A successful transitional and final rehabilitation for a patient with obstructive sleep apnea

A clinical case by our Community member Dr. Sandra Hulac

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

This patient presented with with a worn dentition. Attrition compounded by moderate erosion and abrasion was present on most teeth.
The most likely reason for the attrition was a growth spurt of the mandible post orthodontic treatment, which is common in males, causing and edge to edge situation.
The patient’s medical history listed obstructive sleep apnea (OSA) which had initially been treated with a mandibular advancement device which failed to resolve the issue. With CPAP treatment he managed to reduce his AHI down to 2. A history of nighttime bruxism, GERD, and high blood pressure was also noted.
These pathologies often occurring alongside OSA, all improved after regular CPAP use.
The patient’s treatment plan involved creating restorative space to lengthen the worn upper anteriors by opening the occlusal vertical dimension (OVD) with an additive treatment to the entire upper arch.
As opening the OVD distalizes the mandible, it has a potential negative effect on Sleep Apnea. In order to enable “road testing” the opened vertical, its effect on the patient’s AHI readings and also to visualize the aesthetic changes, it was decided to transition this patient with injectable composite restorations.

styleitaliano style italiano worn smile

Fig.1
Pre-treatment full smile.

styleitaliano style italiano intraoral picture in maximum intercuspation

Fig.2
Pre-treatment maximum intercuspal position.

styleitaliano style italiano occlusal preoperative pictures

Fig.3
Pre-treatment occlusal situation, showing attrition and moderate erosion.

styleitaliano style italiano lip in repose completely hiding the upper teeth

Fig.4
Pre-treatment lip in repose image highlights insufficient incisal reveal.

styleitaliano style italiano labial smile design

Fig.5
Smile design included significant lengthening of anteriors.

styleitaliano style italiano smile design evaluation of additive space

Fig.6
Smile design also incorporated added volume to the facial aspect of the upper anteriors.

styleitaliano style italiano occlusal view of labial volume increase

Fig.7
Occlusal smile design.

styleitaliano style italiano bite registration

Fig.8
A centric bite registration using shims was deemed acceptable in this case as treatment would be initially carried out in composite, allowing for adjustment and adaptation. For porcelain cases the Author prefers the use of a Kois Deprogrammer.

styleitaliano style italiano printed models for matrix injection technique

Fig.9
Printed models for alternating matrix injection technique.

styleitaliano style italiano checking injection hole patency in silicone index

Fig.10
It is advisable to check patency of matrix injection holes for debris before commencing the procedure.

styleitaliano style italiano first step of alternate injection technique

Fig.11
Treatment in progress after use of first matrix and finished treatment. This technique is extremely time efficient and usually an arch can be restored in less than 2 hours.

styleitaliano style italiano fully injected upper arch

Fig.12
Using printed models, will necessitate more polishing to remove print lines. For this reason the Author prefers a traditional wax up for the technique.

styleitaliano style italiano bite check after composite injection

Fig.13
Checking of functional envelope is essential to ensure no chipping of restorations will occur.

styleitaliano style italiano smile with transitional composite injected restorations

Fig.14
Smile with transitional composite restorations. The patient wore these uneventful for one year.

styleitaliano style italiano intraoral view of injected composite restorations

Fig.15
MIP with transitional composite restorations. The patient0s AHI did not increase, in fact, it dropped to 1 and has been stable.

styleitaliano style italiano second smile design to improve transitional restorations

Fig.16
New Smile Design before transfer of case into final porcelain restorations, addressing the shortcomings of the previous aesthetic result, namely a flared appearance of the anterior teeth and prominence of tooth 13. Axial inclinations and zenith positions need to be corrected particularly on centrals.

styleitaliano style italiano substrate color matching before fabrication of ceramic restorations

Fig.17
Conservative tooth preparations, consisting mostly of removal of previous composite restorations and creation of preparation margins.

styleitaliano style italiano substrate color matching before fabrication of ceramic restorations

Fig.18
Seating of the final restorations.

styleitaliano style italiano smile with ceramic restorations

Fig.19
Postoperative smile.

styleitaliano style italiano display of upper ceramic restorations with lip in repose

Fig.20
Postoperative lip in repose.

styleitaliano style italiano stages of increased vertical dimension restoration

Fig.21
Smile before, with transitional restorations, and with final restorations.

styleitaliano style italiano porcelain restorations

Fig.22
Retracted view of the porcelain restorations.

styleitaliano style italiano before and after treatment with ceramic restorations to increase vertical dimension

Fig.23
Smile, before and after.

Conclusions

Transitioning complex cases with injectable composite is a useful tool to ensure occlusal changes do not negatively affect patients, and to non-invasively ensure function and aesthetics of the future permanent restorations. Studies on the longevity of injectable composite restorations are lacking but, anecdotal evidence suggest they can last for 3-5 years, which is in line with other transitional restorative methods.

Bibliography

1. Heij DG, Opdebeek H, Kokich V, Belser U Facial Development, continuous tooth eruption, and mesial drift as compromising factors for implant placement, Int J Oral Maxillofac Implants.2006;2196):867-878.
2. Rowse JS The Bruxism Triad, Inside Dentistry, May 2010.
3. Kois JC, Philips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent. 1997;18(12):1169-1177.
4. Nikolopoulou M, Naeje M, Arab G et al The effect of rising the bite without mandibular protrusion on obstructive sleep apnea, J Oral Rehabil. 2011 Sep; 38(9): 643-647.
5. Coachman C, De Arbeola L, Mahn E. An Improved direct injection technique with flowable composites. A digital workflow case report. Oper Dent.,2020;45(3):235-242.
6. Terry DA. Restoring with flowables. Quintessence Publishing, 2017:242.
7. Bakeman E, Kois J The Myth of Anterior Guidance. J Cos Dent. Fall 2008, Vol 28 (3)
8. Gestakovski D The injectable composite resin technique: minimally invasive reconstruction of esthetics and function. Clinical case report with 2-year follow-up. Quintessence Int. 2019;50(9):712-719.

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