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CLINICAL REPORT

Complete mouth rehabilitation and gastroesophageal reux


disease: Conventional and contemporary treatment approaches
Vasilios Chronopoulos, DDS, MS, PhD,a Georgios Maroulakos, DDS, MS,b Konstantinos Tsoutis, DDS, MS,c
Panagiota Stathopoulou, DDS, MS, PhD,d and William W. Nagy, DDSe

Gastroesophageal reux dis- ABSTRACT


ease (GERD) is a condition
This report describes the diagnosis and prosthodontic management of 2 patients with a history of
which develops when the chronic gastroesophageal reux disease and worn dentition. Different treatment approaches were
reux of stomach contents used for oral rehabilitation. Use of conventional and contemporary restorative materials resulted in
causes troublesome symptoms functional and esthetic prosthodontic rehabilitation with a favorable prognosis. (J Prosthet Dent
and/or complications.1 Reux 2017;117:1-7)
episodes can be intensied by
dietary habits, smoking, physical exercise, and obstruc- appointment was 2 months before the prosthodontic
tive sleep apnea.1-3 Complications of GERD are regur- evaluation for extraction of the mandibular right rst
gitation, chest pain, esophagitis, Barretts esophagus, molar (Fig. 2). The patient underwent monitored occlusal
esophageal adenocarcinoma, cough, asthma, and dental device therapy before any treatment.
erosion.1,4,5 GERD is associated with dental erosion and Diagnostic casts were obtained and mounted (Denar
sleep bruxism,6,7 and dental erosion may be the only Mark II; Whip Mix Corp) using a facebow (Denar Sli-
symptom of GERD.8 dematic; Whip Mix Corp) and centric relation records.
The purpose of this report was to present the oral The occlusal vertical dimension was evaluated, and a 3-
diagnosis and management of 2 patients with chronic mm increase was determined to allow adequate restor-
GERD who presented with tooth wear and required ative space. A diagnostic waxing was used to evaluate
complete mouth rehabilitation. The restoration of denti- esthetics and function and to fabricate interim prostheses
tion was achieved by following different treatment (Fig. 3).
modalities. The problems identied were moderate to severe
dental wear, defective restorations, inadequate tooth
structure on several maxillary and mandibular teeth,
CLINICAL REPORT
inadequate anterior guidance, nonideal gingival display
Patient 1 in an exaggerated smile, loss of attached mucosa, and
A 47-year-old woman presented complaining that her presence of a mandibular right bone defect (Fig. 1). The
teeth have worn out over time. Her medical history denitive diagnosis included worn dentition caused pri-
included mild chronic GERD, controlled with diet. Clin- marily by erosion9-12 and occlusal instability. Her caries
ical and radiographic examinations revealed multiple root risk was low.13 The patient was characterized as category
canal treatments (RCTs), amalgam restorations, and 2 relative to the occlusal vertical dimension associated
metal ceramic (MC) restorations (Fig. 1). Her last dental with a treatment plan14 and as prosthodontic diagnostic

a
Assistant Professor, Department of Prosthodontics, National and Kapodistrian University of Athens, School of Dentistry, Athens, Greece.
b
Assistant Professor, Department of General Dental Sciences, Marquette University School of Dentistry, Milwaukee, Wis.
c
Clinical Instructor, Department of Prosthodontics, National and Kapodistrian University of Athens, School of Dentistry, Athens, Greece.
d
Assistant Professor, Postdoctoral Periodontics, Department of Periodontics, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa.
e
Professor, Graduate Prosthodontics, Department of Restorative Sciences, Texas A&M University, Baylor College of Dentistry, Dallas, Texas.

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Figure 1. Patient 1 pretreatment. A, Maximum intercuspation position frontal view. B, Exaggerated smile. Note nonideal gingival display. C, Maxillary
occlusal view. Note condition of existing restorations. D, Mandibular occlusal view. Note ridge defect at post extraction site of mandibular right rst
molar and formation of amalgam islands on left posterior teeth.

index (PDI) class IV for partial edentulism.15 The treat-


ment objectives were to control GERD, to maintain
periodontal and dental health, and to provide functional
and esthetic restorations. Signicant treatment modiers
were the GERD and nances. The patient declined bone/
soft tissue augmentation and implant placement.
The inadequate tooth structure was managed by
crown lengthening and/or cast post and cores after RCT.
The maxillary central incisors were lengthened to
improve gingival architecture. Strip perforation at the
mesiobuccal canal of the mandibular left rst molar
occurred during RCT. After evaluating the tooth, resec-
tion of the mesial root was proposed,16 as the patient
refused extraction and implant placement (Fig. 4). The
occlusal scheme established with the interim prostheses Figure 2. Panoramic radiograph, pretreatment.
was mutually protected articulation. The patient was
monitored for 4 months to evaluate esthetics, function, communicate the established esthetics (incisal edge po-
oral hygiene, and soft tissue healing. Denitive impres- sition, contours, occlusal plane) and function (occlusal
sions were made with custom trays and polyvinyl scheme, envelope of function, palatal contours of
siloxane material (Aquasil Ultra; Dentsply Intl). Casts of maxillary anterior teeth). The patient received MC xed
interim prostheses were made to facilitate cross dental prostheses (FDPs) on all maxillary and mandibular
mounting of denitive casts and to fabricate a custom teeth. All prostheses were cemented with resin-modied
incisal guide table.17 The interim prostheses were used to glass ionomer cement (Fuji Plus; GC Corp).

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Figure 3. A, Occlusal vertical dimension evaluated with gingival height


of left canines as reference. Monitored splint therapy was executed at
proposed occlusal vertical dimension to locate musculoskeletally stable
treatment position and evaluate patients adaptation to new vertical
dimension. B, Diagnostic waxing at proposed occlusal vertical
dimension.

The patient received follow-up examination 1 week


after insertion and was excited with her rehabilitation. A
maxillary occlusal device was fabricated to protect the
prostheses. The patient entered a 6-month recall mainte-
nance program with favorable long-term prognosis. After
3 years, she was still satised with her prostheses (Fig. 5).
Figure 4. Tooth preparations. A, Maxillary. B, Mandibular. C, Cemented
Patient 2 cast post/core on root-resected mandibular left rst molar.
A 42-year-old woman complained of her short and
ugly teeth. Her medical history included chronic
GERD, controlled with a histamine-2 receptor antag- Diagnostic casts were mounted (Denar Mark II; Whip
onist. The patient had high esthetic expectations. Mix Corp) using a facebow (Denar Slidematic; Whip
Clinical and radiographic examination revealed existing Mix Corp) and centric relation records. The occlusal
RCTs, composite resin restorations, and MC restora- vertical dimension was evaluated, and an increase of 1
tions (Figs. 6, 7). The temporomandibular joint exami- mm was determined to allow space for the restorative
nation revealed clicking sounds on both joints but a materials. Dual-polymerizing composite resin (Integ-
normal range of motion and no pain. The patient rity; Dentsply Intl) was used as a trial restoration to
admitted nocturnal bruxism. An occlusal device was evaluate the diagnostic waxing intraorally (Fig. 8).
fabricated and monitored for 6 weeks to allow the The problems identied were moderate dental wear,
condyles to assume a stable treatment position.18 recurrent caries on several teeth, periapical pathosis on

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Figure 5. Patient 1. Inserted denitive prostheses. A, B, Occlusal views. C, Exaggerated smile. D, Panoramic radiograph 3 years after insertion.

Figure 6. Patient 2 pretreatment. A, Maximum intercuspation position frontal view. B, Exaggerated smile. C, D, Occlusal views.

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Figure 7. Panoramic radiograph, pretreatment.

the mandibular rst molars, inadequate tooth structure


on the maxillary right second premolar, nonrestorable
maxillary right rst premolar and mandibular left rst
molar, occlusal interferences, no anterior guidance in
maximum intercuspation position, and uneven gingival
display in an exaggerated smile (Fig. 6). The denitive
diagnosis included worn dentition due to erosion and
attrition,9-12 caries, and occlusal instability. There was no
periodontal pathosis, and her caries risk was high.13 The
patient was characterized as category 2 relative to
occlusal vertical dimension associated with a treatment
plan14 and as PDI class IV for completely dentate pa-
tients.19 Treatment objectives were to control GERD, to
manage caries by risk assessment, to maintain peri-
odontal health, and to perform functional and esthetic
restorations. Important treatment modiers were GERD,
bruxism, and the patients esthetic demands. Possible
options to restore teeth with poor prognosis were dis-
cussed, and the patient rejected 3-unit FDPs as denitive
prostheses.
Nonrestorable teeth were extracted. At the maxillary
right second premolar extraction site, a ridge preservation
technique was performed with freeze-dried bone allograft
(RegenerOss Allograft; Biomet 3i LLC) and resorbable
collagen membrane (OsseoGuard; Biomet 3i LLC). After 6
months of healing, an implant was placed with the aid of a
Figure 8. A, Diagnostic waxing at proposed occlusal vertical dimension.
surgical guide (Replace Select RP; Nobel Biocare). At the B, Intraoral evaluation of trial restorations from diagnostic waxing.
mandibular left rst molar extraction site, implant place- C, Interim prostheses.
ment and grafting were performed simultaneously
(Replace Select RP; Nobel Biocare). Teeth with inadequate
tooth structure were restored with composite resin core Denitive impressions and a denitive cast mounting
foundation material (FluoroCore 2; Dentsply Intl) after were made as described in patient 1. A custom-made
RCT. The crowns of the maxillary anterior teeth were zirconia abutment (NobelProcera Abutment Zirconia;
lengthened to improve the uneven gingival display. After 4 Nobel Biocare) was fabricated for the maxillary implant,
months of healing, the implants were loaded with interim and a custom-made gold alloy abutment for the
prostheses, which were fabricated based on the diagnostic mandibular implant (Fig. 9). All teeth received lithium
waxing and which established a mutually protected oc- disilicate (IPS e.max Press; Ivoclar Vivadent AG) crowns,
clusion scheme (Fig. 8). Esthetics, function, oral hygiene, which were adhesively cemented (Calibra; Dentsply Intl).
and soft tissue maturation were monitored for 6 months. Layered zirconia crowns were fabricated on custom

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Figure 9. Implant custom abutments. A, Computer-aided designed and computer-aided manufactured (CAD-CAM) custom zirconia abutment on
implant at maxillary right rst premolar site. B, Custom cast gold abutment on implant at mandibular left rst molar site.

Figure 10. Inserted denitive prostheses. A, B, Occlusal views. C, Maximum intercuspation position frontal view. D, Exaggerated smile.

abutments and cemented with resin-modied glass ion- health were emphasized to improve the long-term
omer cement (Fuji Plus, GC Corp) (Fig. 10). prognosis.
At the 1-week follow-up evaluation, the patient was
satised with her new prostheses. A maxillary occlusal
DISCUSSION
device was delivered at that time. The patient entered a
4-month recall maintenance program and has been fol- Based on its cause, tooth wear is characterized as
lowed for 2 years. The maintenance of oral and dental erosion, attrition, and abrasion.10,11 Erosion is further

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January 2017 7

characterized as extrinsic or intrinsic based on the acid REFERENCES


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techniques were used, and every tooth/implant was
restored with a single restoration. The use of contem-
porary ceramic materials resulted in improved esthetics. Corresponding author:
Dr Georgios Maroulakos
Both approaches offered viable solutions. A favorable 415 E. Vine St, #304
long-term prognosis can be achieved by taking into ac- Milwaukee, WI 53212
Email: gmaroulakos@yahoo.gr
count each patients needs along with careful patient
selection and an individualized maintenance program. Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

Chronopoulos et al THE JOURNAL OF PROSTHETIC DENTISTRY

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