Sample Case Presentation 2021

Case Presentation: Full Mouth Rehabilitation¹

Final Year Student
Doctor of Dental Medicine (DMD)
University of Western Australia

Patient Assessment²

Face profile analysis showing 51 year old female patient.

Presenting Complaint and History

Presenting Complaint³

• “I hate the appearance of my lower teeth, I want them all pulled out”
• “Three of my teeth have snapped off”
• “My upper denture keeps falling out”

History of Presenting Complaint

• Colleagues commented negatively on appearance of lower teeth.
• Upper denture needs to be “glued in” with PolyDent Denture Adhesive.
• Deteriorating dentition for many years.

Medical History

Systemic Conditions and Medications⁴

• Bipolar disorder type 2
  • Clozapine 350mg tablet orally 1x/day
  • Ziprasidone 80mg tablet orally 1x/day, as required
• Hashimoto’s thyroiditis
  • Levothyroxine 150µg tablet 2x/day
• Bursitis
  • Tramadol 200mg tablet orally 1x/day
• Hypercholesterolaemia
  • Fenofibrate 145mg tablet orally 1x/day
• Insomnia
  • Zopiclone 2x7.5mg tablet orally 1x/day

Social Habits

• Smoker: 4 pack years
  • 4 cigarettes/day for the past 20 years
  • Recently 2 cigarettes/day
  • Currently attempting to quit

Dental and Social History

Dental History⁵

• History of repeated temporary restorations.
• Loss and fracture of multiple teeth due to caries and periodontal disease.
• Chrome Cobalt (CrCo) partial upper denture (P/-) made 4 years ago at OHCWA.

Oral Hygiene

• Brushing frequency: 2x/day.
• Tool: Electric toothbrush.
• Dentifrice: Charcoal toothpaste (non-fluoridated).

Social History

• Occupation: Works at a bakery.
• Living Situation: Lives at home alone; close relationship with mother, daughter, and grandchildren.
• Smoking: 2 cigarettes/day (attempting to quit).
• Alcohol: Wine, 1-2 glasses/month.

Clinical Examination

Extra-Oral Examination

Facial and Smile Analysis⁶

• Convex facial profile (Class II tendency).
• Elongated lower third of face.
• Smile Aesthetics:
  • Wide buccal corridors.
  • 95% incisal display.
  • 0% gingival display.

Intra-Oral Examination

Soft Tissue and Mucosa⁷

• Maxillary Hard Palate: Diffuse erythematous and edematous appearance.
• Gingiva: Edematous, erythematous, blunting of interdental papilla; very painful to probing; Bleeding on Probing (BoP+).
• Oral Mucosa: Dry appearance.

Occlusion

• Loss of posterior contacts.

Existing Prosthesis Evaluation

Chrome Cobalt Partial Upper Denture (CrCo P/-)⁸

• Age: 4 years.
• Appearance: Poor.
• Retention: Poor.
• Stability: Poor.
• Patient Satisfaction: Poor.

Diagnostic Findings

Periodontal and Dental Charting⁹

Community Periodontal Index of Treatment Needs (CPITN) Definitions¹⁰

Code	Definition
0	Healthy
1	Gingivitis (Bleeding after gentle probing)
2	Calculus or Overhanging Restorations
3	Pocketing of Depth 3-5mm
4	Pocketing of Depth ≥ 6mm
*	Furcation Involvement

Note: Lower scores indicate better periodontal conditions.

Periodontal Findings¹¹

• Mean Probing Depth: 2.9 mm
• Mean Attachment Level: -4.1 mm
• Plaque Score: 54%
• Bleeding on Probing: 72%

Detailed Charting (Maxillary)

Metric	13	12	11	21	22	23	24	25
Mobility	0	0		0	0	0	0
Gingival Margin	0 0 0	-1 0 -1		-1 0 -1	0 0 0	0 -1 0	0 0 0
Probing Depth	1 2 9	3 6 6		3 5 5*	6 3 3	5 2 2	3 2 3

Caries and Periodontal Risk Assessment

Caries Risk Assessment (Evans et al, 2008)¹²

• Diet: High and frequent exposure to sugar and acid.
• Plaque Score: High (54%).
• Saliva Assessment:
  • Resting and stimulated: Adequate quantity and buffering.
  • Resting: Compromised viscosity and pH.
  • Stimulated: Compromised pH.
• Clinical/Radiographic Examination: Frank cavitation affecting multiple teeth.

Overall Risk: HIGH RISK

Periodontal Risk Assessment (Lang & Tonetti, 2003)¹³

• Bleeding on Probing (BOP): 80% (82 of 102 sites).
• Probing Pocket Depths (PPD) ≥ 5mm: 21 sites.
• Missing Teeth: 11.
• Alveolar Bone Loss: Estimated at 70%.
• Environmental Factors: Smoker.
• Polygon Surface: 130.769.

Overall Periodontal Risk: HIGH Suggested Recall Interval: 3 Months

Prognosis and Problem List

Prognosis Summary (Samet & Jotkowski, 2009)¹⁴

• Overall Dentition: Poor to Hopeless.

Restoration and Finding Legend

• Yellow: Composite / GIC - satisfactory.
• Grey: Amalgam - satisfactory.
• Brown: Caries.
• Black: Root stump.
• Darker Brown: Unsatisfactory restoration due to caries.
• Red: Unsatisfactory restoration for other reasons.
• P/ap R: Periapical radiolucency.

Prognosis Categories

• G: Good
• F: Fair
• Q: Questionable
• P: Poor
• H: Hopeless

Note: Overall tooth prognosis is modified downward by patient factors including poor oral hygiene, cariogenic diet, smoking, and high aesthetic expectations.

Pathology and Morphology Problems¹⁵

Aesthetics and Prosthetics

• Poor smile aesthetics and unsatisfactory CrCo P/- (Presenting Complaint).
• Multiple root stumps and discoloration due to caries.
• Loss of retention due to fracture of abutment tooth 24.

Disease Burden

• Carious root stumps: 24, 33, 43.
• Frank cavitation: 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45.
• Periodontitis: Stage 4 Grade C modified by smoking (Papapanou et al, 2017).
• Pulpless/infected root canal systems and chronic apical periodontitis: 24, 32, 33.
• Recurrent aphthous ulcerative disease.
• Denture stomatitis of the anterior hard palate.

Host and Morphological Factors

• Bipolar disorder and hypothyroidism (medication-managed).
• Dry mouth and smoking.
• Frequent high intake of sugary/acidic foods.
• Questionable oral hygiene compliance.
• Class II tendency and loss of posterior support.
• Vertically impacted 38, 48.
• Hypercementosis: 13, 23, 24, 34, 35, 44, 45.
• Missing teeth: Maxillary Kennedy Class I, Mandibular Kennedy Class II Mod 1.
• Large, bulbous maxillary anterior alveolar ridge.

Clinical Diagnoses

• Poor smile aesthetics and unsatisfactory CrCo P/-.
• Unrestorable teeth / Root stumps.
• Dental Caries.
• Periodontal disease.
• Endodontically involved teeth.
• Maxillary Kennedy Class I.
• Mandibular Kennedy Class II Mod 1.

Treatment Planning

Treatment Options and Selection¹⁶

Identified Options¹⁷

1. Immediate acrylic Full/Partial (F/P) dentures.
2. Conventional Full/Partial (F/P) dentures.
3. Immediate or conventional Full/Full (F/F) dentures.
4. Maxillary and Mandibular implant-supported fixed prostheses.
5. Temporization of remaining teeth ± 24 tooth addition to existing CrCo P/-.
6. No treatment.

Selected Treatment: Immediate Acrylic F/P¹⁸

• Rationale:
  • Patient refused to be without teeth during treatment.
  • Provides good aesthetics.
  • Low cost.
  • Reduces disease burden.
  • Simplified course of treatment.

Treatment Plan by Tooth

• Extractions (E): 13, 11, 21, 22, 23, 24, 43, 42, 41, 31, 32, 33.
• Restore/Replace (R): 46, 45, 34, 35.
• Investigate (I): 46, 45, 34, 35.
• Leave Unrestored (L): 37.

Management Plan

Foundational Phase

Addressing the Presenting Complaint¹⁹

• Aesthetics is the primary concern, but is driven by underlying disease.
• Significant disease burden: Caries, periodontitis, and pulpless/infected teeth.
• Treatment strategy: Disease must be managed to achieve and maintain aesthetic improvements; without treatment, progression will worsen aesthetics.

Lifestyle and Oral Hygiene Interventions²⁰

• Dry Mouth Management:
  • Smoking cessation counseling using “The 5As” (eTG, 2012).
  • Increase tap water intake (1L/day).
  • Reduce coffee consumption.
• Dietary Modification:
  • Reduce sugar intake and snacking frequency.
• Oral Hygiene Protocol (Evans et al, 2008):
  • Brush 2x/day (morning and night).
  • Use Neutrafluor 5000 Plus toothpaste.
  • Daily interdental brushing.
  • Strict adherence to dental appointments.

Periodontal and Restorative Procedures (2018)²¹

• Selective Subgingival Root Debridement (SRD):
  • Teeth: 37, 35, 34, 44, 45 (under local anaesthetic).
  • Prophylaxis and topical fluoride application.
• Restorations:
  • 34: MOLiBu Equia Forte + composite (Filtek Supreme) sandwich restoration.
  • 35: BOLBu composite (Filtek Supreme) restoration.
  • 44: DOLiBu Equia Forte restoration.
  • 45: MODLiBu Equia Forte + composite (Filtek Supreme) sandwich restoration.

Reconstructive Phase²²

Immediate Acrylic F/P Work-up (08/2018 - 02/2019)²³

• Alginate impressions and study models.
• Special trays using Campagna impression technique for the Maxilla.
• Master models and fabrication of base and rims.
• Facebow transfer and bite registration.
• Mounting of master models.

Laboratory and Clinical Steps²⁴

• Shade selection: Vita Classical shade B3.
• Maxillary and Mandibular casts marked with Probing Pocket Depths (PPDs) to guide laboratory decoronation.
• Duplication of master casts.
• Wax-up:
  • Reduce maxillary incisal display by 1-2mm.
  • Set maxillary teeth following palatal surfaces.
• Processing of acrylic F/P on mounted duplicates.
• Cross-mounting to verify fit and occlusion.

Patient Education and Informed Consent²⁵

• Extraction Risks:
  • Bleeding, bruising, swelling, and infection.
  • Risk of crown or root fracture.
  • Potential for surgical intervention.
• Immediate F/P Expectations:
  • Significant adaptation period required.
  • Immediate post-operative soreness.
  • Loosening of the prosthesis after 4-6 weeks due to bone resorption.
  • Requirement for temporary chairside relines every 3-4 weeks.
  • Definitive reline or remake scheduled at 6-12 months.

Definitive Phase

Surgical Phase (2019)²⁶

• Extractions:
  • Mandibular: 31, 32, 33, 41, 42, 43.
  • Maxillary: 11, 13, 21, 22, 23, 24.
• Procedure Details:
  • Luxation and forceps extraction.
  • Curettage of sites 24, 32, and 33 (areas with radiolucencies).
  • Alveolar ridge inspection and socket compression.
  • Achievement of haemostasis and delivery of post-operative instructions.

Prosthesis Insertion (2019)

• Maxillary (F/-): No adjustment required.
• Mandibular (-/P): Required adjustments for seating and occlusion.
• Outcome: Excellent fit, retention, stability, and aesthetics.

24-Hour Review (2019)²⁷

• Patient presented with soreness and swelling.
• Patient expressed extreme satisfaction with aesthetic results.
• Clinical actions: Adjusted sore spots and refined occlusion.
• Re-emphasized home care routine for the first week.

1-Week Review (02/03/2019)²⁸

• Patient remains extremely pleased with aesthetics; reported positive feedback from social circle.
• Clinical actions: Relieved sore spots.
• Patient Education: Reinforced home care and explained expected loosening of the F/P as bone remodels.

1-Week Review Continued (2019)²⁹

• Patient reported compliments from friends, family, and colleagues.
• Adjusted sore spots.
• Reinforced home care and the expectation of prosthesis loosening during bone remodeling.

Periodontal Review (2019)³⁰

• Significant improvements noted in oral hygiene.
• Residual Probing Pocket Depths (PPDs) remain.
• Performed Subgingival Root Debridement (SRD).
• Reinforced lifestyle changes and oral hygiene instructions.
• Patient remains in the HIGH RISK category.

Maintenance and Relining (2019)³¹

• First 3-4 Week Review:
  • Complaint: F/P starting to feel loose.
  • Action: Chairside reline with Viscogel soft liner.
• Second 3-4 Week Review:
  • Status: Adapting well, but experiencing some recurrence of looseness.
  • Action: Chairside reline with Viscogel soft liner.
• Third 3-4 Week Review:
  • Status: Minimal looseness; patient very happy with dentures.
  • Action: Final chairside reline with Viscogel liner.
  • Plan: Informed patient that definitive reline can proceed; requires 3 days without dentures.

Clinical Outcomes

Before and After Treatment Photographs³²

• Before (2018)
• After (2018)

References³³

1. Abbott, P. V. (2004). Classification, diagnosis and clinical manifestations of apical periodontitis. Endod Topics, 8: 36-54.

2. Abbott, P. V., Yu, C. (2007). A clinical classification of the status of the pulp and the root canal system. Aust Dent J, 52(1 Suppl): S17-S31.

3. Armitage, G. C. (1999). Development of a classification system for periodontal diseases and conditions. Ann Periodontol 4(1): 1-6.

4. Australian Medicines Handbook (AMH). (2019). Clozapine. Retrieved from: https://amhonline-amh-net-au.ezproxy.library.uwa.edu.au/chapters/psychotropic-drugs/antipsychotics/clozapine

5. Australian Medicines Handbook (AMH). (2019). Fenofibrate. Retrieved from: https://amhonline-amh-net-au.ezproxy.library.uwa.edu.au/chapters/cardiovascular-drugs/drugs-dyslipidaemia/fibrates/fenofibrate

6. Australian Medicines Handbook (AMH). (2019). Levothyroxine. Retrieved from: https://amhonline-amh-net-au.ezproxy.library.uwa.edu.au/search?q=levothyroxine

7. Australian Medicines Handbook (AMH). (2019). Zopiclone. Retrieved from: https://amhonline-amh-net-au.ezproxy.library.uwa.edu.au/chapters/psychotropic-drugs/drugs-anxiety-sleep-disorders/other-drugs-anxiety-sleep-disorders/zopiclone

8. Campagna, S. J. (1968). An impression technique for immediate dentures. J Pros Dent, 20(3): 196-203.

9. Celebic, A., Knezovic-Zlataric, D. (2003). A comparison of patient’s satisfaction between complete and partial removable denture wearers. J Dent, 31: 445-451.

10. Evans, R. W., Pakdaman, A., Dennison, P. J., Howe, E. L. C. (2008). The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J, 53: 83-92.

11. Jogezai, U., Laverty, D., Walmsley, A. D. (2018). Immediate dentures part 1: Assessment and treatment planning. Dent Update, 45: 617-624.

12. Jogezai, U., Laverty, D., Walmsley, A. D. (2018). Immediate dentures part 2: Denture construction. Dent Update, 45: 720-726.

13. Lang, N. P., Tonetti, M. S. (2003). Periodontal risk assessment (PRA) for patients in supportive periodontal therapy (SPT). Oral Health Prev Dent, 1: 7-16.

14. McGarry, T. J., Nimmo, A., Skiba, J. F., Ahlstrom, R. H., Smith, C. R., Koumjian, J. H., Arbree, N. S. (2002). Classification system for partial edentulism. J Prosthodont, 11(3): 181-193.

15. Papapanou, P. N., Sanz, M., Buduneli, N., Dietrich, T., Feres, M., Fine, D. H., … Tonetti, M. S. (2018). Periodontitis: Consensus report of workgroup 2 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol, 45(Suppl 20): S162-S170.

16. Samet, N., Jotkowitz, A. (2009). Classification and prognosis evaluation of individual teeth - A comprehensive approach. Quintessence Int, 40: 377-387.

17. Therapeutic Guidelines. (2012). Dental management of patients with medical conditions. Retrieved from: https://tgldcdp-tg-org-au.ezproxy.library.uwa.edu.au/viewTopic?topicfile=dental-management-of-patients-with-medical-conditions&guidelineName=Oral%20and%20Dental#toc_d1e731

18. The Royal Australian College of General Practitioners (RACGP). (2019). The 5A’s structure for smoking cessation. Retrieved from: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation/the-5as-structure

19. Wolff, A., Joshi, R. K., Ekstrom, J., Aframian, D., Pedersen, A. M. L., Proctor, G., … Dawes, Colin. (2017). A guide to medications inducing salivary gland dysfunction, xerostomia, and subjective sialorrhea: A systematic review sponsored by the World Workshop on Oral Medicine VI. Drugs R D, 17: 1-28.

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