Clinical Case Report: Reconstruction of a Mouth With Erosion and Attrition
Peter M. Yonan, DMD
Private Practice, Bend, Oregon
Age at Initial Presentation: 45
Initial Presentation: July 2008
Active Treatment Completed: May 2009
The patient’s chief concern was: “I have noticed that my teeth have been chipping and getting shorter within the past several years.” The patient was also concerned about costs, trust, and the dentist’s ability to meet his expectations regarding restoration of his mouth. The patient also explained he had trouble chewing and he wanted a bite that would “fit.”
The patient stated that he had had minor acid reflux in his 20s but it was not a current issue.
Temporomandibular Joints: The maximum vertical opening was 48 mm with a 3-mm deviation to the left on opening. There was also a mild bilateral reciprocal click, which was asymptomatic. The patient noted the click had not changed and had always been present. Left to right lateral movement was 12 mm. Muscle palpation findings and joint loading were within normal limits.
Extraoral: A full smile revealed moderate maxillary lip mobility, high mandibular lip mobility, and a reverse smile line (Figure 1, Figure 2, Figure 3). In repose, the patient showed no maxillary incisal edge and had a moderate amount of the mandibular incisal edge exposure (Figure 4).
Intraoral: The patient showed generalized moderate attrition with moderate erosion (Figure 5 and Figure 6). All the existing amalgam restorations were defective with recurrent decay. The gingival display in the maxillary posterior was excessive due to compensatory eruption of the teeth from wear (Figure 3). Probing depths were severe around teeth Nos. 1 to 3, 15, and 16 ranging from 6 mm to 9 mm, with moderate probing depths of 4 mm to 5 mm surrounding teeth Nos. 18, 19, 30, and 31. In addition, there was generalized posterior bleeding on probing.
The occlusion involved a Class III cuspid and Class I molar on the right and Class I cuspid and Class II molar on the left (Figure 7 and Figure 8). Centric relation was not coincident with maximum intercuspation. All teeth showed attrition and erosion. An anterior end-to-end relationship resulted in a lack of anterior guidance (Figure 9 and Figure 10). The patient noted, “There is not really any place where my bite fits together, and I need to clench to get all my teeth to touch.”
Teeth Nos. 1, 2, 15, and 16 showed severe bone loss (Figure 11). Also, a possible periodontic-endodontic lesion was on tooth No 2. (Findings from a pulp test revealed a vital tooth No. 2.)
Periodontal: AAP type 4. Severe chronic periodontitis.
Biomechanical: All restorations defective with recurrent decay. Erosion on all teeth.
Functional: Occlusal dysfunction.
Dentofacial: Inadequate tooth display at rest, discolored teeth, high mandibular lip dynamics.
Medical: History of acid reflux.
Without treatment, the overall prognosis for the dentition was poor to hopeless. As the patient noted in his interview, his teeth were chipping and wearing. He would likely outlive the use of his teeth. With the exception of the periodontal condition of upper posterior molars, with treatment, the overall prognosis was good to fair.
1. Would adequate overjet be achieved through proclination of the upper incisors to create ideal incisor length without compromising function?
2. Would lower incisor length appear too long after restoration due to a hypermobile lower lip?
1. Create ideal shape, position, and teeth length.
2. Create bilateral simultaneous contacts in a coincident, orthopedically stable position.
3. Steepen anterior guidance.
4. Whiten teeth.
During his consultation, the patient gained a thorough understanding of his oral condition. Different treatment options and modalities were discussed with the patient. He agreed that natural esthetics and proper function could be gained only through a complete reconstruction of his mouth.
Phase I: Periodontal and Caries Management
From the diagnostic work-up, it was important to address first the significant periodontal concerns. During the consultation with the patient, the author recommended removal of teeth Nos. 1, 2, 15, and 16. The patient did not object to extraction of teeth Nos. 1 and 16 but was adamant about saving teeth Nos. 2 and 15. Thorough explanations were given regarding the risk in preserving these teeth. The patient understood the high risk for loss and the potential compromise these teeth would impart on the teeth Nos. 3 and 14. The patient willingly accepted this possibility.
Teeth Nos. 1 and 16 were removed. Initial periodontal therapy consisted of using scaling and root planing protocols, with a course of doxycycline (50 mg tablets, 1 tablet daily for 20 days). At the patient’s re-evaluation appointment, decreased probing depths of 2 mm to 3 mm and a decrease in mobility by one classification around teeth Nos. 2 and 15 were noted.
Caries management included the removal of defective restorations and caries with direct composite restorations. Also, the patient was given a caries reduction protocol (CariFree®, Oral Biotech, http://www.carifree.com).
Phase II: Orthodontics
To achieve the ideal length of his upper incisors, it was determined through a preliminary diagnostic waxing that teeth Nos. 7 to 10 would need to be proclined 2 mm. A series of clear aligners was made in the office. The aligners were honed by successively relieving the lingual of teeth Nos. 7 to 10 to give a proclination force to the teeth and adding to the facial of these teeth with block-out resin to provide more space for movement. Four aligners (0.030 Invisacryl, Ministar® positive pressure thermal-forming machine, Great Lakes Orthodontics, http://www.greatlakesortho.com) were made in 0.5-mm increments of tooth movement for a total of 2 mm. This tooth movement occurred in 2 months, and the teeth were then placed in retention for 6 months.
Phase III: Direct Mock-Up
In the patient interview, it was important for the patient to test his bite and smile before he fully committed to treatment. The author discussed a direct mock-up to help the patient establish his goals. Based on preliminary diagnostic waxing, the author and patient determined how far his bite would need to be opened to achieve esthetic and functional goals. Using a Lucia jig, the amount of vertical opening for restoration and an orthopedically stable joint position were verified. First, a direct composite was used on the posterior teeth to determine vertical height with the Lucia jig in place. The bite in the molars and premolars was refined preliminarily to achieve equal simultaneous contacts in conjunction with the incisal stop on the Lucia jig. Next, teeth Nos. 8 and 9 were built up with direct composite, establishing an ideal midline, incisal length, and facial and buccal lingual contours. When the dimensions of teeth Nos. 8 and 9 were verified, the maxillary laterals, canines, and lower anterior six teeth were completed. To determine lip position and dynamics in conjunction with tooth contours and lengths, the complete mock-up was performed without anesthesia.
After the mock-up was completed, esthetics and function were verified with the patient. At this time, the author noted the mandibular incisors were too short (Figure 12). This was due to inadequate space on the linguals of the maxillary incisors to gain additional mandibular incisor length. Clinical chair time was insufficient for making the necessary correction to the mandibular incisors. While the patient was in the chair, a set of photographs and alginate impressions were taken in addition to a facebow (Kois Dento-Facial Analyzer, Panadent, http://www.panadent.com).
In the laboratory, the mandibular incisors were waxed to ideal length. It was determined that the patient’s bite would need to be opened further to accommodate the length of the lower incisors. The patient returned to the office for refinement of the mock-up, and ideal lower incisor length was achieved in conjunction with increasing the occlusal vertical dimension (OVD) (Figure 13).
Phase IV: Restoration
The full-coverage restoration of the teeth was divided into two phases. The first was the preparation and temporization of teeth Nos. 5 to 13 and Nos. 21 to 29. These teeth were prepared for full-coverage lithium disilicate (IPS e.max, Ivoclar Vivadent, http://www.ivoclarvivadent.com) restorations. Impressions were taken using a dual-phase, single-stage setting polyvinyl siloxane impression material (Aquasil Ultra Smart Wetting® Impression Material, DENTSPLY, http://www.dentsply.com). Then, the teeth were temporized with a bis-acryl temporary material (Integrity™, DENTSPLY) using a polysiloxane matrix (Sil-Tech, Ivoclar Vivadent) made from the diagnostic wax-up. The final restorations were cemented with a self-adhesive resin luting cement (RelyX™ Unicem, 3M ESPE). The molars were then prepared for full-coverage porcelain-fused-to-metal restorations, then temporized and cemented with the above protocol and materials (Figure 14, Figure 15, Figure 16, Figure 17 and Figure 18).
Phase V: Maintenance
The patient started a 3-month periodontal recare schedule and was instructed to use a nightguard daily.
The patient was pleased with the results. Not only were his esthetic expectations exceeded but his functional expectations were surpassed, as well. The patient said, “I am very happy with my smile, and it really fits who I am. In addition, I don’t have to search for a place to bite. Everything feels comfortable, and my bite feels like it is in the same place every time.”
To achieve ideal function and esthetics, the patient’s OVD was increased 6.3 mm in the anterior. Also, the patient’s upper central incisors increased in length from 7.5 mm to 11.4 mm.
Despite the long-term prognosis of teeth Nos. 2 and 15 as poor to hopeless, the patient was adamant about preservation. These teeth are at high risk for being lost due to future periodontal compromise. He has committed to a rigorous home care and in-office recare regimen. At this time, mobility of teeth Nos. 2 and 15 has decreased from a Class III to a Class I to II level.
In addition, the parafunctional habits may affect restorative maintenance. His nightguard shows signs of nocturnal bruxism.
Ceramics by Nelson and Juan Rego, Sante Fe Springs, California.