November 23, 2016
by Antonio Mancuso, DDS, MAGD
Every patient with extreme tooth wear has unique treatment needs, and all of these needs may not be addressed specifically in this article. The general guidelines for treatment of these patients include the following: 1. A comprehensive examination, including a thorough medical and dental history, orofacial and dental clinical examination, dental radiographs, TMD screening history and examination, impressions and jaw relation records for mounting casts in a semi-adjustable articulator, 2. A diagnostic wax-up and diagnostic occlusal adjustment on additional or duplicated mounted casts, 3. Careful planning and consultation regarding the need for preparatory treatment. Careful integration and sequencing of the different areas of treatment needed to enhance the finished result, 4. Discussion with the patient of the different treatment alternatives and sequences possible for his or her individual case, with presentation of advantages and disadvantages and prognosis for each, 5. Finally, careful execution of the agreed upon treatment plan by the dentist. Although not specifically mentioned, treatment success requires a highly motivated patient and skilled dental laboratory technicians. These “treatment partners” should be included in the planning stages of treatment as early as possible to enhance the possibility of having a successful treatment result. 1,2
Many patients present today with a chief complaint of: “I don’t like my smile what can you do?” This is typically followed by. “I have only budgeted a certain amount of money for this and I don’t want to take out a second mortgage to pay for this!”
Communication to address the patient’s chief complaint becomes paramount in developing an acceptable treatment plan that achieves the patient’s goals. There are many ways to communicate treatment with our patients. Verbal communication, before and after photos showing similar cases, YouTube videos, and patient education software products such as Casey®, ConsultPro®, My Dental Hub® are just a few. However, in my experience, I have found the intra-oral mock-up to be the most successful in achieving case acceptance. Below is a case study of an accepted full mouth reconstruction case that utilized the intra-oral mock-up to communicate to the patient what can be achieved.
A 60-year-old male presented to the office on referral from his family dentist for consultation. At this appointment the patient presented with his wife who would be instrumental in the decision making process. His chief complaint was that “he can no longer see his front teeth and that he wanted to get rid of his cast PUD, that he had worn for many years” (Figs. 1-9).
A specific cursory exam was performed to get an idea of the present oral state of health. He presented with a partially edentulous dentition exhibiting a deficient smile line. In actual fact, he had a reverse smile line with his PUD denture teeth. He wanted to show his front teeth and also wanted to get rid of his PUD. Periodontally he appeared to be in good shape.
A discussion ensued about the scientific principles of smile design, his present occlusal scheme and what would be required in order to come up with various treatment plans. 3,4,5,6,7
The patient had a negative smile line that appeared to be his greatest chief complaint. He was reclined in the dental chair and using flowable composite, length was added to the incisal edges of his PUD denture incisors. This was quickly shaped, adjusted and polished. Both the patient and, more importantly, his wife were pleased with this look (Fig. 10). This added composite was measured as the new incisal edge position. The patient was asked to close and the occlusion was assessed in this new position. There was a posterior open bite evident. This would be the vertical dimension of occlusion to be opened, in order to have the room for the restorative material of the new incisal edge position (Fig. 11). A bite registration of this new VDO (Vertical Dimension of Occlusion) was taken using Affinity bite registration material (Clinical Research Dental). The added flowable composite of the increased incisal length was removed from the denture teeth, along with the VDO bite. 8,9,10 This was put aside to be used later for the diagnostic wax-up. Full records were taken including a full mouth series of radiographs, a panorex, photographic series, study models with and without the PUD, a KOIS analyzer bite registration and a comprehensive oral examination including an occlusal analysis (Fig. 12).
The patient and his wife were then taken to the Treatment Coordinator’s office and shown numerous cases illustrating full mouth reconstructions and correction of reverse smiles. The Treatment Coordinator also enlightened them on what implants were, what full mouth reconstructions entailed as well as a ballpark on the cost involved. The patient was told that various treatment plans would be developed with all the records taken today and that a follow-up appointment in two weeks would be made by our treatment coordinator. The patient was told that the specifics of his case would be outlined at that appointment and that his wife would need to return with him.
The records were evaluated and various treatment plans were made utilizing traditional crown and bridge, implant crown and bridge and various combinations between the maxillary arch and mandibular arch (Figs. 13-18).
The study models, bite registrations, incisal index and an in-depth laboratory prescription was sent to the dental laboratory for full mouth diagnostic wax-ups and putty with light body wash indexes of both arches for the temporization process10 (Figs. 19-23). The patient had no TMD issues and it was decided to leave him in cross bite on the right posterior area, as he was very comfortable in this occlusal scheme.
The patient and his wife returned in two weeks and all the various treatment plans were discussed along with the risks, benefits and alternatives. The patient and his wife accepted a full mouth reconstruction. This involved the following in the maxilla; a four unit screw-retained implant bridge from #12 to #22, a single implant screw-retained crown in #24 position and crowns on 18, 16, 14, 13, 23, 25, 26. 11 In the mandible the treatment would be; splinted screw-retained implant crowns in the 36, 37 position, a 3-unit PBM bridge from 45 to 47 and single crowns 35, 34, 33, 32, 31, 41, 42, 43, 44. 12
The treatment would be phased with the following timeline:
Phase 1: Implant surgery with the patient continuing to wear his PUD (Figs. 24-26).
Phase 2: Maxillary preparations at uncovering appointment of the implants and complete temporization of the maxillary arch allowing tissues to heal (Fig. 27).
Phase 3: Maxillary arch insertion (Figs. 28-32).
Phase 4: Mandibular preparations and temporization.
Phase 5: Mandibular insertion (Figs. 33-36).
Phase 6: Post-op occlusal equilibration and Essix appliance insertion. 13
The patient’s final result was very pleasing to both himself and his wife (Figs. 37-46). Before and after photos of the case illustrating a successful result (Fig. 47).
The success of a full mouth reconstruction starts with patient education, which leads to case acceptance. Then it becomes a trilogy of the patient’s risk factors and motivation, the operator’s technical abilities, the treatment approach and the biomaterials selected. 14 The operator’s confidence and competence is predicated on his or her commitment to continuing education. The reality is that not all dental practioners want nor are competent to perform these complex treatments. OH
Oral Health welcomes this original article.
Disclaimer: Dr. Mancuso has no financial conflict with any dental manufacturer or products mentioned.
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About the Author
Dr. Mancuso graduated from the University of Toronto in 1985 and has maintained a general dental practice in Welland for the last 32 years. He has published articles for various dental journals and has lectured to various organizations across Canada, the U.S. and internationally. He has been involved in the AGD at all levels and currently is President of the Regional Niagara AGD study club. He was the Director of Millennium Aesthetics from 1999 to 2008. In 2015-16 he served as Co-director for the University of Toronto, Continuing Education, Cosmetic Dentistry Mini-Residency program for practicing dentists. He may be contacted at firstname.lastname@example.org.