Minimally Invasive Rehabilitation: A Case Study

Abstract
Traditionally, full-crown coverage is indicated when doing a full-mouth rehabilitation. Clinicians did not have many other ways to tackle cases of advanced eroded and/or worn down dentition until the improvement of adhesive dentistry was able to meet the requirements for such cases.1 The improvement of materials and the advancement of techniques, such as dental implantology and adhesive dentistry, are now enabling clinicians to move towards less biologically invasive dentistry. A recent systematic review on a patient presenting severely worn dentition found that there was no evidence that any particular material was better than another.2

This article will present a case study of the less invasive nature of modern dentistry, using direct restoration and dental implantology.

Methodology
As for any full-mouth rehabilitation, the crucial element is the treatment plan.

The patient came to our office seeking treatment after breaking his fourth tooth in two years. His main concern was obtaining treatment that would restore and prevent any further breakdown of his dentition. He knew he needed comprehensive work done, but he refused to have any other teeth prepped for crowns and/or bridges. The first image clearly illustrates the patient’s initial condition: moderate to advanced attrition, moderate buccal erosion, edentulous site leading to a lack of posterior support, loss of vertical occlusion dimension (VOD), and brachycephalic tendency (Fig. 1A & 1B).

Fig. 1A
Pre-op condition.

Fig. 1B
Treatment plan.

All the data necessary to create a treatment plan for this case were collected and a diagnosis wax set-up was made according to the newly determined VOD. A treatment plan was created to restore both function and aesthetics. The patient came back for a mock up try-in and treatment options presentation. The mock up is crucial to be able to determine if any of the parameters of the treatment plan have to be changed (Fig. 2A & 2B).

Fig. 2A
Final pictures.

Fig. 2B

After choosing the treatment plan with the patient, the informed consent was duly signed. The first step was to increase the VOD and place the patient in centric occlusion (CO) by placing composite build up on typically three posterior teeth per quadrant. The new position must be tested for a period of four to six weeks (Fig. 3).1

Fig. 3
New VOD reestablished.

The goal of the provisional phase is to ensure that the patient is adapting to the new position before restoring the rest of the occlusion, which is almost always the case when restoring the vertical dimension to where it would be if the dentition was intact.2 This step is done using a micro hybrid composite, which is warmed and placed in a transparent vinyl This article will present a case study of the less invasive nature of modern dentistry, using direct restoration and dental implantology.

polysiloxane (VPS) matrix made from the wax set-up on the conditioned teeth (Fig. 4). The transparent (VPS) has the advantage of letting the curing light through so it can reach the composite.

Six weeks later, when the patient was well adapted to his new occlusal parameters, it was time to restore the anterior teeth with a putty lingual matrix and to start the prosthetically-driven implant therapy. Once done, anterior guidance and lateral eccentric movements have to be assessed and adjusted to ensure proper function. Implants were placed and restored with the new occlusion in mind. A nightguard appliance was also prescribed to minimized further attrition and final pictures were taken (Fig. 5A & 5B).

Fig. 4
Transparent template used.

Fig. 5A

Fig. 5B

Conclusion
The progress of dental materials, including dental implants and adhesive dentistry, are now enabling clinicians to incorporate a more comprehensive and less invasive approach to treatments. OH

Oral Health welcomes this original article.

Bibliography

Vailati F, Belser UC. Full-Mouth Adhesive Rehabilitation of a Severely Eroded Dentition: The Three-Step Technique. The European Journal of Esthetic Dentistry Volume 3, Number 3, Autumn 2008.
Mesko ME, Sarkis-Onofore R, Cenci MS, Opdam NJ, Loomans B, Pereira-Cenci T. Rehabilitation of severely worn teeth: A systematic review. Journal Of Dentistry, 2016 May;48:9-15. doi: 10.1016/j.jdent. 2016.03.003. Epub 2016 Mar 7.
Spreafico RC. Composite Resin Rehabilitation of Eroded Dentition in a Bulimic Patient: a Case Report. The European Journal Of Esthetic Dentistry Volume 5, Number 1, Spring 2010.
Hemmings KW, BDS, MSc, a, Darbar UP, B DS, MSc, b, Vaughan S, BSc, c. Tooth wear treated with direct composite restorations at an increased vertical dimension: Results at 30 months. 2000 May, The Journal Of Prosthetic Dentistry volume 83, number 3.

About the Author
Dr. Sassi completed his Doctorate of Dental Surgery at Laval University in 2013. He has a practice in Ottawa where he focuses on full mouth rehabilitation, sedation dentistry and dental implant treatments.

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