Case Report FULL MOUTH REHABILITATION CASE REPORT Authors: Paras Doshi*, Chirag Chauhan**, Darshana Shah***, Krutika Bhatti****, Rajiv S.***** ABSTRACT Full mouth rehabilitation is a process that rehabilitates the mouth so that the patient can have good oral health that, with proper maintenance, will remain healthy for the long term. Full-mouth rehabilitation (sometimes called reconstruction or restoration) is the individual recreation of each tooth in the mouth. This treatment modality is needed when the teeth are worn down, broken or missing, causing problems in both the arches and appearance of the mouth. The process of full mouth rehabilitation when it is applied to specialist dentistry often implies that serious multiple dental problems are present which need to be treated in a methodical and highly structured fashion to give a desired long term stable result. This article describes the case of one such patient who had severe tooth wear, resulting in reduced vertical dimension. The case was treated by restoring the lost vertical dimension by prosthetic rehabilitation.pankeymann- Schuyler philosophy is followed for the prosthetic rehabilitation because it is a well organized, logical procedure where anterior guidance is first established followed by restoration of the posterior teeth. INTRODUCTION Full mouth rehabilitation cases are one of the most difficult cases to manage in dental practice. This is because such cases involve not only replacement of the lost tooth structure but also restoring the lost vertical dimensions. Full mouth reconstruction is basically a set of procedures that are aimed at correcting an improper bite position as well as restoring chipped or worn out teeth. Improper jaw position is implicated in various neuro-muscular disorders as well as in headache and neck ache. Correcting the jaw position not only restores proper function, but also helps in enhancing the cosmetic [1] appearance of the patient. Reconstructing dental arches with severe attrition is a distinct restorative challenge. The problem is heightened by widely divergent views concerning [2-6] appropriate procedures for successful treatment. Excessive occlusal attrition can result in pulpal pathology, occlusal disharmony, impaired function, Address for Correspondence: Dr Paras Doshi Ahmedabad Dental College Gandhinagar EMAIL ID: parasjdoshi@yahoo.co.in esthetic disfigurement and reduced vertical [7,8] dimension. Before starting actual procedures for the rehabilitation of such patients, the cause of the tooth wear should be found. Most of the time, bruxism is found to be related to extensive tooth [9] wear. The long-term chewing of betel nut and tobacco is also a major cause of attrition. Habits such as excessive tooth picking and self-mutilation of teeth should also be considered. In case of severe attrition, the cuspal anatomy of posterior teeth is lost and the supporting cusps wear more extensively than the non-supporting ones. The characteristic narrowing of the intact occlusal table maintained by the supporting cusp shape is lost. This may result in broad, flat teeth having close to a deep bite relationship. The nonsupporting cusps can no longer keep the soft tissues away from the contacts between supporting cusps, so the patient may well begin to bite his or her [10] cheek, and the problem becomes very complex, as functional and esthetic improvements require [11] modification of the existing vertical dimension. The compromised height of clinical crowns, coupled with a powerful musculature, makes it difficult to reestablish cosmetic proportions and to resist traumatic forces. This article describes the case of a *Reader, ** Professor, *** Professor and Head, **** Post Graduate Student, Dept. of Prosthodontia, Ahmedabad Dental College& Hospital, Gandhinagar. *****Reader, Dept. of Cons. & Endo, Krishnadevaraya Dental College, Bangalore. MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 87
patient who had severe occlusal wear, resulting in esthetic and functional impairment. CASE REPORT A 71 year old female, moderately built with good general health reported to the department of Prosthodontics crown and bridge, Ahmedabad dental college, Ranchhodpura, Ghandhinagar, Gujarat, India with a chief complaint of difficulty in chewing food and worn out teeth. General examination revealed hypertension and asthma's significant systemic history. Patient is on medication for the same since 10years. On clinical examination generalized attrition of the dentition was present (Figure1). Patient, other than difficulty in mastication was also dissatisfied with the unsightly appearance of her face due to a decreased vertical dimension.(figure 2) A treatment plan was developed with the following aims: to reduce effect of loss of teeth and function, to improve the esthetics and to restore masticatory function. A treatment plan was carried out with 3 phases: 1. Pre prosthetic phase: The Oral surgery therapy extraction of root pieces was done. 25 and 26. The Endodontic therapy- root canal treatment was performed in all teeth with severe attrition before further treatment was undertaken. a. In maxillary arch- 11, 12, 13, 16, 17, 21, 22, 23, 24, 27 b. In mandibular arch- 31, 32, 33, 34, 35, 37, 41, 42, 43, 44, 45 The periodontal therapy- full mouth scaling and polishing was done. Transgingival probing was performed to establish the dimension of biologic width prior to Surgical Crown Lengthening procedure. It was decided to perform crown lengthening by gingivectomy on 44,45. 2. Prosthetic phase: 1) Pre-operative photograph of patient with non visible teeth-figure 1 2) Severely attrited teeth with reduced vertical dimension -figure 2 On Intraoral Examination: Teeth present in maxillary arch 11, 12, 13, 16, 17, 21, 22,23,24,27 Teeth present in mandibular arch -31, 32, 33, 34, 35, 37, 38, 41,42,43,44,45 Missing teeth -14,15,36,46,47 Root pieces 25,26 On the basis of clinical and radiographic examination, a diagnosis of worn out dentition with reduced vertical dimension of occlusion was made. Full mouth rehabilitation of the mouth was planned to restore the function, esthetics, speech and comfort of the patient. The patient was informed of the diagnosis, the treatment planning and her consent was taken before the start of the procedure. Due to the presence of decreased VD, an increase in VD was first considered. Vertical dimension was increased by 3mm using an Occlusal splint which was fabricated using self cure acrylic resin (DPI RR Coldcure, India) at the Centric Relation position (Figure 3). 3) Occlusal splint placed -figure 3 MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 88
The patient was asked to wear the occlusal splint for the maximum possible time in a day except while eating and in the night for a period of 3 weeks and was asked to report after 3 weeks. Complete arch maxillary and mandibular impressions were made with irreversible hydrocolloid (Marieflex, Class A, Type II, Septodont healthcare, Panvel, Maharastra, India) and used to obtain diagnostic casts, using type III dental stone (Gold stone, Asian chemicals, Gujarat, India). Face bow transfer was done and interocclusal records were made to mount the casts in centric relation on a semi adjustable articulator (Hanau Wide view; water pik, Fort Collins, USA) (Figure 4). Maxillomandibular relationship record was made with putty and anterior jig at raised vertical dimension (figure 6 & 7). 6) Maxillomandibular relationship record was made with putty at raised VD in patient's mouth 4) Face-bow transfer -figure 4 Special attention was paid in restoring the function and esthetics of the dentition. Due to the presence of generalized attrition, the clinical crown height was reduced such that insufficient crown structure was present in order to prepare the teeth for retention of the full coverage restorations. Hence the patient was referred to department of Periodontics to restore the height of the attrited teeth with gingivectomy on 44,45. Anterior tooth preparation was done with minimal Occlusal reduction with a shoulder finish line on the facial side and chamfer on the lingual side.anterior jig and splint was used as a guide to maintain the raised vertical dimension (figure 5). 7) Maxillomandibular relationship record was made with putty at raised VD on articulator Provisional restorations were given (Temperon; GC corp, Tokyo, Japan) (figure 8 & 9)and the Occlusal plane analysis was done with SOPA( simplified occlusal plane analysis) (figure 10). MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 89
A trial evaluation of the metal substructure done prior to the buildup of ceramic material enabled final Occlusal refinement (figure 13). 10) Simplified occlusal plane analysis Putty index was made to transfer new established occlusal plane(figure 11) and it was giving guidance for posterior tooth preparation. Impressions of the prepared teeth were made with poly vinyl siloxane (Photosil, DPI, Mumbai, India) in stock trays. Definite maxillary and mandibular casts were formed, mounted on an articulator with trimmed dies of the prepared teeth and wax patterns were made on it (figure 12). 13) Trial evaluation of the metal substructure done prior to the buildup of ceramic material The crowns were cemented with Glass Ionomer Cement (GC Fuji I,GC corporation, Tokyo, Japan)(figure 14 & 15). 14) Crowns were cemented in maxillary arch 11) Putty index was made to transfer the new occlusal plane 15) Crowns were cemented in mandibular arch The vertical dimension was carefully maintained during the period of provisionalization and through the completion of restoration (figure 16 & 17). 12) Fabrication of wax-pattern 16) Permanent crowns in place MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 90
dynamic, functional centric occlusion. Thus the aim of rehabilitation includes the health of the periodontium, vertical dimension, interocclusal distance, functional balanced occlusion and esthetics. 17) Past-operative photograph of patient with visible teeth The patient was followed up for 1year on a regular 3month recall appointment schedule. 3. Maintenance phase : Oral hygiene instructions were reviewed, emphasizing cleaning of the restoration margins. Additional instruction was given on the use of floss threaders and superfloss under the FPD. The patient was seen at 1- and 2-week followup appointments. The patient stated that she was pleased with esthetics, function, and comfort of the prosthesis. Oral hygiene was excellent. The patient was given instructions to seek 3- month prosthodontic and periodontic recall appointments. DISCUSSION Reconstruction of severe attrited dentition has been a challenge to a dentist's skill and capabilities. It demands rehabilitation within the physiological and functional harmony of the stomatognathic system. For occlusal rehabilitation two occlusal philosophies exist. One advocates simultaneous reconstruction of both arches and the other advocates complete restoration of one quadrant in a programmed sequence before proceeding to the [ 1 2 ] next. The concept of complete mouth rehabilitation is dependent basically upon three proved and accepted principles. These are; the existence of a physiological rest position of the mandible which is constant, the recognition of a variable vertical dimension of occlusion and the acceptance of a The presence of caries, restoration, attrition or a combination of these conditions can cause teeth to have little intact coronal tooth structure remaining, resulting in loss of vertical dimension of occlusion. Many clinical studies indicate that, vertical dimension of occlusion is maintained even with rapid wear. As the occlusal surface wears, compensatory alveolar process elongates by [13] progressive remodeling of the alveolar bone. As a result there is no loss of vertical dimension unless tooth loss occurs. However, occlusal wear may occur more rapidly than continuous eruption depending [14] on the etiology of the wear. Therefore, it is critical to verify loss of occlusal vertical dimension prior to restoration at an increased vertical dimension. So combination of methods like phonetics, facial appearance and measuring the interocclusal distance are used to verify the lost vertical dimension. Occlusal splint is used as a means to raise the vertical dimension of occlusion for 6 weeks. Basic function of a splint is referred to as muscle deprogrammer and it helps the condyle in [15] returning to their centric relation position. Along with temporary occlusal treatment with occlusal splint, collateral treatment was suggested to the patient like stress relaxation techniques and regular exercises. Definite occlusal treatment includes selective grinding, orthodontic treatment and prosthodontic treatment. Definite occlusal treatment is initiated when subjective and objective symptoms have disappeared permanently or at least improved significantly. Collateral treatment should be continued even after definite occlusal treatment has started. The prognosis of definite occlusal treatment depends upon patient's age, period between onset of symptoms, beginning of treatment and severity of psychogenic factors. MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 91
Correct orientation of occlusal plane with compensating curves incorporate problems in rehabilitation of worn dentition. It is therefore essential that an anterior occlusal plane be established at the temporization stage. Speaking line, smile line and lower lip line may be assessed for optimum visibility of upper and lower anteriors. In addition labiolingual and superio-inferior positioning may be checked using labiodental sound ( F& V) and Silverman's closest speaking space. Once the anterior occlusal plane has been established then it may be extended posteriorly incorporating anteroposterior and mediolateral compensating curves. There is a definite relationship between incisal guidance, condylar guidance and curve of spee. There tends to be a harmony of steepness or flatness which in turn determines the cusp height, fossa depth and occlusal tooth form of the posterior [16] teeth. Cusp fossa arrangement is used commonly in full mouth reconstruction. Lateral guidance can be established by canine guided occlusion, group function and bilateral balanced occlusion. Canine guided occlusion is superior to the other because it is easier to establish anatomically, acceptable and reduces lateral stresses on posterior teeth and ridges. More over canine has a long root surrounded by dense compact bone and least muscular activity is recorded when canines are in function. Hence canine guided occlusion is chosen to for establishing lateral [17] guidance. Treatment of reduced VD is not designed to increase the VD beyond the normal, but is intended to restore the amount of VD that has been lost. In rehabilitation procedures, the masticatory organ must be reconstructed within the limits of physiologic rest position with sufficient allowance for a functional interocclusal distance. CONCLUSION Appropriate case selection and careful treatment planning are critical to a successful outcome and patient satisfaction in multidisciplinary cases. The use of diagnostic elements and a preoperative treatment plan allows the clinician to identify areas of concern, allows the desired protocol for restoration. The restoration of normal healthy function of the masticating apparatus is the ultimate aim of full mouth rehabilitation. REFERENCES 1. Gopal Y, Mallabadi R. FULL MOUTH REHABILITATION. Journal of Clinical and Diagnostic Research [serial online] 2007 April [cited: 2007 April 2]; 1:143-146. Available from http://www.jcdr.net/ back_issues.asp? issn = 0973 709x&year = 2007&month=April & volume = 1&issue = 2&page = 143-146id = 16 2. Schweilzer JM. An evaluation of 50 years of reconstructive dentistry. Part I: Jaw relation and occlusion. J Prosthet Dent l98l;45:383-88. 3. Schweitzer JM. An evaluation of 50 years of r e c o n s t r u c t i v e d e n t i s t r y. P a r t I I : Effectiveness. J Prosthet Dent l98l;45:492-8. 4. Goldman l. The goal of full mouth rehabilitation. J Prosthet Dent 1952;2:246-51. 5. Bronsiein BR. Rationale and technique of biomechanical occlusal rehabilitation. J Prosthet Dent 1954;4;352-67. 6. Schweitzer JM. A conservative approach to oral rehabilitation.. J Prosthet Dent 1961;l 1:119-23. 7. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-474. 8. Clark GT, Beemsterboer PL, Rugh JD. Nocturnal masseter muscle activity and the symptoms of masticatory dysfunction. J Oral Rehabil 1981;8:279-281. 9. Carlsson GE, Johansson A, Lundquist S. Occlusal wear, A follow up study of 18 subjects with extensively worn dentitions. Acta Odontol Scand 1985;43;83. MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 92
10. Setchell DJ. Conventional crown and bridgowork. Br Dent J 1999;187:68-74. 11. Brown KE. Reconstruction considerations for severe dental attrition. J Prosthet Dent l980;44:384-388. 12. Binkley TM, Binkely CJ. A practical approach to full mouth reconstruction. Journal of Prosthetic Dentistry 1987; 57:261-266. 13. Dawson PE. Vertical Dimension. In: Peter E. Dawson. Evaluation, diagnosis and treatment of occlusal problems.1989, 2nd Ed. Cv Mosby Company, St. Louis Baltimore, Toronto. 56-71. 14. Berry DC and Poole DFG. Attrition: Possible mechanism of compensation. Journal of Oral Rehabilitation.1976; 3:201 15. Okeson JP. Occlusal Appliance Therapy. In: J e f f r e y. P. O k e s o n. M a n a g e m e n t o f Te m p o ro m a n d i b u l a r D i s o rd e r s a n d Occlusion., 5th Ed Mosby Company, St. Louis,Missouri.2003; 509-512. 16. Pankey LD, Mann AW. Oral Rehabilitation Part II. Reconstruction of the upper teeth using a functionally generated path technique. Journal of Prosthetic Dentistry 1960; 10,151-162. 17. Dawson PE. Anterior Guidance. In: Peter E. Dawson. Evaluation, diagnosis and treatment of occlusal problems. 1989, 2nd Ed. Cv Mosby Company, St. Louis Baltimore,Toronto.274-297. Source of Support : Conflict of Interest : Date of Submission : Review Completed : NIL NOT DECLARED 20-05-2013 04-12-2013 MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY Vol. 4 Issue-1 January 2014 93