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Module 2 2 October 2008 Case Presentation Adrian Wong Case Presentation Adrian Wong
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61 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-Oral At 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 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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2.5mm increase in length
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Completion of Wax up at increased vertical
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Completion of Wax up at 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 up Rest on 48
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Completion of Provisionals
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Bilateral Canine Guidance
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Lower arch
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Upper Arch
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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
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