Prosthodontics in clinical practice

Prosthodontics in clinical practice
PROSTHODONTICS IN
CLINICAL PRACTICE
PROSTHODONTICS IN
CLINICAL PRACTICE


Robert S Klugman,           DDS

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



Contributions by

Harold Preiskel,       MDS, MSc, FDS RCS

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

and

Avinoam Yaffe,        DMD

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




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Prosthodontics in clinical practice
vi                                                                CONTENTS


     Patient 15 A new vertical occlusion       163
                  Treatment by Shaul Gelbard
     Patient 16 Advanced periodontal disease          173
                  Treatment by Ayal Tagari


              I V CONGENITAL DISORDERS             183
     Patient 17 Severe unilateral cleft lip and palate      185
                  Treatment by Miriam Calev
     Patient 18 Unilateral cleft lip and palate and
                 partial anodontia       197
                  Treatment by Thomas Zahavi
     Patient 19   Generalized amelogenesis imperfecta       207
                  Treatment by David Lavi
     Patient 20 Bilateral cleft palate and Raynaud's disease         215
                  Treatment by Yael Houri

                  I ndex     225
FOREWORD


I t has been a pleasure and privilege to        prosthodontics; it illustrates how relatively
make a contribution to this project. The        i nexperienced colleagues can carry out
book represents the fruits of a lifetime's      i nvolved procedures provided they are set
experience of the principal author; within      out in a step-by-step logical process.
 it you will find pearls of wisdom and a        Make no mistake that there is anything
great deal of common sense. The work            simple about some of the plans of treat-
 represents more than a series of case          ment: adult orthodontics, site preparation
 reports and far more than a technique-         for implants and implant prosthodontics,
oriented clinical manual: it is all about the   together with complex fixed and remov-
treatment of patients and adapting              able prostheses, all feature within the text.
prosthodontic techniques to the individual      Some of the techniques employed have
situation, rather than the other way round.     been available for many years, but
So often overlooked is the fact that            techniques, after all, are only means to an
patients who have suffered severe tooth         end. Dr Klugman has been able to take
l oss do not usually arrive for treatment       advantage of his clinical experience to
with a mouth in pristine condition. Yet Dr      adapt these well-tried          methods to
Klugman and his graduate students take          present-day prosthodontics, and in this
patients, establish rapport, and motivate       he has succeeded admirably.
them. This is a book about the real world,
and one for all who are interested in                                        Harold Preiskel
PREFACE


The idea for writing this book came while             The program is of 3'/ years duration and
sitting in one of the seminars of our gradu-       includes certain clinical and basic science
ate program in Prosthodontics.                     requirements. Successful completion of
   One of our students was presenting a            the program enables the student to be
progress report of his patient, discussing         eligible for the specialty licensing examina-
the diagnosis, and the possible treatment          tion administered by the Ministry of Health
plans. Finally, he showed his treatment and        in order to qualify as a specialist in Oral
explained its rationale. As I sat there, the       Rehabilitation. In the first years, one or two
thought came to me, what a waste of                students were accepted to the program
information this is; the student is present-       and, as time went on, the program was
ing a beautifully documented treatment for         expanded to include up to four students
a very difficult patient with superb radio-        per year. This gave a core group of
graphs and slides. What a shame that only          between 12 and 16 students to participate
the 12 or so people in the room are                in seminars and treat patients.
viewing it.                                           Today the program encompasses four
   The purpose of the book is to share our         days a week, in which the students spend
treatment modalities and rationale of treat-       4 hours in seminars each week. These
 ment with as many dentists as possible.           consist of case presentations, literature
   Our seminars provide at least one hour           reviews, and research on prosthetic
 of case presentation time with a continua-        subjects, and additional full day seminars
tion possible the following week. During           as needed. The students spend 3 days a
the presentation, the instructors and other        week treating clinical patients under the
 students question the diagnosis and treat-        supervision of board certified instructors.
 ment plan, volunteering their opinions and        The remainder of their time is spent in
alternative treatment strategies. It's a give      clinical or original research. Many of the
and take situation. It is our conviction, that     students carry out basic research projects
this is one of the best learning processes         leading to a Masters degree or Doctorate.
for a graduate student.                               The program is integrated with other
   The Graduate Program in Oral                    specialty programs at the Dental School,
 Rehabilitation was initiated in 1978 when          including Periodontics, Orthodontics, Oral
the Israeli Parliament passed a law recog-         Surgery, and Endodontics. The graduate
 nizing dental specialties. Until that year, the   students treat implant patients. They plan
 only specialization recognized by the             and oversee the surgical phase, but do not
 Ministry of Health was Oral and                    perform the surgical procedures. Most
 Maxillofacial Surgery, which was a 5-year          periodontal surgery, endodontic, oral surgi-
 program. In 1979, the Department of Oral          cal, and orthodontic procedures are
 Rehabilitation set up a program to teach           referred to graduate students or specialists
 Graduate Prosthodontics.                           in the other disciplines.
x                                                                                     PREFACE



       The philosophy of treatment in the            I would like to personally thank all the
     program is based on the clinical and learn-   graduate students, former and present,
     ing experiences of the faculty, who have      especially those who contributed to the
    themselves been trained in Prosthodontics      book, the faculty of the program,
    at The University of Pennsylvania, New         Professor Jacob Ehrlich, Professor
    York University, and The University of         Avinoam Yaffe (Program Director), Dr Israel
    Toronto, in the 1960s and 1970s. Thus          Tamari, and Dr Erez Mann. Special thanks
    their diverse backgrounds mean that the        go to Professor Harold Preiskel and
    faculty members bring to the program           Professor Avinoam Yaffe who provided
    varied ideas of treatment. We have tried to    editorial commentaries, who made great
    incorporate the best aspects of each of        efforts in helping me, and without whose
    these programs for our own syllabus.           aid I doubt that the book would have been
    Some of the methods we use have been           written.
    developed here in Israel.
INTRODUCTION


The book is divided into four parts according        necessary, consultations with the patient's
to the primary problem of the patient:               physician are conducted prior to any
Periodontal breakdown, Dysfunctional habit           dental procedures.
patterns, Extensive loss of teeth, and                  One of the philosophies of our treatment is
Congenital disorders. Naturally, most patients       to give the anterior teeth the added function
overlap and fall into more than one category.        of supporting the vertical dimension of occlu-
   The basis for all our prosthodontic treat-        sion. The anterior teeth are customarily only
ment, is a healthy periodontium. The main            used for incising food, speech, esthetics, and
goal of our treatment is to identify the             anterior guidance in eccentric movements of
causative factors of the patient's dental            the mandible. By utilizing the proprioceptive
problem, and thus be able to control them.           properties of the anterior teeth to provide
Therefore a prerequisite of all treatment is for     biological feedback, the occlusal forces
us to determine these causative factors and,         applied to the teeth are reduced. This is
together with the patient, control them. This        especially i mportant for patients with
is done by initiating meticulous oral hygiene        mutilated dentitions, where the vertical dimen-
and controlling dietary habits and food              sion of occlusion has to be changed. It is also
consumption. At the beginning of treatment,          important for patients whose treatment
the patient undergoes initial preparation until      requires increasing the vertical dimension for
they prove that they will cooperate completely       biomechanical reasons, in order to make
in their own treatment, by executing excellent       space available for restorations.
oral hygiene. Techniques include flossing,              It is our experience over many years that
correct toothbrushing, use of stimulators and        opening vertical dimension using the anterior
all periodontal aids necessary to maintain a         teeth, especially the cuspid teeth, will reduce
healthy periodontium. For patients with caries,      biting force and prevent intrusion of the other
a dietary analysis is made and the patient is        teeth. In fact, in most patients, we are most
carefully checked to see that they adhere to         probably restoring vertical dimension that was
their new diet. The initial therapy permits us       lost rather than increasing the vertical dimen-
to check the individual patient's biological         sion. These patients now usually close in a
 response and determine whether the disease          more retruded jaw position than their previous
 activity can be controlled. In some cases, due      acquired one. In patients with a full comple-
to genetic factors or the patient's personality,     ment of teeth where change in the vertical
 the biological response cannot be controlled,       dimension of occlusion is required, we prefer
 and this will naturally alter the treatment plan.   using a 'canine platform',1-3a modified method
 Unless otherwise noted, all patients were           for posterior tooth eruption as opposed to a
 non-smokers.                                        removable appliance (Hawley). We have found
    A speech therapist provides ancillary            that this approach minimizes the need for a full
 treatment, if needed. All past medical              mouth reconstruction and the necessity of
 histories are carefully evaluated and, if           restoring otherwise healthy teeth.
xi                                                                                             I NTRODUCTION



         I n periodontally involved dentitions, and      book to describe tooth position is Palmer's.
     i n patients where the overbite is reduced          Palmer's classification divides the mouth
     and the overjet increased due to opening            i nto four quadrants: the upper (maxillary)
     of the vertical dimension, we strive on one         teeth are noted above a horizontal line; the
     end and are imposed by the other to                 l ower (mandibular) teeth are noted below
     diminish lateral forces that are applied to         the horizontal line; the right side of the
     the teeth by decreasing cuspal angles.              mouth is noted to the left of a vertical line,
     This then requires flattening of cuspal             and the left side of the mouth is noted to
     height in the posterior teeth.                      the right of the vertical line; teeth are
         I n patients where the remaining teeth do       numbered from 1 to 8 in each quadrant,
     not have the ability to support and guide           starting at the center of the mouth.
     the occlusion, due to advanced periodon-                This gives a grid as follows:
     tal disease and alveolar bone loss,
      i mplants are utilized to give additional
      occlusal support. Nevertheless, when
      using implants for occlusal support, we
      prefer that all l ateral and protrusive
      movements of the mandible be guided by
      the remaining natural teeth.4-6
          I n those patients where the vertical dimen-
      sion is altered, the determining factors are
      usually biomechanical, to acquire enough
                                                           (I n the American classification the tooth
     gingival occlusal space for the restorations.
                                                         would be number 5 and in the International
      I n these cases, we try and limit the amount
                                                         classification it would be number 14.)
      of change to the minimum that is necessary.
      Since an increase in vertical dimension of
      occlusion in patients with advanced adult                          REFERENCES
      periodontitis worsens the crown-to-root
                                                         1   Yaffe A, Ehrlich J, The canine platform a
      ratio, we utilize orthodontic treatment of             modified method for posterior tooth eruption,
      passive or active eruption of the teeth to             Compend Cent Education (1985) 6:382-5.
      i mprove this ratio. Using these treatment         2   Abrams L, Occlusal adjustment by selective
      modalities demands meticulous oral hygiene             grinding. In: Goldman HM, Cohen DW, eds,
                                                             Periodontal Therapy, 6th edn (CV Mosby: St
      and constant scaling and curettage to attain           Louis, 1980).
      eruption of the teeth, accompanied by              3   Amsterdam M, Peridontal prosthesis. Twenty-
      healthy supporting tissues.                            five years in retrospect, Alpha Omegan (scientific
                                                             issue) (1974) December.
         All treatment is fully documented by            4   Hannam AG, Matthews B, Reflex jaw opening in
      photographs and radiographs, thus providing            response to         stimulation  of   periodontal
     the source for most of the material for this            mechanoreceptors in the cat, Arch Oral Biol
                                                             (1969) 14:415.
      book. The patient follow-up is usually done        5   Wood WW, Tobias DL, EMG response to alter-
      by the graduate student in their own private           ation of tooth contacts on occlusal splints during
      practice after completion of the treatment.            maximal clenching, J Prosthet Dent (1984)
          Although there are two other systems               51(3):394-6.
                                                         6   Storey AT, Neurophysiological aspects of TMD,
      (the American and the International) in use            presented at the American Dental Association,
      today, the classification system used in this          Chicago, 1982.
TECHNICAL INFORMATION


I n patients receiving fixed partial prosthe-    elastomeric impressions, we find that it is
ses, the graduate students prepare the           very difficult to get an accurate impression
teeth which will be used as abutments for        of all the prepared teeth in one impression,
the prosthesis. The preparation of choice        especially in periodontally involved patients
i n mature and periodontally compromised         where there are long clinical crowns and
patients is the knife edge preparation. We       multiple preparations.1 I n the laboratory
feel that complete shoulder or chamfer           phase, it is also difficult to achieve an
preparations are not suitable in these situa-    undistorted wax pattern on withdrawal for
ti ons since they require too much root          multiple abutment cases. One of the
structure reduction. The students then           advantages of a full arch elastomeric
usually make either single copper band           i mpression is that it permits a single
elastomeric impressions to impression the        casting with accuracy and eliminates the
prepared teeth or elastomeric complete           need for soldering; however, in periodon-
arch impressions. Due to the many                tally involved teeth with long clinical crowns
problems associated with elastomeric             i t is extremely difficult to achieve an undis-
complete arch impressions, such as               torted wax pattern removal for a single
 retraction cord displacement, microhemor-       casting. This usually leads to additional
 rhage, errant air bubbles (usually at the       treatment, which is both time consuming
finishing line), etc, we have found it to be     and traumatic to the patient.
 more accurate to use single copper band              A copper band is measured and
 elastomeric impressions.1 This is especially    tri mmed to fit the prepared tooth, and
true in periodontally involved teeth and         then annealed in an ethyl alcohol 70%
whenever a knife edge preparation is             solution. This produces a softer, more
i ndicated.                                       pliable band with a clean polished surface
    The graduate students prepare all the        which will not have a rebound effect after
teeth to be utilized for the prosthesis and      the acrylic resin is placed. The band is
temporize them in as many visits as neces-        li ned with soft, quick-setting methyl
sary-this will naturally vary with each           methacrylate resin and allowed to set on
patient. After all the teeth have been fully     the prepared tooth.
prepared for the fixed prosthesis and                 The band is removed, and the resin is
checked for proper tooth reduction by             i nternally relieved to a depth of 0.5 mm. An
measuring the thickness of the provisional       escape hole is drilled in the occlusal or
 restoration, and proper finishing lines, each   i ncisal area to prevent air bubbles and then
tooth is impressioned individually and, if       the impression is relined using a blue or
 i ncorrect, it can be easily repeated until a   green Xantropen wash technique. The
 satisfactory result is achieved. Again, we      i mpressions are cast immediately in die
would like to emphasize that in our experi-      stone; the dies are removed and trimmed
 ence, when we have used full arch               after 1 hour. The dies are hardened with a
XIV                                                                              TECHNICAL INFORMATION


        drop of cyanoacrylate (Super Glue-5:              copings are then picked up with a full arch
        Loctite International, Welwyn Garden City,        elastomeric impression (Impregum) mat-
        UK) to give a very fine protective layer, and     erial to capture soft tissue detail.
        coated with a thin layer of petroleum jelly.         At this stage, the individual dies are not
           Duralay (Reliance Dental Manufacturing         needed and the laboratory technician
       Company, Worth, IL, USA) or Pattern resin          places reinforced resin into the lubricated
       copings (GC Company: Kasugai Aichi,                (petroleum jelly) metal framework in the
       Japan) are then made on the prepared               i mpression, and dental stone for the
       dies using a Neylon paintbrush technique.          remainder of the model. This is the final
      The Neylon technique is a brush-on                  master working model. This technique
       technique that uses a fine brush dipped in         gives not only fine tissue detail but also a
       monomer and then in resin powder to pick           reproducible positive seat for the castings
       up a small ball of resin which is then            whenever they are removed from the
        placed on the prepared tooth, starting at         model, thus avoiding damage to the model
       the occlusal or incisal surfaces and               by constant removal and placement.
       working towards the gingival margins. A               The master working models are articu-
        hole is cut in the labial occlusal or incisal     lated to the semi-adjustable articulator
       corner of the coping to ensure that the            (Hanau: Teledyne Hanau, Buffalo, NY USA)
       coping is fully seated on the prepared             by means of a face bow registration and
       tooth during try-in. Pattern resin copings        centric relation records performed at the
       are individually fitted on the prepared teeth     vertical dimension of occlusion as deter-
      and checked clinically for fit and the             mined by the provisional restorations.
      accuracy of their margins. The copings are         Since the working models are articulated
      also used for centric relation recording and       at the vertical dimension of occlusion, it is
      vertical dimension registration. The resin         felt that a fully adjustable articulator is not
       copings are then picked up with a full arch       necessary.4
       elastomeric impression (Impregum) mat-                The porcelain is then baked and fitted
       erial. The individual dies are then placed        i n the patient's mouth, with special atten-
       i nto their respective copings in the impres-     tion paid to fit and occlusion. If neces-
       sion and a master working model is fabri-         sary, the occlusion is adjusted using
       cated.2,3 A centric relation record is then       small round diamond stones until the
       recorded, usually at the vertical dimension       articulating paper shows that there is
      of occlusion, and the models placed in an          uniform and even contact in centric
      articulator and the individual elements of         relation (coincident to centric occlusion)
      the prosthesis are waxed and cast.                 between all the posterior teeth and that
          Once the metal framework of the               the anterior teeth are in light contact only.
      prosthesis is returned by the laboratory,         The prostheses are then returned to the
      the individual metal elements are checked          l aboratory where the final glaze of the
      i n the mouth, and joined together using           porcelain is done.
      resin. The metal framework prosthesis is               At the insertion appointment, the
      then sent to the laboratory for soldering.         prostheses are `cemented' with a paste of
      On return, the prosthesis is then checked          petroleum jelly and zinc oxide ointment
      i n the mouth again and another centric           ( only) for 24-72 hours. The patient then
      relation record made. The soldered                returns and the occlusion is rechecked
TECHNICAL INFORMATION


 and adjusted if necessary. The restora-         cementation, the occlusion is checked
 tions are then cemented with a mixture of       again to verify its accuracy.
 zinc oxide and eugenol cement (Temp-
 Bond: Romulus, MI, USA) and petroleum
j elly for a further 72 hours. If there is no             ACKNOWLEDGEMENT
 washout after 72 hours, the restorations
 are cemented with just Temp-Bond for a          I would like to thank Ardent Dental
 3-week period. They are then carefully          Laboratory who did most of the laboratory
 removed and checked for wash-out, and           work pictured in the book.
adjusted if necessary.
    The patient is questioned at each visit
                                                                 REFERENCES
after the initial insertion as to comfort and
whether there is any sensitivity with the new    1   Gelbard S, Aoskar Y, Zelkind M, Stern N, Effect
 restorations. Only after everything is to the       of impression materials and techniques on the
                                                     marginal fit of metal castings, J Prosthet Dent
 patient's and our satisfaction, are the             (1994) 71(1):1-6.
 restorations permanently cemented with          2   Azizogli MA, Catania EM, Weiner S, Comparison
 zincoxyphosphate cement. The prepared               of the accuracy of working casts made by direct
                                                     and transfer coping procedures, J Prosthet Dent
 teeth are first dried and only then are the         (1999) 81(4):392-8.
 restorations cemented. The restorations are     3   Lin CC, Ziebert GJ, Donegan SJ, Dhuru VB,
 cemented in the smallest individual units           Accuracy of impression materials for complete-
                                                     arch fixed partial dentures, J Prosthet Dent
 possible, one at a time, with the remaining         (1988) 59(3):288-91.
teeth in occlusion and provide the correct       4   Weinberg L, Atlas of Crown and Bridge
 seating forces during cementation. After            Prosthodontics ( Mosby: St Louis, 1965).
Prosthodontics in clinical practice
PATIENT 1                         RETROGRADE WEAR
                                  Treatment by Mordehai Katz




                    THE PATIENT               PAST DENTAL HISTORY

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


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




PAST MEDICAL HISTORY

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

                                              Posterior teeth-right side.




Figure 1.1                                    Figure 1.3

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

                                                                                          3
4                                                             PROSTHODONTICS IN CLINICAL PRACTICE




    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.
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
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.
RETROGRADE WEAR




          t




Figure 1.11
Cephalometric analysis.



                                                               DIAGNOSIS
     CEPHALOMETRIC ANALYSIS
                                                •   Pseudo-Angle class III
The cephalometric analysis (Figure 1.11) was
                                                •   Advanced adult periodontitis
done to evaluate the following relationships:
                                                •   Reduced posterior occlusal support
•   Relation of the maxilla to the skull        •   Missing teeth accompanied by shifting
•   Relation of the mandible to the skull           of teeth
•   Relation of the maxilla to the mandible     •   Extreme wear due to occupational
                                                    involvement
Determined values:                              •   Caries
                                                •   Reduced vertical dimension
                    Measurement Average
                                                •   Faulty occlusal plane with extrusion and
Go-Gn                     82          84
                                                    tipping of teeth
Co-Gn                    125        122.5
                                                •   Secondary occlusal trauma with primary
Palatal plane point A     59          59
                                                    origins
(Go, gonial; Gin, gnathion; Co, condyle.)
                                                •   Periapicallesions
Interarch relationships:

SNA 85                                                   ABOUT THE PATIENT
SNB 83
ANB                        2         2          The patient was very pleasant and willing to
(SNA, seta nasion point A; SNB, sela            do what was necessary to have treatment.
nasion point B; ANB, difference between A       He was cooperative and had no preference
and B.)                                         for a fixed or removable restoration.


    INDIVIDUAL TOOTH PROGNOSIS                         POTENTIAL TREATMENT
                                                            PROBLEMS

                                                •   Many missing teeth accompanied by
                                                    extensive resorption of the residual
PROSTHODONTICS IN CLINICAL PRACTICE


    alveolar ridges, extrusion, and shifting                   TREATMENT
    of teeth
•   Extensive loss of tooth structure due to   I nitial treatment consisted of oral hygiene
    i ntense wear as well as periodontal and   i nstruction, scaling and root planing (Figures
    periapical pathologies                      1.12-1.14) The hopeless teeth, maxillary
•   Many of the remaining teeth had severe     ri ght first premolar, cuspid, left cuspid and
    periodontal problems and their progno-     l eft first molar, were then extracted.
    sis was guarded                            Endodontic therapy was carried out on the
•   Loss of vertical dimension and extrusion   maxillary right first molar, left lateral incisor,
    causing a faulty occlusal plane            l eft second premolar and the left second
                                               and third molars. These teeth were then
                                                restored with composite resin restorations
                                               to replace the material removed in the
            TREATMENT PLAN
                                               endodontic preparation.
PHASE 1: INITIAL PREPARATION                       After ruling out an abrasive diet, erosive
                                               components, and day and night bruxism, it
•    I nitial periodontal therapy including:   was concluded that the retrograde wear of
          oral hygiene instruction             the patient's remaining teeth was due to
          scaling and root planing             the fact that he had lost many teeth over
     Extraction of hopeless teeth              the years and the remaining teeth were
    Caries excavation and endodontic            required to take over all masticatory
    treatment where necessary                  function. I n addition, his professional
    Evaluation of patient cooperation           occupation as a builder, where he was
    Provisional fixed prosthesis restoring      constantly involved in an environment of
    l ost vertical dimension and providing      dust, was also a contributing factor to the
    occlusal support in the new vertical        retrograde wear.
     dimension                                      I n order to restore the loss of coronal
                                               tooth structure over the years, the remain-
Re-evaluation led to the second phase of
the treatment plan.                             i ng maxillary teeth were then prepared and
                                                provisional restorations placed at a new
                                                vertical dimension of occlusion, thus
PHASE 2: TREATMENT OPTIONS                      providing cross-arch splinting. This new
                                                vertical dimension was determined by the
Maxilla:
                                                functional and biomechanical requirements
•   Fixed and partial removable prostheses      for treatment.
•   Fixed prosthesis supported by natural           The provisional restorations in the new
    teeth and implants                          vertical dimension and occlusal scheme
•   Fixed partial prosthesis supported by       provided the following:
    natural teeth
                                                   Maximum occlusal contacts
Mandible:
                                                   Lateral jaw movements without balanc-
•   Fixed and partial removable prostheses         i ng side prematurities
•   Fixed prosthesis supported by natural          Separation of the teeth during lateral
    teeth and implants                             movement of less than 1.0 mm
RETROGRADE WEAR                                                                         9


                                           Change of vertical dimension to enable
                                           maximum contact in centric relation
                                           with the anterior teeth
                                           Better overbite and overjet relationships
                                           for protrusive movement disclusion
                                           (these can be seen clinically and also on
                                           the cephalometric radiograph done
                                           after the insertion of the transitional
                                           restorations)
                                           SNB (after treatment with provisonals) 80
                                           ANB (after treatment with provisonals) 5
Figure 1.12
                                           A CT (computerized tomography) radio-
After initial preparation-front view.
                                        graph was then done to determine the
                                        possibility of implant placement in the
                                        mandible. The radiograph revealed lack of
                                        bone for implants due to the severe
                                        resorption of the alveolar ridge over many
                                        years, most probably due to the early loss
                                        of teeth.
                                            Endodontic therapy was also carried out
                                        on the mandibular left second premolar. To
                                        i mprove its prognosis the tooth was short-
                                        ened, changing its poor crown-to-root ratio,
                                        and then restored with a coping thus
                                        enabling it to be used as an abutment for a
                                        removable partial denture. The mandibular
Figure 1.13
                                        removable partial denture would replace the
After initial preparation-left side.
                                        missing molar teeth as well as the missing
                                        l eft central incisor and second premolar.
                                            There was a dramatic improvement in
                                        the patient's periodontal condition due to
                                        his improved oral hygiene and cooperation,
                                        and it was decided to complete the
                                        patient's treatment with replacing the
                                        transitional restorations in the permanent
                                        prostheses and duplicating both the verti-
                                        cal dimension and occlusal scheme of the
                                        transitional restorations.
                                            I n the maxilla, copper band elastomeric
                                        i mpressions were made of all the prepared
                                        teeth and pattern resin copings made to fit
Figure 1.14                             the stone dies. A polyether full arch impres-
After initial preparation-right side.   sion was then taken of the maxilla and the
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.
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.
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.
Prosthodontics in clinical practice
14                                            PROSTHODONTICS IN CLINICAL PRACTICE




 Figure 2.1                      Figure 2.2
 Face-frontal view.              Face-profile view.




 Figure 2.3                      Figure 2.4
 Mandibular arch-lingual view.   Anterior maxillary teeth-palatal view, showing extensive
                                 wear.
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
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.
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
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.
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.
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,
BRUXISM                                                                                         21


the operators chose to make occlusal             worried the patient's dentist more than the
stops on the canines to allow the molar          patient herself, yet the team were able to
teeth to erupt. Once this had been               motivate their patient to undergo a time-
achieved, it was a relatively straightforward    consuming, if not invasive, course of treat-
process to rebuild the dentition. It is inter-   ment. Equally important in this case is the
esting to note that the original problem         maintenance therapy.
PATIENT 3                        EXTENSIVE TOOTH WEAR
                                 Treatment by Yehuda Shahal




                   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
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
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.
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.
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.
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).
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.
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
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.
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.
EXTENSIVE TOOTH WEAR                                                                       33




Figure 3.28                          Figure 3.29
Duralay copings fitted-maxilla.      Duralay copings fitted-mandible.




Figure 3.30
Centric relation record-left side.




Figure 3.31                          Figure 3.32
Centric relation record-completed.   Flastomeric pick-up impressions of Duralay copings-
                                     maxilla and mandible.
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.
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
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.
Prosthodontics in clinical practice
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
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Prosthodontics in clinical practice

  • 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 by Martin Dunitz Ltd, The Livery House, 7-9 Pratt Street, London NW1 OAE Tel.: +44 (0) 20 74822202 Fax.: +44 (0) 20 72670159 E-mail: info@dunitz.co.uk Website: http://www.dunitz,co.uk All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any li cence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1 P OLP. A CIP record for this book is available from the British Library. ISBN 1-85317-817-9 Distributed in the United States and Canada by: Thieme New York 333 Seventh Avenue New York, NY 10001 Composition by Scribe Design, Gillingham, Kent, UK Printed and bound in Singapore by Kyodo Pte Ltd.
  • 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.
  • 27. 14 PROSTHODONTICS IN CLINICAL PRACTICE Figure 2.1 Figure 2.2 Face-frontal view. Face-profile view. Figure 2.3 Figure 2.4 Mandibular arch-lingual view. Anterior maxillary teeth-palatal view, showing extensive wear.
  • 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.
  • 45. EXTENSIVE TOOTH WEAR 33 Figure 3.28 Figure 3.29 Duralay copings fitted-maxilla. Duralay copings fitted-mandible. Figure 3.30 Centric relation record-left side. Figure 3.31 Figure 3.32 Centric relation record-completed. Flastomeric pick-up impressions of Duralay copings- maxilla and 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