Conceptual Approach to Complex Rehabilitation of a Patient with Bulimia Nervosa: A Case Report

Transcription

1 CASE REPORT Coneptul Approh to Complex Rehilittion of Ptient with Bulimi Nervos: A Cse Report Stefn Shunke, MDT [Au: degree orret?] Fürth, Germny Mrkus Shlee, Dr med dent [Au: Privte prtie?] Forhheim, Germny Correspondene to: Stefn Shunke Alte Reutstr 170, Fürth, Germny; e-mil: st.shunke@gmx.de. 10

2 SCHUNKE/SCHLEE Astrt This se report presents the linil nd tehnil protool involved in treting 32- yer-old ptient whose teeth nd dentl pperne were severely ompromised s result of ulimi nervos. Ptients suffering from this disorder hve high inidene of erosion of dentin nd enmel, whih over time my use loss of vertil dimension. This hs n impt on the ptient s overll pperne, with effets suh s sunken lips, lk of support, nd reses t the orners of the mouth. (Eur J Esthet Dent 2006;1:xxx xxx.) 11

3 CASE REPORT Fig 1 ( nd ) The esthetis of the nterior teeth is severely ompromised. The modern ptient omes to the dentl prtie lredy with ertin mount of inmtion found on the Internet or in mgzines or herd word of mouth. This inmtion gives ptients ertin expettions their tretment outome. However, one of the most diffiult tsks in mediine is to hieve preditle suessful results. This n only e done if thorough se history is tken, model nlyses re permed, nd good ommunition tkes ple etween ptient, dentist, nd dentl tehniin. The requirements re good funtion nd longevity nd, of ourse, exellent estheti results. To hieve this, prtiulrly omplex ses, tretment onept must e estlished. Cse kground A 32-yer-old ptient onsulted the prtie wnting to hieve more estheti smile. As result of ulimi nervos, her whole dentl pperne ws in very ompromised ondition. Bulimi nervos is n eting disorder lssified s psyhogeni disese. Beuse of the purging hits ssoited with the disorder, individuls with ulimi hve high inidene of enmel nd dentin erosion, mking this disese of interest to dentists. Studies suggest the ge of ptients ffeted rnges from 17 to 50 yers, ut most re etween 18 nd 25 yers old. Ninety-five perent of ptients ffeted re women. The inidene of ulimi nervos is generlly thought to e on the inrese in Western soiety. 1 The ptient hd reeived tretment ulimi nervos, nd there were no other disese symptoms. Clinil exmintion The purging ehviors often ssoited with ulimi nervos use ething of the enmel, whih results in erosion nd shortening of the nterior teeth. As result, the overll estheti pperne of the teeth is ompromised (Fig 1). If, s in the present se, the nterior teeth hve een severely eroded, the ptient lso my not e le to perm norml orl funtions, nd the relevnt referene nd funtionl plnes 12

4 SCHUNKE/SCHLEE Fig 2 The ltered estheti nd olusl plnes re evluted using Cndulor ite k with otton rolls. my e destroyed. To hek the estheti plne, Cndulor ite k (Rielsingen- Worlingen) with otton rolls ws pled in the mndile ginst the mxill; then it ws pled in the mxill ginst the mndile to hek the olusl plne (Fig 2). The ptient reported no pin, nd she hd no normlities in the temporomndiulr joint. The next stge of the exmintion ws st nlysis. A regulr impression with vestiule nd plte, s well s n ritrry trnsfer, were required. As no other dmge ws found, it ws not neessry to rry out time-onsuming registrtions. Considering the extent of wer, whih ws lerly evident during exmintion of the sts on the rtiultor (Fig 3), it ws remrkle tht the ptient ws not experiening ny pin. Following the exmintion, it ws deided tht suitle restortions would e pled in the worn regions to restore mstitory funtion nd pproprite esthetis. Fig 3 ( to ) The extent of wer nd resulting mstitory prolems eme evident during st nlysis. 13

5 CASE REPORT V L L I F I S Fig 4 Ftors in the Lotzmnn mul determining olusl loss of sustne. L = the distne from the ondyle to the tip of the inisl pin running perpendiulr to the rtiulr xis, V L = the vertil hnge mesured t the inisl pin, nd I = the distne from the ondyle to the relevnt ontt (nterior [I F ] or posterior [I S ]. Clulting loss of vertil dimension Over time, vertil dimension my e lost euse of erosion nd wer of the teeth. Loss of vertil dimension is evident in the overll fil pperne, whih is hrterized sunken lips, lk of support, nd reses t the orners of the mouth. The diffiulty lies in determining the proper mount whih the ite should e rised. The uthors hve een using the method presented here suessfully severl yers nd hve found it to e quik nd effiient pproh. Prof Dr U. Lotzmnn pulished mul with whih n pproximte lultion of the olusl loss of sustne (V 1 ) n e rried out 2 : (V L x I) / L = V 1 where L = the distne from the ondyle to the tip of the inisl pin running perpendiulr to the rtiultor xis, V L = the vertil hnge mesured t the inisl pin, nd I = the distne from the ondyle to the relevnt ontt (nterior nd posterior) (Fig 4). In this se, two vlues were used VL, 6 nd 7 mm, to determine the impt on the vertil dimension. The ssoited mesured vlues were: L = 120 mm nd I = 110 mm in the nterior re nd 70 mm in the posterior re (Fig 8). The results were: When the support pin ws rised 6.0 mm, V 1 ws 5.5 mm in the nterior region nd 3.5 mm in the posterior region. When the support pin ws rised 7.0 mm, V 1 ws 6.4 mm in the nterior region nd 4.0 mm in the posterior region. 14

6 SCHUNKE/SCHLEE Fig 5 The distnes from the TMJ to n nterior () nd posterior () ontt re mesured. Fig 6 A nturl mndiulr seond molr should hve rown height of pproximtely 7 mm from the ementoenmel juntion to the usp tip. 7.0 mm Fig 7 ( to ) Aording to tooth mesurements, this ptient ould mnge 4-mm ugmenttion of the teeth in the mndile lone. 15

7 CASE REPORT Fig 8 The inorret funtionl nd estheti plnes re demonstrted the morphology of the mxillry teeth lone. Fig 10 ( to ) The wxup is finished. Fig 9 ( nd ) The wxup is initited using prefrited teeth to otin n overview quikly nd effiiently. 16

8 SCHUNKE/SCHLEE These vlues initilly my seem quite high, ut, when distriuted eqully etween the mxill nd mndile, the mount is tully resonle. Mesurement of nturl teeth or referene to suitle ntomy text 3 would revel tht the seond molr (used s the referene euse this ws the ontt used to determine the I vlue the present se) should hve rown height of 7.0 mm in its unworn stte (Fig 6). Assuming tht some of the erosion in the present se my e due to nturl rsion, the sliding llipers were set to 6.0 mm. As shown in Fig 7, the lulted vlues of 3.5- to 4.0-mm rise lmost ould e hieved in the mndile lone (Fig 7). Considering the extent of erosion in the mxill s well (Fig 8) nd the indequte funtionl nd estheti plnes, the proility of ttining this ite ugmenttion ws very high. Wxup The im of dignosti wxup is to define the finl outome, ut the mount of time nd eft invested in this proess should e lned with the ost involved. In this se, it ws still unertin wht the ptient ws willing to er in terms of surgery nd preprtion, so the osts hd to remin mngele. Rther thn uilding up the wx, whih is lorious, time-onsuming, nd hene ost-intensive work, the dentl tehnologist slightly ground k the nterior teeth on the st nd reted horizontl plteu in the posterior dentition, then set up prefrited wx fets with olorless, slightly elsti wx. Prefrited wx olusl surfes were lso pled (Fig 9). One the mxillry nd mndiulr sts were thus set up nd the plnes Fig 11 The plnes estlished in the wxup re verified on the rtiulr mens of the Cndulor ite k. hd een heked, the wxup ws refined nd finlized (Fig 10). Although the wxup provided only n overview of the desired outome, nd not detils suh s speifi tooth ontts, it ws not diffiult to see tht this ws distlized dentition. Theree, only diret tooth-to-tooth reltionship ws possile. As good overite existed, it ws resonle to think tht deep usp-foss reltionship ould e uilt up. As the morphologil pperne of the molrs is influened the TMJ, the usp-foss reltionship should remin reltively flt. [Au: Edit OK?] Finlly, the plnes were heked on the wxup (Fig 11). With the sts mounted on the rtiultor, it ws determined tht the top of the rtiultor ws ligned with the ipupillry line. The Cndulor ite k, whih should run roughly prllel to this plne from the nterior spet, ws inserted etween the sts on the rtiultor. The lterl rms of the k were ligned with the olusl plne, whih runs prllel to Cmper s plne. However, this is only preliminry evlution nd must e onfirmed introrlly. [Au: Edit of ove prgrph OK?] 17

9 CASE REPORT Fig 12 ( nd ) The wxup is duplited nd st in stone. [Au: OK?]Δ Fig 13 ( to ) The vuum-med templtes reted from the dignosti wxup pled on the originl sts, demonstrting the desired tretment hnges. 18

10 SCHUNKE/SCHLEE Fig 14 The vuum-med templte n e used s preprtion guide. Fig 15 An impression ws produed using the dignosti sts. The dignosti wxup ws duplited nd st in stone [Au: OK?] (Fig 12). Vuummed templtes of these sts were then prepred. The tretment hnges ould e visulized when these templtes were pled on the originl sts (Fig 13). The mndiulr vuum-med templte ws trimmed t the ervil mrgin s pproprite to indite where gingivl grfts would e desirle. This would e enefit the estheti pperne s well s the dmged ervil res of the teeth. With ll plnes orreted, the new dimensions were mesured nd ompred. The residul rown length of the entrl inisors [Au: Mxillry or mndiulr? Or oth?] ws pproximtely 3.7 mm. The length to e hieved ws 9.7 mm. Considering the lulted vlues nd the ft tht nturl, unworn entrl inisor hs n pproximte length of 10.5 mm, these results were resonle. The vuum-med templte n lso t s preprtion guide. For exmple, if smll hole is drilled oluslly, the dentist n mesure the sptil reltionships urtely with the id of PA [Au: Wht does PA signify?] proe. This mens tht preprtion is s urte nd onservtive s possile (Fig 14). Preprtory mesures The plnned tretment n e rried out in vrious stges. In some ses, plsti mok-up might e produed try-in. The extent of the inresed olusl vertil dimension nd resulting speeh hnges, s well s the estheti outome, ould thus e lrified in dvne. However, the ptient in the present se wnted to e treted immeditely. No splints were prepred. The visul nd, most importntly, the phoneti hnges were explined to the ptient. The risk omplitions seemed miniml. Silione impressions were mde from the dignosti sts (Fig 15). The ide ws to produe provisionl restortions hirside. After preprtion, the liniin n fill these mtries with suitle mteril nd produe diret provisionl restortions. Support is provided to the silione indies from the lveolr soft tissue. 19

11 CASE REPORT Fig 16 ( to ) The gingivl reessions were ddressed using periodontl surgil intervention. Fig 17 A wxup () ws produed the long-term provisionl restortion, nd the referene plnes were heked using the Cndulor ite k ( nd ). 20

12 SCHUNKE/SCHLEE In the mndile, periodontl surgery ws permed to ddress the gingivl reession (Fig 16). Restortive proedures After the heling phse, the mndile ws definitively restored nd long-term provisionl restortion ws pled in the mxill. The provisionl restortion ws reted in the lortory to very losely pproximte the finl restortion in shpe, position, nd funtion. Esthetis, speeh, nd vertil dimension ould then e nlyzed using this long-term provisionl restortion. Menwhile, the definitive restortion ws pled in the mndile. The qudrnts [Au: wht is ment qudrnts?] nd the nines were inorported into the tretment to estlish the new guidne. The mxillry provisionl restortion ws frited hirside using prefrited silione mtries. The teeth were gin oriented to the pproprite plnes s previously lulted. In the rtiultor, the es- theti plne ws heked with Cndulor ite k (Fig 17). One the mxillry sitution ws set, the mndiulr definitive restortion ould e plnned, mintining the estlished olusl plne (Fig 18). One the mxill nd mndile were in funtionl hrmony, the wxup ws omplete. After rving, the wxup ws pressed in two different phses s thermoplsti polymer (Fig 19). The priniples demonstrted Mgne nd Mgne 4 nd used with highly suessful results Shoerer5 were followed. The restortions were then heked in stti s well s dynmi funtion to ensure tht no displement hd ourred (Fig 20). However, it is the introrl try-in tht determines suess (Fig 21). The estheti hnges with only the plement of this provisionl restortion were onsiderle. The ptient stted tht she immeditely felt omtle with the visul result nd the sujetive senstion of height nd funtion. In pproximtely 2 weeks time she ws le to spek perfetly. In order to finlize the work in n pproprite mount of time, the long-term provi- Fig 18 The mndiulr wxup ws onstruted, mintining the estlished olusl plne. Fig 19 The wxup ws then pressed in two stges using thermoplsti polymer. 21

13 CASE REPORT sionl restortion ws followed definitive work in the mxill. Preprtion refinement ws undertken s neessry, nd the orresponding sts were produed (Figs 22 nd 23). The uthors hose ll-ermi Proer rowns (Noel Biore) frited the dentl tehnologist Ernst A. Hegenrth the definitive mxillry restortions. The nterior teeth were quite short; theree, in order to mintin dequte stility, the sustruture ws uilt up, similr to metlli ore, doule-snning tehnique (Fig 24). A new ermi mteril lled NoelRondo, developed Noel Biore together with Hegenrth, 6 ws used in the lyering of the rowns. The uthors found the hndling of this mteril to e very simple; the lyering tehnique ws similr to their ustomry methods (Fig 25). In the frition of the finl mxillry restortions, the pperne of the lil spet, in prtiulr, ws opied nd trnsferred s urtely s possile from the long-term provisionl restortion. Artiulting pper, pulled from the inisl to the gingivl spet, ws used heking Fig 20 Funtionl movements re evluted on the st with the finished long-term provisionl restortion in the mxill nd the definitive work in the mndile. Fig 21 ( to ) The suess of restortive tretment ultimtely depends on the introrl pperne. 22

14 SCHUNKE/SCHLEE Fig 22 The mxillry teeth re prepred gin s neessry () ee retion of the sts frition of the definitive restortions (). Fig 23 The finlized mxillry () nd mndiulr () sts frition of the definitive mxillry restortions. Fig 24 tehnique. The Proer rowns were produed using doule-snning 23

15 CASE REPORT Fig 25 ( to ) The Proer rowns oted with se liners. The first firing hs just een rried out in the nterior re, nd the onil distriution n e seen on the posterior teeth. Fig 26 ( nd ) Artiulting pper is idel reveling ll onvex nd onve strutures when dupliting restortive situtions. 24

16 SCHUNKE/SCHLEE d e Fig 27 ( to f) The definitive mxillry restortions on the st. f 25

17 CASE REPORT d Fig 28 The plnned outome () should e ompred with the tul outome (). In ddition, the usp inlintion nd the usp-foss reltionship should e heked ( nd d). tiulting pper, nd hene the gingiv. The finl results were exellent, oth in terms of the overll pperne nd smll detils (Fig 27). A finl step ee plement of the restortions ws the omprison of the plnned with the tul outome (Fig 28). As previously mentioned, this ptient hd distlized ite. To tht extent, it ws only possile to rete usp-to-usp reltionship. Although ll the guiding elements were uilt up, no exessively deep uspntomi detil nd lil fullness. Comprison of the rw firing with the ntomi st reveled other importnt spets, suh s differene etween the onvex nd onve strutures (Fig 26). For exmple, the interdentl spe hd no ontt with the rtiulting pper, while the tul fil surfe did hve ontt. The onvex-onve strutures were lso pronouned in the surfe struture. The rowns tpered slightly t the nek of the tooth nd gin hd no ontt with the r- 26

18 SCHUNKE/SCHLEE Fig 29 ( to ) The emergene profile is evluted. foss reltionship ould e reted. The frontl view of the emergene profile nd the horizontl view of the reltionship of the gingiv to the teeth lso hd to e evluted in oth the nterior nd posterior regions (Fig 29). The finl restortive outome is shown in the imges in Fig 30. Diret omprison revels tht the olor of the mxillry teeth is slightly lighter thn tht of the mndiulr teeth (see Figs 30 to 30e). The ptient deided tht she wnted the dentition to e slightly lter shde following plement of the provisionl mxillry restortions nd the definitive mndiulr restortions. It ws explined to the ptient tht the lighter shde ould only e used in the mxill, nd she greed to this sitution. The detiled photogrphs in Figs 30f to 30h onvey exellent gingivl onditions, nd the extrorl imges in Figs 30i to 30k demonstrte the plesing overll pperne. 27

19 CASE REPORT d e f Fig 30 Finl restortions in ple. ( nd ) Olusl views. () Frontl view. (d nd e) Lterl views. (f to h) Detiled views. (i to k) Extrorl views. 28

20 SCHUNKE/SCHLEE g h i j k Referenes 1. Zuhr, O, Shoerer U. Dignostishe Prinzipien im Liht moderner Behndlungsstrtegien. Temwork 2004;7: Bumnn A, Lotzmnn U. Funktionsdignostik und Therpieprinzipien. Stuttgrt: Georg Thieme, 2000: Krus B, Jordn R, Arms L. Dentl Antomy nd Olusion. Hmilton, Ontrio: B.C. Deker, Mgne M, Mgne P. Shlüsselelement eines umfssenden ästhetishen Behndlungskonzeptes. Dent Lor 1999;47: , Shoerer U. Wenn Anspruh und Wirklihkeit üereinstimmen. Interdiszipl J Proth Zhnheilkd 2000;3: Hegenrth EA. Ästhetik, Wissenshft und Ergonomie einer neuen Kermikgenertion. Quintessenz Zhnteh 2004;30: