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1Dr. MOHAMMED ALSHEHRI R 4
SAUDI COUNCIL FOR HEALTH
SPECIALTIES
SBARD
Case Presentation
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2Dr. 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: 1
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3Dr. MOHAMMED ALSHEHRI R 4
Age: 27 years old.
Sex: Female
Nationality: Saudi
Education: Secondary school
Occupation: House wife
Marital & social status: Married
Patient attitude: Positively co-operative
Personal Data
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Medical History
Significant Medical Problems : None
Physical Classification : ASA I
History of Allergic Reaction : None
Family Medical History
None
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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 Chief Complaint
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Dental History
Pain History Form
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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.
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8Dr. MOHAMMED ALSHEHRI R 4
Tooth brushing : Twice / day
Interproximal cleaning : None
Meswak : Once / week
Mouth wash : None
Smoking : None
Habits and Oral Hygiene Activity
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Dietary Survey
,
3
----
----4
2
3
12
---- 1
15
----
3
----
---- ----
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10Dr. MOHAMMED ALSHEHRI R 4
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.
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Clinical Examination
Facial asymmetry NAD
Swelling NAD
Skin NAD
Lips Competent
Muscular Tenderness NAD
Extra-Oral Examination
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12Dr. MOHAMMED ALSHEHRI R 4
Clinical Examination
Clicking : NAD
Crepitus : NAD
Pain : NAD
Limitation On Opening : NAD
Deviation On Opening : NAD
TMJ
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13Dr. MOHAMMED ALSHEHRI R 4
Clinical Examination
Alveolar Mucosa NAD
Tongue NAD
Cheek NAD
Palate NAD
Floor of the mouth NAD
Frenum attachment NAD
Intra-Oral Examination (Soft Tissue)
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Intra-Oral Photographs
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Intra-Oral Photographs
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Intra-Oral Photographs
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Intra-Oral Photographs
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Gingiva
Generalized inflammation of the gingiva and interdentalpapillae with bleeding upon gentile propping
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Oral Hygiene
Date Sep. 4 04Plaque
score
76%
Bleedingscore
55%
* Silness J and Loe,H. 1964
*
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
PP
PP
BOP
BOP
Plaque : Generalized
Calculus : Generalized supra-gingival
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Oral Hygiene
PSR (Periodontal screening & recording system)
Probing depth :
- Generalized: 2-3 mm
Mobility : None Furcation: None
2 2 2
2 2 2
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Occlusion (Angels Classification)
Rt. Class II canine relationship.
Lt. Class I canine relationship.
Rt. & Lt. Class I molar relationship.
Anterior
Horizontal overlap : 1-2 mm.
Vertical overlap : 2 mm.
Mid line shift to the Rt. Side 2 mm
Clinical findings
Rt.
Lt.
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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
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FMX
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FMX
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FMX
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Diagnostic Casts
T i T Pl
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Tentative Treatment Plan
Tooth Condition Recommendation
# 1(18) Missing ---------------------------------------
# 2(17) Occ. & B. caries Cl. I ama. & Cl. V comp.
# 3(16) O.D. caries
Necrotic pulp
RCT, post & core & PFMcrown.
# 4(15) O.D. caries
Irreversible pulpitis
RCT, post & core & PFMcrown.
# 5(14) O.D. & P. caries &sever fluorosis
Cl. II , Cl. V composite &Porcelain veneer.
T i T Pl
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Tentative Treatment Plan
Tooth Condition Recommendation
# 6(13) 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
T t ti T t t Pl
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Tentative Treatment Plan
Tooth Condition Recommendation
# 12(24) O.D. Caries & severfluorosis
Cl. II composite & Porcelainveneer.
# 13(25) MOD caries
irreversible pulpitis
RCT, post & core & PFM
crown.
# 14(26) O.D.P caries & severfluorosis
Composite build up & PFMcrown.
# 15(27) O.M.P. & B. caries Cl. II ama. & Cl. V comp.
# 16(28) Missing ---------------------------------------
T t ti T t t Pl
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Tentative Treatment Plan
Tooth Condition Recommendation
# 17(38) Missing --------------------------------------
# 18(37) O.M. & B. caries Cl II & V amalgam resto.
# 19(36) O.D. caries Cl II amalgam restoration.
# 20(35) O. Caries & Severefluorosis Cl I composite & porcelainveneer.
# 21(34) O.D. caries & Severefluorosis
Cl II composite & porcelainveneer.
T t ti T t t Pl
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Tentative Treatment Plan
Tooth Condition Recommendation# 22(33) Defective restoration
& Severe fluorosisCl. 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 & Severefluorosis
Cl. III composite & porcelain
veneer.
Tentative Treatment Plan
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Tentative Treatment Plan
Tooth Condition Recommendation
# 28(44) M.O. Caries &Severe fluorosis Cl. II comp. & Porcelainveneer.
# 29(45) O.D. caries &Severe fluorosis
Cl. II comp. & Porcelainveneer.
# 30(46) M.O. & O.D. caries Cl. II amalgam restoration.
# 31(47) O. & B Caries Cl. I & V amalgam resto.
# 32(48) Missing -------------------------------------
Problem List
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33Dr. MOHAMMED ALSHEHRI R 4
I had a sever pain related to upper right side and I do not likethe color of my teeth
Problem List
Chief complaint :
Problem List
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Problem List
Risk Factors :
Poor oral hygiene.
Diet high carbohydrate & sugar
Sever fluorosis.
Treatment provided
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dental fluorosis at or above a TFI score of 3
had higher levels of dental caries than thosewith milder degrees of fluorosis present. This
finding suggests that if fluoride intake is toohigh, severe enamel hypomineralization may
result in increased caries risk.
Treatment provided
Cortes DF, et al.
J. of Public Health Dentistry 1996
Treatment provided
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36Dr. MOHAMMED ALSHEHRI R 4
More severe degrees of enamel fluorosis are
associated with an abnormally highincidence of caries. There is thus no doubt
that a high degree of enamel fluorosis causesan increased tendency to caries.
Treatment provided
Carlsson A.
Lakartidningen 1978
Treatment provided
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37Dr. MOHAMMED ALSHEHRI R 4
Children with severe fluorosis have a
significantly higher caries experience than dochildren with lesser degrees of fluososis
Treatment provided
Driscoll WS et. al.
J Am Dent Assoc. 1986
Problem List
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Problem List
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 = 18T = 18
Defective restorations : #22(33)
Generalized severe fluorosis .
Restorative :
Problem List
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Problem List
Periodontal :
Generalized early to moderate plaque induced
gingivitis.
Generalized plaque and calculus .
Problem List
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40Dr. MOHAMMED ALSHEHRI R 4
Problem List
Endodontic :
Irreversible pulpitis : #4(15), 13(25).
Necrotic : #3(16).
T = 2T = 2
Treatment Objectives
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41Dr. MOHAMMED ALSHEHRI R 4
Treatment Objectives
To educate & motivate the patient to improve her oral
hygiene.
To treat caries .
To restore esthetics .
To restore function .
Treatment Phases
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42Dr. MOHAMMED ALSHEHRI R 4
Treatment Phases
Phase I : Clinical diagnosis, ER, prevention, consultationand provisionalization.
Phase II : Resto, endo, & posting .
Phase III: Surgery .
Phase IV: Prosthodontic treatment .
Phase V : Recall & maintenance .
Treatment provided
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43Dr. MOHAMMED ALSHEHRI R 4
Phase I: preventive dentistry phase
Clinical diagnosis
ER treatment
Consultation
Case presentation
Prevention:
Oral Hygiene Instructions
Scaling, root planning and Prophylaxis Fluoride application
Diet analysis
ea e p ov ded
Phase I
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44Dr. MOHAMMED ALSHEHRI R 4
Endodontic emergency treatment #4(15),3(16).
Negotiation Measurements Initial condensation Final
#4(15)
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45Dr. MOHAMMED ALSHEHRI R 4
Measurements Initial condensation Initial condensation Final
#3(16)
Phase II
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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)
Oral hygiene assessment & reinforcement
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Tooth brushing : 3 Times / day Interproximal cleaning : Once / day
Meswak : Once / week
Diet : Patient reduce sugar intakeprognosis : good
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
yg
Date Sep 18 04
Plaque
score
26%
Bleedingscore
19%
* Silness J and Loe,H. 1964
*
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PP
PP
BOP
BOP
Phase II
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Restoration of teeth:#2(17), 15(27), 18(37), 19(36), 30(46), 31(47)
Phase II
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Inverse relationship between shear bond
strength and severity of fluorosis.
Awliya WY et al.
Inter. Dent. Journal 1999
Phase II
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Restoration of teeth:# 20(35), 21(34), 27(43), 28(44), 29(45)
Phase II
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Endodontic treatment of tooth #13(25)Negotiation
measurement
Initial
condensationFinal
obturation
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52Dr. MOHAMMED ALSHEHRI R 4
Having 1 mm of vertical tooth wall between
the margin of the core and the shoulder of thepreparation provide a ferrule effect,
enhancing fracture resistance by 80% to139%.
Sorensen JA, Engelman MJ.
J Prosthet Dent 1990
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53Dr. MOHAMMED ALSHEHRI R 4
67% of the amalgam cores tested in an in
vitro study survived 1,000,000 cycles of 75-lbloading, while 17% of composite resin cores
survived.
Kovarik RE, Breeding LC, Caughman WF.
J Prosthet Dent 1992
Phase IV
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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.
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Cases in which more than 50% of outermost
enamel Loss, i.e. TFI 8 & 9, The teeth shouldbe crowned.
Akpata E S.
Inter. Dent. Journal 2001
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56Dr. MOHAMMED ALSHEHRI R 4
With more severe forms of fluorosis, caries
risk increases because of pitting and loss ofthe outer enamel.
Levy SM
J. of the Canadian Dent Assoc 2001
Diagnostic Wax Up
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Phase IV
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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 = 12T = 12
Porcelain veneers #20(35), 21(34), 22(33), 23(32),
24(31), 25(41), 26(42), 27(43), 28(44), 29(45) T = 10T = 10
Oral hygiene assessment & reinforcement
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Tooth brushing : 3 Times / day
Interproximal cleaning : Once / day
Meswak : Once / week
Prognosis : good
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Date Nov.13
04
Plaque
score
17%
Bleeding
score
15%
* Silness J and Loe,H. 1964
*1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PP
PP
BOP
BOP
Phase IV
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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).
Phase IV
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Porcelain veneers #20(35), 21(34), 22(33), 23(32), 24(31),
25(41), 26(42), 27(43), 28(44), 29(45)
Treatment provided
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Clinical experience had shown that pitted
fluorosed teeth (TFI _ 5 ) can seldom besuccessfully managed by micro-abrasion,
such cases are therefore restored with
composite resin or laminate veneers.
Akpata E S.
Inter. Dent. Journal 2001
Phase IV
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Temporization
Phase IV
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Metal try in.
FMX
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FMX
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FMX
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OPG
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Intraoral Photograph
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Intraoral Photograph
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Intraoral Photograph
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Intraoral Photograph
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Intraoral Photograph
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Phase V: Recall & maintenance phase
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(3 months)
Date Jul. 10 05
Plaque
score
19%
Bleeding
score
21%
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Date Oct. 10 05
Plaque
score
16%
Bleeding
score
19%
(6 months)
Date Apr. 11 06
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Plaquescore 19%
Bleeding
score
25%
(12 months)
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(21 months)
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Date Jan. 7 07
Plaque
score
23%
Bleedingscore
24%
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Treatment summary
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Treatment Duration : 7 MonthsTreatment Duration : 7 Months
Recall & maintenance : 4 visitRecall & maintenance : 4 visit
No. of Restorations : 18No. of Restorations : 18
No. of Crowns : 12No. of Crowns : 12
No. of Veneers : 10No. of Veneers : 10
Objectives where achievedObjectives where achieved
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312312313313 212212 223223 312312 222222 323323 322322 232232 323323 323323 223223 233233 223223
Mobility
Recession
Probing depth
Existing Rest.
1 2 3 4 5 6 71 2 3 4 5 6 7 8 9 10 11 12 13 14 158 9 10 11 12 13 14 15 1616
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++++ ---- ++ ++ ++ ++ ++ ++ ++ ++ ++
Defective Surface (s)
Carious Surface (s)
CO2
F
A
C
I
A
L
P
A
L
A
T
A
L
Recession
Probing depth
Existing Rest.
U
P
P
E
R
324324 324324 222222 212212 313313 211211 211211 112112 212212 222222 224224 324324 433433 224224
323323 322322 222222 322322 222222
22
22
22
22
22
22
22
22
22
22
22
22
233233 322322 322322 333333 332332
MobilityMobility
Recession & BleedingRecession & Bleeding
Probing depthProbing depth
Existing Rest.Existing Rest.
32 31 30 29 28 27 26 2532 31 30 29 28 27 26 25 24 23 22 21 20 19 18 1724 23 22 21 20 19 18 17
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++ ++ ++ ++ ++ ++ ++ ++ ++ ++ ++ ++ ++ ++
Defective Surface (s)Defective Surface (s)
Carious Surface (s)Carious Surface (s)
CO2CO2
F
A
C
I
A
L
L
I
N
G
U
A
L
L
O
W
E
R
RecessionRecession
Probing depthProbing depth
Existing Rest.Existing Rest.
323323 323323 222222 212212 313313 211211 211211 112112 212212 222222 223223 323323 233233 223223