Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

A Multidisciplinary Rehabilitation Case by Andrew Chandrapal, BDS, MFGDP, DPDS, MClinDent(Pros)

View Comments (2) More by this author (1)


Rehabilitation of worn and failing dentition can hold many issues that complicate the process. This case presents a number of clinical issues such as tooth surface loss (TSL) through erosion, abrasion, posterior super-eruption, lack of posterior support, hypodontia and periodontal attachment loss. Within this myriad of complications, the clinician is expected to gather data, plan, execute and maintain such dentitions.

This case highlights some of the techniques employed to achieve a predictable outcome, despite complications.

The patient, who I will refer to as Mr. V, had been a routine patient in private practice for many years. The patient was fully aware of the level of tooth surface loss and occlusal breakdown, although he remained symptom-free and functional for a number of years. Following the breakdown of a posterior tooth, the patient decided to investigate the possibility of improving functionality and aesthetics while retaining many of the individual features of his dentition so the aesthetic change was not too extreme.



The initial visits were focused on data collection and establishing a risk assessment and profile for this patient. This exercise proved to be invaluable given the scale of treatment being proposed to get the patient to a predictable desired outcome.

The patient was provided with updated medical and dental histories that pertained to levels of risk allowing the clinician to form a prognostic value to key areas such as periodontal, dento-facial, functional and bio-mechanical prognoses.



Clinical observations
  • Moderately restored dentition
  • Moderate risk of periodontal breakdown
  • Missing #10
  • Chronic apical infection to #29
  • Severe gum recession to upper posterior teeth—with marked bone loss to upper molars
  • Low sinus levels bilaterally
  • Recently extracted upper right molar due to deep caries
  • Stable diastema of 4-5mm between #8, #9
  • Front teeth progressively chipping and wearing down due to edge-to-edge centric occlusal position
  • High biomechanical risk, observed given levels of chemical erosion and abrasion
  • Loss of vertical dimension leading to slight over-closure
  • Passive super-eruption of upper posterior teeth
  • No current caries
The aim of treatment
  • Stabilize active disease processes
  • Augment upper back jaw areas to accept dental implants
  • Provide implants to the lower and upper arches
  • Gain a stable position for bite and jaw position
  • Build up the dentition to meet this position using a combination of ceramic, gold and composite in the most indicated areas of the mouth
  • Maintain the status for long-term predictability
Treatment planning
Upon treatment review, Mr. V felt that he wanted to have all-natural teeth of the same material and therefore chose ceramic restorations over natural teeth. Composite resin was offered as a treatment option for the immediate anterior teeth although without greater preparation, shade control may have proved more challenging.

The patient had two implants placed and restored on the lower right six years previously and therefore had experience with implant surgery. He was keen to rehabilitate the dentition using fixed restorations.

Full radiographic assessments were carried out as well as a CT scan in order to place the positioning of implants and abutments. The preoperative models were mounted into a semi-adjustable articulator (Denar Mk II). The pin was then opened by 4mm to create 2mm space to the most distal molar. At this time it was found that tooth #3 and #4 remained super-erupted, as well as showing high levels of bone loss. As such, a functional wax-up was created using the same CO position that would then be subject to deprogramming once in the provisional stage.

The patient had consultations for periodontal and endodontics risk factors, and had the necessary processes employed—such as vigorous scaling and prophylaxis—as well as endodontic screening. The patient opted to not have any form of sinus augmentation, so the decision was made to electively remove #4 and #3 in order to reduce the periodontal risk and subsequently place implants in this region. He also elected not to have any form of orthodontics.

Since a space remained to #2, a decision was made to form a distal cantilever from the implant with a rest seat preparation on #1, thereby acting as a stress breaker in the event of high occlusal loads. This and the fact that the opposing arch consisted of implant-retained restorations meant the clinician maintained full control of the occlusal forces when designing the occlusion.

The CT scan was planned and implants were inserted into the sites according to the restoratively led position. Minimal grafting was required as a result of the planning as well as no sinus augmentation, according to the wishes of the patient.

Once the implants had integrated to a suitable level, the arches were prepared according to the functional wax-up. Both arches were prepared simultaneously in an effort to achieve occlusal stability with the new intended design. Preparation guides and putty stents were used to ensure minimal preparations were carried out. The patient had chosen to retain a degree of his diastema. This ensured preparation to anterior teeth remained at a minimum. Tooth #11 required moderate preparation in an effort to convert appearance to a lateral.

Rather than a heavy preparation, a clever use of line angle and primary anatomy of the ceramic restoration were to be used to mimic a lateral as much as possible.

The teeth were provisonalised using luxatemp (DMG) and a provisional adhesive protocol. The preparations were minimal and so no desensitiser was required. The provisional restorations were then equlibrated to ensure simultaneous bilateral posterior contacts alongside a suitable anteriorly guided pathway of closure. The patient was then able to “road test” his provisional restorations in terms of phonetics, mastication and aesthetics for four weeks before confirming a stable CR position and approved aesthetic outcome (Fig. 3).

Custom implant abutments were fabricated and try in procedures were carried out on the bridge units to ensure a passive and positive fit was achieved. These were then recorded against the CO/CR position dictated by the provisionals. Definitive implant-based restorations were then seated using new screws into abutments, allowing for hydrostatic reversal and cement-retained restorations. A decision to use cement-retained restorations was made to allow any occlusal disharmony to show itself by debonding the implant-retained restoration. They were initially seated using tempbond (Kerr).

Ceramics were composed in e.max press (Ivoclar Vivadent) with a ceramic stack apart from the most distal ceramic units that were constructed using monolithic methods. Once checked for marginal seat and intergrity, they were delivered using consepsis cleaner. I used 2 percent chorohexidine—Ultradent, particle abrasion (Prepstart—Danville), of 27 micron alumina at 4-bar of pressure and Rely X Unicem 2 (3M ESPE) for the posterior teeth and a conventional adhesive protocol for the anterior teeth using Variolink II (Ivoclar Vivadent).



Treatment Outcome
The functional element of this proved to be demanding in terms of managing super- eruption, as well as determining what was essentially an adapted CR position, as the patient perceived no functional problems. The TMJ was in good condition. Obtaining an optimal anatomical curve remained challenging as well as placing implants into resorbed bone that had remained redundant for many years.

The functional-aesthetic outcome was successful as the occlusal contacts occurred as planned with a crisp sounding audible CO/CR position as well as recording the contacts as desired. The patient was also very pleased with the aesthetic outcome, even though it had not been his driving force from the outset (Fig. 4).

Oral hygiene instruction was given to the patient so he could manage all areas and regular recalls were set.

Final note
This challenging case proved a success by phasing each part of treatment as well as meticulous treatment planning and attention to detail. The author would like to thank Simon Newbold at Creative Dental, London for his aesthetic and functional ceramic artistry.





Dr. Andrew Chandrapal qualified from Birmingham University in the United Kingdom, and specializes in dental cosmetics, bonding rehabilitation and management of wear. Andrew works with eminent colleagues in various disciplines of dentistry to create smiles that not only look outstanding but also function efficiently and comprehensively. He has gained knowledge in all aspects of restorative disciplines and continues to update his knowledge with international studies on a regular basis.

His interests and skills have led to a focus on prosthodontic interfaces and composite bonding. He is Chair of Communications on the Board of Directors for the British Academy of Cosmetic Dentistry, and is a long-standing member of the AACD, the International Team for Implantology, the Association of Dental Implantology and the British Society of Occlusal Studies. He is also an educator and key opinion leader to the industry in the disciplines of aesthetic dentistry, treatment planning and composite resin artistry. The author can be contacted at andrewchandrapal@mac.com.


Dentaltown Magazine
September 2025
Dentaltown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie Perks
Townie® Poll
Who or what do you turn to for most financial advice regarding your practice?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds Dental News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Dentaltown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450