Manuel Bratos DDS, MSD, CDT / Maria Nart DDS, MSD, ABO / Kenny Choy DDS, MSD – FINALIST TEAM
Complex interdisciplinary case: A minimally invasive approach for a full mouth rehabilitation
ALL CLINICAL CASES
DIAGNOSIS/PROBLEM LIST
Chief Complaint: “My bite is off and I don’t like my smile”
Facial Pattern:
• Convex profile
• Slightly increased lower facial height
• Shallow mento-labial fold
• Slightly steep MPA
• Good chin-throat line
Smile esthetics
• Incisor display at rest 1mm
• Incisor display upon smiling 60%
Antero-Posterior:
• R: Class I Canine, Molar NA
• L: Class I Molar and Canine
• OJ 3.5 mm
• Shift 2mm. CR occludes in E-E
Vertical:
• 4 mm OB
• Mx 2s in crossbite
• Mx & Mn mild-moderate COS
Transverse:
• Mn midline 1mm left of facial
• Right increased buccal corridor
• Tight buccal OJ
• COW Mx & Mn mild, moderate in 7s
Arch Perimeter/Dentition:
• Mx U-Shape arch symmetric, Mn ovoid asymmetric
• ALD: Mx 2mm; Mn 4mm
• Missing teeth: 8s, UR5,6 (14mm space), UL 4,5 (6mm), LR5 (5.8mm) and LL7,
• Bridge with cantilever UL5, LL7
• Lower 3s, 4s are torqued in
• Retroclined Mn incisors
• Bolton: insignificant 3-3: 2mm
• Worn L& U1-1
Periodontal and TMJ Considerations
• Good OH
• Generalized PD 2-3, Localized 4-6 dl #15 with 3mm of excessive gingival tissue
• Generalized recession of 1-2mm
• Significant ridge resorption: UR5,6 (lack of vertical ridge height due to ridge resorption & maxillary sinus pneumatization)
• Asymptomatic bilateral pop/click on opening and closing
Behavior
• Excellent
• Daily vomits during 20 years due to food irritants (Coffee).
TREATMENT OBJECTIVES
Dental:
• Correct anterior crossbite of U2s
• Pre-prosthetic preparation
• Align, level, coordinate arches
• Achieve ideal OB/OJ
• Correct midline discrepancy
• Maintain Class I canine and achieve CI molar
• Replace missing tooth structure to correct tooth proportions
• Establish improved occlusal plane
• Harmonize smile
Facial:
• Maintain profile esthetics
Other:
• Encourage maintenance of good Oral Hygiene
• Periodontal treatment
• Restorative treatment
Interdisciplinary treatment plan:
A) Ideal
1. Periodontal tx:
a. Distal Wedge – UL7
b. Lateral Window Sinus Lift/Osteotome Sinus Lift – Edentulous sites UR5,6
c. Implant Placement – Edentulous spaces UR5,6, UL4,5 and LR5
2. Orthodontic tx (set-up): Mn and mx fixed appliances
a. Procline and align anterior mn and mx teeth to correct anterior crossbite. IPR prn lower Incisors.
b. Make ideal spaces for implants (limited in UL and LR)
c. Intrusion of L1-1to align gingival margins and restore? Look at bone levels!
3. Prosthodontic tx:
a. Restore missing incisal and palatal tooth structure due to erosion
b. Final implant’s crowns for UR5, 6, UL4 and LR5
• Advantages:
–addresses anterior crossbite
–addresses lower incisor crowding and retroclination
–addresses correction of midline discrepancy
–achieves ideal OJ/OB
–addresses periodontal health
–addresses ideal implant placement
–addresses ideal prosthetic outcome
• Disadvantages:
–cost/time/risk of orthodontics
–cost/time/risk of implants
–cost/time/risk restorations
SUMMARY OF THERAPY
Diagnosis: Convex profile; Anterior crossbite of U2s, Mn midline 1mm left of facial; Missing teeth: 8s, UR5, 7, UL 4,5 (cantilever), LL7 (cantilever), LR 5; R CI canine, L CI Canine and molar; increased OB; retroclined L Incisors; good OH, mild generalized bone loss with some recessions.
Objectives: Pre-prosthetic preparation (create ideal space for implants and restorations), correct the anterior crossbite; proclined Mn Incisors; Align, level and coordinate the arches; maintain Class I Canine and molar; maintain profile esthetics.
Treatment: Periodontal tx
a. Distal Wedge – UL7
b. Lateral Window Sinus Lift/Osteotome Sinus Lift – Edentulous sites UR5,6
c. Implant Placement – Edentulous spaces UR6, UL5
Orthodontic tx (set-up 3-3): Mn and mx fixed appliances
d. Procline and align anterior mn and mx teeth to correct anterior crossbite. IPR prn lower incisors.
e. Make ideal spaces for implants
f. Intrusion of L1-1to align gingival margins and restore? Look at bone levels!
Prosthodontic tx:
g. Final implant’s abutments for UR6, and UL5
h. Posterior resin nano ceramic restorations
i. Palatal veneers resin nano ceramic
j. Facial veneers lithium disilicate
Note: Implants UR5, UL4, LR4 were not placed due to financial limitations. Biomechanics and function were tested during 9 months with the cantilever design. Due to the versatility of the nano-ceramic resin material, patient can upgrade and place further implants if desired without compromising our treatment design and outcomes.
Smile esthetics
• Incisor display at rest 1mm
• Incisor display upon smiling 60%
Transverse:
• Mn midline 1mm left of facial
• Right increased buccal corridor
• Tight buccal OJ
• COW Mx & Mn mild, moderate in 7s
Arch Perimeter/Dentition:
• Mx U-Shape arch symmetric, Mn ovoid asymmetric
• ALD: Mx 2mm; Mn 4mm
• Missing teeth: 8s, UR5,6 (14mm space), UL 4,5 (6mm), LR5 (5.8mm) and LL7,
• Bridge with cantilever UL5, LL7
• Lower 3s, 4s are torqued in
• Retroclined Mn incisors
• Bolton: insignificant 3-3: 2mm
• Worn L& U1-1
Facial Pattern:
• Convex profile
• Slightly increased lower facial height
• Shallow mento-labial fold
• Slightly steep MPA
• Good chin-throat line
Antero-Posterior:
• R: Class I Canine, Molar NA
• L: Class I Molar and Canine
• OJ 3.5 mm
• Shift 2mm. CR occludes in E-E
Vertical:
• 4 mm OB
• Mx 2s in crossbite
• Mx & Mn mild-moderate COS
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