Nadine Hassan, a 46-year-old Lebanese housewife, presented with pain and a bad smell when chewing on her old bridge. She wanted to fix her teeth and have a beautiful smile. Her medical history included an allergy to penicillin. Her dental history showed multiple extractions due to decay and pain, root canals, and a bridge. Her oral exam found poor hygiene, decay, failed restorations, and mild to moderate periodontitis. Her treatment plan involved emergency extractions, nonsurgical treatments like cleanings and restorations, surgical treatments like extractions and a sinus lift, and restorative treatments like crowns, bridges, and implants.

2. BIOGRAPHICAL DATA
Name: Nadine Hassan
Age: 46 years
Gender: Female
Nationality: Lebanese
Occupation: housewife
Marital status: Married

3. “I feel severe pain under old
bridge on mastication with bad
smell, I want to fix my teeth and
make new beautiful smile”
«‫عم‬‫بحس‬‫بوجع‬‫كتٌر‬‫لما‬
‫عض‬‫على‬‫الجسر‬‫و‬‫رٌحة‬
‫كرٌهة‬,‫بدي‬‫زبط‬ً‫اسنان‬‫و‬
‫تصٌر‬ً‫ضحكت‬‫حلوة‬»

4. MEDICAL HISTORY
- No medications intake
- No previous surgery
- She doesn’t suffer from any medical condition
except:
Allergy to Penicillin

5. • Anaphylactic reactions
General hypersensitivity reactions (e.g. rashes) to
penicillin occur in between 1 and 10% of exposed
patients
• True anaphylactic shock occur in less than
0.05% of treated patients.
What’s the True Incidence of ‘Penicillin Allergy’?

6. What to do on spot?
• Call 140 or emergency medical help.
• Use an epinephrine injection immediatly, if available, by pressing it
into the person's thigh.
• Oxygen, antihistamine
• Make sure the person is lying down and elevate his or her legs.
• Check the person's pulse and breathing and, if necessary,
administer CPR or other first-aid measures.

7. PAST DENTAL HISTORY
Multiple tooth extraction due to caries and pain
Endodontic treatments
Restorative restorations (Amalgam & composite)
Prosthodontic treatement ( Bridge)

9. ORAL HYGIENE PRACTICE:
Tooth
brush:
yes
Brushing
method:
Horizontally
Frequency: 1 time/day
Smoker: No
Diet: 3 meals daily, Snacks in between, 2-3 cups of “Matteh”
at the morning and night
Type of
patient:
Regular dental attender

11. EXTRA-ORAL EXAMINATION
• She has normal weight, fit &
healthy looking
• No obvious facial asymmetry
• No submental, submandibular or
other lymph nodes are palpable
• TMJ appear normal with
• No clicking, tenderness or
deviation in the mouth openning
• No masticatory muscles
tenderness

12. • Lips are competent
• No loss of VDO
5.9 mm (VD at rest) – 6.2 mm (VD at occlusion) = 3 mm

13. • lateral profile is :
Straight
• Frontal Aspect:
Ovoid

14. INTRA-ORAL EXAMINATION
• The soft tissue (oral mucosa):
healthy & normal
• Oral Hygiene Poor
• Due to excessive sugar intake (matteh)=>CARIES
• soft deposits, stains, slight calculus, Halitosis
DMFT= 15
• DECAYED: #17 #13 #12 #24 #25 #26 #46
• MISSED: #14 #15 #16 #36 #37
• FILLED: #27 #34 #35

16. INTRA-ORAL FINDINGS
Class I occlusion
tertiary/mandibular crowding
(due to forward growth of mandible)
No loss of proximal contact

17. Inter-pupillary line is
parallel to lip line
Lip line parallel to the smile line.Lip Line and the papillary line are congruent

18. Golden proportion:
When viewed from the facial, the width of each anterior tooth is 60% of the
width of the adjacent tooth

19. • NO harmony in gingival level where it is decreased on #12 #13
• No visible Interdental embrasure (cervical embrasure) , Black triangles

20. Increased Buccal Corridor

21. PERIODONTAL EXAMINATION

22. Gingival health
Pale pink in color, stippled, firm and exhibit a matte surface
 pointed
 fill the gingival embrasure right up to the contact area

23. Periodontal Charting

24. PERIODONTAL CHARTING
Absence of Mobility
Absence of furcation involvement

25. PERIODONTITIS: STAGING

26. PERIODONTITIS: GRADING
Mild to Moderate Periodontitis

27. RADIOGRAPHIC EXAMINATION

28. Mandibular posterior area: class II bone loss from
1/3 to 2/3 of original height bone
(wical and swoope classification)
Maxillary Right Quadrant: Severe Bone loss that
need bone graft and sinus lift for future implants
No bone pathology

29. CBCT SHOWING THIN FLOOR OF RIGHT MAXILLARY SINUS

30. RADIOGRAPHIC FINDINGS
• Failed RCT #17 #13 #12 #25
• Failed composite resin restorations and Recurrent caries related to:
#17 #24 #25 #26 #27
#17 #13 #12 #25 #26 #27

31. • Root fracture on tooth #46
• Amalgam restoration on #34 #35

32. DIAGNOSTIC CAST AND MOUNTING

33. •
Treatment of
emergencies
• Dental or
periapical
• Periodontal
• Extraction of
hopeless teeth
Nonsurgical Phase
(Phase I Therapy)
• Plaque control and
patient education:
• Diet control
• Removal of calculus
and root planing
• Correction of
restorative and
prosthetic irritation
factors
• Excavation of caries
and restoration
• Antimicrobial
therapy
• Minor orthodontic
movement
• Provisional splinting
and prosthesis
Surgical Phase
(Phase II Therapy)
• Periodontal
therapy, including
placement of
implants
• Endodontic
therapy
Restorative Phase
(Phase III Therapy)
• Final restorations
• Fixed and
removable
prosthodontic
appliances
• Evaluation of
response to
restorative
procedures

35. PRELIMANERY PHASE:

36. TREATEMENT OF EMERGENCY
• Removal of old Bridge
• Extraction of #47

37. NON-SURGICAL PHASE
• Caries Risk Assessment (ADA)
• Oral hygiene instruction, motivation
• Diet consulting
• Scaling & root planning
• Restoration of the caries teeth

39. A single “high risk” factor is enough to give the patient an overall HIGH.
Conclusion:
Nadine has High caries risk factor

40. SCALING AND ROOT PLANNING

41. • Cl II #34 #35, remake old amalgam with composite
• Cl V #44, composite restoration

42. PHASE II THERAPY : SURGICAL PHASE

43. PHASE II THERAPY: SURGICAL PHASE
• Extraction #24
• Future Sinus lift and maxillary bone augmentation using bone graft
• Laser gingivoplasty

45. PHASE II THERAPY : ENDODONTIC TREATEMENT
• Root canal retreatment
#12 #13 #25 #17

46. PHASE III THERAPY: RESTORATIVE PHASE
• Overlay:
#26 ( old composite remake)

47. Prosthodontics Treatment

49. PROSTHODONTICS TREATMENT
• Fiber post and core build up on:
• #13 #12 #25
#25 #12 #13

50. • Fixed ceramic bridge:
#23 #24 #25
Temporary Bridge
Prepared Teeth

51. • future Splinted Ceramic crowns :
• #13 #12
Provisional CrownsPrepared teeth

52. Ceramic Single
Crowns:
#11 #21 #22
PreparedTeeth
Provisional Crowns

53. PFM crown + occlusal rest seat
On: #45
Old cast post Temporary Crown

55. 4 UNITS SPLINTED BRIDGE OVER IMPLANTS
Treatment protocol:
External Sinus lift/augmentation (through buccal plate) , bone graft
Two-stage approach :
2 Implants will be placed after a healing period of 4-8 months following sinus grafting
3 Abutments
1 Pontic 3 Connectors 3 retainers

56. Overall Provisionals
Before