3. 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
4. 2002 Martin Dunitz Ltd, a member of the Taylor & Francis group
First published in the United Kingdom in 2002
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6. 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
7. 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
8. 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.
9. 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.
10. 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.
11. 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.
12. 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
13. 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
14. 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).
16. 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
17. 4 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 1.4 Figure 1.5
Face-frontal view. Face-side view.
the age of 16 at which time his mandibular Caries
molars were extracted. He claimed that he Spacing between the anterior teeth
always had the spaces between his front Missing right third molar, and left first
teeth, but he felt that they were getting premolar teeth
wider. He brushed his teeth twice a day, Amalgam restorations on the left and
morning and evening; he did not use any right premolars and molars
toothpaste, only a toothbrush. Retrograde wear
Spacing due to the extraction of the left
first premolar and subsequent drifting of
EXTRA-ORAL EXAMINATION the left cuspid distally
( Figures 1.4 and 1.5) Left cuspid-pulp exposure
Symmetrical face Fistulas in the buccal vestibulum of the
Profile-straight to convex area of the right first premolar and left
Normal temporomandibular joint lateral incisor teeth
Normal facial musculature
Maximum opening of 40 mm
Mandibular movements-slight devia-
tion to the left upon opening and the
reverse upon closing
Slight midline discrepancy
I NTRA-ORAL AND FULL-MOUTH
PERIAPICAL RADIOGRAPH
EXAMINATION
Maxilla (Figure 1.6):
• Very poor oral hygiene Figure 1.6
• Parabolic arch Maxillary arch-palatal view.
18. 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
19. 6 PROSTHODONTICS IN CLINICAL PRACTICE
second left molar had class 1 furcation
i nvolvement on the buccal and mesial
surfaces.
FULL-MOUTH PERIAPICAL
SURVEY (Figure 1.10)
Figure 1.8
Periodontal chart-mandible.
Figure 1.9
Periodontal chart-maxilla.
Figure 1.10
Radiographs of maxilla and mandible-
pre-treatment.
20. 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
21. 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
22. 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
23. 10 PROSTHODONTICS IN CLINICAL PRACTICE
the transitional restorations. A facebow
registration was taken and the models
mounted on a Hanau articulator. The
maxillary metal copings were fitted and
connected with pattern resin for solder-
ing. The soldered prosthesis was then
checked in the mouth, and a polyether
impression (Figure 1.16) was then made
for tissue detail and a pick-up of the fixed
prosthesis in order to make a final master
model.
Figure 1.15 This was mounted on a Hanau articula-
Mandible, final impression, Mercaptan rubber
tor by means of a facebow registration
and the pattern resin registration on the
soldered metal prosthesis. The shade
master model poured. Mesio-occlusal rest was chosen and porcelain baked to the
preparations were prepared in the metal. The bisque bake maxillary prosthe-
mandible on the left first premolar and right sis was fitted in the mouth and the occlu-
second premolar teeth. sion checked and adjusted with the
A mercaptan rubber base impression missing mandibular teeth that had been
was then made using a border molded set up on the partial denture. The porce-
custom tray (Figure 1.15). The mandibu- lain was glazed and the mandibular
lar metal framework was fitted and prosthesis processed. The denture teeth
adjusted in the mouth. An acrylic resin were made of porcelain in order to match
bite tray was constructed on the metal the material in the fixed prosthesis in the
framework. This tray and the pattern maxilla.
resin copings of the maxillary teeth were The maxillary prosthesis was cemented
used to record the centric relation at the temporarily and the mandibular prosthesis
same vertical dimension of occlusion as inserted and adjusted. After 2 weeks, the
Figure 1.16 Figure 1.17
Treatment completed-fixed prosthesis, anterior view Treatment completed-restorations, maxilla.
24. RETROGRADE WEAR 11
Figure 1.20 Figure 1.21
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.
25. 12 PROSTHODONTICS IN CLINICAL PRACTICE
CASE DISCUSSION CASE DISCUSSION
AVINOAM YAFFE HAROLD PREISKEL
This 56-year-old person presented to the This sensible plan of treatment involved
graduate clinic with the complaint of diffi- extensive reconstruction of both jaws,
culty in eating, pain, and mobile teeth. It establishing a new occlusal plane and
was the purpose of our treatment to include table. Whether or not there was an erosive
the anterior teeth in occlusal support for component to the loss of tooth substance
several reasons: many posterior teeth were is largely irrevelant. There was almost
missing, thus occlusal support was lacking; certainly a significant forward mandibular
secondly it was intended to achieve anterior posture.
guidance in order to disocclude whatever The decision to use porcelain artificial
posterior teeth were left, and to allow teeth on the removable prosthesis is under-
freedom in lateral excursions. In order to standable, although this requires vertical
accomplish this, we took advantage of the space to allow for the diatoric design to
IC-RC (intercuspal position-retruded cuspal retain the porcelain. In fact, what really
position) discrepancy; and made a slight matters is not so much the hardness of the
change in vertical dimension along with occlusal surface, but the coefficient of
minor adjunctive orthodontics to close the friction between the upper and lower
anterior diastema. These three factors surfaces. Provided the glaze of the oppos-
enabled us to change a pathologic, ing porcelain is not disturbed, modern
malfunctioning, unesthetic occlusion into a cross-linked resin teeth will function perfectly
physiologic, esthetic, long-lasting occlusal well, and if they should need to be changed
scheme, that included the anterior teeth in after 5 to 8 years, it is not such a disaster.
support, along with all the other functions of Furthermore, if an incorrect assessment of
anterior teeth, to the 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.
28. BRUXISM 15
Figure 2.5 Figure 2.6
Anterior teeth-labial view, showing deep overbite. Maxillary arch-palatal view.
Figure 2.7 Figure 2.8
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
29. 16 PROSTHODONTICS IN CLINICAL PRACTICE
mandibular molars and bleeding on • Adequate endodontic therapy with
probing on some teeth (Figure 2.9). some l ocalized periapical rarefying
osteitis (mandibular right first molar)
Radiographic examination (Figure 2.10) • Remnants of an old amalgam restora-
revealed: tion around the mandibular second
premolar and first molar
• Shortened roots • Widened periodontal ligament around
• Secondary caries maxillary right first premolar
• Overhanging margins on mandibular left
first premolar and left second molar
• Minimal generalized horizontal bone
l oss
I NDIVIDUAL TOOTH PROGNOSIS
The prognosis for all the remaining teeth
was good.
DIAGNOSIS
Bruxism and severe wear of the anterior
teeth
Possible loss of vertical dimension
Deep overbite
Primary occlusal trauma
Figure 2.9 Moderate with localized advanced adult
Periodontal chart-maxilla and mandible. periodontitis
Figure 2.10
Radiographs of maxilla and mandible-pre-treatment.
30. 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
31. 18 PROSTHODONTICS IN CLINICAL PRACTICE
PHASE 2
After one month when the patient
appeared to have adapted to this new
vertical dimension of occlusion without any
problems, the maxillary central and lateral
i ncisor teeth were bonded with composite
resin to contact the mandibular incisor
teeth (Figures 2.12 and 2.13).
After three more months, when the
posterior teeth failed to erupt into occlusion,
it was thought that the tongue occupied the
Figure 2.11
opened existing space and prevented the
Anterior maxillary teeth-palatal view, showing canine
platform. eruption of the posterior teeth (Figures 2.14
and 2.15). At that time, the lingual surfaces
of the mandibular premolar and molar teeth
the patient. The patient on her own were built up by bonding composite resin
volition, by concentrating on not bruxing material to create an overbite between the
during her working hours, was able to mandibular lingual cusps and the maxillary
cease bruxing. A new vertical dimension li ngual cusps, in order to prevent the tongue
of occlusion was established by the use from entering the space between the teeth,
of a canine platform to enable passive and interfering with the passive eruption
eruption of the posterior teeth (Figure process (Figures 2.16 and 2.17).
2.11). The canine platform increased the One month later, the posterior maxillary
vertical dimension by about 3.0 mm, as and mandibular teeth erupted into occlusal
measured at the maxillary and mandibular contact and the lingual additions to the
central incisors, and 1.0 mm in the molar mandibular teeth were removed and the
areas. surfaces polished (Figures 2.18 and 2.19).
Figure 2.12 Figure 2.13
Anterior maxillary teeth-palatal view, showing composite Anterior mandibular teeth-lingual view, showing composite
buildup. buildup.
32. BRUXISM 19
Figure 2.14 Figure 2.15
Right side, showing failure of teeth to passively erupt. Left side, showing failure of teeth to passively erupt.
Figure 2.16 Figure 2.17
Mandibular left posterior segment, showing lingual cusp Mandibular right posterior segment, showing lingual cusp
composite buildup. composite buildup.
Figure 2.18 Figure 2.19
Right side, showing teeth passively erupted to contact. Left side, showing teeth passively erupted to contact.
33. 20 PROSTHODONTICS IN CLINICAL PRACTICE
A hard night guard to be worn only at CASE DISCUSSION
night was made for the patient as a protec- AVINOAM YAFFE
tive device to prevent continuing tooth
structure loss. This was done to prevent A 57-year-old woman presented herself to
wear of the composite material that had the graduate program with traumatic deep
been placed on the anterior teeth. overbite accompanied by severe wear with
The patient has been followed for one loss of tooth structure aggravated by
and a half years and there has been no i mpingement and laceration of the inter-
abnormal lose of tooth structure in this dental papillae in the anterior maxilla. At
ti me. that stage no restoration could be done
due to the deep overbite. An increase in
vertical dimension was mandatory in order
to solve the problem. The change in verti-
PHASE 3
cal dimension could be accomplished by
complete mouth restoration of at least two
This was not required.
quadrants, either i n the maxilla or
mandible.
A conservative approach was taken to
SUMMARY solve the problem. Instead of increasing the
vertical dimension by the use of restora-
The patient, a 57-year-old female labora- tions, thus increasing the crown-to-root
tory technician, presented with a severe ratio, a platform was added to the maxillary
problem of abnormal tooth wear due to cuspid teeth using composite resin material.
bruxism. After scaling, curettage and oral This created a space between the maxillary
hygiene instruction, and restoration of and mandibular teeth, enabling these teeth
teeth with faulty restorations and caries, a to erupt towards each other until contact
conservative method of treatment was was established. At that new vertical dimen-
attempted that involved the use of a sion, composite resin was added to the
canine platform to increase the vertical severely worn anterior teeth, thus restoring
dimension of occlusion. The anterior teeth the teeth with minimal expense, and
were then restored to occlusal contact keeping the crown-to-root ratio the same as
with bonding and composite resin that before the increase in vertical dimen-
restorations. sion. Thus a complicated situation was
When the posterior teeth failed to erupt solved by a simple, cost-effective and
passively into occlusion as anticipated, due esthetic restoration.
to tongue interference, an attempt to elimi-
nate this interference by building up the
li ngual cusps of the mandibular posterior CASE DISCUSSION
teeth (through bonding and composite HAROLD PREISKEL
resin) was made. This succeeded, and
within 3 months the posterior teeth were in This 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,
34. 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.
35. PATIENT 3 EXTENSIVE TOOTH WEAR
Treatment by Yehuda Shahal
THE PATIENT PAST DENTAL HISTORY
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
I NTRA-ORAL AND FULL-MOUTH
PERIAPICAL EXAMINATION
Maxilla (Figures 3.4 and 3.5):
Figure 3.1
Front view of anterior teeth.
23
36. 24 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 3.2 Figure 3.3
Frontal facial view. Side face view.
Figure 3.4 Figure 3.5
Maxillary arch. Lingual view of maxillary anterior teeth.
• Veneer crowns and amalgam restora-
tions on some of the teeth
• Large amounts of wear on the anterior
. Extrusion of the right second molar teeth accompanied by chipping of
37. 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.
38. 26 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 3.9 Figure 3.10
Right lateral jaw movement. Left lateral jaw movement.
An occlusal examination revealed that the ( Figures 3.9 and 3.10). There were no
patient was Angle class 1 classification, balancing side contacts. In protrusive
with 0.0 mm overbite and an overjet of movements, there was disarticulation by
2.0 mm (Figure 3.1). The interocclusal rest the anterior teeth and the premolars on the
space was 4.0 mm and the maximum right side, and on the left side the posterior
opening was 46 mm, without deviation in teeth were in contact. There was no fremi-
opening or closing movements. The tus or mobility of any of the teeth. The
mandibular midline was slightly left of the patient had a removable partial mandibular
center of the face. denture, which he felt was unsatisfactory
There was a 1.0 mm discrepancy and did not use.
between centric occlusion (IC) and centric
relation (CR). Lateral jaw movements were The periodontal examination (Figures 3.11
group function on both sides-this in spite and 3.12) revealed probing depths of up to
of the amount of wear of the anterior teeth 3.0 mm on the maxillary teeth and up to
Figure 3.11 Figure 3.12
Maxillary periodontal chart. Mandibular periodontal chart.
39. EXTENSIVE TOOTH WEAR 27
Figure 3.13 Figure 3.14
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.
40. 28 PROSTHODONTICS IN CLINICAL PRACTICE
DIAGNOSIS that before proceeding with treatment, it
would be wise to discern the cause of the
• Gingivitis with localized periodontitis
extreme wear. The dental literature refers to
• Excessive tooth wear
the causative agents in extreme wear as that
• Missing teeth
of multiple factors. Mohl describes the causes
• Faulty restorations
of dental tooth wear as 'contributing factors'
• Poor esthetics
rather than 'etiologic factors'.1 The factors
• Decreased vertical dimension
generally mentioned in the literature are:
• Periapicallesions
parafunction, diet, salivary secretions, exces-
sive biting force, and occupational hazards.
As for parafunction, the patient informed us
PATIENT DISPOSITION AND that he had never bruxed his teeth, and was
EXPECTATION aware what bruxism meant. He also lacked
any of the other symptoms of bruxism, had a
The patient was introverted, hardly ever
normal maximum jaw opening and free lateral
speaking or smiling, but with a strong motiva-
tion for dental treatment. In spite of the excursions without tenderness in his
muscles. In order to examine whether diet
distances involved for him to get to the clinic,
was a contributory factor, the patient was
he was prepared to come at any time for treat-
asked to record in writing all food and bever-
ment. He wanted to save as many teeth as
possible and to improve the esthetic appear- ages that he consumed during the day for a
ance of his mouth. He also preferred to have period of 2 weeks. This revealed that he did
not have an abrasive or erosive diet. With
a fixed rather than a removable restoration.
regard to salivary function, the patient was
examined for three different factors: the rate
of excretion, the pH of the saliva, and the
POTENTIAL TREATMENT PROBLEMS buffer capacity of the saliva. The results
The patient was a relatively young man showed that there were no contributing
with extensive tooth wear factors in his saliva to cause the extreme wear
The many existing restorations were that was evidenced on his anterior teeth.
very large and faulty All these findings led to the conclusion
Some of the teeth had old endodontic that the wear of the 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).
41. EXTENSIVE TOOTH WEAR 29
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
Figure 3.15 Figure 3.16
Clinical view of left maxillary first premolar, pre-treatment. Radiograph of post-treatment left maxillary first premolar.
42. 30 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 3.17 Figure 3.18
Radiograph of right maxillary first premolar, pre-treatment. Radiograph of right maxillary first premolar, post-treatment.
same size and there was no evidence of
healing, and since the walls of the roots of the
tooth were very thin, it was decided to extract
the tooth. The root canal filling was redone on
the maxillary right first premolar and the tooth
was followed up for 1 year (Figures 3.17 and
3.18). Caries was excavated on the mandibu-
lar left premolars and, due to the extensive
caries into the pulp chamber, these teeth
were also treated endodontically (Figure
3.19). The mandibular right second premolar
and first molar were also treated endodonti- Figure 3.19
cally due to the extensive caries extending Radiograph post-treatment of left mandibular premolars.
into the pulp chamber (Figures 3.20 and
3.21). These teeth then received transitional
restorations. Upon excavation, the mandibu- The orthodontic phase of treatment was
l ar right second molar was found to have a started using a coil spring to separate the
cracked mesial root and the root was ri ght mandibular first molar in order to elimi-
removed. nate root proximity and ensure maximum
I n order to satisfy the 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
43. EXTENSIVE TOOTH WEAR 31
Figure 3.20 Figure 3.21
Clinical view of right mandibular premolars and molar area. Radiograph post-treatment of right mandibular premolar
pre-treatment. and molar area.
Figure 3.22 Figure 3.23
Transitional restorations right side. Transitional restorations left side.
Figure 3.24 Figure 3.25
Periodontal chart at re-evaluation-maxilla. Periodontal chart at re-evaluation-mandible.
44. 32 PROSTHODONTICS IN CLINICAL PRACTICE
appearance, the final treatment plan was established vertical dimension dictated by
then carried out. the plane of occlusion and the esthetic
I t was decided to restore the mandible demands of the patient as well as the
with a premolar occlusion on the left side biomechanical considerations (Figures
for the following reasons: 3.26 and 3.27).
After a period of time it was clear that
Since implants could not be done with the patient adapted very well to his new
the amount of remaining bone-to restorations. Copper band impressions
place implants would require additional were then taken of all the prepared teeth
surgical procedures to add bone and Duralay resin copings were made.
The lack of posterior teeth in the These copings were used to record centric
mandibular left quadrant did not bother relation at the vertical dimension of the
the patient temporary restorations and for the final
He very much desired a fixed prosthe- i mpression for the master model (Figures
sis 3.28-3.32). The metal copings were then
The removable partial denture would fitted ( Figures 3.33 and 3.34) and
only replace two teeth, and the patient soldered, and after try-in of the soldered
would most probably not use it metal framework another elastomeric
I t would then require splinting the maxil- i mpression was done for tissue detail.
lary molars on that side in order to These models were mounted on a semi-
prevent overeruption adjustable Hanau articulator utilizing a
facebow registration and centric records
Due to the extensive period of time taken at the vertical dimension of occlu-
i nvolved in the initial treatment phases sion utilizing Duralay with a Neylon
and the periodontal surgery and technique.
orthodontic treatment, the transitional At this point the porcelain was baked
restorations were then replaced by new and the occlusion checked in the mouth at
prostheses. These were built to the new the biscuit bake stage and all adjustments
Figure 3.26 Figure 3.27
New transitional restorations-maxilla. New transitional restorations-mandible.
46. 34 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 3.33 Figure 3.34
Metal copings fitted-maxilla. Metal copings fitted-mandible.
Figure 3.35 Figure 3.36
Incisal platform incorporated into anterior maxillary teeth. Case cemented, post-treatment.
needed were then made. The anterior SUMMARY
maxillary teeth incorporated an incisal
platform (Figure 3.35) to enable continuous The patient presented with a severe problem
contact during jaw movement and to bring of extreme wear on many of his teeth and a
the incisal forces as close as possible to reduced vertical dimension of occlusion. He
the long axis of the teeth. The crowns and also had furcation involvements and periapical
bridges were cemented with Temp-Bond lesions. The wear was correctly diagnosed as
for a period of 1 month. The crowns and due to occupational hazards, which were no
bridges were then cemented with zinc longer a factor in deciding his treatment. With
oxyphosphate cement for permanent endodontic, orthodontic and periodontal
cementation (Figures 3.36-3.38). treatment accompanied by occlusal therapy,
The patient has been returning for follow- the patient received a physiological occlusion
up and maintenance twice a year for three at the optimum vertical dimension of occlu-
years and has had no problems. sion.
47. EXTENSIVE TOOTH WEAR 35
Figure 3.37
Radiographs of case, post-
treatment.
CASE DISCUSSION
AVINOAM YAFFE
This patient represented a severe case of
tooth wear accompanied by reduced verti-
cal dimension and a faulty occlusal plane,
further aggravated by missing teeth, caries,
and faulty endodontic treatment. The
severe wear required periodontal surgery
for crown lengthening procedures, thus
jeopardizing the crown-to-root ratio. The
existence of a free end saddle in the
mandible further reduced occlusal support.
The case was handled with caution by
increasing the vertical dimension and the
crown lengthening procedures to the
minimum required. In order to make up for
the missing posterior support, the anterior
teeth were restored and the incisal areas
were modified to participate in support in
addition to their role in esthetics, speech,
Figure 3.38 and disarticulation of the posterior teeth in
Frontal face view of patient, post-treatment. jaw movements. The cuspal guiding planes
48. 36 PROSTHODONTICS IN CLINICAL PRACTICE
were built to a minimum to reduce lateral the early part of the new century. In this
forces in order to improve the overall particular instance, the operators have
prognosis of the case. presented tooth substance loss, but this will
not apply to many other patients.
The sensibly chosen staged approach
CASE DISCUSSION produced the occasional surprise that all of us
HAROLD PREISKEL find in a long course of treatment. A split root
can be difficult to detect at the outset. While
While patients who have spent many years i ncreasing the vertical dimension of occlusion
driving tanks in dusty environments must be seemed reasonable, it is not clear whether the
a rare breed, those who are suffering exten- operators deliberately increased this measure-
sive tooth wear are abundant. Indeed, with ment beyond the level they estimated had
the increasing life span of our population and existed before the tooth wear occurred. There
the reduced incidence of caries, the treat- was little alternative to making a change if a
ment of worn down dentitions may be one of good looking outcome was to be achieved.
the most difficult situations to confront us in An excellent result was obtained.
50. PATIENT 4 NEGLECTED DENTITION
Treatment by Tzachi Lehr
THE PATIENT PAST DENTAL HISTORY
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.
Figure 4.1 Figure 4.2
Anterior teeth-labial view. Face-frontal view.
39