Marlene Kruger

In Partial fulfilment of BTech: Dental Technology

Department of Dental SciencesTygerberg Campus

CPUT2008

The Dental Rehabilitation of a Patient Suffering from Rampant

Caries

Overview What is rampant caries? Patient history Clinical treatment plan Prosthetic treatment options Maxillary advantages and disadvantages of

prosthetic treatment options Mandibular advantages and disadvantages of

prosthetic treatment options Prosthetic treatment of choice Laboratory procedures Problems experienced Future treatment options References Acknowledgements

What is Rampant Caries?

Fig 1 Rampant caries in a 19 year-old1

Rapid destruction of many teeth, involving surfaces of teeth that are usually caries-free.1

Fig. 2 Rampant caries in 25 year old – 7 years of “meth” use2Fig. 3 Rampant caries – mandible2

Patient History

21 year-old male

In 2003 – age of 16 – rampant caries – 2 ּ1 discoloured

2 ּ1 - intrinsic bleaching3-6 and the rampant caries were treated1

In 2007 – age 20 – bleaching failed5

1 ּ1,1ּ8 and 2 ּ5 restorative work – good condition

1 ּ8, 2ּ7 - additional caries – crowned

Extractions in maxillary arch 1 ּ2-1 ּ4, 1ּ6, 1ּ7 and 2 ּ2-2 ּ6

Extractions in mandibular arch 3 ּ8-4 ּ8

Clinical Treatment Plan

Maxillary Arch

1ּ7, 2ּ1 and 2ּ8 prepared for crowns

Mandibular Arch

Examination of the mandibular alveolar ridge

Prosthetic Treatment Options

Maxillary Arch

1. All ceramic crowns on the 1 ּ7, 2 ּ1 and 2 ּ8 with Co-Cr RPD

2. Implants, full ceramic restoration

3. Implants, full porcelain-fused-to-metal (PFM) restoration

4. PFM crown with ceramic shoulder on 2 ּ1 and gold crowns with milled rest seats on 1 ּ7 and 2 ּ8 with Co-Cr RPD

Mandibular Arch

1. Full acrylic denture with labial gum tinting

2. Implants, over denture

3. Implants, full ceramic restoration

Maxillary Advantages and Disadvantages

Advantages Good aesthetics7

No metal shines through7

Co-Cr is relatively small8

Disadvantages Margin may chip8

More costly to fabricate8

Wear - opposing teeth8

Option 1: All ceramic crowns on the 1ּ7, 2ּ1 and 2ּ8 with Co-Cr RPD

Maxillary Advantages and Disadvantages

Advantages Good aesthetics9

Life-like9

Strong9

Disadvantages Very expensive

More time consuming9

Option 2 :Implant, full ceramic restorations

Maxillary Advantages and Disadvantages (Cont.)

Advantages Strong9

Good aesthetics7

Disadvantages Metal may be visible7

Possible bluish gum7

Implants and crowns are expensive9

Option 3: Implants, full PFM restorations

Maxillary Advantages and Disadvantages (Cont.)

PFM with ceramic shoulder

Advantages Good aesthetics7

Strong7

No metal visible7

Disadvantages Metal, affect on colour

and visible inter proximal7 Ceramic wear acrylic

teeth and natural teeth8,11

Gold milled crowns

Advantages Used in posterior region Rest seats give

retention8

Relatively easy to fabricate10

Disadvantages Expensive – noble metal Not aesthetic for use in

anterior region

Option 4: PFM crown with ceramic shoulder on 2ּ1 and gold crowns on 1ּ7 and 2ּ8 with Co-Cr RPD

Maxillary Advantages and Disadvantages (Cont.)

Co-Cr RPD

Advantages Small12

Heat sensation8, 12

Good retention – milled crowns8

Disadvantages Metal Clasp – visible in

anterior region8, 12

Option 4: PFM crown with ceramic shoulder on 2ּ1 and gold crowns on 1ּ7 and 2ּ8 with Co-Cr RPD

Mandibular Advantages and Disadvantages

Option 1: Full acrylic denture with acrylic teeth with labial gum tinting

Advantages Easy to make13 Inexpensive13

Gum tinting – natural look13

Disadvantages Bulky13

Breaks easily13

Gum tinting – difficult to simulate13

Mandibular Advantages and Disadvantages (Cont.)

Option 2: Implants,

overdenture

Advantages Good stability and

retention9,14

Preserves alveolar bone14

Improved function14

Disadvantages Implants, expensive14

Maintance14

Bulky14

Option 3: Implants, full ceramic restoration

Advantages Good aesthetics Stable, natural look and

feel Fixed9

Disadvantages Extremely expensive Maintance15

Handled with care – copings9

Prosthetic Treatment of Choice

Maxillary arch 1ּ7 and 2ּ8 milled gold

crowns with rest seats

2ּ1 PFM with ceramic shoulder

Co-Cr RPD

Mandibular arch Full acrylic denture

with labial gum tinting Fig. 4 Prepared Crown and Bridge model

M Kruger

M Kruger

Fig. 5 Mandibular model

Laboratory Procedures

Normal laboratory procedures for the manufacturing of the crowns

1ּ7 and 2ּ8 plastic spacers -guide for thickness of precision milled gold crowns

Milling in wax stage as well as in metal7, 10

M Kruger

Fig. 6 Gold crown – rest seats

Laboratory Procedures (cont.)

Conventional laboratory procedures were followed for the manufacturing of Co-Cr RPD12,16

Frame - waxed up

Cast, worked off and highly polished12,17

Ready for a metal try-in

M v Deemter

M v Deemter

Fig. 7 Wax-up Co-Cr frameworkFig. 8 Cast Co-Cr framework

M Kruger

Fig. 8 Finished metal framework

M v Deemter

Laboratory Procedures (cont.)

Acrylic teeth set - maxillary metal framework and mandibular record block -try-in

Finishing – maxillary and mandibular acrylic work – gum tinting – mandible

Ready for placementFig. 10 Acrylic finish on Co-Cr framework

M Kruger

Fig. 8 Mandibular with selective gum tinting

Y. Chen

Y. Chen

Y. Chen

Fig. 11 Finished product

Problems Experienced

Incomplete casting with one milled crown - milled wax area to thin

Porosity in Co-Cr RPD

Closed retention-grid

Future Treatment Options

Maxillary and mandibular implant-retained dentures

Maxillary and mandibular implant-retained bridges

References

1. Kidd E & Joyston-Bechal S. Essentials of Dental Caries. New York: Oxford University Press. 1996: 8-10, 100.

2. Case Report “Meth Mouth”: Rampant Caries in Methamphetamine abusers. Available: http://www.liedertonline.com/doi/pdf/10.1089/apc.2006.20.146. 25 Aug 2008

3. Torres HO. Modern Dental Assisting, 3rd ed. London: WB Saunders Company.1985: 696.

4. Wilkins EM. Clinical Practice of the Dental Hygienist. 9th ed. Philadelphia: Lippincott Williams & Wilkins. 2005:315.

5. Grundy JR. A Colour Atlas of Conservative Dentistry. Rome: Wolfe Medical Publications Ltd. 1980: 96-97.

6. Greenwall L. Bleaching Techniques in Restorative Dentistry. London: Martin Dunitz Ltd. 2001: 25.

7. Goldstein RE. Change Your Smile, 2nd ed. London: Quintessence Publishing Co, Inc. 1988: 69-73.

References8. Henderson D & Steffel VL. McCrackens’s Removable

Partial Prosthodontics. 6th ed. St Louis: The C.V. Mosby Co. 1981: 118-120, 236-241.

9. Jenkins G. Precision Attachments. A link to Successful Restorative Treatment. Chicago: Quintessence Publishing Co Ltd. 1999:89,150,159.

10. Jimenez-Lopez V. Oral Rehabilitation with Implant-Supported

Prostheses. Barcelona: Quintessence Publishing Co, Inc. 2005: 261-263,774-789.

11. Wulfes H. Precision Milling and Partial Denture Construction: A Manual; Modern Design, Efficient Production, 1st ed. Bremen: Academia Dental International School BEGO Germany. 2004: 76-121.

12. Hacker CH, Wagner WC, Razzoog ME. An in Vitro Investigation of the Wear of Enamel on Porcelain and Gold in Saliva. JPD. 1996;75: 14-17.

13. Morrow RM, Rudd KD, Rhoads JE. Dental Laboratory Procedures. 1st ed. St Louis: The C.V. Mosby Co. 1986: 545-550.

References

14. Preiskel HW. Overdentures Made Easy. London: Quintessence Publishing Co, Ltd. 1996: 14-20,

105-138, 233-238.15. Breumer R & Lewis SG. The Branemark Implant

System. St Louis: Ishiyaku EuroAmerica, Inc. 1989: 250.16. Brudvik JS. Advanced Removable Partial

Dentures. Berlin: Quintessence Publishing Co Inc. 1999: 32-34 & 86-89.

17. Carr AB, McGivney GP and Brown DT. McCracken’s Removable Partial Prosthodontics. 11th ed. St Louis: Elsevier Mosby. 2005:56-67.

Acknowledgements

Mr LA Steyn Dr J Wright Mr AK Mazema Mr A Latief Ms A De la Crouse Ms Z Nortje