Limited restorative space: options?

This is a guest case post, from Dr. Ziv Simon, of Surgical Master.

The patient is in his late 70’s, and very intelligent. The patient wants teeth that will last a life time. I referred the patient for a CT. There is limited restorative space. I need to assess all the options for this case. Thoughts?

17 thoughts on: Limited restorative space: options?

  1. Dr Krishan Dudeja says:

    This case requires comprehensive treatment planning as it probably involves generalized attrition and probably a parafunctional habit has a role to play.Kindly check if there is loss of vertical dimension that needs to be restored.Let us know the further details. Articulated casts seen from the lateral view and diagnostic wax up can help inplanning the treatment. Good Luck

  2. Alex Zavyalov says:

    To my mind according to initial X ray, both lateral incisors could have been used as abutments for post and core bridge after root canal filling. It would have made implant insertion unnecessary. Moreover, I think there is a lack of information about posterior area here, and it is impossible to give any appropriate prosthetic treatment advice based on these two pictures only.

    • Ziv Simon says:

      Thanks for the feedback. You’re absolutely right that there isn’t enough information. Both teeth we at gingival level. There was a new bridge that was made and it failed shortly after because of the opposing dentition. We discussed crown lengthening, RCT and a new bridge. In light of the existing occlusal problem we decided to choose an implant solution which is also challenged by the limited restorative space.
      The goal of this post is to bring this problem to the attention of doctors and prevent mishaps.
      Thanks again!

  3. himakshu says:

    This is a great case for discussion
    If there is sufficient posterior support , one could , as a temporary measure consider a Dahl type appliance with anterioir teeth .
    This would allow some over eruption of the posterior dentition and then consider , after 3-6 months , how much space there is anterioirs .
    By allowing building up of the canines , the space can be increased and then some kind of fixed prostheses can be considered
    This is based on just the first view and with more diagnostic records , a more detailed and predictable treatment plan , with all options can be presented and a predictable outcome can be achieved

  4. Dr Amit Duggal says:

    Thanks for the post. Agree need to assess the mouth as a whole.
    If enough posterior support have options to Dahl anterior teeth using composites or an adhesive bridge and once posterior support re-established which can be anything from 6 weeks to 6 months then to re-evaluate anterior region for conventional bridgework or implant retained bridgework. If there is a lack of posterior support then this needs to be a full mouth reconstruction with articulated study casts using a face bow, diagnostic wax ups and then treatment plan. In addition, sometimes with cases like this if the current intercuspal position / centric occlusion does not coincide with retruded contact position / centric relation correcting this can also provide some space. Due to his wear I would suggest a Michigan splint with whichever route is embarked upon. Good luck!

  5. Dr Bob says:

    Not enough info, but first the destructive bruxing must be addressed or the implants will go just like the bridge on the laterals did. Bite must be opened and made stable before implants. This could take a good bit of time as well as money. If this patient wants a fast fix refer to some one who likes to do things that have a very high failure risk.

  6. Mario says:

    Definetely this case needs a full restoration with crowns to lift up the vertical dimension and then have the space enough to complete the work, maybe some root canal and posts.

  7. Gregori Kurtzman, DDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA says:

    I think that the lower anteriors can be leveled to get the incisals in a even horizontal plane that will create more space to place prosthetics. I would recommend extract the maxillary laterals and place an implant at each space and restore with a 4 unit bridge. A waxup viewed from the lateral view will tell us how far facial the 4 incisors can be positioned.

  8. Sharon Goodwin says:

    It would be ideal to level and align the lower anterior teeth with orthodontics to create space and an even plane of occlusion. Then open the vertical a bit restoratively to create more ideal space; you could use transitional bonding with composite to transition the case.

  9. Wayne says:

    A straight forward solution , assuming there is posterior occlusal support, is a diagnostic wax up and then doing whatever is necessary to develop cuspid rise, bilaterally. This could be a fixed bridge or implant supported crowns or bridge to replace 7,8 and9.
    For 35 years I’ve been placing and restoring implants and my mantra has been ‘develop a cuspid rise’.
    Lower incisors may be in ideally equilibrated or crowned .
    Naturally I’d like to include bilateral restorations minally from 6 through 11 .
    A patient in their seventies is less inclined to engage in a lengthy treatment, therefore I would not consider ortho given the patients age and time required.

  10. Tom Henschel says:

    Dr. Ziv,
    First, thanks for your teaching videos… simply love ’em!
    Great case for discussion. While admittedly not the sharpest knife in the drawer, after 32 yrs. I’ve come to the conclusion that the vast, vast majority of RESTORED fractured/missing teeth are the result of parafunction(nonrestored teeth almost never fracture). Every day in my practice I see patients, even teenagers, with flattened cuspids/bi’s in lateral bruxers, and severely worn anteriors in protrusive bruxers, like the case you show above. Start looking and you’ll see them. Clenchers don’t show flattened cusp tips but will also have a broken tooth history. It is estimated that 35% of the population clenches/bruxes at least episodically. As I understand, in normal function(chew, speak, swallow, etc.) it is only when swallowing that the posterior teeth actually touch, and then only with minimal pressure(few pounds per square inch). Certainly there are greater forces when masticating, but normally when chewing our teeth don’t collide as in parafunction. We don’t chew a cud like a horse or sheep. Considering it has been reported that up to 1100 pounds per square inch can be produced by the muscles of mastication in a parafunctioning patient, it is no wonder they break restored teeth necessitating crowns & RCT’s, and then ultimately extraction of hopelessly fractured teeth in many cases. The system was not designed to withstand those types of forces!
    The case you post exhibits severely worn anteriors, closed vertical dimension and resultant deep bite. If you showed a photo of the remaining dentition I would bet we would see a dentition TORN UP by parafunction. Additionally, I would put money on it that the patient has thick buccal/labial bone and tori/exostoses, I feel both are the body’s attempt to increase support for teeth under attack from tremendous parafunctional forces.
    Even properly placed and integrated fixtures with idealized occlusion are doomed to failure in this case(think of the tremendous lateral forces he generates, which would be directly transmitted to the fixtures), if the patient lives long enough, and if they don’t fail he is likely to experience porcelain fracture, possibly fractured abutment screws and continued wear on the md. anteriors.
    Opening the bite might help but is not the total answer…this patient needed an occlusal guard years ago. This patient REQUIRES/DESERVES a frank discussion as to the reasons his teeth are catastrophically failing, and any type of implant therapy, with or without bite opening, demands an occlusal guard.
    Most parafunction patients exhibiting worn/fractured teeth will answer “yes” to one of the following 4 questions:

    * Do you wake EVER up with headaches?
    * Are your masseter/temporalis muscles sore upon awakening(touch these muscles as you ask)
    * Are your teeth ever sore when you wake up?
    * Has anyone ever told you you grind your teeth(least important question…not all bruxers create noise and clenchers don’t ever)?
    Sorry for the lengthy post but if this helps one patient or one dentist it was worth taking the time to post…



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