Fausto Sommovigo
Clinician Dr. Fausto Sommovigo, CDT Mignani Giuseppe
The patient is a woman 50 years old. She is in good health. ASA 2
The chief complaint is the worn dentition of the frontal upper teeth.
The dental formula The dental formula is 1.7 crown ,1.6 (pontic), 1.5 crown, 1.4. crown on implant 1.3.,1.2. 1.1 ,2.1,2.2,2.3 2.4 crown, 2.5.crown, 2.6.pontic, 2.7 crown, 3.7 crown, 3.6 pontic, 3.5 pontic, 3.4 crown , 3.3, 3.2, 3.1, 4.1, 4.2., 4.3, 4.4, 4.5 crown, 4.6. crown, 4.7 crown. On 2.2 there is a decay on 1.3,1.2,1.1, 2.1,2.3 there are filings with secondary decays.
Occlusion In M.I.P. all teeth are in contact. The occlusal planes both upper and and lower are horizontal. During protrusive movement at the beginning 1.1,2.1,2.2 are in contact with 3.1,3.2,3.3,4.1,4.2 ,while at the end of the movement 2.1,2.2 are still in contact with 4.1,3.1,3.2 3.3 . During the left lateral movement teeth from 2.2 to 2.4 have contact with teeth from 3.2.to 3.4 while in the right lateral movement teeth from 1.2 to 1.5 have contact with teeth from 4.2 to 4.5.
Aesthetic analisys The tooth display during the smile is limited and the smile line is medium. Gingival parables of the central incisor are aligned with parables of cuspids while the parables of lateral incisor are under the line connecting cuspids with central incisor. The gingival tissue are in good condition of health. Interdental papilla are present. The axis of central incisor are well oriented, the lateral incisor have a slight vestibulo version like the right upper canine, the zenith are in the correct position. The incisal margins are worn and the incisal embrasures are lost. The contact surface on the anterior upper teeth are all more or less on the same line instead of going up from the central teeth to the distal. Relative dental dimension are generally correct even if 1.3. looks larger than 1.2 during the smile. The two central incisors have lost their width to length ideal ration and 1.2 is particularly short. The surface texture is flat. The incisor shape is between squared triangular. The incisal plane is quite well aligned with the lower lip line. In the lower arch 3.1 is rotated about 90 ° toward left
The periodontal situation is generally healthy. 4.6 at the last visit has an endo-perio problem at the furcation
Tooth Wear The frontal upper teeth are worn and have lost more than 10% of their length, especially 1.2, 1.1,1.3 where the teeth look to be shortened about 20%. Most of these teeth have dentin exposure-In the lower arch especially 3.3,3.1,4.3 are worn and have lost more than 10% of their volume with dentin exposure .
Risk assessment Evaluating the risk assessment as Kois suggest we could assert that the periodontal risk is low, the biomechanical risk is high because of the high number of teeth lost and restored, the functional risk is medium – there are signs of parafunctional activity on the frontal teeth and the dentofacial risk is quite low because of the moderate exposition of the frontal teeth during the smile and the phonation.
Initial treatment planning The first treatment plan provides for oral hygiene, the composite up in order to give to the lab the information about the crown length of the frontal upper teeth, the wax up and the realization of the provisionals, the increase of the VDO, the substitution of old restorations on posterior teeth, the prosthetic treatment of all the upper teeth and the lower teeth from 3.3 to 3.7 and from 4.3 to 4.7. The 4.6 has to be extracted because of an endo-perio lesion at the furcation. Obviously the final evaluation must be done after the removal of the old bridges . The teeth in position 2.4, 2.5, 4.5, and 4.7 have less than 1 mm of sound tissue in the cervical area moreover the endodontic condition of 2.4, 2.5 would request a new endo treatment and all these teeth have posts in the roots. The maintenance of these teeth could be irrational for the limited dental structure , the presence of posts inside the roots, the risk associated with the use of these teeth as abutments for FPD and the need to insert implants in site 2.6 and 4.6
ReevaluationThe final decision is to extract 2.4, 2.5, 4.5, 4.7. the treatment on the implant in 1.4 site is questionable. It is no possible to make a new crown with the original components because the implant is not anymore more sold. The implant is quite large and the bone around the implant is healthy. The removal of the fixture can be complicated by the bone loss and the need of GBR. The final choice in agreement with the patient is to maintain the fixture to build a new abutment after having found a new compatible screw and to realize a new crown on it, after having done a crown lengthening in oder to align margins. On 4.4 a mucogingival surgery has to be done in order to improve the tissue quality and to have a keratinazed tissue around the tooth. The treatment plan provides for three implants in the second quadrant after a GBR and a sinus lifting on 2.4, 2.5,2.6 , two implants in the third quadrant,4.5,4.6 two implants on the fourth quadrant 4.5, 4.7. The final restorations are lithium disilicate crowns on 1.1,1.2,1.3,2.1,2.2,2.3,3.3,3.4,4.3,4.4, zirconia layered with porcelain crowns on natural teeth on 2.7,3.7 zirconia layered with porcelain crown on implant on 1.4 zirconia layered with porcelain bridge on natural teeth on 1.5-1.6 pontic -1.7, zirconia layered with porcelain splinted crowns on implants on 2.4-2.5-2.6, 3.5-3.6 and a zirconia layered with porcelain bridge on implants on 4.5-4.7.
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