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Full Mouth Rehabilitation of a caseof rampant caries using a twin

-Stage procedureAnil Kumar S (Maj)1, Nandkishore Sahoo (Brig)2

Col. Sandhu HS3, Col. Radhakrishnan Vijayanathan4

ABSTRACT:

Purpose: Dental caries is one of the most common chronic

diseases in the world. Restoration of tooth decay is important

not only because of aesthetic and functional concern, but also

because there may be positive psychological impact for the

patient. This case report demonstrates full mouth rehabilitation

of a 26 year old female patient with multiple decayed teeth using

the Hobo and Takayama twin-stage procedure for restoration

of esthetics and function. The patient was rehabilitated with

porcelain fused to metal restorations using the twin stage

procedure where in posterior restorations were fabricated

following which the anterior guidance was set by fabrication of

the anterior restorations. Cast partial dentures were fabricated

for missing posterior teeth.

Discussion: Full mouth rehabilitation of severely decayed teeth

is a challenge in terms of establishing aesthetics and function

to the patient. Hobo and Takayama in their article have clearly

described the means of restoring anterior guidance and

predictable posterior disclusion in harmony with the condylar

path.

Key words: Rampant caries, Twin stage procedure, Hobo and

Takayama

C A S E R E P O R T

doi: 10.5866/4.3.941

1Senior Lecturer (Prosthodontics)Army College of Dental Sciences2Dept of Dental SurgeryArmed Forces Medical CollegeProfessor & Head of Department(Oral And Maxillofacial Surgery), Pune3Army Dental Centre (R&R),Professor (Prosthetic Dentistry)4Army College of Dental Sciences

Article Info:

Received: July 12, 2012;Review Completed: August, 12, 2012;Accepted: September 10, 2012Published Online: October, 2012 (www. nacd. in)© NAD, 2012 - All rights reserved

Email for correspondence: anil.d1@rediffmail.com

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Introduction

Rampant caries is defined as suddenly appearing, widespread, rapidly burrowing type of caries resultingin early involvement of pulp. Patients affected with rampant caries often have compromised aesthetics andfunction. Restoration of the carious lesion is a challenge since they are deeply burrowing into the enamel anddentine. Full mouth rehabilitation and philosophies are often intrigue in nature, but the esthetic and functional

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accomplishment of rehabilitation is alwayssatisfying. Anterior guidance is crucial in humanocclusion because it influences molar disocclusionthat controls horizontal forces. Molar disocclusionis determined by a cusp-shape factor and an angleof hinge rotation. There are three factors thatdetermine disocclusion: condylar path, incisal pathand cusp angle. Condylar path has been regardedas the main determinant for occlusion in prosthetictreatment. It is measured and used as a clinicalreference to restore occlusion. The condylar path hasbeen shown to have deviation within the individualand its influence on disocclusion is minimal (Hoboand Takayama).1, 2 The Hobo and Takayamatechnique develops anterior guidance to create apredetermined, harmonious disocclusion with thecondylar path. Condition 1 is used to incorporate acusp shape factor and condition 2 is used for theangle of hinge rotation.3

This article presents the stages of prosthodonticrehabilitation, from diagnosis to final treatment ofa patient with rampant caries with severely worndentition, some extracted teeth and uneven occlusalplane using light cure core build up, metal ceramicrestorations and maxillary-mandibular castremovable partial dentures.

Case Report

A 26 year old female reported to the Departmentof Prosthodontics, Army Dental Centre Researchand Referral, New Delhi with a chief complaint ofmultiple decayed teeth and unsightly appearancesince few years deteriorating gradually over a periodof time. The patient did not give any medical historyabout previous illness. The patient’s dental historydated back to 6 to 7 years when she noticed darkblack spots on the anterior teeth which deterioratedgradually over a period of time. The patient was notsuffering from any TMJ disorders.

Clinical Examination

Extraoral: No facial asymmetry, Noabnormality in the TMJ.

Intraoral: Multiple decayed upper and lowerdentition with poor oral hygiene. The missing teethwere 24, 26, 36, 37 and 46. Root stumps i.r.t 17, 27,28, 42, 48 and 45 were present [Fig 1]. Fractured

amalgam restoration i.r.t 16. The patient presentedwith a bilateral class I canine relationship. Therewere multiple fractured light cure restorations. Thevertical dimension was adequate. After making adiagnosis of rampant caries, the nature of thedisease was explained to the patient. At the firstvisit, caries was excavated from anterior teeth andprovisional glass ionomer cement restorations placedto improve her appearance immediately. Particularattention was paid to finishing of the gingivalmargins of the provisional restorations to minimizefurther plaque accumulation. In addition, gingivalembrasures were maintained to facilitateinterproximal cleaning.

Analysis of the three-day dietary diary at thesecond visit revealed that the patient drank about10 cups of tea over a period of two hours three timesa day. Each cup (about 25 ml) contained three cubesof sugar. The tea-drinking habit was accompaniedby snacks which comprised mainly nuts. Afterexplaining to the patient the roll of her sugarconsumption pattern in the etiology of rampantcaries, she was advised on the need to greatly reduceher sugar consumption and intensify her oralhygiene practices, i.e. brushing with fluoridetoothpaste. The oral hygiene measures were to bepracticed before and after each meal or snack andbefore bed. She was also requested to bring along tothe clinic the prescribed oral hygiene aids. At thethird visit three weeks later, the patient’scompliance with oral hygiene instruction and dietarycounseling were assessed: plaque index wasmeasured. Grossly carious posterior teeth weretemporized by excavating caries and placingmodified zinc oxide-eugenol cement restorations.Oral health education was reinforced. At the nexttwo visits, the same procedures were repeated, whilesmall and moderate carious cavities on posteriorteeth were restored with amalgam. When thepatient was evaluated at a recall visit three monthslater there was marked improvement in theperiodontal condition, the gingival index havingfallen from 100% to 20%. At the recall appointmentsix months later, oral hygiene was excellent.Permanent restorations were then placed onposterior teeth.

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Treatment Procedure

1. Extraction of the root stumps i.r.t 17, 27, 28,42, 48 and 45

2. Root canal treatment of 21, 22, 23, 24, 31, 32,33, 34, 35, 41, 43, 45, 47 [Fig 2]

3. Repair of the fractured amalgam restorationi.r.t. 16

4. Light cure core build up of the decayed teeth.

5. Maxillary and mandibular impressions weremade in the alginate impression material anddiagnostic casts were obtained. The anteriorportion of the maxillary cast was maderemovable with dowel pins.

6. The maxillary cast was mounted using face-bowtransfer onto a semiadjustable arcon articulator(Whip-mix) and the mandibular cast mountedusing the Lucia jig and centric relation record[Fig 3].

7. Diagnostic wax-up was done at the existingvertical dimension to see the final outcome [Fig4]. The removable anterior segment of themaxillary cast was detached to eliminate theeffects of anterior guidance. The articulator(with waxed maxillary and mandibularposterior teeth) was moved in forward, right andleft directions (with the anterior segment of themaxillary cast removed the posterior teeth donot disclude during eccentric movements, butthe molars should glide smoothly throughmaximum intercuspation). Interferences in theocclusal wax up that was preventing in smootheccentric movements were carved out and waxwas added to the areas where the tooth contactswere not present in eccentric movements. Thiswas mainly done because if the maxillary andmandibular casts interdigitate evenly duringeccentric movement, it means that the cuspbecomes parallel to the condylar path and thecusp shape of the molar has been harmoniouslyestablished in the wax up. The cusp shape factoris incorporated at this stage.

8. Autopolymerizing resin was placed in a doughstage on the flat incisal table and the resin wasmolded by moving the incisal pin through

protrusive and lateral movements. A secondincisal table was prepared identically. Theseincisal tables are referred to as “Incisal tableswithout Disclusion”. The molded incisal tablecoincides three dimensionally with the condylarpath and molar cusp shape.

9. One of the incisal tables without disclusion wasplaced on the articulator so that the tip of theincisal pole contacted the incisal table in centricrelation. Two 3mm thick spacers were preparedto approximate the protrusive movementposition. When the spacers are inserted behindright and left condyles on the articulator,maxillary and mandibular casts are placed in a3mm protrusive position. A vinyl sheet 1.1 mmthick was applied to the mesiobuccal cusp tipsof right and left waxed mandibular first molars,and the articulator was closed. This created anaverage an average disclusion during protrusivemovement of the mandible.

10. The tip of the incisal pin was directed backwardand upward from the incisal table. A brush wasused to build the autopolymerizing resin into acone between the incisal pin and the incisaltable. The cone marked the three dimensionalposition of the tip of the incisal pin at a 3 mmprotrusive movement with 1.1 mm molardisclusion. This created the angle of hingerotation required to produce the averagedisclusion during protrusive movement.

11. The lateral movement was simulated by placinga 3mm spacer behind one of the condyles on thearticulator. A 1.1 mm vinyl sheet was positionedon the tip of the mesiobuccal cusp of waxedmandibular first molar on the non working sideand the articulator was closed, the incisal pinwas directed laterally and upward. Theautopolymerizing resin cone was built betweenthe incisal pin and the table. The sameprocedure was repeated for the other condyle.This created angle of hinge rotation to ensurethe average disclusion during lateral movement.

12. The three resin cones were connected withautopolymerizing resin so as to make wallsbetween cones. The top of the wall followed animaginary line that connected the tips of the

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resin cones. After the walls were created, atriangular space remained between the centricrelation contact of the incisal pin and the top ofthe wall. This space was filled withautopolymerizing resin. The articulator wasmoved through all border and eccentricmovements [Fig 5].

13. The tip of the incisal table was easily moldedbecause the centric contact and the three conetips marked the beginning and end points foreccentric articulator movements. The tip of theincisal pin has a hemispherical shape with adiameter of 8mm and the total articulatormovement is limited to 3mm, restricted by theresin cone placement. This resulted in a moldedsurface that is one continuous concavity fromthe area where the incisal pin contacted incentric relation through all eccentricmovements. This custom incisal table, called anincisal table with disclusion incorporatedpredetermined degrees of disclusion.

14. Before doing the tooth preparation the verticaldimension of occlusion was recorded.

15. Temporary fixed partial dentures of maxillaryand mandibular arch were fabricated using theputty index of the diagnostic wax-up.

16. The teeth were prepared in the maxillary archfirst and the temporary FDP was cementedfollowing which the lower teeth were preparedand temporary FDP cemented with ZnO noneugenol cement [Fig 6, 7]. Since the teeth wereseverely affected by the caries all the activecarious lesions were removed while teeth wereprepared but the teeth were discolored havingarrested caries in few teeth. Maxillary andmandibular interim removable dentalprosthesis were fabricated for the missingposterior teeth [Fig 7].

17. A final full arch impression for maxillary/mandibular teeth was made using heavy-bodyand light-body impression material and pouredin die stone. This assembly was mounted onwhip-mix articulator using the face-bow, Luciajig and centric record at the predeterminedvertical dimension.

18. Wax patterns were fabricated (keeping in viewthat a removable cast partial denture will befabricated at a later stage). The maxillaryworking cast was made with removable dies. Afacebow transfer was used to transfer themaxillary working cast and a centric relationrecord used to articulate the mandibularworking cast. The incisal table withoutdisclusion was initially used in the articulator.The anterior dies from maxillary canine tocanine were removed and the posterior occlusalwax-up was completed. The incisal table waschanged on the articulator to the incisal tablewith disclusion prepared earlier. The anteriorsegment was repositioned for waxing of thelingual surfaces of the maxillary anterior teeth.Melted wax was added to the lingual surfacesand the articulator was closed and movedthrough all border movements. The wax wascontoured by the incisal edges of the mandibularteeth so that they contacted evenly. Thisprocedure established the angle of hingerotation and developed the anterior guidancein harmony with the condylar path. Since theanterior guidance programmed in this manneris steeper than the condylar path and the molarcuspal inclinations, the posterior restorationsprovided a predetermined disclusion duringeccentric movement.

19. The maxillary and the mandibular models withthe wax patterns in place were surveyed usinga micro-surveyor. Occlusal rests and guidingplanes were carved out in the wax pattern andthe wax patterns were cast [Fig 8].

20. The metal copings were tried in [Fig 9]. Definiterestorations with PFM crowns were fabricatedplacing the incisal table with disclusion.Porcelain build up was done in a similar fashionto the wax pattern fabrication taking the guideof incisal table with disclusion. Before doing thefinal glaze of the crowns the restorations wereplaced on the maxillary and mandibular mastercast and surveyed for the fabrication of castremovable partial dentures [Fig 10]. Afterperforming the modifications required on thebisque baked crowns the models were

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articulated back with the restorations onto thewhip mix articulator.

21. Permanent cementation was done with GICtype I luting cement.

22. Maxillary and mandibular impressions weremade with heavy body and light bodyimpression material and master cast wereobtained. Designing of the master cast was donefor the removable partial denture, wax patternwas fabricated [Fig 11] invested and casted.

23. A special tray was fabricated on the mandibularframework. Border moulding and finalimpression of the distal extension edentulousspace was made with ZnO eugenol impressionpaste and the master cast was altered (AlteredCast Technique) [Fig 12]

24. Jaw relations were taken with the removabledentures intraorally, teeth setting were doneand trial was taken. The dentures wereacrylised finished and inserted [Fig 13].

25. Follow up was done once in 15 days for a periodof 3 months and the patient’s post operativecondition was found to be satisfactory [Fig 14,15].

Discussion

There are alternative restorative procedures forthe rehabilitation of mutilated teeth.3-9 Each methodhas limitation and it should be critically reviewedprior to deciding a treatment plan. The treatmentfor patients with mutilated teeth is related to manyfactors including the age of the patients, the socio-economic status, the type and severity of thedisorder. Treatment plan should have common goal-functional, aesthetic and longevity of restoration.Restoring full mouth with twin stage procedure hasits own advantage as the basic concept involved inthe new procedure reproduce the occlusalmorphology of the posterior teeth without theanterior segment and produce the cusp anglecoincidence with standard values of effective cuspangle. Secondly, reproduce anterior morphology withthe anterior segment and provide anterior guidancewhich produces a standard amount of disocclusion.The anterior guidance and the patient’s condylar

inclination might or might not be in harmony. Theamount of disocclusion changes in patient’s mouth,as this technique followed a fixed value of 400 ofcondylar inclination. So the amount of disocclusionvaries from the predetermined value.

Implants have replaced the removable partialdentures in the recent times [10]. But in somecompromised situations it is difficult to placeimplants and hence removable partial dentures arethe alternative to restore the function.

Conclusion

This case report demonstrates full mouthrehabilitation of a female patient who had beenaffected by severe form of rampant caries using theHobo and Takayama twin-stage procedure. The finalprosthesis with this twin stage technique ensured arestoration with a predictable posterior disclusionand anterior guidance in harmony with the condylarpath.

References

1. Hobo S, Takayama H. Effect of canine guidance on theworking condylar path. Int J Prosthodont 1989;2:73-79.

2. Hobo S. Twin-tables technique for occlusal rehabilitation:Part I & Part II: Mechanism of anterior guidance. J ProsthetDent 1991;299-303, 471-477.

3. Soares CJ, Fonseca RB, Martins LR, Giannini M. Estheticrehabilitation of anterior teeth affected by enamelhypoplasia: a case report. J Esthet Restor Dent 2001;14:340-348.

4. Crabb JJ. The restoration of hypoplastic anterior teeth usingan acid-etched technique. J Dent 1975;3:121-124.

5. Peumans M, Van Meerbeek B, Lambrechts P, Vanharle G.Porcelain veneers: a review of the literature. J Dent2000;28:163-177.

6. Zalkind M, Hochman N. Laminate veneer provisionalrestorations: a clinical report. J Prosthet Dent 1997;77:109-110.

7. Karlsson S, Landahl I, Stegersjo G, Milleding P. A clinicalevaluation of ceramic laminate veneers. Int J Prosthodont1992;5:447-451.

8. Meijering AC, Creughers NH, Roeters FJ, Mulder J.Survival of three types of veneer restorations in a clinicaltrial: 2.5-year interim evaluation. J Dent 1998;26:563-568.

9. Rucker LM, Richter W, MacEntee M, Richardson A.Porcelain and resin veneers clinically evaluated: 2 yearresults. J Am Dent Assoc1990;121:594-596.

10. Survival and complication rates of combined tooth-implant-supported fixed and removable partial dentures. J ProsthetDent 2008;100:237.

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Fig 3: Facebow transfer and centric Record

Fig 6: Tooth Preparation and Gingival Retraction

Fig 1: Pre-operative Intraoral

Fig 2: Pre and Post op OPG

Fig 4: Diagnostic Wax-up

Fig 5: Fabrication of custom incisal guide table

Fig 7: Provisional restorations and RPD inserted

Fig 8: Wax patterns With Occlusal rests carved

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Fig 9: Metal coping Try-in

Fig 10: Surveying of Bisque Baked crowns

Fig 11: Designing and wax pattern

Fig 12: Altered Cast Technique

Fig 13: Insertion of PFM crowns and Cast RPDs

Fig 14: Post-operative

Fig 15: Post op Extraoral

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