Comprehensive case 1 - Multiple edentulous areas

 Multiple edentulous areas

Special thanks to :

Dr.Abderrahmane Basta 

Dr.Abdulrahman Abu-Zomer

Dr.Enshirah Jamal 

Dr.Ahmad M. Eid 

Dr.Amaweya 

Dr.Hassan 

Dr.Raeda 

Dr.Walaa Al-Kurdi

Dr.Abdulla 

THE PATIENT
A 31-year-old male patient came to the clinic for dental treatment. His chief complaints were`I can't eat.' My teeth look awful.  Lately, my speech seems to be changing.' `I know that I have no choice and need lots of work done on my teeth. 

PAST MEDICAL HISTORY
The patient's medical history was unremarkable; he had no allergies, and was not taking any medication. 

PAST DENTAL HISTORY
The patient had never visited a dentist regularly.
The last visit to dentist was before 3 years. He claimed that before 1 year his wisdom tooth broken suddenly there was sever pain & he used to take a pain killer to relief the pain.He brushed his teeth twice a day, morning and evening; he used to use a circular motion for brushing.


EXTRAORAL EXAMINATION (Figure 1.1,1.2)

•   Symmetrical face
•  Profile-straight to concave
•  TMJ , not tender ,No clicking normal moth opening 
•  Normal facial musculature
• Maximum opening of 40 mm

(Figure 1.1)frontal view shows round face of the patient 

(Figure 1.2)Profile picture shows straight to concave profile.

INTRAORAL AND FULLL MOUTH EXAMINATIONMaxilla ( Figure 1.3, 1.4, 1.5 )
§  Caries
§  Missing “centrals, premolars & molars” right and left
§  Recession #23
§  Fair Oral Hygiene
§  Torus palatinus (Figure 1.5)§  Parabolic arch 

(Figure 1.3) 
defective teeth in the maxillary left side, third molar & 1^st premolar. 
Inflammation around the teeth. 

(Figure 1.4)
non restorable upper right third molar ,
inflammation around the upper right canine.

(Figure 1.5)
Torus palatinus appear clearly in the middle of the palate.

Mandible (Figure 1.6)§  Parabolic Arch


§  Residual Ridge is thin & slightly resorbed


§  Caries


§  Missing teeth

(Figure 1.6)
Mandibular Arch, defective teeth in the lower right 3^rd molar,
1^st premolar & lower left 2^nd premolar 

FULL MOUTH OPG SURVEY  (Figure 1.7)§  Periapical lesions
§  Caries
§  Bone Loss
§  Bone Support
§  Over Bone support
§  Questionable
§  Poor
§  Fair  

(Figure 1.7)

Occlusal examination revealed that the patient was Angle class III.
Periodontal examination (Figure 1.8, 1.9) revealed small amounts of calculus and plaque. There was bleeding on probing (BOP) in the lower anterior teeth & gingival recession in upper left canine.

(Figure 1.8) 

periodontal inflammation around upper right canine palataly. 

(Figure 1.9) 

Periodontal inflammation lingual to lower incisors & premolars.

About the patient
the patient was very pleasant and willing to do what was necessary to have treatment. He was cooperative and had no preference for a fixed or removable restoration.
TREATMENT PLAN

·         Initial periodontal therapy including:

·         oral hygiene instruction

·         scaling and root planning

·         Extraction of hopeless teeth #18

·         Caries excavation and restoration

·         treatment where necessary

·         Evaluation of patient cooperation

·         Re-evaluation led to the second phase of the treatment plan.

PHASE 2: TREATMENT OPTIONS

Maxilla:

·         Implant prosthesis

·         partial removable prostheses CO/Chr RPD

·         Maxillary Removable Overdenture

Mandible:

·         Implant Prosthesis   

·         partial removable prostheses CO/Chr RPD

TREATMENT

·         Initial treatment consisted of oral hygiene instruction, scaling and root planning.

The hopeless teeth “upper right 3^rd molar #18”, was then extracted

(Figure 1.10)
upper right 3^rd molarRestorative therapy was carried out on the maxillary teeth #24, #28. & in the mandible #38 

(Figure 1.11)
upper left 1^st premolar before and after restorative treatment.

(Figure 1.12)
Upper left canine after class V restorative treatment

 

(Figure 1.13)
Upper left 3^rd molar after restorative treatment with the occlusal rest mesially 

(Figure 1.14)

Lower Right 3^rd molar before , during & after restorative treatment with occlusal rest mesially.

• The radiograph revealed good bone for implants, but the patient can’t offered the implant treatment. 
• Alternative choice was Cobalt chromium removable partial denture. 

PROSTHODONTICS TREATMENT

According to Kennedy classification of dental arches,
this case was Type II in the upper Arch & Type III in the lower Arch.

1^st visit (Figure 1.15, 1.16)
In the clinic :

·         Primary impression taken for upper & lower Arches .

·         In the Lab :

·         Pouring Primary Impression

·         Wax applied on the primary cast with double layer on the teeth

·         Special tray created  using denture base material

·         Smoothen the trays edges & relief the frenum areas.

(Figure 1.15)
Upper cast shows the design selection “Major connector” &
the area of occlusal rests where to be prepared.

(Figure 1.16)

Lower cast shows the design selection “Major connector” & the area of occlusal rests where to be prepared.

2^nd visit (Figure 1.17)
Before bringing the patient , Choose the correct design & draw it in the cast & show it to your instructor

·         In the clinic :

·         Preparation of the guiding plans & occlusal , cingulam rests.

·         Try the special trays in patient mouth

·         Do holes in the special trays & apply adhesive material

        * Medium body used to take the impression 

(Figure 1.17)

3^rd Visit ( in the clinic ) :

·         Metal Try in

·         You have to check :

·         Stability of RPD

·         High points

·         Jaw relation

·         Select the shade of acrylic teeth

4^th visit (Delivery of the RPD) – Figure 1.18, 1.19, 1.20
You have to:

·         Remove The interferences from the acrylic teeth & Base

·         Post-operative instruction 

(Figure 1.18)
frontal view after delivery of the upper and lower cobalt chromium RPD.

(Figure 1.19)
Upper Jaw with the appliance after delivery 

(Figure 1.20)
lower Jaw with the appliance after delivery

ORAL HYIGENE

There was a dramatic improvement in the patient's periodontal condition due to his improved oral hygiene and cooperation.

SUMMARY

The patient came to the clinic for dental treatment complaining of pain, a lost teeth , and difficulty in eating. He had not visited a dentist for 3 years and thought that by brushing his teeth twice daily, it was sufficient.
He has fair oral hygiene, and gingival inflammation.
He had many missing teeth and some of the remaining teeth were carious & some were deep carious teeth. Because of financial problems, implants rolled out.

CASE DISCUSSION

In the case presented above, we have improved the remaining teeth prognosis by periodontal, Surgical

and restorative treatment, along with a carefully planned prosthodontics options.

      The combination of periodontal therapy surgical & restorative treatment with skilled prosthodontics has         produced not only a happy patient but also an esthetic and functioning dentition. Long may it last!