final year dds restorative case

The Restorative Management Of Multiple Carious Lesions And Enamel Hypoplasia in a 57 year old female patient.Restoration of Form and Function

SECTION 1: PRE-TREATMENT ASSESSMENT

Presenting Complaint, History, Examination, Intra-Oral Photography, Study Casts

PRE TREATMENT ASSESSMENT

DEMOGRAPHICS

Patient Name: GD

Date of Birth: 13 /11/1955

Age on Initial Presentation: 55years, 10 months

Gender: Female

Ethnicity: Afro-Caribbean

Address: Arima

Registration Number: 722392

PRE TREATMENT ASSESSMENT

PATIENT COMPLAINT

Cavities

Mobile tooth in the upper arch

Missing teeth

Sensitivity

HISTORY OF PRESENTING COMPLAINT

Missing teeth were extracted due to caries

PATIENT EXPECTATIONS

To have teeth filled

Have a cleaning done

Replace missing teeth

PRE TREATMENT ASSESSMENT

RELEVANT MEDICAL HISTORY

Pneumonia as an infant

Contracted measles/mumps/chickenpox as a toddler (patient is not sure which one).

DENTAL HISTORY

Previous extractions for caries

Cleanings

Restorations

PRE TREATMENT ASSESSMENT

SOCIAL HISTORY

Non-drinker, non-smoker

GD is married with two children

Owns and runs a daycare

Stress level: 6/10

PRE TREATMENT ASSESSMENT

EXTRA-ORAL EXAMINATION

The following findings were within normal limits including: Facial tissues and Sensory Nerves Motor Nerves Lips Salivary Glands

The following findings were of note: Lymph Node: A right palpable tender submandibular lymph node was found TMJ :deviation of the jaw to the right on closing

PRE TREATMENT ASSESSMENT

INTRA-ORAL EXAMINATION

The following findings were within normal limits including: Gingivae Mucosa/Floor of the Mouth Palate Throat

The following finding was of note: Tongue: Geographic tongue

PRE-TREATMENT CLINICAL PHOTOGRAPHS

Clinical Photographs

Pre- Treatment Assessment: Portrait

Clinical Photographs

Pre- Treatment Assessment

• Smile: Front, R & L

Clinical Photographs

Pre- Treatment Assessment• Right and Left buccal segment (post

temporization of #35)

Clinical Photographs

Pre- Treatment Assessment • Labial segment

Clinical Photographs

• Retracted Front & L post restoration of #12 M

Pre- Treatment Assessment

Clinical Photographs

Pre- Treatment Assessment

Central incisor edges not evenly on a horizontal plane

Clinical PhotographsPre- Treatment Assessment

• Upper occlusal • Lower occlusal

DENTAL CHARTING AND EXAMINATION

Skeletal pattern Class IIIncreased overbite

Molar relationship Molar relationship not available

RCP/ICP slide The contacts are stable in RCP, no detectable slide into ICP3 3 4 72 3 5 7

Guidance from ICP Right and Left- Canine guidance

Interferences Nil

Occlusal stability Lack of posterior support for the right side (loss of all premolars and molars in the upper right quadrant)-Supra eruption of #35

Occlusion

PRE TREATMENT ASSESSMENT

TOOTH QUALITY

• Deficient in tooth structure: All upper anterior teeth and lower

canines and lower left lateral incisor

Dental Charting and Findings

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

KEYCaries

Composite restoration

Absent

Classification Caries Restorations

Class 1

#27#28#37#46#47

Class 2

#24 D#35 M#34 D#44 D#45 M

#22D composite

Class 3

#12 M#11 D

#21 M & D#22 M#23 M

• 24-Grade 2 mobile

• Five (5) Class 1 cavities• Five (5) Class 2 cavities• Six (6) Class 3 cavities• White spot lesions on the buccal of #27 and #37• Total: 15 of 22 teeth affected

PRE TREATMENT ASSESSMENT

2 2

2 2 2

PERIODONTAL EXAMINATION

• Full Mouth Plaque Score: 78%

• BPE

• Presenting oral hygiene: Twice daily brushing with a medium toothbrush and adult toothpaste, does not floss and does not use a mouthrinse. Used a personal explorer to “pick” between teeth throughout the day.

RADIOGRAPHIC ASSESSMENT

Radiographic report

• #46 - occlusal caries possibly into pulp• #45 – mesial caries into dentine• #44 – distal caries into dentine

• #35 - mesial caries possibly into pulp

• #34 – distal caries into dentine• #24 – distal caries into dentine

Right and Left Bitewings including after #46 was temporized

Radiographic report

Right and Left buccal segment Periapicals

• #46 & #35 – healthy periodontal and periradicular tissue

Radiographic report

Anterior Sextant Periapicals

• #12 – mesial caries into dentine• #11 – distal caries into dentine• #21 – distal caries into dentine

• Area of linear rarefaction across mid-portion of the crowns of #12 to #22 (wider on #22)

PRE TREATMENT ASSESSMENT

SPECIAL TESTS

• #35 & #46 were vitality tested using cold testing (Endo Ice®)

• Results included a quick positive response both lasting < 3s

PRE TREATMENT ASSESSMENT

Period Day 1 Day 2 Day 3

Before breakfast

Water Water

Breakfast Milk and cereal Toast and cheese

Milk and cereal

Between meals Water Peanut punch Water

Lunch Water and coconut crackers

Rice, vegetables with minced chicken

Peanut punch, crackers and jam

Between meals Coconut water and jelly

Preserved mango, water

Cashew nuts, water

Dinner Provision and saltfish with patchoi

Macaroni pie Macaroni and vegetables

After dinner Water Chocolate wafer

Aloo pie

3 DAY DIET SHEET

PRE TREATMENT ASSESSMENT

DIET REPORT (including diet interview)

• Number of times sugary food were consumed on average per day – 3 (including occasional ice-cream at nights before bed)

• Processed starch- sugared breakfast cereal most mornings

• Fresh Fruit: Once or none per week but dried fruit in cookies between meals

• Drinks: Frequent bottles of water throughout the day, occasionally soft drink at night with dinner

ANALYSIS

Frequent Non Milk Extrinsic Sugar consumption including between meals

Large sugar load before bed time (coupled with improper brushing technique)

PRE TREATMENT ASSESSMENT

CARIES RISK

High Risk

Frequent intakes of NME sugars

Poor plaque control

Multiple carious lesions both anterior and posterior

Multiple missing teeth due to caries resulting in extraction

No fissure sealants

Exposed dentine in hypoplastic regions

PRE TREATMENT ASSESSMENT

PROGNOSIS

Good

DIAGNOSIS

Generalized gingivitis (Plaque and Calculus etiology)

Active Caries in both anterior and posterior regions

#46 and #35 are vital

Environmental Enamel Hypoplasia (as opposed to systemic)

PROBLEM LIST

1. Poor oral hygiene

2. Caries

3. Deficient tooth structure

4. Partially dentate with unilateral loss of posterior support

TREATMENT PLAN

TREATMENT PLAN (01/11/11)

1. Emergency/Disease

Stabilization Phase

a. Temporize #35 and #46

2. Preventive Phase

a. Oral Hygiene Instruction and

Dietary Advice

b. Supragingival Scaling and

polishing

3. Restorative

Phase

1. #12 M&D

2. #11 D

3. #21 M&D

4. #22 M

5. #23 M

6. #24 D

7. #27 O

8. #28 O

9. #37 O

10. #35 M

(possibly RCT)

11. #34 D

12. #44 D

13. #45 M

14. #46 O (possibly

RCT)

15. #47 O

TREATMENT PLAN

4. Advanced Restorative Phase

a. Six (6) direct resin composite veneers in the upper anterior sextant (the worse

affected teeth may be regarded as buildups).

b. Upper Co-Cr denture

5. Review/Maintenance

a. 6monthly then yearly recall

AMMENDED TREATMENT PLAN

1. #35 came to involve the pulp during caries removal , non –surgical root canal

therapy followed by placement of a PFM crown was then included in the

treatment plan (08/11/11)

2. Extraction of #24 due to vertical crown-root fracture (11/06/12)

Patient complained that #24 showed increase in mobility and experienced a lancing type pain

radiating to the left ear and upper jaw. Patient also experienced a salty and “bad” taste from fluid

coming from the tooth.

Examination revealed cervical regional lyphadenopathy (left), buccal and palatal mucosal swelling

and a vertical crown-root fracture, tooth tender to percussion

Radiographic assessment (Periapical) showed a diffuse periapical radiolucency

With loss of apical lamina dura and pdl widening

Diagnosis: acute periradicular abscess (True Perio-endo lesion)

TREATMENT COMPLETED

1. Oral hygiene instruction

including modified bass

technique and substitution of

“picking” teeth with proper

flossing technique and dietary

advice

2. Fifteen (15) restorations. #24

D was not completed-

subsequently extracted

3. NSRCT of #35

4. Six (6) upper anterior

composite veneers; (#13 and

#23 were more extensive –

buildups)

5. PFM crown preparation and

delivery of #35

6. Mouth preparation and

delivery of upper Co-Cr

denture

TREATMENT COMPLETED- NSRCT #35

MID-TREATMENT CLINICAL PHOTOGRAPHS

Mid-Treatment Photographs

Mid-Treatment Photographs

Mid-Treatment Photographs

CHALLENGES

Challenges

1. An attempt at the sandwich

technique was made resulting

in a less than ideal restoration

in #45 and #44 interproximal

restoration

Challenges

2. 11 days after restoring #46 O the distolingual wall that remained after the amalgam restoration fractured.• Increased buccolingual width of the cavity preparation for amalgam

predisposes teeth to fracture• Was removed and replaced using the Automatrix system

Challenges

Challenges

3. Loss of supporting abutment in the #24 for upper Co-Cr denture (11/06/12)

Challenges

4. Due to the hypoplastic tooth form of the #13 and #23 undercut was found to be insufficient for the I bars, that were proposed for the upper Co-Cr denture direct retention.

• During the veneering process these were re-contoured to achieve desired undercut

Challenges

5. A2 shade Z100 composite was inadvertently used for #12 veneer (Z350 A3 used for prior restoration was lost) resulting in undesirable show through of underlying hypolplastic area (and thus visible dentine).

• Portion was removed to place A3 but addition has not been stable over two visits

• Area requires additional retentive features and proper use of adhesive to add new composite to the old.

Challenges

6. Lack of completely harmonious occlusion due to denture made posterior open bite

• Problem was detected during wax trial stage, wax became dislodged from frame.

• Technician was notified but denture was processed before re-trial• Possible causes: Insufficient bite registration; in the least a wax bite was not

supplied to the technician and teeth were set abritrarily.

CURRENT STATUS

1. Oral hygiene: Recent

unanticipated (by the patient)

plaque score: 15%

2. BPE:

01/11/11

05/03/13

3. PFM crown has been

temporarily cemented

pending full satisfaction on

esthetics.

4. No signs of recurrent caries

1 1

1 1 1

2 2

2 2 2

FURTHER TREATMENT

1. Short Term

Rebonding/glazing of all anterior

veneers (Placement a thin layer of

unfilled resin to improve marginal

integrity, improve early wear

resistance and help reduce staining

of the restorations

2. Medium Term

Permanently cement PFM on #35

providing the patient is fully

satisfied

Repair occlusion error on upper Co-

Cr denture

Monitor longevity of canine veneers

under functional loading

3. Long Term

Possible placement of porcelain

veneers on the anterior teeth with

the exception of the canines. All

porcelain dentine bonded or

polycrystalline crowns for the

canines

Post-Treatment Photographs

Post-Treatment Photographs

Post-Treatment Photographs

The upper denture is not well seated here

Post-Treatment Photographs

Conclusion

Recall the aim: To restore form and function. I will say that the aims have notcompletely been carried out. Function, the more important aspect of the stomatognathic

can be found lacking and every step should be taken to fully restore it.

Thank You