Case Conference. Basic Information. Chief Complaint PMH PDH. 2013/06/22 台南奇美醫院 Reporter: 黃鈺芬醫師. Gender: female Age: 68 y/o Attitude: philosophical

Transcription

1 Case Conference Basic Information 2013/06/22 台南奇美醫院 Reporter: 黃鈺芬醫師 Gender: female Age: 68 y/o Attitude: philosophical Chief Complaint Pus discharge over upper anterior area for several days PMH PDH Hypertension under medication control Denied any food and drug allergy OD endo extraction fixed prosthesis removable prosthesis

2 Extraoral Examination Front facial view: symmetry Facial profile: straight Lip line: low TMJ pain and click: no Jaw deviation: no Maximum mouth opening: 50mm Bruxism: [-] Intraoral Examination Missing: 11, 12, 15, 21, 23, 25, 26, 35, 36, 37, 46 Ill-fitting FDPs: 22, Caries: 17, 13, 24, 27,33 Residual roots: 14, 16, 23 Fremitus: 13, 22, 24, 34

3 Information related to denture construction: Arch form: ovoid Ridge form: maxilla Type II [Atwood s classification] mandible Type III Palate form: Class II [House s classification] Lateral throat form: Class II [Neil s classification] Muscle tonus: flaccid Tongue size & position: normal Salivation: serous Radiographic Examination Probing Data

4 Distal Buccal Mesial A.L RR RR P.D P.D A.L Mobility II I F.I. III III II Palatal Distal Buccal Mesial A.L. RR RR P.D P.D A.L Mobility III II F.I. I II II Palatal Mesial Lingual Distal A.L P.D P.D A.L Mobility III F.I. Facial Distal Lingual Mesial A.L P.D P.D A.L Mobility F.I. 0 Facial

5 Problem List Caries: 17, 13, 24, 27, 33 Residual roots: 14, 16, 23 Ill-fitting FDPs: 22, Poor oral hygiene Trauma from occlusion: 13, 22, 24, 34 Apical lesions: 33, 32, 31, 41, 42 Soft and hard tissue undercut: 13, 33 Diagnosis Generalized chronic periodontitis Caries: 17, 13, 24, 27, 33 Residual roots: 14, 16, pulp: pulp necrosis periapical: chronic apical abscess 32, 31, 41, 42, 43 pulp: previously treated periapical: chronic apical periodontitis Pre-prosthetic treatment plan Remove FDPs and evaluation Control oral hygiene Consult ortho. for 47 uprighting

6 Tentative Treatment Plan-Option 1 Diagnostic wax up Extraction: 14, 16, 17, 23, 27, 32, 31, 42, 41, 47 Provisional restorations: 22x24, 33, 43 Delivery of interim denture [ maxilla and mandible] Endo. Treatment : 33 Crown lengthening procedure: 33 Periodontal phase I treatment Re-evaluation Surveyed crown: 22x24, 33, 43 Maxillary Kennedy Class I, modification I RPD Mandibular Kennedy Class I, modification I RPD Tentative Treatment Plan-Option2 Extraction : 14, 16,17, 22, 23, 27, 32, 31, 42, 41, 47 Provisional restoration of 33, 43 Endo. Treatment: 13, 24 [coping], 33 Delivery of interim denture [maxilla and mandible] Crown lengthening procedure: 33 Periodontal phase I treatment Re-evaluation Surveyed crown: 33, 43 Maxillary overdenture [13, 24 coping] Mandibular Kennedy Class I, modification I RPD

7 Tentative Treatment Plan-Option3 Extraction: 13, 14, 16,17, 22, 23, 24, 27, 32, 31, 42, 41, 47 Delivery of interim denture [maxilla and mandible] Endo. Treatment of 33 Crown lengthening procedure: 33 Periodontal phase I treatment Re-evaluation Surveyed crown: 33, 43 Maxillary complete denture Mandibular Kennedy Class I, modification I RPD Treatment Course

8 Definitive Treatment Plan Surveyed crown: 33, 43 Maxillary complete denture Mandiblular Kennedy Class I, modification 1 RPD Definitive Treatment Course

9 Centric relation record Diagnostic Wax-up 33, 43 wax up and tooth arrangement

10 Surveyed Crowns RPD design and framework

11 Wax Denture Try-in Laboratory remounting

12 Clinical remounting Denture Delivery Protrusion and lateral excursion

13 1 year follow up

14 2 years follow up

15 Q&A Q1: 預計拔除的 牙 齒雖然有 mobility 的現象, 但是對於 occlusion 多少都還有 一些功能, 為什麼最後選擇拔除呢? A1: 主要是因為病患的選擇, 這位病 人最後選擇上顎做 CD, 下顎做 Kennedy Class I division I 的 RPD, 所以參考價值較低 Q2: 未拔 牙前 #17 27 都仍與對咬有 contact, 此時的 VD 是否有參考價值? 製作過程中對於 VD 有哪些需要注意的地 方? A1: 治療中會配戴 interim denture, 會參考病 人使 用的狀況來做修整, 另外發 音 吞嚥 美觀等等也都是需要注意的地 方 Q3: 下顎為何是使 用 wrought wire 而不 用 I bar? A3: 一開始有考慮 I bar, 然 而因為這位病 人軟組織硬組織間的 undercut, 以及後 方是無 牙區的關係, 所以最後使 用 wrought wire Q4:wrought wire 似乎離 gingiva 不到 1mm? A4: 這邊是當初設計時的疏失 Q5:47 原先有考慮做 ortho 去 upright, 那請問這顆 牙 齒留下來或不留下來你所考慮的點是? A5: 不留下來的考量是因為這位病 人本 身的 oral hygiene 很差, 長遠來看這顆 牙 齒最後可能會拔掉, 因此不如 一開始就拔除減少之後重做的可能 ; 另外希望這顆 牙 齒留下來所考慮的是在 RPD 的 distal end 可以有 一個 abutment 提供 support, 增加整個 denture 的 stability 建議 :lingual plate 設計的 支點放在 mesial side 的話, 會失去 support 的作 用, 沒有考慮到 physical movement 沉降的變化,guding plane 會失去原有的效果

16 Case Conference Basic Information 2013/06/22 台南奇美醫院 Reporter: 林正忠醫師 Gender: male Age: 31 y/o Attitude: philosophical Chief Complaint PMH PDH I wanted to restore my anterior teeth which were broken at a car accident. Denied any systemic disease Denied any food or drug allergy At Chimei ER: 11 extrusive luxation; 12, 23 crown fracture; 21 crown-root fracture; 22 subluxation and crown fracture Regular follow up at OS department and extracted hopeless teeth of 11, 22

17 Extraoral Examination Facial Asymmetry : yes Facial profile: straight smile line : low TMJ pain : No TMJ click : No Jaw deviation : No Bruxism: No Intraoral Examination Dentition: Missing or extracted teeth: 11, 21, 22 Supernumerary tooth: 49 Tooth fracture: 12, 23

18 Occlusion Analysis: Midline: maxilla N/A mandible shift to R t 2 mm Occlusion: canine R t: class I L t: N/A molar R t: class III L t: class I Overjet: N/A ; Overbite: N/A Occlusal scheme: Group function Radiographic Examination 44-34:EPT(+). Percussion(-). Mobility:0 Buccal A.L P.D P.D A.L Mobili ty Percus sion EPT + + x x + Palatal

19 Problem List Maxillary anterior area Class III bone deficiency (Seibert s classification) 12,23 crown fracture Scar formation over upper anterior vestibule Diagnosis and Problem List Maxillary anterior area Class III bone deficiency (Seibert s classification) 12, 23 crown fracture & pulp necrosis Tentative Treatment Plan-Option 1 Periodontal phase I therapy 12, 23 endodontic treatment 13~23 provisional fixed dental prostheses 13~23 definitive fixed dental prostheses Tentative Treatment Plan-Option 2 Periodontal phase I therapy Soft tissue augmentation or guided bone regeneration of anterior maxilla 12, 23 endodontic treatment 13~23 provisional fixed dental prostheses 13~23 definitive fixed dental prostheses

20 Provisional Fixed Partial Denture Definitive Treatment Plan 13~23 fixed dental prostheses Treatment Course: Periodontal phase I therapy 12,23 endodontic treatment Casting post :23 Parapost:12

21 Definitive Treatment Course Incisal guide table

22 Wax pattern and cut-back

23 Definitive prostheses

24 Lateral excursion Definitive restoration radiography

25 Q&A 1. Q: Tooth 24, 25 有 apical lesion? A: 再 check EPT, 從 x-ray 上的確可能有 lesion, 這部分可能有疏忽 2. Q: Tooth 11 為什麼拔掉? A: X-ray 看起來還好, 但實際狀況不好,buccal plate 已不 見 3. Q: 有考慮 RPD 嗎? A: 病 人希望 用固定的贗復物 4. Q: Anterior defect 那麼 大, 使 用 implant 治療是 首選嗎? 成功率如何? A: 不是 首選,implant 成功率要看 GBR 效果決定,interdental papilla 可能會較差, 會有 black triangle, 但病 人是 long lip, 所以也還好 5. A: 牙 齒都有受傷,cantilever 是否合適? Q: 病 人才 30 歲,cantilever 負擔太 大, 應請病 人考慮 implant 治療, 才是 長遠之計 6. Q: Tooth 13 clinical crown 是否有點短? A: 可以建議 13, 14 一起做 CLP,clinical crown 會較美觀, 也可以考慮 CT graft 7. Q: Abutment 的選擇是否有別種考量? A: terminal abutment 可以做到 23, 24, 以 力學 角度分擔 力量較佳,24 應該也要做 endo, 可以考慮這種作法 另 一位醫師提出,23 是較好的 abutment, 延伸到 24 的實際效果如何, 要再評估 可能也要考慮到 anterior posterior spread 的影響

26 Case Conference Basic Information 2013/06/22 台南奇美醫院 Reporter: 葉松穎醫師 Gender: male Age: 42 y/o Occupation: 鏡 片拋光師 Attitude: Philosophical Chief Complaint PMH PDH I want to improve the swelling of upper anterior gum and remake my lower denture. Hutchinson-Gilford Progeria syndrome Denied any food and drug allergy OD endo extraction fixed prosthesis periodontal surgery removable prosthesis Cellulitis of 13 s/p at ER on 101/01/05

27 Personal habit ABC history: Smoking: denied Betel nuts: denied Drinking: denied Parafunction: denied Oral hygiene care: Dental brush: 1 times per day ( 起床和睡前 ) 3 mins, arbitrary Dental floss: never Other appliances: nil Extraoral Examination (With denture) Facial Asymmetry: No Facial profile: Convex Lip line: Low TMJ pain: No TMJ click: No Maximum mouth opening: 30 mm Jaw deviation: No Bruxism: No Numbness: No Weak chin: Yes

28 (Without denture) Radiographic Examination Missing: 11, 15, 16, 18, 22, 24, 25, 26, 28, 34~38, 45~48 Ill-fitted Crown: 12, 21 Residual roots: 14, 23, 27, 44 Caries: 12~14, 21, 27,42~44 Crowding: 32,33; 42,43 Spacing: 33, 34 #13 residual root #21-x-23 bridge, advanced periodontitis #11,12,14,15,16,17,24,25,26,27 missing

29 Intraoral Examination Asymmertry UA gingival zenith and tooth size Flareout and attrition of lower anterior teeth Missing: 11, 15, 16, 18, 22, 24, 25, 26, 28, 34~38, 45~48 Information related to denture construction: Arch form: Maxillary and mandibular ovoid Ridge form: Maxillary type I and mandibular type V (Atwood s classification) Palate form: Class II (House s classification) Lat. Throat form: Class II (Neil s classification) Muscle tonus: Flaccid Tongue position: Normal Tongue size: Normal Salivation: Serous

30 Probing Data Distal Facial Mesial M F D A.L P.D P.D A.L Mobili F.I Distal Palatal Mesial Mesial Lingual Distal A.L P.D P.D A.L Mobilit y F.I Mesial Buccal Distal Distal Lingual Mesial A.L P.D P.D A.L Mobilit y F.I Distal Buccal Mesial

31 Problem List Ill-fitted Crown: 12, 21 Residual roots: 14, 23, 27, 44 Caries: 12~14, 21, 27, 42, 43 Lower anterior teeth: spacing & crowding, flare out & attrition Deep bite occlusion Insufficient R t inter-occlusal space Skeletal class II Diagnosis Generalized chronic gingivitis Residual roots: 14, 21, 23, 27, 44 Caries: 12~14, 21, 27, 42, 43 12, 23, 42: Previously endodontic treatment, Normal apical tissue 13: Previously endodontic treatment, Asymptomatic apical periodontitis Hutchinson-Gilford Progeria Tentative Treatment Plan-Option 1 (12, 13, 21 with poor prognosis) FM scaling and OHI Evaluation of 12, 13, 21 Extraction of all maxillary retained teeth, 44 Delivery of maxillary interim CD and mandibular interim RPD OD: 43 Delivery of 42 provisional crown RCT: 42

32 Definitive prostheses: Maxillary implant-supported overdenture Mandibular Kennedy I RPD with 42 surveyed crown Tentative Treatment Plan-Option 2 (12, 13, 21 with poor prognosis) FM scaling and OHI Evaluation of 12, 13, 21 Extraction of all maxillary retained teeth, 44 Delivery of maxillary interim CD and mandibular interim RPD OD: 43 Delivery of 42 provisional crown RCT: 42 Definitive prostheses: Maxillary complete denture Mandibular Kennedy I RPD with 42 surveyed crown

33 Tentative Treatment Plan-Option 3 (12, 13, 21 good prognosis) FM scaling and OHI Evaluation of 12, 13, 21 and delivery of 12~21 provisional FPD OD: 43 Delivery of maxillary and mandibular interim RPD; Extraction of 14, 23, 44 Delivery of 42 provisional crown Forced eruption and crown lengthening procedure: 12, 13, 21 Definitive prostheses: Maxillary Kennedy II RPD mod. 1 with 12~21 FPD Mandibular Kennedy I RPD with 42 surveyed crown Pt s expectation No orthodontic treatment Preserve more teeth Financial consideration

34 Definitive Treatment Course FM scaling and OHI Evaluation of 12, 21, 43 12, 43 OD Removal of 13 prosthesis and 23 caries Occlusal rim

35 Interim wax denture Lateral excursion Protrusion Lateral excursion Delivery of interim complete denture Extraction of 12, 13, 14, 17, 21, 23, 27, 44

36 Provisionals and Interim Dentures- Extraoral Perio. re-evaluation A.L P.D P.D A.L Mobility F.I.

37 Definitive Treatment Plan Delivery of 42 provisional crown 42 endodontic treatment Definitive prostheses Maxilla: complete denture Mandibular: Kennedy I RPD with 42 surveyed crown Border molding & final impression Bite Registration and Facebow Transfer

38 Diagnostic wax up and tooth arrangement Nonworking side Nonworking side Working side Working side Wax denture try-in

39 #42 surveyed crown

40 Border molding and final impression of mandibular arch CR record

41 Definitive wax denture L t Lateral movement

42 Lab remounting R t Lateral movement L t Lateral movement Clinical remounting

43 R t Lateral movement L t Lateral movement R t Lateral movement L t Lateral movement Definitive prostheses R t Lateral movement L t Lateral movement

44 Protrusion

45 6 months f/u 74

46 Q&A Q1: 這位病 人的 upper abutment 看起來還不錯, 請問最後決定拔掉的原因是什麼? A1: 原本 一開始的確是有考慮幫病 人留住 upper 牙 齒製作 overdenture, 可以避免 resorption 保留住 ridge 也可仰賴 abutment 增加 retention, 但最後因為種種因素決定把 牙 齒全部拔掉然後作上顎的 CD 原因如下 : 1. 若要製作 overdenture 那麼上顎的 abutment teeth 還要 coping, 病 人無法多負擔這些費 用 2. 病 人的開 口度只有 30mm, 第 一考慮到 tray 置 入的困難性與整個治療的 方便性, 希望能夠拔 牙騰出空間, 第 二張 口度太 小要放兩個假 牙進去也有困難, 拔 牙會可以增加空間 方便假 牙的置 入 3. 病 人的 arch discrepancy 很 大, 拔完 牙後會希望 upper resorption 以後降低 arch discrepancy Q2: 這個 case 最 大的困難點在那兒? A2: 1. 第 一是剛剛提到的 vertical dimension 的問題 2. 第 二就是 CR 的位置, 因為這位病 人 dentition 是 Class II, 有習慣向前咬的習慣, 也可以看到他前 面的 牙 齒就是因為有習慣 protrusion 所以在 incisal edge 上都有 attrition 所以在找 CR 點時時常都咬不太到, 碰到的點通常都是病 人前突下顎時, 所以在製作上有經過多次的測試然後 一邊訓練病 人咬到正確的 CR 點 Q3 : 請問是何時拔除 upper 牙 齒? A3: 並不是 一開始就把 upper 牙 齒拔除, 一開始有先保留住然後印模準備製作 interium denture, 等印完模做完 cast 後才同時在 口內跟 cast 上拔除 牙 齒 Q4 : 請問早衰症的症狀是如何? A4 : 壽命較短 通常男性好發率 比 女性 高, 同家族出線機率也較 高, 是因為 LMNA gene 出現問題, 這類患者的 心 血管常有問題需要 長期服 用 asprin 控制 另外 文獻也指出他們的鎖 骨 hip bone 也會出現問題, 比較可惜的是我們沒有幫他拍攝 pano, 所以並不曉得這個病 人他 TMJ 的情形如何, 不知是否也有受到影響 另外有發現這個病 人的傷 口癒合的 比 一般 人慢 Q5 : 請問原本考慮的矯正計畫是要做什麼事情? A5 : 希望能關閉 space 然後改正 occlusal plan, 這個病 人不會去考慮 upright 他的 牙 齒, upright 後會造成咬合更不好 Q6:class II, 病 人會有習慣往前咬的問題, 如何設計前 牙的咬合關係? A6: 在 CR 時 light contact, 前凸運動時有 contact Q7: 下顎前 牙 flare out, 製作過程中遇到的問題? A7: 的確會不利於製作, 所以在治療計畫中有建議病 人矯正 建議 : 取完 bite 之後可將 bite 取下再去照相, 可以較清楚的看到上下顎的相對位置 治療上似乎缺乏對這個病 人的好奇 心, 沒有去觀察病 人較適合那 一種的治療計畫選擇, 或許的可再多花點時間去觀察病 人的狀況