Module 2 2 October 2008

Module 2 2 October 2008

Case Presentation Adrian Wong

Case Presentation Adrian Wong

61 year old Male61 year old Male

• Cheek biting +++

• Food packing +++

Chief Complaint

• high blood pressure (controlled)

• gastro- eosophageal reflux

Medical History

• RCTS +++

• Restorations +++

• Failing Crown and Bridge

Dental History

Extra-OralAt rest

Extra-OralAt rest

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

Reverse Smile LineReverse Smile Line

• 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

INTRA-ORAL

Occlusal View LOWER

OCCLUSAL VIEW UPPER

• 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

OPG

Risk Factor assessment

• Heavy bite

• Parafunction

• Past # porcelain ++++

• RCT reinfection/Mechanical failure

• High rate of recurrent caries

• Acidic mouth (Reflux)

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

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

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

Centric Relation Record

Composite Mock up

Composite Mock Up at Rest

Composite Mock up

Composite Mock Up

Diagnostic Wax up

Test Wax up

Test Wax up

2.5mm increase in length

Completion of Wax up at increased vertical

Completion of Wax upat increase Vertical

Upper cast

lower cast

3-3 Lower Composite buildups 2-4mm

Transfer to mouth

Transfer to Mouth

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

Impression of Wax upRest on 48

Completion of Provisionals

Completion of Provisionals

Completion of Provisionals

Bilateral Canine Guidance

Lower arch

Lower arch

Upper Arch

Upper Arch

Before and After Smile

Before and After Smile

Before and After Smile

Before and After Smile

Final restorations

• Full coverage zirconia crowns 17-22, 26, 37-34, 44

• 3U Zirconia Bridge 23-25, 45-47

• Porcelain Veneers 33-43