A 74 year old gentleman with severe anterior deepbite and generalised attrition, with severely attrited mandibular anterior teeth insisting on full mouth rehabilitation. Bite (vertical dimension) to be raised minimum by 5mm-6mm. Please give your opinions / suggestions/ experiences of such cases with possible prognostic outcomes. Thanks & regards
These are tough cases with many aspects to consider in treatment planning such as occlusion, VDO, continued parafunctional habit, skeletal relationship, speech, etc....and there are many approaches to treatment as you know is typical in dentistry. Working closely with a lab tech or ceramist, and systematically, is also important in these cases. Consider referral or assistance from specialists such as a prosthodontist for the restorative work and a periodontist for crown lengthening work since they have more experience with such complex cases, and because these type of full mouth rehabilitations can impact speech and mastication and occlusion to name a few. Here are some useful exemplars or publications on the topic for reference:
Jain AR, Nallaswamy D, Ariga P, Philip JM. Full mouth rehabilitation of a patient with reduced vertical dimension using multiple metal ceramic restorations. Contemp Clin Dent. 2013 Oct;4(4):531-5.
http://glidewelldental.com/education/chairside-dental-magazine/volume-8-issue-2/a-systematic-approach-to-full-mouth-reconstruction-of-the-severely-worn-dentition/
Full mouth rehabilitation
Articulation after facebow transfer--------- diagnostic waxup-----provisionals for posteriors {up to 3 mm} for 4 weeks to settle down TMJ by remodeling of articular disc and fibrous detachment in TMJ if any. -------crown lengthening procedure for anteriors C/R ratio keeping in mind------ replaced all with suitable restoration----in group functional occlusion scheme.
OVD in my opinion is the least problematic aspect of the described case. I agree with Dr. Sedghhizadeh in that these are difficult cases and are best managed by specialists.
Fabricate an occlusal splint to create a posterior open bite that allows you to get a good length of the incisors and reconstruct the posterior teeth first then the anteriors second. Consider the TMJ condition and associated muscles of mastication.
I typically use resin "onlays" for all of the posteriors to open the VD. I don't prep anything unless decay is present. If the patient's TMJ complex cannot tolerate the ideal VD, these are easily adjusted, or even removed without harming the underlying enamel. If the new VD is successful, then move on to the final prosthetics.
I have developed a device that takes into account many of the neuromuscular and anatomic concerns of pathologies and reconstructions suggested in your paper. The NiteBite assists in creating a working and indexable VDO. Utilizing the NiteBite, the jaw muscles respond and release to a centric relation (NiteBite centric) within the freeway space at physiologic rest position. This is a neuromuscularly determined position. No teeth touch each other or the the device as the result of functional, proprioceptive and neuromuscular forces that allow the mandibular muscles to respond and come to rest within the freeway space at physiologic rest position. With the NiteBite in place at night there is no centric relation guidance except that physiologically determined in the absence of all tooth to tooth and absence of tooth to device guidance. There is no tendency to posteriorize the condyles beyond physiologic rest as the jaw is open. The NiteBite resides in the freeway space and because of its thinness, cannot open the mandible past physiologic rest position.
In order to test VDO's and physiologic rest positions, acrylic is incrementally added to the palatal surface of the NiteBite to observe patient tolerance to an increased VDO over a time interval where the patient is free of parafunction. If an acceptable VDO is exceeded by observing wear on the palatal platform, acrylic can be removed so that an acceptable freeway space (1.5mm+ anterior) is observed. These VDO's can be indexed at any time for transfer to articulator
https://nitebite.us
In Nijmegen at our university, we treat these patients routinely with direct composites. 5-6 mm increase of VDO is not a problem. The technique we use is the DSO technique as described in our paper in Operative Dentistry 2016. Because these patients have a high risk for fracturing restorations, ceramics could be contrindicated.
Before I begin treatment, I would do a complete head and neck examination with an extensive history and subsequent CBCT scan to determine:1- the cause of his attrition 2- the condition of the craniofacial muscles and the TMJ. 3-the systemic condition and medications intake.
1- The cause of his attrition
2- The condition of the craniofacial muscles and the TMJ. 3-The systemic condition and medications intake.
This way is very important not only to avoid high incidence of future fracture but also to avoid the aggravation of the TMD/MPD. Many of these patients have obstructive sleep apnea because when the VD is compromised the tongue goes backward causing narrowing of the upper airway with a subsequnt sleep-breathing disorder.
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