Rethinking the traditional full-mouth rehabilitation by applying minimal prosthetic for maximum patient benefit Miles R. Cone, DMD, MS, CDT, FACP

The field of dentistry is an ever-evolving discipline. A he partially edentulous patient may present to the marked rise in the use of endosseous implants, adhesive dental office in myriad configurations, and the imple- ceramic bonding, and composite resins, as well as contin- mentation of restorative treatment will vary greatly ued patient desire for minimally invasive procedures, T depending on the needs and circumstances of the individual. has created a new conservative era in the practices of Clinical variations range from minor cosmetic issues, such many restorative . These trends, coupled with the as bilateral congenitally missing maxillary lateral incisors, to significant financial impact associated with the recon- scenarios in which the patient exhibits a shortened dental arch, struction of failing, worn, and esthetically compromised potentially challenging the function of his or her masticatory 1 dentition, have facilitated a paradigm shift in the way apparatus. Perhaps the most challenging and complex treat- that individual patient cases are being treatment planned ments, however, are those that involve severe dental agenesis, today. Applying restraint to conventional practices supraeruption of unopposed teeth, and an esthetically compro- involving the unnecessary gross removal of hard tooth mised, “mutilated” dentition in which there is a disfigurement structure is both a skill that needs to be cultivated as well in the way of both function and appearance. as an evident obligation to the patient. A case report Implicit in the successful treatment of a mutilated dentition demonstrates the utilization of multiple restorative mate- are the numerous biological, functional, and esthetic demands rials to provide a minimally invasive definitive treatment that ultimately pose challenges to the restorative : an that was biomechanically, esthetically, and financially undulating occlusal plane (typified by edentulous areas with satisfactory for the patient. overerupted opposing dentition), physiological tipping and mesialization of freestanding teeth, potential collapse of occlu- Received: June 19, 2016 sal vertical dimension, untoward masticatory forces resulting Revised: August 6, 2016 from an unstable occlusal scheme, and, frequently, years of 2 Accepted: August 24, 2016 neglected oral healthcare. Patients’ motivations for seeking dental treatment of a Key words: adhesive bonding, full-mouth rehabilitation, mutilated dentition are largely focused on a personal desire for 3,4 minimally invasive dentistry, mutilated dentition improved esthetics. The technically intricate and biologically sophisticated procedures frequently required for such large- scale oral rehabilitations, however, present financial limitations that often render these intensive restorative treatments unat- 5 tainable for many individuals. Historically, the treatment planning modalities for such extensive and complex cases focused on complete reorganiza- tion of the through various combinations of metal- ceramic restorations, splinted dentition across tooth-bound edentulous spaces, nonrigid connectors, semiprecision attach- 6 ments, and removable partial prosthetics. The dental treatment concepts of the contemporary restorative dentist have evolved over the last 20 years with the advent of adhesive bonding and all-ceramic restorations. Indeed, the liberal removal of precious tooth structure—once necessary to achieve retention for luted cast metal copings and to obtain sufficient space for porcelain to block out the metal copings—is no longer necessary or 7 advised. Further, the replacement of individual missing teeth Published with permission of the Academy of General Dentistry. and the achievement of long-lasting and functional esthetics © Copyright 2016 by the Academy of General Dentistry. are no longer dependent on the aggressive preparation of the All rights reserved. For printed and electronic reprints of this dentition to accommodate more destructive and costly ortho- article for distribution, please contact [email protected]. dox fixed prosthetics. Marked advances in endosseous implant

46 GENERAL DENTISTRY November/December 2016 A B C D

Fig 1. Patient at initial presentation. A. Frontal view in repose. B. Profile view in repose. C. Frontal view of full smile. D. Profile view of full smile.

Fig 2. Preoperative panoramic radiograph.

11,12 therapy, coupled with conventional minimally invasive dental factors are known to play a key role. Additionally, the patient techniques, have driven the paradigm shift to refocus treatment displayed bilateral microdontia, affecting the maxillary lateral 8,9 options regarding the traditional full-mouth rehabilitation. incisors. These conditions presented clinically in this patient as The following case report describes the utilization of multiple a nonuniform distribution of the existing dentition, resulting in restorative materials, acting in concert, to provide a minimally diastemas throughout the anterior sextant and supraeruption of invasive definitive treatment that was biomechanically, estheti- teeth with diminutive opposing dentition (notably the maxillary cally, and financially satisfactory for the patient. left canine), all of which are common in individuals who possess 13 extensive . Further examination revealed that the Case report maxillary right first molar (tooth 3) and second molar (tooth 2) Diagnosis and treatment planning and the mandibular right second molar (tooth 31) presented A healthy 42-year-old man presented to the prosthodontic clinic with defective amalgam restorations and secondary caries. as a self-referral regarding the development of a comprehensive No deviation or deflection of the jaw was detected on maxi- dental treatment plan (Fig 1). A meticulous and thorough medi- mum opening and closing to the physiological rest position, and cal and dental history for this patient was recorded, and compre- an analysis of the patient’s occlusion revealed that his centric hensive radiographic and intraoral examinations were performed. occlusion and maximum intercuspal positions were nearly coinci- A preoperative panoramic radiograph revealed that the patient dent; anteroposterior displacement of the dentition was insignifi- possessed retained primary teeth: the maxillary right canine cant. A group function occlusal scheme was noted in right and (tooth C); the maxillary left lateral incisor (tooth G); the man- left laterotrusive, working movements; mediotrusive, nonwork- dibular left first molar (tooth L) and second molar (tooth K); ing tooth contacts were noted between teeth 2 and 31 as well as and the mandibular right lateral incisor (tooth Q) and second between tooth 3 and the mandibular right first molar (tooth 30). molar (tooth T). He was also diagnosed with a severe form of An evaluation of the patient’s dental and facial esthetics was congenital tooth agenesis known as oligodontia, that is, 6 or also undertaken during this phase of the examination. In a 10 more missing permanent teeth, excluding third molars (Fig 2). coronal view, the maxillary and mandibular dental midlines The specific etiology of permanent tooth agenesis remains were found to be coincident with his facial midline. External poorly understood; however, the phenomenon occurs with a soft tissue support and skin contour were considered by viewing proportionately high incidence rate of 2.5%-6.9%, and genetic the sagittal profile of the patient’s head. In conjunction with the

Special PROSTHODONTICS Section 47 Rethinking the traditional full-mouth rehabilitation by applying minimal prosthetic dentistry for maximum patient benefit

Location and Extent of Edentulous Area Class I Class II Class III Class IV One arch, MX < 2 incisors, MD < 4 incisors, < 2 premolars, < 1 premolar and a molar Both arches and otherwise same as above, or 1 or both arches and missing canine(s) X One or both arches, posterior area > 3 teeth or 2 molars, anteroposterior > 3 teeth Requiring high degree of patient compliance; guarded prognosis Congenital or acquired maxillofacial defect Abutment Condition Localized adjunctive treatment (periodontal, endodontic, orthodontic) None 1-2 sextants X 3 sextants > 4 sextants Insufficient tooth structure None X 1-2 sextants 3 sextants > 4 sextants Occlusion No preprosthetic therapy X Localized adjunctive therapy Reestablish entire occlusion, no change in OVD Reestablish entire occlusion, with change in OVD Residual Ridge Class I edentulous Class II edentulous Class III edentulous Class IV edentulous Conditions Creating a Guarded Prognosis Serere oral manifestations of systemic disease Maxillomandibular dyskinesia and/or ataxia Refractory patient

Fig 3. Completed Prosthodontic Diagnostic Index checklist. Due to the complex esthetic concerns, the patient’s classification is graded upward from Class II to Class III. Abbreviations: MD, mandibular; MX, maxillary; OVD, occlusal vertical dimension. (Prosthodontic Diagnostic Index adapted from McGarry et al26 with the permission of the American College of Prosthodontists.) patient’s tooth display in repose, an assessment of his true high Diagnostic maxillary and mandibular casts were fabricated 14 lip line was made through the elicitation of a Duchenne smile. from type III dental stone utilizing impressions that were made Phonetic analysis was conducted utilizing fricatives (eg, /f/ with irreversible hydrocolloid. Three records and /v/ sounds) and sibilants (eg, /s/ sounds). Fricatives are were then made using compression-resistant polyvinyl siloxane an essential diagnostic tool that aid in determining the cor- (PVS) interocclusal registration material (Blu-Mousse, Parkell, 15 17-19 rect incisal edge position of the maxillary anterior dentition. Inc). An arbitrary earbow-facebow (Pana-Mount Face-Bow, Sibilants serve as a useful means of assessing the closest speak- Panadent Corporation) was used in conjunction with a class 16 ing space—a key component of the occlusal vertical dimension. III-B semiadjustable articulator (PCH Articulator, Panadent 20-23 For this patient, the phonetic analysis revealed that the length of Corporation) to mount the diagnostic casts. Programming the maxillary central incisors was appropriate and there was no of the posterior determinates of occlusion was accomplished apparent loss of occlusal vertical dimension. using information obtained from a pantographic recording

48 GENERAL DENTISTRY November/December 2016 A B

C

D E

Fig 4. Dentition after phase 2 of treatment. A. Right lateral view of maximum intercuspal position. B. Left lateral view of maximum intercuspal position. C. Anterior view of maximum intercuspal position. D. Postsurgical occlusal view of the maxillary arch. E. Postsurgical occlusal view of the mandibular arch. device (Axi-Path III Recorder, Panadent Corporation). A diag- The patient’s checklist revealed an overall PDI 2 classification nostic wax-up was then completed at the existing occlusal ver- rating for this patient (Fig 3); however, additional guidelines for tical dimension, and an appropriate occlusal plane and scheme the PDI stipulate that esthetic concerns or challenges augment the were established. complexity of the final PDI classification by 1 level, from a PDI At the following visit, an esthetic trial mock-up was carried classification 2 to a PDI classification 3, for the partially edentulous out for the maxillary right (tooth 7) and left (tooth 10) lateral patient. This classification system provides all restorative practitio- 24,25 incisors. The mock-up was fabricated with a heavy-bodied ners, generalists and specialists alike, with a simplified and orga- 26 PVS putty matrix (Extrude, Kerr Corporation), an extra-low– nized aid for determining whether to treat or refer the patient. viscosity PVS wash (Aquasil, Dentsply Sirona), and a Bis-acryl Following all initial diagnostic phases, a formal treatment provisional material (Luxatemp, DMG America). plan was developed in conjunction with the adjunct specialists, At the conclusion of the patient’s comprehensive evaluation, a periodontist and an endodontist, utilizing the PDI checklist. all observed information was entered into the Prosthodontic The comprehensive treatment plan was then reviewed with 26 Diagnostic Index (PDI), which is a standardized checklist (Fig 3). the patient and would ultimately involve elimination of caries, The PDI serves as a streamlined and objective screening tool that placement and restoration of endosseous implants, and realiza- facilitates communication between colleagues. This categorical tion of the following esthetic desires: creation of full-contour system is available for individuals who are fully dentate, partially lateral incisors, correction of supraerupted dentition, and res- edentulous, and completely edentulous. The PDI is structured into toration of the maxillary right posterior quadrant with type III classes based on varying degrees of compromise (ideal/minimal, gold restorations. All possible risks, complications, and postop- moderate, substantial, and severe) for the following 4 diagnostic erative requirements, including regular follow-up criteria: location and extent of the edentulous areas; condition of visits and utilization of a protective occlusal device, were also the abutment teeth; occlusal scheme; and residual ridge. discussed and agreed on between the provider and patient.

Special PROSTHODONTICS Section 49 Rethinking the traditional full-mouth rehabilitation by applying minimal prosthetic dentistry for maximum patient benefit

Fig 5. Custom open-tray final impressions.

Treatment Phase 3 of treatment involved preoperative tooth shade verifi- Phase 1 of treatment included oral hygiene instruction and cation (VITA Linearguide 3D-MASTER, VITA North America) an adult prophylaxis followed by extraction of all remaining and the preparation and temporization of all maxillary and primary dentition and immediate placement of 7 endosseous mandibular teeth (including dental implants). As anticipated, 27 implants (Nobel Biocare USA, LLC). Taking into consideration the aggressive tooth preparation of the maxillary right canine the high functional success and long-term survival rate of dental that was necessary to establish an appropriate plane of occlusion implants, modern dentistry currently recognizes implant ther- resulted in a mechanical pulp exposure. Following conservative apy as the treatment of choice for replacement of single teeth nonsurgical root canal therapy, it was determined that the exist- 28,29 and multiple individual teeth. Removable partial prosthetics, ing tooth structure was substantial enough to support a full- although cost effective, rapidly fabricated, and generally nonin- coverage restoration without adjunctive prosthodontic therapy 37,38 vasive, are not well tolerated and may potentiate accumulation such as placement of a . The pulp chamber was of plaque. Fixed dental prosthetics do have a distinct advantage, filled with a dual-cure composite resin core build-up material in that much of the tenuousness and instability associated with a (FluoroCore 2+, Dentsply Sirona). removable prosthesis is eliminated; however, conventional fixed The final impressions for the maxilla and mandible were restorations are often inherently destructive and may prove to conducted with a customized acrylic resin open-tray technique 30-32 39,40 be detrimental to the patient’s oral hygiene. (Triad TruTray, Dentsply Sirona). Impressions consisted of Positioning of all implants was aided by a surgical guide an extra-low–viscosity PVS wash and a heavy-bodied PVS tray established from the diagnostic wax-up and a 2-dimensional material, and all implant impression copings were left unsplinted 41 panoramic radiograph. Panoramic radiography, when compared (Fig 5). Following completion of the final impressions, a centric to cone beam computed tomography, has been shown to be relation record was also fabricated with the aid of a leaf gauge 42,43 effective and accurate for the planning of dental implants and (Bite Leaf/Gage, Artus Corporation) (Fig 6). follows guidelines for the appropriate radiation dosage in accor- The final impressions for each arch were poured in a type IV dance with the principle known as ALARA (as low as reasonably resin–fortified, low-expansion gypsum stone (ResinRock, Whip 33,34 44,45 achievable). The preoperative panoramic radiograph revealed Mix Corporation). Each die was then trimmed, and the mar- diminutive roots anchoring the retained primary teeth and an gins were marked and sealed with cyanoacrylate. Then 4 alternat- ideal volume of alveolar bone to house each implant (ie, 6 mm of ing, uniform coats (~25 μm) of gold and silver die spacer (Tru-Fit, 46-48 bone buccolingually and 5-6 mm of bone mesiodistally), render- George Taub Products) were applied. To assist in the wax up, 35 ing bone grafting procedures unnecessary. All implants were development, and occlusion of the final restorations, irreversible placed 3-4 mm apical to the cementoenamel junction of the hydrocolloid impressions were made of the provisional restora- 49 adjacent natural teeth to enable the development of an appropri- tions in place to guide fabrication of a custom incisal guide table. 36 ate emergence profile. This surgical phase was initiated first so Once the crowns for both maxillary lateral incisors were that the natural teeth and implants could be restored simultane- waxed to full contour, the press ceramic ingot (Creation CP, ously and the patient could avoid provisional restorations during Creation Willi Geller International GmbH) was selected based the 4-month process. on prior dental shade analysis. These ingots are leucite rein- Phase 2 of treatment entailed the removal of all recurrent forced and were selected because they have greater glass content caries, nonsurgical endodontic therapy in tooth 3, replacement than alternative ceramic materials, such as zirconia, alumina, of failing restorations with amalgam core build-ups in teeth and lithium disilicate, and therefore provide improved esthetics. 2 and 3, and placement of interim restorative material (IRM, All remaining restorations that did not involve cast metal alloys Dentsply Sirona) in tooth 31 (Fig 4). were fabricated with lithium disilicate press ceramic ingots (IPS

50 GENERAL DENTISTRY November/December 2016 Fig 6. Centric relation record (leaf gauge).

A B

C

Fig 7. Definitive restorations. A. Right laterotrusion. B. Left laterotrusion. C. Anterior view in right laterotrusion. e.max, Ivoclar Vivadent, Inc). To allow for maximum possible implant framework for the implant in the position of the man- strength, all lithium disilicate crowns remained monolithic fol- dibular right canine (implant 27). lowing divestment and were characterized with a set stain and Phase 4 of treatment involved the final delivery of each defini- glaze prior to delivery. tive restoration. All implant abutments were tried in, and, follow- To aid in establishment of an appropriate emergence profile ing periapical radiographic verification that appropriate seating for each implant restoration, customizable and castable abut- was established, the abutments for all implants were torqued to ments were selected over the more common prefabricated 35 N/cm. The screw access channel for each implant was sealed 50 stock abutments. Type III gold alloy (JCB, Jensen Dental) with a light-bodied PVS material (Fit Checker II, GC America, 51 was used to cast all of the custom abutments for implants in Inc). The occlusal inlay and the full-gold crowns, including the positions of the maxillary right second premolar (implant natural teeth and splinted implant restorations, were seated and 4), maxillary right first premolar (implant 5), maxillary left cemented with a resin-modified glass ionomer (Fuji 52 canine (implant 11), mandibular left second premolar (implant PLUS, GC America, Inc). The implant-supported full-gold res- 20), mandibular left first premolar (implant 21), and man- torations replacing teeth 4 and 5 were splinted to provide better dibular right second premolar (implant 29); the inlay on tooth load sharing between the implants and ultimately luted with 31; both full-gold crowns on teeth 2 and 3; and the splinted, zinc phosphate cement (DeTrey Zinc, Dentsply Sirona) to aid in 53,54 implant-supported fixed on implants 4 and 5. immediate cleansibility. The remaining all-ceramic restora- A high-noble white gold dental porcelain alloy (FOUNDATION, tions were cemented with a dual-cure resin luting agent (NX3 55 Jensen Dental) was used to fabricate the 1-piece, screw-retained Nexus Third Generation, Kerr Corporation) (Fig 7).

Special PROSTHODONTICS Section 51 Rethinking the traditional full-mouth rehabilitation by applying minimal prosthetic dentistry for maximum patient benefit

Fig 8. Postoperative panoramic radiograph of completed treatment.

Immediately following delivery of all final restorations, phase 5 and acceptance of treatment, material options for each defini- of treatment commenced with a full-mouth radiographic survey tive restoration were carefully selected in collaboration with (Fig 8). A strong emphasis was placed on the patient’s daily the patient: all-ceramic crowns in the anterior and premolar home care routine as well as the need for continued follow-up regions, full-coverage cast gold crowns for the molars and max- and oral hygiene visits. illary premolar implants (as per patient preference), and a cast Following treatment, the patient indicated that he was very gold inlay. Materials were chosen to enable the most esthetic satisfied with the esthetics and function of his new dentition. and conservative course of treatment while simultaneously The patient was instructed to return for a 48-hour postinsertion providing a favorable medium- to long-term functional and 64-66 examination for evaluation of the restorations and completion biomechanical prognosis for this patient. of any necessary occlusal adjustments; no gingival irritation was present at the 48-hour recall. The patient reported that he was Conclusion very pleased with the comfort and esthetics of all prosthetic Meticulous patient evaluation and a logically organized prepros- treatment. The patient was then placed on a 4-month adult pro- thetic diagnostic work-up are necessary to achieve success in phylaxis and recall schedule for continued evaluation of all oral any complex treatment plan. Utilization of endosseous implant tissues and dental restorations. therapy in conjunction with materials that are compatible with minimally invasive dental procedures, such as full-gold Discussion restorations and adhesively bonded ceramic crowns, enabled Congenitally missing and malpositioned teeth possess great the realization of a conservative, esthetic, and functional oral potential to impact an individual’s physical appearance, oral rehabilitation for a patient diagnosed with severe dental agen- 56,57 function, finances, and overall quality of life. Dental anoma- esis. The selection and sequencing of these treatment modali- lies, including hypodontia and microdontia, often occur together ties obviated the need for more aggressive and costly treatment 58,59 and are not uncommon in many populations. However, there procedures and resulted in an overall favorable long-term prog- is currently no standardized protocol for treating the patient who nosis for the patient. presents with more severe forms of tooth agenesis and malfor- 60 mation that result in a mutilated dentition. Author information A thorough evaluation, correct diagnosis, and a multidisci- Dr Cone is an assistant clinical professor, University of New plinary approach are required as part of the successful com- England, College of Dental Medicine, Portland, Maine. 61 prehensive treatment for patients with a mutilated dentition. In this case, a provisional mock-up, based on a fabricated diag- References 1. Käyser AF. Shortened dental arches and oral function. J Oral Rehabil. 1981;8(5):457-462. nostic wax pattern of the patient’s dentition, was utilized to 2. Barman J. Occlusal considerations, concepts and treatment planning for full mouth rehabili- create a blueprint for the operative phase of the treatment plan tation of mutilated dentition. Indian J Stomatol. 2014;5(3):102-107. and to manage the patient’s expectations regarding definitive 3. Goldstein RE. Study of need for esthetics in dentistry. J Prosthet Dent. 1969;21(6):589-598. 62 esthetic outcomes. 4. Levinson NA. Psychological facets of esthetic dental health care: a developmental perspec- tive. J Prosthet Dent. 1990;64(4):486-491. The patient presented for the restorative phases of care with 5. Chapin R. Dental benefits improve access to oral care. Dent Clin North Am. 2009;53(3): the surgical implant phase of his treatment already completed. 505-509. Clinical studies have demonstrated that patients with exten- 6. Balshi JT, Balshi SF, Wolfinger GJ. The evolution of advanced prosthodontic care: a 30-year patient report. J Prosthodont. 2007;16(1):43-49. sive tooth agenesis, such as oligodontia, report a significant 7. Bruguera A, Gurrea J, Kina S. Evolution of conservative odontology. J Cosmet Dent. 2014; improvement in quality of life when endosseous implants are 30(1):104-112. 63 involved in the treatment plan. To augment the satisfaction

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Special PROSTHODONTICS Section 53 GUEST EDITORIAL A shared commitment to patient care

his special issue of General treating patients with temporomandibu- Dentistry is another step in the lar disorder. The aRticle underscores the Tongoing collaboration between importance of occlusal devices in aiding the American College of Prosthodontists diagnosis, the true backbone of all care. (ACP) and the Academy of General Dr Aaron Omura and his coauthors Dentistry (AGD). Starting with a shared write on utilizing implants as an adjunct to desire to provide the best possible care removable partial . The number to our patients, both organizations have and location of the implants are discussed worked with the Commission on Dental in biomechanical terms to help restorative Accreditation on educational standards dentists better distribute occlusal forces and have joined forces to offer an educa- and decrease the effects of fulcrum lines. tional webinar presented by a prosthodon- In addition, framework design and attach- tist. Now, this issue contains 5 articles ment considerations are reviewed. written by Board-certified prosthodontists. Dr Miles Cone demonstrates the value Dr Mark Hutten discusses the elderly of taking a minimally invasive, but bio- population, which continues to grow at mechanically sound, approach to oral a record pace. There are staggering esti- rehabilitation, even in complex cases. mates that the US population of people He reports a case in which principles of Published with permission of the over the age of 65 years will be as high as were combined Academy of General Dentistry. 88 million by 2050. These patients will with all the planning of a full-mouth reha- © Copyright 2016 by the become a major portion of our practice as bilitation involving implants, all-ceramic Academy of General Dentistry. dental professionals, despite predictions crowns, and gold onlays to provide suc- All rights reserved. For printed and electronic reprints of this article for that almost half of them will not seek cessful treatment for a patient with con- distribution, please contact care due to financial straits. The care that genitally missing teeth. [email protected]. these patients need will certainly be of a These topics touch on many aspects of complex nature. prosthodontics that can be utilized by the Dr Nadim Baba and his colleagues write general dentist in patient care. In addi- on the integration of computer-aided tion to providing practical management design and manufacturing into complete- techniques, these articles are intended to denture design. We are committed to the show that prosthodontists are a resource development of , which for referral of patients whose needs may started in the 1980s with the fabrication be out of the reader’s comfort zone. of single crowns and holds such extraor- Members of the AGD and the ACP dinary promise today. This is an exciting are bound together by a commitment to era to be a dentist, as the digital workflow delivering the best possible care to our concept continues to expand treatment patients. The collaboration between our horizons for our patients. It may allow us organizations is intended to drive that to reach many of those financially strapped process forward. “Good enough” will patients that Dr Hutten writes about. never be acceptable to any of us. There is In his article, Dr Jonathan Wiens tackles much that we can share with each other the management of temporomandibu- as practitioners and much that we can do lar joint disorders in an open-minded together to shape the future of dentistry. manner. His many years of experience are evident as he discusses the factors that need to be considered in diagnosing and

Carl F. Driscoll, DMD, FACP Immediate Past President, American College of Prosthodontists

8 GENERAL DENTISTRY November/December 2016