3M Oral Care –

MAP Intervarsity Case: Anterior 3-

Prosthodontics unit fixed-fixed
bridge
Competition
2015/2016
Mohd Herie Dahlan
(1017641)
Kulliyyah of Dentistry,
IIUM Kuantan
CASE SUMMARY:
Mr AH, a 43 years old male teacher presented with missing right central incisor and
concern of unaesthetic removable partial denture. Advice from Prosthodontist was
sought after in planning of restoration of the edentulous space as well as improving
the shape and shade of the adjacent incisors. He was provided with 3-unit anterior
fixed-fixed metal ceramic bridge. Occlusion was conformed at his existing vertical
dimension.

Patient’s detail:
 Initial: Mr AH
 Age: 43 years old
 Occupation: teacher

Chief Complaint:
 Uncomfortable with upper removable denture
 Wish to have a fixed prosthesis to replace his missing upper front tooth

History of presenting complaints:

 According to Mr AH, his upper right central incisor was subjected to root
canal treatment after his dentist found deep carious lesion few years back.
 However due to unforeseen circumstances, his endodontic treatment failed
and he was advised to have the tooth extracted.
 He was provided with an immediate upper partial acrylic denture since.
 He was not happy with the prosthesis and would like to have a fixed rather
than a removable prosthesis.
 He reported that he could not chew his food well with the denture and was
not happy with his appearance.

Medical history:
 Diagnosed with hypertension but he is currently not under medication.
 No known allergy.

Dental History:
 Regular dental attender, at least twice a year.
 History of multiple restorations.
 No known complication after dental extraction.

Oral hygiene habit:

 Brushes his teeth twice daily with fluoridated toothpaste.
 Uses medium bristle manual toothbrush.
 Do not use floss and mouthwash.

Social history:
 Never smokes.
 Never take alcohol.
 Married with 6 children, live with his family.
Diet history:
Parafunctional habits:
 Not known

CLINICAL EXAMINATION
Extra-oral examination:
 Face symmetry
 Competent lips at rest
 Class I facial profile
 No abnormality detected on temporomandibular joints
 No lymphadenopathy
 Average smile line

Intra-oral examination:
 Soft tissues
o Oral mucosa appeared healthy.
o Presence of buccal keratosis.

 Periodontal status
o Fair oral hygiene with minimal plaque.
o Gingival tissue bleeding upon probing.
o Basic Periodontal Examination (BPE):
2 2 2
2 2 2
Dentition and restoration present:

 Missing 11
 Need to know the mesio-distal width of the missing space

Occlusion:
 Class I incisal relationship
 Cross bite over right canine.
 Midline shifted about 1-2 mm to the left in relation to upper labial frenum.
 Canine guidance on both lateral excursions.
 Incisal guidance on protrusion.
SPECIAL INVESTIGATIONS:
Radiographic findings:
  Periapical x rays of 12 and 21 were taken to assess the suitability of the teeth
as abutments
 Both teeth were endodontically treated and no abnormality detected over
the periapical areas. No widening of lamina dura observed.
 However, evidence of bone loss about 1/3 of the root lengths on both teeth
were noted.
 GP was also not obturated up to the apex on 21 but because there was no
evidence of sign and symptoms and no periapical radiolucency, this tooth
was considered stable.

DIAGNOSIS:
 Chronic localized gingivitis
 Partially-dentate upper and lower arches
 Poorly constructed upper removable partial denture

TREATMENT AIMS:
1. Stabilize periodontal condition and improve oral hygiene.
2. Provide dietary advice.
3. Improve function and aesthetics.
4. Provide patient with maintainable treatment outcome.

TREATMENT OPTIONS:

Management options for edentulous space

Removable prosthesis
o Either with acrylic or cobalt-chrome partial denture
o This is the cheapest treatment option for the patient
o Although it is viable option to replace missing anterior tooth, the
aesthetic and comfort of the patient need to be taken care of.
o As a teacher, he prefers to have something fixed anteriorly.

Conventional bridges
o Due to the discoloration of both teeth 21 and 12, as well as protruded
12, this option would be better as we can change not only the shades
but also the shape of the teeth to give him a more aesthetic outcome.
 o Cost of the treatment would depend on the material used for
construction of the fixed-fixed bridge.

Implant-retained prosthesis
o Implant prosthesis has been the first choice of treatment for many
dentist, however many considerations have to be taken into account
for.
o For the patient, the cost of the implant and prosthesis is high
o Clinically, there was also buccal bone concavity over the edentulous
space, which will complicate the selection of suitable diameter of
implants as well as the positioning of implant.
o Besides, presence of maxillary sinus also increases the complexity of
the treatment.
o However, there are options of bone grafting or sinus lift procedure to
encounter these, but will also incur more cost to the patient and
increased healing period.
o Apart from these factors, the mesio-distal width of the space for his
right central incisor was large in comparison to the mesio-distal
width of the adjacent incisor, which will compromised the aesthetic
appearance of the final crown.

TREATMENT CARE PLAN:

1. Stabilization phase
a) Prevention:
o Provides oral hygiene and dietary advices.
o Emphasize on the importance of fluoride, duration and frequency of
acid in diet and to limit acidic food intake during mealtime and do not
brush immediately after meals.

b) Periodontic intervention:
o Full mouth scaling, oral hygiene reinforcement and monitoring

2. Restorative phase
A. Planning stage:
o Primary impressions of maxillary and mandibular arches taken with
alginate impression material.
o Diagnostic wax-ups performed on articulated study casts.
B. Tooth preparation:

o A silicone matrix of the upper teeth was made from the study cast.
o The teeth were prepared for metal ceramic restorations
o Once tooth preparations were done, temporary linked crowns were
made using temporary composite material (Protemp™ 4) and silicone
matrix that were constructed according to diagnostic wax up.
o The bridge were designed to have shared incisal guidance on
protrusion with light shimstock contact on the pontic in intercuspal
position (ICP)
o Cementation with Tempbond®.
o At the next visit, the temporary bridge was reviewed.
o As the occlusion was stable and no chipping or fracture of the
temporary bridge observed, tooth preparations were refined
o Definitive impression was taken with light-bodied and heavy-bodied
polyvinyl siloxane.
C. Final fitting stage (issue):
o The final prosthesis (bridge) was checked on the working cast. Its
margins adaptability on abutment as well as presence of any worn
adjacent contact surfaces were observed carefully.
o In the patient’s mouth, temporary bridge was removed. The
abutments were cleaned and polished with pumice.
o Then the bridge was tried. The marginal adaptability, occlusion (both
in ICP and protrusion) and appearance were assessed.
o Patient was also given mirror in order for him to give feedback on the
prosthesis.
o Once patient was happy, the prosthesis was cemented with resin
cement (NAME).
o Final occlusion was checked with shimstock foils.
Discussion:
Mr AH whom presented with dissatisfaction on his unaesthetic upper removable
partial denture exhibited a fairly complex treatment planning. This was due to the
large mesio-distal space for the restoration of missing right central incisor, which
was not proportional to the mesio-distal width of the adjacent incisor. In order to
provide Mr AH with a symmetrical central incisor, the space should ideally be
reduced or the width of the adjacent central incisor be increased.

Few options were discussed with Mr AH from the most conservative treatment to
more invasive approaches, which include a new removable partial denture
combined with composite build ups, cantilever fixed bridge in combination of
composite build ups, conventional fixed-fixed bridge as well as implant-supported
crown combined with composite build ups.

As Mr AH did not want any removable prosthesis anymore, implant-supported

crown with composite build ups were deemed to be the better option. However due
to the lack of bucco-palatal bone width, restoration of the aesthetic zone would be
difficult and might need further bone augmentation surgeries. Moreover, cost of the
treatment would be increased.

After discussion with Mr AH, supplemented with diagnostic wax up, he agreed to go
for conventional fixed-fixed bridge. This option not only able to restore the shape of
the adjacent teeth, it also helps to match the shades of several incisors. Besides, the
bridge can also provide coronal seals to both root canal treated incisors and to
distribute the occlusal load along the bridge abutments when patient is in function.
Metal ceramic bridge was chosen for its cost, strength and aesthetic.

Overall, the prognosis for the case is considered good as his function and aesthetic
were restored successfully. His appearance could be improved should he agreed to
go for orthodontic treatment prior to prosthesis construction which would greatly
improve his smile. Orthodontic treatment not only can correct his crossbite on 23
but also retrude the anterior teeth and reduce the edentulous space for a more
favourable crown width.