Prosthodontic Rehabilitation for a Worn Out Dentition Using Aesthetic Preevaluative Temporaries and Dental GPS Smile Designing Concepts: A Clinical Report.

An optimally created occlusion will be better able to deal with the forces generated in function and parafunction. This case report will highlight the full-mouth rehabilitation of a patient with worn out dentition in the minimally invasive way which offers the users a more systematic and a precise treatment. CLINICAL RELEVANCE: It gives us an idea of a treatment modality for full-mouth rehabilitation whereby the anterior teeth cause a uniform disocclusion of the posterior teeth during excursive movements, thereby protecting the teeth from the harmful effects of the cuspal interference.

Introduction

Haramoto et al.[1] stated that disocclusion is needed for:

Protecting the teeth from the harmful effects of cuspal interference that may occur due to the difference between the eccentric and returning condylar path

A need to protect the teeth from the harmful effects of cuspal interferences and lateral stresses as the anterior guidance varies among individuals.

Schuyler[2] stated that thorough understanding of the factors that help control the patterns or contours of occluding surfaces is of paramount importance for planning and maintenance of oral health and function. D’Amico[3] stated that it was important to correlate the mechanics of occlusion and articulators with the functional and biological factors involved in the stomatognathic system. Weinberg[4] found out that 2-mm discrepancy between centric relation and centric occlusion in individuals with temporomandibular joint disturbances leads to the association of centric occlusal disharmony and joint pathology.

Case Report

The following is a case report of a patient treated using dental GPS concept in the minimally invasive way. A 39-year-old patient came to the dental clinic with a chief complaint of poor appearance with difficulty in chewing the food particles properly from the left side with occasional pain and tenderness in the upper front teeth. She had a past dental history of undergoing tooth-colored fillings on few teeth but kept feeling it high even after repeated corrections. She also had root canal treatment done on upper front teeth and wanted crowns on them too. On further discussion, it was found that the patient has acidic regurgitation and sometimes complains of a burning fluid in the mouth, does not use a mouthwash or dental floss, and also brushes once a day. The patient is a front desk manager in a restaurant based out of Mumbai.

Extraoral examination

No pain, clicking, crepitation, or deviation of the mandible was noted [Figure 1].

Figure 1

Extra oral examination with emphasis on lower third of the face for smile analysis

Intraoral examination

On intraoral examination, generalized gingival inflammation was seen along with stains and calculus present. Soft edematous gingiva, loss of stippling, and secondary decay around the previous fillings were noted [Figure 2].

Figure 2

Intra oral view with teeth in occlusion

Periodontal assessment

BPE

The patient had a group function occlusion with premolars and 1st molar occluding in eccentric positions. There were premature contacts seen when the patient was made to close in centric relation onto maximum intercuspation position.

Special investigations

Radiograph report

Orthopantomogram (OPG) [Figure 3] shows close proximity of the radiolucent pulp chambers to the occlusal surfaces in relation to upper right four, one, and two. OPG shows overextension of the root canal filling material in the upper right one and two. OPG shows adequate bone height in relation to the missing lower right six and upper right five; however, due to mesial drifting of the adjacent teeth due to longstanding edentulous areas, there is insufficient space available for prosthetic replacement.

Figure 3

OPG

Diagnosis

Chronic generalized gingivitis with localized gingival recession in relation to the lower left one and lower right three

Edentulous areas in relation to the missing teeth seen in the lower right six and upper right five

Enamel loss of cuspal anatomy and yellowing of teeth due to acid regurgitation

Secondary decay due to previous restorative work and overextension of the obturating material beyond the apex.

Prognosis

The prognosis is favorable after scaling and root planing with restoration of optimal health.

prognosis is favorable for the optimal establishment of the occlusal scheme post-occlusal equilibration and maintenance of patient's vertical dimensions with indirect restorations.

Treatment

Options presented to patient

Orthodontic treatment for uprighting lower right seven to create optimal mesiodistal space for lower right six and upper right five followed by implant placement and restorations for the missing teeth

Full-mouth rehabilitation with maintenance of vertical dimension

Implants/fixed partial dentures for the missing teeth at the optimal vertical dimension

Scaling and root planing for oral prophylaxis

root canal treatments needed for teeth 11, 12, 15 and repeat root canal treatment needed for 21, 22 for better prognosis and longevity of the restorations.

Treatment plan

The patient refused any orthodontic intervention and refused implant treatment as it was expensive for her.

Hence, it was decided to have a complete, thorough oral prophylaxis in the form of scaling and root planing with maintenance and periodic recall.

The patient accepted and consented for full-mouth reconstruction with fixed prosthodontics (crowns for the root canal treated teeth, ceramic onlays and veneers for the other teeth to help restore vertical dimension and esthetics) which would commence after root canal treatment and repeat root canal treatment of the abovementioned teeth.

Since the patient was highly apprehensive as to how she would look, we decided to use dental GPS concept for getting the patient acceptance and commencement of the treatment [Figure 4].

Figure 4

Dental GPS simulation helping in patient acceptance for the treatment plan

Treatment sequence

Oral prophylaxis was carried out in the form of scaling and root planing. Two sets of diagnostic impressions were taken with elastomeric impressions in the combination of double mix single step technique with putty consistency (affinis, Coltene) and light body consistency materials (affinis, Coltene). Measurements were taken to obtain the vertical dimension at rest (67 mm) and vertical dimension at occlusion (63 mm) for calculating the available freeway space (04 mm). Hence, it was decided to maintain the vertical dimension of occlusion giving us an acceptable freeway space of 4 mm. Bimanual palpation (Dawson's technique) was used for recording the centric relation at the proposed vertical dimension. Bite registration material (Jet Bite, COLTENE) was used for recording this centric relation. Earpiece Facebow (Hanau Springbow) was used for recording the orientation relation and transferring the relation to the articulator (Hanau Wide-Vue Arcon Semi-adjustable articulator) [Figure 5].

Figure 5

Mechanical facebow for orientation relation

The patient was then scheduled for the root canal treatments and repeat root canal treatments of the upper teeth.

Laboratory steps

The maxillary cast was mounted using the Face-bow record, and the mandibular cast was mounted using the centric relation record. Programming of the articulator was done based on the zeroing of the articulator first followed by setting the values based on the excursive records. Simultaneously, a digital facebow concept (Methot A. Facial Proportions. CJCD 2006) was used to print the M Lines [Figure 5] followed by a guided wax up with tooth coloured wax (Dental Restoration material wax [Figure 6], ZOGEAR, CHINA).

Figure 6

Digital Facebow transfer plate for mounting the upper casts after printing the M lines

Broadrick's occlusal plane analysis was carried out to determine the desired occlusal plane, and the final occlusal morphology was outlined. Silicone index (putty consistency elastomeric impression material) was recorded of the finished wax up for the fabrication of the temporaries and for guiding in the tooth reduction.

Clinical steps

After the root canal treatment was completed on all the desired teeth, esthetic preevaluative temporaries were fabricated using Galip Gurel's concept for evaluation of function, esthetics, and phonetics [Figure 7]. On subsequent recall, as the patient tolerance was acceptable without any discomfort or complaint, the patient was scheduled for tooth preparation.

Figure 7

Aesthetic pre-evaluative temporaries for phonetic, aesthetic and functional evaluation

The tooth preparation was carried out [Figure 9] through the temporaries for minimally invasive dentistry protocols to preserve the enamel and be as conservative as possible (after placement of retraction cords) in tooth reduction. The tooth preparations carried out were for porcelain fused to metal crowns and bridges, full-ceramic crowns, ceramic veneers, and nonlays [Figure 8] (crowns were only given for root canal treated teeth – upper right 1, 2, and 5; upper left 1 and 2); 2nd set of retraction cords (Ultrapak, Ultradent) impregnated with hemostatic agent (Racestyptine solution, Septodont) were then placed into the gingival sulcus and elastomeric impressions were taken. Centric relation was recorded at the proposed vertical dimension. Facebow record was taken and transferred onto the articulator. Irreversible hydrocolloid material was used for a check cast impression, and provisionals (Cooltemp, COLTENE) were fabricated, checked for its fit, occlusal interference, esthetics, phonetics, trimmed, polished, and cemented (Temposil, COLTENE). Final impressions were taken with elastomeric impression materials (Affinis, COLTENE) [Figure 9].

Figure 9

Heavy body- light body combination impression technique

Figure 8

Guided tooth preparation

The master casts were poured with the help of Type IV dental stone (Elite Base, ZHERMACK). Pindex system was used for placement of die pins and sleeves followed by die cutting and die ditching. The upper cast was mounted with the help of facebow record, and the centric record was used for mounting the lower cast.

Wax copings were fabricated which were then invested; cast and metal copings were fabricated.

Clinical visit

Metal copings (for PFM crowns) and zirconia copings (for full-ceramic crowns) along with wax trials for ceramic veneers and onlays were tried in the patient's mouth to evaluate for the fit and marginal integrity. Shade selection was done (VITA toothguide three-dimensional [3D]-Master, VITA) and temporaries were recemented.

Laboratory step

Ceramic layering was done for the teeth with a combination of opaquer, dentin shades, enamel shades, translucent, and stains in line with the clinical pictures and laboratory notes for characterization.

Clinical visit

Bisque trial was carried out to evaluate for the occlusal interferences [Figure 10] in centric and eccentric positions which were subsequently removed using articulating paper (Bausch articulating paper) Temporaries were recemented again.

Figure 10

Bisque trial and transfer of proposed transitional line angles, lobes and incisal translucency

The interfering marks were removed, and the final glazing was carried out [Figure 11].

Figure 11

Finished restorations on the master cast

Occlusion was verified again with articulating paper. PFM crowns were cemented using glass ionomer cement (GC FUJI), full-ceramic crowns and onlays were cemented using resin cement (Calibra, Dentsply), and ceramic veneers were cemented using variolink veneer cement (Ivoclar Vivadent). Excess cement was removed, and dental floss was passed interproximally [Figure 12]. Oral hygiene instructions were given. A night guard was given to the patient as a precautionary measure to avoid any kind of parafunctional habits that might wear off the restorations.

Figure 12

Finished restorations cemented in the mouth - intra oral and extra oral views

The patient was recalled after 3 months and reevaluated for maintenance of the oral hygiene instructions.

Discussion

Since the existing plane of occlusion (before treatment) was irregularly arranged, effort was taken not to incorporate any major changes in the final restorations that would have detrimental results keeping in mind that the patient had altered heavy biting forces. Hence, a uniform disocclusion was the ultimate aim at various eccentric movements in lines with a selected occlusal scheme in lateral scheme.

Dental GPS is not only a simulation software but helps us use the 2D image for 3D planning and execution with precision and accuracy with the usage of printable M lines.

Summary and Conclusion

Dental GPS is not only a simulation software but helps us use the 2D image for 3D planning and execution with precision and accuracy with the usage of printable M lines. Complex procedures such as full-mouth rehabilitation with minimally invasive dentistry protocols can be used with precision and success for full-mouth occlusal rehabilitation, posterior quadrant restorations, and anterior restorations with optimum esthetics and function.

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.