|Year : 2020 | Volume
| Issue : 4 | Page : 214-218
Full-mouth rehabilitation for severely attrited dentition by simplified approach
S Devameena1, PS Manoharan2, Vivek Rajasimhan3, B Vidhya1
1 Department of Prosthodontics and Crown and Bridge, Sri Venketeshwara Dental College, Puducherry, Tamil Nadu, India
2 Department of Prosthodontics and Crown and Bridge, Indira Gandhi Institute of Dental Sciences, MGMCRI Campus, Puducherry, Tamil Nadu, India
3 Department of Prosthodontics and Crown and Bridge, Tagore Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||23-May-2020|
|Date of Decision||05-Jun-2020|
|Date of Acceptance||20-Jun-2020|
|Date of Web Publication||30-Nov-2020|
Department of Prosthodontics and Crown and Bridge, Sri Venketeshwara Dental College, Ariyur, Puducherry - 605 102
Source of Support: None, Conflict of Interest: None
Several reasons may cause attrition of dentition which could collapse the occlusal harmony. Apart from esthetic challenges, the dentition needs to be carefully evaluated for biological and mechanical reasons. Several techniques were formulated as a management for attrited dentition to meet esthetics and functional harmony. This paper describes a simplified systematic approach and management of a 45-year-old male with attrited dentition which helped the patient to adapt well to new restoration.
Keywords: Dental attrition, esthetics, full-mouth rehabilitation, metal-ceramic restorations
|How to cite this article:|
Devameena S, Manoharan P S, Rajasimhan V, Vidhya B. Full-mouth rehabilitation for severely attrited dentition by simplified approach. J Dent Res Rev 2020;7:214-8
|How to cite this URL:|
Devameena S, Manoharan P S, Rajasimhan V, Vidhya B. Full-mouth rehabilitation for severely attrited dentition by simplified approach. J Dent Res Rev [serial online] 2020 [cited 2021 Jan 18];7:214-8. Available from: https://www.jdrr.org/text.asp?2020/7/4/214/302051
| Introduction|| |
Attrition is defined as a loss of tooth structure caused by tooth-to-tooth friction without any intervening substance. Occlusal and incisal attrition may occur during deglutition (physiological wear) and may be severe if associated with parafunctional activities such as bruxism and clenching habits (pathologic wear). Shiny dental surface and well-defined facets are considered as reliable signs of attrition that usually present with facets on antagonizing teeth., Severe attrition proximal to pulp may lead to pulpal pathologies, impaired occlusal function, and esthetics. Full-mouth rehabilitation is a dynamic functional endeavor, and it embodies the correlation and integration of all component parts into one functioning unit. The aim of this treatment plan was to restore the tooth to its natural form, function, and esthetics with physiologic integrity and harmonious relationship with the adjacent hard and soft tissues. Therefore, the objective was reconstruction and rehabilitation of the entire dentition, satisfying all the related factors.
| Case Report|| |
A 45-year-old male reported to the department of prosthodontics with complaint of worn-out teeth that inhibit him in socializing with community. On examination, generalized attrition with missing 11, 21, 22, 26 [Figure 1], [Figure 2], [Figure 3]. Orthopantography (OPG) advised and the patient was explained about severe loss of tooth structure. His history revealed habit of faulty vigorous brushing with hard brush. The patient was asymptomatic and not willing for intentional root canal treatment in attrited teeth. He was informed about the necessity of endodontic treatment through the crown if it becomes symptomatic.
Primary impression was made using alginate, and cast was made using Type III Dental Stone. Orientation of the maxilla recorded and transferred to Hanau Wide-Vue II articulator using self-centering arbitrary face bow [Figure 4]. Muscle deprogramming was done by asking the patient to bite on cotton rolls in premolar area for 5 min, followed by centric record using impression compound by placing on upper anteriors and guiding the patient to centric and recorded. The cast was articulated in centric using the compound jig. Interocclusal distance measured intraorally using divider in between maxillary and mandibular anterior when mandible is at rest. Vertical height measured at occlusion. Freeway space was observed to be 6 mm. 2 mm increase in vertical dimension (VD) was planned. Mock wax-up done to increased VD [Figure 5]. Putty index of mockup was made using polyvinyl siloxane material for provisionalization. Tooth preparation was done following principles with very minimal reduction in occlusal aspect for all the teeth in single visit and provisionalization done with self-polymerizing resin by indirect technique. Occlusion checked and the patient was kept in temporary for 1 month for adaptation of condyles to increased VD. The patient had a good adaptation to provisional restoration. After 1 month of time, the patient was called, and all the provisional restorations were removed.
Gingival retraction was done using braided cord (Ultrapak 000). Final impression of the maxilla and mandibular arch was done using addition silicone putty and light body by dual impression technique. Face bow transfer was done again to orient master cast after tooth preparation in Hanau Wide-Vue II articulator. Centric record and protrusive record were taken in putty and mandibular cast articulated in centric. After articulation, 2 mm incisal pin raised for increasing VD as done for provisional restoration. Casting was done and metal trial was checked for marginal fit and clearance [Figure 6]. Except missing teeth, other crowns were planned as individual crowns for maintenance of periodontal health. Standard values of Hobo's technique were calibrated in articulator [Table 1]. Group function occlusion was established with Condition I values without anterior segment in semi adjustable hanau articulator. Condition II values were calibrated with anterior segment. Metal-ceramic crowns were fabricated and delivered. Canine-guided occlusion with uniform disocclusion of posteriors and cusp-fossa relation was planned and executed [Figure 7]. Occlusal interferences were checked and metal-ceramic crowns were luted with GIC Type I cement [Figure 8]. The patient was satisfied about enhancement of esthetics. He was called for review and checked for complaints. The patient was very much comfortable with the new restorations.
As the patient was with same 2 mm increase in VD with provisional crowns, he adapted well with definitive restorations.
| Discussion|| |
Based on various concepts discussed in the literature, two concepts have been found accepted for natural dentition and fixed prosthesis: the “gnathologic” and the “freedom-in-centric” concepts, respectively. An organized approach for oral rehabilitation was introduced by Pankey,,, following the principles of occlusion advocated by Schuyler, known as the Pankey–Mann–Schuyler (PMS) Philosophy of Oral Rehabilitation. Their philosophy was pertinently based on the spherical theory of occlusion, the “wax chew-in” technique described by Meyer and Brenner,, and also based on the importance of cuspid teeth as discussed by D'Amico. In PMS philosophy, simultaneous contacts of the canine and posterior teeth on the lateral excursion (group function), and only anterior teeth contact in the protrusive excursive movement.,
Hobo and Takayama in their research concluded that cuspal angle is a primary factor that does not deviate and four times reliable than condylar and incisal path which shows deviation. They believed in posterior disocclusion in eccentric movements and did not include freedom in centric. In twin stage or hobo's procedure, the main determinant of occlusion is standard cusp angle. There is no need to record condylar path. Therefore, complicated instruments such as the pantograph and fully adjustable articulators are not required.
Occlusal approach for restorative therapy can be either confirmative approach (often advisable) or a reorganized approach. In confirmative approach, occlusion is reconstructed in pursuance of the patient's existing intercuspal position. It is adopted when small amount of restorative treatment is undertaken. Reorganized approach of occlusion can be considered if the existing intercuspal position considered unsatisfactory for various reasons such as repeated fracture of teeth or restorations, severe attritional wear, lack of interocclusal space for restoration, unacceptable function, unacceptable esthetics, sensitive teeth, and painful musculature due to disharmony between occlusion and temporomandibular joint. To achieve the various goals of full-mouth rehabilitation, certain biological considerations are necessary along with treatment protocols. Adoption of an alternative strategy by establishing a new occlusal scheme around a stable condylar position (termed “centric relation”) should be considered. The decision to organize the occlusion in a patient is done only after a detailed and careful examination of the occlusion using study models, etc. Muscle deprogramming was done by biting on cotton rolls in premolar area for 5 min, followed by centric record with impression compound instead of leaf gauge for this patient to simplify the procedure.
Decision-making full-mouth rehabilitation may be simultaneous restorations of full arch or segmental/sequential technique. However, each treatment has its pros and cons. Hence, treatment plan to be done in consideration of clinical condition and patient expectation and operators experience. In this case, sequential steps of diagnosis, evaluation of loss of vertical dimension, preparation of teeth, provisionalization for one month and finally definitive restorations was done. followed by provisionalization for 1 month in increased vertical dimension (VD) for adaptation, and finalized restoration in conformation with centric relation (CR). Cusp-fossa arrangement was followed for rehabilitation. Using standard cusp angle in harmony with anterior guidance and condylar path, posterior occlusion generated in group function. Finally, canine is modified to convert the occlusion to canine-guided occlusion with uniform disocclusion of posteriors. In this case report, we advocated Hobo's technique of full-mouth rehabilitation where standard cuspal angle was followed. Other techniques also have been followed in clinical practice where tooth surface etched with phosphoric acid to bond with composite material. As it could be a doubtful procedure for vital attrited teeth and there are chances for debonding of material on occlusal load, this technique was not followed.
As a definitive treatment plan, metal-ceramic individual crowns were preferred. Canine-guided occlusion is superior because it is easier to establish, acceptable, reduces lateral interferences, and stress on posterior teeth. Canine has a long root and dense compact bone and least muscular activity when canine is in function. Hence, canine-guided occlusion was our preference for lateral occlusion.
Some authors recommend occlusal splints at increased VD for adaptation. Here, provisional restoration at increased VD at longer period of time was given for adaptation. Occlusal equilibration and interferences eliminated during this period. The patient had only a very few adjustments at the time of delivery and good occlusal contacts established. The treatment plan was simplified using impression compound jig instead of other custom-made jigs on cast, so the use of occlusal splints eliminated which reduced extra clinical steps and also resulted with satisfactory outcome.
| Conclusion|| |
Full-mouth rehabilitation at increased VD is a challenging clinical scenario where esthetics, function, and adaptation have to be considered. Treatment plan was executed in functional harmony with the clinical situation. In this case, simplified clinical procedures yielded better results and satisfied psychologically and esthetically which could gain confidence in socializing with public.
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
Conflicts of interest
There are no conflicts of interest.
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