Professional Documents
Culture Documents
CLINICAL PRACTICE
PROSTHODONTICS IN
CLINICAL PRACTICE
Contributions by
and
MARTIN DUNITZ
2002 Martin Dunitz Ltd, a member of the Taylor & Francis group
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I ndex 225
FOREWORD
The idea for writing this book came while The program is of 3'/ years duration and
sitting in one of the seminars of our gradu- includes certain clinical and basic science
ate program in Prosthodontics. requirements. Successful completion of
One of our students was presenting a the program enables the student to be
progress report of his patient, discussing eligible for the specialty licensing examina-
the diagnosis, and the possible treatment tion administered by the Ministry of Health
plans. Finally, he showed his treatment and in order to qualify as a specialist in Oral
explained its rationale. As I sat there, the Rehabilitation. In the first years, one or two
thought came to me, what a waste of students were accepted to the program
information this is; the student is present- and, as time went on, the program was
ing a beautifully documented treatment for expanded to include up to four students
a very difficult patient with superb radio- per year. This gave a core group of
graphs and slides. What a shame that only between 12 and 16 students to participate
the 12 or so people in the room are in seminars and treat patients.
viewing it. Today the program encompasses four
The purpose of the book is to share our days a week, in which the students spend
treatment modalities and rationale of treat- 4 hours in seminars each week. These
ment with as many dentists as possible. consist of case presentations, literature
Our seminars provide at least one hour reviews, and research on prosthetic
of case presentation time with a continua- subjects, and additional full day seminars
tion possible the following week. During as needed. The students spend 3 days a
the presentation, the instructors and other week treating clinical patients under the
students question the diagnosis and treat- supervision of board certified instructors.
ment plan, volunteering their opinions and The remainder of their time is spent in
alternative treatment strategies. It's a give clinical or original research. Many of the
and take situation. It is our conviction, that students carry out basic research projects
this is one of the best learning processes leading to a Masters degree or Doctorate.
for a graduate student. The program is integrated with other
The Graduate Program in Oral specialty programs at the Dental School,
Rehabilitation was initiated in 1978 when including Periodontics, Orthodontics, Oral
the Israeli Parliament passed a law recog- Surgery, and Endodontics. The graduate
nizing dental specialties. Until that year, the students treat implant patients. They plan
only specialization recognized by the and oversee the surgical phase, but do not
Ministry of Health was Oral and perform the surgical procedures. Most
Maxillofacial Surgery, which was a 5-year periodontal surgery, endodontic, oral surgi-
program. In 1979, the Department of Oral cal, and orthodontic procedures are
Rehabilitation set up a program to teach referred to graduate students or specialists
Graduate Prosthodontics. in the other disciplines.
x PREFACE
The philosophy of treatment in the I would like to personally thank all the
program is based on the clinical and learn- graduate students, former and present,
ing experiences of the faculty, who have especially those who contributed to the
themselves been trained in Prosthodontics book, the faculty of the program,
at The University of Pennsylvania, New Professor Jacob Ehrlich, Professor
York University, and The University of Avinoam Yaffe (Program Director), Dr Israel
Toronto, in the 1960s and 1970s. Thus Tamari, and Dr Erez Mann. Special thanks
their diverse backgrounds mean that the go to Professor Harold Preiskel and
faculty members bring to the program Professor Avinoam Yaffe who provided
varied ideas of treatment. We have tried to editorial commentaries, who made great
incorporate the best aspects of each of efforts in helping me, and without whose
these programs for our own syllabus. aid I doubt that the book would have been
Some of the methods we use have been written.
developed here in Israel.
INTRODUCTION
The book is divided into four parts according necessary, consultations with the patient's
to the primary problem of the patient: physician are conducted prior to any
Periodontal breakdown, Dysfunctional habit dental procedures.
patterns, Extensive loss of teeth, and One of the philosophies of our treatment is
Congenital disorders. Naturally, most patients to give the anterior teeth the added function
overlap and fall into more than one category. of supporting the vertical dimension of occlu-
The basis for all our prosthodontic treat- sion. The anterior teeth are customarily only
ment, is a healthy periodontium. The main used for incising food, speech, esthetics, and
goal of our treatment is to identify the anterior guidance in eccentric movements of
causative factors of the patient's dental the mandible. By utilizing the proprioceptive
problem, and thus be able to control them. properties of the anterior teeth to provide
Therefore a prerequisite of all treatment is for biological feedback, the occlusal forces
us to determine these causative factors and, applied to the teeth are reduced. This is
together with the patient, control them. This especially i mportant for patients with
is done by initiating meticulous oral hygiene mutilated dentitions, where the vertical dimen-
and controlling dietary habits and food sion of occlusion has to be changed. It is also
consumption. At the beginning of treatment, important for patients whose treatment
the patient undergoes initial preparation until requires increasing the vertical dimension for
they prove that they will cooperate completely biomechanical reasons, in order to make
in their own treatment, by executing excellent space available for restorations.
oral hygiene. Techniques include flossing, It is our experience over many years that
correct toothbrushing, use of stimulators and opening vertical dimension using the anterior
all periodontal aids necessary to maintain a teeth, especially the cuspid teeth, will reduce
healthy periodontium. For patients with caries, biting force and prevent intrusion of the other
a dietary analysis is made and the patient is teeth. In fact, in most patients, we are most
carefully checked to see that they adhere to probably restoring vertical dimension that was
their new diet. The initial therapy permits us lost rather than increasing the vertical dimen-
to check the individual patient's biological sion. These patients now usually close in a
response and determine whether the disease more retruded jaw position than their previous
activity can be controlled. In some cases, due acquired one. In patients with a full comple-
to genetic factors or the patient's personality, ment of teeth where change in the vertical
the biological response cannot be controlled, dimension of occlusion is required, we prefer
and this will naturally alter the treatment plan. using a 'canine platform',1-3a modified method
Unless otherwise noted, all patients were for posterior tooth eruption as opposed to a
non-smokers. removable appliance (Hawley). We have found
A speech therapist provides ancillary that this approach minimizes the need for a full
treatment, if needed. All past medical mouth reconstruction and the necessity of
histories are carefully evaluated and, if restoring otherwise healthy teeth.
xi I NTRODUCTION
drop of cyanoacrylate (Super Glue-5: copings are then picked up with a full arch
Loctite International, Welwyn Garden City, elastomeric impression (Impregum) mat-
UK) to give a very fine protective layer, and erial to capture soft tissue detail.
coated with a thin layer of petroleum jelly. At this stage, the individual dies are not
Duralay (Reliance Dental Manufacturing needed and the laboratory technician
Company, Worth, IL, USA) or Pattern resin places reinforced resin into the lubricated
copings (GC Company: Kasugai Aichi, (petroleum jelly) metal framework in the
Japan) are then made on the prepared i mpression, and dental stone for the
dies using a Neylon paintbrush technique. remainder of the model. This is the final
The Neylon technique is a brush-on master working model. This technique
technique that uses a fine brush dipped in gives not only fine tissue detail but also a
monomer and then in resin powder to pick reproducible positive seat for the castings
up a small ball of resin which is then whenever they are removed from the
placed on the prepared tooth, starting at model, thus avoiding damage to the model
the occlusal or incisal surfaces and by constant removal and placement.
working towards the gingival margins. A The master working models are articu-
hole is cut in the labial occlusal or incisal lated to the semi-adjustable articulator
corner of the coping to ensure that the (Hanau: Teledyne Hanau, Buffalo, NY USA)
coping is fully seated on the prepared by means of a face bow registration and
tooth during try-in. Pattern resin copings centric relation records performed at the
are individually fitted on the prepared teeth vertical dimension of occlusion as deter-
and checked clinically for fit and the mined by the provisional restorations.
accuracy of their margins. The copings are Since the working models are articulated
also used for centric relation recording and at the vertical dimension of occlusion, it is
vertical dimension registration. The resin felt that a fully adjustable articulator is not
copings are then picked up with a full arch necessary.4
elastomeric impression (Impregum) mat- The porcelain is then baked and fitted
erial. The individual dies are then placed i n the patient's mouth, with special atten-
i nto their respective copings in the impres- tion paid to fit and occlusion. If neces-
sion and a master working model is fabri- sary, the occlusion is adjusted using
cated.2,3 A centric relation record is then small round diamond stones until the
recorded, usually at the vertical dimension articulating paper shows that there is
of occlusion, and the models placed in an uniform and even contact in centric
articulator and the individual elements of relation (coincident to centric occlusion)
the prosthesis are waxed and cast. between all the posterior teeth and that
Once the metal framework of the the anterior teeth are in light contact only.
prosthesis is returned by the laboratory, The prostheses are then returned to the
the individual metal elements are checked l aboratory where the final glaze of the
i n the mouth, and joined together using porcelain is done.
resin. The metal framework prosthesis is At the insertion appointment, the
then sent to the laboratory for soldering. prostheses are `cemented' with a paste of
On return, the prosthesis is then checked petroleum jelly and zinc oxide ointment
i n the mouth again and another centric ( only) for 24-72 hours. The patient then
relation record made. The soldered returns and the occlusion is rechecked
TECHNICAL INFORMATION
The patient, a 56-year-old self-employed The patient had never visited a dentist
building contractor, came to the clinic for regularly. The last visit to a dentist was at
dental treatment. His chief complaints were
( Figures 1.1-1.3):
`I can't eat.'
' My lower front tooth is shaky.'
` Sometimes my side teeth hurt me.'
3
4 PROSTHODONTICS IN CLINICAL PRACTICE
FULL-MOUTH PERIAPICAL
SURVEY (Figure 1.10)
Figure 1.8
Periodontal chart-mandible.
Figure 1.9
Periodontal chart-maxilla.
Figure 1.10
Radiographs of maxilla and mandible-
pre-treatment.
RETROGRADE WEAR
Figure 1.11
Cephalometric analysis.
DIAGNOSIS
CEPHALOMETRIC ANALYSIS
• Pseudo-Angle class III
The cephalometric analysis (Figure 1.11) was
• Advanced adult periodontitis
done to evaluate the following relationships:
• Reduced posterior occlusal support
• Relation of the maxilla to the skull • Missing teeth accompanied by shifting
• Relation of the mandible to the skull of teeth
• Relation of the maxilla to the mandible • Extreme wear due to occupational
involvement
Determined values: • Caries
• Reduced vertical dimension
Measurement Average
• Faulty occlusal plane with extrusion and
Go-Gn 82 84
tipping of teeth
Co-Gn 125 122.5
• Secondary occlusal trauma with primary
Palatal plane point A 59 59
origins
(Go, gonial; Gin, gnathion; Co, condyle.)
• Periapicallesions
Interarch relationships:
maxillary prosthesis was cemented with a disease. He had many missing teeth and
permanent cement (zinc oxyphosphate) some of the remaining teeth were mobile
(Figures 1.17-1.21). with fremitus and periapical pathology.
There was extensive wear, severe extru-
sion of teeth, midline discrepancy, poor
SUMMARY occlusal relationships, anterior cross-bite,
spacing in the maxilla, and caries.
The patient came to the clinic for dental Radiographs ruled out the use of implants
treatment complaining of pain, a loose i n the mandible without pre-prosthetic
tooth, and difficulty in eating. He had not surgery. Through increased awareness of
visited a dentist for 40 years and thought the importance of oral hygiene, extensive
that by brushing his teeth twice daily, it periodontal, endodontic and prosthetic
was sufficient. He suffered from very poor treatment, a functional and esthetic result
oral hygiene, and advanced periodontal was attained.
12 PROSTHODONTICS IN CLINICAL PRACTICE
premolar, as well as that between the i ncisor, left central incisor, and left cuspid
maxillary right cuspid and first premolar. and fremitus class 2 on the maxillary left
According to the patient, these spaces l ateral incisor. The maximum opening was
always existed and did not bother her 42.0 mm and the interocclusal rest space
• Mandibular right third molar was was 3.0 mm. There was palatal impinge-
missing (Figure 2.10). ment of the anterior mandibular teeth
onto the gingiva of the right maxillary
Occlusal analysis (Figures 2.7 and 2.8) central incisor and both lateral incisor
revealed that the patient was Angle class 1 teeth.
with a vertical overbite of 6.0 mm and a
horizontal overjet of 3.0 mm. Periodontal examination revealed moderate
I n addition, she has Fremitus class 1 on with localized advanced periodontitis with
the maxillary right cuspid, right central probing depths up to 5-6 mm on the
16 PROSTHODONTICS IN CLINICAL PRACTICE
DIAGNOSIS
Figure 2.10
POTENTIAL DIFFICULTIES
I NVOLVED IN THE TREATMENT PHASE Z
The traumatic deep overbite, coupled with Conservative dentistry to restore the teeth
the great amount of tooth structure lost, in the new vertical dimension, after passive
j eopardized the maxillary anterior teeth, eruption.
thus requiring a quick solution. Another
difficulty would be the adaptation of the
patient to the required changes in her PHASE 3
daytime habit patterns (avoiding bruxism)
which, at the age of 57, is not easy. Any If passive eruption did not take place,
possible restoration would require change restoration of the teeth with fixed
i n the vertical dimension of occlusion in prosthodontics to the new vertical dimen-
order to restore the anterior teeth and sion.
adaptation of the patient to this procedure
could not be forecast. Another possible
problem with multiple restorations might be
TREATMENT
the unfavorable change in the crown-to-
root ratio and the possibility that tooth PHASE 1
eruption would not succeed. After discus-
sion with the patient, it was concluded that The treatment included scaling, root
the patient was not a `night grinder' but planing, oral hygiene instruction, and
rather, bruxed her teeth during the day restoration of teeth with faulty restora-
while working in the laboratory and peering tions and caries. The daytime bruxing
through a microscope, concentrating on problem and the resultant harm that it
her work. causes was stressed in discussions with
18 PROSTHODONTICS IN CLINICAL PRACTICE
PHASE 2
the operators chose to make occlusal worried the patient's dentist more than the
stops on the canines to allow the molar patient herself, yet the team were able to
teeth to erupt. Once this had been motivate their patient to undergo a time-
achieved, it was a relatively straightforward consuming, if not invasive, course of treat-
process to rebuild the dentition. It is inter- ment. Equally important in this case is the
esting to note that the original problem maintenance therapy.
PATIENT 3 EXTENSIVE TOOTH WEAR
Treatment by Yehuda Shahal
A 43-year-old retired army officer presented His dental history was uneventful. He only
himself for examination and consultation went to the dentist when he had pain.
with the following complaints:
Figure 3.1
Front view of anterior teeth.
23
24 PROSTHODONTICS IN CLINICAL PRACTICE
Missing teeth:
An occlusal examination revealed that the ( Figures 3.9 and 3.10). There were no
patient was Angle class 1 classification, balancing side contacts. In protrusive
with 0.0 mm overbite and an overjet of movements, there was disarticulation by
2.0 mm (Figure 3.1). The interocclusal rest the anterior teeth and the premolars on the
space was 4.0 mm and the maximum right side, and on the left side the posterior
opening was 46 mm, without deviation in teeth were in contact. There was no fremi-
opening or closing movements. The tus or mobility of any of the teeth. The
mandibular midline was slightly left of the patient had a removable partial mandibular
center of the face. denture, which he felt was unsatisfactory
There was a 1.0 mm discrepancy and did not use.
between centric occlusion (IC) and centric
relation (CR). Lateral jaw movements were The periodontal examination (Figures 3.11
group function on both sides-this in spite and 3.12) revealed probing depths of up to
of the amount of wear of the anterior teeth 3.0 mm on the maxillary teeth and up to
Considering that this patient exhibited Mohl ND, Zarb GA, Carlsson GE, Rugh JD, Textbook of
extreme wear in some of his teeth, it was felt Occlusion (Quintessence: London, 1988).
EXTENSIVE TOOTH WEAR 29
Clinical view of left maxillary first premolar, pre-treatment. Radiograph of post-treatment left maxillary first premolar.
30 PROSTHODONTICS IN CLINICAL PRACTICE
appearance, the final treatment plan was established vertical dimension dictated by
then carried out. the plane of occlusion and the esthetic
I t was decided to restore the mandible demands of the patient as well as the
with a premolar occlusion on the left side biomechanical considerations (Figures
for the following reasons: 3.26 and 3.27).
After a period of time it was clear that
Since implants could not be done with the patient adapted very well to his new
the amount of remaining bone-to restorations. Copper band impressions
place implants would require additional were then taken of all the prepared teeth
surgical procedures to add bone and Duralay resin copings were made.
The lack of posterior teeth in the These copings were used to record centric
mandibular left quadrant did not bother relation at the vertical dimension of the
the patient temporary restorations and for the final
He very much desired a fixed prosthe- i mpression for the master model (Figures
sis 3.28-3.32). The metal copings were then
The removable partial denture would fitted ( Figures 3.33 and 3.34) and
only replace two teeth, and the patient soldered, and after try-in of the soldered
would most probably not use it metal framework another elastomeric
I t would then require splinting the maxil- i mpression was done for tissue detail.
lary molars on that side in order to These models were mounted on a semi-
prevent overeruption adjustable Hanau articulator utilizing a
facebow registration and centric records
Due to the extensive period of time taken at the vertical dimension of occlu-
i nvolved in the initial treatment phases sion utilizing Duralay with a Neylon
and the periodontal surgery and technique.
orthodontic treatment, the transitional At this point the porcelain was baked
restorations were then replaced by new and the occlusion checked in the mouth at
prostheses. These were built to the new the biscuit bake stage and all adjustments
Figure 3.30
Centric relation record-left side.
Incisal platform incorporated into anterior maxillary teeth. Case cemented, post-treatment.
Figure 3.37
Radiographs of case, post-
treatment.
CASE DISCUSSION
AVINOAM YAFFE
were built to a minimum to reduce lateral the early part of the new century. In this
forces in order to improve the overall particular instance, the operators have
prognosis of the case. presented tooth substance loss, but this will
not apply to many other patients.
The sensibly chosen staged approach
CASE DISCUSSION produced the occasional surprise that all of us
HAROLD PREISKEL find in a long course of treatment. A split root
can be difficult to detect at the outset. While
While patients who have spent many years i ncreasing the vertical dimension of occlusion
driving tanks in dusty environments must be seemed reasonable, it is not clear whether the
a rare breed, those who are suffering exten- operators deliberately increased this measure-
sive tooth wear are abundant. Indeed, with ment beyond the level they estimated had
the increasing life span of our population and existed before the tooth wear occurred. There
the reduced incidence of caries, the treat- was little alternative to making a change if a
ment of worn down dentitions may be one of good looking outcome was to be achieved.
the most difficult situations to confront us in An excellent result was obtained.
PATIENT 4 NEGLECTED DENTITION
Treatment by Tzachi Lehr
A 50-year-old woman, employed as a senior The patient had never gone regularly to a
secretary, came to the clinic for dental treat- dentist. The last visit to a dentist was 10
ment. Her chief complaints were (Figures 4.1 years ago, and she could not recall what
and 4.2): treatment she received then. Recently she
found it difficult to chew her food. She had
` My teeth look awful.'
` My front tooth is loose.'
` My front teeth stick out.'
` Lately, my speech seems to be changing.'
`I know that I have no choice and need
l ots of work done on my teeth.'
39
40 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 4.3
• Missing teeth: right and left second and discrepancy. There was spacing between
third molars, and left second premolar the maxillary incisor teeth and the left
• Exudate around right cuspid l ateral incisor and left cuspid, and drifting
• Caries: of teeth.
Fremitus:
Figure 4.11
Radiographs of maxilla and
mandible-pre-treatment.
Periodontal examination (Figures 4.9 and mobility was observed on many of the maxil-
4.10) revealed calculus and plaque, probing lary teeth and class 3 on the maxillary right
depths of up to 8.0 mm on most of the maxil- central incisor and the maxillary right first
lary teeth and up to 7.0 mm on some of the premolar. The mandibular molars had class 1
mandibular teeth. There was bleeding of the furcation involvement on the buccal and
gingiva on probing (BOP) on most of the li ngual surfaces. The maxillary right second
teeth. There was slight gingival recession molar had class 1 furcation involvement on
around some of the teeth. Class 1 and 2 the buccal surfaces.
NEGLECTED DENTITION 43
POTENTIAL TREATMENT
PROBLEMS
SUMMARY OF FINDINGS
Many missing teeth
A 50-year-old patient, in good health, came The distribution of the remaining teeth
to the clinic complaining of poor esthetics, was unfavorable
44 PROSTHODONTICS IN CLINICAL PRACTICE
• Many of the remaining teeth had severe • Fixed and partial removable prostheses
periodontal problems and their progno- • Overdenture
sis was guarded
• Treatment would possibly include Mandible:
opening the vertical dimension of occlu-
sion in order to retract the maxillary • Fixed prosthesis supported by natural
anterior teeth, which would cause an teeth
unfavorable crown-to-root ratio on • Fixed and partial removable prostheses
periodontally involved teeth • Fixed prosthesis supported by natural
teeth and implants
TREATMENT PLAN
TREATMENT
PHASE 1: INITIAL PREPARATION
Figure 4.18
CT radiograph of mandible.
check the quality and quantity of bone and transitional removable partial denture by
the possibility of implant therapy. The radio- means of the Pattern resin centric record.
graph showed that it would be possible to Metal copings for the natural teeth and
place three implants on the right side, distal gold copings were then cast and fitted in the
to the first premolar, and a single implant on mouth and connected by Pattern resin for
the left side in the area of the second soldering. These were soldered together,
premolar (Figures 4.18-4.20). An acrylic refitted and a new centric relation record
resin surgical stent was prepared and used made. A polyether impression was then
during the implant placement, and three taken for tissue detail and a pick-up of the
Branemark implants were placed in the right fixed prosthesis in the maxilla in order to
posterior region of the mandible and one make a final master model. This was
between the left first premolar and the left mounted on a Hanau articulator by means
first molar (Figures 4.21 and 4.22). After 3 of a facebow registration (Figure 4.24) and
months, the implants were exposed and the Pattern resin registration on the soldered
abutments placed. New provisional restora- metal prosthesis. The shade was chosen
tions were made for the implants (Figure and porcelain baked to the metal. This was
4.23). fitted in the mouth and the occlusion
Copper band elastomeric impressions adjusted to the lower jaw. The porcelain was
were made of all the prepared teeth and then glazed and the prostheses on the
pattern resin copings made to fit the stone natural teeth cemented with Temp-Bond for
dies. These copings and transfer copings 2 weeks. The implant supported prostheses
for the implants were fitted in the mouth were screw retained (Figures 4.25-4.29).
and used to record centric relation at the
vertical dimension of occlusion of the provi-
sional restorations. A polyether full arch SUMMARY
impression was then taken of the maxilla
and the master model poured and This patient presented with a very severe
mounted to the mandibular model of the case of adult periodontitis. She also had
48 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 4.28
Figure 4.29
Treatment completed-permanent restorations, mandible.
CASE DISCUSSION
AVINOAM YAFFE
THE PATIENT
Figure 5.2
PAST MEDICAL HISTORY Face-frontal view (forced smile).
51
PROSTHODONTICS IN CLINICAL PRACTICE
• Parabolic arch
• Missing left third molar tooth
• Amalgam restorations on the molar teeth
Figure 5.12
Radiographs of maxilla and
mandible-pre-treatment.
both in centric (occlusion) and protru- teeth and up to 9.0 mm on the mandibular
sive jaw movements teeth with bleeding on probing on almost all
of the teeth. There was slight gingival reces-
Periodontal examination (Figures 5.10 and sion around most of the teeth. The maxillary
5.11) revealed calculus and plaque, probing left first premolar and left first molar had
depths of up to 8.0 mm on the maxillary class I furcation involvement on the mesial.
UNNOTICED PERIODONTAL DETERIORATION 55
Figure 5.16
Anterior teeth, orthodontic treatment to close spaces and
retract teeth.
PHASE 2
TREATMENT
Figure 5.18
I nitial treatment consisted of scaling, root Maxillary teeth showing provisional restoration.
planing, curettage, oral hygiene instruction,
and extraction of the mandibular right third
molar. At re-evaluation, after initial prepara-
tion, bleeding on probing had diminished to When the orthodontic treatment was
a great extent. However, the probing completed and the anterior spacing elimi-
depths remained deep and showed almost nated, the maxillary teeth from the second
no improvement (Figures 5.13 and 5.14). right premolar to the left cuspid were
I n order to increase vertical dimension to prepared for full coverage, and a provi-
enable posterior tooth eruption along with sional fixed restoration was inserted. At the
their supporting bone and provide space same time, the hopeless maxillary right
for maxillary anterior tooth retraction, a central incisor was extracted (Figure 5.18).
canine platform was constructed on the At the second re-evaluation, the
maxillary cuspid teeth (Figure 5.15). As recorded probing depths were greater than
eruption of posterior teeth took place, 5 mm and the decision was made to
orthodontic treatment was then started to undertake periodontal surgery (Figure
retract the maxillary anterior teeth and 5.19). The goal of the periodontal surgery
close the spaces (Figure 5.16). Lingual was to achieve an open clean-up and
buttons were placed on the first premolars pocket elimination. During the periodontal
and elastics were then used to close the surgery, the decision was made to resect
spacing between the teeth (Figure 5.17). To the disto-buccal roots of both second
prevent drifting of the elastics gingivally, molars in order to eliminate the trifurcation
composite stops were placed on the labial involvements of these teeth and improve
surfaces of the anterior teeth. This treat- their prognosis (Figures 5.20 and 5.21).
ment was accompanied by constant Selective grinding and reshaping of the
scaling, root planing, and curettage. Since buccal cusps of the maxillary molar and
the patient had a pulmonary valve regurgi- premolar teeth was performed to diminish
tation problem, this necessitated the use of the strong lateral forces upon them.
prophylactic antibiotics (ERIC: coated At the following re-evaluation, it was
erythromycin 1 g an hour before treatment, noted that the maxillary right first premolar
and 500 mg 6 hours after treatment) for still showed unacceptable probing depths.
each visit. Orthodontic treatment was then started to
58 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 5.20
Periodontal surgery, maxillary left posterior quadrant.
extrude the tooth and, it was hoped, the taking tissue from the palate (`pouch
supporting bone with it as a future implant technique') (Figure 5.23).
site development (Figure 5.22). After the Since the vertical dimension had been
orthodontic treatment, charting revealed increased during treatment, a minimal
that the probing depths were still occlusal adjustment was made to return
unchanged and it was then decided to the patient to her original vertical dimension
extract the tooth. Upon extraction, a crack of occlusion.
in the buccal root was seen along the At the final re-evaluation, it was deter-
palatal side, which explained why the tooth mined that probing depths and mobility
did not respond to all the treatment. had been greatly diminished, and the final
Periodontal surgery (soft tissue augmen- treatment was carried out. This included
tation) was then carried out in the maxillary fi nalizing the teeth preparations. Copper
central incisor area to reshape the area, band elastomeric impressions were made
UNNOTICED PERIODONTAL DETERIORATION 59
Orthodontic treatment to extrude maxillary first premolar. Maxillary right central incisor area-soft tissue graft, suturing.
of the prepared teeth, and stone dies and cemented in the mouth with Temp-Bond
pattern resin copings produced. These for a period of 2 weeks. The prosthesis
copings were fitted in the mouth and was then cemented permanently with
used to record centric occlusion, and a zinc oxyphosphate cement (Figures
polyether impression was taken for the 5.24-5.27).
working model. A master model was cast
from this impression with the stone dies in
place. This model was articulated to the SUMMARY
model of the mandibular teeth made with
an alginate impression. Metal copings The patient presented with what she
were then cast and fitted on the individual thought was a simple problem of a loose
prepared teeth with the pontics attached front tooth and the start of spacing in her
to the adjacent tooth. These were maxillary anterior teeth. Even though she
connected with pattern resin and had periodontal surgery 2 years previ-
soldered, and the soldered prosthesis ously, she was not aware of the impor-
fitted in the mouth. A centric record in tance of good oral hygiene and her
Duralay at the vertical dimension of occlu- periodontal condition had thus deterio-
sion was made in the mouth and another rated. The initial treatment consisted of
polyether full arch impression done for the oral hygiene instruction and scaling and
tissue details. This impression was cast curettage. When the probing depths did
and mounted to the lower model and the not improve, orthodontic treatment was
articulator by means of a facebow trans- initiated as well as periodontal surgery in
fer and the Duralay centric record. The order to eliminate the deep pockets
shade was chosen and the porcelain around the teeth. Even after this treat-
baked. The bridge was then fitted and ment, the maxillary first premolar did not
final adjustments were done in the mouth respond and had to be extracted. Only
in the biscque bake stage. The prosthesis then, it was discovered that the root was
was then glazed and temporarily cracked and thus had been untreatable.
60 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 5.24
Treatment completed-permanent restorations, left side.
Figure 5.27
Treatment completed-face, frontal view.
Figure 5.25
Treatment completed-permanent restorations, right side.
What appeared to be a relatively easy
treatment turned out to be rather involved,
with orthodontic therapy and periodontal
surgery needed in order to achieve an
esthetic and functional result.
CASE DISCUSSION
AVINOAM YAFFE
The patient, a male 49-year-old clerk, The patient clenches his teeth.
presented for dental treatment. His main
complaints were the following:
DIET
`I have difficulty eating.'
` My front tooth is loose and hurts when I The patient drinks about five mugs of
chew.' coffee and tea per day, with three
` The spaces between my teeth appear to teaspoons of sugar.
be getting bigger.' (Figures 6.1 and 6.2)
` Due to the spaces between my front
teeth, I have problems speaking clearly.' PAST DENTAL HISTORY
63
PROSTHODONTICS IN CLINICAL PRACTICE
EXTRA-ORAL EXAMINATION
( Figures 6.3 and 6.4)
Figure 6.5
I NTRA-ORAL AND FULL-MOUTH Maxillary arch.
PERIAPICAL RADIOGRAPH
EXAMINATION
• Flaring of the anterior teeth
Maxilla (Figure 6.5): • Palatal surfaces show wear facets
• Crown and root caries
• Resorbed alveolar ridges especially on
the left side (Figure 6.6)
• Flat hard palate
COMPLICATED ADVANCED ADULT PERIODONTITIS 65
Figure 6.6
Maxillary arch-left posterior quadrant.
Figure 6.7
Occlusal examination revealed that the
patient was Angle class II division I, with
Mandibular arch.
an overbite of 9.0 mm and an overjet of
4.0 mm The interocclusal rest space was
3.0 mm and, as noted, the maximum
opening between the incisors was
56.0 mm, which if added to the 9.0 mm
overbite would mean that the maximum
opening movement was actually
65.0 mm. There was no discrepancy
between centric occlusion (IC) and
centric relation (CR). Fremitus and mobil-
ity were evident on the anterior maxillary
teeth. There were two planes of occlu-
sion in the mandible and a marked step
i n the occlusal plane distal to the cuspid
Figure 6.8 teeth. There was loss of posterior
Mandibular arch-anterior teeth. occlusal support.
66 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 6.9
Radiographs of maxilla and
mandible-pre-treatment.
TREATMENT
Figure 6.24
Radiographs of patient-
post-treatment.
for function and esthetics. The removable removable denture supported by a fixed
maxillary partial denture and mandibular anterior bridge and a complete mandibu-
complete overdenture were processed. The lar overdenture on gold copings on the
restorations were then inserted and have remaining teeth.
been followed up since then with no deteri-
oration (Figures 6.20-6.24).
CASE DISCUSSION
AVINOAM YAFFE
SUMMARY
This was a challenging patient, being
The patient presented with a severe case effected both by caries and advanced
of advanced adult periodontitis, many periodontal disease complicated by loss
missing teeth, crowding, mobility and of posterior support, aggravated by drift-
fremitus of teeth, faulty restorations, and i ng and flaring of teeth. This case was
poor dietary habits. He was a clencher. treated by stretching the biological
He had difficulty in eating and was in response of the patient to its maximum,
pain. A compromise solution had to be allowing it to benefit from mechanical
found in this case because of the limited i mprovement by redirection of the forces
financial means available to the patient to improve the crown-to-root ratio and
for his dental treatment. He also wanted creating a flat occlusion to minimize lateral
to retain as many of his remaining teeth forces. The continued success of this
as possible. The solution consisted of treatment will be dependent on the
eliminating the infection, orthodontic cooperation of the patient, by controlling
treatment to improve tooth position, his oral hygiene as well as his diet. Thus
changing his dietary pattern, and the overall prognosis of this case is
construction of a partial maxillary guarded.
72 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 7.3
the anterior teeth and causing the food planing, and a periodontal re-evaluation, a
bolus to go down into the esophagus final treatment plan was then chosen which
before it had been triturated completely. consisted of selective grinding and
Consequently, the patient was orthodontic treatment to improve the
constantly dripping liquids from the occlusal relationship and close the existing
sides of his mouth spaces between the anterior teeth. This
• His difficulty in hearing (left side) and would improve the anterior tooth position
seeing (right side) made it more difficult and enable these teeth to participate in
to teach him proper oral hygiene vertical dimension support. Following the
orthodontic treatment a provisional full arch
fixed maxillary and mandibular prostheses
TREATMENT ALTERNATIVES would be done and carefully followed over
a period of at least 6 months to ascertain
Maxilla:
the ability of the abutment teeth to support
Fixed anterior partial prosthesis and a the fixed prostheses. If this phase was
removable posterior partial prosthesis, successful, complete arch maxillary and
supported by implants mandibular fixed prostheses would be
Fixed anterior partial prosthesis and a constructed.
removable posterior partial prosthesis,
supported by the anterior fixed prosthe-
sis with either clasps and rests, or TREATMENT
attachments Initial preparation included scaling, curet-
Fixed maxillary restoration as a short- tage, root planing, and oral hygiene instruc-
ened arch with only a premolar occlu- tion. At the end of this stage, an obvious
sion on the left side improvement in the soft tissue could be
Fixed maxillary restoration with a weak discerned. At this time a periodontal re-
terminal abutment on the right side evaluation was done and it was observed
that the pockets depths had greatly dimin-
Mandible: ished and that the bleeding on probing had
disappeared.
Fixed anterior partial prosthesis with
The orthodontic phase of treatment was
removable tooth supported posterior
then started using elastics to retract the
partial prosthesis
mandibular and maxillary anterior teeth
Fixed tooth and implant supported
(Figure 7.8) and close the spaces. This was
partial prosthesis
done in order to achieve better esthetics
Fixed partial prosthesis with the cuspid
and move the teeth into a better position in
as the terminal abutment on the left side
the alveolar bone for occlusal support and
Fixed mandibular restoration with a
with the intent to prepare the site for future
weak terminal abutment on the left side
development should implants be needed.
When the orthodontic stage was
successfully completed (Figure 7.9), the
TREATMENT PLAN
supporting teeth were prepared and
Following initial preparation, including oral temporary restorations were placed (Figure
hygiene instruction, scaling and root 7.10). Periodontal evaluation was again
ADVANCED PERIODONTITIS IN THE RELATIVELY YOUNG 77
The patient was healthy, and did not take any Asymmetrical face, with lower third
medication. He had no known sensitivity or being greater than the middle third
81
82 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 8.5
Radiographs of maxilla
and mandible, pre-
treatment.
Fremitus:
• Maxillary cuspids-grade II
• Maxillary left central incisor-grade III
• Left second premolar-grade III
• Left third molar-grade III
Mandibular anterior teeth-lingual view, showing calculus Maxillary anterior teeth showing periodontal inflammation.
accumulation.
Mandibular right posterior teeth showing calculus accumulation. Mandibular anterior teeth-labial view, showing calculus
accumulation.
TREATMENT
first maxillary premolar. When that stage was an acrylic stent with gutta percha points
completed, minor orthodontic treatment i n the areas that required implants (Figure
was undertaken to open up root proximity 8.18). The CT radiographs indicated that
between the right first maxillary premolar the bone type was class IV, and on the
and the right canine (Figure 8.14). At that l eft side, the width of the bone was
stage all the remaining maxillary teeth and i nadequate for implant placement. An
the mandibular teeth from the left third molar autogenous bone graft from the chin was
to the right cuspid were prepared for provi- placed on the left side 6 months before
sional restorations. On the left side, the the implant insertion. Two Branmark
second maxillary premolar was forced to i mplants (Nobel Biocare USA, Inc: Yorba
erupt. This was achieved by first separating Linda, CA) were then placed on each
the first and second premolars (Figure 8.15), side in the maxilla in the premolar and
and then by use of a coil spring. The second molar areas (Figure 8.19). In the right
premolar was extruded along with the side, self-tapping 15 and 13 mm long,
accompanying bone into position. This 3.75 mm diameter implants were used,
procedure eliminated the deep infrabony and on the left side self-tapping 12 mm
pocket around the second premolar (Figures l ong and 5.0 mm diameter implants were
8.16 and 8.17). i nserted.
Due to the severe gag reflex, and in spite of New provisional transitional prostheses
great effort on his part, the patient could not were then constructed after the uncovering
adapt to the provisional maxillary partial of the implants. At that point, copper band
removable prosthesis that was made for him, elastomeric impressions were taken of all the
and it was discarded. At that point it was prepared teeth and Duralay copings were
decided that a maxillary removable prosthesis made. These copings were used to record
was not viable, and the treatment plan of fixed centric relation at the vertical dimension of
maxillary posterior prostheses on implants the temporary restorations, together with the
was chosen. teeth position in the arch for the final impres-
Computerized tomographic (CT) radio- sion for the working model. A polyether
graphs were made of the maxilla utilizing complete arch impression in a custom tray
88 PROSTHODONTICS IN CLINICAL PRACTICE
was made to pick up the Duralay and was very difficult. Even though at the begin-
implant impression copings. The metal ning the patient was very satisfied with his
copings were then cast, fitted and soldered. appearance, as the treatment continued, he
After try-in of the soldered metal framework, became more and more involved in his treat-
another polyether impression was made for ment. The treatment was long and extensive,
tissue detail for the final master model. These encompassing a long initial treatment due to
models were mounted on a semi-adjustable the language barrier. Once the patient under-
articulator (Hanau) utilizing a facebow regis- stood the importance of good oral hygiene,
tration and centric records were taken at the he collaborated and became an important
vertical dimension of occlusion utilizing accessory to his care. The treatment
Duralay with a Neylon technique. The porce- extended over more than a 2-year period, but
lain was baked and the occlusion checked at both the patient and the dentist thought that
the biscuit bake stage in the mouth and all
adjustments needed were then made. The
porcelain was then glazed and the crowns
and bridges were cemented with Temp-
Bond on the prepared teeth for a period of 3
weeks. The implant-supported bridges were
screwed in to the implants and were not This 64-year-old-patient presented for
attached to the natural teeth supported treatment in the Graduate Prosthodontics
bridges. The crowns and bridges were then clinic. He had advanced adult periodonti-
permanently cemented with zinc oxyphos- tis which was complicated by missing
phate cement for permanent cementation teeth, decreased vertical dimension
(Figures 8.20-8.29). aggravated by deep bite and faulty
restorations with midline deviation. All
these findings demanded comprehensive
SUMMARY
i ntegrated treatment planning that
The patient presented with various problems. i ncluded orthodontic treatment for both
Due to a language problem, communication periodontal and teeth alignment problems,
Treatment completed-permanent restorations, left side. Post-treatment radiographs, maxillary right posterior area.
Figure 8.25
Figure 8.23
Figure 8.26
Figure 8.27
Post-treatment radiograph, maxillary left posterior area.
CASE DISCUSSION
HAROLD PREISKEL
and replaced by an implant. She was Smiling revealed spacing between the
seeking a fixed restoration on the implant. i ncisor teeth
Due to slight drooping of the left upper
li p, the patient exposed more of her
teeth on the right side than the left side
EXTRA-ORAL EXAMINATION
( Figure 9.3)
Caries
60% bone loss around the maxillary left
first molar
Spacing between the anterior teeth
Maxillary right first premolar rotated 90°
8.0 mm i mplant i n the first ri ght
mandibular area
Mid-line discrepancy of the maxillary
i ncisors
Figure 9.8
Radiographs of maxilla and mandible.
94 PROSTHODONTICS IN CLINICAL PRACTICE
right side of the maxilla, it was decided to re-evaluation was made and it was
rotate the maxillary premolar in order to observed that the pocket depths had
open space for an additional tooth to be greatly diminished, while bleeding on
placed. probing had disappeared.
Endodontic therapy was undertaken on
the palatal root of the maxillary left first
TREATMENT ALTERNATIVES molar; the mesial and disto-buccal tooth
roots were resected. The maxillary second
Maxilla: molar was also prepared and a transitional
fixed acrylic resin restoration was made
Fixed posterior partial prostheses (Figure 9.9). In the mandible, the right
Fixed anterior partial prosthesis and a second premolar and the right second molar
removable posterior partial prosthesis were prepared for fixed restorations and a
fixed transitional acrylic resin prosthesis was
Mandible: made (Figure 9.10). The implant in the right
mandibular first molar area was left
Fixed partial posterior prosthesis unexposed, in the bone.
Fixed tooth and implant supported Before the orthodontic phase of treat-
partial prosthesis ment started, a diagnostic set-up was
made, and the anterior maxillary teeth were
repositioned on a study model as a guide
TREATMENT for the treatment goal (Figure 9.11).
Using fixed brackets and a labial arch
Initial preparation included scaling, curet- wire, the maxillary incisor teeth were
tage, root planing and oral hygiene repositioned to their correct position (Figure
i nstruction. At the end of this stage, 9.12) They were then retained in this
an obvious improvement in the soft position utilizing a modified Hawley appli-
tissue could be discerned. A periodontal ance (Figures 9.13 and 9.14).
Wire splint for maxillary teeth retention (on model). Transitional restorations-anterior view.
Polyether maxillary impression of metal copings. Polyether mandibular impression of metal copings.
1 01
1 02 PROSTHODONTICS IN CLINICAL PRACTICE
• Caries
• Low maxillary sinuses
• 60% bone loss around some teeth
• Spacing between the anterior teeth
on some of the teeth, with the condition Anterior overjet and overbite.
SEVERE ADVANCED ADULT PERIODONTITIS 1 03
Figure 10.8
Mandibular periodontal chart. Figure 10.9
Radiographs of maxillary and mandibular anterior quadrant.
being more severe in the maxilla than the • The existing restorations were inade-
mandible. quate
• The patient refused to wear a remov-
able mandibular partial denture
I NDIVIDUAL TOOTH PROGNOSIS
TREATMENT POSSIBILITIES
Maxilla:
TREATMENT
then fitted and soldered and, after try-in of the mouth and all adjustments needed were then
soldered metal framework, another made. Rest preparations were then milled into
elastomeric impression was done for tissue the fixed prosthesis in the lingual of the right
detail and for the final master model. These molar area pontic as well as the distal surface
models were mounted on a semi-adjustable of the left cuspid. The porcelain was then
articulator (Hanau) utilizing a facebow registra- glazed and the final elastomeric impression for
tion and centric records were taken at the the removable mandibular partial denture was
vertical dimension of occlusion utilizing done. The framework for the partial denture
Duralay with a Neylon technique. At this point was then cast and fitted and a bite tray
the patient was finally convinced of the impor- constructed on it for centric registration
tance of a partial removable mandibular record. This was done and the denture teeth
denture and agreed to try and adjust to one. were set up and checked in the mouth for
The porcelain was baked and the occlusion esthetics and occlusion. The denture was
checked at the biscuit bake stage in the then processed (Figure 10.23). The crowns
1 08 PROSTHODONTICS IN CLINICAL PRACTICE
and bridges were cemented with Temp- Hebrew University Dental School of
Bond and the partial removable mandibular Medicine as a last resort. She had been to
denture inserted. The crowns and bridges three dentists who had all told her that it
were then cemented with zinc oxyphosphate would be impossible to save any of her
cement for permanent cementation (Figures remaining teeth and that she would need
10.24-10.29). complete dentures. She was told that there
The patient has been returning for follow- might be a chance to save some of her
up and maintenance twice a year since then teeth to support an overdenture, but only if
and adjusted to her removable mandibular she went to the Dental Clinic at Hadassah.
partial denture (Figures 10.30 and 10.31). The patient presented with a severe
problem of advanced adult periodontitis.
She had many missing teeth, considerable
SUMMARY
alveolar bone loss around the remaining
The 58-year-old patient came to the teeth, and faulty restorations in both jaws.
Graduate Prosthodontics Clinic of the There was much bone resorption but the
Figure 10.25
Case cemented-post-treatment, anterior view. Case cemented-maxilla.
probing depth around the remaining teeth at the optimum vertical dimension of occlu-
was not excessive, mostly 4.0 mm or less, sion for this periodontal condition. The
except for the right mandibular premolar patient was adamant about not having a
and the right maxillary second premolar removable prosthesis and refused to use
and third molar. Her fixed and removable one during the course of treatment. Only
restorations were inadequate and she when she was told that the case could not
hardly ever wore her removable partial be completed ending in a cuspid occlusion
mandibular denture. There was mobility on the left side, did she agree to try to use
and fremitus in the maxillary anterior teeth a removable partial mandibular denture.
and mobility of the mandibular anterior She successfully overcame her aversion to
teeth. the removable denture and today, 10 years
With orthodontic and periodontal treat- post-treatment, functions very well with her
ment accompanied by occlusal therapy, partial removable denture. As a compro-
the patient received a physiologic occlusion mise solution, the missing posterior
11 0 PROSTILODONTICS IN CLINICAL PRACTICE
mandibular teeth were replaced as pontics prognosis of the treatment and serving the
on a fixed prosthesis as opposed to the patient for the past 10 years with no signs
removable mandibular partial denture, as of breakdown.
we felt that the patient might not wear the
partial denture. If that did occur, at least
she would have full occlusion on the right
CASE DISCUSSION
side.
HAROLD PREISKEL
Commenting on a treatment plan with the
CASE DISCUSSION benefit of the successful 10-year follow-up
AVINOAM YAFFE i s relatively simple as it is hard to argue with
a good result. The treatment, however, was
This patient represents a complicated case far from straightforward. In addition to the
with advanced periodontal disease and problems of advanced periodontitis, lack of
missing teeth accompanied by drifting posterior support, flaring of the maxillary
and flaring of anterior teeth with mobility teeth, and caries, the operators were faced
and fremitus. The patient was treated with with a patient who adamantly refused to
the intent to address both the occlusal and wear a removable prosthesis. The fact that
periodontal problem that affected her they were able to undertake a comprehen-
periodontal condition. Once the occlusion sive plan of treatment and motivate the
was stabilized and with successful oral patient to the extent of wearing a remov-
hygiene instruction, scaling and curettage, able prosthesis, is eloquent testimony to
the periodontal condition improved consid- their communication skills as well as their
erably-to such an extent that there was clinical expertise. Bearing in mind that the
no need for any surgical periodontal proce- patient was treated in the early 1990s, the
dures. The new position of the anterior use of orthodontics to improve a potential
teeth enabled them to participate in i mplant site must be considered well ahead
occlusal support, thus improving the of its time.
112 PROSTHODONTICS IN CLINICAL PRACTICE
which the buccal outer line angle of the The periodontal examination (Figures
mandibular supporting cusp was lingual to 11.5 and 11.6) revealed probing depths of
the functional outer aspect (FOA) of the up to 5.0 mm on the maxillary teeth and up
maxillary supporting cusp (Figures 11.3 to 10.0 mm on the mandibular teeth, with
and 11.4). There was no discrepancy bleeding of the gingiva on probing (BOP)
between centric occlusion (IC) and centric on most of teeth, with the condition being
relation (CR). Fremitus and mobility were more severe in the mandible than the
found on several teeth. maxilla (Figures 11.7-11.9).
Figure 11.7
Radiographs of maxilla and
mandible-pre-treatment
TREATMENT
FINAL TREATMENT PLAN
Initial preparation included scaling, curet-
A final treatment plan was then chosen tage, root planing and oral hygiene instruc-
which consisted of orthodontic treatment to tion. At the end of this stage, an obvious
improve the occlusal relationship, a fixed
improvement of the soft tissue could be
discerned (Figure 11.10). At this time a
periodontal recharting and evaluation was
done and it was observed that the pockets
depths had greatly diminished and that the
bleeding on probing had disappeared
(Figures 11.11 and 11.12).
The orthodontic phase of treatment was
then started using a Hawley bite plane
Figure 11.10
retainer (Figure 11.13), the goals of which prepared and transitional (provisional) res-
were to increase the vertical dimension of torations were placed (Figure 11.16).
occlusion, add occlusal support, induce Radiographs and periodontal evaluation
muscular relaxation, and make sure that were again performed and disclosed that
retruded cuspal position (RC) and intercus- the probing depth were less than 3.0 mm
pal position (IC) were co-incidental. i n all areas except the mandibular second
The maxillary incisor teeth, despite their right molar. A transitional removable maxil-
hopeless prognosis, were also treated l ary partial denture was also fabricated to
orthodontically to extrude them in order to get the patient acclimated to a removable
achieve better esthetics and prepare the site prosthesis (Figure 11.17).
for future development if implants were to be Periodontal surgery was performed on
used in the future (Figures 11.14 and 11.15). the mandibular right second molar for
When the orthodontic stage was success- pocket elimination; it was decided that the
fully completed, the supporting teeth were tooth was hopeless and it was thus
SEVERE ADVANCED ADULT PERIODONTITIS 117
bridges were cemented with Temp-Bond missing teeth, scissors bite, and loss of
and the partial removable maxillary denture posterior occlusal support. With orthodon-
i nserted. The crowns and bridges were tic and periodontal treatment accompanied
then cemented with zinc oxyphosphate by occlusal therapy, the patient received a
cement for permanent cementation physiological occlusion at the optimum
(Figures 11.27-11.30). vertical dimension of occlusion.
The patient has been returning for follow-
up and maintenance twice a year.
CASE DISCUSSION
AVINOAM YAFFE
SUMMARY
This patient was a relatively young individ-
The patient presented with a severe ual, 46 years old, with a complicated dental
problem of advanced adult periodontitis, situation due to many missing teeth, and
1 20 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 11.30
Post-treatment radiographs
loss of support, accompanied by a deep the periodontal disease which would have
overbite and aggravated by a scissors bite been aggravated by the increased vertical
that along with a severe periodontitis dimension. The orthodontic treatment also
caused a total loss of vertical support. included future site development before the
There were several alternative methods extraction of the maxillary central incisor
of treatment possible for this patient: teeth. All this, along with the esthetic
considerations, contributed to the
An overlay partial denture successful treatment of the patient.
A removable partial denture after
extraction of the maxillary anterior teeth
Orthognathic surgery
the patient motivation achieved and upon decision involves the missing maxillary
the successful outcome. It is always impor- molars. Is it necessary to replace them or
tant to have a fallback position in case the could a shortened arch be accepted? The
patient's interest wanes and a simpler plan shortened arch would be far simpler from the
can be substituted. The step-by-step prosthodontic point of view, for no-one
approach employed has considerable should underestimate the complications of
advantage in this respect. producing a removable prosthesis. The
Another laudable aspect of the therapy maxillo-mandibular relations of this patient
was an appreciation of the three-dimensional helped make the decision to replace the
problems associated with a marked discrep- missing maxillary molars, leaving open the
ancy of arch size. At an early stage it was possibility of employing a distal cantilever
i mportant to establish how much of the pontic on each side to produce some molar
deranged occlusion was as a result of loss of support without the need for a denture.
posterior occlusal support and how much as However, it can be seen that the upper left
a result of the decrease of vertical dimension second pre-molar is root filled and we know
of occlusion. Of course the two are inter- from the work of Glantz and others that the
related, with a decrease of vertical dimension prognosis of a restoration with a distal
accentuating the effect of a forward cantilever pontic is not good when the distal
mandibular posture. The use of transitional abutment is root filled. The clinicians there-
restorations to determine maxillo-mandibular fore elected to construct a partial denture
relationships is an important aspect of the with all the difficulties involved, to say nothing
treatment. Forward thinking has also been of the maintenance requirements. They
demonstrated with the extrusion of anterior ensured that the patient understood the
teeth to be subsequently extracted to rationale of the treatment from the outset.
encourage bone growth for possible implant I ndividual techniques are simply tools of
placement at a later date. our trade; it is the planning and results that
Alternative avenues of approach were matter. This patient's treatment represents
discussed at the very outset. Having both a success in patient education and in
selected root-supported fixed prosthodon- clinical dentistry. I hope that the patient
tics as the primary support, a difficult returns for routine maintenance.
PATIENT 12 REFUSAL OF
ORTHOGNATHIC SURGERY
Treatment by Miriam Calev
The patient, a 26-year-old housewife, came Past dental history was non-contributory.
to the clinic for consultation. Her com-
plaints were as follows:
' Everything related to my mouth bothers
me.' (Figure 12.1) EXTRA-ORAL EXAMINATION
`I am missing lots of teeth.' (Figures 12.2 and 12.3)
' My front teeth stick out.'
' My palate hurts.' Symmetrical face
' Due to my fear of dentists, I have Competent lips
neglected my teeth for many years.' Slightly convex profile
Accentuated labio-mental fold
Normally functioning temporomandibu-
l arjoints
Maximum opening 42 mm without
The medical history was non-contributory. deviation
1 25
126 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 12.4
Figure 12.3
Face-side view
I NTRA-ORAL EXAMINATION
FIGURE 12.1U
Radiographs of maxilla and
mandible-pre-treatment,
periapical
Figure 12.11
Radiographs of maxilla and
mandible-pre-treatment,
panoramic
POTENTIAL TREATMENT
PROBLEMS
but would require pre-implant surgery. The • Orthodontic treatment for uprighting
problem of the rampant caries had to be and realigning teeth
overcome before any permanent restora- • Re-evaluation and planning of pre-
tions were undertaken. prosthetic periodontal surgery
New provisional fixed acrylic restora-
tions at the new vertical dimension of
TREATMENT POSSIBILITIES occlusion in order to check patient
adaptation
Maxilla: Re-evaluation
Fixed partial prostheses for both the
Fixed and removable partial prostheses maxilla and the mandible
Fixed partial prosthesis supported by
remaining teeth and implants (would
necessitate pre-implant surgery) TREATMENT
Fixed prosthesis
Orthognathic surgery, orthodontic treat- I nitial preparation included oral hygiene
ment and fixed prosthesis i nstruction, scaling, and curettage. Canine
platforms were then built on the lingual
Mandible: surfaces of the maxillary cuspid teeth
opening the vertical dimension of occlusion
Fixed partial prosthesis by approximately 2.5 mm (Figure 12.13).
Fixed partial prosthesis supported by This allowed healing of the palatal gingiva
remaining teeth and implant by preventing i mpingement of the
mandibular anterior teeth on the palate
( Figure 12.14).
Endodontic treatment was performed on
TREATMENT PLAN
the maxillary left third molar and the
I NITIAL PREPARATION mandibular left second molar. Caries
removal and provisional restorations were
• Dietary changes done where indicated. At this time the
• Oral hygiene instruction anterior maxillary splint was sectioned and
• Fluoride rinses and gel application removed (Figure 12.15). Transitional acrylic
• Changing the vertical dimension to crowns were then made for these teeth
relieve the palatal tissue impingement ( Figure 12.16). CT radiographs were then
• Caries removal taken of the maxilla to determine the
• Referral for endodontic therapy amount and quality of bone available for
• Evaluation of patient cooperation i mplant placement (Figures 12.17 and
• Referral for computerized tomography 12.18). After extraction of the maxillary right
( CT) radiographs to determine implant premolars, the remaining maxillary teeth
possibility were then prepared for full crowns and
• Restorative treatment with restorations transitional fixed partial prostheses
and provisional fixed acrylic restorations constructed (Figures 12.19 and 12.20).
for the teeth with a sizeable loss of Re-evaluation at this time showed that
tooth structure the bucco-lingual jaw relationships on the
REFUSAL OF ORTHOGNATHIC SURGERY 1 31
right side had worsened with the opening of The first option was chosen and
the vertical dimension. Therefore there orthodontic treatment was instituted to
remained two options for restoring the upright the mandibular third molar (Figure
mandible on the right side. The first option 12.21). At this time, a further re-evaluation
was orthodontic uprighting of the mandibu- was done. It was decided that due to the
lar third molar and then a fixed partial relatively young age of the patient (26), the
prosthesis from the second premolar to the fact that she did not want implants, and
third molar to replace the missing molar that there was only a relatively small span
teeth. The second option would be to to be restored on the mandibular right
implant a single wide body implant in the side, a fixed partial prosthesis was
area of the mandibular right first molar and chosen.
then do a fixed restoration on it, thus not Periodontal surgery was performed in
i nvolving the third molar in posterior support. the anterior segment of the maxilla in order
REFUSAL OF ORTHOGNATHIC SURGERY 1 33
SUMMARY
The patient presented with a severe
problem of Angle class II deep bite with
i mpingement of the palatal tissues by the
mandibular anterior teeth. She had missing
and malpositioned teeth. There was a loss
of vertical dimension and malocclusion
complicated by rampant caries. All these
factors made it mandatory to open the
vertical dimension in order to restore the
Figure 12.28 patient to a healthy and physiological
Centric relation record on pattern resin copings at new
occlusion. This would worsen the occlusal
vertical dimension relationship and prevent anterior occlusal
support. By means of limited orthodontic
treatment and modification of the occlusal
Full arch polyether impressions were relationships, we were able to give the
made for tissue detail. The models were patient a fixed restoration that included the
then mounted on a Hanau articulator with support of many of the remaining teeth,
the aid of a face bow registration, and the thus giving the patient a functional and
porcelain was baked. esthetic solution to her dental problems.
The final and minute adjustments of the
biscuit bake porcelain were carried out in
the mouth. The final glaze was applied to CASE DISCUSSION
the prostheses, and the prostheses were AVINOAM YAFFE
cemented with Temp-Bond for a period of
2 weeks. They were then cemented with The patient presented to our clinic with a
zinc oxyphosphate cement for permanent complicated situation of missing teeth,
cementation (Figures 12.29-12.32). rampant caries, loss of the coronal tooth
REFUSAL OF ORTHOGNATHIC SURGERY 1 35
Figure 12.31
Treatment completed-radiographs, maxilla
Figure 12.32
Treatment completed-radiographs, mandible
1 36 PROSTHODONTICS IN CLINICAL PRACTICE
structure in most of the remaining teeth, surgery, to which the patient objected. She
loss of vertical dimension and soft tissue received a functional physiologic and
i mpingement causing suppuration. The esthetic solution to an almost impossible
treatment of choice should have been problem.
orthognathic surgery, but the patient
refused to undergo this. This situation
presented us with a challenge, which CASE DISCUSSION
would be difficult to cope with. By using the HAROLD PREISKEL
canine platform as a tool, and guide, we
changed the vertical dimension to a The management of this patient's treatment
workable situation and worked out the demonstrates what can be achieved using
occlusal relationships and occlusal scheme conventional periodontal and prosthodon-
to this pre-determined scheme. We aimed tic therapy when orthognathic surgery is
at including as many teeth as possible to contraindicated or unwanted by the
participate in occlusal support using patient. The key to rebuilding the occlusal
adjunctive orthodontics and including the scheme appeared to rest with the clever
canine teeth in support and guidance by use of the upper canines as a platform. Of
the placement of platforms on both the course without the patient's motivation, the
maxillary and mandibular canine teeth. endodontic therapy, and the periodontal
The periodontal surgery performed to therapy, nothing would have been of avail.
reach both sound tooth structure and a The combination of motivation, clever
pleasant appearing smile in the anterior planning, and meticulous execution of
region was successful. In this patient, the relatively conventional techniques appears
almost impossible has been achieved to have produced a good-looking and
without orthognathic surgery and implants functional occlusion that I hope will last for
that would have required pre-prosthetic years.
1 38 PROSTHODONTICS IN CLINICAL PRACTICE
Parabolic arch
Mesial inclination of the left second and
third molars
Amalgam restorations on the posterior
teeth
Missing teeth:
7643 56
Provisional acrylic crowns on the central
i ncisors Figure 13.8
Deep caries: Occlusion-left side
Figure 13.11
Radiographs of maxilla and
mandible-pre-treatment
8.0 mm on many of the mandibular teeth. molars had class I-II furcation involvement
There was bleeding of the gingiva on on the mesial and distal surfaces. The
probing on all the teeth. There was slight maxillary first premolar had both class III
gingival recession around some of the mesial and lingual furcation involvement.
teeth. Class 1 mobility was found on the The mandibular molars had class I furcation
mandibular incisor teeth. The maxillary i nvolvement on the buccal surfaces.
TREATMENT WITH LIMITED FINANCIAL RESOURCES 141
TREATMENT PLAN
PHASE 1: INITIAL PREPARATION
remaining teeth were endodontically treated maxilla. During the surgery, it was decided
(Figure 13.14). Due to crown proximity, to extract the maxillary left first premolar
orthodontic treatment was performed to due to the extensive furcation involvement
separate the left cuspid from the first (class III).
premolar (Figures 13.15 and 13.16). The The second re-evaluation was now done
remaining teeth were then prepared, provi- and revealed that the probing depths had
sional acrylic copings were made and a greatly diminished and the bleeding on
transitional removable partial overdenture probing had disappeared. Except for the
was made (Figures 13.17 and 13.18). mandibular right lateral incisor (class I
Periodontal surgery (open flap curettage) mobility), there was no mobility of the teeth
i n order to reduce pocket depths as well as ( Figures 13.19 and 13.20).
to determine the prognosis of the left first The disto-buccal roots of the maxillary
premolar was then performed in the first molars were amputated and the
1 44 PROSTHODONTICS IN CLINICAL PRACTICE
also then used for a centric relation record resin registration on the soldered metal
at the vertical dimension of occlusion of the prosthesis. The shade was chosen and
provisional restorations. This was done by porcelain baked to the metal. This was
cutting the provisional bridge between the fitted in the mouth and the occlusion
central incisors and leaving one side in adjusted to the lower jaw.
place, while recording the centric relation in At this point, impressions were done to
Pattern resin on the copings on the other make magnetic copings for the remaining
side. The provisional remaining bridge was l ower teeth. These were fitted and
then removed and the vertical dimension cemented into place (Figure 13.22). A final
recorded on the Pattern resin copings while i mpression in a custom tray was taken of
on the contralateral side, the Pattern resin the mandible and cast in albastone. A
copings maintained the vertical dimension chrome cobalt metal framework was then
of occlusion. A polyether full arch impres- cast and fitted in the mouth.
sion was then taken of the maxilla, the An acrylic and wax bite tray was then
master model was poured and mounted to made on this model over the metal frame-
the mandibular model of the transitional work and fitted in the mouth. The centric
removable partial denture by means of the relation record was then taken at the estab-
Pattern resin centric record. l i shed vertical dimension of occlusion. This
Metal copings were then cast and fitted model was then mounted on the articulator
i n the mouth and connected by Pattern by means of the bite tray with the centric
resin for soldering. These were soldered record. The mandibular teeth were then set
together, refitted and a new centric relation up (Figure 13.23) and checked in the
record made. A polyether impression was mouth. The denture teeth were made of
then undertaken for tissue detail and a porcelain in order to match the material in
pick-up of the fixed prosthesis in order to the fixed prosthesis in the maxilla.
make a final master model. This was The mandibular removable partial
mounted on a Hanau articulator by means denture was processed and inserted. The
of a facebow registration and the Pattern maxillary fixed prosthesis was glazed and
1 46 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 13.25
Radiographs of completed treatment, maxilla
Figure 13.26
Radiographs of completed treatment, mandible
TREATMENT WITH LIMITED FINANCIAL RESOURCES 14 7
1 49
1 50 PROSTHODONTICS IN CLINICAL PRACTICE
the condition of his teeth before the The temporomandibular joints were
assault, but thought that some of them asymptomatic but the patient had
had crowns. Following his assault, his limited mandibular movements
mandible was fixated with a titanium mesh There was a deviation to the left at the
and intra-arch wiring for one month at the end of the jaw opening movement
Department of Oral and Maxillofacial The maximum opening between the
Surgery at Hadassah. After removal of the incisors was 50 mm, measured from
wiring, he was not able to open his mouth the mandibular incisal edge to the
more than 26 mm as measured at the incisal papillae
maxillary and mandibular central incisor Straight profile
teeth. Physiotherapy brought about
gradual improvement of the condition.
I NTRA-ORAL AND FULL-MOUTH
PERIAPICAL RADIOGRAPH
EXTRA-ORAL EXAMINATION EXAMINATION
( Figures 14.3 and 14.4) (Figures 14.1,14.2,14.5-14.9)
Caries
Extensive bone loss around some
teeth
Titanium mesh in the left mandible
Tipping and rotation of some teeth
Nasopalatine duct cyst
Periapical abscesses around some
maxillary teeth
• The interocclusal rest space was
3.0 mm
Restricted mandibular movements
Figure 14.7 Discrepancy between centric occlusion
( CO) and centric relation (CR) of
Anterior mandibular teeth-lingual view, close-up
0.5 mm, with an anterior slide
I n all lateral excursions, contact was on
second premolar, and the left second the right side, on the maxillary and
and third molars mandibular premolars and molars
The large scar on the inner left side of • I n protrusive movements, contacts
the cheek severely limited the opening were between the maxillary and
of his mouth mandibular right molars
High palate and loss of soft tissue and
bone in the anterior part of the maxilla Periodontal examination revealed poor oral
( Figure 14.5) hygiene accompanied by large amounts of
Mandibular left second and third molar, plaque and calculus (Figure 14.7), probing
ri ght first molar, and the right central depths of up to 4.0 mm on the maxillary
i ncisor teeth were missing teeth and up to 5.0 mm on the mandibular
The anterior teeth were rotated and teeth (mandibular left third molar), with
crowded. The lower left third molar was bleeding of the gingiva on probing on some
covered by soft tissue (Figure 14.6) of the teeth (Figure 14.8).
PROSTHODONTICS IN CLINICAL PRACTICE
Figure 14.9
Radiographs of maxilla
and mandible-pre-
treatment
Figure 14.10
Radiographs of maxilla-anterior teeth, pre-treatment
TRAUMATIC SEQUELAE 1 53
lateral incisor, and a maxillary fixed partial the end of this stage, significant improve-
prosthesis supported by implants from the ment of the soft tissue could be discerned
ri ght maxillary central incisor to the left maxil- ( Figures 14.11 and 14.12). At this time,
l ary second premolar. A crown was also to periodontal re-charting and evaluation
be fabricated for maxillary left first molar demonstrated that the pockets depths had
tooth. The missing mandibular right first diminished greatly and that the bleeding on
molar would not be replaced. probing had disappeared.
Endodontic therapy was performed on
the maxillary right cuspid and maxillary left
TREATMENT first molar. The mandibular left first premo-
l ar and right third molar and left second
I nitial preparation included scaling, curettage, molar were restored with amalgam restora-
root planing and oral hygiene instruction. At ti ons. The maxillary right lateral incisor,
TRAUMATIC SEQUELAE 155
Wax-up of maxillary anterior crowns-frontal view Wax-up of maxillary anterior crowns-left side
the central incisor as a cantilever (Figure was an extension of granulation tissue from
1 4.22). The implants had been placed in a the failed implant in the maxillary right
curve and thus provided resistance to central incisor area.
multidirectional forces. Copper band elastomeric impressions were
During the course of treatment, it was made of all the prepared teeth and Duralay
discovered that the maxillary right cuspid copings were constructed. These copings
had a periapical lesion. The tooth was were used for the final impression for the
asymptomatic, was not sensitive to percus- master model and to record centric relation at
sion, and did not have deep probing the vertical dimension of the temporary
depths. An exploratory surgical procedure restorations (Figures 14.23 and 14.24).
revealed granulation tissue around the root Unfortunately, at the metal coping fitting
apex, which was enucleated. It was stage, a fistula was noticed round the
thought at that time that the periapical area maxillary right cuspid and a 10 mm probing
15 8 PROSTHODONTICS IN CLINICAL PRACTICE
SUMMARY
CASE DISCUSSION
The patient presented with a variety of AVINOAM YAFFE
problems. Due to his unfortunate accident,
he had been left with scalp wounds, The patient, a 44-year-old male, was
fractures of the right side of his skull and referred for treatment at the Graduate Clinic
the left mandible, left maxillary sinus following a traumatic injury that changed
hemorrhage, lacerations of the cheek, and overnight his general well-being and
1 60 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 14.31
Post-treatment radiographs
primarily affected his masticatory system. to provide some fixation for the bridge
He was a very pleasant and accommodat- during lateral movements.
ing patient who adjusted easily to the The restorations were monitored very
constant changes in his treatment plan. He carefully during the last 2 years and it is our
did, however, insist on having a fixed hope that the customized restoration,
restoration, and was willing to go through along with meticulous planning of the
whatever procedures were needed to occlusion, will provide many years of lasting
achieve this goal. The treatment plan had service. It was also planned that, in the
to be modified during treatment and even future, if the teeth supporting the maxillary
at a final stage, due to unexpected compli- prosthesis on the right side were to fail,
cations. In the final treatment, a fixed additional implants would be implanted and
prosthesis was fabricated and special their prosthesis would be connected to the
emphasis was placed on the occlusal existing implant-supported prosthesis.
scheme to protect both the natural teeth
and the implants. A non-working contact
that existed on the right side during lateral CASE DISCUSSION
j aw movements was adjusted to a situation HAROLD PREISKEL
that maintained contact there, while at the
same time kept working contacts on the A particularly interesting facet of this
implants on the left side. The semi- patient's treatment represents his reaction
precision attachment between the implant to the appalling physical injuries he
and tooth-supported bridges was intended received. It is apparent that before the
TRAUMATIC SEQUELAE 1 61
attack the state of his dentition was not of and obliged the patient to be without his
particular interest to him. One might have removable prosthesis for some time. The
expected the inevitable psychological net result was that the implants were
reaction to his experience to have made positioned slightly palatal to the ideal
him even less interested in looking after his position, but in a perfectly acceptable
teeth. Quite the reverse happened, and I relationship. The price to pay was the need
am confident that the team treating him to construct the facial surfaces of the
had a significant influence upon his restorations considerably labial to the
attitude: they are to be congratulated. implant which, in turn, leads to a mainte-
I t is also intriguing to note that the patient nance problem. It is encouraging that so far
insisted on a fixed maxillary prosthesis the patient has maintained a good level of
despite the fact that such an approach plaque control and his motivation has not
both complicated and lengthened the waned.
treatment, compromised the esthetics Connecting the maxillary-implant-
(although not by very much), and made supported section to the tooth-supported
maintenance far more difficult. The step- prosthesis by means of a semi-precision
by-step approach employed provided retainer is not universally accepted. There
versatility that was put to good use to have been suggestions that there is a
overcome a few unexpected events. In a serious risk of intrusion of the tooth-
l ong and complex course of treatment, we supported section. Only time will tell and I
all receive the occasional surprise. look forward to an update. From every
I quite understand why a premature onlay point of view, the operators are to be
graft was not employed, since this would congratulated on the outcome of this
have complicated the treatment still further patient's treatment.
1 64 PROSTHODONTICS IN CLINICAL PRACTICE
EXTRA-ORAL EXAMINATION
(Figures 1 5.4 and 15.5)
INTRA-ORAL EXAMINATION
(Figures 15.6 and 15.7)
• Scarring of the tissue from the surgery ( CR). The lateral jaw movements were in
to decrease the size of the chin group function. In protrusive movements,
there was complete balance. There were
An occlusal examination revealed that balancing side interferences in lateral
the patient was Angle class III modification movements. There was fremitus class I on
2 according to Ross (Figures 15.8 and the maxillary incisor teeth, and a faulty
1 5.9). There was a reversed overbite of occlusal plane.
1.0 mm and an overjet of 1.0 mm. The
i nterocclusal rest space was 8.0 mm and The periodontal examination revealed plaque,
the maximum opening between the calculus, inflammation around most of the
i ncisors was 46 mm, with an `S' deviation teeth, probing depths of up to 9.0 mm on the
i n opening or closing movements. There maxillary teeth and up to 7.0 mm on the
was a 2.0 mm discrepancy between mandibular teeth, with bleeding on probing
centric occlusion (CO) and centric relation on some teeth (Figures 15.10 and 15.11).
1 66
SUMMARY OF FINDINGS
DIAGNOSIS
SUMMARY
Figure 15.23
Treatment completed-permanent restorations The patient presented with a severe
problem of extreme wear on many teeth
and a reduced vertical dimension of occlu-
Centric relation was recorded in Duralay sion. She also had a pathologic occlusion
( Figure 15.22), and another elastomeric with serious balancing side and protrusive
impression was made for tissue detail. The premature contacts during mandibular
models were then mounted on a Hanau movements. In addition to these problems,
articulator, again with the aid of a facebow she suffered from a severe periodontal
registration, and the porcelain was baked. problem and was very concerned about
Models of the transitional restorations her esthetics. The treatment consisted of
provided a buccal key for the position and changing the vertical dimension of occlu-
shape of the porcelain, thus copying the sion by selective grinding and addition of
transitional restorations. The biscuit bake restorative material, where needed, in order
porcelain was checked and adjusted in the to provide a physiological occlusion. The
mouth. After the occlusion was finalized, final restorations thus provided a physio-
the final glaze was applied to the prosthe- logical, functional and esthetic solution for
ses. The prostheses were cemented with her problems.
A NEW VERTICAL OCCLUSION 1 71
Figure 15.24
Post-treatment radiographs
Figure 16.3
Mandibular arch
Figure 16.2
Figure 16.7
Radiographs of maxillary and
mandibular teeth
POTENTIAL TREATMENT
DIAGNOSIS PROBLEMS
Figure 16.16
Soldered metal copings being fitted-mandible
PHASE J
tissue duplication (Figure 16.18). At the parotid gland. His face drooped, and was
same time, a soft wax occlusal record was asymmetrical. The mandibular anterior teeth
taken to mount the model on the articula- exhibited class 3 mobility, which gave a
tor (Figure 16.19). Teeth were set up on the poor prognosis for their long-term retention.
partial denture and fitted in the mouth. The He had rampant caries, related to his
porcelain was then glazed. The crowns and medical history, and many broken teeth. His
bridges were cemented with Temp-Bond vertical dimension of occlusion was
and the removable mandibular partial overclosed and he was traumatizing the
prosthesis inserted. The crowns and anterior palatal tissue when closing his
bridges were then cemented with zinc mouth. The patient requested a fixed
oxyphosphate cement for permanent prosthesis, even though during treatment
cementation (Figures 16.20-16.22). A he agreed to accept a removable prosthe-
complete series of radiographs was done sis. I n the course of treatment many
after completion of treatment (Figures problems arose, and his treatment had to
1 6.23-16.25). be adjusted to the new circumstances. In
spite of all these problems, an excellent
result was achieved using a combination of
SUMMARY fixed and removable prostheses.
The patient, a 70-year-old retired school
principal, presented with many varied CASE DISCUSSION
problems. He had undergone a number of AVINOAM YAFFE
surgical procedures to remove a pleomor-
phic adenoma, which left him with perma- The patient, a 70-year-old male,
nent facial nerve damage and loss of the left presented to the clinic for treatment. He
1 82 PROSTHODONTICS IN CLINICAL PRACTICE
EXTRA-ORAL EXAMINATION
PAST MEDICAL HISTORY (Figures 17.2 and 17.3)
The patient suffered from a peptic ulcer for • Asymmetrical face on right side due to
which he was taking medication (Gastro unilateral cleft lip and palatal scar, and
40 mg daily) and congenital unilateral cleft lip nose deformity
Figure 17.2
Figure 17.1
Face-frontal
Maxillary arch-palatal view
view
185
186 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 17.4
Face-side view
Competent lips
Straight profile with slight concavity and
depression of the nose
Normally functioning temporomandibu-
lar joint, with bilateral clicking on
opening
Maximum opening 38 mm, with a slight
deviation to the left upon opening
Negative overbite of 8.0 mm
Figure 17.5
Enlarged lower third of the face
Anterior teeth-labial view
SEVERE UNILATERAL CLEFT LIP AND PALATE 1 87
Figure 17.7
Figure 17.6
Occlusion-left side
Occlusion-right side
Occlusal examination revealed that the cuspids, and left second molars.
patient was Angle class III (Figures Occlusal balancing side and protrusive
17.5-17.7), with a reverse overbite of 8.0 premature contacts during lateral and
mm and a reverse overjet of 3.0 mm. protrusive mandibular movements were
There were wear facets on the right noted.
second premolar and second molars.
The interocclusal rest space was Periodontal examination (Figures 17.8
3.0 mm, measured between the incisors. and 17.9) revealed unsatisfactory oral
There was a slight discrepancy between hygiene with plaque and calculus.
centric occlusion ( CO) and centric Probing depths were found of up to
relation (CR). Anterior and bilateral poste- 4.0 mm on the maxillary teeth and up to
ri or cross-bite was found. Centric 3.0 mm on the mandibular teeth, with
occlusal contacts were found on the right bleeding on probing on some teeth. There
second molars, right maxillary cuspid to was inflammation around most of the
ri ght mandibular first premolar, l eft teeth.
188 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 17.10
Radiographs of maxilla and
mandible-pre-treatment
He presented with poor oral hygiene, significance of proper oral hygiene and its
plaque, gingival inflammation, and shallow i mportance in his treatment.
and intermediate probing depths. He had
deep caries, residual roots, crowded
anterior mandibular teeth, defective POTENTIAL TREATMENT PROBLEMS
endodontic treatment and restorations.
There were periapical lesions around four Cleft lip and palate:
mandibular teeth and occlusal interfer- • Scarred lip
ences during lateral and protrusive • Esthetic problems
mandibular movements. • Limited opening
Oronasal fistula:
DIAGNOSIS • Breathing problems
• Eating problems
• Cleft lip and palate (oronasal fistula) • Phonetic problems
(status post surgery)
• Angle class III with anterior and bilateral Underdevelopment of the maxilla:
posterior cross-bite accompanied by • Missing teeth
severe interarch discrepancy • Jaw discrepancy
• Faulty occlusal relationship, and faulty • Failure of osseous union
occlusal plane
• Carious lesions Arch level
• Defective restorations and endodontic Maxilla:
treatment (periapical lesions)
• Crowded anterior mandibular teeth • Few remaining teeth with unfavorable
• Poor esthetics distribution and malposition of the right
• Gingivitis cuspid
• Reduced anterior and posterior • Open oronasal fistula
support
Mandible:
• Reduced vertical dimension
• Residual root • Remaining teeth had poor prognosis
due to caries and defective restorations.
removable gold foil prosthesis was then concerned about esthetics. The treatment
made to seal the oronasal fistula by attach- was further complicated by the severe
i ng it to the fixed prosthesis by means of Angle class III jaw relationships and the
the precision attachment. negative overbite and overjet. Another
Full arch polyether impressions were problem was that the patient had no under-
made for tissue detail. The models were standing of good oral hygiene. Due the
then mounted on a Hanau articulator with decision after consultation with the plastic
the aid of a facebow registration (Figure surgery and oral and maxillofacial surgery
17.21) and the porcelain was baked. The departments, that additional surgery would
final and minute adjustments of the biscuit- not contribute to the success of the treat-
bake porcelain were carried out in the ment and would only cause more trauma
mouth. The final glaze was applied to the to the patient, surgery was not performed.
prostheses, and they were cemented with
Temp-Bond for a period of 2 weeks. They
were then cemented with zinc oxyphos-
phate cement for permanent cementation
(Figures 17.22-17.26).
SUMMARY
Figure 17.25
Radiographs-post-treatment, maxilla
Figure 17.26
Radiographs-post-treatment, mandible
SEVERE UNILATERAL CLEFT LIP AND PALATE 195
Treatment consisted of oral hygiene oronasal fistula. A gold foil was fabricated to
i nstruction, periodontal surgery, endodontic seal the oronasal fistula by attaching to the
therapy, oral surgery, removal of caries, fixed prosthesis by means of the precision
orthodontic treatment, and altering the attachment, thus providing a fixed prosthe-
vertical dimension of occlusion in order to sis along with a seal of the oronasal fistula
provide a physiological occlusion and and potential access for cleaning when
change the jaw relationship from Angle needed. In the execution of this treatment
class III to that of edge-to-edge. The final plan, this young patient was provided with a
restorations accomplished all of these solution to his functional and esthetic
goals as well as providing an esthetic demands, providing him with a much better
solution to the patient's problems. quality of life.
Triangular arch
High palate
Unilateral closed cleft palate
Deciduous teeth:
Figure 18.10
Radiographs of maxilla and
mandible-pre-treatment,
periapical
The patient was motivated for dental I nitial periodontal therapy including oral
treatment in spite of his years of unsuc- hygiene instruction, scaling and root
cessful treatment. He was unaware of the planing
20 2 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 18.20
Treatment completed-
radiographs
for a period of 2 weeks. The prostheses The first bridge extended from the left
were then cemented permanently with zinc mandibular first molar to the left first premo-
oxyphosphate cement (Figures 18.19 and l ar, and the second, from the left mandibu-
18.20). Due to the difficulty in obtaining a lar cuspid to the right mandibular second
parallel path of insertion in the mandible, the molar. The maxillary restoration was
l ower prosthesis was built in two sections. constructed in one unit.
UNILATERAL CLEFT LIP AND PALATE AND PARTIAL ANODONTIA 205
The patient, a 25-year-old woman (Figure The patient had suffered some illnesses in
19.1), presented herself for examination childhood, but was currently in good
and consultation. Her complaints were as health.
follows:
207
208 PROSTHODONTICS IN CLINICAL PRACTICE
EXTRA-ORAL EXAMINATION
(Figures 19.1 and 1 9.3)
Symmetrical face
Competent lips
Straight profile
Normal temporomandibular joint
Maximum opening 60 mm, with a slight
deviation to the left upon opening
Exposed dentin
Extensive caries
Rounded arch form
Wear of teeth accompanied by chipping
of the enamel and cupping of the
dentine
Missing teeth:
and the left mandibular central and lateral FULL-MOUTH PERIAPICAL AND
incisor teeth (as restored by the provi- CEPHALOMETRIC SURVEY
sional restoration). (Figures 19.10 and 19.11)
Figure 19.10
Radiographs of maxilla and mandible
SUMMARY OF FINDINGS
DIAGNOSIS
TREATMENT PLAN
TREATMENT
Once the esthetic, physiological and out in the mouth (Figure 19.17). The final
functional expectations of the patient and glaze was applied to the prostheses (Figure
the dentist had been attained in the transi- 19.18), and the prostheses were cemented
ti onal restorations, the teeth were repre- with Temp-Bond for a period of 2 weeks.
pared, individual copper band elastomeric They were then cemented with zinc
i mpressions were taken, and stone dies and oxyphosphate cement for permanent
Pattern resin copings made as described in cementation in 1999 (Figures 19.19-19.21).
the Technical Information chapter. The
metal copings were fitted, connected,
soldered and refitted as previously SUMMARY
described and the porcelain biscuit bake
applied. The final and minute adjustments The patient presented with a severe
of the biscuit bake porcelain were carried problem of enamel hypoplasia on all of her
Figure 19.21
Radiographs after treatment completed
21 4 PROSTHODONTICS IN CLINICAL PRACTICE
I NTRA-ORAL EXAMINATION
compromised and sometimes difficult to
understand. At age 14, he underwent
Maxilla (Figure 20.6):
orthopedic surgery to build up his nose and
also to close the boney hard palate clefts. Jaw-normal size, asymmetrical, trian-
There was a family history of sensitivity to gular, with a class 3 soft palate and
Optalgin (glucose-6-phosphate dehydroge- shallow vestibulum
nase deficiency). Amalgam restorations on some of the
molar teeth
Caries on the left maxillary molars and
EXTRA-ORAL EXAMINATION the right maxillary first molar
Very poor oral hygiene with inflamed
• Straight profile with incompetent lips gingivae accompanied by calculus and
( Figures 20.1 and 20.4) plaque
BILATERAL CLEFT PALATE AND RAYNAUD'S DISEASE 217
Figure 20.11
Radiographs of maxillary
and mandibular anterior
quadrant
FULL-MOUTH PERIAPICAL
SURVEY (Figure 20.11)
BILATERAL CLEFT PALATE AND RAYNAUD'S DISEASE 21 9
• Maxillary left first molar had an mesio- missing and the maxillary third molars were
occlusal amalgam restoration with impacted. Some of the existing restorations
mesial caries were faulty and there was extrusion of the
• Small distal caries in the maxillary left mandibular right third molar. There was
cuspid caries on many teeth. He was Angle class
Distal caries in the right maxillary central I II with an anterior cross-bite as well as an
incisor anterior open bite, with a faulty plane of
Occlusal amalgam restorations in the occlusion.
second molar teeth
DIAGNOSIS
I NDIVIDUAL TOOTH PROGNOSIS
• Bilateral cleft lip and palate s/p (status
All the teeth had a good prognosis. post) surgery
Oral-nasal fistula
Congenitally missing teeth
SUMMARY OF FINDINGS Poor esthetics
Anterior cross-bite
The patient, a 17-year-old high school Anterior open bite
student, came to the clinic complaining of Gingivitis
poor esthetics and missing front teeth. He Caries
was very concerned about his appearance Raynaud's disease
and wanted to have a fixed prosthesis to Impacted maxillary third molars
replace his removable one.
His previous medical history consisted of
congenital bilateral cleft palate and lip with ABOUT THE PATIENT
many unsuccessful attempts at surgical
repair, and he remained with much The young patient seemed to have no
scarring. He suffered from Raynaud's understanding of the importance of the
disease. There was a lack of bone between need for his cooperation in his dental treat-
the premaxilla and the maxilla on the left ment. He was strongly motivated to have
side, and on the right side there was a dental treatment for esthetic reasons, and
narrow bridge of bone connecting the wanted his teeth fixed before he was
premaxilla and maxilla. He had undergone inducted into army service.
orthodontic treatment and had removable
maxillary and mandibular orthodontic
maintainers, which also replaced the POTENTIAL TREATMENT
missing maxillary lateral incisor teeth. There PROBLEMS
was an oral-nasal fistula between his hard
palate and premaxilla on the right side. The patient was a young man who had
His oral hygiene was poor. He had large undergone multiple, extensive, but unsuc-
amounts of plaque and calculus causing cessful surgical procedures to repair a
gingivitis, but with good bone support. The congenital condition, and was therefore
maxillary lateral incisors were congenitally wary of extensive dental treatment.
220 PROSTHODONTICS IN CLINICAL PRACTICE
TREATMENT PLAN
Maxilla:
TREATMENT
prosthesis from the right cuspid to the left l ary prepared teeth, and Duralay copings
cuspid, with provision for a removable palatal were made (Figure 20.15). These copings
attachment to cover the palatal fistula. A very were used to record centric relation at the
accurately fitting gold palatal leaf (denture) vertical dimension of occlusion as determined
that would seal the fistula was chosen. It by the posterior teeth, and for the impression
would be retained by a precision attachment for the model to make the metal copings. The
fitting into the maxillary right lateral incisor metal copings were built with a semi-preci-
pontic (split lingual attachment). sion attachment in the maxillary right lateral
The maxillary central incisor and cuspid i ncisor pontic. These were then fitted and
teeth were prepared and temporized with a soldered and, after try-in of the soldered
transitional fixed prosthesis, which also metal framework, a centric registration record
corrected the cross-bite and gave anterior was made in Duralay (Figure 20.16) and an
contact in centric relation and anterior elastomeric impression was made for the
guidance in lateral and protrusive movements tissue pick-up for the master model.
of the mandible (Figures 20.13 and 20.14). In The models were mounted on a semi-
addition, `guided' passive eruption allowed adjustable articulator ( Hanau) utilizing a
the molars on the right side to erupt into facebow registration and centric records
contact. This was accomplished by building were taken at the vertical dimension of occlu-
up the mandibular lingual cusps with sion utilizing Duralay with a Neylon
composite resin in order to prevent lateral technique. At this point the porcelain was
tongue thrust, which was preventing the teeth baked and the occlusion checked at the
from erupting to contact. The composite was biscuit bake stage in the mouth and all
removed after occlusal contact had been adjustments needed were then made. A
achieved and the surfaces finely polished. Duralay palatal attachment was fitted and
After the patient adapted to his new rest- relined in the mouth with Duralay (Figure
orations, copper band impressions of methyl- 20.17). This palatal attachment was then
methacrylate and elastomeric impression cast in gold, with a male attachment to fit the
material (Xantropen) were taken of the maxil- female attachment in the right maxillary
222 PROSTHODONTICS IN CLINICAL PRACTICE
Figure 20.19
Figure 20.20
l ateral incisor pontic (Figure 20.18). The gold Frontal facial view of patient after treatment completion
removable palatal attachment was fitted and
checked in the mouth. The maxillary fixed
prosthesis was glazed and polished, as was
the gold palatal attachment. The prosthesis SUMMARY
was cemented with Temp-Bond for a period
of 2 weeks and the palatal attachment The patient presented after many unsuc-
inserted (Figures 20.19 and 20.20). The cessful surgical attempts to close a bilateral
patient was taught how to insert and remove congenital palate and lip cleft. He had poor
the palatal attachment for cleaning purposes. oral hygiene, difficulties with speech and a
The crowns and bridges were then very poor self-image due to severely
cemented with zinc oxyphosphate cement compromised esthetics. The patient was
for permanent cementation. restored to form and function with the
BILATERAL CLEFT PALATE AND RAYNAUD'S DISEASE 223
congenital cleft lip/ palate 185, 215-23 crown-to-root ratios 9, 17, 20, 114, 211
congenital partial anodontia 92, 94 change 171
contacts, premature 187, 193, 214 i mprovement xii, 50, 61, 71, 79, 182
copings 106 minimizing increase 120
abutment impression 157 potential problems 44, 48
Duralay xiv, 107, 169 curettage scc root planing/scaling/curettage
after trauma 157
cleft lip /palate 221 deciduous teeth, retained 199, 201
extensive wear patient 32, 33 dentine exposure 25, 208
periodontal disease 179 dentures
periodontitis 77, 87, 88, 97, 117 existing 102, 103, 137
gold 47 partial 107, 146
i mpression 88 overlay 120
magnetic 145 removable 9, 26, 117, 118, 120, 144
metal 10, 32, 34 removable 179
cleft lip/palate 221 attitude to 28, 67, 75
neglected dentition 47, 59 severe periodontitis 104, 105, 107, 108, 109
new vertical occlusion 169 teeth 117, 145
patient with limited finances 145 transitional 116, 154, 155
periodontitis 70, 97, 106-7, 117 diagnosis
and refusal of surgery 133 advanced periodontal disease 176
Pattern resin xiv after trauma 153
amelogenesis imperfecta 213 amelogenesis imperfecta 210
cleft lip/palate 203 i n bruxism 16-17
neglected dentition 47, 59 cleft lip/palate 189, 201, 219
patient with limited finances 144, 145 with deterioration 55
and refusal of surgery 133 excessive wear patient 7, 28
retrograde wear patient 9 new vertical occlusion 166
provisional acrylic 144 periodontitis 67, 85, 94, 104, 113
transfer 47, 69 and refusal of surgery 129
try-in 118, 134, 158, 170 diagnostic set-ups 95, 99
coronal structure loss 8, 112, 126, 128, 174 dietary factors xi, 28, 63, 130, 137, 141
cross-arch splinting 8 cleft lip/palate 190
cross-bite 164, 187, 189, 219, 211 i mprovement 67, 68
cleft lip/palate 199, 201, 205 periodontitis 71, 72
bilateral 217, 221 disarticulation 26, 35
crowding of teeth 65, 71, 82, 126, 151 Durafil vs 97
crown lengthening 30, 35, 69 Duralay 32, 78, 88, 97
after trauma 155 after trauma 158
amelogenesis imperfecta 211, 212, 214 cleft lip/palate 221
cleft lip/palate 191 with deterioration 59
new vertical occlusion 167 new vertical occlusion 169, 170
periodontal disease 178, 179 periodontitis 107, 117
crowns 167 see also under copings
fabrication of prostheses on 117 dust in tooth wear 18, 28-9
preparation 130, 202
provisional 142 elastics 44, 57, 76, 105
short clinical 211, 214 Elmex gel 142
splinted 182 enamel chipping 24-5
transitional 44, 130, 154 enamel hypoplasia 213-14
periodontal disease 177 endodontic therapy 114
periodontitis 77, 116 after trauma 154, 155
I NDEX 22 7
periapical full-mouth examinations (coat.) pick-up impressions 33, 47, 48, 97, 133
extensive wear patient 23-7
new vertical occlusion 166 platforms 97
patient with limited finances 141 canine xi
radiographic 82-4, 92-4, 174-5 in bruxism 17-18, 20
after trauma 150-2 with deterioration 56, 57
i n bruxism 13, 15-16 and refusal of surgery 130, 131, 136
cleft lip/palate 188, 198-9 incisal 34
neglected dentition 40-2, 52-5 lingual 85
periodontitis 64-5, 74-5, 102-4, 112-13 see also rests
and refusal of surgery 127 pleomorphic adenoma 173, 181, 182
retrograde wear patient 4-6 pocket elimination 69
survey 6, 42, 55, 65-6 ' pouch technique' 58
periodontal charts probing/ pocket depth
after trauma 152 after trauma 151, 154, 157-8
amelogenesis imperfecta 209 amelogenesis imperfecta 209
i n bruxism 16 in bruxism 15-16
cleft lip/palate 187, 190, 192, 200, 218 cleft lip/palate 187, 199, 217, 220
excessive wear patients 6, 26, 31 excessive wear patients 5, 26-7
neglected dentition 42, 54, 56, 58 i mprovement 76, 95
new vertical occlusion 165, 169 neglected dentition 42-3, 54, 57-8, 59
patient with limited finances 140, 142, 143, 144 new vertical occlusion 165, 168
periodontal disease 176 patient with limited finances 139-40, 142-3
periodontitis 66, 75, 84, 92 periodontal disease 175, 177
severe 103, 112, 115 periodontitis 75, 83, 92, 94
and refusal of surgery 126 complicated 66, 69
periodontal deterioration 51-61 improvement 76-7
periodontal disease, advanced 173-82 severe 102, 105-6, 109, 113, 115-16
periodontal examinations 116 and refusal of surgery 127
amelogenesis imperfecta 209 prophylaxis 52, 57, 61, 63
i n bruxism 15-16 prostheses
cleft lip/palate 187, 199, 217 fixed 44, 48, 76, 79, 95, 203
excessive wear patients 5-6, 26-7 insistence on 153, 159, 160, 161
li mited finances 139-40 partial 69, 79, 130, 177
neglected dentition 42, 54 permanent 222, 223
new vertical occlusion 165 provisional 130
periodontal disease 175 six-unit 156
periodontitis 75, 83, 92-3 transitional 177, 179, 221
complicated 66 fixed vs removable 109-10, 141, 142
severe 102-4, 113 implant-supported 156
periodontal surgery 69, 132-3, 203 insertion difficulties 204, 223
advanced periodontal disease 177 provisional 87
amelogenesis imperfecta 212 removable 67, 69, 87, 177, 223
cleft lip/palate 190, 195 tooth-supported 201
patient with limited finances 143 transitional 178
periodontitis 116-17 see also bridges; crowns; restorations
periodontitis 7, 16, 47, 55, 176 proximity 132, 209, 211, 214
advanced 73-9, 81-90, 167 pseudo pockets 167
complicated 63-79 pulpitis, acute 85
severe 101-10, 111-21
moderate to advanced 91-9 radiographic examinations 16, 27
phenytoin 73 see also under periapical full-mouth examinations
231
232 I NDEX
speech problems 35, 79, 220 periodontitis 76-9, 85-8, 94-8, 104-8
cleft lip/palate 197, 198, 215, 222 complicated 67-71
splinting 85, 96, 97, 130, 177 and refusal of surgery 129-34
cross-arch 8 trifurcation involvements 57, 167
of retracted teeth 44, 45
stents 47, 87 valproic acid 73
stone dies xiii-xiv vertical dimension of occlusion xi, 17, 30, 58, 192
amelogenesis imperfecta 213 adaptation to new 205
cleft lip/palate 203 alteration of xii, 8, 12, 18, 20, 214
with deterioration 59 cleft lip/palate 195, 203
patient with limited finances 144 centric relation record 145, 157, 158
periodontitis 69 advanced periodontal disease 179
and refusal of surgery 133 cleft lip/palate 221
stops see platforms; rests periodontitis 77-8, 88, 97
support, posterior 129-34, 141 severe 106, 107, 117
suppuration 136 and refusal of surgery 133, 134
swallowing problems 75-6, 79 increase of 48, 130
extensive wear patient 35, 36, 116
technical information xiii-xv neglected dentition 44, 57
telescopic prostheses 147, 190, 201 loss of 16, 134, 135, 167, 176
Temp-Bond see cementation of prostheses reduced 121, 153
tilting/tipping 65, 82, 151 neglected dentition 55
titanium mesh 150 new vertical occlusion 170
tongue patient with limited finances 141
interference from 18, 221, 223 periodontitis 88, 94, 104, 114
lack of control 73 and refusal of surgery 129
pressure from 75-6, 79 vertical occlusion, new 163-71
tooth material, choice of 10, 12, 145 vestibulum, shallow 153, 190, 216, 217
tooth position classification xii vibration in tooth wear 28-9
tooth preparation 105, 205-6
tooth structure loss 8, 112, 126, 128, 174, wax-ups 156, 167, 202
214 wear
transfer copings 47, 69 anterior teeth 24, 25
traumatic sequelae 149-61 excessive 20, 28-9, 36
trays, bite 10, 107, 145 extensive 23-36
custom 10, 87, 117 extreme 13, 14, 16, 164, 170
treatment 85, 114-19 new vertical occlusion 166, 167, 171
after trauma 153-9 retrograde 3-12
in bruxism 17-20 wear facets 25, 64, 187
cleft lip/palate 189, 189-93, 201-4, 219-22 wire/ wiring 44, 95, 97, 150
excessive wear patients 7-11, 29-34 Worth's disease 163
neglected dentition 44-7, 55-60
new vertical occlusion 167-70 Xantropen xiii, 221
patient with limited finances 141-6
periodontal disease 176-81 zinc oxyphosphate cement see cementation