Posted 1516 days ago
One of the most difficult and misunderstood aspects of integral dentistry is how to address seriously worn teeth. The patient who has been his teeth so severe that both aesthetics and function have a significantly compromised leg. We all want to help these patients, but we need a place to start. How do we determine what starting point? Can we open a vertical dimension or do we need to start orthodontics, crown length or all of the above? In this letter article and case study, we will discuss a method to determine a restorative position that works “could”.
A patient presented my office with the main complaint that I had lost tooth #7 and was interested in an implant to replace the tooth. Duration The exam we notice the extensive wear and erosion present and the significant loss of the vertical dimension (Figures 1 and 2). After reviewing the clinical situation with the patient, he was interested in at least exploring the options to restore his bite. However, at this point, we cannot definitely tell the patient what options are available, we need to collect information and work diagnostically the case to determine what is possible.
Figure 1: Closed Pre -Coup.
Figure 2: Open Preop.
Before the patient left that day, we took a complete series of photographs and an upper and lower scan of their teeth with Cerec® Primeescan. He had the suspicion that he would have the ability to extend his teeth and open his vertical dimension based on his lip in resting photo (Figure 3). How much I would need to open the vertical, I didn’t know this point.
Figure 3: Lip at rest.
So, here is an effective technique that can be used to determine an initial restoration position.
Step 1: Build the upper and lower central incisors to correct proportions (in compounds). Personally, I will begin with the upper central incisors and create an ideal shape that establishes the right lip on the screen of the rest teeth. Once the superiors are performed, I will make fun of the lower central incisors (Figure 4). These models have not been perfect, but simply establish a “baseline” teeth position
Figure 4: Mobile composed of 8,9,24,25 open.
Step 2. Have the patient close the teeth. This is a new proposed vertical dimension … In this new position, the patient should only listen to the central incisors. The previous contact without subsequent contact should help the patient’s condyle seat and help them a CR position. The use of a sheet meter with this previous contact can also help the patient to move to Cr (Figure 5)
Figure 5: Mobile composed of 8,9,24.25 closed.
Step 3: Have the patient in the new CR position with the anterior model that maintains this position (or can sustain through the bite registration material), take the image of double oral bite to relate the upper and lower arch in the new vertical dimension.
Step 4: Finally, before eliminating composite models, score them in biocopy brochures with primescan.
Now that you have compiled all the information, you can tell the patient to make fun of the case (through digital wax) to see what is possible. We can program the patient for a second consultation to discuss and finish the plan.
Using INLAB 20, we import all the information collected with the primescan and made a complete digital wax. Once completed, the wax was printed in 3D and copy templates were made to transfer the wax to the patients’ mouth and determine if this restorative position was going to work.
Using Copyplast and Bis-Acryl, we transfer the wax to the mouth and the patient was quite satisfied with the plan (Figures 6 and 7). This definitely created the value for the patient to advance with the treatment and complete the case. Around the following month, the full case was completed using Circonium (Figure 8).
Figure 6: Wax transferred in closed bisacryl.
Figure 7: Wax transferred in Bisacryl Open.
Figure 8: Final result circumstance.
Understanding how to address cases of wear can be a discouraging task. However, always remember that you simply need a starting point. The best way I think about this is that aesthetics is always the goal. Start with the ideal tooth shape and try to develop the function around that. Sometimes (such as this case) you can do it completely restoratively by increasing the vertical dimension. Other times, building the tooth to the ideal position will result in a 7 mm teeth screen in the resting position … but that counts important information on how to restore the case. That is, in many cases of wear, orthodontics and/or crown lengthening are required.
