Monday, February 9, 2009

Help on this case


































































































What you are looking at are casts and diagnostic photos of a patient that started with the practice several years ago. In the photo above, the 2nd PM is actually #4.
Here's a little history...
The patient presented with extensive caries and fractured teeth. RCT #s 4 & 5 necessary and post placement. The crowns were in occlusion and functional approximately 3 years. Tooth # 12 has a floating pontic. Teeth #'s 8, 9 & 10 are veneered, #s 10 & 11 are crowns. She has had several fractured teeth which required extraction.
Every 3 months she is seen by a periodontist.
Teeth #'s 4 & 5 fractured at the alveolar crest and were extracted. Implants have been placed. She states her mother also fractured her PMs.
I hesitate to restore her implants with the occlusal issues. Where to begin?
My observations are these-
1. She appears to have immediate disclusion on protrusion- interference noted in the posterior.
2. Deep bite with lingual and facial wear.
3. No stable posterior occlusion.
4. Repeated fracturing of teeth.
5. Left side- all the crowns have fractured porcelain.
6. No pain.
Questions:
1. Here envelope of function seems violated- is that right and where do I even begin on this one?
2. Do I temporize the implants and place her in a splint?
3. Do I place her in partials and expect to temporize the anterior teeth to work out occlusion?
4. Do I punt this one to a prosthodontist?
5. What do I tell the patient as to why this occurred?

2 comments:

Karen Altszuler said...

There are a few things I'm concerned about from what you presented:
1-The patients deep overbite. What is the patient's profile like? Could you do ortho to flare the anteriors and decrease the anterior guidance?
2- From the models I see a lot of posterior wear, possible bruxer. I would start by restoring the implants with temporary crowns and put the pateint into splint therapy and work out the occlusion. If the patient is o.k. without breaking anything else you can go and restore the case.

Herb Blumenthal said...

I think what Karen said was good... The first thing I would do is to make her a splint and make sure she wears it... see what her occlusion looks like without the anterior teeth guiding her to MI ... I would also want to know what happened to her front teeth ..did she wear them or did they fracture? What is her medical history tell you? What kind of medication is she taking? As far as what to tell her as to why she is doing this is a difficult thing to say without knowing the patient... There are lots of reasons why people clench their teeth... the splint is a good place to start to begin to find out the answer... hope this helps Herb