A mrehexcerepo

Alireza Moshave

aAssistant Professor, Division of BiobAssociate Professor of Clinical DencAssistant Clinical Professor, AdvancdDirector, Oral Design Center of LoseAssociate Professor of Clinical DentfRalph and Jean Bleak Professor of R

Moshaverinia et al

ultidisciplinary approach for theabilitation of a patient with anssively worn dentition: A clinicalrt

rinia, DDS, MS, PhD,a Kian Kar, DDS, MS,b

Alexandre Amir Aalam, DDS, MS,c Kazunari Takanashi, RDT,d

James W. Kim, DDS,e and Winston W. Chee, DDSf

Herman Ostrow School of Dentistry, University of Southern California,Los Angeles, Calif

This clinical report describes amultidisciplinary approach to thediagnosis and treatment of apatientwith a severelyworndentition.The treatment included osteotomyand immediate implant placement and loading in themandible. The definitive restorationswereimplant- and tooth-supported metal ceramic restorations. These restorations were fabricated with metal occlusal surfaces at anincreased occlusal vertical dimension, which provided acceptable esthetics and function. (J Prosthet Dent 2014;111:259-263)

Dental wear occurs in patients ofall ages across the globe.1 Studies haveprovided important information aboutthe anatomy and origin of dentalwear.1,2 Occlusal wear has mostly beenattributed to attrition, which is definedas the loss of tooth structure by me-chanical wear from another tooth sur-face.2 However, several other etiologicfactors, such as erosion, abrasion, andparafunctional habits (bruxism), havebeen reported to have a significantrole in the process of excessive occlusalwear.1-3 Diet and diseases, such asgastric reflux, congenital abnormalities,and eating disorders, are importantcontributors to excessive occlusalwear.2,3 A differential diagnosis is notalways possible because a combinationof these conditions may be present.Nevertheless, identifying the etiology ofthe excessive wear and evaluating thediagnostic data, especially the occlusalvertical dimension, are important. Anestimation of the presenting occlusalvertical dimension, together with theextent of noncarious tooth loss, isessential before deciding upon a treat-ment plan.2-4

medical Sctistry, Clined PeriodAngeles,istry, Clinestorative

Loss of the occlusal vertical dimen-sion caused by physiologic tooth weardoes not occur when compensated forby continuous tooth eruption, togetherwith the development of the associatedalveolar bone.4 When the rate of toothwear exceeds the compensatory mecha-nisms, a loss of occlusal vertical dimen-sion is observed.4,5 Occlusal verticaldimension can be estimated with severalmethods, for example, phonetics, inter-occlusal distance, and swallowing.4-10

The management of severely worndentition is challenging for clinicians,both from a preventive aspect and arestorative aspect.

Turner and Missirilian11 classifiedpatients with extensively worn denti-tions into 3 categories. Patients incategory I exhibit excessive wear, withloss of the occlusal vertical dimension.Patients in category II exhibit excessivewear, without loss of the occlusal ver-tical dimension but with space avail-able for the placement of restorations.Patients in this group typically haveadequate posterior support and a longhistory of bruxism. The continuouseruption of the teeth in these patients

ience, Center for Craniofacial Molecular Bioloical Director of Advanced Periodontology.ontology.Calif.ical Director of Advanced Prosthodontics.Dentistry, Program Director, Advanced Prosth

can maintain the occlusal verticaldimension. Finally, patients in categoryIII present with excessive wear and noloss of occlusal vertical dimension butdiffer from category II in having limitedspace available. Providing sufficientspace for restorative materials is chal-lenging, and, with any increase in theocclusal vertical dimension, the pa-tient is committed to having all theoccluding surfaces of at least 1 archrestored. When there is an occlusalplane discrepancy. This is further com-plicated because an uneven amount ofrestorative space across the arch maybe required. This clinical report de-scribes a multidisciplinary approach tothe diagnosis and treatment of a pa-tient with excessively worn dentition ofovererupted mandibular anterior teeth.

CLINICAL REPORT

A 64-year-old white man was re-ferred by his previous dental provider tothe Advanced Prosthodontics Depart-ment, Ostrow School of Dentistry,University of Southern California, fortreatment. His stated chief complaint

gy.

odontics.

1 Pretreatment intraoral view. 2 Pretreatment panoramic radiograph.

3 Intraoral view of failing implants andrelated periapical radiograph.

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was, “I grind my teeth and all of themare worn out; I would like to have goodlooking teeth again” (Fig. 1). The pa-tient reported that he lost his teethbecause of fracture and recurrentcaries. Upon examination, the patientwas found to have worn and supra-erupted mandibular anterior teeth(Fig. 1). Sharp enamel edges withdentinal craters were observed on theanterior mandibular teeth, which indi-cated active wear and an erosivecomponent that caused loss of toothstructure.12 Abrasive wear facets alsopresented on the maxillary anteriorsextant. An occlusal plane discrepancywhere the mandibular anterior teethwere supraerupted and the porcelainhad fractured also was observed in theintraoral examination. Noncarious cer-vical lesions were noted on teeth in themaxillary arch. However, the patienthad no tooth sensitivity or pain.

Results of clinical and radiographicexaminations revealed the presence ofcarious lesions. Also, the previousdental provider had placed 6 implantsfor the patient, 3 Mk III RP (NobelBiocare) in the mandibular posterior, 2Osseospeed TX (Dentsply Implants) inthe maxillary left posterior, and 1 reg-ular neck Straumann implant (Stan-dard Plus RN; Straumann USA LLC) inthe mandibular right posterior (Fig. 2).The 2 implants on the left mandibleexhibited periimplant bone loss (Fig. 3).Both of the implants were mobile, andthe patient experienced moderate levelsof pain upon loading. A diagnosis of

The Journal of Prosthetic Dentis

periimplant bone loss associated withmalplaced implants was made. Extrao-ral examination revealed no facialasymmetry or muscle tenderness. Thepatient did not have any symptoms oftemporomandibular joint dysfunction.The dental disease diagnosis of thepatient included dental caries, peri-apical periodontitis, generalized mod-erate with localized severe chronicperiodontitis, partial edentulism, andnocturnal bruxism. He was also diag-nosed with loss of tooth structure dueto abrasion. The patient was classifiedas class III, according to the prosthodon-tic diagnostic index (PDI) classification.13

The treatment objectives were toimprove oral hygiene and restore func-tion by providing implant-supportedpartial fixed dental prostheses to re-place teeth in the mandible, togetherwitha combinationof implant-supportedfixed restorations (single units andfixed dental prostheses) and metalceramic restorations for the remainingteeth in the maxilla. The availabletreatment options were presented anddiscussed with the patient, as was theneed to increase the occlusal verticaldimension to obtain restorative space,especially in the anterior region ofthe maxilla and mandible. At thispoint, an esthetic intraoral interimacrylic resin (Jet Acrylic; Lang DentalManufacturing Co Inc) restoration wasfabricated to establish parameters ofesthetics to include the incisal edgeposition of the maxillary anterior teethand to display the teeth when smiling.

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To provide space for the componentsand develop proper contours forthe implant-supported restorations, 10mm of space from the implant plat-form to the opposing occlusal surfacehas been recommended.14 Therefore,an occlusal device was provided at anincreased occlusal vertical dimension(4 mm at the incisal pin) with in-structions that the patient wear thedevice constantly except for hygieneand eating. After a 4-week period,the patient did not report any mus-cle tenderness or temporomandibularjoint discomfort. A diagnostic waxingwas completed at this occlusal

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April 2014 261

vertical dimension, which satisfied theesthetic parameters for the maxilla.

In spite of the increased occlusalvertical dimension, the supraeruption ofthe mandibular anterior teeth deman-ded additional restorative space. A vari-ety of procedures were considered,including orthodontic intrusion,15

crown lengthening surgery togetherwith reduction of clinical crown height,elective endodontic therapy with re-duction of clinical crown height, extrac-tion of the supraerupted teeth, andan increase in the occlusal verticaldimension.16,17 These options also were

4 Diagnostic waxing.

5 A, B, Six-mm-long heaC, D, Extraction of remainimplants.

Moshaverinia et al

considered in combination. After con-sidering the severity of the malpositionof the mandibular anterior teeth, theirremaining tooth structure, and thelength of treatment time, the restorationwith the best long-term outcome wasdetermined to be an implant-supportedrestoration. Apart from the 2 failing im-plants of the mandibular left side, thispatient had a history of success withimplant integration and presented withno systemic risk factors; moreover, theanterior mandible was anatomicallyconducive to implant placement. Aspace analysis indicated that an

ling abutments on implants as indices foring teeth followed by osteotomy and imm

ostectomy would also be required afterthe removal of the mandibular anteriorteeth to allow for appropriate contoursof the implant-supported restoration. Ifthe implants were deemed to haveadequate primary stability, then theywere to be loaded at the time ofplacement.

In accordance with the diagnosticwaxing (Fig. 4), a surgical template wasfabricated to guide both the ostectomyand implant placement after theextraction of the mandibular anteriorteeth. The posterior mandibular im-plants were used to index the surgicaltemplate. This procedure was carriedout by attaching three 6-mm-longhealing abutments (4-mm-diameterHealing cap; 3i Biomet) to the implantanalogs on a cast in positions of theexisting posterior mandibular implants,then replicating the diagnostic waxingin polymethyl methacrylate (Jet Acrylic;Lang Dental Manufacturing Co Inc) onthis cast. Similar healing caps wereplaced on the implants intraorally toallow accurate placement of the surgi-cal guide (Fig. 5). With this surgicalguide, 5 implants (Osseotite; 3i Bio-met) were placed in the mandibularanterior region. All the procedures were

surgical template.ediate loading of

6 Interim restorations. 7 Definitive restorations.

8 Definitive restorations, includingmetal occlusal surfaces.

9 Posttreatment panoramic radiograph.

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completed at the same appointment.Similar to the surgical guide, the diag-nostic waxing was duplicated withpolymethyl methacrylate (Ena Temp;Micerium) to form an interim restora-tion, which was inserted immediatelyafter placing the implants. At anotherappointment, 2 implants (Osseotite; 3iBiomet) were placed in the maxilla, andthe fixed interim restorations (Ena Temp;Micerium)were fabricated and cementedwith TempBond (Kerr Dental).

After confirming that the patient wassatisfied with the form, color, shape,and function of the interim restorations(Fig. 6), the tooth preparations were

The Journal of Prosthetic Dentis

completed and impressions were madewith polyvinyl siloxane impressionmaterial (Extrude; Kerr Corp). Theframework (Au-Pd alloy, Argdent30;Argen Corp) was fabricated with poste-rior teeth with metal occlusal surfacesbecause of the self-reported paraf-unction. In the maxillary arch, single-unit tooth-supported metal ceramicrestorations were inserted and cementedwith resin-modified glass ionomercement (FujiCEM; GC America). Splintedscrew–retained metal ceramic restora-tions were inserted for the maxillary leftposterior implants, whereas single-unitscrew-retained implant-supported res-torations were placed in the anteriormaxilla. In addition, screw-retainedimplant-supported splinted metal ce-ramic restorations were inserted in themandible in 2 segments. The restorationswere satisfactory in terms of form, color,phonetics, and function (Figs. 7-9).

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DISCUSSION

The management of excessively worndentition is a major challenge for dentalprofessionals.Oneof themost importantconsiderations before diagnosis andtreatment planning is to identify, elimi-nate, or reduce the factors that causedthe excessive wear. Failure to eliminatethe causemay compromise the long-termsurvivalof restorations and lead to furtherdeterioration of the dentition.18-21 Attri-tion has been assumed to be a physio-logically normal process that is necessaryfor function.18 Xhonga19 found the rateof normal attrition for nonbruxers to be35 to 65 mm in 6 months. In anotherstudy, Lambrechts et al20 reported thatthe normal amount of tooth wear is68 mm per year.

The patient in this clinical reportpresented with excessive wear withlimited space available for restorations

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April 2014 263

and excessive wear in existing restora-tions, attributed to nocturnal bruxism.A sufficient amount of restorative spacewas gained by combining surgicalosteotomy in the anterior region of themandible, with an increase in theocclusal vertical dimension. Approxi-mately 5 mm of restorative space wasobtained with the surgical procedure inaddition to a 5-mm increase in theocclusal vertical dimension. Maxillaryand mandibular metal restorationswere inserted at the new occlusal verti-cal dimension, which resulted inacceptable esthetics and function. Inaddition, the patient presented with 3different types of implant systems,which complicated procedures for therestorative dentist because 3 differentsets of screws, drivers, and wrencheswere required. This further illustratesthe benefit of having a comprehensivetreatment plan before implant place-ment and mutual understandingamong different specialists of interdis-ciplinary treatment planning.

SUMMARY

In this clinical report, the patientpresented with excessive wear withoutloss of the occlusal vertical dimension,with limited restorative space together,and with overerupted mandibular an-terior teeth. The treatment plan usedosteotomy, immediate implant place-ment, and loading in the mandible, anddelivery of implant and tooth-supported

Moshaverinia et al

metal ceramic restorations in the maxillaand mandible. These restorations usedmetal for the posterior occluding sur-faces at an increased occlusal verticaldimension, which provided acceptableesthetics and function.

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17. Misch CE. Clinical indications for alteringvertical dimension of occlusion. Objective vssubjective methods for determining verticaldimension of occlusion. Quintessence Int2000;31:280-2.

18. Carlsson GE, Johansson A, Lundquist S.Occlusal wear. A follow-up study of 18 sub-jects with extensively worn dentitions. ActaOdontol Scand 1985;43:83-9.

19. Xhonga F. Bruxism and its effect on teeth.J Oral Rehabil 1977;4:65-72.

20. Lambrechts P, Vanherle G, Vuylsteke M,Davidson CL. Quantitative evaluation ofthe wear resistance of posterior dentalrestorations: a new three-dimensionalmeasuring technique. J Dent 1984;12:252-61.

21. Johansson A, Johansson AK, Omar R,Carlsson GE. Rehabilitation of theworn dentition. J Oral Rehabil 2008;35:548-66.

Corresponding author:Dr Alireza MoshaveriniaCenter for Craniofacial Molecular BiologyOstrow School of DentistryUniversity of Southern California2250 Alcazar Street - CSA 103Los Angeles, CA 90033E-mail: moshaver@usc.edu

Copyright ª 2014 by the Editorial Council forThe Journal of Prosthetic Dentistry.