pattern removal for a single retraction cord displacement, microhemor- casting. This usually leads to additional rhage, errant air bubbles (usually at the treatment, which is both time consumingfinishing line), etc, we have found it to be and traumatic to the patient. more accurate to use single copper band A copper band is measured and elastomeric impressions.1 This is especially tri mmed to fit the prepared tooth, andtrue in periodontally involved teeth and then annealed in an ethyl alcohol 70%whenever a knife edge preparation is solution. This produces a softer, morei ndicated. pliable band with a clean polished surface The graduate students prepare all the which will not have a rebound effect afterteeth to be utilized for the prosthesis and the acrylic resin is placed. The band istemporize them in as many visits as neces- li ned with soft, quick-setting methylsary-this will naturally vary with each methacrylate resin and allowed to set onpatient. After all the teeth have been fully the prepared tooth.prepared for the fixed prosthesis and The band is removed, and the resin ischecked for proper tooth reduction by i nternally relieved to a depth of 0.5 mm. Anmeasuring the thickness of the provisional escape hole is drilled in the occlusal or restoration, and proper finishing lines, each i ncisal area to prevent air bubbles and thentooth is impressioned individually and, if the impression is relined using a blue or i ncorrect, it can be easily repeated until a green Xantropen wash technique. The satisfactory result is achieved. Again, we i mpressions are cast immediately in diewould like to emphasize that in our experi- stone; the dies are removed and trimmed ence, when we have used full arch after 1 hour. The dies are hardened with a
XIV TECHNICAL INFORMATION drop of cyanoacrylate (Super Glue-5: copings are then picked up with a full arch Loctite International, Welwyn Garden City, elastomeric impression (Impregum) mat- UK) to give a very fine protective layer, and erial to capture soft tissue detail. coated with a thin layer of petroleum jelly. At this stage, the individual dies are not Duralay (Reliance Dental Manufacturing needed and the laboratory technician Company, Worth, IL, USA) or Pattern resin places reinforced resin into the lubricated copings (GC Company: Kasugai Aichi, (petroleum jelly) metal framework in the Japan) are then made on the prepared i mpression, and dental stone for the dies using a Neylon paintbrush technique. remainder of the model. This is the final The Neylon technique is a brush-on master working model. This technique technique that uses a fine brush dipped in gives not only fine tissue detail but also a monomer and then in resin powder to pick reproducible positive seat for the castings up a small ball of resin which is then whenever they are removed from the placed on the prepared tooth, starting at model, thus avoiding damage to the model the occlusal or incisal surfaces and by constant removal and placement. working towards the gingival margins. A The master working models are articu- hole is cut in the labial occlusal or incisal lated to the semi-adjustable articulator corner of the coping to ensure that the (Hanau: Teledyne Hanau, Buffalo, NY USA) coping is fully seated on the prepared by means of a face bow registration and tooth during try-in. Pattern resin copings centric relation records performed at the are individually fitted on the prepared teeth vertical dimension of occlusion as deter- and checked clinically for fit and the mined by the provisional restorations. accuracy of their margins. The copings are Since the working models are articulated also used for centric relation recording and at the vertical dimension of occlusion, it is vertical dimension registration. The resin felt that a fully adjustable articulator is not copings are then picked up with a full arch necessary.4 elastomeric impression (Impregum) mat- The porcelain is then baked and fitted erial. The individual dies are then placed i n the patients mouth, with special atten- i nto their respective copings in the impres- tion paid to fit and occlusion. If neces- sion and a master working model is fabri- sary, the occlusion is adjusted using cated.2,3 A centric relation record is then small round diamond stones until the recorded, usually at the vertical dimension articulating paper shows that there is of occlusion, and the models placed in an uniform and even contact in centric articulator and the individual elements of relation (coincident to centric occlusion) the prosthesis are waxed and cast. between all the posterior teeth and that Once the metal framework of the the anterior teeth are in light contact only. prosthesis is returned by the laboratory, The prostheses are then returned to the the individual metal elements are checked l aboratory where the final glaze of the i n the mouth, and joined together using porcelain is done. resin. The metal framework prosthesis is At the insertion appointment, the then sent to the laboratory for soldering. prostheses are `cemented with a paste of On return, the prosthesis is then checked petroleum jelly and zinc oxide ointment i n the mouth again and another centric ( only) for 24-72 hours. The patient then relation record made. The soldered returns and the occlusion is rechecked
TECHNICAL INFORMATION and adjusted if necessary. The restora- cementation, the occlusion is checked tions are then cemented with a mixture of again to verify its accuracy. zinc oxide and eugenol cement (Temp- Bond: Romulus, MI, USA) and petroleumj elly for a further 72 hours. If there is no ACKNOWLEDGEMENT washout after 72 hours, the restorations are cemented with just Temp-Bond for a I would like to thank Ardent Dental 3-week period. They are then carefully Laboratory who did most of the laboratory removed and checked for wash-out, and work pictured in the book.adjusted if necessary. The patient is questioned at each visit REFERENCESafter the initial insertion as to comfort andwhether there is any sensitivity with the new 1 Gelbard S, Aoskar Y, Zelkind M, Stern N, Effect restorations. Only after everything is to the of impression materials and techniques on the marginal fit of metal castings, J Prosthet Dent patients and our satisfaction, are the (1994) 71(1):1-6. restorations permanently cemented with 2 Azizogli MA, Catania EM, Weiner S, Comparison zincoxyphosphate cement. The prepared of the accuracy of working casts made by direct and transfer coping procedures, J Prosthet Dent teeth are first dried and only then are the (1999) 81(4):392-8. restorations cemented. The restorations are 3 Lin CC, Ziebert GJ, Donegan SJ, Dhuru VB, cemented in the smallest individual units Accuracy of impression materials for complete- arch fixed partial dentures, J Prosthet Dent possible, one at a time, with the remaining (1988) 59(3):288-91.teeth in occlusion and provide the correct 4 Weinberg L, Atlas of Crown and Bridge seating forces during cementation. After Prosthodontics ( Mosby: St Louis, 1965).
PATIENT 1 RETROGRADE WEAR Treatment by Mordehai Katz THE PATIENT PAST DENTAL HISTORYThe patient, a 56-year-old self-employed The patient had never visited a dentistbuilding contractor, came to the clinic for regularly. The last visit to a dentist was atdental treatment. His chief complaints were( Figures 1.1-1.3):`I cant eat. My lower front tooth is shaky.` Sometimes my side teeth hurt me.PAST MEDICAL HISTORYThe patients 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 1.3Front view of anterior teeth. Posterior teeth-left side. 3
4 PROSTHODONTICS IN CLINICAL PRACTICE Figure 1.4 Figure 1.5 Face-frontal view. Face-side view. the age of 16 at which time his mandibular Caries molars were extracted. He claimed that he Spacing between the anterior teeth always had the spaces between his front Missing right third molar, and left first teeth, but he felt that they were getting premolar teeth wider. He brushed his teeth twice a day, Amalgam restorations on the left and morning and evening; he did not use any right premolars and molars toothpaste, only a toothbrush. Retrograde wear Spacing due to the extraction of the left first premolar and subsequent drifting of EXTRA-ORAL EXAMINATION the left cuspid distally ( Figures 1.4 and 1.5) Left cuspid-pulp exposure Symmetrical face Fistulas in the buccal vestibulum of the Profile-straight to convex area of the right first premolar and left Normal temporomandibular joint lateral incisor teeth Normal facial musculature Maximum opening of 40 mm Mandibular movements-slight devia- tion to the left upon opening and the reverse upon closing Slight midline discrepancy I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH EXAMINATION Maxilla (Figure 1.6): • Very poor oral hygiene Figure 1.6 • Parabolic arch Maxillary arch-palatal view.
RETROGRADE WEAR mandibular lateral incisor, and class 1/2 on the right mandibular cuspid. Fremitus in closing movements on maxillary ri ght first premolar and i ncisor teeth. Non-working side interferences in left l ateral movements between the maxil- l ary ri ght lateral incisor and the mandibular first premolar, and the maxillary right central incisor and the mandibular cuspid.Figure 1.7 Non-working side interferences in right l ateral movements between the maxil-Mandibular arch. l ary left central incisor and the left mandibular cuspid and left lateral• Overeruption of the first premolars and i ncisor. molars on both sides Anterior guidance at the beginning of protrusive movements, including theMandible (Figure 1.7): mandibular right premolars and at the end of the protrusive movement, the left first premolar also participates. There was working side contact in right l ateral movements between the right maxil- l ary second premolar and the right mandibular second premolar, and in left l ateral movements between the maxillary l eft second premolar and the mandibular l eft second premolar.Occlusal examination (Figures 1.1-1.3)revealed that the patient was Angle class III Periodontal examination (Figures 1.8 andwith anterior cross-bite. The interocclusal rest 1.9) revealed large amounts of calculus andspace was 5.0 mm. Overjet was -1.0 mm plaque, probing depths of up to 6.0 mm onand overbite was 3.0 mm. The difference some of the mandibular teeth and up to 7.0between centric relation and centric occlusion mm on some of the maxillary teeth. Therewas 1.0 mm anterio-posteriorly. was bleeding on probing (BOP) on most of the teeth. There was gingival recession Mobility class 2 on the maxillary left first around some of the teeth (Figures 1.1-1.3). molar, class 1 on the maxillary left The maxillary right first molar had class 2 second molar, and 1/2 on the maxillary furcation i nvolvement on the buccal l eft lateral incisor teeth. surface, and class 1 furcation on the mesial Mobility class 3 on the mandibular left surface, and the maxillary left first molar central incisor, class 2 on the mandibu- had class 3 furcation involvement on l ar right central incisor, class 1 on the buccal, mesial and distal surfaces. The
6 PROSTHODONTICS IN CLINICAL PRACTICE second left molar had class 1 furcation i nvolvement on the buccal and mesial surfaces. FULL-MOUTH PERIAPICAL SURVEY (Figure 1.10) Figure 1.8 Periodontal chart-mandible. Figure 1.9 Periodontal chart-maxilla. Figure 1.10 Radiographs of maxilla and mandible- pre-treatment.
RETROGRADE WEAR tFigure 1.11Cephalometric analysis. DIAGNOSIS CEPHALOMETRIC ANALYSIS • Pseudo-Angle class IIIThe cephalometric analysis (Figure 1.11) was • Advanced adult periodontitisdone to evaluate the following relationships: • Reduced posterior occlusal support• Relation of the maxilla to the skull • Missing teeth accompanied by shifting• Relation of the mandible to the skull of teeth• Relation of the maxilla to the mandible • Extreme wear due to occupational involvementDetermined values: • Caries • Reduced vertical dimension Measurement Average • Faulty occlusal plane with extrusion andGo-Gn 82 84 tipping of teethCo-Gn 125 122.5 • Secondary occlusal trauma with primaryPalatal plane point A 59 59 origins(Go, gonial; Gin, gnathion; Co, condyle.) • PeriapicallesionsInterarch relationships:SNA 85 ABOUT THE PATIENTSNB 83ANB 2 2 The patient was very pleasant and willing to(SNA, seta nasion point A; SNB, sela do what was necessary to have treatment.nasion point B; ANB, difference between A He was cooperative and had no preferenceand B.) for a fixed or removable restoration. INDIVIDUAL TOOTH PROGNOSIS POTENTIAL TREATMENT PROBLEMS • Many missing teeth accompanied by extensive resorption of the residual
PROSTHODONTICS IN CLINICAL PRACTICE alveolar ridges, extrusion, and shifting TREATMENT of teeth• Extensive loss of tooth structure due to I nitial treatment consisted of oral hygiene i ntense wear as well as periodontal and i nstruction, scaling and root planing (Figures periapical pathologies 1.12-1.14) The hopeless teeth, maxillary• Many of the remaining teeth had severe ri ght first premolar, cuspid, left cuspid and periodontal problems and their progno- l eft first molar, were then extracted. sis was guarded Endodontic therapy was carried out on the• Loss of vertical dimension and extrusion maxillary right first molar, left lateral incisor, causing a faulty occlusal plane l eft second premolar and the left second and third molars. These teeth were then restored with composite resin restorations to replace the material removed in the TREATMENT PLAN endodontic preparation.PHASE 1: INITIAL PREPARATION After ruling out an abrasive diet, erosive components, and day and night bruxism, it• I nitial periodontal therapy including: was concluded that the retrograde wear of oral hygiene instruction the patients remaining teeth was due to scaling and root planing the fact that he had lost many teeth over Extraction of hopeless teeth the years and the remaining teeth were Caries excavation and endodontic required to take over all masticatory treatment where necessary function. I n addition, his professional Evaluation of patient cooperation occupation as a builder, where he was Provisional fixed prosthesis restoring constantly involved in an environment of l ost vertical dimension and providing dust, was also a contributing factor to the occlusal support in the new vertical retrograde wear. dimension I n order to restore the loss of coronal tooth structure over the years, the remain-Re-evaluation led to the second phase ofthe treatment plan. i ng maxillary teeth were then prepared and provisional restorations placed at a new vertical dimension of occlusion, thusPHASE 2: TREATMENT OPTIONS providing cross-arch splinting. This new vertical dimension was determined by theMaxilla: functional and biomechanical requirements• Fixed and partial removable prostheses for treatment.• Fixed prosthesis supported by natural The provisional restorations in the new teeth and implants vertical dimension and occlusal scheme• Fixed partial prosthesis supported by provided the following: natural teeth Maximum occlusal contactsMandible: Lateral jaw movements without balanc-• Fixed and partial removable prostheses i ng side prematurities• Fixed prosthesis supported by natural Separation of the teeth during lateral teeth and implants movement of less than 1.0 mm
RETROGRADE WEAR 9 Change of vertical dimension to enable maximum contact in centric relation with the anterior teeth Better overbite and overjet relationships for protrusive movement disclusion (these can be seen clinically and also on the cephalometric radiograph done after the insertion of the transitional restorations) SNB (after treatment with provisonals) 80 ANB (after treatment with provisonals) 5Figure 1.12 A CT (computerized tomography) radio-After initial preparation-front view. graph was then done to determine the possibility of implant placement in the mandible. The radiograph revealed lack of bone for implants due to the severe resorption of the alveolar ridge over many years, most probably due to the early loss of teeth. Endodontic therapy was also carried out on the mandibular left second premolar. To i mprove its prognosis the tooth was short- ened, changing its poor crown-to-root ratio, and then restored with a coping thus enabling it to be used as an abutment for a removable partial denture. The mandibularFigure 1.13 removable partial denture would replace theAfter initial preparation-left side. missing molar teeth as well as the missing l eft central incisor and second premolar. There was a dramatic improvement in the patients periodontal condition due to his improved oral hygiene and cooperation, and it was decided to complete the patients treatment with replacing the transitional restorations in the permanent prostheses and duplicating both the verti- cal dimension and occlusal scheme of the transitional restorations. I n the maxilla, copper band elastomeric i mpressions were made of all the prepared teeth and pattern resin copings made to fitFigure 1.14 the stone dies. A polyether full arch impres-After initial preparation-right side. sion was then taken of the maxilla and the
10 PROSTHODONTICS IN CLINICAL PRACTICE the transitional restorations. A facebow registration was taken and the models mounted on a Hanau articulator. The maxillary metal copings were fitted and connected with pattern resin for solder- ing. The soldered prosthesis was then checked in the mouth, and a polyether impression (Figure 1.16) was then made for tissue detail and a pick-up of the fixed prosthesis in order to make a final master model. Figure 1.15 This was mounted on a Hanau articula- Mandible, final impression, Mercaptan rubber tor by means of a facebow registration and the pattern resin registration on the soldered metal prosthesis. The shade master model poured. Mesio-occlusal rest was chosen and porcelain baked to the preparations were prepared in the metal. The bisque bake maxillary prosthe- mandible on the left first premolar and right sis was fitted in the mouth and the occlu- second premolar teeth. sion checked and adjusted with the A mercaptan rubber base impression missing mandibular teeth that had been was then made using a border molded set up on the partial denture. The porce- custom tray (Figure 1.15). The mandibu- lain was glazed and the mandibular lar metal framework was fitted and prosthesis processed. The denture teeth adjusted in the mouth. An acrylic resin were made of porcelain in order to match bite tray was constructed on the metal the material in the fixed prosthesis in the framework. This tray and the pattern maxilla. resin copings of the maxillary teeth were The maxillary prosthesis was cemented used to record the centric relation at the temporarily and the mandibular prosthesis same vertical dimension of occlusion as inserted and adjusted. After 2 weeks, the Figure 1.16 Figure 1.17 Treatment completed-fixed prosthesis, anterior view Treatment completed-restorations, maxilla.
RETROGRADE WEAR 11Figure 1.20 Figure 1.21Treatment completed-restorations, right side. Treatment completed-restorations, anterior teeth, close-up.maxillary prosthesis was cemented with a disease. He had many missing teeth andpermanent cement (zinc oxyphosphate) some of the remaining teeth were mobile(Figures 1.17-1.21). with fremitus and periapical pathology. There was extensive wear, severe extru- sion of teeth, midline discrepancy, poor SUMMARY occlusal relationships, anterior cross-bite, spacing in the maxilla, and caries.The patient came to the clinic for dental Radiographs ruled out the use of implantstreatment complaining of pain, a loose i n the mandible without pre-prosthetictooth, and difficulty in eating. He had not surgery. Through increased awareness ofvisited a dentist for 40 years and thought the importance of oral hygiene, extensivethat by brushing his teeth twice daily, it periodontal, endodontic and prostheticwas sufficient. He suffered from very poor treatment, a functional and esthetic resultoral hygiene, and advanced periodontal was attained.
12 PROSTHODONTICS IN CLINICAL PRACTICE CASE DISCUSSION CASE DISCUSSION AVINOAM YAFFE HAROLD PREISKEL This 56-year-old person presented to the This sensible plan of treatment involved graduate clinic with the complaint of diffi- extensive reconstruction of both jaws, culty in eating, pain, and mobile teeth. It establishing a new occlusal plane and was the purpose of our treatment to include table. Whether or not there was an erosive the anterior teeth in occlusal support for component to the loss of tooth substance several reasons: many posterior teeth were is largely irrevelant. There was almost missing, thus occlusal support was lacking; certainly a significant forward mandibular secondly it was intended to achieve anterior posture. guidance in order to disocclude whatever The decision to use porcelain artificial posterior teeth were left, and to allow teeth on the removable prosthesis is under- freedom in lateral excursions. In order to standable, although this requires vertical accomplish this, we took advantage of the space to allow for the diatoric design to IC-RC (intercuspal position-retruded cuspal retain the porcelain. In fact, what really position) discrepancy; and made a slight matters is not so much the hardness of the change in vertical dimension along with occlusal surface, but the coefficient of minor adjunctive orthodontics to close the friction between the upper and lower anterior diastema. These three factors surfaces. Provided the glaze of the oppos- enabled us to change a pathologic, ing porcelain is not disturbed, modern malfunctioning, unesthetic occlusion into a cross-linked resin teeth will function perfectly physiologic, esthetic, long-lasting occlusal well, and if they should need to be changed scheme, that included the anterior teeth in after 5 to 8 years, it is not such a disaster. support, along with all the other functions of Furthermore, if an incorrect assessment of anterior teeth, to the patients satisfaction. the maxillo/mandibular relations had been made at the outset, which is quite likely in long-term cases of forward mandibular posture, then resetting or replacing, or even adjusting resin teeth would be considerably easier. I would expect this restoration to function well for many years.
BRUXISM 15Figure 2.5 Figure 2.6Anterior teeth-labial view, showing deep overbite. Maxillary arch-palatal view.Figure 2.7 Figure 2.8Occlusion-left side. Occlusion-right side. premolar, as well as that between the i ncisor, left central incisor, and left cuspid maxillary right cuspid and first premolar. and fremitus class 2 on the maxillary left According to the patient, these spaces l ateral incisor. The maximum opening was always existed and did not bother her 42.0 mm and the interocclusal rest space• Mandibular right third molar was was 3.0 mm. There was palatal impinge- missing (Figure 2.10). ment of the anterior mandibular teeth onto the gingiva of the right maxillaryOcclusal analysis (Figures 2.7 and 2.8) central incisor and both lateral incisorrevealed that the patient was Angle class 1 teeth.with a vertical overbite of 6.0 mm and ahorizontal overjet of 3.0 mm. Periodontal examination revealed moderate I n addition, she has Fremitus class 1 on with localized advanced periodontitis withthe maxillary right cuspid, right central probing depths up to 5-6 mm on the
16 PROSTHODONTICS IN CLINICAL PRACTICE mandibular molars and bleeding on • Adequate endodontic therapy with probing on some teeth (Figure 2.9). some l ocalized periapical rarefying osteitis (mandibular right first molar) Radiographic examination (Figure 2.10) • Remnants of an old amalgam restora- revealed: tion around the mandibular second premolar and first molar • Shortened roots • Widened periodontal ligament around • Secondary caries maxillary right first premolar • Overhanging margins on mandibular left first premolar and left second molar • Minimal generalized horizontal bone l oss I NDIVIDUAL TOOTH PROGNOSIS The prognosis for all the remaining teeth was good. DIAGNOSIS Bruxism and severe wear of the anterior teeth Possible loss of vertical dimension Deep overbite Primary occlusal trauma Figure 2.9 Moderate with localized advanced adult Periodontal chart-maxilla and mandible. periodontitis Figure 2.10 Radiographs of maxilla and mandible-pre-treatment.
BRUXISM 17• Secondary caries TREATMENT PLAN• Chronic periapical area• Faulty restoration (secondary caries) PHASE 1• Spaced dentition• High blood pressure Scaling, root planing and oral hygiene• Hormonal imbalance instruction Conservative dentistry to replace faulty restoration and restore carious teeth Explanation of the bruxing problem to ABOUT THE PATIENT the patient and making her aware of the harm that it causes in order to convinceThe patient was punctual for her appoint- her that she should stop bruxing of herments, cooperated in her treatment, and own volitionunderstood the reasons for her treatment • Changing the vertical dimension ofeven though she had no subjective occlusion by the use of a caninecomplaints. platform to allow eruption of the poste- ri or teeth POTENTIAL DIFFICULTIES I NVOLVED IN THE TREATMENT PHASE Z The traumatic deep overbite, coupled with Conservative dentistry to restore the teeth the great amount of tooth structure lost, in the new vertical dimension, after passivej eopardized the maxillary anterior teeth, eruption. thus requiring a quick solution. Another difficulty would be the adaptation of the patient to the required changes in her PHASE 3 daytime habit patterns (avoiding bruxism) which, at the age of 57, is not easy. Any If passive eruption did not take place, possible restoration would require change restoration of the teeth with fixed i n the vertical dimension of occlusion in prosthodontics to the new vertical dimen- order to restore the anterior teeth and sion. adaptation of the patient to this procedure could not be forecast. Another possible problem with multiple restorations might be TREATMENT the unfavorable change in the crown-to- root ratio and the possibility that tooth PHASE 1 eruption would not succeed. After discus- sion with the patient, it was concluded that The treatment included scaling, root the patient was not a `night grinder but planing, oral hygiene instruction, and rather, bruxed her teeth during the day restoration of teeth with faulty restora- while working in the laboratory and peering tions and caries. The daytime bruxing through a microscope, concentrating on problem and the resultant harm that it her work. causes was stressed in discussions with
18 PROSTHODONTICS IN CLINICAL PRACTICE PHASE 2 After one month when the patient appeared to have adapted to this new vertical dimension of occlusion without any problems, the maxillary central and lateral i ncisor teeth were bonded with composite resin to contact the mandibular incisor teeth (Figures 2.12 and 2.13). After three more months, when the posterior teeth failed to erupt into occlusion, it was thought that the tongue occupied the Figure 2.11 opened existing space and prevented the Anterior maxillary teeth-palatal view, showing canine platform. eruption of the posterior teeth (Figures 2.14 and 2.15). At that time, the lingual surfaces of the mandibular premolar and molar teeth the patient. The patient on her own were built up by bonding composite resin volition, by concentrating on not bruxing material to create an overbite between the during her working hours, was able to mandibular lingual cusps and the maxillary cease bruxing. A new vertical dimension li ngual cusps, in order to prevent the tongue of occlusion was established by the use from entering the space between the teeth, of a canine platform to enable passive and interfering with the passive eruption eruption of the posterior teeth (Figure process (Figures 2.16 and 2.17). 2.11). The canine platform increased the One month later, the posterior maxillary vertical dimension by about 3.0 mm, as and mandibular teeth erupted into occlusal measured at the maxillary and mandibular contact and the lingual additions to the central incisors, and 1.0 mm in the molar mandibular teeth were removed and the areas. surfaces polished (Figures 2.18 and 2.19). Figure 2.12 Figure 2.13 Anterior maxillary teeth-palatal view, showing composite Anterior mandibular teeth-lingual view, showing composite buildup. buildup.
BRUXISM 19Figure 2.14 Figure 2.15Right side, showing failure of teeth to passively erupt. Left side, showing failure of teeth to passively erupt.Figure 2.16 Figure 2.17Mandibular left posterior segment, showing lingual cusp Mandibular right posterior segment, showing lingual cuspcomposite buildup. composite buildup.Figure 2.18 Figure 2.19Right side, showing teeth passively erupted to contact. Left side, showing teeth passively erupted to contact.
20 PROSTHODONTICS IN CLINICAL PRACTICE A hard night guard to be worn only at CASE DISCUSSION night was made for the patient as a protec- AVINOAM YAFFE tive device to prevent continuing tooth structure loss. This was done to prevent A 57-year-old woman presented herself to wear of the composite material that had the graduate program with traumatic deep been placed on the anterior teeth. overbite accompanied by severe wear with The patient has been followed for one loss of tooth structure aggravated by and a half years and there has been no i mpingement and laceration of the inter- abnormal lose of tooth structure in this dental papillae in the anterior maxilla. At ti me. that stage no restoration could be done due to the deep overbite. An increase in vertical dimension was mandatory in order to solve the problem. The change in verti- PHASE 3 cal dimension could be accomplished by complete mouth restoration of at least two This was not required. quadrants, either i n the maxilla or mandible. A conservative approach was taken to SUMMARY solve the problem. Instead of increasing the vertical dimension by the use of restora- The patient, a 57-year-old female labora- tions, thus increasing the crown-to-root tory technician, presented with a severe ratio, a platform was added to the maxillary problem of abnormal tooth wear due to cuspid teeth using composite resin material. bruxism. After scaling, curettage and oral This created a space between the maxillary hygiene instruction, and restoration of and mandibular teeth, enabling these teeth teeth with faulty restorations and caries, a to erupt towards each other until contact conservative method of treatment was was established. At that new vertical dimen- attempted that involved the use of a sion, composite resin was added to the canine platform to increase the vertical severely worn anterior teeth, thus restoring dimension of occlusion. The anterior teeth the teeth with minimal expense, and were then restored to occlusal contact keeping the crown-to-root ratio the same as with bonding and composite resin that before the increase in vertical dimen- restorations. sion. Thus a complicated situation was When the posterior teeth failed to erupt solved by a simple, cost-effective and passively into occlusion as anticipated, due esthetic restoration. to tongue interference, an attempt to elimi- nate this interference by building up the li ngual cusps of the mandibular posterior CASE DISCUSSION teeth (through bonding and composite HAROLD PREISKEL resin) was made. This succeeded, and within 3 months the posterior teeth were in This patients treatment represents an contact. The patient has maintained this example of sensible planning. Instead of new vertical dimension of occlusion for leading with the air turbine, a mistake that over 18 months. i s so easily made in these circumstances,
BRUXISM 21the operators chose to make occlusal worried the patients dentist more than thestops on the canines to allow the molar patient herself, yet the team were able toteeth to erupt. Once this had been motivate their patient to undergo a time-achieved, it was a relatively straightforward consuming, if not invasive, course of treat-process to rebuild the dentition. It is inter- ment. Equally important in this case is theesting to note that the original problem maintenance therapy.
PATIENT 3 EXTENSIVE TOOTH WEAR Treatment by Yehuda Shahal THE PATIENT PAST DENTAL HISTORYA 43-year-old retired army officer presented His dental history was uneventful. He onlyhimself for examination and consultation went to the dentist when he had pain.with the following complaints: ` I have small and worn teeth and they are ugly (Figure 3.1). EXTRA-ORAL EXAMINATION `If I dont have them treated now, I am ( Figures 3.2 and 3.3) afraid that I will lose my teeth. Normal facial symmetryDuring his military service, he served as a Slightly square facial outlinetank mechanic and at the time of his treat- Straight profile with competent lipsment had his own garage. Lower third of the face was slightly smaller than the other two thirds Accentuated labio-mental foldPAST MEDICAL HISTORY Maximum opening was 46 mm No deviation in either opening or closingHis medical history was negative with no movementsunusual findings. No muscle sensitivity was noted Jaw movements were normal I NTRA-ORAL AND FULL-MOUTH PERIAPICAL EXAMINATION Maxilla (Figures 3.4 and 3.5):Figure 3.1Front view of anterior teeth. 23
24 PROSTHODONTICS IN CLINICAL PRACTICE 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 anterior . Extrusion of the right second molar teeth accompanied by chipping of
EXTENSIVE TOOTH WEAR 25 the enamel and cupping of the dentine Wear facets on the left maxillary premo- l ars were noted, but not on the left maxillary molars Absence of wear facets on the left maxillary second molar tooth There were wear facets on the surfaces of the guiding cusps of the fixed maxil- lary prosthesis on the right side and the veneer crown on the left first premolar tooth (Figures 3.4 and 3.6): Figure 3.6 Maxillary right posterior quadrant. The first left maxillary premolar had a 1 0-year-old veneer crown with inflamed soft tissue around it.Mandible (Figure 3.7): Missing teeth: Ovoid jaw shape High floor of the mouth with wide and Figure 3.7 broad muscle attachments Mandibular arch. Shallow vestibulum Edentulous areas of the jaw showed resorption in the both the vertical and bucco-lingual dimensions Right first molar had a broken amalgam restoration with overhang Right second premolar had a faulty disto-occlusal amalgam restoration with marginal overhang and wear facets Veneer crowns on the left premolar teeth with slight inflammation around the crowns Left premolars had gingival class V amalgam restorations Severe wear patterns on the anterior teeth with open contact points due to Figure 3.8 the wear (Figure 3.8) Lingual view of mandibular anterior teeth.
26 PROSTHODONTICS IN CLINICAL PRACTICE Figure 3.9 Figure 3.10 Right lateral jaw movement. Left lateral jaw movement. An occlusal examination revealed that the ( Figures 3.9 and 3.10). There were no patient was Angle class 1 classification, balancing side contacts. In protrusive with 0.0 mm overbite and an overjet of movements, there was disarticulation by 2.0 mm (Figure 3.1). The interocclusal rest the anterior teeth and the premolars on the space was 4.0 mm and the maximum right side, and on the left side the posterior opening was 46 mm, without deviation in teeth were in contact. There was no fremi- opening or closing movements. The tus or mobility of any of the teeth. The mandibular midline was slightly left of the patient had a removable partial mandibular center of the face. denture, which he felt was unsatisfactory There was a 1.0 mm discrepancy and did not use. between centric occlusion (IC) and centric relation (CR). Lateral jaw movements were The periodontal examination (Figures 3.11 group function on both sides-this in spite and 3.12) revealed probing depths of up to of the amount of wear of the anterior teeth 3.0 mm on the maxillary teeth and up to Figure 3.11 Figure 3.12 Maxillary periodontal chart. Mandibular periodontal chart.
EXTENSIVE TOOTH WEAR 27Figure 3.13 Figure 3.14Radiographs of right maxillary posterior quadrant. Radiographs of left maxillary posterior quadrant.3.0 mm on most of the mandibular teeth, I NDIVIDUAL TOOTH PROGNOSISwith slight bleeding on probing (BOP) onsome of the teeth with restorations. There • Hopeless: nonewas inflammation around the fixed bridge in • Poor:the right posterior maxilla. The right 4 4mandibular molars had probing depths of 75.0-8.0 mm, and furcation involvementclass I was found on the right secondmolar, both in the buccal as well as theli ngual furcas. There was a boney defect onthe mesial surface of the right secondmolar. Good: the remaining teeth Note: The first maxillary premolar teeth RADIOGRAPH EXAMINATION had existing root canals with periapical (Figures 3.13 and 3.14) lesions that, although asymptomatic, would require removal of the posts andThe right first maxillary premolar had renewal of the root canal therapy shouldnarrow roots, an old root canal restora- new restorations be required. The rootstion, a dentatus type post, and an asymp- were also very thin, making the removaltomatic periapical lesion. The left maxillary of the existing posts very difficult withoutfirst premolar had narrow roots, an old fracturing the teeth. Therefore theseroot canal filling, a dentatus type post, and teeth were considered to have a pooran asymptomatic periapical lesion. There prognosis. The second right mandibularwas extended root trunk in the left maxil- molar tooth had an infraboney pocket onlary first and second molars. The right the mesial and also a furcation involve-mandibular second molar had a tempo- ment and a very broken down coronalrary restoration following root canal portion, leaving a very doubtful prognosistherapy. for the long term for this tooth.
28 PROSTHODONTICS IN CLINICAL PRACTICE DIAGNOSIS that before proceeding with treatment, it would be wise to discern the cause of the • Gingivitis with localized periodontitis extreme wear. The dental literature refers to • Excessive tooth wear the causative agents in extreme wear as that • Missing teeth of multiple factors. Mohl describes the causes • Faulty restorations of dental tooth wear as contributing factors • Poor esthetics rather than etiologic factors.1 The factors • Decreased vertical dimension generally mentioned in the literature are: • Periapicallesions parafunction, diet, salivary secretions, exces- sive biting force, and occupational hazards. As for parafunction, the patient informed us PATIENT DISPOSITION AND that he had never bruxed his teeth, and was EXPECTATION aware what bruxism meant. He also lacked any of the other symptoms of bruxism, had a The patient was introverted, hardly ever normal maximum jaw opening and free lateral speaking or smiling, but with a strong motiva- tion for dental treatment. In spite of the excursions without tenderness in his muscles. In order to examine whether diet distances involved for him to get to the clinic, was a contributory factor, the patient was he was prepared to come at any time for treat- asked to record in writing all food and bever- ment. He wanted to save as many teeth as possible and to improve the esthetic appear- ages that he consumed during the day for a ance of his mouth. He also preferred to have period of 2 weeks. This revealed that he did not have an abrasive or erosive diet. With a fixed rather than a removable restoration. regard to salivary function, the patient was examined for three different factors: the rate of excretion, the pH of the saliva, and the POTENTIAL TREATMENT PROBLEMS buffer capacity of the saliva. The results The patient was a relatively young man showed that there were no contributing with extensive tooth wear factors in his saliva to cause the extreme wear The many existing restorations were that was evidenced on his anterior teeth. very large and faulty All these findings led to the conclusion Some of the teeth had old endodontic that the wear of the patients teeth was treatments with periapical lesions probably a result of the fact that he was a Many of the teeth had calcification of the tank driver and mechanic for 20 years in an pulp chambers and some of the canals army field unit that involved testing and The patient expressed his desire not to driving tanks many hours a day in a dusty have a removable mandibular partial environment. This was in the era when tanks denture were not air-conditioned and the mixture of dust and vibration encountered during his many hours in the open tank thus caused the excessive wear of his front teeth. The DISCUSSION OF THE CAUSES OF contributing facts for this theory were that in WEAR IN THIS PATIENT Considering that this patient exhibited Mohl ND, Zarb GA, Carlsson GE, Rugh JD, Textbook of extreme wear in some of his teeth, it was felt Occlusion (Quintessence: London, 1988).
EXTENSIVE TOOTH WEAR 29the posterior maxillary teeth, there was no Mandible:wear of the teeth. This was due to the fact • Fixed partial prosthesis with a short-that the opposing mandibular posterior teeth ened arch formwere extracted early in his army career and • Fixed partial prosthesis with implanttherefore could not cause wear of the supportopposing maxillary teeth. These teeth • Fixed partial prosthesis with cantilevershowed no signs of wear, even though they • Fixed and removable partial prostheseswere present for 26 years prior to the periodwhen he worked as a mechanic on tanks.Further proof of this theory could be found TREATMENTi n the fact that the greatest amount of wearwas found mostly in the anterior teeth. This I nitial preparation included scaling, curet-was due to the fact that the amplitude of jaw tage, root planing, and oral hygiene instruc-movements during vibrations of the body tion. At the end of this stage, an obviousencountered while driving the tank is greater i mprovement in the periodontal supportingi n the anterior region than in the posterior tissue could be seen and at the periodon-region. Therefore, it was felt that as the tal recharting it was observed that thepatient had retired from the army, and was pocket depths had diminished greatly andnot involved in testing and repairing heavy that the bleeding on probing had disap-tanks any more, the wear would not be a peared.factor. This was also proven by the fact that Existing restorations that contributed to theduring the transitional phase of treatment, periodontal problems were removed early inthe restorations did not undergo any wear. treatment. The crown on the maxillary left first premolar was removed, and since there was a periapical lesion on the tooth, the root canal TREATMENT ALTERNATIVES therapy was redone after removal of the two dentatus type posts (Figures 3.15 and 3.16).Maxilla: The tooth was followed up for 1 year, during• Fixed anterior partial prosthesis which the periapical lesion remained theFigure 3.15 Figure 3.16Clinical view of left maxillary first premolar, pre-treatment. Radiograph of post-treatment left maxillary first premolar.
30 PROSTHODONTICS IN CLINICAL PRACTICE Figure 3.17 Figure 3.18 Radiograph of right maxillary first premolar, pre-treatment. Radiograph of right maxillary first premolar, post-treatment. same size and there was no evidence of healing, and since the walls of the roots of the tooth were very thin, it was decided to extract the tooth. The root canal filling was redone on the maxillary right first premolar and the tooth was followed up for 1 year (Figures 3.17 and 3.18). Caries was excavated on the mandibu- lar left premolars and, due to the extensive caries into the pulp chamber, these teeth were also treated endodontically (Figure 3.19). The mandibular right second premolar and first molar were also treated endodonti- Figure 3.19 cally due to the extensive caries extending Radiograph post-treatment of left mandibular premolars. into the pulp chamber (Figures 3.20 and 3.21). These teeth then received transitional restorations. Upon excavation, the mandibu- The orthodontic phase of treatment was l ar right second molar was found to have a started using a coil spring to separate the cracked mesial root and the root was ri ght mandibular first molar in order to elimi- removed. nate root proximity and ensure maximum I n order to satisfy the patients desire for embrasure space for periodontal mainte- improved esthetics, the vertical dimension nance.Upon completion of the orthodontic of occlusion was increased and esthetic treatment, followed by periodontal re- transitional restorations were done on the evaluation (Figures 3.24 and 3.25), cast anterior maxillary and mandibular teeth posts were placed in the endodontically ( Figures 3.22 and 3.23). Due to the short treated teeth. As the patient had no clinical crown in the mandibular incisor problems with the increased vertical dimen- teeth, and the mandibular left first premo- sion, and the periodontal tissues reacted l ar, crown lengthening procedures were favorably to the treatment, and the patient done on those teeth. was very satisfied with his new esthetic
EXTENSIVE TOOTH WEAR 31Figure 3.20 Figure 3.21Clinical view of right mandibular premolars and molar area. Radiograph post-treatment of right mandibular premolarpre-treatment. and molar area.Figure 3.22 Figure 3.23Transitional restorations right side. Transitional restorations left side.Figure 3.24 Figure 3.25Periodontal chart at re-evaluation-maxilla. Periodontal chart at re-evaluation-mandible.
32 PROSTHODONTICS IN CLINICAL PRACTICE appearance, the final treatment plan was established vertical dimension dictated by then carried out. the plane of occlusion and the esthetic I t was decided to restore the mandible demands of the patient as well as the with a premolar occlusion on the left side biomechanical considerations (Figures for the following reasons: 3.26 and 3.27). After a period of time it was clear that Since implants could not be done with the patient adapted very well to his new the amount of remaining bone-to restorations. Copper band impressions place implants would require additional were then taken of all the prepared teeth surgical procedures to add bone and Duralay resin copings were made. The lack of posterior teeth in the These copings were used to record centric mandibular left quadrant did not bother relation at the vertical dimension of the the patient temporary restorations and for the final He very much desired a fixed prosthe- i mpression for the master model (Figures sis 3.28-3.32). The metal copings were then The removable partial denture would fitted ( Figures 3.33 and 3.34) and only replace two teeth, and the patient soldered, and after try-in of the soldered would most probably not use it metal framework another elastomeric I t would then require splinting the maxil- i mpression was done for tissue detail. lary molars on that side in order to These models were mounted on a semi- prevent overeruption adjustable Hanau articulator utilizing a facebow registration and centric records Due to the extensive period of time taken at the vertical dimension of occlu- i nvolved in the initial treatment phases sion utilizing Duralay with a Neylon and the periodontal surgery and technique. orthodontic treatment, the transitional At this point the porcelain was baked restorations were then replaced by new and the occlusion checked in the mouth at prostheses. These were built to the new the biscuit bake stage and all adjustments Figure 3.26 Figure 3.27 New transitional restorations-maxilla. New transitional restorations-mandible.
34 PROSTHODONTICS IN CLINICAL PRACTICE Figure 3.33 Figure 3.34 Metal copings fitted-maxilla. Metal copings fitted-mandible. Figure 3.35 Figure 3.36 Incisal platform incorporated into anterior maxillary teeth. Case cemented, post-treatment. needed were then made. The anterior SUMMARY maxillary teeth incorporated an incisal platform (Figure 3.35) to enable continuous The patient presented with a severe problem contact during jaw movement and to bring of extreme wear on many of his teeth and a the incisal forces as close as possible to reduced vertical dimension of occlusion. He the long axis of the teeth. The crowns and also had furcation involvements and periapical bridges were cemented with Temp-Bond lesions. The wear was correctly diagnosed as for a period of 1 month. The crowns and due to occupational hazards, which were no bridges were then cemented with zinc longer a factor in deciding his treatment. With oxyphosphate cement for permanent endodontic, orthodontic and periodontal cementation (Figures 3.36-3.38). treatment accompanied by occlusal therapy, The patient has been returning for follow- the patient received a physiological occlusion up and maintenance twice a year for three at the optimum vertical dimension of occlu- years and has had no problems. sion.
EXTENSIVE TOOTH WEAR 35 Figure 3.37 Radiographs of case, post- treatment. CASE DISCUSSION AVINOAM YAFFE This patient represented a severe case of tooth wear accompanied by reduced verti- cal dimension and a faulty occlusal plane, further aggravated by missing teeth, caries, and faulty endodontic treatment. The severe wear required periodontal surgery for crown lengthening procedures, thus jeopardizing the crown-to-root ratio. The existence of a free end saddle in the mandible further reduced occlusal support. The case was handled with caution by increasing the vertical dimension and the crown lengthening procedures to the minimum required. In order to make up for the missing posterior support, the anterior teeth were restored and the incisal areas were modified to participate in support in addition to their role in esthetics, speech,Figure 3.38 and disarticulation of the posterior teeth inFrontal face view of patient, post-treatment. jaw movements. The cuspal guiding planes
36 PROSTHODONTICS IN CLINICAL PRACTICE were built to a minimum to reduce lateral the early part of the new century. In this forces in order to improve the overall particular instance, the operators have prognosis of the case. presented tooth substance loss, but this will not apply to many other patients. The sensibly chosen staged approach CASE DISCUSSION produced the occasional surprise that all of us HAROLD PREISKEL find in a long course of treatment. A split root can be difficult to detect at the outset. While While patients who have spent many years i ncreasing the vertical dimension of occlusion driving tanks in dusty environments must be seemed reasonable, it is not clear whether the a rare breed, those who are suffering exten- operators deliberately increased this measure- sive tooth wear are abundant. Indeed, with ment beyond the level they estimated had the increasing life span of our population and existed before the tooth wear occurred. There the reduced incidence of caries, the treat- was little alternative to making a change if a ment of worn down dentitions may be one of good looking outcome was to be achieved. the most difficult situations to confront us in An excellent result was obtained.
PATIENT 4 NEGLECTED DENTITION Treatment by Tzachi Lehr THE PATIENT PAST DENTAL HISTORYA 50-year-old woman, employed as a senior The patient had never gone regularly to asecretary, came to the clinic for dental treat- dentist. The last visit to a dentist was 10ment. Her chief complaints were (Figures 4.1 years ago, and she could not recall whatand 4.2): treatment she received then. Recently she found 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 need l ots of work done on my teeth.PAST MEDICAL HISTORYThe patients medical history was unremark-able.Figure 4.1 Figure 4.2Anterior teeth-labial view. Face-frontal view. 39