Full mouth rehabilitation: a case report and review of the literature


Dr. Ali E Al-Kandari  Postgraduate student, Department of Prosthodontics & Medical materials, University Hospital Tuebingen, Germany, ( Kuwait National Guard, Ministry of Interior, Ministry of Defense, State of Kuwait )

Dr. Hassan Albakkar  Specialist in department of Prosthodontics, dental center, (Ministry of health, Riyadh, KSA)

Dr. Fatema N Alrayes  Specialist in department of Periodontology, dental center, (Ministry of health, State of Kuwait)

Dr. Abdulaziz Alduwaisan  Postgraduate student, Department of Prosthodontics & Medical materials, University Hospital Tuebingen, Germany, ( Kuwait National Guard, Ministry of Interior, Ministry of Defense, State of Kuwait )

Dr. Hamad Alyaseen  Postgraduate student, Department of Prosthodontics & Medical materials, University Hospital Tuebingen, Germany, ( Kuwait National Guard, Ministry of Interior, Ministry of Defense, State of Kuwait )

Dr. Abdulrahman B Alawadhi  Postgraduate student, Department of Prosthodontics & Medical materials, University Hospital Tuebingen, Germany, ( Kuwait National Guard, Ministry of Interior, Ministry of Defense, State of Kuwait )



Abstract

Background
Full mouth rehabilitation should be focused on restoring natural appearance. Achieving natural esthetics during full mouth rehabilitation is possible with modern all ceramic restorations. Choosing the right materials is of paramount importance to achieve good result. 
Case presentation
We report a case of a full mouth rehabilitation of a 65 years old male, who had no medical problems and is not taking any medications. A clinical evaluation revealed a loss of the vertical dimension. Patient’s smile was restored to natural esthetic and function, by restoring the upper arch with lithium disilicate glass ceramic and the lower arch with partial telescope denture. 
Conclusions
Full mouth rehabilitation should be achieved by restoring patient mouth back to its natural appearance and normal vertical dimension. Natural esthetic can be achieved using lithium disilicate glass ceramic.
Keywords
Full mouth rehabilitation, lithium disilicate glass ceramic, partial telescope denture

Background

Full mouth rehabilitation should be focused on restoring natural appearance. Achieving natural esthetics during full mouth rehabilitation is possible with modern all ceramic restorations. Choosing the right materials is of paramount importance to achieve good result. The combination of different materials and techniques allows for restoring patient’s mouth back to normal esthetic and vertical dimension.

Case presentation

A healthy 65-year-old male presented to our clinic requesting to improve his esthetic appearance as well as his chewing ability. Clinical examination revealed multiple old restorations and crowns, multiple missing teeth, attrition of remaining anterior teeth as well as loss of vertical dimension (Fig 1- 4). 

Fig. 1 : Pre-operative smile view

Fig. 2 : Pre-operative frontal view

Fig. 3 : Pre-operative left lateral view
Fig. 4 : Pre-operative right lateral view
Fig. 5:  Pre-operative panoramic radiograph

Radiographic evaluation (Fig 5) showed heavily restored dentition with multiple missing teeth. Bone and maxillary sinuses appeared to be within normal limits.

The aim of the treatment is to restore the patient mouth to full dentition with normal vertical dimension. Therefore, different treatment options were discussed with the patient. 

The procedures of the chosen treatment plan were clarified to the patient. 
The chosen treatment plan aimed for increasing the vertical dimension by 2 mm, through wearing a removable partial denture to allow adequate space for composite build up of the lower teeth. 


Fig. 6: Diagram of the treatment plan

Fig. 7: Final preparation of upper teeth
 
Fig. 8: Final preparation of lower teeth

Fig. 9: Final impression of the upper arch

Fig. 10: Final impression of the lower arch

Once the desired vertical dimension is achieved, the final restorations of the upper arch included ceramic bridges (zirconium) in teeth 17-15-13 and all ceramic crowns (Emax.press) in teeth 12-17. Whereas for the lower arch, telescopic crowns for teeth (hybrid crowns) 34, 33, 44, 47. 
Porcelain fused to metal crown, for tooth 38 and a partial denture with an E-clasp and sublingual bar to replace missing teeth 37, 36, 35, 45 and 46 (Fig 6). 

The treatment plan was initiated following the removal of the old bridge and crowns in upper and lower jaws; using Ti-core build up and new temporary bridge and crowns (ProtempTM4®) (3M ESPE-Seefeld-Germany). This was followed by final preparation (Fig. 7-8) and final impression (Fig. 9-10) with polyether impression material (Impregum® and Permadyne®) (3M Espe-Seefeld-Germany) of the upper and lower arches. Newtemporary bridges were fabricated to maintain the new vertical dimension. 

Metal crown 38 and telescopic crowns on 33, 34, 44 and 47 were tried in (Fig 11). Fixation Impression of the lower jaw with the primary telescopic crowns in mouth using polyether impression material (Impregum® and Permadyne®) was done.

Following metal framework try-in and aesthetic check of the first porcelain bake of upper crowns, the finished final prostheses (Figure 12-14) were delivered. All-ceramic crowns of  Emax press as well as the zirconium bridge of upper jaw were cemented using Multilink® (Ivoclar-Schaan-Liechtenstein), whereas the primary crowns were cemented using phosphate cement (Harvard cement).

Fig. 11 : Metal crown and telescopic crowns try-in

Fig. 12 : Frontal view of the final prosthesis

Fig. 13 : Right lateral view of the final prosthesis

Fig. 14 : Left lateral view of the final prosthesis


Discussion

The patient’s prime concern was the aesthetic appearance of upper teeth. He cannot freely laugh or show his teeth without feeling shame how ugly they are. After examination, the problem of the secondary reduction of the vertical dimension was found. It was caused by worn dentition in the lower front teeth, several restorations in upper front teeth and chipping in the secondary crowns of 33, 34 and 44. After explaining to the patient his situation, the patient refused the treatment with Porcelain Fused to Metal crowns, his argument was that he wants natural appearance and good esthetic teeth in the upper jaw. The high esthetic properties of the lithium disilicate glass ceramic meet the patient’s wish of having natural good esthetic appearance 1,2. Silicate ceramics has a high content of glass matrix in which crystalline particles are distributed. This microstructural composition makes them thefirst choice when the aesthetic needs to be restored 3, 4. Also the biocompatibility of the all-ceramic restoration is considered as an advantage of having such a restoration rather than Porcelain Fused to Metal crowns 5, 6. Besides that, zirconia veneered with ceramic is strong enough to be a good alternative of metal ceramic fixed dental prosthesis in the anterior and posterior dentition 7.
Restoring the upper right side bridge by zirconium   dioxide bridge does also make sense, in order to overcome the huge bite force in the posterior teeth. And restoring the lower jaw with partial telescope denture was the first treatment choice compared to fixed partial dentures.
Telescopic retained partial denture prosthesis is mainly used in Germany to replace multiple missing teeth instead of using the conventional removable partial denture. It is a good treatment option for patient with reduced dentition which provide good retention and the patient can maintain good oral hygiene 8, 9.

Hybrid telescopic prosthesis is one type of this technique, which contains friction pins to increase the retention 10.
Based on the finding of the speaking distance (4 mm), minimal increase of the occlusal vertical dimension by 2 mm at the incisal pin of the articulator could be done without using an occlusal splint pretreatment 11
The wax up casts was done with increasing the occlusal vertical dimension by 2 mm in the articulator pin. That helped in restoring the worn dentition in the front teeth and had no major effect on the posterior teeth. It was very important to finish the preparation in upper and lower teeth as soon as possible to let the patient get used to the raised occlusal vertical dimension when the provisional crowns were cemented. 
We need to have the patients’ feedback after placing all the ceramic crowns, bridges and partial telescope denture. In the recall appointment one week after seating, the patient came with much confidence, he was more satisfied with the results. In the recall appointment after one and half year, the patient came for routine recall appointment. He was very happy without any complication. 
The success of such treatment lies mainly on the patient. Keeping good oral hygiene, attendance in the routine recall appointment, and not ignoring any problems regarding his facial muscles and Temporomandibular joint are the important factors that will help in the success of such a treatment.

Conclusions

Full mouth rehabilitation should be achieved by restoring patient’s mouth back to its natural appearance with normal vertical dimension. 
Natural esthetic can be achieved using lithium disilicate glass ceramic. 

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions


All authors read and approved the final manuscript.


References

1. Abdou J. :Safety of increasing vertical dimension of occlusion: a systematic review. Quintessence Int. 2012:43:S:369-380.

2. Agustin-Panadero R. et al., Zirconia in fixed prosthesis. A literature review, J Clin Exp Dent. 2014;6(1):e66-73.

3. Kern, M., Kohal, R., Mehl, A., Pospiech, P., Frankenberger, R., Reiss, B., Kunzelmann, K. (2006). Vollkeramik auf einen Blick. QUINTESSENZ ZAHNTECHNIK, 32(5),514. 

4. Strub, J. R. (1994). Curriculum Prothetik: Quintessenz-Verl.

5. Sailer, I., et al., Asystematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part II: Fixed dental prostheses. Clin Oral Implants Res, 2007.18Suppl 3:86-96.

6. P jetursson, B. E., et al., A systematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part I: Single crowns. Clin Oral Implants Res, 2007.18 Suppl 3:73-85.

7. Raigrodski, A. J., et al., Survival and complications of zirconia-based fixed dental prostheses: A systematic review. J Prostate Dent, 2012.107(3):170-177.

8. Groten, M., et al., Hybridteleskope zur Verankerung von kombiniert festsitzend

9. Schwindling FS, Dittmann B, Rammelsberg P, Double-Crown-Retained removable dental Prostheses: A retrospective study of survival and complications J Prosthet Dent. 2014 Sept;112(3):488-93

10. Breitman JB, Nakamura S, Freedman AL, Yalisove IL, Telescopic Retainers: An Old or New Solution? A Second Chance to Have Normal Dental Function J Prosth 2012;21:79-83 herausnehmbarem Zahnersatz.Quintessenz Zahntech 2009; 35(12):1568-1580.

11. Harper RP. Indication for altering occlusal vertical dimension. Quintessence Int. 2000;31:S:275-280.


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