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The Restorative Management Of Multiple Carious Lesions And Enamel Hypoplasia in a 57 year old female patient.Restoration of Form and Function
SECTION 1: PRE-TREATMENT ASSESSMENT
Presenting Complaint, History, Examination, Intra-Oral Photography, Study Casts
PRE TREATMENT ASSESSMENT
DEMOGRAPHICS
Patient Name: GD
Date of Birth: 13 /11/1955
Age on Initial Presentation: 55years, 10 months
Gender: Female
Ethnicity: Afro-Caribbean
Address: Arima
Registration Number: 722392
PRE TREATMENT ASSESSMENT
PATIENT COMPLAINT
Cavities
Mobile tooth in the upper arch
Missing teeth
Sensitivity
HISTORY OF PRESENTING COMPLAINT
Missing teeth were extracted due to caries
PATIENT EXPECTATIONS
To have teeth filled
Have a cleaning done
Replace missing teeth
PRE TREATMENT ASSESSMENT
RELEVANT MEDICAL HISTORY
Pneumonia as an infant
Contracted measles/mumps/chickenpox as a toddler (patient is not sure which one).
DENTAL HISTORY
Previous extractions for caries
Cleanings
Restorations
PRE TREATMENT ASSESSMENT
SOCIAL HISTORY
Non-drinker, non-smoker
GD is married with two children
Owns and runs a daycare
Stress level: 6/10
PRE TREATMENT ASSESSMENT
EXTRA-ORAL EXAMINATION
The following findings were within normal limits including: Facial tissues and Sensory Nerves Motor Nerves Lips Salivary Glands
The following findings were of note: Lymph Node: A right palpable tender submandibular lymph node was found TMJ :deviation of the jaw to the right on closing
PRE TREATMENT ASSESSMENT
INTRA-ORAL EXAMINATION
The following findings were within normal limits including: Gingivae Mucosa/Floor of the Mouth Palate Throat
The following finding was of note: Tongue: Geographic tongue
PRE-TREATMENT CLINICAL PHOTOGRAPHS
Clinical Photographs
Pre- Treatment Assessment: Portrait
Clinical Photographs
Pre- Treatment Assessment
• Smile: Front, R & L
Clinical Photographs
Pre- Treatment Assessment• Right and Left buccal segment (post
temporization of #35)
Clinical Photographs
Pre- Treatment Assessment • Labial segment
Clinical Photographs
• Retracted Front & L post restoration of #12 M
Pre- Treatment Assessment
Clinical Photographs
Pre- Treatment Assessment
Central incisor edges not evenly on a horizontal plane
Clinical PhotographsPre- Treatment Assessment
• Upper occlusal • Lower occlusal
DENTAL CHARTING AND EXAMINATION
Skeletal pattern Class IIIncreased overbite
Molar relationship Molar relationship not available
RCP/ICP slide The contacts are stable in RCP, no detectable slide into ICP3 3 4 72 3 5 7
Guidance from ICP Right and Left- Canine guidance
Interferences Nil
Occlusal stability Lack of posterior support for the right side (loss of all premolars and molars in the upper right quadrant)-Supra eruption of #35
Occlusion
PRE TREATMENT ASSESSMENT
TOOTH QUALITY
• Deficient in tooth structure: All upper anterior teeth and lower
canines and lower left lateral incisor
Dental Charting and Findings
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
KEYCaries
Composite restoration
Absent
Classification Caries Restorations
Class 1
#27#28#37#46#47
Class 2
#24 D#35 M#34 D#44 D#45 M
#22D composite
Class 3
#12 M#11 D
#21 M & D#22 M#23 M
• 24-Grade 2 mobile
• Five (5) Class 1 cavities• Five (5) Class 2 cavities• Six (6) Class 3 cavities• White spot lesions on the buccal of #27 and #37• Total: 15 of 22 teeth affected
PRE TREATMENT ASSESSMENT
2 2
2 2 2
PERIODONTAL EXAMINATION
• Full Mouth Plaque Score: 78%
• BPE
• Presenting oral hygiene: Twice daily brushing with a medium toothbrush and adult toothpaste, does not floss and does not use a mouthrinse. Used a personal explorer to “pick” between teeth throughout the day.
RADIOGRAPHIC ASSESSMENT
Radiographic report
• #46 - occlusal caries possibly into pulp• #45 – mesial caries into dentine• #44 – distal caries into dentine
• #35 - mesial caries possibly into pulp
• #34 – distal caries into dentine• #24 – distal caries into dentine
Right and Left Bitewings including after #46 was temporized
Radiographic report
Right and Left buccal segment Periapicals
• #46 & #35 – healthy periodontal and periradicular tissue
Radiographic report
Anterior Sextant Periapicals
• #12 – mesial caries into dentine• #11 – distal caries into dentine• #21 – distal caries into dentine
• Area of linear rarefaction across mid-portion of the crowns of #12 to #22 (wider on #22)
PRE TREATMENT ASSESSMENT
SPECIAL TESTS
• #35 & #46 were vitality tested using cold testing (Endo Ice®)
• Results included a quick positive response both lasting < 3s
PRE TREATMENT ASSESSMENT
Period Day 1 Day 2 Day 3
Before breakfast
Water Water
Breakfast Milk and cereal Toast and cheese
Milk and cereal
Between meals Water Peanut punch Water
Lunch Water and coconut crackers
Rice, vegetables with minced chicken
Peanut punch, crackers and jam
Between meals Coconut water and jelly
Preserved mango, water
Cashew nuts, water
Dinner Provision and saltfish with patchoi
Macaroni pie Macaroni and vegetables
After dinner Water Chocolate wafer
Aloo pie
3 DAY DIET SHEET
PRE TREATMENT ASSESSMENT
DIET REPORT (including diet interview)
• Number of times sugary food were consumed on average per day – 3 (including occasional ice-cream at nights before bed)
• Processed starch- sugared breakfast cereal most mornings
• Fresh Fruit: Once or none per week but dried fruit in cookies between meals
• Drinks: Frequent bottles of water throughout the day, occasionally soft drink at night with dinner
ANALYSIS
Frequent Non Milk Extrinsic Sugar consumption including between meals
Large sugar load before bed time (coupled with improper brushing technique)
PRE TREATMENT ASSESSMENT
CARIES RISK
High Risk
Frequent intakes of NME sugars
Poor plaque control
Multiple carious lesions both anterior and posterior
Multiple missing teeth due to caries resulting in extraction
No fissure sealants
Exposed dentine in hypoplastic regions
PRE TREATMENT ASSESSMENT
PROGNOSIS
Good
DIAGNOSIS
Generalized gingivitis (Plaque and Calculus etiology)
Active Caries in both anterior and posterior regions
#46 and #35 are vital
Environmental Enamel Hypoplasia (as opposed to systemic)
PROBLEM LIST
1. Poor oral hygiene
2. Caries
3. Deficient tooth structure
4. Partially dentate with unilateral loss of posterior support
TREATMENT PLAN
TREATMENT PLAN (01/11/11)
1. Emergency/Disease
Stabilization Phase
a. Temporize #35 and #46
2. Preventive Phase
a. Oral Hygiene Instruction and
Dietary Advice
b. Supragingival Scaling and
polishing
3. Restorative
Phase
1. #12 M&D
2. #11 D
3. #21 M&D
4. #22 M
5. #23 M
6. #24 D
7. #27 O
8. #28 O
9. #37 O
10. #35 M
(possibly RCT)
11. #34 D
12. #44 D
13. #45 M
14. #46 O (possibly
RCT)
15. #47 O
TREATMENT PLAN
4. Advanced Restorative Phase
a. Six (6) direct resin composite veneers in the upper anterior sextant (the worse
affected teeth may be regarded as buildups).
b. Upper Co-Cr denture
5. Review/Maintenance
a. 6monthly then yearly recall
AMMENDED TREATMENT PLAN
1. #35 came to involve the pulp during caries removal , non –surgical root canal
therapy followed by placement of a PFM crown was then included in the
treatment plan (08/11/11)
2. Extraction of #24 due to vertical crown-root fracture (11/06/12)
Patient complained that #24 showed increase in mobility and experienced a lancing type pain
radiating to the left ear and upper jaw. Patient also experienced a salty and “bad” taste from fluid
coming from the tooth.
Examination revealed cervical regional lyphadenopathy (left), buccal and palatal mucosal swelling
and a vertical crown-root fracture, tooth tender to percussion
Radiographic assessment (Periapical) showed a diffuse periapical radiolucency
With loss of apical lamina dura and pdl widening
Diagnosis: acute periradicular abscess (True Perio-endo lesion)
TREATMENT COMPLETED
1. Oral hygiene instruction
including modified bass
technique and substitution of
“picking” teeth with proper
flossing technique and dietary
advice
2. Fifteen (15) restorations. #24
D was not completed-
subsequently extracted
3. NSRCT of #35
4. Six (6) upper anterior
composite veneers; (#13 and
#23 were more extensive –
buildups)
5. PFM crown preparation and
delivery of #35
6. Mouth preparation and
delivery of upper Co-Cr
denture
TREATMENT COMPLETED- NSRCT #35
MID-TREATMENT CLINICAL PHOTOGRAPHS
Mid-Treatment Photographs
Mid-Treatment Photographs
Mid-Treatment Photographs
CHALLENGES
Challenges
1. An attempt at the sandwich
technique was made resulting
in a less than ideal restoration
in #45 and #44 interproximal
restoration
Challenges
2. 11 days after restoring #46 O the distolingual wall that remained after the amalgam restoration fractured.• Increased buccolingual width of the cavity preparation for amalgam
predisposes teeth to fracture• Was removed and replaced using the Automatrix system
Challenges
Challenges
3. Loss of supporting abutment in the #24 for upper Co-Cr denture (11/06/12)
Challenges
4. Due to the hypoplastic tooth form of the #13 and #23 undercut was found to be insufficient for the I bars, that were proposed for the upper Co-Cr denture direct retention.
• During the veneering process these were re-contoured to achieve desired undercut
Challenges
5. A2 shade Z100 composite was inadvertently used for #12 veneer (Z350 A3 used for prior restoration was lost) resulting in undesirable show through of underlying hypolplastic area (and thus visible dentine).
• Portion was removed to place A3 but addition has not been stable over two visits
• Area requires additional retentive features and proper use of adhesive to add new composite to the old.
Challenges
6. Lack of completely harmonious occlusion due to denture made posterior open bite
• Problem was detected during wax trial stage, wax became dislodged from frame.
• Technician was notified but denture was processed before re-trial• Possible causes: Insufficient bite registration; in the least a wax bite was not
supplied to the technician and teeth were set abritrarily.
CURRENT STATUS
1. Oral hygiene: Recent
unanticipated (by the patient)
plaque score: 15%
2. BPE:
01/11/11
05/03/13
3. PFM crown has been
temporarily cemented
pending full satisfaction on
esthetics.
4. No signs of recurrent caries
1 1
1 1 1
2 2
2 2 2
FURTHER TREATMENT
1. Short Term
Rebonding/glazing of all anterior
veneers (Placement a thin layer of
unfilled resin to improve marginal
integrity, improve early wear
resistance and help reduce staining
of the restorations
2. Medium Term
Permanently cement PFM on #35
providing the patient is fully
satisfied
Repair occlusion error on upper Co-
Cr denture
Monitor longevity of canine veneers
under functional loading
3. Long Term
Possible placement of porcelain
veneers on the anterior teeth with
the exception of the canines. All
porcelain dentine bonded or
polycrystalline crowns for the
canines
Post-Treatment Photographs
Post-Treatment Photographs
Post-Treatment Photographs
The upper denture is not well seated here
Post-Treatment Photographs
Conclusion
Recall the aim: To restore form and function. I will say that the aims have notcompletely been carried out. Function, the more important aspect of the stomatognathic
can be found lacking and every step should be taken to fully restore it.
Thank You