Transcript Case presentation Simon Sweeetnam IFPDC Bursary

Case presentation
Simon Sweeetnam
IFPDC Bursary
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
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.
Past dental & medical history
 Nothing adverse in medical history.
 Patient has no complaints regarding general health
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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.
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.
Presenting dentition
4321 123467
7 4321 123
Patient has a Class 1 incisal relationship on a Class 1
skeletal base.
CPITN-
x
1
2
2
1
x
4.4 was grade 1 mobile, due to a premature contact.
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.
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.
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.
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.
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.
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.
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.
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 2nd try in all was satisfactory and sent for
delivery.
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.
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.
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.
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.
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.
References