9 DECEMBER 2015

Patient: Mr. Timothy H
Dentist: Dr. Tim Struwig

Reason for visit

Timothy told me that his main reason for visiting me was to “fix his smile” so that he did not have to feel embarrassed anymore when smiling. At the time of our first visit he informed me that he was a high profile photographer and to top things off he was getting married in 8 months’ time.

He therefore wanted his “smile fixed” as quickly and painlessly as possible. Timothy did not have any other complaints except that he would sometimes wake up and it would feel like there were fine sand particles in his mouth.

History of present complaint

Timothy said that over the last 10 years or so he had noticed that his front teeth were gradually getting shorter and shorter and it had now gotten to a stage where it was embarrassing him so much that it was affecting his career as an international high profile modeling photographer and his fiancé had also mentioned that he had better get his teeth sorted out before the wedding. He assured me that nothing else in his mouth was worrying him at this stage, just his smile.

Medical History

Timothy was 31 years old at the time of his initial consultation with me and he was in exceptional health. He informed me that he was allergic to iodine. 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

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

- Root treated T31 restored with a poorly shade matched porcelain fused to metal crown
- Root treated T32 with a leaking (secondary caries) resin veneer with the darkness of the dentine due to the tooth being non-vital shining through slightly
- Leaking occlusal resin restoration on T36
- Good occlusal resin restoration on T37
- Very little of the occlusal resin restoration left over on the T46 due to severe attrition caused by bruxism/parafunction

Patient attitude and expectation

Timothy although being very friendly was also very much a perfectionist and I would even go as far as calling him pedantic. He actually informed me right from the get go that he was going to see two other dentists to compare what type of treatment we all suggested and what our prices were. When asked what his expectations were he said that he wanted his teeth to look like they did before they started getting shorter about 10 years ago.

Full extra oral and intra oral examination and charting

Upon completion of the extra oral examination it became evident that Timothy was suffering from severe bruxism due to his hypertrophic masseter muscles as well as some discomfort when I palpated these muscles. There was also slight tenderness over the left temporal area 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 but especially his upper anterior teeth. I also noted immediately that his oral hygiene was very good. Other intra oral findings included a healthy periodontium and no signs of pathology, there was a leaking restoration (secondary caries) on T36, good restoration on T37, poorly shaded crown on T31, leaking (secondary caries) resin veneer on T32 with the slightly discolored dentine from the tooth’s non-vitality shining through, most of the occlusal restoration on T46 was missing due to attrition and there were fairly superficial caries on T47, T16, T17, T26 and T27.

Special test reports

Not applicable

Problem list/ diagnosis

- Severe bruxism/parafunction and resultant loss of vertical height of occlusion
- Unaesthetic appearance of smile
- Very poorly shaded/unaesthetic crown on T31
- Secondary caries (leaking restoration) T32 with discoloration from the tooth being non-vital (root canal treated) shining through labially
- Leaking restoration (secondary caries) T36
- Largest part of restoration missing on T46 due to attrition
- Relatively superficial caries on T47, T16, T17, T26 and T27

Treatment planned and treatment provided

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

Timothy’s treatment plan revolved around a complete bite/occlusal rehabilitation by opening his bite by between 2 and 3mm 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 his teeth had already been worn down to within a few millimeters or of the pulp.

The treatment plan was as follows:

- Remove all caries (where applicable) and place resin restorations on T36, T46, T16, T17, T26, T27 and T47
- Make him a full upper arch functional appliance (acrylic bite plate) to open up his bite posteriorly between 2 and 3 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 6 weeks that it started to feel very comfortable when he wore it.
- Vital bleaching of all his lower anterior teeth besides T31 (existing crown) and T32 (non-vital)
- Remove secondary caries and prepare T32 for a Full Monolithic Zirconium Crown (Bruxzir) with a shade that will match his newly bleached lower anterior teeth
- Remove old porcelain fused to metal crown on T31 that was very poorly color matched to the rest of his teeth and replace it with a Full Monolithic Zirconium Crown (Bruxzir) with a shade that will match his newly bleached lower anterior teeth.
- Prepare T17, T16, T15, T27, T26, T25, and T24 for Full Monolithic Zirconium Crowns (Bruxzir Crowns). These crowns were manufactured roughly 2mm 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 and of course his fiancé 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 Timothy gave us the go ahead 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. We then place the final upper anterior crowns 2 weeks later – he was overjoyed 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 Timothy understands full well what the consequences would be if he were not to wear his occlusal guard.

Follow up visits

Timothy 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)

Unfortunately although I had explained in great detail the benefits of regular dental check-ups Timothy had not returned for another follow up right up to the time that I sold my practice in 2019.

I think that his disappearing might have also had something to do with the fact that I had brought to his attention the large chronic abscess (asymptomatic) which had formed around the root apex of his T31 after I had taken the OPG Radiograph. We tried contacting him numerous times but personally I think he felt he was not up to any more dental work and if it was not hurting then why mess with it…………of course I completely disagree with this way of thinking and I can only speculate as to why he decided not to return.

Before and after (taken at 6 month follow up) Pantomogram’s (OPG’s)

Before and after clinical photos