Complex Case Presentation

 
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Winner FGDP Yorkshire complex case 2019

APLAN Case 963–Summary

Pt. c/o

Pt doesn't like to smile due to the state of her teeth. She knows she grinds her teeth and has a lab made bite guard but poured boiling water on it and now it doesn't fit.

 
 

PDH

Previous regular attender at another practice. Changed to this practice as it was closer to home for her. First time attendance at my examination apt. Dentally anxious.

Relevant MH

Type II diabetes - taking metformin. Well controlled. History of strangulated pancreatitis in 2011. Spent 6 months in hospital.

Relevant Key Examination Findings

EO - NAD IO: ST - Bilateral lesions of reticular pattern and erythema covering the majority of the buccal mucosa. Areas of erosionpresent in posterior area in line with occlusal plane. HT - Severe TSL. P/E LR3. U/E UL3 & UR3.

Special Tests Carried Out

  • TTP: nil Endofrost test: All tested gave +ve result (UR2, UR1, UL1; LR6, LL1, LL2, LL3) Mobility: all = 0 (Miller Classification) TSL

  • Questionnaire: Attrition + Erosion

Radiographs Taken

  • Pre-operative PAs

  • Intra-operative PAs

  • Post-operative PAs

Carries Risk

Low

Peridontal Disease Risk

Low

Cancer Risk

Low

Diagnosis

  1. Localised, severe multifactoral (attrition + erosion) TSL exacerbated by loss of posterior support and no canine guidance. TSL currently active.

  2. Lichen planus

  3. Ectopic and partially erupted LR3

  4. Ectopic, unerupted UR3 + UL3

  5. Partial edentulism

  6. Reduced OVD

Treatment Plan

Stage 1: Initial Assessment and Emergency Treatment

  1. Full Examination and assessment as outlined previously

  2. TSL specific assessment including TSL questionnaire

Stage 2: Control of Disease/Stabilisation

  1. Diet advice & OHI

  2. Patient education regarding the aetiology, pathogenesis and history of TSL

Stage 4: Advanced Restorative Treatment

  1. Composite build-up of anterior teeth

  2. Provision of bite guard

  3. Provision of upper and lower CoCr prostheses

Stage 5: Evaluation of Outcomes Review outcomes and assess any improvements in oral health

Prognosis for Treatment

From Diagnoses: 1. Guarded 2. Guarded 3. Poor 4. Guarded 5. Poor 6. Good

Recall Period

3/12

Presenting Complaint / History

Pt details

Mrs B, 49-year-old female.

PCO: (in own words)

Pt doesn't like to smile due to the state of her teeth. She knows she grinds her teeth and has a lab made bite guard but poured boiling water on it and now it doesn't fit. Bought one off the internet and it doesn't fit as well. Had been quoted implants at £24,000 and metal dentures at £4,000 this was out of her price range so wanted to know what we can do.

HPC

Duration of condition: can't remember a time when she didn't grind her teeth. When pt spent 6 months in hospital with strangulated pancreatitis (2011) she didn't have a mirror and it was when she got out of hospital that she noticed her teeth were worn down. Pain/sensitivity: Nil

DH

Previous regular attender at another practice. Changed to this practice as it was closer to home for her. First time attendance at my examination apt. Pt dentally anxious. Oral hygiene regime: ETB (Oral B) x2 day. No interdental cleaning. No mouthwash. TP used - Oral B.

MH

Type II diabetes - taking metformin. Well controlled. History of strangulated pancreatitis in 2011. Spent 6 months in hospital.

SH

Occupation: cook at a nursing home. Home: has 2 children who are now adult and live in local area. Father passed away 2 years ago due to motor neurone disease. Smoker: nil Alcohol: 5 units/week.

Examination Findings

Extra Oral Exam

Asymmetry: Nil TMJ: Nil Muscles of Mastication: Tender on palpation (masseter, medial pterygoid and temporalis) Lymph nodes: Nil Salivary Glands: Nil Other: NAD Access: no limited opening

Intra Oral Exam

Floor of Mouth: Nil Soft Palate: Nil Hard Palate: Nil Tongue: Nil

Buccal Mucosa: Bilateral lesions of reticular pattern and erythema covering the majority of the buccal mucosa. Areas of erosion present in posterior area in line with occlusal plane.

Gingivae: Gingivae similarly affected as the buccal mucosa.

Periodontal Examination

BPE: 1s & 0s - see chart. Plaque control: Good; Isolated bleeding on probing Calculus: nil Mobility: nil

 
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Hard tissues

Caries: Nil Other: Ectopic P/E LR3 lingually placed.

Tooth Surface Loss

Cause: Attrition & Erosion. Distribution: Anteriors teeth Severity: Severe. Worst affected tooth = UL1 with 1mm supragingival enamel present labially and epigingival at distal aspect. Arrested or active: Active

Other findings: Occlusal kant of anterior teeth from left to right with well worn occlusal contacts. No canine guidance.

Occlusion

Incisors: Class III (due to worn dentition) Molar relationship: Un-assessable due to partial edentulism Canines: Un-assessable due to partial edentulism Excursions: group function on L&R excursion OVD: Reduced

Special Test Results / Reports

TTP/Sensibility/Mobility/Other Testing:

TTP: nil Endofrost test: All tested gave +ve result (UR2, UR1, UL1; LR6, LL1, LL2, LL3) Mobility: all = 0 (Miller Classification)

Radiographs

Pre-Operative (Photos taken of WET FILMS)

PAs taken

Justification: assessment of PAP and investigation of ectopic LR3 Grade: 1 Report: no PAP associated with any teeth. Caries: nil

Other: LR3 ectopic and partially erupted. UR3 and UL3 ectopic and palatally placed, superimposed over roots of upper centrals. No cystic change noted. No resorption of roots of centrals noted. UL1 slight distal curve at apical 1/3 of root.

Intra-operative (DIGITAL)

PA UL1

Justification: master cone assessment Grade: 1 Report: master cone within 1mm of apex of tooth.

Post-operative (DIGITAL)

PA UL1

Justification: assessment of RCT and post Grade: 1 Report: RCT fill to length, no voids present. Post placed centrally in canal up to apical 1/3 of tooth where there is distal deflection of the root. Iatrogenic damage visible to coronal structure where access was initially too mesially angulated. No perforation present but close and restored with radio-opaque material. Coronal structure restored.

 
 

Investigation of TSL (adapted from RSC guidelines 2013)

First aware of grinding teeth

When spent 6 months in hospital with strangulating pancreatitis (2011). Didn't have a mirror and noticed when got out of hospital

Parafunction/Occlusion

  1. Any knowledge of parafunction/bruxism?

  • grind at night - other half says so! "go at it - intensely"

  • maybe when concentrating

Intrinsic Acids

  1. History of GORD? No.

  2. Vomiting due to:

Pregnancy? Yes - vomiting during pregnancy, esp. first trimesters for both children.

Chronic alcoholism? No

Eating disorders (bulimia/anorexia) No

  1. Obesity/eating late at night? No

  2. Rumination syndrome? No

  3. Medications (chemo drugs)? No

Extrinsic Acids

Dietary acids

  • Soft drinks (carbonated drinks/fruit juice/flavoured mineral water)? 2L/day Pepsi Max

  • Acidic beverages (dry wine, cider, alcopops)? No

  • Flavoured chewing gums? No

  • Acid based foods (vinegar/fruits/ketchup)? Vinegar/ketchup - not excessive

  • Dietary supplements (vit C/Fe)? No

Lifestyle

  • Swimming? No

  • Mood enhancing drugs (ecstasy)? No

Occupational

  • Acidic liquids/vapours e.g. batteries/galvanising products? No

Pre-disposing factors

  • Low saliva flow? No

  • Dry mouth? No

Diagnosis

Diagnoses

  1. Localised, severe multifactoral (attrition + erosion) TSL exacerbated by loss of posterior support and no canine guidance. TSL currently active.
    Prognosis: guarded due to severity and currently active TSL.

  2. Lichen planus (combination of reticular and erosive pattern)
    Prognosis: guarded due to more severe erosive element and small subsequent risk of malignant change.

  3. Ectopic and partially erupted LR3
    Prognosis: Poor due to difficulties cleaning tooth and non-functionality.

  4. Ectopic, unerupted UR3 + UL3
    Prognosis: guarded as have potential to erupt under any prosthodontic work.

  5. Partial edentulism
    Prognosis: poor due to loss of posterior support and canine guidance combined with TSL suggestive that other teeth may be lost.

  6. Reduced OVD
    Prognosis: Good if pt can tolerate rehabilitation at new OVD through restorative approach.

Risk Assessment

  • Caries – low (no active caries clinically detected)

  • Perio – low (BPEs of 0/1)

  • Tooth surface loss – high (due to TSL as stated above)

  • Cancer – low (non-smoker and low alcohol intake)

Treatment Options

1. Lichen Planus

a) Review and monitor in primary care. (Benefits: no additional apts, single centre care. Risks/costs: No definitive diagnosis or specialist led care)

b) Referral to Oral Medicine Specialist (Benefits: definitive diagnosis and specialist led care. Risks/costs: multi-site care and multiple apts). Pt chose this option.

2. Severe Multifactoral TSL + Partial Edentulism & Reduced OVD

a) Accept current clinical scenario and monitor TSL. (Benefits: least invasive option, lowest financial cost, lowest maintenance burden. Risks/costs: Continued TSL, poor aesthetics, reduced function)

b) Extract most severely affected teeth (UL1 & LL1) provide partial dentures to increase OVD. (Benefits: lower invasive option, improvements made to aesthetics and function. Risks/costs: risks of XLA, aesthetic result still compromised, higher financial cost)

c) Create overdenture design for most severely affected teeth (UL1 & LL1). (Benefits: retain proprioception from overdenture abutments, no XLA necessary, improvements made to aesthetics and function. Risks/costs: increased risk of caries/periodontal disease with overabutment design, aethetic result still compromised, higher financial cost)

d) Composite build up of affected teeth, provision of partial dentures. (Benefits: improvements to aesthetics and function, no XLA, keep proprioception from natural teeth, psychological benefit from keeping "own teeth". Risks/costs: Long treatment times and multiple apts, maintenance burden of restorative work with risk of fracture to composites, higher financial costs). Pt chose this option.

3. Ectopic and Partially Erupted LR3

a) Retain LR3 (Benefits: no XLA, maintains bone around tooth. Risks/costs: compromised RPD design, can erupt under future prosthetics). Pt initially chose this option.

b) XLA LR3 (Benefits: uncompromised denture design and no risk to future stability. Risks/costs: risks of XLA, denture area may need to be relined in future in that area, loss of bone).

4. Ectopic and Unerupted UR3 & UL3

a) Leave and monitor (Benefits: no XLA, no immediate risk to denture design. Risks/costs: can erupt under future prosthetics, may cause resorption to adjacent teeth, risk of future pathology). Pt chose this option.

b) Surgical XLA (Benefits: no risk of erupting later under prosthesis. Risks/costs: risks of surgical XLA).

Treatment Plan

Aim

To prevent future disease experience, treat current disease consequences and to retain a dentition amenable to patient-led maintenance

Stage 1: Initial Assessment and Emergency Treatment

  1. Full Examination and assessment as outlined previously

  2. TSL specific assessment including TSL questionnaire

Stage 2: Control of Disease/Stabilisation

  1. Diet advice & OHI

  2. Patient education regarding the aetiology, pathogenesis and history of TSL

Stage 4: Advanced Restorative Treatment

  1. Composite build-up of anterior teeth

  2. Provision of bite guard

  3. Provision of upper and lower CoCr prostheses

Stage 5: Evaluation of Outcomes

Review outcomes and assess any improvements in oral health.

Treatment Carried Out

Treatment for this patient was carried out over 17 appointments with an overall chair time of 17.5hrs so for brevity the treatment will be summarised below:

Control of Disease/Stabilisation

  • Dietary counselling was provided for specific risk factors that were identified

  • Tailored OHI and education

  • Regular review apts were made to assess and monitor the patient's plaque control

  • Study casts were made to monitor the TSL and to aid planning

Planning Phase

A detailed occlusal analysis was carried out showing that there was group function in lateral excursions and protrusion and the mandible could be easily guided reproducibly into RCP. Bite registration was taken using Doric Bite in RCP along with new impressions and a facebow record. This was then mounted on a semi-adjustable articulator to allow the construction of a diagnostic wax-up of the upper and lower anterior teeth (UR2, UR1, UL1 and LL1, LL2, LL3). This wax-up was then used to communicate the anticipated changes in occlusion to the patient at a consultation apt.

Composite Build-Ups

A silicone putty index was then made of the palatal surfaces of the upper and lower anterior teeth to aid accurate reproduction of the wax-ed up model in the mouth. Adjacent teeth were isolated with PTFE tape, and each tooth was then roughened with a round diamond bur to remove the most exterior sclerotic dentine, then a two-step etch-and-rinse dentine bonding protocol was applied before incremental layers of single shade composite were built up (Filtek Supreme, 3M ESPE, A2b). All available enamel was etch and bonded to, to maximise adhesion. The patient was then provided with a soft bite splint to prevent damage to the restorations and their remaining dentition from parafunctional loading. Oral hygiene was reinforced.

Review

A review appointment two weeks after composite placement revealed that the patient was adapting well to the new occlusion and OH regime.

Provision of Upper and Lower CoCr RPDs

A special tray was constructed using the diagnostic wax-up and the study models were surveyed to create a suitable RPD design for both the upper and lower arches (see images). This design focused on keeping an open palatal design to allow the patient to taste and feel the temperature of her food (as she was employed as a chef) as well as building in redundancy for poor prognosis teeth. Using these special trays, secondary impressions were taken using greenstick compound (border moulding) and alginate. From these a metal try-in was constructed along with subsequent wax registration and wax try-in. Finally both upper and lower CoCr RPDs were fitted giving posterior support.

Evaluation of Outcomes

Overall the patient was pleased with the appearance of their teeth and ability to eat and taste their food. The patient was reviewed at one week and one month post-RPD insertion and during this time did not develop any temporomandibular symptoms nor fracture any of their restorations.

The patient is planned to be reviewed again three months post-RPD insertion to ensure excellent oral hygiene and to monitor the restorations and prostheses.

 
 

Change to Treament Plan / Prognosis / Follow Up

Changes to Treatment Plan

1) XLA LR3

During the metal try-in stage it was found that the LR3 was acting as a fulcrum causing instability in the lower metal framework. This was discussed with the patient and it was decided to XLA the LR3. The extraction was uneventful however the patient suffered from a dry socket post-operatively. Subsequently the lower metal try-in was more stabile and good healing was achieved from the site.

2) Elective RCT + Post UL1

Between building up the anterior teeth and providing the CoCr RPDs the UL1's composite restoration fractured off. The UL1 has the worst prognosis of the remaining dentition due to the severity of the TSL and therefore at this point it was decided that if the tooth was to be retained, further retention would be necessary for the composite build up. After discussion with the patient it was decided that the UL1 would be electively RCTed and a composite fibre post placed to aid retention.

The RCT was complicated by the superimposition of the U/E UL3 over the apical portion of the root which made it complex to assess the EWL for the tooth radiographically (see radiographs & test for reports). The superimposition of the follicle of the UL3 also gives the illusion of a root fracture at the apical third. It was also important to consider the possibility of root resorption from the UL3 on the UL1 however consistent apex locator readings gave confidence of achieving an apical seal. This was confirmed with a post-operative radiograph.

This also shows the difficulties I found when achieving access to the root canal as it can be seen that I very nearly perforated out of the mesial aspect of the root. This was due to the limited amount of coronal structure that was left masking the true inclination of the tooth.

Follow Up

As previously stated the patient was reviewed a 1 week and 1 month post-treatment to ensure no subsequent complications were found.

The patient is due to be recalled 3 months post-treatment for continual assessment. The UL1 will be assessed at appropriate clinical and radiographic recall periods to assess the outcome.

Reflection & References

Reflection Points

1) Case Complexity

Overall this was one of the most complex cases that I have attempted during my dental training. I found the planning for this case crucial to its success and that it took a lot of clinical and mental time to come up with the most appropriate treatment options and to be able to discuss them confidently with the patient. I felt that I learnt a lot from each stage that was completed and from each set-back that was encountered and now have more confidence taking on cases such as these. Given that 17% of 70 year-olds have severe tooth wear, cases such as these are increasingly common (Van't Spijker, 2009).

2) Prognosis UL1

Given the overall poor prognosis for the UL1 there was some discussion whether this tooth should have been extracted from the outset. However the tooth did had a "ring of confidence" (ring of circumferential enamel) and there is evidence that teeth with even 75% TSL can be restored predictably (Robinson, et al. 2008). On top of this the patient was keen to keep all remaining teeth and has subsequently reported appreciating the proprioception from her anterior teeth when biting, etc. It was also important to plan for failure in the denture design and the UL1 could relatively easily be added to the denture if necessary. The current evidence for survival of anterior composites in tooth wear cases suggests that there is a 50% survival rate at 5 years (Ahmed & Murbay, 2016).

3) Try-in mock up

Upon reflection it would have been useful to have created a trial of the diagnostic wax up in the patient's mouth using a temporary restorative material to aid communication/consent/planning for this case. In subsequent cases such as this I have used QuickTemp in a soft-splint to mock-up the suggested design for the patient and have found that this greatly improves the patient's understanding of the treatment and procedure.

4) CBCT for Resorption UL1

When the UL1 restoration failed and necessitated the elective RCT and fibre post it might have been prudent to consider a CBCT scan to assess the proximity of the U/E UL3 to the root of the UL1 and if any resorption had taken place. On reflection this could have been a useful tool for the consent process and also for improving the predictability of any result.

References

Ahmed, K. and Murbay, S. (2016). Survival rates of anterior composites in managing tooth wear: systematic review. Journal of Oral Rehabilitation, 43(2), pp.145-153.

Robinson, S., Nixon, P., Gahan, M. and Chan, M. (2008). Techniques for Restoring Worn Anterior Teeth with Direct Composite Resin. Dental Update, 35(8), pp.551-558.

Royal College of Surgeons (2013). Diagnosis, Prevention and Management of Dental Erosion. London: RCS Eng.

Van't Spijker, A. (2009). Prevalence of Tooth Wear in Adults. INTERNATIONAL JOURNAL OF PROSTHODONTICS, 22(1), pp.35-42.