module 2 2 october 2008 case presentation adrian wong case presentation adrian wong
TRANSCRIPT
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Module 2 2 October 2008
Module 2 2 October 2008
Case Presentation Adrian Wong
Case Presentation Adrian Wong
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61 year old Male61 year old Male
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• Cheek biting +++
• Food packing +++
Chief Complaint
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• high blood pressure (controlled)
• gastro- eosophageal reflux
Medical History
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• RCTS +++
• Restorations +++
• Failing Crown and Bridge
Dental History
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Extra-OralAt rest
Extra-OralAt rest
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Extra- Oral• No tooth display at rest
• Reverse smile
• Low lip line
• Tenderness in Lateral Pterygoids
• No joint sounds
• phonetics - “F” not clear and “S” not crisp
• brachio facial type
• enlarge massetters and tempoarlis (no tenderness)
• Class 1 skeletal
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Reverse Smile LineReverse Smile Line
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• Low Smile line
• Poor incisor edge position
• Central incisors -1:1 square
• Good midline and no cant (co-incident with facial mid-line)
• Reasonable Zenith Points
• Good Buccal Corridor
• Over eruption Q1
• Reverse Smile
• Diastema
Aesthetic assessment
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INTRA-ORAL
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Occlusal View LOWER
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OCCLUSAL VIEW UPPER
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• Caries
• Attrition
• severe erosion
• slight periodontal disease
• existing crown and bridge
• failing restorations
• missing teeth
• short crown height esp lower posteriors (reflux pattern?)
• alveolar ridges well developed
• over-eruption Q1
• RCTs +++
• Porcelain #+++
• Group function - no anterior guidance
• Slide form CRCP to MIP 0.5mm anteriorly, 0.25mm to RHS, 0.25mm vertical
Intra-Oral
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OPG
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Risk Factor assessment
• Heavy bite
• Parafunction
• Past # porcelain ++++
• RCT reinfection/Mechanical failure
• High rate of recurrent caries
• Acidic mouth (Reflux)
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Treatment plan• Preventive treatment - medical
assessment and treatment of reflux, use of recaldent chewing gum/tooth mousse, fluoride mouth rinse.
• Periodontal treatment and maintenance.
• Endodontic assessment - 25, 26, 37, 36, 35, 47, 48
• extraction of 48
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Full mouth Rehabilitation
• Rehabilitate to CR/CR with long centric
• Increase OVD and length of anterior to predetermined position- single point contact cusp-fossa contact posteriorly and immediate disclusion during all excursions.(anterior guidance)
• Long term laboratory constructed provisionals
• Composite buildups on lower incisors
• Gradual conversion of provisionals to final restorations
• 24, 25, 37, 36, 35, 46 - consider implant replacement
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Uncertainties• Increase in OVD sufficient to eliminate
cheek biting?
• Gold restorations should be material of choice?
• Composite buildups on lower anterior sufficient?
• Longevity of Provisionals
• Incisors too long?
• Too much anterior tooth display given age and long upper lip
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Centric Relation Record
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Composite Mock up
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Composite Mock Up at Rest
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Composite Mock up
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Composite Mock Up
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Diagnostic Wax up
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Test Wax up
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Test Wax up
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2.5mm increase in length
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Completion of Wax up at increased vertical
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Completion of Wax upat increase Vertical
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Upper cast
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lower cast
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3-3 Lower Composite buildups 2-4mm
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Transfer to mouth
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Transfer to Mouth
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Provisional Stage treatment completed
• 14, 15 buccal cusp tips resin build ups
• 13-22 putty index ,full coverage direct composite buildups
• 23-25 bridge fractured porcelain repaired, HF silane, composite - improve buccal corridor
• 37-34 chairside ,Protemp4, provisional crowns
• 33-43 putty index, direct composite buildups
• 44 chairside ,Protemp4, provisional crowns
• 45-47 chairside ,Protemp4, provisional bridge
• 48 to be extracted
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Impression of Wax upRest on 48
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Completion of Provisionals
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Completion of Provisionals
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Completion of Provisionals
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Bilateral Canine Guidance
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Lower arch
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Lower arch
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Upper Arch
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Upper Arch
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Before and After Smile
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Before and After Smile
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Before and After Smile
Before and After Smile
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Final restorations
• Full coverage zirconia crowns 17-22, 26, 37-34, 44
• 3U Zirconia Bridge 23-25, 45-47
• Porcelain Veneers 33-43