Case Presentation
Kathleen McCarthy
IFPDC Bursary Entry
Visits: 20
Estimated Cost of Treatment: €1200
History
• Reason for Attendance:
The patient was concerned about the
appearance of her maxillary incisors as she
thought they were “very worn down”. She also
requested a new upper partial denture
because an upper anterior natural tooth had
fractured.
History
• Social history:
– The patient lives approximately one hour from CDH.
– She is 53 years old.
• Medical history:
– The patient quit smoking in March 2010.
– The patient is currently fit and well
• Dental history
–
–
–
–
Brushes twice a day, with irregular use of dental floss and mouthwash.
Last dental visit was about 2 years ago.
The patient is aware that she grinds her teeth at night.
She used smoker’s toothpaste for over 30 years
History
• Denture history:
The patient wears an upper acrylic partial
denture, replacing 15, 23, 24.
The denture is 25 years old, and is worn at night.
She cleans the denture twice a day with
toothpaste.
The patient was provided with a lower RPD
(acrylic) but never used it.
Exam
• Extra-oral: NAD
• Intra-oral: NAD except hard palate appeared red and slightly
swollen (on questioning the patient said it was not painful).
The redness was underneath the fitting surface of the acrylic
partial denture.
• CPITN:
1
1
1
0
0
0
• Plaque score: 25%. (The patient maintained good oral
hygiene and low plaque scores throughout treatment.)
Exam
Teeth present: 16, 14, 13, 12, 11, 21, 22, 25, 26, 38, 34,
33, 32, 31, 41, 42, 43, 44, 45
• The crown of the 13 tooth was fractured, with little
coronal tooth structure remaining. This tooth had
previously been root filled and there was caries
undermining the remaining coronal tooth structure.
• On examination, the patient’s four maxillary incisors
appeared worn with jagged edges of enamel.
• There is a non-carious cervical lesion (NCCL) on the 34.
Maxillary incisors
appeared worn with
jagged edges of enamel
Non-carious
cervical lesion
(NCCL) on the 34.
Aids to diagnosis
• Upper and lower study casts mounted on a semiadjustable articulator.
• OPG radiograph.
– OPG showed that 23 is unerupted. (The upper left c
was extracted at about 30 years of age.)
• Previously taken PA of 13 to evaluate RCT.
• After mounting the study casts, it became
obvious that the patients occluding vertical
dimension (OVD) would have to be increased
before restoring the anterior teeth.
OPG
PA
Diagnosis
• Denture stomatitis on hard palate
• Severe toothwear on upper anterior teeth 12, 11, 21,
22 due to attrition and abrasion
• 34 has a NCCL due to abrasion
• 13 has no clinical crown but has been root treated.
There is caries on the retained root.
• 23 is unerrupted
• Missing teeth: 16, 15, 23, 24, 27, 35, 36, 37, 46, 47.
• The vertical dimension is decreased, with insufficient
space available to restore the anterior dentition
Aids to treatment planning
• Using a wax occlusal rim, I determined that an increase of 2.5mm would
be acceptable aesthetically.
• I completed a diagnostic wax-up of the proposed anterior restorations and
applied sticky wax to hold denture teeth in place.
• The completed wax-up at the increased vertical dimension highlighted an
extra issue: some of the existing natural teeth would be out of occlusion.
Treatment Plan
1.
2.
3.
4.
5.
6.
7.
Oral and denture hygiene instruction
Caries removal and placement of a composite dome on retained root of
13
Replacement of an amalgam restoration with composite resin in the
14mo tooth to bring it into occlusion at the increased vertical dimension
Addition of amalgam to existing amalgam restorations on 26 and 38 to
bring these teeth into occlusion at the increased vertical dimension
Add cold-cure acrylic resin to the patient’s existing partial denture to
increase her OVD
If the patient tolerates the increase in OVD, restore the upper anterior
teeth 12, 11, 21, 22 with composite resin. These teeth are significantly
worn and may require crowns as definitive restorations
Provide upper and lower cobalt chrome partial dentures
Treatment carried out:
• Caries removal 13o. Composite dome (shade A3) over the retained root.
• Added self-cure acrylic resin to the patient’s existing partial denture to
increase her OVD.
• Replaced amalgam in 14mo with composite resin shade A3, and restored
into occlusion at the increased vertical dimension.
• Cut an occlusal lock into 38o, and added amalgam to occlude at increased
vertical dimension.
Composite dome 13
Addition of cold cure
acrylic to RPD to increase
the vertical dimension.
14mo
Amalgam
in 14mo
replaced
with
composite
resin
38o
Occlusal lock
into 38o, and
added amalgam
to occlude at
increased O.V.D.
Composite
dome 13
Treatment carried out:
Restored 4 maxillary incisors (composite resin
shade A3). Adjusted existing RPD.
P/P
P/P
Review after 3 months
• Caries on composite dome 13 (caries removal and restoration completed).
• Patient happy with P/P but wanted to discuss improving the appearance of
her lateral incisors.
Treatment planning
• The central incisors were aesthetically and functionally sound.
• The lateral incisors were weaker as they both had more composite than
tooth structure coronally. The aesthetics were also poor, especially the 22
because the tooth is rotated.
• Decided that these teeth should be crowned.
• All-ceramic crowns would be aesthetic and would have an additional
benefit of bonded retention by using resin cement.
• However, the significant preparation required risks devitalising the tooth
• N.B. for 12 because pre-op periapical radiograph showed that the root
canal narrow and difficult to root treat.
• Patient agreed to treatment.
Treatment carried out
• Prepared 12 and 22 for all-ceramic crowns using retraction cord to
place labial margin 0.5mm subgingivally.
• Shade: A3 (body) and A2 (incisal edge).
• Definitive impression using light and heavy bodied silicone material.
• Temporary crowns using Integrity material and TempBond cement.
Crown prep 12
Shade matching
Temporary crowns
Try-in and delivery
• No problems with try-in once temporary
cement removed!
• Cemented crowns with Nexus resin based
cement.
Reflection
• I learned a lot from this case, especially about how to treat
broken down teeth where there has been a loss of vertical
space.
• I did a lot of extra reading especially in the treatment planning
stages, and I benefited by learning about other possible
treatment options.
• I went through a lot of ‘firsts’ with this patient including
toothwear, cobalt chrome partial dentures and crown
preparations.
• I believe the improvement in both strength and aesthetics
achieved by crowning the 12 and 21 was worthwhile.
• However, I believe that the central incisors did not require
crowning and I am quite proud of the composite restorations
on these teeth!
• The result was a very satisfied patient!