Case 112 | The Award 2017 | India
Dr Debashree Chandak / Dt- Amir Raza and Neelu
Prosthodontia is not just about the dentist and the teeth. The involvement of various people makes it one of the most difficult jobs in the world!. A great clinic staff will help you keep calm and move on. A skilled technician will make your work beautiful.
My mentor always tells me to develop a team for future….. I cannot put my hands in all work. So i need skilled and trained staff to reduce the workload. They will be there in the long run to help me with complications and make the best use of time. Team work divides the task and multiplies the success.
This case is dedicated to my clinic staff,boss, patient and to the lab!!
A very dear case of ours. Hope you enjoyed it like we did!
Chief Complaint- Patient wants the dislodged bridge to be recemented back.
Past dental history- His village dentist told him that he needed full mouth rehabiliation and he agreed for the treatment. Few extractions and root canal treatment were done before the treatment. All teeth were prepared and he was given bridges. This happened 4 years ago. Occasionally the bridge would come off, so the dentist would recement it back or make a new one.
Vertical has been raised by the previous dentist but its not in the proper way. It is not divided properly in the arches. The old bridges in the mandibular arch are near to flat and short height. The upper bridges are wide and tall taking up more space. There are few occlusal contacts in the old bridges
We need to divide the restorative space equally between maxillary and mandibular teeth and maintain the arches and curves.
Class I molar incisor relationship
Prosthetic assessment – the patient was given brides at increased vertical height. What I had to do was use the same increased height and divide it equally amongst both the arches and do build ups accordingly
Definitive Comprehensive Treatment Plan – including whole patient care
1. Appointment 1- patients walks in. Explain the patient about ongoing problems. Explain methods of stabilization prevention and treatment and expenses. Patient agreed for treatment, plan for making new provisionals.
2. Appointment 2- gingivectomy of both the arches. A day long procedure. Provisionals were ready. There were relined inside the mouth and cemented. Patient was given oral hygiene instructions. Asked to start chlorhexidine mouthwash and warm saline gargles alternate weeks. Also topical rexidine-metronidazole gel application and massaging the gums till treatment finishes.
Why gingivectomy and surgical crown lengthening- there was gingival enlargement and inflammation. First we cut the gums to desired level and then did bone probing. We had bone at about 2 mm from the gingival margin. So we decided there was no need to osteoplasty.
Patient was given suitable appointments to finish required RCT’s and extraction.
3. Appointment 4- prosthetic appointment given two months post gingivectomy. Maxillary teeth core build ups done. Single cord (00) placed as after the surgery patient had a shallow sulcus and I did not want to intentionally push two cords fearing recession
Two stage putty impression taken. Removing the cord and drying the teeth. Placing putty in the tray and taking an impression. Before complete setting, removing the putty. Using putty knife, removing putty of the area concerned for wash. Removing all undercuts and trying in the tray. Dry the tray and teeth. Inject light body on the tray and the teeth. Lightly air dry the teeth to remove any air bubbles. Place the tray and wait for it to set. Disinfect and sent it the lab with instructions.
Repeat the same procedure for an extra same impression just incase first one has porblems.
Provisionals hollowed and relined in the mouth as new build ups were done.
4. Appointment 5- mandibular build ups done. Same procedure as above done.
5. Appointment 6- Facebow record and centric bite taken. Shade decided. Here we will use A3-A3.5. call for metal trial
6. Appointment 7 – provisionals removed, teeth cleaned and metal trial done. Check fit of all crowns. All ok. Send for bisque trial
7. Appointment 8- Bisque trial is back. Remove the provisionals and polish the teeth. Using the trying paste on the bisque trial place in mouth and check. Check for open margins and fit, aesthetics and phonetics, high points in occlusion and excursion.
Occlusal features to be checked
a) Simultaneous bilateral contacts
c) Canine guidance with disclusion of non working side
d) Shared anterior guidance with posterior disclusion
8. Appointment 9 -final cementation day. Polish teeth. Place cord. Isolate teeth and start cementation usually the posteriors first. Conventional glass ionomer cement (ketac) was used. Using floss before complete setting of cement.
Show the patient. I usually ask the patient to sit for an hour and have small meal at the clinic. This helps the patient to gain confidence in eating. If there any small occlusal changes, they can be chair side. Oral hygiene instructions reinforced.
9. Appointment 10- patient is back after 10 days. He can eat properly. Enjoying food like never before. Minor occlusal changes done and polished.
10. Appointment 11- after 1 year- happy patient. Interdental papilla present. No black triangles. He is happy with chewing. Said can eat on bone, sugar canes and everything hard which he could not eat earlier!!
Special instructions given to the patient-
• Use soft brush and fluoridated paste and brush twice daily.
• Floss daily
• Incase of any pain or discomfort call the clinic
• To avoid extremely hard food stuff like betel nut and biting directly on sugarcane or some Indian sweets ( toot hard) (common in India)
• To massage the gums regularly
• Use a soft brush and change brush every three months or frayed and use moderate pressure
• Come in for a regular check up initially for 1 month, 3 months, 6 months and then yearly.
Overview of materials used- Why was PFM selected for this case??
1. Major reason was cost
2. PFM requires 2mm occlusal clearance which was present tin this case. I did not do any occlusal reductions. Just a few modifications and finish line changes.
3. Good aesthetic result
4. Good strength
Details of difficulties faced
First look into the mouth scared me. I thought It’s going to be very difficult. Proper planning and patient’s co operation made the treatment a smooth process. He followed every instruction we gave him and we did whatever clinical procedures were required.
How else could we manage the case?
Use better materials like Zirconia…may be…making it more expensive only. I think the outcome for eating and in terms of occlusion would not change, whatever material we choose
We could have done implants where teeth are missing. But I think that would just be over treatment. Teeth adjacent to the edentulous area were already prepped so giving a bridge made more sense looking at the cost of the treatment and age.
Areas of error and improvements-
1. Lower canine anatomy could be improved
2. At some places the margins may be short which should have been sent back. But time and money constraints did not make it possible.
3. Better Photography
4. Better Impressions
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