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Module 2 2 October 2008

Module 2 2 October 2008. Case Presentation Adrian Wong. 61 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.

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Module 2 2 October 2008

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  1. Module 2 2 October 2008 • Case Presentation • Adrian Wong

  2. 61 year old Male

  3. Cheek biting +++ • Food packing +++ Chief Complaint

  4. high blood pressure (controlled) • gastro- eosophageal reflux Medical History

  5. RCTS +++ • Restorations +++ • Failing Crown and Bridge Dental History

  6. Extra-OralAt rest

  7. 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

  8. Reverse Smile Line

  9. Aesthetic assessment • 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

  10. INTRA-ORAL

  11. Occlusal View LOWER

  12. OCCLUSAL VIEW UPPER

  13. Intra-Oral • 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

  14. OPG

  15. Risk Factor assessment • Heavy bite • Parafunction • Past # porcelain ++++ • RCT reinfection/Mechanical failure • High rate of recurrent caries • Acidic mouth (Reflux)

  16. 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

  17. 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

  18. 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

  19. Centric Relation Record

  20. Composite Mock up

  21. Composite Mock Up at Rest

  22. Composite Mock up

  23. Composite Mock Up

  24. Diagnostic Wax up

  25. Test Wax up

  26. Test Wax up

  27. 2.5mm increase in length

  28. Completion of Wax up at increased vertical

  29. Completion of Wax upat increase Vertical

  30. Upper cast

  31. lower cast

  32. 3-3 Lower Composite buildups 2-4mm

  33. Transfer to mouth

  34. Transfer to Mouth

  35. 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

  36. Impression of Wax upRest on 48

  37. Completion of Provisionals

  38. Completion of Provisionals

  39. Completion of Provisionals

  40. Bilateral Canine Guidance

  41. Lower arch

  42. Lower arch

  43. Upper Arch

  44. Upper Arch

  45. Before and After Smile

  46. Before and After Smile

  47. Before and After Smile

  48. Final restorations • Full coverage zirconia crowns 17-22, 26, 37-34, 44 • 3U Zirconia Bridge 23-25, 45-47 • Porcelain Veneers 33-43

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