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Michelle McSweeney

on 10 May 2013

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Michelle McSweeney 5.3 5th Year Case Presentation
26th March 2013 RFA Patient wanted crown of 12 replaced - 12 crown fractured off 1 year ago -currently crown splinted in place with GIC.
Root of 12 still present. Asymptomatic

Patient concerned about gaps in upper arch, 14 and 24 missing. 14 and 24 extracted ''few years ago''.
Patient preferably wants fixed prostheses replacement

PFM 25 kept falling out.
25 had to be recemented 6mnths after placement. Patient planning on returning to own GDP. Med History Dental History Patient visits dentist every 2 years
unless there is a problem.

Brush 3 times a day and uses mouthwash

Patient has had ''a few crowns and fillings''
placed previously.
Pt unhappy with some fixed prosthetic work
Feels 11 'crooked' and chipped mesioincisally Exam EOF NAD

IOF Gingiva : Mod red, inflam generally. Localised acute inflam 13 -11 area due to retained root and splinted tooth

Palate: Sinus on left posteriorly adjacent to 26

Mirror and cotton rolls sticking to buccal mucosa and tongue -dry mouth?? Tongue fissured

Teeth present 18 17 16 15 13 11 21 22 23 25 26 28
45 44 43 42 41 31 32 33 34 35

Teeth Carious 12 root, 26 (D)

CPITN Score 2 in all sextants

BOP 15% Plaque Score 68% Aids to Diagnosis Social History Hypertension Taking Levatol beta blocker

Patient stated that she feels she is ''prone to infections''

During treatment patient fell ill with pneumonia

Mother had NIDDM -dry mouth? Diagnosis Dentition: Partially dentate with heavily restored dentition.
12 retained root carious coronally (crown splinted in place presently )
Generalised staining.
Mild wear and drifting of lower anterior teeth due to lack of posterior support in lower arch.
25 dentatus post and crown temporarily cemented
Dry mouth?? On questioning patient does not feel as though she does

Occlusion: Class II div 1 incisal malocclusion.
Canine guidance.
Mild loss space in edentulous areas due to
overeruption of lower teeth and drift of adjacent teeth

Perio: Generalised chronic gingivitis complicated by calculus and plaque retentive factors
Localised acute gingivitis 13-11 due to carious root 12

Pulpal:Chronic periapical infection 12 root with crown fracture due to caries (PA shows periapical radiolucency 12 root but asymptomatic)
Chronic PA lesion 26 irreversible pulpitis and associated sinus draining onto palate

Aesthetic: Moderate to high smile line, upper lip resting ~4mm above incisal edge
Shade varies between natural teeth and existing fixed prosthetics ~Shade C3
Square shape Treatment Plan Patient referred to endodontist to have 26 RCT and rest replaced

1) NSPT: OHI and Supragingival scaling

2) EXT 12 retained root

3)Remove 11 PFM and place temporary cantilever bridge to replace 12 to allow healing

3)RBBs to replace 14 and 24 using 13 and 23, repectively as abutment/retainer teeth

4) Conventional cantilever PFM bridge to replec 12 using 11 as abutment

5) 31, 41 Resin composite tip restorations(later reduced gap between 41 and 42)

6) Later advised patient on protection/prophylaxis with dry mouth

*patient was returning to own GDP to have 25 recemented Discussed treatment options -initially patient was inclined to choose CoCr P/- but next visit decided fixed prostheses
Problem! Explained limited abutment teeth
-on further history patient unhappy with appearance 11
-happy to replace 11 to provide retainer 12

Articulated study models and diagnostic wax ups examined
Space interocclusally and mesiodistally assessed -drift/overeruption
ICP and excursions

Space assessed -limited space for 14 MD but patient happy with wax up
Buccal cusp of 15 added to-aesthetics '' NSPT Resin Bonded Bridges Retired

Mother of 6, 2 still live at home . Daughter is nurse in OS

Lives in Coachford, Co.Cork. Originally from Donegal and visits regularly

No problem making appointments at any time. Treatment Options To replace missing teeth :
Conventional bridge
Implants(ruled out by patient -cost)

WHY? Function, Aesthetics, Speech, Occlusal stability, Psychological wellbeing

RPD: Multiple spaces(spaced out throughout arch), Least expensive option, Removable, Soft tissue replacement, can accommodate tilt/rotations adjacent teeth,weaker perio abutments, spaced teeth, diastema
Plaque accumulation/OH, Dry mouth, Patients attitude

Bridge: Fixed, suitable space, suitable abutment/retention, suitable occlusion, cannot replace soft tissue, OH may be better managed

RBB: rest and caries free abutment, conserve tooth, light forces, abutment suitable orientation, best to replace just 1 tooth

Conventional: Relatively destructive, can slightly alter contour/orientation of adjacent teeth, teeth can have restorations Before definitive treatment plan Importance of OH in the maintenence and improving longevity of fixed prostheses explained to patient.

Toothbrush instruction, Tepe instruction and superfloss instruction given to patient in order to prepare for upkeep of cantilever bridges

Supragingival scaling with ultrasonic and polish

2nd visit plaque score reduced 68% -> 34%

4mnths later plaque score 24% BOP 26% ->25%

Adressed possibilty of dry mouth again (antihypertensives?) Patient did not think she did but I recommended frequent water intake and use of mouthwash and decrease tea/coffee/spicy food(would also help with staining) If patient felt this makes a noticable difference -accommodated? EXT 12 root Localised acute gingivitis in this area - Crown of 12 temp splinted in place on top of carious root 12. Temp kept falling out

Before extraction patient expressed worry to me regarding removal 11 PFM. I revised treatment plan and all options to patient and patient was happy to continue

After scale and polish booked appt in OS asap to coincide with clinic time to extract 12 root.
LA and high volume suction. 12 extracted w/o complications using elevator and forceps. Haemostasis acheived. Post LA instructions given

Patient did not want to be without tooth -same visit 11 PFM removed Resin Bonded Bridges Minimally invasive adhesive technique for replacing missing teeth
Relies on resin cement, good bonding substrate and minimal if any parafunction
Metal alloy retainer bonded to enamel with resin cement(Panavia 21 in this case)
Conserve tooth, less expensive than conventional, shorter total treatment time, little or no anaesthetic BUT case sensitive
Patient selection
Abutment selection
Occlusal factors
Bridge Design

Investigations carried out on abutment teeth -not TTP or mobile, vital and PA taken, abutment teeth in line of arch

Adequate bond surface(slight loss of enamel due to wear-creates room), canines chosen -> increased surface area and no restorations

Articulated study models and diagnostic wax ups
Adequate space MD and occlusally for pontic -light contact in ICP
and out of occlusion in all excursions 13 and 23 Preparations: Cantilever RBB more successful -less risk of partial debond and caries than fixed-fixed design

Retainer should cover as much surface area as possible while still being aesthetic (180degrees)
1-3mm short of incisal/cusp edge should prevent metal shine through

Cast metal alloy NiCr used -air abraded with alumina particles to increase surface area

Mesial or distal grooves increases surface area ,retention and decreases stress of cement lute at the expense of potential compromising bond substrate and tooth tissue(was not used in this case)

0.7-0.8mm base metal (rigid) retainer thickness to minimise flexing(any flexing -stress cement lute -increase fail). If not enough room sufficient reduction carried out -was not necessary in this case). Bridge can be cemented slightly high (minimal and controlled changes)Let occlusion re establish

Only cingulum rests used in this case for positive seating. (or ask for seat tag -polish)

Pontic: Modified Ridge lap, closed embrasure, Shade C3(photograph sent to lab)

Impressions taken with light(preps) and medium bodied polyvinylsilixane, disinfection and send to lab with casts and wax ups and prescription
Shade C3 vitapan Resin Bonded Bridges Bridges tried in on cast and in mouth(patient up right and monitored at all times - 14 too loose a fit to check occlusion)

Light bodied silicone used to retain while a rough assessment carried out. Retainers satisfactory

Occlusion adjusted on both -out of contact in excursion especially 24. Pontics repolished in lab and retainers sandblasted

Rubber dam ->Resin cement -Panavia 21 high bond strength when paired with adequate substrate

Cement cleaned away and OH revised

On reflection -I would change shade -C3 too grey gingivally
Patient very happy with aesthetics and gingival 1/3rd not visible

Reviewed 2weeks later Cotton pellet placed in socket before treatment

11 PFM was removed without removing any more tooth tissue.
Sectioned and levered off

Preparation examined - better aesthetics and retention could be achieved by extending prep more gingivally(especially distally) while still remaining cleansable.

Carried out before def impression sent to lab. Putty matrix made in silicone from study models and disinfected
Temporary conventional bridge made with Integrity. Refined and polished
Cemented with TempBond noneugenol.

Occlusion and margins checked

Flowable composite was used to modify temp bridge to adapt to change in shape of socket with healing throughout temporisation - avoid food/plaque trap

On reflection -pay more attention to aesthetics -incisal chip on PFM reproduced in temporary bridge -should have wax up cast or added to bridge Temporisation On diagnostic wax up of resin bonded bridges I had added wax to buccal cusp of 15(small tooth) to improve aesthetics in line with adjacent cusps.

when carrying out composite tips suggested to patient but patient very happy with result of bridges and had no more concerns about aesthetics of posterior teeth PFM Conventional cantilever bridge Extraction space allowed to heal 3mnths

Temporary bridge using 11 as retainer in place -monitored regularly

Preparation 11 modified -extended prep more gingivally and reduced slightly mesiobuccally(bulky) to improve aesthetics and retention

Old prep -very conical, walls not as parallel as modern preps (although still retentive -15/20 years)

Impressions taken of modified prep and arch with light and medium bodied polyvinylsiloxane

PFM chosen -PFM prep present, match adjacent 21, metal palatally -any wear/parafunction

Shade was compromised -21 very white and bright compared to natural dentition
Tried to get a balance between natural teeth shade and adjacent PFM

Replaced temporary bridge PFM bridge delivery Tooth cleaned
Tried on cast and then in mouth -fit, retention, margins, occlusion (fixed in place with light bodied silicone for try in)

Patient happy with aesthetics

Metal retainer lightly sandblasted

Tooth isolated and RelyX resin cement used

Resin cement: Adhesive -increased bond strength(compressive and tensile)
-technique sensitive
-RelyX self adhesive (no light -metal)

Revised OH with patient -superfloss and Tepe Before After Personal Reflection References Questions?? Patient CDS 24606

Female, 66 yrs old

Number of Visits 8

Date of first visit 08/10/12 Radiographs History and Exam

Articulated study models and diagnostic wax ups

Vitality test
13, 11, 23 with ethyl chloride all ++
26 --

PA 13 12, 11 (radiolucency apex of retained
root 12, caries at gingival height 12)
PA taken 18 17 16 15
PA 25 26 28 (radiolucency apex 26
recurrent caries distally 26)

Clinical photographs Wear of lower anterior teeth previously -uneven edges
Resin Composite (C2 Herculite) tips added to lower anteriors for more even incisal edges

Patient also concerned with gap between 42 and 41 -resin composite added to distal 41 and mesial 42 to reduce ( closing gap completely compromised OH -emergence profile/create overhand and aesthetics?)

Polished with soflex discs and interproximal strips Resin Composite Restorations Lower anterior composite restorations Before Before Learning from past experience -determine cause of failure

Have a systematic approach to exam and treatment and adhere to it

Attention to detail improved throughout - not seeing sinus first visit, colour of 14 and 24, shape temporary

Dry mouth -take more action

Follow up -OH, dry mouth and 26 Predictable Resin Bonded Bridges Dent Update. 2001 Dec;28(10):501-6, 508. Morgan C, Djemal S, Gilmour G.

Crowns and other extracoronal restorations Part 6: Aesthetic control F S A Nohl, J G Steele, R W Wassell Volume 192 | Issue 8 | BDJ 2002

Resin bonded bridges: techniques for success K. A. Durey, P. J. Nixon, S. Robinson & M. F. W.-Y. Chan BDJ 2011

BDJ Crowns and other extracoronal restorations Series:
Part 8: Preparations for full veneer crowns F. M. Blair, R. W. Wassell and J. G. Steele Volume 192 | Issue 10 | 25 May 2002

Part 5: Occlusal considerations and articulator selection J G Steele, F S A Nohl, R W Wassell Volume 192 | Issue 7 | BDJ 13 April 2002

Part 9: Provisional restorations
R W Wassell, George G St., R P Ingledew and J G Steele BDJ 2002

Fundamentals of operative dentistry Summitt et al Quintpub 2006

Fundamentals of fixed prosthodontics Shillingburg et al Quintpub 1997
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