Diagnosis, treatment planning, and comprehensive restoration of a patient with Costello syndrome: rationale and application of indirect composite resin onlays.

Patients with a complex problem set involving multiple levels of altered structure challenge the clinician to develop an individualized, appropriate treatment plan. Dentofacial deficiency, occlusal problems, and loss of tooth structure require intervention to establish stability and regain function, speech, esthetics, and masticatory muscle comfort. The comprehensive examination must quantify each problem to specify the diagnosis for realistic treatment planning. The clinical case of a patient with Costello syndrome is presented to illustrate essential concepts in diagnosis and treatment of complex cases, including (1) Global Diagnosis of anterior esthetic relationships, (2) occlusal analysis with diagnostic casts verified in centric relation, (3) comprehensive restoration previewed with a diagnostic wax-up and removable acrylic resin overlay, (4) adhesive monobody composite resin onlays that preserve tooth structure, and (5) programmed occlusion, quantified with digital occlusal analysis, to ensure stability and comfort. Costello syndrome is a neurodevelopmental syndrome causing multisystem effects, including a distinctive craniofacial phenotype, cardiovascular disease, intellectual disability, growth hormone deficiency, and dental abnormalities such as delayed dental development, bruxism, and demineralized enamel lesions. In the present case, quantification of the patient's problem set allowed precise treatment planning that resulted in predictable restoration.

Clinical protocol for occlusal adjustment: Rationale and application.

BACKGROUND: Occlusal adjustment can optimize the result of orthodontics, orthognathic surgery, and comprehensive restoration, and resolve adverse forces to the dentition that affect the entire masticatory system. Mounted diagnostic casts and computerized occlusal analysis offer complementary advantages for evaluating occlusal problems. Predictable occlusal adjustment is facilitated by precise, measured documentation of occlusal force by computerized occlusal analysis. CLINICAL PRESENTATION: A conservative, structural correction of a pronounced, chronic occlusal problem by additive and subtractive occlusal adjustment was performed after a previous failed occlusal adjustment. The patient's chief concerns were significant anterior teeth fremitus in maximum intercuspation and "pain in the teeth and a poor bite" after 30+ adjustments over 2.5 years. CLINICAL RELEVANCE: Confirmation of specific criteria for a therapeutic occlusion resolved the anterior teeth fremitus and uneven bite. Traumatic occlusal contact on posterior teeth may elicit protective mandibular repositioning affecting anterior teeth relationships and should be considered during comprehensive diagnosis.