Esthetic reparation of the dental consequences of Celiac disease – A case report
James Fondriest, DDS
Matt Roberts, CDT
Hypo-calcification 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 disease 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.
What is Celiac Disease?
Celiac disease is a digestive disease 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, medicines, and vitamins. When people with celiac disease eat foods containing gluten, their immune system responds by damaging the fingerlike 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 are anemia, delayed growth, weight loss, joint problems, and the bones become weak, brittle, and prone to breaking. Celiac disease is a genetic condition that can become active or is 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 somewhat common oral manifestation of celiac disease is abnormal tooth shape and/or appearance. The teeth can be discolored with hypo-calcified enamel ( figures 1- 3). The teeth can be slightly small and widely spaced. 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 every one hundred individuals and 97% of those affected are undiagnosed 3.
Dental Presentation of Celiac
This patient had been unhappy with the esthetics of her smile. She presented with composite bonding that had been applied to the buccal surfaces of her maxillary front teeth which had been maintained for 18 months (see figure 4). Though the marginal integrity was already staining and failing, 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 quality of her enamel and dentin may have affected the bond strength of the composite compromising the longevity of her previous restorations. At age 26, she was referred in to have her teeth restored by more permanent and esthetic means. The goal was to limit the ongoing changes that had been occurring in her bite and to create an improved esthetic display. Due to the poor bonding qualities of the enamel, the night time bruxism, and the ongoing loss of vertical dimension, it was decided to do full coverage restorations on all of her teeth.
Planning for Treatment of Dental Manifestations
The planning phase included acquiring diagnostic photographs of the patient, radiographs, mounted models, and 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) suggested that she/they would know it when it was achieved. Much time was spent clarifying exactly what their definition of natural was.
Although we are sometimes referred new patients that think, believe, imagine, and assume everything is possible, the majority of clients don’t know what really is possible and even if they do, they don’t know what the dentistry will look like in their own smile. Many practitioners have the digital ability to create images that represent potential outcomes 4,5. These are helpful but can easily give patients unrealistic expectations due to the fact that changing real teeth is far more difficult than doing it digitally. Applying composite “mock-ups” to the teeth will give the patient a good impression of how it could look, but this is not a substitute for diagnostic longer term provisionals 6,7. It helps to both see and “feel it” to judge it. Wearing provisionals a month or two could serve to develop my patient’s understanding of what was possible esthetically and offer her more opportunity for growth and involvement in the process. Instead of preparing the teeth and taking final impressions for completion of the case, it was decided to do a wax-up and subsequent provisionals to test the outcome. The wax-up would serve as the first rendering of the final product. All too often the final restoration serves as the only rendering, especially with implant restorations. This limits the many lessons that the intermediate steps of doing a wax-up and provisionals can provide.
Figure 5. Line drawings of agreed upon outline form of future teeth used as a guide in creation of wax-up. A periodontal consultation recommended a muco-gingival connective tissue graft on the buccals of teeth 21 and 25.
When the patient’s vision was clear, an assembly of portraits, intra-oral images, scanned magazine picture cut-outs, and line drawings (see Figure 4) were then collated together in a PowerPoint™ presentation. This served as the laboratory prescription for a wax-up of the treatment plan. The visual guidance that the lab technician received as to how to create the esthetic contours of the wax-up in this PowerPoint™ presentation was of far greater value than any written document.
From the esthetic perspective, the purpose of the wax-up was more than just as a guide for the laboratory to complete the project. The wax-up allowed tooth reduction guides to be made which guided tooth preparation 8. Because the wax-up was a rendering of my understanding of what the patient wanted esthetically, it served as the template for the provisionals, the second rendering of the final product. The wax-up could be used to fabricate the provisionals directly in the mouth or indirectly in the lab.
The wax-up yielded significant pertinent information. Due to the already significant loss of tooth structure, the wax-up gave a better feel for just how much reduction needed to be done to move her posterior teeth into preferred orientations and positions 9. 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 cross-over in excursive movements was created. The vertical dimension of occlusion was opened 3mm measured from the incisal edge of the maxillary centrals. The wax-up allowed detailing for ideal placement of the cusp fossae relationships and the ridge blade placements for the premolars. The restorative plan was to restore all posterior teeth with porcelain fused to gold crowns and pressed Empress™ crowns in the anterior teeth.
Use of Temporaries to Model final outcome
When the wax-up was completed, a reduction guide was prepared and the patient was scheduled for preparation and provisionalization of the maxillary arch. The lower arch was built up with composite to help open the vertical. It was at the first placement of the provisionals that the patient saw her new smile start to materialize. No matter how well the contours were planned with the pre-operative photos and wax up, until we placed these provisionals into the 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 7, 10. She got to see for herself how the amended length, shapes, incisal embrasures, etc. that she chose for her teeth looked like behind the drape of her own lips (See figures 5).
Wearing the provisionals allowed for 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 11, 12. Often patients are startled by the quick and profound changes that can be made by doing dentistry. The provisionals allow a non-final intermediate place so that the patient can become accustomed to the changes. Occasionally a patient will pull back on the degree of change because of the difficulty in getting used to a new look. When they look at a smile for their entire life and suddenly it is gone, there can be a sort of disorientation. If the practitioner gives the patient the time to live in the provisionals prior to taking final impressions, the patient can be brought farther along.
Completing the Dental Treatment
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, then the lab just had to duplicate the contours of the provisionals to achieve an esthetic and comfortable result 9. Documenting the provisionals included straight on portraits, portraits taken from the side, close up extra-oral and intra-oral photographs, retracted images from all angles when teeth are together and then when they are apart, stick bite, mounted models of the provisionals, and bite registration records of your provisionals and prepped teeth. Offering a critique of the provisionals (yours and your 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 provisionals with the final prosthetics, this patient was restored one sextant at a time. The trauma at any given appointment was far less. No master impression required capturing more than 6 teeth at a time (see Figure 6). This also decreased the risk of bite registration errors which are far more frequent when doing an entire arch.
Conclusion and Review of Treatment
This patient suffered the dental consequences of Celiac disease in combination with severe bruxism. The resultant significant dental attrition caused the loss of vertical dimension and diminished esthetics. A custom smile (see Figure 7) 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.
Many thanks to the laboratory contributions of Mark Kajfez, CDT who did the posterior crowns, Dave Rice, DDS of Elgin, IL for the graphics help, and Dave McClenahan, DDS for the perio-plastic surgery.
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