19 JANUARY 2018

Patient: Mrs. Mary M
Dentist: Dr. Tim Struwig

Reason for visit

Mary worked at a primary school and told me that the Grade 1 children that she taught would sometimes ask her why her teeth were so yellow and so skew. She mentioned that this was starting to happen even more than before now and that it was beginning to make her very self-conscious and that she had now decided that it was time to rectify the problem.

History of present complaint

Mary said that although she had mentioned to her dentists before that she would really like to have her smile fixed they seemed to not really take her seriously and simply fixed the immediate problem at hand for example a chipped front tooth or a filling that had come out and then sent her on her way promising to send her a quote to fix her front teeth, but on more than one occasion that quote never came.

Besides her main complaint she was in need of numerous restorations but she was only aware that there was “a piece missing” on her lower left first molar (T36) and not at all aware of the other 7 restorations that she needed. Mary did also mention in passing that when she bit on her upper left lateral incisor (T22) it would cause her a sharp pain that would sometimes last for a while.

Medical History

Mary was 51 years old at the time of her initial consultation with me and she was relatively healthy besides being treated by his medical doctor with Simvastatin for her higher than normal cholesterol levels and Pharmapress for the treatment of her hypertension. 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 other medication and had not been hospitalized in the last 5 years.

Dental History

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

- >Class 4 MPBDI leaking (secondary caries) resin restoration on T11
- Good Class 1 P amalgam restoration on T12
- Good Class 2 DP amalgam restoration on T13
- Class 3 MOP leaking (secondary caries) amalgam restoration on T16
- Good Class 1 O amalgam restoration on T17
- >Class 4 MPBDI leaking fractured resin restoration on T21
- Leaking (secondary caries) Class 2 MB resin restoration as well as leaking (secondary caries) Class 1 P amalgam restoration on T22 (T22 also tested to be non-vital and was slightly tender to percussion)
- Good Class 3 MOP amalgam restoration on T26
- Good Class 3 DOP amalgam restoration on T27
- Leaking (secondary caries) Class 3 DOB amalgam restoration as well as a good Class 1 Li resin restoration on T36
- Good Class 2 MO amalgam restoration on T37
- Good Class 2 DO amalgam restoration on T45
- Leaking (secondary caries) Class 3 DOB amalgam restoration on T46
- Good Class 2 DO amalgam restoration on T47
- T34 and T44 had been extracted during her childhood to create space and reduce crowding of her lower teeth ( I am not necessarily in agreement with this treatment regime)

Patient attitude and expectation

Mary was a fairly relaxed patient. Her words to me when I asked her what her expectations were, were as follows “I really want the kids at my school to stop teasing me. As long as we can achieve that I will be completely satisfied.”
Full extra oral and intra oral examination and charting

Upon completion of the extra oral examination it became evident that there were no signs of bruxism/parafunction. There were also no extra oral sings of pathology detected.

Intra orally the first thing that I noticed was that her oral hygiene was rather poor. Other intra oral findings included gingivitis (fortunately no pockets over 3mm were detected and therefore she did not appear to have periodontitis present.) There were no signs of any intra oral pathology.

There were numerous restorations present with a large number of them leaking (having secondary caries) and a relatively large amount of new carious teeth. It was also noted that T22 tested to be non-vital and that it was tender to percussion. T22 was also the only tooth that was severely buccally displaced, which was one of the main factors contributing to Mary’s unaesthetic smile.

Special test reports

Not applicable

Problem list/ diagnosis

- Non-vital T22 which is tender to percussion and severely buccally displaced from the dental arch. Both restorations on T22 were also leaking (secondary caries)
- Unaesthetic appearance of smile
- Secondary caries (leaking restoration) on T11
- DOP caries on T14
- Secondary caries (leaking restoration) on T16
- DO caries on T18
- OB caries on T24
- OP caries on T28
- Secondary caries (leaking restoration) T36
- O caries on T38
- Secondary caries (leaking restoration) T46 as well as new mesial caries on T46

Treatment planned and treatment provided

Fortunately the treatment planned and the treatment provided were more or less the same in this case. The only difference was that instead of the 8 upper anterior crowns/veneers that I wanted to do Mary chose to do 6 upper anterior crowns/veneers and this was purely due to financial constraints. (As it turned out I ended up giving her a good discount as well as my dental technicians also giving her a good discount in order for her to afford the 6 upper anterior crowns/veneers)

Mary also chose to rather do a resin restoration on her leaking (secondary caries) T36 instead of a Lithium Disilicate (Emax) Overlay as per my suggestion once again due to financial constraints.

Mary’s treatment plan revolved around us firstly getting her oral hygiene up to an acceptable standard. I started by giving her comprehensive oral hygiene instructions and doing a scale and polish (dental prophylactic treatment) and then informing her that unless she can get her oral hygiene up to an acceptable standard I would not be willing to perform cosmetic dentistry for her because at the end of the day my hard work would simply not last long term in a mouth full of plaque.

Mary understood very well why she needed to reduce the amount of plaque in her mouth and when she returned three weeks later to restore her carious teeth her oral hygiene was excellent with no signs of gingivitis whatsoever.

The treatment plan was as follows:

- Achieve an acceptable level of oral hygiene
- Remove caries (primary and secondary) on T12,T14,T18,T24,T28,T36,T38 and T46 and then replace with new resin restorations
- Do an atraumatic extraction of T22 (non-vital and tender to percussion with a poor long term prognosis as well as being severely buccally positioned in relation to the rest upper dental arch) and prepare T21 and T23 for the placement of an immediate temporary acrylic bridge to be worn for 8 weeks whilst waiting for healing to take place in the T22 area. (Root canal treatment for T22 as well as orthodontics to bring T22 back into the arch were mentioned to the patient as an alternative treatment but she opted to go for the quicker and more cost effective option to get the smile she desired)
- Placement of the permanent Monolithic Zirconium (Bruxzir) 3 unit bridge T21-23 ten weeks after the extraction of T22 as well as crown preparation for T11 (Bruxzir) and then Lithium Disilicate (Emax) Veneer preparations (minimally invasive treatment) for T12 and T13 in order to repair these chipped teeth as well as lighten them in color and straighten them out a little more. (Temporary acrylic crown worn on T11 in the meantime as well as temporary acrylic veneers worn on T12 and T13)- Placement of the final crown (Bruxzir) on T11 and final porcelain veneers (Emax) on T12 and T13

Follow up visits

Unfortunately despite my best efforts to explain the importance of follow up visits as well as annual check-ups and prophylactic treatments Mary did not return for a follow up right up until the time that I had sold my practice in 2019.

Mary’s bitewings at our initial consultation

 

Peri-apical radiograph showing the temporary 3-unit acrylic bridge in place after prepping for Mary’s immediate bridge T21-T23

Before and after clinical photos**

 

**Mary gave me her full consent to use her clinical photos and radiographs in any way I deemed fit.