Oral Rehabilitation Avoiding Orthognatic Surgery

A clinical case written by Margarida Henrique and Fernando Autrán

A full oral rehabilitation implies a process where the knowledge of various specialties is involved, as well as the capacity to integrate them, both in the diagnostic process as in the subsequent treatment. The analysis of all the patient data must be carried out in a very detailed way, covering biological, structural, functional, aesthetic and psychosocial aspects (1). For that, an exhaustive initial interview with the patient and documentation of the clinical case is needed (photos, videos, dental impressions, occlusal registration, x-rays,…), in order to have access to all of the information in the moment of the case study and analysis. With all this data gathered, and the model mounted in an articulator, a diagnostic hypothesis can be done, and therefore, a treatment plan.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.1
This patient arrived to the clinic with the purpose of rehabilitating his entire mouth. The patient reported that he had already consulted several dentists with the same request, and all the treatment plans involved undergoing an orthodontic treatment and orthognathic surgery, prior to the oral rehabilitation, in order to treat his Angle Class III occlusal intermaxillary relationship.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.2
Intra-oral initial frontal and lateral photographs. In these photos we can appreciate the anterior cross-bite.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.3
Intra-oral initial occlusal photographs. In these photos we can notice that the upper arch is not aligned, and it would be ideal to make an expansion and protrusion in the anterior sector for the future articulation.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.4
When analyzing all the data of the patient, it was noticed in the planning that he needed an oral rehabilitation. So it was decided to deprogram the patient in Centric Relation (CR) in order to analyze the intermaxillary relationship. These photos correspond to that position. Given the edge to edge position achieved, and in order to avoid an orthognatic surgery, it was decided to manage the clinical case with an orthodontic treatment increasing the posterior occlusal vertical dimension (OVD) (in order to be able to decross the anterior sector), prior to the full mouth rehabilitation.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.5
After one year of orthodontic treatment, without any ortognathic surgery, note that by increasing OVD in the posterior teeth, it was possible to decross the anterior sector by expanding and protruding the anterior upper arch.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.6
After one year of orthodontic treatment (occlusal view).

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.7
After the orthodontic treatment, another complete study of the actual situation of the patient was carried out with the documentation of the case with photos and new dental impressions.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.8
Another deprogramation in CR was done here, using a Lucia Jig as a deprogrammer device. Picture 1 corresponds to the maximum intercuspation (MIC) and CR positions (CR is the more posterior than MIC). Picture 2 corresponds to the marking of the CR with a single anterior centered point, which is normally positioned in the middle of the central inferior incisors. Picture 3 corresponds to the gothic arch (extrusive guidances). And picture 4 corresponds to the confirmation of the CR asking the patient to move his mandible everywhere he can (this confirms that all the movements begin in this point, so it is the more repeatable and reliable position to rehabilitate the patient).

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.9
All the documentation was studied once again, in order to plan the final ideal prosthetic situation. The Rest Position indicated the need to increase the length of the central incisors.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.10
A full analysis of the facial planes was done in order to transfer the planes into the intra-oral frame.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.11
A DSD analysis was done in order to plan the approximate position of the future restorations, and with this information, a full mouth wax-up was made (except in 1st and 4th quadrants because of the need of subtraction of teeth 14, 15 and 16).

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.12
A mock-up was made based on the wax-up.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.13
Intra-oral view of the mock up (right side was not waxed because of the need of subtraction of the superior pre-molars and molar). In order to improve the edge to edge anterior occlusal situation and since the rest position revealed the need of increasing the length of the upper central incisors, it was decided to increase the OVD. This way, since the mandible works like a hinge, if we increased the OVD, we would increase the overjet, which would greatly benefit this case in terms of prosthetic space.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.14
The OVD was increased in 2.1mm in the pin of the articulator, to make this wax-up. 4 weeks functional test of the provisional restorations, doing subtraction of the 1st quadrant.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.15
After 4 weeks of functional test of the provisional restorations, the posterior sectors were prepared and rehabilitated. The preparations were all guided by the mock up. To achieve esthetics and function, premolars were prepared as Veneerlays. In order to be as minimally invasive as possible, and since the patient didn’t show the molars in full smile, molar restorations were designed as tabletops on both sides and arches.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.16
Lithium disilicate was the material of choice for these restorations, since we needed a highly aesthetic outcome and minimally invasive preparations. The restorations were prepared for adhesion following the protocol of lithium disilicate restorations (application of Hydrofluoric acid 5% for 20 sec, rinsing with water, application of orthophosphoric acid 35% rubbing with a microbrush for 1 min, rinsing with water, drying of the restoration and applying Ceramic Primer (Clearfil™ Ceramic Primer, Kuraray).

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.17
After the rehabilitation of the posterior sectors in the desired OVD, the anterior sectors were prepared guided by the mock up.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.18
Removal of the mock up after the guided preparation.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.19
After preparation, the retraction of the soft tissues was made by using 2 chords. The first one used was the size 000 Ultrapack® (Ultradent, Utah, USA) (to achieve the vertical retraction) and the second one was size 1 Ultrapack® (Ultradent, Utah, USA) (to achieve the horizontal retraction), soaked in Viscostat Clear (Ultradent®, Utah, USA)(25% Aluminum Chloride) to promote hemostasis of the gingival margin.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.20
Polarized photographs were made with Vita 3D Master and Natural Die shade guides, to determine the color that was going to be used, for better communication with the lab technician.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.21
Anterior lithium disilicate monolithic restorations ready for adhesion. The restorations were prepared for adhesion following the protocol of lithium disilicate restorations (application of Hydrofluoric acid 5% for 20 sec, rinsing with water, application of orthophosphoric acid 35% rotating with a microbrush for 1 min, rinsing with water, drying of the restoration and application of a Clearfil™ Ceramic Primer (Kuraray) DT Victor Fabuel.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.22
The adhesion protocol was carried out under rubber dam isolation, in order to control the contamination of the adhesive surface. The preparations were within enamel, so the protocol used was sandblasting followed by application of orthophosphoric acid 35% for 30 sec, rinsing with water for 30 sec, drying with air, application of the adhesive system (Clearfil™ SE Bond Kuraray) and adhesion of the lithium disilicate restorations with Allcem Veneer APS A1 Cement (FGM Dental, Joinville, Brasil).

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.23
Anterior upper restorations bonded.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.24
Isolation and conditioning for the adhesion of the anterior lower restorations using the same adhesive protocol.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.25
Anterior lower restorations bonded.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.26
Immediate result after cementation of the anterior restorations.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.27
Immediate result after cementation of the anterior restorations.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.28
2 months recall, we can notice the healing of the gingival tissues.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.29
2 months recall.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.30
Initial and final situation.

styleitaliano style italiano Oral Rehabilitation Avoiding Orthognatic Surgery full mouth rehabilitation OVD

Fig.31
Initial and final situation.

Conclusions

In the most difficult situations of full mouth rehabilitation, planning is the key to have the best possible outcome. Planning must include photos, videos, impressions, x-rays and occlusal registration of the more reliable and repeatable position for the patient (CR). Every small detail matters to solve the puzzle to restore aesthetic and function of the patient in the new occlusal scheme.

Bibliography

    1. Soler D. Diagnóstico oclusal/funcional. El comienzo de la rehabilitación oral. Rev Int Prot Estomatol. 2020;8(6):468-475.
    2. Lucia VO. A technique for recording centric relation. J Prosthet Dent 1964; 14: 492-505.
    3. Cortellini D, Canale A. Bonding lithium disilicate ceramic to feather-edge tooth preparations: a minimally invasive treatment concept. J Adhes Dent 2012; 14: 7-10.
    4. Koyano K, Tsukiyama Y, Kuwatsuru R. Rehabilitation of occlusion – science or art? J Oral Rehabil 2012; 39: 513-21.
    5. Spear FM. Approaches to vertical dimension. Advanced Esthetics & Inter- disciplinary Dentistry 2006; 2: 2-12.
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