|Year : 2012 | Volume
| Issue : 3 | Page : 205-210
Comprehensive treatment of compromised dentition: An interdisciplinary approach
Gulab Chand Baid1, Sarandha D Lakshman2, Anand Marilingaiah2, Honey Lunkad3
1 Department of Prosthodontics, Maitri College of Dentistry and Research Centre, Durg, Chhattisgarh, India
2 Department of Prosthodontics, Dr. Syamala Reddy Dental College and Hospital, Bangalore, Karnataka, India
3 Department of Prosthodontics, Daswani Dental College and Research Centre, Kota, Rajasthan, India
|Date of Web Publication||11-Jun-2013|
Gulab Chand Baid
Department of Prosthodontics, Maitri College of Dentistry and Research Centre, Durg, Chhattisgarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The objective of full mouth rehabilitation must be the reconstruction, restoration and maintenance of the health of the entire oral mechanism. It demands rehabilitation within the physiological and functional harmony of the stomatoganthic system. One of the most demanding aspects essential to long-term success of such cases involves the development of sufficient restorative space, while simultaneously fulfilling aesthetic, occlusal and functional parameters. Different philosophies have been documented for rehabilitation of such cases and the choice of the treatment plan depends on the skill and experience of the clinician. 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.
Clinical Relevance to Interdisciplinary Dentistry
- Patient with severely attrited teeth have decreased vertical dimension which causes decrease in vertical dimension.
- Prosthetic rehabilitation is not possible without restoring the dentition to optimal health.
- Treatment approach requires and interdisciplinary approach with periodontal and endodontic proceduresfor an aesthetically and functionally acceptable results.
Keywords: Anterior guidance, occlusal splint, provisionalization, restored teeth
|How to cite this article:|
Baid GC, Lakshman SD, Marilingaiah A, Lunkad H. Comprehensive treatment of compromised dentition: An interdisciplinary approach. J Interdiscip Dentistry 2012;2:205-10
|How to cite this URL:|
Baid GC, Lakshman SD, Marilingaiah A, Lunkad H. Comprehensive treatment of compromised dentition: An interdisciplinary approach. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Feb 21];2:205-10. Available from: http://www.jidonline.com/text.asp?2012/2/3/205/113263
| Introduction|| |
Planning and executing the restorative rehabilitation of a decimated occlusion is probably one of the most intellectually and technically demanding tasks facing a restorative dentist. Occlusal rehabilitation involves restoring the dentate or a partially dentate mouth with the aim to provide an orderly pattern of occlusal contact and articulation that will optimize oral function, occlusal stability and esthetics. Full mouth reconstruction includes therapy which will, by improving the relationship of the teeth, improve the condition and health of the supporting structures as well.
Two philosophies are widely documented and used for full mouth rehabilitations
The PMS philosophy , aims at achieving the following principles of occlusion advocated by Schuyler.
- Hobo's technique
- Pankey-Mann-Schuyler (PMS) philosophy
The sequence advocated by the PMS philosophy is as follows:
- Coordinated and static contacts of the maximum number of posterior teeth in centric relation position of the mandible.
- Functionally harmonious anterior guidance during the lateral excursive movements.
- Disclusion of the posterior teeth during protrusion determined by the anterior guidance.
- Absence of interferences during lateral excursions on the non-working side.
- Group function on the working side during the lateral excursions.
PMS's philosophy of full mouth rehabilitation was used for the restoration of all teeth, which is the simplest and effective means of achieving treatment objectives in a stepwise manner. 
- Part I: Examination, diagnosis, treatment planning, and prognosis.
- Part II: Harmonization of the anterior guidance for best possible function, esthetics, and comfort.
- Part III: Restoration of the mandibular posterior occlusion after selecting an acceptable occlusal plane so that it will not interfere with condylar guidance and is in harmony with the anterior guidance.
- Part IV: Restoration of the maxillary posterior occlusion so that it is in harmony with the anterior and condylar guidance. The functionally generated path is an important aspect of this technique and is often considered a part of it.
This clinical report demonstrates successful multidisciplinary approach to a full mouth rehabilitation of a patient whose dentition has been esthetically and functionally compromised.
| Case Report|| |
A healthy 75-year-old male patient reported to the Department of Prosthetics Dentistry, Dr. Syamala Reddy Dental College and Research Center, Bangalore, with a chief complaint of difficulty in chewing, drooling of saliva, and generalized decrease in height of teeth. The patient's dental history indicated periodic dental examination, oral prophylaxis, extraction of 23, 25, 37, 16, 17; RCT in relation to 24, 36, fixed partial denture in relation to 21, 22, 23, 24, 25, 26, and crown irt 27. The patient denied any symptoms of temporomandibular joint disorder or myofacial pain dysfunction.
The patient had no facial asymmetry or muscle tenderness but decrease in facial height. Mandibular range of motion was within normal limits. The temporomandibular joints, the muscles of mastication and facial expression were asymptomatic.
The maxillary and mandibular arch was partially dentate with missing teeth in relation to 16, 17, 23, 25, 37. No gross abnormalities were detected in the overall soft-tissue of the lips, cheeks, tongue, oral mucosa, and pharynx. Generalized attrition and abrasion were noted. Fixed partial denture spanning 21-27, grossly decayed teeth irt 28 and 38, endodontically treated 24 and 36 with metal crowns were observed.
An initial evaluation indicated decreased vertical dimension secondary to bruxism (5 mm). As per Turner and Missirlian classification of occlusal vertical dimension, the patient's condition was category 1 i.e., excessive wear with the loss of occlusal vertical dimension. Category 2 of this classification represents excessive wear without loss of occlusal vertical dimension, but with inter occlusal space available, while category 3 includes patients with the excessive wear without loss of occlusal vertical dimension and limited space.  Oral hygiene was average with no symptoms of periodontal affliction. Clinical and radiographic examination and diagnostic cast's revealed severe attrition resulting in reduced clinical crown length, especially pronounced in anterior teeth and prominent masseter muscle activity [Figure 1].
A multiphase treatment protocol was planned as follows:
Phase 1: Initial education and motivation of the patient, psychological counseling, Comprehensive oral evaluation, and pretreatment records.
Phase 2: Periodontal prophylaxis and maintenance, oral hygiene instruction, crown lengthening.
Phase 3: Impressions, jaw relation record, mock wax-up at increased vertical dimension and occlusal splint at increased vertical dimension.
Phase 4: Tooth preparations, impressions, jaw relation recording, provisionalization.
Phase 5: Definitive restorations.
Phase 6: Post-operative follow-up.
The initial phase began with patient education and motivation about the cause of his present oral condition and treatment plan to correct the same. Psychological counseling was done.
Crown lengthening was essential to achieve proper abutment height irt 12, 22, 34, 35. We had two options perform endodontic treatment of vital non infected teeth and fabricate posts and cores or achieve required clinical crown height by gingivectomy. We opted for the latter as it was a more conservative approach, preserving the vitality of affected Teeth. Oral prophylaxis was followed by crown lengthening (FDI Federation Dentaire Internationale nomenclature) of about 3 mm by electro-cauterization followed by osteoplasty to exposed adequate clinical crown height.
Occlusal splint fabrication
A mandibular occlusal splint was fabricated enabling favorable condylar repositioning, avoiding habitual harmful neuromuscular reflexes and re-establishing vertical dimension. A Permissive full arch occlusal splint made up of heat cured clear poly methyl methacrylate was fabricated. ,, The occlusal splint was fabricated to incrementally restore the 3 mm vertical dimension of occlusion (VDO) deficit. The adjustments were made according to the parameters of organic occlusion: Occlusal forces directed along the long axis of posterior teeth in occlusion and no contact among maxillary and mandibular anterior teeth. The occlusal splint was used for 12 weeks, with regular clinical review appointments [Figure 2].
The full mouth rehabilitation technique used was advocated by Pankey, Mann and Schuyler as modified by Dawson.  Preparation of anterior teeth and 24 (23 is missing) was carried out first (Dawson) following which provisionals were made using an additional silicone (Aquasil, Dentsply Caulk) putty index of the mock wax-up [Figure 3] and [Figure 4]. The occlusal splint was modified to make space for newly cemented anterior provisional crowns by removing its anterior portion from canine to canine. The modified splint maintained VDO by providing posterior occlusal stops. Post cementation, anterior provisional restorations were evaluated for optimum anterior guidance [Figure 5]. After confirming that the anterior guidance was comfortable and harmonious with functional movements, tooth preparation and provisionalization of posterior teeth was completed segmentally. 
|Figure 4: Mock wax-up duplicated and poured in dental stone and additional silicone putty index made|
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|Figure 5: Anterior restoration evaluated for optimum anterior guidance's|
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Patient's occlusion and comfort was again evaluated for next 3 weeks. When provisional restorations were considered acceptable, impressions of maxillary, and mandibular arches with these crowns were made. Casts thus obtained were used to make putty indices for developing form and contour of definitive restorations.
Definitive mandibular anterior restorations
An impression of prepared mandibular anterior teeth was made using the additional silicone impression material (Aquasil, Dentsply Caulk) by dual stage impression technique. The cast thus obtained was articulated against the replica of cemented maxillary provisional restorations using the jaw relation records as before. The putty indices of mandibular anterior provisionals were used for establishing similar contours in definitive restorations (porcelain fused to metal). The mandibular anterior crowns thus fabricated were temporarily cemented (IRM, Dentsply Caulk) and evaluated for functional harmony, esthetics, and comfort, following which they were permanently cemented Glass Inomer cement luting cement, GC Corp. Tokyo, Japan).
Definitive maxillary anterior restorations
An impression of prepared maxillary anterior teeth was made and the cast was articulated with a replica of the permanent mandibular anterior crowns using the jaw relation records. The contours of maxillary anterior definitive restorations were developed as was carried out previously for mandibular crowns. The maxillary anterior crowns thus fabricated were temporarily cemented and evaluated for esthetics, functional harmony, and comfort, following which they were permanently cemented.
Definitive posterior restorations
The posterior teeth were restored segmentally, first completing one side and then the other. Occlusal plane was determined using Broderick occlusal plane analyzer principle.  An impression and cast of the prepared posterior quadrant was made followed by the articulation against a cast containing the replica of the provisional/definitive restorations of the opposing quadrant. The programmed articulator and putty indices of provisional restorations were used to give proper contours to the definitive prosthesis. Rhein attachment was fabricated on 14, 15, which served as an anchor for replacing 16, 17 [Figure 6] and [Figure 7]. The crowns thus fabricated were first cemented temporarily and then permanently as before [Figure 8]. A maxillary occlusal splint was fabricated for protecting the restorations from patient's parafunction.
| Discussion|| |
Fixed prosthodontic procedures fall in one of two categories, conformative or re-organized.
Conformative occlusal approach is generally followed when relatively small amount of restorative treatment is required and is designed around the patients existing Inter Cuspal Position (ICP) (or Maximum Intercuspation) which may or may not coincide with the centric relation. It is limited to localized occlusal adjustments involving the tooth to be prepared or its immediate vicinity such as removal of deflecting contact, shortening of the opposing cusp, elimination of non-working side interferences. Reorganized approach is needed when the present ICP is unacceptable and needs to be changed or when extensive restorations are required to optimize the patient's occlusion. Herein, the ICP is developed at the centric relation position of the mandible or the ICP is made coincident with the centric relation contact position. This provides an even and stable occlusion and ensures there are no pathogenic deflective contacts. Therefore, most of all full mouth rehabilitations tread the reorganized approach as it restores the structural and functional integrity of the dental arches that are compromised extensively by decayed, missing, broken, worn, discolored teeth or teeth suffering from the developmental defects or faulty fixed prosthodontic work. Once, the decision of full mouth rehabilitation is arrived at two questions need to be answered, what sequence of tooth preparation and restoration is to be followed and what occlusal scheme to establish. Choices range from simultaneous full arch or Segmental/Quadrant or Sequential simultaneous techniques and group function or canine guided occlusal schemes. Each comes with its own merits and demerits. The choice is balanced between what is best for the patient given the clinical condition and patient's expectation and the operators experience and understanding.
Irrespective of the choice, the treatment protocol should essentially include, preliminary procedures directed towards eliminating pain, infection, carious lesions, and teeth with poor prognosis by an interdisciplinary team of specialists followed by a full analysis of occlusion as it exists.
Occlusal adjustment therapy is used in an attempt to provide stable occlusal contacts during the bruxism or clenching episodes.  The occlusal adjustment contributes to comfort and better function of the stomatognathic system.  Providing esthetics with the correct anterior guidance and occlusal contacts are the key to long-term occlusal stability.  Depending on the degree of tooth wear, full mouth rehabilitation of worn dentition can be accomplished by conservative composite resin restorations, crowns and post- and -core restorations. 
The success of cast restorations is linked to patient related factors (oral hygiene, eating habits etc.) and treatment plan related factors (occlusal adjustment, bruxism control etc.) in addition to the technique and materials employed. , According to Dawson, anterior teeth play a dominant role in establishing the functional path that the mandible can travel. Therefore, the position and contours of lower anterior teeth should be the starting point of occlusal design as they are the beginning of functional movements that establish anterior guidance and the envelope of motion. 
A flat occlusal plane can be harmful by creating stressful crown-root ratios since the curvature of the supporting alveolar bone does not match to a reasonable degree with the curvature of the occlusal plane. The curvature given to the posterior plane of occlusion, in an anteroposterior direction to avoid this stress, is called the "curve 'of Spee" and is based on the spherical theory of occlusion. The Broderick occlusal plane analyzer as suggested by the PMS occlusal rehabilitation concept helps to develop this curve. 
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 teeth.  Cuspfossa 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. Moreover, 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 guidance  on the right side and group function occlusion on the left side.
Some authors have recommended occlusal splints as an efficient treatment approach.  With their insertion, it is important to recognize the location and extent of damage to teeth and the corrections necessary to reduce the wear.
| Conclusion|| |
Abnormal occlusal conditions are overlooked by dentists in many patients, because of lack of knowledge or interest. The key to success is a multidisciplinary treatment approach and constant communication with patients to make them understand the disorder and proactively participate in treating , it. In the treatment of severely worn teeth, an anterior guidance should be established in harmony with functional jaw movements and all posterior teeth should discluded during any eccentric jaw movement. Taking the guidance into account during provisionalization, ensures minimal adjustments in the definitive restorations and greater long term predictability [Figure 9]. If there is habitual bruxism, an occlusal splint should also be delivered post rehabilitation of the patient. Psychological counseling is of immense value in ensuring favorable treatment prognosis.
| Summary|| |
Case report is presented to describe the functional and esthetic rehabilitation of patient with decrease vertical dimension using the PMS philosophy of occlusal rehabilitation. Treatment objectives were achieved by accurate diagnosis, meticulous treatment planning together with a dedicated team approach involving different disciplines in dentistry.
| References|| |
|1.||Dawson PE. Pankay-Mann-Schuyler philosophy of complete occlusal rehabilitaton. In: Dawson PE, editor. Evaluation Diagnosis and Treatment of Occlusal Problems. 2 nd ed. Toronto: Cv Mosby Company, St. Louis Baltimore; 1989. p. 261-3. |
|2.||Turner KA, Missirlian DM. The P.M. philosophy of occlusal rehabilitation. Dent Clin North Am 1963;7:621-38. |
|3.||Mann A, Pankey L. Part I: Use of the P-M instrument in treatment planning and in restoring the lower posterior teeth. J Prosthet Dent 1960;10:135-50. |
|4.||Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74. |
|5.||Kirveskari P, Alanen P, Jämsä T. Association between craniomandibular disorders and occlusal interferences. J Prosthet Dent 1989;62:66-9. |
|6.||Huynh NT, Rompré PH, Montplaisir JY, Manzini C, Okura K, Lavigne GJ. Comparison of various treatments for sleep bruxism using determinants of number needed to treat and effect size. Int J Prosthodont 2006;19:435-41. |
|7.||Wassell RW, Adams N, Kelly PJ. The treatment of temporomandibular disorders with stabilizing splints in general dental practice: One-year follow-up. J Am Dent Assoc 2006;137:1089-98. |
|8.||Dawson PE, editor. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: CV Mosby; 2007. p. 114-29. |
|9.||Dawson PE, editor. Functional Occlusion: From TMJ to Smile Design. St. Louis: Mosby Elsevier; 2007. p. 429-52. |
|10.||Laskin DM, Greene CS, Hylander WL, editors. Temporomandibular Disorders an Evidence-Based Approach to Diagnosis and Treatment. 1 st ed. Chicago: Quintessence Publishing Co Inc.; 2006. p. 377-90. |
|11.||Christensen GJ. Abnormal occlusal conditions: A forgotten part of dentistry. J Am Dent Assoc 1995;126:1667-8. |
|12.||Gray HS. Occlusal adjustment: Principles and practice. N Z Dent J 1994;90:13-9. |
|13.||McIntyre F. Restoring esthetics and anterior guidance in worn anterior teeth. A conservative multidisciplinary approach. J Am Dent Assoc 2000;131:1279-83. |
|14.||Smales RJ, Berekally TL. Long-term survival of direct and indirect restorations placed for the treatment of advanced tooth wear. Eur J Prosthodont Restor Dent 2007;15:2-6. |
|15.||Parker MW. The significance of occlusion in restorative dentistry. Dent Clin North Am 1993;37:341-51. |
|16.||van 't Spijker A, Kreulen CM, Creugers NH. Attrition, occlusion, (dys) function, and intervention: A systematic review. Clin Oral Implants Res 2007;18:117-26. |
|17.||Pankey LD, Mann AW. Oral rehabilitation Part II. Reconstruction of the upper teeth using a functionally generated path technique. J Prosthet Dent 1960;10:151-62. |
|18.||Dawson PE. Anterior guidance. In: Dawson PE, editor. Evaluation Diagnosis and Treatment of Occlusal Problems. 2 nd ed. Toronto: Cv Mosby Company, St. Louis Baltimore; 1989. p. 274-97. |
|19.||Shulman J. Teaching patients how to stop bruxing habits. J Am Dent Assoc 2001;132:1275-7. |
|20.||Christensen GJ. Abnormal occlusal conditions: A forgotten part of dentistry. J Am Dent Assoc 1995;126:1667-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]