Treating a Collapsed Bite – Dr Reema Aggarwal

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  Posted by: The Probe      6th January 2020

A 60-year old female patient presented with a collapsed bite due to lack of posterior support and supra-eruption of the anterior maxillary segment. Her medical history was clear and she had been a regular attender to the practice for the past eight years. The patient was referred in-house by a colleague to discuss options for replacement of her missing teeth with a new denture or dental implants. She also wanted to restore her smile line and claimed that in her profession where smiling and talking was paramount, she had found it “really difficult” as she had stopped smiling completely and was “ashamed of showing her teeth.”

Clinical Assessment

The patient presented with good general oral health – there was no inflammation of the periodontal tissues and only minor deposits of calculus on the lower anterior. UL2, UL3, LR5, LR6 and LR7 were missing. The existing molars and premolars had large restorations, with composite fillings on LL4, LL7, UL1 and UR1; porcelain crowns on UR2 and UL4; and large amalgam fillings on LR4, LR5, LL5, UR3, UR4, UR5, UR6, UR7, UL5 and UL7, which all showed signs of secondary caries, ditching and fractures.

A full gold crown was present on LL7 and a full metal cast crown was on the UL6.
UL4, UR5, LL4 and LL5 had minimal tooth structure remaining and crowns could not be placed. The collapsed bite looked to have been caused by the loss of lower back teeth and LR2 a long time ago, with compensatory tooth movement to close the space.  The patient currently had a spoon denture to replace UL2 and UL3.

Treatment options discussed included:

  • No treatment, with monitoring of present denture and fillings required.
  • Implant to replace the missing UL2 and acceptance of the other failing fillings, which could be extracted and replaced over time.
    The need to establish a stable dentition first was highlighted to the patient.
  • Multiple implants to replace all upper teeth with currently failing restorations. The same need to improve the general condition of the mouth was discussed with the patient.
  • Ceramic veneers on the upper maxillary anterior: although the substantially higher costs involved and destructive nature of treatment were inhibitive for the patient. Plus, this would not address the primary concern to restore the missing tooth structure or restore the smile, which the patient was particularly concerned about.
  • Restore upper and lower anterior teeth with fillings to regain lost tooth structure and restore the height of the lower face. This was preferable to crowns on these teeth, which would be more destructive and most of these teeth had insufficient tooth structure anyway.
  • Adhesive bridge to replace the missing upper lateral incisor – this would provide minimally invasive dentistry (MID) and a less expensive solution, but there would be a risk of de-bonding from time-to-time.
  • Chrome cobalt denture to replace the missing lower teeth on the right-hand side in order to restore the collapsed bite and provide posterior support to encourage longevity of all new restorations.

 

Treatment Proposal

In order to replace the existing failing restorations in the most conservative way and build up the premolars to their original size for restoration of the smile line and facial height, composite veneers on all upper anterior teeth were selected. We also planned to reduce the length of UL1, UR1 and UR2, reducing the inciso-gingival length by 1.5 mm and replacement of the failing crown on UR2.

Jaw relation recordings were performed in order to reorganise the occlusion and increase the Occlusal Vertical Dimension. The Vertical Dimension was increased by 6.0 mm posteriorly.

Composite onlays were planned for UL5, UR4 and UR5, although the patient was warned about the risk of UL5, UR4, UR5 not being restorable or offering a limited prognosis when the present fillings were removed. A chrome denture would then be fitted to replace the missing lower teeth, with an implant-supported denture replacing LR5, LR6 and LR7 to help stabilise the bite and provide posterior support to reduce future tooth surface loss (TSL).

We planned to complete treatment in six to eight visits.

Treatment

A thorough scale and polish was required before restorative treatment could begin and the patient was educated on the importance of achieving healthy dentition for long-term treatment outcomes. A full mouth wax-up was created according to the plan, establishing the new smile line and ensuring the new fillings would give us the correct canine protected anterior guidance and sufficient space to place restorations anteriorly and posteriorly on the teeth with wear.

The restorations on the upper and lower anteriors and posteriors (composite veneers and crown using Filtek Supreme XTE Universal restorative from 3M) were completed in one appointment. All the existing fillings on the maxillary and mandibular teeth were removed and replaced with composite veneers and onlays with 3M Filtek Supreme XE Universal restorative. Astringent Retraction Paste from 3M was used for all restorations to control belleding and allow for good margin fit. The restorations were finished using the Sof-Lex Diamond polishing system from 3M. The UR2 crown was removed and a temporary placed.

The fillings and raised bite were reviewed a week later and impressions were taken for the new UR2 crown and cantilever bridge from UL4 (supported on UL4), which were fitted two weeks later. Fabrication of the chrome denture was started at the same appointment and was fitted approximately six weeks later.

DiscussionAs outlined above, the major benefit of treating the reorganisation of the smile line using MID is that there is no, or very little, removal of healthy tooth structure. We were able to restore the patients smile, improve the appearance of the anterior teeth and the denture provided sufficient posterior support to prevent further wear of the upper and lower anterior teeth while also stopping any further movement of the maxillary teeth. The only limitation of this treatment is that some minor repair may be needed to the restorations over the next few years in the case of any chipping or staining.

Annual review appointments will therefore be required for a thorough examination and on-going monitoring. Radiographs and photographs will be taken and all data

recorded. The patient has also been instructed to keep six-monthly maintenance visits with the dental hygienist to ensure longevity of the restorations and the health of her teeth and gums.

IMAGES

Figure: 1 Dentition pre-treatment

Figure: 2 Dentition pre-treatment with lips retracted

Figure: 3 Lower arch pre-treatment

Figure: 4 Upper arch pre-treatment

Figure: 5 Right laterial view of pre-treatment dentition

Figure: 6 Left lateral view of pre-treatment dentition

Figure: 7 Lower arch post treatment

Figure: 8 Dentition post treatment

 

For more information, call 0800 626 578 or visit www.3M.co.uk/Dental

 

 

Author bio:

 Reema gained a national scholarship to practice medicine and dentistry and graduated in dentistry from Bangalore University in 1995. On graduating she took up a position in a private practice in Delhi before moving to the UK in 2003.

Since then Reema has worked in a private practice in Cheltenham and in Wincanton, and has devoted most of her spare time to postgraduate study, both in the UK and USA. She gained the MJDF from Royal College of Surgeons in 2009 and her Diploma in Restorative Dentistry from the Royal College of Surgeons in 2013. She was awarded a Gold Medal by the Royal College for “Excellence in Restorative Dentistry” by the Royal College of Surgeons, England. Subsequently she completed an MSc in Restorative Dentistry from Leeds University in 2016. Reema currently accepts referral cases for Periodontics, Endodontics and Restorative Dentistry for the Oasis Group in their Cheltenham and Hereford practices.

 


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