Many patients present to the clinical environment without an understanding of the etiology that has placed them in their current position. Pain, wear, movement/migration, and mostly a lack of esthetics are their normal driving forces for seeking treatment. Our job as healthcare providers is to evaluate all the causes related to their current issues and provide a clear path forward to improve their dental and physical health.
Case Study
A 38-year-old patient sought treatment for what he called his "disappearing teeth." Throughout his previous dental journey, it was suggested to him that removing all his worn teeth and replacing them with implants and a hybrid type of restoration was his best option.
The All-on concept has become a very popular treatment plan today and can be the ultimate in life-changing restorative. Nevertheless, the authors would suggest it is overprescribed and relied upon as a quick fix for most dentists, as less invasive treatment typically requires more extensive planning and proper management.
The patient made a visit to the periodontist for a "hybrid" solution, which included removal of his existing teeth and subsequent boney structure. The periodontist knew that edentulating him and placing dental implants was overtreatment for a young individual who lacked both periodontal and cariogenic issues. The patient was then referred to a restorative dentist, Dane Avondoglio, MS, DMD.
Upon referral, the patient presented to Avondoglio for a consultation. The new patient evaluation consisted of a full-mouth series of radiographs and digital photographs, followed by a detailed dental and medical history review (Figure 1 through Figure 4).
The dental history revealed that the patient had been a regular, faithful patient to his small-town family dentist since he was a young child. When he was about twenty, his dentist prescribed him an occlusal nightguard, which he wore for years. The patient said that he would "chew through them" and needed a new one every couple of years. His challenges at such a young age required a deeper dive into his medical history and the underlying causes.
Many difficult cases require a team approach, and a conversation was initiated with lab technician, Peter Pizzi, MDT, CDT, before delving into treatment options with the patient.
Extensive questionnaires were filled out to evaluate all aspects of the patient's medical and dental history. His medical history was non-contributory, according to his filled-out questionnaire. Further clarifying questions were asked because the obvious functional and chemical components that his wear patterns showed were not just from functional wear. Chemical components of wear are often not diagnosed. Understanding whether the wear is due to a chemical imbalance or a secondary cause after enamel has already been worn and dentin has been exposed, is paramount to proper diagnosis. To evaluate the patient's history and if there was a chemical component playing a role in the erosive nature of his dentition, more information needed to be gathered; questions about diet, including food and soft drinks, were asked. Besides daily soda as a teen, nothing more could be gleaned about the chemical wear in his mouth.
Intrinsic factors were considered to play a role. Normally, the clinician can run a saliva test to see if there is a chemical imbalance in the patient's saliva (OralDNA). The patient denied having any eating disorders but did state that he often gets heartburn. Due to the amount of chemical erosion in such a short period of time, the patient was advised to see his primary care physician, who diagnosed him with gastroesophageal reflux disease (GERD) and placed him on a proton-pump inhibitor (PPI). PPIs work by inhibiting the production of gastric acid in the stomach and thereby reducing the secretion of gastric acid.
Dentally, the patient presented with Stage I, grade A periodontitis and gingivitis. Besides a few small composite restorations in his upper arch on teeth Nos. 3 and 13, his mouth was clear of any significant dental work. He had orthodontic treatment as a teenager and shortly after completion, his wisdom teeth were extracted. Based on his dental history, he denied jaw pain, but he stated that he had to squeeze his teeth together to "find his bite," and that it was getting more and more difficult to chew his food. Over 50% of the enamel was missing from all his teeth and there was cupping of occlusal surfaces in his dentin. He complained of moderate, generalized tooth sensitivity.
Vertical Dimension of Occlusion
Although cases of severe wear can usually be attributed to a loss of vertical dimension, dentists always need to evaluate the timing of the wear and the possibility of compensatory eruption. Clinicians may be comfortable with changing the occlusal vertical dimension (OVD), but should always confirm the centric related position and the amount of vertical loss or need for space in restorative materials before assuming the OVD should change.
Esthetic Evaluation
Due to the amount of lost tooth structure, especially enamel, it was decided to perform a full-mouth rehabilitation on the patient consisting of build-ups, where necessary, and 360° full-coverage restorations, resulting in 28 indirect restorations. The patient underwent negative load and immobilization tests to rule out temporomandibular joint (TMJ) and muscle dysfunction, respectively. It was thus decided to deprogram the patient to find a repeatable orthopedic position of the jaw, from which a wax-up could be made. The patient was fitted for a Kois deprogrammer, which he wore for 2 weeks. Information can also be gathered with the use of deprogrammers to determine their type of functionality. The patient was very comfortable wearing the deprogrammer and even stated that he liked how it made his jaw feel.
A physical centric relation record was taken with bite registration material, and the maxillary and mandibular arches were recorded using a Medit i700 scanner. After the printing, and the evaluation of the patient's facial features and horizontal plane to confirm the facial analyzer transfer, the digital casts were mounted. A diagnostic wax-up was started by evaluating the new Incisal Edge Position (IEP), the horizontal plane on the maxillary arch for the esthetic parameters, and then the mandibular anterior teeth were fabricated to follow the author's new envelope of function (Figure 5 and Figure 6). Finally, the mandibular posterior teeth were waxed to provide bilateral and equal simultaneous contacts.
The authors decided to prepare the maxillary arch to evaluate the esthetic parameters, incisal edge position, and occlusal plane and confirm the evaluation position of the wax-up. The IEP and the horizontal plane established in the wax-up were all considered "esthetic evaluations," a term created by Pizzi. When smile design parameters are made or even changed, the esthetics need to be evaluated in the face for confirmation of parameters and for harmonization of facial features.
The upper arch was prepared, impressed with polyvinyl siloxane (PVS; Aquasil Ultra, Dentsply Sirona), and provisionalized with shade B1 (Integrity, Dentsply Sirona) (Figure 7). Due to the additive nature of the wax-up, virtually no occlusal or palatal reduction was needed. Because the lower arch's occlusal plane was less than desirable and there was very little enamel to grab onto, the lower arch needed splinted overlays to closely replicate the desired occlusion. After the uppers were provisionalized, the lower teeth were prepared with 27-micron air particle abrasion, acid etched, the bonding agent was applied, and then the lower-arch wax-up was transferred to the lower teeth via a clear PVS matrix in a bisacryl material. Since this overlay was entirely splinted, instructions were given to the patient for cleaning underneath with the use of a Waterpik.
Laboratory Process
The final physical impressions were poured, mounted, and confirmed with the combination of the dento-facial analyzer and patient photographs. For certain cases, including non-broken contact veneers, the authors always prefer a physical impression, as even though the digital impressions offer many great details and information, some critical information is lost. For example, surface texture and the ability to reproduce defined margins that are in contact, like on minimally invasive preparations, may be lost both in the scanning and post-model production. After mounting, all restorations were hand waxed and invested for a lithium disilicate press (VITA AMBRIA). Restorations were fit, and the anterior teeth were layered with ceramic material (VITA LUMEX AC). Final restorations were hand polished (Diashine polishing pastes) and etched with 9% hydrofluoric acid before returning to the clinical practice.
The next appointment consisted of seating the upper-arch restorations, which were facially layered lithium disilicate from premolars forward. The molars were monolithic lithium disilicate. When the patient returned, he had some issues retaining the lower splinted bisacryl as the lack of tooth structure was very evident. It was decided at this time that the initial lower wax-up would need to be redone bearing in mind that the lowers would need at least 2 mm of build-ups to have adequate retention and resistance form. Adhesive restorations were considered, but the lack of enamel was the ultimate contraindication. The upper restorations were cemented with a self-adhesive resin cement (RelyX Unicem2). They were each cleaned with 37% phosphoric acid following their try-in. A silane coupling agent was placed in the restorations and allowed to air dry. The preps were air particle abraded (27-micron aluminum oxide) and then rinsed and dried for cementation. The teeth were seated beginning with the centrals, then tack cured, the excess was removed, and then a full cure and clean up was completed.
The patient returned the following week for a new centric relation record to wax up the lower arch to gain more clinical crown height for the final restorations. An anterior jig made from composite was used to determine the desired vertical height needed in the posterior for adequate retention and resistance form. The lower anterior shell bisacryl material placed at the initial upper-arch prep appointment was still present. A PVS record was taken bilaterally and sent to the lab (Figure 8).
The lower posterior teeth, which were the most affected by erosion and attrition, were isolated with a rubber dam and core build-ups were bonded to the facial and occlusal surfaces. Preparations were completed and a PVS impression was made for the lower eight posterior teeth (Figure 9 and Figure 10).
During the next visit, the restorations were seated with the same protocol as the uppers, and then the lower six anterior teeth were prepared (Figure 11). Small, incisal build-ups were necessary for adequate preparation height (Figure 12 and Figure 13). The lower six teeth were impressed with PVS and provisionalized. The restorations were made and cemented with the same protocol as the rest of the teeth (Figure 14 through Figure 18). As with the upper arch, the molars were monolithic lithium disilicate, and the premolars and anterior teeth were facially layered lithium disilicate.
The final six teeth were cemented following the same protocols as the prior
22 restorations. The occlusion was checked, ensuring the occlusal scheme of posterior disocclusion based on the canine path and bilateral centric stops on the posterior restorations. Avondoglio prefers to ensure adequate anterior clearance in the front four teeth during function by pulling 200-micron articulating paper through the teeth while they are in maximum intercuspation.
Discussion
Due to the lack of tooth structure on the lower arch, keeping the original waxed-up bite proved extremely difficult.
A thorough dental history is a given when dealing with the restorations of teeth, but a medical history is often overlooked. In this patient's case, erosion was a rather obvious factor during his initial examination. Ruling out extrinsic sources, such as diet, allowed for the determination of an intrinsic source causing the chemically mediated tooth damage-either GERD or vomiting from an eating disorder. Given that vomiting more commonly affects the palatal surfaces of maxillary anterior teeth and GERD more commonly affects the mandibular posterior teeth, the patient's wear was considered pathognomonic for his GERD diagnosis.
Certain pathological behaviors lead to sleep bruxism, one of which is GERD.1,2Bruxism is no longer thought of as a parafunctional pathology, but instead as a motor activity during sleep as an arousal response, especially in the masseter muscles, termed rhythmic masticatory muscle activity (RMMA).3 Sleep bruxism contributed to the attrition of his teeth, which, together with the erosion from his GERD, caused rapid tooth loss well before the age of 40. It is normal for a person to lose just 0.1 mm every 10 years, a fraction of what the patient lost in just a couple of decades.4
Conclusion
By controlling the GERD with a PPI, it is hoped that his RMMA will be suppressed, thus controlling his sleep bruxism. The patient was still fitted for an occlusal nightguard.
The patient was ecstatic each step of the way throughout the treatment. Several weeks later, the patient returned for his recare exam, which consisted of final radiographs and photographs (Figure 14 through Figure 28). He was beaming and had this to say about the process: "I have regained self-confidence from knowing my teeth look amazing again, and I can smile once more."
References
1. Li Y, Yu F, Niu L, et al. Association between bruxism and symptomatic gastroesophageal reflux disease: a case control study. J Dent. 2018;77:51-58.
2. Mengatto CM, Dalberto CS, Scheeren B, de Barros SGS. Association between sleep bruxism and gastroesophageal reflux disease. J Prosthetic Dent.2013;110(5):349-355.
3. Manfredini D, Ahlberg J, Lobbezoo F. Bruxism definition: past, present, and future - what should a prosthodontist know? J Prosthetic Dent. 2022;128(5):905-912.
4. Kois JC. Treatment planning and occlusion load and immobilization tests.165: Treatment Planning & Functional Occlusion. 972-973.
Figures and Images
Dane Avondoglio, MS, DMD
Peter Pizzi, MDT, CDT
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