ABSTRACT: The wear and loss of anterior and posterior teeth results in the loss of normal occlusal plane
and the reduction of the vertical dimension. This case report describes functional and esthetic oral
rehabilitation of a 55 year old female with severely mutilated dentition and loss of vertical dimension. It
was planned to increase the vertical dimension to restore collapsed bite. As there was loss of upper and
lower posteriors, acrylic removable partial dentures were fabricated instead of splint at increased vertical
dimension to restore the collapsed bite and to deprogram the muscles. Once the patient was adjusted to new
occlusal vertical dimension definitive treatment with fixed and cast partial dentures were planned for
anterior and posterior teeth respectively. A satisfactory clinical result was achieved by restoring the vertical
dimension with this combined approach of fixed and removable prosthesis.
1 2Dr.AbhinavAgarwal, Dr. VarunSingla,1,2Reader, Dept. of Prosthodontics & Crown and Bridge,
K.D. Dental College and Hospital, Mathura (U.P.)
INTRODUCTION:
Oral rehabilitation of dental arches with severe attrition is a
distinct restorative challenge.1 Stress-induced grinding
habits can seriously compromise mastication and esthetics,
and a reduction in the vertical dimension of occlusion can
result in facial collapse compromising function and esthetics.
The problem becomes very complex as functional or esthetic
improvements require modification of the acquired vertical
dimension. Management of worn dentition using fixed or
removable prostheses is complex and among the most
difficult cases to restore. Assessment of the vertical
dimension is important for the management, and careful
comprehensive treatment plan is required for each individual
case.2,3,4,5,6
This clinical report describes the treatment of a patient who
was clinically monitored to evaluate the adaptation to a
combined approach of fixed and removable prosthesis after 6
weeks trial period with acrylic removable partial dentures and
temporary restorations for muscle deprogramming.
CASE REPORT:
A Female patient aged 55 years came to department of
prosthodontics with severely mutilated dentition and missing
posteriors (fig.01).
On intraoral examination- there was loss of vertical
dimension 12,14,16,17,24,26,27,35,36,37,46,47 teeth were
missing & 11,13,22 were grossly decayed. Patient had past
history of dental treatment but she was unable to explain about
previous procedures and could not produce any records also.
On radiographic examination 11,13,21,22,23,25,34,41,42,45
were found to be endodontically treated (fig.02).
FIGURE 1: Pre-operative
FIGURE 2: OPG
ORAL REHABILITATION WITH FIXED AND REMOVABLE PROSTHESIS IN SEVERELY MUTILATED DENTITION – A CASE REPORT.
Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 66
University J Dent Scie 2018; Vol. 4, Issue 3
CaseReport
Keywords :
Tooth wear, Vertical
dimension, cast
partial dentures.
Conflict of interest: Nil
No conflicts of interest : Nil
Treatment procedure-
Diagnostic impressions were made with alginate [Zhermack
,tropicalgin]. Impressions were poured in die stone
[Ultrarock,kalabhai]. Face bow transfer was done (fig.03) and
upper cast was mounted on semiadjustable articulator
[Artex]. Interocclusal record was made with jet bite [coltene
whaledent] and lower cast was mounted. Diagnostic wax up
[Belle sculpturing wax,Kerr] was done to visualize outcome
of the treatment(fig.04).
It was planned to raise the vertical dimension by 3 mm due to
collapsed bite. Acrylic removable partial dentures were
fabricated wrt 14,16,17,24,26,27,35,36,37,46,47 with
increased vertical dimension and delivered to patient (fig.05).
FIGURE 3: Face-bow transfer
FIGURE 4: Diagnostic wax-up
Patient was asked to wear the prosthesis for 6 weeks. During
this period post and core build up was done wrt 11,13,22
(fig.06). Glass fiber post( RelyX,3M) was chosen as it has
modulus of elasticity close to human dentin hence there are
less chances of root fracture compared to metal posts. It has
got more translucency so curing light can pass deep it to root
canal and it can be efficiently cured with resin cement.
Composite material [ Filtek Z250,3M] was used for core build
up.
FIGURE 5: Acrylic partial denture
FIGURE 6: Post& core
All remaining teeth were prepared in upper arch and 45 was
prepared in lower arch (fig.07).Temporary crowns were made
with tooth colored acrylic resin using putty index of
diagnostic wax up and cemented with temporary cement
[RelyX,3M](fig.08).
FIGURE 7: Tooth preparation
FIGURE 8: Temporization
After 6 weeks once the patient was comfortable with the
temporary crowns at increased vertical dimension final
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 67
University J Dent Scie 2018; Vol. 4, Issue 3
impressions were made with putty wash technique using light
body and putty elastomeric impression material
[Aquasil,Dentsply]. Final impressions were delayed for one
week as gingiva around the abutments was inflamed. Patient
was asked to maintain oral hygiene and also advised to apply
gum astringent gel to reduce inflammation. To maintain the
same vertical dimension as provided in temporary crowns and
acrylic partial denture, interocclusal records of both side of
arches were made one by one after removing temporary
crowns and acrylic partial denture on one side first followed
by other side. PFM crowns (fig.09) were cemented wrt
11,12,13,14,15,21,22,23,24,25,45 using glass ionomer
cement[GC Fuji Type-1] (fig.10).
FIGURE 9: PFM crowns with rest seats
FIGURE 10: Cementation of PFM crowns
Later cast partial dentures were planned to replace upper and
lower posteriors therefore rest seats were planned in porcelain
fused to metal crowns during fabrication of wax patterns to
receive rests (fig.09). First alginate impressions [Zhermack
,tropicalgin] of both the arches were made and custom trays
were fabricated. Later border molding of both upper and
lower arch was done for the distal extension areas and final
impressions were made with monophase elastomeric
impression material [Aquasil Monophase,Dentsply] (fig.11)
Impressions were poured with die stone to obtain master cast
which was duplicated to make refractory cast
[Wirovest,Bego]. Cast partial denture frameworks were
designed on refractory cast and later casted with
[ ,Bego] and tried in
the patient's mouth (fig.12)& (fig.13). Jaw relation was
chrome
cobalt partial denture alloy Wironium Plus
recorded and trial was done. Later cast partial dentures were
placed in patient's mouth and required adjustments were done
(fig.14). Occlusion was assessed for any premature contacts.
FIGURE 11: Final impressions
FIGURE 12: Cast partial dentures framework
FIGURE 13: Framework after acrylization
FIGURE 14: Post-operative
DISCUSSION:
Full moth rehabilitation for mutilated dentition is a difficult
and complex procedure. Tooth wear has a multifactorial
etiology therefore reason for tooth wear should be identified
for the long term success of treatment. So to identify the cause
of tooth wear complete medical and dental history was
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 68
University J Dent Scie 2018; Vol. 4, Issue 3
recorded from patient. On examination patient did not have
any signs and symptoms of bruxism. Patient had severe gastro
oesophageal reflux which attributed to severe erosion of the
teeth.7
In this case report a combined fixed and removable approach
was planned due to unhealthy condition of abutments and loss
of upper and lower posterior teeth. Due to collapsed bite it was
decided to increase vertical dimension. But if we are planning
to increase the occlusal vertical dimension it should be within
physiological limit of the patient. Excessive increase in
vertical dimension is not advisable.8,9,10 Acrylic removable
partial dentures were fabricated and given to patient for 6
weeks to restore occlusal vertical dimension and for muscle
deprogramming.
Patient had few anterior teeth which were severely decayed
hence post and core was planned for these teeth. There are
many types of prefabricated post systems available in the
market and we had an option of customized cast post also but
glass fiber post was preferred as its modulus of elasticity is
close to dentin so there were less chances of root fracture
during function compared to metal posts.
Rehabilitation with a fixed partial denture supported by
means of osseointegrated implants is the optimal solution in
Kennedy Class II cases provided that the bone conditions are
appropriate Cross-arch cantilevered fixed partial dentures are
primarily indicated for stabilization of periodontally
weakened abutments. Short unilateral or bilateral bridges are
a solution in patients who refuse removable appliances and
who cannot afford more extensive rehabilitation with fixed
prosthodontics.10 Implants could have been a better option
for missing posteriors in upper and lower arch but due to
financial and medical condition of the patient it was omitted.
CONCLUSION:
In this case report a combined approach of fixed and
removable prosthesis was planned for oral rehabilitation.
Treatment planning for such cases should be done depending
on the condition of the patient which can differ from case to
case. We have many treatment options for every case but the
treatment option should be selected depending on overall
condition of the patient and skills of the operator.
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1. Kenneth E. Brown. Reconstruction considerations for
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2. Mi-Young Song, Ji-Man Park. Full mouth rehabilitation
of the patient with severely worn dentition: a case report.
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3. S.Chrles Brecker. A practical approach to extensive
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4. Joseph S.Landa. An analysis of current practices in
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5. Kazis H. Complete mouth rehabilitation through
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6. Braly BV. A preliminary wax-up as a diagnostic aid in
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7. Snoring and sleep apnea. Journal of California dental
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8. Dawson PE .Evaluation, diagnosis and treatment of
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9. Okeson JP. Management of temporomandibular
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Mosby company, st. Louis,missouri.2003; 509-512
10. Goldman.I. The goal of full mouth rehabilitation journal
of Prosthetic dentistry.1952; 2: 246-251
11. Budtz-Jörgensen E. Restoration of the partially
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CORRESPONDENCE AUTHOR:
Dr. Abhinav Agarwal, M.D.S.
K.D. Dental College and Hospital
Mathura (U.P.)- 281006
Mobile: 09720666536
Email: [email protected]
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 69
University J Dent Scie 2018; Vol. 4, Issue 3
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