Robert,

Where to begin? Actually, there are four categories where we can start. First, perio. What is his perio status? Type II, III, IV? Any mobility? Any teeth lost due to periodontitis? If you were to do absolutely nothing to his teeth, would you expect his condition to be excellent, good, fair, poor, or hopeless in the future? Obviously, this gives us a great foundation.
Second, the biomechanical aspect. What is his caries rate/risk? How many defective restorations? Questionable restorations? Structural compromises? (i.e. RCT’s, posts, crowns, large BU restorations) Were any teeth lost in the past due to caries or biomechanical purposes?
Third, the functional aspect. You said there is bruxism, but is it parafunction or a constricted neuromuscular envelope? Is there any wear in the posterior that matches the anterior? What is the Angles Classification? Is there a loss of VDO? Any TMD? What is the maximal opening? Any deviation upon opening?
Fourth, the dentofacial aspect. Simply put, are the teeth in the right place? This one is obvious . . . NO! But, how long are the central incisors? Is the maxillary incisal edge position about in the right place? What is his smile line like . . . high or low? Is the maxillary occlusal plane flat or curved? From the pics, it looks pretty flat, but I’m thrown off by that blue thing in his mouth. Also, it’s difficult to tell if the angle of the first picture is too low, thus altering the image of the occlusal plane.
These are all questions I ask myself for my complex cases, and I give credit to John Kois who has had this mapped out for years, in obviously much greater detail. (I highly recommend his course, BTW . . . [url=”http://www.drkois.com)”]www.drkois.com)[/url] Not knowing all the details, I would definitely recommend an ortho consult. He may be an orthognathic case. I myself have had a mandibular advancement and I highly recommend orthognathic treatment when appropriate.
After that, I would mount his case on the articulator and create a GC resin pattern of his envelope of function. It looks like his teeth are short and that the VDO is closed, so, most likely it’s looking like a full mouth rehab where you’d open the VDO. If he truly does have a constricted envelope, that needs to be addressed and changed, otherwise any restoration you place in there will be guaranteed to fracture.
Just my . . . well more than two cents worth anyway. Thank you for sharing the case! I’d love to see more pictures!

aaroN