module 2 2 october 2008 case presentation adrian wong case presentation adrian wong
TRANSCRIPT
Module 2 2 October 2008
Module 2 2 October 2008
Case Presentation Adrian Wong
Case Presentation Adrian Wong
61 year old Male61 year old Male
• Cheek biting +++
• Food packing +++
Chief Complaint
• high blood pressure (controlled)
• gastro- eosophageal reflux
Medical History
• RCTS +++
• Restorations +++
• Failing Crown and Bridge
Dental History
Extra-OralAt rest
Extra-OralAt rest
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
Reverse Smile LineReverse Smile Line
• 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
INTRA-ORAL
Occlusal View LOWER
OCCLUSAL VIEW UPPER
• 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
OPG
Risk Factor assessment
• Heavy bite
• Parafunction
• Past # porcelain ++++
• RCT reinfection/Mechanical failure
• High rate of recurrent caries
• Acidic mouth (Reflux)
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
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
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
Centric Relation Record
Composite Mock up
Composite Mock Up at Rest
Composite Mock up
Composite Mock Up
Diagnostic Wax up
Test Wax up
Test Wax up
2.5mm increase in length
Completion of Wax up at increased vertical
Completion of Wax upat increase Vertical
Upper cast
lower cast
3-3 Lower Composite buildups 2-4mm
Transfer to mouth
Transfer to Mouth
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
Impression of Wax upRest on 48
Completion of Provisionals
Completion of Provisionals
Completion of Provisionals
Bilateral Canine Guidance
Lower arch
Lower arch
Upper Arch
Upper Arch
Before and After Smile
Before and After Smile
Before and After Smile
Before and After Smile
Final restorations
• Full coverage zirconia crowns 17-22, 26, 37-34, 44
• 3U Zirconia Bridge 23-25, 45-47
• Porcelain Veneers 33-43