An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities

University Journal of Surgery and Surgical Specialities

ISSN 2455-2860 2020, Vol. 6(8)

ABSTRACT Rehabilitation of debilitated dentitions presents a greatest challenge for dentist to bring esthetics and functional acceptance to the patients. These patients often exhibit the loss of vertical dimension, loss of anterior guidance and collapsed posterior occlusion. Careful and comprehensive treatment planning has to be done for these patients. This case report describes the restoration of lost esthetics and function of 42 year female patient with bruxism by prosthetic rehabilitation. Keywords: vertical dimension, rehabilitation, bruxism, attachments INTRODUCTION Full mouth rehabilitation entails the performance of all the procedures necessary to produce a healthy, esthetic, wel l - funct ioning, sel f maintain ing mast icatory mechanism. - VICTOR .O. LUCIA. Tooth wear which was caused by parafunctional abnormality estimated that their occurrence rate was three times faster than physiological tooth wear.1 Rehabilitation of such worn dentition becomes a challenge as the space availability for prostheses becomes limited. The prerequisites in restoring worn dentition are to understand the determinants of the OVD and the effects of its alteration on the temporomandibular joint (TMJ), muscle comfort, bite force, speech and long-term occlusal stability. When there is loss of tooth structure, it doesn’t mean loss of OVD and it is difficult to determine if OVD has been lost. Therefore careful evaluation and decision has to be made about the alteration in OVD. This paper describes the stages in restoration of severely worn dentition due to bruxism. The steps in treatment of these patients include a comprehensive examination, diagnostic mounting and diagnostic wax-up, careful planning and sequencing of various steps, and careful execution of the treatment plan. CASE REPORT A 42 year old man reported to the DEPARTMENT OF PROSTHODONTICS, TAMILNADU GOVERMENT DENTAL COLLEGE AND HOSPITAL for replacement of missing teeth. On extra oral examination no facial asymmetry or muscle

tenderness, TMJ function was normal. On intra oral examination generalized attrition seen in both upper and lower teeth region and missing lower posterior. Vertical dimension for the patient was lost. It was considered as TURNER classification category 2. Patient reveals has no habit of any parafunctional activities but their relatives pointed out the habit of night grinding. No history of any medical problems. Complete diagnostic and radiographic evaluation was done and the treatment plan was executed and explained to the patient.

Pre operative (fig;1) Radiograph (fig; 2) Intra oral view (fig; 3) TREATMENT PROCEDURE Patient was first treated with oral prophylaxis and extraction of 35 done which had periapical infection. Root canal treatment was planned in 33, 32, 31,41,42,43,44,16, 25. Lost vertical dimension was restored by 3 mm. Upper and lower impressions were made with irreversible hydrocolloid material and diagnostic casts were obtained. Maxillary cast was mounted in a Bio art semi adjustable articulator. Mandibular cast was mounted by using interocclusal record. Removable partial denture was fabricated with restored vertical dimension. RPD was delivered and asked

FULL MOUTH REHABILTATION FOR A PATIENT WITH BRUXISM – CASE REPORT Dr.A.Meenakshi (Professor & HOD) , Dr.V.Harishnath (Sr.Asst.Professor)

Corresponding Author: Dr.V.Harishnath MDS., Department of Prosthodontics, Tamilnadu Government Dental College & Hospital

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities

the patient to wear for three weeks till the patient adapt to the restored vertical dimension.

Face bow transfer (fig; 4)

RPD delivered (Fig; 5)

After one month again impression were made and facebow transfer done for diagnostic wax up with restored VD. Crown preparation was done in upper and lower anterior teeth region. Self cure acrylic Provisional restoration was given from putty index of diagnostic wax up . Anterior guidance was checked and then left side of upper and lower posterior region was prepared and provisional restoration was given and similarly it was done in right side. This provisional restoration was asked by the patient to wear for one month.

Mock wax up (fig: 6) Crown preparation (fig: 7)

Crown preparation (fig: 7) Provisional restoration (fig: 9)

After one month old provisional restoration and cement was removed, gingival retraction cord 000 size was placed after 7 minutes it was removed. Upper and lower impression was made with double step putty and light bodied impression. Then master cast was obtained. Provisional restoration was placed in the mouth; upper maxillary cast was articulated by using face bow. Centric and protrusive inter occlusal record was made by bite registration silicone. With this lower cast was articulated in bio art semiadjusatable articulator.

Bite registration placed (fig: 10) Wax pattern (fig; 11) Inlay wax pattern was made with cusp to fossa relationship; whereas in lower we planned for removable type since it is a long span, so wax pattern from lower posterior was removed. Using parallelometer rhein 83 attachments was placed in distal to 44 and 33. Metal units was fabricated and trimmed. With this in place lower cast was duplicated and refractory cast was obtained for metal framework. After hardening of cast CPD wax was placed and casting done metal framework was trimmed and polished. All the metal units and metal framework was tried in patient and checked for marginal fit and occlusion. Metal ceramic prosthesis was fabricated and was cemented with type I GIC for upper and resin cement was used in lower teeth region and pink cap was placed in framework and inserted. Post insertion instructions are given. Patient was satisfied with esthetic and final outcome of the treatment.

Rhein 83 attachment placed (fig: 12)

Metal try in (fig: 13)

Metal Frame work (fig:14) Finished framework (fig:15)

Metal ceramic prosthesis (fig: 16)

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities

Post operative (fig: 17)

DISCUSSION Tooth wear can be classified as attrition, abrasion, and erosion depending on its cause. A differential diagnosis is not always possible because, in many situations, a combination of these processes has seen.4 Therefore, it is important to identify the factors that contribute to excessive wear and to evaluate alteration of the VDO caused by the worn dentition.5

The etiology of occlusal wear for our patient is not fully understood; however, from the patient, he had history of stress which may have led to parafunctional occlusal habit and started grinding his anterior teeth. Once the anterior teeth got shorter, the patient lost anterior guidance and developed posterior interferences. The posterior interferences in lateral excursions can activate the masseter and temporalis muscles, enabling the patient to generate more forces to grind his teeth more aggressively and lost posterior teeth also.6 Three important requirements to be considered in occlusal rehabilitation are TMJ with no disorders, harmonious anterior guidance and no posterior interferences.7 Temporary restoration not only serves to improve and maintain the prepared tooth condition but also the patient’s mental well being. The provisional restoration serves as a medium of communication of many of the patient’s fears, anxieties and deep concerns about the loss of facial appearance.8 In this case report careful treatment plan was carried out from beginning, endodontic procedure was done to receive the retentive restorations with reduced postoperative sensitivity and precision attachment has planned for lower posterior region due to the presence of long span where fixed partial denture was contraindicated. The presence of excessive wear favoured the use of group function occlusion. CONCLUSION Severe tooth wear present many challenges to the prosthodontist, since we have to gain the space to create restorations in order to satisfy the patient's aesthetic desire, but this treatment modality not only focuses on the esthetics and functional aspect of the dentition but also improves upon the health of the whole stomatognathic system. Patient cooperation, detailed diagnosis and treatment planning are necessary to achieve predictable success of the prosthesis. REFERENCE 1. Xhonga FA. Bruxism and its effect on the teeth. J Oral Rehabil 1997; 4:65–67. 2. Lerner J. A systematic approach to full-mouth reconstruction of the severely worn dentition. Pract Proced Aesthet Dent 2008;20(2):81-87. 3. Vinay Chila Bachhav and Meene Ajay Altering occlusal vertical dimension in functional and esthetic rehabilitation of severly worn dentition. Journal of Oral Health Research, Volume 1, Issue 1, January 2010 4. Smith BG. Toothwear: aetiology and diagnosis. Dent Update 1989;16:204-12. 5. Prasad S, Kuracina J, Monaco EA Jr. Altering occlusal vertical dimension provisionally with base metal onlays: a clinical report.J Prosthet Dent 2008;100:338-42

6. E. H. Williamson and D. O. Lundquist, “Anterior guidance: its effect on electromyographic activity of the temporal and masseter muscles,” The Journal of Prosthetic Dentistry, vol. 49, no. 6, pp. 816–823, 1983 7. Nanda R. Correction of deep bite in adults. Dent Clin North Am 1997;41:67-87. 8. Ramasamy Chidambaram, Manita Grover, Padmanabhan Thallam Veeravalli Full Mouth Rehabilitation of a Worn Out Dentition using Multidisciplinary Approach Journal of Orofacial Research, January-March 2013;3(1):54-56

An Initiative of The Tamil Nadu Dr. M.G.R. Medical University University Journal of Surgery and Surgical Specialities