Art-7-Re
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Case Report
AN ANTERIOR RECONSTRUCTION: INCREASE THE OCCLUSAL
VERTICAL DIMENSION OR REDUCE PERIODONTAL SUPPORT?
Jean-Philippe Ré1a* , Jean-Daniel Orthlieb1b , Anne Giraudeau1c , Estelle Casazza1d
1
Departement of Occlusodontology, School of Dental Medicine, Aix-Marseille University, Marseille, France
a
DDS, PhD, Associate Professor; e-mail: jeanphilippe.re@gmail.com; ORCIDiD : https://orcid.org/0000-0002-3265-141X
b
DDS, PhD, Professor; e-mail: jdorthlieb@orange.fr; ORCIDiD : https://orcid.org/0000-0002-8565-8922
c
DDS, Associate Professor; e-mail: anne.giraudeau@free.fr; ORCIDiD : https://orcid.org/0000-0001-8363-5367
d
DDS, Assistant Professor; e-mail: estelle.casazza@gmail.com; ORCIDiD : https://orcid.org/0000-0002-3316-7267
ABSTRACT https://doi.org/10.25241/stomaeduj.2022.9(3-4).art.7
Aim The aim was to document a clinical situation which was managed at minimal biological cost and with
straightforward implementation.
Summary Challenges of space management may arise in prosthetic dentistry as a minimum height is needed
for the supporting tissues and the restorative material.
While increasing the vertical occlusal dimension allows an increase in the height of the prostheses, the
option may be complex and has disadvantages, including the need to modify the entire occlusion. Crown
lengthening is an alternative therapeutic option, but it results in a decrease in periodontal support.
Nevertheless, it allows less extensive prostheses to be provided without impacting the rest of the arch.
Managing complex clinical situations with moderate biological cost and straightforward implementation is
possible, as illustrated in this clinical report.
Key learning points
1. Crown lengthening is a solution to increasing the tooth surfaces necessary at prosthetic rehabilitation.
2. Increasing occlusal vertical dimension (OVD) is a solution to providing the occlusal space necessary for the
restorative material without reducing the supporting tissues.
3. Crown lengthening reduces periodontal support but can be considered when the root length of the
affected teeth is sufficient.
4. Increasing the OVD requires modification of the entire occlusion.
5. Crown lengthening offers the advantage of not modifying OVD or intercuspal position (ICP).
KEYWORDS
Crown Lengthening; Deep Bite; Prosthodontic Treatment Planning; Dental Occlusion; Therapeutic Decision
1. INTRODUCTION her smile (Fig. 1). However, she wished to avoid
The management of dental wear is frequently extensive or invasive procedures and categorically
encountered in prosthodontic practice [1]. declined orthodontic treatment such as intrusion of
Interventions can range from straightforward lifestyle the front teeth.
advice to complete-mouth rehabilitation [2]. While
contemporary dentistry advocates the conservation
of tooth structure and pulpal vitality [3] and the
application of adhesive dentistry with minimal tooth
preparation [4], complete-mouth rehabilitation
typically involves extensive tooth preparation. The
purpose of this clinical report was to document a clinical
situation which was managed at minimal biological
cost and with straightforward implementation.
2. CASE PRESENTATION
A 76-year-old woman sought treatment in 2011 Figure 1A. Pretreatment: (A) Intercuspal position.
because she was concerned about the wear of her Clinical examination showed, on palpation, large
mandibular anterior teeth which were sensitive to and dense masseter muscles but less complaints
cold, leading to mastication difficulties, and also from the patient, suggesting oral habits like frequent
because the patient's chief concern was to improve parafunctional muscle activity, observed by family
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Ré JP, Orthlieb JD, Giraudeau A, Casazza E. An anterior reconstruction: increase the occlusal vertical dimension or reduce periodontal sup-
port?. Stoma Edu J. 2022;9(3-4):121-124.
Received: March 27, 2022; Revised: April 11, 2022; Accepted: April 20, 2022; Published: May 17, 2022.
*Corresponding author: Jean-Philippe RÉ; Departement of Occlusodontology, School of Dental Medicine, Aix-Marseille University, Marseille, France
Address: 27, Boulevard Jean Moulin, 13355 Marseille Cedex 5, France, Tel.: +33494923491; Fax: +33494910965; e-mail: jeanphilippe.re@gmail.com
Copyright: © 2022 the Editorial Council for the Stomatology Edu Journal.
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Ré J-P, et al.
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members. She had a reproducible, stabilized, and The treatment plan involved the reconstruction of the
Case Report nondeflected intercuspal position (ICP), despite anterior teeth to recreate the correct anatomy of the
worn incisors and mandibular canines. The posterior maxillary and mandibular incisors and canines and to
teeth were in good condition and unrestored, were restore the anterior vertical and horizontal overlaps,
in good alignment, and had a seemingly unaltered approaching average values of 3 to 4 mm with
occlusal vertical dimension (OVD). She had group optimized mandibular function [6]. A major difficulty
function eccentric guidance on the right side and was the lack of space available at the anterior sector;
canine disclusion on the left side. Some mandibular the maxillary and mandibular gingiva appeared to
anterior teeth were worn almost to the gingival meet in the frontal plane in the ICP (Fig. 1A).
margin, with the dental pulp almost exposed by The mandibular incisors and the right canine teeth
wear (Fig. 1B). The maxillary incisors and canines had minimal coronal height, and enamel was almost
also showed wear, and the location of their gingival entirely missing. The left mandibular canine was
margins suggested extrusion. The maxillary incisors
intact but was extruded above the occlusal plane.
completely overlapped the mandibular incisors in the
The mandibular and maxillary anterior teeth required
intercuspal position (ICP). (Fig. 1A) The periodontal
restoration, and the maxillary anterior teeth also
examination, with normal probing depth and zone
needed reshaping to correct their extrusion. Various
of attached gingiva, and the radiological examination
treatment options were considered, but first the
did not reveal any periodontal lesions and none of
the teeth had received or required endodontic occlusal vertical dimension (OVD) was considered.
treatment. The teeth had roots of normal size, and An increase in the OVD would minimize the
the left maxillary canine had been replaced by an preparation of the maxillary anterior teeth and provide
implant-supported crown a few years previously. the occlusal space necessary to restore the coronal
(Fig. 1C) The skeletal and dental relationships were anatomy of the mandibular anterior teeth. However,
Angle class I with normal mandibular movements, an increase in OVD would require restoration of the
with no temporomandibular joint (TMJ) sounds or posterior occlusion. In addition, esthetics would be
complaints from the patient. In addition, the patient compromised with the lengthened maxillary posterior
had no medical history of gastroesophageal reflux teeth.
disease, xerostomia, consumption of excess acidic soft Because the posterior teeth were unrestored and
drinks and her conventional diet habits did not appear in good functional occlusion, her existing OVD was
to affect the anterior teeth. preserved.
Bonded anterior ceramic restorations were
problematic in the absence of sufficient enamel to
ensure a durable and effective adhesion [7]. However,
cemented ceramic crowns were also problematic
because of the lack of resistance and retention form.
Maintaining her OVD and intercuspal position (ICP)
required the exposure of sufficient tooth structure to
provide resistance form.
This could only be achieved by reducing the
periodontal support with maxillary and mandibular
Figure 1B. Pretreatment: Extensive wear particularly on anterior anterior crown lengthening [8]. Crown lengthening
mandibular teeth and more extensive on the right side. and retaining OVD and ICP created sufficient resistance
and retention, at least 4 mm in height (Fig. 2) [9].
Also, respecting the interproximal papillary area, the
gingival margins of the anterior teeth were aligned
with those of the posterior teeth to improve esthetics.
Figure 1C. Pretreatment: Initial panoramic radiograph.
A diagnosis of bruxism (including attrition) was made
with increased occlusal loading of the anterior teeth.
Complete restoration of the anterior teeth was
indicated to address esthetic [5], sensitivity, and
functional concerns and also to preserve these teeth Figure 2A. Tooth preparations 3 months after crown lengthening:
Mandibular
from further damage.
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The management of space in anterior reconstruction
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Case Report
A recall appointment after 11 years confirmed that
the patient's complaints (wear, sensitivity, function,
and esthetics) had been addressed and that crown
lengthening instead of an increase in OVD was an
appropriate choice (Fig. 4).
Figure 2B. Tooth preparations 3 months after crown lengthening:
Maxillary
Ceramic crowns (IPS e.max Press MO, A3 shade;
Ivoclar Vivadent) with minimal tooth preparation
were provided, although 2 teeth required endodontic
treatment (Fig. 3). Figure 4. Eleven years after treatment.
3. DISCUSSION
Clinical situations may require deciding between
the need for space management to accommodate
the restorative material or reducing the supporting
tissues. Crown lengthening is a solution to increasing
the tooth surfaces necessary and increasing OVD is
a solution to providing the occlusal space necessary
for the restorative material without reducing the
supporting tissues.
Figure 3A. After treatment: Clinical photograph showing harmonious
smile line and occlusion. Crown lengthening reduces periodontal support
but can be considered when the root length of the
affected teeth is sufficient and reduces the prosthetic
dentistry required. It offers the advantage of not
modifying OVD or ICP and therefore simplifies the
prosthetic treatment. Increasing the OVD should be
reserved for complete dental arch rehabilitation. It is
more complex because it requires modification of the
entire occlusion
4. DISCUSSION
Figure 3B. After treatment: Panoramic radiograph, two teeth required
endodontic therapy.
A 76-year-old woman patient sought treatment in
2011 because her mandibular anterior teeth were
worn, sensitive to cold, nonfunctional and unesthetic.
Despite a complex clinical situation caused by the
extrusion of the maxillary anterior teeth causing a lack
of space in the anterior teeth, the posterior teeth were
in good condition. Crown lengthening of the anterior
teeth was chosen to simplify treatment, without an
increase in OVD, which meant that the entire occlusion
did not have to be modified. Clinical follow-up at 11
Figure 3C. After treatment: Mandibular occlusal view. years, accompanied by behavioral counselling but
without splint therapy, confirmed the durability of a
classic prosthetic treatment, despite the development
of new techniques, and that the patient's concerns
had been addressed.
ACKNOWLEDGMENTS
None.
AUTHOR CONTRIBUTIONS
JPR, AG, EC: wrote the manuscript in consultation with JDO.
All authors provided critical feedback and helped shape the
Figure 3D. After treatment: Maxillary occlusal view. manuscript.
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Ré J-P, et al.
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Jean-Philippe RÉ
DDS, PhD, Associate Professor
Departement of Occlusodontology
School of Dental Medicine
Aix-Marseille University
CV Marseille, France
Dr. Ré, DDS, PhD has been an occlusodontist and Associate Professor at the Department of Oral Functions/Dysfunctions, School
of Dental Medicine, Aix-Marseille University, France since 2008. He runs a private practice oriented to prosthodontics in Toulon.
He is good at treating prosthetic patients, especially complex case treated with the multidisciplinary approach. He authored the
book titled “Orthèses orales”.
Questions
1. What is the recommendation of contemporary dentistry?
qa. No conservation of teeth;
qb. No conservation of pulpal vitality;
qc. Extensive tooth preparation;
qd. Adhesive dentistry.
2. What is the diagnosis of dental wear?
qa. Bruxism;
qb. Absence of gastroesophageal reflux disease;
qc. Absence of consumption of excess acidic soft drinks;
qd. Conventional diet habits.
3. What is the consequence of dental crown lengthening?
qa. Cannot be a solution to increasing the tooth surfaces necessary for prosthetic retention;
qb. Reduces periodontal support;
qc. Alters OVD or ICP;
qd. Cannot be sectorial.
4. What is the consequence of increasing OVD?
qa. Does not avoid reducing the supporting tissues;
qb. Should be reserved only for complete both dental arches rehabilitation;
qc. Requires modification of the entire occlusion;
qd. Is not a solution to provide the occlusal space necessary for the restorative material.
124 Stoma Edu J. 2022;9(3-4):121-124 pISSN 2360-2406; eISSN 2502-0285