Written by Joseph Whitehouse, DDS Thursday, 31 March 2005 19:00
In a time when we are seeing the media full of makeovers from Botox to extensive, even radical, body reshaping, a group of aged individuals believe that to look nicer, not younger, is a worthy goal. The patient who sees value in restoring a mouth for better function may also obtain an outcome leading to an enhanced look.
The patient in this article had been seeing a dentist for years and continues to have her hygiene visits at that office. The desire of restoring her mouth arose through the patient's daughter learning through marketing of more comprehensive care provided by my office. Both the daughter and the patient wanted to embark on a course of action leading to restored function and a more pleasing look.
"AN INSURMOUNTABLE OPPORTUNITY"
|Figure 1. The 71-year-old patient.||Figure 2. Natural smile.|
|Figure 3. Bite without partials.||Figure 4. Right lateral view.|
|Figure 5. Left lateral view.||Figure 6. Upper arch without partial.|
|Figure 7. Lower arch without partial.|
There are cases dentists see that need extensive knowledge of treatment planning and technical skill in order to render a functional and aesthetically pleasing outcome. It is Yogi Berra's shortest phrase that can describe these cases: "an insurmountable opportunity." For as can be seen in Figures 1 to 7, the patient presents numerous issues that do not lend themselves to quick solutions.
The patient wore both upper and lower partial dentures that held her bite slightly open. As can be seen, upon removal of these appliances, her bite was totally closed. It could not be discerned whether her bite had collapsed or had been like this originally. However, as with cases of periodontal bone loss, anterior teeth often move apart and facially. This did not seem to be the case. The periodontium was sound, with minor recession for her age. The patient did not exhibit any bone loss and had a bruxing habit as exhibited in Figure 7. The tooth surface loss on tooth No. 22 was caused by the patient's deep bite wearing against the porcelain of the lingual aspect of tooth No. 11.
The patient's goal for her mouth was to preserve as many teeth as possible. She wanted to improve her smile if possible and have a healthy mouth. A treatment plan was formulated that would meet her goals, but only if the problems that led to the issues were discovered and treated. As mentioned, the patient had been receiving care from the same dentist for some time.
Related to the patient's goals was the issue that minimally invasive dentistry demands: CAMBRA (caries management by risk assessment1). Seeking a long-lasting outcome for this 71-year-old patient required that an analysis of her diet, saliva flow, bacterial type and count, and brushing habits be evaluated. Using an Ivoclar Vivadent CRT Caries Risk Test found that the patient had a slightly reduced saliva flow from normal and bacterial counts of moderately elevated Streptococcus mutans and Lactobacillus mutans. A habit of chewing sugar-containing cough drops was discovered. Her brushing habit and ability needed addressing.
CAMBRA is designed to be a tool enabling control of the oral environment. Knowledge of these statistics and information led to a very compliant, motived patient eliminating the cough drops, drinking more water throughout the day, following an increased schedule of brushing and flossing, brushing with Peridex once per day, and using a fluoride rinse. Once this author knew of her compliance, the outcome of reconstruction could be much more predictable. Two years later, no decay was diagnosed upon the patient's return for an evaluation.
A course of action incorporating the patient's goals led to the following:
•controlling the caries-producing bacteria
•orthodontically closing her wide diastema
•opening her bite to a predetermined position
•eliminating her partial dentures in favor of bridges
•veneering and crowning anterior teeth for a more pleasing smile
•providing a night guard.
|Figure 8. Closeup anterior segment.||Figure 9. Patient in braces.|
|Figure 10. Braces removed.|
The presence of a wide diastema (Figure 8) would prevent any restoration that would close the space and look normal. When the patient was offered an orthodontic solution, she was open to the idea. In fact, once the brackets (Roth, DENTSPLY GAC) were placed, her comment was "I feel like a kid again" (Figure 9). The closure took 4 months and resulted in measurements that led to a more ideal smile, namely a width-to-height ratio of 75% on the final crowns. Figure 10 shows the teeth in a more ideal position post orthodontic treatment. (During the 4-month orthodontic treatment, the lower arch was restored.)
OPENING THE BITE
|Figure 11. Triad added to open bite.|
Because the entire dentition for this case was going to be restored, it made sense to open the severe deep bite as seen in Figure 3. Over the years, issues have been raised concerning the opening of a patient's bite.2 This area has been researched by Kois, who provides a guideline confirming that opening bites usually occurs without incident.3 However, it is never an issue to test that proposed opening. As can be seen in Figure 11, Triad Rope material (DENTSPLY) was added to her partial denture on both the right and left sides, positioning her bite to a predetermined elevation that was more open than the original partial teeth provided. The patient wore the partial to open the bite for 3 months during her 4-month orthodontic movement. The opened bite was well tolerated.
RESTORING THE MANDIBULAR ARCH
Christensen points out that when restoring a bite, the more of the original occlusion that can remain, the better.4 Therefore, in deciding to proceed with restoration of both arches, a foundation would be laid by restoring the lower arch first. The patient could function on that arch for the period of time that remained for the orthodontic treatment.
|Figure 12. The restored lower arch.|
In this case, the benefit of restoring the mandibular arch first was getting the anterior position prepared to couple with the linguals of the upper anterior teeth, so all teeth could be supporting the whole arch (Figure 12). To eliminate the partial denture, a bridge Nos. 19 to 21 and a cantilever bridge using Nos. 28 and 29 as abutments with a pontic in the No. 30 position were prepared. (An implant was offered in each of these locations, but the patient decided to have bridges.) Once the mandibular arch was completed and the orthodontic treatment was completed (movement for 2 months, retained for 2 months), the maxillary arch was ready for preparation.
ESTABLISHING THE BITE
|Figure 13. Temp Tabs stabilization.|
When prepping a whole arch, the major concern is communicating an accurate bite to the laboratory. In this case, a new technique using a thermoplastic material (Temp Tabs, All Dental ProdX) was modified, whereby the edentulous area of the maxillary left was stabilized as seen in Figure 13. This stabilization shows how the par-tial teeth were cut away from the existing maxillary partial on the left side for placement of the thermoplastic, while the right side was held stable with a bite created with Blu-Mousse (Parkell). The bite material as seen in Figure 13 needs to be very stable, using the ridge form completely without interfering with the partial. The material is heated according to the manufacturer's instructions, using several tabs as needed. It is placed and then cooled with air and water spray.
All of the teeth on the right side of the maxillary arch (teeth Nos. 3 and 6 to 10) were prepared for crowns and a bridge. The original bite described was replaced on the left side, and another bite with the same material was taken on the right side with the patient closing into the left side bite. Thus, a very rigid registration of the new desired bite was made. Once the right side bite was completed, the remaining teeth on the left were prepared, and a new bite was taken to include all of the teeth on the left using the right bite as a stopping point. These bites were very solid.
Both bites were sent to the lab for mounting along with the Kois Dento-Facial Analyzer System (Panodent) to be used on a Panodent semiadjustible articulator. This "facebow" is, according to Kois, accurate for 95% of the population.
|Figure 14. Restored upper arch.||Figure 15. Lingual coupling.|
Upon seating of the maxillary bridges and crowns, the bite was adjusted for patient comfort. The lab had done a commendable job of placing a compatible occlusion to the lower arch. Figure 14 shows the upper arch, with the lingual areas of the anterior teeth extended for coupling with the lower arch as seen in Figure 15. Working with a deep overbite (Figure 3) and keeping in mind that "locking in" the patient's bite was to be avoided, the slope of the lingual aspects of the maxillary anterior crowns were designed for a smooth transition at a somewhat flattened angle. The contact on each anterior tooth in protrusive and working bite was designed for optimal disclusion.5
Although full porcelain crowns are commonly used for restoring anterior teeth, with the extent of lingual extension it was decided to use porcelain-to-gold crowns for strength. Porcelain margins were used on the maxillary anterior teeth. The maxillary bicuspids were pontics. Thin metal margins were used on the remaining teeth with beveled margins.
|Figure 16. Patient's smile.||Figure 17. Anterior closeup.|
The designed proportions of the anterior crowns were based on the "golden proportion" and width-to-height ratio of the central incisors (75%). Although I measure teeth constantly, especially during crown lengthening, I do not believe that these proportions are absolutely necessary in every case. For example, a low smile line can eliminate the need for ideal crown height. In this case, the smile line was taken into consideration. Figure 16 shows an outcome where the proportions appear pleasing. The central maxillary crowns in Figure 17 show the proportion of 75% width to height. This was accomplished to obtain a pleasing smile line, but as seen in Figure 16, the crowns could have been shorter had the gingival position been lower. In other words, had the margins ended just above the lip line, the crowns would not have needed the more ideal height.
|Figure 18. Restored arches.||Figure 19. Cuspid rise.|
The retracted view in Figure 18 shows the completed case. Because the patient had tested the opening of the bite to this position, the outcome was good. Figure 19 shows the cuspid rise built for bite protection. Because the lower arch was restored first and the patient had maxillary cuspid crowns before restoration, the lab worked to build the final cuspid rise to simulate what the patient was accustomed to. Christensen4 points out that restoring a difficult case to be as similar as possible to what the patient is accustomed to facilitates a more successful outcome. Mounted models of the original maxillary dentition and the new mandibular restorations were used to determine the angle of cuspid rise.
|Figure 20. Makeover complete.|
Finally, Figure 20 can be compared to Figure 1 to see what a smile makeover can contribute to a restyled face. The patient was "delighted with [her] nice white teeth."
"Older patients" are often treated with indifference when it comes to how they look.6 The result may often be a patient not receiving the care that his or her goals would dictate. In the featured case, the patient had received dental hygiene care in a dental office for years. The fact that the patient's daughter had to take the initiative to seek care for a very motivated patient indicates a lack of understanding and communication in the patient's original dental office.
The treatment plan that met the patient's goals was presented and accepted. It involved a full-mouth reconstruction, eliminating partial dentures, opening a deep bite, treating a diastema with orthodontics, and constructing a new smile. This makeover lent itself to the current trend of improving a smile, but it accomplished much more. The patient now has a firm foundation for better chewing, but perhaps more importantly, the patient, through CAMBRA, has the knowledge to control the disease process that caused the breakdown of her original dentition.
1. Featherstone JD, Adair SM, Anderson MH, et al. Caries management by risk assessment: consensus statement, April 2002. J Calif Dent Assoc. 2003;31:257-269.
2. Thompson JR. The rest position of the mandible and its significance to dental science. J Am Dent Assoc. 1946;33:151-180.
3. Kois JC, Phillips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent. 1997;18:1169-1177.
4. Christensen GJ. Is occlusion becoming more confusing? A plea for simplicity. J Am Dent Assoc. 2004;135:767-770.
5. Fillastre A. Anterior guidance. Continuum (N Y). 1981:12-13.
6. Whitehouse J. Missed opportunities. Patients lost to lack of understanding and marketing. Dent Today. Mar 2003;22:112-117.
The author wishes to thank San Ramon Dental Laboratory for the fine work for this case.
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