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Case Presentation 1

First 5th year case presentation case: Noel Shannon 3rd Feb 13

Raj Sobti Orla Walsh

on 4 February 2013

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Transcript of Case Presentation 1

CDS: 179838
Number of visits: 9
Cost of treatment: 1849 euros Questions? 5th Year Case Presentation 54 year old male
lives in Cork
first attended at Oral Cancer Screening Day September 2012 Patient History Reason for attending Relevant Medical and
Dental History Past Dental History Social History Diet History appearance: unhappy with smile due to missing teeth and worn front teeth
psychological: would like full complement of teeth if possible
finance: bridges had been suggested by GDP but very expensive to have spaces filled privately in this way
has had several restorations and extractions (decay)
not a regular attender
last visit to GDP was mid 2012 for restoration replacement although scale and polish also performed
has never had any adverse reactions to any form of dental treatment no significant medical history
history of night-time grinding but not for many years
both GDP and patient have monitored tooth wear over years and are satisfied that process has ceased to progress
brushes twice daily but seldom flosses
reports no bleeding on brushing but feels that "gums have shrank back" works for an employment agency, specifically involved in psychological motivation of job seekers
self-employed within agency allowing flexible and self-determined working hours
married with two adolescent children
clearly intelligent and well-informed patient self-appraised balanced diet
drinks 5 cups of tea or coffee every day with no sugar
7-10 units of alcohol per week, generally wine
diet diary: presence of tooth wear necessitated this although patient admitted to filling it out retrospectively Clinical Examination extra-oral: NAD
gingivae: mildly inflamed with marked areas of recession on buccal aspects of molars
BPE: 2 in each sextent due to mild calculus build-up
hard tissue charting
mild to moderate resorption of lower right edentulous ridge
over-eruption of opposing teeth into all edentulous spaces
anterior tooth wear of upper and lower 3 to 3 (mainly attrition but also erosive elements) Aids to Diagnosis plaque score: 46%
bleeding score: 20%
peri-apical radiographs of potential bridge abutment teeth
electric pulp vitality tests of same teeth all of which were positive
mounted study models
clinical photos Diagnosis chronic gingivitis complicated by generalised mild calculus
missing teeth 24, 25, 36, 45, 46 resulting in unaesthetic appearance
anterior tooth wear caused primarily by attrition (night-time grinding) Treatment Planning Treatment Planning Cont. Final Treatment Plan
options for replacing missing teeth:
CoCr removable partial denture
resin-bonded bridge
conventional fixed cantilever
conventional fixed-fixed
wax-ups used to illustrate aesthetic considerations to the patient compensating for over-eruption and providing space for anterior restorations:
Dahl effect
occlusal stripping
posterior composite onlays
RPD extension onlay
orthodontics wax-up to trial increase in OVD 1. supragingival scaling and oral hygiene instruction
2. lower 3 to3 composite additions to increase OVD 2mm
3. monitor progress of Dahl effect
4. replace missing teeth: 45 RBB, 46 conventional cantilever, 24, 25 conventional cantilever (single molar pontic)
5. upper 3 to 3 composite additions First and Second Visits history and examination
upper and lower alginate impressions for study models
discussion and finalisation of treatment plan
costing of treatment plan
supragingival scaling
putty matrix impressions Third and Fourth Visits lower 3 to 3 composite additions to provide new anterior occlusion and 2mm increase in OVD
very difficult due to tight interproximal contacts and necessity of even occlusal contacts across all the restorations
Ceram-X shade E2 used for entire restorations rather than preferred dentine and enamel shades
restorations reviewed and refined at third visit Fifth Visit 44 resin-bonded bridge preparation and impression for premolar pontic replacing 45
preferred to conventional cantilever as abutment tooth was relatively unrestored, with suitable enamel surface area for bonding
small occlusal amalgam replaced with composite
light chamfer preparation carried out on lingual half of 44 but omitting lingual cusp to aid resistance to rotation
monitoring of Dahl effect which could now be observed Sixth Visit delivery of 44 resin-bonded bridge
tried in and sanblasted
cemented using Panavia
patient very happy with appearance
personally unhappy with mesio-distal angulation, absence of light occlusal contact and colour of premolar pontic and felt that aesthetics of planned molar pontic may now be compromised Seventh and Eight Visits preparation, impression and temporisation of 47 for PFM conventional cantilever bridge to replace 46
chosen as 47 was heavily restored with unfavourable angulation and to provide adequate support for large pontic
porcelain preparation restricted to buccal wall and mesio-buccal cusp to maximise aesthetics and minimise tooth preparation
preparation, impression and temporisation of 26 for PFM conventional cantilever bridge to replace 24 and 25 with single large molar pontic
chosen largely to avoid preparation of unrestored 23 and due to large amalgam restoration and need to support large molar pontic
molar pontic preferred as inadequate spacing for two premolars Ninth Visit delivery of 47 and 26 conventional cantilever bridges
tried in and occlusion checked
patient was very happy with appearance although again I had concerns about shading
cemented using Rely X
unfortunately inadequate seating of 47 bridge resulting in occlusal interference and defective margin
pontic reduced but with show through of metal necessitating re-make
26 cemented without incident
patient to return for anterior composite additions and impressions for re-make Reflection and Criticisms improve putty matrix
unsatisfactory resin-bonded bridge pontic
poor operator technique using Rely X

enthusiastic and friendly patient who easily understood aspects of treatment and implication
study models and wax-up essential to illustrate treatment plan and for informed consent Treatment
Sequence Diagnosis
Treatment Plan History method of creating interocclusal spacing using a combination of intrusion and induced eruption reference: Dental update Volume 35 Number 8 Page 551 - October 2008
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