2. Clinical Case Presentation One Ross Chapman Student Number: 20579504

3. Background 89 yr old Male Presenting Complaint Poorly fitting F/F dentures Poor retention on upper denture Struggling to eat comfortably History of presenting complaint Current dentures 10+ yrs old Has had various new dentures made but not tolerated Dental History Denture wearer 50+ yrs Regular attendee at this practice

4. Background Medical history Previous heart attack 20+ yrs ago Pace maker fitted Patient quite unsteady on feet High blood pressure Medication: Bendroflumethiazide Asprin

5. Background Social history Tea total and non smoker (quit smoking 25+ years) Widower and lives alone with daily family contact Active patient considering age and health

6. Background Family history No history of dental disease Family history of heart problems Current OH regime Cleans mouth and dentures twice daily with soft brush Soaks denture in cleaning solution weekly Dentures in good condition for age yet worn

7. Extra-Oral Examination No facial asymmetry Nil pain in trismus No palpable lymph nodes Lips and soft tissue all competent TMJ – NAD Nil clicking, pain, normal opening, deviation Skeletal class I

8. Chart Key:= Acrylic Denture

9. Intra-oral Examination Soft tissues Lips – Nothing abnormal detected (NAD), Competent lips, medium lip line Tongue – NAD Floor of Mouth – NAD Buccal Mucosa – NAD Parotid Secretion - NAD Palate - NAD

10. Intra-oral Examination Upper and lower arches Gross resorption on upper ridge with flabby anterior residual alveolar process Gross resorption on lower residual alveolar process leaving very flat ridge Existing denture F/F very loose F/- dropping on patient opening -F rotates in mouth with no lateral retention Reduced OVD through wear X bite on LHS

11. Initial Photographs

12. Diagnosis/Treatment Plan Diagnosis No retention on upper denture Very ill fitting lower denture Patient quite old and unable to tolerate major change Reduced OVD Treatment plan Make new Full/Full dentures using copy technique Improve fit in all areas Increase OVD to restore wear (no more than 2mm) Add soft lining on lower to aid comfort

13. Possible referral Patient has had many set made in previous years, informed if this set is still not able to meet expectations we may refer to dental hospital for specialist treatment. Patient happy to have one last go before referral Patient referred into myself internally as routine for prosthetics cases

14. Appointment 1 Consent for examination taken Consultation – C/O, History of complaint MH, DH, SH checked as taken by referring GDP Exam E/O & I/O Consent to dental photographs given

15. Appointment 2 Current F/F dentures copied using stock trays and “Sheradup” 50/50 duplication putty

16. Appointment 2 Current F/F dentures copied using stock trays and “Sheradup” 50/50 duplication putty

17. Appointment 3 Wash impressions and moose bite registration taken

18. Appointment 3 Wash impressions and moose bite registration taken

19. Appointment 4 Try-in ready

20. Appointment 4 Try-in Stage Delphic V teeth used for set up at laboratory OVD opened on articulator by 2mm to restore worn teeth Bite checked and adjusted chair side for high spots Upper try in not as retentive as expected. Light bodied silicone wash taken to improve. Patient happy with feel and aesthetics of denture

21. Appointment 5 Denture fit Stage Upper denture retention good at rest yet still dropping when patient opens wide No adjustment required to lower denture No adjustment needed to bite Patient happy to wear for 1/52 to see if upper retention improves when bedded in

22. Appointment 6 Review Stage 1 weeks post insertion review Patient feels upper retention not adequate, still dropping on opening and unable to eat. Denture dropping causing sore lower ridge as interfering with bite Reline imp taken on upper to improve retention

23. Appointment 7 Review Stage Assessed fit of relined upper still not happy so have decided to remake upper denture S/T and bite made from existing upper Secondary imp and bite against existing lower at N/V

24. Appointment 8 Review Stage Secondary impression taken in window tray to allow for flabby anterior ridge Bite registration rim recorded Existing lower denture fine

25. Appointment 9 Review Stage New F/- retention greatly improved. Patient can fully open and close with no dropping Slight inter-cuspal interference so blue moose taken between upper and lower for adjustment prior to finish

26. Appointment 10 Review Stage F/F fitted good retention on upper Slight adjustment to bite and pain on lower RHS R/V in 2 weeks

27. Appointment 11 Review Stage 2 week review Patient only wore denture for 2 days as painful on lower Upper retention good and now not a problem Decided to double the thickness of soft lining as patient unable to tolerate new bite and increased OVD

28. Appointment 12 Review Stage -F rebase try in with 5 mm thick spacer for extra soft lining Bite and fit good. Patient able to open and close returning to bite every time. Patient happy to proceed to fit

29. Appointment 13 Review Stage F/F with extra thick soft lining fitted Minor adjustment to buccal extension on RHS Patient happy with fit of dentures R/V in 1 week

30. Appointment 14 Review Stage R/V 1 week post insertion Patient able to eat pain free F/- retentive on function Patient very happy TCA if problems arise ! Phew

31. Post treatment photographs

32. Maintenance/Recall Patient given instruction on cleaning the denture and maintaining the soft lining without damaging the soft material Patient to continue annual check up at practice Told TCA if any problems occur Treatment complete

33. Reflection Case started off as a simple copy and morphed into really complex case In hindsight should have insisted that we made new dentures from scratch at the beginning of treatment course and not used copy technique to appease the patient Patient was a pleasure to work with and understood problems we were having however a less amiable patient may have been frustrated by amount of appointments

34. Reflection Not a problem when working as a student but this case would have financially cost the practice when taking into account repeated clinic visits and laboratory expenditure. On reflection some basic mistakes were made during this treatment plan, however my mentor insists these are the cases you learn and take the most from.