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
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, 33-43 Caries: 17, 13, 24, 27,33 Residual roots: 14, 16, 23 Fremitus: 13, 22, 24, 34
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
Distal Buccal Mesial 18 17 16 15 14 13 12 11 A.L. 10 8 5 RR RR 5 5 4 P.D. 7 6 4 2 2 2 P.D. 5 2 6 2 2 2 A.L. 8 5 8 4 3 5 Mobility II I F.I. III III II Palatal Distal Buccal Mesial 21 22 23 24 25 26 27 A.L. RR 4 3 6 RR 4 3 5 6 8 6 P.D. 2 3 4 5 2 5 3 3 2 P.D. 2 2 4 5 3 4 4 5 2 A.L. 4 3 4 4 5 4 8 8 5 Mobility III II F.I. I II II Palatal Mesial Lingual Distal 31 32 33 34 35 36 37 38 A.L. 5 5 4 3 4 3 3 4 4 6 5 5 P.D. 2 2 2 2 2 2 2 2 2 2 2 3 P.D. 2 3 2 2 2 6 4 2 2 2 2 2 A.L. 3 4 5 5 2 6 4 2 4 4 4 5 Mobility 0 0 0 III F.I. Facial Distal Lingual Mesial 48 47 46 45 44 43 42 41 A.L. 5 8 5 6 7 6 5 4 7 5 5 5 6 5 4 5 5 5 P.D. 2 5 5 2 2 2 2 2 5 3 2 2 5 4 3 3 3 2 P.D. 2 2 2 2 2 3 2 2 2 2 2 3 3 2 2 2 2 5 A.L. 3 3 5 7 5 5 5 2 5 3 3 5 5 2 5 4 3 6 Mobility 0 0 0 0 0 0 F.I. 0 Facial
Problem List Caries: 17, 13, 24, 27, 33 Residual roots: 14, 16, 23 Ill-fitting FDPs: 22, 33-43 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, 23 33 pulp: pulp necrosis periapical: chronic apical abscess 32, 31, 41, 42, 43 pulp: previously treated periapical: chronic apical periodontitis Pre-prosthetic treatment plan Remove 33-43 FDPs and evaluation Control oral hygiene Consult ortho. for 47 uprighting
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
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
Definitive Treatment Plan Surveyed crown: 33, 43 Maxillary complete denture Mandiblular Kennedy Class I, modification 1 RPD Definitive Treatment Course
Centric relation record Diagnostic Wax-up 33, 43 wax up and tooth arrangement
Surveyed Crowns RPD design and framework
Wax Denture Try-in Laboratory remounting
Clinical remounting Denture Delivery Protrusion and lateral excursion
1 year follow up
2 years follow up
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