Upper Arch Rehabilitation - Utilizing Fixed and Removable Prosthodontics and a Novel Bite Registration Appliance - A Case Report

M Praveen Kumar*, S Varalakshmi**, T Suman***, T Neeraja***

Abstract
Full arch reconstructions can be challenging clinical procedures. As more patients are living longer, and retaining their teeth longer, clinicians will increasingly be called upon to provide these types of dental therapies. The success of functional and esthetic dentistry depends on the clinicians and technicians understanding of natural unworn tooth morphology, Temporomandibular joint function, the muscles of mastication, a tooths function and position in the arch, gingival contours, and the way all these elements interact. Harmonious long -term function and reliability depend upon correct relationships between the anterior and posterior dentitions, the periodontal support, the TMJs, the patients neuromuscular system (i.e. Central Nervous System activity can cause bruxism) and the quality of the patients oral home care, nutrition, and overall physical and emotional health. Key Words : Upper arch rehabilitation, Fixed prosthesis, Removal prosthesis, Bite registration, Appliance

INTRODUCTION

valuation of tooth wear and its causative factors, allows the clinician to select the dental materials best suited to the individual patients needs. A full mouth reconstruction should not be a mystical and difficult undertaking, but rather a methodical, orderly procedure. The use of comprehensive diagnostic records and proper treatment planning can produce esthetic and biologically compatible results which can be maintained for many years.6 The functional goals of a full mouth reconstruction are to maximize anterior guidance in lateral and protrusive excursions (i.e. immediate posterior disclusion), and to allow the TMJ condyles to achieve their ideal physiologic position in centric relation as defined by Dawson, Pankey and others.2 Proper anterior guidance will allow for the creation of natural crown forms with enhanced function and esthetics. Latero-canine guidance has been established as being highly beneficial. This occlusal scheme is protective not only of masticatory musculature and joints, but also of the dentition. Only when posterior disocclussion is obtained by an appropriate anterior guidance can elevating activity of the Temporalis and Masseter muscles be reduced. It is not only the contact of the canines that reduces the activity of the elevator muscles, but elimination of posterior eccentric contacts
*Reader, **Professor, ***Senior Lecturer, Department of Prosthodontics, MMR Dental College, Sangareddy, Andhra Pradesh. JIDA, Vol. 5, No. 6, June 2011

and interferences.7 Symptoms of biomechanical overload of the masticatory system include tooth wear (attrition), mobility, migration, gingival stripping or clefting, cervical abfractions, fracture, temperature sensitivity, and restorative failure.5,8 Through a variety of means, dentists doing full arch or full mouth dentistry strive to establish the MaxilloMandibular relationship they feel will be most appropriate for the patient. A challenge in extensive restorative treatment is the ability to accurately communicate the relationship of the arches following preparation, to the technician.9-11 This challenge is increased if there will be changes in the vertical dimension, or when all teeth in one or both arches will be prepared and vertical stops are no longer present. Once an intended bite relationship is determined, holding the intended maxillo-mandibular relationship, especially during the preparation appointments becomes very critical. This relationship is determined through a comprehensive history taking, mounted study cast analysis, and detailed clinical examination of the TMJs and teeth. Various methods exist for recording the vertical dimension and interarch relationship.

CASE REPORT
A 65 year old female reported with a chief complaint of yellow, chipped, and worn down teeth. The patient has been partially edentulous on the maxillary right side (missing #16, #17, #18) for over fifteen years. Teeth #15, 14, 25 have been endodontically treated, and the patient has some porcelain fused to metal crowns present in the
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maxillary and mandibular arches, placed by her previous dentist approx. fifteen to twenty years ago. Some of the porcelain fused to metal crowns show evidence of wear and porcelain fracture. Examination of the teeth reveals generalized advanced tooth attrition/erosion. Periodontally, some areas exhibit 4 mm. pockets, and the posteriors demonstrate moderate bone loss. The anterior teeth demonstrate slight blunted papillas and dark triangles interproximally. This is consistent with the patients age, history and biotype. The relationship of the papillas presence or absence as it relates to the underlying crestal bone levels is well understood. The periodontal condition, while not ideal, is stable, with no signs of ongoing breakdown. Referral to a periodontist for evaluation was offered, and refused, on numerous occasions. After numerous consultations with the patient, the decision was made to restore her maxillary arch with a combination approach utilizing crown and bridge, and a removable partial denture (RPD) with precision attachments. Pre-operative and Laboratory Steps Centric relation records and diagnostic chairside mockup: Preoperative study models were taken (two sets), along with centric relation records and a face-bow transfer. Protrusive and right and left lateral check bites were obtained to program the articulator with the correct condylar settings. These casts were poured up and mounted in CR (or a close approximation) on a Denar Combi- semi-adjustable articulator, and a trial equilibration was performed on the casts. Protrusive and lateral excursions were not adjusted at this time because the anterior guidance has not yet been perfected. If lateroprotrusive adjustments are made at this time, especially if the anterior teeth are severely worn, the final posterior tooth forms will not have a well shaped occlusal anatomy, and the flatter profiles required as a result, would be less efficient in masticatory functioning.13 The issue of the blunted papillas and dark triangles in the anterior regions was noted to the patient. Using a chair side composite resin mock-up procedure, it was determined that the contact points could be lowered gingivally, to decrease or eliminate the dark triangles; however this would result in unaesthetic bulky looking restorations. Gingival grafting was suggested to the patient to correct any soft tissue concerns and to maximize the esthetic outcome. The patient refused periodontal treatment and understood the esthetic compromise. A tentative shade and tooth shape were selected, and an alginate was taken of the mock up on the teeth. Diagnostic Wax-up and Fabrication of Bite Registration Appliance The mounted diagnostic casts, mock up study
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impression and lateral and protrusive check bites taken a few weeks earlier were sent to the dental laboratory. A diagnostic wax-up was done on one of the maxillary models at the proposed new vertical dimension and tooth mold (determined with the patients input at the chair side mock up appointment), and designed to provide protrusive and latero-trusive disclusion to help decrease bruxing type damage in the future restorations, and a matrix guide fabricated from a polyvinyl material, to be used during the temporization of the case. The other model acted as a baseline record, and assisted in the fabrication of the bite registration appliance. The technician fabricated a thin rigid acrylic stent to securely fit over the unprepared mandibular teeth. It was slightly indexed so that all the unprepared maxillary teeth would be simultaneously engaged, but have complete freedom of entry. The distance from the CEJ of the maxillary central incisors to the CEJ of the mandibular incisors, with this appliance in place, was recorded. This allows the technician to know the initial starting vertical dimensions prior to tooth preparation. Operative and Laboratory Steps Teeth preparation, temporization, laboratory steps: Following local anesthetic administration, PFMs on #15, #14, #25 were removed using the Metalift crown remover. Following PFM removal, core build-ups as needed were completed on the above teeth, as well as tooth #28 using Core Paste (Denmat), and the preparations refined using carbide and diamond burs in a Kavo electric handpiece. Margin placements were supra-gingival and/or equi-gingival depending on the tooths location in the arch, and the height needed for adequate retention purposes (Fig. 1) The bite registration appliance, previously fabricated, was seated over the mandibular teeth, and the mandible was guided into centric relation, by bi-manual manipulation and the bite registration appliance itself acting as a Lucia jig, now that the posterior teeth were out of contact. Next, a bite registration material was injected, through the mixing tip and dispenser, from the buccal aspect over the prepared posterior segments, and allowed to set for thirty seconds (Fig. 2). The remaining anterior teeth were prepared for full coverage PFMs. The existing porcelain veneers and the PFM on #22 were removed using a selection of carbide and diamond burs in a Kavo electric handpiece, and the tooth preparations refined, with core build-ups as needed. The bite registration appliance was reinserted in the patients mouth, and the mandible carefully guided to the previously recorded position. Again, bite registration material was applied from the labial aspect to the prepared anterior teeth, and allowed to set for thirty seconds. The teeth were dried and a thin mixture of Provilink
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Fig. 1 : Intra oral photograph

Fig. 2 : Preparation

Fig. 3 : Stent seabed in position

(Ivoclar) was applied to the prepared teeth. Using the polyvinyl guide previously fabricated from the diagnostic wax-up, Luxatemp (Zenith DMG) was injected into the guide, taking care not to incorporate any air bubbles, and the stent was fully seated over the prepared teeth and allowed to set for 120 seconds (Fig. 3). Once polymerization was complete, the guide was removed, with the temporary crowns in it. The temporary crowns were trimmed and polished, and embrasures opened up to allow for oral hygiene procedures and overall gingival tissue health. The temporaries were cemented with Temp-bond mixed with Vaseline. The occlusion was checked, and instructions given in oral hygiene, and the patient dismissed. Chlorhexidine rinse (Peridex) was given to the patient, and daily rinsing advised. The laboratory was provided with all the records obtained, as well as detailed instructions regarding the desired occlusal scheme, tooth shade, shape, texture etc., RPD design, and type of precision attachment. PFMs were selected and designed according to the patients occlusion and need for stable occlusal stops, history of bruxing, history of GERD, tooth conservation vs. all ceramic systems reduction requirements, and ease of cementation and clean up (Fig. 4). A gold crown was selected for #28, and teeth #15 and #14 were to be splinted together to provide additional support for the precision attachment. The precision partial denture has long been considered the highest form of removable partial denture therapy. It combines fixed and removable prosthetics in such a way as to create the most esthetic RPD possible. It also has the reputation of lasting far longer than conventional RPDs.14 Compass precision attachments (Ivoclar) were selected due to their minimal size and space requirements, and their relative ease of use, and the authors previous experience with this system.14,2 There are numerous good attachment systems available on the market. Case Inspection, Cementation of PFMs, RPD Insertion The patient was seen one week later. Using a combination of Bi-manual manipulation and the patients own subjective experience, the occlusion was carefully evaluated and slight adjustments made. The patient was
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Fig. 4 : Removable partial denture

Fig. 5 : Post OP intra oral photograph

advised to contact our office if any discomfort was experienced or loosening of the provisionals occurred. The patient was seen again at three weeks post tooth preparation, and reported she was very comfortable at the new vertical dimension, and liked the appearance and shape and function of the provisionals. A new set of impressions was taken of the provisionals, along with a new face-bow and CR record, to assist the dental laboratory in fabricating an anterior guide table. Protrusive and right and left lateral check bites previously obtained helped to program the articulator with the correct condylar settings, and as phonetics and the lip closure path had already been worked out in the provisionals, the laboratory was instructed to copy the length and labial/lingual contours in the definitive restorations. At five weeks the patient was reappointed. The temporaries were removed and the crown and bridge units (in a biscuit bake state) were tried in the mouth and the marginal fit, shade, shape and occlusion evaluated. Temp bond and Vaseline was used to hold the copings on the teeth, and an alginate pick-up impression was taken to record the position of the copings for the fabrication of the RPD . The removable partial denture design called for precision attachments on the distal of #15 and on the distal of #25, with a traditional rest and clasp on #28. A minor connector/ rest at #23 would provide additional anti-rotation and stability. The provisionals were recemented with Temp bond and Vaseline. Two weeks later, the patient was seen for the framework and waxed set up for verification of fit and esthetics. Ten days later the patient was reappointed. Local anesthesia was administered, and the temporary crowns removed. The tooth preparations were scrubbed with
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slurry of pumice and water in a rubber cup, taking care not to irritate the gingival tissues, and thoroughly rinsed and dried. The soft tissues appeared to be in good health. Gluma desensitizer was applied to the nonendodontically treated tooth preps with a micro brush and air dried. The restorations and the RPD were first examined on the stone model, and then in the patients mouth, both individually and all together. The dental laboratory left the access openings housing the plunger type portion of the attachments open, so that the degree of retention could be adjusted if needed (these access openings were sealed with composite a few weeks later). Contacts and marginal fit were verified. Crowns #15, 14, 28, and fixed bridge #23, 24, 25 were cemented simultaneously using Flecks zinc phosphate cement. The RPD was seated at the same time to ensure that everything was in place correctly relating to the precision attachments. Following cement set, meticulous cement clean up followed. Crowns #13, 12, 11, 21, 22, were next cemented simultaneously using Flecks zinc phosphate cement. Following cement set and clean up, the patient was instructed in oral hygiene and the correct method for insertion and removal of her RPD. The patient was seen the following week and two weeks later for follow up and monitoring of the occlusion. She reported great satisfaction with the esthetics and occlusion.

for aesthetic reasons, therefore the maxillary arch was selected first. Careful treatment planning can allow the dentist to satisfy a patients more immediate functional and esthetic needs, and still perform complete needed full mouth dentistry, phased over a defined time period, so that financial concerns can also be addressed.

CONCLUSION
Reduced stress, predictable results, and near elimination of adjustments are easily obtainable when attention to detail is carried from the records and treatment planning phase to tooth preparation and provisionalization, through to case completion. The simplified method of bite record transfer and registration presented in this article can be of help to the clinician, technician, and ultimately benefit our patients. A full arch rehabilitation involving crowns, a bridge, and a removable partial denture utilizing precision attachments was demonstrated, resulting in an esthetic and functional result for the patient, and personal satisfaction for the clinician.

REFERENCES
1. 2. 3. 4. Stevens C. Close First, Squirt Second Aesthetic Dentistry Arrowhead Dental Labs Newsletter 2005; 4(1): 12-13. Dawson PE. Evaluation, Diagnosis, and Treatment of Occlusal Problems CV Mosby Co. 1989. Rufenacht CR. Fundamentals of Esthetics Quintessence 1990. Lee RL. Esthetics and Its Relationship to Function In Rufenacht C.R. Fundamentals of Esthetics Chapter 5 Quintessence 1990. Spear F. Fundamental Occlusal Therapy Considerations in McNeill C. Science and Practice of Occlusion Quintessence 1997. Haupt J. A Team Approach to Full Mouth Rejuvenation. Journal of Cosmetic Dentistry 2002; 18(1): 42-47. Davis M.W. Comparative Mammalian Study of Human Canine Form and Function. Journal of Cosmetic Dentistry 2000; 16(2): 49-58. Williamson EH, Lundquist DO. Anterior Guidance: Its Effect on Electromyographic activity of the Temporal and Masseter Muscles. J Prosthet Dent 1983; 49:816-823. Chiche GJ, Pinault A. Esthetics of Fixed Anterior Prosthodontics Quintessence 1994.

DISCUSSION
As is evident from the post-op photos, a very esthetic result was achieved. The teeth have a natural age and shade appropriate appearance. The buccal corridor is adequately filled and the facial and maxillary midlines are coincident. The maxillary and mandibular midlines do not coincide, which was the case pre-operatively. Proper cusp/fossae relationships have been recreated. Lateral excursions are canine guided. The maxillary centrals have been lengthened 1.5mm and are now properly proportioned and visible during speech and light lip repose. Phonetics have not been altered or compromised. The patient is thrilled with the result, which has greatly exceeded her expectations (Fig. 5). The mandibular anterior dentition, while not aesthetic, is performing its function and assisting in anterior and latero-disclusion. Dawson advocates beginning a reconstruction or rehabilitation with the mandibular anterior teeth as the starting point. The complete treatment plan developed will restore the mandibular anteriors to correct form and function. Ideally, orthodontic treatment to correct #33s rotation and mandibular crowding will be performed. At that time, PFM #22 can be remade to suit the new occlusion, if required. This patient was anxious to begin treatment
5. 6. 7.

8.

9.

10. Roberts M, Trinkner T. Communication guidelines for Achieving Aesthetic Success. Signature 1998; 5(3): 18-21 1998. 11. Melkers RJ, Roberts MR. Enhancing Restorative Team Communication: A Predictable Protocol for Esthetic, Full Mouth RehabilitationJournal of Cosmetic Dentistry 2002; 18(3): 86-95. 12. Tarnow DP, Magner AW, Flecher P. The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interdental Papilla. J Periodont 1992; 63(12): 995-6. 13. Hunt KH. Bioesthetics: Working with Nature to Improve Function and Appearance. Journal of Cosmetic Dentistry 1996; 12(2): 45-49. 14. Brudvik JS. Advanced removable partial dentures Quintessence Publishing 1999.

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