Case report

Oral rehabilitation of severely worn dentition using an overlay for immediate re-establishment of occlusal vertical dimension
nio Materson Silva2, Marcus Aure lio Rabelo Lima Verde2 ` nior1, Anto Amilcar Chagas Freitas Ju and Juliana Ribeiro Pala Jorge de Aguiar1
1

Department of Dental Materials and Prosthodontics, Arac atuba School of Dentistry UNESP, Sa atuba, Sa o Paulo State University, Arac o Federal University UFC, Fortaleza, Ceara , Brazil Paulo, Brazil; 2Department of Restorative Dentistry, Ceara

doi: 10.1111/j.1741-2358.2010.00372.x Oral rehabilitation of severely worn dentition using an overlay for immediate re-establishment of occlusal vertical dimension The aim of this study was to describe the treatment used in an elderly patient presenting with bruxism and dental erosion, with good gingival health and bone support, but with decreased occlusal vertical dimension (OVD). The oral rehabilitation of elderly patients presenting with bruxism in association with tooth erosion has been a great challenge for dentists. The loss of OVD, the presence of occlusal instability and the absence of an effective anterior guide due excessive dental wear, can damage stomatognathic system (SS) biology, the function and the aesthetics. In the rst treatment stage, an overlay removable partial denture (ORPD) was fabricated for the immediate re-establishment of function and aesthetics. After a 2-month follow up, with the patient presenting no symptoms, a second rehabilitation stage was accomplished, with xed and removable prostheses. Oral rehabilitation with an ORPD was able to re-establish the SS biology, but a correct diagnosis and treatment plan are essential for success. The ORPD is a non-invasive and reversible restoring modality for general dentists that allow the re-establishment of the patients immediate aesthetics and function at low cost. Keywords: Tooth wear, tooth erosion, dental care for aged, patient satisfaction. Accepted 16 January 2010

Introduction
Oral rehabilitation of elderly patients presenting with severe parafunction has been a great challenge for dentists and is dened as postural habits or dynamic atypical habits that affect the stomatognathic system (SS). Consequently, it is possible to observe loss of the occlusal vertical dimension (OVD), occlusal instability and absence of an effective anterior guide, due to excessive dental wear, damaging function and aesthetics1,2. The most common parafunction in elderly people is bruxism, a manifestation of the bio-psychological imbalance that affects the SS and is characterised by dental attrition or heavy tooth-to-tooth contact, in a centric or eccentric way, occurring during daytime or night-time, with its deleterious effects varying according to the resistance, occurrence time period, frequency and general patient health3. It can be associated with sleep disorders, emotional

stress, occlusal discrepancies, anxiety, fear or tension, usually resulting in abnormal patterns of dental wear46. There are several types of therapies for this problem, but the efcacy is still unclear7, especially when bruxism is associated with other problems, such as tooth erosion. Tooth erosion represents pathological dental wear that occurs through chemical substances, such as excessive ingestion of soda, acid fruits or even the presence of gastric reux, also known as perimolysis8. Severe tooth wear is a condition difcult to treat due to the limited amount of remaining dental structure. These patients frequently exhibit loss of OVD and aesthetic problems. When properly treated, the remaining teeth may require periodontal surgery, endodontic treatment, intraradicular postand-cores and xed crowns. Limitations related to costs and other priorities frequently restrict the choice of the most suitable treatment. Thus, an
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overlay removable partial denture (ORPD) allows covering of the roots or implants, being considered an effective method for the treatment of elderly patients with severely worn dentition9. For this reason, a correct diagnosis and treatment plan are essential and this fact has motivated studies with the purpose of developing effective therapies for parafunction treatment or control. Therefore, our objective was to describe a therapeutic modality used in an elderly patient presenting with severe bruxism in association with dental erosion, good bone support and gingival health, but with a decrease in OVD and posterior occlusal collapse.

Figure 2 Initial clinical aspect, showing the loss of OVD caused by tooth surface loss.

Case report
A 61-year-old white male, presenting with good gingival health and satisfactory support and periodontium condition (Fig. 1), complained about excessive wear of the upper anterior teeth and absence of posterior dental support, factors that caused masticatory, aesthetic and phonetic difculties, which was very dissatisfying for the patient and restricted his social life (Figs 2 and 3). Clinical and radiographic examinations showed vertical dimension (VD) loss because of excessive dental wear, with no symptoms of pain. It was also possible to observe that the patient had severe bruxism in association with dental erosion. Through anamnesis analysis, it was concluded that the erosion was due to gastric reux in association with excessive ingestion of acid solutions, such as sodas. An occlusal analysis and a functional evaluation of the SS were accomplished, from which a high level of functional adaptation of the muscles and

Figure 3 Initial clinical aspect of the patient presenting severe wear of the upper anterior teeth, causing problems at phonation, mastication and aesthetic.

temporomandibular joints was detected. Because of the number of support teeth present in the oral cavity and the complexity of the oral rehabilitation, it was suggested that treatment with a xed partial prosthesis (FPP) in both arches, in association with a removable partial prosthesis (RPP) in the lower arch be considered. However, the treatment was with a reversible procedure (transition stage, temporary treatment), using an ORPD. In this way, the treatment consisted of two stages: First stage (temporary) Initially the moulding procedures were accomplished with irreversible hydrocolloid (Hydrogum, Zhermack, Badia Polesine, RO, Italy) and the plaster casts were obtained with dental stone (Durone IV, Dentsply, York, PA, USA). These casts were set up in a semi-adjustable articulator (SAA) in centric relation position. The new OVD was

Figure 1 Initial radiographic aspect, showing satisfactory periodontal tissue, with the bone level compatible to the patients age.

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Figure 4 ORPD adapted without the need of dental preparations.

obtained from a range of physiological, metric, phonetic and aesthetic methods in order to favour prosthetic planning regarding the ideal space for the dental replacement. At this point, the patients opinion must be considered. It is important to observe if the initial OVD can be altered, decreased or increased, during the initial treatment phase, through the decrease or increase in the thickness of the ORPD. This has the advantage in it is possible to achieve an appropriate OVD in a conservative and reversible way. Afterwards, a diagnostic waxing of the upper cast was carried out in order to clearly establish the correct solution for the problem presented and later the ORPD resin polymerisation. The ORPD was adapted to the occlusal surfaces without any dental preparation (Fig. 4). The patient should also be instructed as to how to use the ORPD in a continuous way, just removing it for cleaning. It is very important to have continuous follow up for achieving successful occlusal adjustments, relining with soft materials (when necessary),

muscular evaluation through masticatory comfort and phonation. Thus, it is possible to follow up the SS reaction to the re-establishment of the OVD. Aesthetic aspects must be also analysed. This device is fabricated mainly with acrylic resin, and the palatal area must be thicker in order to provide more resistance and prevent fractures (Fig. 5). During the period of adaptation to the new OVD, a general treatment of the patients oral cavity was carried out: periodontal treatment (root scaling) of the remaining teeth, endodontic treatment (teeth 1323) and oral hygiene adaptation. The ORPD was used by the patient for a period of 2 months, as this was necessary for appropriate follow up and observation of the effects. Meanwhile, we attempted to address the problems associated with the gastric reux, the main cause of dental erosion. Second stage (denitive) When the SS normality was veried, it was possible to begin the gradual substitution of the ORPD for temporary xed unitary prostheses (Fig. 6). In this treatment stage, care must be taken in order to maintain the OVD previously obtained, especially during the inter-occlusal records stage. For this reason, this procedure was accomplished in each hemi-arch separately, so that the OVD was maintained with half of the ORPD, which had previously been divided. The intraradicular core casts of the upper anterior teeth were made with an indirect technique for later cementation. After re-preparing the teeth, the functional moulding of the upper and lower abutment teeth was made by means of

Figure 5 ORPD occlusal view, showing the thicker palatine area, in order to give more resistance and prevent fractures.

Figure 6 Temporary individual crowns positioned, maintaining the OVD previously obtained with the ORPD.

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individual devices made with Duralay self-curing acrylic resin (Reliance Dental MFG Co, Worth, IL, USA), following placement of a relief, approximately 0.5 mm thick in order to allow for the polyester impression material (Impregum F, 3M ESPE, St. Paul, MN, USA). The handling and application of the moulding material were carried out following the manufacturers recommendations. After the moulding material polymerised, the devices were removed with the use of a customised tray also lled with Impregum F. The moulds were then poured with Durone IV dental stone, to obtain the working casts, from which the metallic infrastructure (MI) of the individual xed crowns could be fabricated The ceramic application on the MI was accomplished following the same OVD previously obtained. Therefore, the temporary crowns of each opposite hemi-arch were maintained in position during the recording with Duralay resin. After resin polymerisation, the MI with the respective records were transferred with vinyl polysiloxane impression material (Adsil, Vigodent, Rio de Janeiro, RJ, Brazil). Once the ceramic was applied in laboratory and the necessary adjustments were carried out, the individual xed crowns were cemented (Fig. 7). Teeth 27 and 37 are total metallic crowns as it was observed that there was no space for a satisfactory thickness of porcelain. For the mandibular arch, it was also necessary to make an RPP (Fig. 8). After setting up the teeth, a functional and aesthetic test of the lower RPP in association with the not cemented xed crowns in the patients oral cavity was carried out. After this evaluation, the nal laboratory stages and the RPP installation were carried out. The denitive cementation of the xed individual crowns with

Figure 8 Lower RPP occlusal view before its installation. Notice the metal crown for tooth 37.

Figure 9 Final view of the patient.

Figure 7 Upper and lower xed crowns in position.

zinc phosphate cement (SS White Burs, Lakewood, NJ, USA) was completed with the RPP installation. A myo-relaxant plate made from thermopolymerising acrylic resin was made immediately after prostheses insertion and it was inserted into the patients mouth, as a protection option against parafunctional habits. Figure 9 shows completion of all stages and the patient was extremely satised with the results obtained. For the long-term success of treatment, the patient received clear instructions. Initially he was guided as to how to place and remove the RPP as the rst time would only be after 24 h following the denitive cementation of the crowns. The patient was also instructed regarding the hygiene of the abutment teeth and RPP and the periodic reviews. These must be approximately every 6 months in order to evaluate retention, oral hygiene, the degree of wear and the need for prostheses relining4,10. However, in patients with severe parafunction, the time between reviews should be reduced1.

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Discussion
The presence of parafunctional habits is an extremely important factor to be considered during treatment planning stages, treatment and maintenance in oral rehabilitation of patients. In cases where possible problems related to stress or other psychological or sleep disturbances are identied, other specialised professionals should be included, otherwise, failure of treatment can occur1. In the present case, an ORPD was used to re-establish the patients correct VD before the installation of denitive prostheses. This is a simple, non-invasive and totally reversible procedure (as the remaining teeth are not prepared) and allows re-establishment of the patients immediate aesthetic and functional concerns11. When there is a metallic substructure in the ORPD, an improved load distribution to the support tooth in a parallel direction to its long axis is achieved, increasing the rigidity of the prosthesis and its resistance to dimensional alterations related to the acrylic resin polymerisation. In addition, the registration of the inter-maxillary relationship will be improved due to the stabilising effect of the substructure, once incorporated into the occlusal plane11. According to Langer and Langer12, in situations where a considerable amount of radicular decay with poor oral hygiene is observed in older patient, the provision of protection copings of the supporting roots is the preferred treatment method. However, whenever OVD is increased, the patients should be aware of the possibility of some movement of the treated teeth until the occlusion is fully stabilised. For this reason, periodic occlusal adjustments should be carried out before the establishment of normal occlusal stability1. The necessary time for the ORPD use is 13 months11, and it is important that the patient begins denitive treatment when the SS normality has been veried. The evaluation of the new OVD obtained through the ORPD should take place during this period (13 months), after which this splint can be substituted by any one of the rehabilitation treatments: Prosthesis supported by implants Conventional or overlay RPP, in association or not with xed prosthesis or individual crowns; Fixed partial prosthesis, individual crowns or metallic restorations; Total prostheses.

It is of fundamental importance that the patient understands the presence of their parafunctional activity. It then becomes easier to convince the patient to use the myo-relaxant plate, preferably made in acrylic as this plate will help in the stabilisation of the denitive prostheses.

Conclusions
The dentist must be able to select the technique that satises the situation for each patient, always seeking to re-establish the aesthetic and function of the SS. Oral rehabilitation with ORPD can re-establish the SS biology but correct diagnosis and treatment planning are essential for success.

Clinical implications
The ORPD is a simple, non-invasive and reversible restoring modality for general dentists who allow the elderly patient to recover their self-esteem and social life.

References
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restoration of worn teeth. A three-year follow-up. NY State Dent J 2006; 72: 3235. 11. Badr SE, Unger JW. Reconstruction of a severely abraded dentition using an overdenture. Quintessence Int 1986; 17: 293297. 12. Langer Y, Langer A. Root-retained overdentures: part I Biomechanical and clinical aspects. J Prosthet Dent 1991; 66: 784789.

Correspondence to: Amilcar Chagas Freitas Ju ` nior., 1560 Waldir Feli , Arac zola de Moraes Jd. Sumare atuba, Sa o Paulo 16015-295, Brazil. Tel.: + 55 (18)91012849 E-mail: dr.amilcar.jr@hotmail.com

2012 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 7580