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Restorative Dentistry

How would you manage and restore this severely worn dentition?

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This question was submitted by Dr. Stephen Abrams from Cliffcrest Dental. Dr. Abrams is seeking colleagues’ opinions about the best approach to the video case that is presented below.

Readers are invited to comment on this initial response and provide further insights by posting in the comment box which you will find by clicking on “Post a reply” below. You are welcome to remain anonymous and your email address will not be posted.

 

11 Comments

  1. Terry Shaw February 27, 2013

    This fellow should be considered a geriatric patient based on medical history and a good candidate for a rehab with composite. Doing a rehab with conventional C&B would cost 30-40 thousand. I have done many of these in composite and they last easily 10 years and more if well done. If I can send some pics in the attachment I will of cases I have done.

    Reply
  2. Terry Shaw February 27, 2013

    FINISHED UPPER TEETH

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  3. TERRY Shaw February 27, 2013

    Another case of 70 plus lady including a RPUD

    Reply
  4. Terry Shaw February 27, 2013

    Restored with composite

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  5. Terry Shaw February 27, 2013

    New RPUD, pics are several years after restoration was done

    Reply
  6. Terry Shaw February 27, 2013

    RPUD and pics are several years later

    Reply
  7. Mark Venditti March 7, 2013

    Big case. Some attrition and erosion. Protective appliance after treatment a must. Looks like lower anteriors have erupted into worn upper anteriors. Ortho or crown lengthening then some crowns and bridges to level the arches and improve esthetics so that upper anteriors look pleasing in the face.

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  8. Brian Kucey March 20, 2013

    This is an extremely complex case requiring multidisciplinary specialty care. A comprehensive diagnosis, determination of etiologies, prognosis with and without care, etc. is needed. I would definately not recommend a “full mouth composite resin rehab”. This patient is 52 years old and may require his dentition for another 25 to 30 years. The real question is how determined is this patient to retain and maintain his teeth, and what is he prepared to do as a patient? It appears that he teeth could be restored if he wants to do that. As he has lost his anterior guidance for a mutually protected occlusion and modified his vertical dimension of occlusion, he is not yet in his “treatment position” to begin a comprehensive reconstruction.
    Send this patient directly to the prosthodontist. There is no substitue for approapriate care. He needs plan “A” done.

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  9. George Cadigan March 20, 2013

    One alternative which might make the patient happy is a “Snap on Smile” type appliance. This would give an instant improvement in esthetics which is perhaps all he wants. It would involve increasing the vertical dimension and would enable an assessment of the patient’s motivation to have a full mouth reconstruction with ortho and the whole nine yards. Judging by the history of chronic neglect I suspect a lack of financial or emotional commitment.

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  10. ron Kellen March 21, 2013

    Dr. Kucey is RIGHT on.
    Patient attitude and cooperation, maintenance, 3 mo recall, etc. is critical to any success. MUST have an overnight sleep apnea test. (Most apneics grind AND keep their mandibles forward for airway.) Cause #1
    HABIT has to be dealt with. (If you have a pimple on your face, you pick and pick and pick — until it goes away. Then you just stop.) His awful occlusion is giving him lots to pick on. Cause #2.
    Poor oral hyiene – plaque builduip causes an icky feelilng on teeth – pick and brux to relieve it Cause #3.
    Occlusion now forces mandible forward and up to chew, as posterior teethy are not worn –> premature contacts –> forward & R/L as equivalent of molars and anteriors cannot take that. Cause #4.
    Check Tonsils & Adenoids – if large still — ENT stat.
    Look at normal airway size in mouth / pharynx.
    Bilateral lower tori are body response to bruxing / clenching.
    But this raises the tongue and helps to reduce the airway.
    The worn anteriors mean the tongue has to push forward against the closing lips to get a seal on swallowing.
    All of the above mean difficulty with partials.

    My Rx, IF patient is motivated, has $, and will maintain. FULL informed consent, written, documented re time, who, what aids, etc etc.

    1 Full scale, ohi, diet.
    2. Exo 18, Do occlusal equilibration in true centric to stop any forward slide, and enable r/l excursions from true centric. Minimal protrusive easing – only for major posterior interferences that deflect the mandible. Now, composite restos in the large hollows, then lesser ones, to the new correct centric. Now, do composite buldups as “temp crowns” and do a clear acrylic full arch occlusal onlay, removable, on lower, at a thicknelss to establish a reasonable vertical so no mandible up and forward overclosure forces. Make an upper night guard – flat plane posterior thermoflex, with little palate (no tongue crowd) for all night. Correct vertical and centric will let muscles relax, no “pimple” to pick on. Note, mandible often seats further and you need more bite adj on teeth and on guards. Every week –> 2 weeks –> 3 week intervals till stable.

    Will patient require hypnosis help to stop brux, clench? I have done it on several patients and it works.

    When all is stable for 3 months, Now you know correct vertical, centric, etc. Plan full mouth cr & br, place 46 implant, etc.
    OR secondary and far poorer option of U & L partials – can be with onlay occlusals to increase vertical correctly (N.G. essential at correct vertical, to be worn every night.

    Can also do direct composite onlays on some teeth, mix and match etc.

    Sleep apnea VERY likely, MUST be thoroughly controlled, EVERY night. NO exceptions. Diet (low cariogenic) essential, EXCELLENT home care essential. Adquate hydration as mouth breathing causes dryness –> stickiness –> bruxing. NEED good salivation, (some of his meds will incresase oral dryness — compensate or change etc.)

    Anyway, that’s my take. Look forward to feedback.

    Ron

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  11. Stephen Abrams May 26, 2013

    Thank you to everyone that provided comments. I have just started to restore the dentition. The first step was to place a mandibular flat plane bite splint and make sure that the patient was able to wear it while sleeping. I have checked for GERD but the patient denies this. He does claim that he was hit in the mouth a number of years ago which chipped the incisal edges of the maxillary teeth and lead to where he is today. This is a nice story and the blow may have initiated some chipping but parafunction and possibly GERD finished things up. I will keep you posted.

    Stephen

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