Full Mouth Case With With 21 Months Follow Up2

SAUDI COUNCIL FOR HEALTH
SPECIALTIES
SBARD
Case Presentation
Dr. MOHAMMED ALSHEHRI R 4
Case NO. : 05/USC-RKH/R2 04

Date Started:
04 Sep. 2004
Date Completed:
05 Apr. 2005
Treatment Duration:
7 months
Total Number Of Visits :
35
Number Of Visits Attended:
34
Number Of cancelled visits:
Personal Data
Age: 27 years old.
Sex: Female
Nationality: Saudi
Education: Secondary school
Occupation: House wife
Marital & social status: Married
Patient attitude: Positively co-operative
Medical History
Significant Medical Problems : None
Physical Classification : ASA I
History of Allergic Reaction : None
Family Medical History

None
Dental Chief Complaint

I had a sever pain related to upper right side and I do not
like the color of my teeth.
Pain started 3 weeks ago.

Severe fluorosis which led to difficult oral hygiene and
unacceptable esthetic.
Dental History
Pain History Form
Past Dental History

Patient had one restoration.
The last dental visit 1year ago for restoration.
Patient Attitude
The patient is rational, well balanced and intelligent.
Habits and Oral Hygiene Activity

Tooth brushing :
Twice / day
Interproximal cleaning : None

Meswak :
Once / week
Mouth wash :
None
Smoking :
None
Dietary Survey
----
----
2

3
----
----
----
----
----
Conclusion
3 meals / day.
High sugar intake.
Low amounts of fruits and vegetables.
Snacks between meals .
7 Cups of tea and coffee (three tea spoon of sugar) / week.
Dietary advice
Encourage reduction of sugar and carbohydrates intake.
Increase the intake of fruits and vegetables.
Confine snacks intake to meals time.
10
Clinical Examination
Extra-Oral Examination
Facial asymmetry
NAD
Swelling
NAD
Skin
NAD
Lips
Competent
Muscular Tenderness
NAD
11
TMJ
Clicking :
NAD
Crepitus :
NAD
Pain :
NAD
Limitation On Opening :
NAD
Deviation On Opening :
NAD
12
Intra-Oral Examination (Soft Tissue)
Alveolar Mucosa NAD
Tongue
NAD
Cheek
NAD
Palate
NAD
Floor of the mouth NAD

Frenum attachment NAD
13
Intra-Oral Photographs
14
15
16
17
Gingiva
Generalized inflammation of the gingiva and interdental
papillae with bleeding upon gentile propping
18
Oral Hygiene
Date
Sep. 4 04
Plaque
76%
score
Bleeding
55%
score
Plaque : Generalized
Calculus : Generalized supra-gingival
10 11
12
13 14
15
16
32 31 30 29 28 27 26 25
24
23 22
21
20 19
18
17
PP
BOP
BOP
PP
* Silness J and Loe,H. 1964
19
Oral Hygiene
PSR (Periodontal screening & recording system)

2
2
2
2
Probing depth :
- Generalized: 2-3 mm
Mobility : None
Furcation: None
20
Occlusion (Angels Classification)

Rt. Class II canine relationship.
Lt. Class I canine relationship.
Rt. & Lt. Class I molar relationship.
Rt.
Anterior
Horizontal overlap : 1-2 mm.
Vertical overlap : 2 mm.
Lt.
Clinical findings
Mid line shift to the Rt. Side 2 mm
21
Diagnostic Tools
1. FMX and OPG.
2. Diagnostic Casts & Diagnostic wax up.
3. 4Rs System :
R1: Patients report
R2: Radiographic findings
R3: Stimulus response testing:
P1: Pulp testing using Co2
P2: Periodontal condition
P3: Palpation
P4: Percussion
R4: Restorative index
22
FMX
23
FMX
24
FMX
25
Diagnostic Casts
26
Tentative Treatment Plan
Tooth
# 1(18)
Condition
Missing
Recommendation
---------------------------------------
# 2(17)
Occ. & B. caries
Cl. I ama. & Cl. V comp.
# 3(16)
O.D. caries
RCT, post & core & PFM

crown.
# 4(15)
Necrotic pulp
O.D. caries
# 5(14)
Irreversible pulpitis
O.D. & P. caries &
sever fluorosis

crown.
Cl. II , Cl. V composite &
Porcelain veneer.
27
Tooth
# 6(13)
Condition
Severe fluorosis &
facial caries
Porcelain veneer
# 7(12)
Severe fluorosis
Porcelain veneer
# 8(11)
Severe fluorosis
Porcelain veneer
# 9(21)
Severe fluorosis
Porcelain veneer
# 10(22)
Severe fluorosis
Porcelain veneer
# 11(23)
Severe fluorosis
Porcelain veneer
Recommendation
28
Tooth
# 12(24)
Condition
O.D. Caries & sever
fluorosis
Recommendation
Cl. II composite & Porcelain
veneer.
# 13(25)
MOD caries

crown.
# 14(26)
irreversible pulpitis
O.D.P caries & sever
fluorosis
Composite build up & PFM

crown.
# 15(27)
O.M.P. & B. caries
Cl. II ama. & Cl. V comp.
# 16(28)
Missing
---------------------------------------
29
Tooth
# 17(38)
Condition
Missing
Recommendation
--------------------------------------
# 18(37)
O.M. & B. caries
Cl II & V amalgam resto.
# 19(36)
O.D. caries
Cl II amalgam restoration.
# 20(35)
O. Caries & Severe

fluorosis
Cl I composite & porcelain

veneer.
# 21(34)
O.D. caries & Severe

fluorosis
Cl II composite & porcelain

veneer.
30
Tooth
# 22(33)
Condition
Defective restoration
& Severe fluorosis
Cl. V composite & porcelain

veneer.
# 23(32)
Severe fluorosis
Porcelain veneer.
# 24(31)
Severe fluorosis
Porcelain veneer.
# 25(41)
Severe fluorosis
Porcelain veneer.
# 26(42)
Severe fluorosis
Porcelain veneer.
# 27(43)
D. caries & Severe

fluorosis
Cl. III composite & porcelain

veneer.
Recommendation
31
Tooth
# 28(44)
Condition
M.O. Caries &
Severe fluorosis
Recommendation
Cl. II comp. & Porcelain
veneer.
# 29(45)
O.D. caries &

Severe fluorosis
Cl. II comp. & Porcelain

veneer.
# 30(46)
M.O. & O.D. caries
Cl. II amalgam restoration.
# 31(47)
O. & B Caries
Cl. I & V amalgam resto.
# 32(48)
Missing
-------------------------------------
32
Problem List
Chief complaint :
I had a sever pain related to upper right side and I do not like
the color of my teeth
33
Problem List
Risk Factors :
Poor oral hygiene.
Diet high carbohydrate & sugar
Sever fluorosis.
34
Treatment provided
dental fluorosis at or above a TFI score of 3

had higher levels of dental caries than those
with milder degrees of fluorosis present. This
finding suggests that if fluoride intake is too
high, severe enamel hypomineralization may
result in increased caries risk.
Cortes DF, et al.
J. of Public Health Dentistry 1996
35
Treatment provided
More severe degrees of enamel fluorosis are

associated with an abnormally high
incidence of caries. There is thus no doubt
that a high degree of enamel fluorosis causes
an increased tendency to caries.
Carlsson A.
Lakartidningen 1978
36
Treatment provided
Children with severe fluorosis have a

significantly higher caries experience than do
children with lesser degrees of fluososis
Driscoll WS et. al.

J Am Dent Assoc. 1986
37
Problem List
Restorative :
Caries lesions : #2(17), 3(16), 4(15), 5(14), 6(13), 12(24),
13(25), 14(26), 15(27), 18(37), 19(36), 20(35), 21(34),
27(43), 28(44), 29(45), 30(46), 31(47) T = 18
Defective restorations : #22(33)
Generalized severe fluorosis .
38
Problem List
Periodontal :
Generalized early to moderate plaque induced

gingivitis.
Generalized plaque and calculus .
39
Problem List
Endodontic :
Irreversible pulpitis : #4(15), 13(25).
Necrotic : #3(16).
T=2
40
Treatment Objectives
To educate & motivate the patient to improve her oral
hygiene.
To treat caries .
To restore esthetics .
To restore function .
41
Treatment Phases
Phase I : Clinical diagnosis, ER, prevention, consultation
and provisionalization.
Phase II : Resto, endo, & posting .
Phase III : Surgery .
Phase IV : Prosthodontic treatment .
Phase V : Recall & maintenance .
42
Treatment provided
Phase I: preventive dentistry phase

Clinical diagnosis
ER treatment
Consultation
Case presentation
Prevention:
9 Oral Hygiene Instructions
9 Scaling, root planning and Prophylaxis
9 Fluoride application
9 Diet analysis
43
Phase I
Endodontic emergency treatment #4(15),3(16).
#4(15)
Negotiation
Measurements
Initial condensation
Final
44
#3(16)
Measurements
Final
45
Phase II
Phase II: Resto., endo., & posting

Oral hygiene assessment & reinforcement.
Restoration of teeth:
#2(17), 3(16), 4(15), 5(14), 6(13), 12(24), 13(25), 14(26),
15(27), 18(37), 19(36), 20(35), 21(34), 27(43), 28(44),
29(45), 30(46), 31(47)
Endodontic treatment of teeth:

#13(25)
46
Oral hygiene assessment & reinforcement

Date
Tooth brushing :
3 Times / day
Plaque
Interproximal cleaning : Once / day
score
Meswak :
Once / week
Diet :
Patient reduce sugar intake Bleeding
score
prognosis :
good
1
Sep 18 04
26%
19%
10 11
12
13 14
15
16
32 31 30 29 28 27 26 25
24
23 22
21
20 19
18
17
PP
BOP
BOP
PP
47
Phase II
#2(17), 15(27), 18(37), 19(36), 30(46), 31(47)
48
Phase II
Inverse relationship between shear bond

strength and severity of fluorosis.
Awliya WY et al.
Inter. Dent. Journal 1999
49
Phase II
# 20(35), 21(34), 27(43), 28(44), 29(45)
50
Phase II
Endodontic treatment of tooth #13(25)
Negotiation
Initial
condensation
measurement
Final
obturation
51
Having 1 mm of vertical tooth wall between

the margin of the core and the shoulder of the
preparation provide a ferrule effect,
enhancing fracture resistance by 80% to
139%.
Sorensen JA, Engelman MJ.

J Prosthet Dent 1990
52
67% of the amalgam cores tested in an in

vitro study survived 1,000,000 cycles of 75-lb
loading, while 17% of composite resin cores
survived.
Kovarik RE, Breeding LC, Caughman WF.

J Prosthet Dent 1992
53
Phase IV
After initial preparation of Maxillary teeth, enamel where

easily chipped in the proximal surfaces with areas of enamel
defect, So treatment modified to a full coverage restoration.
54
Cases in which more than 50% of outermost

enamel Loss, i.e. TFI 8 & 9, The teeth should
be crowned.
Akpata E S.
55
With more severe forms of fluorosis, caries

risk increases because of pitting and loss of
the outer enamel.
Levy SM
J. of the Canadian Dent Assoc 2001
56
Diagnostic Wax Up
57
Phase IV
Oral hygiene assessment & reinforcement.

PFM crown # 3(16), 4(15), 5(14), 6(13), 7(12), 8(11),
9(21), 10(22), 11(23), 12(24), 13(25), 14(26). T = 12
Porcelain veneers #20(35), 21(34), 22(33), 23(32),
24(31), 25(41), 26(42), 27(43), 28(44), 29(45) T = 10
58
Oral hygiene assessment & reinforcement

Tooth brushing :
3 Times / day
Interproximal cleaning : Once / day
Meswak :
Once / week
Prognosis :
good
Date
Nov.13
04
Plaque
score
17%
Bleeding
score
15%
10 11
12
13 14
15
16
32 31 30 29 28 27 26 25
24
23 22
21
20 19
18
17
PP
BOP
BOP
PP
59
Phase IV
PFM crown # 3(16), 4(15), 5(14), 6(13), 7(12), 8(11), 9(21),
10(22), 11(23), 12(24), 13(25), 14(26).
60
Phase IV
Porcelain veneers #20(35), 21(34), 22(33), 23(32), 24(31),
25(41), 26(42), 27(43), 28(44), 29(45)
61
Treatment provided
Clinical experience had shown that pitted

fluorosed teeth (TFI _ 5 ) can seldom be
successfully managed by micro-abrasion,
such cases are therefore restored with
composite resin or laminate veneers.
Akpata E S.
62
Phase IV
Temporization
63
Phase IV
Metal try in.
64
FMX
65
FMX
66
FMX
67
OPG
68
Intraoral Photograph
69
70
71
72
73
Phase V: Recall & maintenance phase
(3 months)
Date
Jul. 10 05
Plaque
19%
score
Bleeding
21%
score
74
(6 months)
Date
Oct. 10 05
Plaque
score
16%
Bleeding
score
19%
75
(12 months)
Date
Apr. 11 06
Plaque
score
19%
Bleeding
score
25%
76
77
(21 months)
Date
Jan. 7 07
Plaque
score
23%
Bleeding
score
24%
78
79
80
Treatment summary
Treatment Duration :
Recall & maintenance : 4 visit
No. of Restorations :
18
No. of Crowns :
12
No. of Veneers :
10
7 Months
Objectives where achieved
81
82
313
212
223
312
--
10
11
12
13
14
15
312
222
323
322
232
323
323
223
233
223
313
211
112
212
222
224
Mobility
Recession
Probing depth
Existing Rest.
Defective Surface (s)
Carious Surface (s)
CO2
U
P
P
E
R
F
A
C
I
A
L
P
A
L
A
T
A
L
Recession
Probing depth
Existing Rest.
324
324
222
212
211
324
433
224
16
32
31
30
29
28
27
26 25
24
23 22
21
20
233
322
322
19
18
Mobility
222
2
2
2
2
2
2
2
2
2
2
2
2
313
211
Recession & Bleeding

323
Probing depth
322
222
322
212
333
332
Existing Rest.
Defective Surface (s)
Carious Surface (s)
+
CO2
L
O
W
E
R
F
A
C
I
A
L
L
I
N
G
U
A
L
Recession
Probing depth
Existing Rest.
323
323
222
211
112
212
222
223
323
233
223
17

Full Mouth Case With With 21 Months Follow Up2

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SAUDI COUNCIL FOR HEALTH

Dr. MOHAMMED ALSHEHRI R 4

Case NO. : 05/USC-RKH/R2 04

Total Number Of Visits :

Number Of Visits Attended:

Number Of cancelled visits:

Dr. MOHAMMED ALSHEHRI R 4

Family Medical History

Dr. MOHAMMED ALSHEHRI R 4

Dental Chief Complaint

Pain started 3 weeks ago.

Dr. MOHAMMED ALSHEHRI R 4

Past Dental History

Dr. MOHAMMED ALSHEHRI R 4

Habits and Oral Hygiene Activity

Interproximal cleaning : None

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Floor of the mouth NAD

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

* Silness J and Loe,H. 1964

PSR (Periodontal screening & recording system)

Dr. MOHAMMED ALSHEHRI R 4

Occlusion (Angels Classification)

Vertical overlap : 2 mm.

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Dr. MOHAMMED ALSHEHRI R 4

Tentative Treatment Plan

Occ. & B. caries

Cl. I ama. & Cl. V comp.

RCT, post & core & PFM

Dr. MOHAMMED ALSHEHRI R 4

RCT, post & core & PFM

Tentative Treatment Plan

Dr. MOHAMMED ALSHEHRI R 4

Tentative Treatment Plan

RCT, post & core & PFM

Composite build up & PFM

O.M.P. & B. caries

Cl. II ama. & Cl. V comp.

Dr. MOHAMMED ALSHEHRI R 4

Tentative Treatment Plan

O.M. & B. caries

Cl II & V amalgam resto.

O. Caries & Severe

Cl I composite & porcelain

O.D. caries & Severe

Cl II composite & porcelain

Dr. MOHAMMED ALSHEHRI R 4

Tentative Treatment Plan

Cl. V composite & porcelain

D. caries & Severe

Cl. III composite & porcelain

Dr. MOHAMMED ALSHEHRI R 4