1. Module 2 2 October 2008 Case Presentation Adrian Wong Case Presentation Adrian Wong

2. 61 year old Male

3. Cheek biting +++ Food packing +++ Chief Complaint

4. high blood pressure (controlled) gastro- eosophageal reflux Medical History

5. RCTS +++ Restorations +++ Failing Crown and Bridge Dental History

6. Extra-Oral At rest

7. Extra- Oral No tooth display at rest Reverse smile Low lip line Tenderness in Lateral Pterygoids No joint sounds phonetics - “F” not clear and “S” not crisp brachio facial type enlarge massetters and tempoarlis (no tenderness) Class 1 skeletal

8. Reverse Smile Line

9. Low Smile line Poor incisor edge position Central incisors -1:1 square Good midline and no cant (co-incident with facial mid-line) Reasonable Zenith Points Good Buccal Corridor Over eruption Q1 Reverse Smile Diastema Aesthetic assessment

10. INTRA-ORAL

11. Occlusal View LOWER

12. OCCLUSAL VIEW UPPER

13. Caries Attrition severe erosion slight periodontal disease existing crown and bridge failing restorations missing teeth short crown height esp lower posteriors (reflux pattern?) alveolar ridges well developed over-eruption Q1 RCTs +++ Porcelain #+++ Group function - no anterior guidance Slide form CRCP to MIP 0.5mm anteriorly, 0.25mm to RHS, 0.25mm vertical Intra-Oral

14. OPG

15. Risk Factor assessment Heavy bite Parafunction Past # porcelain ++++ RCT reinfection/Mechanical failure High rate of recurrent caries Acidic mouth (Reflux)

16. Treatment plan Preventive treatment - medical assessment and treatment of reflux, use of recaldent chewing gum/tooth mousse, fluoride mouth rinse. Periodontal treatment and maintenance. Endodontic assessment - 25, 26, 37, 36, 35, 47, 48 extraction of 48

17. Full mouth Rehabilitation Rehabilitate to CR/CR with long centric Increase OVD and length of anterior to predetermined position- single point contact cusp-fossa contact posteriorly and immediate disclusion during all excursions.(anterior guidance) Long term laboratory constructed provisionals Composite buildups on lower incisors Gradual conversion of provisionals to final restorations 24, 25, 37, 36, 35, 46 - consider implant replacement

18. Uncertainties Increase in OVD sufficient to eliminate cheek biting? Gold restorations should be material of choice? Composite buildups on lower anterior sufficient? Longevity of Provisionals Incisors too long? Too much anterior tooth display given age and long upper lip

19. Centric Relation Record

20. Composite Mock up

21. Composite Mock Up at Rest

22. Composite Mock up

23. Composite Mock Up

24. Diagnostic Wax up

25. Test Wax up

27. 2.5mm increase in length

28. Completion of Wax up at increased vertical

29. Completion of Wax up at increase Vertical

30. Upper cast

31. lower cast

32. 3-3 Lower Composite buildups 2-4mm

33. Transfer to mouth

34. Transfer to Mouth

35. Provisional Stage treatment completed 14, 15 buccal cusp tips resin build ups 13-22 putty index,full coverage direct composite buildups 23-25 bridge fractured porcelain repaired, HF silane, composite - improve buccal corridor 37-34 chairside,Protemp4, provisional crowns 33-43 putty index, direct composite buildups 44 chairside,Protemp4, provisional crowns 45-47 chairside,Protemp4, provisional bridge 48 to be extracted

36. Impression of Wax up Rest on 48

37. Completion of Provisionals

40. Bilateral Canine Guidance

41. Lower arch

43. Upper Arch

45. Before and After Smile

48. Final restorations Full coverage zirconia crowns 17- 22, 26, 37-34, 44 3U Zirconia Bridge 23- 25, 45-47 Porcelain Veneers 33-43