1. Case presentation Simon Sweeetnam IFPDC Bursary

2. Patient profile 56 year old female Lives approx 15 miles away and relies on husband for transport. Was told she had gum disease 2 years ago and attends the hygienist every 6 months now and meticulous OH. 9 visits and treatment now complete Cost of treatment was €970

3. Reason for attending Patient admits she neglected her teeth over the years. Was made aware that she had gum disease (generalised moderate periodontitis) 2 years ago by GDP. Visits hygienist privately and now that it is stabilised would like “to get teeth sorted out” in terms of edentulous spaces. No complaints in terms of pain.

4. Past dental & medical history Nothing adverse in medical history. Patient has no complaints regarding general health and is taking no medications. Smokes 15-20 cigarettes a day Neglected teeth over the years and only got motivated 2 years ago when GDP made her aware of the consequences of untreated gum disease. Has had various fillings and extractions over the years. Brushes twice a day and uses interdental brushes.

5. Intra oral and extra oral exam Extra orally the patient has a normal symmetrical facial profile and no problems detected. Intra orally the 2.2 is discoloured and no aspects of the history such as trauma to support this. Generalised recession, esp. on buccal/lingual aspect of teeth. This is in keeping with the healing pattern of a smoker suffering from periodontal disease. Brushing technique was also covered throughout treatment.

6. Presenting dentition 4321123467 7 4321123 Patient has a Class 1 incisal relationship on a Class 1 skeletal base. CPITN- 4.4 was grade 1 mobile, due to a premature contact. x12 21x

7. Investigations and special tests PA of 2.2 taken and no pathology present. PA of 4.4. No pathology but widening of the PDL, in keeping with occlusal trauma. Vitality of 2.2 assessed with endofrost and ethyl chloride. Both were negative. Impressions taken for study models. These will be surveyed and dentures designed + occlusal impact on 2.1 for future restoration.

8. Treatment options Option 1-Co-Cr upper/lower, RCT 2.2 + Crown and a filling on 4.7. (Treatment plan chosen) Option 2- Implants to replace edentulous spaces and RCT 2.2 + Crown and a filling on 4.7. Option 3-No prosthetic treatment and just address the filling on 4.7, the 2.2 is asymptomatic with no pathology so to a certain degree could be defined as elective.

9. Planning Models surveyed and needed undercuts on labial of 3.3 and 4.3. This was overcome by the addition of composite resin. Wax rims fabricated so casts could be mounted with correct occlusal plane. 4.4 is compromised due to occlusal trauma, minor adjustment took this out of occlusion.

10. Dentures With regard to 4.4, denture plan included a parallel guide plane to stabilise tooth and to facilitate future addition. This tooth will be clasp free also. Lower-composite addition on both lower canines and rests on the cingulum of these, along with a rest seat on 4.7 Upper- Rest seats on 2.6/2.7 and 2.3 an RPI system on 1.4.

11. Lower right second molar Strategic tooth to prevent bilateral free end saddle. Amalgam with ditched margin on disto–buccal aspect. Conservative approach by cutting a dovetail into amalgam and repairing over replacing.

12. RCT 2.1 This aspect of the treatment of was commenced first and its success could be assessed while dentures were being made. This allowed success to be assessed before going ahead with crown. RCT completed with rotary system and the final obturation was satisfactory. Prior to endo all restorations on this tooth were removed and replaced to ensure it was pathology free.

13. Free end saddle on lower arch Free end saddle is always going to be a problem in terms of retention and is a contributing factor to dentures not being worn. I used altercast technique and RPI clasp system to maximise retention. RPI allows vertical rotation of the distal extension upon loading, which protects the abutment.

14. Denture progress Try in of framework presented with rest on 2.3 being too bulky and teeth setup with an increased OVD which is not what was requested. Sent back for adjustment so that all natural teeth have the same contact with and without dentures in place. Addressed the issue here also that two Co-Cr can feel bulky in the mouth and will take getting used to. At the 2 nd try in all was satisfactory and sent for delivery.

15. Smoking cessation Facts and general and dental implications explained to the patient on first visit and she has no desire to quit but is aware its bad for her. At every subsequent visit the topic as approached in a light hearted manner to reiterate the point. Aim was to cut down and not zero tolerance as I felt it had a more realistic chance of success. Behavioural management is a lot more challenging than physical treatment.

16. Crown 2.1 Light palatal contact so indication for PFM over ACC. Shade matched to natural teeth as 1.1 has “patchwork” restorations that are pathology free. Will review patient at 2 weeks post delivery and can make changes to 1.1 if needed. Easier to change composite than porcelain.

17. Deliverance day PFM fitted very well. Margins were a good fit and shade was a great match. Both dentures fitted well and had even occlusion across the arch. Only point to note is that 2.6/2.7 only had single contact points on cusps, as when the teeth over erupted, they rotated bucally.

18. Future treatment All prosthesis will fail eventually and these prosthesis will need management. Future proofed the lower denture to an extent by facilitating that 4.4 can be added, as it is probably most compromised tooth in the mouth, but patient is eager to maintain it. Perio is a chronic inflammatory condition that requires life long management as there is no cure. 1.1 may be adjusted with composite to match shade if patient desires. Patient will be reviewed in 1 month.

19. Learning outcomes Smoking cessation is desirable but at times an unrealistic goal. This patient now smokes 10-12/day so it is an improvement. Shade taking can be challenging, esp. when trying to match porcelain/natural teeth/composite/denture. Focus was on matching porcelain/natural teeth as composite can be changed. Planning is essential. A conformative approach with this case and there are compromises because of this. E.g.. Single cusp contact on 2.6/2.7.

20. References