A Systematic Method for a Full-Mouth Rehabilitation of a Dentition With Extensive Overjet and Occlusal Dysfunction

When approaching a full-mouth rehabilitation, dental clinicians often encounter worn dentition and collapsed vertical dimension that requires opening the bite to achieve adequate space to place restorations, attain a balanced and functional occlusion, and meet the patient's esthetic goals. These objectives are less commonly achieved by decreasing the vertical dimension of occlusion (VDO), which was necessary in the present case involving a patient who wanted to enhance her esthetics and reduce masseter muscle pain in advance of her upcoming wedding. After the clinician performed a detailed clinical examination, record-taking, and an analysis of the data collected, occlusal dysfunction was diagnosed. It was determined that the occlusion could be improved by reducing the patient's VDO to couple the second bicuspids and canines, and the esthetics could be improved with better contoured restorations. Correcting the occlusal dysfunction would also decrease the patient's need to clench, relieving her masseter muscle soreness.

A 34-year-old woman presented at her initial appointment stating she wanted to recreate the smile she had prior to dental treatment that was performed when she was a teenager. She desired a whiter smile, a flatter contour of her teeth, and more prominent central incisors. The patient had received Invisalign^® (Align Technology, Inc., invisalign.com) treatment from age 14 to 16 years old, which was immediately followed by full-mouth rehabilitation with porcelain crowns and the fabrication of an anterior bite plate to wear at night. She reported the full-mouth rehabilitation was recommended at the time because after the aligner treatment she was unhappy with unesthetic "white spots" on her teeth and was told that due to her weak enamel, full-coverage restorations were the best way to achieve her esthetic goals. She now presented with extensive caries and overjet, and teeth Nos. 5 through 12 were not in occlusion. Her pretreatment smile is depicted in Figure 1 through Figure 3.

The patient also reported painful masseter muscles for which she regularly received Botox (onabotulinumtoxinA) injections. She denied any oral habits such as thumb sucking or tongue thrusting. The case was treatment planned using a systematic assessment that employs principles the clinician learned at the Kois Center (koiscenter.com),¹ taking a facially driven approach to restore a balanced and functional occlusion with canine coupling.

The patient had a noncontributory medical history except for receiving Botox injections in her masseter muscles every 6 to 8 months for the past 5 years. Therefore, her American Society of Anesthesiologists (ASA) classification was I.²

As for her dental history the patient reported that she had unpleasant dental experiences, including multiple root canal treatments and more than 30 visits beginning at age 16 to restore her entire dentition one or two teeth at a time. She also reported, as mentioned above, that when she was younger she had enamel decalcifications on the front of her teeth and a high caries rate.

Periodontal: The alveolar bone levels were within 2 mm of the cementoenamel junction with pocket depths of 4 mm or less and generalized bleeding on probing. Generalized recession was noted on teeth Nos. 2, 4, 8 through 13, 18 through 24, and 26 through 31. Therefore, the patient was classified as American Academy of Periodontology (AAP) stage I, grade B.³

Risk: Low

Prognosis: Good

Biomechanical: The patient reported that her crowns on teeth Nos. 14 and 15 had been replaced 2 years ago due to porcelain fractures. On her mandibular teeth she was aware of notches near the gumline. Recurrent decay was present on teeth Nos. 2, 14, 18 through 21, and 28 through 31. Enamel decalcifications were noted on teeth Nos. 18 through 21 and 28 through 31, and all crown margins were defective.

Risk: High (multiple areas of decay)

Prognosis: Poor to hopeless

Functional: The patient answered "no" to all questions regarding function on the dental history questionnaire. She reported that she felt her lower jaw appeared pushed back/recessed esthetically from a profile view, but functionally she did not feel that her jaw had to move back to get her teeth to touch. She reported a history of daytime clenching and nighttime masseter muscle soreness, which began after her teeth were restored at age 16. An anterior bite plate covering teeth Nos. 5 through 12, which she wore most nights, was fabricated to relieve these symptoms. She stated that during the daytime she found a comfortable jaw position by placing her tongue behind her front teeth. She had received Botox injections in her masseter muscles for the previous 5 years, and after several treatments she noted that the lower third of her face was slimmer (Figure 4), muscle soreness was decreased, and daytime clenching occurred less often. Examination of the temporomandibular joint revealed normal joint function with a 40-mm range of motion, no deviation upon opening, no joint sounds, and a negative load test. It was determined that the lack of equal simultaneous bilateral posterior contacts caused her to clench to find the maximum intercuspation position (MIP). She was, therefore, diagnosed with occlusal dysfunction.⁴

Risk: Moderate

Prognosis: Poor

Dentofacial: All of the patient's gingiva was visible in her Duchenne smile. She desired a more natural, brighter smile, with a flatter and less flared tooth contour.

Risk: High

Prognosis: Poor

The goals of the treatment plan were to reduce the patient's high biomechanical risk due to recurrent caries under many of her existing restorations, improve her periodontal health, manage her muscle pain by restoring her to a functional and balanced occlusion, and enhance her smile. Her new restorations would be designed to reduce excessive overjet, couple her canines, and create a harmonious, bilateral balanced occlusion that would also stop her daytime and nighttime clenching.

The treatment plan comprised three main elements: (1) Design a facially and functionally driven treatment plan using Kois Center protocols¹ and digital technology to decrease the patient's biomechanical and functional risk. (2) Use a Kois deprogrammer to confirm the diagnosis of dysfunction. (3) Close the vertical dimension with new, full-coverage, adhesively retained restorations on all 28 teeth using a facially driven treatment plan to improve the patient's occlusion and esthetics and reduce her muscle pain.

Several treatment options were considered. The first was to deprogram and equilibrate the existing restorations to achieve bilateral balanced occlusion. This would improve the occlusion and provide relief to the muscles; however, the patient's biomechanical risk would remain high due to the untreated caries under the margins of many of the restorations, and esthetics would remain unchanged.

The second treatment option was to deprogram and replace restorations at the patient's current VDO. This would reduce the biomechanical risk, but esthetics would not be improved as wider, thicker crowns would be needed to reduce the overjet and achieve premolar and canine coupling.

Lastly, the third option was to deprogram, find centric relation (CR), and close the vertical dimension with new restorations. Biomechanical risk would be decreased and esthetics improved.

After discussing the options with the patient, the clinician recommended the third option and utilized a systematic plan derived using concepts taught at the Kois Center.⁴ A digital dentofacial analysis using a digital hub (Evident Hub, Evident, hub.evidentdigital.com) was used to create a facially driven plan.

Phase 1: Records, Deprogrammer Delivery, and Centric Relation Verification

A full diagnostic workup was initiated, including digital scans, full-mouth radiographs, periodontal probing, prophylaxis, and oral hygiene instruction. Full-face and retracted photographs were taken with the patient wearing facial reference glasses (Kois Facial Reference Glasses, Kois Center). The patient was placed on an anticavity mouthrinse and treatment rinse (CTx3 Rinse and CTx4 Treatment Rinse, CariFree, carifree.com) and anticavity toothpaste (CTx4, CariFree) to reduce caries risk.

A Kois deprogrammer was adjusted and delivered to confirm the clinician's diagnosis of occlusal dysfunction and find a repeatable bite position (Figure 5). After wearing the deprogrammer for 4 weeks, the patient felt more comfortable, reported less jaw muscle tightness, and no longer had any awareness of her tongue position. She was unable to clench as much while wearing the deprogrammer, and once her muscles relaxed, a reproducible bite position was achieved. When she removed the deprogrammer, the first point of contact was on her maxillary right second molar. Using this reference position, the clinician performed an occlusal equilibration to locate CR, closing her VDO (Figure 6 and Figure 7).

Phase 2: Functional Wax-up and Analysis Using the Hub System

Once the patient was equilibrated and CR was captured, impressions were taken of both the upper and lower arches and sent to the dental laboratory for a functional diagnostic full-mouth wax-up.⁵ The patient provided a photograph of her taken at age 15 prior to her orthodontic treatment and full-mouth reconstruction, and said she would like to have longer central incisors similar to when she was younger.

A series of photographs taken with the facial reference glasses in place (Figure 8) was submitted to the aforementioned digital hub (Evident Hub) for a digital smile analysis. The photo series included the lips in repose, the patient saying "shush," and a wide (Duchenne) smile. The "shush" and Duchenne smile photographs were superimposed to gather more information on the maxillary and mandibular lip dynamics, tooth display, and individual tooth measurements. The dentofacial analysis revealed the cuspid position with the lips at rest to be -1.5 mm, and therefore it was decided to lengthen all the anterior teeth by 1.5 mm to achieve cuspid zero.⁶ A plan was devised to close the VDO to allow for proper canine coupling, level the canted maxillary occlusal plane, and blend the posterior occlusal plane to match.

Phase 3: Provisionalization

The patient returned for preparation and temporization of the maxillary arch based on the diagnostic wax-up. Existing crowns on teeth Nos. 2 through 15 were removed, all recurrent decay was excavated, and tooth No. 5 underwent transulcular crown lengthening using a KB-1 chisel.⁷ Prior caries and tooth preparation had resulted in extensive previous loss of tooth structure, so decay excavation was carried out very conservatively to preserve the remaining tooth structure (Figure 9 and Figure 10).

Dentin shades of the prepared teeth were recorded. A putty matrix of the functional diagnostic wax-up was used to provisionalize the maxillary arch with bisacryl material in shade B1 (Luxatemp, DMG America, dmg-america.com) and luted with a eugenol-free, dual-cured provisional cement (Temp-Bond^™ Clear^™, Kerr, kerrdental.com).

The patient returned 1 week later for preparation and temporization of the mandibular arch in the same manner (Figure 11 and Figure 12).

Phase 4: Verification of Esthetics and Function

The patient returned 1 week later for evaluation of esthetics and function of the provisionals before the clinician proceeded with final fabrication of the porcelain restorations. Necessary esthetic changes were made and occlusion and function were carefully assessed, as these restorations would serve as a blueprint for the final restorations (Figure 13). Gingival embrasures were opened with a fine mosquito diamond bur (Brasseler USA, brasselerusa.com) to allow for cleansability, and proper oral hygiene was reinforced to the patient. Use of an antioxidant gel (AO ProVantage Gel, Periosciences, periosciences.com) and anticavity products (CariFree) was encouraged to ensure the health of the gingival tissues at the seat appointment.

Phase 5: Final Impressions of Maxillary and Mandibular Teeth

Final impressions of the maxillary and mandibular arches (from premolar to premolar) were taken. Double-zero cord (Ultrapak^™, Ultradent, ultradent.com) was packed, and polyether material (3M^™ Impregum^™, 3M Oral Care, 3m.com) was used to take the final impressions. The molar provisionals on both arches were kept in place to retain the proper vertical dimension. A bite registration was recorded (Futar^®, Kettenbach USA, kettenbach.com), photographs of the provisional restorations were taken, and the anterior teeth were measured using digital calipers. Digital scans of the provisionals were taken and sent to the lab for final porcelain fabrication.

Phase 6: Cementation of Maxillary and Mandibular Final Restorations

Four weeks later the patient returned for insertion of the maxillary and mandibular lithium-disilicate crowns (IPS e.max^®, Ivoclar, ivoclar.com) on teeth Nos. 4 through 13 and 20 through 29 (Figure 14 and Figure 15). The full-coverage crowns were adhesively placed with a dual-cure cement (Variolink^® Esthetic LC, Ivoclar) in a neutral shade. The crowns were adjusted, and vertical dimension was verified by the posterior provisional molars holding shimstock. Once the fit was verified clinically and radiographically, the final restorations were cemented using a dual-cured resin (RelyX^™ Unicem 2, 3M Oral Care) in a translucent shade. Occlusion was evaluated in MIP using blue 200-µm articulating paper (Bausch, bauschpaper.com). The patient chewed on 200-µm articulating paper to identify any chewing interferences, which would be removed.

Phase 7: Final Impressions and Cementation of Molar Restorations

The protocol described above was used for the provisionalization and delivery of the maxillary and mandibular posterior molar restorations made from zirconia (Jensen XT Zirconia with Miyo^® finishing system, Jensen Dental, jensendental.com). Final occlusal adjustments were made by evaluating MIP using blue articulating paper and 8-µm articulating paper (Bausch). Bilateral balanced occlusion was verified, and the maxillary arch was scanned for a full-coverage hard occlusal splint.

Figure 16 through Figure 19 show the final restorations in place.

Phase 8: Maintenance

Due to the patient's history of high caries risk, it was recommended that she maintain the use of a high pH xylitol rinse and toothpaste (CariFree). The use of a hard splint at nighttime was recommended due to previous clenching. Although the functional risk was greatly improved and the patient was comfortable with her new bite, a hard splint was fabricated for the patient to wear during sleep as a precaution to protect the restored dentition.

This case demonstrates a complex restorative full-mouth treatment plan in which the vertical dimension was closed to relieve excess overjet and lack of occlusal contact from teeth Nos. 5 through 12. The patient's teeth were restored with 20 porcelain crowns (e.max) and eight zirconia crowns (Jensen XT Zirconia) that enhanced esthetics and decreased both the biomechanical and functional risks. Typically in full-mouth rehabilitation cases, the vertical dimension is opened to allow for the needed restorative space. However, the systematic diagnosis and treatment planning process used in this case resulted in closing the VDO, which relieved the patient's muscle pain and helped improve her smile.

Only through a detailed history and structured application of risk-based patient evaluation and treatment planning was it possible to determine the best treatment to enhance esthetics while improving function and prognosis for long-lasting restorations. The patient's goals were achieved, and she obtained a beautiful smile for her wedding day. Because the patient was highly motivated and compliant, the case was finished in a timely manner over the course of 5 months. The patient has continued with Botox treatments for the masseters due to the added benefit of facial slimming.⁸

The author thanks Calvin Munn, CDT, of Jason J. Kim Dental Aesthetics for the beautiful lab work in this case, and members of the Kois Center for editing assistance on this article.

Bridget Glazarov, DDS
Private Practice, Manhattan, New York