Dental Tribune Middle East & Africa Edition

By Dr. Thomas Colina, DMD C omplex treatment needs can ne- cessitate oral rehabilitation of patients. Often these patients will require a multi-disciplinary approach to correct problems. When pa- tients have significant concerns, such as se- vere malocclusions or destruction of den- tal tissue, oral rehabilitation can entail ex- tensive treatment that may involve recon- structions. To return the patient to optimal function, regain normal form and address possible concerns such as esthetics, an integrated approach that involves various disciplines needs to be taken. The challenge posed to a particular treatment plan may involve the treatment of many teeth and possibly the need to prepare a significant number of teeth and corresponding dental tissue. Another challenge in reconstruction cases is the cost associated with the restoration of numerous teeth. Cost may be a factor for patients. There are often many options and approaches that can lead to the same suc- cessful treatment outcome. The variety of options can be at different ends of the spec- trum. Diagnostic tools, including tomo- grams and the use of CAD/CAM systems, are useful in achieving complex treatment goals. This paper presents a treatment op- tion that is an alternative to the reconstruc- tion approach through the innovative ap- plication of multiple disciplines and cur- rent technology. Casepresentation A 31-year-old male patient presented with the chief complaint of his upper front teeth restorations breaking off a few months after being placed. He has had the front teeth re- stored numerous times with the same out- come. A comprehensive examination and records revealed the following findings. Medicalhistory andfunctionalconcerns There is a history of arthritis in the fami- ly. The patient experiences transient pain from his back, neck and shoulders. He has noted he clenches and grinds his teeth day Conservative dentistry achieved through a multi-disciplinary approach Combining orthodontics and CAD/CAM technology to achieve conservatism for a rehabilitation case mCME articles in Dental Tribune have been approved by HAAD as having educational content for CME credit hours. This article has been approved for 2 CME credit hours. Fig. 2 Pretreatment photos. Fig. 3 Gelb 4/7 physiologic position. 2 Hours by use of a CranexTome (Soredex, Tuusu- la, Finland). The CranexTome has a unique spiral tomography for cross-sectional im- ages. Interpretation of hard tissue imag- ing study would include the evaluation of condylar and temporal component mor- phology and integrity of the bony articulat- ing surfaces. The TMJ is assessed for signs of remodeling, degenerative joint disease or morphological variations affecting the TMJ, jaw and skull. Condylar position in maximum intercuspa- tion is evaluated. The diagnostic tools are used not only for initial assessment to at- tain a working and definitive diagnosis, but during and after treatment to assess at- tainment of the treatment objectives. The corrected lateral TMJ view taken at max- imum intercuspation reveals a posterior- ly displaced condyle and morphological bending of the condyles (Fig. 1). The joint vibration analysis (JVA Bioresearch Inter- national, Milwaukee, Wis.) is used to assess TMJ health for patients and yielded fairly normal vibrations of the TMJ. Skeletalpattern Based on a cephalometric analysis, the pa- tient presented with a Class I skeletal pat- tern with a slight retrognathic mandible. Occlusion A visual examination and cast analysis re- vealed a Class II dental pattern with a deep overbite and tight overjet, fractured upper incisor restorations, slight crowding of the upper and lower arches, and severe worn dentition (especially the anterior teeth). The upper incisors were retroclined, and the upper and lower incisors had severe wear (Fig. 2). There was generalized moderate wear on the posterior teeth. The patient presented with a posterior shift of 2 mm from centric relation to maximum intercuspation. Treatmentoptions The following treatment options were pre- sented to the patient: • Reconstruction of the arches to achieve an ide- alized occlusion. This first option would entail splint therapy and eventual reconstruction to achieve a stabilized occlusion. This approach will provide a stable occlusion and would en- tail restoration of numerous teeth — both an- terior and posterior — to support the antici- pated change in vertical dimension. The dis- advantage to the approach is the introduc- tion of artificial material in the mouth and the need for maintenance of the restorations. Of course, this approach also entails significant dental tissue reduction to provide partial and full coverage restorations to support the oc- clusal scheme. In addition, although the treatment can be provided in a fairly short amount of time, the cost for the restorations can be signifi- cant for most patients. • Orthodontic approach to achieve the best possible occlusion and orthopedic alignment. This approach provides for the patient an option to conserve dental structure, mini- mize the number of restorations to provide a stable and functional occlusion, and al- lows cost for the treatment to be more man- ageable. The disadvantage is the time re- quired to achieve orthopedic and orth- odontic correction. Treatmentplandetails Straight wire appliance treatment (SWA) was proposed to attain ideal inter- and in- tra-arch alignment augmented by a man- dibular repositioning mechanics by way of posterior build-ups and elastics or a fixed orthotic or use of a Twin Force Appliance. This phase of treatment was anticipat- ed to last 20 months. After the orthodon- tic treatment, restoration of the six anteri- or maxillary teeth with porcelain restora- tions would follow. The lower incisors will be evaluated for the need of restorations. The need for an upper bruxing appliance would also be evaluated after the comple- tion of the restorations. Discussionofthetreatment The first phase of the treatment was the pro- vision of orthodontic therapy using GAC In- novation C Self Ligating Bracket System. The Innovation C bracket system has a highly translucent porcelain structure and a rhodi- um coated clip, which provide superb esthet- ics as well as a high-torque component for the incisors of 17 degrees for the upper central and 10 degrees for the upper lateral incisors. One of the main goals for the treatment was the correction of the maxillary incisor torque. The retroclined upper incisors had contribut- ed significantly to the severe wear of the an- terior teeth and had resulted in an intercus- pation that produced a posteriorly displaced condyle. The correction of the incisor torque brought about a natural repositioning of the mandible, which was a treatment goal for the patient. The JVA, which has been prov- en effective in discriminating joint vibrations to assess TMJ1,2 conditions, was utilized to evaluate the TMJ during and after treatment. Anterior repositioning of the mandible has been described in the literature as a viable ap- proach in the treatment of Class II malocclu- sions and TMJ dysfunction. Fig. 1 Corrected lateral tomograms of the TMJ at maximum intercuspation. Note the posteriorly dis- placed condyles that have undergone morpholog- ical bending. (Photos/Provided by Dr. Thomas Co- lina) Fig. 1 Fig. 2 Fig. 2 and night. He was involved in a motor ve- hicle accident and sustained head trauma 12 years before his presentation to our of- fice. Along with routine examination pro- tocols, the temporomandibular joint (TMJ) was examined using a TMJ health question- naire, range of motion examination, muscle palpation and TMJ imaging. TMJ findings and symptoms were: nor- mal maximum opening to 53 mm; no lim- itation in excursion; at opening, there is a 2 mm deviation to the left. There is a poste- rior slide from centric relation to maximum intercuspation. The patient noted cracking noises from the TMJ at opening and clos- ing, and there has been occasional locking of the TMJ through the years. He has slight hearing loss and tinnitus. As a routine for patients exhibiting TMJ dysfunction, a TMJ tomogram series was taken. Tomographic series was achieved 6 MEdIa cME Dental tribune Middle East & Africa Edition | November 2012