August 1, 2015
by Blake Nicolucci, BSc, DDS
The following is a case study that involves a patient who has lost vertical dimension, lost posterior teeth, worn down his anterior teeth from bruxing and attrition, and with a diet that became almost completely liquid. Although it seemed like a daunting task, once his jaw was repositioned back to 80 percent of his original rest vertical dimension with a posterior bite plate/splint, and after a four-month trial period of not developing any TMJ symptoms, the task became very straightforward. Basically, the hopeless teeth were extracted and the areas were left to heal for the same four-month period that the bite splint was worn. The attrition and functional breakdown of the salvageable teeth were restored with pins and composite build-ups before the crown preparations were completed. Again, after the build-ups, the teeth were given a ‘healing’ period to make sure root canals or other more extensive treatments weren’t required as a result of the restorations. This also allowed the patient to examine his anterior profile before we even started the prosthetic phase of treatment. Because of the attrition and breakdown of the anteriors that we observed before treatment had commenced, it was decided (and accepted by the patient) to splint the anteriors together – both for the mutual support of the teeth and to protect the fragile reconstruction of each tooth with pins and composite resins. The maxillary teeth were completed first and the bite plane/splint was adjusted so that the original 80 percent vertical dimension was maintained until the lower arch was completed. Treatment planning involved having two stage implants placed so that while they were buried under the tissues, the patient could wear the bite plane/splint. The splint would be relieved directly over the implants so there would be a minimal amount of force transmitted to the implants during healing. Unfortunately, one implant in the fourth quadrant had to be replaced after it became infected (this was probably caused by splint pressure over the implant and set back threw off our initial treatment plan timing). The fourth quadrant was subsequently finished after the rest of the treatment was completed with no post-operative issues. The following photos will paint a complete story of how this type of patient can be handled. This process took the better part of a year to complete but when it was finished, the patient was very happy. Is the case picture perfect? No – not by a long shot, but the patient was pleased with the esthetics and shade he had chosen and his masticatory function had been completely restored. Here is the case for your perusal.OHFIGURE 1. Patients initial occlusion illustrating over-closure, attrition, and loss of vertical dimension. FIGURE 2. Left side centric occlusion.
FIGURE 3. Right side centric occlusion.
FIGURE 4. Attrition of the lower anterior – (note: lower third quadrant posteriors have been missing for years allowing for bone resorption which will affect implant placement.)
FIGURE 5. Attrition of maxillary anteriors, over eruption of posteriors due to lack of occlusion.
FIGURE 6A. Records taken to mount casts on a ‘Sam 2’ articulator.
FIGURE 6B. Articulated right side opened to 80 percent of his original contact vertical dimension.FIGURE 6C. Articulated left side opened to 80 percent of his original contact vertical dimension.
FIGURE 6D. Right side articulated wax-up for patient approval.
FIGURE 6E. Left side articulated wax-up for patient approval.
FIGURE 7. Patients left side contact with splint in place. Patient wore a splint to open his bite for four months before any prosthetics was started to make sure his TMJ could handle the increased vertical dimension. I’ve found that patients have no problems when the bite is opened up 75-80 percent (rather than 100 percent) of their original contact vertical dimension.
FIGURE 8. Patients right side contact with bite opening occlusal splint in place.
FIGURE 9. Splint in place illustrating the amount of opening required after prosthetic completion.
FIGURE 10. Coping constructed for maxillary teeth. We decided that because of the para-functional habits the patient acquired, that porcelain fused to gold prosthetics would be appropriate (joining the anteriors in two segments for mutual support during function).FGURE 11. Copings fitted and margins checked before the prosthesis’ went to completion with a new final impression. FIGURE 12. Left maxillary copings in on the casting.
FIGURE 13. Right side maxillary copings on the casting.
FIGURE 14. Left maxillary copings in the mouth — margins checked on abutments.
FIGURE 15. Right maxillary copings in the mouth – margins checked on the abutments.
FIGURE 16. Maxillary crowns cemented and their bite is fitted to the bite splint which is to be worn constantly until the mandibular teeth have been restored.
FIGURE 17. Implants in position in the third quadrant.
FIGURE 18. Implants in position in the fourth quadrant.
FIGURE 19. Implants have been placed in the third and fourth quadrants before the anterior teeth are prepared for crown placement, and the splint has been adjusted around the implant heads so there is no contact. Crestal bone has been reduced on fourth quadrant p
osterior implants to increase bone width. Indelible pencil was used as a transfer medium on the acrylic.
FIGURE 20. Mirror image: lower anteriors are prepared for crowns and a lab fabricated temporary is placed to splint them for strength from a wax up that has been accepted by the patient. This will allow the patient to stop wearing his bite splint since the plane of occlusion has now been established and refined with the laboratory temporary. A liquid and soft food diet is advised.
FIGURE 21. The implant in the #44 position developed infection and required removal, re-grafting, and replacement. We felt it was appropriate to let it heal while the final crowns were cemented on the anteriors and the third quadrant implants (#35 and #37).
FIGURE 22. The final prosthesis was cemented on the lower anteriors and the implants in the third quadrant. The patient was now allowed to insert some firmer foods into his soft food diet until the fourth quadrant implants had integrated.
FIGURE 23. Implants in the fourth quadrant (#44, #46 and #47) all tested as having been ‘integrated’ with the ‘periotest’. Posts were then prepared for completion of the prosthetics. Each post was indexed to assure proper placement and positioning.
FIGURE 24. The implant bridge has been prepared by the lab and is ready for insertion.
FIGURE 25. With the implants restored on the fourth quadrant, and the occlusion (with right and left lateral and protrusive function) checked, the case has been completed. Continued follow-up and radiographic checks will need to be performed periodically to check on the implants.
FIGURE 26. Panorex of the patient before treatment.
FIGURE 27. Panorex of the patient at completion of treatment. The patient can now be advanced slowly into a diet with more solid foods. A night guard is absolutely a must with this type of patient (with this type of function). Bruxing is a disease to dental implants, and they must be protected.
Dr. Nicolucci is president of the Canadian Society of Oral Implantology and is Oral Health’s editorial board member for Implantology.
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