Full mouth rehabilitation of a patient with reduced vertical dimension using multiple metal ce ramic restorations
A 45-year-old man reported for the treatment of his severely worn dentition and his chief complaint was that he could not eat anything because his teeth were worn too much, were hypersensitive and had an unesthetic appearance. Patient had no relevant medical history. Intraoral examination revealed a generalized loss of tooth structure that was greater in the maxillary anteriors and mandibular posteriors. Mandibular canines, left lateral incisor and first premolars were severely worn [Figure –]. Maxillary left first molar was grossly decayed. The anterior teeth had sharp enamel edges, dentinal craters and attritional wear due to the loss of posterior support. 26, 47, 42, 41 and 31 were missing []. The facial type of patient was square and his lip was hypertonic. Patient did not have temporomandibular disorders, but a discrepancy between centric occlusion (CO) and maximum intercuspal position was found when she was guided to centric relation (CR) with bimanual technique.\nTo determine whether VDO had been altered, the following aspects were investigated.[]\nHistory of wear: Physiologic wear can be compensated by tooth eruption in general, but accelerated wear may exceed the rate of eruption. The patient liked vegetables and acidic fruits and her favourite food was tough and fibrous Phonetic evaluation: If the distance between the incisal edge of the mandibular incisors and lingual surface of the maxillary incisors is about 1 mm, the patient is able to pronounce “s” normally. The patient's increased space altered the “s” sound to “sh” Interocclusal rest space: The patient's interocclusal rest space that was measured to be 5-6 mm. This was greater than the normal value of 2-4 mm Facial appearance: Wrinkles and drooping commissures around the mouth were observed The possible causes of patient's worn dentition might include posterior interferences, parafunction, eating habit and dental ignorance.\nThe options presented to the patient were removable partial dentures and full mouth rehabilitation with metal ceramic restoration with or without crown lengthening procedure and implant retained replacement of missing teeth. The patient was anxious about implant surgery, so this option was excluded. As there was clinical evidence of reduced VDO, full mouth rehabilitation with increasing VDO was planned.\nPatient's casts were mounted on a semi-adjustable articulator (Hanau™ Modular Articulator; Whip Mix Corp., Louisville, USA) using a face-bow record and an interocclusal record was made with the aid of a lucia jig and polyvinylsiloxane occlusal registration material (Exabite II; GC Corp., Tokyo, Japan).\nVertical dimension at rest was found to be 68 mm by using facial measurements after swallowing and relaxing and was verified using phonetics. VDO was found to be 61 mm using Niswonger's and Thomson's technique. Freeway space was 7 mm.\nThe existing VDO was increased by 4 mm using the incisal guidance pin of the articulator to a new VDO of 65 mm. The splint was designed to offer bilateral contacts of all posterior teeth in CR and guide the anterior teeth in excursive movements. The anterior guidance disoccluded the posterior teeth in all jaw positions except CR.\nThe adaptation of the patient to the increased VDO was evaluated during a 1 month period using the orthodontic appliance. No muscle tenderness or temporomandibular discomfort was found. Increasing the VDO was mandatory to allow the condyles to assume their most SAM position in intimate contact with the thinnest part of biconcavity of disc. It permitted the entire temporomandibular joint (TMJ) complex to attain an improved functional health and allowed the posterior avoidance patterns of occlusion to wane and a new vertical dimension to be established.\nAfter recording the CR using lucia jig and wax-rim, diagnostic wax-up was performed.