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CLINICAL REPORT Complete mouth rehabilitation and gastroesophageal reflux disease: Conventional and contemporary treatment approaches Vasilios Chronopoulos, DDS, MS, PhD,a Georgios Maroulakos, DDS, MS,b Konstantinos Tsoutis, DDS, MS,c Panagiota Stathopoulou, DDS, MS, PhD,d and William W. Nagy, DDSe Gastroesophageal reflux dis- ABSTRACT ease (GERD) is a “condition
  CLINICAL REPORT  Complete mouth rehabilitation and gastroesophageal re 󿬂 uxdisease: Conventional and contemporary treatment approaches Vasilios Chronopoulos, DDS, MS, PhD, a Georgios Maroulak os, DDS, MS, b Konstantinos Tsoutis, DDS, MS, c Panagiota Stathopoulou, DDS, MS, PhD, d and William W. Nagy, DDS e Gastroesophageal re 󿬂 ux dis-ease (GERD) is a  “ condition which develops when there 󿬂 ux of stomach contentscauses troublesome sy mptomsand/or complications. ” 1 Re 󿬂 ux episodes can be intensi 󿬁 ed by dietary habits, smoking, physical exercise, and obstruc-tive sleep apnea. 1-3 Complications of GERD are regur-gitation, chest pain, esophagitis, Barrett ’ s esophagus,esophag eal adenocarcinoma, cough, asthma, and dentalerosion. 1,4,5 GER D is associated with dental erosion andsleep bruxism, 6,7 and dental erosion may be the only symptom of GERD. 8 The purpose of this report was to present the oraldiagnosis and management of 2 patients with chronicGERD who presented with tooth wear and requiredcomplete mouth rehabilitation. The restoration of denti-tion was achieved by following different treatmentmodalities. CLINICAL REPORTPatient 1  A 47-year-old woman presented complaining that her “ teeth have worn out over time. ”  Her medical history included mild chronic GERD, controlled with diet. Clin-ical and radiographic examinations revealed multiple rootcanal treatments (RCTs), amalgam restorations, andmetal ceramic (MC) restorations ( Fig. 1 ). Her last dentalappointment was 2 months before the prosthodonticevaluation for extraction of the mandibular right  󿬁 rstmolar ( Fig. 2 ). The patient underwent monitored occlusaldevice therapy before any treatment.Diagnostic casts were obtained and mounted (DenarMark II; Whip Mix Corp) using a facebow (Denar Sli-dematic; Whip Mix Corp) and centric relation records.The occlusal vertical dimension was evaluated, and a 3-mm increase was determined to allow adequate restor-ative space. A diagnostic waxing was used to evaluateesthetics and function and to fabricate interim prostheses( Fig. 3 ).The problems identi 󿬁 ed were moderate to severedental wear, defective restorations, inadequate toothstructure on several maxillary and mandibular teeth,inadequate anterior guidance, nonideal gingival display in an exaggerated smile, loss of attached mucosa, andpresence of a mandibular right bone defect ( Fig. 1 ). Thede 󿬁 nitive diagnosis included worn dentition caused pri-marily by erosion 9-12 and occlusal instability. Her cariesrisk was low. 13 The patient was characterized as category 2 relative to the occlusal vertical dimension associated with a treatment plan 14 and as prosthodontic diagnostic a Assistant Professor, Department of Prosthodontics, National and Kapodistrian University of Athens, School of Dentistry, Athens, Greece. b Assistant Professor, Department of General Dental Sciences, Marquette University School of Dentistry, Milwaukee, Wis. c Clinical Instructor, Department of Prosthodontics, National and Kapodistrian University of Athens, School of Dentistry, Athens, Greece. d Assistant Professor, Postdoctoral Periodontics, Department of Periodontics, University of Pennsylvania, School of Dental Medicine, Philadelphia, Pa. e Professor, Graduate Prosthodontics, Department of Restorative Sciences, Texas A&M University, Baylor College of Dentistry, Dallas, Texas. ABSTRACT  This report describes the diagnosis and prosthodontic management of 2 patients with a history of chronic gastroesophageal re 󿬂 ux disease and worn dentition. Different treatment approaches wereused for oral rehabilitation. Use of conventional and contemporary restorative materials resulted infunctional and esthetic prosthodontic rehabilitation with a favorable prognosis. (J Prosthet Dent2017;117:1-7) THE JOURNAL OF PROSTHETIC DENTISTRY  1  index (PDI) class IV for partial edentulism. 15 The treat-ment objectives were to control GERD, to maintainperiodontal and dental health, and to provide functionaland esthetic restorations. Signi 󿬁 cant treatment modi 󿬁 ers were the GERD and  󿬁 nances. The patient declined bone/soft tissue augmentation and implant placement.The inadequate tooth structure was managed by crown lengthening and/or cast post and cores after RCT.The maxillary central incisors were lengthened toimprove gingival architecture. Strip perforation at themesiobuccal canal of the mandibular left  󿬁 rst molaroccurred during RCT. After evaluating  the tooth, resec-tion of the mesial root was proposed, 16 as the patientrefused extraction and implant placement ( Fig. 4 ). Theocclusal scheme established with the interim prostheses was mutually protected articulation. The patient wasmonitored for 4 months to evaluate esthetics, function,oral hygiene, and soft tissue healing. De 󿬁 nitive impres-sions were made with custom trays and polyvinylsiloxane material (Aquasil Ultra; Dentsply Intl). Casts of interim prostheses were made to facilitate crossmounting of de 󿬁 nitive casts and to fabricate a customincisal guide table. 17 The interim prostheses were used tocommunicate the established esthetics (incisal edge po-sition, contours, occlusal plane) and function (occlusalscheme, envelope of function, palatal contours of maxillary anterior teeth). The patient received MC  󿬁 xeddental prostheses (FDPs) on all maxillary and mandibularteeth. All prostheses were cemented with resin-modi 󿬁 edglass ionomer cement (Fuji Plus; GC Corp). Figure 1.  Patient 1 pretreatment. A, Maximum intercuspation position frontal view. B, Exaggerated smile. Note nonideal gingival display. C, Maxillaryocclusal view. Note condition of existing restorations. D, Mandibular occlusal view. Note ridge defect at post extraction site of mandibular right  󿬁 rstmolar and formation of amalgam islands on left posterior teeth. Figure 2.  Panoramic radiograph, pretreatment. 2 Volume 117 Issue 1 THE JOURNAL OF PROSTHETIC DENTISTRY  Chronopoulos et al  The patient received follow-up examination 1 weekafter insertion and was excited with her rehabilitation. A maxillary occlusal device was fabricated to protect theprostheses. The patient entered a 6-month recall mainte-nance program with favorable long-term prognosis. After3 years, she was still satis 󿬁 ed with her prostheses ( Fig. 5 ). Patient 2  A 42-year-old woman complained of her  “ short andugly teeth. ”  Her medical history included chronicGERD, controlled with a histamine-2 receptor antag-onist. The patient had high esthetic expectations.Clinical and radiographic examination revealed existing RCTs, composite resin restorations, and MC restora-tions ( Figs. 6 , 7 ). The temporomandibular joint exami- nation revealed clicking sounds on both joints but anormal range of motion and no pain. The patientadmitted nocturnal bruxism. An occlusal device wasfabricated and monitored for 6 weeks to allow thecondyles to assume a stable treatment position. 18 Diagnostic casts were mounted (Denar Mark II; WhipMix Corp) using a facebow (Denar Slidematic; WhipMix Corp) and centric relation records. The occlusal vertical dimension was evaluated, and an increase of 1mm was determined to allow space for the restorativematerials. Dual-polymerizing composite resin (Integ-rity; Dentsply Intl) was used as a trial restoration toevaluate the diagnostic waxing intraorally ( Fig. 8 ).The problems identi 󿬁 ed were moderate dental wear,recurrent caries on several teeth, periapical pathosis on Figure 3.  A, Occlusal vertical dimension evaluated with gingival heightof left canines as reference. Monitored splint therapy was executed atproposed occlusal vertical dimension to locate musculoskeletally stabletreatment position and evaluate patient ’ s adaptation to new verticaldimension. B, Diagnostic waxing at proposed occlusal verticaldimension. Figure 4.  Tooth preparations. A, Maxillary. B, Mandibular. C, Cementedcast post/core on root-resected mandibular left  󿬁 rst molar. January 2017 3Chronopoulos et al  THE JOURNAL OF PROSTHETIC DENTISTRY  Figure 5.  Patient 1. Inserted de 󿬁 nitive prostheses. A, B, Occlusal views. C, Exaggerated smile. D, Panoramic radiograph 3 years after insertion. Figure 6.  Patient 2 pretreatment. A, Maximum intercuspation position frontal view. B, Exaggerated smile. C, D, Occlusal views. 4 Volume 117 Issue 1 THE JOURNAL OF PROSTHETIC DENTISTRY  Chronopoulos et al
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