View
6
Download
0
Category
Preview:
Citation preview
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan26
病例討論專欄
復科臨床病例報告二
時間:中華民國一○三年六月七日Instructor: 傅立志醫師、陸泰年醫師、沈嬿文醫師
報告/R4黃若婷
█ Chief complaint
█ Past medical history ● HTN under medical control ● N�
█ Personal habits ● Smoking (-) ● Alcohol : (-) ● Betel nut chewing (-)
█ General data
Name : 洪X池
Chart number : 16767959
Gender : Male
Age : 79 y/o
Marriage : married
Occupation : farmer
Attitude : cooperation and comprehensive
First visit : 102.06.13
Came for dental examination. Request for denture evaluation.
102.06.13
● Bruxism(-) ● Oral hygiene
● Brushing teeth: one time/day
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 27
病例討論專欄
█ Extra-oral examination
█ Extra-oral examination
█ Extra-oral examination
█ Extra-oral examination
Frontal view ● Facial midline : on ● Face form : long ovoid ● Front facial view : symmetry
Frontal view (with retractor) ● Facial midline : on ● Facial to maxilla midline : shi� to right side about 1mm
Frontal view (smile) ● Facial midline : on ● Face form : long ovoid ● Front facial view : symmetry ● Gummy smile: no
Lateral view :45°
● Malar area: � at ● Paransal area: � at
102.07.15
102.07.15
102.07.15
102.07.15
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan28
病例討論專欄
█ Extra-oral examination █ TMJ-related examination
█ Intra-oral examination
█ Occlusal view
Lateral view :90°
● Pro� le: cave ● E-line: ● Upper lip: retrued ● Lower lip : on ● Nasolabial angle: 100°
● Maximum mouth opening :50 mm (edentulous ridge-41incisor edge)
● Clicking sounds: (-) ● Jaw deviation when opening mouth : (-) ● Muscle palpation pain(-) ● Joint palpation pain(-)
● A� er extraction for a week102.07.15
◆ Arch form : square ◆ Maxillary edentulous ridge ◆ Multiple extraction sockets ◆ Ulcer at incisive papilla
◆ Arch form : tapper ◆ Remaining teeth: 34, 33,
32, 31, 43 ◆ FPD:32-31-X, 43-X-X-X ◆ Caries:34
102.07.15
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 29
病例討論專欄
█ Study cast
█ Panoramic fi lm
◆ Shallow vestibular at bilateral posterior area
◆ No obviously bony under cut
◆ Multiple extraction sockets
◆ Lingual frenum to gingival line: > 8mm
◆ Very bulky of old LA FPD ◆ No tissue undercut at 34,
43 buccal area ◆ FPD:32-31-X, 43-X-X-X ◆ Caries:34102.07.15
● Maxillary edentulous ridge ● Missing:38,37,36,35,41,42,44,45,46,47,48 ● FPD:32-31-X, 43-X-X-X ● RCT:31,32
● Apical lesion at 34 ● Generalized moderate alveolar bone loss ● Normal TMJ, No obviously bony lesion
102.06.13
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan30
病例討論專欄
█ Periapical fi lm
█ Intra-oral Examination
102.07.15
102.07.15
Lower Left SextantCAL&BOPPD&plaqueCEJ.GM
Facial
Lingual
CEJ.GMPD&plaqueCAL&BOP
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 31
病例討論專欄
█ Intra-oral Examination
█ Charting data102.07.15
Lower Left SextantCAL&BOPPD&plaqueCEJ.GM
Facial
Lingual
CEJ.GMPD&plaqueCAL&BOP
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan32
病例討論專欄
Provisional Prognosis (1991 McGuire MK.)
Overall prognosis:Fair
Individual prognosis:
X X X X X X X X X X X X X X X X
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
X X X X X F X X Q Q F F X X X X
良好 Good 尚可 Fair 差 Poor 可疑 Questionable 放棄 Hopeless
■ Adequate remaining bone
■ Possibilities to control etiologic factors
■ Maintainable dentition
■ Patient cooperation
■ Less than adequate remaining bone support
■ Some tooth mobility ■ Degree I furcation-
involvement ■ Adequate maintenance
possible ■ Patient cooperation
■ Moderate to advanced bone loss
■ Tooth mobility ■ Degree I~II furcation-
involvement ■ Di� cult to maintain areas ■ Doubtful patient
compliance
■ Advanced bone loss ■ Degree II~III furcation-
involvement ■ Tooth mobility ■ Inaccessible area
■ Advanced bone loss ■ Nonmaintainable
area ■ Extraction indicated
█ Diagnosis
█ Problems list
● Generalized periodontitis ● Caries:34,33,32,31,43 ● Apical periodontitis :34 ● Missing teeth: 18, 17, 16, 15, 14, 13, 12, 11, 21, 22,
23, 24, 25, 26, 27, 28, 38, 37, 36, 35, 41, 42, 44, 45, 46, 47, 48
● Traumatic ulceration lesion at incisive papilla
● Poor oral hygiene ● Inadequate space of 41,42 ● Ill-� � ed old FPD: 32-31-X (patient refused remove
this FPD) ● Limited budget ● Gingival recession
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 33
病例討論專欄
█ Preliminary treatment options
█ Prosthetic treatment options
█ Prosthetic treatment options-I █ Prosthetic treatment options-II
● Oral hygiene instruction ● Full mouth scaling ● RCT: 33, 34 ● Remove FPD: 43-XXX,41 ● Provisional crown fabrication of 33,34, and 43 ● Interim maxillary CD and mandibular RPD
患者不想花太多錢,不想花錢做臨時活動假牙也不願意植牙和根管重新治療
Maxilla ● Complete denture
Mandible ● Kennedy class I RPD ● 33-43, 34 surveyed crown
Maxilla ● Complete denture
Mandible ● Kennedy class I modi� cation 1 RPD ● 33-34, 43 surveyed crown
患者選擇第二個治療計畫
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan34
病例討論專欄
█ Survey and RPD design
█ Design
█ Prosthetic treatment course
Defi nite treatment plans ● Maxilla: complete denture ● Mandible: Kennedy class I modi� cation 1 RPD
● Major connector : lingual plate ● Cingulum rest :33, 43 ● Occlusal rest: 34(M) ● Guiding plane :34(D), 31(M), 43(MD) ● I-bar clasp : 34, 43
● 102.07.15 : pre-treatment data collection ● 102.08.10 : 33,34,43 tooth preparation and provisional crown fabrication ● 102.09.11 : 33,34 post ● 102.09.19 : 33,34,43 impression ● 102.09.25 : border molding of maxilla ● 102.10.12 : VD and CR record ● 102.10.28 : Wax denture try in ● 102.11.16 : 33,34,43 deliver and cementation. OHI ● 102.11.21 : border molding of mandible ● 102.11.27 : framework try in and take CR bite ● 102.12.03 : denture try in ● 102.12.06 : deliver CD+ RPD ● 102.12.09 : follow up(3 days) ● 102.12.23 : follow up(2 weeks) ● 103.01.21 : follow up(1.5 M) 但沒來 ● 103.03.13 : follow up(3 M) ● 103.06 : follow up (6M)
I-bar clasp : 43 - 43 into mesio-buccal 0.01 inch
I-bar clasp : 33 - 33 into mesio-buccal 0.01 inch
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 35
病例討論專欄
█ Tooth preparation and provisional crown fabrication (33,34,43)
● Referred to endo dept. for 33 and 34 RCT. ● 43 keep follow up ● Deliver so� occlusal splint for prevention of the traumatic injury
102.08.10
█ Impression: 33,34,43102.09.19
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan36
病例討論專欄
█ Border molding of maxilla
█ Occlusal rim
102.09.25
102.10.12
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 37
病例討論專欄
█ VD and CR record
█ VD and CR record
102.10.12
102.10.12
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan38
病例討論專欄
█ Wax denture try in
█ Fully wax up
◆ Occlusal view
102.10.28
Profi le (frontal view) Profi le (smile) Profi le (frontal view) Profi le (lateral view)
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 39
病例討論專欄
█ Occlusal analysis
█ Cut back
█ Metal framework
W B B W
Lateral and protrusive movement
Right excursion Left excursion
R't L't
Protrusion
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan40
病例討論專欄
█ FPD delivery
33,34,43 deliver and cementation. OHI ● Occlusal view
102.11.16
█ Occlusal analysis
102.11.16
W B
B
R't L't
W
Lateral and protrusive movementRight excursion
Left excursion
Protrusion
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 41
病例討論專欄
█ FPD delivery102.11.16
102.11.21
43 33,34Occlussion
OHICheck with PA fi lm
Study cast impression and plan to do border molding (one piece)
█ Border molding of mandible
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan42
病例討論專欄
█ Border molding of mandible
█ Framework try in
Before After
102.11.27
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 43
病例討論專欄
█ Take CR record
102.11.27
█ Wax denture try in
◆ Check CR and VD
102.12.03
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan44
病例討論專欄
█ Wax denture try in
◆ Check CR and VD
102.12.03
█ Wax denture try in
102.12.03
W B
B
R't L't
W
Lateral and protrusive movementRight excursion
Left excursion
Protrusion
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 45
病例討論專欄
█ Denture try in
102.12.03Profi le (frontal view)
Before tooth extraction Now With retractor
Profi le (lateral view)
Before Nasolabial angle: 95°
NowNasolabial angle: 85°
█ Delivery
102.12.06組織面
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan46
病例討論專欄
102.12.06
Occlusal view
█ Delivery
102.12.06咬點
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 47
病例討論專欄
█ Occlusal analysis
102.12.06
W B
B
R't L't
W
Lateral and protrusive movementRight excursion
Left excursion
Protrusion
█ Delivery
102.12.06 102.12.06
102.12.06
Profi le (frontal view) Profi le (lateral view-45 °)
Profi le (lateral view-90 °)Before Before
Before
Now Now
Now
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan48
病例討論專欄
█ Delivery
102.12.06
Mounting cast
█ Follow up
● 102.12.09 : follow up(3 days) ● Ulcer at le� cheek
● 102.12.23 : follow up(2 weeks) ● No speci� c complaint
● 103.01.21 : follow up(1.5 M) 但沒來 ● No any complaint
● 103.03.13 : follow up(3 M) ● No speci� c complaint
● 103.06 : follow up(6 M)
◆ Overjet :1mm ◆ Overbite: 1mm
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 49
病例討論專欄
█ Follow up (3M)
103.03.13
Occlusal view
Mucosa103.03.13
中華民國贋復牙科學會/ The Academy of Prosthetic Dentistry, Republic of China,Taiwan50
病例討論專欄
Q1: 36有磨耗是否有考慮提高VD,則可以不必將34進行根管
治療?
A1: 36咬合面雖然有磨耗,但是磨耗的咬合面36往近心傾
斜,且34 elongation的狀況較為嚴重,故還是建議患者
34進行根管治療以建立較適宜的咬合平面和避免日後34如果牙髓神經發炎必須要重新製作一個34固定式假牙來
配合已經存在的下顎部分活動假牙之困擾。
Q2: 有確認VD是否有loss?
A2: 本Case只有以患者的臉型初略評估垂直高度沒有嚴重尚失和不足。日後如果遇到
類似的case將會製作上下顎的咬合蠟堤進行較準確的垂直高度是否合宜的確認。
Q3: 13和47為何要拔?如果不拔,可能會影響RPD的設計。
A3: 臨床上,13的牙周狀況不佳、位置過度偏於頰側且齒槽骨過度突出,47的位置
過度偏於舌側,這2顆牙齒在以修磨牙齒型態的處置下是無法讓部分活動假牙獲
得適當的置入和取出路徑,故建議患者拔除。
Q4: 如果預算不是問題,Orthodox. Tx.和植牙如何設計?
A4: 如果患者沒有預算上的考量,進行全口重建時,Orthodox. Tx.和植牙是治療計畫
的選項之一,如果是製作固定式假牙步驟如下:
(1) 拔除牙周狀況預後不佳和影響決定人工牙根位置的牙齒。
(13的牙周狀況不佳故還是建議拔除,47的牙周狀況尚可,則可以考慮保
留。人工牙根位置預定在13, 11, 21, 23, 25, 37, 33, 31, 42, 45, 46)
(2) 製作符合初步美觀和功能的過渡性活動假牙。
(3) 進行Orthodox. Tx.。
(上顎和下顎如果要矯正都沒有足夠的牙齒當作anchorage,必須使用矯正用
的小植體來當作anchorage)
(4) 當牙齒的位置和角度調整後,重新製作第2個過渡性活動假牙,並重新評估
上述步驟(1) 預定的人工牙根位置是否要調整。
(5) 依據第2個過渡性活動假牙製作手術導引版。
(6) 進行軟硬組織的移植和植牙手術。
(7) 製作固定式假牙。
(Tooth-supported fixed bridge:16-14; 34-36。Implant-supported fixed bridge:13-11; 21-23-25; 37; 33-31-42; 45-46)
The Academy of Prosthetic Dentistry, Republic of China,Taiwan/中華民國贋復牙科學會 51
病例討論專欄
Case I和Case II結論: 治療前,要先有diagnostic wax-up or denture確認VD and CR。如果有活動假牙要先
想好path of insertion和考慮力量的分配下設計rest and clasp的位置。
Case I 1. 如果可以重新製作,流程和設計該如何調整?
2. 沒有美觀問題,建議用metal collar
3. 牙齒顏色和形態可以調整符合患者年紀和個性
4. 拆除舊假牙之前上顎無牙,沒有辦法確認咬合平面,無法評估牙
齒要修多少,建議要先取VD、CR和預估舊假牙與RPD的path of insertion。
Case II 1. 36 有磨耗是否有考慮提高VD,則可以不必將34進行根管治療?
2. 是否有確認VD 是否有loss
3. 13和47為何要拔?可能會影響RPD的設計
4. 如果預算不是問題,Orthodox. Tx. 和 植牙如何設計?上顎如果要矯
正沒有足夠的牙齒?
5. 植牙前是否有評估製作假牙的空間?
檢查graft 的質地、厚度和移動量、舌頭的移動度、假牙的穩定度決
定牙齒要排到哪裡 ?
治療後牙的固定補綴前,要先評估高速手機是否可以在正確的軸向
移動,也就是要確認張口度。
Recommended