16 APRIL 2015

Patient: Mr. Glenn J
Dentist: Dr. Tim Struwig

Reason for visit
Glenn came to see me because his wife kept complaining about the appearance of his two upper front teeth. She said that the one tooth was horribly grey and the other had a distinct silver line near the gum. She did not even want to walk next to him in the mall or take photos together with him anymore due to the appearance of his teeth.

He said that his teeth were not worrying him at all because he himself only saw them when he looked in the mirror from time to time but he admitted that he could no longer stand his wives incessant complaining about his teeth and had decided that it was now time to do something about the problem.

History of present complaint
Glenn told me that he fell off his bicycle and knocked his front teeth on the pavement when he was about 13 (roughly 34 years before consulting with me) and broke half of his upper left front tooth (T21) clean off. His childhood dentist then did a root canal treatment on that tooth as well as a filling (assumedly a resin restoration).

Glenn said that the filling on his T21 kept breaking and when he was about 21 (roughly 26 years before our consult) his dentist at the time decided to rather crown this tooth but to leave the root canal treatment as it was (Glenn was informed that the root canal was not great but the dentist said that there were no signs of any problems and that it would be better not to mess with the existing root canal performed roughly 8 years previously)

After this when Glenn was roughly 24 his upper right front tooth (T11) just starting paining out of the blue when he touched it or bit on something with it. He went to his dentist and they informed him that the nerve in the tooth had now completely died off (become non-vital) as a result of the trauma when he fell of his bicycle roughly 11 years before. The dentist then completed a root canal treatment on the tooth but due to financial constraints at the time Glenn could not afford to crown this tooth as advised after his root canal treatment.
Roughly 2 years later one of Glenn’s lower front teeth (T41) went through the exact same process as his upper right front tooth (T11) the only difference was that this time his gum swelled up around the tooth as well as it being very sensitive to touch so he recalls having to first go on a course of antibiotics before the dentist could do the root canal treatment on this tooth (T41). Once again due to financial constraints Glenn could not have the tooth crowned after his root canal as suggested by his dentist at the time.

Medical History
Glenn was 47 years old at the time of his initial consultation with me and he was in excellent health. 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 medication and had not been hospitalized in the last 5 years.

Dental History
Glenn presented with the following previously completed dental work at his initial consultation with me:

- Root canal treatment on T11 (roughly 23 years ago) with a good Class 1 P resin restoration
- Good Class 2 DO resin restoration on T15
- Good Class 2 OP amalgam restoration on T16
- Good Class 1 O amalgam restoration on T17
- Root canal treatment on T21 (roughly 34 years ago) as well as a porcelain fused to metal crown on T21 (roughly 26 years ago) which later presented an unaesthetically exposed metal buccal margin
- Good Class 1 P amalgam restoration on T22
- Good Class 2 DO resin restoration on T25
- Very large Class 3 MOD resin restoration on T26 with buccal caries present
- Good Class 2 MO amalgam restoration on T27
- Good Class 2 DO amalgam restoration on T36
- Good Class 3 DOB resin restoration on T37
- Root canal treatment on T41 (roughly 21 years ago) with a good Class 1 P resin restoration
- Good Class 3 MOLi amalgam restoration on T46
- Good Class 1 O resin restoration on T47

Patient attitude and expectation
Glenn is a laid back, friendly and easy going person and truly was only visiting me to satisfy his wife. His words to me when I asked him what his expectations were, were as follows “If you can make my wife happy again, I will be forever indebted to you.”

Full extra oral and intra oral examination and charting
Upon completion of the extra oral examination it became clear that there was nothing extra orally to be concerned about. No extra oral pathologies were detected.

Intra orally the only caries that were noted were buccally to the T26. I also noted immediately that his oral hygiene was rather good. Other intra oral findings included the discovery of the badly discolored T11, slightly discolored T41 and unaesthetically visible metal margin of the porcelain fused to metal crown on T21. The unaesthetic appearance of T11 and T21 were blatantly obvious when he smiled and I could not help but mention to him that I was in agreement with his wife on this one.

Charting:

Special test reports

Not applicable

Problem list/ diagnosis

- Buccal caries T26
- Unaesthetic appearance of smile and generally stained teeth
- Severely discolored T11 (although the root canal treatment was not perfect by any means there had been no symptoms or signs of pathology on this tooth for roughly the last 23 years)
- Unaesthetic metal margin of old porcelain fused to metal crown on T21 is visible (although the root canal treatment on this tooth was not perfect by any means there had been no symptoms or signs of pathology on this tooth for roughly the last 34 years)
- Slightly discolored T41 which was non-vital due to being root canal treated roughly 21 years earlier

Treatment planned and treatment provided

Most of the treatment planned and the treatment provided were the same except for the fact that I had suggested a Lithium Disilicate (Emax) Overlay for T26 due to the large size of the existing resin restoration and the fact that the restoration was now going to be even larger after I remove the buccal caries. The reason we did not do the Emax Overlay on T26 was due to financial constraints.

Glenn also decided not go ahead with the non-vial bleaching of T41 which was slightly discolored. He said that it was not visible when he smiled and that his wife had not yet complained about it. I assume another reason for him not going ahead with this suggested treatment was because of financial as well as time constraints.

  

Glenn’s treatment plan revolved around improving the appearance of his smile and removing the buccal caries on his T26.

The treatment plan was as follows:

- Remove buccal caries and place a Class 1 B resin restoration on T26 which would be adjacent to the existing large restoration on T26
- Do vital bleaching of all anterior teeth besides T11,T21 and T41
- Do a Lithium Disilicate (Emax) Veneer on T11 in order to be minimally invasive on a tooth that has been working perfectly for the last 23 years and at the same time achieve a good aesthetic result.
- Remove the old porcelain fused to metal crown on T21 with the unaesthetically exposed metal margin on its buccal/labial side and replace it with a Lithium Disilicate (Emax) Crown in order to improve its aesthetics and to allow its shade to match the newly bleached surrounding teeth.

Follow up visits

Glenn returned roughly 7 months later for me to repair a fracture on the large resin restoration on his T26 (the same tooth which I had suggested he rather do an Emax Overlay a few months earlier). Unfortunately he would still not allow me to do the Emax Overlay on T26 so I proceeded to repair the resin restoration with yet another restoration.

Glenn also did not want me to perform a check-up or prophylaxis but assured me he would come back soon for that.

Unfortunately up until the time that I sold my practice in 2019 I had not seen Glenn for another follow up visit. I assume his wife had stopped complaining about his teeth.

Before and after Peri-apical radiographs of T11 and T21

Testimonial letter from Glenn as well as Before and after clinical photos and a photo of Glenn with his “happy” wife**

**Please note that in 2015 I had attained Glenn’s full permission to use his testimonial, clinical photos/photo of him and his wife and his actual name however I deemed fit