Prosthodontics in clinical practice

PROSTHODONTICS IN
CLINICAL PRACTICE

PROSTHODONTICS IN
CLINICAL PRACTICE

Robert S Klugman, DDS

Former Senior Clinical Lecturer
Department of Prosthodontics
Hebrew University-Hadassah School of Dental Medicine
Private practice
Jerusalem, Israel

Contributions by

Harold Preiskel, MDS, MSc, FDS RCS

Consultant in Prosthetic Dentistry
Guy's Hospital
Private practice
London, UK

and

Avinoam Yaffe, DMD

Professor, Department of Prosthodontics
Director, Graduate Training Program
Hebrew University-Hadassah School of Dental Medicine
Jerusalem, Israel

MARTIN DUNITZ

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

First published in the United Kingdom in 2002
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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 Raynaud's disease 215
Treatment by Yael Houri

I ndex 225

FOREWORD

I t has been a pleasure and privilege to prosthodontics; it illustrates how relatively
make a contribution to this project. The i nexperienced colleagues can carry out
book represents the fruits of a lifetime's i nvolved procedures provided they are set
experience 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 anything
great 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 have
situation, rather than the other way round. been available for many years, but
So often overlooked is the fact that techniques, after all, are only means to an
patients who have suffered severe tooth end. Dr Klugman has been able to take
l oss do not usually arrive for treatment advantage of his clinical experience to
with a mouth in pristine condition. Yet Dr adapt these well-tried methods to
Klugman and his graduate students take present-day prosthodontics, and in this
patients, 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

PREFACE

The idea for writing this book came while The program is of 3'/ years duration and
sitting in one of the seminars of our gradu- includes certain clinical and basic science
ate program in Prosthodontics. requirements. Successful completion of
One of our students was presenting a the program enables the student to be
progress report of his patient, discussing eligible for the specialty licensing examina-
the diagnosis, and the possible treatment tion administered by the Ministry of Health
plans. Finally, he showed his treatment and in order to qualify as a specialist in Oral
explained its rationale. As I sat there, the Rehabilitation. In the first years, one or two
thought came to me, what a waste of students were accepted to the program
information this is; the student is present- and, as time went on, the program was
ing a beautifully documented treatment for expanded to include up to four students
a very difficult patient with superb radio- per year. This gave a core group of
graphs and slides. What a shame that only between 12 and 16 students to participate
the 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 spend
treatment 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 seminars
tion possible the following week. During as needed. The students spend 3 days a
the 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 in
alternative treatment strategies. It's a give clinical or original research. Many of the
and take situation. It is our conviction, that students carry out basic research projects
this 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, Oral
the 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.

INTRODUCTION

The book is divided into four parts according necessary, consultations with the patient's
to the primary problem of the patient: physician are conducted prior to any
Periodontal breakdown, Dysfunctional habit dental procedures.
patterns, Extensive loss of teeth, and One of the philosophies of our treatment is
Congenital disorders. Naturally, most patients to give the anterior teeth the added function
overlap 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 only
ment, is a healthy periodontium. The main used for incising food, speech, esthetics, and
goal of our treatment is to identify the anterior guidance in eccentric movements of
causative factors of the patient's dental the mandible. By utilizing the proprioceptive
problem, and thus be able to control them. properties of the anterior teeth to provide
Therefore a prerequisite of all treatment is for biological feedback, the occlusal forces
us to determine these causative factors and, applied to the teeth are reduced. This is
together with the patient, control them. This especially i mportant for patients with
is 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 also
consumption. At the beginning of treatment, important for patients whose treatment
the patient undergoes initial preparation until requires increasing the vertical dimension for
they prove that they will cooperate completely biomechanical reasons, in order to make
in their own treatment, by executing excellent space available for restorations.
oral hygiene. Techniques include flossing, It is our experience over many years that
correct toothbrushing, use of stimulators and opening vertical dimension using the anterior
all periodontal aids necessary to maintain a teeth, especially the cuspid teeth, will reduce
healthy periodontium. For patients with caries, biting force and prevent intrusion of the other
a dietary analysis is made and the patient is teeth. In fact, in most patients, we are most
carefully checked to see that they adhere to probably restoring vertical dimension that was
their new diet. The initial therapy permits us lost rather than increasing the vertical dimen-
to check the individual patient's 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 patient's 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 Palmer's.
i n patients where the overbite is reduced Palmer's 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 INFORMATION

I n patients receiving fixed partial prosthe- elastomeric impressions, we find that it is
ses, the graduate students prepare the very difficult to get an accurate impression
teeth 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 patients
i n mature and periodontally compromised where there are long clinical crowns and
patients is the knife edge preparation. We multiple preparations.1 I n the laboratory
feel that complete shoulder or chamfer phase, it is also difficult to achieve an
preparations are not suitable in these situa- undistorted wax pattern on withdrawal for
ti ons since they require too much root multiple abutment cases. One of the
structure reduction. The students then advantages of a full arch elastomeric
usually make either single copper band i mpression is that it permits a single
elastomeric impressions to impression the casting with accuracy and eliminates the
prepared teeth or elastomeric complete need for soldering; however, in periodon-
arch impressions. Due to the many tally involved teeth with long clinical crowns
problems 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 consuming
finishing 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, and
true in periodontally involved teeth and then annealed in an ethyl alcohol 70%
whenever a knife edge preparation is solution. This produces a softer, more
i ndicated. pliable band with a clean polished surface
The graduate students prepare all the which will not have a rebound effect after
teeth to be utilized for the prosthesis and the acrylic resin is placed. The band is
temporize them in as many visits as neces- li ned with soft, quick-setting methyl
sary-this will naturally vary with each methacrylate resin and allowed to set on
patient. After all the teeth have been fully the prepared tooth.
prepared for the fixed prosthesis and The band is removed, and the resin is
checked for proper tooth reduction by i nternally relieved to a depth of 0.5 mm. An
measuring 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 then
tooth 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 die
would 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 patient's 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 petroleum
j 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
REFERENCES
after the initial insertion as to comfort and
whether 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
patient's 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 HISTORY

The patient, a 56-year-old self-employed The patient had never visited a dentist
building contractor, came to the clinic for regularly. The last visit to a dentist was at
dental treatment. His chief complaints were
( Figures 1.1-1.3):

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

PAST MEDICAL HISTORY

The patient's medical history was un-
remarkable; he had no allergies, and was
not taking any medication.
Figure 1.2

Posterior teeth-right side.

Figure 1.1 Figure 1.3

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

3

4 PROSTHODONTICS IN CLINICAL PRACTICE

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 the
Mandible (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 and
with anterior cross-bite. The interocclusal rest 1.9) revealed large amounts of calculus and
space was 5.0 mm. Overjet was -1.0 mm plaque, probing depths of up to 6.0 mm on
and overbite was 3.0 mm. The difference some of the mandibular teeth and up to 7.0
between centric relation and centric occlusion mm on some of the maxillary teeth. There
was 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


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

t

Figure 1.11
Cephalometric analysis.

DIAGNOSIS
CEPHALOMETRIC ANALYSIS
• Pseudo-Angle class III
The cephalometric analysis (Figure 1.11) was
• Advanced adult periodontitis
done 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
involvement
Determined values: • Caries
• Reduced vertical dimension
Measurement Average
• Faulty occlusal plane with extrusion and
Go-Gn 82 84
tipping of teeth
Co-Gn 125 122.5
• Secondary occlusal trauma with primary
Palatal plane point A 59 59
origins
(Go, gonial; Gin, gnathion; Co, condyle.)
• Periapicallesions
Interarch relationships:

SNA 85 ABOUT THE PATIENT
SNB 83
ANB 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 preference
and 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 patient's 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 of
the treatment plan. i ng maxillary teeth were then prepared and
provisional restorations placed at a new
vertical dimension of occlusion, thus
PHASE 2: TREATMENT OPTIONS providing cross-arch splinting. This new
vertical dimension was determined by the
Maxilla:
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 contacts
Mandible:
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) 5
Figure 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 mandibular
Figure 1.13
removable partial denture would replace the
After 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 patient's periodontal condition due to
his improved oral hygiene and cooperation,
and it was decided to complete the
patient's 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 fit
Figure 1.14 the stone dies. A polyether full arch impres-
After initial preparation-right side. sion was then taken of the maxilla and the


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

Treatment completed-fixed prosthesis, anterior view Treatment completed-restorations, maxilla.

RETROGRADE WEAR 11

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

maxillary prosthesis was cemented with a disease. He had many missing teeth and
permanent 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 implants
treatment complaining of pain, a loose i n the mandible without pre-prosthetic
tooth, and difficulty in eating. He had not surgery. Through increased awareness of
visited a dentist for 40 years and thought the importance of oral hygiene, extensive
that by brushing his teeth twice daily, it periodontal, endodontic and prosthetic
was sufficient. He suffered from very poor treatment, a functional and esthetic result
oral hygiene, and advanced periodontal was attained.


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 patient's 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.


Face-frontal view. Face-profile view.

Mandibular arch-lingual view. Anterior maxillary teeth-palatal view, showing extensive
wear.

BRUXISM 15

Anterior teeth-labial view, showing deep overbite. Maxillary arch-palatal view.

Occlusion-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 maxillary
Occlusal analysis (Figures 2.7 and 2.8) central incisor and both lateral incisor
revealed that the patient was Angle class 1 teeth.
with a vertical overbite of 6.0 mm and a
horizontal overjet of 3.0 mm. Periodontal examination revealed moderate
I n addition, she has Fremitus class 1 on with localized advanced periodontitis with
the maxillary right cuspid, right central probing depths up to 5-6 mm on the


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 convince
The patient was punctual for her appoint- her that she should stop bruxing of her
ments, cooperated in her treatment, and own volition
understood the reasons for her treatment • Changing the vertical dimension of
even though she had no subjective occlusion by the use of a canine
complaints. 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 passive
j 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


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).

Anterior maxillary teeth-palatal view, showing composite Anterior mandibular teeth-lingual view, showing composite
buildup. buildup.

BRUXISM 19

Right side, showing failure of teeth to passively erupt. Left side, showing failure of teeth to passively erupt.

Mandibular left posterior segment, showing lingual cusp Mandibular right posterior segment, showing lingual cusp
composite buildup. composite buildup.

Right side, showing teeth passively erupted to contact. Left side, showing teeth passively erupted to contact.


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 patient's 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 21

the operators chose to make occlusal worried the patient's dentist more than the
stops on the canines to allow the molar patient herself, yet the team were able to
teeth 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 the
esting to note that the original problem maintenance therapy.

PATIENT 3 EXTENSIVE TOOTH WEAR
Treatment by Yehuda Shahal


A 43-year-old retired army officer presented His dental history was uneventful. He only
himself 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 don't have them treated now, I am ( Figures 3.2 and 3.3)
afraid that I will lose my teeth.'
Normal facial symmetry
During his military service, he served as a Slightly square facial outline
tank mechanic and at the time of his treat- Straight profile with competent lips
ment had his own garage. Lower third of the face was slightly
smaller than the other two thirds
Accentuated labio-mental fold
PAST MEDICAL HISTORY Maximum opening was 46 mm
No deviation in either opening or closing
His medical history was negative with no movements
unusual findings. No muscle sensitivity was noted
Jaw movements were normal

PERIAPICAL EXAMINATION

Maxilla (Figures 3.4 and 3.5):

Figure 3.1
Front view of anterior teeth.

23


Frontal facial view. Side face view.

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.


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

Maxillary periodontal chart. Mandibular periodontal chart.


Radiographs of right maxillary posterior quadrant. Radiographs of left maxillary posterior quadrant.

3.0 mm on most of the mandibular teeth, I NDIVIDUAL TOOTH PROGNOSIS
with slight bleeding on probing (BOP) on
some of the teeth with restorations. There • Hopeless: none
was inflammation around the fixed bridge in • Poor:
the right posterior maxilla. The right
4 4
mandibular molars had probing depths of
7
5.0-8.0 mm, and furcation involvement
class I was found on the right second
molar, both in the buccal as well as the
li ngual furcas. There was a boney defect on
the mesial surface of the right second
molar. 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 and
The right first maxillary premolar had renewal of the root canal therapy should
narrow roots, an old root canal restora- new restorations be required. The roots
tion, a dentatus type post, and an asymp- were also very thin, making the removal
tomatic periapical lesion. The left maxillary of the existing posts very difficult without
first premolar had narrow roots, an old fracturing the teeth. Therefore these
root canal filling, a dentatus type post, and teeth were considered to have a poor
an asymptomatic periapical lesion. There prognosis. The second right mandibular
was extended root trunk in the left maxil- molar tooth had an infraboney pocket on
lary 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 coronal
rary restoration following root canal portion, leaving a very doubtful prognosis
therapy. for the long term for this tooth.


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 patient's 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).


the 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 form
were extracted early in his army career and
• Fixed partial prosthesis with implant
therefore could not cause wear of the
support
opposing maxillary teeth. These teeth
• Fixed partial prosthesis with cantilever
showed no signs of wear, even though they
• Fixed and removable partial prostheses
were present for 26 years prior to the period
when he worked as a mechanic on tanks.
Further proof of this theory could be found TREATMENT
i n the fact that the greatest amount of wear
was 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 obvious
encountered while driving the tank is greater i mprovement in the periodontal supporting
i 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 the
patient had retired from the army, and was pocket depths had diminished greatly and
not 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 the
during the transitional phase of treatment, periodontal problems were removed early in
the 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 the


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


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 patient's 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


Clinical view of right mandibular premolars and molar area. Radiograph post-treatment of right mandibular premolar
pre-treatment. and molar area.

Transitional restorations right side. Transitional restorations left side.

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


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

New transitional restorations-maxilla. New transitional restorations-mandible.


Duralay copings fitted-maxilla. Duralay copings fitted-mandible.

Figure 3.30
Centric relation record-left side.

Centric relation record-completed. Flastomeric pick-up impressions of Duralay copings-
maxilla and mandible.


Metal copings fitted-maxilla. Metal copings fitted-mandible.


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.


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 in
Frontal face view of patient, post-treatment. jaw movements. The cuspal guiding planes


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


A 50-year-old woman, employed as a senior The patient had never gone regularly to a
secretary, came to the clinic for dental treat- dentist. The last visit to a dentist was 10
ment. Her chief complaints were (Figures 4.1 years ago, and she could not recall what
and 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 HISTORY

The patient's medical history was unremark-
able.

Anterior teeth-labial view. Face-frontal view.

39


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
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 41


Maxillary arch-palatal view. Mandibular arch-lingual view.


Occlusion-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 III
Occlusal examination (Figures 4.7 and 4.8) i n closing and protrusive movements
revealed that the patient was Angle class I. Maxillary right lateral incisor-grade II in
The interocclusal rest space was 4.0 mm. closing and protrusive movements
Overjet was 7.0 mm and overbite was 2.0 Maxillary right first premolar-grade I in
mm. There was a difference between closing movements
centric 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


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.


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 teeth
A 50-year-old patient, in good health, came The distribution of the remaining teeth
to the clinic complaining of poor esthetics, was unfavorable


• 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 patient's
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


Anterior teeth-labial view, after initial preparation. Anterior teeth-orthodontic treatment to close spaces and
retract teeth: mandible, start.

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

Orthodontic treatment, retraction of anterior maxillary teeth, Maxillary teeth showing provisional splints.
l eft side.


Figure 4.18
CT radiograph of mandible.

CT radiograph of mandible, left side. CT radiograph of mandible, right side.

I mplant placement, right side. I mplant placement, left side.

NEGLECTED DENTITION

Mandible 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 by
the 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 the
to the first premolar, and a single implant on mouth and connected by Pattern resin for
the 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 then
during the implant placement, and three taken for tissue detail and a pick-up of the
Branemark implants were placed in the right fixed prosthesis in the maxilla in order to
posterior region of the mandible and one make a final master model. This was
between the left first premolar and the left mounted on a Hanau articulator by means
first molar (Figures 4.21 and 4.22). After 3 of a facebow registration (Figure 4.24) and
months, the implants were exposed and the Pattern resin registration on the soldered
abutments placed. New provisional restora- metal prosthesis. The shade was chosen
tions were made for the implants (Figure and porcelain baked to the metal. This was
4.23). fitted in the mouth and the occlusion
Copper band elastomeric impressions adjusted to the lower jaw. The porcelain was
were made of all the prepared teeth and then glazed and the prostheses on the
pattern resin copings made to fit the stone natural teeth cemented with Temp-Bond for
dies. These copings and transfer copings 2 weeks. The implant supported prostheses
for the implants were fitted in the mouth were screw retained (Figures 4.25-4.29).
and used to record centric relation at the
vertical dimension of occlusion of the provi-
sional restorations. A polyether full arch SUMMARY
impression was then taken of the maxilla
and the master model poured and This patient presented with a very severe
mounted to the mandibular model of the case of adult periodontitis. She also had


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.


Figure 4.29
Treatment 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 patient's 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 by
Figure 4.30 periodontal and orthodontic treatment, along
Treatment completed-face, frontal view with a carefully planned occlusal scheme.


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 PATIENT

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

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

Figure 5.2
PAST MEDICAL HISTORY Face-frontal view (forced smile).

The patient suffered from pulmonary valve
regurgitation and an allergy to penicillin,

Anterior teeth-labial view. Face-frontal view (from 23 years ago).

51


thus, 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 mm
PAST DENTAL HISTORY • Incompetent lips-habitually apart

The patient underwent periodontal surgery
2 years ago. She also disclosed that she I NTRA-ORAL AND FULL-MOUTH
had a habit of cracking nuts. PERIAPICAL RADIOGRAPH
EXAMINATION

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


• 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 (see
Figure 5.4 Figure 5.1). Lateral jaw movements were
Face-side view. guided by the canine and premolar teeth

UNNOTICED PERIODONTAL DETERIORATION 53


Occlusion-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 movements
Figure 5.9 • Maxillary left central incisor, left lateral
Occlusion-anterior view of overbite and overjet. i ncisor, and right lateral incisor-grade I


Periodontal chart-pre-treatment, maxilla. Periodontal chart-pre-treatment, mandible.

Figure 5.12

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.


FULL-MOUTH PERIAPICAL DIAGNOSIS
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 FINDINGS

The 47-year-old patient, who suffered from TREATMENT PLAN
pulmonary valve regurgitation, came to the
clinic complaining of recent spacing PHASE 1: INITIAL PREPARATION
between her front teeth, a foul odor in her
mouth, and pain when chewing on the left • Initial periodontal therapy including:
side of her mouth. She presented with poor oral hygiene instruction
oral hygiene, plaque and calculus, and scaling and root planing
severe inflammation accompanied by deep caries excavation
probing depths, furcation involvements, • Occlusal adjustment of the (maxillary
and bleeding upon probing. The teeth were right central incisor) by selective grind-
mobile and had fremitus in closing and jaw ing to reduce occlusal trauma
movements. The maxillary right central
i ncisor was extruded and had a suppurat- The first re-evaluation led to the second
i ng periodontal abscess. phase of the treatment plan.


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.

Periodontal chart-first re-evaluation. Anterior teeth, orthodontic treatment completed.


PHASE 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 5.18
I nitial treatment consisted of scaling, root Maxillary teeth showing provisional restoration.
planing, curettage, oral hygiene instruction,
and extraction of the mandibular right third
molar. At re-evaluation, after initial prepara-
tion, bleeding on probing had diminished to When the orthodontic treatment was
a great extent. However, the probing completed and the anterior spacing elimi-
depths remained deep and showed almost nated, the maxillary teeth from the second
no 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 the
their supporting bone and provide space same time, the hopeless maxillary right
for maxillary anterior tooth retraction, a central incisor was extracted (Figure 5.18).
canine platform was constructed on the At the second re-evaluation, the
maxillary cuspid teeth (Figure 5.15). As recorded probing depths were greater than
eruption of posterior teeth took place, 5 mm and the decision was made to
orthodontic treatment was then started to undertake periodontal surgery (Figure
retract the maxillary anterior teeth and 5.19). The goal of the periodontal surgery
close the spaces (Figure 5.16). Lingual was to achieve an open clean-up and
buttons were placed on the first premolars pocket elimination. During the periodontal
and elastics were then used to close the surgery, the decision was made to resect
spacing between the teeth (Figure 5.17). To the disto-buccal roots of both second
prevent drifting of the elastics gingivally, molars in order to eliminate the trifurcation
composite stops were placed on the labial involvements of these teeth and improve
surfaces of the anterior teeth. This treat- their prognosis (Figures 5.20 and 5.21).
ment was accompanied by constant Selective grinding and reshaping of the
scaling, root planing, and curettage. Since buccal cusps of the maxillary molar and
the patient had a pulmonary valve regurgi- premolar teeth was performed to diminish
tation problem, this necessitated the use of the strong lateral forces upon them.
prophylactic antibiotics (ERIC: coated At the following re-evaluation, it was
erythromycin 1 g an hour before treatment, noted that the maxillary right first premolar
and 500 mg 6 hours after treatment) for still showed unacceptable probing depths.
each visit. Orthodontic treatment was then started to


Figure 5.20
Periodontal surgery, maxillary left posterior quadrant.

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



Orthodontic 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-Bond
pattern resin copings produced. These for a period of 2 weeks. The prosthesis
copings were fitted in the mouth and was then cemented permanently with
used to record centric occlusion, and a zinc oxyphosphate cement (Figures
polyether impression was taken for the 5.24-5.27).
working model. A master model was cast
from this impression with the stone dies in
place. This model was articulated to the SUMMARY
model of the mandibular teeth made with
an alginate impression. Metal copings The patient presented with what she
were then cast and fitted on the individual thought was a simple problem of a loose
prepared teeth with the pontics attached front tooth and the start of spacing in her
to the adjacent tooth. These were maxillary anterior teeth. Even though she
connected 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 her
Duralay at the vertical dimension of occlu- periodontal condition had thus deterio-
sion was made in the mouth and another rated. The initial treatment consisted of
polyether full arch impression done for the oral hygiene instruction and scaling and
tissue details. This impression was cast curettage. When the probing depths did
and mounted to the lower model and the not improve, orthodontic treatment was
articulator by means of a facebow trans- initiated as well as periodontal surgery in
fer and the Duralay centric record. The order to eliminate the deep pockets
shade 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 not
final adjustments were done in the mouth respond and had to be extracted. Only
in the biscque bake stage. The prosthesis then, it was discovered that the root was
was then glazed and temporarily cracked and thus had been untreatable.


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


the goal of physiologic and esthetic occlu- CASE DISCUSSION
sion with the periodontal condition that the HAROLD PREISKEL
patient presented with, we utilized the
potential of tooth eruption both to reduce Patients requiring antibiotic prophylaxis
periodontal defects and minimize the pose particular problems due to the need
damage 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 the
reduced posterior support both by patient was understandably concerned
periodontal involvement and missing teeth, about her appearance, she appeared to
the anterior teeth were incorporated into have no idea of the severity of the problems
support by retracting them lingually, thus i n her mouth, or of what would be required
improving their position over the alveolar to correct them. This is another example of
ri dge and redirecting the occlusal forces in what skilled operators can achieve with
a more favorable position. By improving the patient motivation, and with success on
overall periodontal condition, improving oral that front everything else falls into place.
hygiene habits, and compensating for The combination of periodontal therapy
reduced posterior support by including the and orthodontic treatment with skilled
anterior group of teeth in vertical support, prosthodontics has produced not only a
we have accomplished an esthetic long happy patient but also an esthetic and
l asting physiologic occlusion. functioning dentition. Long may it last!

PATIENT 6 COMPLICATED ADVANCED
ADULT PERIODONTITIS
Treatment by Miriam Oppenheimer

THE PATIENT HABITS

The patient, a male 49-year-old clerk, The patient clenches his teeth.
presented for dental treatment. His main
complaints 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 Graduate
PAST MEDICAL HISTORY Prosthodontics Dental Clinic by a private
dentist who felt that the case was too difficult
The patient had mitral valve prolapse with for him to treat. The patient had recently lost
mitral valve regurgitation requiring antibiotic t wo molar teeth and thought that most of his
prophylaxsis before any dental procedures. teeth had been extracted due to caries.

Frontal facial view of patient (on right) 20 years previously. Anterior teeth showing spacing.

63




• 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.
EXAMINATION
• Flaring of the anterior teeth
Maxilla (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 65

Figure 6.6
Maxillary arch-left posterior quadrant.

FULL MOUTH PERIAPICAL SURVEY
(Figure 6.9)

Failing endodontic therapy accompa-
nied by periapical lesions
Ridge resorption in the edentulous
areas

Figure 6.7
Occlusal examination revealed that the
patient was Angle class II division I, with
Mandibular 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 cuspid
Figure 6.8 teeth. There was loss of posterior
Mandibular arch-anterior teeth. occlusal support.


Figure 6.9

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


• 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 implants
was interested in his dental treatment, and natural teeth-rejected by patient
followed instructions, but not always, and due to cost
was generally cooperative. He wanted to Crowns on
keep as many of his remaining teeth as possi-
ble, and specifically requested not to have a
complete maxillary denture. He was not inter-
ested in implants because his finances were copings on
li mited. He also had never worn a removable
prosthesis 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
PROBLEMS

The patient had never worn a removable FINAL TREATMENT PLAN
prosthesis, had limited finances for dental
treatment, had poor eating habits, and A final treatment plan was chosen which
clenched his teeth. He also was completely consisted, in the first phase, of oral hygiene
unaware of the severity of his problem. He instruction, changing dietary habits, and
suffered from advanced adult periodontitis fluoride rinses. This was followed by scaling


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
patient's 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.


Provisional removable partial mandibular denture. Treatment completed-maxilla.

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


Figure 6.24
Radiographs of patient-
post-treatment.

for function and esthetics. The removable removable denture supported by a fixed
maxillary partial denture and mandibular anterior bridge and a complete mandibu-
complete overdenture were processed. The lar overdenture on gold copings on the
restorations 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, being
The patient presented with a severe case effected both by caries and advanced
of advanced adult periodontitis, many periodontal disease complicated by loss
missing teeth, crowding, mobility and of posterior support, aggravated by drift-
fremitus of teeth, faulty restorations, and i ng and flaring of teeth. This case was
poor dietary habits. He was a clencher. treated by stretching the biological
He 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 mechanical
found in this case because of the limited i mprovement by redirection of the forces
financial means available to the patient to improve the crown-to-root ratio and
for his dental treatment. He also wanted creating a flat occlusion to minimize lateral
to retain as many of his remaining teeth forces. The continued success of this
as possible. The solution consisted of treatment will be dependent on the
eliminating the infection, orthodontic cooperation of the patient, by controlling
treatment to improve tooth position, his oral hygiene as well as his diet. Thus
changing his dietary pattern, and the overall prognosis of this case is
construction of a partial maxillary guarded.


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 patient's
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.


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
• 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.

Left side-pre-treatment. Right side-pre-treatment.

ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG 75

Periodontal chart-maxilla. Periodontal chart-mandible.

Periodontal examination (Figures 7.6 and Reduced posterior occlusal support
7.7) revealed probing depths of up to Flaring of anterior teeth
7.0 mm on most of the remaining teeth, with Caries
bleeding of the gingiva on probing on most Faulty restorations
of the teeth, with the condition being more Poor esthetics
severe 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.
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


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


Teeth before orthodontic treatment. Teeth after orthodontic treatment.

Transitional 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 centric
Working models. records were taken at the vertical dimension


Working models mounted on Hanau articulator. I mpression of soldered castings for tissue detail-mandible.

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


oxyphosphate 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 by
up 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-root
The patient, a 36-year-old computer engineer, ratio of the posterior teeth (which were
came to the Graduate Prosthodontics Clinic of periodontally involved) was improved.
the Hebrew University Dental School of Reasonable overjet and overbite were also
Medicine for treatment. He presented with a achieved, gaining mutual protection of the
severe problem of advanced adult periodonti- anterior teeth during jaw movements. These
tis. He had many missing teeth, much alveo- procedures enabled us to achieve an
l ar bone loss around the remaining teeth, and esthetic and physiological occlusal scheme
faulty 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 DISCUSSION
the maxillary anterior teeth and mobility of the HAROLD PREISKEL
mandibular anterior teeth. His dental condition
was further complicated by his medical condi- Relatively young patients with advanced
tion (neurofibromatosis type 2), which periodontal disease present challenging
rendered him unable to close his mouth problems. Very sensibly, the initial treatment
properly, and caused trauma to the anterior was not side tracked from attention to
teeth 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 an
partial prostheses that provided him with a active tongue thrust was contributing to the
physiological occlusion at the optimum vertical i nitial breakdown of the arcade is not
dimension of occlusion for his periodontal mentioned, but it appears that there were
condition. 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 guidance
The patient presented himself for treatment was an added bonus. However, the
suffering from advanced periodontitis aggra- maintenance of the restorations, particu-
vated by the loss of many teeth and compli- larly the lower anterior fixed prosthesis, will
cated by an anterior open bite. The treatment require particular care on the part of the
goals were to restore esthetic function and patient. An excellent result appears to have
give 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 and
a recent immigrant, came to the
Graduate Prosthodontics Clinic for dental PAST DENTAL HISTORY
treatment ( 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, `It's
` Due to my missing teeth, I have difficulty
hard to explain, but because it's been like
eating on the right side.'
this for a long time, I feel that it's natural.'
` Usually I only eat soft food.'
` Food packs underneath my bridge.'
PAST MEDICAL HISTORY (Figure 8.2)

The patient was healthy, and did not take any Asymmetrical face, with lower third
medication. He had no known sensitivity or being greater than the middle third


Anterior teeth-labial view. Face-frontal view.

81


• 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.


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 and
Figure 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 2
and by the canine with incisal contacts on furcation on the mesial and distal. The
the 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 1
non-working side interference was noted. furcation involvements.



Mandibular anterior teeth-lingual view, showing calculus Maxillary anterior teeth showing periodontal inflammation.
accumulation.


Mandibular right posterior teeth showing calculus accumulation. Mandibular anterior teeth-labial view, showing calculus
accumulation.


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


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 PATIENT

He was a highly motivated immigrant who RE-EVALUATION II
wanted to improve his oral condition, and
was highly disciplined and very patient. His PHASE 3: TREATMENT PLAN
expectations were to improve his oral
condition by all means, and despite his Adjunctive orthodontics-forced eruption
poor financial condition, he insisted on a of the upper right premolar, to eliminate
fixed oral rehabilitation. He had a very the deep osseous deformity
sensitive gag reflex. Initial language I nsertion of two implants on each side
problems 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 6: TREATMENT PLAN
• I nitial periodontal therapy
• Oral hygiene instruction Recall and maintenance.


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.

Maxillary canine and first premolar after minor orthodontic Orthodontic treatment to extrude maxillary left second
tooth movement. premolar.

Radiograph before extrusion of maxillary left second Radiograph after extrusion of maxillary left second premolar,
premolar. showing accompanying bone.



CT 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 points
completed, minor orthodontic treatment i n the areas that required implants (Figure
was undertaken to open up root proximity 8.18). The CT radiographs indicated that
between the right first maxillary premolar the bone type was class IV, and on the
and the right canine (Figure 8.14). At that l eft side, the width of the bone was
stage all the remaining maxillary teeth and i nadequate for implant placement. An
the mandibular teeth from the left third molar autogenous bone graft from the chin was
to the right cuspid were prepared for provi- placed on the left side 6 months before
sional restorations. On the left side, the the implant insertion. Two Branmark
second maxillary premolar was forced to i mplants (Nobel Biocare USA, Inc: Yorba
erupt. This was achieved by first separating Linda, CA) were then placed on each
the first and second premolars (Figure 8.15), side in the maxilla in the premolar and
and then by use of a coil spring. The second molar areas (Figure 8.19). In the right
premolar 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 mm
pocket around the second premolar (Figures l ong and 5.0 mm diameter implants were
8.16 and 8.17). i nserted.
Due to the severe gag reflex, and in spite of New provisional transitional prostheses
great effort on his part, the patient could not were then constructed after the uncovering
adapt to the provisional maxillary partial of the implants. At that point, copper band
removable prosthesis that was made for him, elastomeric impressions were taken of all the
and it was discarded. At that point it was prepared teeth and Duralay copings were
decided that a maxillary removable prosthesis made. These copings were used to record
was not viable, and the treatment plan of fixed centric relation at the vertical dimension of
maxillary posterior prostheses on implants the temporary restorations, together with the
was chosen. teeth position in the arch for the final impres-
Computerized tomographic (CT) radio- sion for the working model. A polyether
graphs were made of the maxilla utilizing complete arch impression in a custom tray


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,

Treatment completed-permanent restorations, anterior view. Treatment completed-permanent restorations, right side.



Treatment completed-permanent restorations, left side. Post-treatment radiographs, maxillary right posterior area.

Figure 8.25

Maxillary right posterior area, clinical view.

Figure 8.23

Post-treatment radiographs, anterior mandibular area.

Figure 8.26

Maxillary left posterior area, clinical view.


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 patient's and the dentist's
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 patient's therapy makes interesting
Figure 8.28 reading, with the patient himself becoming
ever increasingly involved in his own treat-
Patient's 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-
Patient's forced smile before treatment. pated in the initial treatment.


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
( 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

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 93

Maxillary arch. Mandibular arch.

Periodontal chart-maxilla. Periodontal chart-mandible.

Figure 9.8
Radiographs of maxilla and mandible.


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


right side of the maxilla, it was decided to re-evaluation was made and it was
rotate the maxillary premolar in order to observed that the pocket depths had
open space for an additional tooth to be greatly diminished, while bleeding on
placed. 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 second
Maxilla: 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 was
Mandible: 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 arch
Initial preparation included scaling, curet- wire, the maxillary incisor teeth were
tage, root planing and oral hygiene repositioned to their correct position (Figure
i nstruction. At the end of this stage, 9.12) They were then retained in this
an obvious improvement in the soft position utilizing a modified Hawley appli-
tissue could be discerned. A periodontal ance (Figures 9.13 and 9.14).

Maxilla showing transitional restorations. Mandible showing transitional restorations.



Palatal view of maxillary anterior teeth repositioned on Orthodontic treatment-spaces closed.
model.


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 PERIODONTITS


Wire 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 teeth
Figure 9.18 ( Figures 9.19 and 9.20). The metal
Duralay copings fitted in maxilla. copings were then cast, fitted and
soldered, and after try-in of the soldered
metal framework another polyether
the anterior maxillary teeth were pumiced, i mpression was made for the final master
etched, bonded, and built to occlusal model. These models were mounted on a
contact with mandibular anterior teeth by semi-adjustable articulator (Hanau) utiliz-
adding microfil composite resin (Durafil i ng a facebow registration. Centric
vs). 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 a
orthodontic wire was fitted and bonded in Neylon technique. The porcelain was
place (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 the
ses and transitional acrylic resin restora- crowns and bridges were cemented with
tions were placed (Figure 9.17). Temp-Bond for a period of 3 weeks. The



Polyether maxillary impression of metal copings. Polyether mandibular impression of metal copings.


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


replaced a missing lower first right molar by
an 8.0 mm implant, even though the
adjacent teeth had been previously treated.
The patient's advanced periodontal disease,
accompanied by flaring of anterior teeth
along with several missing teeth, was quite
challenging. The orthodontic treatment
addressed the patient's esthetic complaints
and improved the periodontal condition.
Figure 9.23 This facilitated participation of the anterior
Frontal 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 periodontal
crown on a recently placed implant. The situation. A functional physiologic occlusion
patient presented with moderate to was established.
advanced adult periodontitis. She had
many missing teeth, advanced alveolar
bone loss around some teeth, and faulty
CASE DISCUSSION
restorations in both jaws. There was mobil-
HAROLD PREISKEL
ity and fremitus in the maxillary anterior
teeth. The treatment received by this patient
After a complete examination, diagnosis, underscores the importance of establishing
and consultation, the patient agreed to a a comprehensive program of therapy at the
comprehensive treatment plan, and not just outset, together with achievable goals. The
a 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 evidenced
ment accompanied by occlusal therapy, the by earlier attempts at treatment.
patient received a physiologic occlusion at Computer simulation has been employed
the 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 good
The patient presented herself to the effect. The patient's treatment has trans-
Graduate Prosthodontics Program, seeking formed her mouth from an unsightly,
treatment for various complaints. She had diseased and rapidly deteriorating situation
been 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 and
consultation at the Hadassah Hebrew PAST MEDICAL HISTORY
University School of Dental Medicine
Graduate Prosthodontics Clinic with the Past medical history was non-contributory.
following complaint:
` My upper and lower front teeth are
l oose.' EXTRA-ORAL EXAMINATION
She had been to several dentists, all of
whom had told her that she would most Normal facial symmetry
probably need complete dentures or, at Slightly convex profile



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

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

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 03

Patient's removable mandibular partial denture. Maxillary periodontal chart.

Figure 10.8
Mandibular periodontal chart. Figure 10.9
Radiographs of maxillary and mandibular anterior quadrant.

Radiographs of right posterior quadrant. Radiographs of left posterior quadrant.


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

TREATMENT POSSIBILITIES

Maxilla:

Fixed anterior partial prosthesis and a
removable posterior partial prosthesis
supported by implants
DIAGNOSIS
sis with either clasps and rests, or
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
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


vertical dimension support and to reduce
the root proximity between the mandibular
right cuspid and the first premolar.
Following the orthodontic treatment, a
provisional fixed maxillary prosthesis termi-
nating with a premolar occlusion on the left
side would be done. The mandible would
be treated with a provisional fixed prosthe-
sis on the remaining teeth, which extended
from the right third molar to the left cuspid.
At the time the treatment plan was chosen
the patient still refused to consider a Figure 10.12
removable mandibular prosthesis. Elastic retraction of mandibular anterior teeth.

TREATMENT

I nitial preparation included scaling, curettage,
root planing and oral hygiene instruction. At
the end of this stage, an obvious improve-
ment in the soft tissue could be discerned. At
this time a periodontal re-evaluation was
done and it was observed that the pocket
depth had greatly diminished and that the
bleeding on probing had disappeared.
Figure 10.13
then started using elastics to retract the
Hawley orthodontic appliance.
mandibular anterior teeth (Figure 10.12).
The maxillary incisor teeth were also treated
orthodontically with a modified Hawley
appliance (Figure 10.13). This retracted the
maxillary anterior teeth and closed the
spaces. This was done in order to achieve
better esthetics and move the teeth into
better position in the alveolar bone for
occlusal support, and with the intent to
prepare the site for future development
should 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 and
temporary restorations were placed (Figures
10.17-10.19). A coil spring was then inserted Figure 10.14
to separate the right mandibular cuspid from Clinical view of Hawley appliance-pre-treatment.


Maxillary anterior teeth after orthodontic treatment. Anterior teeth after orthodontic treatment.

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


Coil spring to separate the right mandibular cuspid and Completed teeth preparations-maxilla and mandible,
premolar teeth. radiographs.

Duralay 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 then
soldered metal framework, another made. Rest preparations were then milled into
elastomeric impression was done for tissue the fixed prosthesis in the lingual of the right
detail and for the final master model. These molar area pontic as well as the distal surface
models were mounted on a semi-adjustable of the left cuspid. The porcelain was then
articulator (Hanau) utilizing a facebow registra- glazed and the final elastomeric impression for
tion and centric records were taken at the the removable mandibular partial denture was
vertical dimension of occlusion utilizing done. The framework for the partial denture
Duralay with a Neylon technique. At this point was then cast and fitted and a bite tray
the patient was finally convinced of the impor- constructed on it for centric registration
tance of a partial removable mandibular record. This was done and the denture teeth
denture and agreed to try and adjust to one. were set up and checked in the mouth for
The porcelain was baked and the occlusion esthetics and occlusion. The denture was
checked at the biscuit bake stage in the then processed (Figure 10.23). The crowns


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.

Case cemented-mandible. Case cemented-right side.

SEVERE ADVANCED ADULT PERIODONTITIS 109

Case cemented-left side. Radiographs of case-post-treatment.

Patient 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. The
except for the right mandibular premolar patient was adamant about not having a
and the right maxillary second premolar removable prosthesis and refused to use
and third molar. Her fixed and removable one during the course of treatment. Only
restorations were inadequate and she when she was told that the case could not
hardly ever wore her removable partial be completed ending in a cuspid occlusion
mandibular denture. There was mobility on the left side, did she agree to try to use
and fremitus in the maxillary anterior teeth a removable partial mandibular denture.
and mobility of the mandibular anterior She successfully overcame her aversion to
teeth. the removable denture and today, 10 years
With orthodontic and periodontal treat- post-treatment, functions very well with her
ment 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.


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

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

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


which the buccal outer line angle of the The periodontal examination (Figures
mandibular supporting cusp was lingual to 11.5 and 11.6) revealed probing depths of
the functional outer aspect (FOA) of the up to 5.0 mm on the maxillary teeth and up
maxillary supporting cusp (Figures 11.3 to 10.0 mm on the mandibular teeth, with
and 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 being
relation (CR). Fremitus and mobility were more severe in the mandible than the
found on several teeth. maxilla (Figures 11.7-11.9).

Figure 11.7
mandible-pre-treatment

Maxillary arch Mandibular arch


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.
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:
ABOUT THE PATIENT fixed posterior partial prosthesis sup-
ported by implants
The patient was young and optimistic and
understood the severity of his dental condi-
tion and came to the clinic hoping to avoid
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


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 obvious
improve 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).
then started using a Hawley bite plane

Figure 11.10

Maxillary anterior teeth after initial treatment


Periodontal chart at re-evaluation-maxilla Periodontal chart at re-evaluation-mandible


Clinical view of Hawley appliance-pre-treatment Maxillary teeth-orthodontic treatment, extrusion of central
incisor teeth

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


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 metal
Figure 11.17 copings were then fitted and soldered and
after try-in of the soldered metal framework
Transitional 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 a
Figure 11.18
close-fitting individual tray was made on
Periodontal 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 for
Figure 11.19 esthetics and occlusion.
Duralay copings fitted-maxilla and mandible and centric The denture was then processed and
relation record i nserted into the mouth. The crowns and


Metal copings try-in-maxilla Metal copings try-in-mandible

Centric relation record on Hanau articulator-right side Centric relation record on Hanau articulator-left side

Elastomeric impression for maxillary removable partial Fitting of maxillary removable partial denture framework
denture framework


Centric relation record on occlusal tray on removable partial Case completed-anterior view
denture

Case completed-left side Case completed-right side

bridges were cemented with Temp-Bond missing teeth, scissors bite, and loss of
and the partial removable maxillary denture posterior occlusal support. With orthodon-
i nserted. The crowns and bridges were tic and periodontal treatment accompanied
then cemented with zinc oxyphosphate by occlusal therapy, the patient received a
cement 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 dental
problem of advanced adult periodontitis, situation due to many missing teeth, and


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 patient's treatment represents more
tions and the patient's 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


the patient motivation achieved and upon decision involves the missing maxillary
the successful outcome. It is always impor- molars. Is it necessary to replace them or
tant to have a fallback position in case the could a shortened arch be accepted? The
patient's interest wanes and a simpler plan shortened arch would be far simpler from the
can be substituted. The step-by-step prosthodontic point of view, for no-one
approach employed has considerable should underestimate the complications of
advantage in this respect. producing a removable prosthesis. The
Another laudable aspect of the therapy maxillo-mandibular relations of this patient
was an appreciation of the three-dimensional helped make the decision to replace the
problems associated with a marked discrep- missing maxillary molars, leaving open the
ancy of arch size. At an early stage it was possibility of employing a distal cantilever
i mportant to establish how much of the pontic on each side to produce some molar
deranged 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 left
a result of the decrease of vertical dimension second pre-molar is root filled and we know
of 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 distal
accentuating 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 patient's 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 patient
tics as the primary support, a difficult returns for routine maintenance.

PATIENT 12 REFUSAL OF
ORTHOGNATHIC SURGERY


The 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 without
The medical history was non-contributory. deviation

Anterior teeth-labial view Face-frontal view

1 25


Figure 12.4

Maxillary arch-palatal view


Figure 12.3
Face-side view

I NTRA-ORAL EXAMINATION


• 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 127

Occlusion-right side Occlusion-left side

Periodontal chart-pre-treatment, maxilla Periodontal chart-pre-treatment, mandible

An occlusal examination revealed that plaque and calculus. Probing depths of up
the patient was Angle class II division I, with to 4.0 mm on the maxillary teeth and up to
deep impinging bite (Figures 12.1, 12.6 4.0 mm on the mandibular teeth were
and 12.7). There was an overbite of found, with bleeding on probing on some
8.0 mm with tissue impingement and an of the mandibular teeth. Inflamed tissue
overjet 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 therapy
12.9) revealed poor oral hygiene with • Periapical radiolucent areas


FIGURE 12.1U
mandible-pre-treatment,
periapical

Figure 12.11
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
Primary occlusal trauma
Figure 12.12 Loss of tooth structure
Anterior 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,


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 31

Canine platform to open vertical dimension Healing of the palatal gingiva

Removing existing crowns Transitional prosthesis-maxilla

CT scan, maxilla-right side CT scan, maxilla-left side


New transitional prosthesis-maxilla, right side New transitional prosthesis-maxilla left side

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


Final 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 dies
Figure 12.25 were placed into the impression and the
Final 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 side
additional tooth structure for retention of while fitting the Pattern resin copings and
the fixed prosthesis (Figure 12.22). recording the centric relation record on the
At completion of orthodontic and copings on the right side. The provisional
periodontal treatment the teeth were repre- restorations were then removed on the left
pared and new provisional restorations side and the Pattern resin copings placed
were 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 fitted
the orthodontic treatment. These transi- i n the mouth, and the copings connected
tional restorations also enabled the dentist for soldering. The copings were soldered
to evaluate the patient's adaptation to the and checked again for proper fit in the
new occlusal j aw relations (Figures mouth and a new centric registration
12.23-12.25). record was done in Pattern resin material.


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


Treatment completed-permanent treatment completed, Treatment completed-patient smiling
anterior view

Figure 12.31
Treatment completed-radiographs, maxilla

Figure 12.32
Treatment completed-radiographs, mandible


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 patient's 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 patient's 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.


• Temporomandibular joint was normal
• Mandibular motions were within normal
l imits
Normal facial musculature
Maximum opening of 45 mm
Incompetent lips
Trapped lower lip

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
premolars and molars
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

Face-side view Maxillary arch-palatal view

TREATMENT WITH LIMITED FINANCIAL RESOURCES 139

Mandibular arch-lingual view Occlusion-right side


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 Angle
class I. The interocclusal rest space was Maxillary right central incisor-grade I in
3.0-4.0 mm. Overjet was 2.0 mm and closing and ri ght working j aw
overbite was 3.0 mm. There was no differ- movements
ence between centric relation and centric Maxillary left central incisor, left lateral
occlusion. There was a midline discrep- i ncisor, and right lateral incisor-grade I
ancy. There was spacing between the i n centric occlusion and protrusive jaw
maxillary incisor teeth and the left lateral movements
i ncisor and left cuspid were slightly
rotated. Non-working side interferences The periodontal examination (Figures
were noted between the mandibular right 13.9 and 13.10) revealed calculus and
third molar and the maxillary right second plaque, probing depths of up to 10.0 mm
molar. on most of the maxillary teeth and up to



Figure 13.11

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

Initial treatment including:
SUMMARY OF FINDINGS
• Oral hygiene instruction
The patient, a 40-year-old male in good • Scaling and root planing
health, came to the clinic complaining of • Diet counseling regarding cariogenic
difficulty in eating, poor esthetics, food food


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 patient's
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

Anterior teeth-labial view, after initial preparation Periodontal chart-first re-evaluation

TREATMENT WITH LIMITED FINANCIAL RESOURCES 1 43

Figure 13.14 a Figure 13.14 b
Mandibular anterior teeth-occlusal view after extractions Periodontal chart-re-evaluation of mandible
and endodontic treatment

Anterior teeth-orthodontic treatment to close spaces and Anterior teeth-orthodontic treatment completed
retract teeth

remaining teeth were endodontically treated maxilla. During the surgery, it was decided
(Figure 13.14). Due to crown proximity, to extract the maxillary left first premolar
orthodontic treatment was performed to due to the extensive furcation involvement
separate the left cuspid from the first (class III).
premolar (Figures 13.15 and 13.16). The The second re-evaluation was now done
remaining teeth were then prepared, provi- and revealed that the probing depths had
sional acrylic copings were made and a greatly diminished and the bleeding on
transitional removable partial overdenture probing had disappeared. Except for the
was 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 teeth
i 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 maxillary
premolar was then performed in the first molars were amputated and the


Mandibular removable partial denture Mandible-provisional acrylic copings for overdenture

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


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

also 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 remaining
side. The provisional remaining bridge was l ower teeth. These were fitted and
then 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 of
on the contralateral side, the Pattern resin the mandible and cast in albastone. A
copings maintained the vertical dimension chrome cobalt metal framework was then
of 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 then
master 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 centric
removable 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 articulator
i n the mouth and connected by Pattern by means of the bite tray with the centric
resin for soldering. These were soldered record. The mandibular teeth were then set
together, refitted and a new centric relation up (Figure 13.23) and checked in the
record made. A polyether impression was mouth. The denture teeth were made of
then undertaken for tissue detail and a porcelain in order to match the material in
pick-up of the fixed prosthesis in order to the fixed prosthesis in the maxilla.
make a final master model. This was The mandibular removable partial
mounted on a Hanau articulator by means denture was processed and inserted. The
of a facebow registration and the Pattern maxillary fixed prosthesis was glazed and


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


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 13.27
Treatment completed-permanent resorations, anterior view
CASE DISCUSSION
HAROLD PREISKEL
his general good health, he had rampant I f the implant option is to be excluded, then
caries and severe advanced periodontitis, the amount of dental support available effec-
many missing teeth, the majority in the tively dictates a removable lower prosthesis
mandible, and severe bone loss. There opposing an upper fixed restoration. Such
were tipped, malposed, and extruded an approach dictates meticulous planning of
teeth. There were many hopeless and the occlusal surfaces and, naturally,
questionable teeth among his few remain- assumes that the supporting structures are
i ng teeth, yet the patient wanted a fixed not only healthy but that the patient can
prosthesis. Due to the patient's financial maintain them in this state. It might be
condition, this could not be achieved. argued that as a telescopic approach was
However, an esthetic and functional used on most of the lower abutments then
solution was found for his dental a telescopic retainer could have been
problems. 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 produce
This case presentation describes a young a clicking sensation. The other problem is
patient with a severe caries problem aggra- simply finding room for the underlying
vated by neglect, and complicated by substructure while providing retention for the
periodontal condition and a poor economic artificial teeth. The operator appears to have
situation. The patient was treated with the produced a functional and good-looking
i dea of supplying the best cost-efficient restoration.

PATIENT 14 TRAUMATIC SEQUELAE
Treatment by Irit Kupershmidt

THE PATIENT ' The esthetics doesn't bother me that
much.' (Figure 14.2)
The patient, a 44-year-old man, had been
assaulted with an ax about 6 months
before visiting the Hadassah School of PAST MEDICAL HISTORY
Dental Medicine Graduate Prosthodontic
Clinic. 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, was
hemorrhage, lacerations of the cheek, and treated with angioplasty. He suffered from
many broken teeth (Figure 14.1). His main high blood pressure and was being treated
complaints 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 recall


Maxillary teeth-palatal view Anterior teeth-labial view

1 49


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.
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

Face-frontal view Face-left profile view

TRAUMATIC SEQUELAE 1 51


Anterior 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 movements
Figure 14.7 Discrepancy between centric occlusion
( CO) and centric relation (CR) of
Anterior 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).


Figure 14.8a Figure 14.8b
Periodontal chart Periodontal chart

Figure 14.9
Radiographs of maxilla
and mandible-pre-
treatment

Figure 14.10
Radiographs of maxilla-anterior teeth, pre-treatment


I NDIVIDUAL TOOTH PROGNOSIS a removable prosthesis as a temporary
solution to his problems.
The prognosis for the remaining teeth was
the 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 PATIENT

The patient, who suffered from poor health, TREATMENT PLAN
had had a severe traumatic experience that,
due to his injuries, would still require The final treatment plan was then chosen
additional extensive medical treatment. In an which consisted of pre-prosthetic surgery to
i nstant, he went from a full dentition to a prepare the site in the maxilla for implants, a
condition where he felt that most of his maxil- fixed anterior maxillary prosthesis supported
lary teeth were missing. The patient wanted by the maxillary right second premolar, the
a fixed prosthesis, but was willing to accept maxillary right cuspid and the maxillary right


Mandibular arch-lingual view, after initial treatment Anterior teeth after initial treatment

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 155

CT 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 was
Figure 14.17
taken from the chin area and checked for
I 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 two
which 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 root
l engthening procedure, followed by of the mandibular third molar. The mesial
endodontic therapy. root was extracted and two implants were
A transitional removable maxillary partial placed (Figure 14.17). The distal root was
denture was then made to replace the l eft in place, temporarily, to maintain
missing anterior teeth (even though the occlusal support for a transitional fixed
roots were not yet extracted) to stabilize the partial prosthesis during implant placement
occlusion 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 of
performed on the mandibular third molar to fixed partial prostheses supported by both
expose it in order to perform endodontic natural teeth and implants. A fixed partial



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


Figure 1 4.21 Figure 14.22
Stage two surgery-exposure of maxillary implants Maxillary implants after healing after second stage surgery

Duralay and abutment impression copings fitted-maxilla Duralay copings fitted-centric relation record

the central incisor as a cantilever (Figure was an extension of granulation tissue from
1 4.22). The implants had been placed in a the failed implant in the maxillary right
curve 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 Duralay
discovered that the maxillary right cuspid copings were constructed. These copings
had a periapical lesion. The tooth was were used for the final impression for the
asymptomatic, was not sensitive to percus- master model and to record centric relation at
sion, and did not have deep probing the vertical dimension of the temporary
depths. An exploratory surgical procedure restorations (Figures 14.23 and 14.24).
revealed granulation tissue around the root Unfortunately, at the metal coping fitting
apex, which was enucleated. It was stage, a fistula was noticed round the
thought at that time that the periapical area maxillary right cuspid and a 10 mm probing


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


Treatment 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 a
Figure 14.30 removable prosthesis during treatment, but
Treatment 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 spite
14.28-14.30). A complete series of radio- of all these problems, an excellent result
graphs was taken after completion of treat- was achieved using a combination of
ment (Figure 14.31). natural teeth and implant-supported fixed
prostheses.

SUMMARY
CASE DISCUSSION
The patient presented with a variety of AVINOAM YAFFE
problems. Due to his unfortunate accident,
he had been left with scalp wounds, The patient, a 44-year-old male, was
fractures of the right side of his skull and referred for treatment at the Graduate Clinic
the left mandible, left maxillary sinus following a traumatic injury that changed
hemorrhage, lacerations of the cheek, and overnight his general well-being and


Figure 14.31

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- patient's 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


attack the state of his dentition was not of and obliged the patient to be without his
particular interest to him. One might have removable prosthesis for some time. The
expected the inevitable psychological net result was that the implants were
reaction to his experience to have made positioned slightly palatal to the ideal
him even less interested in looking after his position, but in a perfectly acceptable
teeth. Quite the reverse happened, and I relationship. The price to pay was the need
am confident that the team treating him to construct the facial surfaces of the
had a significant influence upon his restorations considerably labial to the
attitude: 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 of
despite 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-supported
maintenance far more difficult. The step- prosthesis by means of a semi-precision
by-step approach employed provided retainer is not universally accepted. There
versatility that was put to good use to have been suggestions that there is a
overcome 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 I
all 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 be
graft was not employed, since this would congratulated on the outcome of this
have complicated the treatment still further patient's treatment.


Extreme wear of the teeth accompanied
by chipping of the enamel and cupping
of the dentine
Rounded arch form, with broad
ridges

Face-frontal view Face-profile

(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

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 65


Periodontal 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 lateral
the patient was Angle class III modification movements. There was fremitus class I on
2 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. The
i nterocclusal rest space was 8.0 mm and The periodontal examination revealed plaque,
the maximum opening between the calculus, inflammation around most of the
i ncisors was 46 mm, with an `S' deviation teeth, probing depths of up to 9.0 mm on the
i n opening or closing movements. There maxillary teeth and up to 7.0 mm on the
was a 2.0 mm discrepancy between mandibular teeth, with bleeding on probing
centric 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
teeth. She exhibited extreme wear of her
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.


POTENTIAL TREATMENT For the loss of vertical dimension:
PROBLEMS
After the occlusal equilibration, the
optimum vertical dimension for an
The patient presented with a variety of
esthetic result would be determined
problems:
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 would
For 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).
patient's 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


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

Teeth-right side, after initial preparation Teeth-left side, after initial preparation


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

Transitional 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 metal
Figure 15.20 copings were cast and fitted. They were
Centric relation record in Duralay connected with Duralay for soldering.


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.


Figure 15.24

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 a
complicated situation: missing teeth,
severe wear, overeruption of posterior CASE DISCUSSION
teeth, combined with advanced periodon- HAROLD PREISKEL
tal disease aggravated by a class III maloc-
clusion with occlusal interferences. The This patient presented an interesting treatment
situation necessitated a dramatic change in planning problem. Apart from the unusual
the vertical dimension that had a negative medical complication, the operator had to
as 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 incisor
involvement of the anterior teeth in relationship. By how much was it safe to
guidance and support. It also facilitated increase the vertical dimension of occlusion?
restoration of the posterior quadrants that His treatment appears to have followed a
had undergone severe overeruption. The logical pattern with alternative avenues
negative effect was the change in the considered at the outset. Apart from the all
crown-to-root ratio. This, however, was important periodontal and endodontic
minimal due to the compensatory eruption therapy, the use of transitional restorations is
of the teeth during the retrograde wear. In mandatory with problems like these. The
summary, a 43-year-old patient was planning of the occlusal scheme is to be
treated successfully and the pathological commended and the overall result is gratifying.


Figure 16.3

Mandibular arch

Figure 16.2

Frontal facial view

EXAMINATION
( Figures 16.1-16.9)


• 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

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 5

Occlusion-left side Occlusion-right side

Figure 16.7
Radiographs of maxillary and
mandibular teeth

An occlusal examination revealed extru- second premolars. The mandibular
sion of many teeth, a faulty plane of occlu- anterior teeth occluded with the palatal
sion, vertical overbite of 8.0 mm, and gingival tissue (see Figure 16.5).
horizontal overjet of 4.0 mm (Figures 16.5
and 16.6). The patient had difficulty The periodontal examination revealed
executing lateral and protrusive gingival recession, but with minimal probing
movements of the mandible. The only depths-up to 3.0 mm at the maximum
occlusal contacts were between the left ( Figures 16.8 and 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


• 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 maxillary
Maxilla: 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 wire
Mandible: ( 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 crown
The treatment was divided into five was made for the maxillary left second
phases: premolar tooth and a transitional fixed
prosthesis was made from the mandibular
l eft cuspid to the left second premolar
PHASE 1 ( Figure 16.11). The periodontal re-evalua-
tion revealed that the pockets depths had
After initial treatment consisting of oral diminished greatly and that bleeding on
hygiene instruction, scaling and root planing, probing had disappeared.
the patient showed a marked improvement
i n his home care and the periodontal tissues
exhibited great improvement. It was then PHASE 3
decided to splint the anterior mandibular
teeth with orthodontic ligature for stabiliza- At this point, after the periodontal evalua-
tion. Following re-evaluation, a final treat- tion, additional occlusal support was
ment plan was discussed. This would then established by means of a transitional,
be a fixed partial prosthesis in the maxilla, mandibular, removable partial prosthesis
and a fixed anterior partial prosthesis with a (Figure 16.12). Periodontal surgery on the
removable clasp retained posterior partial maxillary left first molar revealed a perfora-
prosthesis in the mandible. tion. The disto-buccal root was removed.


Lingual view of anterior mandibular teeth Frontal view of teeth

Lingual view of mandibular temporized teeth Forced eruption of maxillary cuspid

Crown lengthening procedure-maxillary cuspid Maxillary transitional prosthesis


During caries excavation, additional nec- models were mounted on a semi-
essary endodontic treatments were done. adjustable articulator ( Hanau) using a
Orthodontic treatment, which consisted of facebow registration and centric records
forced eruption of the maxillary left cuspid, taken at the vertical dimension of occlusion
was 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 at
done to gain sound tooth structure (Figure the biscuit bake stage; all adjustments
16.14). 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 soft
PHASE 4

At the completion of orthodontic and
periodontal treatment, a transitional fixed
partial prosthesis was made, extending from
the maxillary right first molar to the maxillary
l eft second premolar (Figure 1 6.15).
Endodontic treatment on the mandibular right
cuspid and the mandibular left second premo-
l ar was then done. Due to continual infection,
and pocketing, the two remaining roots of the
maxillary left first molar were extracted. Due to
severe pain, the mandibular left cuspid was
then endodontically treated.

Figure 16.16
Soldered metal copings being fitted-mandible
PHASE J

At completion of initial preparation and re-
evaluation, the final phase of treatment was
carried out. Copper band elastomeric
i mpressions were taken of all the prepared
teeth and Duralay copings were made.
These copings were used for the final
i mpression for the master model and to
record centric relation at the vertical dimen-
sion of the temporary restorations. The
metal copings were then fitted and
soldered. After try-in of the soldered metal
framework ( Figure 1 6.16), another
elastomeric impression was done to repro- Figure 16.17
duce an accurate tissue transfer. These Biscuit bake try-in


Altered cast impression Centric occlusion recording in wax

Treatment completed-post-treatment anterior view Treatment completed-maxilla

Treatment completed-mandible Treatment completed-radiographs, anterior teeth


tissue duplication (Figure 16.18). At the parotid gland. His face drooped, and was
same time, a soft wax occlusal record was asymmetrical. The mandibular anterior teeth
taken to mount the model on the articula- exhibited class 3 mobility, which gave a
tor (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 his
porcelain was then glazed. The crowns and medical history, and many broken teeth. His
bridges were cemented with Temp-Bond vertical dimension of occlusion was
and the removable mandibular partial overclosed and he was traumatizing the
prosthesis inserted. The crowns and anterior palatal tissue when closing his
bridges were then cemented with zinc mouth. The patient requested a fixed
oxyphosphate cement for permanent prosthesis, even though during treatment
cementation (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 many
after completion of treatment (Figures problems arose, and his treatment had to
1 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 school
principal, presented with many varied CASE DISCUSSION
problems. He had undergone a number of AVINOAM YAFFE
surgical 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


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
patient's 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 patient's 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

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 and
consultation. His complaints were as
follows: 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.'

PAST MEDICAL HISTORY (Figures 17.2 and 17.3)

The patient suffered from a peptic ulcer for • Asymmetrical face on right side due to
which he was taking medication (Gastro unilateral cleft lip and palatal scar, and
40 mg daily) and congenital unilateral cleft lip nose deformity

Figure 17.2
Figure 17.1
Face-frontal
Maxillary arch-palatal view
view

185


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 17.7
Figure 17.6
Occlusion-left side
Occlusion-right side



Occlusal examination revealed that the cuspids, and left second molars.
patient was Angle class III (Figures Occlusal balancing side and protrusive
17.5-17.7), with a reverse overbite of 8.0 premature contacts during lateral and
mm and a reverse overjet of 3.0 mm. protrusive mandibular movements were
There were wear facets on the right noted.
second premolar and second molars.
The interocclusal rest space was Periodontal examination (Figures 17.8
3.0 mm, measured between the incisors. and 17.9) revealed unsatisfactory oral
There was a slight discrepancy between hygiene with plaque and calculus.
centric occlusion ( CO) and centric Probing depths were found of up to
relation (CR). Anterior and bilateral poste- 4.0 mm on the maxillary teeth and up to
ri or cross-bite was found. Centric 3.0 mm on the mandibular teeth, with
occlusal contacts were found on the right bleeding on probing on some teeth. There
second molars, right maxillary cuspid to was inflammation around most of the
ri ght mandibular first premolar, l eft teeth.


Figure 17.10

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.
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.


He presented with poor oral hygiene, significance of proper oral hygiene and its
plaque, gingival inflammation, and shallow i mportance in his treatment.
and intermediate probing depths. He had
deep caries, residual roots, crowded
anterior mandibular teeth, defective POTENTIAL TREATMENT PROBLEMS
endodontic treatment and restorations.
There were periapical lesions around four Cleft lip and palate:
mandibular teeth and occlusal interfer- • Scarred lip
ences during lateral and protrusive • Esthetic problems
mandibular 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 ship
willing to cooperate in spite of his physical
handicaps (scar, limited mouth opening). He • Large interarch discrepancy
had high expectations from his dental treat- • Limited mouth opening and limited
ment and even more so from the planned mandibular movements
plastic 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 mouth
any preferences for fixed versus removable • The small difference between centric
restorations. He did not appreciate the relation and centric occlusion


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 191

Anterior maxillary teeth-palatal view, after initial preparation Anterior mandibular teeth-lingual view, after initial prepa-
ration

Periodontal 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 also
Figure 17.15 treated orthodontically to bring it to a more
Provisional restorations-anterior view l abial position (Figure 17.16).


Orthodontic treatment, mandible Provisional acrylic resin restorations

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 patient's 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


Figure 1 7.20 Figure 17.21
Final 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 the
the 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 the
then mounted on a Hanau articulator with decision after consultation with the plastic
the aid of a facebow registration (Figure surgery and oral and maxillofacial surgery
17.21) and the porcelain was baked. The departments, that additional surgery would
final 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 trauma
mouth. The final glaze was applied to the to the patient, surgery was not performed.
prostheses, and they were cemented with
Temp-Bond for a period of 2 weeks. They
were then cemented with zinc oxyphos-
phate cement for permanent cementation
(Figures 17.22-17.26).

SUMMARY

The patient presented with a severe
problem of unilateral cleft lip and palate,
remaining residual roots, caries, and
malpositioned teeth. There was a patho-
logic occlusion with serious balancing side
and protrusive premature contacts during Figure 17.22
mandibular movements. He was very Gold foil obturator to close palatal cleft


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 195

Treatment consisted of oral hygiene oronasal fistula. A gold foil was fabricated to
i nstruction, periodontal surgery, endodontic seal the oronasal fistula by attaching to the
therapy, oral surgery, removal of caries, fixed prosthesis by means of the precision
orthodontic 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 fistula
provide a physiological occlusion and and potential access for cleaning when
change the jaw relationship from Angle needed. In the execution of this treatment
class III to that of edge-to-edge. The final plan, this young patient was provided with a
restorations accomplished all of these solution to his functional and esthetic
goals as well as providing an esthetic demands, providing him with a much better
solution to the patient's 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 was
along with optimal increase of the vertical a requirement if a good-looking outcome
dimension and utilizing adjunctive orthodon- was to be achieved. Indeed, the maxillary
tics, the pathologic occlusion of Angle class orthodontic treatment involved crossing
I II was converted to an esthetically satisfac- the cleft, but the subsequent construc-
tory functional physiologic occlusion with tion of a fixed prosthesis should prevent
minute anterior guidance. In order to seal any relapse. The use of transitional
the oronasal fistula, and avoid a removable restorations in the evaluation of changes
appliance, a precision attachment was of a dimension of occlusion is to be
i ncorporated on the lingual aspect of the recommended and the result achieved
anterior fixed prosthesis opposite the eminently satisfactory.


• 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
• 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

Face-frontal view Face-side view

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 cuspid


• Sharp conical-shaped cuspids
• Narrow V-shaped residual ridges Figure 18.7
Occlusion-left side
Occlusal examination (Figures 18.6 and
18.7) revealed that the patient was Angle
class 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 mandibular
measured due to the missing anterior teeth ri ght cuspid (due to the cross-bite).
( Figure 18.1). There was no discrepancy
between centric relation and centric occlu- The periodontal examination (Figures
sion. 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 the
lary lateral incisor and the mandibular maxillary and mandibular teeth and
cuspid 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 recession
the mandibular left central incisor and first around most of the teeth and severe
molar on the l eft side. Protrusive vertical recession on the lingual surfaces
movements were guided by the left first of the mandibular right second and left
molar maxillary and mandibular teeth. first molar teeth.


Periodontal chart-pre-treatment, mandible Periodontal chart-pre-treatment, maxilla

Figure 18.10
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


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 denture
j 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 PREPARATION

The patient was motivated for dental I nitial periodontal therapy including oral
treatment in spite of his years of unsuc- hygiene instruction, scaling and root
cessful treatment. He was unaware of the planing


Patient after initial preparation Wax-up

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.


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 a
Figure 18.15 second set of transitional restorations. In
Transitional 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 to
The decision to make a fixed restoration check the vitality of the prepared teeth, the
was 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 clinical
and vitality of the teeth, thus minimizing the situation was stable and there were no
need 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), and
this new vertical dimension (Figure 18.15). i ndividual copper band elastomeric impres-
At this time, endodontic treatment was sions were taken, and stone dies and
undertaken on the maxillary central incisors Pattern resin copings made as described in
which had pulp tested non-vital. the Technical Information chapter. The
Endodontic 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-Bond


Transitional prosthesis II-right side Transitional prosthesis II-left side


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.


SUMMARY CASE DISCUSSION
AVINOAM YAFFE
This patient presented with severe
problems. He was status post (S/P) This case represents a rather controversial
surgery 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 for
any orthodontic or surgical treatment. He fixed partial restoration, and at the same time
had many missing teeth, mostly congeni- the vertical dimension of occlusion was
tal. He had a severe cross-bite and increased by 5 mm. This further jeopardized
scissor bite with a very difficult anterio- the survival of the deciduous teeth. All that
posterior 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 partial
restoration yet was ignorant of good oral restoration. This case was executed with
hygiene. A careful evaluation was made caution at each step. The team was aware of
using mounted study models on an artic- the risk, therefore the diagnostic wax-up
ulator and a tentative wax-up was done to took into account existing tooth position, and
determine 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 with
year, in order to make sure that he could minimum rise on lateral excursions to
adapt 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 a
anterior teeth were restored in a class I physiologic therapeutic occlusion.
relationship although in the posterior
region, a slight cross-bite was built in
order to improve function. The cuspids CASE DISCUSSION
guided lateral movements without any HAROLD PREISKEL
non-balancing side contacts. The maxil-
l ary left central incisor tooth was restored Treating a patient with a cleft palate and
with supra-gingival margins in order to collapse of the maxillary dentition together
achieve 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 decision
li p line and esthetics was not a problem. to increase the vertical dimension by some
Total treatment time was 2 years and all 5 mm was probably correct, although the
the 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 more
at the beginning of the treatment. The cautious approach would have been to
treatment gave the patient esthetics and i ncrease the vertical dimension using
function that he had never had previously, removable prostheses until the correct
due to his pre-existing congenital difficul- vertical dimension had been established,
ties. and only at this stage to undertake


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 patient's
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 HISTORY

The patient, a 25-year-old woman (Figure The patient had suffered some illnesses in
19.1), presented herself for examination childhood, but was currently in good
and 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).

Face-frontal view Anterior teeth-labial view

207


(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 209




Periodontal chart-mandible Periodontal chart-maxilla

and the left mandibular central and lateral FULL-MOUTH PERIAPICAL AND
incisor teeth (as restored by the provi- CEPHALOMETRIC SURVEY
sional restoration). (Figures 19.10 and 19.11)

The periodontal examination (Figures 19.8
and 19.9) showed unsatisfactory oral
hygiene with large amounts of plaque and
calculus. Probing depths were found of up
to 5.0 mm on the maxillary teeth and up to
4.0 mm on the mandibular teeth, with
bleeding on probing on some teeth. There
was inflammation around most of the
teeth.


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 first
The 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 second
her periodontal condition improved. She molars, as indicated. The endodontically
wanted an esthetic, fixed restoration and treated teeth were restored with amalgam
had high expectations of how much it would post and cores. Full coverage provisional
i 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

TREATMENT

Initial preparation included oral hygiene Figure 19.13
i nstruction, scaling, and curettage. Caries Orthodontic treatment-to alleviate root and crown proximity


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).

Orthodontic treatment to re-align anterior maxillary teeth New transitional restorations after periodontal surgery

Biscuit bake porcelain try-in Finished restorations on Quick articulator

GENERALIZED AMELOGENESIS IMPERFECTA 21 3

Facial view of patient's smile after treatment completion Finished restorations in mouth

Once the esthetic, physiological and out in the mouth (Figure 19.17). The final
functional expectations of the patient and glaze was applied to the prostheses (Figure
the dentist had been attained in the transi- 19.18), and the prostheses were cemented
ti 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 zinc
i mpressions were taken, and stone dies and oxyphosphate cement for permanent
Pattern resin copings made as described in cementation in 1999 (Figures 19.19-19.21).
the Technical Information chapter. The
metal copings were fitted, connected,
soldered and refitted as previously SUMMARY
described and the porcelain biscuit bake
applied. The final and minute adjustments The patient presented with a severe
of the biscuit bake porcelain were carried problem of enamel hypoplasia on all of her

Figure 19.21
Radiographs after treatment completed


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 patient's 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.


Frontal view of teeth showing orthodontic retainers Face in profile

• Lower lip exhibited two PITS, indicative
of the Raynaud's 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 the
Figure 20.5 bilateral lip clefts and the missing maxil-
View of lips showing PITS
l ary lateral incisor teeth

I NTRA-ORAL EXAMINATION
compromised and sometimes difficult to
understand. At age 14, he underwent
orthopedic surgery to build up his nose and
also 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 and
Optalgin (glucose-6-phosphate dehydroge- shallow vestibulum
nase 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 RAYNAUD'S DISEASE 217

Maxillary 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 impacted


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, there
the patient was Angle class III, with an
was no anterior disclusion and the only
open 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 revealed
ri or teeth were in an edge to edge relation- probing depths of up to 5.0 mm on the
ship bucco-lingually. The plane of occlusion maxillary teeth and up to 4.0 mm on most
was faulty, with incomplete contacts of the mandibular teeth, with bleeding on
between the maxillary and mandibular probing on some teeth (Figures 20.9 and
teeth (Figure 20.8). The only working side 20.10). There was slight inflammation
contacts in lateral jaw movements were on around the maxillary and mandibular
the second molars. There were balancing molars.


Maxillary periodontal chart Mandibular periodontal chart

Figure 20.11
Radiographs of maxillary
and mandibular anterior
quadrant


BILATERAL CLEFT PALATE AND RAYNAUD'S 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
• Bilateral cleft lip and palate s/p (status
All the teeth had a good prognosis. post) surgery
Oral-nasal fistula
Congenitally missing teeth
SUMMARY OF FINDINGS Poor esthetics
Anterior cross-bite
The patient, a 17-year-old high school Anterior open bite
student, came to the clinic complaining of Gingivitis
poor esthetics and missing front teeth. He Caries
was very concerned about his appearance Raynaud's disease
and wanted to have a fixed prosthesis to Impacted maxillary third molars
replace his removable one.
His previous medical history consisted of
congenital bilateral cleft palate and lip with ABOUT THE PATIENT
many unsuccessful attempts at surgical
repair, and he remained with much The young patient seemed to have no
scarring. He suffered from Raynaud's understanding of the importance of the
disease. 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 have
side, and on the right side there was a dental treatment for esthetic reasons, and
narrow bridge of bone connecting the wanted his teeth fixed before he was
premaxilla and maxilla. He had undergone inducted into army service.
orthodontic treatment and had removable
maxillary and mandibular orthodontic
maintainers, which also replaced the POTENTIAL TREATMENT
missing maxillary lateral incisor teeth. There PROBLEMS
was an oral-nasal fistula between his hard
palate 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 a
gingivitis, but with good bone support. The congenital condition, and was therefore
maxillary lateral incisors were congenitally wary of extensive dental treatment.


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


Dies and Duralay copings Soldered metal copings being fitted

prosthesis from the right cuspid to the left l ary prepared teeth, and Duralay copings
cuspid, with provision for a removable palatal were made (Figure 20.15). These copings
attachment to cover the palatal fistula. A very were used to record centric relation at the
accurately fitting gold palatal leaf (denture) vertical dimension of occlusion as determined
that would seal the fistula was chosen. It by the posterior teeth, and for the impression
would be retained by a precision attachment for the model to make the metal copings. The
fitting 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 and
teeth were prepared and temporized with a soldered and, after try-in of the soldered
transitional fixed prosthesis, which also metal framework, a centric registration record
corrected the cross-bite and gave anterior was made in Duralay (Figure 20.16) and an
contact in centric relation and anterior elastomeric impression was made for the
guidance 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 a
the molars on the right side to erupt into facebow registration and centric records
contact. This was accomplished by building were taken at the vertical dimension of occlu-
up the mandibular lingual cusps with sion utilizing Duralay with a Neylon
composite resin in order to prevent lateral technique. At this point the porcelain was
tongue thrust, which was preventing the teeth baked and the occlusion checked at the
from erupting to contact. The composite was biscuit bake stage in the mouth and all
removed after occlusal contact had been adjustments needed were then made. A
achieved 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 (Figure
orations, copper band impressions of methyl- 20.17). This palatal attachment was then
methacrylate and elastomeric impression cast in gold, with a male attachment to fit the
material (Xantropen) were taken of the maxil- female attachment in the right maxillary


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


minimal treatment necessary, which anterior fixed prosthesis. Additional
i ncluded a fixed partial prosthesis to occlusal support was also obtained by
replace the congenitally missing maxillary passive eruption of posterior teeth that
l 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 food
and liquids from entering the nasal cavity. CASE DISCUSSION
HAROLD PREISKEL

CASE DISCUSSION The successful outcome of this young
AVINOAM YAFFE man's treatment appears to have been
achieved as a result of a team approach
The patient, a 17-year-old high school with successful patient motivation. As a
student, presented to the clinic seeking result, the tongue thrust that was causing
treatment to solve esthetic and functional molar separation on the right hand side
problems. He was anxious to get rid of his was overcome with the aid of transitional
removable partial orthodontic retainer, composite additions to the lower teeth and
which also restored his missing lateral occlusal stability obtained. Missing lateral
i 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 wanted
negated, the patient, in order to prevent from the outset-while the obturation of an
having a removable prosthesis, claimed oro-nasal defect was obtained by means
that 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 pontic
problem, a solution was found that could replacing the lateral incisor. In order to
satisfy the patient's wishes as well as seal obtain a perfect seal, the path of insertion
the fistula. This was a fixed partial prosthe- of the obturator had to be carefully
sis with a small removable partial denture planned and this, in turn, was decided by
to cover the oral-ateral fistula. Prior to fabri- the alignment of the attachment in the
cating the provisional prosthesis, selective pontic. This highlights the importance of
grinding was performed, with the intention an overall plan of treatment, that included
of obtaining a stable occlusion and the path of insertion for the removable
freedom 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

I NDEX 22 7

amelogenesis imperfecta 211 new vertical occlusion 167, 169, 170
cleft lip/palate 190, 195, 203 patient with limited finances 145
patient with limited finances 142, 143 periodontal disease 179
periodontal disease 177, 179 periodontitis 70, 77, 88, 97. 107, 117
periodontitis 95 and refusal of surgery 134
and refusal of surgery 130 financial factors 67, 71, 85
retrograde wear patient 8, 9 financial resources, limited 137-47
eruption xii fistulas 157, 215
compensatory 171 covering attachments 193, 221
forced 85, 178, 182 oro-antral 197, 223
passive 20, 21 oronasal 189, 193, 195, 217, 219, 223
in bruxism 17, 18, 19 oronasal-palatal 186
with deterioration 57, 61 retrograde wear patient 4
guided 221, 223 flaring of teeth l10
esthetics 35, 79, 128-9 neglected dentition 43
amelogenesis imperfecta 214 periodontitis 64, 75, 94, 99, 104
cleft lip/palate 193, 197, 216, 222 fluoride gel 142, 190
neglected dentition 43 fluoride rinses 67, 68, 130, 182, 190
patient with limited finances 141 fremitus
patient's attitude to 28, 30-1 in bruxism 15
periodontitis 76, 99, 104, 105, 114 cleft lip /palate 199
and refusal of surgery 129 neglected dentition 41, 53-4, 55
extractions 86, 142, 143, 158 new vertical occlusion 165
extra-oral examinations patient with limited finances 139
after trauma 150 periodontitis 65, 71, 79, 99
amelogenesis imperfecta 208 severe 102, 109, 110, 112, 113
in bruxism 13 retrograde wear patient 5, 11
cleft lip/palate 185-6, 198, 216 friction coefficient 12
excessive wear patients 4, 23 furcation involvements
li mited finances 138 extensive wear patient 27
neglected dentition 40, 52 li mited finances 140
new vertical occlusion 164 neglected dentition 42, 43, 55
periodontal disease 173 periodontitis 66, 83, 94, 112
periodontitis 74, 81-2, 92, 92-4
complicated 64 gag reflex 85, 87, 90
severe 101-2, 111-12 gingival disorders 15, 20, 73, 127, 136
and refusal of surgery 125 gingival margins 128, 132-3, 212, 214
extrusion gingival recession
cleft lip/palate 218 cleft lip/palate 199
deliberate 58, 59, 86, 116, 121 limited finances 140
with deterioration 52, 55 neglected dentition 42, 54
new vertical occlusion 164 periodontal disease 175
periodontal disease 175, 176 periodontitis 66, 83
periodontitis 65 retrograde wear patient 5
retrograde wear patient 7, 11 gingivitis 129, 153, 186, 201, 210, 219
roots 69 grafts 87, 155, 190
exudate 40, 41, 186 see also augmentation
grinding/ reshaping of teeth 57, 76, 79, 170,
facebow registrations 10, 32, 59 223
after trauma 158
cleft lip/palate 193, 221 Hawley appliance xi, 68, 95, 96, 105
neglected dentition 47 bite plane retainer 115-16

22 8 I NDEX

heart disorders 51, 55, 57, 63, 159 j aw relationships
hormonal therapy 13 i n cleft lip/palate 187, 193, 195, 205
hyperostosis corticalis generalista 163, 166 occlusal 133
j aw size disparity 114, 121, 201
impacted teeth 209, 218
implant placement 156 l abiomental fold, accentuated 23, 112
i mplants 47, 85, 87, 153, 169 l anguage barrier 85, 88, 90
existing 92, 99 l ateral force reduction xii, 90
failed 156 l esions 43
i nsertion/ exposure 155, 157 apical 28, 29
placement 46, 87, 130 periapical 29-30, 141, 156, 189
i mplant-supported prostheses 47, 156 perio-endo 94
Impregum xiv l eveling of teeth 49, 50
i mpressions xiii lingual additions/ buttons 18, 44, 57
alginate 59 lingual cusp buildup 19, 20
altered cast 179, 180 lip line, high 128, 205
copper band elastomeric xiii-xiv, 33, 69, 77, 169, lip seal 73, 79
221 lips
advanced periodontal disease 179 i ncompetent 138
after trauma 157 trapped lower 40, 112, 138
amelogenesis imperfecta 213
cleft lip/palate 193, 203 magnets 146, 147
excessive wear patients 9, 32 maintenance 21, 206, 214
neglected dentition 47, 58 methyl-methacrylate 221
patient with limited finances 144 midline discrepancy 52, 92, 126, 129, 139, 212
periodontitis 70, 87, 106, 107, 117 mid-palatal suture deviation 82
and refusal of surgery 133 missing teeth 104
elastomeric 117, 118, 158, 170, 179 after trauma 150, 151
mercaptan rubber base 10 amelogenesis imperfecta 208
polyether full-arch 59, 87, 145 cleft lip/palate 186, 199
cleft lip/palate 193 congenital 92, 217
neglected dentition 47, 59 neglected dentition 40, 43
periodontitis 97, 98 new vertical occlusion 166, 171
and refusal of surgery 134 patient with limited finances 138, 139
retrograde wear patient 9 periodontal disease 174, 176
of soldered castings 78 periodontitis 64, 65, 73, 108, 114
inflammation 84, 127, 165, 209 and refusal of surgery 126, 129
cleft lip/palate 187, 216, 217 retrograde wear 4, 5
severe 43, 55, 141 mobility of teeth 110
infraboney pockets 66 neglected dentition 42, 43, 55, 58
intra-oral examinations 82-4 patient with limited finances 140, 141, 142,
advanced periodontal disease 174-5 143
after trauma 150-2 periodontal disease 174, 181
amelogenesis imperfecta 208-9 periodontitis 74, 79, 99
i n bruxism 13, 15-16 complicated 65, 71
cleft lip/palate 186-7, 198-9, 216-17 severe 102, 109, 112, 113
excessive wear patients 4-6, 23-7 retrograde wear patient 5, 11
neglected dentition 40-2, 52-5 models xiv, 10, 144, 145, 157, 179
new vertical occlusion 164-5 periodontitis 77, 117
patient with limited finances 138-40 study 95, 96, 202
periodontitis 64-5, 74-5, 102-4, 112-13 working 77, 78
and refusal of surgery 126-7 mouth, inability to close 73, 79

230 I NDEX

periapical full-mouth examinations (coat.) pick-up impressions 33, 47, 48, 97, 133
extensive wear patient 23-7
new vertical occlusion 166 platforms 97
patient with limited finances 141 canine xi
radiographic 82-4, 92-4, 174-5 in bruxism 17-18, 20
after trauma 150-2 with deterioration 56, 57
i n bruxism 13, 15-16 and refusal of surgery 130, 131, 136
cleft lip/palate 188, 198-9 incisal 34
neglected dentition 40-2, 52-5 lingual 85
periodontitis 64-5, 74-5, 102-4, 112-13 see also rests
and refusal of surgery 127 pleomorphic adenoma 173, 181, 182
retrograde wear patient 4-6 pocket elimination 69
survey 6, 42, 55, 65-6 ' pouch technique' 58
periodontal charts probing/ pocket depth
after trauma 152 after trauma 151, 154, 157-8
amelogenesis imperfecta 209 amelogenesis imperfecta 209
i n bruxism 16 in bruxism 15-16
cleft lip/palate 187, 190, 192, 200, 218 cleft lip/palate 187, 199, 217, 220
excessive wear patients 6, 26, 31 excessive wear patients 5, 26-7
neglected dentition 42, 54, 56, 58 i mprovement 76, 95
new vertical occlusion 165, 169 neglected dentition 42-3, 54, 57-8, 59
patient with limited finances 140, 142, 143, 144 new vertical occlusion 165, 168
periodontal disease 176 patient with limited finances 139-40, 142-3
periodontitis 66, 75, 84, 92 periodontal disease 175, 177
severe 103, 112, 115 periodontitis 75, 83, 92, 94
and refusal of surgery 126 complicated 66, 69
periodontal deterioration 51-61 improvement 76-7
periodontal disease, advanced 173-82 severe 102, 105-6, 109, 113, 115-16
periodontal examinations 116 and refusal of surgery 127
amelogenesis imperfecta 209 prophylaxis 52, 57, 61, 63
i n bruxism 15-16 prostheses
cleft lip/palate 187, 199, 217 fixed 44, 48, 76, 79, 95, 203
excessive wear patients 5-6, 26-7 insistence on 153, 159, 160, 161
li mited finances 139-40 partial 69, 79, 130, 177
neglected dentition 42, 54 permanent 222, 223
new vertical occlusion 165 provisional 130
periodontal disease 175 six-unit 156
periodontitis 75, 83, 92-3 transitional 177, 179, 221
complicated 66 fixed vs removable 109-10, 141, 142
severe 102-4, 113 implant-supported 156
periodontal surgery 69, 132-3, 203 insertion difficulties 204, 223
advanced periodontal disease 177 provisional 87
amelogenesis imperfecta 212 removable 67, 69, 87, 177, 223
cleft lip/palate 190, 195 tooth-supported 201
patient with limited finances 143 transitional 178
periodontitis 116-17 see also bridges; crowns; restorations
periodontitis 7, 16, 47, 55, 176 proximity 132, 209, 211, 214
advanced 73-9, 81-90, 167 pseudo pockets 167
complicated 63-79 pulpitis, acute 85
severe 101-10, 111-21
moderate to advanced 91-9 radiographic examinations 16, 27
phenytoin 73 see also under periapical full-mouth examinations

232 I NDEX

speech problems 35, 79, 220 periodontitis 76-9, 85-8, 94-8, 104-8
cleft lip/palate 197, 198, 215, 222 complicated 67-71
splinting 85, 96, 97, 130, 177 and refusal of surgery 129-34
cross-arch 8 trifurcation involvements 57, 167
of retracted teeth 44, 45
stents 47, 87 valproic acid 73
stone dies xiii-xiv vertical dimension of occlusion xi, 17, 30, 58, 192
amelogenesis imperfecta 213 adaptation to new 205
cleft lip/palate 203 alteration of xii, 8, 12, 18, 20, 214
with deterioration 59 cleft lip/palate 195, 203
patient with limited finances 144 centric relation record 145, 157, 158
periodontitis 69 advanced periodontal disease 179
and refusal of surgery 133 cleft lip/palate 221
stops see platforms; rests periodontitis 77-8, 88, 97
support, posterior 129-34, 141 severe 106, 107, 117
suppuration 136 and refusal of surgery 133, 134
swallowing problems 75-6, 79 increase of 48, 130
extensive wear patient 35, 36, 116
technical information xiii-xv neglected dentition 44, 57
telescopic prostheses 147, 190, 201 loss of 16, 134, 135, 167, 176
Temp-Bond see cementation of prostheses reduced 121, 153
tilting/tipping 65, 82, 151 neglected dentition 55
titanium mesh 150 new vertical occlusion 170
tongue patient with limited finances 141
interference from 18, 221, 223 periodontitis 88, 94, 104, 114
lack of control 73 and refusal of surgery 129
pressure from 75-6, 79 vertical occlusion, new 163-71
tooth material, choice of 10, 12, 145 vestibulum, shallow 153, 190, 216, 217
tooth position classification xii vibration in tooth wear 28-9
tooth preparation 105, 205-6
tooth structure loss 8, 112, 126, 128, 174, wax-ups 156, 167, 202
214 wear
transfer copings 47, 69 anterior teeth 24, 25
traumatic sequelae 149-61 excessive 20, 28-9, 36
trays, bite 10, 107, 145 extensive 23-36
custom 10, 87, 117 extreme 13, 14, 16, 164, 170
treatment 85, 114-19 new vertical occlusion 166, 167, 171
after trauma 153-9 retrograde 3-12
in bruxism 17-20 wear facets 25, 64, 187
cleft lip/palate 189, 189-93, 201-4, 219-22 wire/ wiring 44, 95, 97, 150
excessive wear patients 7-11, 29-34 Worth's disease 163
neglected dentition 44-7, 55-60
new vertical occlusion 167-70 Xantropen xiii, 221
patient with limited finances 141-6
periodontal disease 176-81 zinc oxyphosphate cement see cementation

Prosthodontics in clinical practice

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