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Authors: Dr. Abdul Bari, Dr. Sameer Ahmed

Abstract

Dentistry seeks to increase the lifespan of the functioning dentition, as medicine increases the lifespan of the functioning individual so the responsibility of dentistry increases proportionately. Full mouth rehabilitation always claims careful attention and meticulous treatment planning as it continues to be the biggest challenge to any clinician in restorative dentistry. This case report is of a full mouth rehabilitation of a 31 years old male patient with grossly decayed posterior teeth which resulted in loss of Vertical Dimension of Occlusion (VDO) who had been rehabilitated with fixed partial denture after root canal therapy and post and core.

Key Words

Vertical Dimension of Occlusion (VDO), Fixed Partial Denture, Grossly decayed tooth, Root canal Treatment, Post and Core.

Introduction

“Every tooth in a human head is more valuable than a diamond.” Importance of awareness among patients for full mouth rehabilitation is increasing these days and it requires efficient diagnosis with elaborate treatment planning to develop ordered occlusal contacts and harmonious articulation in order to optimize stomathognathic function, health and aesthetics which then translates to patient’s comfort and satisfaction. On examination of this case intraorally, patient presented with grossly decayed posterior teeth, missing tooth and few teeth migrated which resulted in reduced VDO. So the restoration was fabricated with increased VDO to optimize occlusion. Anatomic landmarks, facial measurements, and the resting position of mandibular jaw were used to determine appropriate vertical dimension for the patient. It was found that there was decreased VDO as the bite had collapsed due to posterior tooth gross decay which resulted in unsatisfactory occlusion. The freeway space was found to be increased to about 6-7 mm which was more than the physiologic space of 2-3 mm1.

Case Presentation

A moderately built 31 years old male patient reported to California Dental Centre, Bangalore complaining of his inability to chew food and displeasing facial appearance. A detailed case history was recorded and was found that patient does not have any Medical history and Oral hygiene status was poor. Patient gave a history of smoking 6- 10 cigarettes per day for the last 3 years and he was later counselled to quit smoking and improve oral hygiene.

Extra-oral and Intraoral examination was done and the summarised findings are as follows;

Soft Tissues:

Gingiva - Red, inflamed- Chronic generalized gingivitis.

Tongue - Normal in shape, form and Function.

Mucosa - Normal in colour, form and function.

Hard tissue examination was done along with radiographic interpretations which are as follows:

  • Clinically missing tooth with respect to 46.
  • Root stumps with respect to 16, 14, 24, 25, 37, 36, 34.
  • Grossly decayed tooth with respect to 17, 12, 23, 26, 27, 44, 45, 47, 48.
  • Deep Dental Caries with respect to 15, 35, 33.
  • Composite Restoration with respect to 11, 21, 43.
  • Root canal treated tooth with respect to 22.
  • Metal Ceramic Crown with respect to 13, 22.
  • Impacted tooth with respect to 48.
  • Clinically and healthy tooth with respect to 18, 28, 32, 31, 41, 42.
Treatment Plan

Patient was given multiple treatment options including implants on edentulous area and crowns to decayed tooth but the patient opted for metal ceramic crowns and bridges.

The final treatment plan was as follows;

  • Oral Prophylaxis
  • Extraction of 16, 24, 25, 37, 36, 34.
  • Root canal treatment to 17, 15, 14, 13, 12, 11, 21, 22, 23, 26, 27, 35, 33, 32, 31, 41, 42, 43, 44, 45, 46, 47.
  • Crown lengthening of 14, 24, 46.
  • Post and core to 17, 14, 12, 11, 21, 22, 23, 26, 27, 35, 44, 45, 46, 47.
  • Metal Ceramic Crowns and Bridges to ( 17,16,15,14,13 ) + ( 12, 11, 21, 22 ) + ( 23, 24, 25, 26, 27 ) + ( 37, 36, 35, 34, 33 ) + ( 32, 31, 41, 42 ) + ( 43, 44, 45 ) + ( 46, 47 ) .
Discussion

Full mouth rehabilitation requires meticulous treatment planning with expert opinion from many branches of dentistry. In this case care was taken to do the best possible within about 60 days as the patient was flying abroad after that. In the first visit, pre- operative photos and impressions were made followed by Oral Prophylaxis and counselling to quit smoking and improve oral hygiene measures. In the second visit, all the extractions needed were performed under Local Anaesthesia and the patient was recalled after few days for Root Canal Treatment. The third visit was planned for Root Canal Treatment and then it was found that after treatment few teeth were not having enough coronal tooth structure, due to which it might not have Ferrule Effect2, so crown lengthening was performed to 14, 23, 46. After the crown lengthening procedure, metal post and core was given to 17, 12, 11, 21, 22, 23, 35, 44, 45, 46, 47 as Mentick et al reported 82% success with metal posts for more than 10 years and many other literature supports Post and Core treatment 3,4,5,6. All these teeth which are endodontically treated are ready to take up prosthesis as the study of a 25 year follow up says the longevity of teeth after endodontic treatment with a post and core were the same as teeth with vital pulp and crown7. As the posterior teeth were grossly decayed, the vertical dimension of occlusion had collapsed and it has to be raised in order to give an effective occlusion. This raise in vertical dimension of occlusion is done using a diagnostic/ occlusal splint and then by provisional prosthesis8. Crown preparation was done to all the teeth and an occlusal splint was fabricated. The patient was monitored to evaluate the adaptation to this removable occlusal overlay splint during a 2 week trial period and then provisional prosthesis was made and evaluated for one month9, 10. The adaptation of patient to the increased VDO was carefully evaluated during this one month trial period for any muscle tenderness, tempero-mandibular joint discomfort and any other disturbances. Following the evaluation period, definitive restoration of metal ceramic was fabricated and for teeth which were not symmetrical in size, gingival shade ceramic was added. After having checked a bisque trial as well, the prosthesis was cemented. Routine clinical assessment was done after one week, one month and six months. Then after one year and then two years with visual and radiographic examination11.

Conclusion

A thorough knowledge about the hard and soft tissues of the oral cavity, tempero-mandibular joint, muscles of mastication apart from patient’s health and economic status is very important in treating patients of full mouth rehabilitation and also efficient lab technicians and good communication with them cannot be over ruled.

References
  1. “The free-way space and its significance in the rehabilitation of the masticatory apparatus”- Joseph S. Linda- J Prosthet Dent- Vol.2, issue 6, Nov 1952, 756-779.
  2. “Comtemporary crown-lengthening theraphy ” ; a review – Hempton T J, Dominici JT- J AM Dent Assoc. 2010; 141:647-655 (PubMed).
  3. “Survival rate and Failure characteristics of the all metal post and core restoration”- Mentick AGB, Meeuwiseen R, Kayser AF, Mulder J- J. Oral Rehabil 1993;20:455-61.
  4. “ Survival rate and failure characteristics for two posts designs ”- Torbjorner. A, Karlsson S, Odman PA- J. Prosthet Dent 1995;73:439-44.
  5. “Retrospective analysis of factors affecting the longevity of post crowns” – Nanayakkara L, McDonald A, Set chell DJ.- ( Abstract 932) J Dent Res 1999;78:222.
  6. “Retrospective study of tapered smooth post system in place for 10 years or more”- Weine FS,Wax AH, Wenckus CS. – J endodon 1991;17:293-7.
  7. “ Assessment of the periapical and clinical status of crowned teeth over 25 years” – valderhaug J, Jokstad A, Ambjornsen E, Northeim PW – J Dent 1997;25:97-105.
  8. “ Partial dentures for patients with advanced tooth wear” – Hemming KW, Howlett JA, Woodley NJ, Griffiths – Dent Update 1995;22:52-59 (PubMed).
  9. “ The use of implants in the occlusal rehabilitation of a partially edentulous patient” – a clinical report – Yunus N, Abdullah H, Hanapiah F – J Prosthet Dent 2001;85:540-543 (PubMed).
  10. “ Maxillary and mandibular overlay removable partial dentures for the restoration of worn teeth”- Ganddini MR, Al- Mardini M, Graser GN, Almog D – J Prosthet Dent. 2004; 91: 210-214 (PubMed).

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