Case Presentation Final Year Student Doctor of Dental Medicine (DMD) University of Western Australia Final Year Student Doctor of Dental Medicine (DMD) University of Western Australia <input> Face profile analysis showing 51 year old female patient. </input>  Face profile analysis showing 51 year old female patient. Clinical facial photograph series of a 51-year-old female patient. The image displays five distinct views: front-on smiling, front-on neutral expression, three-quarter view smiling, right profile view, and left profile view. Each photo has the eyes redacted for privacy. These images are used to demonstrate facial profile analysis. 1.1 Presenting complaint - “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” 1.2 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 #### Presenting Complaint - “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. **1.3 Medical history** * 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 * Smoker – 4 pack years * 4 cigarettes/day for the past 20yrs * Recently 2 cigarettes/day * Trying to quit #### Systemic Conditions and Medications - **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 # **1.4 Dental history** - Repeated temporary restorations - Loss / fracture of multiple teeth due to caries and periodontal disease - CrCo P/- made **4 years ago** in OHCWA ### # **1.5 Oral hygiene** - Brushing **2x/day** - Electric toothbrush - Charcoal toothpaste (**no fluoride**) ### # **1.6 Social history** - Works at a bakery - Lives at home alone - Close to mother, daughter and grandchildren - Smokes **2 cigarettes/day** – trying to quit - Drinks wine **1-2 glasses/month** #### Dental History - 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. 1.7 **Extra-oral examination** * Convex facial profile (CI II tendency) * Elongated lower third of face * Smile aesthetics * Wide buccal corridors * 95% incisal display * 0% gingival display  #### Facial and Smile Analysis - Convex facial profile (Class II tendency). - Elongated lower third of face. - **Smile Aesthetics**: - Wide buccal corridors. - 95% incisal display. - 0% gingival display. Clinical composite photo demonstrating extra-oral examination findings. The image displays four views of a female patient: front view with facial thirds markings (indicating elongated lower third), smiling front view showing wide buccal corridors and 95% incisal display, profile view showing smile aesthetics, and side profile illustrating convex facial profile. **1.8, **1.9** Intra-oral examination** - **Mx hard palate** - Diffuse erythematous & edematous appearance - **Gingiva** - Edematous, erythematous, blunting of interdental papilla, very painful to probing, BoP+ - Dry appearance of oral mucosa - **Occlusion** - Loss of posterior contacts       #### Soft Tissue and Mucosa - **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. Clinical photos of intra-oral examination. Top-left image shows the maxillary anterior teeth with significant gingival inflammation and staining. Top-right image shows the mandibular anterior teeth with similar signs of periodontal disease. Clinical photo of the maxillary hard palate showing diffuse erythematous and edematous appearance, consistent with the text description. Clinical photo of the lower right posterior region showing gingival inflammation and potential tooth loss or extraction site. Clinical photo of the lower left posterior region showing severe gingival recession, calculus deposits, and exposed root surfaces. Clinical photo of the occlusion showing a lack of posterior contacts between upper and lower teeth. Clinical photo of the mandibular arch showing multiple missing teeth, remaining roots, and generalized periodontal involvement. **1.10 Dental prosthesis – CrCo P/-** * Age – 4yrs * Appearance – POOR * Retention – POOR * Stability – POOR * Pt satisfaction – POOR   #### Chrome Cobalt Partial Upper Denture (CrCo P/-) - **Age**: 4 years. - **Appearance**: Poor. - **Retention**: Poor. - **Stability**: Poor. - **Patient Satisfaction**: Poor. Clinical intraoral photograph showing a child's anterior dentition with significant plaque accumulation and poor gingival health. The image demonstrates the 'Appearance – POOR' condition mentioned in the text. Clinical intraoral photograph displaying an upper removable partial denture (CrCo P/-) in place. The metal framework is clearly visible against the patient's gums, illustrating the 'Dental prosthesis' component of the case study. # 1.11 Tooth charting ### Slides: ### Community Periodontal Index of Treatment Needs (CPITN): #### Code: | Codes | Definition | | :--- | :--- | | 0 | Healthy | | 1 | Gingivitis | | 2 | Calculus or Overhanging Restorations | | 3 | Pocketing of Depth 3-5mm | | 4 | Pocketing of Depth $\ge$ 6mm | | * | Furcation Involvement | > This citation is to a guide for Dental Health Indices. > **CPITN - Community Periodontal Index of Treatment Needs** #### Guide: | I (1st) | II (2nd) | III (3rd) | IV (4th) | | :--- | :--- | :--- | :--- | | 1 | Gingival Bleeding | Bleeding after Gentle Probing | | | 2 | Calculus | Calculus or Overhanging Restoration | | | 3 | Pocket 3-5mm | | | | 4 | Pocket 6mm | | | | * | Furcation Involvement | | | *Note: The better the periodontal condition the lower the score.*   #### Community Periodontal Index of Treatment Needs (CPITN) Definitions | 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.* Clinical photos showing multiple intraoral views of teeth with visible calculus, gingival inflammation, and restorations, used to demonstrate the conditions being charted. A comprehensive tooth charting grid displaying a full dental arch (teeth 18-38) with color-coded squares representing ICDAS5 caries findings and CPITN periodontal codes. Includes rows for CO2, Mobility (Mob), TTP, and Periapical Radiolucency (P/ap R). A legend on the left explains color codes for restorations and findings, while a key on the right defines CPITN scores from 0 to * based on pocket depth and bleeding. 1.12 Periodontal charting | | 18 | 17 | 16 | 15 | 14 | 13 | 12 | 11 | | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | |---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---| | Mobility | | | | | | 0 | 0 | | | 0 | 0 | 0 | 0 | | | | | | Implant | | | | | | | | | | | | | | | | | | | Furcation | | | | | | | | | | | | | | | | | | | Bleeding on Probing | | | | | | ❖❖ | | ❖❖ | | ❖❖ | ❖❖ | ❖❖ | ❖ | ❖ | | | | Plaque | | | | | | ❖ ❖ | | ❖ | | ❖ ❖ | ❖❖ | ❖ | ❖ | ❖ | ❖ | | | 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 | | | | | | Note | UE | UE | |---|---|---| | Furcation | | | | Bleeding on Probing | ❖ ❖ | ❖ ❖ | | Plaque | ❖ | ❖ | | Gingival Margin | -2 -1 -2 -1 -1 0 0 0 0 -1 -2 -1 -2 -2 -2 -3 -2 -3 -2 -3 -2 -1 -3 -2 -3 -3 -3 -2 -2 -2 | 0 0 0 | | Probing Depth | 2 3 3 4 2 2 3 2 4 4 2 2 4 2 2 3 3 3 5 2 5 3 1 1 3 4 3 4 2 2 3 2 3 | 0 0 0 | Mean Probing Depth = **2.9** mm Mean Attachment Level = **-4.1** mm **54%** Plaque **72%** Bleeding on Probing    #### Periodontal Findings - **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 | | Periodontal charting diagram for the left side of the mouth. The visual combines a grid data table with anatomical illustrations of teeth arranged in Buccal and Lingual rows. Blue shaded areas on the tooth diagrams visually represent 'Plaque' accumulation, while red squares in the corresponding data grid indicate 'Bleeding on Probing'. Below the diagrams, a smaller data table lists Gingival Margin, Probing Depth, Plaque, Bleeding on Probing, Furcation, and Note values. Periodontal charting diagram for the right side of the mouth (UE). Similar to the left chart, it features a large data table at the top and bottom, and central anatomical illustrations of teeth labeled 'Lingual' and 'Buccal'. The diagrams use blue shading to depict plaque and red squares to denote bleeding sites. The accompanying tables provide specific numerical data for Gingival Margin, Probing Depth, Plaque, Bleeding on Probing, Furcation, Implant, and Mobility. A summary statistics bar located at the bottom of the image. It displays four key metrics: Mean Probing Depth = 2.9 mm, Mean Attachment Level = -4.1 mm, 54% Plaque, and 72% Bleeding on Probing.         Overbite radiograph (OPG) showing the full dentition of the upper and lower jaws. Several teeth are visible with dental restorations (fillings or crowns), particularly in the posterior regions. Another overbite radiograph (OPG) showing similar dental anatomy to the one above but possibly from a different date or angle. Again, multiple teeth with restorations are evident. Periapical radiograph (PA) focusing on specific teeth in the upper jaw, showing detailed root structure and surrounding bone. Some teeth have fillings or crowns. Periapical radiograph (PA) showing anterior teeth in the upper jaw with clear visibility of roots and periodontal ligament spaces. Restorations are present on some teeth. Periapical radiograph (PA) capturing lateral aspect of upper teeth, revealing root morphology and possible periapical changes. A restoration is visible on one tooth. Periapical radiograph (PA) showing posterior teeth in the upper jaw with significant restorative work. Root canal treatment may be indicated by filled canals. Periapical radiograph (PA) displaying multiple upper teeth with varying degrees of restorations and potential endodontic treatments. Bone levels appear relatively intact. Periapical radiograph (PA) focusing on posterior teeth in the upper jaw, showing large restorations and possible root canal therapy. Surrounding bone appears healthy. 1.14 Caries risk assessment (Evans et al, 2008) - Diet assessment - High & frequent exposure to sugar & acid - Plaque score - High – 54% - Saliva assessment - Resting & stimulated adequate quantity & buffering - Resting compromised viscosity & pH - Stimulated compromised pH - Clinical/radiographic examination - Frank cavitation affecting multiple teeth <p style="color:red; font-weight:bold;">HIGH RISK</p> #### Caries Risk Assessment (Evans et al, 2008) - **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** 1.15 Periodontal risk assessment (Lang & Tonetti, 2003) **BOP%** = **80%** PD≥5mm Age |[51](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) Number of teeth and implants | [17](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) | (1 - 32) Number of sites per tooth / implant | [2](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [4](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [6](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) Number of BOP-pos. sites | [82](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) | of [102](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) Number of sites with **PPD**≥5mm | [21](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) Number of missing teeth | [11](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) % **Alveolar** bone loss (estimated in % or 10% per 1mm) | [70](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) | % Syst./Gen. | [Yes](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [No](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) **Environ.** | [Non smoker (NS)](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [Former smoker (FS)](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [Occasional smoker (OS)](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [Smoker (S)](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) [Heavy smoker (HS)](file:///Users/mushros/Library/CloudStorage/OneDrive-uploads/PTO_3459032/1.15%20Periodontal%20risk%20assessment%20(Lang%20%26%20Tonetti,%202003).png) **WARNING** **HIGH RISK** **Polygon** surface: **130.769** Periodontal Risk: **high** Suggested **Recall** interval: 3 Months  #### Periodontal Risk Assessment (Lang & Tonetti, 2003) - **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 Periodontal risk assessment radar chart and data form. The visual displays a hexagonal radar chart (left) plotting six variables: BOP% (80%), PD≥5mm, Tooth loss, BL/Age (1.37254), Syst./Gen., and Envir. A shaded polygon connects the values, with a calculated surface area of 130.769. To the right is a structured input form listing specific patient metrics including Age (51), Number of teeth/implants (17), Sites per tooth (selected as 6), Number of BOP-pos sites (82 of 102), PPD≥5mm sites (21), Missing teeth (11), Alveolar bone loss (70%), Systemic factors (No selected), and Environmental factors (Occasional smoker selected). Below the chart, the result is summarized as 'Periodontal Risk: high' with a 'Suggested Recall interval: 3 Months'. A large red text overlay on the right side explicitly states 'HIGH RISK'. # 1.16 Prognosis (Samet & Jotkowski, 2009) Overall dentition - **POOR TO HOPELESS** <table> <tr> <td colspan="15"></td> <td rowspan="2">Prognoses*</td> <td rowspan="2">Perio</td> <td rowspan="5">18</td> <td rowspan="5">17</td> <td rowspan="5">16</td> <td rowspan="5">15</td> <td rowspan="5">14</td> <td rowspan="2" colspan="2">13</td> <td rowspan="2" colspan="2">12</td> <td rowspan="2" colspan="2">11</td> <td rowspan="2" colspan="2">21</td> <td rowspan="2" colspan="2">22</td> <td rowspan="2" colspan="2">23</td> <td rowspan="2" colspan="2">24</td> <td rowspan="5" colspan="2">25</td> <td rowspan="5" colspan="2">26</td> <td rowspan="5" colspan="2">27</td> <td rowspan="5" colspan="2">28</td> </tr> <tr> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> </tr> <tr> <td>H</td> <td></td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>P</td> <td></td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>H</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>F</td> <td></td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>G</td> <td></td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>Overall**</td> <td>H</td> <td></td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="5"></td> <td rowspan="2">ICDASS</td> <td rowspan="2">ICDASS</td> <td rowspan="2">ICDASS</td> <td rowspan="2">ICDASS</td> <td rowspan="2">ICDASS</td> <td rowspan="2">ICDASS</td> <td rowspan="2" colspan="2">31</td> <td rowspan="2" colspan="2">32</td> <td rowspan="2" colspan="2">33</td> <td rowspan="2" colspan="2">34</td> <td rowspan="2" colspan="2">35</td> <td rowspan="2" colspan="2">36</td> <td rowspan="2" colspan="2">37</td> <td rowspan="2" colspan="2">38</td> <td rowspan="5">UE</td> <td rowspan="5"></td> </tr> <tr> <td>48</td> <td>47</td> <td>46</td> <td>45</td> <td>44</td> <td>43</td> <td>42</td> <td>41</td> </tr> <tr> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> <td rowspan="4"></td> </tr> <tr> <td>F</td> <td>F</td> <td>Q</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>Q</td> <td>F</td> <td>F</td> <td>F</td> </tr> <tr> <td>Q</td> <td>Q</td> <td>H</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>H</td> <td>Q</td> <td>Q</td> <td></td> </tr> <tr> <td>G</td> <td>G</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>G</td> <td>G</td> <td>G</td> </tr> <tr> <td>Overall**</td> <td>P</td> <td>P</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>H</td> <td>P</td> <td>P</td> <td>Q</td> </tr> <tr> <td colspan="15"></td> <td rowspan="13">LEGENDD</td> <td rowspan="11">Restorations /findings</td> <td rowspan="11" colspan="2">Prognoses</td> <td colspan="6" rowspan="11">CPITN - Community Periodontal Index of Treatment Needs</td> </tr> <tr> <td>Yellow</td> <td>Comp / GIC - sat</td> </tr> <tr> <td>Grey</td> <td>Amalgam - sat</td> </tr> <tr> <td>Brown</td> <td>Caries</td> </tr> <tr> <td>Black</td> <td>Root stump</td> </tr> <tr> <td>Darker Brown</td> <td>Unsat restn due to caries</td> </tr> <tr> <td>Red</td> <td>Unsat restn for other reasons</td> </tr> <tr> <td>Periapical Radiolucency</td> <td rowspan="5">Colaboring</td> <td>P</td> <td>Good</td> <td colspan="2">-</td> <td colspan="2">4*</td> <td colspan="2">4</td> <td>1</td> <td>Gingival bleeding after gentle probing</td> </tr> <tr> <td rowspan="5">Q</td> <td colspan="2" rowspan="4"></td> <td>3</td> <td colspan="2">4*</td> <td colspan="2">3*</td> <td>2</td> <td>Supragingival or subgingival calculus</td> </tr> <tr> <td>4</td> <td>Pathologic pockets 4-5mm</td> </tr> <tr> <td>*</td> <td>Furcation involvement or recession 4mm</td> </tr> <tr> <td>Periapical Radiolucency</td> <td></td> <td></td> </tr> </table> *Prognosis categories are based on a classification proposed by Samet & Jotkowski (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.  #### Prognosis Summary (Samet & Jotkowski, 2009) - **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.* A detailed dental prognosis chart for a patient's dentition (teeth 18-28), organized by tooth number. The table includes columns for 'Prognoses*', 'Perio', and specific ICDAS5 scores (e.g., 43, 44, 45). Rows indicate findings such as 'Comp / GIC - sat' (yellow), 'Amalgam - sat' (gray), 'Caries' (brown), 'Root stump' (black), and 'Unsat restn due to caries' (dark brown). Prognosis categories are color-coded: Green (Good), Yellow (Fair), Orange (Questionable), Red (Poor), Black (Hopeless). Additional rows show 'Overall**' prognosis per tooth. A legend at the bottom explains restoration types, prognosis codes, and CPITN indices. # 1.17 Problem list | **Left Column** | **Right Column** | | :--- | :--- | | **Poor smile aesthetics and unsatistactory CrCo P/- (presenting complaint)** | • Pathology | | • Multiple root stumps, discolouration due to caries | • Carious root stumps 24, 33, 43 | | • Unsatisfactory CrCo P/- design and loss of retention due to fracture of abutment tooth 24 | • Frank cavitation due to caries 11, 13, 21, 22, 23, 31, 32, 34, 35, 41, 44, 45 | | | • Moderate to severe generalized chronic periodontitis modified by smoking (AAPD, 1999) / Periodontitis Stage 4 Grade C modified by smoking (Papapanou et al, 2017) | | **Host-related** | • Pulpless and infected RCS and chronic apical periodontitis due to caries 24, 32, 33 (Abbott & Yu, 2004; Abbott, 2004) | | • Bipolar disorder & hypothyroidism managed by medication | • Recurrent aphthous ulcerative disease | | • Dry mouth | • Denture stomatitis of the anterior hard palate | | • Smoker | | | • Frequent and high intake of sugary & acidic foods and drinks | • Morphology | | • Questionable OH compliance / dental attendance record | • CI II tendency | | | • Vertically impacted 38, 48 | | | • Hypercementosis 13, 23, 24, 34, 35, 44, 45 | | | • Missing teeth - Mx Kennedy CI I, Md Kennedy CI II Mod 1 | | | • Large, bulbous Mx anterior alveolar ridge | | | • Loss of posterior support | #### Pathology and Morphology Problems **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. # 1.18 Diagnoses - Poor smile aesthetics and unsatisfactory CrCo P/- (presenting complaint) - Root stumps / “unrestorable” teeth - Caries - Periodontal disease - Endodontically involved teeth - Mx Kennedy CI I - Md Kennedy CI II Mod 1 #### 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. 1.19 **Treatment options**   Composite clinical photo showing multiple intraoral views of a patient's dentition with severe periodontal disease and caries. Includes frontal occlusal view (top left), upper anterior view (top right), upper palatal view (center top), lower anterior view (bottom center), and lateral views (left and right). Shows extensive calculus, gingival inflammation, missing teeth, and decayed molars — critical for demonstrating treatment necessity. Set of six dental radiographs arranged in two rows of three. Top row: periapical films showing root structure, bone levels, and restorations; bottom row: bitewing or periapical views highlighting interproximal caries, periapical pathology, and endodontic treatments. Essential for diagnosing underlying pathology not visible clinically. **1.19 Treatment options** 1. Immediate acrylic F/P 2. Conventional F/P 3. Immediate or conventional F/F 4. Mx and Md implant-supported fixed prostheses 5. Temporization of remaining teeth ± 24 tooth addition to CrCo P/- 6. No treatment #### Identified Options 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. # 1.19 Treatment options * **Pt decided on immediate acrylic F/P** * Pt refused to go without teeth for any period * Good aesthetics * Low cost * Reduce disease burden * Simplified course of treatment <table> <tr> <th colspan="2">Prognoses*</th> <th>Perio</th> <th></th> <th></th> <th></th> <th></th> <th>Q</th> <th></th> <th>Q</th> <th>Q</th> <th>Q</th> <th>Q</th> <th>Q</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <th colspan="2"></th> <th>Resto</th> <th></th> <th></th> <th></th> <th></th> <th>P</th> <th></th> <th>P</th> <th>P</th> <th>P</th> <th>P</th> <th>H</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <th colspan="2"></th> <th>Endo</th> <th></th> <th></th> <th></th> <th></th> <th>F</th> <th></th> <th>F</th> <th>F</th> <th>F</th> <th>F</th> <th>F</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <th colspan="2"></th> <th>Occ</th> <th></th> <th></th> <th></th> <th></th> <th>G</th> <th></th> <th>G</th> <th>G</th> <th>G</th> <th>G</th> <th>G</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <th colspan="2"></th> <th>Overall**</th> <th></th> <th></th> <th></th> <th></th> <th style="background-color: black; color: white;">H</th> <th></th> <th style="background-color: black; color: white;">H</th> <th style="background-color: black; color: white;">H</th> <th style="background-color: black; color: white;">H</th> <th style="background-color: black; color: white;">H</th> <th style="background-color: black; color: white;">H</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <th colspan="2"></th> <th>Tx</th> <th></th> <th></th> <th></th> <th></th> <th>E</th> <th></th> <th>E</th> <th>E</th> <th>E</th> <th>E</th> <th>E</th> <th></th> <th></th> <th></th> <th></th> </tr> <tr> <td></td> <td>18</td> <td>17</td> <td>16</td> <td>15</td> <td>14</td> <td>13</td> <td>12</td> <td>11</td> <td>21</td> <td>22</td> <td>23</td> <td>24</td> <td>25</td> <td>26</td> <td>27</td> <td>28</td> </tr> <tr> <td colspan="17"></td> </tr> <tr> <td></td> <td>48</td> <td>47</td> <td>46</td> <td>45</td> <td>44</td> <td>43</td> <td>42</td> <td>41</td> <td>31</td> <td>32</td> <td>33</td> <td>34</td> <td>35</td> <td>36</td> <td>37</td> <td>38</td> </tr> <tr> <th colspan="2">Prognoses*</th> <th>Perio</th> <td></td> <td></td> <td>F</td> <td>F</td> <td>Q</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>Q</td> <td>F</td> <td>F</td> <td></td> <td>F</td> <td></td> </tr> <tr> <th colspan="2"></th> <th>Resto</th> <td></td> <td></td> <td>Q</td> <td>Q</td> <td>H</td> <td>P</td> <td>P</td> <td>P</td> <td>P</td> <td>H</td> <td>Q</td> <td>Q</td> <td></td> <td>F</td> <td></td> </tr> <tr> <th colspan="2"></th> <th>Endo</th> <td></td> <td></td> <td>G</td> <td>G</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>F</td> <td>G</td> <td>G</td> <td></td> <td>G</td> <td></td> </tr> <tr> <th colspan="2"></th> <th>Occ</th> <td></td> <td></td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td>G</td> <td></td> <td>G</td> <td></td> </tr> <tr> <th colspan="2"></th> <th>Overall**</th> <td></td> <td></td> <td style="background-color: red;">P</td> <td style="background-color: red;">P</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: black; color: white;">H</td> <td style="background-color: red;">P</td> <td style="background-color: red;">P</td> <td></td> <td style="background-color: orange;">Q</td> <td></td> </tr> <tr> <th colspan="2"></th> <th>Tx</th> <td></td> <td></td> <td>I + R</td> <td>I + R</td> <td>E</td> <td>E</td> <td>E</td> <td>E</td> <td>E</td> <td>E</td> <td>I + R</td> <td>I + R</td> <td></td> <td>L</td> <td></td> </tr> </table> ### LEGEND: <table> <tr> <th colspan="2">Restorations / findings</th> <th colspan="2">Prognoses</th> <th colspan="2">Treatment</th> </tr> <tr> <td style="background-color: yellow;"></td> <td>Comp / GIC - sat</td> <td style="background-color: green;">G</td> <td>Good prognosis</td> <td>A</td> <td>Adjustment</td> </tr> <tr> <td style="background-color: silver;"></td> <td>Amalgam - sat</td> <td style="background-color: yellow;">F</td> <td>Fair prognosis</td> <td>E</td> <td>Extraction</td> </tr> <tr> <td style="background-color: red;"></td> <td>Caries</td> <td style="background-color: orange;">Q</td> <td>Questionable prognosis</td> <td>M</td> <td>Monitor</td> </tr> <tr> <td style="background-color: black;"></td> <td>Root stump</td> <td style="background-color: red;">P</td> <td>Poor prognosis</td> <td>R</td> <td>Restore / replace</td> </tr> <tr> <td style="background-color: brown;"></td> <td>Unsat restn due to caries</td> <td style="background-color: black; color: white;">H</td> <td>Hopeless prognosis</td> <td>I</td> <td>Investigate</td> </tr> <tr> <td></td> <td>Unsat restn for other reasons</td> <td></td> <td></td> <td>L</td> <td>Leave unrestored</td> </tr> <tr> <td>P/ap R</td> <td>Periapical radiolucency</td> <td></td> <td></td> <td></td> <td></td> </tr> <tr> <td>UE</td> <td>Unerupted</td> <td></td> <td></td> <td></td> <td></td> </tr> </table> **CPITN - Community Periodontal Index of Treatment Needs** <table> <tr> <td>-</td> <td>4*</td> <td>4</td> <td>1</td> <td>Gingival bleeding after gentle probing</td> </tr> <tr> <td>3</td> <td>4*</td> <td>3*</td> <td>2</td> <td>Supragingival or subgingival calculus</td> </tr> <tr> <td></td> <td></td> <td></td> <td>3</td> <td>Pathologic pockets 4-5mm</td> </tr> <tr> <td></td> <td></td> <td></td> <td>4</td> <td>Pathologic pockets ≥6mm</td> </tr> <tr> <td></td> <td></td> <td></td> <td>*</td> <td>Furcation involvement or recession ≥4mm</td> </tr> </table>  #### Selected Treatment: Immediate Acrylic F/P - **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. A complex dental treatment planning chart titled 'Prognoses'. The table is structured with columns representing tooth positions (e.g., 18-28) and rows for Periodontal (Perio), Restorative (Resto), Endodontic (Endo), Occlusal (Occ), and Overall prognosis. It contains visual icons depicting restorations (fillings, crowns) in various colors corresponding to a legend below. The legend defines symbols for 'Comp / GIC', 'Amalgam', 'Caries', 'Root stump', etc. A second legend decodes the prognostic codes: G (Good), F (Fair), Q (Questionable), P (Poor), H (Hopeless). A third section lists Treatment codes (A, E, M, R, I, L). At the bottom, there is a reference table for 'CPITN - Community Periodontal Index of Treatment Needs'. 1.20 **Management plan – Foundational phase** * Address the presenting complaint ( * Can understand the basis for pt’s presenting complaint * **Aesthetics is the main concern BUT** there are many other issues going on * Huge burden of disease – caries, periodontitis, pulpless and infected teeth * Diseases processes are the underlying cause of aesthetic issues * Must treat the disease to improve aesthetics * Without treatment, diseases will continue to progress and aesthetics will worsen #### Addressing the Presenting Complaint - 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. **1.20 Management plan – Foundational phase** * Discussing lifestyle factors / OH routine ([***Occlusion visual Aid***](brief description)) * **Dry mouth** * Smoking cessation counselling – “The 5As” (eTG, 2012) * Drink enough tap water – 1L/day * Reduce coffee intake * **Diet** * Reduce sugar intake * Reduce snacking * **Oral hygiene and dental visits** (Evans et al, 2008) * Brush 2x/day morning and night * Neutrafluor 5000 Plus toothpaste * Interdental brushes 1x/day at night * Attend all dental appointments #### Lifestyle and Oral Hygiene Interventions - **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. # 1.20 Management plan – Foundational phase ## Text Content * **Selective SRD (2018)** * 37, 35, 34, 44, 45 SRD under LA * Prophylaxis * Topical fluoride * **Restorations (2018)** * 34 M̅OLiBu Equia Forte + composite (Filtek Supreme) sandwich restoration * 35 ̴B̸OLBu composite (Filtek Supreme) restoration * 44 D̅OLiBu Equia Forte restoration * 45 MODl̄̄̈iBu Equia Forte + composite (Filtek Supreme) sandwich restoration         #### Periodontal and Restorative Procedures (2018) - **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. Clinical intraoral photo showing the right posterior mandibular region. Visible teeth include 37 and 35 (and likely 34). The image demonstrates significant carious lesions, discoloration, and structural breakdown of the molars prior to treatment. Clinical intraoral photo showing the occlusal view of the mandibular arch. It displays severe generalized dental decay affecting multiple lower teeth, consistent with the 'Selective SRD' management plan described in the text. Clinical intraoral photo showing the left posterior mandibular region. Teeth 44 and 45 are visible with extensive caries and loss of tooth structure, requiring restoration as noted in the text. Dental radiograph (periapical X-ray) focusing on the right mandibular molar area. It shows a large restoration or root canal filling in one tooth and the remaining roots of an adjacent tooth, illustrating the internal pathology addressed during the restorative phase. Dental radiograph (periapical X-ray) focusing on the left mandibular molar area. It depicts the internal structure of teeth 44 and 45, showing the extent of caries and the placement of restorations. Post-treatment clinical photo of the right posterior mandibular region. Teeth 34, 35, and 37 show restored crowns with visible composite material, indicating successful completion of the 'Restorations' phase. Post-treatment clinical photo of the mandibular arch. The restored teeth appear more uniform compared to the pre-treatment images, demonstrating the outcome of the foundational phase management. Post-treatment clinical photo of the left posterior mandibular region. Teeth 44 and 45 display completed restorations using Equia Forte and Filtek Supreme materials as specified in the text. **1.20 Management plan – Reconstructive phase** * Immediate acrylic F/P work-up (Jorgezai et al, 2018) ( 8/2018 - 2/2019) * Alginate impressions * Study models * Special trays – Campagna impression technique (Campagna, 1968) for Mx * Master models * Base and rims * Facebow & bite registration * Mounted master models         #### Immediate Acrylic F/P Work-up (08/2018 - 02/2019) - 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. Clinical photo of a white alginate impression model of the maxillary (upper) dental arch, showing the cast of teeth and palate used for study models. Clinical photo of a white alginate impression model of the mandibular (lower) dental arch, showing the cast of teeth and floor of the mouth. Clinical photo of mounted master models in occlusion, demonstrating the bite registration and relationship between the upper and lower dental casts. Clinical photo of a blue silicone facebow attachment or rim component, used to transfer the spatial relationship of the maxilla to an articulator. Clinical photo of a blue and white base with rims, likely part of the bite registration setup for mounting the master models on an articulator. Clinical photo of a pink and purple custom tray or impression material, illustrating the 'Special trays – Campagna impression technique' mentioned in the text. Clinical photo of a refined white master model of the maxillary arch, prepared for prosthetic work-up. Clinical photo of a refined white master model of the mandibular arch, showing detailed tooth structure for the reconstructive phase. - Acrylic F/P work-up (Jogezai et al, 2018) (2018 - 2019) - Shade selection - Vita Classical shade B3 - Mx and Md casts marked with PPDs for teeth to be extracted to guide lab decoronation - Duplication of master casts - Wax up - Reduce Mx inc display by 1-2mm - Set Mx teeth following Pal surfaces - Process → acrylic F/P on mounted duplicates - Cross-mount to check fit and occlusion   #### Laboratory and Clinical Steps - 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. Clinical photo showing a patient's mouth with an acrylic temporary restoration in place. The image highlights the shade selection process (Vita Classical shade B3) and the fit of the provisional prosthesis. Close-up clinical photo of a patient's smile demonstrating the final aesthetic result after the reductive phase. This corresponds to the 'Shade selection' step mentioned in the text. 1.20 Management plan – Reconstructive phase  Clinical figure showing multiple views of a dental prosthesis on stone models. The top row includes three views: left lateral, frontal occlusal, and right lateral. The bottom row shows two additional views: an occlusal view of the maxillary arch and an occlusal view of the mandibular arch. The title '1.20 Management plan – Reconstructive phase' is visible at the top. # 1.20 Management plan – Reconstructive phase - Pre-op extraction warnings - Risk of bleeding, bruising, swelling, infection - Risk crown or root breaking - May require surgical procedure - Immediate F/P expectations - Significant adaptation - Soreness immediately following exos - F/P will become loose after 4-6wks due to resorption of bone following exos - Temporary chairside relines every 3-4wks - Definitive reline at 6-12mths OR remake #### Patient Education and Informed Consent - **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. 1.20 **Management plan – Definitive phase** * Extractions (**BLACKED OUT** 2019) * Md – 31, 32, 33, 41, 42, 43 * Mx – 11, 13, 21, 22, 23, 24 * Luxation of all teeth, extraction with forceps of intact teeth * Curettage – 24, 32, 33 (teeth with radiolucencies) * Exo sites checked for sharp bony protuberances * Sockets squeezed buccal-lingually * Haemostasis achieved * Post-op instructions * Insert of acrylic F/P (**BLACKED OUT** 2019) * F/- did not require adjustment * -/P required adjustment for full seating and occlusal adjustment * Excellent fit, retention, stability and aesthetics * Post-op instructions #### Surgical Phase (2019) - **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. <table> <colgroup> <col/> </colgroup> <thead> <tr> <th class="blockheader"> 1.20 <span style="text-decoration:underline;">Management plan – Definitive phase</span> </th> </tr> <tr> <td> • 24hr review (** 2019) - Pt returned sore and swollen - Extremely pleased with aesthetic result - Adjusted sore spots and occlusion - Re-emphasised home care routine for the next week </td> </tr> </thead> <tbody> <tr> <td> <img src="handle_with_biggest_care"> </td> </tr> <tr> <td> <img src="handle_with_biggest_care"> </td> </tr> </tbody> </table>  #### 24-Hour Review (2019) - 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. Clinical photo set showing a female patient from three angles (frontal, left profile, and right profile) during the definitive phase of treatment in 2019. The images demonstrate the aesthetic result after management plan adjustments for sore spots and occlusion; the patient is smiling with visible orthodontic braces. Eyes are redacted for privacy. # 1.20 Management plan – Definitive phase * 1wk review (02/03/2019) * Pt remained extremely pleased with the aesthetic result * Compliments from friends, family, colleagues * Adjusted to relieve sore spots * Reinforced home care routine, and that acrylic F/P will become "loose" over the next few weeks as bone remodels <img>Female patient with acrylic flat plate in three views (frontal, lateral oblique, and oblique) showing aesthetic result  #### 1-Week Review (02/03/2019) - 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. Clinical photo: Three views (frontal, lateral oblique, and oblique) of a female patient with an acrylic flat plate in place, demonstrating the aesthetic result. The images show her smiling, highlighting the improved facial profile and smile line. Eyes are redacted for privacy. **1.20 Management plan – Definitive phase • 1wk review (**2019**) * Pt remained extremely pleased with the aesthetic result * **Compliments from friends, family, colleagues** * Adjusted to relieve sore spots * Reinforced home care routine, and that acrylic F/P will become “loose” over the next few weeks as bone remodels</img>  #### 1-Week Review Continued (2019) - Patient reported compliments from friends, family, and colleagues. - Adjusted sore spots. - Reinforced home care and the expectation of prosthesis loosening during bone remodeling. Clinical photo collage showing five intraoral views of a patient's dentition and gingiva. The images display the maxillary arch from an occlusal view, multiple frontal facial views with teeth in occlusion, and a mandibular occlusal view. These photos serve to demonstrate the aesthetic result mentioned in the text, specifically the alignment of the teeth and the condition of the gums following the placement of an acrylic F/P (Fixed Partial Denture). The visual evidence supports the text's claim that the patient was pleased with the aesthetic outcome. # 1.20 Management plan – Definitive phase * **Perio review ( /2019)** * Significant improvements in oral hygiene * PPDs remain * SRD * Reinforced lifestyle changes and OHI * Pt remains in **HIGH RISK** category  #### Periodontal Review (2019) - 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. Periodontal chart summarizing a definitive phase management plan review from 2019. The table includes summary statistics at the top (Mean Probing Depth = 0.5 mm, Mean Attachment Level = -0.8 mm, 9% Plaque, 10% Bleeding on Probing) and visualizes clinical data for upper right quadrant teeth (UE). It contains rows for Gingival Margin, Probing Depth, Plaque, and Bleeding on Probing, with numerical values and color-coded indicators (red for bleeding, blue for plaque) aligned with tooth diagrams showing Lingual and Buccal surfaces. # 1.20 Management plan – Definitive phase * First 3-4wk review (____ /2019) * F/P starting to feel loose * Chairside reline with Viscogel soft liner * Second 3-4wk review (____ 19 and ____ /19) * Pt adapting well to F/P, some looseness again * Chairside reline with Viscogel soft liner * Third 3-4wk review (____ 19) * Delayed review appt due to pt travelling * Pt reports minimal looseness of F/P, very happy w/ dentures * Final chairside reline with Viscogel liner * Informed pt definitive F/P reline can now take place, need to schedule 3 days for pt to be without dentures #### Maintenance and Relining (2019) - **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. 1.21 Before and after treatment photographs Before (2018) After (2018)   #### Before and After Treatment Photographs - Before (2018) - After (2018) Clinical before-treatment photographs (2018) showing a patient's facial profile and intraoral views. Includes frontal face shot, side profile, and close-ups of teeth with visible discoloration, crowding, and gingival inflammation. Clinical after-treatment photographs (2018) showing the same patient post-intervention. Includes frontal face shot, side profile, and intraoral views displaying aligned teeth, improved gum health, and restored dental aesthetics. **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. 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. [^1]: Original PDF page 1: [[Sample Case Presentation 2021.pdf#page=1|Sample Case Presentation 2021, p.1]] [^2]: Original PDF page 2: [[Sample Case Presentation 2021.pdf#page=2|Sample Case Presentation 2021, p.2]] [^3]: Original PDF page 3: [[Sample Case Presentation 2021.pdf#page=3|Sample Case Presentation 2021, p.3]] [^4]: Original PDF page 4: [[Sample Case Presentation 2021.pdf#page=4|Sample Case Presentation 2021, p.4]] [^5]: Original PDF page 5: [[Sample Case Presentation 2021.pdf#page=5|Sample Case Presentation 2021, p.5]] [^6]: Original PDF page 6: [[Sample Case Presentation 2021.pdf#page=6|Sample Case Presentation 2021, p.6]] [^7]: Original PDF page 7: [[Sample Case Presentation 2021.pdf#page=7|Sample Case Presentation 2021, p.7]] [^8]: Original PDF page 8: [[Sample Case Presentation 2021.pdf#page=8|Sample Case Presentation 2021, p.8]] [^9]: Original PDF page 9: [[Sample Case Presentation 2021.pdf#page=9|Sample Case Presentation 2021, p.9]] [^10]: Original PDF page 10: [[Sample Case Presentation 2021.pdf#page=10|Sample Case Presentation 2021, p.10]] [^11]: Original PDF page 11: [[Sample Case Presentation 2021.pdf#page=11|Sample Case Presentation 2021, p.11]] [^12]: Original PDF page 12: [[Sample Case Presentation 2021.pdf#page=12|Sample Case Presentation 2021, p.12]] [^13]: Original PDF page 13: [[Sample Case Presentation 2021.pdf#page=13|Sample Case Presentation 2021, p.13]] [^14]: Original PDF page 14: [[Sample Case Presentation 2021.pdf#page=14|Sample Case Presentation 2021, p.14]] [^15]: Original PDF page 15: [[Sample Case Presentation 2021.pdf#page=15|Sample Case Presentation 2021, p.15]] [^16]: Original PDF page 16: [[Sample Case Presentation 2021.pdf#page=16|Sample Case Presentation 2021, p.16]] [^17]: Original PDF page 17: [[Sample Case Presentation 2021.pdf#page=17|Sample Case Presentation 2021, p.17]] [^18]: Original PDF page 18: [[Sample Case Presentation 2021.pdf#page=18|Sample Case Presentation 2021, p.18]] [^19]: Original PDF page 19: [[Sample Case Presentation 2021.pdf#page=19|Sample Case Presentation 2021, p.19]] [^20]: Original PDF page 20: [[Sample Case Presentation 2021.pdf#page=20|Sample Case Presentation 2021, p.20]] [^21]: Original PDF page 21: [[Sample Case Presentation 2021.pdf#page=21|Sample Case Presentation 2021, p.21]] [^22]: Original PDF page 22: [[Sample Case Presentation 2021.pdf#page=22|Sample Case Presentation 2021, p.22]] [^23]: Original PDF page 23: [[Sample Case Presentation 2021.pdf#page=23|Sample Case Presentation 2021, p.23]] [^24]: Original PDF page 24: [[Sample Case Presentation 2021.pdf#page=24|Sample Case Presentation 2021, p.24]] [^25]: Original PDF page 25: [[Sample Case Presentation 2021.pdf#page=25|Sample Case Presentation 2021, p.25]] [^26]: Original PDF page 26: [[Sample Case Presentation 2021.pdf#page=26|Sample Case Presentation 2021, p.26]] [^27]: Original PDF page 27: [[Sample Case Presentation 2021.pdf#page=27|Sample Case Presentation 2021, p.27]] [^28]: Original PDF page 28: [[Sample Case Presentation 2021.pdf#page=28|Sample Case Presentation 2021, p.28]] [^29]: Original PDF page 29: [[Sample Case Presentation 2021.pdf#page=29|Sample Case Presentation 2021, p.29]] [^30]: Original PDF page 30: [[Sample Case Presentation 2021.pdf#page=30|Sample Case Presentation 2021, p.30]] [^31]: Original PDF page 31: [[Sample Case Presentation 2021.pdf#page=31|Sample Case Presentation 2021, p.31]] [^32]: Original PDF page 32: [[Sample Case Presentation 2021.pdf#page=32|Sample Case Presentation 2021, p.32]] [^33]: Original PDF page 33: [[Sample Case Presentation 2021.pdf#page=33|Sample Case Presentation 2021, p.33]] [^34]: Original PDF page 34: [[Sample Case Presentation 2021.pdf#page=34|Sample Case Presentation 2021, p.34]]