Our patient is a married, healthy, 63-year-old female, a long-time resident of San Antonio, and is employed as an actuary at a local insurance company. She presented with a complaint of pain to biting pressure in a tooth on the lower left.
A limited examination revealed tooth no. 19 was restored with a ceramometal crown. A large amalgam restoration had been placed on the distal root surface well beyond the biologic width. There was considerable recurrent decay distally and into the furcation, which rendered this tooth non-restorable. To alleviate her pain, this tooth was excavated and temporarily restored and she was then scheduled for a comprehensive examination. Prior to her scheduled comprehensive examination appointment, she developed significant biting pressure pain in the lower right quadrant. Tooth no. 30 was determined to be the source of her discomfort. It was very minimally restored with a buccal pit amalgam, but had a substantial crack in the mesial marginal ridge. Radiographic evaluation revealed bone loss surrounding the entire mesial root consistent with a vertical root fracture. This tooth, being non-restorable, was extracted. Having eliminated her pain complaints, we proceeded to the comprehensive examination.
The patient was receiving routine preventive care every six months. She had undergone orthodontic treatment from 1966-1969 when the first bicuspids were extracted, and the spaces closed. She had been challenged with temporomandibular joint pain for years with a recent flare up on the right side. In 2012 she had arthrocentesis that alleviated the pain. She wears an interocclusal splint during sleep.
The patient also told us she was unhappy with her previous dentist saying he was unresponsive to her pain. She also told us that her teeth are sensitive to cold and heat, that she grinds her teeth, and that dental treatment makes her nervous.
Extraoral/Facial
TMJ/Mandibular Range of Motion/Muscles of Mastication
Dental
Periodontal
Our non-clinical goals in this case were to convey to the patient that her problems were an interdisciplinary, complex issue that had been ongoing and worsening for many years. Our solution to these problems would require the collaborative efforts of a team of dentists. The objective clinical goals were to orthodontically move her teeth into a less restrictive position and create room for restoration of lost tooth structure. Implants would be used not only to replace missing teeth but to provide orthodontic anchorage to facilitate movements that would not be possible with conventional orthodontics. Our final restorative goals were to reestablish ideal form and function, creating an occlusion that was stable and comfortable, enabling long term dental health. As her desires were specifically not to address esthetics, we were clear esthetic improvements were the result of correcting form and function. Of note is the fact that this case, from the restorative and surgical standpoint, was to be accomplished, with few small exceptions, entirely digitally.
Tooth no. 19 was isolated with a dental dam under local anesthesia. All existing restorative material and decay was excavated leaving a very evident crack into the pulp, down to the pulpal floor. The mesial canals were completely calcified, the decay extended beyond the bone level. This tooth was diagnosed as hopeless and scheduled for removal. A provisional was placed at this appointment.
Tooth no. 30 was deemed hopeless at initial evaluation and extracted.
Full Mouth Radiographic Series, Maxillary and Mandibular Intraoral Scans, Digital Jaw Relation Recording with a Leaf Gauge, Complete Photographic Series, Periodontal Charting, Restorative Charting.
In considering a treatment plan for our patient, it is important to note that in our initial information gathering she was clear she had no esthetic concerns. Further, her desires were single tooth in nature, specifically to replace her missing lower molar teeth. The most challenging aspect of this plan was communicating to the patient what her true problem was and having her accept that the problem, if left untreated, was a challenge to her dental health for life. She must also understand the solution to the problem and to appreciate that comprehensive care with orthodontics and restorative dentistry is to solve a long standing functional and structural problem. Esthetic improvements are a consequence of restorative and structural improvements, not a primary driver in the plan. In our multiple consultation appointments, we allowed the patient to ask as many questions as she needed answered. In short, it took her about six months to overcome the single tooth mindset that she had been taught by her previous dental experiences. Photographs were a significant component in our explanation. They demonstrated the excessive wear resulting in the extractions and were an indicator of what she should expect if she chose only to have the missing lower molars replaced. The orthodontic consultation was a key in her accepting care. An opinion from one of our specialist colleagues, another set of eyes if you will, added support for our recommendations. The plan ultimately accepted by the patient was altered from our originally proposed plan per the patient’s request to only restore the mandibular posterior teeth leaving the mandibular anterior teeth unrestored. With this compromise we still felt we could achieve acceptable anterior function. That altered our overall plan in two ways. First, the orthodontic plan would now not include intrusion of the lower anterior teeth as the incisal edges will dictate tooth position, not the gingival levels. The orthodontist would place the incisal edges of these teeth in ideal position. And second, when restoring the mandibular posteriors after placement of the maxillary restorations, we will not alter the VDO.
Connective tissue grafting was accomplished pre orthodontically to cover the root surfaces in teeth nos. 11 and 12.
Orthodontic therapy was initiated in January 2016. At the midpoint of her orthodontic treatment, a CBCT was obtained as well as an intraoral scan (3M Tru Def). These data files were uploaded to the Implant Concierge website with a treatment plan to place implants in the position of teeth nos. 19 and 30. When the Level 2 technician at IC had the initial plan designed, we held a GoToMeeting with the orthodontist, restorative dentist, and the technician present, all in their respective offices.
At this meeting, the orthodontist was instrumental in planning the implants in a more mesial position in the edentulous spaces. A surgical guide was then fabricated and implants (Straumann) were placed in an ectopic position. Screw retained provisional crowns (Bisacryl) were placed on the implants providing anchorage for the orthodontist to move the anterior sextant mesially to correct the A/P relationship between the arches. Composite resin was gradually removed from the distal of the provisionals and added to the mesial to maintain ideal contours.
At the conclusion of orthodontic therapy, we obtained new intraoral scans and a jaw relation recording using a leaf gauge. We sent photographs and the IOS to the laboratory (Summit Dental Lab) for digital design of the maxillary restorations. The lower posterior design was completed opposing the newly designed maxillary arch. Digital design enables very efficient review of the plan between the lab technicians and the restorative doctor. Modifications can be communicated easily, and the final plans can be 3D printed. These models were then used for preparation guidance and provisional matrices.
Under oral sedation in a six-hour appointment, the maxillary teeth were prepared as follows. The original leaf gauge jaw relation recording was retained to be used to replicate the preoperative A/P and vertical position as closely as possible. After the anterior teeth were prepared, we used these records to obtain an anterior jaw relation recording. We then prepared the UR and placed the new anterior record and the original left side posterior record in place to capture the right posterior inter arch relationship. We followed with preparation of the left posterior teeth and got the final piece of the inter arch position using the new records previously obtained. Retraction cords were placed (Ultradent) and margins refined. Second cords were placed for lateral retraction and a complete arch IOS was recorded (3M Tru Def). The lower arch was scanned, and provisional restorations were fabricated using matrices from the digitally designed and 3D printed model. A detailed laboratory prescription, face bow recording, and the analog jaw relation recording were then forwarded to the laboratory for fabrication of the final restorations. The provisional maxillary restorations were scanned and forwarded to the laboratory along with the preparation scan. This scan of the provisional restorations was merged with the preparation scan in the laboratory, giving direction in final restoration design and enabling replication of the provisionals that have been accepted by ourselves and the patient.
Digital design again provides efficient interchange between the technician and dentist.
Six weeks later the final restorations were tried in. After confirmation of fit and esthetics, they were bonded in place (3M Rely X Ultimate).
Our original plan had been altered by the patient to not include restoring the lower anterior teeth. However, when the patient arrived for the mandibular prep appointment, she informed us that due to the dramatic esthetic improvement of her maxillary teeth she now wanted to restore all the mandibular teeth including the anteriors. The fact that we did not pressure her during the initial consultation visits ultimately led to her choosing ideal care.
After preparing the mandibular posterior teeth this change in plan was accommodated by increasing her VDO arbitrarily, again with a leaf gauge. Scans were sent to the lab for construction of the posterior crowns at this new VDO. The technicians then conventionally waxed the mandibular anteriors to that new VDO.
Six weeks later the final mandibular posterior restorations were tried in and bonded in place (3M Rely X Ultimate). The implant crowns were torqued to 35nCm. Teflon tape and composite resin were used to close the access openings.
Minimal preparation veneers were designed to restore the mandibular anteriors and six weeks later they were bonded in place (3M Rely X Ultimate).
An interocclusal splint was fabricated to serve as a means of protection against parafunction and as an orthodontic retainer.
The overall success with this case came about because of our team’s patience in allowing time for the patient’s thinking to shift from single tooth emergency type dentistry to a more comprehensive approach. Too many times we as clinicians follow our natural tendencies to just get going with the dentistry instead of taking the time to allow our patients to evolve into choosing optimum care.
In this case, one primary retrospective consideration is the potential impact that airway restriction/obstruction may have played. While she reported no prior diagnoses at her initial assessment, many clinical observations indicated otherwise. Previous orthodontic therapy with bicuspid extractions, anterior retraction, bruxism, TMJ dysfunction and GERD are all co-diagnoses in airway disease. Our treatment included maxillary and mandibular protraction and increased vertical dimension. Both of these changes increase oral volume and potentially improve air flow. Our patient has had no TM related pain or problems in the 2 years since completion of her care. Future patients with similar situations will be screened for airway disease.
A review of treatment goals indicates complete resolution of structural and functional disease with the expectation of long-term stability.
Dr Brian Schroder is a general dentist practicing in San Antonio, Texas. He is an assistant professor in the AEGD Program at the UT San Antonio Dental School, a member of the Speakers Bureau of the Seattle Study Club, and the director of the Alamo Collaborative Dental Forum Seattle Study Club.
Dr Tyler Ferris is an orthodontist practicing in San Antonio, Texas
Dr Amir Hosseini is a periodontist practicing in San Antonio, Texas and is the director of The South Texas Advanced Restorative Seminars Seattle Study Club.
