Case Report; Mile Stone 3
Best FD milestone 3 case 2017
Kenny Strain BDS, Dip H&T.
I qualified as a Hygiene / Therapist from Sheffield Dental School in 2012 and worked in the Lake District for a dental corporate before deciding to pursue a career as a Dentist. I gained a place on the graduate entry dental programme at Aberdeen Dental School and graduated in 2016. I moved to Yorkshire to complete my foundation training in Barnsley with Michael Speakman as my FD trainer. His guidance and support has been outstanding and helped me to win the FGDP Yorkshire prize for best clinical case in foundation training.
This patient presented for a routine dental examination. He was a regular attender and long-standing patient of the practice. I initially gave the patient a personal dental assessment form. This form is given to patients in the waiting room and allows them time to think about their main concerns, and for me to assess their level of motivation. It also ensures efficient use of surgery time. Following this, during a discussion about his oral health, he reported that his existing upper partial denture was “hitting off the gum” when he tried to eat. Although the patient was keen to have a denture, he found it uncomfortable to wear.
History and Examination findings
ASA status class 1: Fit and well with no known allergies.
Attending the practice for over 5 years during this time he had received a large amount of complex care. The majority of his care was provided at the practice but he had also travelled abroad to have a number of crowns fitted.
The patient was married with one son. He is a retired engineer that now helps his son run a business. He says “Since retiring, I’ve never been busier”
Smoking and alcohol status
Ex-smoker, stopped over 5 years ago. Occasional drinker.
The patient’s primary complaint was that the “denture that keeps hitting into the gum when I eat”. The patient likes to eat roasted nuts and his existing denture presses into his gum when he tries to do this. As a result of this, the patient had become reluctant to use the denture and was now leaving it out for protracted periods of time. The prosthesis was a mucosa-bourne partial acrylic denture replacing teeth UL6, UR 6, UR7.
Good, brushing twice per day with a manual toothbrush and fluoride toothpaste, no interdental cleaning.
Examination and Diagnosis
While working in practice, I used the FGDP and SDCEP guidelines to create customisable templates. This ensured that I was consistent in my examination and treatment of patients. It was also time efficient and good practice medico-legally.
Intra oral soft tissues
Key Dental findings
- UR5 recurrent caries and marginal failure of crown
- Edentulous Spaces: UL6, UR6 and UR7
- Existing denture: unstable upper partial acrylic, non-retentive, poorly supported leading to compression of mucosa and tenderness in function. The UL6 denture tooth is not engaging with the UL5, resulting in a space of about 1.5mm which was plaque retentive
- Marginal failure of composite restorations on UL1 and UL2
Moderate, justification heavily restored dentition with a removable appliance but good oral hygiene
Periodontal disease risk
Low, consistent BPE scores over a number of years
Oral Cancer risk
Low [non-smoker, low alcohol consumption]
Basic Periodontal Examination results:
A number of radiographs were taken to assess for caries, bone levels, periapical pathology and to assess crown: root ratios and root fractures of potential denture abutment teeth.
Justification: Caries & bone level assessment.
Teeth and restorations as charted.
Caries: UR5 Distal radiolucency at margin
Bone levels: Generalised horizontal bone loss in edentulous areas, generalised loss of mandibular crestal bone. Furcation radiolucency LR6
Calculus present: no
Other: LR6 furcation lesion.
UR5 Pre-crown and Denture abutment assessment:
Crown – Root ratio: Root length > crown height
Bone levels: sufficient
Endodontic assessment: normal periapical tissues
A number of treatment options and their advantages and disadvantages were discussed with the patient:
- Maxillary shortened dental arch
- Remove UR5 crown, assess restorability. If non -restorable then extract tooth and add to partial denture.
- Remove UR5 crown, assess restorability. If restorable then new crown with precision attachments and new Co-Cr denture
- Acrylic partial denture
- Additional clasps to existing denture
- New acrylic denture
- Referral for implant placement
The patient was keen to avoid having a shortened dental arch as he wanted to “feel like eating with the back teeth”. The patient was previously interested in going overseas for the provision of implants. However, following a discussion of the above options he opted for removal of the UR5 crown, restoration of the abutment with a new metal-ceramic crown incorporating rest seats and a palatal shelf, along with a Co-Cr denture.
- Hygiene phase - OHI, Scale and Polish, Fluoride application
- Immediate restorative phase – UL1 distal, and UL2 Mesial and distal composite restorations
- Definitive restorative phase –
- UR5 MCC crown with mesial and distal rest seats, buccal bulbosity and palatal shoulder
- Upper partial Cobalt Chrome Denture replacing UL6 and UR6, UR7
Treatment carried out
Treatment started with a hygiene phase followed by composite restorations placed under rubber dam using Microhybrid Composite from Henry Schein. The UR5 MCC was removed and the abutment assessed for restorability. Caries was removed and a composite restoration placed. The abutment was altered to improve the taper angle to increase the retention and resistance form. An impression was taken using a two stage, two phase technique. A technique that I have found particularly useful, is to take a first impression in heavy body VPS, create channels on the buccal and palatal aspects of the preparation and then drill a hole in the tray over the tooth you want the impression of. Air dry the tooth, place the tray in the mouth and then inject the light body VPS into the hole. This is in effect an injected moulded impression with a lower risk of moisture contamination due to the protection of the tray. The crown was temporised using a bisacrylic composite material, Maxitemp.
As the crown contained precision attachments for the Co-Cro denture communication with the dental laboratory was key. I discussed the case with the lab to explain the treatment plan and ensure that the lab was happy to provide both the crown and the Co-Cro denture.
The patient has a history of multiple restorations which made matching the denture teeth to the natural teeth was difficult. As a result, multiple shades were used. A9 for the UL6 and G9 for the UR6 and UR7.
At the metal try-in (with teeth) stage, the patient reported some tenderness on biting in the URQ. On examination the UR6 alveolus had narrowed following its extraction, this was most likely due to loss of the buccal plate during the extraction. This had led to the keratinised tissue on buccal aspect of ridge thickening. The patient reports that this area was causing tenderness on pressure from the denture. Using a technique that I learned at an FGDP study day, I created a pressure paste of zinc oxide powder and Vaseline, this was used to assess the area of rubbing and the denture was relieved in the area of rubbing.
The denture was then finished and provided to the patient. The patient was kept under review and was very happy with the final denture.
Treatment outcome and reflection
As consent is an on-going process, a number of discussions were had with the patient regarding the treatment. This gave the patient the option to alter his treatment as he wished but also ensured that he felt some “ownership” of the treatment plan
This has been a very interesting case from which I have learnt a number of things. Particularly the importance of socket preservation during extraction even in cases where future implant placement is unlikely. The loss of the buccal plate following XLA of the UR6 had led to unfavourable bone resorption, this negatively impacted the anatomy of the denture bearing area.
Overall, I feel that the treatment achieved a good clinical outcome. The denture is more retentive and better supported than the previous partial denture. The increased rigidity provided by the Co-Cro framework has allowed the patient to continue eating the roasted nuts that he had been unable to with his previous appliance resulting in a very happy patient.
Editor, FGDP Yorkshire Newsletter