Indian Journal of Dental ResearchIndian Journal of Dental ResearchIndian Journal of Dental Research
HOME | ABOUT US | EDITORIAL BOARD | AHEAD OF PRINT | CURRENT ISSUE | ARCHIVES | INSTRUCTIONS | SUBSCRIBE | ADVERTISE | CONTACT
Indian Journal of Dental Research   Login   |  Users online: 1935

Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size         

 


 
Table of Contents   
CASE REPORT  
Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 505-508
An alternative adhesive based technique of raising the occlusal vertical dimension


1 Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, Mamc Campus, New Delhi, India
2 Department of Prosthodontics, Centre for Dental Education and Research, New Delhi, India
3 Department of Prosthodontics, Private Practitioner, New Delhi, India

Click here for correspondence address and email

Date of Submission03-Oct-2013
Date of Decision28-Jun-2014
Date of Acceptance14-Jul-2014
Date of Web Publication10-Oct-2014
 

   Abstract 

Purpose: Decimated dentitions may require raising the vertical dimension in some conditions while performing a full mouth rehabilitation treatment. Increase in a vertical dimension should be diagnosed by reversible methods prior to performing any irreversible methods for a minimum time period. Reversible methods like splints and overlay dentures are often used for this purpose. These methods however cannot be used in some conditions like in cases of brittle teeth.
Method: An alternative technique based on adhesive technology has been described which is reversible and yet minimally traumatic to teeth.
Conclusions: The technique has two basic aims. The first is to accurately implement the occlusal scheme as planned in the diagnostic wax-up in the reversible method of altering the vertical dimension. The second aim is to increase the vertical dimension with minimal damage to the teeth.

Keywords: Adhesive, increase, vertical

How to cite this article:
Nanda A, Jain V, Manak K, Verma M. An alternative adhesive based technique of raising the occlusal vertical dimension. Indian J Dent Res 2014;25:505-8

How to cite this URL:
Nanda A, Jain V, Manak K, Verma M. An alternative adhesive based technique of raising the occlusal vertical dimension. Indian J Dent Res [serial online] 2014 [cited 2020 Feb 20];25:505-8. Available from: http://www.ijdr.in/text.asp?2014/25/4/505/142549
Rehabilitation of patients with mutilated dentition can often confront a restorative dentist with a situation that demands raising of occlusal vertical dimension. [1] Hypothetical increase in occlusal vertical dimension (based on evaluation of mounted casts in centric relation) is never performed as a single definitive procedure. It is done in three different stages. Literature suggests diagnosis and observation of raised vertical dimension for 4-6 weeks prior to any irreversible tooth reduction procedure. [2] The various reversible interventional modalities that have been suggested prior to definitive restorations are - splints, Dahl's modality, orthodontic appliance and overlay removable partial denture. [3] Use of fixed provisional is the 2 nd stage of assessing raised vertical dimension. This is however done only after the 1 st stage is suggestive of satisfactory results. This is also an irreversible procedure as provisional can be given only after teeth have been prepared. The 3 rd stage involves using definitive restorations, given after satisfactory performance of fixed provisional.

There are however certain tooth abnormalities which impose restrictions that preclude the use of splints and overlay dentures used in preliminary diagnostic procedure to raise the vertical dimension. One such condition is that of brittle teeth disease - dentinogenesis imperfecta. Dentinogenesis imperfecta is a hereditary condition, which is associated with a defective scalloping at the dentinoenamel junction. This lead to easy enamel fracture from the defective dentin, followed by severe and rapid attrition of dentin. [4],[5]

The article describes an alternative technique of raising the occlusal vertical dimension, prior to any irreversible tooth reduction is done in a patient with dentinogenesis imperfecta, confirmed by history and radiograph [Figure 1], with Category 1 wear with loss of occlusal vertical dimension. The technique has two basic aims. The first is to accurately implement the occlusal scheme as planned in the diagnostic wax-up in the reversible method of altering the vertical dimension. The second aim is to increase the vertical dimension with minimal damage to the teeth technique:
Figure 1: Preoperative radiograph

Click here to view


  1. After preliminary diagnostic impression in irreversible hydrocolloid (Tropicalgin, Zhermack, Italy) two pair of casts both for maxillary and mandibular arch [Figure 2], [Figure 3], [Figure 4] are obtained in dental stone (Kalabhai, Mumbai, India). Face bow record (authors chose Whip Mix Quickmount facebow, Louisville, USA) and freeways space is assessed (authors chose Niswonger's method). Hypothetical increase in a vertical dimension is determined on articulator (Whip Mix 8500 series, Louisville, USA) and diagnostic wax-up is done, using wax (inlay wax, Crown and Bridge waxes, Bego, USA) [Figure 5]. Authors followed the Hobo and Takayama's twin table concept. [6],[7] According to the established technique, the diagnostic casts are sectioned so that the maxillary anterior section is removed, and posterior cuspal morphology is formed at 25΀ cuspal angle in order to attain balanced occlusion in protrusive and lateral movements. In the 2 nd stage of the wax up the anterior sextent is replaced and anterior teeth morphology is formed to bring about anterior teeth contact during protrusion with posterior disclusion and canine guidance in lateral movements. The waxed up cast is duplicated in silicone duplicating material (Wirosil duplicating silicone, Bego, USA) and a set of casts duplicating the wax up in dental stone are obtained
  2. Fabrication of clear template [Figure 6] is then done on the duplicated cast (of the wax-up). Bioplast insulator is painted on the duplicated casts, and clear bioplast material is adapted on the duplicated cast using Biostar V machine using 6 bar pressure for 30 s. The thickness of the sheet should be about 1 mm, the sheet should be clear to transmit light and soft in order to avoid any abrasion in case of any tooth contact. The soft splint thus obtained should be trimmed to cover 3 mm of tissue beyond free gingival margin on the buccal side of both maxillary and mandibular cast and 8 mm from free gingival margin on the lingual side of mandibular cast and 12 mm from free gingival margin on the palatal side of the maxillary cast. The extensions should have intimate adaptation with the tissues and hence improve retention of the soft splint in patients mouth. The template is then removed and used to build up composite on the affected teeth in the patients mouth
  3. For the procedure of composite build up, after adequate isolation, self-etching adhesive (AdheSe One F, Ivoclar Vivadent AG, Liechtenstein) is applied on the teeth and cured with 500 mW/cm 2 for 10 s. Single-step adhesive is preferred to minimize the risk of contamination associated with multiple steps and thus minimizing the risk of failure of bonding. Furthermore, in cases where enamel is lost like in dentinogenesis imperfecta cases, etching is not useful. The presence of Fluoride in the adhesive is beneficial in providing protection to the teeth from caries susceptibility
  4. Following this initial 1 mm of dentin shade of composite (Ivoclar Vivadent AG, Liechtenstein) is applied with an instrument and cured for each tooth. To create adequate proximal  contact, matrix band is used. The next 1 mm of composite build up is again done but prior to curing, Vaseline  was applied to the corresponding clear template, and the template was placed over the composite build up. The composite was then polymerized through the clear template. In this manner, the composite build up was accomplished according to the diagnostic wax up planned. The composite build up was then polished using silicone polishers (OPtra Pol, Ivoclar Vivadent AG, Liechtenstein) [Figure 7], [Figure 8], [Figure 9]
  5. For the fabrication of missing teeth, an acrylic partial denture in heat polymerized resin is fabricated. In the partial denture, the teeth to be replaced are fabricated according to the wax up. A silicone putty index of the diagnostic wax up is made (Reprosil, Dentsply, USA). Temperon (GC Europe) was added in the putty index in the dough stage in the region corresponding to missing teeth wax up and the index is seated back on the second set of diagnostic cast that is obtained in 1 st step. In this manner, the anatomical pattern of missing teeth as planned in the wax up is attained. The artificial tooth thus formed is then seated back on the diagnostic cast and the flange extensions are made in modeling wax (Ruby Dental Pvt. Ltd., Delhi). The cast with wax up is invested in a flask and cured with a heat polymerized resin (DPI Heat Cure, Dental Products India Ltd., Mumbai).
Figure 2: Preoperative frontal view

Click here to view
Figure 3: Preoperative view maxillary arch

Click here to view
Figure 4: Preoperative view mandibular arch

Click here to view
Figure 5: Diagnostic wax up according to Hobo and Takayama technique

Click here to view
Figure 6: Clear template

Click here to view
Figure 7: Final composite build up mandibular arch

Click here to view
Figure 8: Final composite build up maxillary arch

Click here to view
Figure 9: Final composite build up frontal view

Click here to view


The patient was followed for a period of 7 weeks at the raised vertical dimension. Once the patient adjusted to the change, the authors proceeded with definitive rehabilitation using full coverage porcelain fused to metal restorations.


   Discussion Top


The main aim in managing such mutilated dentition with brittle teeth (like Dentinogenesis imperfecta) is to reduce the wear of teeth further. Though eventually full coverage restorations may be planned for such patients, yet all that remains should be preferred rather than the meticulous replacement of that what has been lost. Using hard splints or overlays can further wear the enamel and dentin and thus making it less supportive for any type of restoration if indicated at a later date. Furthermore, though soft splints are beneficial in such cases to prevent wear, yet their main drawback is a lack of maintenance of the vertical dimension of occlusion due to the property of compressibility in their structure.

An alternative is to use material which is the kind to remaining natural teeth, requires no or minimal preparation of remaining natural teeth and is yet rigid enough to maintain vertical dimension. The ideal material is adhesive based composites, and the technique is minimally invasive for the same.

The technique also allows the anatomic pattern of the composite build up to precisely mimic the diagnostic wax up, and hence the occlusal scheme planned. This also permits control on the amount of increase of vertical dimension. Due to this there is minimum chair side time required to create the occlusal harmony that is desired.

The other benefit of implementing this technique is gaining patient acceptance, which is a limiting factor while using splints or any overlay prosthesis. The composite build up is more esthetic. Moreover, the patient compliance is not a limiting factor as it cannot be removed, unlike with a removable prosthesis used to raise the vertical dimension (where we depend on patient compliance to wear the appliance). Also, the patients perform all functional activity like chewing and swallowing at raised vertical enabling a better assessment of raised vertical which will be provided in the definitive prosthesis.

A fourth advantage of the technique is the formation of anatomical contours, which act as a guide in the reduction of teeth for a full coverage/partial coverage restoration, and this provides a better adherence to the biomechanical principles of tooth preparation.

The main  shortcoming of the procedure is technique sensitivity. Also, if there are multiple missing teeth, it is not possible to replace those teeth by this technique. Hence the authors have recommended an acrylic partial denture with a method to customize the pontic. The large amount of use of composite material when compared to hard splint or overlay denture increases the overall cost of the treatment.


   Conclusion Top


The technique described is an interim step and should ideally be followed by conventional prosthetic rehabilitation procedures like full coverage crowns. Though the authors have practiced the technique in teeth susceptible to wear by use of hard splints or overlays, yet one can perform this technique in situations otherwise and where occlusal vertical dimension needs to be raised.

 
   References Top

1.Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74.  Back to cited text no. 1
    
2.Dylina TJ. A common-sense approach to splint therapy. J Prosthet Dent 2001;86:539-45.  Back to cited text no. 2
    
3.Gopi Chander N, Venkat R. An appraisal on increasing the occlusal vertical dimension in full occlusal rehabilitation and its outcome. J Indian Prosthodont Soc 2011;11:77-81.  Back to cited text no. 3
    
4.Witkop CJ Jr. Hereditary defects of dentin. Dent Clin North Am 1975;19:25-45.  Back to cited text no. 4
    
5.Shields ED, Bixler D, el-Kafrawy AM. A proposed classification for heritable human dentine defects with a description of a new entity. Arch Oral Biol 1973;18:543-53.  Back to cited text no. 5
    
6.Hobo S, Takayama H. Twin-stage procedure. Part 1: A new method to reproduce precise eccentric occlusal relations. Int J Periodontics Restorative Dent 1997;17:112-23.  Back to cited text no. 6
    
7.Hobo S, Takayama H. Effect of canine guidance on the working condylar path. Int J Prosthodont 1989;2:73-9.  Back to cited text no. 7
    

Top
Correspondence Address:
Aditi Nanda
Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, Mamc Campus, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.142549

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

Top
 
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  
 


    Abstract
   Discussion
   Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed2490    
    Printed79    
    Emailed5    
    PDF Downloaded174    
    Comments [Add]    

Recommend this journal