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International Journal of Clinical Dentistry Volume 12, Issue 1

ISSN: 1939-5833 © 2019 Nova Science Publishers, Inc.

INCREASE IN OCCLUSAL VERTICAL DIMENSION USING PREHEATED RESINS AS LONG-TERM INTERIM RESTORATIONS: A CLINICAL REPORT José M. Olivares1,†, DDS, Eduardo Pino1, DDS, and Dafna Benadof2, DDS, PhD 1

Facultad de Odontología, Especialización en Implantología Buco maxilofacial, 2 Facultad de Odontología Universidad Andres Bello, Santiago, Chile

ABSTRACT A decrease in the occlusal vertical dimension can negatively affect patients’ facial esthetics, chewing, phonetics, and social relationships. Traditional prosthetic treatment consists of determining the ideal vertical dimension of occlusion through objective and subjective methods, then a diagnostic waxing is made on this new position; followed by tooth preparations associated with interim restorations for occlusal stabilization; and, finally, removable partial denture or fixed definitive restorations. This case report presents a new method to reestablish and maintain the vertical dimension throughout a long-term interim restoration stage. It describes the results of direct bonded restorations with preheated compactable resins, applied to transparent silicone matrixes made from a diagnostic waxing. The main advantages of this procedure are that it is fast, reversible, and low cost. This manuscript shows a case report resolved by means of a defined clinical protocol for vertical dimension increase and evaluation, during the interim restoration stage. This procedure is performed using widely available materials as composite resins, modifying its viscosity and improving their mechanical properties by a preheating procedure and then applied to transparent silicone matrixes made from a diagnostic waxing. This protocol allows restorations that are easy to perform, accurate, reversible, low cost and repairable by any dentist. Although this technique has been previously described in the literature, this manuscript contributes to the current knowledge by describing a sound restorative protocol and informing the clinical properties of preheated composite resins.

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This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Nevertheless, Ivoclar Vivadent provided the materials for restorations free of charge. † Professor. Corresponding Author’s E-mail: [email protected].

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José M. Olivares, Eduardo Pino and Dafna Benadof

INTRODUCTION The vertical dimension of occlusion (VDO) is defined as the distance between two selected anatomic or marked points (usually the tip of the nose and the chin) when in maximal intercuspal position [1]. A decrease in the VDO can negatively affect patients’ quality of life and social interactions by altering their facial esthetics, chewing, and phonetics. The literature reports mixed results regarding the association of changes to the VDO and potentially detrimental alterations of the temporomandibular joint and masticatory muscles [2, 3]. All these effects show the relevance of reestablishing the VDO in people. To evaluate the degree of loss in VDO there are objective and subjective methods, which must be complemented with esthetic, phonetic, facial profile, muscular, temporomandibular joint, and intraoral asssesments [4-8]. The first step to reestablish the VDO is to decide if the treatment will be done in centric relation or in maximal intercuspal position. Then, a diagnostic waxing must be made, followed by tooth preparation and the installation of interim restorations, traditionally, acrylic crowns. Finally, definitive removable denture or fixed restorations are made and installed [9, 10]. Published literature on the adaptation process of the stomatognathic system to modified VDO are scarce and usually report short-term follow-ups [5, 11, 12]. The negative consequences of increasing VDO (up to 5 mm) are minimal and reversible, and the reported signs and symptoms are usually resolved within two weeks.5 Even though it is advisable to monitor patients’ adaptation to the restored VDO, by using interim restorations, there is no consensus regarding the duration of the observation period needed to ensure long-term stability. Indeed, existing studies present patient evaluation periods ranging from a few weeks to various months, while others fail to mention a follow-up period [9, 10, 13-17]. Acrylic interim restorations require tooth preparations to provide adequate thickness and retention for the definite restoration. Different studies show that they can have potential negative consequences such as: material fracture, dissolution of the tooth/cement interface, sensitivity, percolation, and secondary caries formation [18]. An alternative to this type of interim restorations are direct bonded restorations. These restorations require minimal or no tooth preparations and have different application techniques and consistencies for the used materials [14-17, 19-20]. The primary difficulty of using direct bonded interim restorations is to have a result that is true to the diagnostic waxing. To address this issue, conventional silicone matrixes loaded with resin composite have been used. Nevertheless, this approach has some challenges, namely achieving the material to flow against all surfaces of the teeth, and obtaining a correct polymerization. These difficulties can be explained because of its consistency at room temperature and on the account of the opaque nature of the silicone, respectively. In this context, the recent development of clear silicone matrixes can be used as a new approach to facilitate intraoral light polymerization of composite resins, through the silicone matrix. By using this method prior limitations of using only autopolymerizing materials such as acrylic or bis-acryl resins can be resolved, thus permitting the clinical use of composite resins as an interim material. Furthermore, by preheating the composite resins physical and biomechanical properties are modified, which translates into a more fluid consistency, easier manipulation within the silicone matrix, and homogenous flow against all of the involved tooth surfaces [21, 22]. Some commonly cited advantages include a greater monomer to polymer

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conversion than room temperature resins, better color stability, more micro-hardness, decreased film thickness, and improved marginal adaptation [23-29]. However, long-term clinical studies are needed to confirm these prior findings. This clinical report describes the restorative treatment of a patient with decreased VDO and who additionally required an implant assisted prosthetic rehabilitation of the anterior maxilla. Preheated compactable resins applied through transparent silicone matrixes were used as the interim treatment approach. This method resulted in a conservative and reversible increase in VDO over a long period of time, thus removing the need for tooth preparations and interim acrylic resin crowns during the adaptation period.

CLINICAL REPORT A 47-year-old male was referred to the postgraduate program in oral implantology, of the Andrés Bello National University, in Santiago, Chile for evaluation and treatment. The patient used a removable partial denture and consulted because he was concerned about esthetic and functional aspects of his teeth. In particular, the patient was missing his superior incisors and requested a fixed treatment option. Treatment began by reviewing the clinical history of the patient, followed by a clinical examination. Objective and subjective parameters, applied during facial examination, determined a 2 mm decrease in VDO and a concave facial profile. Intraoral examination revealed partial edentulism in both maxillaries, malocclusion with supraeruption of the inferior incisors, limited prosthesis space in the anteriorsuperior sector, denture stomatitis, caries, and defective restorations (Figures 1-3). A two-stage treatment plan was designed based on the patient’s concerns and on the observations made during clinical examination. The first stage included the study of mounted casts in a semi-adjustable articulator; diagnostic waxing of the new VDO position; increasing the vertical dimension through interim restorations; repairing the existing removable prosthesis; and treating the denture stomatitis. The second stage considered implant surgery, and definitive restorations. Conventional treatment considers that tooth preparations must be made for definitive fixed restorations and/or onlays. Interim acrylic crowns must be kept in position during the entire implant treatment and osseintegration period, until being replaced by definitive restorations [18]. The limitation of this approach is that during the adaptation process teeth can undergo occlusal adjustments. Indeed, discrepancies can exist between initial tooth preparations and the definitive restorations. To prevent tooth reductions needed for interim acrylic resin crowns, the following technique proposes to create long-term composite direct bonded interim restorations that could be used until achieving patient’s stabilization. This procedure has the following stages:

Initial Assessment and Preparation of Silicone Matrix Treatment began with a full review of the patient’s clinical history. This was followed by clinical examination, assessing the temporomandibular joint, neuromusculature, VDO, and initial working position in the centric relation [30] Diagnostic photographs and impressions

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José M. Olivares, Eduardo Pino and Dafna Benadof

were taken. The study models were mounted in a semi-adjustable articulator (Model 2240 Articulator; Whip Mix Corp), and a diagnostic wax-up in the new position and VDO was performed aiming to achieve occlusal stability. Attention was strictly given to adding wax only on the tooth surfaces requiring modification, whereas alterations were avoided for the surfaces supporting the removable prosthesis components, in order not to alter its intraoral position. Once approved, a stock tray was used to make an impression with transparent silicone (Elite Glass; Zhermack) of the waxed-up models of both maxillaries (Figure 4). The silicone was removed from the tray and sectioned into two separate segments. Excess silicone and retentive undercuts were removed with a #15 sterile surgical blade (15# Surgical Blade; Dochem). This process resulted in two findividual silicone matrixes that allowed for light-induced polymerization of the composite resin [14, 16, 20].

Figure 1. Intraoral frontal photograph showing missing maxillary incisors and decreased prosthetic space.

Figure 2. Intraoral upper occlusal photograph.

Figure 3. Intraoral lower occlusal photograph.

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Figure 4. Clear silicone impression of diagnostic cast waxing.

Figure 5. Each tooth was isolated with polytetrafluoroethylene tape from neighboring teeth.

Clinical Bonding Protocol Amalgam fillings were removed, only in teeth requiring an occlusal increase, using diamond burs (Gold Diamons; DiaTech). Teeth were prepared to receive the preheated composite resins through a conventional adhesion method [31]. Each tooth needing intervention underwent individual relative isolation, with the interproximal areas of adjacent teeth covered by polytetrafluoroethylene tape (Tape;Stretto) (Figure 5). Then, the surfaces of teeth selected for treatment were etched with 37% orthophosphoric acid for 30 seconds and washed for 1 minute. After air drying, the adhesive system was applied (OptiBond FL; Kerr Corp). Each surface was polymerized for 20 seconds (Bluephase Style N; Ivoclar Vivadent AG). Then, A3 compactable composite resin (Tetric N Ceram; Ivoclar Vivadent AG), was applied on the cavity floor of teeth where the amalgam fillings were removed.

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José M. Olivares, Eduardo Pino and Dafna Benadof

Application of Preheated Composite Resin Afterwards, the following process was separately performed for each tooth: the A3 compactable composite resin (Tetric N Ceram; Ivoclar Vivadent AG) was plasticized at 58 oC for 5 min in a laboratory wax heater (Wax Heater Pot 4; Denshine), and the resulting fluidconsistency resin was transferred to the transparent silicone matrix.32 The silicone matrix was positioned in the mouth, using constant, firm pressure to maintain positioning. Each tooth surface was polymerized for 60 seconds. Then the matrix was removed, and the polymerization cycle was repeated (Figure 6). Any excess was removed with a #12 sterile surgical blade (#12 Surgical Blade; Dochem Dental) and rotary instrument (Gold Diamonds; DiaTech). Then, a surface sealant (Fortify; Bisco) was applied for 20 seconds to each restoration individually; polymerizing each side for 20 seconds. Glycerin jelly was applied to remove the superficial inhibition layer, followed by an additional 60 seconds of polymerization. Occlusal adjustments were made, and the restorations were finished with disks (Optidisc; Kerr Dental), interproximal finishing (Sof-Lex Finishing Strips; 3M ESPE), rubber points (Astropol; Ivoclar Vivadent AG) and diamond paste (Diamond Excel; FGM) (Figures 7-8). Then the removable partial denture was repaired and installed.

Protection Devices and Follow-Up A mouth guard was created for nocturnal use, thereby protecting the restorations and achieving equilibrated contact between all teeth during the stabilization period. Clinical followups were scheduled at 7 days, 14 days, and 1, 3, and 6 months. Excellent maintenance of the rehabilitation was evidenced, obtaining an Alpha score, according to the Ryge-USPHS criteria stablished for direct clinical evaluation of restoration. The only reported incident was a partial fracture of the restoration at the 2-month follow-up visit, which was reshaped [17, 33-35]. Occlusal stability was checked at every session requiring minimal adjustment at the first 14 days and then it was maintained throughout the following appointments, observing repeated occlusal contact points patterns.

Figure 6. After adhesion, preheated resin (58°C) was applied into the silicone matrix and firmly positioned intraorally. Each surface was polymerized for 60 seconds. Restoration developed individually for each tooth.

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Figure 7. Intraoral postoperative lower occlusal photograph.

Figure 8. Intraoral postoperative frontal photograph.

DISCUSSION Patients with a decreased VDO traditionally are treated with interim crowns made of acrylic resin or removable prostheses. These are maintained for an indeterminate amount of time, which can range from weeks to months, until neuromuscular, joint, and occlusal adaptation are achieved. Only then definitive restoration treatment can be prepared and installed [5, 11, 18]. During this adaptation period, occlusal adjustments and anatomic corrections of the restorations are frequently needed, but these needs do not always coincide with the previously performed tooth preparations. Consequently, tooth wear may be insufficient or exaggerated, depending on the clinical situation. Furthermore, the use of interim restorations for a long period of time can give rise to potential complications, such as sensitivity and caries formation [18]. Previous studies have reported the results of increasing the VDO through directly bonded restorations using silicone matrixes. Nevertheless, these have been limited to the assessment of splinted interim restorations in the short- to mid-term. Therefore, scarce information exists regarding performance of individual restorations using this technique [10, 14-16]. Ramseyer et al. in 2015 analyzed 98 restorations in 7 patients over a follow-up period of 40 months. Good

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results were reported according to modified USPHS criteria. However, more studies with standardized methodologies are needed to corroborate these findings [17, 34]. In the present clinical report, interim restorations were created using preheated compactable composite resin, a material with superior physical and biomechanical properties as compared to flow resins or room temperature compactable resins [36]. Using preheated resins removed the need for dental preparations in the interim stage, in addition to providing a minimally invasive way to assess long term patient adaptation [22, 26]. Furthermore, the applied procedure fully captured the information obtained from the diagnostic waxing, achieving a precise transference of the designed teeth anatomy and occlusal contacts. These traits translate into a technique that is quick, reversible, and reproducible [20]. The innovation of the treatment provided for this patient relays in the transparent silicon used for making two separate matrixes that were taken to the mouth without a tray. This procedure, which is similar to clinical reports by other authors, facilitates intraoral positioning of the matrixes sections and prevents the tray from blocking light during polymerization [14, 15, 37]. On the other hand, since this process did not considered the use of a rigid element, such as a containment tray, and the consistency of the silicone used is flexible, deformation could easily occur during the intraoral insertion of the matrix. Indeed, this technique is particularly pressure sensitive. One solution for this particular problem could be to use individual vacumformed trays or transparent acrylic resin trays as a containing material for the clear silicone [19]. Other procedure described in this technique is the removal of resin excess. Given the hardness of the compactable composite resin, excess was individually removed using a #12 surgical blade and polishing stones from each restoration. Splinting was avoided to facilitate hygiene maintenance by the patient, thus reducing risks for caries and periodontal inflammation during the stabilization period. Marginal adaptation of the impression, should always be verified to decrease the flow of excesses. Laboratory-based research have recently reported contradicting results in regards to the properties of preheated compactable resins [25, 27, 28]. These results could be explained by the use of different composite resin brands that differ in the chemical composition and filler percentages [24]. On the other hand the existing literature shows that preheating resin composites reduces its viscosity, thus facilitating handling and adaptation [21, 22]. There is also an increase in micro-hardness that could be explained by a larger degree of monomer to polymer conversion observed in preheated resins compared to room-temperature resins. Film thickness decreases and marginal adaptation increases, while, translating into better adjustment than with traditional methods [21, 22, 28]. One of the limitations of this approach, is that preheated resins produce a slight transitory increase in intrapulpal temperature compared to the room temperature composite resins. Nevertheless this thermal increase is less than the one caused by light-induced polymerization [24]. The limitations of this clinical report are that the technique was implemented in a single patient and that the follow-up period was short. Future randomized controlled trials should be conducted to evaluate the long-term benefits and drawbacks of preheated resins, its adaptation and its stability in time.

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CONCLUSION This clinical report describes the case of a 47-year-old man with a decreased occlusal vertical dimension, partial edentulism, and missing anterior maxillary teeth. The patient required combined restorative and implant rehabilitation. Treatment consisted in direct bonded preheated composite resin restorations applied by using a clear silicone matrix. This initial stabilization phase of interim restorative treatment represents a conservative, reversible, and predictable approach for long term interim restorations.

ACKNOWLEDGMENTS The authors thank Ivoclar for providing their materials for restorations.

ETHICAL COMPLIANCE 1) Sources of Funding This clinical report didn’t received any funding. 2) Potential conflicts of interest Disclosure of Interest: The authors declare that they have no conflict of interest. 3) Informed Consent Informed consent was obtained from the participant involved in this clinical report. 4) Statement of human rights This study was conducted in accordance with the 1964 Declaration of Helsinki and its subsequent amendments. 5) Statement of animal wellfare No animals were involved in this clinical report

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