|Year : 2016 | Volume
| Issue : 1 | Page : 39-43
Occlusal rehabilitation of a geriatric patient with multiple failed fixed prostheses: A clinical report
Ravindra S Pawar, Rahul Shyamrao Kulkarni
Department of Prosthodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India
|Date of Web Publication||10-Aug-2016|
Ravindra S Pawar
Department of Prosthodontics, Nair Hospital Dental College, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Commonly observed complications or clinical failures related to fixed dental prostheses (FDPs) include inferior esthetics, loss of retention, loss of tooth vitality due to secondary caries, periodontal disease, tooth fracture, and prosthesis fracture. While treatment of such complications is usually more demanding for the operator, psychological reassurance to the patient is an integral and often the foremost part of the retreatment procedure. This clinical report describes occlusal rehabilitation of a geriatric patient presented with multiple failed FDPs. Endodontic retreatment of abutments and meticulously designed ceramometal FDPs resulted in alleviation of dental pain, improvement in esthetics, gingival health, and enhanced masticatory efficiency while no complaints were reported during 1-year follow-up period.
Clinical Relevance to Interdisciplinary Dentistry
Complete mouth rehabilitation of a patient with previously failed prostheses often requires an interdisciplinary approach. In this patient, functional, esthetic, biological and restorative goals were defined before starting the treatment. Careful intraoral examination and radiographic analysis, occlusal analysis by mounting diagnostic casts on semi adjustable articulator, patient counselling to understand their expectations from treatment, and diagnostic wax up procedures, to determine approximate protocol of the treatment were performed. Satisfactory gingival health, esthetics, and function were reported at end of treatment and subsequent recall visits.
Keywords: Fixed dental prosthesis, geriatric, occlusal rehabilitation, prosthodontics
|How to cite this article:|
Pawar RS, Kulkarni RS. Occlusal rehabilitation of a geriatric patient with multiple failed fixed prostheses: A clinical report. J Interdiscip Dentistry 2016;6:39-43
|How to cite this URL:|
Pawar RS, Kulkarni RS. Occlusal rehabilitation of a geriatric patient with multiple failed fixed prostheses: A clinical report. J Interdiscip Dentistry [serial online] 2016 [cited 2020 Jan 18];6:39-43. Available from: http://www.jidonline.com/text.asp?2016/6/1/39/188170
| Introduction|| |
It is not uncommon in clinical practice to encounter patients with "complications" or "clinical failures" related to fixed dental prostheses (FDPs), arising from inadequately performed or even appropriately delivered treatment procedures.  Commonly observed failures in fixed prosthodontics include inferior esthetics, loss of retention, secondary caries and need for endodontic treatment, periodontal disease, tooth fracture, and prosthesis fracture. Different fixed prostheses, for instance, all metal crowns, ceramometal FDPs, resin-bonded prostheses, all ceramic prostheses, post and cores have different indications, and also differ in their modes of failure. In a review of literature pertaining to fixed prosthodontic failures, Goodacre et al. found that most commonly reported complications with FDPs were caries of abutments, need for endodontic treatment, and loss of retention; while debonding, tooth discoloration and secondary caries were more common with resin-bonded prostheses.  Clinically, patients with failed FDPs may present with variable signs and symptoms depending on nature of failure, such as dissatisfaction with esthetics, pain and sensitivity, dislodged prostheses, fractured prostheses, gingival bleeding, or combinations thereof. Whereas treatment of such complications is usually more demanding for the operator, psychological reassurance to the patient is an integral and often the foremost part of the retreatment procedure. This clinical report describes prosthodontic retreatment procedure of a geriatric patient presented with multiple failed FDPs.
| Case report|| |
A 65-year-old female patient presented for treatment with a chief complaint of dislodged FDPs, dental pain, and bleeding gums [Figure 1]. The patient had difficulty during incising and mastication when the prostheses were in place, had inferior esthetics, and reported frequent dislodgement of the prostheses. Patient's dental history revealed that she had received crown and bridge prostheses in entire maxillary arch excluding right second molar and mandibular posterior region 2 years ago [Figure 2]. Patient's intraoral examination during the first visit revealed tooth preparation of remaining maxillary teeth, and mandibular premolars and third molars on both sides, while she carried dislodged prostheses with her. Mandibular first and second molars of both sides, both maxillary lateral incisors, and right maxillary canine had been extracted previously. Mandibular anterior teeth were intact, without any evidence of tooth structure loss due to attrition or caries, and had healthy periodontium without loss of attachment or gingival recession. The patient did not have a defined occlusal scheme at presentation, since tooth preparation was done on maxillary teeth and mandibular posterior teeth. Gingival margins of maxillary central incisors were at different levels. The patient had received endodontic treatment for both maxillary central incisors, right maxillary canine and premolars, both mandibular second premolars, and mandibular left third molar. Radiographs revealed inadequate root canal treatment with maxillary right first premolar, and mandibular left second premolar and third molar [Figure 2]. Periodontal examination revealed sufficient width of keratinized attached gingiva, normal pocket depth, and adequate alveolar bone support (radiographically) to all the teeth including potential abutments. Patient's medical history was noncontributory while dietary history revealed that she had a vegetarian diet. An important aspect of clinical examination was evaluation of the existing vertical dimension of occlusion (VDO) and assessment of need to increase the VDO in final restorations.  This was carried out by evaluating the anterior speaking space , patient's previous photographs, and facial soft-tissue contours. The patient was given the following treatment options: Endodontic retreatment and post and core of teeth with inadequate treatment followed by their crowns, and replacement of missing teeth with dental implants or conventional FDPs. The patient declined the option of implants citing financial reasons and opted for porcelain fused to metal (PFM) crowns and FDPs. The treatment plan was explained to the patient, and her informed consent was obtained.
|Figure 1: Frontal view of patient's maxillomandibular dentition when patient presented for treatment|
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|Figure 2: Orthopantomogram made after previous treatment. Note inadequate endodontic treatment, uneven occlusal plane, and secondary caries of abutments|
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Diagnostic impressions were made using alginate (Neocolloid, Zhermack, Badia Polesine, Italy) and poured in Type III dental stone (Denstone, Kalabhai Karson, Mumbai, India). The casts were mounted on a semi-adjustable articulator (Hanau Wide-Vue, Whip Mix Corporation, Fort Collins, CO, USA) using a face-bow record and an interocclusal record that was made with the aid of a Lucia Jig and polyvinylsiloxane occlusal registration material (Exabite II; GC Corp., Tokyo, Japan). The protrusive record was obtained to set horizontal condylar inclination and Bennett angle.  Diagnostic wax-up was developed on mounted diagnostic casts.  The posterior occlusal plane was determined with the help of Broderick occlusal plane analyzer [Figure 3] and [Figure 4]. Midpoint on distoincisal edge of mandibular canine was taken as anterior survey point to draw an arc of 4-inch radius on flag with a compass. Posterior survey point was located on the distobuccal cusp of the second molar, and an arc was drawn to intersect the previously drawn arc on flag. The point of compass was placed at the intersection of arcs, and the occlusal plane was derived [Figure 3]. The anterior guidance and posterior disclusion on excursive movement were established in the diagnostic wax-up, following the Pankey-Mann-Schuyler philosophy.  Wax patterns were acrylized using heat polymerized poly(methyl methacrylate) resin (Acrylin, DPI, Mumbai, India) following standard laboratory procedure, to form provisional restorations. Maxillary and mandibular teeth were modified for metal-ceramic restorations following biological, mechanical, and esthetic principles of tooth preparation.  Temporary restorations formed previously were lined with methyl methacrylate acrylic resin (Alike Temporary C & B Resin; GC America) and cemented with temporary luting cement (Freegenol, GC Corp., Tokyo, Japan) [Figure 5]. Centric occlusion, even protrusive contacts, canine guidance, and disclusion of posterior teeth during eccentric movements of the mandible were verified in the provisionals before discharging patient. The patient wore the provisional restorations for 4 months without complications. During the evaluation period, the patient's anterior speaking space, esthetics, and function were assessed. The muscles of mastication and the temporomandibular joint were evaluated for clinical signs of discomfort, and it was observed that the patient was asymptomatic and comfortable during this period.  Endodontic retreatment and post and core using esthetic fiber posts (RelyX, 3M ESPE, Seefeld, Germany) were carried out for teeth with previous inadequate treatment. To record and preserve the anterior guidance of the provisional restorations, irreversible hydrocolloid impressions were obtained and poured in dental stone. Maxillary and mandibular casts were mounted to the semi-adjustable articulator using face-bow transfer and centric record, and custom anterior guide table was fabricated from the acrylic resin (Pattern Resin LS; GC America). 
|Figure 3: Broderick occlusal plane analyzer was used to determine occlusal plane during wax-up procedure|
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|Figure 4: Diagnostic wax-up. Disclusion of posterior teeth by anterior during protrusion can be seen|
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|Figure 5: Provisional restorations in place. Crown lengthening procedure was advised to improve soft-tissue profile of maxillary right central incisor; however, the patient declined this treatment option due to apprehension|
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A staged approach was followed during fabrication of definitive PFM restorations, in which maxillary crowns and FDPs were fabricated and cemented initially, followed by fabrication of the mandibular prostheses [Figure 6]. Definitive impression of the maxillary arch was recorded using polyvinyl siloxane impression material (Affinis; Coltène/Whaledent Inc., Cuyahoga Falls, Ohio) after carrying out a gingival retraction, and the master cast was obtained using die stone. The cast was mounted using face-bow transfer and articulated to the mandibular cast using centric record made with Lucia Jig at the predetermined vertical dimension. PFM (SuperCast, Talladium Inc., Valencia, USA; IPS Classic, Ivoclar Vivadent AG, Schaan, Liechtenstein) restorations were made using customized anterior guide table fabricated previously. Individual crowns were made for maxillary right first molar and left second premolar whereas FDPs were made to replace the missing maxillary teeth. The trial of metal copings, bisque trial, glazing, and cementation with phosphate cement (SuperCement, Shofu, Kyoto, Japan) were carried out in that order in the maxillary arch, followed by fabrication and cementation of mandibular FDPs in similar manner [Figure 6] and [Figure 7]. During bisque trial, centric occlusion, anterior guidance, and posterior disclusion were verified in the definitive restorations. Long centric occlusion was developed in the maxillary anterior restoration to allow for freedom in anterior-posterior movement. The prostheses were designed using mutually protected occlusion in which the anterior teeth protected the posterior teeth from excursive force and wear, and posterior teeth supported the bite force [Figure 8] and [Figure 9]. The interocclusal space was ultimately evenly divided between the maxillary and mandibular arches at the time of definitive restorations. Oral hygiene instructions were given, and brushing technique was demonstrated. Recall evaluations were carried out at 3-month intervals for 1 year. The patient's esthetic and functional expectations were satisfied, and she did not have pain or sensitivity after the treatment.
|Figure 6: Full-arch maxillary ceramometal crowns and fixed dental prostheses. Cementation of these prostheses was followed by fabrication of mandibular fixed dental prostheses|
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|Figure 7: Mandibular fixed dental prostheses during laboratory fabrication|
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|Figure 8: Maxillary and mandibular final restorations in centric occlusion|
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| Discussion and conclusion|| |
The patient described here presented with chief complaint of inferior esthetics, difficulty during mastication and recurrent dislodgement of FDPs. Patient's detailed dental, medical, and social history was obtained, and meticulous diagnosis and stepwise treatment planning were carried out. During initial appointments, a detailed treatment plan was explained to the patient, which primarily comprised of endodontic retreatment and post and core restorations with some of the abutments, and fabrication of new ceramometal FDPs. Gingival margins of maxillary incisors were at the asymmetric position. To correct the unequal position of gingiva in maxillary incisors, crown lengthening procedure was advised with maxillary right central incisor so as to increase its clinical crown height and make it esthetically symmetric [Figure 5]; however, patient declined this treatment option due to apprehension. The patient was treated with provisional restorations for 4 months to evaluate esthetics, function and provide psychological reassurance, which were replaced by definitive prostheses. Meticulously designed ceramometal FDPs resulted in alleviation of dental pain, improvement in esthetics, gingival health, and enhanced masticatory efficiency. Recall appointments were scheduled at weekly intervals during the 1 st month postoperatively, followed by one recall visit every 3 months, for 1 year. During recall visits, the importance of night brushing of teeth was emphasized, and accurate brushing technique was demonstrated. It was observed that patient's esthetic and functional requirements were fulfilled, and no complications or failures were reported during 1-year follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]