Functional and Aesthetical Full Mouth Rehabilitation of a patient with
severely worn Dentition and Deep bite: A 3-Year Follow-Up
Negin Yaghoobi1, Azam Mostafavi2 , *Soolmaz Barati 3
1 Assistant Professor, Dental Research Center, Dentistry Research
Institute, Department of Prosthodontics, Tehran University of Medical
Science, Tehran,
2 Associate Professor, Dental Research Center, Dentistry Research
Institute, Department of Prosthodontics, Tehran University of Medical
Science, Tehran,
*3 Postgraduate Prosthodontics Resident, Dental Research Center,
Dentistry Research Institute, Department of Prosthodontics, Tehran
University of Medical Science, Tehran, Iran.
Correspondence
Soolmaz Barati , Department of Prosthodontics, School of Dentistry,
Tehran University of Medical Sciences, Tehran 1439955991, Iran.
Email: barati27.s@gmail.com
Key Clinical Message:
Full mouth reconstruction in a patient with deep bite and bruxism and
worn dentition is a challenging situation. Minimally invasive approach
by using CAD-CAM restorations is recommended in these cases.
Abstract
Full mouth reconstruction of a deep bite patient with severely worn
dentition is a challenging situation for the prosthodontists. This study
represents minimally invasive procedures in mentioned condition without
increasing vertical dimension. After 3 years of follow up no
complication was observed.
Keywords: Bruxism, Full mouth reconstruction, Tooth wear, Computer-Aided
Design
INTRODUCTION
Tooth surface loss (TSL) or tooth wear (TW) is an irreversible loss of
hard teeth structure which is observed clinically as attrition,
abrasion, abfraction and erosion (1). Different types of tooth wear
frequently coexist, making it difficult to determine the type of wear
present (2).
Abrasion is defined as physical wear of the teeth caused by something
other than tooth-to-tooth contact like inappropriate toothbrushing or
repeated use of a toothpick (2). Furthermore, the loss of tooth
structure may occur when the teeth are in contact with one another, as a
result of attrition or dental erosion caused by acids in the mouth. An
abfraction, a wedge-shaped lesion with sharp line angles, has been
attributed to eccentric forces acting on the natural dentition (3),
whereas Dawson believed it is the result of tooth brushing rather than
occlusal overload (4, 5).
Severe tooth wear could cause tooth hypersensitivity related to dentine
exposure, morphological change of occlusal surfaces of teeth, occlusal
disharmony, functional impairment, temporomandibular joint disorders
(TMD) and also poor aesthetic (1, 6, 7). In addition, loss of occlusal
vertical dimension (OVD) may lead to dentoalveolar compensation or
increased interocclusal rest space (8).
Due to progress in restorative methods and modified materials there are
many treatment options for patients with worn dentition such as:
conventional full coverage restorations, direct or indirect composite
resin restorations, cast adhesive alloys (metal palatal veneers) and
bonded ceramic restorations (9).
Malocclusion, which can be defined as ”an abnormal occlusion in which
teeth are out of alignment with adjacent teeth in the same jaw or the
opposing teeth when the jaws are closed” (3), can result in oral health
complications if left untreated. As a specific type of malocclusion,
deep bite is defined as an increased vertical overlap between the upper
and lower incisors which is treated by several methods range from
removable appliances to fixed appliances with or without orthognathic
surgery (10); It is however believed that deep overbite with stable
holding contacts constitute one of the most stable dentitions, in which
case no dental treatment is necessary (5).
Although restoration of worn teeth by reorganizing the occlusion at an
increased VDO has been well documented, some complaints, such as TMD,
chipping of unsupported ceramics, and relapse to previous conditions are
frequent (6, 7, 11). For worn teeth with insufficient restorative space,
intentional endodontic treatment, crown lengthening, and full coverage
restorations have been recommended (5, 12).
While full coverage restorations have been recommended to restore worn
teeth with insufficient restorative space, based on the available
literature, conservative approaches such as minimally invasive
restorations have been found to be more conservative than conventional
procedures (13, 14).
A few examples of minimally invasive approaches that might be indicated
in such worn dentition include establishing occlusal harmony with an
ideal occlusal plane through laminate veneer restorations, as well as
occlusal veneers (15-17).
Consequently, a full-mouth rehabilitation involving an interdisciplinary
approach for a patient with severe deep bite and worn dentition is
described in this clinical report.
CASE PRESENTATION
A 54- year-old man was referred to the department of prosthodontics for
oral rehabilitation. His chief complaint was being worry about worn
dentition and poor esthetic especially in anterior teeth. There was no
specific diet or mal habit mentioned by the patient other than clenching
and bruxism during the night. Extra oral examination revealed almost
symmetrical esthetic proportions and no limitations or deviation was
observed during maximum mouth opening. palpation of muscles, lymph
nodes, and temporomandibular joints confirmed normal conditions.
Intraoral examination revealed uneven incisal plane, smile disharmony
and uneven gingival plane in both arches. General tooth surface loss and
dentin exposure especially in mandibular incisors were detected without
pain. (Figure 1)
Abfraction of teeth #4 and #5 and unilateral lingual torus
mandibularis in right canine/premolar area was observed (figure 2).
Caries in teeth #3 #17#32 were detected. There was an amalgam filling
in tooth number #5 that was not appropriate from both an aesthetic
perspective and in terms of durability (figure 3). In the first visit,
tooth number 7 had a metal ceramic full crown which did not match the
color of the other teeth, showed metal margin exposure and an incorrect
contour, all of which were noted in the smile view. Missing teeth of
number #19 #20 #30, mesiolpalatal tilt of tooth number 2, mesial
drift of #18 and #31 that caused insufficient space for replacement of
missing teeth and also disharmonic occlusal plane was evident. Oral
hygiene was appropriate but there was insufficient attached mucosa in
teeth number #18 #31. All teeth had good crown root ratio in
radiographic periapical view except #16. Tooth number #5 had
unacceptable RCT (figure 4). VDO was evaluated and the freeway space was
measured to be 4 mm (normal value is 2–4 mm) (18). Dense bone island
detected as localized area of radiopacity near mesial root of tooth
#18. These localized, well-defined, radiopaque lesions are asymptomatic
and found more often in the mandible, especially in the molar region.
Since their cause is unknown and their presence has no clinical
significance, extraction of a tooth inserted into a DBI may result in an
infected socket and bone resorption, therefore no specific treatment has
been recommended (19). After related consultation, it was suggested that
excess occlusal stress could be a contributing factor to DBI associated
with the roots of the tooth, and that no treatment was indicated.
For the diagnostic stage, primary impressions one-stage putty-wash
(speedex coltene/switzerlan,) were made and poured by plaster (Moldano
Dental Stone, Bayer Co). Centric relation was recorded by bimanual
manipulation technique using acrylic anterior deprogrammer (Pattern
Resin LS, GC Dental Corp) and bite registration silicone (Futar D;
Kettenbach GmbH & Co) as bite registration material. The record was
used for mounting the primary casts in a semi-adjustable articulator
(Hanau Wide-Vue Whip Mix) by an arbitrary facebow (Hanau Springbow-Whip
Mix). Posterior occlusion revealed interferences on teeth number #12,
#13 and #20, #21. The possible treatment plan would be established
according to investigation the space in vertical dimension at rest and
occlusion and the space available for teeth restorations. Based on
speech, smile evaluation and amount of restorative space in CR position
it was decided to rehabilitate the dentition in the existing VDO. As a
result, VDO was considered in CR at the interference point, which was
approximately a 0.5 mm opening in the posterior segment and a 1 mm
increase in the anterior one. Wax-up for lower anterior teeth was
carried out after determination of mandibular canine level at the corner
of the resting lips, followed by upper anterior teeth waxing. The
quality and correctness of wax-up were verified by chairside mock-up
(temporary crown and bridge material, master-dent, USA) in the mouth
during phonetics, smile, and rest position. Then occlusal plane was
determined using a Broadrick occlusal plane analyzer and that was
verified in mouth in centric occlusion and eccentric movements. It is
important to mention that mutually protection occlusal scheme was
considered. Based on occlusal plane, inserting implant to replace teeth
#3 and #15, RCT for teeth #8 #24 #25 #26, re-RCT of #5, crown
lengthening of maxillary and mandibular anterior segment (from canine to
canine), full crown of #4 #6 #8 #11, post and core crown #5 #23
#24 #25, fixed partial denture #18 #19 #20 and #29 #30 #31,
porcelain laminate veneers of #7 #9 #10 #23 and occlusal veneers
#12 #32 were decided.
Once the treatment plan was accepted, provisional restorations were made
using temporary crown and bridge material (master-dent, USA) for
treatment sessions until the teeth preparation were finalized and
printed temporary restorations were prepared. After scaling and root
planning, caries removal was done and teeth were filled with composite
(3M™ Filtek™ Z350 XT Universal Restorative/ USA). Crown lengthening
stent for both jaws were made and gingival leveling in anterior segments
of maxillary and mandibular arch was done in one session. Implant
insertion was carried out using a semi-guided surgical guide
(radiographic stent converted to surgical stent) in location of teeth
number #3 (Ø 4.8mm RN, SLA® 8mm Straumann® Dental Implant System), #15
(Ø 4.8mm RN, SLA® 12mm Straumann® Dental Implant System) (figure 5).
Fabrication of post resin pattern according to affirmed occlusal plane
by index was done. Nickel-chrome casting post was cemented by Glass
ionomer luting cement (GC Fuji I®Enhanced America).
Preparation was done in this way: circumferential radial shoulder finish
line was prepared for FPDs and crowns, light chamfer for laminates and
conventional design (planar straight bevel) was considered for occlusal
veneers.
Impressions for temporary restorations were taken (Betasil Vario Putty
Soft Muller Germany/Betasil Vario Light Body Muller Germany); CR
registration according to past method and facebow transfer & mounting
was done. After abutment selection (straight and angled tissue level
regular neck), temporary restorations design was done in Exocad
DentalCAD software, then they were printed (DigiDent Lite 4K, IRAN) by
PMMA material shade A2 (kucco-koul, China).
In try-in session, smile view, occlusal plane and occlusal contacts were
assessed during CR and eccentric movements, and canine guidance and
mutually protected occlusion was established. After assessing occlusion,
marginal fitness and phonetic, impression making from temporary
restorations & making Casts were done. Protrusive record for
determining condylar inclination (R:30, L:26) and bennet angle (R:16,
L:15) was completed and final impression from temporary restorations was
taken. One stage putty-wash (speedex coltene/switzerlan,) and customized
occlusal table were prepared. Then, final Impression was made in the
same way mentioned before. Casts were mounted by cross mount technique
(every other mounting procedure), cores were designed using Exocad
software, then frameworks were milled IPS e.max®ZirCAD (Ivoclar
Vivadent,Germany) for PFZ crowns and IPS Empress CAD( Ivoclar Vivadent ,
Germany) for PLV and occlusal veneers.
Next, occlusal veneers were checked in mouth and radiographies were
taken to check the marginal integrity. The porcelain was then applied to
the frames (according to the manufacturer’s instructions) and a
porcelain try-in session was conducted. After confirming restorations
aesthetic and contours, final glaze and delivery was done.
In the delivery session, laminates were cemented by Choice 2 Veneer
Cement (BISCO Dental, USA). Dual-cure resin cement (Panavia V5, Kuraray
Co) was used for occlusal veneers, full coverage restorations cemented
by glass ionomer cement (Fuji II, GC Dental Corp), for implant
restorations abutments were torqued to 35N according to manufacturer
instruction and temp bond (NE kerr S.R.I. Scafatia, Italia) was used
(figure 6,7,8,9).
After delivery of restorations, oral hygiene instructions using water
jet and super floss was explained for the patient, and follow-up
sessions were set for 1, 6, and 12 months later, and annually afterward.
After that an impression (Alginate, Chromogel) was taken for making
occlusal dual splint. Delivery of occlusal splint was done in next
session.
DISCUSSION
The case that was presented focused on the treatment procedure of a
patient suffered from progressive wear and parafunctional habits.
The challenges in this specific case were anterior deep bite, severe
worn teeth, the need of esthetic and functional rehabilitation in the
existing vertical dimension due to patient‘s intolerance of increasing
VD and also the resultant interference of elongated maxillary incisors
following with phonetics and lower smile line. It is also challenging to
achieve good alignment and occlusal harmony within abutments that have
different natures (tooth abutments and implant abutments) simultaneously
in full mouth rehabilitation with dental implants. Moreover, material
selection is a critical factor that needs special attention in worn
dentitions since minimal preparation must be performed on the teeth, as
well as materials that have sufficient strength in a low thickness must
be chosen.
Another challenge was the need to rehabilitate some areas by implant
prostheses due to the reported potential failure risk of implant
prostheses because of occlusal overload (20-22); however, few
researchers have assessed the impact of bruxism on dental implant
outcome, and the results obtained are contradictory (22-24). At present,
there are some expert opinions and cautionary approaches that should be
considered in order to minimize the risk of implant failure in cases of
bruxism (22). In this case, zirconia crown was selected for
rehabilitating due to its superior esthetics and wear resistance (25).
Based on studies, an appropriate occlusal scheme (Canine-guided occlusal
concept to reduce occlusal forces during jaw movement) was selected and
stable contacts and an equal distribution of forces were established
(22, 26).
It is obvious that the loss and wear of the posterior teeth will cause a
deeper overbite (27).There are several options for gaining space
necessary for restorations in these patients who have attrition combined
with a deep bite, including restorative dentistry, orthodontics, and
oral surgery.
Dawson recommended the following methods for correcting deep bites: 1.
Reshaping of anterior teeth as needed in mild cases 2. Orthodontics 3.
Restorative procedures 4. Surgery (5). There are some cases in which
increasing VDO is considered to provide enough space for restorations
and to reduce anterior overbite. An alteration in VDO may cause
adaptable reactions in the temporomandibular joint (TMJ), periodontium,
and occlusal morphology (28). In contrast, previous studies have
reported that increasing VDO during restorative procedures could be
harmful to patients, disrupting their dental physiology and adaptability
(29, 30). Hyperactivity of the masticatory muscles, elevation in
occlusal forces, bruxism, and temporomandibular disorders (TMDs) are
reported as consequences of increasing the VDO from the literature
reviews (26, 27, 31). The VDO should not be increased in cases such as
full occlusal rehabilitation where restorative space can be created by
crown lengthening or reshaping the teeth (31). In the present case,
after apace analyzing, gaining space by crown lengthening and
restorations was done.
The most important goal of treatment is to form stable occlusal contact
in centric relation. The concept of minimally invasive dentistry in
appropriate cases preserves dentitions and supporting structures; it has
also positive effects on patients’ attitude who are impressed by
conservative approaches (28). Consequently, in this case, stable
occlusal contacts were provided for some intact teeth (#2, #13, #14,
#17) since they were in appropriate contour and position. It was
decided to prepare lithium disilicate laminates as thin as possible
(0.3-0.5 mm) for teeth (#7, #9, #10, #23). Occlusal veneers, which
are considered minimally invasive procedures, were considered for teeth
# 12 and # 28. Ceramic occlusal veneers are also known for their
superior abrasion and wear resistance, biocompatibility, color
stability, and low amount of preparation needed, which is confined to 1
mm (24). Planar straight bevel occlusal veneer preparation was
considered for occlusal veneers in light of its desirable fracture
resistance, decrease in the amount of enamel reduction, favorable
fracture load, and lowest maximum principal stress (29, 30).
Finally, the patient’s chief complaints were effectively resolved, and
he was satisfied with the functional and aesthetic outcomes of his
treatment. After 2 years, no evidence of bone loss or loss of VDO and no
signs of TMD were noted. The restorations had no signs of chipping or
wear, and all the surfaces were smooth.
CONCLUSION
Full-mouth rehabilitation requires the proper interdisciplinary concepts
to achieve acceptable functional and aesthetic results. It is important
to note that the present case report emphasized the steps and phases of
the treatment process as well as the use of existing VDO for meeting the
biologic, restorative, and esthetic requirements.
Data Availability
The data used to support the findings of this study are available from
the corresponding author upon request.
Conflicts of Interest
The authors have no conflict of interest in this study.
Author Contributions
NY: prosthodontic treatment of patient, wrote the manuscript
AM: prosthodontic treatment of patient, study conception and design
SB: study conception and design, wrote the manuscript
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Figures
Figure 1. Intraoral frontal view.
Figure 2. Mandibular occlusal view.
Figure 3. Maxillary occlusal view.
Figure 4. Initial panoramic view.
Figure 5. Panoramic view after implant surgery
Figure 6. Intraoral frontal view after cementation.
Figure 7. Mandibular occlusal view after cementation.
Figure 8. Maxillary occlusal view after cementation.
Figure 9. Final panoramic view
Figure 1