11 NOVEMBER 2016

Patient: Mrs. Doris H
Dentist: Dr. Tim Struwig

Reason for visit

Doris told me that she was very unhappy with her current dentist (she did not say why and I decided not to ask why either) and that she then asked her Maxillo-Facial and Oral Surgeon who had recently placed all 10 her implants namely Dr. Paul Betts as well as the dental technician at her church that had made her current temporary fixed upper acrylic hybrid denture Mr. Wayne Toweel (who happened to be one of my dental technicians) who the best “other” dentist in the area was that would be able to complete the work she had started with her dentist as she definitely did not want to go back to him and that they both had recommended me.

She said that she did not want him to make her permanent teeth on her implants for her because she no longer trusted him and did not want him to touch her mouth ever again. When I asked her if she would mind if I phone her previous dentist to inform him that she prefer I take over the case she said that she would really appreciate it if I did not contact him so I decided to respect her wishes on the matter.

Doris told me that besides the fact that she wanted me to make permanent teeth to fit on her implants she would also like me to do porcelain veneers on her lower anterior teeth because they were so “worn down and yellow” and she wanted them to match with her brand new white teeth that were going to fit on her implants.

History of present complaint

Doris actually did not really have any complaints besides the fact that she no longer wanted to see her previous general dentist and that she would really like to get her dental work completed as soon as possible because according to her she was rather tired of seeing the dentist so often.

She did also mention that her remaining “worn down” teeth would sometimes be slightly sensitive after eating ice cream.

Medical History

Doris was 57 years old at the time of her initial consultation with me and she was in excellent health. She informed me that she did not have any allergies. She also said that she did not have any prosthesis in her body, was not on any medication and had not been hospitalized in the last 5 years.

Dental History

Doris presented with the following previously completed dental work at her initial consultation with me:

- Previously extracted T18-T28 as well as T35-T38 and T45-T48
- DO resin restoration with a TMS titanium pin on T34 which was in a good condition
- Very large leaking (secondary caries) DBP resin restoration on T42
- Attrition resulting in exposed dentine on all remaining teeth
- Dental implants placed by Dr. Paul Betts (MFOS) in the T11,T13,T16,T22,T23,T25 as well as T45,T46,T36 and T37 areas
- A fixed acrylic full upper temporary hybrid prosthesis (supported by the upper six implants) made by her previous general dentist

Patient attitude and expectation

Doris had a great sense of humor and always attended my practice together with her best friend who apparently tagged along for moral support since her husband (a famous motorcyclist in South Africa) passed away about a year ago. She always claimed to be very nervous but she never came across as being such.

When asked about what her expectations were she simply said “make me look beautiful so I can find a new husband and don’t upset me like my previous dentist did”

Full extra oral and intra oral examination and charting

Upon completion of the extra oral examination it became evident that Doris was grinding or clenching her teeth at night due to the fact that her masseter muscles especially on the left were rather tender when I palpated them. She also mentioned that now and then she would wake up with a slight headache or neck ache. No extra oral pathology was detected.

Intra orally I noticed that her oral hygiene was fairly good and that her periodontium was altogether healthy. I noticed a large leaking (secondary caries) restoration on her T42 as well as the fact that the T42 was slightly discolored. I also noted a good DO restoration on her T34.

Charting:

Special test reports

Not applicable

Problem list/ diagnosis

- Long term bruxism/parafunction resulting in attrition and therefore dentine exposure which in turn caused sensitivity to cold on all her remaining teeth as well as causing a rather unaesthetic and short appearance of her lower anterior teeth and first premolars.
- Deep secondary caries (severely leaking large restoration) on the slightly discolored T42 that was fortunately asymptomatic but upon testing proved to be completely non-vital as well as a large chronic abscess was noted radiographically associated with the T42.
- Permanent full upper prosthesis needed to fit on 6 upper implants.
- Permanent crowns needed to fit on implants T45,T46,T35 and T36

Treatment planned and treatment provided

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

Doris’s treatment plan revolved around her either having a fixed or removable acrylic or porcelain full upper prosthesis to fit on her 6 implants (she was quoted on all these different options as well as an in depth discussion of the advantages and disadvantages of each option after which she chose to go ahead with the fixed porcelain prosthesis)

Doris also needed Zirconium Crowns made to fit on her lower 4 implants. We decided to join the T45 and T46 crowns together as well as join the T35 and T36 crowns together to help with long term stability and bone preservation through a more evened out distribution of occlusal forces in this way. It was also decided to increase her posterior vertical height of occlusion by roughly 2mm in order to allow for space anteriorly to increase the height of the shortened remaining lower anterior teeth.

We would also need to do a root canal treatment on the non-vital T42 and then do 6 Porcelain Veneers from T43-T33 and also Porcelain Overlays with a buccal facing on T44 and T34.

After all the treatment was completed we would make the patient an occlusal guard/ night guard to be worn every night to preserve the work we had done.

The treatment plan was as follows:

- Perform a root canal treatment on T42 and as well as remove secondary caries and replace the restoration
- Fabricate and place full monolithic zirconium (Bruxzir) permanent crowns for T34, T35, T45 and T46 with increase vertical height of 1mm in order to create space anteriorly where the “longer” teeth are desired for aesthetic reasons.
- Fabricate and place a new temporary acrylic fixed full upper prosthesis (also with an increase in vertical height of 1mm to create space anteriorly) to fit on the upper 6 implants for the patient to “test drive” and see if she and her friends and family like the way it looks and whether or not she can function adequately with it and whether or not she can adjust to her new bite which has now been effectively opened by 2mm (1mm from the top temporary prosthesis and 1mm by the posterior lower permanent crowns on the 4 implants) – the reason we needed to make a new temporary prosthesis was firstly because she despised the look of her current one (from her previous dentist) as well as the fact that we needed to test her new bite.
- Once Doris was happy with the function and appearance of her new temporary upper prosthesis we would send it back to my lab (Dimension Dental) for scanning in order for them to fabricate her permanent fixed full upper porcelain prosthesis. Doris did come in twice for some minor aesthetic adjustments on the temporary upper prosthesis over a course of about three weeks where we simply added resin in some areas and removed from the acrylic prosthesis in other areas of the temporary prosthesis. She adapted to her new bite immediately however.
- After the three week trial and adjustment period Doris was happy for us to go ahead with the manufacture of the final upper prosthesis

- We then placed the final upper full fixed porcelain (monolithic zirconium) prosthesis that would be supported by her 6 upper implants and Doris was extremely happy with the final result.
- After this we prepared and placed T43 to T33 Lithium Disilicate (Emax) veneers as well as Emax overlays with buccal facings on T44 and T34.
- The last but also very important step was to make her occlusal guard /night guard and stress the importance of her wearing it every night in order to maintain her teeth and smile.

Follow up visits

Doris returned 2 weeks later not because she had anything worrying her in her mouth but rather to present us with a delicious carrot cake to say thank you for her new smile.

I did stress to Doris the importance of annual check-ups in order for us to be able to detect problems early if any were to arise but unfortunately up until the time that I had sold my practice in April 2019 she had never returned for a check-up.

Before and after Pantomogram’s (OPG’s)

Example of a Peri-Apical Radiograph taken to see if the impression copings were seated properly when making the upper full fixed prosthesis