Case Conference

Reporter : 許珮寧 Instructor :蔡宗伯醫師

Date: 2013/09/14

1. Basic Information

Name :詹吳x妹

Chart No. : 2765225

Gender : female

Birth : 1926/05/17

Occupation : nil

Patient identification -

This 85 years-old female came to our dental OPD for full mouth dental check and treatment

2. Chief Complaint

I want to restore my upper missing teeth with removable denture

3. PMH Hypertension D.M. Peptic ulcer Drug allergy: Pyrine

4. PDH FPDs made at LDC

Extraction (O.S. department)

Scaling at LDC

PERSONAL HABITS ØSmoking (-)

ØBetal-nut chewing (-)

ØDrinking (-)

ØBruxism (-)

5.present Illness

This 85 years old female came to our OPD on 99.06.11 for full mouth prosthesis fabrication. She have never worn any removable denture. Her remnant teeth were #12, #13, #14, #15 and #32, #33, #34, #35. Teeth of #14 #15 #33 #34 #35 have been restored with metal splinted crowns without antagonists for several years. Upper and lower edentulous ridge were severe resorbed. (#12,#13,#32) Dental caries, poor oral hygiene and gingival inflammation were noted .

6.Extraoral Examination

Frontal view -- facial asymmetry(-)

•Lateral view -- convex profile

•No gummy smile

7. Intraoral Examination

Present dentition: 5 4 3 2 2 3 4 5

•FPDs:#14#15,#33#34#35

•Dental caries:12,13,32

14,15 metal crowns

12,Atrophy edentulous ridge 33,34,35 metal crowns

8.Radiographic examination

13,15,33,34,35 incomplete endo. Tx teeth 33,34 apical lesion 14,15,33,34,35 metal crowns 32 moderate bone destruction

9.Probing Data

#15 #14 #13 #12 #32 #33 #34 #35PD-B 212 413 213 423 223 322 996 222

PD-L 422 443 334 422 233 322 1098 322

10.Diagnosis and Problem List

DENTAL PROBLEM LIST ØFull mouth plaque deposition

ØChronic periodontitis

ØMissing:

7 6 1 1 2 3 4 5 6 7

7 6 5 4 3 2 1 1 6 7

ØDental caries :12,13,32

TREATMENT SEQUENCE ØEmergency care

ØPre-prosthetic corrective care

ØHygienic and maintenance care

ØRehabilitative care

ØMaintenance and supportive care

TREATMENT OBJECTIVES ØRemove ill-fitted prostheses (99.07.23) ØRemove hopeless teeth (99.08.03) ØEndodontic treatment ( 99.08.10~99.10.27) ØPeriodontal treatment (99.07.23~) ØFull mouth prostheses fabrication

- provisional restoration (99.07.23~99.09.17) - definitive restoration (100.10.27~101.01.03)

11.Diagnostic Wax-up

Tentative Treatment

34 extraction

•13,15,33,35 endo. Tx

•Present dentition : 5 4 3 2 2 3 5 •13,14,15,33x35 provisional FPDs

• Upper and lower interim removable partial denture

12.Provisionals and Interim Dentures- Intraoral

13.Provisionals and Interim Dentures- extraoral

14.Definitive Treatment Plan-Option 1•Maxilla: 12,13,14,15 surveyed crowns Kennedy class I R.P.D. •Mandible:

32,33x35 surveyed crowns Kennedy class I R.P.D.

15.Definitive Treatment Plan-Option2

Maxilla: 13,14,15 surveyed crowns Kennedy class I R.P.D. •Mandible:

33x35 surveyed crowns Kennedy class I R.P.D.

16.Definitive Treatment Plan-Option3

Maxilla: 12,13,14,15 surveyed crowns implants assisted Kennedy class I R.P.D. •Mandible:

32,33x35 surveyed crowns implants assisted Kennedy class I R.P.D. 17.Definitive Treatment CourseSurveyed Crowns

18.RPD design and framework

19.Altered cast and wax up

20.Denture Delivery

MIP protrusion

Excentric movement21.Months Follow-up22.Q&A病例討論會Q&AQ1:請問你所取的咬合紀錄是C.O.還是C.R.  bite?怎麼取?A1:CR;利用bilateral  manipula8on  of  the  mandible的方式:使用此法時每隻手的四根手指放在病患下顎的下緣，拇指放置於靠近顎部隆突處。當

病患下顎可自由地旋轉時，以手指施予一結實向上的壓力，拇指則施予一往上和往後的壓力。這些動作將引導一往後旋轉的下顎運動(hinge  movement)。Q2:有考慮swing-­‐lock的設計嗎?為何最後沒有做此設計?A2:一開始有考慮swing-­‐lock的設計，但因為病患年紀較大，手的靈巧度比較不      好，所以後來就沒有作此設計。Q3:如何決定咬合平面?A3:利用上頷的recording  base與occlual  rim，incisal  plane平行interpupillary  line而側方平行Camper’s  line而決定。Q4:作surveyed  crown時bite時如何取的?A4:印製有裝戴上下provisional  restora8on的study  cast，取咬合紀錄及facebow  transfer，及印製上下surveyed  crown的master  cast,分別取下顎及上頷study  cast  對master  cast的咬合紀錄，作cross  mount將製作surveyed  crown的上下master  cast轉移至半調節咬合器上。    Q5:請問這患者在假牙製作後，在病人卸下活動假牙時，有什麼方式可以保護他        的無牙嵴?A5:可以製作occlusal  splint去保護無牙嵴或如果病患口腔衛生照顧許可的話，可在睡覺時只裝其中一頷的活動假牙。Q6:在這類有牙對上無牙的患者，就mechanical方面在咬合上請問有什麼考量或        想法嗎?A6:希望減少自然牙對咬側無牙嵴的受力，所以occlusal  scheme設計成group  func8on以分擔咬合力量，減緩其吸收速度。

Case Conference

 Reporter  :  魏敏佳醫師 Instructor:  徐光蔚醫師

Date:  2013/09/14  

1. General  informa8onName  :李x英 Gender  :  Female  

Age  :  69  y/o  

Marriage:  married  

Occupa8on:  re8red  

AXtude  :  philosophic,  live  in  Chiayi  and  Taoyuan  

2.Chief  complaint  :  My  teeth  are  loosening  

Referred  from  periodontal  department  for  prosthe8c  treatment  

3. Past  History•Past  Medical  History  -­‐  Denied  of  major  systemic  disease  -­‐  Denied  any  drug  allergy  •Past  Dental  History  

-­‐  OD,  Endo,  Ext,  FPD  

-­‐  Examina8on  and  treatment  at  LDC  4. Personal  habit

Smoking  (-­‐)  

Betal-­‐nut  chewing  (-­‐)  

Drinking  (-­‐)  

Bruxism  (-­‐)  

TMD  symptom/sign  :  denied  

5. Pre-­‐treatment  X-­‐ray  

6. Extra-­‐oral  examina8on:

Frontal  view  -­‐  facial  asymmetry  (-­‐)  Ovoid  outline  form  Low  smile  line  Lateral  view  -­‐  convex  profile  (class  III  profile)  

Nasolabial  angle:  nearly  90°

7. Intra-­‐oral  examina8on  2012.02.21:

#13-12-11-xx-23 ext    Arch form: upper & lower -- taper

   

#18-28,38-33,44-48 missing #32,31,41 residual roots #42 advanced periodontitis with mobility Gr II #43 periodontitis with caries

FM chronic periodontitis  lower anterior teeth and bone protrude to buccal side Edentulous area with moderate to severe alveolar bone resorption

                     8. Diagnosis  &  problem  listdiagnosis:

#18-­‐28,38-­‐33,44-­‐48  missing  

FM  chronic  periodon88s  

Ø #42  advanced  periodon88s  

Ø #43  caries  and  apical  periodon88s  

#32,31,41  residual  roots  

Lower  anterior  teeth  and  bone  protrude  to  buccal  side  

Edentulous  area  with  moderate  to  severe  alveolar  bone  resorp8on  

Problem  list:

#18-­‐28,38-­‐33,44-­‐48  missing  

Lower  anterior  teeth  and  bone  protrude  to  buccal  side  

Edentulous  area  with  moderate  to  severe  alveolar  bone  resorp8on  

Unesthe8c  profile  

Poor  chewing  func8on  

9. Tenta8ve  treatment  plan

Op8on  1.  -­‐  #32,31,41,42  extrac8on  -­‐  #33  endodon8c  treatment  -­‐  upper  and  lower  interim  denture  Op8on  2.  

-­‐  Extract  all  teeth  -­‐ Upper  and  lower  interim  denture  -­‐-­‐ preprosthe8c  correc8ve  phase:  -­‐

2012/02/21:  #13-­‐12-­‐11-­‐xx-­‐23  extrac8on  

2012/02/24:  #32,31,41,42,43  extrac8on  -­‐10. Interim  denture  fabrica8on

Lower anterior teeth lingual tilting 11.  interim  denture  photosintraoral

extraoral

12. Treatment  sequence

Preprosthe8c  correc8on  and  interim  prosthesis  phase  2012/02/24:primary  impression  and  #32,31,41,42,43  extrac8on  2012/03/02:bite  registra8on,  facebow  transfer  2012/03/09:wax  denture  try-­‐in  2012/03/19:interim  denture  delivery  2012/04/25:alveoloplasty  2012/06/29:interim  denture  adjustment  for  teeth  re-­‐arrangement  

Defini8ve  prosthesis  treatment  phase  2012/08/01:CT  taken  2012/10/12:#33,43  implanta8on  

2013/02/19:primary  impression  2013/03/26:maxilla  final  impression  2013/03/26:locator  abutment  selec8on  2013/03/29:locator  abutment  delivery  and  mandible  final  impression  2013/04/12:bite  registra8on  with  base  plate  and  wax  rim,  facebow  transfer  2013/04/17:metal  framework  fabrica8on  2013/04/26:wax  denture  try-­‐in  2013/05/09:denture  delivery  and  pick  up  locator  aiachment  2013/06/18:replace  locator  aiachment  

13.Plan  for  alveoloplasty

1 month after lower teeth extraction prominent alveolar height & width (to buccal side) between #33-45

Fitchecker + PVS light body (Imprint II)

OSSEOUS FINDING: incomplete healed sockets with granulation tissue invaded, sharp edge

before after

OSSEOUS  CORRECTION:  osteoplasty  to  reduce  the  height  &  buccal  prominence,  approximately  3mm  in  height  &  2mm  in  width,  using  rotary  instrument  &  bone  file  

SOFT  TISSUE  CORRECTION:  B  &  L  flaps  were  apically  posi8oned  

14.Aker  alveoloplastya. relief  denture  and  cover  with  sok  liner(12/05/02)b.  repair  resin(12/05/29)c. 34-­‐43  re-­‐arrange  teeth

15.Prepare  for  implanta8on

a.Duplicated  lower  interim  denture  as  stent  for  CT  scan  

b.CT  evalua8on

16.Implanta8on  for  lower  arch

SURGERY:  #33,43  implant  installa8on  

SOCKET:  complete  healed  

SOFT  TISSUE:  TH:  B=2mm;  W:  B=7,7;  L=4,4  

BONE  QUALITY:  type  II  

BONE  QUANTITY:  sufficient  OSSEOUS:  4mm  reduc8on  of  ridge  height  

IMPLANT:  Straumann  @4.1x12mm  SP  RNI  at  #33  &  43  

BC-­‐SHOULDER:  #33=1.5,  2,  1,  1;  #43=  1.5,  2,  1.5,  1.5  

BONE  TH:  #33=1,  1.5;  #43=1,  1.5mm  

ISQ:  #33=75,75;  #43=76,75  

HEALING  ABUTMENT:  1.5mm  

STAGE:  non-­‐submerged  

SOFT  TISSUE:  B-­‐flap  spliced  &  apically  posi8oned  

 

   17.Aker  surgerya.  Not  to  wear  denture  for  2  weeks

b. aker  2  wks,  reline  with  Soklinerc. one  month  later,  reline  with  Sokliner  Tough18.Defini8ve  Prosthesesa. Primary  impression

                           

                         

b. Final  impression/Maxilla

c. Final  impression/Mandible

19.Bite  registra8on  with  wax  rim,  and  facebow  transfer

20.Metal  framework  fabrica8on

21.Teeth  arrangementa. CO

b. Rt  working

c. Lt  working

d. protrusion

   

e. intraoral  view

                                                                                 

                                                                                   

f. extra-­‐oral  view

22.Packing,  lab  remount  and  intraoral  pick  up  locator  aiachment

23.  Clinical  remount  and  delivery

                                                                               

                                                                                                 

24.Before  and  aker

Q  &  A  (by魏敏佳)Q1.  為何不在拔牙的同時做alveoloplasty?A1:  確實可以在拔牙的同時做alveoloplasty或是針對比較sharp的bone做修整，但當時是只有單純做拔牙並沒有翻開flap去做alveoloplasty，是等bone經過一段時間自行remodeling後覺得bone仍然偏向buccal  side  protrusion才決定進行alveoloplasty，或許若預先知道resorp8on後的bone型態仍會不如預期，應該可以在拔牙就同時翻開flap做alveoloplasty。

Q2.  選擇在chair-­‐side  pick  up  aiachment的時機應該在denture  delivery當次或是應讓病患戴denture一段時間後再pick  up?A2:  理論上應先讓denture戴一段時間，讓sok  8ssue適當seiling，確保sok  8ssue與implant能同時均勻受力之後再pick  up  aiachment會更好，但研究上沒有確切數據指出應該要戴denture多長的時間才能達到效果，且此患者在deliver  new  denture之前已經有一副interim  denture，sok  8ssue已經過一段時間的受力，而new  denture在pick  up  aiachment之前的reten8on效果與interim  denture也差不多，因此這個case是在deliver當次就直接pick  up  aiachment。

Q3.  為什麼沒有在pick  up  aiachment之後立刻換藍色male  part?A3:  在此case是隔了一段時間才換藍色male  part，原先是想讓病患先適應denture  reten8on增加的感覺，follow  up就換藍色，只是病患後來回南部一段時間才回來換，這段期間病患表示denture沒有不舒服的狀況。

Q4.  Aiachment在lab  processing過程直接完成與臨床上chair-­‐side  pick  up有何差異?A4:  在locator操作說明是寫可以lab  processing直接完成，但由於臨床操作經驗覺得由lab直接完成的aiachment位置常有誤差，需要整個挖掉重新pick  up，因此在此case是選擇最後再進行chair-­‐side  pick  up。

Q5.  此case是否考慮過增加implant數量或使用其他aiachment方式?A5:  以2  implants  overdenture而言locator是簡易又方便的aiachment方式。曾與病患討論過是否增加到4  implants，但病患表示費用上考量，選擇2  implants贋復方式，若增加到4  implants，implant種植位置、aiachcment方式或是否配合使用bar，則需要再另外分析討論。

Q6.  在chair-­‐side  pick  up  aiachment時應請病患輕咬或是咬緊?A6:  依照locator的操作說明是請病患輕咬到MICP的位置來做pick  up，但要讓sok  8ssue達到一定的沉降量似乎又應該請病患咬緊，而目前沒有針對咬力大小對於aiachment  pick  up精準度的相關研究。因為locator  aiachment本身有resilient，因此臨床上大多數醫師還是選擇請病患輕咬到MICP做chair-­‐side  pick  up。

Case Conference

Reporter : 簡君倩 醫師 Instructor : 徐光蔚 醫師

Date : 2013/09/14

1. General informationName :李 X 風

pGender : male

pBirth : 1960.07.10

pOccupation : 南亞成品課

pFirst visit :2010/10/05

pAttitude: philosophic

pPast medical history :

ØDM (-)

ØHTN (-)

ØDenied other systemic disease

ØDenied any drug allergy

ØTMD (-)

pPast dental history :

ØOD at LDC

ØExtraction at LDC

ØRoot canal treatment at LDC

ØFPDs were made at LDC

2. Chief complaintI had toothache at upper right side for almost a month, and the local dentist suggested me to receive FM periodontal treatment.

3. Personal habit

Cigarette (+,1 ppd/day for 20yrs)

ØBetel-nut chewing (-)

ØDrinking (+,高粱 1-2 cup/week)

ØBruxism(-)

4. Pretreatment x-ray check

5. Extraoral examination:Frontal view － facial asymmetry(-)

pFacial proportion － 1:1:1.2

pGummy smile (-)

pLateral view － straight profile

pNasolabial angle － <90°

6. Intraoral examination• Arch form: upper ovoid lower ovoid • Deep bite • Vertical overjet : 4 mm Horizontal overjet : 2 mm •Canine relationship: R’t Class I L’t Class III •#16,17,21,22,24,25,27, 34,36,37,46,47 missing •FM periodontitis •#23,26,35 supraeruption •insufficient interocclusal space

7. Diagnosisp#18,17,15,21,22,24,27,45 extraction

p#33x35, #43-44-45x FPDs removal then abutment reevaluation

pFM periodontal treatment

p#14 endodontic retreatment

pInterim denture

Problem list

pInsufficient interocclusal space for prostheses

p#23,26,35 supra-eruption

pChronic periodontitis

8. Periodontal probing data

Tooth

18 17 16 15 14 13 12 11

PD(B) 665866637 535525 426 636 PD(B)

665 PD(B)

665 866 637

PD(P) 10 86

67 10

10 12 8

445535 436 635 PD(P)

10 86

PD(P)

10 86

67 10

10 12 8

M III II III I - II I M III M III II III

7. Treatment  planning

Option 1) maintain VD

n#35 CLP and LL residual ridge alveoloplasty

nUR and UL tuberosity alveoloplasty

n#23,26,35 occlusal adjustment

n#14,26,33,35,43,44 FPDs

nmaxillary and mandibular RPDs

Option 2) maintain VD

n#35 extraction

nUR and UL tuberosity alveoloplasty

n#23,26 occlusal adjustment

n#14,26,33,43,44 FPDs

nmaxillary and mandibular RPD

Option 3) maintain VD

n#35 extraction

nLL alveoloplasty

n#23,26 occlusal adjustment

n#14,26,33,43,44 FPDs

n#34x36,45x47 implant-supported FPDs

nmaxillary RPD

Option 4) increase VD

n#11,12,13,14,26,33,35,43,44 FPDs

n#35 CLP

nmaxillary and mandibular RPD

8. Treatment  Course

2011.01.02 FM periodontal charting, OHI and FM scaling #24,27 extraction

p2011.03.07 UR and LR subgingival root planing p2011.03.18 #26 emergency open chamber and occlusal reduction p2011.03.25 #33x35 ill-fitted FPDs removal

#26 occlusal reduction impression for upper interim denture fabrication section at #44 distal side and #45 extraction p2011.04.04 LL subgingival root planing

#18,17,15 extraction p2011.04.11 #21,22 extraction p2011.04.12 upper interim denture delivery

p2011.04.13 #35 root canal treatment p2011.05.15 #14 root canal treatment p2011.05.16 FM periodontal charting(reevaluation) p2011.05.17 #26 local periodontal flap operation p2011.05.31 #33,35,43,44 local periodontal flap operation p2012.06.11 #26 root canal treatment p2012.08.10 #43-44 FPDs removal p2012.08.12~2012.08.25 #43 root canal treatment

9. Defini8ve  treatment

CT  scan

UR and UL alveoloplasty 2012.06.05

p#35 CLP and LL alveoloplasty 2012.08.01

Aker  surgery,  the  final  ver8cal  height  

 

#11→#41: 14 mm #13→#43: 16 mm

Diagnostic wax up

Tooth preparation index

surveyed crown impression and take bite

Fully wax up and surveyed

Take RPD impression

wax denture try in

Delivery and occlusion check

Q:6個Txplan中，哪一個是最理想的？A:   op8on  3能夠維持原本的ver8cal  dimension來進行贗復，而不需要面對增加VD的風險，而上顎因為8ssue  support較足夠以及deep   bite的顧慮，所以維持RPD的設計；而lower  den88on是以#34x36和#45x47  implant-­‐supported  FPDs來restore，這樣的優點是能夠增加occluding  pair，左側也可建立  ver8cal  stop，但缺點是要犧牲#35，並且implant  的費用也較高，所以仍然需要與病人完整的溝通。

Q:  若lower  den88on以implant-­‐supported  FPDs來贗復，則#45x47  進行implant的意義為何？A:   lower   den88on以#34x36和#45x47   implant-­‐supported   FPDs來restore，是希望lower   den88on能夠全部做為fixed   prostheses，而不考慮做implant-­‐assisted  RPD。

Q:  若不做alveoloplasty，有其他的治療計畫嗎？A:   可以選擇單純以RPD來提高ver8cal   dimension，讓病人不戴RPD的時候是咬在自己的牙齒上，而戴上RPD時，是在提高VD的狀態下，咬在RPD的framework上。

Q:  若上顎前牙做成#12-­‐#23  FPDs，是否更為理想？A:  因為病人沒有意願再多prepare牙齒，所以上顎最後只有做#14,26兩顆surveyed   crowns，此外考慮病人為deep   bite，且#21,22缺牙的space較大，所以在前牙prostheses的製作上會比較保守。

Q:  預計#35的prognosis與後續追蹤的情況？A:  #35  的crown-­‐root  ra8o  約為5:9，也沒有明顯的mobility，surveyed  crown的設計為short  guiding  plane，再加上病人經過OHI後，oral  hygiene維持得還不錯，所以prognosis還算理想；但之後仍然須維持  regular  follow  up，評估RPD與abutments的狀況，若#35的情況變差需要拔除，也已跟病人告知RPD  repair的處理方式。