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

61 year old Male

Cheek biting +++ Food packing +++ Chief Complaint

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

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

Extra-Oral At rest

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

Reverse Smile Line

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

INTRA-ORAL

Occlusal View LOWER

OCCLUSAL VIEW UPPER

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

OPG

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

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

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

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

Centric Relation Record

Composite Mock up

Composite Mock Up at Rest

Composite Mock up

Composite Mock Up

Diagnostic Wax up

Test Wax up

2.5mm increase in length

Completion of Wax up at increased vertical

Completion of Wax up at increase Vertical

Upper cast

lower cast

3-3 Lower Composite buildups 2-4mm

Transfer to mouth

Transfer to Mouth

Provisional Stage treatment completed 14, 15 buccal cusp tips resin build ups putty index,full coverage direct composite buildups bridge fractured porcelain repaired, HF silane, composite - improve buccal corridor chairside,Protemp4, provisional crowns putty index, direct composite buildups 44 chairside,Protemp4, provisional crowns chairside,Protemp4, provisional bridge 48 to be extracted

Impression of Wax up Rest on 48

Completion of Provisionals

Bilateral Canine Guidance

Lower arch

Upper Arch

Before and After Smile

Final restorations Full coverage zirconia crowns , 26, 37-34, 44 3U Zirconia Bridge , Porcelain Veneers 33-43