A Systematic Approach to Altering Occlusal Vertical Dimension in a Patient With Functional and Esthetic Concerns

After enduring recurring failures of her anterior restorations, the patient in this case was seeking treatment that would last and improve her esthetics. Long-term success in treating broken and worn teeth can best be achieved with a systematic approach to diagnosis and treatment planning, which can reduce risk through the management of dentofacial, periodontal, functional, and biomechanical issues.

Clinical Case Overview

A 68-year-old female patient presented complaining of a recently chipped mandibular left lateral incisor and a crack in her existing maxillary right central incisor veneer. In addition to wanting to correct the chipped teeth and cracked veneer, she expressed a desire for whiter and longer teeth and wanted to prevent further chipping (Figure 1 and Figure 2). The patient also explained that she wanted a full set of teeth with a smile "worthy of a Hollywood movie."

Industry Spotlight

Request your sample today!

OMNICHROMA Flow BULK, a one-shade bulk fill composite, shade-matches any tooth color from A1 to D4. A low viscosity, light-cured material, placed in 3.5mm increments.

Medical and Dental History

Relevant medical history included occasional acid reflux managed by pantoprazole, a proton pump inhibitor. Pantoprazole can impair bone healing, which could lead to complications with implant osseointegration.¹ The patient also indicated that she was often fatigued. The combination of reflux and frequent fatigue raised the question of airway concerns and potential sleep apnea. The patient was evaluated with a sleep study and her physician ruled out a diagnosis of obstructive sleep apnea. The patient was classified as American Society of Anesthesiologists (ASA) II because she was over the age of 60.

The patient reported being anxious about dental visits, describing her fear level as 9 out of 10. Previous unfavorable dental experiences related to difficulty becoming numb and having anesthetic wear off too quickly. Additional "yes" answers in the dental history indicated the presence of rough areas on the chewing surfaces of her teeth, a food trap distal to her maxillary left canine, sensitivity to cold, and a history of multiple broken teeth and toothaches. The patient reported an asymptomatic click in her left temporomandibular joint (TMJ) and that her jaw felt more comfortable when she rested her tongue between the front teeth. She said she occasionally clenched her teeth when she was stressed and noted that tooth No. 13 had been removed after it fractured below the gumline. She noticed her teeth becoming shorter over the previous 5 years and was self-conscious about her missing and broken teeth. She desired whiter, longer, more symmetrical teeth and a full smile.

Diagnosis, Risk Assessment, and Prognosis

Periodontal: Teeth Nos. 2, 5, 12, 14, and 15 had 2 mm to 3 mm of radiographic horizontal bone loss and 3 mm to 4 mm of clinical attachment loss (CAL). These teeth had probing depths of 4 mm or less with generalized bleeding, classified as American Academy of Periodontology (AAP) stage II, grade B. All other teeth had less than 2 mm of horizontal bone loss radiographically, probing depths of less than 4 mm, and CAL of less than 2 mm, classified as AAP stage 1, grade B.² The overall periodontal risk was moderate based on the most severe area of disease (Figure 3).

Risk:Moderate

Prognosis:   Fair

Biomechanical: Teeth Nos. 3 and 31 had defective restorations with recurrent decay. Tooth No. 4 was deemed nonrestorable due to a defective root canal, a subgingival fracture, and inadequate remaining tooth structure. These teeth had a hopeless prognosis without treatment. Teeth Nos. 2, 3, 5, 8, 9, 12, 14, 15, 19 through 21, and 28 through 30 had structural compromises in the form of root canals and/or restorations greater than one-third of the intercuspal width.³ These teeth were given a poor prognosis (Figure 4 and Figure 5). Unrestored teeth with moderate erosion (Nos. 6 and 11), crowned teeth without root canal therapy (Nos. 18 and 31), and teeth with minor restorations (Nos. 7 and 10) were given a fair prognosis. Tooth No. 9 had a questionable root canal and was sent for endodontic evaluation.

Risk: High

Prognosis: Poor

Functional: Maximum opening was 52 mm with a click in the patient's left TMJ. Her left masseter muscle was sore to palpation. Over the past 5 years her mandibular anterior composite fillings had continued to chip and break. Most of the attrition was located on the lingual surfaces of maxillary anterior teeth and the facial surfaces of mandibular anterior teeth. The pattern of tooth wear along with the positive answers in the bite and jaw joint section of her dental history were consistent with the diagnosis of constricted chewing pattern.⁴

Risk: Moderate

Prognosis: Fair

Dentofacial: The patient's cuspid display at rest was zero, and she showed excessive gingival display in Duchenne smile (Figure 6 and Figure 7).⁵ The upper lip moved 12 mm from rest position to maximum smile indicating lip hypermobility.^6,7 The maxillary incisal edge position was determined to be acceptable, but the teeth needed to be lengthened for more ideal esthetic proportions. Tooth No. 9 had been endodontically treated and the dark underlying tooth structure was visible through her existing veneer.

Risk: High

Prognosis: Poor

Treatment Goals

The treatment was aimed at satisfying the patient's esthetic concerns by making her teeth longer and whiter. Resolving the patient's occlusal problems before placing the final restorations would allow for a more predictable outcome. Transitional restorations would be used to increase the occlusal vertical dimension (OVD) and allow the patient to test the new occlusion and esthetic design prior to the placement of the definitive restorations. Once the patient was comfortable and stable, biomechanical risk would be addressed by protecting structurally compromised teeth with full-coverage restorations. Esthetic goals would be met by changing the color, length, and shape of the anterior teeth with esthetic crown lengthening and crowns.

Treatment Plan

The treatment plan was segmented into five stages: disease control, deprogramming and diagnostic wax-up, transitional bonding, osseous crown lengthening and implant placement, and definitive restorations.

Treatment Phases

Phase 1: Disease Control

The patient was placed on a caries management program that included twice-daily use of an anticavity rinse (Treatment Rinse, CariFree, carifree.com), brushing with an electric toothbrush, and use of a 1.1% neutral sodium fluoride dentifrice (3M^™ ClinPro^™ 5000, 3M Oral Care, 3m.com). Carious lesions on teeth Nos. 3 and 31 were removed and interim restorations were placed. Tooth No. 9 was confirmed to have asymptomatic apical periodontitis and was retreated by an endodontist. The patient's periodontal condition was managed with initial scaling and root planing with a 6-week follow-up. Once the tissues were stable and bleeding was minimized, definitive treatment began.

Phase 2: Deprogramming and Diagnostic Wax-up

Kois dentofacial reference glasses (Kois Center, koiscenter.com) were used to find the horizontal plane in the patient's natural head position, which could then be used with the Kois dentofacial analyzer (Kois Center) to mount the maxillary model on a Panadent articulator (Panadent, panadent.com) (Figure 8 and Figure 9). The patient wore a Kois deprogrammer (Kois Center) for 3 weeks. Deprogramming was confirmed when a single point on the deprogrammer was repeated (Figure 10). A centric occlusion wax bite registration (Bite Tabs, Great Lakes Dental Technologies, greatlakesdentaltech.com) was taken to mount the mandibular model to the maxillary model on the articulator. The diagnosis of a constricted chewing pattern was confirmed when the initial point of contact was determined to be between teeth Nos. 9 and 23.⁴

A photograph showing the incisal edge of the maxillary canine level with the border of the upper lip at rest verified that the canine display was zero (Figure 6). This established that the existing maxillary incisal edge position was acceptable, and therefore it would not be altered. The increase in length would be obtained in the apical direction using esthetic crown lengthening.⁵

A wax-up of the maxillary anterior six teeth was tried in the mouth with temporization material (3M^™ Protemp^™, 3M Oral Care) to verify maxillary mounting and replicate the length and color of the new restorations (Figure 11 and Figure 12). A retracted view photograph of the mandibular occlusal plane (Figure 2) was used to determine that the mandibular posterior teeth were deficient in height, and a wax-up was used to increase the height of these teeth to level the occlusal plane (Figure 13).

Phase 3: Transitional Bonding

The goal of transitional bonding was to increase the OVD and eliminate premature anterior occlusal contacts that infringed on the patient's envelope of function. Transitional bonding was completed from teeth Nos. 19 through 22 and 30 through 27. An index of the mandibular wax-up was made with clear impression material (RSVP^™ Clear PVS, Cosmedent, cosmedent.com). The index was filled with a dual-cure build-up material (Cosmecore^™, Cosmedent) and then placed over the teeth.⁸ The temporaries were removed and trimmed outside of the mouth. The teeth were air-abraded, etched with 35% phosphoric acid, and bonded (All-Bond Universal^®, Bisco, bisco.com), and the provisional restorations were cemented using flowable composite (Beautifil Flow Plus^®, Shofu, shofu.com).

The transitional restorations were equilibrated by carefully reducing the anterior platform of the deprogrammer and adjusting each contact until equal, bilateral, and simultaneous contacts were achieved (Figure 14). The patient's chewing envelope was checked with the patient in an upright position using 200-µm articulating paper (Bausch, bauschpaper.com).⁹ Chewing interferences were eliminated by removing any blue streaks that did not correspond with a cusp/fossa relationship. Direct composite restorations (3M^™ Filtek^™ Supreme, 3M Oral Care) were completed on the chipped mandibular incisors at the same appointment. The patient remained in the transitional bonding restorations for 3 months. She was comfortable and adapted well to the new OVD.

Phase 4: Osseous Crown Lengthening and Implant Placement

Osseous crown lengthening was completed using the wax-up as a guide. The wax-up was duplicated and a stent of the new free gingival margins was made (Essix PLUS Plastic, Dentsply Sirona, dentsplysirona.com). Before surgery, local anesthetic was administered and trans-sulcular probing was performed to determine the patient's crest type. Due to a low crest height, a full-thickness flap with a papilla-sparing incision was raised from teeth Nos. 3 through 14. The stent was used as a guide to move the new crestal bone level to 3 mm from the new anticipated free gingival margin, from line angle to line angle.¹⁰ Osseous recontouring was performed from teeth Nos. 5 through 13 using an Ochsenbein chisel (Hu-Friedy, hufriedygroup.com) and a titan scaler to smooth residual bone edges. The patient was referred to a periodontal specialist for implant placement at the positions of teeth Nos. 4 and 13.

Phase 5: Definitive Restorations

After 3 months of healing, the final tissue level and integration of the implants were evaluated. The transitional restorations were assessed for fractures, high spots, or deficiencies to ensure occlusion was acceptable. No issues or problems were noted.

The definitive restorations were delivered in multiple appointments to segment treatment. Teeth previously restored with transitional bonding were converted first. Next, the maxillary posterior teeth were completed to create a reproducible and stable OVD. The maxillary, and then mandibular, anterior definitive restorations were finished respectively.

Full-contour zirconia (Prettau^® 2, Zirkonzahn, zirkonzahn.com) was selected as the indirect restorative material because of its strength and ability to block out the dark underlying tooth structure of tooth No. 9. Prior to cementation, the teeth were isolated and particle-abraded with 27-µm aluminum oxide (PrepStart^™, Zest Dental Solutions, zestdent.com). The intaglio surfaces of the crowns were cleaned with a zirconia cleansing paste (Ivoclean^®, Ivoclar, ivoclar.com), and a 10-methacryloyloxydecyl dihydrogen phosphate (MDP) primer (Z-Prime^™ Plus, Bisco) was applied before cementation was performed with a self-adhesive resin cement (RelyX^™ Unicem 2, 3M Oral Care). The final restorations are depicted in Figure 15 through Figure 17.

The patient continued on a 4-month periodontal maintenance program and caries management protocol.

Discussion

The patient was very happy with the final esthetic and functional results. The treatment reduced the patient's functional risk by creating a comfortable bite that relieved a constricted chewing pattern and improved the functional prognosis to good. The functional risk could have been improved using orthodontics, however the patient declined this option because she preferred to achieve her goals and lower her overall risk more quickly through restorative dentistry.

The overall biomechanical risk was reduced by converting many of the heavily restored teeth to full-coverage restorations, which offer a better long-term prognosis. The patient's periodontal risk remains moderate, and she continues on a 4-month periodontal maintenance program. The patient's dentofacial risk remains the same due to her high lip dynamics. Her prognosis improved from poor to good, and she was extremely pleased with her new smile.

Conclusion

Multiple attempts had been made to restore the patient's mandibular incisors with direct composites unsuccessfully. The goal of the clinician and patient in this case was to create a comfortable and functional bite that would allow for a more predictable esthetic solution. This case illustrates the benefit of using the Kois dental history questionnaire in conjunction with the Kois deprogrammer to help diagnose an underlying occlusal problem.

Acknowledgment

The author thanks John Kois, DMD, MSD, and Richard Burns, BPT, DDS, for their mentorship; Lars Schneider, RDT, MDT, of Vai Dental Lab for laboratory support and ceramic work; and Tarek Ali, BDS, DDS, MSc, for implant surgery.

About the Author

Andrew Sweet, BSc, DMD
Private Practice, Victoria, British Columbia, Canada

Figures and Images

Figure 1

Figure 2

Figure 3

Figure 4

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

Figure 5

Figure 1

Fig 1. On presentation, the patient was self-conscious of her smile and concerned about chipped mandibular teeth and a cracked maxillary veneer on tooth No. 8.

Figure 2

Fig 2. Retracted view showing chipping and breakage of previous restorative work. Note the crack line on the distal aspect of the tooth No. 8 veneer. Also notable was the deficient height of the mandibular posterior teeth compared to the “step up” of the mandibular anterior teeth.

Figure 3

Fig 3. Preoperative panoramic radiograph.

Figure 4

Fig 4. Preoperative occlusal view of the maxillary dentition showing biomechanical compromises of multiple teeth.

Figure 6

Fig 6. The patient had zero canine display in repose.

Figure 7

Fig 7. The patient’s Duchenne smile exhibited hyper lip mobility.

Figure 8

Fig 8. The patient shown wearing the facial reference glasses, which were used to find the horizontal plane in the patient’s natural head position. This photograph was used to determine the appropriate plane for the maxillary wax-up using a facebow transfer and the articulator.

Figure 9

Fig 9. Maxillary model mounted on the articulator in natural head position.

Figure 10

Fig 10. Single point on the deprogrammer (blue dot) confirming deprogramming.

Figure 11

Fig 11. Maxillary anterior wax-up.

Figure 12

Fig 12. Bis-acrylic composite try-in of wax prototype with patient’s natural smile.

Figure 13

Fig 13. Mandibular wax-up, occlusal view.

Figure 14

Fig 14. Transitional bonding was completed from teeth Nos. 19 through 22 and 30 through 27. Freehand composites were completed on teeth Nos. 23 through 26.

Figure 15

Fig 15. Retracted view of final restorations.

Figure 16

Fig 16. Postoperative full-face smile.

Figure 17

Fig 17. Postoperative panoramic radiograph.

Figure 5

Fig 5. Preoperative occlusal view of the mandibular dentition showing biomechanical compromises of multiple teeth.