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CasePresentation-I

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CasePresentation-I

  1. 1. Clinical Case Presentation Majd Sameer, Level IX, 42620112
  2. 2. Patient’s Personal Data• Age: Fifteen Years Old• Gender: Female• Nationality: Saudi• Occupation: Student (Intermediate stage)• Marital Status: Single• Patient’s Attitude: Uncooperative
  3. 3. Chief Complaint “‫”ما أتحمل األكل في الجهة اليسار فوق, مرة يألمني‬“Intolerant discomfort and pain upon chewing and at rest in the upper left area”History of chief complaint:Started around one week before her visit to theclinics.
  4. 4. Chief Complaint
  5. 5. Medical History Patient and her guardian denied having any medical condition.Family Medical History Not significant.
  6. 6. Past Dental History Multiple restored teeth. Different intervals starting from about five “5” yrs back till recently. Previously traumatized upper central incisor when she was eight “8” yrs of age.
  7. 7. Past Dental History Traumatized and restored tooth Multiple restored teeth
  8. 8. Habits and Oral Hygiene Activities Patient brushes once daily. Technique of brushing: Horizontal Scrub. Uses a “soft” brush. Doesn’t change her tooth brush very often. Doesn’t floss. Doesn’t visit the dentist nor the hygienist periodically.
  9. 9. Pretreatment Photographs
  10. 10. Extra-oral Photographs
  11. 11. Intra-oral Photos “Frontal”
  12. 12. Intra-oral Photos “Upper Arch”
  13. 13. Intra-oral Photos “Lower Arch”
  14. 14. Intra-oral Photos “Right Side”
  15. 15. Intra-oral Photos “Left Side”
  16. 16. Diagnostic Aids
  17. 17. Panoramic Radiograph
  18. 18. Radiographs-Bitewings
  19. 19. Radiographs-PeriapicalsU Rt U LtL Rt L Lt
  20. 20. Mounted Diagnostic Casts
  21. 21. Mounted Diagnostic Casts
  22. 22. Diagnostic Casts Maxillary Occlusal View Mandibular Occlusal View
  23. 23. Clinical Examination
  24. 24. Extra-oral ExaminationTransverse “non-smile”: Symmetrical face.
  25. 25. Extra-oral Examination• Antro-posterior, Vertical: Convex profile. Class II extra-orally. Incompetent lips. Normal NLA (Nasiolabial Angle “90⁰”). Lower facial height is higher.
  26. 26. Intra-oral ExaminationLower midline is deviated to the right around 1.0mm in comparison to the upper midline.
  27. 27. Intra-oral Examination Multiple restored teeth Multiple carious teeth
  28. 28. Clinical Examination PSR(Periodontal Screening and Recording) Pocket Depth < 3.5 mm, bleeding upon probing, no calculus
  29. 29. Clinical Examination  Gingival Index (GI): By: “Leo and Silness,1963” 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 6” = 2 / Moderate Gingival Inflammation
  30. 30. Clinical Examination  Plaque Index (PI): By: “Silness & Loe”,1964 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 6” = 2 / Moderate Plaque accumulation
  31. 31. Clinical Examination Calculus Index: is: “Zero”
  32. 32. Key: Clinical Examination Restoration Caries Root Canal Tx Post and Core Recurrent Dental Charting “Upper Arch” Granuloma Rotation18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
  33. 33. Key: Clinical Examination Restoration Caries Root Canal Tx Post and Core  Dental Charting “Lower Arch” Recurrent Granuloma Rotation48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
  34. 34. Clinical Examination Pulpal and Periapical Tests for suspected teeth Tooth No. Cold Test Vertical Percussion Horizontal Percussion 26 +ve(Prolonged) +ve -ve 11 -ve -ve -ve 46 +ve (late) -ve -ve 25 +ve -ve -ve 47 +ve -ve -ve 21 +ve -ve -ve
  35. 35. Laboratory Investigations CRT (Caries Risk Test)  Saliva Flow Rate : 12 ml in 5 min = 2.4 ml/min (above standard) Low Caries Risk  Saliva Viscosity : Watery  Saliva Buffer Capacity : Between 4.5-7 PH Low to Medium Caries Risk
  36. 36. Laboratory Investigations CRT (Caries Risk Test) Measuring the Acid Production by the microorganism in the saliva; According to the “Standard chart”: 1 and 2 = Low Risk 3 and 4 = High Risk S.M L.B
  37. 37. Laboratory Investigations CRT (Caries Risk Test) Results have revealed the following: •S.M = 2 < 100,000 CFU Low Risk •L.B = 3 > 100,000 CFU  High Risk S.M L.B
  38. 38. Diagnosis and Treatment Planning
  39. 39. Preliminary “Emergency”• Diagnosis for tooth # 26  Badly Decayed tooth  Symptomatic Irreversible Pulpitis  Symptomatic Apical Periodontitis• Proposed Tx.  Caries excavation & emergency pulp extirpation.
  40. 40. Phase I (Restorative)
  41. 41. Phase I: (Periodontic Therapy)• Diagnosis for the “Periodontium”:  Chronic Generalized Moderate Gingivitis, resulting from local factors “Plaque”.• Prognosis: Diagnostic: Fair. Therapeutic: Excellent.• Proposed Tx.  Removal of the local factor, by ultrasonic scaling  Modifying and emphasizing on the Oral Hygiene Instructions.  Re-evaluation in 4-6 weeks.  Maintenance ever 4 months.
  42. 42. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Includes the demonstration of the right technique in brushing and flossing: Brushing “Modified Bass” technique
  43. 43. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Flossing:
  44. 44. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  General Instructions regarding the tooth brush:
  45. 45. Phase I: (Preventive Therapy)• Based upon the CRT the patient will need:  Diet Alteration (less Sweets, CHO Balance , more Protein & Vitamins).  Fissure Sealant (for intact sound teeth). S.M L.B
  46. 46. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 17:  Shallow Occlusal Caries• Proposed Tx.  Conventional Class I composite restoration.
  47. 47. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 16:  Defective Amalgam Restoration.  Recurrent caries beneath the amalgam restoration.• Proposed Tx.  Excavation of recurrent caries.  Redo the amalgam restoration (Class II)
  48. 48. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 14:  Occlusal caries.• Proposed Tx.  Class I composite restoration.
  49. 49. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 13:  Mesial caries.• Proposed Tx.  Class III composite restoration.
  50. 50. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 11:  Defective Composite Restoration  Necrotic Pulp.  Well defined radiolucent area at the apex of the root, resulting from recurrent caries beneath the restored traumatized upper incisor. It is clinically asymptomatic resulting in a definitive diagnosis “Granuloma”.• Proposed Tx.  Removal of the restoration.  Excavating the recurrent caries.
  51. 51. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 22:  Distal Caries.• Proposed Tx.  Class III composite restoration.
  52. 52. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 24:  Occlusal Caries.• Proposed Tx.  Class I composite restoration.
  53. 53. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 25:  Occlusal Caries.• Proposed Tx.  Class I composite restoration.
  54. 54. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 27:  Deep Fissure in a high risk caries patient.• Proposed Tx.  Fissure Sealant.
  55. 55. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 37:  Occlusal Caries• Proposed Tx.  Class I composite or amalgam restoration; (depending on the clinical judgment)
  56. 56. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 35:  Occlusal and Distal Caries.• Proposed Tx.  Class II composite restoration.
  57. 57. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 34:  Occlusal Caries.• Proposed Tx.  Class I composite restoration.
  58. 58. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 33:  Mesial Caries.• Proposed Tx.  Class III composite restoration.
  59. 59. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 43:  Distal Caries.• Proposed Tx.  Class III composite restoration.
  60. 60. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 44:  Occlusal Caries.  Mesial Caries.  Cervical (Buccal) Caries.• Proposed Tx.  Class II composite restoration.  Class V composite or GIC (Depending on the isolation).
  61. 61. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 45:  Occlusal Caries.• Proposed Tx.  Class I composite restoration.
  62. 62. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 46:  Defective composite restoration  Recurrent Caries.• Proposed Tx.  Removal of the old restoration.
  63. 63. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 47:  Occlusal Caries• Proposed Tx.  Class I amalgam or composite restoration (Depending on the clinical judgment)
  64. 64. Phase II (Endodontic)
  65. 65. Phase II: (Endodontic Therapy)• Diagnosis for tooth # 11:  Necrotic Pulp.  Well defined radiolucent area at the apex of the root, resulting from recurrent caries beneath the restored traumatized upper incisor. It is clinically asymptomatic resulting in a definitive diagnosis “Granuloma”.• Proposed Tx.  Conventional RCT.
  66. 66. Phase II: (Endodontic Therapy)• Diagnosis for tooth # 26  Badly Decayed tooth.  Symptomatic Irreversible Pulpitis.  Symptomatic Apical Periodontitis.• Proposed Tx.  Conventional RCT.
  67. 67. Phase II: (Endodontic Therapy)• Diagnosis for tooth # 46:  Defective composite restoration.  Deep Recurrent Caries.• Proposed Tx.  Elective Endodontic Treatment.
  68. 68. Phase III (Periodontal Surgical Therapy)
  69. 69. Phase III: (Periodontal Surgical Therapy)• Diagnosis for tooth # 26  Not enough coronal tooth structure for crowning.• Proposed Tx.  Crown Lengthening palatally.
  70. 70. Phase III: (Periodontal Surgical Therapy)• Diagnosis for tooth # 46:  Not enough coronal tooth structure for crowning.• Proposed Tx.  Crown Lengthening lingually and mesially.
  71. 71. Phase III (Prosthetic Therapy)
  72. 72. Phase III (Prosthetic Therapy)• Diagnosis for tooth # 11:  Week remaining tooth structure.  RCT.• Proposed Tx.  Fiber Post and Core.  Full Ceramic Crown.
  73. 73. Phase III (Prosthetic Therapy)• Diagnosis for tooth # 26  Week remaining tooth structure.  RCT.• Proposed Tx.  Cast Post and Core.  Ceramo-metal Crown.
  74. 74. Phase III (Prosthetic Therapy)• Diagnosis for tooth # 46:  Week remaining tooth structure.  RCT.• Proposed Tx.  Cast Post and Core.  Ceramo-metal Crown.
  75. 75. Phase III (Orthodontic Therapy)
  76. 76. Orthodontic Consultation• Orthodontic Problem List:• Antro-posterior: Rt. Molar relationship: ½ unit class II. Proclination of the upper incisors Overjet is about 9.0 mm.• Transverse: Lower midline is deviated around 1 mm to the right.
  77. 77. Orthodontic Consultation• Orthodontic Problem List:• Intra-Arch: Multiple rotations in the upper and lower arches. Mild crowding in the upper posterior teeth, accompanied with mild diastemas between the anterior teeth. Mild crowding in the lower arches.
  78. 78. Orthodontic Consultation Objectives of the Orthodontic tx: Correction of the Rt molar relationship into a class I. Retroclination of the upper incisors. Decreasing the OJ. Correction of the deviated lower midline. Fix alignment of the rotated teeth “De-rotation”. Proposed Orthodontic tx: Comprehensive Orthodontic treatment, non-surgical, extraction.
  79. 79. Phase IV (Maintenance)
  80. 80. Phase IV (Maintenance)  Recall the patient every 4 months to: • Do periodontal maintenance. • Emphasize on the oral hygiene. • Maintain good relationship with the patient. “Treating the patient as an all NOT a hole” is very important to always keep in mind.  Recall the patient every 6 months to: • Do full mouth X-Ray, check all restorations and crowns.
  81. 81. Thank you all for your kind attention Any Questions?

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