Dental clinical case presentation

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two clinical cases in dental clinic

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  • Hello everybody. Happy to have you here again with another presentation.This time it is clinical presentation for two of case s that I have treated during my master education.
  • Lets start with the first case
  • In this case. The patient who visited our clinic is 65 years old. With no history of allergy or relevant medical problems.He only complain form peptic ulcer and use some medications for that.
  • The main reason for this patient to seek dental treatment was because of presence of many missing teeth in his mouth. And we are talking about posterior teeth in particular. Which is effecting the function and grinding food abilities.He informed us that he would like to get fixed set of teeth if it possible.Which is possible of course in his case as you will see in the coming slides.
  • After getting all history information we performed quick extra oral exam.And nothing was appearing abnormal.
  • During staring doing the intr oral exam.One is central incisors was restored with old metal ceramic restoration which showed un-esthetic appearance.The upper and lower arch showed many fillings many missing teeth.
  • From the occlusal view its clear how large and how many the fillings that the patient have in his mouth.And I actually we discovered some 2nd caries underneath some of this fillings.There was a fracture cusp in tooth 16.And temporary restoration in 27
  • During the OPG evaluation.We didn't’t see sings for bone pathology or decay.Accept for apical radiolucency in lower anterior teeth related to 41.It will be more obvious in the periapical X-ray.
  • Apical and bitewing x-ray large and deep filling that extend in some area close to alveolar bone level like in tooth 47.In the 1st quadrant the x-ray is showing expanding maxilllary sinus the reduce bone quantity.In the lower anterior area apical lesions seems to be related to tooth 41 (ENTER). tooth vitality test was applied to the tooth but it showed negative respond.
  • During evaluating the periodental and general oral cavity health.No deep pocket more than 4 mm was detected but the patient showed fair oral hygiene with some staining and plaque accumulation.
  • After gathering all the information from our clinical and radiographical exams.The patient diagnosed to have
  • The patient chief complaint SEEMS NOT TO BE different from his needs according to our clinical evaluation.Which is good since this mean that restore the missing teeth can restore function and meet patient expectation as possible.While restoring the discolored will help to improve the esthetic tooth in most aesthetic zone.
  • So to replace missing teeth.We had long discussion to reach the best treatment options for his case.(ENTER)Implant restoration showed in many studies that it can insure high success rate in long term follow up. But we can see in this case that we maybe don'ts enough bone in 1st quadrant. We have also risk to injured the mental nerve in 4th quadrant.(ENTER)RPD was one of possible option. (advantages and dis-advantages).(ENTER)But at the end we though its FPD seems the best option. Since its can provide fixed set of teeth with good aesthetic appearance. But most importantly, because we do have heavily restored neighboring teeth. (ENTER)Some of teeth already showed decay and fracture part that can be removed and restored with the FPD.
  • According to literature: The fixed partial dentures were estimated to have survived up 92% after 10 years in the meta-analyses conducted by Scurria in 1998.This percentage drop to become 75% after 15 years.
  • While in condition like this one, anterior tooth with discolored post need to be covered.zirconia has not only a color similar to teeth but is also opaque and mask the dischromic tooth.
  • We start the treatment by motivating instructing the patient in order to maintain good oral health.And to control the the active disease.Composite filling for the carious teeth.And root canal treatment for 41
  • Now we can take a look on the prosthetic part of our treatment plan.
  • Here, the Tooth 21 was restored with .. (ENTER) Zirconia based crown.
  • And we decided to restore the missing posterior teeth with(ENTER) fixed partial denture.
  • Here is occlucal view for upper and lower arch after finishing the prosthetic phase.
  • we believe the treatment performed will have good prognosis in the anterior zirconia crown.But fair prognosis expected for the posterior fixed bridge. Since it heavily restored with deep fillings with deep restoration margin especially in the 4th quadrant were we have deep margin in slightly tilted and non vital 47.
  • AStudy reported that caries or pulp vitality problems could be the most common complication associated with FPB.This will be the last slide for this case
  • And now for the 2nd case
  • Here Our patient is 46 year old He is Non smoker and without any relevant medical problems.
  • His main complaint was regarding un-aesthetic smile. Due to presence of large diastema and metal screw and upper anterior area.And he came to the clinic to fix his teeth problems.
  • Frontal and lateral few for the patient bite showing that previously mentioned problemsIn addition to large edentulous are in right side.
  • Occlusal view for the upper and lower arch
  • The panoramic x-ray can shows us general view of how far this edounleous area is extending. It can show also the genaral alveolar bone loss in upper and lower teeth
  • During our apical x-ray examinationIts clear the amount of alveolar bone resorption especially in upper incisors area.Probing depth values shoed deep pockets that reached 7mm in the central incisors. (ENTER)There was also sign of apical radioleucency related to tooth 35. (ENTER)
  • After gathering all the information from our clinical and radiographical exams.The patient diagnosed to have
  • Theunesthetic smile is the main reason for this patient seeks dental treatment. We have to take on consideration the missing teeth in right side. Which make the patient only able to bit in one side.
  • Since the patient is periodontal therapy to restore the teeth support. We designed our treatment plan into two phase.Phase 1 can work as temporary stage in order to restore aesthetic in anterior area and to fabricate removable denture for the long edentulous posterior area.The periondental condition will be re-evaluated after 6 month and if it showed improved teeth support condition we can proceed by doing porcelain veneer in upper centrals. And maybe implant restoration in the posterior region.
  • closing anterior diastemaand avoiding "black triangle "between the teeth is One of the most challenging task to most dentists.So, willlhite in his paper in 2005 proposed 3 criteria to close diastema in successful way.
  • In his book: removable partial prosthodontics, Mcgivney listed main 3 objectives of prosthodontics therapy, which is:the elimination of disease.the preservation of the health and relationship of the teeth and the health of the remaining oral tissues,. the selected replacement of lost teeth, and the restoration of function in an esthetically pleasing manner."
  • And lets take a look on the treatment that have been performed to this patient
  • To close the diastema, and restore lateral incisor with metal screw.We treat the centrals with composite veneer. (ENTER)And E max crown was the material of choice for tooth 12.
  • For the edentulous area in 1st quadrant.RPD was designed and fabricated to replace missing teeth in that area(ENTER)
  • Here frontal view for the pre- and post operative images for the anterior teeth
  • Pre and post operative images for the area that restored with RPD
  • at the end of this presentation I would to thank you all for listening. And special thank of course to : Armanameri for being supportive friendly. and for being allways their during the clinical time to help us and to answer our question. Thank you
  • Dental clinical case presentation

    1. 1. Clinical Case presentation Ali Al Enezi 2014
    2. 2. Case 1
    3. 3. • 65 years old • Non smoker • Don’t have history with any systemic disease or allergy. • Only complain from Peptic ulcer. • Medications: omeprazole 1-2/day.
    4. 4. I lost some of my posterior teeth long time ago. And now I want it to be replaced • He is not able to eat properly . This was since he lost some of his posterior teeth. • Chief complaint Expectations to have the best available treatment option for his teeth. He want it to be (fixed).
    5. 5. Clinical Examination Extra-oral exam • • • Nothing abnormal was detected. No sign of Pain or tenderness in the head and neck area. TMJ: no clicking or tenderness in TMJ area or muscles of mastication.
    6. 6. Intra- oral examination
    7. 7. Intra- oral examination
    8. 8. Radiographic examination
    9. 9. Radiographic examination
    10. 10. Periodontium • • • • fair Oral hygiene. Staining & general plaque accumulation. Normal pocket depth around his teeth (1-3 mm). Generalized mild to moderate gingival recession in upper and lower teeth.
    11. 11. DIAGNOSIS 523.00: plaque induced gingivitis. 521.09: secondary caries. 38,36,47 525.1: Loss of teeth due to extraction: 15,14,37,35,44,45,47. 521.81: fractured DB cusp : 17 522.6: Chronic apical periodontitis 41 521.20: Abrasion in the buccal surface 16,34,44
    12. 12. chief complaint - not eating properly since he lost multiple posterior teeth. - Ugly smile - Many missing and heavily restored teeth - Discolored upper incisor Main problems
    13. 13. Treatment options • Single implants restoration • Removable denture • Fixed bridge restoration
    14. 14. Meta-analysis of fixed partial denture survival (Scurria, Bader et al. 1998) 10 years: 92% 15 years: 75% *(failure was defined as fixed partial denture removal)
    15. 15. Discolored crown with metal core “Zirconia opacity is very useful in adverse clinical situations, for example, for masking of dyschromic abutment teeth”. (Paolo Manicone, 2007).
    16. 16. Treatment Procedures
    17. 17. Disease Control Phase • Patient motivation & Oral hygiene instructions. • scaling and root planning. dental polishing • endodontic treatment for 41 • Composite restorations : 17,16,27, 38. • Referral to the hygienist for oral hygiene care.
    18. 18. Prosthodontics phase
    19. 19. • Zirconia based single crown #21 Before After
    20. 20. Before porcelain fused to metal bridges: • (13-16,h14,15) • (43,44-47,h4546). porcelain fused to metal bridge: • (36-34 h35) After
    21. 21. Before After
    22. 22. (Fair to Good) All the teeth showed good periodontal condition and bone support. However, having many large filling and fixed prosthesis are factors that could affect the prognosis Prognosis
    23. 23. Caries 18% Prosthesis fracture Need for Endo- therapy 2% 11% most common fixed partial denture complications Tooth fracture Loss of retention 3% 7% Periodontal disease Esthetics 4% 6% (Goodacre, Bernal et al. 2003): average 8 years of observation.
    24. 24. Case 2
    25. 25. • 46 years old • Non smoker • No history with any systemic disease or allergy.
    26. 26. • not happy with his smile as it shows metal screw in the upper anterior region (Chief complaint). • He want to close the diastema between the upper central incisors. Chief complaint Expectations • He wishes to get restorations for the missing teeth that will fit very well with other existing teeth. • to restore the esthetic appearance of his smile.
    27. 27. Clinical Examination
    28. 28. Clinical Examination
    29. 29. Radiographic examination
    30. 30. Radiographic examination
    31. 31. DIAGNOSIS 523.42: Chronic periodontitis, generalized. 525.51: Partial edentulism (14-18). 525.64: Fractured dental restorative material with loss of material (tooth 12). 524.30: Unspecified anomaly of tooth position (diastema between 11.21)
    32. 32. chief complaint Metal screw in upper interior effect esthetic appearance - Failure in old crown restoration - long edentulous posterior area - Deep gingival pockets (more than 7 mm upper centrals. Main problems
    33. 33. Phase 1: • • Proposed treatment plan • Composite veneer (11,12). (post & core) and crown restoration (21) Removable partial denture Phase 2: (After 6 months of 1st phase). • Re-evaluation of periodontal condition. • Bridge restoration supported by implant (14-16,h15) • Implant insertion with crown restoration 46. • Porcelain veneer (11,21).
    34. 34. (Willhite, 2005) proposed three criteria for successful diastema closure: 1. increase emergence profile with natural contours at the gingiva and tooth interface. 1. a completely closed gingival embrasure. 1. a smooth subgingival margin that does not catch on or shred dental floss.
    35. 35. The objectives of prosthodontics treatment 1. Elimination. 1. Preservation. 2. Replacement. ( McGivney et al, McCracken's Removable Partial Prosthodontics, 2000).
    36. 36. Treatment procedures
    37. 37. • Composite veneers (11,21) • E.Max crown for 12
    38. 38. Removable partial denture
    39. 39. Before and after
    40. 40. Before After
    41. 41. Before After
    42. 42. Prognosis dependent on patients ability to sustain stable periodontal condition, this will be evaluated throughout phase 1. Prognosis for removable denture: fair to poor (due to inability of patient to accept this as definitive treatment), Crown restoration 12 : good prognosis (dependent on quality of remaining tooth structure, ferule, periodontal support, lack of heavy occlusal loading, etc). Prognosis
    43. 43. More references: • • • • • • • Chu, C. H., et al. (2011). "Treating a maxillary midline diastema in adult patients: a general dentist's perspective." J Am Dent Assoc 142(11): 1258-1264. Spear, F. and J. Holloway (2008). "Which all-ceramic system is optimal for anterior esthetics?" J Am Dent Assoc 139 Suppl: 19S-24S. Scurria, M. S., et al. (1998). "Meta-analysis of fixed partial denture survival: prostheses and abutments." J Prosthet Dent 79(4): 459-464. Goodacre, C. J., et al. (2003). "Clinical complications in fixed prosthodontics." J Prosthet Dent 90(1): 31-41. Manicone, P. F., et al. (2007). "An overview of zirconia ceramics: basic properties and clinical applications." J Dent 35(11): 819-826. Beaumont, A. J., Jr. (2002). "An overview of esthetics with removable partial dentures." Quintessence Int 33(10): 747-755. Chang, Y.Y., Maximizing esthetic results on zirconia-based restorations. Gen Dent, 2011. 59(6): p. 440-5; quiz 446-7.
    44. 44. Christensen, G.J., Porcelain-fused-to-metal versus zirconia-based ceramic restorations, 2009. J Am Dent Assoc, 2009. 140(8): p. 1036-9. Eliasson, A., C.F. Arnelund, and A. Johansson, A clinical evaluation of cobalt-chromium metalceramic fixed partial dentures and crowns: A three- to seven-year retrospective study. J Prosthet Dent, 2007. 98(1): p. 6-16. Heintze, S.D. and V. Rousson, Survival of zirconia- and metal-supported fixed dental prostheses: a systematic review. Int J Prosthodont, 2010. 23(6): p. 493-502. Tinschert, J., et al., Structural reliability of alumina-, feldspar-, leucite-, mica- and zirconia-based ceramics. J Dent, 2000. 28(7): p. 529-35. Zarone, F., S. Russo, and R. Sorrentino, From porcelain-fused-to-metal to zirconia: clinical and experimental considerations. Dent Mater, 2011. 27(1): p. 83-96.
    45. 45. Thank you

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