Aesthetically compromised patient with reduced VDO. comprehensive evaluation and proposed treatment plan.

1. Welcome
To
Weekly Clinical Case Discussion Session
Presented by- Dr. Rajesh Karmaker
MS Resident Phase-B
Dept. of Prosthodontics, BSMMU

2.  42 years old
 Female
 Muslim
 Housewife
 Currently Living in Mirpur 12
 Has a Habit of chewing betal nut for 2 Years
 Not known to have any systemic diseases or illness.
 Medications:
Amitriptyline 10mg once daily for last 2 years for migraine
Esomeprazole 20 mg twice daily for last 8-10 years for gastritis
Patient Demographics

3. • Embarrassed with the current look
• Struggle to eat
• Food impaction between the crown of the right side of the lower jaw
• Excessive salivation for 1 year
Concerns of the patient

4.  To look like natural teeth
 Eat properly
 Comfortable dentures
Expectations of the patient

5.  She has no history of any systemic diseases or allergies.
 Covid Vaccinated.
Medical History

6.  The last extraction was done 1 year ago.
 The last restorative treatment was also done 1 year ago.
 She only visits the dentist when experiencing toothache and does not
regularly attend recall visits for maintenance.
 She has a history of wearing a dental bridge in the maxillary anterior
segment for 13 years, which got dislodged a year ago, and a local dentist
checked and confirmed it was irreparable.
Dental History

7. • Socio-economic status: Lower middle class
• Attitude: Philosophical
Social history

8. • She has two daughters- one is 21 years old and studying BDS, and the
other is 14 years old and in class 10.
• Her husband works in a security company and is a former army
personnel.
Family History

9. • She brushes her teeth once a day using toothpaste.
• She has been addicted to chewing betal nut for the past 2 Years.
• She has a significant inclination toward sweet foods and consumes them
frequently.
Habits

10. Systemic examination:
 The patient appears to be in a healthy state with no known history of
systemic diseases or major illnesses.
Examination

11. Visual examination:
 Face is approximately Symmetrical
 Face form: Ovoid
 Face profile: Straight
 Narrowing of upper lip
 No deviation or deflection upon
mouth opening.
Examination

12. Palpation:
 No clicking or tenderness in the TMJ area.
 Muscles of mastication were also non-tender.
Examination

13. Radiographic Examination
Orthopantomograph

14. Examination
Extra-oral
Photograph
Left Lateral view Right Lateral view
Front view

15. Examination
Intra Oral Photograph

16. Examination
Intra Oral Photograph

17. Examination
Intra Oral Photograph

18. Examination
Intra Oral Photograph

19. Examination
Intra Oral Photograph

20. Examination
Intra Oral Photograph

21. Examination
Diagnostic Model

22. Examination
Diagnostic Model

23.  Intra-oral soft tissue condition
 Mild gingival swelling on buccal to tooth no 24;
 Periodontal pocket on tooth no. 47
 Otherwise, healthy oral mucosa.
Specific Observation

24.  Intra-oral hard tissue condition
 Missing teeth no 11,14,16,21,25, 26, 37
 Dental caries of tooth no 13, 15, 35, 47
 Broken down root no 18, 12, 22, 23, 24
 Restoration on tooth no 17, 27, 28, 34, 45, 46
 Pain on percussion 22,23,35, 46
Specific Observation

25. • Extra-oral condition
 Vertical dimension at rest (VDR) measuring from tip of nose to least
movable part of chin is 67mm
 Vertical dimension at occlusion (VDO) measuring from tip of nose to least
movable part of chin is 62mm
 Here Free way space (67-62) mm = 5mm
 Taking a 3mm as a standard, a 2mm loss in the VDO has been observed.
Specific Observation

26.  Partial Edentulism Of Maxillary Ach
 Dental Caries on teeth no. 35, 47
 Chronic Apical Periodontitis of tooth no 12,13, 23, 24, 35, 46
 Reduced vertical dimension of occlusion due to dislodgement of
restorations
Diagnosis

27. Treatment Planning

28. 1. Elimination
2. Preservation
3. Replacement
The Objectives Of Prosthodontic Treatment
Ref. McGivney et al McCracken’s Removable Partial Prosthodontics, 2000

29. • Extraction Of Teeth No. 18, 23, 24, 36
• Removal of Crown of Teeth no. 45, 46
• Periodontal therapy on Teeth no. 46, 47
• Endodontic Treatment on Teeth No. 12, 13, 35, 47
• Composite Restoration on Teeth No. 15, 47
• Full Veneer Crown On 13, 45, 46
• Upper Tooth-supported Overdenture (tooth no. 12, 22)
• Lower Tooth-supported Overdenture (tooth no. 35)
Proposed Treatment Sequences
Elimination
Restoration
Preservation

30. Proposed Treatment Sequences

31. Thank you 

32. Alternative treatment
approaches?