Making full mouth rehabilitation possible. Early Christmas present from Dr. DiVito. The jaw joint was corrected with a mandibular stabilization prosthesis. Crowns to stabilize the bite

Giving the gift of a smile is one of the most rewarding parts of the dental profession. Bree’s story started at the beginning of my junior year when she came to the Arizona Dental Clinic to get something “fixed.” Because of trauma to her front teeth and congenitally missing premolars, she presented with an interim partial denture. Wearing a flipper was not the most appealing option to a 20-year-old woman.

With so much emphasis on cosmetic dentistry today, we spent time discussing her expectations and ideal smile.

Full Mouth Rehabilitation

After determining Bree’s goals and restrictions, we completed an initial consultation. The thorough evaluation involved a comprehensive examination, evaluation of the TMJ, occlusion and periodontal health of potential abutment teeth. Because the case was so complicated, I completed my own wax-up and presented it to her during the treatment plan discussion. She was overwhelmed with excitement and could not wait to begin to treatment.

Despite her excitement, everything comes with a price and unfortunately, full-mouth rehabilitation was not in the budget. Time passed, and I did everything possible to investigate various patient payment plans. I promised not to give up. We kept in touch and I hoped to find a way to make things happen.

As fate would have it, I was glancing through Bree’s treatment plan when Dr. Enrico DiVito, ASDOH adjunct faculty, took interest in her unique case. After looking at her portfolio and discussing the situation, he asked what I thought. I turned to him and said, “If it were me and my private practice, this is a case that would be done…just because it has to be. No questions asked.” Dr. DiVito agreed and offered to complete the case in his Scottsdale office, with me serving as his associate student dentist. By then it was nearly Christmas, and I couldn’t wait to break the news to Bree. After hearing of Dr. DiVito’s generosity, Ahwatukee Dental Lab (housed in Arizona’s Dental Clinic) offered to provide all the crown and bridgework for the case. I called Bree and said I had an early Christmas present. It was a very emotional call, truly a dream come true.

After we both calmed down from all the excitement, it was time to get the ball rolling. We met at Dr. DiVito’s Scottsdale office, where he completed his own medical history and examination. Using both polar and axial corrected tomography, Bree’s jaw joints were imaged to visualize their respective relationships in the fossa. Using the pretreatment radiographs, a tracing overlay was completed. This tracing made it possible to objectively measure and assess both the vertical and horizontal relationship of the condyles in the fossa. It would also allow Dr. DiVito to visualize and measure a more ideal rearticulation of this patient’s condylar/fossa complex.

Using these new values derived from vector analysis tracing, diagnostic facebow mounted casts were placed on a Hanau articulator and the new dental/alveolar relationship observed. Using this corrected set-up, a mandibular stabilization prosthesis (MSP) appliance was fabricated from acrylic.

Bree wore the MSPappliance 24/7 for nearly four months, removing it only to maintain oral hygiene.

During this time, Dr. DiVito monitored her progress by measuring her range of motion, proprioception and velocity values on a weekly basis. Bree wore the acrylic appliance for nearly four months, confirming dramatic remission of her pretreatment symptoms and sterilization. Using this therapeutic approach, Bree’s treatment was entirely reversible and could be re-accommodated if needed. Dr. DiVito ordered an MRI to both assess and verify the physiological relationship of her joints and objectively stage the degree of internal derangement of both hard and soft tissue structures. Although orthodontics and implants were some of the many treatment alternatives, the patient declined these options due to timing.

Once the bite was stabilized and #19 had retreat root canal therapy, it was time for Dr. DiVito to begin dental rehabilitation. Beginning with the upper arch, remaining primary teeth were extracted and provisionals fabricated to duplicate the patient’s current dentition so the newly established relationship with the MSPcould be maintained during treatment. After completing the preparations on Bree’s lower arch in a similar fashion, a mock wax-up representing the new stabilized occlusal/anatomic relationship with her MSP, indexing bite and final impressions were sent to the Ahwatukee Dental Laboratory for crown and bridge completion. In total, this crown and bridge TMJ rehabilitation included 21 PFM crowns and three all-ceramic crowns. Overall, the project was a great learning experience, and I will always remember Bree for her genuine personality and gratitude. Cases like hers make dentistry a truly unique and rewarding profession.

In a letter to Dr. DiVito, Bree wrote
“You gave me the best gift I could ever receive. Your work went above and beyond what I ever imagined. Thank you from the bottom of my heart.

For the first time in years, I have the confidence to smile in crowds and especially around cameras. I am able to enjoy food I once had to give up. This blessing has really changed my life and I can’t thank you enough.”