Case study

Rehabilitation of anterior guidance in a combined prosthesis.

Abstract :

Estblishing anterior guidance in prosthetic rehabilitation should not compromise esthetics nor
function, the functional aspect must represent the starting point for achieving the optimal esthetics.

The ultimate goal of a correct anterior guidance is that it should be comfortable, functional and
stable even without posterior teeth contact.

The anterior guide table serves as a device for transferring the unique features of a specific anterior
guidance developed in provisional restorations to final resotrations.

The purpose of this article is to describe a technique for construction a custom incisal guide table.

Key words : Anterior guidance, function, esthetics, provisional restorations, custom incisal guide
table.

Introduction :

Any prosthetic rehabilitation of the anterior region raises two concerns ; The first concern is about
esthetics, dento-facial harmony.The second concern is about function. The restoration of anterior
guidance is the example that combines these two inseparable parameters. (1,2,10)

It’s described as the sliding of the mandibular anterior teeth against the lingual faces of maxillary
anterior teeth during mandibular excursions from maximum intercuspation to edge to edge occlusion
.known as the mutual protection concept,this anterior guide plays a very important role in protecting
the posterior teeth from protrusive and lateral stresses by discluding effect, thus avoiding posterior
interference. (6)

Proprioception which is at the origin of programming functional movements enhances energy

effeciency and improves sustainability of the manducatory system.(1,2)

these functional movements thus reduce: dental overloads (low frequency of contact on the
anterior teeth, absence on the posterior teeth) ,muscle work by symmetrization of functions
(neuromuscular facilitation, phonation and mastication optimization), and temporomandibular joint
constraints. (1,2)

This article is presenting a case report highlighting the restoration steps of anterior guidance.

Case report :
A 60 year old patient with no relevant medical history was referred to the department of
prosthodontics of the faculty of dentistry in Monastir . her chief complaint was restoring missing
teeth .

Intraoral examination revealed in the maxilla ,the presence of a defective metal acrylic bridge
restoration replacing teeth number 11,24 supported by 12,21,21,23,25,26, cervical margin was non
hermetic with a detached acrylic veneer on tooth 12.(Fig 1)

The upper right canine was mesioverted and dilapitated.(Fig1)

Panoramic radiograph showed insuffisant endodontic treatment for abutment teeth , crown to root
ratio was equal to 1 for all remaining teeth except the 26 ,CR/RR>1.(Fig 2)

The upper right second premolar and first molar were already extracted by the time of the
consultation.

For the Mandibule ,all teeth were present exept 47,48,38.(Fig 1)

Two defective metalic crowns covering teeth number 36,37. (Fig 1)

On the right side , supraeruption for tooth number 44,45,46 was noticed with a disrupted spee
curve.(Fig1)

radiographic examination , revealed defective endodontic treatment for tooth number 37 and a
massive carious root lesion on the distal side of tooth number 36 with favorable crown to root ratio
for all remaining teeth.(Fig 2)

Occlusion examination revealed a maintained occlusal vertical dimension,uneven occlusal plane due
to the supraeruption of tooth 46,dyfunctional anterior guidance, insuffisant prosthetic space and
disruption of spee curve on the right side.(Fig1)

Before proceeding with prosthetic rehabilitation , a sanative phase had to be done first;

Motivation to oral hygiene, extraction of compromised teeth 36,26 , removal of the defective metal
acrylic bridge.and endodontic treatment was performed on teeth 37,23,25,12. Teeth 23,25 were
reconstituted by an inlay core to improve retention value .

Upon clinical and radiographic examination and after obtaining patient’s consent :

the decision was to make at the maxilla a fixed metal ceramic bridge supported by teeth number
13,12,21,22,23,25 replacing teeth number 11,24 associated with a removable partial prosthesis
replacing missing teeth .

For the Mandible, the decision was to make a fixed metal ceramic bridge replacing tooth 36
supported by 35,37. And metal ceramic crown covering tooth number 46.

First of all ,a diagnostic wax up was used to evaluate and predicte the faisability of the treatment
plan and to restore occlual parameters .(Fig3)
 Temporary acrylic fixed restorations and provisional removable prosthesis were fabricated using
the diagnostic wax up ,and were clinically evaluated and adjusted based on the criteria dictating
esthetics,phonetics,and occlusion. (Fig 4)(7)

After reestablishing the anterior guidance in the mouth ; sliding the mandibular incisors over the
palatal faces of maxillary incisros,with minimal posterior disclusion is necessary ,thus the importance
of making the provisional removable partial prosthesis respecting esthetic and function imperatives.
(Fig 5)(7)

once it’s validated by the dentist and the patient ,impressions of these temporary restorations were
made and the casts issued from these impressions were articulated on a semi –adjustable
articulater and a custom incisal guide table is fabricated for a accurate reproduction of anterior
guidance.(Fig 6)

custom incisal guide table illsutration :

1/ lubricate the insical guide table with vaselin to prevent adherence of resin(Auto-Cured Acrylic
Material, Tab 2000™).

2/ place the resin on the incisal guide table with condyle locked ,this allows for the incisal pin to be
firmly positioned on the incisal table, and this establishes the initial position which represents
maximum intercuspation.

3/ unclock the condyles and move the articulator through prostrusive and lateral excursions.

This process should be repeated until the setting of the resin.

This custom incisal guide table will guide the lab technician in making the final restorations.(Fig 7)

After completion of teeth preparation , gingival retraction was achieved with a single cord technique
and impressions was made using silicone of low and heavy viscosity.( Fig 8)

Casts were poured and bite registration was performed, occlusal references are the centric relation
and a correct occlusal vertical dimension. Casts were then mounted on a semi adjutable articulator
using a face bow .

In laboratory, the crowns have been waxed according to custom incisal guide table and the casting
of the wax patten was done . the metal copings were verified and ajusted in the patients mouth ,the
cervical margins were examined.

the space needed for ceramic build up was also evaluated, Then the unglazed ceramic was clinically

tried to confirm the shade matching of the ceramic and also to adjust the occlusion.

Final fixed restorations were tried in the patients mouth and cemented.(Fig 9)

The next appointement , a coronoplasty was done for teeth 44,45 to reestablish the correct occlusal
plane then an anatomo-fuctional impression with a cutom tray and border molding with silicone
impession material was made for the maxilla and cast was poured (Fig 10).
The metal framework of removable partial prosthesis was fabricated and the try-in was carried in the
patient’s mouth. (Fig 11).

Acrylic teeth were sculpted on the prosthetic saddle , due to the lack of sufficient prosthetic space ,
Finally ,Occlusion and esthetics was verified in patient’s mouth.(Fig 12)

Follow up appointements were programmed to ensure long term preservation.

Discussion :

Anterior guidance is the guidance provided by anterior teeth when the mandible goes into a lateral
or protrusive movements ,it’s determined by a vertical overlap (overbite) and a horizontal overlap
(overbite) .(11)

Anterior teeth have major role in protecting posterior teeth during protrusive and lateral movements
and this is due to their biomechanical and proprioceptive features ,firstly anterior teeth have
biomechanical advantage over posterior teeth because they are farther away from the
fulcrum(condyles), since the mandible is considered as a type III lever (like anut cracker); hence, the
occlusal force on these teeth will be less than that imposed on the posterior teeth which minimize
force of muscle contractions,secondly ,the importance of proprioceptive sensitivity of anterior teeth
compared to posterior teeth allow the central nervous system to program and reprogram the speed
and envelope of mandibular functional movements .(11,12)

The restoration of a functional anterior guidance is fundamental to the success and sustainability of
any prothetic treatment of the anterior region . this goal cannot be achieved without a proper
clinical examination of anterior occlusal contacts. (3)

During maximum intercuspation contacts must be distributed symmetrically on either side of the
sagittal plane, the incisal edges of mandibular teeth should be in contact with marginal ridges of
maxillary anterior teeth.(8)

During protrusion , the incisal edges of the mandibular teeth should slide forward from the
maximum intercuspation following continuous linear paths, against the proximal marginal ridges of
maxillary anterior teeth with minimal posterior disclusion.(8)

During lateral excursions , the tip of the mandibular canine slides against the maxillary canine with
disclusion of posterior teeth on the working and non-working side , its called the canine guidance .
(8,9)

Anterior guidance clinical evaluation makes it possible to determine whether the existing anterior
guidance should be maintained or recreated .

The anterior guidance can be considered functional and should be kept if it has predetermined
characteristics. Otherwise, it must be recreated.

The anterior guidance can be considered as non functional when it’s not existent ( in case of an
open bite,excessive overjet, edge to edge occlusion), or if it does not ensure immediate disclusion
during the movement of protrusion and lateral excursions in the presence of interferences.
The anterior guidance is considered as dysfunctional when it’s existent but constitute an obstacle
to mandibular movement (in case of class II, division 2, with reduced functional freedom ).

When the anterior guidance is judged unsatisfactory clinically, only the posterior determinants of
occlusion can be used to recreate the anterior guidance ,thus by making a record of the protrusive
relation we can register the condylar path of the patient and adjust the condylar guides of the
articulator so it’s the equivalent of the condylar path of the patient and the adujtable incisor table of
the articulator is then tilted by 10° from the angle of the condylar path( I=C+10), by doing this
provisional prosthesis can be elaborated on a finely programmed articular and adjusted later in the
patient’s mouth.(3)

The best way to register the condylar path is by using axiography to provide more accurate
measuremenrs.(3)

Anterior guidance developed in the provisional restorations fabricated according to the diagnostic
wax, provided an opportunity to evalute aesthetics and function. (5)

Communicating the custom incisal guide table to the laboratory technician is a valuble aid in
making the final restorations.(5)

Conclusion :

If a dental restoration of the anterior region must respect esthetic criteria, it must imperatively meet
functional criteria. By its lingual face, it will directly influence the mandibular dynamics and if, in
adults, there are fortunately some adaptive capacities of the temporomandibular joint with the
potential of flexibility and resilience, there is neither flexibility, nor resilience of the fixed prosthetic
elements. It is therefore necessary to ensure that the anterior prosthetic elements are in functional
agreement with the skeletal frame.(4)

Références :

1 / Laplanche O, Pedeutour P, Laurent M, Mahler P, Orthlieb J-D. The previous guide and

its anomalies: incidence on the condylar kinematics. Cah Prosthesis 2002; 117: 43-55.

2 / S. Ourad, R.Elouali, A.Elyamani. Maxillary anterior restoration: aesthetic and functional

compromise. Prosthetic Strategy n ° 3 - June 30, 2017 (203-210).

3 / El Ouali R., El Figuigui L., Zouhair I., El Yamani A. The therapeutic challenge in the anterior
maxillary region: about a case. Actual. Odonto-Stomatol. Issue 270, November 2014.

4 / Orthlieb J-D, Bezzina S, El Zoghby A, Giraudeau A. Prosthetic reconstruction of the anterior

guidance. Cah Prosthesis 2004; 128: 55-64.

5 / Priyanka Mall, Kamleshwar Singh, Jitendra Rao, Lakshya Kumar. Rehabilitation of anterior teeth
with customized incisal guide table. BMJ Case Rep 2013. doi: 10.1136 / bcr-2013-009484.
6 / Laurent M, Orthlieb J-D. Occlusal approach to a restoration of the maxillary incisors. Cah
Prosthesis 1997; 99: 11-19.

7 / H Soualhi, L Assila. Interest of provisional prostheses in the restoration of the anterior guide. AT

About a clinical case. Odonto-Stomatological News • June 2011.

8 / O. Iraqui, S. Berrada, N. Merzouk, A. Abdedine. Anterior guide, physiological requirements and

prosthetic restoration. Odonto-Stomatologic News - n ° 245 - March 2009.

9 / Casteyde J-P. Canine occlusion. Importance, setting options, risks and precautions. AOS 2008; 244:
355-366.

10 / Dawson PE. The problems of clinical occlusion: assessment, diagnosis, treatment.

Paris¬: Editions CdP, 1992.

11 / Warreth, Abdulhadi. Fundamentals of occlusion and restorative dentistry. Part I: basic

principles.Journal of the Irish Dental Association | Aug / Sep 2015: Vol 61.

12 / Harry C. Lundeen, Charles H. Gibbs. ADVANCES IN OCCLUSION.

Fig1 : A: view of the maxillary arch, B:vien of the mandibular arch,C: static occlusion D: occlusion on
the left side,E, occlusion on the right side.
 Fig 2:Panoramic x-ray before treatment

Fig 3: A : mounted diagnostic casts right side, B: mounted diagnostic casts left side, C: diagnostic wax
up.

Fig 4: provisional anterior fixed restorations and removable posterior restorations, A:right side,
B:frontal view, C: left side.

Fig 5: anterior guidance developed in provisional restorations:

A: right side, B:frontal view,C: left side .

Fig 6:Provisional restorations casts mounted on a semi-adjustable articulator.

Fig 7:Custom guide incisal table.

Fig 8:Impressions of prepared teeth.

Fig 9: cemented fixed final restorations, A: right side, B: frontal view, C: left side.
Fig 10 : anatomo-functional impression.

Fig 11:Removable prosthesis metal framework try-in.

Fig 12:Final restorations : fixed and removable partial prosthesis. : A : right side view ; B : frontal
view,C : left side view.