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A Multidisciplinary Approach for the Management of Extremely Abraded Dentition

Tzanakakis Emmanouil-Georgios
Published: 22 July 2020
Modern Research in Dentistry , Volume 5, pp 496-503; doi:10.31031/mrd.2020.05.000612

Abstract: Dr.Tzanakakis Emmanouil-Georgios* Department of Operative Dentistry, Dental School of Athens, National and Kapodistrian University of Athens, Greece *Corresponding author: Dr.Tzanakakis Emmanouil-Georgios, Department of Operative Dentistry, Dental School of Athens, National and Kapodistrian University of Athens, Greece Submission: June 25, 2020;Published: July 22, 2020 DOI: 10.31031/MRD.2020.05.000612 ISSN:2637-7764Volume5 Issue3 Restoring extremely abraded dentition is considered as one of the most demanding and time consuming clinical challenges. Patients are often unaware of the complexity of these treatment plans and are usually reluctant to accept major prosthetic interventions. Proper coordination of the clinicians involved in the treatment plan is essential and saves valuable clinical time. This clinical report describes thoroughly a complicated treatment plan that involves periodontic and endodontic treatment, dental implants, orthodontic extrusion and a full-mouth rehabilitation with a combination of all-ceramic and metal-ceramic restorations. In this case report the role of temporary restorations in increased VDO is emphasized and with an extended discussion on clinical steps. Keywords: Abraded dentition; VDO; Bruxism; Metal-ceramic; All-ceramic Abbreviations: TMJ: Temporomandibular Joint; VDO: Vertical Dimension of Occlusion; RPD: Removable Partial Denture The management of complicated cases of extremely abraded dentition is a difficult task for the clinician. It has a negative impact on quality of life comparable with that of edentulousness [1]. The reconstruction of dental arches requires extensive restorative treatment [2,3]. Every patient requires unique treatment, however most of them at the beginning of treatment are not aware of the cost and time that is necessary for a proper and long term treatment plan and postpone the therapeutic interventions. Moreover they are usually confused because specialized clinicians may propose different treatment plans. A team of experienced clinicians can suggest an appropriate treatment planning [2]. Nowadays, the increase of mechanical strength and adhesive potential of new dental materials may offer new possibilities in reconstructive techniques and digital workflow can minimize invasive tooth preparations [4,5]. Bruxism is a repetitive parafunctional activity and the main cause for temporo-mandibular disorders (TMD) [6]. Wear facets along with masseter muscle hypertrophy other clinical are common findings that indicate the presence of bruxism [6]. Masticatory forces in bruxing patients are much higher than maximum biting forces measured during chewing cycles, which partially explains the catastrophic impact to dental restorative materials. It is widely considered that bruxism has also a negative impact on the periodontal tissues and is a main cause of loss of osseointegration of dental implants [7-9]. Loss of posterior support causes difficulty in mastication especially in young and middle aged population. In these patients, anterior teeth are overloaded. The results are either tooth mobility or extensive wear of the clinical crown. Restoration of posterior support is necessary as early as possible with provisional restorations to restore periodontic and mechanical overload of the remaining dentition [2]. Fixed implants restorations are more attractive for the patients especially when the alternative treatment plan includes a removable device. If a patient can afford the increased cost and accepts the minor surgical procedure, implants are a reliable solution to partial edentulism [10]. The aim of this case report was to analyze the therapeutic management of a patient presenting generalized excessive tooth wear in the mandibular dentition involving decreased VDO and loss of posterior support. The treatment included a combination of periodontic and endodontic therapies, implants placement, minor orthodontic treatment and optimum prosthodontic rehabilitation with fixed dental prostheses, cast posts and all ceramic veneers in increased VDO. Patient presentation The Caucasian 53-year-old male patient was seeking treatment. His chief complaint was difficulty in chewing and his anticipation for a fixed restoration (Figure 1). Figure 1: Preoperative intraoral frontal view. Initial clinical situation, radiographic examination Figure 2: Preoperative panoramic radiograph. The patient reported a free medical history, but admitted smoking habit (20+cig/day). He was not taking any medication and reported pain in facial muscles during stressful periods. The patient was subjected to thorough clinical and radiographic examination (panoramic x-ray) (Figure 2). Intraorally, he presented severe abrasion most observed in mandibulary dentition, reduced VDO, and several missing mandibular teeth (#44,45,46,47 and 36,37). In the maxilla, a 4-unit metal ceramic bridge with a cantilever was found on the incisors {12-11-21-(22)}, and one 4-unit metal-acrylic bridge in the posterior segment {23-(24)-(26)-27}. The visible diastemmas between #12,#13 and #13,#14 were due to a missing premolar #15 which probably caused distal migration of #14 and 13 (Figure 3-5). The smile line was evaluated as medium (Figure 6). Secondary caries was visible in amalgam restorations in #14 and #16 and was inspected under the abutment #12. A significant change in the occlusal plane was obvious, defined by significant protrusion of #13, #14 and #16. In the mandible acrylic crowns were positioned in #44, 33, 34. Initial radiographic examination revealed endodontic therapies in #12, 34, 35, 42 and #43 and it was estimated that the bone level averaged at 70%. Clinical examination of the stomatognathic system revealed bilateral myalgia of the lateral pterygoid muscles on palpation, unilateral clicking on the left TMJ and limitation in mouth opening. All other masseter muscles were free of symptoms. Figure 3: Preoperative occlusal view of the maxilla. Figure 4: Preoperative intraoral...
Keywords: Treatment / quality of life / masseter muscle / dental implants / restorations / metal ceramic / increased VDO

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