Upper and Lower RPD. Increasing VDO? Please Help. Photos in Thread.

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1 Upper and Lower RPD. Increasing VDO? Please Help. Photos in Thread. A Townie shares a challenging removable case with good feedback Post: 1 of 40 Hello, all Inexperienced dentist (two years since graduation in Sweden) looking for guidance with this case. I haven t done many RPDs. I m trying to help this man and as you can see he s got a deep bite and no occluding posterior teeth. He s currently using a lower RPD but to me it seems that it is not giving any posterior support at all and I m not really sure what it does. My plan is: 1. Extract tooth #7 (12). 2. Upper RPD + new lower RPD with increase in vertical dimension of occlusion (VDO). I ponder about increasing the VDO. Is it possible to achieve a reliable and lasting result without doing any fixed prosthetics/implants? And is it possible to increase the VDO so the posterior maxillary teeth occlude with the lower RPD? And what do you think about my workflow? I m thinking since the maxilla has molars I cannot alter the occlusal height very much here without doing crowns or implants, and this man cannot afford that for the time being. So, the increase in VDO has to come from a new lower RPD. Yes? Any input is appreciated. n 44 OCTOBER 2018 // dentaltown.com

2 Mount models and practice these changes in wax: Don t extract #7 (12). Tom Mitchell Member Since: 02/16/04 Post: 2 of 40 Rebuild the existing teeth in composite, shaping them to normal anatomic contours and heights to open VDO and establish some semblance of reasonable function. Upper RPD + new lower RPD with good strong direct and indirect retainers at the nowincreased VDO. Current VDO is where he used to be before all the neglect that got him here. Is it possible to achieve a reliable and lasting result without doing any fixed prosthetics/implants? Yes. See Dr. Terry Shaw s work here on DT. He s got a thread going now about rebuilding a lower arch in composite. And is it possible to increase the VDO so as the posterior maxillary teeth occlude with the lower RPD? Yes, but you ll have to ignore those molars. Your workflow is now correct, as long as you start with models and waxing so you know what you re trying to accomplish. For the maxilla, ignore those molars as well. Your increase in vertical comes from rebuilding the worn teeth in composite, returning them to the shape and height they were before he went AWOL. Best of luck. This is an easy and fun case. n FREE FACTS, circle 25 on card dentaltown.com \\ OCTOBER

3 RubinsteinDDS Member Since: 08/15/07 Post: 3 of 40 Richy Member Since: 03/30/10 Post: 6 of 40 Post: 9 of 40 Qun Collins DDS... Member Since: 04/07/04 Post: 11 of 40 Tom Mitchell Member Since: 02/16/04 Post: 14 of 40 stevo-1 Member Since: 02/22/04 Post: 15 of 40 Post: 17 of 40 The OP just got himself a full-day CE course worth of advice. I hope he ll use it. n I would not say this is easy at all. This man has years of neglect and I seriously doubt his ability to keep an entire mouth of composites clean and maintain them enough to support partials. This is an immediate upper and lower full denture with implants if patient wants. Ideally, implant lower overdenture at the minimum. n Thank you all very much for the input, and thank you, Tom Mitchell, for thorough guidance. I do not think this man is keen on extracting all his teeth for the time being. Tom, can you elaborate on this, please: The vertical being where he used to be before all the neglect that got him here? How can you tell this is his original VDO? I really don t get it. n Keeping a lot of composites intact to support partials will be hard for this patient, so this is not a long-term treatment. It is mentioned that this patient doesn t have much money, so if the composites start to break down in a year or two, the patient will think you did a bad job. It is better to offer him a long-term option, which is an immediate upper and lower. n You already know from complete dentures that you can open VDO, within reason, as much as you need. You just have to come close. If you go too far, the patient will tell you and you make a simple change. These cases are too easy! Just think about establishing reasonably shaped anterior teeth (that s where A and B points come from) with a level occlusal plane. Simple stuff! n Tom is not saying this is his original VDO at his current condition. What he is saying is: Be OK with opening his VDO because his VDO was more open before all the lost teeth/neglect of his mouth occurred and you ll be restoring to a VDO he had when he was younger. Maybe dental school is no longer teaching this, but it s a fundamental concept and understanding for removable prosthodontics and full-mouth rehabilitation treatment. n Thanks, Stevo-1, for the clarification. I was taught the mere basics of altering VDO for complete dentures. Haven t really altered VDO in a partial dentition. Tom, I misunderstood you but I get it now. Thanks! I read your statement as if the VDO is intact and shouldn t be altered. So, to sum it up: I do build-ups in composite (after trying it out with wax) and when patient feels comfortable with the new VDO, I do the RPDs. What is your take on doing crowns on the remaining teeth and increase the VDO that way instead? Assuming the patient can afford, and exhibit good oral care. n 2/10/2018 2/10/2018 likeaduck Member Since: 08/15/16 Post: 20 of 40 I understand conceptually what Tom describes, but can someone explain how, if those anterior composites are all the patient has to preserve the VDO, they don t fracture off within a week? n 2/13/ OCTOBER 2018 // dentaltown.com

4 Prologue Member Since: 12/07/14 Post: 21 of 40 molarmann Member Since: 01/06/17 Post: 22 of 40 AZCrazy Member Since: 12/20/01 Post: 23 of 40 What s the reasoning behind increasing VDO through composite, compared with just the RPDs? Wouldn t traumatic occlusion be an issue eventually for the anteriors? Thanks for your feedback. n This is a denture case. Anything else is likely to be a waste of this patient s time and money. n Unless you are into block bone grafting and implants, it s the dentures that will never work. I ll bet those teeth are rock solid in his jaw. Keep them, build them up and maybe experiment with his vertical and with getting a reliable provisional posterior bite with Valplast partials to test his comfort and to let you restore his anteriors. Then solid RPDs once it is made to comfort. 1. Pain control if needed. 2. Infection control (perio and gross caries). 3. Use provisional RPDs or bite planes to establish occlusal plane; modify as needed to comfort over a few appointments if necessary. 4. Use that vertical to restore the remaining anteriors to fit, with crowns, composites, etc. 5. Finalize the posterior bite with final posterior RPDs to fit your reorganized anterior bite. No, it s not the perfect treatment plan. In an ideal world, you ll rebuild his bone and get a bunch of implants and full-mouth fixed restorative. Is that going to happen? From your notes, not likely. This will give him a reasonable alternative that will function, but you ll need to converse with him in detail about the urgent need for hygiene and maintenance, and to not use his front teeth as tools or weapons or to aggressively tear into food. Composites won t hold long without solid posterior support, but once you have it, you ll still need to be very careful. n jaysmasher Member Since: 02/28/10 Post: 26 of 40 estarr Member Since: 12/27/14 Post: 31 of 40 jaysmasher Member Since: 02/28/10 Post: 32 of 40 estarr Member Since: 12/27/14 Post: 33 of 40 I don t see the patient s CC listed by the OP. If the patient wants things to look perfect, then this is a CD/RPD case. If the patients wants to chew better or doesn t want dentures, cast upper and lower partials. If you want to play with VDO, add composite, docterry style. I wouldn t do it, but nothing wrong with doing it if you feel it is needed. As far as #7, it would depend on if the patient wants to pay me to fix it vs. slick it. n Recent grad here as well. If the VDO is opened with RPDs, what will happen at night when the patient removes his prosthetics? Will the teeth rebuilt in composite just take additional stress? Will he find a comfortable jaw position at night? n Same thing that happens when dentures patients remove their prosthetics at night. n I understand that, jaysmasher, but complete denture patients don t have any teeth to get in the way. What happens to the teeth rebuilt with composite at the new VDO? n 7/21/2018 7/21/2018 7/22/ OCTOBER 2018 // dentaltown.com

5 Patient has neglected his teeth for some time now. Composites and a partial denture will only buy him time. Who knows if he will wear your partial denture? If he wears it and complains, you ll be losing a lot of time and effort adjusting and just trying to make him happy. Both you and he will be unhappy. His existing lower teeth will have little to no retention for his new lower partial denture, the new lower partial denture that you make him will move and be very unstable, and the patient will not wear it. If you do go with composites and partial denture treatment plan, have a very honest and frank talk with him and lower his expectations of a prosthesis that will feel amazing. Composites on the front teeth will break, given his deep bite and occlusion in the anterior region. My optimal treatment plan: Upper and lower implant overdentures. Alternative treatment plan #1: Upper complete and lower complete dentures. Alternative treatment plan #2: Upper partial denture and lower complete denture. As for VDO: I would do upper and lower wax rims. Determine vertical dimension at rest and vertical dimension in occlusion. Make your dentures from there. I hope this helps! Keep us posted on what you plan to do. n Clenching is clenching, if it happens. All RPD patients could have the same concern. You could make a splint as a diagnostic before even opening in composites and have the patient keep wearing if that s a concern. Realistically, you should be improving the bite compared to what they currently have, and wear doesn t look like concern #1 in this case. n 7/31/2018 8/9/2018 mcd80 Member Since: 12/17/12 Post: 39 of 40 jgne Member Since: 03/20/14 Post: 40 of 40 Ask for advice online! Dentaltown s s make it easy to ask questions and get feedback from other Townies or just to show off your great work. To start a case or simply ask a question, go to dentaltown.com and under message boards, select Forum Categories. Select the appropriate forum, then click New Case and follow the prompts. dentaltown.com \\ OCTOBER