Sample Portfolio 1

Case Portfolio 2019¹

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

1. Aesthetic removable restorative case²

• 1.1 Presenting complaint (Page 3)
• 1.3 Medical history (Page 3)
• 1.17 Problem list (Page 14)
• 1.18 Diagnosis (Page 14)
• 1.19 Treatment options (Page 15)
• 1.20 Management plan (Page 18)
• 1.22 Before and after treatment photographs (Page 26)

2. Functional removable restorative case

• 2.1 Presenting complaint (Page 27)
• 2.3 Medical history (Page 27)
• 2.15 Problem list (Page 36)
• 2.16 Diagnosis (Page 36)
• 2.17 Treatment options (Page 37)
• 2.28 Management plan (Page 39)
• 2.19 Before and after treatment photographs (Page 42)

3. Aesthetic fixed restorative case

• 3.1 Presenting complaint (Page 43)
• 3.3 Medical history (Page 43)
• 3.14 Problem list (Page 51)
• 3.15 Diagnosis (Page 51)
• 3.16 Treatment options (Page 52)
• 3.17 Management plan (Page 55)
• 3.18 Before and after treatment photographs (Page 60)

4. Functional fixed restorative case

• 4.1 Presenting complaint (Page 61)
• 4.3 Medical history (Page 61)
• 4.15 Problem list (Page 70)
• 4.16 Diagnosis (Page 70)
• 4.17 Treatment options (Page 71)
• 4.18 Management plan (Page 73)
• 4.19 Before and after treatment photographs (Page 77)

5. Multidisciplinary case

• 5.1 Presenting complaint (Page 78)
• 5.3 Medical history (Page 78)
• 5.16 Problem list (Page 90)
• 5.17 Diagnosis (Page 90)
• 5.18 Treatment options (Page 91)
• 5.19 Management plan (Page 93)
• 5.20 Before and after treatment photographs (Page 98)

6. References

• References (Page 99)

Case 1: Aesthetic Removable Restorative Case

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

• Aesthetics: The patient decided she can no longer tolerate the appearance of her lower teeth following negative comments from colleagues. This is the main driving factor for treatment.
• Denture Stability: The upper denture requires daily use of PolyDent Denture Adhesive since the loss of an upper tooth.
• Dental History and Attitude:
  • Long-term deteriorating dentition due to patient neglect and multiple missed/cancelled appointments.
  • Patient expresses embarrassment and admits to allowing decay and gum disease to progress.
  • Loss of faith in the dental profession due to the failure of previous restorations (falling out or recurring decay).

Clinical Presentation and History

Medical History Summary

• Bipolar Disorder Type 2: Characterized by major depressive episodes (≥2 weeks) and at least one hypomanic episode.
• Hashimoto’s Thyroiditis: Autoimmune condition resulting in impaired thyroid hormone production.
• Bursitis: Inflammation of the joint bursae.
• Hypercholesterolaemia: Elevated total or LDL cholesterol.
• Smoking Status: 2 cigarettes/day for 37 years (4 pack years).

Medical History and Medications

Current Medications⁴

Medication	Dosage	Use / Mechanism	Dental Implications
Clozapine	350mg daily (night)	Atypical antipsychotic for bipolar disorder.	Strong evidence of xerostomia. Metabolized by CYP1A2; smoking cessation requires GP management to avoid toxicity.
Ziprasidone	80mg daily (PRN)	Atypical antipsychotic for bipolar disorder.	Risk of xerostomia.
Zopiclone	15mg daily (night)	Non-benzodiazepine hypnotic for insomnia.	Moderate evidence for inducing xerostomia.
Tramadol	200mg daily (PRN)	Opioid analgesic for bursitis pain.	Moderate evidence for xerostomia; potentially reduced perception of dental pain.
Fenofibrate	145mg daily	Fibrate for hypercholesterolaemia.	None noted.
Levothyroxine	150μg 2x/day	Thyroid hormone replacement.	Poorly managed hypothyroidism may cause macroglossia, dysgeusia, and delayed healing.

Hospitalization and Allergies

• Surgery: Laser eye surgery.
• Allergies: No known allergies.

Clinical Examination⁵

Dental and Social History⁶

• Restorative History: Repeated temporary restorations for rampant caries over the past 5 years. Multiple teeth lost or fractured due to untreated caries and periodontal disease.
• Prosthetic History: Chrome Cobalt partial denture (CrCo P/-) made 4 years ago; patient is dissatisfied with retention following the fracture of an abutment tooth.
• Oral Hygiene: Brushes 2x/day with an electric toothbrush and charcoal (non-fluoridated) toothpaste. No interdental cleaning.
• Social Factors: Works in a bakery; lives alone but has regular family visits. Occasional alcohol consumption (1-2 times per month).

Extra-Oral Examination Findings

• Facial Features: Symmetrical face with a slight deviation of the nose tip to the right. Healthy complexion.
• Anatomy: No enlargement or tenderness of the thyroid gland or muscles of mastication. TMJ shows smooth movement in translation and rotation.
• Proportions: Elongated lower third of the face; balanced facial fifths. Convex profile.
• Lips: Distinct vermillion borders with a healthy appearance.
• Smile Analysis:
  • 95% incisal display on smile; 0% gingival display.
  • 0% incisal display at rest.
  • Wide buccal corridors due to missing upper posterior teeth.

Intra-Oral Soft Tissue Examination⁷

• Labial Mucosa: 2x2mm ulcer with yellow base and red halo (Right side). Differential Diagnosis: Aphthous ulcer (most likely), Traumatic ulcer, or OSCC. Management: 2-week review.
• Palate: Diffuse erythematous and edematous appearance of the anterior hard palate. Differential Diagnosis: Denture stomatitis (most likely due to poor retention and adhesive use), Traumatic lesion, or Allergic reaction. Management: Leave denture out at night, clean meticulously, and 2-week review.
• Gingiva: Edematous, erythematous, and painful to probing. Positive Bleeding on Probing (BoP+), blunting of interdental papilla, and recession.
• Saliva: Inadequate volume; dry appearance of gingiva, tongue, cheeks, and teeth.
• Alveolar Ridge: Large, bulbous anterior maxillary ridge; comparatively small posterior ridges.
• Other: White dorsal surface of the tongue. Sulci, frena, oropharynx, buccal mucosa, and floor of mouth appear healthy and intact.

Occlusion and Alignment

• Partially dentate Maxilla (Mx) and Mandible (Md).
• Dental midlines are coincident, but the Mx dental midline is left of the facial midline.

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Diagnostic Findings and Risk Assessment⁸

Tooth Charting and Vitality Testing⁹

Maxillary Findings:

• Vitality (CO2): Negative for 13, 21, 24. Positive for 22, 23.
• Mobility: Grade II (21, 22), Grade I (24).
• Radiographic Findings: Periapical radiolucencies (P/ap R) noted at 13 and 21.

Mandibular Findings:

• Vitality (CO2): Positive for 48, 47, 45, 44, 43, 31, 32, 36. Negative for 46, 42, 41.
• Mobility: Grade II (45, 44, 43, 42), Grade I (48, 47).
• Radiographic Findings: Periapical radiolucencies (P/ap R) noted at 41 and 31.
• Tenderness to Percussion (TTP): Positive at 36.

Charting Legend

• Caries: Dark Brown
• Root Stump: Black
• Unsatisfactory Restoration (Caries): Maroon
• Unsatisfactory Restoration (Other): Red
• Non-Carious Tooth Surface Loss (NCTSL): Pink
• Sound Restorations: Yellow (Comp/GIC), Gray (Amalgam)

Community Periodontal Index of Treatment Needs (CPITN)

1. Gingival bleeding after gentle probing
2. Supragingival or subgingival calculus
3. Pathologic pockets 4-5mm
4. Pathologic pockets ≥6mm

• Furcation involvement or recession ≥4mm

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Radiographic Interpretation¹⁰

• Comparison (2016 vs 2018): Significant increase in caries experience.
• Caries: Frank cavitation now affects almost every tooth.
• Endodontic Status: Periapical lesions involving teeth 13, 21, 24, 33, and 32.
• Periodontal Status: Moderate to severe bone loss. Bone levels have remained relatively constant between recent imaging intervals.

Diet and Plaque Assessment¹¹

• Dietary Habits: High frequency of sugar and acid. Includes 3-5 cups of coffee with sugar, sweet lollies, cake/pastries at work, and Pepsi Max sipped throughout the afternoon. No tap water consumption.
• Plaque Score: 59% (40/68 sites).

Saliva Assessment

Resting Saliva:

• Hydration: >60s (Poor)
• Viscosity: Sticky/stringy
• pH: 6.0-6.6

Stimulated Saliva:

• Quantity: 3.5-5.0mL (Low-Normal)
• pH: 6.0-6.6
• Buffering: 10-12pt (High)

Risk Summary¹²

• Caries Risk: HIGH

  • Multiple untreated frank cavities.
  • Deep carious lesions extending into pulp chambers.
  • Multiple periapical radiolucencies.

• Periodontal Risk: HIGH

  • Bleeding on Probing (BOP): 80% (82 of 102 sites).
  • Probing Depths: 21 sites with PPD ≥5mm.
  • Bone Loss: Estimated at 70% (BL/Age ratio = 1.37).
  • Missing Teeth: 11.
  • Environmental Factors: Occasional smoker.
  • Recall Interval: 3 months suggested.

Problem List and Prognosis

Individual and Overall Prognosis¹³

• Prognosis Determination: Based on Samet & Jotkowitz (2009), integrating periodontal, restorative, endodontic, and occlusal factors.
• Modifying Factors: Prognosis is adjusted downward due to poor oral hygiene, cariogenic diet, smoking, and high aesthetic expectations.
• Overall Dentition Prognosis: POOR to HOPELESS.

Problem List¹⁴

Aesthetics and Prosthetics:

• Poor smile aesthetics and unsatisfactory CrCo P/-.
• Multiple root stumps and carious discoloration.
• Fractured abutment tooth (24) causing loss of denture retention.

Host and Behavioral Factors:

• Systemic: Bipolar disorder and hypothyroidism (medicated).
• Oral Environment: Dry mouth (xerostomia).
• Habits: Smoker; frequent high intake of sugar/acidic food and drinks.
• Compliance: Questionable oral hygiene and attendance record.

Pathology:

• Carious root stumps: 24, 33, 43.
• Frank cavitation: 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45.
• Periodontal: Stage 4 Grade C Periodontitis (modified by smoking).
• Endodontic: Infected root canal systems and chronic apical periodontitis (24, 32, 33).
• Soft Tissue: Recurrent aphthous ulcers and denture stomatitis.

Morphology:

• Skeletal/Dental: Class II Division 1.
• Impactions: Vertically impacted 38, 48.
• Anatomy: Hypercementosis (multiple teeth); large bulbous maxillary anterior ridge.
• Arch Status: Maxillary Kennedy Class I; Mandibular Kennedy Class II Modification 1; loss of posterior support.

Diagnoses¹⁵

• Poor smile aesthetics and unsatisfactory CrCo P/-.
• Unrestorable teeth / Root stumps.
• Dental Caries.
• Periodontal Disease.
• Endodontic Involvement.
• Maxillary Kennedy Class I.
• Mandibular Kennedy Class II Modification 1.

Treatment Options and Management Plan¹⁶¹⁷

Rejected Treatment Options¹⁸

Option 4: Limited Restoration and Denture Modification

• Description: Stabilize remaining teeth and add tooth 24 to existing CrCo P/-.
• Advantages: Fastest address of complaint.
• Disadvantages: Short-term outcome; highly compromised result.

Option 5: Full Clearance and Complete Dentures (F/F)

• Description: Immediate or conventional full dentures.
• Advantages: Significant aesthetic improvement; eliminates all dental disease.
• Disadvantages: Difficult transition to edentulous state; poor retention of mandibular denture.

Option 6: No Treatment

• Advantages: No patient action required.
• Disadvantages: Unpredictable progression of pain and infection; worsening aesthetics; eventual tooth loss.

Selected Treatment Plan¹⁹

Option 1: Immediate Acrylic Maxillary Full / Mandibular Partial Denture (F/P)

Rationale for Selection:

• Significant aesthetic improvement potential.
• Relatively low cost.
• Reduction of disease burden via extraction of hopeless teeth.
• Simplified treatment course.
• Patient refusal to be without teeth during healing.

Clinical Coding Legend

• Prognosis: Good (P), Questionable (Q), Hopeless (H), Fair (F), Extraction (E).
• Treatment: Adjustment (A), Restore/Replace (R), Leave Unrestored (L), Monitor (M).
• CPITN: 1 (Bleeding), 2 (Calculus), 3 (4-5mm pockets), 4 (≥6mm pockets).

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Clinical Procedures and Reviews

Prosthetic Fabrication Procedures²⁰

• Registration: Base and rims fabricated for facebow and bite registration, maintaining existing Occlusal Vertical Dimension (OVD).
• Shade: Vita Classical shade B3.
• Lab Instructions:
  • Maxillary and Mandibular casts marked with PPDs to guide decoronation.
  • Reduce maxillary incisal display by 1-2mm.
  • Set maxillary teeth following palatal surfaces of natural teeth to reduce overjet and Class II appearance.
  • Set mandibular teeth following the line of occlusion.
• Try-in: Wax try-in was not possible due to remaining teeth; patient viewed the wax-up on articulated casts.

Pre-Operative Counseling²¹

• Surgical Risks: Patient informed of risks including bleeding, bruising, swelling, and infection.
• Immediate Denture Expectations:
  • Significant adjustment period for speech and mastication.
  • Post-extraction soreness and pain expected during initial healing.
  • Looseness expected within 4-6 weeks due to bone resorption.
  • Requirement for temporary chairside relines every 3-4 weeks.
  • Definitive reline planned for 6-12 months post-extraction.
  • Possibility of unsatisfactory fit/aesthetics requiring a complete remake.

Definitive Phase²²

• Execution of extractions.
• Insertion of the immediate acrylic F/P denture.
• Provision of post-operative instructions for both the extractions and the new prosthesis.

24-Hour Review²³

• Patient Status: Sore and swollen but extremely pleased with the aesthetic result.
• Clinical Actions:
  • Occlusion checked and refined for balanced contacts.
  • Reinforced post-operative instructions and home care routine.
  • Advised that a future remake may be necessary if significant changes occur.

Follow-up Reviews²⁴

1-Week Review:

• Patient reported high satisfaction and positive feedback from others.
• Soreness and swelling mostly resolved.
• Minor adjustments made to relieve sore spots.
• Reiteration of expected looseness due to bone resorption.

First 3-4 Week Review:

• Patient reported slight looseness of the F/P.
• Minor adjustments to sharp edges.
• Action: Viscogel soft liner added to the intaglio surface to improve retention and stability.

Periodontal and Maintenance Reviews²⁵

Periodontal Review:

• Significant improvement in oral hygiene (Plaque 9%, BoP 10%).
• Mean Probing Depth: 0.5mm; Mean Attachment Level: -0.8mm.
• Subgingival Debridement (SRD) performed on remaining teeth.

Subsequent Denture Reviews:

• Second 3-4 Week Review: Further looseness addressed with a second Viscogel soft liner application.
• Third 3-4 Week Review: Patient reported minimal looseness and high satisfaction with comfort and appearance.
• Final Chairside Reline: Performed with Viscogel.
• Long-term Plan: Definitive reline scheduled for November, as soft tissue stability has been achieved.

Initial Clinical Assessment²⁶

The patient presented with a chief complaint regarding the poor aesthetics and lack of stability of her existing maxillary partial denture. Clinical examination revealed:

• Multiple missing maxillary teeth.
• Advanced periodontal bone loss on remaining abutments.
• Generalized mobility of the remaining maxillary dentition.
• Compromised occlusal vertical dimension.

Treatment Planning and Sequence

Following a comprehensive evaluation, a treatment plan was developed to restore function and aesthetics using a removable prosthetic approach. The sequence included:

1. Phase I: Stabilization

   • Periodontal therapy and extraction of non-retainable teeth.
   • Fabrication of a transitional maxillary complete denture to evaluate aesthetics and vertical dimension.

2. Phase II: Definitive Restoration

   • Final impressions using a border-molded custom tray technique.
   • Maxillomandibular relationship records at the established vertical dimension.
   • Trial evaluation of the wax tooth arrangement to confirm phonetics and lip support.

Final Delivery and Follow-up

The definitive maxillary removable prosthesis was processed and delivered. Post-insertion reviews focused on:

• Occlusal Harmony: Verification of bilateral simultaneous contacts in centric relation.
• Tissue Adaptation: Assessment of the intaglio surface for pressure points.
• Patient Satisfaction: The patient reported significant improvement in confidence, speech, and masticatory efficiency.

Case 2: Functional Removable Restorative Case

Presenting Complaint²⁷

• “My upper denture is loose. It comes out when I chew.”
• “I’ve never really liked the look of the big tooth in the middle of my bottom denture.”

History of Presenting Complaint

• Patient has noticed over the past 2–3 months that his upper denture dislodges when he eats hard foods.
• Otherwise, the upper denture stays in place (e.g., when speaking, laughing, or sneezing).

Medical History

Conditions	Description
History of gastric cancer (2014)	- Pt underwent surgery to remove a significant portion of the stomach & chemotherapy. - Currently presents to oncologist 6-monthly for CT scans to monitor condition. - Recent visits (Mar 2019) to GP / oncologist for blood tests & evaluation of scans revealed no abnormalities & were consistent with health.
Asthma*	- Chronic inflammatory disorder of the airways associated with airway hypersensitivity that leads to recurrent episodes of wheezing, breathlessness, chest tightness & coughing.
Gastro-oesophageal reflux disease (GORD)	- Chronic digestive disease with symptoms of esophageal burning and heartburn.

Clinical Presentation and History²⁸

*Conditions managed by medication.

Medications

Medications	Dosage	Use / Mechanism of Action	Dental Implication
Pantoprazole	40mg tablet orally 1x/day	- For GORD - Proton pump inhibitor - irreversibly inactivates the hydrogen/potassium ATPase enzyme system (proton pump), suppressing both stimulated & basal acid secretion (AMH, 2019).	- Chronic regurgitation of gastric contents (pH as low as 1) can cause dental erosion.

Medications	Dosage	Use / Mechanism of Action	Dental Implication
Paracetamol	500mg tablet orally 1x/day, as required	- For stomach pain - Mode of action not fully determined - may include inhibition of central prostaglandin synthesis & modulation of inhibitory descending serotonergic pathways (AMH, 2019).	- May affect perception of dental pain if taken recently.
Indometacin	25mg capsule orally 1x/day, as required	- For neck pain - Non-selective NSAID - inhibits synthesis of prostaglandins by inhibiting COX-1 and COX-2 (AMH, 2019).	- May affect perception of dental pain if taken recently.
Salmeterol + Fluticasone (Seretide)	1 puff 2x/day	- For asthma - Salmeterol is a β2 agonist - relax bronchial smooth muscle by stimulating β2 adrenoreceptors (AMH, 2019). - Fluticasone is a corticosteroid - reduces airway inflammation & bronchial hyper-reactivity (AMH, 2019).	- Advise pt to rinse mouth out with water following use to reduce risk of oropharyngeal candidiasis & systemic corticosteroid absorption. - Consider potential for adrenal suppression (generally require higher corticosteroid dose).
Salbutamol	1-2 puffs/wk, as required	- For asthma - β2 agonist - relax bronchial smooth muscle by stimulating β2 adrenoreceptors (AMH, 2019).	- Advise pt to bring puffer to dental appointment for use in case dental treatment triggers an asthma attack.
Supplements	1 tablet 1x/day	- Magnesium, calcium, vit D, folic acid (5mg) for general health.	-

Hospitalization and Surgery²⁹

• 2014 gastric surgery for stomach cancer.

Allergies

• No known allergies.

Dental History

• Acrylic F/ made 6 years ago as immediate denture.
• Acrylic /P made 4 years ago.
• Previous private practice patient who regularly attended 12-monthly dental recalls.

Oral Hygiene

• Toothbrushing 2x/day with manual toothbrush and 1000ppm fluoride toothpaste.
• Interdental brushes (Piksters) 1x/day.
• Acrylic F/P removed at night, brushed with toothpaste & soaked overnight in Sterident solution.

Clinical Examination and Charting³⁰

Intra-oral Examination³¹

Feature	Findings
Labial Mucosa	Smooth, pink, intact mucosa
Sulci	Smooth, pink, intact mucosa
Frena	Smooth, pink, intact mucosa
Gingiva	Coral pink, stippled appearance
Palate	U-shaped arch
Oropharynx	Smooth, pink, intact mucosa
Alveolar Ridge	U-shaped alveolar ridges
Buccal Mucosa	Smooth, pink, intact mucosa
Tongue	Dorsal surface: white plaque; Ventral surface: pink, intact mucosa
Floor of Mouth	No tenderness to palpation or evidence of swelling
Saliva	Appears adequate
Dentition	Edentulous Maxilla (Mx); Partially dentate Mandible (Md)

Tooth Charting³²

Diagnosis and Risk Assessment³³

Radiographic Findings³⁴

• OPG taken 18th Sept [redacted]
• 2x PAs taken 22nd Oct [redacted]
• Findings: No evidence of caries, adequate bone support, incisal wear.

Prognosis (Samet & Jotkowitz, 2009)³⁵

Individual Tooth Prognosis Legend:

Restorations / Findings	Prognoses	CPITN (Periodontal Index)
Comp / GIC - sat (Green)	G Good	1 Gingival bleeding after gentle probing
Amalgam - sat (Yellow)	F Fair	2 Supragingival or subgingival calculus
Caries (Orange)	Q Questionable	3 Pathologic pockets 4-5mm
Root stump (Red)	P Poor	4 Pathologic pockets ≥6mm
Unsat restn due to caries (Black)	H Hopeless	* Furcation involvement or recession ≥4mm
Unsat restn for other reasons (Green)
P/ap R (Blue) Periapical radiolucency
UE (Grey) Unerupted

Notes on Prognosis:

• Prognosis categories are based on a classification proposed by Samet & Jotkowitz (2009), where overall prognosis is the worst of periodontal, restorative, endodontic and occlusal prognoses.
• Anatomic, iatrogenic and patient factors modify the overall prognosis.
• Overall tooth prognosis modified downward by patient factors: poor OH, cariogenic diet, smoking, aesthetics as motivation for treatment, and high aesthetic expectations.

Overall Dentition Prognosis: FAIR (Yellow)

Treatment Planning and Management

Problem List³⁶³⁷

• Unsatisfactory F/P (Presenting Complaint)
  • Lack of posterior support leading to loss of retention during function.
  • Patient unhappy with appearance of lower middle denture tooth.
• Host Related
  • N/A
• Pathology
  • Mild generalized gingivitis on a reduced periodontium.
• Morphology
  • Class III skeletal relationship.
  • Missing teeth: Maxilla (Mx) edentulous, Mandible (Md) Kennedy Cl I Mod 1.
  • Lack of posterior support.
  • Negative smile arc.

Diagnoses

• Unsatisfactory F/P (presenting complaint)
• Gingivitis
• Mx edentulous
• Md Kennedy Cl I Mod 1
• Lack of posterior support
• Negative smile arc

Treatment Selection³⁸

Patient decided on treatment option 1: remake acrylic F/P due to:

• Patient happy with existing F/P aside from loss of retention in function.
• Able to improve aesthetics & occlusion.
• Relatively low cost of treatment.

Management Plan: Foundational Phase³⁹

• Address the Presenting Complaint

  • Explain to patient that loss of retention of F/ occurs during function due to lack of posterior support provided by F/P.
  • Because it is an occlusal problem, both dentures will need to be replaced to address the issue.
  • A new set of dentures will also address the aesthetic complaints.

• Address Lifestyle Factors / OH Routine (4/10)

  • Diet (Evans et al, 2008): Patient encouraged to continue balanced diet with low sugar intake, and to drink tap water regularly.
  • Oral Hygiene and Dental Visits (Evans et al, 2008):
    • Patient encouraged to continue good OH habits for natural teeth.
    • For denture hygiene, recommended using a separate toothbrush and brushing the dentures with detergent & water.
    • Patient to leave dentures out at night dry in the denture case.
    • Patient encouraged to continue attending recall appointments; emphasized that dentures require maintenance as oral tissues change over time.

• Clinical Procedures

  • Scale and clean, prophylaxis paste applied (4/10).

Management Plan: Definitive Phase

• Acrylic F/P Work-up (9/10 - 22/1)
  • Mx & Md primary alginate impressions → primary casts.
  • Mx & Md special tray fabrication → Mx & Md alginate PVS impressions → secondary / master casts.
  • Base & rims fabrication for facebow & bite registration → mounted master casts.
  • /P denture design to include lingual wire reinforcement if insufficient thickness of acrylic achievable for torsional strength.

Management Plan: Definitive Phase (Continued)⁴⁰

• Shade and Try-in
  • Shade selection: Vita Classical shade A3.5.
  • Anterior tooth try-in to confirm patient is happy with aesthetics.
  • Posterior tooth try-in to confirm satisfactory occlusion.

Initial Phase and Stabilization⁴¹

• Oral Hygiene Instruction (OHI): Comprehensive review of brushing and flossing techniques to improve periodontal health.
• Periodontal Therapy: Full mouth debridement and scaling and root planing (SRP) to address existing periodontal concerns.
• Caries Management:
  • Tooth #14: Composite restoration.
  • Tooth #19: Composite restoration.
  • Tooth #31: Composite restoration.

Endodontic and Restorative Preparation

• Endodontic Treatment: Root canal therapy (RCT) performed on tooth #20.
• Post and Core Build-up: Placement of a post and core on tooth #20 to provide adequate structural support for future restoration.
• Provisionalization: Fabrication of a long-term provisional crown for tooth #20 to assess stability and function prior to final restoration.

Definitive Restorative Phase⁴²

• Fixed Prosthodontics: Fabrication and delivery of a Porcelain-Fused-to-Metal (PFM) crown for tooth #20, designed with a distal rest seat to support the planned removable prosthesis.
• Removable Prosthodontics:
  • Design and fabrication of a Mandibular Cast Partial Denture (CPD).
  • Framework try-in and adjustment.
  • Final delivery of the mandibular CPD to restore missing dentition and improve masticatory function.

Maintenance and Follow-up

• Post-Insertion Care: Evaluation of the fit, occlusion, and patient comfort following the delivery of the PFM crown and partial denture.
• Recall Schedule: Establishment of a 6-month periodic oral examination and prophylaxis schedule to monitor oral health and the integrity of the restorations.

Case 3: Aesthetic Fixed Restorative Case

Presenting Complaint⁴³

• “I’ve had a toothache on and off for the past year in one of my upper right back teeth.”
• “I’ve never liked that two of my teeth on the left hand side are stained.”

History of Presenting Complaint

Clinical Presentation and History⁴⁴

• Spontaneous dull aching sensation on/off in upper right posterior starting February (12 months ago). Pain is exacerbated by hot/cold food and drink. Pain lingers for about an hour.
• In February, an amalgam restoration on tooth 15 was replaced with an indirect composite onlay prepared and cemented in a single visit. Patient reports toothache began after onlay was prepared and did not improve with time.
• In June/July, the patient’s private GDP recommended RCT for tooth 15 but was unavailable for treatment. When the patient re-presented to the private GDP clinic, she was seen by a different GDP who believed “cracks” in the tooth were responsible for symptoms. A “sealant” was placed over the cracks, but symptoms persisted. Patient would like the toothache resolved.
• Patient identified “stained” teeth as 22 and 24. Patient recalls the staining appeared some time ago.

Medical History

• Hypertension: Long term high blood pressure (consistently over 140/90mmHg). (Optimal blood pressure <120/80mmHg; 120/80mmHg to 139/89mmHg are in the normal to high range). Managed by medication.
• Lower back pain: Due to previous back muscle injury. Managed by medication.

Clinical Examination and Radiographs⁴⁵⁴⁶⁴⁷

Extra-oral Examination⁴⁸

• Facial appearance: Healthy, clear complexion
• Facial symmetry: Symmetrical
• Thyroid gland: No noticeable enlargement or tenderness to palpation
• Muscles of mastication: No noticeable enlargement or tenderness to palpation or clenching
• TMJ: Left TMJ click on opening and closing, asymptomatic
• Facial thirds: Balanced facial thirds
• Facial fifths: Balanced and symmetrical facial fifths
• Upper lip: Dry, patchy appearance consistent with solar keratosis
• Lower lip: Dry, patchy appearance consistent with solar keratosis; multiple melanotic macules
• Smile analysis: On smile, 90% incisal display, 0% gingival display. At rest, 0% incisal display
• Profile: Straight

Tooth Charting⁴⁹

Radiographic Findings⁵⁰

OPG (taken 20th March)

• 11, 21: Previous RCT
• Heavily restored dentition
• Missing tooth 36; mesially tilted 37 & 38

3x PAs (taken 13th February)

• 16: Root remnant at sinus floor; no periapical radiolucency or clinical evidence of infection
• 13: External invasive resorption Class III
• 14, 15, 24: No evidence of periapical radiolucencies
• 11: Previous RCT, technically inadequate & periapical radiolucency
• 23: Unsatisfactory distal restoration
• 24: Non-ideal distal contact

Diagnosis and Problem List⁵¹⁵²

Problem List⁵³

Presenting Complaints

• 15: Chronic irreversible pulpitis with primary acute apical periodontitis due to tooth preparation.
• Discolouration: Associated with 22 and 24 restoration breakdown.

Pathology

• Generalised mild gingivitis.
• 11: Previous root canal treatment (technically unsatisfactory), infected root canal system, and chronic apical periodontitis due to restoration breakdown.
• 13: External invasive resorption Class III.
• 28: Occlusal caries.
• 23: Restoration breakdown.
• 35: Buccal Non-Carious Cervical Tooth Surface Loss (NCTSL).

Morphology

• Skeletal Class I.
• Stable MIP, acceptable VD, canine guidance in dynamic occlusion.
• 16: Root remnant at Right sinus floor.
• Missing 36.
• Mesially tilted 17 & 37.

Diagnoses

• Endodontically involved teeth (includes presenting complaint)
• Discoloured teeth (presenting complaint)
• Gingivitis
• Caries
• Restoration breakdown
• NCTSL

Footnotes

1. Original PDF page 1: Sample portfolio 1, p.1 ↩

2. Original PDF page 2: Sample portfolio 1, p.2 ↩

3. Original PDF page 3: Sample portfolio 1, p.3 ↩

4. Original PDF page 4: Sample portfolio 1, p.4 ↩

5. Original PDF page 7: Sample portfolio 1, p.7 ↩

6. Original PDF page 5: Sample portfolio 1, p.5 ↩

7. Original PDF page 6: Sample portfolio 1, p.6 ↩

8. Original PDF page 9: Sample portfolio 1, p.9 ↩

9. Original PDF page 8: Sample portfolio 1, p.8 ↩

10. Original PDF page 10: Sample portfolio 1, p.10 ↩

11. Original PDF page 11: Sample portfolio 1, p.11 ↩

12. Original PDF page 12: Sample portfolio 1, p.12 ↩

13. Original PDF page 13: Sample portfolio 1, p.13 ↩

14. Original PDF page 14: Sample portfolio 1, p.14 ↩

15. Original PDF page 15: Sample portfolio 1, p.15 ↩

16. Original PDF page 18: Sample portfolio 1, p.18 ↩

17. Original PDF page 19: Sample portfolio 1, p.19 ↩

18. Original PDF page 16: Sample portfolio 1, p.16 ↩

19. Original PDF page 17: Sample portfolio 1, p.17 ↩

20. Original PDF page 20: Sample portfolio 1, p.20 ↩

21. Original PDF page 21: Sample portfolio 1, p.21 ↩

22. Original PDF page 22: Sample portfolio 1, p.22 ↩

23. Original PDF page 23: Sample portfolio 1, p.23 ↩

24. Original PDF page 24: Sample portfolio 1, p.24 ↩

25. Original PDF page 25: Sample portfolio 1, p.25 ↩

26. Original PDF page 26: Sample portfolio 1, p.26 ↩

27. Original PDF page 27: Sample portfolio 1, p.27 ↩

28. Original PDF page 29: Sample portfolio 1, p.29 ↩

29. Original PDF page 28: Sample portfolio 1, p.28 ↩

30. Original PDF page 31: Sample portfolio 1, p.31 ↩

31. Original PDF page 30: Sample portfolio 1, p.30 ↩

32. Original PDF page 32: Sample portfolio 1, p.32 ↩

33. Original PDF page 34: Sample portfolio 1, p.34 ↩

34. Original PDF page 33: Sample portfolio 1, p.33 ↩

35. Original PDF page 35: Sample portfolio 1, p.35 ↩

36. Original PDF page 36: Sample portfolio 1, p.36 ↩

37. Original PDF page 37: Sample portfolio 1, p.37 ↩

38. Original PDF page 38: Sample portfolio 1, p.38 ↩

39. Original PDF page 39: Sample portfolio 1, p.39 ↩

40. Original PDF page 40: Sample portfolio 1, p.40 ↩

41. Original PDF page 41: Sample portfolio 1, p.41 ↩

42. Original PDF page 42: Sample portfolio 1, p.42 ↩

43. Original PDF page 43: Sample portfolio 1, p.43 ↩

44. Original PDF page 44: Sample portfolio 1, p.44 ↩

45. Original PDF page 46: Sample portfolio 1, p.46 ↩

46. Original PDF page 49: Sample portfolio 1, p.49 ↩

47. Original PDF page 50: Sample portfolio 1, p.50 ↩

48. Original PDF page 45: Sample portfolio 1, p.45 ↩

49. Original PDF page 47: Sample portfolio 1, p.47 ↩

50. Original PDF page 48: Sample portfolio 1, p.48 ↩

51. Original PDF page 52: Sample portfolio 1, p.52 ↩

52. Original PDF page 53: Sample portfolio 1, p.53 ↩

53. Original PDF page 51: Sample portfolio 1, p.51 ↩