BDS Finals Case Presentation - Excellent Grade

Clinical Dentistry 5Case 1 | Candidate S18

Case Presentation

Background

Age: 59

Gender: Male

Occupation: Maintenance man at a student letting company

Presenting Complaint: Appearance of upper dentureLoose upper dentureUnable to eat with dentures inBleeding gumsOccasional sensitivity from upper canines

History Of Presenting Complaint:

Has lost his teeth progressively over the years due to neglectHas had his current set of dentures for over 5 yearsHasn’t worn his lower denture for over 5 years – bulky/poor retentionPrevious negative experiences with dentures and dentists

Initially requested a full clearance and F/F’s

Previous Dental History: Non-regular attender – LDV – 3 years agoPartially dentate

Background

Medical History High cholesterol (2004)– controlled with medicationIBS (2005) – occasionally gets symptoms controlled with medicationNo known allergies

Medications Prescribed medications:- Sulpiride – TDS when symptomatic, approximately 1/12- AtorvastatinNo over the counter medications

Social History Divorced - No childrenResides in PlymouthUsed to smoke 15 cigarettes per day for 30 years, stopped 7 years agoAlcohol consumption – approximately 8 units per week

Hobbies: Science fiction films

Family History No history of familial disease, dental or medical.

Patient Expectations To regain confidence in himself “To be able to eat foods I haven’t been able to eat in years”

Patient Anxiety: High

Examination

Extra-Oral Examination No facial swelling or asymmetry

No lymphadenopathy associated with the head and neck

No clicking, pain, discomfort, limitation or crepitus in movement of TMJ and musculature

Normal mouth opening

Low smile line with symmetrical and competent lips

Class I skeletal pattern

Examination Intra-Oral Examination

Soft tissues – numerous lingual varicosities on ventral surface of tongue, otherwise NAD

Gingivae – moderate phenotype, otherwise NAD

Static occlusion –

Incisal relationship – n/a

Molar relationship: n/a

Centre lines – n/a

Dynamic occlusion

Left & right lateral excursion – canine guidance

Incisal guidance – n/a

Summary Of Dentition

Charting

3 3

3 2 1 1 2 3

KEY:

Composite

Tooth Surface Loss SL

Caries

Denture Tooth

W

Examination

Basic Periodontal Examination (BPE)

Oral Hygiene RegimeBrushes approximately once per week with a manual toothbrush Uses fluoride toothpaste No interdental cleaning or mouthwash usage

DietAssessed via general discussions and in conjunction with a 3 day diet sheet:

Has on average 4 sugar hits a day Drinks tea and coffee without sugar

Caries Risk Assessment

High caries risk

Plaque Score 56.3% Bleeding Score 87.5%

X 2 X

X 4 X

Pre-Treatment Photographs...with upper denture

Pre-Treatment Photographs...without upper denture

Investigations and Justification

Radiographs Full Mouth Periapicals:• To check periapical pathology• To assess for carious lesions• To assess bone loss• Pre-treatment assessment to aid diagnosis

Sensibility Testing

Endo Cold Spray Electric Pulp Test

UR3 Positive Positive

UL3 Positive Positive

LR3 Positive Positive



LL1 Positive Positive



Percussion Testing All teeth negative response

Full Periodontal Assessment

6 point pocket chart, gingival recession, furcation grading, mobility score, suppuration, O’Leary plaque score, bleeding score

Diagnostic Study Models

To assess occlusion and aid treatment planning prior to treatment

Periapical Radiographs

Grade 1

UR3: Circular coronal radiolucency No periapical pathologySubgingival calculusModerate horizontal bone loss Maxillary antrum visible

Grade 1

UL3: Circular coronal radiolucency No periapical pathologySubgingival calculusModerate horizontal bone loss Maxillary antrum visible

Periapical Radiographs

Grade 2

LR3: Circular coronal radiolucency No periapical pathology

LR2: UnrestoredNo periapical pathology

LR1: UnrestoredNo periapical pathology

General:• Subgingival interproximal calculus• Moderate generalised horizontal bone

loss

Grade 2

LL1: UnrestoredNo periapical pathology



loss

Grade 2



loss

Full Periodontal Assessment

Initial Bleeding

87.5%

Initial Plaque 56.3% (O’Leary)

Pockets 7 pockets ≥4mm

Recession All teeth within class I, (Miller’s Index).

Mobility All teeth within Class 0 (Millers Index)

Furcation nil

Suppuration nil

KEYPocket Depth RecessionBleeding Pockets ≥4mm

Diagnoses / Problem List

Generalised (moderate) chronic periodontitis

Marginal Gingivitis with plaque retentive factors

Secondary Caries - LR3 B, UR3 B, UL3 B

Poor oral hygiene & dietary habits

Pathological Tooth Surface Loss – Attrition

Dentine Hypersensitivity – UR3, UL3, LL3, LL2

Arrested Caries – UR3B, LL2B

Acquired tooth loss – UL8-4, UL2-UR2, UR4-8, LR8-4, LL4-8

Dentures Unsatisfactory

Aesthetic concerns

Generalised gingival recession

Pre-Treatment Tooth Prognosis

Good ✔

Guarded | Questionable ?

Poor X

PERIO.

ENDO.

PROS. Overall

UR3 ✔ ✔ ✔ ✔

UL3 ✔ ✔ ? ?

PERIO.

ENDO. PROS. Overall

LR3 ✔ ✔ ✔ ✔

LR2 ? ✔ ✔ ?

LR1 ? ✔ ✔ ?

LL1 ? ✔ ✔ ?

LL2 ? ✔ ✔ ?

LL3 ? ✔ ? ?

✔

✔ ? ? ? ??

Guarded Teeth Justification

LR2-LL3 Periodontal, therefore overall prognosis guarded due to pockets greater than 4mm

UL3 + LL3 Active TSL (Grade III - Smith & Knight Index)

?

Treatment Aims

Aims Of Treatment

To educate patient about the importance of OH

To improve the oral-hygiene, dietary habits

Improve gingival & periodontal health

To arrest & secondary caries beneath failed restorations

To improve on anterior aesthetics

To regain posterior support

To improve function – ability to eat

To fill spaces from acquired tooth loss

To enable long term maintenance of oral/dental health

PATIENT FACTORS:- Realistic expectations- Patient motivation- Chair time- Home care and

maintenance- High caries risk

Education A Holistic approach - Explanation into caries progression and the aetiology of periodontal disease. Convey the importance of good OHI and keeping remaining teeth

Case Discussion..understanding the holistic needs of the patient

Primary Concerns

Appearance • “Stained fillings” – A thorough clinical examination revealed failed restorations.

① Caries removal + restorations with a better shade match improved aesthetics

Sensitivity

• Sensitivity due to exposed dentine in 6 of the patients 8 teeth• Options given:

① Leave, monitor, re-assess – rejected② Composite build ups

Unsatisfactory dentures

• Patient requested new set of upper dentures • Better Aesthetics / More retentive / Less bulky

• Treatment options ① Leave, monitor, re-assess - rejected② Bridgework (shortened dental arch) - rejected③ acrylic dentures④ cobalt chrome dentures⑤ implant retained dentures - rejected

Education • A Holistic approach • explanation into caries progression and the aetiology of periodontal disease.

Convey the importance of good OHI and keeping remaining teeth

Definitive Treatment Plan

Phase 1 – Short-Term Management

1 Dietary analysis and diet advice

2 OHI, supra-gingival debridementFluoride mouthwash and interdental cleaning aidsFluoride Varnish Application on susceptible sites (arrested caries)Prescription of high fluoride toothpaste

3 Root Surface Debridement (RSD) on pockets ≥ 4mm – with 2 month review

4 Composite restorations – UR3, UL3, LL3

Phase 2 – Medium Term Management

5 Diagnostic wax-up’s of LL1-3 to match anatomy of LR1-3

6 Composite build ups – LL1-3 LR3 DB, UR3, UL3

7 Upper acrylic RPD – Kennedy Classification I mod ILower cobalt-chrome RPD – Kennedy Classification I

Phase 3 – Long Term Management

8 6 monthly dental recall appointments 3 monthly periodontal maintenance appointments

Phase 1 – Short-Term

1 2 3 4 5 6 7 8 9 100

20

40

60

80

100Plaque Score Bleeding Score

Appointments

%

2 Month Periodontal Review

Pockets ≥4mm reduced from 70 No. of bleeding sites reduced 251

KEYPocket Depth Recession Bleeding

Phase 2 - Lower Composite Build-ups

Diagnostic wax ups

requested for LL1-3

Optosil putty

matrix used to create

stent

Rubber dam placement

Total-Etch Bonding

Technique

Composite (shade A4) build up

Polishing

Clinical Stages

Phase 2 – Lower CoCr RPD Design

Saddles To replace missing teethLR4-7, LL4-7

Support Tooth-mucosal support 1) From underlying mucosa 2) From abutment teethCingulum rest encompassing mesial aspect – similar to RPI

Retention DirectOn abutment teeth- Gingivally approaching roach clasps

IndirectKennedy bar connector on cingulum of LR2 and LL2

Bracing Reciprocating action of framework above survey line on LR3/LL3

Connectors Kennedy Bar- Lingual bar + continuous barHygiene - Avoided minor connectors + incisal rests to prevent food packing / plaque trapping

Post-Treatment Tooth Prognosis

Good ✔

Guarded | Questionable ?

Poor X

PERIO.

ENDO.

PROS. Overall

UR3 ✔ ✔ ✔ ✔

UL3 ✔ ✔ ✔ ✔

PERIO.

ENDO. PROS. Overall

LR3 ✔ ✔ ✔ ✔

LR2 ✔ ✔ ✔ ✔

LR1 ✔ ✔ ✔ ✔

LL1 ✔ ✔ ✔ ✔

LL2 ✔ ✔ ✔ ✔

LL3 ✔ ✔ ✔ ✔

Improvements Justification

LR2-LL3 First round of RSD successful. Pockets reduced to 3mm or less

UL3 + LL3 Composite build ups to stabilise and protect against further tooth surface loss – restored function. Long term success dependent on review/monitoring

Maintenance and Recall

Maintenance

Home:• Regular interdental cleaning• Maintaining good OHI and diet• Denture hygiene

Professional:• Reinforce home regime

Recall

Dental Recall:• 6 month recall interval – high caries risk• Monitor/assess for caries and restorations

clinically and radiographically.• Biannual fluoride varnish application

Periodontal Health Recall:• 3 monthly periodontal screening• Full periodontal assessment & 6 point

pocket chart (if indicated)• Plaque and bleeding scores

Monitor:• Review Upper and lower dentures • Lower build ups – staining / repairs• UL3B/LL2B arrested caries

Post-Treatment Photographs

Case Reflection

What went well…① I felt I understood the patients concerns and motivations, and this enabled me to produce a result which helped his confidence.

② Patient specific OH education, the patient now has a meticulous OHI regime at home and understands why

③ It was rewarding to hear that once I had fitted his dentures, he hadn’t taken them out to eat a single meal

④ The 7 pockets ≥4mm healed well within the first round of RSD.

⑤ I was really happy with the final result from my composite build ups and dentures.

⑥ I am happy I decided to go with the modified Kennedy bar design.

Challenges / What could I have done differently..

① I could have requested articulated diagnostic wax-ups for the upper canines also, and build them out more mesially occlusal stop + more stable occlusion. This may have ensured canine guidance.

② I worked closely with the patient and the technician in order to improve the denture design. I realised my limitations and consequently sought to seek additional advice to achieve the best possible result for the patient.

③ I could have used the Altered Cast Technique for a functional impression of the lower alveolar ridges.

Learning Experience

I now understand the importance photography skills and taking good clinical photos: 1) for the patient records and the dento-legal perspective 2) to be able to self-critique my own work to improve upon for future cases

The importance of listening to the patients concerns and taking them into consideration when treatment planning.

The importance of good communication with the lab. For the lower denture I was in constant communication with the chrome department at Phoenix and I think this helped in the final result of the denture

Over the course of this treatment plan and my final year at PDS, I feel I have grown as a clinician and as a professional and hopefully I can transfer these qualities going forward in my career

“Thank you for everything Shamir, these are the best dentures I have ever had, I can’t describe how happy I am with them.

Thank you for listening

I welcome your questions

“Thank you for everything Shamir, these are the best

dentures I have ever had, I can’t

describe how happy I am with

them.”

BDS Finals Case Presentation - Excellent Grade

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