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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 73-77

Full-mouth rehabilitation of severely mutilated dentition with loss of vertical dimension using an interdisciplinary approach


1 Department of Conservative Dentistry and Endodontics, C. K. S. Teja Institute of Dental Sciences and Research, Tirupati, Andhra Pradesh, India
2 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India
3 Department of Prosthodontics, Manipal College of Dental Sciences, Manipal University, Manipal, Karnataka, India

Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. Sree Theja Upadhyay
Department of Conservative Dentistry and Endodontics, C. K. S. Teja Institute of Dental Sciences and Research, Tirupati, Chittoor - 517 501, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_5_18

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   Abstract 


Comprehensive treatment planning of multiple teeth involvement is challenging, especially in cases of decreased vertical dimension (VD) of occlusion. This case report describes the sequential methodical interdisciplinary approach employed to treat severely mutilated dentition with a loss of VD. After performing endodontic treatment for required teeth, a bite raising transitional prosthesis was given for increasing the VD to acquire essential interocclusal space for post and core buildups and full coverage restorations. After the validation of new VD, reconstruction was performed with the permanent prosthesis. Thus, a satisfactory clinical result was achieved by restoring the VD with the reestablishment of function and esthetics.

Keywords: Bite raising, full-mouth rehabilitation, transitional prosthesis, vertical dimension of occlusion


How to cite this article:
Upadhyay ST, Acharya SR, Kumar A. Full-mouth rehabilitation of severely mutilated dentition with loss of vertical dimension using an interdisciplinary approach. J Interdiscip Dentistry 2019;9:73-7

How to cite this URL:
Upadhyay ST, Acharya SR, Kumar A. Full-mouth rehabilitation of severely mutilated dentition with loss of vertical dimension using an interdisciplinary approach. J Interdiscip Dentistry [serial online] 2019 [cited 2019 Nov 22];9:73-7. Available from: http://www.jidonline.com/text.asp?2019/9/2/73/268372




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Treatment planning becomes challenging when full-mouth rehabilitation is necessary in a dentition with minimal amount of tooth structure along with loss of vertical dimension (VD)
  • A meticulous interdisciplinary approach is warranted to achieve a clinical success in cases of full-mouth rehabilitation
  • This case required a multidisciplinary approach in which an endodontist, a prosthodontist, a periodontist, and an orthodontist worked as a team for occlusal rehabilitation of mutilated dentition by replacement of missing tooth structure and by restoration of the lost VD.



   Introduction Top


Severe caries and attrition of the anterior teeth often lead to loss of anterior guidance, which might be challenging to achieve space for esthetic rehabilitation. The prosthetic rehabilitation of a patient with a functionally compromised dentition frequently involves a multidisciplinary approach that requires critical treatment planning for determining occlusal vertical dimension (VD) and interocclusal rest space.[1]

This case report describes a detailed multidisciplinary approach in which an endodontist, a prosthodontist, a periodontist, and an orthodontist worked as a team for occlusal rehabilitation of mutilated dentition by replacement of missing tooth structure and restoration of the lost VD.


   Case Report Top


A 42-year-old female patient reported to the department with a chief complaint of slight discomfort in the upper front teeth region. The medical and dental history were noncontributory. On intraoral examination, the maxillary arch showed a fixed partial denture (FPD) extending from 15 to 24 with retroclined incisors and edge-to-edge bite [Figure 1]a, [Figure 1]b, [Figure 1]c. The defective amalgam restorations with secondary caries were seen in relation to 16, 17, 25, and 26 [Figure 1]d. The mandibular arch showed a grossly decayed 33, metal ceramic crown in relation to 35, and missing 36, 37, 45, 46, and 47 which were extracted 5 years back due to caries [Figure 1]e. For these missing mandibular posterior teeth, the patient received an ill-fitting removable partial denture (RPD) 6 months back which was causing abnormal function and improper mastication.
Figure 1: (a) Preoperative frontal view, (b) preoperative right lateral view, (c) preoperative left lateral view, (d) preoperative maxillary occlusal view, (e) preoperative mandibular occlusal view, (f) preoperative orthopantomogram, (g) preoperative bite view, (h) excessively prepared teeth after removal of fixed partial denture extending from 15 to 24, (i) sufficient bite clearance after fabrication of transitional removable partial denture, (j) transitional bite raising removable partial denture for missing 34, 36, 37, 45, 46, 47

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The patient was advised orthopantomogram (OPG), and to the surprise, it was observed that the long span FPD was given just for the replacement of one missing canine, i.e., 13. OPG also revealed that all the crowned teeth 11, 12, 14, 15, 21, 22, 23, and 24 along with 16 and 34 showed periapical lesions. 35 showed improper root canal treatment (RCT) with huge periapical radiolucency, and radiolucencies below the restorations were observed in 16, 17, 25 and 26, which was suggestive of secondary caries [Figure 1]f and [Figure 1]g.

After removal of FPD, excessively prepared teeth with minimal tooth structures were observed from 15 to 24 which were access opened, left with a cotton pellet and temporary restoration [Figure 1]h. All these crown prepared teeth exhibited absolutely no clearance with opposing dentition due to decrease in the VD of occlusion (VDO), thus creating a “restorative challenge”

A treatment plan of full-mouth rehabilitation with raise in occlusal VD was devised. A multiphase treatment protocol includes:

  • Initial education and motivation of the patient
  • Extraction of hopeless teeth
  • Oral prophylaxis and oral hygiene instructions
  • RCT
  • Bite raising with transitional RPD
  • Post and core buildups
  • Definitive restorations
  • Tooth preparations and provisionalization
  • Full coverage restorations
  • Cast partial denture (CPD) at increased VD
  • Maintenance and postoperative follow-up.


The patient was explained about the entire treatment procedure, for which she readily agreed. The photographs and diagnostic casts were prepared for pretreatment records. The grossly decayed 33 was extracted, and supragingival scaling along with oral hygiene instructions was given.

A multi-visit RCT was initiated for maxillary teeth 11, 12, 14, 15, 16, 17, 21, 22, 23, 24, 26 and for the tooth 35, the old gutta-percha (GP) was removed using combination of xylene (Sigma-Aldrich, Germany) and ProTaper retreatment files (Dentsply IH, surrey, UK) for performing the re-RCT. Triple antibiotic paste (TAP) (Woodland Hills Pharmacy CA), which is a combination of metronidazole, ciprofloxacin, and minocycline mixed with propylene glycol as vehicle, was used as inter-appointment intracanal medicament (ICM). The biggest challenge in this case was to temporize all the crown prepared teeth in between the appointments. Hence, the old FPD luted with temporary cement (Provicol, VOCO GmbH, Germany) was used to temporize the teeth until the completion of post and core buildup.

Utilizing the prosthodontic approach, a transitional/provisional RPD was given at an increased VD for the missing 36, 37, 45, 46, and 47 to allow space for post core buildup and crowns [Figure 1]i and [Figure 1]j. For fabricating the RPD, the diagnostic casts were mounted on a semi-adjustable articulator (Hanau Wide-Vue Arcon Articulator, Water Pik, USA) with facebow and centric relation (CR) record. Based on VD of rest, interocclusal distance and sibilant sounds, it was determined that the VDO can be increased by 3 mm at CR position. Heat cure acrylic RPD was fabricated at this increased VDO and delivered to the patient. Patient did not report any muscle or temporomandibular joint tenderness when it was vertically loaded. This bite raising achieved sufficient clearance for post and core buildups and full coverage restorations.

After two rounds of ICM change, the obturation was completed for 11, 12, 21, 22, 23, 24, 26, 14, 15, 16, 17, and 35 using single cone technique with AH Plus (Dentsply DeTrey, Konstanz, Germany) as a sealer. Then, post space preparation was done using Peeso reamers (Mani, Tochigi, Japan) for 11, 12, 21, 22, and 23 by leaving 5 mm of apical GP. After lubricating the post space, a direct pattern was made for custom cast post and core with a plastic carrier and self-cure resin (GC Pattern Resin LS, Newport Pagnell, UK) using bead-brush technique. Custom cast post and core were casted using Ni-Cr alloy and cemented using glass ionomer cement (GIC) (GC Fuji I, Tokyo, Japan) for 11, 12, 21, 22, and 23 [Figure 2]a. After cementation, putty index (Aquasil Soft Putty, Dentsply IH Ltd, UK) was made on the cast with wax mockup and the temporary crowns were fabricated intraorally using self-cure bisacryl resin (Luxatemp, DMG, New Jersey). These crowns were then trimmed, polished, and luted with temporary luting cement (Provicol, VOCO GmbH, Germany).
Figure 2: (a) Custom cast post and core fabrication for 11, 12, 21, 22, 23, (b) orthodontic band placement on 15, (c) postoperative bite view, (d) postoperative frontal view, (e) postoperative right lateral view, (f) postoperative left lateral view, (g) postoperative maxillary occlusal view, (h) postoperative mandibular occlusal view, (i) postoperative orthopantomogram

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For teeth 14, 15, 16 and 26, a short, thin, parallel-sided, threaded prefabricated metal post (H Nordin SA, Chailly, Switzerland) was cemented, and core buildup was done using silver amalgam (DPI Fine Grain Alloy, Mumbai, India). As the tooth 15 has minimal coronal tooth structure with the palatal wall deep under the gingival level, the placement of matrix band has become difficult. With the periodontal intervention, the crown lengthening was performed using electrocautery to expose the tooth margin palatally. Then, with the use of orthodontic intervention, a band was pinched around the tooth 15 using pinching pliers, spot welded, and cemented in place using GIC (GC Fuji I, Tokyo, Japan). This band was later cut off after completion of post and core [Figure 2]b.

After the removal of old restoration on 25, mesio-occluso-distal cavity preparation followed by silver amalgam (DPI Fine Grain Alloy, Mumbai, India) restoration was done, whereas for 27, a Class II (slot preparation) was made for mild caries on mesial side and restored with GIC (GC Fuji IX, Tokyo, Japan). The crown preparations were then performed for all maxillary teeth except 25 and 27 and impression was made using polyvinyl siloxane impression material (Aquasil LV, Dentsply caulk, USA). With the casts mounted on Hanau's articulator, metal-ceramic crowns for 11, 15, 16, 17, 21, 22, 23, 24, and 26 and metal-ceramic FPD from 12 to 14 were fabricated using the occlusion of transitional RPD [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f.

After completion of rehabilitation of maxillary arch [Figure 2]g, metal-ceramic FPD was given from 33 to 35 for the missing 34. Subsequent to the cementation of FPD, the mandibular arch had converted to Kennedy's Class I edentulism. Using the prosthodontic intervention, VDO was again determined and mandibular CPD was fabricated for 36, 37, 45, 46, and 47 [Figure 2]h. This CPD was made using I bar clasp design with the occlusal rest on premolar and cingulam rest on canine. The patient was comfortable with the prostheses and functioned well with it. One-year follow-up OPG revealed complete healing with resolution of all periapical radiolecencies of the teeth [Figure 2]i.


   Discussion Top


Successful occlusal rehabilitation of a functionally compromised dentition requires an interdisciplinary treatment approach that requires a correlation of biological factors and mechanical principles. Apart from esthetics and functional aspect of the dentition, the ultimate aim of full-mouth rehabilitation is to restore the normal healthy function of the masticating apparatus.[2]

The single visit RCT was not advised in the present case because the teeth were non-vital with periapical pathology.[3] Hence, multi-visit endodontics was performed with TAP as an ICM as it has been proved to be successful in promoting the healing and repair of the periapical tissue by controlling the root canal pathogens.[4]

The decrease of VDO in the present case might be because of the long neglect of the edentulous lower bilateral molars and ill-fitting RPD without proper occlusal stabilization. As this case presented with a huge challenge of a lack of restorative space, the VDO was increased for the best functional and esthetic anterior contact in CR.[5] The transitional prosthesis allows validation of VDO and functional occlusion prior to initiation of definitive CPD.[1] This trial phase of wearing transitional RPD allows neuromuscular adjustment to a change in VDO and helps to determine patient's comfortability with the increased VDO.[6] The minimum recommended period for adaptation to this increased VDO has been determined to be 6–8 weeks.[7]

Custom cast post and core was selected for maxillary anteriors in this case as they require change in the angulation of core to achieve a proper over jet. As there was extensive loss of tooth structure, a custom cast post preserved maximum tooth structure as it was fabricated to fit the radicular space for achieving higher strength and greater fracture resistance.[8] The advantages of use of resin over wax for post and core pattern are its low polymerization shrinkage (0.37%), greater dimension accuracy with precise margins, and its higher stability in thin layers.

Prefabricated posts were given to posterior teeth as these are simple to use that require less chair side time. Since forces get concentrated at the crest of bone during function, the post was placed to extend at least 4 mm apical to the crest of the bone for minimizing stress in the dentin and post.[8] A short, thin, parallel-sided threaded post was selected in the present case because the short post prevents lateral strip perforation in mid-root portion from excessive dentin removal, thin post minimizes canal preparation by maintaining as much residual dentin as possible according to “conservationist approach,” threaded post provides highest resistance to rotational forces and parallel-sided post increases retention and produce uniform stress distribution along the post length.[9]

Crown lengthening along with orthodontic intervention by band pinching for the tooth 15 facilitated extension of band margin subgingivally onto the natural tooth structure for a proper core buildup.[10] Therefore, the interdisciplinary management of this case resulted in enhanced esthetics, improved function, and increased comfort by reestablishment of lost VD along with protection of the remaining tooth structure by restoring with individual full coverage restorations.


   Conclusion Top


Full-mouth rehabilitation requires the proper implication of interdisciplinary concepts to achieve functional and esthetic success. Treatment plan should target at deciding the need of altering the VD for meeting the biologic, restorative, and esthetic requirements.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Jaikumar RA, Madhulika N, Kumar RP, Vijayalakshmi K. Prosthetic rehabilitation in a partially edentulous patient with lost vertical dimension: A case report. J Indian Acad Dent Spec Res 2014;1:70-3.  Back to cited text no. 1
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2.
Slavicek G, Makarevich A, Makarevich I, Bulatova K. Concepts, aims, and drawbacks in interdisciplinary dentistry: Results of an international questionnaire. J Interdiscip Dent 2013;3:91-102.  Back to cited text no. 2
    
3.
Schwendicke F, Göstemeyer G. Single-visit or multiple-visit root canal treatment: Systematic review, meta-analysis and trial sequential analysis. BMJ Open 2017;7:e013115.  Back to cited text no. 3
    
4.
Vijayaraghavan R, Mathian VM, Sundaram AM, Karunakaran R, Vinodh S. Triple antibiotic paste in root canal therapy. J Pharm Bioallied Sci 2012;4:S230-3.  Back to cited text no. 4
    
5.
Gopi Chander N, Venkat R. An appraisal on increasing the occlusal vertical dimension in full occlusal rehabilitation and its outcome. J Indian Prosthodont Soc 2011;11:77-81.  Back to cited text no. 5
    
6.
Jahangiri L, Jang S. Onlay partial denture technique for assessment of adequate occlusal vertical dimension: A clinical report. J Prosthet Dent 2002;87:1-4.  Back to cited text no. 6
    
7.
Patel MB, Bencharit S. A treatment protocol for restoring occlusal vertical dimension using an overlay removable partial denture as an alternative to extensive fixed restorations: A clinical report. Open Dent J 2009;3:213-8.  Back to cited text no. 7
    
8.
Terry DA, Swift EJ. Post and cores: Past to present. Int Dent SA 2010;12:20-8.  Back to cited text no. 8
    
9.
Standlee JP, Caputo AA, Collard EW, Pollack MH. Analysis of stress distribution by endodontic posts. Oral Surg Oral Med Oral Pathol 1972;33:952-60.  Back to cited text no. 9
    
10.
Lai YY, Yu DC, Chen CP. Application of a copper band in complex endodontic access preparations. J Dent Sci 2006;1:44-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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