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| CASE REPORT |
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| Year : 2020 | Volume
: 4
| Issue : 1 | Page : 33-38 |
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Holistic management of mutilated dentition
Vidyalakshmi Chandrasekar, Ahila Singaravel Chidembaranathan, Muthukumar Balasubramanium
Department of Prosthodontics, SRM Dental College, Chennai, Tamil Nadu, India
| Date of Submission | 23-Oct-2019 |
| Date of Acceptance | 11-Jan-2020 |
| Date of Web Publication | 7-Feb-2020 |
Correspondence Address:
Dr. Ahila Singaravel Chidembaranathan
Department of Prosthodontics, SRM Dental College, Ramapuram, Chennai, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/SDJ.SDJ_46_19
Background: Worn dentition has become a common and crucial issue, especially in the older generation. Beyond esthetics, functional diminution can create a serious impact on the overall well-being of the individual. The etiology of the worn dentition can be multifactorial; therefore, the treatment approach should be systematic and must not only address the existing problem but also prevent any recurrence. Case Report: Rehabilitation of a patient with worn dentition requires proper clinical, radiographic examination and recording of the occlusal vertical dimension (OVD). In this case report, a 65-year-old male patient presented with worn out and missing teeth in his upper and lower jaws. An arbitrary face-bow transfer was conducted, and the diagnostic casts were articulated. A mock full contoured wax up with a raised OVD of approximately 4 mm was completed. After 3 months of interocclusal splint therapy with the raised OVD, temporary restoration was cemented. After a follow-up period of 3 months, when the patient was devoid of any signs and symptoms, permanent restorations fabricated using computer-aided design and computer-aided manufacturing were cemented. An interocclusal splint was provided to preserve the restorations. Conclusion: Rehabilitating patients with worn dentition involves careful decision-making during the diagnosis as it will direct the entire treatment sequence. This case report and the resulting steps involved might serve as guidelines for other clinicians while treating similar patients.
Keywords: Computer-aided design and computer-aided manufacturing, occlusal splints, rehabilitation, tooth wear
How to cite this article:
Chandrasekar V, Chidembaranathan AS, Balasubramanium M. Holistic management of mutilated dentition. Sci Dent J 2020;4:33-8 |
| Background | |  |
Teeth are an integral part of the concept of “facial esthetics.” Equal complementation by both the facial and dental components is critical for a pleasing facial appearance.[1] Apart from being noted as an element of beauty, teeth contribute to other major activities such as speech, mastication, and swallowing. As age advances, regressive physiological changes such as attrition, abrasion, abfraction, and gingival recession set in. These changes are quite inevitable as they result from physiological wear and tear.[2] Moreover, a few other deteriorating changes encountered in the tooth structure are due to congenital anomalies (e.g., amelogenesis imperfecta).[3],[4] Altered lifestyle and food habits (consumption of high amounts of citrus foods, aerated drinks, acid regurgitation, etc.,) can result in enamel erosion. However, these regressive changes in the clinical crown height are compensated by the continuous eruption of the teeth. Hence, the onset of this disease is most often overlooked because of it being gradual in nature.[5],[6],[7]
These above-mentioned factors, alone or in combination, can lead to a gradual loss of tooth structure, causing sensitivity, wear facets, decreased masticatory ability, loss of vertical dimension, temporomandibular disorders, gastrointestinal and psychological problems. As these problems are multifactorial, so is the approach for treating them.[8],[9] This case report discusses a systematic approach to establish the lost vertical dimension without disturbing the temporomandibular joint (TMJ) and also emphasizes the importance of incorporating occlusal splint therapy for raising the vertical dimension.
| Case Report | | |
A 65-year-old male patient reported to the Department of Prosthodontics and Implantology at SRM Dental College, Ramapuram, Chennai, India. The patient's chief complaint was trouble while chewing and ragged teeth. The patient revealed a history of gradual wear of teeth and increased sensitivity over the years.
Initially, a detailed history regarding the patient's occupation, dietary habits, and lifestyle revealed that the patient had a mixed diet, brushed once daily, and had smoking habit 10 years ago. Furthermore, the patient reported no para-functional habits. The patient was clearly informed regarding the course and nature of the treatment, and a written consent also was obtained stating that the doctor could utilize the treatment information for educational and publication purposes.
Clinical examination
Extraoral examination of the face showed no gross facial asymmetry. The temporomandibular joint (TMJ) was assessed using a TMJ radiograph, and it showed no abnormalities. Intraoral examination revealed severe attrition of the mandibular anterior and posterior teeth (regions 31–35 and 41–45) and scattered hyperpigmentations in the palate and buccal mucosa [Figure 1], [Figure 2], [Figure 3]. The upper central incisors showed attrition exclusively in the palatal region and slightly in the incisal region. The upper posteriors showed attrition on the masticatory surface. Reduction in the vertical dimension was evident. There was complete obliteration of the overjet and overbite. Regions 26, 28, 37, 38, and 48 showed missing teeth. The left upper molar (27) was mesiotilted, the left lower molar (36) showed pain on percussion, and the right upper third molar was supraerupted. The diagnostic casts, preoperative intraoral and extraoral photographs, were documented for the study purposes.
Radiographic examination
On radiographic examination, the left mandibular first molar revealed root canal treatment and periapical inflammation of the distal root [Figure 4]. The wear patterns of the upper posteriors and lower posteriors were directed on the mesiobuccal cusps and toward the distobuccal cusps, respectively.
Diagnostic procedures
The severe wear facets on the occlusal surfaces of all the anterior and posterior teeth during intraoral examination suggested a differential diagnosis of para-functional habits leading to a gradual attrition of the posterior and lower anterior teeth resulting in the loss of vertical dimension.
Preprosthetic procedures
A treatment plan, which involved the removal of the left mandibular first molar and the right upper third molar, was drawn. Root canal treatment was advised for all the mandibular anterior teeth. Following this, an increase in the vertical dimension was planned to correct the obliterated overjet and overbite. The discrepancy in the vertical dimension was elicited using Silverman's method.[1] The patient was classified under Turner's category No. 2: Excessive wear without the loss of occlusal vertical dimension (OVD) but space available.[1] It is concluded that all the teeth required full veneered crowns to compensate for the lost vertical clinical crown length.
Mock wax-up
Two pairs of irreversible hydrocolloid impressions were made using Zelgan Plus Alginate Impression Material (Dentsply, International, Inc., New York, USA). The casts were poured using Type II gypsum products (Golden Stone, Golden Stone Ramaraju Traders, Chennai, Tamil Nadu, India) and mounted on a semi-adjustable articulator (Whip Mix Hanau, Louisville, Kentucky, USA). A face-bow transfer was done to mount the maxillary cast. The existing centric bite of the patient was used to mount the mandibular cast. Of the two pairs, one set of the cast was used for the fabrication of the interocclusal splint with an increased OVD. Another set was used for creating the full contoured mock wax-up with an increased vertical dimension [Figure 5].
Raising the occlusal vertical dimension
A drastic and sudden rise in the vertical dimension would cause damage to the TMJ.[8] Hence, a deliberate and steady increase in the vertical dimension was carried out. Initially, a 2-mm soft splint was given to the patient for use during day and night time for 3 weeks. The patient's acceptance, muscle tenderness, and state of the TMJ were examined. The patient complained of initial discomfort and slight pain that gradually disappeared at the end of 3 weeks. Following this, an anterior deprogramming device, the Lucia jig, was used to record the centric relation of the patient at the desired OVD. The patient was guided to the centric relation using the bimanual manipulation technique. The centric relation was registered using the bite registration paste. This bite was used to rearticulate the stone casts. An interocclusal splint fabricated as per the new OVD using self-cure clear acrylic was delivered to the patient [Figure 6]. The patient was instructed to use it throughout the day and night time for 4 weeks. The patient's feedback indicated initial muscle tenderness and TMJ pain that subsided after continued usage.
In the second set of casts, which were articulated with an increased OVD, the occlusal plane was determined with the help of a Broadrick occlusal plane analyzer. This occlusal plane was maintained during the mock wax-up. The mock wax-up was utilized for the treatment outcome explanation, and a putty index was prepared from the same for the fabrication of temporary restoration.
Preparation for restoration
Teeth preparation was carried out according to the Pankey–Mann–Schuyler concept.[4] Initially, the upper and lower anterior teeth were prepared to restore proper anterior guidance. Following this, the lower and upper posteriors were prepared. The patient was restored with temporary crowns made from the putty index of the mock wax-up using tooth-colored acrylic resin (Dental Products of India, Mumbai, Maharashtra, India). The temporary restoration was cemented; the high points were reduced, and a recall appointment was scheduled after 4 weeks.
Definitive impression and bite registration
The patient was comfortable with the new OVD. The temporary restoration was removed, and gingival retraction was conducted for definitive impression making. Definitive impressions were made using putty and light body addition silicone (Aquasil, Dentsply International, INC., New York, USA). Definitive casts were poured using type IV gypsum (Kalabhai, Ultrarock Die Stone, Vikhroli West, Mumbai, Maharashtra, India). Bite registration was done using Bona-Bite bite vinyl polysiloxane registration paste (DMP, Europe) on the right side, with the temporary restoration intact on the left side. The same technique was repeated for the opposite side. Thus, the increased vertical dimension was maintained throughout the procedure. Definitive casts were articulated with the obtained bite. The articulated casts were scanned using a laser scanner (SHINNING 3D, Hangzhou China), following which the STL files were processed using EXOCAD software [Figure 7]. Metal copings of 0.3 mm were fabricated by the direct metal laser sintering method. This was followed by conventional ceramic layering. A bisque trial was conducted. The final prosthesis was cemented using intermediated restorative cement for approximately 4 weeks, which was later recemented using glass-ionomer cement (GC Corporation, Tokyo, Japan) [Figure 8], [Figure 9], [Figure 10], [Figure 11]. The patient was given a soft splint and instructed to wear it during night time.
| Discussion | | |
Worn dentition can cause multiple orofacial problems when ignored. Negligence of the signs and symptoms during the early onset of the disease is a primary cause for the cascade of events that occur during the course of the condition.[10] Oral health-related awareness in respect to missing and worn out dentition is still lacking.[11] Appropriate clinical judgment while devising the treatment plan is crucial. Proper recording and maintenance of the correct OVD throughout the treatment are the most crucial while rehabilitating worn dentition.[12],[13] Accomplishing the lost vertical dimension without hampering the other integral structures of the stomatognathic system is essential.[14]
Diverse approaches, such as interocclusal distance, phonetics, swallowing, and patient predilection, have been proposed to determine the measurements for the correct OVD.[15] Turner classified worn dentition into three categories based on the loss of the vertical dimension and available space.[1] His conventional approaches, such as raising the OVD, crown lengthening, and restoring the worn teeth, are still practiced. However, a hard and fast rule for the absolute management of attrited dentition is still elusive.[15] This is because every individual patient requires a tailor-made approach. Substantiating long-term studies and clinical trials are much needed to clarify and resolve the technical difficulties encountered during decision-making.[16]
Roark et al. investigated the electromyographic activity during para-functional habits using interocclusal splints and reported a significant decrease in the temporal and masseter muscle activities during minimal and maximal clenching.[16] Interocclusal appliances for patients with TMJ disorder may vary in thickness, duration of use, placement on the mandibular arch, presence or absence of any adjustments, etc., Moreover, different types of splints may have different modes of action.[8] Yet, the judicious usage of such splints for raising the vertical dimension is still not widely practiced. Hence, in this study, a customized interocclusal splint therapy was carried out to eliminate any undesirable muscle activity and to help the patient to accommodate to the increased vertical dimension. The use of an interocclusal splint for increasing the vertical dimension was predictable. It helps the clinician to assess and monitor the changes in the muscles and TMJ during the initial training period. Thus, the vertical dimension can be increased in a well-organized manner. Our case report validates the use of such interocclusal splints for relaxing the masticatory muscles and increasing the vertical dimension for full mouth rehabilitation cases.
Computer-aided design and computer-aided manufacturing (CAD-CAM) technology has not only reduced laboratory and chairside time but has also greatly evolved in terms of restoration precision.[17] In this study, CAD-CAM fabrication of the definitive restoration was attempted to utilize the precision rendered by the technology. It was followed by the conventional method of ceramic layering to achieve life-like restorations.[18]
| Conclusion | | |
Worn dentition requires a very careful and calculative approach due to its complex nature. A thorough understanding of the stomatognathic system and its components will aid in arriving at better treatment outcomes. A clear and straightforward approach while correcting the OVD is the key to successful full mouth rehabilitation of severely worn dentition. Moreover, subjective preferences and other associated elements, such as phonetics and mastication, are to be considered during the course of the treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
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