James F. Fondriest, DDS and Matthew R. Roberts, CDT
Hypocalcification of her tooth enamel had created occlusal and esthetic problems for a 26-year-old patient with celiac disease. Celiac disease is an autoimmune digestive disorder that damages the villi of the small intestine and interferes with absorption of nutrients from food. This disease can cause the improper development of enamel on adult teeth. The combination of bruxism with weak and poorly developed enamel had caused significant loss of tooth structure for this patient. Bonded composite did not serve well on functional occlusal surfaces. Full fixed prosthodontic coverage of her teeth was performed. The details of creating a customized appearance of the prosthesis for this patient are discussed.
Celiac disease is a digestive disorder that damages the small intestine and interferes with absorption of nutrients such as calcium from food.1 People who have celiac disease cannot tolerate a protein called gluten, found in wheat, rye, and barley. Gluten is found mainly in foods but may also be found in products we use every day, such as stamp and envelope adhesive, certain medicines, and vitamins. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the finger-like villi of the small intestine. When the villi become damaged, the body is unable to absorb nutrients into the bloodstream, which can lead to malnourishment. Failure to thrive during childhood development is a common indicator of celiac. Common signs of celiac disease include anemia, delayed growth, weight loss, and joint problems; and the bones become weak, brittle, and prone to fracture. Celiac disease is a genetic condition that can be triggered by events such as surgery, pregnancy, childbirth, viral infection, or severe emotional stress. The only treatment for celiac disease is a lifelong gluten-free diet.
A fairly common oral manifestation of celiac disease is abnormal tooth shape and/or appearance. The teeth can be slightly small, widely spaced, and discolored with hypo-calcified enamel (Figs 1-3). Patients with dental enamel defects of the entire secondary dentition should be screened for celiac disease even in the absence of gastrointestinal symptoms.2 There can also be recurrent aphthous stomatitis. This disease affects one in 100 individuals, and 97% of those affected are undiagnosed.3
Patient History and Goals
The patient discussed here had been diagnosed with celiac disease at age 13. Although she continued to have occasional minor gastrointestinal flare-ups, her medical/dietary therapy had mainly quieted the manifestations of the disease after diagnosis. The damage to her teeth had been done as the teeth were being formed prior to diagnosis.
She was unhappy with the esthetics of her smile. She presented at age 26 with composite bonding that had been applied to the buccal surfaces of her maxillary front teeth, which had been maintained for 18 months (Fig 4). Although the marginal integrity was already staining and failing, the patient’s former dentist reported that the composite improved the esthetics of her smile greatly. Previous composite restorations had not been retained for very long, especially on chewing surfaces or functional occlusal surfaces. The qualities of her enamel and dentin as a result of celiac disease might have affected the bond strength of the composite, compromising the longevity of her previous restorations. She had been referred to us to have her teeth restored by more permanent and esthetic means. The goals were to create an improved esthetic display, establish ideal tooth anatomy, and more permanently impede the ongoing changes that had been occurring in her bite.
Due to the poor bonding qualities of the teeth, nighttime bruxism, and the ongoing loss of vertical dimension, it was decided to do full-coverage restorations on all of her teeth. Due to the lack of certainty in reliably achieving a strong dentin bond, the tooth preparations were designed with maximum retention and resistance form. All posterior teeth would be restored with porcelain-fused-to-gold crowns and pressed Empress (Ivoclar Vivadent; Amherst, NY) crowns in the anterior teeth.
The planning phase included acquiring diagnostic photographs of the patient, radiographs, and mounted models; and ascertaining the patient’s desires and expectations. The more information-sharing that was done, the more the patient took an active role in the planning process. She had definite opinions on what specific shapes she wanted her new teeth to have, as well as the level of brightness and translucency. Her request was to have “natural-looking teeth, but a little brighter.” The patient did not have the knowledge or vocabulary to describe her understanding of what a beautiful smile was, but she (and her mother) indicated that they would know it when it was achieved. Much time was spent clarifying what their definition of natural was.
When the wax-up was completed and the reduction guides and putty matrix impressions were created, the patient was scheduled for preparation and provisionalization of the maxillary arch. The lower arch was temporarily built up with composite to help open the vertical. It was at the first placement of the maxillary provisionals that the patient saw her new smile start to materialize. No matter how well the contours were planned with the preoperative photographs and wax-up, until we placed these provisionals into her mouth we did not know what it would look like or how it interacted with the tissue to create scallop forms and inter-dental papillae.9,12 She got to see for herself what the amended length, shapes, incisal embrasures, etc. that she chose for her teeth looked like behind the drape of her own lips (Figs 9-11).
Wearing the provisionals allowed the patient to adapt to the changes in the phonetic interplay between the teeth and the occlusal changes that had been created by the significant prosthetic reorientation of her teeth prior to the delivery of her final restorations.13,14 Due to the increased functional stresses and potential for porcelain fracture from the occlusal trauma that comes with bruxism, a shallow-to-flat anterior guidance with a smooth crossover in excursive movements was created.
When the maxillary provisionals had fulfilled all of the goals for esthetics, function, phonetics, and cleansability, it was time to send the case to the laboratory. Because all of the criteria for acceptance had been worked out in the provisional stage, the laboratory just had to duplicate the contours of the provisionals to achieve an esthetic and comfortable result.10 Documenting the provisionals included straight-on portraits, portraits taken from the side, close up extraoral and intraoral photographs, retracted images from all angles when teeth were together and then when they were apart, stick bite, mounted models of the provisionals, and bite registration records of the provisionals and prepared teeth. Offering a critique of the provisionals (mine and the patient’s) was helpful to my technician partner. The technician was given direction as to how much artistic license there was with the duplication of the contours of the accepted provisionals.
To decrease the level of difficulty of replacing the maxillary provisionals with the final prosthetics, this patient was restored one sextant at a time. This way, the trauma at any given appointment was far less. No master impression required capturing more than six teeth at a time (Figs 12 & 13). This also decreased the risk of bite registration errors, which are far more frequent when doing an entire arch.
The lower arch was completed in three segments like the upper arch but without a wax-up and prolonged use of provisionals (Figs 14-18). All posterior crowns were luted with Rely X luting cement (3M ESPE; St. Paul. MN). The anterior teeth were bonded with Optibond FL (Kerr; Orange, CA) and Rely X ARC dual- cure resin. Assuming that high bond strengths were unlikely with any cementation system, the choice of luting agents was based on what is commonly used in the office.
This patient suffered the dental consequences of celiac disease in combination with severe bruxism. The resulting significant dental attrition caused the loss of vertical dimension and diminished esthetics. A custom smile was produced by collaborating with the patient in the design on every level of the final prostheses. Specific shapes, textures, translucency gradients, and chroma and value gradients were created to fashion this patient’s definition of a beautiful smile.
The author thanks the laboratory contributions of Mark Kajfez, CDT (Waukegan, IL), who did the posterior crowns; Dave Rice, DDS (Elgin, IL), for the graphics help; and Dave McClenahan, DDS (Lake Forest, IL), for the muco-gingival grafts.
The American Academy of Cosmetic Dentistry recognizes Matthew R. Roberts, CDT, as an AACD Accredited Member (AAACD).