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					                                                                   Case presentation by Hoo Yin Shi


Case Introduction

Mrs. S, a 38 years old Malay employee in a law firm, sought for comprehensive dental treatment
in UKM Dental Clinic due to the difficulty faced during mastication.




                                          Pre-operative




                                          Post-operative

                        Teeth Present with Teeth Treated Highlighted

                    7   6       4    3    2   1   1   2              /          8
               8                4    3    /   /   /   /    3   4    5       7


                /       Extracted tooth
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                                                                  Case presentation by Hoo Yin Shi


Patient Complaint

Her main concern was with the difficulty of eating due to mobile mandibular anterior teeth and
missing maxillary and mandibular posterior teeth.




History

Present complaint:    Patient first noticed the problem about one year ago. She requested for
                      dentures to replace the missing posterior teeth.

Dental history:       Attended general dental practitioner irregularly. Multiple restorations and
                      extractions were done over the years without complications.

Medical history:      Good general health.

Social history:       Working as a clerk in a busy law firm and a mother with four children.




Examination

Extra-orally:         Right TMJ clicks during closing but not associated with pain. Competent
                      lips with low upper lip line, not showing any gingival tissues.

Intra-orally:         A moderately restored dentition with poor oral hygiene and halitosis.

Soft tissues:         Sinus track presented at the lingual mucosa of 31 and 41. Pus discharged
                      upon palpation.

Periodontal status:   Poor oral hygiene with generalized deposition of plaque and calculus. In
                      general, gingiva appeared red, soft, swollen and shiny with blunt
                      interdental papilla. Probing depths of more than 4mm were detected in the
                      first, third and fifth sextants with bleeding on probing. Tooth mobility was
                      detected in the third and fifth sextants.




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                                                             Case presentation by Hoo Yin Shi


                    BPE:                   3    1       4*
                                           2    4*      2


                                           * Mobility

Teeth:              Multiple faulty restorations and new caries lesions were detected as well
                    as non-vital teeth of 22 and 35. Multiple extractions were done for caries
                    and periodontal disease.

Occlusion:          Intercuspal position (ICP) coincided with the retruded contact position
                    (RCP). Canine guidance on right lateral excursion. No group function or
                    canine guidance on left lateral excursion. No anterior guidance on
                    protrusion.

                    22 was in contact with 33 during ICP, RCP, left lateral excursion and
                    protrusion.




                   A




         B                                      C

  Occlusion of primary casts. (A. Front view; B. Right buccal view; C. Left buccal view)

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                                                                               Case presentation by Hoo Yin Shi


 Restorative and Periodontal Chart



Buccal    -       115    312    - 112     312     111    212   212   212   - -        397       -   -   312
Palatal   -       005    305    - 222     112     113    112   111   212   - -        777       -   -   323




      Maxillary teeth




      Mandibular teeth



Buccal        324       - - -   015     422     333     445    333   -   555     733        533     -   223   -
Palatal       213       - - -   003     305     515     715    524   -   513     314        512     -   212   -




 Prognosis

      -       G     G      -    G     G       G    G     G     G     -     -      P         -       -   Q
      G       -     -      -    G     G       P    P     P     P     G     G      Q         -       G   -

      G: good             P: poor         Q: questionable


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                                                 Case presentation by Hoo Yin Shi


Pre-operative Photographs




                               Extra-oral view




                               Intra-oral view




           Right buccal view                       Left buccal view


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                                                               Case presentation by Hoo Yin Shi


Special Tests

Vitality test:              All teeth gave positive response with pulp sensitibility tests except
                            22 and 35.

Radiographic examination:   OPG

                            Generalized horizontal bone loss. Crown:root was 1:1 except 25
                            (11:1); 31 (4:1); 33 (2:1); 41 (4:1) and 42 (3:1).

                            Periapical radiographs (Pa)

                            Vertical bone loss (90%) was observed at 25, 31 and 41. Retained
                            root of 32 was observed. Radiolucency indicated caries was found
                            at 34 (DO) and 35(DO).




                 Pa (25)                 Pa (32-42)                       Pa (35, 37)
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                                                                    Case presentation by Hoo Yin Shi




Diagnosis

   1. 25, 32, 31, 41 and 42: Severe chronic periodontitis with severe bone loss
   2. 31 and 41: Chronic periapical abscess
   3. Generalized chronic periodontitis
   4. Caries on 12, 34 and 35
   5. Faulty restorations on 12, 21, 22, 28, 44 and 48
   6. Periapical periodontitis: 22 and 35
   7. Partially edentulous maxillary and mandibular arch



Treatment Aim

   1. To improve oral hygiene.
   2. To eradicate periodontal infections.
   3. To restore caries, faulty restorations and non-vital teeth.
   4. To restore function and aesthetic.



Treatment Options

Options to restore function and aesthetic include:

   1. Implants supported maxillary and mandibular fixed partial dentures.
   2. Immediate maxillary and mandibular acrylic removable partial dentures to be
       constructed at an increased vertical dimension. Followed by crown construction on root
       treated 22 and 35, as abutments for definitive restoration with maxillary and
       mandibular cobalt-chrome removable partial dentures.



Treatment Plan

Treatment option no. 2 was selected.



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                                                               Case presentation by Hoo Yin Shi




Treatment sequence

A. Initial/Diagnostic Phase

   1. Oral health education and oral hygiene instructions.
   2. Scaling and root debridement.
   3. Fluoride therapy.
   4. Diet analysis and advice.
   5. Restorative treatments: 12, 21, 22, 28, 34, 35, 44 and 48.
   6. Endodontic treatments: 22 and 35.



B. Restorative Phase

Part I        Construction of immediate acrylic removable partial dentures




Part II       Construction of Porcelain Fused-to-Metal (PFM) crown on 22

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                                                             Case presentation by Hoo Yin Shi


1. Root canal treatment was completed prior to the commencement of the crown preparation.




      Pre-operative        Working Length           Master GP               Obturation
2. Composite resin core was restored subsequent to the root canal treatment.




                               CR




3. The design of the crown on 22 was done based on the denture design.




                                Cobalt-chrome denture design

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                                                                 Case presentation by Hoo Yin Shi




                                        Porcelain
                                                        Metal

                   A3                                                      Metal


                                                                         Porcelain
                   B3



                                                                    of color were
4. Shades selection and related information to the three dimensionsPalatal view measured
              Labial view              Proximal view
   using shade tabs.




5. Tooth preparation was done with cautious consideration as 22 had heavy contacts with 33
   during RCP, ICP, left lateral excursion and protrusion. Thus, more tooth reduction was
   needed at the palatal surface especially at the cervical one third.




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              Case presentation by Hoo Yin Shi




Labial view




                                           11
                                                            Case presentation by Hoo Yin Shi




                                            Palatal view

6. Putty matrix (Express XT Putty) was used as a guide for tooth reduction as well as in the
   construction of the provisional restoration.




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                                                              Case presentation by Hoo Yin Shi


7. Provisional restoration on 22 was done using Protemp 4 (3M ESPE). It was cemented in
   place with temporary cement (Temp Bond). Provisionalization included adequate papilla
   support and contact points to maintain soft tissue architecture and health for the definitive
   restoration.




                                         Labial view




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                                                               Case presentation by Hoo Yin Shi




                                         Lateral view


8. Patient complaint that the provisional restoration on 22 was too long. Careful reduction of
   incisal edges was done with polishing discs. She was satisfied with the appearance of 22 after
   the reduction.


9. Retraction cord impregnated with Hemodent was used around the gingival margin. Final
   impression was made by Express XT Putty and light body PVS. A bite registration and an
   opposing impression were taken at this time.




                       Express XT Putty and light body PVS (3M ESPE)


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                                                               Case presentation by Hoo Yin Shi




10. Master cast was fabricated in the laboratory for the construction of PFM crown.




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                                                             Case presentation by Hoo Yin Shi


11. Fitting of the PFM crown on 22.




12. Patient was satisfied and happy with the appearance of the PFM crown. The occlusion of the
   PFM crown was checked and the high bite was removed. It was sand-blasted followed by
   cementation with definitive cement (Panavia). Acrylic denture fitted well after cementation
   of the crown.




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                             Case presentation by Hoo Yin Shi




Post-operative Photographs




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                                                              Case presentation by Hoo Yin Shi




Progressive treatments

B. Continuation of Restorative phase
   Part III    Construction of PFM crown on 35 (with post and core)
               To continue from canal preparation for placement of post.




                   Obturation radiograph of 35
                  (With temporary restoration)


   Part IV     Construction of Cobalt-chrome maxillary and mandibular removable partial
               denture


C. Review/Maintenance phase
   3 monthly



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                                                               Case presentation by Hoo Yin Shi



Discussion

       PFM crown on 22 was chosen instead of full ceramic crown due to several reasons. The
main reason was due to heavy contact on palatal surface of 22 from opposing 33 during ICP,
RCP, left lateral excursion and protrusive movement. The reduction of tooth structure on cervical
1/3 of palatal surface was greater from the recommended measurement for durability of metal
substructure.
       During review session, the crown remained in function and had good periodontal health
which implied a good prognosis of the tooth.




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