PMC8684530_01
(a) Dystrophy of toe nails, (b-d) pretreatment occlusal vertical dimension loss, (e) pretreatment orthopantomogram, (f) pretreatment maxillary, and (g) mandibular arch.
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fig1
Extraoral examination revealed sunken cheeks, deep nasolabial fold, mild frontal bossing, thin sparse facial hair, and normal nails (Figure 1(a)). The teeth present were 17, 16, 55, 11, 21, 22, 63, 65, 26, 27, 71, 81, 82, 36, 35, 85, and 46 (Figures 1(b)-1(g)).
(a) Flexible occlusal splint, (b) final wax-up at desired vertical dimension, (c) minimal tooth preparation with polished metal copings, (d) maxillary and (e) mandibular provisional restorations, (f) metal coping try-in, (g) ceramic layering of prosthesis, and Rhein 83 attachment.
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fig2
Therefore, conforming to the "two splint concept," a removable flexible splint of 2 mm thickness was worn by the patient in mandibular arch for initial 6 weeks and in the maxilla for next 6 weeks (Figure 2(a)). Aluwax for recording the cusp indentations (Aluwax Dental Products Co), followed by mounting of the mandibular casts. A complete tentative wax-up was performed on diagnostic mounting and putty index (Dentsply Aquasil) were made (Figure 2(b)). No occlusal reduction was attempted as increase in vertical dimension was planned (Figure 2(c)). Final impressions were made using two-stage putty wash impression technique, and provisional restorations were fabricated directly using the final putty indices and luted with noneugenol temporary luting cement (3M ESPE RelyX Temp NE) (Figures 2(d) and 2(e)). Metal trial made using direct metal laser sintering technique was tried in patient's mouth to ensure marginal adaptation (Figure 2(f)). The ceramic layering with feldspathic porcelain established the occlusion plane using the final wax-up as a reference (Figure 2(g)). A mandibular cast removable partial denture framework (Co-Cr alloy) was then designed over Rhein 83 attachment using yellow extrasoft nylon retentive cap, and passive circumferential clasps were given (Figures 2(g) and 2(h)). Occlusal contacts in maximum intercuspation position were checked before luting the fixed restoration (Figure 2(a)). Finally, the luting of the fixed partial denture using glass ionomer cement (GC Gold Label 1 Luting & Lining Cement) and final denture insertion was done after ensuring Christensen's phenomenon as well as bilateral group function occlusion intraorally (Figure 2(b)).
(a) Final prosthesis in maximum intercuspation, (b) group function occlusion on lateral excursion movement. (c) Posttreatment esthetics, (d, e) 3-year periodic review intraoral photographs, and (f) follow-up orthopantomogram.
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fig3
The esthetics and phonetics of the patient were verified (Figure 3(c)). Figures 3(d) and 3(e) depict a healthy periodontal condition and good oral hygiene maintenance at a periodic recall visit after 3 years. An orthopantomogram taken after 2.5 years showed healthy abutments with minimal alveolar changes (Figure 3(f)).