A 59 year old female patient reported to Denty’s Vsp1 with a chief complaint of poor appearance of her upper front teeth due to severe proclination and also missing teeth in both her upper and lower back region of jaw. She had a previous dental history of orthodontic correction which was done twice for her upper anterior teeth when she was young (which was like 35years back) but couldn’t get the treatment completed due to health issues at both the times.
Extra oral examination revealed that the face is bilaterally symmetrical with poor aesthetics confined to maxillary and mandibular incisors. Maxillary central incisors were proclined with spacing between maxillary incisors (Figure 1). Skeletal class II pattern was noticed. On intra oral examination 15, 25, 26, 31, 32, 33, 36, 37, 44, 46 and 47 were missing. Carious lesions were identified in 17, 14 and generalised calculus deposits were observed. Patient was psychologically very apprehensive to dental treatments.
The treatment planned for this patient was scaling and polishing followed by root planing and curettage, composite restorations for 17 & 14, extraction of 11, 21, 41. Alveoloplasty was planned after extractions for surgical remodelling of maxilla for camouflaging the overjet, overbite and smile designing. Intentional root canal treatments were planned for 12, 13, 22, 23, 24, 27, 34, 35, 42, 43, 45. Zirconium crowns were planned for 14, 13, 12, 11, 21, 22, 23, 24, 25, 26, 27, 31, 32, 33, 34, 35, 41, 42, 43, 44, 45 to acheive both aesthetics and functional demands. Bite was raised by 1 mm to establish the Vertical Dimension. Valplast flexible removable denture was planned for 36, 37 and 46, 47.
Systematic desensitization was carried out in every step by gradual exposure of instruments and treatments by all the doctors in team for alleviating the fears and anxiety of the patient, which improved the psychological well being and increased treatment acceptance. Inter doctoral communication was strong enough for rendering the treatments harmoniously.
After scaling and polishing, root planing and curettage was done to establish periodontal health. Carious lesions were restored and intentional root canal treatments were performed. Extraction of 11, 21 and 41 were done along with alveoloplasty in maxillary and mandibular anterior regions. After adequate healing of the tissues, gingivoplasty was performed in areas with excess flabby tissue. Maxillary and mandibular alginate impressions were made. bite registration was done.
Preliminary casts were mounted for guiding the horizontal and vertical jaw relations. Removable partial denture was placed for mandibular molars, which acted as a vertical stop for crown preparations. Crown preparations were done for abutments 12, 13, 14, 22, 23, 24, 27, 34, 35, 42, 43, 45. Master impressions were made using putty wash technique. Bite registration was done using jet bite. Models were mounted on fully adjustable stratos 300 articulator, which has ergonomic design and advanced guided joint axis. Shade selection was done through vita shade guide and the chosen shade was A2/A3. Temporary crowns were cemented with Relyx temp for maintaining the bite.
The bite was raised by 1 mm for establishing the vertical dimension. Bisque trial was done with the crowns for assessing the fit, marginal accuracy and verification and simultaneous correction of protrusive and lateral interferences. After adequate corrections, new bite was registered and casts were remounted in accordance with new bite. Another bisque trial was done for evaluating the phonetics and interferences. Wax trial was done for mandibular removable denture. After glazing the bridges, they were cemented initially with relyx temp for a period of 3 days for checking the acceptance of the patient and their peers and family members. The permanent cementation of bridges was done with relyx u 200 resin cement (Figure 2) and removable partial denture was delivered for mandibular molars. Post cementation instructions were given and followed up after 7 days, 1 month and 9 months.
The total treatment execution took 3 months for its completion. The task was nearly herculean as the patient was extremely apprehensive and the tissue healing was slow and gradual. Systematic desensitization was carried out towards alleviating the apprehension and Multi-vitamin supplements were prescribed to aid in the process of healing. The end result of aesthetics, phonetics and other functional aspects were dramatic. After the treatment completion, patient conveyed that she felt wonderful about the outcome and smiled whole heartedly (after a really long time of about 35-40 years). Her confidence soared to new heights and surprisingly she became more talkative and cheerful.
Awesome to say the least, as it took more than 3 decades for her to smile profoundly and her choosing of DENTY’S fulfilled the long awaited dream.
Dr. Rajesh Reddy, Prosthodontist
Dr. Padmakanth, Periodontist
Dr. Subba rao, Endodontist
Dr. Shameen, Prosthodontist
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