Dental Asia March/April 2019

Behind the Scenes
to be immediately addressed, which was
constituted by a holistic rehabilitative
approach in order to best save the
remaining natural dentition. A systemic
approach and assessment of periodontal,
biomechanical, functional and dentofacial
risk had to be carried out in order to
lay down the most ideal treatment plan
which will add to the overall “predictable
success” of the treatment which is our
top priority.
The collapsed/traumatic bite had to be
altered by increasing the overall vertical
height thus ensuring good occlusal
clearance especially in the right side
and overall replacement of the degraded
enamel had to be carried out. The patient
was initially briefed in detail about the
clinical observations and the need to
commence the treatment without any
further delay.
Orthodontic Intervention in order to
correct the bite and mal aligned teeth was
explained but the patient was not willing
to undergo the treatment. Replacement
of missing tooth nos. 14 and 15 with
implants was another option but it was
constituted by few retarding factors
such as high cost of sinus lift and Guided
Bone Regeneration (GBR) procedures,
which was a concern for the patient.
Furthermore, the possibility of implant
failure especially in the tooth 14 region
because of reduced bone width and
interocclusal clearance was another
factor. Another major factor was scissor
bite which will received load on implants
from different direction.
Hence, Treatment plan was laid out with
rehabilitation of all the teeth with ceramic
crowns. Selection of the type of ceramics
would be decided as the treatment
progressed with the bite raised to get a
clear picture on the clearance and other
bite related information. Since it involved
overall occlusal collapse/discrepancies,
centric occlusion was considered the
starting point of treatment. The treatment
commenced and was divided into four
phases right from preliminary basic
treatment procedures followed by raising
the bite and stabilising occlusion to
overall replacement and rehabilitation
with prosthetics.
Phase 1
The first phase involved all the preliminary
procedures comprising of removal of all
faulty/old restorations in both arches,
root canal treatment procedures and
necessary composite fillings. Then, crown
lengthening procedure was carried out on
tooth nos. 16, 36 and 37 to increase the
overall surface area of the tooth for the
prosthetic crown (Figs. 7-8).
Fig. 7
Fig. 8
Phase 2
A customised deprogrammer from pattern
resin was fabricated in order to deprogram
the muscles and destress muscles in order
to guide the TMJ and the mandible to an
optimum position of comfort (Fig. 9).
Centric Record was taken to mount the
lower cast to the articulator while the
Upper Cast was transferred using the face
bow record (Figs. 10-11). The centric
pin of the articulator was lowered down
and all premature contact points were
checked, ensuring that all the teeth were
occluding and then the pin was raised
by 5mm. (We have decided to raise the
bite by 5mm initially, once we loaded
the temporaries in patient’s mouth, after
checking dentolabial and facial analysis
we will increase or decrease VOD).
Wax mock-up was done on the cast as
per ideal proportions to emulate natural
anatomy. An occlusal putty index was
made after the mock up. Spot Etching
was done over the natural teeth followed
by application of bonding agent over the
spots (Fig. 12). A temporary bis-acrylic
composite( Protemp -4) is injected into
putty index and transferred into the
patient’s mouth and allowed to set for
3-4 minutes. The index was then removed,
the excess luting material was scraped
out and finishing was done for the mock
up. The white metal acrylic facing fixed
prosthesis is placed on 13 to 16 regions
because of the high chance of fracturing
the temporary material due to clearance
(Fig. 13).
After careful study of the facial and
dentolabial analysis at rest position,
display of maxillary anterior teeth
(4 mm), we have decided not to increase
any VDO to maintain smile design
principles (Fig. 14).
Fig. 9
Fig. 10
MARCH / APRIL 2019 DENTAL ASIA 69