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: firstname.lastname@example.orgWebsite: 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
40 PROSTHODONTICS IN CLINICAL PRACTICE Figure 4.3 Face-frontal view (from 27 years ago). no habits that she was aware of, but was very conscious of her poor appearance. She compared her current appearance with that of herself almost 30 years ago, showing a l arge smile and healthy teeth (Figure 4.3). EXTRA-ORAL EXAMINATION Figure 4.4 ( Figures 4.2 and 4.4) Face-side view. Symmetrical face Profile-slight tendency to bi-maxillary protrusion Spacing between the anterior teeth (see Temporomandibular joint was normal Figure 4.1) Normal facial musculature Missing right and left third molar, and Maximum opening of 50 mm left second molar teeth Mandibular movements were within Right and left first molars-residual roots normal limits Exudate around right central incisor Trapped lower lip Large amalgam restorations on the left and right premolars Left cuspid with large caries in the I NTRA-ORAL AND FULL-MOUTH coronal section, extending into the root PERIAPICAL RADIOGRAPH EXAMINATION Mandible (Figure 4.6): Maxilla (Figure 4.5): • Parabolic arch • Amalgam restorations on the posterior • Parabolic arch teeth • Caries • Right second premolar-residual root
NEGLECTED DENTITION 41Figure 4.5 Figure 4.6Maxillary arch-palatal view. Mandibular arch-lingual view.Figure 4.7 Figure 4.8Occlusion-right side. Occlusion-left side.• Missing teeth: right and left second and discrepancy. There was spacing between third molars, and left second premolar the maxillary incisor teeth and the left• Exudate around right cuspid l ateral incisor and left cuspid, and drifting• Caries: of teeth. Fremitus: Maxillary right central incisor-grade IIIOcclusal examination (Figures 4.7 and 4.8) i n closing and protrusive movementsrevealed that the patient was Angle class I. Maxillary right lateral incisor-grade II inThe interocclusal rest space was 4.0 mm. closing and protrusive movementsOverjet was 7.0 mm and overbite was 2.0 Maxillary right first premolar-grade I inmm. There was a difference between closing movementscentric relation and centric occlusion of Maxillary left central and lateral incisors-l ess than 1.0 mm. There was a midline grade 11 in protrusive movement
42 PROSTHODONTICS IN CLINICAL PRACTICE Figure 4.9 Figure 4.10 Periodontal chart-pre-treatment, maxilla. Periodontal chart-pre-treatment, mandible. Figure 4.11 Radiographs of maxilla and mandible-pre-treatment. Periodontal examination (Figures 4.9 and mobility was observed on many of the maxil- 4.10) revealed calculus and plaque, probing lary teeth and class 3 on the maxillary right depths of up to 8.0 mm on most of the maxil- central incisor and the maxillary right first lary teeth and up to 7.0 mm on some of the premolar. The mandibular molars had class 1 mandibular teeth. There was bleeding of the furcation involvement on the buccal and gingiva on probing (BOP) on most of the li ngual surfaces. The maxillary right second teeth. There was slight gingival recession molar had class 1 furcation involvement on around some of the teeth. Class 1 and 2 the buccal surfaces.
NEGLECTED DENTITION 43 FULL-MOUTH PERIAPICAL and mobility of a front tooth. She had poor SURVEY (Figure 4.11) oral hygiene, plaque and calculus, and severe inflammation accompanied by deep• Endodontic treatment: 5 5 probing depths, reduced alveolar bone 65 6 support and furcation involvements. Some of the teeth were mobile and had under- Perio-endo lesion around the right gone shifting. There was anterior flaring maxillary central incisor and spacing in the maxilla and mandible, Periapical lesions around the left maxil- residual roots, and deep caries in many lary cuspid and residual roots of the first teeth. maxillary molars, and mandibular right second premolar Rampant caries and secondary caries DIAGNOSIS Extensive horizontal and vertical bone loss around most of the remaining teeth Advanced adult periodontitis Missing teeth accompanied by shifting and drifting of teeth I NDIVIDUAL TOOTH PROGNOSIS Reduced posterior occlusal support Reduced vertical dimension Secondary occlusal trauma Trapped lower lip Faulty esthetics Faulty restorations Rampant caries Periapical lesions Faulty occlusal plane ABOUT THE PATIENT The patient was highly motivated for treat- ment. She was aware of her condition. She requested a fixed rather than a removable restoration and would be willing to have implants if they were necessary for a fixed prosthesis. POTENTIAL TREATMENT PROBLEMS SUMMARY OF FINDINGS Many missing teethA 50-year-old patient, in good health, came The distribution of the remaining teethto the clinic complaining of poor esthetics, was unfavorable
44 PROSTHODONTICS IN CLINICAL PRACTICE • Many of the remaining teeth had severe • Fixed and partial removable prostheses periodontal problems and their progno- • Overdenture sis was guarded • Treatment would possibly include Mandible: opening the vertical dimension of occlu- sion in order to retract the maxillary • Fixed prosthesis supported by natural anterior teeth, which would cause an teeth unfavorable crown-to-root ratio on • Fixed and partial removable prostheses periodontally involved teeth • Fixed prosthesis supported by natural teeth and implants TREATMENT PLAN TREATMENT PHASE 1: INITIAL PREPARATION I nitial treatment consisted of oral hygiene • I nitial periodontal therapy including: instruction, scaling and root planing. The oral hygiene instruction maxillary left lateral incisor was reprepared, scaling and root planing the caries excavated, and a provisional • Extraction of the hopeless teeth except crown made. Provisional crown restorations for the maxillary right central incisor were made on the mandibular right first Endodontic treatment for the maxillary molar and left first molar. Due to the patients l eft lateral incisor tooth i mproved oral hygiene and cooperation • Provisional restoration for the maxillary there was a dramatic improvement in her l eft lateral incisor tooth periodontal condition (Figure 4.12). • Caries excavation • These teeth as well as the mandibular Evaluation of patient cooperation • right first and mandibular left first premolars Retraction of the mandibular anterior were utilized as anchorage for orthodontic teeth and temporary fixation • retraction of the mandibular anterior teeth Retraction of the maxillary anterior teeth, extraction of the right central by means of elastics (Figures 4.13 and 4.14). The maxillary premolars were i ncisor, and fixation by means of a provi- prepared for full coverage and transitional sional fixed prosthesis crowns were placed. Then, with lingual buttons used on these teeth for retention, Re-evaluation of the first phase of the treat- ment plan. the maxillary anterior teeth were retracted to close the spaces (Figures 4.15 and 4.16). The retracted mandibular teeth were PHASE 2: TREATMENT OPTIONS splinted with orthodontic wiring, and the remaining maxillary teeth were prepared for Maxilla: full coverage and provisionally restored ( Figure 4.17). At this time the maxillary • Fixed prosthesis, with premolar occlu- central incisor was extracted. sion in maxilla on left side I n the mandible it was decided to make a • Fixed prosthesis supported by teeth fixed prosthesis, and thus a computerized and implants tomography (CT) radiograph was made to
NEGLECTED DENTITION 45Figure 4.12 Figure 4.13Anterior teeth-labial view, after initial preparation. Anterior teeth-orthodontic treatment to close spaces and retract teeth: mandible, start.Figure 4.14 Figure 4.15Orthodontic treatment, mandible, finish. Orthodontic treatment, retraction of anterior maxillary teeth, ri ght side.Figure 4.16 Figure 4.17Orthodontic treatment, retraction of anterior maxillary teeth, Maxillary teeth showing provisional splints.l eft side.
46 PROSTHODONTICS IN CLINICAL PRACTICE 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 DENTITIONFigure 4.23 Figure 4.24Mandible with provisional restorations on implants. Mounting of maxillary model on Hanau articulator with facebow registration.check the quality and quantity of bone and transitional removable partial denture bythe possibility of implant therapy. The radio- means of the Pattern resin centric record.graph showed that it would be possible to Metal copings for the natural teeth and place three implants on the right side, distal gold copings were then cast and fitted in theto the first premolar, and a single implant on mouth and connected by Pattern resin forthe left side in the area of the second soldering. These were soldered together, premolar (Figures 4.18-4.20). An acrylic refitted and a new centric relation record resin surgical stent was prepared and used made. A polyether impression was thenduring the implant placement, and three taken for tissue detail and a pick-up of theBranemark implants were placed in the right fixed prosthesis in the maxilla in order toposterior region of the mandible and one make a final master model. This wasbetween the left first premolar and the left mounted on a Hanau articulator by meansfirst molar (Figures 4.21 and 4.22). After 3 of a facebow registration (Figure 4.24) andmonths, the implants were exposed and the Pattern resin registration on the solderedabutments placed. New provisional restora- metal prosthesis. The shade was chosentions were made for the implants (Figure and porcelain baked to the metal. This was4.23). fitted in the mouth and the occlusion Copper band elastomeric impressions adjusted to the lower jaw. The porcelain waswere made of all the prepared teeth and then glazed and the prostheses on thepattern resin copings made to fit the stone natural teeth cemented with Temp-Bond fordies. These copings and transfer copings 2 weeks. The implant supported prosthesesfor the implants were fitted in the mouth were screw retained (Figures 4.25-4.29).and used to record centric relation at thevertical dimension of occlusion of the provi-sional restorations. A polyether full arch SUMMARYimpression was then taken of the maxillaand the master model poured and This patient presented with a very severemounted to the mandibular model of the case of adult periodontitis. She also had
48 PROSTHODONTICS IN CLINICAL PRACTICE Figure 4.25 Figure 4.26 Mandible-polyether impression for coping pick-up. Maxilla-polyether impression for coping pick-up. rampant caries and several hopeless teeth, many missing teeth, and severe bone loss. There were tipped, malpositioned, and extruded teeth. The patient wanted fixed prostheses and was willing to change her oral hygiene habits and cooperate in her treatment. However, one of the potential problems with the treatment plan was that by increasing vertical dimension, the crown-to-root ratio would increase the lever forces on the teeth. This was avoided Figure 4.27 by first retracting the mandibular anterior Treatment completed-permanent restorations, anterior teeth, and then the maxillary anterior teeth, view. and then leveling the mandibular anterior Figure 4.28 Treatment completed-permanent restorations, maxilla.
NEGLECTED DENTITION 49Figure 4.29Treatment completed-permanent restorations, mandible. teeth, thus bringing the patient from inter- cuspal position (IC) to retruded cuspal position (RC): this enabled retraction of these without a change in vertical dimen- sion. It was thus possible to restore the maxilla with a fixed prosthesis in spite of the poor prognosis of the teeth when the patient initially presented, by means of the biomechanical changes that occurred during treatment. These included improve- ment of the patients periodontal condition not only due to her improved oral hygiene, but also by the new position of the teeth in the alveolar bone, which directed the occlusal forces in the long axis of the tooth. All the teeth, including the anterior teeth, were now utilized for occlusal support and also reducing lateral forces to a minimum. With periodontal, endodontic, orthodontic, implant therapy, an esthetic and functional result was achieved. CASE DISCUSSION AVINOAM YAFFE In the case presented above, we have improved the remaining teeth prognosis byFigure 4.30 periodontal and orthodontic treatment, alongTreatment completed-face, frontal view with a carefully planned occlusal scheme.
50 PROSTHODONTICS IN CLINICAL PRACTICE The orthodontic retraction of the lower CASE DISCUSSION anterior teeth improved the periodontal HAROLD PREISKEL condition of the teeth, redirected the occlusal forces in a more favorable direc- Many prosthodontists dread a patient with a tion, and the leveling of the teeth that neglected dentition who presents with a followed their retraction improved the photograph taken three decades previously crown-to-root ratio. The same can be and expects the clock turned back with a claimed for the upper remaining anterior magic wand. Although no such device was teeth. Additional support was gained by available to the operators, they have achieved i mplants that are carefully protected from an excellent result with sensibly planned l ateral forces by the occlusal scheme that periodontal and orthodontic treatment. was applied in this case. It can be Retracting the mandibular anterior teeth at an concluded that by utilizing a multidisci- early stage avoided the hazards of increasing plinary approach, we maximized tooth the crown-to-root ratio of the maxillary teeth potential and provided a functional, that had such poor bone support. The timing physiologic and esthetic restoration to and the placement of the mandibular the patient with minimal surgical inter- i mplants was sensible and allowed the vention. restoration of a full arcade of teeth.
PATIENT 5 UNNOTICED PERIODONTAL DETERIORATION Treatment by Tzachi Lehr THE PATIENTThe 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 teeth which I didnt have when I was younger. (see Figure 5.3) `My mouth has an odor. `When I chew, it hurts. Figure 5.2PAST MEDICAL HISTORY Face-frontal view (forced smile).The patient suffered from pulmonary valveregurgitation and an allergy to penicillin,Figure 5.1 Figure 5.3Anterior teeth-labial view. Face-frontal view (from 23 years ago). 51
PROSTHODONTICS IN CLINICAL PRACTICEthus, would require prophylaxsis with ERIC • High lip line(erythromycin capsules) prior to dental • Temporomandibular joint was normal,treatment. mandibular motions were within normal limits • Maximum opening of 50 mmPAST DENTAL HISTORY • Incompetent lips-habitually apartThe patient underwent periodontal surgery2 years ago. She also disclosed that she I NTRA-ORAL AND FULL-MOUTHhad a habit of cracking nuts. PERIAPICAL RADIOGRAPH EXAMINATION Maxilla (Figure 5.5): EXTRA-ORAL EXAMINATION (Figures 5.2 and 5.4) • Parabolic arch• Symmetrical face, although the right • High palate masseter muscle was more developed • Spacing between the anterior teeth than the left one • Missing third molar teeth• In profile, she had a tendency to bi- • Porcelain fused to metal crowns on the maxillary protrusion right premolar teeth • Amalgam restorations on the right molars and left first premolar and second molar Mandible (Figure 5.6): • Parabolic arch • Missing left third molar tooth • Amalgam restorations on the molar teeth 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 centric occlusion with both anterior and vertical components. There was a midline discrep- ancy. The maxillary right central incisor was extruded (see Figure 5.1). There was spacing between the maxillary incisor teeth and they were also slightly rotated (seeFigure 5.4 Figure 5.1). Lateral jaw movements wereFace-side view. guided by the canine and premolar teeth
UNNOTICED PERIODONTAL DETERIORATION 53Figure 5.5 Figure 5.6Maxillary arch-palatal view. Mandibular arch-lingual view.Figure 5.7 Figure 5.8Occlusion-right side. Occlusion-left side. on the left side, and by group function followed by the canine teeth with incisal contacts on the right side. Protrusive movements were guided by the canines and incisors. No non-working side interfer- ences were noted. Fremitus: • Maxillary right central incisor-grade I I-III both in centric occlusion and protrusive jaw movementsFigure 5.9 • Maxillary left central incisor, left lateralOcclusion-anterior view of overbite and overjet. i ncisor, and right lateral incisor-grade I
54 PROSTHODONTICS IN CLINICAL PRACTICE Figure 5.10 Figure 5.11 Periodontal chart-pre-treatment, maxilla. Periodontal chart-pre-treatment, mandible. Figure 5.12 Radiographs of maxilla and mandible-pre-treatment. both in centric (occlusion) and protru- teeth and up to 9.0 mm on the mandibular sive jaw movements teeth with bleeding on probing on almost all of the teeth. There was slight gingival reces- Periodontal examination (Figures 5.10 and sion around most of the teeth. The maxillary 5.11) revealed calculus and plaque, probing left first premolar and left first molar had depths of up to 8.0 mm on the maxillary class I furcation involvement on the mesial.
UNNOTICED PERIODONTAL DETERIORATION 55 FULL-MOUTH PERIAPICAL DIAGNOSIS SURVEY (Figure 5.12) Advanced adult periodontitis• Endodontic treatment-maxillary right • Secondary occlusal trauma with premolars slightly short of apex primary origin of occlusal trauma from* Horizontal and vertical bone loss chewing on nuts around most (of the) molar teeth Loss of posterior support, reduced occlusal support Deep bite • Decreased vertical dimension of occlu- I NDIVIDUAL TOOTH PROGNOSIS sion Acute dentoalveolar periodontal ab- scess-maxillary right central incisor tooth Faultv esthetics ABOUT THE PATIENT The patient was highly motivated for dental treatment due to the poor esthetic condition of her teeth. However, the poor oral hygiene she presented with, just 2 years following periodontal treatment and surgery, attested to the fact that she was unaware of the importance of good dental hygiene, and the direct relationship that it had to the success or failure of her dental treatment. SUMMARY OF FINDINGSThe 47-year-old patient, who suffered from TREATMENT PLANpulmonary valve regurgitation, came to theclinic complaining of recent spacing PHASE 1: INITIAL PREPARATIONbetween her front teeth, a foul odor in hermouth, and pain when chewing on the left • Initial periodontal therapy including:side of her mouth. She presented with poor oral hygiene instructionoral hygiene, plaque and calculus, and scaling and root planingsevere inflammation accompanied by deep caries excavationprobing depths, furcation involvements, • Occlusal adjustment of the (maxillaryand bleeding upon probing. The teeth were right central incisor) by selective grind-mobile and had fremitus in closing and jaw ing to reduce occlusal traumamovements. The maxillary right centrali ncisor was extruded and had a suppurat- The first re-evaluation led to the secondi ng periodontal abscess. phase of the treatment plan.
56 PROSTHODONTICS IN CLINICAL PRACTICE Figure 5.13 Figure 5.15 Anterior teeth after initial preparation, labial view. Anterior teeth, lingual view, canine platform. Figure 5.16 Anterior teeth, orthodontic treatment to close spaces and retract teeth. Figure 5.14 Figure 5.17 Periodontal chart-first re-evaluation. Anterior teeth, orthodontic treatment completed.
UNNOTICED PERIODONTAL DETERIORATION 57PHASE 2 Eruption of the posterior teeth Retraction of the maxillary anterior teeth Temporary fixed maxillary prosthesis Re-establishment of an acceptable vertical dimension of occlusion, and a physiologic occlusal plane TREATMENT Figure 5.18I nitial treatment consisted of scaling, root Maxillary teeth showing provisional restoration.planing, curettage, oral hygiene instruction,and extraction of the mandibular right thirdmolar. At re-evaluation, after initial prepara-tion, bleeding on probing had diminished to When the orthodontic treatment wasa great extent. However, the probing completed and the anterior spacing elimi-depths remained deep and showed almost nated, the maxillary teeth from the secondno improvement (Figures 5.13 and 5.14). right premolar to the left cuspid were I n order to increase vertical dimension to prepared for full coverage, and a provi-enable posterior tooth eruption along with sional fixed restoration was inserted. At thetheir supporting bone and provide space same time, the hopeless maxillary rightfor maxillary anterior tooth retraction, a central incisor was extracted (Figure 5.18).canine platform was constructed on the At the second re-evaluation, themaxillary cuspid teeth (Figure 5.15). As recorded probing depths were greater thaneruption of posterior teeth took place, 5 mm and the decision was made toorthodontic treatment was then started to undertake periodontal surgery (Figureretract the maxillary anterior teeth and 5.19). The goal of the periodontal surgeryclose the spaces (Figure 5.16). Lingual was to achieve an open clean-up andbuttons were placed on the first premolars pocket elimination. During the periodontaland elastics were then used to close the surgery, the decision was made to resectspacing between the teeth (Figure 5.17). To the disto-buccal roots of both secondprevent drifting of the elastics gingivally, molars in order to eliminate the trifurcationcomposite stops were placed on the labial involvements of these teeth and improvesurfaces of the anterior teeth. This treat- their prognosis (Figures 5.20 and 5.21).ment was accompanied by constant Selective grinding and reshaping of thescaling, root planing, and curettage. Since buccal cusps of the maxillary molar andthe patient had a pulmonary valve regurgi- premolar teeth was performed to diminishtation problem, this necessitated the use of the strong lateral forces upon them.prophylactic antibiotics (ERIC: coated At the following re-evaluation, it waserythromycin 1 g an hour before treatment, noted that the maxillary right first premolarand 500 mg 6 hours after treatment) for still showed unacceptable probing depths.each visit. Orthodontic treatment was then started to
58 PROSTHODONTICS IN CLINICAL PRACTICE Figure 5.20 Periodontal surgery, maxillary left posterior quadrant. Figure 5.19 Figure 5.21 Periodontal chart: maxilla and mandible, re-evaluation. Periodontal surgery-maxillary left posterior quadrant, suturing. extrude the tooth and, it was hoped, the taking tissue from the palate (`pouch supporting bone with it as a future implant technique) (Figure 5.23). site development (Figure 5.22). After the Since the vertical dimension had been orthodontic treatment, charting revealed increased during treatment, a minimal that the probing depths were still occlusal adjustment was made to return unchanged and it was then decided to the patient to her original vertical dimension extract the tooth. Upon extraction, a crack of occlusion. in the buccal root was seen along the At the final re-evaluation, it was deter- palatal side, which explained why the tooth mined that probing depths and mobility did not respond to all the treatment. had been greatly diminished, and the final Periodontal surgery (soft tissue augmen- treatment was carried out. This included tation) was then carried out in the maxillary fi nalizing the teeth preparations. Copper central incisor area to reshape the area, band elastomeric impressions were made
UNNOTICED PERIODONTAL DETERIORATION 59Figure 5.22 Figure 5.23Orthodontic treatment to extrude maxillary first premolar. Maxillary right central incisor area-soft tissue graft, suturing.of the prepared teeth, and stone dies and cemented in the mouth with Temp-Bondpattern resin copings produced. These for a period of 2 weeks. The prosthesiscopings were fitted in the mouth and was then cemented permanently withused to record centric occlusion, and a zinc oxyphosphate cement (Figurespolyether impression was taken for the 5.24-5.27).working model. A master model was castfrom this impression with the stone dies inplace. This model was articulated to the SUMMARYmodel of the mandibular teeth made withan alginate impression. Metal copings The patient presented with what shewere then cast and fitted on the individual thought was a simple problem of a looseprepared teeth with the pontics attached front tooth and the start of spacing in herto the adjacent tooth. These were maxillary anterior teeth. Even though sheconnected with pattern resin and had periodontal surgery 2 years previ-soldered, and the soldered prosthesis ously, she was not aware of the impor-fitted in the mouth. A centric record in tance of good oral hygiene and herDuralay at the vertical dimension of occlu- periodontal condition had thus deterio-sion was made in the mouth and another rated. The initial treatment consisted ofpolyether full arch impression done for the oral hygiene instruction and scaling andtissue details. This impression was cast curettage. When the probing depths didand mounted to the lower model and the not improve, orthodontic treatment wasarticulator by means of a facebow trans- initiated as well as periodontal surgery infer and the Duralay centric record. The order to eliminate the deep pocketsshade was chosen and the porcelain around the teeth. Even after this treat-baked. The bridge was then fitted and ment, the maxillary first premolar did notfinal adjustments were done in the mouth respond and had to be extracted. Onlyin the biscque bake stage. The prosthesis then, it was discovered that the root waswas then glazed and temporarily cracked and thus had been untreatable.
60 PROSTHODONTICS IN CLINICAL PRACTICE Figure 5.24 Treatment completed-permanent restorations, left side. Figure 5.27 Treatment completed-face, frontal view. Figure 5.25 Treatment completed-permanent restorations, right side. What appeared to be a relatively easy treatment turned out to be rather involved, with orthodontic therapy and periodontal surgery needed in order to achieve an esthetic and functional result. CASE DISCUSSION AVINOAM YAFFE This case presentation describes a rather bizarre situation of a 47-year-old woman with a `tiny chief complaint that led to a Figure 5.26 comprehensive treatment plan in order to Treatment completed-permanent restorations, anterior restore esthetics and regain long-lasting view. physiologic occlusion. In order to achieve
UNNOTICED PERIODONTAL DETERIORATION 61the goal of physiologic and esthetic occlu- CASE DISCUSSIONsion with the periodontal condition that the HAROLD PREISKELpatient presented with, we utilized thepotential of tooth eruption both to reduce Patients requiring antibiotic prophylaxisperiodontal defects and minimize the pose particular problems due to the needdamage of increasing the crown-to-root to reduce the number of courses of antibi-ratio. I n order to compensate for the otic therapy to a minimum. While thereduced posterior support both by patient was understandably concernedperiodontal involvement and missing teeth, about her appearance, she appeared tothe anterior teeth were incorporated into have no idea of the severity of the problemssupport by retracting them lingually, thus i n her mouth, or of what would be requiredimproving their position over the alveolar to correct them. This is another example ofri dge and redirecting the occlusal forces in what skilled operators can achieve witha more favorable position. By improving the patient motivation, and with success onoverall periodontal condition, improving oral that front everything else falls into place.hygiene habits, and compensating for The combination of periodontal therapyreduced posterior support by including the and orthodontic treatment with skilledanterior group of teeth in vertical support, prosthodontics has produced not only awe have accomplished an esthetic long happy patient but also an esthetic andl asting physiologic occlusion. functioning dentition. Long may it last!
PATIENT 6 COMPLICATED ADVANCED ADULT PERIODONTITIS Treatment by Miriam Oppenheimer THE PATIENT HABITSThe patient, a male 49-year-old clerk, The patient clenches his teeth.presented for dental treatment. His maincomplaints were the following: DIET `I have difficulty eating. ` My front tooth is loose and hurts when I The patient drinks about five mugs of chew. coffee and tea per day, with three ` The spaces between my teeth appear to teaspoons of sugar. be getting bigger. (Figures 6.1 and 6.2) ` Due to the spaces between my front teeth, I have problems speaking clearly. PAST DENTAL HISTORY The patient was referred to the GraduatePAST MEDICAL HISTORY Prosthodontics Dental Clinic by a private dentist who felt that the case was too difficultThe patient had mitral valve prolapse with for him to treat. The patient had recently lostmitral valve regurgitation requiring antibiotic t wo molar teeth and thought that most of hisprophylaxsis before any dental procedures. teeth had been extracted due to caries.Figure 6.1 Figure 6.2Frontal facial view of patient (on right) 20 years previously. Anterior teeth showing spacing. 63
PROSTHODONTICS IN CLINICAL PRACTICEFigure 6.3 Figure 6.4Frontal facial view. Side face view. EXTRA-ORAL EXAMINATION ( Figures 6.3 and 6.4)• Slight facial asymmetry• Normally functioning muscles of masti- cation• Temporomandibular joints were normal with freedom of eccentric movements• Maximum opening between the incisors was 56.0 mm Figure 6.5 I NTRA-ORAL AND FULL-MOUTH Maxillary arch. PERIAPICAL RADIOGRAPH EXAMINATION • Flaring of the anterior teethMaxilla (Figure 6.5): • Palatal surfaces show wear facets • Crown and root caries • Resorbed alveolar ridges especially on the left side (Figure 6.6) • Flat hard palate
COMPLICATED ADVANCED ADULT PERIODONTITIS 65Figure 6.6Maxillary arch-left posterior quadrant. FULL MOUTH PERIAPICAL SURVEY (Figure 6.9) Failing endodontic therapy accompa- nied by periapical lesions Ridge resorption in the edentulous areasFigure 6.7 Occlusal examination revealed that the patient was Angle class II division I, withMandibular arch. an overbite of 9.0 mm and an overjet of 4.0 mm The interocclusal rest space was 3.0 mm and, as noted, the maximum opening between the incisors was 56.0 mm, which if added to the 9.0 mm overbite would mean that the maximum opening movement was actually 65.0 mm. There was no discrepancy between centric occlusion (IC) and centric relation (CR). Fremitus and mobil- ity were evident on the anterior maxillary teeth. There were two planes of occlu- sion in the mandible and a marked step i n the occlusal plane distal to the cuspidFigure 6.8 teeth. There was loss of posteriorMandibular arch-anterior teeth. occlusal support.
66 PROSTHODONTICS IN CLINICAL PRACTICE Figure 6.9 Radiographs of maxilla and mandible-pre-treatment. Figure 6.10 Figure 6.11 Maxillary periodontal chart. Mandibular periodontal chart. Periodontal examination (Figures 6.10 and infraboney pockets, furcation involvement 6.11) revealed poor oral hygiene accom- and gingival recession. panied by large amounts of plaque and calculus. Probing depths of up to 11.0 mm INDIVIDUAL TOOTH PROGNOSES were noted on the maxillary teeth and up to 7.0 mm on the mandibular teeth, with The prognoses for the remaining teeth bleeding on probing on most of the teeth. were the following: There was 60% bone loss around some teeth. The condition was more severe in the maxilla than the mandible. There was reduced periodontal support due to
COMPLICATED ADVANCED ADULT PERIODONTITIS 67• Fair: with infraboney pockets, mobility, and fremitus. There were many missing teeth and the remaining residual ridges were resorbed, he had extensive caries and faulty restorations, all of which contributed to the difficulty of the treatment. DIAGNOSIS• Advanced adult periodontitis TREATMENT PLAN ALTERNATIVES• Missing teeth accompanied by edentu- lous ridge resorption Maxilla: Loss of posterior support Loss of vertical dimension Fixed and removable prostheses if there Secondary occlusal trauma with was a marked improvement in the primary origins periodontal condition and the transi-• Faulty restorations tional restorations were maintainable• Irregular occlusal plane A complete maxillary overdenture• Caries An implant supported fixed or remov-• Periapicallesions able prosthesis-rejected by the patient due to cost ABOUT THE PATIENT Mandible:The patient was of a philosophical nature; he Fixed prosthesis supported by implantswas interested in his dental treatment, and natural teeth-rejected by patientfollowed instructions, but not always, and due to costwas generally cooperative. He wanted to Crowns onkeep 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 were copings onli mited. He also had never worn a removableprosthesis and was concerned as to how he and a removable partial denture.would adjust to one. Telescopic removable denture-rejected due to the cost Complete overdenture supported by POTENTIAL TREATMENT copings PROBLEMSThe patient had never worn a removable FINAL TREATMENT PLANprosthesis, had limited finances for dentaltreatment, had poor eating habits, and A final treatment plan was chosen whichclenched his teeth. He also was completely consisted, in the first phase, of oral hygieneunaware of the severity of his problem. He instruction, changing dietary habits, andsuffered from advanced adult periodontitis fluoride rinses. This was followed by scaling
68 PROSTHODONTICS IN CLINICAL PRACTICE and curettage, root planing, extraction of the left maxillary incisor tooth and immedi- ate replacement with an orthodontic appli- ance, removal of caries, and provisional restorations. This would be followed by re- evaluation. The second phase of treatment would depend upon improvement in the patients periodontal condition and his determination to change his dietary habits and oral hygiene. To improve the periodon- tal condition and change the force direction of the maxillary anterior teeth, to be paral- Figure 6.12 lel to the long axis of the tooth, the maxil- Maxillary anterior teeth after extraction of left central incisor. lary anterior teeth would be orthodontically moved in a palatal direction. Then, after making a transitional fixed anterior prosthe- sis with an incisal platform, provisional partial removable dentures would be constructed for both the maxilla and mandible to restore lost occlusal support. Another re-evaluation would then be made to determine whether periodontal surgery would be necessary. The prognosis of the mandibular anterior teeth and the mandibu- lar left third molar would be assessed together with the condition of the maxillary remaining teeth to support a permanent Figure 6.13 fixed and removable prosthesis. Clinical view of Hawley appliance-pre-treatment. TREATMENT The initial phase of treatment was completed with oral hygiene instruction, the introduction of new dietary habits, fluoride rinses, scaling and curettage, root planing, extraction of the left maxillary incisor tooth and immediate replacement with an orthodontic appliance (Figures 6.12 and 6.13). Caries was removed and provisional restorations were then fabricated for both jaws (Figures 6.14 and 6.15). The patient Figure 6.14 exhibited increased dental hygiene aware Maxillary anterior teeth after orthodontic treatment with ness and the soft tissues showed great provisional crowns.
70 PROSTHODONTICS IN CLINICAL PRACTICE 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. restorations. The metal copings were fitted i n the mouth, connected with Duralay, soldered and rechecked in the mouth after soldering. Elastomeric master impressions were then made of each jaw in order to fabricate the removable frameworks for the prostheses. The frameworks were fitted, and a facebow index together with a centric relation record at the vertical dimension of occlusion was made. The models were mounted on a Hanau articulator. The Figure 6.23 denture teeth were set up on the acrylic Treatment completed-left side. resin denture bases and checked clinically
COMPLICATED ADVANCED ADULT PERIODONTITIS 71 Figure 6.24 Radiographs of patient- post-treatment.for function and esthetics. The removable removable denture supported by a fixedmaxillary partial denture and mandibular anterior bridge and a complete mandibu-complete overdenture were processed. The lar overdenture on gold copings on therestorations were then inserted and have remaining teeth.been followed up since then with no deteri-oration (Figures 6.20-6.24). CASE DISCUSSION AVINOAM YAFFE SUMMARY This was a challenging patient, beingThe patient presented with a severe case effected both by caries and advancedof advanced adult periodontitis, many periodontal disease complicated by lossmissing teeth, crowding, mobility and of posterior support, aggravated by drift-fremitus of teeth, faulty restorations, and i ng and flaring of teeth. This case waspoor dietary habits. He was a clencher. treated by stretching the biologicalHe had difficulty in eating and was in response of the patient to its maximum,pain. A compromise solution had to be allowing it to benefit from mechanicalfound in this case because of the limited i mprovement by redirection of the forcesfinancial means available to the patient to improve the crown-to-root ratio andfor his dental treatment. He also wanted creating a flat occlusion to minimize lateralto retain as many of his remaining teeth forces. The continued success of thisas possible. The solution consisted of treatment will be dependent on theeliminating the infection, orthodontic cooperation of the patient, by controllingtreatment to improve tooth position, his oral hygiene as well as his diet. Thuschanging his dietary pattern, and the overall prognosis of this case isconstruction of a partial maxillary guarded.
72 PROSTHODONTICS IN CLINICAL PRACTICE CASE DISCUSSION A mandibular overdenture opposing HAROLD PREISKEL natural teeth could be vulnerable to the destabilizing influences of an irregular Patients who seek professional help only occlusal plane. Indeed, the planning and when their dentition is in a terminal state orientation of the occlusal plane is an pose particular difficulties. These problems i mportant part of the therapy and this are accentuated if the patient is unaware of seems to have been undertaken. The the severity of the dental problem, eats a planning of the treatment appears to have cariogenic diet, and has medical complica- been thought out in depth and well ti ons. In this instance, the need for antibi- executed. It is the long term that gives rise otic prophylaxsis dictated that as much for concern, although the overdenture work as possible be undertaken during approach provides considerable versatility each period of antibiotic cover to avoid of treatment options should the patients unnecessary administration of the agent. home care become less enthusiastic. The Very sensibly, disease control procedures patient, like many who present with a denti- were undertaken to begin with. Additional tion in a terminal state, would not usually measures included changing dietary habits have been in such a situation if their home and fluoride rinses followed by a re-evalua- care had been meticulous and they had tion. Once the patient exhibited increased always sought regular professional help. dental awareness, demonstrated coopera- The prospect of losing all the teeth certainly tion, and the soft tissue showed a corre- concentrates the mind, but once the sponding improvement, the stage could be danger has passed the danger of old habits set for planning the definitive treatment. This reverting is never far away. The overden- therapy included periodontal surgery, and ture, by its very nature, covers root the extrusion of a maxillary root to provide surfaces and gingivae as well as the more tooth substance for the permanent mucosa, so that plaque control is essential restoration. The definitive treatment plan for long-term success. I was therefore also included construction of an upper happy to read of the outcome of this partial denture and a mandibular overden- therapy, particularly the follow-ups that ture covering precious metal copings. were taken.
74 PROSTHODONTICS IN CLINICAL PRACTICE PAST DENTAL HISTORY I NTRA-ORAL AND FULL-MOUTH The existing prostheses were completed PERIAPICAL RADIOGRAPH EXAMINATION (Figures 7.1, 7.3-7.5) about 7 years previously, but the patient could not remember the exact dates. • Angle class I • Open bite minus 4.0 mm (Figure 7.1) • Overjet minus 4.0 mm EXTRA-ORAL EXAMINATION • I nterocclusal rest space 3.0 mm (Figure 7.2) • Maximum opening between the incisors • Facial asymmetry 48 mm • Slightly convex profile • Mobility class 1-2 on the maxillary • Normally functioning muscles of masti- anterior teeth cation • Class 2 mobility of the mandibular • Normal temporomandibular joints anterior teeth • Maximum opening 48 mm • Discrepancy between centric occlusion • Incompetent lips (I C) and centric relation (CR) 0.5 mm Figure 7.3 Radiographs of maxilla and mandible-pre-treatment. Figure 7.4 Figure 7.5 Left side-pre-treatment. Right side-pre-treatment.
ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG 75Figure 7.6 Figure 7.7Periodontal chart-maxilla. Periodontal chart-mandible.Periodontal examination (Figures 7.6 and Reduced posterior occlusal support7.7) revealed probing depths of up to Flaring of anterior teeth7.0 mm on most of the remaining teeth, with Cariesbleeding of the gingiva on probing on most Faulty restorationsof the teeth, with the condition being more Poor estheticssevere in the maxilla than the mandible: Open bite Neurofibromatosis type 2• Missing teeth: ABOUT THE PATIENT Caries The patient understood the severity of his Low maxillary sinuses dental condition but was highly motivated 60% bone loss around some teeth as he thought that the dental treatment Anterior spacing would enable him to be able to close his mouth. However, he absolutely refused to consider a removable prosthesis. I NDIVIDUAL TOOTH PROGNOSIS Hopeless: none POTENTIAL TREATMENT Poor: PROBLEMS Advanced periodontitis and poor oral hygiene, accompanied by many missing Fair: the remaining teeth teeth Good: none Existing restorations were faulty Open anterior bite Due to facial nerve damage, the patient DIAGNOSIS could not close his lips or eyelids. During• Advanced adult type periodontitis swallowing, his tongue moved anteriorly• Missing teeth to close the space, putting pressure on
76 PROSTHODONTICS IN CLINICAL PRACTICE the anterior teeth and causing the food planing, and a periodontal re-evaluation, a bolus to go down into the esophagus final treatment plan was then chosen which before it had been triturated completely. consisted of selective grinding and Consequently, the patient was orthodontic treatment to improve the constantly dripping liquids from the occlusal relationship and close the existing sides of his mouth spaces between the anterior teeth. This • His difficulty in hearing (left side) and would improve the anterior tooth position seeing (right side) made it more difficult and enable these teeth to participate in to teach him proper oral hygiene vertical dimension support. Following the orthodontic treatment a provisional full arch fixed maxillary and mandibular prostheses TREATMENT ALTERNATIVES would be done and carefully followed over a period of at least 6 months to ascertain Maxilla: the ability of the abutment teeth to support Fixed anterior partial prosthesis and a the fixed prostheses. If this phase was removable posterior partial prosthesis, successful, complete arch maxillary and supported by implants mandibular fixed prostheses would be Fixed anterior partial prosthesis and a constructed. removable posterior partial prosthesis, supported by the anterior fixed prosthe- sis with either clasps and rests, or TREATMENT attachments Initial preparation included scaling, curet- Fixed maxillary restoration as a short- tage, root planing, and oral hygiene instruc- ened arch with only a premolar occlu- tion. At the end of this stage, an obvious sion on the left side improvement in the soft tissue could be Fixed maxillary restoration with a weak discerned. At this time a periodontal re- terminal abutment on the right side evaluation was done and it was observed that the pockets depths had greatly dimin- Mandible: ished and that the bleeding on probing had disappeared. Fixed anterior partial prosthesis with The orthodontic phase of treatment was removable tooth supported posterior then started using elastics to retract the partial prosthesis mandibular and maxillary anterior teeth Fixed tooth and implant supported (Figure 7.8) and close the spaces. This was partial prosthesis done in order to achieve better esthetics Fixed partial prosthesis with the cuspid and move the teeth into a better position in as the terminal abutment on the left side the alveolar bone for occlusal support and Fixed mandibular restoration with a with the intent to prepare the site for future weak terminal abutment on the left side development should implants be needed. When the orthodontic stage was successfully completed (Figure 7.9), the TREATMENT PLAN supporting teeth were prepared and Following initial preparation, including oral temporary restorations were placed (Figure hygiene instruction, scaling and root 7.10). Periodontal evaluation was again
ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG 77Figure 7.8 Figure 7.9Teeth before orthodontic treatment. Teeth after orthodontic treatment.Figure 7.10 Figure 7.11Transitional crowns. Fitting of Duralay copings. performed and disclosed that the probing depths were less than 3.0 mm in all areas. Copper band elastomeric impressions were then taken of all the prepared teeth and Duralay copings were made. These copings were used to record centric relation at the vertical dimension of the temporary restorations (Figure 7.11), and for the final i mpression for the working die model (Figure 7.12). These models were mounted on a semi-adjustable articulator (Hanau)Figure 7.12 utilizing a facebow registration, and centricWorking models. records were taken at the vertical dimension
78 PROSTHODONTICS IN CLINICAL PRACTICE 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. of occlusion utilizing Duralay with a Neylon technique (Figure 7.13). The metal copings were then fitted and soldered and, after try- in of the soldered metal framework and centric records had been made, another elastomeric impression was done for the final tissue detail model (Figure 7.14). The porcelain was baked and the occlusion checked at the biscuit bake stage in the mouth and all adjustments needed were then made. The porcelain was then glazed Figure 7.17 and the crowns and bridges were Treatment completed-anterior view. cemented with Temp-Bond. The crowns and bridges were then cemented with zinc
ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG 79oxyphosphate cement for permanent occlusion. By meticulous oral hygiene,cementation in 1995 (Figures 7.15-7.17). scaling and root planing, his periodontal The patient has been returning for follow- condition was greatly improved. Then byup and maintenance twice a year since then. means of orthodontic treatment that moved the teeth lingually, and selective grinding to reduce the open bite, the esthetic and SUMMARY functional goals were achieved. In reducing the vertical dimension, the crown-to-rootThe patient, a 36-year-old computer engineer, ratio of the posterior teeth (which werecame to the Graduate Prosthodontics Clinic of periodontally involved) was improved.the Hebrew University Dental School of Reasonable overjet and overbite were alsoMedicine for treatment. He presented with a achieved, gaining mutual protection of thesevere problem of advanced adult periodonti- anterior teeth during jaw movements. Thesetis. He had many missing teeth, much alveo- procedures enabled us to achieve anl ar bone loss around the remaining teeth, and esthetic and physiological occlusal schemefaulty restorations in both jaws. There was that will last for many years.considerable bone resorption and probing of up to 7.0 mm His fixed restorations were inadequate. There was mobility and fremitus in CASE DISCUSSIONthe maxillary anterior teeth and mobility of the HAROLD PREISKEL mandibular anterior teeth. His dental conditionwas further complicated by his medical condi- Relatively young patients with advancedtion (neurofibromatosis type 2), which periodontal disease present challenging rendered him unable to close his mouth problems. Very sensibly, the initial treatmentproperly, and caused trauma to the anterior was not side tracked from attention toteeth during swallowing. With orthodontic and disease control procedures until a satisfac-periodontal treatment accompanied by tory outcome of this aspect of the treat-occlusal therapy, the patient received fixed ment had been assured. Whether or not anpartial prostheses that provided him with a active tongue thrust was contributing to thephysiological occlusion at the optimum vertical i nitial breakdown of the arcade is notdimension of occlusion for his periodontal mentioned, but it appears that there werecondition. no speech difficulties when the teeth were retracted into a more ideal relationship. I assume that the rebuilt occlusion provided CASE DISCUSSION the patient with a competent lip seal, which AVINOAM YAFFE was lacking when he first attended for therapy. Providing some anterior guidanceThe patient presented himself for treatment was an added bonus. However, thesuffering from advanced periodontitis aggra- maintenance of the restorations, particu-vated by the loss of many teeth and compli- larly the lower anterior fixed prosthesis, willcated by an anterior open bite. The treatment require particular care on the part of thegoals were to restore esthetic function and patient. An excellent result appears to havegive the patient a long-lasting physiologic been obtained.
PATIENT 8 ADVANCED ADULT PERIODONTITIS Treatment by Eyal Tarazi THE PATIENT allergy to food or medications. About 40 years ago, he suffered from hepatitis A.The patient, a 64-year-old radiologist anda recent immigrant, came to theGraduate Prosthodontics Clinic for dental PAST DENTAL HISTORYtreatment ( Figure 8.1). His chief His last dental treatment was 7 years previ-complaints were: ously. His upper anterior teeth were restored 15 years previously. The mandible `I am extremely sensitive to hot and cold was treated about 18 years previously. As foods on the lower left side. for his esthetic appearance, he stated, `Its ` Due to my missing teeth, I have difficulty hard to explain, but because its been like eating on the right side. this for a long time, I feel that its natural. ` Usually I only eat soft food. ` Food packs underneath my bridge. EXTRA-ORAL EXAMINATIONPAST MEDICAL HISTORY (Figure 8.2)The patient was healthy, and did not take any Asymmetrical face, with lower thirdmedication. He had no known sensitivity or being greater than the middle thirdFigure 8.1 Figure 8.2Anterior teeth-labial view. Face-frontal view. 81
82 PROSTHODONTICS IN CLINICAL PRACTICE • Long chin and prominent nose, in Mandible (Figures 8.4-8.6): profile Wide parabolic arch He `smiled with his lips closed Crowding on the left side Tenderness of the left masseter muscle Spacing in the right side because of during palpation missing teeth • Maximum opening of 52 mm, with Distal tilting of the right canine and deviation to the left on opening lateral Mandibular motions within normal limits Rotations, overlapping and tooth abrasion INTRA-ORAL AND FULL-MOUTH High floor of the mouth PERIAPICAL RADIOGRAPH Retained deciduous root instead of right EXAMINATION second premolar Caries: Maxilla (Figures 8.3, 8.5 and 8.6): Wide parabolic arch Restorations: fixed all metal (gold) Deviation of the mid-palatal suture to partial prosthesis: the right side Narrowed space for the right central i ncisor Occlusal examination revealed that the Left first premolar pontic restored by patient was Angle classification class II two units occlusion on the right side and class I Right first premolar tilted mesially and in occlusion on the left side. The interocclusal close proximity to the canine rest space was 3-4 mm. Overjet was Flat palate and residual ridges 3-5 mm and overbite was 4-6 mm. There Restorations: fixed all metal partial was a 1.0 mm hit and slide from centric prosthesis: relation to centric occlusion anteriorly and vertically. The mandibular anterior segment showed overeruption. Figure 8.3 Figure 8.4 Maxillary arch-palatal view. Mandibular arch-lingual view.
ADVANCED ADULT PERIODONTITIS 83 Figure 8.5 Radiographs of maxilla and mandible, pre- treatment. Fremitus: • Maxillary cuspids-grade II • Maxillary left central incisor-grade III • Left second premolar-grade III • Left third molar-grade III Periodontal examination ( Figures 8.7-8.12) revealed large amounts of calculus and plaque, probing depths of up to 10.0 mm on the maxillary teeth andFigure 8.6 up to 8.0 mm on the mandibular teeth,Panoramic radiograph-pre-treatment. with bleeding of the gingival tissues on probing on most of the teeth. There was gingival recession around almost all of the Lateral jaw movements were guided by teeth.the canine and premolar on the left side, The maxillary left third molar had class 2and by the canine with incisal contacts on furcation on the mesial and distal. Thethe right side. Protrusive movements were mandibular left second and third molars,guided by the canines and the incisors. No and the right first molar all had class 1non-working side interference was noted. furcation involvements.
ADVANCED ADULT PERIODONTITIS 85 DIAGNOSIS Scaling and root planing Caries excavation Advanced adult type periodontitis Occlusal adjustment by selective grind- Multiple defective restorations i ng to reduce occlusal trauma Carious lesions and secondary caries Abrasion and abfraction Missing teeth-partially edentulous arches RE-EVALUATION I Deep bite Compromised posterior occlusion PHASE Z: TREATMENT PLAN Decreased vertical dimension of occlu- sion Replacement of inadequate restorations Poor occlusal plane by provisional restorations Secondary occlusal trauma Further elimination of occlusal trauma Acute pulpitis-lower left third molar by splinting and stabilization with provi- Chronic apical period ontitis-upper left sional restorations molar Re-establishment of an acceptable Esthetic impairment (although it did not vertical dimension of occlusion, and a appear to effect the patient) physiologic occlusal plane Creation of anterior contacts by the use of a lingual platform ABOUT THE PATIENTHe was a highly motivated immigrant who RE-EVALUATION IIwanted to improve his oral condition, andwas highly disciplined and very patient. His PHASE 3: TREATMENT PLANexpectations were to improve his oralcondition by all means, and despite his Adjunctive orthodontics-forced eruptionpoor financial condition, he insisted on a of the upper right premolar, to eliminatefixed oral rehabilitation. He had a very the deep osseous deformitysensitive gag reflex. Initial language I nsertion of two implants on each sideproblems were later surmounted. of the maxilla EMERGENCY TREATMENT PLAN PHASE 4: TREATMENT PLAN• Control of acute conditions Provisional restorations.• Endodontic therapy-lower third molar• Extraction of the upper left third molar PHASE 5: TREATMENT PLAN TREATMENT PLAN Prosthetic phase.PHASE 1: INITIAL PREPARATION PHASE 6: TREATMENT PLAN• I nitial periodontal therapy• Oral hygiene instruction Recall and maintenance.
86 PROSTHODONTICS IN CLINICAL PRACTICE TREATMENT I nitial treatment consisted of scaling, curet- tage, oral hygiene instruction, and extraction of the third left maxillary molar. This phase of treatment took almost 6 months due to communication problems, until the patient was able to improve his oral hygiene to the extent that the treatment could continue (Figure 8.13). The left second mandibular premolar was also extracted. Root canal therapy was carried out on the second and Figure 8.13 third left mandibular molars, and the right 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 second tooth 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.
ADVANCED ADULT PERIODONTITIS 87Figure 8.18 Figure 8.19CT radiograph of maxilla for implant placement. I mplants-mandible left posterior region.first maxillary premolar. When that stage was an acrylic stent with gutta percha pointscompleted, minor orthodontic treatment i n the areas that required implants (Figurewas undertaken to open up root proximity 8.18). The CT radiographs indicated thatbetween the right first maxillary premolar the bone type was class IV, and on theand the right canine (Figure 8.14). At that l eft side, the width of the bone wasstage all the remaining maxillary teeth and i nadequate for implant placement. Anthe mandibular teeth from the left third molar autogenous bone graft from the chin wasto the right cuspid were prepared for provi- placed on the left side 6 months beforesional restorations. On the left side, the the implant insertion. Two Branmarksecond maxillary premolar was forced to i mplants (Nobel Biocare USA, Inc: Yorbaerupt. This was achieved by first separating Linda, CA) were then placed on eachthe first and second premolars (Figure 8.15), side in the maxilla in the premolar andand then by use of a coil spring. The second molar areas (Figure 8.19). In the rightpremolar was extruded along with the side, self-tapping 15 and 13 mm long,accompanying bone into position. This 3.75 mm diameter implants were used,procedure eliminated the deep infrabony and on the left side self-tapping 12 mmpocket around the second premolar (Figures l ong and 5.0 mm diameter implants were8.16 and 8.17). i nserted. Due to the severe gag reflex, and in spite of New provisional transitional prosthesesgreat effort on his part, the patient could not were then constructed after the uncoveringadapt to the provisional maxillary partial of the implants. At that point, copper bandremovable prosthesis that was made for him, elastomeric impressions were taken of all theand it was discarded. At that point it was prepared teeth and Duralay copings weredecided that a maxillary removable prosthesis made. These copings were used to recordwas not viable, and the treatment plan of fixed centric relation at the vertical dimension ofmaxillary posterior prostheses on implants the temporary restorations, together with thewas chosen. teeth position in the arch for the final impres- Computerized tomographic (CT) radio- sion for the working model. A polyethergraphs were made of the maxilla utilizing complete arch impression in a custom tray
88 PROSTHODONTICS IN CLINICAL PRACTICE was made to pick up the Duralay and was very difficult. Even though at the begin- implant impression copings. The metal ning the patient was very satisfied with his copings were then cast, fitted and soldered. appearance, as the treatment continued, he After try-in of the soldered metal framework, became more and more involved in his treat- another polyether impression was made for ment. The treatment was long and extensive, tissue detail for the final master model. These encompassing a long initial treatment due to models were mounted on a semi-adjustable the language barrier. Once the patient under- articulator (Hanau) utilizing a facebow regis- stood the importance of good oral hygiene, tration and centric records were taken at the he collaborated and became an important vertical dimension of occlusion utilizing accessory to his care. The treatment Duralay with a Neylon technique. The porce- extended over more than a 2-year period, but lain was baked and the occlusion checked at both the patient and the dentist thought that the biscuit bake stage in the mouth and all adjustments needed were then made. The porcelain was then glazed and the crowns and bridges were cemented with Temp- Bond on the prepared teeth for a period of 3 weeks. The implant-supported bridges were screwed in to the implants and were not This 64-year-old-patient presented for attached to the natural teeth supported treatment in the Graduate Prosthodontics bridges. The crowns and bridges were then clinic. He had advanced adult periodonti- permanently cemented with zinc oxyphos- tis which was complicated by missing phate cement for permanent cementation teeth, decreased vertical dimension (Figures 8.20-8.29). aggravated by deep bite and faulty restorations with midline deviation. All these findings demanded comprehensive SUMMARY i ntegrated treatment planning that The patient presented with various problems. i ncluded orthodontic treatment for both Due to a language problem, communication periodontal and teeth alignment problems, Figure 8.20 Figure 8.21 Treatment completed-permanent restorations, anterior view. Treatment completed-permanent restorations, right side.
ADVANCED ADULT PERIODONTITIS 89Figure 8.22 Figure 8.24Treatment completed-permanent restorations, left side. Post-treatment radiographs, maxillary right posterior area. Figure 8.25 Maxillary right posterior area, clinical view.Figure 8.23Post-treatment radiographs, anterior mandibular area. Figure 8.26 Maxillary left posterior area, clinical view.
90 PROSTHODONTICS IN CLINICAL PRACTICE a new occlusal scheme to reduce lateral forces on remaining teeth, and reducing occlusal forces by including the anterior group of teeth in support. At the comple- tion of treatment these objectives were met. The occlusal support was restored, a physiologic occlusal scheme was placed, and functional and esthetic demands were met, to both the patients and the dentists satisfaction. Figure 8.27 Post-treatment radiograph, maxillary left posterior area. CASE DISCUSSION HAROLD PREISKEL This highly educated patient received treatment involving a combination of skills and techniques that would stretch the capabilities of an experienced specialist, let alone a graduate working under super- vision. A pronounced gag reflex and a language barrier that initially prevented direct communication were yet further obstacles to be overcome. The saga of this patients therapy makes interesting Figure 8.28 reading, with the patient himself becoming ever increasingly involved in his own treat- Patients smile after treatment. ment and appreciating the impressive skills and care that he was receiving. The gag reflex ruled out the use of a removable prosthesis that would have simplified the restoration of the maxillary arcade. Another, simpler, alternative might have been to have left a shortened arch in the new right posterior maxillary area. I nstead I am sure that the patient benefited from the more complex but comprehensive restoration that was constructed and I trust that his ongoing maintenance will be continued with the Figure 8.29 same enthusiasm with which he partici- Patients forced smile before treatment. pated in the initial treatment.
92 PROSTHODONTICS IN CLINICAL PRACTICE and replaced by an implant. She was Smiling revealed spacing between the seeking a fixed restoration on the implant. i ncisor teeth Due to slight drooping of the left upper li p, the patient exposed more of her teeth on the right side than the left side EXTRA-ORAL EXAMINATION ( Figure 9.3) Slight facial asymmetry I NTRA-ORAL AND FULL-MOUTH Slightly convex profile PERIAPICAL RADIOGRAPH Muscles and temporomandibular joints EXAMINATION ( Figures 9.4-9.8) normal Maximum opening 46.0 mm with a Missing teeth (the maxillary missing 3.0 mm deviation to the left side on premolars were congenitally missing): opening. Caries 60% bone loss around the maxillary left first molar Spacing between the anterior teeth Maxillary right first premolar rotated 90° 8.0 mm i mplant i n the first ri ght mandibular area Mid-line discrepancy of the maxillary i ncisors Occlusal examination revealed that the patient was Angle class 1, with an overbite of 2.0 mm and overjet of 3.0 mm. The interocclusal rest space was 3.0. Mobility class 1 and fremitus class I -II were found on the maxillary anterior teeth. A 0.5 mm discrepancy existed between centric occlusion (CO) and centric relation (CR). There was distal drifting of the maxillary canine teeth, with the left canine in the left first premolar position. In lateral movements there was cuspid protection and in protrusive movements there was anterior disclusion. Periodontal examination (Figures 9.6 and Figure 9.3 9.7) showed probing depths of up to 9.0 mm Frontal facial view. on the maxillary teeth and up to 4.0 mm on
MODERATE TO ADVANCED ADULT PERIODONTITS 93Figure 9.4 Figure 9.5Maxillary arch. Mandibular arch.Figure 9.6 Figure 9.7Periodontal chart-maxilla. Periodontal chart-mandible. Figure 9.8 Radiographs of maxilla and mandible.
94 PROSTHODONTICS IN CLINICAL PRACTICE the mandibular teeth; bleeding on probing a comprehensive treatment plan was was more severe in the maxilla than in the necessary. After explanation and consulta- mandible. The maxillary left first molar had tion, she accepted the suggested treat- class 2 furcation involvement on the buccal ment plan. She was very cooperative in and mesial surfaces, and the left second her dental treatment and was ready to do molar had class 2 furcation involvement on everything necessary in order to save her the mesial and buccal surfaces. teeth. I NDIVIDUAL TOOTH PROGNOSIS POTENTIAL TREATMENT PROBLEMS Advanced periodontitis complicated by loss of teeth, aggravated by faulty restoration and flaring of anterior teeth There were large spaces between the maxillary anterior teeth due to the DIAGNOSIS congenitally missing teeth and the subsequent drifting of her other teeth Moderate with localized advanced adult The existing restorations were inadequate periodontitis The maxillary left first molar had a Congenital partial anodontia severe perio-endo lesion Missing teeth accompanied by loss of posterior occlusal support Faulty restorations TREATMENT GOALS Caries Reduced vertical dimension I n order to attain a more favorable tooth Flaring of maxillary anterior teeth position, orthodontic treatment would be Compromised esthetics required. Orthodontic treatment goals were: Secondary occlusal trauma Perio-endo lesion on the maxillary first Close the anterior spaces molar accompanied by probing depths Extrude teeth of 9.0 mm Level gingival margins Correct the misaligned center line of the maxillary teeth ABOUT THE PATIENT Open space posteriorly for fixed partial prostheses The patient had come to the clinic complaining of difficulty in chewing and A computerized digital picture was made, concern with her appearance. However, and different treatment options were then her main request was for a restoration of a presented to the patient. The treatment single crown on the implant placed plan chosen was to orthodontically close recently in her mandible. In order to the anterior spaces, and leave the maxillary address her complaints she was told that l eft cuspid in the premolar position. On the
MODERATE TO ADVANCED ADULT PERIODONTITS 95right side of the maxilla, it was decided to re-evaluation was made and it wasrotate the maxillary premolar in order to observed that the pocket depths hadopen space for an additional tooth to be greatly diminished, while bleeding onplaced. probing had disappeared. Endodontic therapy was undertaken on the palatal root of the maxillary left first TREATMENT ALTERNATIVES molar; the mesial and disto-buccal tooth roots were resected. The maxillary secondMaxilla: molar was also prepared and a transitional fixed acrylic resin restoration was made Fixed posterior partial prostheses (Figure 9.9). In the mandible, the right Fixed anterior partial prosthesis and a second premolar and the right second molar removable posterior partial prosthesis were prepared for fixed restorations and a fixed transitional acrylic resin prosthesis wasMandible: made (Figure 9.10). The implant in the right mandibular first molar area was left Fixed partial posterior prosthesis unexposed, in the bone. Fixed tooth and implant supported Before the orthodontic phase of treat- partial prosthesis ment started, a diagnostic set-up was made, and the anterior maxillary teeth were repositioned on a study model as a guide TREATMENT for the treatment goal (Figure 9.11). Using fixed brackets and a labial archInitial preparation included scaling, curet- wire, the maxillary incisor teeth weretage, root planing and oral hygiene repositioned to their correct position (Figurei nstruction. At the end of this stage, 9.12) They were then retained in thisan obvious improvement in the soft position utilizing a modified Hawley appli-tissue could be discerned. A periodontal ance (Figures 9.13 and 9.14).Figure 9.9 Figure 9.10Maxilla showing transitional restorations. Mandible showing transitional restorations.
96 PROSTHODONTICS IN CLINICAL PRACTICE 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 treatment plans were considered. The first was to splint the anterior teeth with porcelain fused to metal crowns with precision attachments in the distal of the canines. This would enable the posterior splints to be fixed to the anterior splints. The second option was to use a lingual wire to splint the maxillary anterior teeth and have a free-standing posterior restoration. Figure 9.15 The second option for retention of these Maxilla-after closing of anterior spaces. teeth was chosen. The lingual surfaces of
MODERATE TO ADVANCED ADULT PERIODONTITSFigure 9.16 Figure 9.17Wire splint for maxillary teeth retention (on model). Transitional restorations-anterior view. Copper band elastomeric impressions were then taken of all the prepared teeth and Duralay copings were made. These copings (Figure 9.18) were used to record the teeth position in the arch for the final i mpression for the working model and also centric relation at the vertical dimen- sion of the temporary restorations. A polyether complete arch impression was made to pick up the copings and their relationship to the remaining teethFigure 9.18 ( Figures 9.19 and 9.20). The metalDuralay copings fitted in maxilla. copings were then cast, fitted and soldered, and after try-in of the soldered metal framework another polyetherthe anterior maxillary teeth were pumiced, i mpression was made for the final masteretched, bonded, and built to occlusal model. These models were mounted on acontact with mandibular anterior teeth by semi-adjustable articulator (Hanau) utiliz-adding microfil composite resin (Durafil i ng a facebow registration. Centricvs). A groove was then made in the records were made at the vertical dimen-composite platform and a nitinol sion of occlusion utilizing Duralay with aorthodontic wire was fitted and bonded in Neylon technique. The porcelain wasplace (Figure 9.16). baked and the occlusion checked at the The remaining maxillary teeth were biscuit bake stage in the mouth and all prepared and a transitional acrylic resin adjustments needed were then made. restoration was prepared for fixed prosthe- The porcelain was then glazed and theses and transitional acrylic resin restora- crowns and bridges were cemented withtions were placed (Figure 9.17). Temp-Bond for a period of 3 weeks. The
98 PROSTHODONTICS IN CLINICAL PRACTICE Figure 9.19 Figure 9.20 Polyether maxillary impression of metal copings. Polyether mandibular impression of metal copings. Figure 9.21 Figure 9.22 Maxillary restorations-right side. Maxillary restorations-left side. crowns and bridges were then perma- SUMMARY nently cemented with zinc oxyphosphate cement for cementation ( Figures The 40-year-old female patient came to the 9.21-9.23). Graduate Prosthodontics Clinic of the The patient has been returning for follow- Hebrew University Dental School of up and maintenance twice a year. Medicine for a simple restoration of a
MODERATE TO ADVANCED ADULT PERIODONTITS 99 replaced a missing lower first right molar by an 8.0 mm implant, even though the adjacent teeth had been previously treated. The patients advanced periodontal disease, accompanied by flaring of anterior teeth along with several missing teeth, was quite challenging. The orthodontic treatment addressed the patients esthetic complaints and improved the periodontal condition.Figure 9.23 This facilitated participation of the anteriorFrontal facial view of patient after treatment completion. teeth in occlusal support in their new favor- able position. The occlusal scheme was tailor made to address the periodontalcrown on a recently placed implant. The situation. A functional physiologic occlusionpatient presented with moderate to was established.advanced adult periodontitis. She hadmany missing teeth, advanced alveolarbone loss around some teeth, and faulty CASE DISCUSSIONrestorations in both jaws. There was mobil- HAROLD PREISKELity and fremitus in the maxillary anteriorteeth. The treatment received by this patient After a complete examination, diagnosis, underscores the importance of establishingand consultation, the patient agreed to a a comprehensive program of therapy at thecomprehensive treatment plan, and not just outset, together with achievable goals. Thea single crown for her implant. hazards of treating a patient on a quadrant With orthodontic and periodontal treat- or tooth-by-tooth basis is clearly evidencedment accompanied by occlusal therapy, the by earlier attempts at treatment.patient received a physiologic occlusion at Computer simulation has been employedthe optimum vertical dimension of occlusion. to augment the more standardized radio- graphic and diagnostic case investigation techniques. Modifying an existent diagnos- CASE DISCUSSION tic cast is a relatively straightforward and AVINOAM YAFFE extremely effective way of assessing the results of therapy and was used to goodThe patient presented herself to the effect. The patients treatment has trans-Graduate Prosthodontics Program, seeking formed her mouth from an unsightly,treatment for various complaints. She had diseased and rapidly deteriorating situationbeen treated earlier by a periodontist who i nto one of health, function, and good looks.
PATIENT 10 SEVERE ADVANCED ADULT PERIODONTITIS 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 are l oose. EXTRA-ORAL EXAMINATION ( Figures 10.1 and 10.2)She had been to several dentists, all ofwhom had told her that she would most Normal facial symmetryprobably need complete dentures or, at Slightly convex profileFigure 10.1 Figure 10.2Frontal facial view. Side face view. 1 01
1 02 PROSTHODONTICS IN CLINICAL PRACTICE Normally functioning muscles of masti- cation The temporomandibular joints were normal The maximum opening was 48 mm with a 2.0 mm deviation to the left side on opening and a 2.0 mm deviation to the right side in the closing movement I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH Figure 10.3 EXAMINATION (Figures 10.3-10.11) Maxillary arch. • Caries • Low maxillary sinuses • 60% bone loss around some teeth • Spacing between the anterior teeth Occlusal examination revealed that the patient was Angle class 1, with an overbite of 2.0 mm and overjet of 3.0 mm (Figure 1 0.5). The interocclusal rest space was Figure 10.4 3.0 mm and the maximum opening between the incisors was 48 mm. Fremitus Mandibular arch. class I-II was found on the maxillary anterior teeth and there was mobility of the mandibular anterior teeth. There was a 0.5 mm discrepancy between centric occlusion (IC) and centric relation (CR). The patient had a removable partial mandibular denture which was unsatisfactory and was not used (Figure 10.6). Periodontal examination (Figures 10.7 and 1 0.8) revealed probing depths of up to 5.0 mm on the maxillary teeth and up to 5.0 mm on the mandibular teeth, with slight bleeding of the gingiva on probing (BOP) Figure 10.5 on some of the teeth, with the condition Anterior overjet and overbite.
SEVERE ADVANCED ADULT PERIODONTITIS 1 03Figure 10.6 Figure 10.7Patients removable mandibular partial denture. Maxillary periodontal chart.Figure 10.8Mandibular periodontal chart. Figure 10.9 Radiographs of maxillary and mandibular anterior quadrant.Figure 10.10 Figure 10.11Radiographs of right posterior quadrant. Radiographs of left posterior quadrant.
104 PROSTHODONTICS IN CLINICAL PRACTICE being more severe in the maxilla than the • The existing restorations were inade- mandible. quate • The patient refused to wear a remov- able mandibular partial denture I NDIVIDUAL TOOTH PROGNOSIS TREATMENT POSSIBILITIES Maxilla: Fixed anterior partial prosthesis and a removable posterior partial prosthesis supported by implants Fixed anterior partial prosthesis and a removable posterior partial prosthesis DIAGNOSIS supported by the anterior fixed prosthe- sis with either clasps and rests, or Advanced adult periodontitis attachments Missing teeth accompanied by loss of Fixed maxillary restoration as a short- posterior occlusal support, and flaring ened arch with only a premolar occlu- of maxillary anterior teeth sion on the left side Caries Faulty restorations Mandible: Poor esthetics Reduced vertical dimension Fixed anterior partial prosthesis with removable tooth supported posterior partial prosthesis ABOUT THE PATIENT Fixed tooth and implant supported The patient understood the severity of her partial prosthesis dental condition and came to the clinic Fixed partial prosthesis with the cuspid hoping to avoid construction of complete as the terminal abutment on the left side maxillary and mandibular dentures, because that was what other dentists had told her was the only possible treatment. She was very cooperative in her dental treatment, and was prepared for any financial outlay neces- Following initial preparation including oral sary in order to save her remaining teeth. hygiene instruction, scaling and root planing, and periodontal re-evaluation a final treatment plan was then chosen which POTENTIAL TREATMENT consisted of orthodontic treatment to PROBLEMS i mprove the occlusal relationship and close the existing spaces between the anterior • The advanced periodontitis was teeth. This would improve the anterior accompanied by many missing teeth tooth position to facilitate participation in
SEVERE ADVANCED ADULT PERIODONTITIS 10 5vertical 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 a Figure 10.12removable mandibular prosthesis. Elastic retraction of mandibular anterior teeth. TREATMENTI 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 was Figure 10.13then started using elastics to retract the Hawley orthodontic appliance.mandibular 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 inserted Figure 10.14to separate the right mandibular cuspid from Clinical view of Hawley appliance-pre-treatment.
106 PROSTHODONTICS IN CLINICAL PRACTICE 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. the ri ght first premolar (Figure 10.20). Radiographs (Figure 10.21) and periodontal evaluation were again performed and disclosed that the probing depth were less than 3.0 mm in all areas. A transitional remov- able mandibular partial denture was also suggested to the patient, and again rejected. Copper band elastomeric impressions were then taken of all the prepared teeth and Duralay copings were made. These copings (Figure 10.22) were used to record centric Figure 10.19 relation at the vertical dimension of the tempo- Transitional restorations-maxilla and mandible. rary restorations and for the final impression for the master model. The metal copings were
SEVERE ADVANCED ADULT PERIODONTITIS 1 07Figure 10.20 Figure 10.21Coil spring to separate the right mandibular cuspid and Completed teeth preparations-maxilla and mandible,premolar teeth. radiographs.Figure 10.22 Figure 10.23Duralay copings fitted-maxilla and mandible. Removable partial mandibular denture.then fitted and soldered and, after try-in of the mouth and all adjustments needed were thensoldered metal framework, another made. Rest preparations were then milled intoelastomeric impression was done for tissue the fixed prosthesis in the lingual of the rightdetail and for the final master model. These molar area pontic as well as the distal surfacemodels were mounted on a semi-adjustable of the left cuspid. The porcelain was thenarticulator (Hanau) utilizing a facebow registra- glazed and the final elastomeric impression fortion and centric records were taken at the the removable mandibular partial denture wasvertical dimension of occlusion utilizing done. The framework for the partial dentureDuralay with a Neylon technique. At this point was then cast and fitted and a bite traythe patient was finally convinced of the impor- constructed on it for centric registrationtance of a partial removable mandibular record. This was done and the denture teethdenture and agreed to try and adjust to one. were set up and checked in the mouth forThe porcelain was baked and the occlusion esthetics and occlusion. The denture waschecked at the biscuit bake stage in the then processed (Figure 10.23). The crowns
1 08 PROSTHODONTICS IN CLINICAL PRACTICE and bridges were cemented with Temp- Hebrew University Dental School of Bond and the partial removable mandibular Medicine as a last resort. She had been to denture inserted. The crowns and bridges three dentists who had all told her that it were then cemented with zinc oxyphosphate would be impossible to save any of her cement for permanent cementation (Figures remaining teeth and that she would need 10.24-10.29). complete dentures. She was told that there The patient has been returning for follow- might be a chance to save some of her up and maintenance twice a year since then teeth to support an overdenture, but only if and adjusted to her removable mandibular she went to the Dental Clinic at Hadassah. partial denture (Figures 10.30 and 10.31). The patient presented with a severe problem of advanced adult periodontitis. She had many missing teeth, considerable SUMMARY alveolar bone loss around the remaining The 58-year-old patient came to the teeth, and faulty restorations in both jaws. Graduate Prosthodontics Clinic of the There was much bone resorption but the Figure 10.25 Case cemented-post-treatment, anterior view. Case cemented-maxilla. Figure 10.26 Figure 10.27 Case cemented-mandible. Case cemented-right side.
SEVERE ADVANCED ADULT PERIODONTITIS 109Figure 10.28 Figure 10.29Case cemented-left side. Radiographs of case-post-treatment.Figure 10.30 Figure 10.31Patient clinically-five years post-cementation. Patient radiographs-five years post-cementation.probing depth around the remaining teeth at the optimum vertical dimension of occlu-was not excessive, mostly 4.0 mm or less, sion for this periodontal condition. Theexcept for the right mandibular premolar patient was adamant about not having aand the right maxillary second premolar removable prosthesis and refused to useand third molar. Her fixed and removable one during the course of treatment. Onlyrestorations were inadequate and she when she was told that the case could nothardly ever wore her removable partial be completed ending in a cuspid occlusionmandibular denture. There was mobility on the left side, did she agree to try to useand fremitus in the maxillary anterior teeth a removable partial mandibular denture.and mobility of the mandibular anterior She successfully overcame her aversion toteeth. the removable denture and today, 10 years With orthodontic and periodontal treat- post-treatment, functions very well with herment accompanied by occlusal therapy, partial removable denture. As a compro-the patient received a physiologic occlusion mise solution, the missing posterior
11 0 PROSTILODONTICS IN CLINICAL PRACTICE mandibular teeth were replaced as pontics prognosis of the treatment and serving the on a fixed prosthesis as opposed to the patient for the past 10 years with no signs removable mandibular partial denture, as of breakdown. we felt that the patient might not wear the partial denture. If that did occur, at least she would have full occlusion on the right CASE DISCUSSION side. HAROLD PREISKEL Commenting on a treatment plan with the CASE DISCUSSION benefit of the successful 10-year follow-up AVINOAM YAFFE i s relatively simple as it is hard to argue with a good result. The treatment, however, was This patient represents a complicated case far from straightforward. In addition to the with advanced periodontal disease and problems of advanced periodontitis, lack of missing teeth accompanied by drifting posterior support, flaring of the maxillary and flaring of anterior teeth with mobility teeth, and caries, the operators were faced and fremitus. The patient was treated with with a patient who adamantly refused to the intent to address both the occlusal and wear a removable prosthesis. The fact that periodontal problem that affected her they were able to undertake a comprehen- periodontal condition. Once the occlusion sive plan of treatment and motivate the was stabilized and with successful oral patient to the extent of wearing a remov- hygiene instruction, scaling and curettage, able prosthesis, is eloquent testimony to the periodontal condition improved consid- their communication skills as well as their erably-to such an extent that there was clinical expertise. Bearing in mind that the no need for any surgical periodontal proce- patient was treated in the early 1990s, the dures. The new position of the anterior use of orthodontics to improve a potential teeth enabled them to participate in i mplant site must be considered well ahead occlusal support, thus improving the of its time.
112 PROSTHODONTICS IN CLINICAL PRACTICE Straight profile with accentuated labio- mental fold, and trapped lower lip Normally functioning muscles of masti- cation Temporomandibular joints were normal The patient also exhibited solar kerato- sis in the lower lip I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH Figure 11.4 EXAMINATION (Figures 11.1-11.9) Scissor bite right side Extensive caries and loss of crown structure Low maxillary sinuses Widened periodontal ligament around Figure 11.5 the mandibular third molars Mandibular periodontal chart 60% bone loss around some teeth Furcation involvement of the mandibular ri ght second molar tooth Radio-opacity in the maxillary left sinus area Occlusal examination revealed that the patient was Angle class II division I, with an overbite of 1 0.0 mm and overjet of 7.0 mm. The interocclusal rest space was 5.0 mm and the maximum opening was 52.0 mm. Fremitus and mobility were found on the maxillary incisor teeth as well as the left maxillary first premolar. In the intercuspal Figure 11.6 position (IC) a `scissors bite existed in Maxillary periodontal chart
SEVERE ADVANCED ADULT PERIODONTITIS 11 3which the buccal outer line angle of the The periodontal examination (Figuresmandibular supporting cusp was lingual to 11.5 and 11.6) revealed probing depths ofthe functional outer aspect (FOA) of the up to 5.0 mm on the maxillary teeth and upmaxillary supporting cusp (Figures 11.3 to 10.0 mm on the mandibular teeth, withand 11.4). There was no discrepancy bleeding of the gingiva on probing (BOP)between centric occlusion (IC) and centric on most of teeth, with the condition beingrelation (CR). Fremitus and mobility were more severe in the mandible than thefound on several teeth. maxilla (Figures 11.7-11.9). Figure 11.7 Radiographs of maxilla and mandible-pre-treatmentFigure 11.8 Figure 11.9Maxillary arch Mandibular arch
114 PROSTHODONTICS IN CLINICAL PRACTICE INDIVIDUAL TOOTH PROGNOSIS The disparity of jaw size caused the scissors bite and lack of occlusal support The deep overbite would cause biome- chanical problems for the restorations and increasing the vertical dimension of occlusion would accentuate the unfavorable bucco-lingual relationship between the jaws and also worsen the crown-root ratio of the teeth, putting more stress on the periodontium Because of the primary and secondary occlusal trauma, a complete mouth DIAGNOSIS rehabilitation would be difficult to do. Advanced adult periodontitis Missing teeth Note: from old radiographs we concluded Loss of occlusal support that the existing radio-opacity in the maxil- Scissors bite - jaw size disparity lary left sinus area was due to a molar tooth Decreased vertical dimension that had endodontic therapy which was Secondary occlusal trauma with overfilled with cement entering the sinus. primary origins The tooth had subsequently been extracted. Caries Faulty restorations Poor esthetics TREATMENT ALTERNATIVES Periapical changes Maxilla: Fixed anterior partial prosthesis and a ABOUT THE PATIENT fixed posterior partial prosthesis sup- ported by implants The patient was young and optimistic and Fixed anterior partial prosthesis and a understood the severity of his dental condi- removable posterior partial prosthesis tion and came to the clinic hoping to avoid supported by the anterior fixed prosthe- construction of complete maxillary and sis with either clasps and rests or mandibular dentures because other attachments dentists had told him that was the only A fixed maxillary restoration as a short- possible treatment. His expectations ened arch with only a premolar occlusion. regarding his treatment were functional and esthetic improvement to his mouth. Mandible: • Fixed partial prosthesis • Removable tooth-supported partial POTENTIAL TREATMENT prosthesis PROBLEMS • Fixed tooth and implant-supported • The advanced periodontitis was partial prosthesis accompanied by missing teeth Fixed and removable partial prosthesis
SEVERE ADVANCED ADULT PERIODONTITIS 115 TREATMENT PREREQUISITES anterior maxillary prosthesis and a removable posterior maxillary prosthesis with semi-• In order to achieve a tooth-supported precision attachments, and a fixed partial prosthesis, orthodontic treatment to prosthesis in the mandible. change the bucco-lingual relationship of The maxillary second molars that were the maxillary and mandibular teeth was considered hopeless would be restored mandatory with temporary restorations to augment• In order to do an implant-supported posterior occlusal support during the maxillary fixed prosthesis, maxillary orthodontic treatment. sinus augmentation would be required TREATMENT FINAL TREATMENT PLAN Initial preparation included scaling, curet-A final treatment plan was then chosen tage, root planing and oral hygiene instruc-which consisted of orthodontic treatment to tion. At the end of this stage, an obviousimprove the occlusal relationship, a fixed improvement of the soft tissue could be discerned (Figure 11.10). At this time a periodontal recharting and evaluation was done and it was observed that the pockets depths had greatly diminished and that the bleeding on probing had disappeared (Figures 11.11 and 11.12). The orthodontic phase of treatment was then started using a Hawley bite plane Figure 11.10 Maxillary anterior teeth after initial treatmentFigure 11.11 Figure 11.12Periodontal chart at re-evaluation-maxilla Periodontal chart at re-evaluation-mandible
11 6 PROSTHODONTICS IN CLINICAL PRACTICE Figure 11.13 Figure 11.14 Clinical view of Hawley appliance-pre-treatment Maxillary teeth-orthodontic treatment, extrusion of central incisor teeth Figure 11.15 Figure 11.16 Maxillary teeth-radiograph, extrusion of central incisor teeth Transitional crowns and removable partial denture retainer (Figure 11.13), the goals of which prepared and transitional (provisional) res- were to increase the vertical dimension of torations were placed (Figure 11.16). occlusion, add occlusal support, induce Radiographs and periodontal evaluation muscular relaxation, and make sure that were again performed and disclosed that retruded cuspal position (RC) and intercus- the probing depth were less than 3.0 mm pal position (IC) were co-incidental. i n all areas except the mandibular second The maxillary incisor teeth, despite their right molar. A transitional removable maxil- hopeless prognosis, were also treated l ary partial denture was also fabricated to orthodontically to extrude them in order to get the patient acclimated to a removable achieve better esthetics and prepare the site prosthesis (Figure 11.17). for future development if implants were to be Periodontal surgery was performed on used in the future (Figures 11.14 and 11.15). the mandibular right second molar for When the orthodontic stage was success- pocket elimination; it was decided that the fully completed, the supporting teeth were tooth was hopeless and it was thus
SEVERE ADVANCED ADULT PERIODONTITIS 117 extracted at the time of the periodontal surgery (Figure 11.18). Following healing, the teeth were repre- pared and copper band elastomeric i mpressions were then taken of all the prepared teeth and Duralay copings were made. These copings were used for the final impression for the master model. They were also used to record centric relation at the vertical dimension of the temporary restorations (Figure 11.19). The metalFigure 11.17 copings were then fitted and soldered and after try-in of the soldered metal frameworkTransitional crowns and removable partial denture-maxilla ( Figures 11.20 and 11.21), another elas- tomeric impression was done for tissue transfer for the final master model. These models were mounted on a semi- adjustable articulator (Hanau) utilizing a facebow registration and centric records taken at the vertical dimension of occlusion utilizing 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 in the mouth and all adjustments needed were then made. The porcelain was then glazed. An elastomeric impression in aFigure 11.18 close-fitting individual tray was made onPeriodontal surgery-right mandibular second molar the non-cemented fixed prosthesis and the edentulous areas, so that the removable maxillary partial denture framework could be fabricated on the crowns and bridges, as opposed to a stone model of them ( Figure 11.24). The framework for the partial denture was then cast and fitted and a bite tray constructed on it for centric record regis- tration (Figure 11.25). This registration was done in Duralay using the Neylon technique ( Figure 11.26) and the denture teeth were set up and checked in the mouth forFigure 11.19 esthetics and occlusion.Duralay copings fitted-maxilla and mandible and centric The denture was then processed andrelation record i nserted into the mouth. The crowns and
118 PROSTHODONTICS IN CLINICAL PRACTICE 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 framework denture framework
SEVERE ADVANCED ADULT PERIODONTITIS 119Figure 11.26 Figure 11.27Centric relation record on occlusal tray on removable partial Case completed-anterior viewdentureFigure 11.28 Figure 11.29Case completed-left side Case completed-right side bridges were cemented with Temp-Bond missing teeth, scissors bite, and loss ofand the partial removable maxillary denture posterior occlusal support. With orthodon-i nserted. The crowns and bridges were tic and periodontal treatment accompaniedthen cemented with zinc oxyphosphate by occlusal therapy, the patient received acement for permanent cementation physiological occlusion at the optimum(Figures 11.27-11.30). vertical dimension of occlusion. The patient has been returning for follow-up and maintenance twice a year. CASE DISCUSSION AVINOAM YAFFE SUMMARY This patient was a relatively young individ-The patient presented with a severe ual, 46 years old, with a complicated dentalproblem of advanced adult periodontitis, situation due to many missing teeth, and
1 20 PROSTHODONTICS IN CLINICAL PRACTICE Figure 11.30 Post-treatment radiographs loss of support, accompanied by a deep the periodontal disease which would have overbite and aggravated by a scissors bite been aggravated by the increased vertical that along with a severe periodontitis dimension. The orthodontic treatment also caused a total loss of vertical support. included future site development before the There were several alternative methods extraction of the maxillary central incisor of treatment possible for this patient: teeth. All this, along with the esthetic considerations, contributed to the An overlay partial denture successful treatment of the patient. A removable partial denture after extraction of the maxillary anterior teeth Orthognathic surgery The solution that was utilized in this case encompassed biomechanical considera- The patients treatment represents more tions and the patients well-being as well as than a complex plan of dental therapy. It satisfaction with the final result. The marks the transition from a patient who had orthodontic treatment achieved support no motivation into one who was prepared from the teeth in scissors bite as well as to undertake multiple visits to a dental minimal bite opening (needed for the office involving an impressive amount of prosthetic treatment) and thus minimized treatment over an extended period of time. the increased crown-root ratio caused by The clinicians are to be congratulated on
SEVERE ADVANCED ADULT PERIODONTITIS 121the patient motivation achieved and upon decision involves the missing maxillarythe successful outcome. It is always impor- molars. Is it necessary to replace them ortant to have a fallback position in case the could a shortened arch be accepted? Thepatients interest wanes and a simpler plan shortened arch would be far simpler from thecan be substituted. The step-by-step prosthodontic point of view, for no-oneapproach employed has considerable should underestimate the complications ofadvantage in this respect. producing a removable prosthesis. The Another laudable aspect of the therapy maxillo-mandibular relations of this patientwas an appreciation of the three-dimensional helped make the decision to replace theproblems associated with a marked discrep- missing maxillary molars, leaving open theancy of arch size. At an early stage it was possibility of employing a distal cantileveri mportant to establish how much of the pontic on each side to produce some molarderanged occlusion was as a result of loss of support without the need for a denture.posterior occlusal support and how much as However, it can be seen that the upper lefta result of the decrease of vertical dimension second pre-molar is root filled and we knowof occlusion. Of course the two are inter- from the work of Glantz and others that the related, with a decrease of vertical dimension prognosis of a restoration with a distalaccentuating the effect of a forward cantilever pontic is not good when the distal mandibular posture. The use of transitional abutment is root filled. The clinicians there- restorations to determine maxillo-mandibular fore elected to construct a partial denture relationships is an important aspect of the with all the difficulties involved, to say nothing treatment. Forward thinking has also been of the maintenance requirements. They demonstrated with the extrusion of anterior ensured that the patient understood the teeth to be subsequently extracted to rationale of the treatment from the outset. encourage bone growth for possible implant I ndividual techniques are simply tools of placement at a later date. our trade; it is the planning and results that Alternative avenues of approach were matter. This patients treatment represents discussed at the very outset. Having both a success in patient education and in selected root-supported fixed prosthodon- clinical dentistry. I hope that the patienttics as the primary support, a difficult returns for routine maintenance.
PATIENT 12 REFUSAL OF ORTHOGNATHIC SURGERY Treatment by Miriam Calev THE PATIENT PAST DENTAL HISTORYThe patient, a 26-year-old housewife, came Past dental history was non-contributory.to the clinic for consultation. Her com-plaints were as follows: Everything related to my mouth bothers me. (Figure 12.1) EXTRA-ORAL EXAMINATION `I am missing lots of teeth. (Figures 12.2 and 12.3) My front teeth stick out. My palate hurts. Symmetrical face Due to my fear of dentists, I have Competent lips neglected my teeth for many years. Slightly convex profile Accentuated labio-mental fold Normally functioning temporomandibu- l arjoints Maximum opening 42 mm withoutThe medical history was non-contributory. deviationFigure 12.1 Figure 12.2Anterior teeth-labial view Face-frontal view 1 25
126 PROSTHODONTICS IN CLINICAL PRACTICE Figure 12.4 Maxillary arch-palatal view Mandible (Figure 12.5): Figure 12.3 Face-side view I NTRA-ORAL EXAMINATION Maxilla (Figure 12.4): • Discrepancy between dental and facial midlines • Parabolic asymmetric arch form • Evidence of previous sores in the anterior palate • Maxillary right premolars lacking coronal elements due to severe caries • Caries • Porcelain fused to metal crowns on the right central and both left incisor Figure 12.5 teeth Mandibular arch-lingual view
REFUSAL OF ORTHOGNATHIC SURGERY 127Figure 12.6 Figure 12.7Occlusion-right side Occlusion-left sideFigure 12.8 Figure 12.9Periodontal chart-pre-treatment, maxilla Periodontal chart-pre-treatment, mandible An occlusal examination revealed that plaque and calculus. Probing depths of upthe patient was Angle class II division I, with to 4.0 mm on the maxillary teeth and up todeep impinging bite (Figures 12.1, 12.6 4.0 mm on the mandibular teeth wereand 12.7). There was an overbite of found, with bleeding on probing on some8.0 mm with tissue impingement and an of the mandibular teeth. Inflamed tissueoverjet of 6.0 mm. The interocclusal rest was noted.space was 1.0 mm. Centric occlusion (CO)was concentric to centric relation (CR).Fremitus in centric occlusion: FULL MOUTH PERIAPICAL RADIOGRAPHIC EXAMINATION ( Figures 12.10 and 12.11)Periodontal examination (Figures 12.8 and • Defective root canal therapy12.9) revealed poor oral hygiene with • Periapical radiolucent areas
1 28 PROSTHODONTICS IN CLINICAL PRACTICE FIGURE 12.1U Radiographs of maxilla and mandible-pre-treatment, periapical Figure 12.11 Radiographs of maxilla and mandible-pre-treatment, panoramic • Good bone support on all remaining ESTHETIC EVALUATION AND teeth PROBLEMS (Figure 12.12) • Rampant caries • Destroyed coronal structure • High lip line • Low maxillary sinus floor on both sides • Anterior maxillary gingival margins no of maxilla continuous
REFUSAL OF ORTHOGNATHIC SURGERY 129 • Faulty occlusal relationship, and faulty occlusal plane Rampant carious lesions Defective restorations and endodontic treatment (periapical lesions) Missing teeth Poor esthetics Gingivitis Reduced posterior support Reduced vertical dimension Primary occlusal traumaFigure 12.12 Loss of tooth structureAnterior teeth-labial view, esthetic problem ABOUT THE PATIENT• The maxillary incisor teeth were large The patient was a young woman with a and stuck out• Discrepancy between maxillary and large amount of coronal tooth structure loss due to rampant caries. She was very mandibular midlines apprehensive but had finally overcome her• The maxillary incisors did not contact fear of dentists and, after visiting many the lower lip dental clinics, decided on having her dental• A wide smile exposed the gingival treatment as soon as possible. She had tissues in the maxilla high expectations from her dental treat- ment. She wanted to improve her esthetic appearance and would have preferred fixed I NDIVIDUAL TOOTH PROGNOSIS restorations, but understood the difficulty involved. POTENTIAL TREATMENT PROBLEMS A deep bite accompanied by loss of verti- cal dimension and an increased overjet, along with the great difference in jaw size and tooth position, made it very difficult to achieve good occlusal relationships which enabled the inclusion of the anterior segments in occlusal support. By restoring DIAGNOSIS lost vertical dimension, needed for the rehabilitation, the jaw relations would be• Angle class II division I, with deep made worse. To utilize implants for poste- impinging bite ri or support would improve the situation,
130 PROSTHODONTICS IN CLINICAL PRACTICE but would require pre-implant surgery. The • Orthodontic treatment for uprighting problem of the rampant caries had to be and realigning teeth overcome before any permanent restora- • Re-evaluation and planning of pre- tions were undertaken. prosthetic periodontal surgery New provisional fixed acrylic restora- tions at the new vertical dimension of TREATMENT POSSIBILITIES occlusion in order to check patient adaptation Maxilla: Re-evaluation Fixed partial prostheses for both the Fixed and removable partial prostheses maxilla and the mandible Fixed partial prosthesis supported by remaining teeth and implants (would necessitate pre-implant surgery) TREATMENT Fixed prosthesis Orthognathic surgery, orthodontic treat- I nitial preparation included oral hygiene ment and fixed prosthesis i nstruction, scaling, and curettage. Canine platforms were then built on the lingual Mandible: surfaces of the maxillary cuspid teeth opening the vertical dimension of occlusion Fixed partial prosthesis by approximately 2.5 mm (Figure 12.13). Fixed partial prosthesis supported by This allowed healing of the palatal gingiva remaining teeth and implant by preventing i mpingement of the mandibular anterior teeth on the palate ( Figure 12.14). Endodontic treatment was performed on TREATMENT PLAN the maxillary left third molar and the I NITIAL PREPARATION mandibular left second molar. Caries removal and provisional restorations were • Dietary changes done where indicated. At this time the • Oral hygiene instruction anterior maxillary splint was sectioned and • Fluoride rinses and gel application removed (Figure 12.15). Transitional acrylic • Changing the vertical dimension to crowns were then made for these teeth relieve the palatal tissue impingement ( Figure 12.16). CT radiographs were then • Caries removal taken of the maxilla to determine the • Referral for endodontic therapy amount and quality of bone available for • Evaluation of patient cooperation i mplant placement (Figures 12.17 and • Referral for computerized tomography 12.18). After extraction of the maxillary right ( CT) radiographs to determine implant premolars, the remaining maxillary teeth possibility were then prepared for full crowns and • Restorative treatment with restorations transitional fixed partial prostheses and provisional fixed acrylic restorations constructed (Figures 12.19 and 12.20). for the teeth with a sizeable loss of Re-evaluation at this time showed that tooth structure the bucco-lingual jaw relationships on the
REFUSAL OF ORTHOGNATHIC SURGERY 1 31Figure 12.13 Figure 12.14Canine platform to open vertical dimension Healing of the palatal gingivaFigure 12.15 Figure 12.16Removing existing crowns Transitional prosthesis-maxillaFigure 12.17 Figure 12.18CT scan, maxilla-right side CT scan, maxilla-left side
1 32 PROSTHODONTICS IN CLINICAL PRACTICE Figure 12.19 Figure 12.20 New transitional prosthesis-maxilla, right side New transitional prosthesis-maxilla left side Figure 12.21 Figure 12.22 Orthodontic treatment-uprighting right mandibular third Periodontal surgery-anterior maxilla, after healing molar right side had worsened with the opening of The first option was chosen and the vertical dimension. Therefore there orthodontic treatment was instituted to remained two options for restoring the upright the mandibular third molar (Figure mandible on the right side. The first option 12.21). At this time, a further re-evaluation was orthodontic uprighting of the mandibu- was done. It was decided that due to the lar third molar and then a fixed partial relatively young age of the patient (26), the prosthesis from the second premolar to the fact that she did not want implants, and third molar to replace the missing molar that there was only a relatively small span teeth. The second option would be to to be restored on the mandibular right implant a single wide body implant in the side, a fixed partial prosthesis was area of the mandibular right first molar and chosen. then do a fixed restoration on it, thus not Periodontal surgery was performed in i nvolving the third molar in posterior support. the anterior segment of the maxilla in order
REFUSAL OF ORTHOGNATHIC SURGERY 1 33Figure 12.23 Figure 12.24Final preparation of maxillary teeth Final transitional prosthesis-maxilla During a period of 3 months with the provisional restorations at the new vertical dimension of occlusion, the patient exhib- i ted no temporomandibular joint or muscu- l ar problems. Copper band elastomeric i mpressions were taken and stone dies were fabricated from the individual impres- sions. On these dies, Pattern resin copings were made and fitted in the mouth. Polyether pick-up impressions were done for the working models. The individual diesFigure 12.25 were placed into the impression and theFinal transitional prosthesis-mandible model was made. Centric relation was recorded at the new proven vertical dimen- sion using Pattern resin (Figures 12.26 and 1 2.27). This was done by leaving the provi-to even up the gingival margins and provide sional restorations in place on the left sideadditional tooth structure for retention of while fitting the Pattern resin copings andthe fixed prosthesis (Figure 12.22). recording the centric relation record on the At completion of orthodontic and copings on the right side. The provisionalperiodontal treatment the teeth were repre- restorations were then removed on the leftpared and new provisional restorations side and the Pattern resin copings placedwere made to maintain the new vertical on the supporting teeth (Figure 12.28).dimension and to stabilize the teeth after Metal copings were then cast and fittedthe orthodontic treatment. These transi- i n the mouth, and the copings connectedtional restorations also enabled the dentist for soldering. The copings were solderedto evaluate the patients adaptation to the and checked again for proper fit in thenew occlusal j aw relations (Figures mouth and a new centric registration12.23-12.25). record was done in Pattern resin material.
1 34 PROSTHODONTICS IN CLINICAL PRACTICE Figure 12.26 Figure 12.27 Pattern resin coping try-in-maxilla Pattern resin coping try-in-mandible SUMMARY The patient presented with a severe problem of Angle class II deep bite with i mpingement of the palatal tissues by the mandibular anterior teeth. She had missing and malpositioned teeth. There was a loss of vertical dimension and malocclusion complicated by rampant caries. All these factors made it mandatory to open the vertical dimension in order to restore the Figure 12.28 patient to a healthy and physiological Centric relation record on pattern resin copings at new occlusion. This would worsen the occlusal vertical dimension relationship and prevent anterior occlusal support. By means of limited orthodontic treatment and modification of the occlusal Full arch polyether impressions were relationships, we were able to give the made for tissue detail. The models were patient a fixed restoration that included the then mounted on a Hanau articulator with support of many of the remaining teeth, the aid of a face bow registration, and the thus giving the patient a functional and porcelain was baked. esthetic solution to her dental problems. The final and minute adjustments of the biscuit bake porcelain were carried out in the mouth. The final glaze was applied to CASE DISCUSSION the prostheses, and the prostheses were AVINOAM YAFFE cemented with Temp-Bond for a period of 2 weeks. They were then cemented with The patient presented to our clinic with a zinc oxyphosphate cement for permanent complicated situation of missing teeth, cementation (Figures 12.29-12.32). rampant caries, loss of the coronal tooth
1 36 PROSTHODONTICS IN CLINICAL PRACTICE structure in most of the remaining teeth, surgery, to which the patient objected. She loss of vertical dimension and soft tissue received a functional physiologic and i mpingement causing suppuration. The esthetic solution to an almost impossible treatment of choice should have been problem. orthognathic surgery, but the patient refused to undergo this. This situation presented us with a challenge, which CASE DISCUSSION would be difficult to cope with. By using the HAROLD PREISKEL canine platform as a tool, and guide, we changed the vertical dimension to a The management of this patients treatment workable situation and worked out the demonstrates what can be achieved using occlusal relationships and occlusal scheme conventional periodontal and prosthodon- to this pre-determined scheme. We aimed tic therapy when orthognathic surgery is at including as many teeth as possible to contraindicated or unwanted by the participate in occlusal support using patient. The key to rebuilding the occlusal adjunctive orthodontics and including the scheme appeared to rest with the clever canine teeth in support and guidance by use of the upper canines as a platform. Of the placement of platforms on both the course without the patients motivation, the maxillary and mandibular canine teeth. endodontic therapy, and the periodontal The periodontal surgery performed to therapy, nothing would have been of avail. reach both sound tooth structure and a The combination of motivation, clever pleasant appearing smile in the anterior planning, and meticulous execution of region was successful. In this patient, the relatively conventional techniques appears almost impossible has been achieved to have produced a good-looking and without orthognathic surgery and implants functional occlusion that I hope will last for that would have required pre-prosthetic years.
1 38 PROSTHODONTICS IN CLINICAL PRACTICE • Temporomandibular joint was normal • Mandibular motions were within normal l imits Normal facial musculature Maximum opening of 45 mm Incompetent lips Trapped lower lip I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH EXAMINATION Figure 13.3 Maxilla (Figure 13.5): Face-frontal view (from 23 years ago) Parabolic arch Caries He showed pictures of himself when he Spacing between the anterior teeth was younger, showing a large smile and Missing left third molar tooth healthy teeth (Figure 13.3). Right lateral incisor and right first premolar prepared for full coverage but without provisional restorations Large amalgam restorations on the left EXTRA-ORAL EXAMINATION premolars and molars (Figures 13.2 and 13.4) Left second molar and right third molar • Symmetrical face with large caries in the crown section, • Straight profile extending into the root Missing right first molar with anterior drifting of the second and third molars Figure 13.4 Figure 13.5 Face-side view Maxillary arch-palatal view
TREATMENT WITH LIMITED FINANCIAL RESOURCES 139Figure 13.6 Figure 13.7Mandibular arch-lingual view Occlusion-right sideMandible (Figure 13.6): Parabolic arch Mesial inclination of the left second and third molars Amalgam restorations on the posterior teeth Missing teeth: 7643 56 Provisional acrylic crowns on the central i ncisors Figure 13.8 Deep caries: Occlusion-left side Occlusal examination (Figures 13.7 and Fremitus:13.8) revealed that the patient was Angleclass I. The interocclusal rest space was Maxillary right central incisor-grade I in3.0-4.0 mm. Overjet was 2.0 mm and closing and ri ght working j awoverbite was 3.0 mm. There was no differ- movementsence between centric relation and centric Maxillary left central incisor, left lateralocclusion. There was a midline discrep- i ncisor, and right lateral incisor-grade Iancy. There was spacing between the i n centric occlusion and protrusive jawmaxillary incisor teeth and the left lateral movementsi ncisor and left cuspid were slightlyrotated. Non-working side interferences The periodontal examination (Figureswere noted between the mandibular right 13.9 and 13.10) revealed calculus andthird molar and the maxillary right second plaque, probing depths of up to 10.0 mmmolar. on most of the maxillary teeth and up to
1 40 PROSTHODONTICS IN CLINICAL PRACTICE Figure 13.9 Figure 13.10 Periodontal chart-pre-treatment, maxilla Periodontal chart-pre-treatment, mandible Figure 13.11 Radiographs of maxilla and mandible-pre-treatment 8.0 mm on many of the mandibular teeth. molars had class I-II furcation involvement There was bleeding of the gingiva on on the mesial and distal surfaces. The probing on all the teeth. There was slight maxillary first premolar had both class III gingival recession around some of the mesial and lingual furcation involvement. teeth. Class 1 mobility was found on the The mandibular molars had class I furcation mandibular incisor teeth. The maxillary i nvolvement on the buccal surfaces.
TREATMENT WITH LIMITED FINANCIAL RESOURCES 141 FULL-MOUTH PERIAPICAL packing between his teeth and a bad taste SURVEY (Figure 13.11) in his mouth. He had poor oral hygiene, plaque and calculus, and severe inflamma- Endodontic treatment: tion accompanied by deep probing depths and furcation involvements. Some of the teeth were mobile. Perio-endo lesion on left maxillary first molar DIAGNOSIS Periapical lesion on left maxillary second molar Advanced adult periodontitis Recent extraction site-mandibular left Missing teeth second premolar Loss of posterior support Rampant caries and secondary caries Decreased vertical dimension of occlusion around cast post in maxillary right Rampant primary and secondary caries central incisor Faulty restorations Extensive horizontal and vertical bone Periapical lesions loss around most of the remaining teeth Faulty occlusal planes Shifting of teeth Primary occlusal trauma (due to I NDIVIDUAL TOOTH PROGNOSIS trapped lower lip) Secondary occlusal trauma with primary origin 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 a removable restoration, but his financial capabilities were limited. TREATMENT PLAN PHASE 1: INITIAL PREPARATION Initial treatment including: SUMMARY OF FINDINGS • Oral hygiene instructionThe patient, a 40-year-old male in good • Scaling and root planinghealth, came to the clinic complaining of • Diet counseling regarding cariogenicdifficulty in eating, poor esthetics, food food
1 42 PROSTHODONTICS IN CLINICAL PRACTICE Topical fluoride treatment with Elmex • Fixed prosthesis supported by natural gel (GABA Ltd; Basel, Switzerland) teeth and implants (rejected by the • Caries excavation patient due to cost) • Maxillary left second molar-distal buccal root resection • Mandibular right third molar-distal root TREATMENT resection Extractions: I nitial treatment consisted of oral hygiene i nstruction, scaling and root planing. The maxillary right lateral incisor was repre- pared, the caries excavated, and a provi- sional crown made. Endodontic treatment was done on the maxillary lateral incisors and the maxillary left second premolar, and left first molar. At this point, a re-evaluation was done and even though the patients oral hygiene had greatly improved, bleeding PHASE 2: POSSIBILITIES on probing and the probing depths had Maxilla: only been slightly reduced (Figures 13.12 and 13.13). Fixed prosthesis I n the mandible where pocket depths and Fixed and partial removable prostheses mobility also had not been significantly if maxillary left first premolar and molar reduced, and considering the limited finan- could not be saved cial means of the patient, and the poor prognosis of the remaining teeth, it was Mandible: decided to make a removable prosthesis rather than a fixed one. The mandibular left • Complete overdenture second molar, central incisors, and left • Fixed and partial removable prostheses lateral incisor were extracted and the Figure 13.12 Figure 13.13 Anterior teeth-labial view, after initial preparation Periodontal chart-first re-evaluation
TREATMENT WITH LIMITED FINANCIAL RESOURCES 1 43Figure 13.14 a Figure 13.14 bMandibular anterior teeth-occlusal view after extractions Periodontal chart-re-evaluation of mandibleand endodontic treatmentFigure 13.15 Figure 13.16Anterior teeth-orthodontic treatment to close spaces and Anterior teeth-orthodontic treatment completedretract teethremaining teeth were endodontically treated maxilla. During the surgery, it was decided(Figure 13.14). Due to crown proximity, to extract the maxillary left first premolarorthodontic treatment was performed to due to the extensive furcation involvementseparate the left cuspid from the first (class III).premolar (Figures 13.15 and 13.16). The The second re-evaluation was now doneremaining teeth were then prepared, provi- and revealed that the probing depths hadsional acrylic copings were made and a greatly diminished and the bleeding ontransitional removable partial overdenture probing had disappeared. Except for thewas made (Figures 13.17 and 13.18). mandibular right lateral incisor (class I Periodontal surgery (open flap curettage) mobility), there was no mobility of the teethi n order to reduce pocket depths as well as ( Figures 13.19 and 13.20).to determine the prognosis of the left first The disto-buccal roots of the maxillarypremolar was then performed in the first molars were amputated and the
1 44 PROSTHODONTICS IN CLINICAL PRACTICE Figure 13.17 Figure 13.18 Mandibular removable partial denture Mandible-provisional acrylic copings for overdenture Figure 13.19 Figure 13.20 Periodontal chart-maxilla, re-evaluation Periodontal chart-mandible, re-evaluation remaining maxillary teeth were prepared for full coverage and a provisional acrylic restoration was made (Figure 13.21): In the maxilla, copper band elastomeric impressions were made of all the prepared teeth and Pattern resin copings made to fit the stone dies. These copings were fitted in the mouth and a polyether full arch impres- Figure 13.21 sion was then taken of the maxilla and the Transitional restorations-maxilla and mandible master model made. The copings were
TREATMENT WITH LIMITED FINANCIAL RESOURCES 1 45Figure 13.22 Figure 13.23Mandible-magnetic copings for overdenture Maxillary bisc-bake and mandibular overdenture set up on Hanau articulatoralso then used for a centric relation record resin registration on the soldered metal at the vertical dimension of occlusion of the prosthesis. The shade was chosen and provisional restorations. This was done by porcelain baked to the metal. This was cutting the provisional bridge between the fitted in the mouth and the occlusion central incisors and leaving one side in adjusted to the lower jaw. place, while recording the centric relation in At this point, impressions were done to Pattern resin on the copings on the other make magnetic copings for the remainingside. The provisional remaining bridge was l ower teeth. These were fitted andthen removed and the vertical dimension cemented into place (Figure 13.22). A final recorded on the Pattern resin copings while i mpression in a custom tray was taken ofon the contralateral side, the Pattern resin the mandible and cast in albastone. Acopings maintained the vertical dimension chrome cobalt metal framework was thenof occlusion. A polyether full arch impres- cast and fitted in the mouth.sion was then taken of the maxilla, the An acrylic and wax bite tray was thenmaster model was poured and mounted to made on this model over the metal frame-the mandibular model of the transitional work and fitted in the mouth. The centricremovable partial denture by means of the relation record was then taken at the estab-Pattern resin centric record. l i shed vertical dimension of occlusion. This Metal copings were then cast and fitted model was then mounted on the articulatori n the mouth and connected by Pattern by means of the bite tray with the centricresin for soldering. These were soldered record. The mandibular teeth were then settogether, refitted and a new centric relation up (Figure 13.23) and checked in therecord made. A polyether impression was mouth. The denture teeth were made ofthen undertaken for tissue detail and a porcelain in order to match the material inpick-up of the fixed prosthesis in order to the fixed prosthesis in the maxilla.make a final master model. This was The mandibular removable partialmounted on a Hanau articulator by means denture was processed and inserted. Theof a facebow registration and the Pattern maxillary fixed prosthesis was glazed and
1 46 PROSTHODONTICS IN CLINICAL PRACTICE cemented, with Temp-bond cement. After one week, the magnets were cold cured with 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, second premolar, lateral incisor, and left first premolar. The left cuspid area did not have a magnet (Figures 13.24-13.27). Figure 13.24 SUMMARY Completed mandibular partial denture-tissue view This patient presented with a very deteri- orating situation in his mouth. In spite of Figure 13.25 Radiographs of completed treatment, maxilla Figure 13.26 Radiographs of completed treatment, mandible
TREATMENT WITH LIMITED FINANCIAL RESOURCES 14 7 restoration with the greatest possible prognosis. For obvious esthetic reasons the maxillary fixed restoration was made of porcelain fused to metal restoration. In order to cope with the attrition that would take place, porcelain teeth were installed in the removable, magnet-supported, fixed partial denture. It can be concluded that with the economic restriction we faced the young patient received an esthetic and functional solution.Figure 13.27Treatment completed-permanent resorations, anterior view CASE DISCUSSION HAROLD PREISKELhis general good health, he had rampant I f the implant option is to be excluded, thencaries and severe advanced periodontitis, the amount of dental support available effec-many missing teeth, the majority in the tively dictates a removable lower prosthesismandible, and severe bone loss. There opposing an upper fixed restoration. Suchwere tipped, malposed, and extruded an approach dictates meticulous planning ofteeth. There were many hopeless and the occlusal surfaces and, naturally,questionable teeth among his few remain- assumes that the supporting structures arei ng teeth, yet the patient wanted a fixed not only healthy but that the patient canprosthesis. Due to the patients financial maintain them in this state. It might becondition, this could not be achieved. argued that as a telescopic approach wasHowever, an esthetic and functional used on most of the lower abutments thensolution was found for his dental a telescopic retainer could have beenproblems. i ncluded on the left molar rather than employing a conventional clasp. Using more than two magnets and porcelain teeth for CASE DISCUSSION the denture involves a possibility that during AVINOAM YAFFE chewing the leverages may disengage one of the magnets from its keeper and produceThis case presentation describes a young a clicking sensation. The other problem ispatient with a severe caries problem aggra- simply finding room for the underlyingvated by neglect, and complicated by substructure while providing retention for theperiodontal condition and a poor economic artificial teeth. The operator appears to havesituation. The patient was treated with the produced a functional and good-lookingi dea of supplying the best cost-efficient restoration.
PATIENT 14 TRAUMATIC SEQUELAE Treatment by Irit Kupershmidt THE PATIENT The esthetics doesnt bother me that much. (Figure 14.2)The patient, a 44-year-old man, had beenassaulted with an ax about 6 monthsbefore visiting the Hadassah School of PAST MEDICAL HISTORYDental Medicine Graduate ProsthodonticClinic. His injuries included scalp wounds, A year and a half prior to his coming for treat-fracture of the right side of his skull, fracture ment, the patient had a myocardial infarct,of the left mandible, left maxillary sinus and after undergoing an angiogram, washemorrhage, lacerations of the cheek, and treated with angioplasty. He suffered frommany broken teeth (Figure 14.1). His main high blood pressure and was being treatedcomplaints were the following: with Cartia (aspirin 100 mg), Normiten (altenolol), and Cordil (isosorbide dinitrate). I have no sensations in my upper and l ower lips on the left side and it gives me a bad feeling. PAST DENTAL HISTORY It hurts when I eat on my left side. The missing teeth bother me when For 10 years previous to his assault, he chewing, but not so much during speech. had not seen a dentist and could not recallFigure 14.1 Figure 14.2Maxillary teeth-palatal view Anterior teeth-labial view 1 49
1 50 PROSTHODONTICS IN CLINICAL PRACTICE the condition of his teeth before the The temporomandibular joints were assault, but thought that some of them asymptomatic but the patient had had crowns. Following his assault, his limited mandibular movements mandible was fixated with a titanium mesh There was a deviation to the left at the and intra-arch wiring for one month at the end of the jaw opening movement Department of Oral and Maxillofacial The maximum opening between the Surgery at Hadassah. After removal of the incisors was 50 mm, measured from wiring, he was not able to open his mouth the mandibular incisal edge to the more than 26 mm as measured at the incisal papillae maxillary and mandibular central incisor Straight profile teeth. Physiotherapy brought about gradual improvement of the condition. I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH EXTRA-ORAL EXAMINATION EXAMINATION ( Figures 14.3 and 14.4) (Figures 14.1,14.2,14.5-14.9) • Facial asymmetry, with a large scar on Missing teeth the left side All the maxillary teeth were fractured, Normally functioning muscles of masti- most of them beneath the gum line, cation except for the right molars, the right Figure 14.3 Figure 14.4 Face-frontal view Face-left profile view
TRAUMATIC SEQUELAE 1 51Figure 14.5 Figure 14.6Anterior maxillary teeth-palatal view, close-up Mandibular arch Caries Extensive bone loss around some teeth Titanium mesh in the left mandible Tipping and rotation of some teeth Nasopalatine duct cyst Periapical abscesses around some maxillary teeth • The interocclusal rest space was 3.0 mm Restricted mandibular movementsFigure 14.7 Discrepancy between centric occlusion ( CO) and centric relation (CR) ofAnterior mandibular teeth-lingual view, close-up 0.5 mm, with an anterior slide I n all lateral excursions, contact was on second premolar, and the left second the right side, on the maxillary and and third molars mandibular premolars and molars The large scar on the inner left side of • I n protrusive movements, contacts the cheek severely limited the opening were between the maxillary and of his mouth mandibular right molars High palate and loss of soft tissue and bone in the anterior part of the maxilla Periodontal examination revealed poor oral ( Figure 14.5) hygiene accompanied by large amounts of Mandibular left second and third molar, plaque and calculus (Figure 14.7), probing ri ght first molar, and the right central depths of up to 4.0 mm on the maxillary i ncisor teeth were missing teeth and up to 5.0 mm on the mandibular The anterior teeth were rotated and teeth (mandibular left third molar), with crowded. The lower left third molar was bleeding of the gingiva on probing on some covered by soft tissue (Figure 14.6) of the teeth (Figure 14.8).
PROSTHODONTICS IN CLINICAL PRACTICEFigure 14.8a Figure 14.8bPeriodontal chart Periodontal chart Figure 14.9 Radiographs of maxilla and mandible-pre- treatment Figure 14.10 Radiographs of maxilla-anterior teeth, pre-treatment
TRAUMATIC SEQUELAE 1 53 I NDIVIDUAL TOOTH PROGNOSIS a removable prosthesis as a temporary solution to his problems.The prognosis for the remaining teeth wasthe following: POTENTIAL TREATMENT PROBLEMS Widespread fractured maxillary teeth due to trauma, accompanied by loss of bone and soft tissue support, compli- cating a full mouth rehabilitation Reduced vestibulum space due to the scarring, limiting movement A nasopalatine duct cyst that might jeopardize implant placement for DIAGNOSIS prosthetic support• Multiple fractured teeth, status post- trauma TREATMENT ALTERNATIVES• Loss of bony and soft tissue support in the maxilla status post-trauma• Reduced occlusal support Removable partial denture• Shallow vestibulum space• Removable partial denture supported Loss of sensation in the lips on the left by natural teeth and implants side• Fixed partial prosthesis or prostheses Status post-mandibular fracture supported by implants and remaining• Caries and faulty restorations• teeth Poor esthetics• Periapical changes• Decreased vertical dimension• Nasopalatine duct cyst Removable tooth-supported partial• Gingivitis prosthesis Fixed partial prosthesis, each either tooth- or implant-supported ABOUT THE PATIENTThe patient, who suffered from poor health, TREATMENT PLANhad had a severe traumatic experience that,due to his injuries, would still require The final treatment plan was then chosenadditional extensive medical treatment. In an which consisted of pre-prosthetic surgery toi nstant, he went from a full dentition to a prepare the site in the maxilla for implants, acondition where he felt that most of his maxil- fixed anterior maxillary prosthesis supportedlary teeth were missing. The patient wanted by the maxillary right second premolar, thea fixed prosthesis, but was willing to accept maxillary right cuspid and the maxillary right
15 4 PROSTHODONTICS IN CLINICAL PRACTICE Figure 14.11 Figure 14.12 Mandibular arch-lingual view, after initial treatment Anterior teeth after initial treatment Figure 14.13 Figure 14.14 Transitional crowns and maxillary removable partial denture Mandibular left third molar after periodontal surgery lateral incisor, and a maxillary fixed partial the end of this stage, significant improve- prosthesis supported by implants from the ment of the soft tissue could be discerned ri ght maxillary central incisor to the left maxil- ( Figures 14.11 and 14.12). At this time, l ary second premolar. A crown was also to periodontal re-charting and evaluation be fabricated for maxillary left first molar demonstrated that the pockets depths had tooth. The missing mandibular right first diminished greatly and that the bleeding on molar would not be replaced. probing had disappeared. Endodontic therapy was performed on the maxillary right cuspid and maxillary left TREATMENT first molar. The mandibular left first premo- l ar and right third molar and left second I nitial preparation included scaling, curettage, molar were restored with amalgam restora- root planing and oral hygiene instruction. At ti ons. The maxillary right lateral incisor,
TRAUMATIC SEQUELAE 155Figure 14.15 Figure 14.16CT scan-maxilla CT scan-mandible therapy (Figure 14.14). The prognosis was not favorable, but it was decided to keep the tooth as it was the only tooth in the mandible maintaining occlusal support on the left side. A CT radiograph of the maxilla (Figure 1 4.15) revealed a large radiolucent area which, at surgery, was confirmed as a nasopalatine cyst. It was then decided to place an autogenous bone implant on the pre-maxilla to provide bone support for future implant placement. The bone wasFigure 14.17 taken from the chin area and checked forI mplant insertion-left mandibular molar area i ntegration after 6 months. A CT radiograph of the mandible (Figure 14.16) showed that there was room for twowhich was fractured and buried under the i mplants in the left mandibular molar area,gingival tissue, was exposed with a crown but this required removal of the mesial rootl engthening procedure, followed by of the mandibular third molar. The mesialendodontic therapy. root was extracted and two implants were A transitional removable maxillary partial placed (Figure 14.17). The distal root wasdenture was then made to replace the l eft in place, temporarily, to maintainmissing anterior teeth (even though the occlusal support for a transitional fixedroots were not yet extracted) to stabilize the partial prosthesis during implant placementocclusion and push back the vestibulum as and healing.much as possible in the scarred area (Figure The treatment for the maxilla was then 1 4.13). Crown lengthening was then commenced. It was planned to consist ofperformed on the mandibular third molar to fixed partial prostheses supported by bothexpose it in order to perform endodontic natural teeth and implants. A fixed partial
1 56 PROSTHODONTICS IN CLINICAL PRACTICE Figure 14.18 Figure 14.19 Wax-up of maxillary anterior crowns-frontal view Wax-up of maxillary anterior crowns-left side replaced as the occlusion had been stable i n the area despite the tooth being missing for many years. There were no gingival or caries problems in the area, and to replace the missing tooth with an implant- supported fixed partial prosthesis would require orthodontic therapy to upright the second and third molar teeth. To replace the tooth with a fixed prosthesis would necessitate preparing the second premolar, which had no restorations or caries. Figure 14.20 Following successful bone implantation i n the area of the nasopalatine cyst, a Wax- I mplant insertion-maxillary anterior area up was done to determine the ideal l ocation of the maxillary and mandibular teeth that were to be replaced by the prosthesis would extend from the maxillary i mplant supported fixed prosthesis (Figures right second premolar to the right lateral 14.18 and 14.19). Five implants were i ncisor, replacing the missing right first i nserted in the maxilla (Figure 14.20). In the premolar. A single crown for the maxillary mandible two implants were inserted. l eft first molar and a six-unit fixed partial When the implants were uncovered, it was prosthesis supported by five implants from discovered that the implant in the maxillary the maxillary right central incisor area to the central incisor area had failed and, due to maxillary left second premolar area were to the extensive bone loss, it would be impos- be constructed. sible to replace it with a wide-body type I n the mandible, an implant-supported i mplant (Figure 14.21). fixed partial prosthesis was proposed to Following a re-evaluation, it was decided replace the missing left molars. The missing to make an anterior maxillary fixed prosthe- right first molar tooth was not to be sis supported by only four implants, with
TRAUMATIC SEQUELAE 1 57Figure 1 4.21 Figure 14.22Stage two surgery-exposure of maxillary implants Maxillary implants after healing after second stage surgeryFigure 14.23 Figure 14.24Duralay and abutment impression copings fitted-maxilla Duralay copings fitted-centric relation recordthe central incisor as a cantilever (Figure was an extension of granulation tissue from1 4.22). The implants had been placed in a the failed implant in the maxillary rightcurve and thus provided resistance to central incisor area.multidirectional forces. Copper band elastomeric impressions were During the course of treatment, it was made of all the prepared teeth and Duralaydiscovered that the maxillary right cuspid copings were constructed. These copingshad a periapical lesion. The tooth was were used for the final impression for theasymptomatic, was not sensitive to percus- master model and to record centric relation atsion, and did not have deep probing the vertical dimension of the temporarydepths. An exploratory surgical procedure restorations (Figures 14.23 and 14.24).revealed granulation tissue around the root Unfortunately, at the metal coping fittingapex, which was enucleated. It was stage, a fistula was noticed round thethought at that time that the periapical area maxillary right cuspid and a 10 mm probing
15 8 PROSTHODONTICS IN CLINICAL PRACTICE Figure 14.25 Figure 14.26 Maxilla after extraction of right cuspid Extracted right cuspid-showing fracture excellent bone support. A semi-precision attachment was made to connect this prosthesis and the anterior and left poste- rior prosthesis supported by the four implants. The implants would help support the fixed prosthesis in lateral j aw movements, and the attachment would also allow the teeth to move apically within the limits of the periodontal membrane in centric occlusion. The metal copings were soldered and, Figure 14.27 after try-in of the soldered metal framework Metal copings try-in maxilla-after soldering and showing (Figure 14.27), another elastomeric impres- semi-precision attachment connecting tooth- and implant- sion was made for the tissue reproduction supported prostheses model. These models were mounted on a semi-adjustable articulator (Hanau) using a facebow registration, and centric records depth was found on the palatal aspect of were taken at the vertical dimension of the tooth. A second exploratory surgical occlusion using Duralay with a Neylon procedure was then performed, which technique. revealed massive bone loss on the palatal The porcelain was baked and the occlu- aspect of the tooth (Figure 14.25). The sion checked at the biscuit bake stage in tooth was extracted and a longitudinal the mouth and all adjustments needed fracture of the root was discovered (Figure were then made. The porcelain was then 1 4.26). glazed. The crowns and bridges were The treatment plan was again modified, cemented with Temp-Bond. After one to a fixed partial prosthesis from the right month the crowns and bridges were maxillary second premolar to the right cemented with zinc oxyphosphate cement maxillary lateral incisor. These teeth had for permanent cementation (Figures
TRAUMATIC SEQUELAE 15 9Figure 14.28 Figure 14.29Treatment completed-anterior view Treatment completed-left side many broken teeth. Though he had large amounts of calculus and plaque, he was periodontally resistant. The attack left him with scarred tissue, and also limited ability to open his mouth. He had many broken teeth and was also missing hard and soft tissue in the maxilla. A year previous to the attack, he had a myocardial infarct and was still being treated with assorted medication. The patient requested a fixed prosthesis even though he was prepared to accept aFigure 14.30 removable prosthesis during treatment, butTreatment completed-right side only on a temporary basis. During treat- ment many unsuspected problems arose and the treatment had to be constantly adjusted to the new circumstances. In spite14.28-14.30). A complete series of radio- of all these problems, an excellent resultgraphs was taken after completion of treat- was achieved using a combination ofment (Figure 14.31). natural teeth and implant-supported fixed prostheses. SUMMARY CASE DISCUSSIONThe patient presented with a variety of AVINOAM YAFFEproblems. Due to his unfortunate accident,he had been left with scalp wounds, The patient, a 44-year-old male, wasfractures of the right side of his skull and referred for treatment at the Graduate Clinicthe left mandible, left maxillary sinus following a traumatic injury that changedhemorrhage, lacerations of the cheek, and overnight his general well-being and
1 60 PROSTHODONTICS IN CLINICAL PRACTICE Figure 14.31 Post-treatment radiographs primarily affected his masticatory system. to provide some fixation for the bridge He was a very pleasant and accommodat- during lateral movements. ing patient who adjusted easily to the The restorations were monitored very constant changes in his treatment plan. He carefully during the last 2 years and it is our did, however, insist on having a fixed hope that the customized restoration, restoration, and was willing to go through along with meticulous planning of the whatever procedures were needed to occlusion, will provide many years of lasting achieve this goal. The treatment plan had service. It was also planned that, in the to be modified during treatment and even future, if the teeth supporting the maxillary at a final stage, due to unexpected compli- prosthesis on the right side were to fail, cations. In the final treatment, a fixed additional implants would be implanted and prosthesis was fabricated and special their prosthesis would be connected to the emphasis was placed on the occlusal existing implant-supported prosthesis. scheme to protect both the natural teeth and the implants. A non-working contact that existed on the right side during lateral CASE DISCUSSION j aw movements was adjusted to a situation HAROLD PREISKEL that maintained contact there, while at the same time kept working contacts on the A particularly interesting facet of this implants on the left side. The semi- patients treatment represents his reaction precision attachment between the implant to the appalling physical injuries he and tooth-supported bridges was intended received. It is apparent that before the
TRAUMATIC SEQUELAE 1 61attack the state of his dentition was not of and obliged the patient to be without hisparticular interest to him. One might have removable prosthesis for some time. Theexpected the inevitable psychological net result was that the implants werereaction to his experience to have made positioned slightly palatal to the idealhim even less interested in looking after his position, but in a perfectly acceptableteeth. Quite the reverse happened, and I relationship. The price to pay was the needam confident that the team treating him to construct the facial surfaces of thehad a significant influence upon his restorations considerably labial to theattitude: they are to be congratulated. implant which, in turn, leads to a mainte- I t is also intriguing to note that the patient nance problem. It is encouraging that so far insisted on a fixed maxillary prosthesis the patient has maintained a good level ofdespite the fact that such an approach plaque control and his motivation has not both complicated and lengthened the waned.treatment, compromised the esthetics Connecting the maxillary-implant-(although not by very much), and made supported section to the tooth-supportedmaintenance far more difficult. The step- prosthesis by means of a semi-precisionby-step approach employed provided retainer is not universally accepted. Thereversatility that was put to good use to have been suggestions that there is aovercome a few unexpected events. In a serious risk of intrusion of the tooth-l ong and complex course of treatment, we supported section. Only time will tell and Iall receive the occasional surprise. look forward to an update. From every I quite understand why a premature onlay point of view, the operators are to begraft was not employed, since this would congratulated on the outcome of this have complicated the treatment still further patients treatment.
1 64 PROSTHODONTICS IN CLINICAL PRACTICE Extreme wear of the teeth accompanied by chipping of the enamel and cupping of the dentine Rounded arch form, with broad ridges Figure 15.4 Figure 15.5 Face-frontal view Face-profile EXTRA-ORAL EXAMINATION (Figures 1 5.4 and 15.5) Asymmetric and wide face Drooping eyes Narrow lips Enlarged lower third of the face Figure 15.6 Straight profile Maxillary arch-palatal view Protruding chin with a wide mandible Wide smile, without showing any teeth Maximum opening was 38.0 cm INTRA-ORAL EXAMINATION (Figures 15.6 and 15.7) Anterior cross bite (see Figure 15.1) Distorted occlusal plane Extrusion of the maxillary left posterior and mandibular anterior teeth (Figures 15.8 and 15.9) Amalgam restoration on maxillary right Figure 15.7 second molar Mandibular arch-lingual view
A NEW VERTICAL OCCLUSION 1 65Figure 15.8 Figure 15.9Occlusion-right side Occlusion-left sideFigure 15.10 Figure 15.11Periodontal chart-maxilla Periodontal chart-mandible• Scarring of the tissue from the surgery ( CR). The lateral jaw movements were in to decrease the size of the chin group function. In protrusive movements, there was complete balance. There were An occlusal examination revealed that balancing side interferences in lateralthe patient was Angle class III modification movements. There was fremitus class I on2 according to Ross (Figures 15.8 and the maxillary incisor teeth, and a faulty 1 5.9). There was a reversed overbite of occlusal plane. 1.0 mm and an overjet of 1.0 mm. Thei nterocclusal rest space was 8.0 mm and The periodontal examination revealed plaque,the maximum opening between the calculus, inflammation around most of thei ncisors was 46 mm, with an `S deviation teeth, probing depths of up to 9.0 mm on thei n opening or closing movements. There maxillary teeth and up to 7.0 mm on thewas a 2.0 mm discrepancy between mandibular teeth, with bleeding on probingcentric occlusion (CO) and centric relation on some teeth (Figures 15.10 and 15.11).
1 66 SUMMARY OF FINDINGS The 43-year-old patient with Angle class III Figure 15.12 modification 2 occlusion, status post-surgery, and suffering from hyperostosis corticalis Panoramic radiograph-pre-treatment generalista, came to the clinic complaining of extreme wear of her teeth and the fear that her teeth would soon disappear. She also noticed that her gums bled when she brushed her FULL-MOUTH PERIAPICAL teeth. She exhibited extreme wear of her SURVEY (Figure 15.12) teeth, extrusion of many teeth, plaque, calcu- A complete series of X-rays revealed the lus, missing teeth, and faulty restorations. following findings: DIAGNOSIS Hyperostosis corticalis generalista Moderate with localized advanced adult type periodontitis Excessive tooth wear • Occlusal disharmony with reduced occlusal support • Missing teeth • Small caries lesion in the mandibular • Faulty restorations right first molar tooth • Poor esthetics Thickening and condensation of the • Reduced vertical dimension bone to such an extent that it was very • Caries difficult to differentiate between the roots of the teeth and the surrounding bone ABOUT THE PATIENT • Hyperostosis corticalis generalista The patient was very cooperative; her main desire was to have an esthetic and fixed I NDIVIDUAL TOOTH PROGNOSIS restoration. Within a short period of time, she improved her oral hygiene, and her • Hopeless: none periodontal condition improved.
A NEW VERTICAL OCCLUSION 1 67 POTENTIAL TREATMENT For the loss of vertical dimension: PROBLEMS After the occlusal equilibration, the optimum vertical dimension for anThe patient presented with a variety of esthetic result would be determinedproblems: and, according to that, the vertical• Poor occlusal relationships dimension would be opened by means• Loss of vertical dimension of an occlusal appliance.• Lack of occlusal posterior support For the extreme wear:• Extreme wear• • The teeth that were very worn would Moderate with localized advanced perio- receive crown restorations to replace dontitis the lost tooth structure. For the moderate to advanced periodontitis: POSSIBLE TREATMENT Most of the probing depths were due to SOLUTIONS `pseudo pockets, and it was felt that after initial preparation, these wouldFor the poor occlusal relationships: diminish in size. If not, the problem would be solved with periodontal surgery. A sliding surgical osteotomy procedure in which a block of bone including the teeth is removed and reset in a more TREATMENT PLAN favorable position. This was rejected because the patient refused to undergo Before treatment was started, a diagnostic any extensive surgical procedure. wax-up was done on study models• Orthodontic treatment to intrude the mounted on a Hanau articulator with a teeth to acquire a physiological occlusion. facebow registration and a centric relation This option was also rejected because of record in order to evaluate the esthetic and the fear of root resorption due to the occlusal solutions (Figure 15.13). patients unique bone condition. Crown lengthening periodontal surgery to enable the teeth to be reduced in occlusal height in order to achieve a physiological occlusion and expose sound tooth struc- ture for the margins of the restorations. This option was also rejected as it was felt that the surgery would cause bifurcation and trifurcation involvement of the premo- lar and molar teeth. Gradual selective equilibration of the teeth and the addition of acrylic to the transitional restorations in the opposing jaws in order to improve the occlusal Figure 15.13 plane. Diagnostic wax-up on Hanau articulator
168 PROSTHODONTICS IN CLINICAL PRACTICE TREATMENT ALTERNATIVES weeks. At that time, an obvious improve- ment in the periodontal supporting tissue Maxilla: could be seen, pockets depths had dimin- ished greatly and bleeding on probing had • Fixed partial prosthesis disappeared. It also was evident that the • Fixed and removable partial prosthesis patient had completely adjusted to the new vertical dimension (Figures 15.16 and Mandible: 1 5.17). • Fixed partial prosthesis At this time, transitional restorations were made at the new vertical dimension (Figure • Fixed and removable partial prosthesis • Fixed partial prosthesis with implants 15.18). Implants were also done in the left support mandibular posterior quadrant as it was felt that the mandibular left first premolar and second molar did not provide enough TREATMENT support for a fixed partial prosthesis (Figure 15.19). Initial preparation included scaling, root Due to the faulty plane of occlusion on planing, curettage, and oral hygiene the left side, the maxillary premolars and instruction (Figures 15.14 and 15.15), molars were gradually selectively equili- caries removal, and a mandibular diagnos- brated and acrylic was added to the transi- tic appliance due to the class III occlusion tional mandibular restorations to prevent to evaluate the change in vertical dimen- overeruption of the equilibrated teeth. In sion, followed by transitional restorations. this manner, an optimal plane of occlusion At the completion of this stage, a clinical was achieved. re-evaluation was done to determine Once the transitional restorations fulfilled whether there had been periodontal, all the esthetic, physiological and functional esthetic and occlusal improvement. The expectations of the patient and the dentist, occlusal appliance was observed for 8 the teeth were reprepared and individual Figure 15.14 Figure 15.15 Teeth-right side, after initial preparation Teeth-left side, after initial preparation
A NEW VERTICAL OCCLUSION 16 9Figure 15.16 Figure 15.17Periodontal chart-maxilla, re-evaluation Periodontal chart-mandible, re-evaluationFigure 15.18 Figure 15.19Transitional restorations Implants-mandible, left posterior region copper band impressions were made of all the prepared teeth. Duralay copings were then made and the vertical dimension of occlusion was recorded with these copings ( Figure 15.20). An elastomeric impression (I mpergum) was then done to provide a working model which included the dies and the implant analogues (Figure 15.21). A facebow registration was taken to facilitate mounting the maxillary cast on a semi- adjustable articulator (Hanau). The metalFigure 15.20 copings were cast and fitted. They wereCentric relation record in Duralay connected with Duralay for soldering.
1 70 PROSTHODONTICS IN CLINICAL PRACTICE Figure 15.21 Figure 15.22 Elastomeric impressions Soldered coping try-in and centric relation registration Temp-Bond for a period of 2 weeks. They were 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 since then and has not had any problems (Figure 15.24). SUMMARY Figure 15.23 Treatment completed-permanent restorations The patient presented with a severe problem of extreme wear on many teeth and a reduced vertical dimension of occlu- Centric relation was recorded in Duralay sion. She also had a pathologic occlusion ( Figure 15.22), and another elastomeric with serious balancing side and protrusive impression was made for tissue detail. The premature contacts during mandibular models were then mounted on a Hanau movements. In addition to these problems, articulator, again with the aid of a facebow she suffered from a severe periodontal registration, and the porcelain was baked. problem and was very concerned about Models of the transitional restorations her esthetics. The treatment consisted of provided a buccal key for the position and changing the vertical dimension of occlu- shape of the porcelain, thus copying the sion by selective grinding and addition of transitional restorations. The biscuit bake restorative material, where needed, in order porcelain was checked and adjusted in the to provide a physiological occlusion. The mouth. After the occlusion was finalized, final restorations thus provided a physio- the final glaze was applied to the prosthe- logical, functional and esthetic solution for ses. The prostheses were cemented with her problems.
A NEW VERTICAL OCCLUSION 1 71 Figure 15.24 Post-treatment radiographs CASE DISCUSSION occlusion that was on a course of self AVINOAM YAFFE destruction was changed to a long-lasting therapeutic, physiological occlusion.The patient presented in the clinic with acomplicated situation: missing teeth,severe wear, overeruption of posterior CASE DISCUSSIONteeth, combined with advanced periodon- HAROLD PREISKELtal disease aggravated by a class III maloc-clusion with occlusal interferences. The This patient presented an interesting treatmentsituation necessitated a dramatic change in planning problem. Apart from the unusualthe vertical dimension that had a negative medical complication, the operator had toas well as a positive effect. The positive assess a new vertical dimension of occlusion.effect was in the relationship between the A combination of tooth loss and tooth wear,anterior teeth, changing a class III relation possibly accentuated by a forward mandibu-to an almost class I relation, thus facilitating lar posture, have all led to a class III incisorinvolvement of the anterior teeth in relationship. By how much was it safe toguidance and support. It also facilitated increase the vertical dimension of occlusion?restoration of the posterior quadrants that His treatment appears to have followed ahad undergone severe overeruption. The logical pattern with alternative avenuesnegative effect was the change in the considered at the outset. Apart from the allcrown-to-root ratio. This, however, was important periodontal and endodonticminimal due to the compensatory eruption therapy, the use of transitional restorations isof the teeth during the retrograde wear. In mandatory with problems like these. Thesummary, a 43-year-old patient was planning of the occlusal scheme is to betreated successfully and the pathological commended and the overall result is gratifying.
174 PROSTHODONTICS IN CLINICAL PRACTICE Figure 16.3 Mandibular arch Figure 16.2 Frontal facial view I NTRA-ORAL AND FULL-MOUTH PERIAPICAL RADIOGRAPH EXAMINATION ( Figures 16.1-16.9) Maxilla (Figure 16.3): • The left cuspid and first molar were Figure 16.4 fractured beneath the gingival tissue; Maxillary arch the left central incisor had a provisional restoration There was class 1 mobility on the left central incisor, the left premolars, and the left second molar teeth Mandible (Figure 16.4): The right cuspid was fractured beneath the gingival tissue • Extensive caries and loss of crown There was class 3 mobility on all the structure i ncisor teeth and class 2 mobility on the 50% bone loss around the mandibular left second premolar anterior teeth The left cuspid had class 1 mobility • Periapical abscess maxillary central There were faulty restorations and i ncisor tooth extensive caries on most of the remain- • Radio-opacity in the periapical area of ing teeth the left mandibular first premolar
ADVANCED PERIODONTAL DISEASE 17 5Figure 16.5 Figure 16.6Occlusion-left side Occlusion-right side Figure 16.7 Radiographs of maxillary and mandibular teeth An occlusal examination revealed extru- second premolars. The mandibularsion of many teeth, a faulty plane of occlu- anterior teeth occluded with the palatalsion, vertical overbite of 8.0 mm, and gingival tissue (see Figure 16.5).horizontal overjet of 4.0 mm (Figures 16.5and 16.6). The patient had difficulty The periodontal examination revealedexecuting lateral and protrusive gingival recession, but with minimal probingmovements of the mandible. The only depths-up to 3.0 mm at the maximumocclusal contacts were between the left ( Figures 16.8 and 16.9).
176 PROSTHODONTICS IN CLINICAL PRACTICE Figure 16.8 Figure 16.9 Mandibular periodontal chart Maxillary periodontal chart I NDIVIDUAL TOOTH PROGNOSIS Periapical lesions Resorbed alveolar ridges The prognosis for the remaining teeth was Anterior traumatic overbite the following: Adult type periodontitis Peripheral seventh cranial nerve damage ABOUT THE PATIENT The patient understood that his dental treat- ment would be complex and extend over a Fair: the rest of the teeth long period of time. He agreed to the need to try and save as many teeth as possible. I n the past, the patient had difficulty adjust- He also voiced his preference for a fixed i ng to a removable partial denture and had prosthesis rather than a removable one. discarded it. POTENTIAL TREATMENT DIAGNOSIS PROBLEMS Missing teeth The patient had many missing teeth Extruded teeth Due to rampant caries, some of the Reduced occlusal support remaining teeth were almost totally Loss of vertical dimension destroyed Occlusal trauma There was reduced alveolar bone Mobile teeth support in the anterior part of the Rampant caries mandible and increased mobility in the Faulty restorations mandibular incisor teeth
ADVANCED PERIODONTAL DISEASE 17 7• The patient was in occlusal trauma and PHASE 2 biting on the maxillary palatal tissues during chewing I n the second phase, the priority was treat- Due to the fact that the patient objected ment of pain and infection, stabilizing the to a removable prosthesis, the treat- occlusion, and obtaining occlusal support. ment might have to be compromised After completion of the initial preparation. The right mandibular cuspid and the left maxillary central incisor were treated endodontically. The left maxillary second molar was TREATMENT PLAN ALTERNATIVES extracted. The faulty crown on the maxillaryMaxilla: l eft second premolar was removed and the tooth was treated endodontically. Excavation Fixed partial prosthesis of caries and restoration of the left maxillary Fixed and removable partial prostheses cuspid and premolars was then done. The Fixed telescopic prosthesis mandibular anterior teeth were shortened in height and splinted with orthodontic wireMandible: ( Figures 16.10 and 16.11). At this time a transitional fixed prosthe-• Fixed and removable partial prostheses sis was made, extending from the maxil-• Removable telescopic prosthesis l ary right lateral incisor to the left first• Overdenture premolar tooth. The mandibular right cuspid was then orthodontically separated from the mandibular right lateral incisor, and this was added to the anterior TREATMENT mandibular splint. A transitional crownThe treatment was divided into five was made for the maxillary left secondphases: premolar tooth and a transitional fixed prosthesis was made from the mandibular l eft cuspid to the left second premolarPHASE 1 ( Figure 16.11). The periodontal re-evalua- tion revealed that the pockets depths hadAfter initial treatment consisting of oral diminished greatly and that bleeding onhygiene instruction, scaling and root planing, probing had disappeared.the patient showed a marked improvementi n his home care and the periodontal tissuesexhibited great improvement. It was then PHASE 3decided to splint the anterior mandibularteeth with orthodontic ligature for stabiliza- At this point, after the periodontal evalua-tion. Following re-evaluation, a final treat- tion, additional occlusal support wasment plan was discussed. This would then established by means of a transitional,be a fixed partial prosthesis in the maxilla, mandibular, removable partial prosthesisand a fixed anterior partial prosthesis with a (Figure 16.12). Periodontal surgery on theremovable clasp retained posterior partial maxillary left first molar revealed a perfora-prosthesis in the mandible. tion. The disto-buccal root was removed.
178 PROSTHODONTICS IN CLINICAL PRACTICE Figure 16.10 Figure 16.11 Lingual view of anterior mandibular teeth Frontal view of teeth Figure 16.12 Figure 16.13 Lingual view of mandibular temporized teeth Forced eruption of maxillary cuspid Figure 16.14 Figure 16.15 Crown lengthening procedure-maxillary cuspid Maxillary transitional prosthesis
ADVANCED PERIODONTAL DISEASE 1 79 During caries excavation, additional nec- models were mounted on a semi-essary endodontic treatments were done. adjustable articulator ( Hanau) using aOrthodontic treatment, which consisted of facebow registration and centric recordsforced eruption of the maxillary left cuspid, taken at the vertical dimension of occlusionwas then performed (Figure 16.13). In prepa- i n Pattern resin using the Neylon technique.ration for the crown, a crown lengthening I n the mandible, the porcelain was baked,periodontal surgical procedure (CLP) was and the occlusion checked in the mouth atdone to gain sound tooth structure (Figure the biscuit bake stage; all adjustments16.14). needed were then made (Figure 16.17). The removable partial denture framework was constructed. It was fitted and an altered cast impression was then made for softPHASE 4At 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-l ar 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. Figure 16.16 Soldered metal copings being fitted-mandiblePHASE JAt completion of initial preparation and re-evaluation, the final phase of treatment wascarried out. Copper band elastomerici mpressions were taken of all the preparedteeth and Duralay copings were made.These copings were used for the finali mpression 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- Figure 16.17duce an accurate tissue transfer. These Biscuit bake try-in
ADVANCED PERIODONTAL DISEASE 1 81tissue duplication (Figure 16.18). At the parotid gland. His face drooped, and wassame time, a soft wax occlusal record was asymmetrical. The mandibular anterior teethtaken to mount the model on the articula- exhibited class 3 mobility, which gave ator (Figure 16.19). Teeth were set up on the poor prognosis for their long-term retention.partial denture and fitted in the mouth. The He had rampant caries, related to hisporcelain was then glazed. The crowns and medical history, and many broken teeth. Hisbridges were cemented with Temp-Bond vertical dimension of occlusion wasand the removable mandibular partial overclosed and he was traumatizing theprosthesis inserted. The crowns and anterior palatal tissue when closing hisbridges were then cemented with zinc mouth. The patient requested a fixedoxyphosphate cement for permanent prosthesis, even though during treatmentcementation (Figures 16.20-16.22). A he agreed to accept a removable prosthe-complete series of radiographs was done sis. I n the course of treatment manyafter completion of treatment (Figures problems arose, and his treatment had to1 6.23-16.25). be adjusted to the new circumstances. In spite of all these problems, an excellent result was achieved using a combination of SUMMARY fixed and removable prostheses.The patient, a 70-year-old retired schoolprincipal, presented with many varied CASE DISCUSSIONproblems. He had undergone a number of AVINOAM YAFFEsurgical procedures to remove a pleomor-phic adenoma, which left him with perma- The patient, a 70-year-old male,nent facial nerve damage and loss of the left presented to the clinic for treatment. He
1 82 PROSTHODONTICS IN CLINICAL PRACTICE had many missing teeth, loss of occlusal CASE DISCUSSION support, and anterior traumatic overbite HAROLD PREISKEL aggravated by advanced periodontal disease. His condition was complicated The treatment team demonstrated their by status post- pleomorphic adenoma of ability to take the failing dentition of a 70- the left parotid gland, that left him with year-old patient with a compromised medical facial asymmetry and paralysis of the history and to transform it into healthy, seventh cranial nerve. The treatment was functional, and good-looking units. To started in 1989, when the use of dental achieve this, most of the specialities within i mplants was just beginning in Israel, and dentistry were involved. Forced eruption and they were mainly placed in the anterior other orthodontic treatment, endodontic region of the mandible. At that time, a treatment, and, naturally, periodontal therapy great effort was made to save the are all involved in this well thought out plan. I patients remaining teeth. His vertical was pleased to note that the mandibular dimension was changed, and his bilateral distal extension removal prosthesis mandibular anterior teeth were shortened was made with an altered cast technique. to improve the crown-to-root ratio, while Since the anterior teeth were splinted creating an incisal platform for the maxil- crowns, a better looking restoration might l ary transitional restoration. The aim of his have been achieved using attachments, treatment was to join tooth support for albeit at the cost of increased complexity to vertical dimension to posterior occlusal manufacture and to maintain. This treatment support by means of the removable was commenced well over a decade ago. partial denture. In order to cope with his Professor Yaffe has intimated that today it is problem of severe caries, fluoride rinses j ust possible that the use of implants might were administered as well as the use of realize the patients dream of fixed prostheses artificial saliva. The restorations that were i n both jaws. Naturally, this may be feasible. made restored function, esthetics, and However, what is for sure is that the principle occlusal support to the complete satis- of treatment carried out in the previous decade faction of both the patient and the treat- is just as sound today as it was then, and will ment team. probably be good for many years to come.
PATIENT 17 SEVERE UNILATERAL CLEFT LIP AND PALATE Treatment by Miriam Calev THE PATIENT and palate. He only had one kidney, having donated a kidney to his father for transplan-The patient, a 27-year-old builder, tation.presented himself for examination andconsultation. His complaints were asfollows: PAST DENTAL HISTORY `I have difficulties in eating and breathing In the past, a general dentist had treated him because of the hole in my palate. (Figure in his village and had referred him for 17.1) orthodontic treatment at Hadassah Dental `Sometimes my teeth hurt. School. ` My scar is ugly but it will be fixed soon. EXTRA-ORAL EXAMINATION PAST MEDICAL HISTORY (Figures 17.2 and 17.3)The patient suffered from a peptic ulcer for • Asymmetrical face on right side due towhich he was taking medication (Gastro unilateral cleft lip and palatal scar, and40 mg daily) and congenital unilateral cleft lip nose deformity Figure 17.2Figure 17.1 Face-frontalMaxillary arch-palatal view view 185
186 PROSTHODONTICS IN CLINICAL PRACTICE Figure 17.4 Figure 17.3 Mandibular arch-lingual view Face-side view Competent lips Straight profile with slight concavity and depression of the nose Normally functioning temporomandibu- lar joint, with bilateral clicking on opening Maximum opening 38 mm, with a slight deviation to the left upon opening Negative overbite of 8.0 mm Figure 17.5 Enlarged lower third of the face Anterior teeth-labial view
SEVERE UNILATERAL CLEFT LIP AND PALATE 1 87 Figure 17.7Figure 17.6 Occlusion-left sideOcclusion-right sideFigure 17.8 Figure 17.9Periodontal chart-pre-treatment, maxilla Periodontal chart-pre-treatment, mandible Occlusal examination revealed that the cuspids, and left second molars.patient was Angle class III (Figures Occlusal balancing side and protrusive17.5-17.7), with a reverse overbite of 8.0 premature contacts during lateral andmm and a reverse overjet of 3.0 mm. protrusive mandibular movements wereThere were wear facets on the right noted.second premolar and second molars.The interocclusal rest space was Periodontal examination (Figures 17.83.0 mm, measured between the incisors. and 17.9) revealed unsatisfactory oralThere was a slight discrepancy between hygiene with plaque and calculus.centric occlusion ( CO) and centric Probing depths were found of up torelation (CR). Anterior and bilateral poste- 4.0 mm on the maxillary teeth and up tori or cross-bite was found. Centric 3.0 mm on the mandibular teeth, withocclusal contacts were found on the right bleeding on probing on some teeth. Theresecond molars, right maxillary cuspid to was inflammation around most of theri ght mandibular first premolar, l eft teeth.
188 PROSTHODONTICS IN CLINICAL PRACTICE Figure 17.10 Radiographs of maxilla and mandible-pre-treatment FULL MOUTH PERIAPICAL RADIOGRAPHIC EXAMINATION (Figure 17.10) Endodontic treatment-mandibular right lateral incisor with poor condensation Periapical radiolucent areas around the right mandibular third molar and lateral incisor, and the left lateral incisor and third molar Good bone support of all remaining teeth SUMMARY OF FINDINGS Caries Lateral maxillary right alveolar and The patient, a 27-year-old man, suffering palatal cleft from a peptic ulcer and status post-surgery Short roots of the maxillary anterior teeth for congenitally unilateral cleft lip and Residual roots-maxillary right first molar palate, and complaining of difficulty in eating, bleeding gums, and esthetic problems, came to the clinic for treatment. I NDIVIDUAL TOOTH PROGNOSIS Teeth 8 8 are listed in the periodontal chart as 7 7. As determined by radiographic evaluation, they really are third molar teeth that have shifted mesially to the second molar position.
SEVERE UNILATERAL CLEFT LIP AND PALATE 1 89He presented with poor oral hygiene, significance of proper oral hygiene and itsplaque, gingival inflammation, and shallow i mportance in his treatment.and intermediate probing depths. He haddeep caries, residual roots, crowdedanterior mandibular teeth, defective POTENTIAL TREATMENT PROBLEMSendodontic treatment and restorations.There were periapical lesions around four Cleft lip and palate:mandibular teeth and occlusal interfer- • Scarred lipences during lateral and protrusive • Esthetic problemsmandibular movements. • Limited opening Oronasal fistula: DIAGNOSIS • Breathing problems • Eating problems• Cleft lip and palate (oronasal fistula) • Phonetic problems (status post surgery)• Angle class III with anterior and bilateral Underdevelopment of the maxilla: posterior cross-bite accompanied by • Missing teeth severe interarch discrepancy • Jaw discrepancy• Faulty occlusal relationship, and faulty • Failure of osseous union occlusal plane• Carious lesions Arch level• Defective restorations and endodontic Maxilla: treatment (periapical lesions)• Crowded anterior mandibular teeth • Few remaining teeth with unfavorable• Poor esthetics distribution and malposition of the right• Gingivitis cuspid• Reduced anterior and posterior • Open oronasal fistula support Mandible:• Reduced vertical dimension• Residual root • Remaining teeth had poor prognosis due to caries and defective restorations. ABOUT THE PATIENT I nter-arch level Cross-bite and Angle class III jaw relation-The patient was very conscientious, and shipwilling to cooperate in spite of his physicalhandicaps (scar, limited mouth opening). He • Large interarch discrepancyhad high expectations from his dental treat- • Limited mouth opening and limitedment and even more so from the planned mandibular movementsplastic surgery procedures. He wanted to • The need to change the vertical dimen-i mprove his appearance but did not have sion in order to restore the mouthany preferences for fixed versus removable • The small difference between centricrestorations. He did not appreciate the relation and centric occlusion
1 90 PROSTHODONTICS IN CLINICAL PRACTICE TREATMENT ALTERNATIVES occlusion in order to check patient adaptation Maxilla: • Re-evaluation Telescopic, removable partial denture Fixed partial prosthesis and small PHASE 4 obturator Fixed and removable partial prostheses • Fixed partial prostheses for both the maxilla and the mandible Mandible: • Fixed partial prosthesis TREATMENT I nitial preparation included oral hygiene TREATMENT PLAN i nstruction, scaling, and curettage. Caries PHASE 1: INITIAL PREPARATION removal and provisional restorations were done where indicated. The maxillary right Oral hygiene instruction first molar roots were extracted. Endo- Scaling and curettage dontic therapy was performed on the Dietary changes mandibular right premolars, the mandibular Fluoride rinses and gel application right third molar, the maxillary left central Extraction of residual roots and lateral incisors, and all the mandibular Caries removal i ncisors. Evaluation of patient cooperation At this point, it was determined that the patient was actively participating in his treatment, as his oral hygiene was greatly PHASE Z i mproved (Figures 17.11-17.14). Upon completion of the endodontic • Orthodontic and surgical consultations treatment, the right mandibular third molar • Endodontic therapy where indicated was restored with an amalgam post and • Restorative treatment with restorations core, and the other endodontically treated and provisional fixed acrylic restorations teeth were prepared for cast post and for the teeth with ample loss of tooth cores and provisional restorations. structure After consultation with the plastic surgery and oral and maxillofacial surgery depart- ments, the decision was made by all PHASE 3 concerned that additional surgery would not contribute to the success of the treat- • Orthodontic treatment for uprighting ment, and would probably only traumatize and realigning teeth the patient. Periodontal surgery (vestibulum Re-evaluation and planning of pre- deepening), due to the lack of attached prosthetic periodontal surgery gingiva, was performed upon the maxillary New provisional fixed acrylic restora- right cuspid, including a soft tissue graft tions at the new vertical dimension of from a donor site in the palate, and the
SEVERE UNILATERAL CLEFT LIP AND PALATE 191Figure 17.11 Figure 17.12Anterior maxillary teeth-palatal view, after initial preparation Anterior mandibular teeth-lingual view, after initial prepa- rationFigure 17.13 Figure 17.14Periodontal chart-mandible, first re-evaluation Periodontal chart-maxilla, first re-evaluation remaining endodontically treated mandibu- lar teeth (crown lengthening procedures). The anterior maxillary teeth were prepared for full crown restorations and temporized with provisional restorations at an i ncreased vertical dimension (Figure 17.15). Orthodontic treatment was planned and executed to expand the maxillary arch in order to attain an incisal tip-to-tip relation- ship, rather than the class III Angle that existed. The maxillary right cuspid was alsoFigure 17.15 treated orthodontically to bring it to a moreProvisional restorations-anterior view l abial position (Figure 17.16).
192 PROSTHODONTICS IN CLINICAL PRACTICE Figure 17.16 Figure 17.17 Orthodontic treatment, mandible Provisional acrylic resin restorations Figure 17.18 Figure 17.19 Periodontal chart-mandible, second re-evaluation Periodontal chart-maxilla, second re-evaluation At completion of orthodontic and After a period of 6 months with the provi- periodontal treatment, the cast posts and sional restorations at the new vertical cores were finished and cemented into dimension of occlusion, the patient exhib- place on the endodontically treated teeth. ited no temporomandibular joint or muscu- A re-evaluation regarding the final treat- lar problems. The teeth were re-prepared ment plan was then carried out. New (Figure 17.20), copper band elastomeric provisional restorations were made to i mpressions were taken and the treatment maintain the new vertical dimension and to was continued as outlined in the Technical stabilize the teeth after the orthodontic Information chapter. treatment. These provisional restorations The treatment for the oronasal fistula also enabled us to evaluate patients was to incorporate a precision attachment adaptation to the new occlusal jaw on the lingual aspect of the anterior fixed relations (Figures 17.17-17.19). prosthesis opposite the oronasal fistula. A
SEVERE UNILATERAL CLEFT LIP AND PALATE 1 93Figure 1 7.20 Figure 17.21Final tooth preparation-mandible Facebow registration removable gold foil prosthesis was then concerned about esthetics. The treatment made to seal the oronasal fistula by attach- was further complicated by the severe i ng it to the fixed prosthesis by means of Angle class III jaw relationships and thethe precision attachment. negative overbite and overjet. Another Full arch polyether impressions were problem was that the patient had no under-made for tissue detail. The models were standing of good oral hygiene. Due thethen mounted on a Hanau articulator with decision after consultation with the plasticthe aid of a facebow registration (Figure surgery and oral and maxillofacial surgery 17.21) and the porcelain was baked. The departments, that additional surgery wouldfinal and minute adjustments of the biscuit- not contribute to the success of the treat-bake porcelain were carried out in the ment and would only cause more traumamouth. The final glaze was applied to the to the patient, surgery was not performed.prostheses, 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). SUMMARYThe 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 during Figure 17.22mandibular movements. He was very Gold foil obturator to close palatal cleft
1 94 PROSTHODONTICS IN CLINICAL PRACTICE Figure 17.23 Figure 17.24 Treatment completed-anterior view Treatment completed-anterior view, close up Figure 17.25 Radiographs-post-treatment, maxilla Figure 17.26 Radiographs-post-treatment, mandible
SEVERE UNILATERAL CLEFT LIP AND PALATE 195Treatment consisted of oral hygiene oronasal fistula. A gold foil was fabricated toi nstruction, periodontal surgery, endodontic seal the oronasal fistula by attaching to thetherapy, oral surgery, removal of caries, fixed prosthesis by means of the precisionorthodontic treatment, and altering the attachment, thus providing a fixed prosthe-vertical dimension of occlusion in order to sis along with a seal of the oronasal fistulaprovide a physiological occlusion and and potential access for cleaning whenchange the jaw relationship from Angle needed. In the execution of this treatmentclass III to that of edge-to-edge. The final plan, this young patient was provided with arestorations accomplished all of these solution to his functional and estheticgoals as well as providing an esthetic demands, providing him with a much bettersolution to the patients problems. quality of life. CASE DISCUSSION CASE DISCUSSION AVINOAM YAFFE HAROLD PREISKEL This treatment represents a prosthodontic This patient appeared to combine a solution to a severe unilateral cleft lip and challenging cocktail of prosthodontic palate, with pathologic occlusion along with difficulties. Naturally, surgical closure of i nterarch discrepancy. Further problems the naso-palatine fistula would have been i ncluded esthetic complaints that could not preferable, but in this case had not be otherwise solved, due to an unsuccess- proved feasible. The need to construct ful previous attempt for orthodontic treat- an obturator added yet one more ment and limited surgical success to prosthodontic difficulty. The degree of remedy the situation of the oronasal fistula patient cooperation achieved was quite along with the unilateral cleft lip and palate. remarkable in view of the past history, By using the existing small amount of and orthodontic treatment for both i ntercuspal/retruded cuspal discrepancy arches following periodontal therapy wasalong with optimal increase of the vertical a requirement if a good-looking outcomedimension and utilizing adjunctive orthodon- was to be achieved. Indeed, the maxillarytics, the pathologic occlusion of Angle class orthodontic treatment involved crossingI II was converted to an esthetically satisfac- the cleft, but the subsequent construc-tory functional physiologic occlusion with tion of a fixed prosthesis should preventminute anterior guidance. In order to seal any relapse. The use of transitionalthe oronasal fistula, and avoid a removable restorations in the evaluation of changesappliance, a precision attachment was of a dimension of occlusion is to bei ncorporated on the lingual aspect of the recommended and the result achievedanterior fixed prosthesis opposite the eminently satisfactory.
1 98 PROSTHODONTICS IN CLINICAL PRACTICE • Speech difficulty Maximum opening of 46 mm without • His front teeth are sensitive to hot and deviation (measured from the maxillary cold right central incisor to the mandibular anterior edentulous ridge) Scarred left lip EXTRA-ORAL EXAMINATION (Figures 18.2 and 18.3) I NTRA-ORAL AND FULL-MOUTH • Asymmetrical face: non-alignment of PERIAPICAL RADIOGRAPHIC li ps, nose and eyes EXAMINATION (Figures 18.4 and 18.5) • Normal profile with a sharp naso-labial angle and full lips Maxilla (Figure 18.4): Temporomandibular joint had a recipro- cal click in the right joint • Narrow ridges Figure 18.2 Figure 18.3 Face-frontal view Face-side view Figure 18.4 Figure 18.5 Maxillary arch-palatal view Mandibular arch-lingual view
UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA 199 Triangular arch High palate Unilateral closed cleft palate Deciduous teeth: Amalgam restorations on the right deciduous second molar Figure 18.6 Maxillary central incisors in labio- Occlusion-right side version Sharp conical-shaped cuspids Spacing between the right lateral incisor and right cuspidMandible (Figure 18.5):• Sharp conical-shaped cuspids• Narrow V-shaped residual ridges Figure 18.7 Occlusion-left sideOcclusal examination (Figures 18.6 and 18.7) revealed that the patient was Angleclass III. The interocclusal rest space was Fremitus class 1 was noted on the maxil-5.0 mm. Overjet and overbite could not be lary right lateral incisor and the mandibularmeasured due to the missing anterior teeth ri ght cuspid (due to the cross-bite).( Figure 18.1). There was no discrepancybetween centric relation and centric occlu- The periodontal examination (Figuression. Lateral jaw movements were guided 1 8.8 and 18.9) revealed some plaque,only on the non-working side of the maxil- probing depths of up to 3.0 mm on thelary lateral incisor and the mandibular maxillary and mandibular teeth andcuspid teeth on the right side, and by the bleeding (of the gingiva) on probing.maxillary central incisor and first molar and There was slight gingival recessionthe mandibular left central incisor and first around most of the teeth and severemolar on the l eft side. Protrusive vertical recession on the lingual surfacesmovements were guided by the left first of the mandibular right second and leftmolar maxillary and mandibular teeth. first molar teeth.
200 PROSTHODONTICS IN CLINICAL PRACTICE Figure 18.8 Figure 18.9 Periodontal chart-pre-treatment, mandible Periodontal chart-pre-treatment, maxilla Figure 18.10 Radiographs of maxilla and mandible-pre-treatment, periapical FULL-MOUTH PERIAPICAL I NDIVIDUAL TOOTH PROGNOSIS SURVEY (Figure 18.10) • Severe bone loss around the distal surface of the maxillary left central incisor • Vertical bone loss approximate to the areas of missing teeth
UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA 201 SUMMARY OF FINDINGS i mportance of good oral hygiene, in particular in relation to his dental treat-The 24-year-old patient, status post surgery ment. He wanted a fixed restoration, if of unilateral cleft lip and palate, came to the possible. clinic complaining of missing teeth, difficulty when chewing food, difficulties in speaking, and esthetic problems. He presented with TREATMENT POSSIBILITIES poor oral hygiene, plaque and calculus, and bleeding upon probing. The jaws were Maxilla: undeveloped in the areas where there were missing teeth. There was a discrepancy in Telescopic removable partial denturej aw size, a significant amount of missing Overdenture alveolar bone in the area of the cleft, and Fixed partial prosthesis-tooth- partial anodontia. The occlusion was Cross- supported bite, with a scissors bite between the remain- i ng teeth. The only teeth in occlusal contact Mandible: were the left first molars and the right maxil- l ary cuspid with the mandibular lateral incisor. Fixed prosthesis-tooth-supported There were retained deciduous teeth and Fixed prosthesis-tooth- and implant- sharp-pointed conical cuspids. supported DIAGNOSIS POTENTIAL TREATMENT PROBLEMS• Status post closed unilateral cleft lip and palate (left side) with scarring that Cross-bite and missing teeth resulted in a small maxilla, both antero- Difference in jaw size posteriorly and bucco-lingually Congenital lack of many teeth• Poor occlusal plane Lack of bone support in the area of the• Cross-bite and scissors bite missing teeth• Partial anodontia Developmental defects in the jaw• Reduced occlusal support I nability to incorporate orthodontic and• Primary occlusal trauma surgical treatment• Decreased vertical dimension of occlu- Some of the supporting teeth were sion (questionable) deciduous and their long-term progno- Retained deciduous teeth sis was unknown Gingivitis Faulty esthetics TREATMENT PLAN ABOUT THE PATIENT PHASE 1: INITIAL PREPARATIONThe patient was motivated for dental I nitial periodontal therapy including oraltreatment in spite of his years of unsuc- hygiene instruction, scaling and rootcessful treatment. He was unaware of the planing
20 2 PROSTHODONTICS IN CLINICAL PRACTICE Figure 18.11 Figure 18.12 Patient after initial preparation Wax-up Figure 18.13 Figure 18.14 Wax-up Wax-up • Diagnostic wax-up mounted on an articulator to determine the • Transitional restorations possibility of fixed prostheses at the exist- ing bucco-lingual jaw relationship. This was PHASE 2 found to be impossible and a wax-up was made in which the vertical dimension was • Fixed restorations opened 5.0 mm in the incisor area (Figures 18.12-18.14). After the wax-up on the articulator had TREATMENT been examined, and the amount of wax needed to build up the teeth to occlusion After a short period of initial treatment determined, it was decided to undertake consisting of scaling, root planing, curet- minimal crown preparation of the teeth tage, and oral hygiene instruction (Figure which were to be restored and normal 18.11), study models were taken and crown preparation of the remaining teeth.
UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA 203 i mprove their bucco-lingual relationships. The problem of crowding between the maxillary incisor teeth was then treated by separating them using wedges. Due to the fact that the mandibular incisors never formed, the vertical level of the soft tissue was lower than normal, thus necessitating periodontal surgery to add papillae to the mesial of the mandibular cuspid teeth. The vertical dimension of the transitional restorations was then duplicated in aFigure 18.15 second set of transitional restorations. InTransitional prosthesis I-anterior view order to be sure that the patient adapted to the new increased vertical dimension, and that the occlusion was stable, as well as toThe decision to make a fixed restoration check the vitality of the prepared teeth, thewas taken with the understanding that patient was maintained in these restora-there would be minimal tooth preparation tions for one year.and thus conservation of tooth structure At re-evaluation one year later, the clinicaland vitality of the teeth, thus minimizing the situation was stable and there were noneed for endodontic therapy. problems (Figures 18.16-18.18). The final The teeth were then prepared and the phase of treatment was then carried out.first transitional restorations were made at The teeth were reprepared (slightly), andthis new vertical dimension (Figure 18.15). i ndividual copper band elastomeric impres-At this time, endodontic treatment was sions were taken, and stone dies andundertaken on the maxillary central incisors Pattern resin copings made as described inwhich had pulp tested non-vital. the Technical Information chapter. TheEndodontic treatment was also carried out prostheses were then glazed and temporar-on the mandibular cuspids in order to il y cemented in the mouth with Temp-BondFigure 18.16 Figure 18.17Transitional prosthesis II-right side Transitional prosthesis II-left side
20 4 PROSTHODONTICS IN CLINICAL PRACTICE Figure 18.18 Figure 18.19 Transitional prosthesis II-patient smile Treatment completed-anterior view Figure 18.20 Treatment completed- radiographs for a period of 2 weeks. The prostheses The first bridge extended from the left were then cemented permanently with zinc mandibular first molar to the left first premo- oxyphosphate cement (Figures 18.19 and l ar, and the second, from the left mandibu- 18.20). Due to the difficulty in obtaining a lar cuspid to the right mandibular second parallel path of insertion in the mandible, the molar. The maxillary restoration was l ower prosthesis was built in two sections. constructed in one unit.
UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA 205 SUMMARY CASE DISCUSSION AVINOAM YAFFEThis patient presented with severeproblems. He was status post (S/P) This case represents a rather controversialsurgery for unilateral cleft lip and palate, treatment plan. On one hand, retained decid-which left him with scarring that negated uous teeth served as abutment teeth forany orthodontic or surgical treatment. He fixed partial restoration, and at the same timehad many missing teeth, mostly congeni- the vertical dimension of occlusion wastal. He had a severe cross-bite and increased by 5 mm. This further jeopardizedscissor bite with a very difficult anterio- the survival of the deciduous teeth. All thatposterior and bucco-lingual jaw relation- with the intention to facilitate, from a biome-ships to deal with. He wanted a fixed chanical aspect, fabrication of a fixed partialrestoration yet was ignorant of good oral restoration. This case was executed withhygiene. A careful evaluation was made caution at each step. The team was aware ofusing mounted study models on an artic- the risk, therefore the diagnostic wax-upulator and a tentative wax-up was done to took into account existing tooth position, anddetermine whether fixed treatment was the food table was thus designed to possible. The patient was then treated minimize the off-center loading on the teeth.with transitional restorations for over one The occlusal scheme was performed withyear, in order to make sure that he could minimum rise on lateral excursions toadapt to the increased vertical dimension. minimize load and trauma to the teeth. At the Only then were permanent restorations completion of this restoration, it can be made. The maxillary anterior teeth were claimed that the solution provided in this restored esthetically in spite of the severe case is esthetic, satisfactory from a functional l i mitations that the patient presented. The standpoint, and provides the patient with aanterior teeth were restored in a class I physiologic therapeutic occlusion. relationship although in the posterior region, a slight cross-bite was built inorder to improve function. The cuspids CASE DISCUSSIONguided lateral movements without any HAROLD PREISKELnon-balancing side contacts. The maxil-l ary left central incisor tooth was restored Treating a patient with a cleft palate andwith supra-gingival margins in order to collapse of the maxillary dentition togetherachieve a better path of insertion. This with the associated derangement of occlu-could be done as the patient had a high sion is never straightforward. The decisionli p line and esthetics was not a problem. to increase the vertical dimension by someTotal treatment time was 2 years and all 5 mm was probably correct, although thethe teeth remained vital, except for the preparing of teeth at an early stage of treat-four teeth that were treated endodontically ment must be considered brave. A moreat the beginning of the treatment. The cautious approach would have been totreatment gave the patient esthetics and i ncrease the vertical dimension usingfunction that he had never had previously, removable prostheses until the correctdue to his pre-existing congenital difficul- vertical dimension had been established,ties. and only at this stage to undertake
20 6 PROSTHODONTICS IN CLINICAL PRACTICE i rreversible procedures such as tooth pose maintenance problems in the longer preparation. It is not simply the inter-arch term. One can only hope that the patients space that poses the problem, it is the motivation is preserved, along with all the i nter-abutment space and the cleansability hard work that went into construction of of the resultant prosthesis that is likely to the restoration.
PATIENT 19 GENERALIZED AMELOGENESIS I MPERFECTA Treatment by David Lavi THE PATIENT PAST MEDICAL HISTORYThe patient, a 25-year-old woman (Figure The patient had suffered some illnesses in19.1), presented herself for examination childhood, but was currently in goodand consultation. Her complaints were as health.follows: ` My teeth are ugly. PAST DENTAL HISTORY The color of my teeth is awful. ` My gums bleed and hurt when I brush Treatment at a local dental clinic included them. two root canal treatments, two posts, and `I feel that my mouth is one big mess. some amalgam restorations. Previously, ` Food sticks between my teeth after because of an accident, some of her every meal. anterior maxillary teeth were extracted and My teeth are sensitive to anything hot or a provisional fixed acrylic restoration was cold. placed (Figure 19.2).Figure 19.1 Figure 19.2Face-frontal view Anterior teeth-labial view 207
208 PROSTHODONTICS IN CLINICAL PRACTICE EXTRA-ORAL EXAMINATION (Figures 19.1 and 1 9.3) Symmetrical face Competent lips Straight profile Normal temporomandibular joint Maximum opening 60 mm, with a slight deviation to the left upon opening Figure 19.3 I NTRA-ORAL EXAMINATION Face-profile view (Figures 19.4 and 1 9.5) Exposed dentin Extensive caries Rounded arch form Wear of teeth accompanied by chipping of the enamel and cupping of the dentine Missing teeth: Fixed provisional acrylic partial prosthe- Figure 19.4 sis: Mandibular arch I rregular occlusal plane (Figures 1 9.6 and 19.7) An occlusal examination revealed that the patient was Angle class III (Figures 19.6 and 1 9.7), with an overbite of 0.0 mm and an overjet of -1.0 to -1.5 mm. The interocclusal rest space was 2.0 mm, measured between the incisors. There was no discrepancy between centric occlusion (CO) and centric relation (CR). Balanced occlusion and anterior and bilat- eral posterior cross-bite were noted. Figure 19.5 There was edge to edge occlusion Maxillary arch between the left maxillary central incisor
GENERALIZED AMELOGENESIS IMPERFECTA 209Figure 19.6 Figure 19.7Occlusion-right side Occlusion-left sideFigure 19.8 Figure 19.9Periodontal chart-mandible Periodontal chart-maxillaand the left mandibular central and lateral FULL-MOUTH PERIAPICAL ANDincisor teeth (as restored by the provi- CEPHALOMETRIC SURVEYsional restoration). (Figures 19.10 and 19.11)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.
21 0 PROSTHODONTICS IN CLINICAL PRACTICE Figure 19.10 Radiographs of maxilla and mandible SUMMARY OF FINDINGS The 25-year-old patient complained of poor esthetics, sensitivity in her teeth and gums, and bleeding gums on brushing. She suffered from exposed dentine, short clinical crowns, noticeable changes in the shape and color of her teeth, and root and crown proximity. She had poor oral hygiene, caries, missing anterior maxillary teeth, and faulty restora- tions. Probing depth was average, and there was a radiolucent area in the right maxilla. DIAGNOSIS Angle class III with bilateral posterior cross-bite Figure 19.11 Amelogenesis imperfecta Cephalometric radiograph Multiple carious lesions Root and crown proximity Faulty restorations I NDIVIDUAL TOOTH PROGNOSIS Occlusal disharmony and faulty occlusal plane Missing maxillary teeth Poor esthetics Gingivitis Radiolucent area in the right maxilla Impacted maxillary left cuspid
GENERALIZED AMELOGENESIS IMPERFECTA 211 ABOUT THE PATIENT removal and endodontic therapy were performed on the mandibular left firstThe patient was very cooperative, and within molar, second right mandibular premolar,a short period of time, her oral hygiene and and the right mandibular first and secondher periodontal condition improved. She molars, as indicated. The endodonticallywanted an esthetic, fixed restoration and treated teeth were restored with amalgamhad high expectations of how much it would post and cores. Full coverage provisionali mprove her appearance. restorations were made serially in order to restore extensive lost tooth structure (Figure 19.12).POTENTIAL TREATMENT PROBLEMS Orthodontic treatment was performed to alleviate root and crown proximity (Figure• Amelogenesis imperfecta complicated 19.13). At this point, after re-evaluation, by root and crown proximity• Poor occlusal relationships-Angle class III with bilateral cross-bite• Short clinical crowns that would require crown-lengthening procedures, thereby increasing the crown-to-root ratio, which might worsen the overall prognosis TREATMENT PLAN• Oral hygiene instruction• Scaling and curettage• Caries removal and endodontic therapy, where indicated Figure 19.12 Evaluation of patient cooperation Immediate provisional fixed acrylic Transitional restorations restorations for the teeth with consider- able loss of coronal tooth structure Orthodontic treatment to alleviate root and crown proximity Crown-lengthening surgery, where indi- cated Re-evaluation Fixed partial prostheses for both the maxilla and the mandible TREATMENTInitial preparation included oral hygiene Figure 19.13i nstruction, scaling, and curettage. Caries Orthodontic treatment-to alleviate root and crown proximity
21 2 PROSTHODONTICS IN CLINICAL PRACTICE l ocalized crown lengthening was under- taken on the left maxillary and mandibular second molars. Periodontal surgery to align the gingival margins of the maxillary anterior teeth was carried out (Figure 19.14). Additional orthodontic treatment was then performed to realign the maxillary left central i ncisor tooth, correcting the existing midline discrepancy (Figure 19.15). At completion of orthodontic and periodontal treatment, new provisional restorations were made to Figure 19.14 maintain the newly acquired interproximal Periodontal surgery-crown lengthening procedure space 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 Figure 19.18 Biscuit bake porcelain try-in Finished restorations on Quick articulator
GENERALIZED AMELOGENESIS IMPERFECTA 21 3Figure 19.19 Figure 19.20Facial view of patients smile after treatment completion Finished restorations in mouth Once the esthetic, physiological and out in the mouth (Figure 19.17). The finalfunctional expectations of the patient and glaze was applied to the prostheses (Figurethe dentist had been attained in the transi- 19.18), and the prostheses were cementedti onal restorations, the teeth were repre- with Temp-Bond for a period of 2 weeks.pared, individual copper band elastomeric They were then cemented with zinci mpressions were taken, and stone dies and oxyphosphate cement for permanentPattern resin copings made as described in cementation in 1999 (Figures 19.19-19.21).the Technical Information chapter. Themetal copings were fitted, connected,soldered and refitted as previously SUMMARYdescribed and the porcelain biscuit bakeapplied. The final and minute adjustments The patient presented with a severeof the biscuit bake porcelain were carried problem of enamel hypoplasia on all of herFigure 19.21Radiographs after treatment completed
21 4 PROSTHODONTICS IN CLINICAL PRACTICE teeth, multiple carious lesions, massive loss anterior-posterior occlusal relationship, of tooth structure, and root and crown gaining 1.5 mm of overjet and 1.0 mm of proximity. There was a pathologic occlusion overbite, thus enabling a physiologic occlu- with serious non-working side and protrusive sion and minimally jeopardizing long-term premature contacts during mandibular tooth survival. At completion of the rehabil- movements. She was very concerned about itation, all the esthetic, functional, and her esthetics. The treatment consisted of physiologic criteria were accomplished. changing the vertical dimension of occlusion, orthodontic treatment, in order to provide a physiological occlusion and decrease the CASE DISCUSSION root proximity, and provide a proper founda- HAROLD PREISKEL tion for the future fixed restorations. Periodontal surgery was also undertaken for This patients treatment represents another crown lengthening as well as gingival align- example of what can be achieved with ment. The final restorations provided her with dedicated and skilled operators and a a functional, physiological, and esthetic motivated patient. The daunting problem of solution. amelogenesis imperfecta, malpositioned roots, caries, and active periodontal disease, were overcome in a sensible manner. It is CASE DISCUSSION hard to believe that little more than one AVINOAM YAFFE practicing generation ago such a combina- tion of problems would have been treated by The 25-year-old patient presented to the the removal of the roots and the construc- clinic with generalized amelogenesis imper- tion of complete upper and lower dentures. fecta complicated by multiple carious Nowadays, the combination of difficult root l esions with massive loss of tooth structure, position, short clinical crowns, and caries, and aggravated by close proximity of roots might have tempted operators to consider and crowns. The solution provided took the implant approach. Indeed, this may have i nto consideration all of these factors. In been a viable option, but I feel that Dr Lavi order to solve the problem of short crowns made the right decision and in the unlikely (retention for a fixed prosthesis) due to the event that the restoration should not survive l oss of enamel (Amelogenesis imperfecta) a reasonable period of time the implant the vertical dimension of occlusion was option still remains. The periodontal care, i ncreased so that there was minimal orthodontic therapy, and restorative treat- occlusal reduction. This reduced the need ment have produced an excellent result, but for crown-lengthening procedures on one that will require unwavering enthusiasm one hand, and also i mproved the if it is to be maintained.
PROSTHODONTICS IN CLINICAL PRACTICEFigure 20.3 Figure 20.4Frontal view of teeth showing orthodontic retainers Face in profile • Lower lip exhibited two PITS, indicative of the Raynauds disease (Figure 20.5) • Bridge of the nose was very wide and the nostrils were without bone support and were enlarged (Figure 20.1) Maximum opening was 53 mm, and there was no deviation in either opening or closing movements No muscle sensitivity was noted and the jaw movements were normal Compromised esthetics due to theFigure 20.5 bilateral lip clefts and the missing maxil-View of lips showing PITS l ary lateral incisor teeth I NTRA-ORAL EXAMINATIONcompromised and sometimes difficult tounderstand. At age 14, he underwent Maxilla (Figure 20.6):orthopedic surgery to build up his nose andalso to close the boney hard palate clefts. Jaw-normal size, asymmetrical, trian-There was a family history of sensitivity to gular, with a class 3 soft palate andOptalgin (glucose-6-phosphate dehydroge- shallow vestibulumnase deficiency). Amalgam restorations on some of the molar teeth Caries on the left maxillary molars and EXTRA-ORAL EXAMINATION the right maxillary first molar Very poor oral hygiene with inflamed• Straight profile with incompetent lips gingivae accompanied by calculus and ( Figures 20.1 and 20.4) plaque
BILATERAL CLEFT PALATE AND RAYNAUDS DISEASE 217Figure 20.6 Figure 20.7Maxillary arch Mandibular arch• Congenital absence of the maxillary l ateral incisor teeth, an oral nasal fistula on the right side between the hard palate and the premaxilla; the pre- maxilla was slightly mobile Palatal scar above the left molar teeth Third molar teeth impactedMandible (Figure 20.7): Ovoid jaw shape High floor of the mouth with wide and Figure 20.8 broad muscle attachments and shallow Open bite right side vestibulum Amalgam restorations on some of the molar teeth side contacts between the maxillary second molars and the mandibular third An occlusal examination revealed that molars. In protrusive movements, therethe patient was Angle class III, with an was no anterior disclusion and the onlyopen anterior cross-bite (Figure 20.3). The contacts were on the second molars.i nterocclusal rest space was 2.0 mm.There was no midline deviation. The poste- The periodontal examination revealedri or teeth were in an edge to edge relation- probing depths of up to 5.0 mm on theship bucco-lingually. The plane of occlusion maxillary teeth and up to 4.0 mm on mostwas faulty, with incomplete contacts of the mandibular teeth, with bleeding onbetween the maxillary and mandibular probing on some teeth (Figures 20.9 andteeth (Figure 20.8). The only working side 20.10). There was slight inflammationcontacts in lateral jaw movements were on around the maxillary and mandibularthe second molars. There were balancing molars.
218 PROSTHODONTICS IN CLINICAL PRACTICE Figure 20.9 Figure 20.10 Maxillary periodontal chart Mandibular periodontal chart Figure 20.11 Radiographs of maxillary and mandibular anterior quadrant FULL-MOUTH PERIAPICAL SURVEY (Figure 20.11)
BILATERAL CLEFT PALATE AND RAYNAUDS DISEASE 21 9• Maxillary left first molar had an mesio- missing and the maxillary third molars were occlusal amalgam restoration with impacted. Some of the existing restorations mesial caries were faulty and there was extrusion of the• Small distal caries in the maxillary left mandibular right third molar. There was cuspid caries on many teeth. He was Angle class Distal caries in the right maxillary central I II with an anterior cross-bite as well as an incisor anterior open bite, with a faulty plane of Occlusal amalgam restorations in the occlusion. second molar teeth DIAGNOSIS I NDIVIDUAL TOOTH PROGNOSIS • Bilateral cleft lip and palate s/p (statusAll the teeth had a good prognosis. post) surgery Oral-nasal fistula Congenitally missing teeth SUMMARY OF FINDINGS Poor esthetics Anterior cross-biteThe patient, a 17-year-old high school Anterior open bitestudent, came to the clinic complaining of Gingivitispoor esthetics and missing front teeth. He Carieswas very concerned about his appearance Raynauds diseaseand wanted to have a fixed prosthesis to Impacted maxillary third molarsreplace his removable one. His previous medical history consisted ofcongenital bilateral cleft palate and lip with ABOUT THE PATIENTmany unsuccessful attempts at surgicalrepair, and he remained with much The young patient seemed to have noscarring. He suffered from Raynauds understanding of the importance of thedisease. There was a lack of bone between need for his cooperation in his dental treat-the premaxilla and the maxilla on the left ment. He was strongly motivated to haveside, and on the right side there was a dental treatment for esthetic reasons, andnarrow bridge of bone connecting the wanted his teeth fixed before he waspremaxilla and maxilla. He had undergone inducted into army service.orthodontic treatment and had removablemaxillary and mandibular orthodonticmaintainers, which also replaced the POTENTIAL TREATMENTmissing maxillary lateral incisor teeth. There PROBLEMSwas an oral-nasal fistula between his hardpalate and premaxilla on the right side. The patient was a young man who had His oral hygiene was poor. He had large undergone multiple, extensive, but unsuc-amounts of plaque and calculus causing cessful surgical procedures to repair agingivitis, but with good bone support. The congenital condition, and was thereforemaxillary lateral incisors were congenitally wary of extensive dental treatment.
220 PROSTHODONTICS IN CLINICAL PRACTICE TREATMENT PLAN Maxilla: • Maxillofacial surgery to add needed bone i 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 the missing lateral incisor teeth with a remov- able prosthesis to seal the oral-nasal fistula • Removable partial denture Figure 20.12 • Restoration of carious teeth CT radiographs of the maxilla Mandible: • Restoration of carious teeth TREATMENT I nitial preparation included oral hygiene i nstruction, scaling, curettage, and root planing. The carious teeth were then restored. At the end of this stage, an obvious improvement in the periodontal supporting tissue could be seen, and it was observed that the pocket depths had diminished and that the bleeding on Figure 20.13 probing had disappeared. Anterior view of teeth Occlusal equilibration was performed to reduce the anterior open bite and obtain stable intercuspal position. The patient was also referred for speech therapy. Following a CT radiograph (Figure 20.12), consultation with the oral and maxillofacial surgery depart- ment revealed that the chance for success- ful augmentation of the cleft on the left side and closure of the fistula was almost negligi- ble. The possibilities of treatment of the maxilla were then limited to a removable partial denture to replace the missing maxil- l ary lateral incisor teeth and to cover the opening of the fistula, or to restore the Figure 20.14 missing lateral incisors with a fixed partial Palatal view of maxillary anterior teeth
BILATERAL CLEFT PALATE AND RAYNAUDS DISEASE 221Figure 20.15 Figure 20.16Dies and Duralay copings Soldered metal copings being fittedprosthesis from the right cuspid to the left l ary prepared teeth, and Duralay copingscuspid, with provision for a removable palatal were made (Figure 20.15). These copingsattachment to cover the palatal fistula. A very were used to record centric relation at theaccurately fitting gold palatal leaf (denture) vertical dimension of occlusion as determinedthat would seal the fistula was chosen. It by the posterior teeth, and for the impressionwould be retained by a precision attachment for the model to make the metal copings. Thefitting into the maxillary right lateral incisor metal copings were built with a semi-preci-pontic (split lingual attachment). sion attachment in the maxillary right lateral The maxillary central incisor and cuspid i ncisor pontic. These were then fitted andteeth were prepared and temporized with a soldered and, after try-in of the solderedtransitional fixed prosthesis, which also metal framework, a centric registration recordcorrected the cross-bite and gave anterior was made in Duralay (Figure 20.16) and ancontact in centric relation and anterior elastomeric impression was made for theguidance in lateral and protrusive movements tissue pick-up for the master model.of the mandible (Figures 20.13 and 20.14). In The models were mounted on a semi-addition, `guided passive eruption allowed adjustable articulator ( Hanau) utilizing athe molars on the right side to erupt into facebow registration and centric recordscontact. This was accomplished by building were taken at the vertical dimension of occlu-up the mandibular lingual cusps with sion utilizing Duralay with a Neyloncomposite resin in order to prevent lateral technique. At this point the porcelain wastongue thrust, which was preventing the teeth baked and the occlusion checked at thefrom erupting to contact. The composite was biscuit bake stage in the mouth and allremoved after occlusal contact had been adjustments needed were then made. Aachieved and the surfaces finely polished. Duralay palatal attachment was fitted and After the patient adapted to his new rest- relined in the mouth with Duralay (Figureorations, copper band impressions of methyl- 20.17). This palatal attachment was thenmethacrylate and elastomeric impression cast in gold, with a male attachment to fit thematerial (Xantropen) were taken of the maxil- female attachment in the right maxillary
222 PROSTHODONTICS IN CLINICAL PRACTICE Figure 20.17 Figure 20.18 Palatal seal in Duralay Palatal seal in gold Figure 20.19 Case cemented-post-treatment anterior palatal view Figure 20.20 l ateral incisor pontic (Figure 20.18). The gold Frontal facial view of patient after treatment completion removable palatal attachment was fitted and checked in the mouth. The maxillary fixed prosthesis was glazed and polished, as was the gold palatal attachment. The prosthesis SUMMARY was cemented with Temp-Bond for a period of 2 weeks and the palatal attachment The patient presented after many unsuc- inserted (Figures 20.19 and 20.20). The cessful surgical attempts to close a bilateral patient was taught how to insert and remove congenital palate and lip cleft. He had poor the palatal attachment for cleaning purposes. oral hygiene, difficulties with speech and a The crowns and bridges were then very poor self-image due to severely cemented with zinc oxyphosphate cement compromised esthetics. The patient was for permanent cementation. restored to form and function with the
BILATERAL CLEFT PALATE AND RAYNAUDS DISEASE 223minimal treatment necessary, which anterior fixed prosthesis. Additionali ncluded a fixed partial prosthesis to occlusal support was also obtained byreplace the congenitally missing maxillary passive eruption of posterior teeth thatl ateral incisor teeth, and a semi-precision formerly were not in contact.gold palatal attachment to cover the exist-i ng oral-nasal fistula, thus preventing foodand liquids from entering the nasal cavity. CASE DISCUSSION HAROLD PREISKEL CASE DISCUSSION The successful outcome of this young AVINOAM YAFFE mans treatment appears to have been achieved as a result of a team approachThe patient, a 17-year-old high school with successful patient motivation. As astudent, presented to the clinic seeking result, the tongue thrust that was causingtreatment to solve esthetic and functional molar separation on the right hand sideproblems. He was anxious to get rid of his was overcome with the aid of transitionalremovable partial orthodontic retainer, composite additions to the lower teeth andwhich also restored his missing lateral occlusal stability obtained. Missing laterali ncisor teeth. Once the possibility for a i ncisors were restored with fixed prosthe-surgical correction of the fistula was ses-something the patient had wantednegated, the patient, in order to prevent from the outset-while the obturation of anhaving a removable prosthesis, claimed oro-nasal defect was obtained by meansthat the fistula really did not bother him. of a very small removable device incorpo-However, as the fistula did create a rating an attachment within the ponticproblem, a solution was found that could replacing the lateral incisor. In order tosatisfy the patients wishes as well as seal obtain a perfect seal, the path of insertionthe fistula. This was a fixed partial prosthe- of the obturator had to be carefullysis with a small removable partial denture planned and this, in turn, was decided byto cover the oral-ateral fistula. Prior to fabri- the alignment of the attachment in thecating the provisional prosthesis, selective pontic. This highlights the importance ofgrinding was performed, with the intention an overall plan of treatment, that includedof obtaining a stable occlusion and the path of insertion for the removablefreedom in mandibular movements for the prosthesis.
226 I NDEX congenital cleft lip/ palate 185, 215-23 crown-to-root ratios 9, 17, 20, 114, 211 congenital partial anodontia 92, 94 change 171 contacts, premature 187, 193, 214 i mprovement xii, 50, 61, 71, 79, 182 copings 106 minimizing increase 120 abutment impression 157 potential problems 44, 48 Duralay xiv, 107, 169 curettage scc root planing/scaling/curettage after trauma 157 cleft lip /palate 221 deciduous teeth, retained 199, 201 extensive wear patient 32, 33 dentine exposure 25, 208 periodontal disease 179 dentures periodontitis 77, 87, 88, 97, 117 existing 102, 103, 137 gold 47 partial 107, 146 i mpression 88 overlay 120 magnetic 145 removable 9, 26, 117, 118, 120, 144 metal 10, 32, 34 removable 179 cleft lip/palate 221 attitude to 28, 67, 75 neglected dentition 47, 59 severe periodontitis 104, 105, 107, 108, 109 new vertical occlusion 169 teeth 117, 145 patient with limited finances 145 transitional 116, 154, 155 periodontitis 70, 97, 106-7, 117 diagnosis and refusal of surgery 133 advanced periodontal disease 176 Pattern resin xiv after trauma 153 amelogenesis imperfecta 213 amelogenesis imperfecta 210 cleft lip/palate 203 i n bruxism 16-17 neglected dentition 47, 59 cleft lip/palate 189, 201, 219 patient with limited finances 144, 145 with deterioration 55 and refusal of surgery 133 excessive wear patient 7, 28 retrograde wear patient 9 new vertical occlusion 166 provisional acrylic 144 periodontitis 67, 85, 94, 104, 113 transfer 47, 69 and refusal of surgery 129 try-in 118, 134, 158, 170 diagnostic set-ups 95, 99 coronal structure loss 8, 112, 126, 128, 174 dietary factors xi, 28, 63, 130, 137, 141 cross-arch splinting 8 cleft lip/palate 190 cross-bite 164, 187, 189, 219, 211 i mprovement 67, 68 cleft lip/palate 199, 201, 205 periodontitis 71, 72 bilateral 217, 221 disarticulation 26, 35 crowding of teeth 65, 71, 82, 126, 151 Durafil vs 97 crown lengthening 30, 35, 69 Duralay 32, 78, 88, 97 after trauma 155 after trauma 158 amelogenesis imperfecta 211, 212, 214 cleft lip/palate 221 cleft lip/palate 191 with deterioration 59 new vertical occlusion 167 new vertical occlusion 169, 170 periodontal disease 178, 179 periodontitis 107, 117 crowns 167 see also under copings fabrication of prostheses on 117 dust in tooth wear 18, 28-9 preparation 130, 202 provisional 142 elastics 44, 57, 76, 105 short clinical 211, 214 Elmex gel 142 splinted 182 enamel chipping 24-5 transitional 44, 130, 154 enamel hypoplasia 213-14 periodontal disease 177 endodontic therapy 114 periodontitis 77, 116 after trauma 154, 155