Cas e r epor t

Oral rehabilitation of severely worn dentition using an overlay

for immediate re-establishment of occlusal vertical dimension
Amilcar Chagas Freitas Ju` nior
1
, Anto nio Materson Silva
2
, Marcus Aure lio Rabelo Lima Verde
2
and Juliana Ribeiro Pala Jorge de Aguiar
1
1
Department of Dental Materials and Prosthodontics, Aracatuba School of Dentistry UNESP, Sa o Paulo State University, Aracatuba, Sa o
Paulo, Brazil;
2
Department of Restorative Dentistry, Ceara Federal University UFC, Fortaleza, Ceara , Brazil
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 chal-
lenge for dentists and is dened as postural habits
or dynamic atypical habits that affect the stomato-
gnathic 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 aesthetics
1,2
.
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 health
3
.
It can be associated with sleep disorders, emotional
stress, occlusal discrepancies, anxiety, fear or
tension, usually resulting in abnormal patterns of
dental wear
46
.
There are several types of therapies for this
problem, but the efcacy is still unclear
7
, 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 perimolysis
8
.
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 trea-
ted, the remaining teeth may require periodontal
surgery, endodontic treatment, intraradicular post-
and-cores and xed crowns. Limitations related to
costs and other priorities frequently restrict the
choice of the most suitable treatment. Thus, an
2012 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 7580 75
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 dentition
9
.
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 thera-
peutic 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.
Case report
A 61-year-old white male, presenting with good
gingival health and satisfactory support and peri-
odontium 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 dif-
culties, 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
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 accom-
plished 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 satisfac-
tory periodontal tissue, with the bone level compatible to
the patients age.
Figure 2 Initial clinical aspect, showing the loss of OVD
caused by tooth surface loss.
Figure 3 Initial clinical aspect of the patient presenting
severe wear of the upper anterior teeth, causing problems
at phonation, mastication and aesthetic.
2012 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 7580
76 A. C. Freitas Ju` nior et al.
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 contin-
uous 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. Mean-
while, 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 main-
tained with half of the ORPD, which had previ-
ously been divided.
The intraradicular core casts of the upper
anterior teeth were made with an indirect tech-
nique for later cementation. After re-preparing the
teeth, the functional moulding of the upper and
lower abutment teeth was made by means of
Figure 4 ORPD adapted without the need of dental
preparations.
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.
2012 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 7580
Oral rehabilitation using overlay 77
individual devices made with Duralay self-curing
acrylic resin (Reliance Dental MFG Co, Worth, IL,
USA), following placement of a relief, approxi-
mately 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 recommenda-
tions. 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 infra-
structure (MI) of the individual xed crowns could
be fabricated
The ceramic application on the MI was accom-
plished 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 impres-
sion 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
zinc phosphate cement (SS White Burs, Lakewood,
NJ, USA) was completed with the RPP installation.
A myo-relaxant plate made from thermop-
olymerising 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 relining
4,10
. However, in patients with
severe parafunction, the time between reviews
should be reduced
1
.
Figure 7 Upper and lower xed crowns in position.
Figure 8 Lower RPP occlusal view before its installation.
Notice the metal crown for tooth 37.
Figure 9 Final view of the patient.
2012 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: 7580
78 A. C. Freitas Ju` nior et al.
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
occur
1
.
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 concerns
11
.
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
plane
11
.
According to Langer and Langer
12
, 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
stability
1
.
The necessary time for the ORPD use is
13 months
11
, 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 reha-
bilitation 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.
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Correspondence to:
Amilcar Chagas Freitas Ju` nior., 1560 Waldir Feli-
zola de Moraes Jd. Sumare , Aracatuba, 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
80 A. C. Freitas Ju` nior et al.