ODA FEATURE
CASE REPORT:
COMPLEX RESTORATIVE DENTISTRY By: Joe F. Maltsberger, DDS
Complex restorative dentistry requires a detailed approach to every step of treatment. Appropriate data must be gathered to facilitate a proper diagnosis and critically evaluate different treatment approaches. Discussions with the patient (and spouse if possible) along with photos and models of previous similar cases will allow the patient to choose the treatment they want, and will also facilitate development of a written financial arrangement. Once treatment has been determined the dentist can work out a detailed sequence of treatment and an appointment schedule based on the patient’s needs and preferences. Complex restorative treatment is within the reach of many dentists, but it requires a commitment to detail, extra training, finding and working with an exceptional lab, and a desire to do what is best for the patient. Your professional fulfillment and enjoyment is virtually guaranteed as you see beautiful and long-lasting results and, most importantly, a happy and satisfied patient. A thorough accumulation and review of all relevant data is critical to the success of any complex case. This process involves consideration of the following areas: • Registration/Insurance Issues • Medical History - A detailed history, including a thorough patient interview and calls to medical providers as necessary to gain knowledge of any medical conditions that could be pertinent to the treatment. • FMX – A 20-film full mouth series to fully examine root tips, interproximal areas, and the bone levels of every tooth. In cases where gagging or tori are problems, a panoramic x-ray may be needed as well.
38 journal | March/April 2021
• Periodontal Probing – Probing/ documenting six measurements around each tooth, and recording any areas of bleeding, recession or mobility. • Hard and soft tissue evaluation - This includes a cancer evaluation of the head and neck, as well as carefully documenting all caries or tooth anomalies. • TMJ Evaluation/Occlusal Evaluation using Mounted Models – Mounting accurate upper and lower arch models on a semi-adjustable articulator with facebow transfer and a centric relation bite using the Lucia Jig. • Intraoral/Extraoral Photographs A minimum of eight photographs is recommended. • Patient interview – The interview outlines the patient’s objectives and goals, allows for a consideration of treatment alternatives and budgetary matters, and may reveal other hot button issues pertinent to treatment recommendations. CASE REPORT A 50-year-old female presented to my office with no evident medical issues or current medication history. The following is a brief summary of examination findings: FMX revealed multiple restorations, but no evident decay. Bone levels appeared within normal limits, but there were areas of severe wear, most notably in teeth #21-28. Periodontal probing found no pockets exceeding 4mm; there was minimal bleeding with probing and no mobility or other periodontal concerns. Hard tissue examination revealed no caries, but an upper right bridge was broken in the pontic area (#4) and the wear noted on the radiographs
was corroborated intraorally. This was a red flag that she was grinding her teeth at night (and possibly during the day); along with associated muscle problems this could affect any new restorations. TMJ evaluation produced reciprocal clicks in both joints. The muscles were very tense, and it was difficult to manipulate her jaw into centric relation. There was muscle sensitivity upon palpation of the left and right anterior temporalis and masseter muscles; the patient reported headaches in these areas 2-3 times per week. There was no deviation upon opening. Her mounted and articulated models showed a discrepancy between centric occlusion and centric relation. She had a mutually protected occlusion with canine lift on both sides, a 7mm overbite, and a 3mm overjet. Extraoral photographs showed prominent spacing between her upper central incisors, a high lip line, and color variations in her teeth due to tetracycline staining, poorly matching restorations and failing composites. (Figs 1-3) Her concerns about the gap between her upper centrals and the color variance in her upper teeth were reinforced during our interview. In addition, she wanted her teeth to be lighter. I explained that to get the results she desired would require multiple crowns in the upper arch, placed in correct position when finished, so that the final result would be fully functional as well as esthetic. I informed her that she might need to wear an appliance at night for the rest of her life; she would also need to commit to an aggressive preventative plan with consistent daily care at home and regular visits to our office for cleaning and check-ups. TREATMENT PLAN Based on these findings the following comprised the elements of my
