15 APRIL 2016

Patient: Mr. Chris W
Dentist: Dr. Tim Struwig

Reason for visit

Chris told me that despite the rather bad pain which he experienced from time to time in his upper right jaw his main reason for visiting me was to “improve his smile” so that he could regain the confidence he used to have while smiling.

History of present complaint

Chris said that after his filling came out about a month ago on his upper right first premolar it would be really painful for a long time after biting on something hard or after eating or drinking anything cold. He also said that the tooth would sometimes pain spontaneously and that the only way that he would be able to get rid of the pain would be to take anti-inflammatory drugs such as Myprodol.

As far as the extremely severe attrition that he presented with he simply said that his teeth have been gradually getting shorter and shorter and that now he felt it had got to a point where they were causing him a great deal of embarrassment. Chris also mentioned that some mornings especially during times that he was under a lot of stress at work he would wake up with a headache or neck ache.

He also complained about having to remove large quantities of food from “gaping holes” in his upper right first molar and lower right first molar with a tooth peck and this would often mean he would have to go to the bathroom straight after a meal to remove the food from his teeth.

Medical History

Chris was 39 years old at the time of his initial consultation with me and he was very healthy besides being treated by his medical doctor with Simvastatin for his higher than normal cholesterol levels. He informed me that he did not have any allergies. He also said that he did not have any prosthesis in his body, was not on any other medication and had not been hospitalized in the last 5 years.

Dental History

Chris presented with the following previously completed dental work at his initial consultation with me:

- Class 3 MBP resin restoration which was leaking (secondary caries) on T12
- Good class 3 P resin restoration on T13
- Absent large restoration on T14 (only a small part of the palatal aspect of the resin restoration remained)
- Below average Root Canal Treatment on T16 with restoration completely absent
- Fairly good Class 2 OB resin restoration on T17
- Severely leaking (deep secondary caries) class 2 OB resin restoration on T27
- Leaking (secondary caries) class 5 B resin restoration on T34
- Good Class 5 B resin restorations on T35 and T36
- Completely absent large restoration on T46
- Good Class 5 B resin restoration on T47

Patient attitude and expectation

Chris is a laid back, friendly and easy going person but yet he was very serious about fixing up all the problems in his mouth. His words to me when I asked him what his expectations were, were as follows “As long as you give me a half decent smile and take away my pain I will be more than happy.”

Full extra oral and intra oral examination and charting

 

Upon completion of the extra oral examination it became evident that Chris was suffering from severe bruxism due to his hypertrophic masseter muscles as well as some discomfort when I palpated these muscles especially on the right side. There was also slight tenderness over the right and left temporal areas which was also indicative of his parafunction (bruxism). There were no extra oral sings of pathology detected.

Intra orally the first thing which became very obvious was the extreme attrition and abrasion on most of his teeth. I also noted immediately that his oral hygiene was rather good. Other intra oral findings included a healthy periodontium and no signs of pathology, there was a leaking restoration (secondary caries) on T12, good restoration on T13, largest part of the restoration on T14 was absent (only a small part of the palatal aspect of the resin restoration remained) with some caries and likely pulp exposure, large missing restoration on T16 which had a below average quality root canal treatment and very extensive caries as well as a vertical root fracture, fairly good restoration on T17, DO caries on T24, O caries on T26, severely leaking restoration (deep secondary caries) on T27, leaking (secondary caries) restoration on T34, good restorations on T35 and T36, large missing restoration on T46 but fortunately no sign of caries and lastly a good restoration on T47.

Special test reports

Not applicable

Problem list/ diagnosis

- Severe bruxism/parafunction with resultant loss of vertical height of occlusion
- Unaesthetic appearance of smile
- Secondary caries (leaking restoration) T12
- Largest part of restoration missing on T14 with caries and likely pulp exposure (symptoms were indicative of an irreversible pulpitis)
- Large missing restoration on T16 which had a below average quality root canal treatment and very extensive caries as well as a vertical root fracture, this tooth was only painful for a second sometimes directly after biting into something hard
- DO caries on T24
- O caries on T26
- Deep secondary caries (severely leaking restoration) on T27 but fortunately was asymptomatic and tested to still be vital.
- Secondary caries (leaking restoration) T34
- Large missing restoration T46 but fortunately no symptoms or caries present

Treatment planned and treatment provided

Fortunately the treatment planned and the treatment provided were the same in this case.

Chris’s treatment plan revolved around a complete bite/occlusal rehabilitation by opening his bite by between 3 and 4mm posteriorly thereby restoring the ideal occlusal relations that he had lost over time due to severe bruxism/parafunction and the resulting loss in his vertical height of occlusion causing him to have a really unaesthetic smile and if left untreated would inevitably have resulted in him eventually losing all his teeth as a number of teeth had already been worn down to within a millimeter or so from the pulp.

The treatment plan was as follows:

- Alleviate pain experienced from the irreversible pulpitis on T14 by means of a root canal treatment.
- Make him a full upper arch functional appliance (acrylic bite plate) to open up his bite posteriorly between 3 and 4 mm that he needed to wear as often as possible and let us know whether or not it started to become comfortable – He let us know after about 2 months that it started to feel very comfortable when he wore it.
- Surgically extract T16 and immediately place an implant to allow for osseointegration for roughly 3 months before placing the permanent crown on the implant. (The patient chose not to have a temporary crown placed on his immediately placed implant T16 in order to save on cost- I therefore placed a healing abutment on the implant for the 3 months that we waited for integration
- Remove caries and do restorations on T24 and T26
- Remove secondary caries and re-do restorations on T12,T27 and T34
- Prepare T17,T16,T15,T27,T26,T25,T24 for Full Monolithic Zirconium Crowns (Bruxzir Crowns) as well as T14 and T46 with a Lithium Disilicate Overlays (Emax Overlays to preserve the maximum amount of remaining tooth structure on these teeth) – These crowns were manufactured roughly 3mm higher than his existing teeth in order to open up his bite and temporary acrylic restorations were then placed on his T13-T23 for him to “test drive” and see if he and his friends and family liked the way it looks before committing to it with the final crowns as well as making it a shorter visit which is easier to manage for the patient and the dentist as opposed to prepping all the teeth at once. Of course it is also much easier to maintain a stable bite throughout by doing it this way.
- Once Chris gave us the thumbs up after “test driving” his new smile we booked him in for the Full Monolithic Zirconium Crown preps on his T13, T12, T11, T21, T22 and T23 and the final impression for the Full Monolithic Zirconium Crown on T16 which by now had osseointegrated and 2 weeks later placed his final upper anterior crowns as well as his final crown on his implant T16 – he was ecstatic with the final result.
- The last but MOST IMPORTANT step in his treatment was to make him an occlusal guard/night guard to protect him from his parafunction/bruxism which occurred mainly whilst sleeping and I made absolutely sure that he understood perfectly that his smile and teeth would not remain unless he religiously wore his occlusal guard/night guard every night for the rest of his life. I kept drilling through this point from the first visit with him right up to the last and I made sure that he still understood the importance of it every time he came in even after his rehabilitation was completed. I firmly believe that Chris understands fully how important it is to wear his occlusal guard every single night for the rest of his life.

Follow up visits

Chris returned for a follow up visit 6 months later for a check-up and prophylaxis treatment at which stage all was looking great (see below bitewings taken at this visit)

Another 5 months later Chris returned to my practice again because he was battling with a slight food trap between his implant crown T16 and crown T17. I introduced him to interdental brushes and demonstrated to him how to use them. He then asked me to once again do a check-up and prophylactic treatment for him as 6 months had almost passed. There were no other problems detected with the check-up.

He then returned another 10 months later in need of a new occlusal guard (I was relieved because at least I knew he was wearing it as promised) he reported that the food trap between T16 and T17 was now under control but there is now a food trap between T26 and T27 also which he said he is also learning to manage. He also requested another check-up and prophylactic treatment. There were no other problems detected with the check-up.

Before and after Pantomogram’s (OPG’s)

Before and after clinical photos