oprm-web-case-fd-10

Terry is a 41 year old male with limited finances who is concerned about the appearance of his teeth. He is seeking the best treatment plan for the least amount of money.

Medical History:
The patient is alert, normally developed, and is in no distress. Patient takes no medications, denies all organ system disease and allergies.

Dental History:
He has received intermittent treatment, and the following teeth were extracted due to caries: #14, 15, 19, 20, 21, 30, 31.

Clinical Findings:
Generalized plaque and calculus with staining are evident. There are focal white rough lesions on the mandibular left and right alveolar ridges. These white lesions are asymptomatic and do not rub off.

Examine the images and create a treatment plan for Terry.

There are no lab reports available for this case.

There are no charts available for this case.

Periodontal Considerations:
Some maxillary teeth have furcation involvement, however, all are planned for extraction at this point. In the mandibular arch #21 and #29 have a lot of bone loss and would not be good RPD abutments. Remaining teeth would require perio evaluation regarding mobility, pocket depths, and amount of attached gingival tissue. Treatment may include root planing and then regular and frequent prophy follow up.

Oral Surgical considerations: Extraction of all maxillary teeth and indicated mandibular teeth. Patient will require maxillary alveoloplasty in both quadrants.

Prosthetic considerations: Patient has loss of vertical dimension with maxillary furcation involvement and requests an economical but sound treatment plan. Maxillary denture with mandibular RPD meet these requirements. If mandibular incisors are not somewhat firm, then they could be retained with a RPD design that plans for the eventual loss of these incisors and addition to the existing RPD.

A more detailed treatment plan would include the following making some assumptions as will be indicated and staying with a treatment plan that is "less expensive".

Observations:

1. Patient is missing 1, 3, 14, 15, 16, 17, 19, 20, 30, 31.
2. Patient has severe abrasion with loss of vertical dimension. Patient has 2 RCTs that may be a result of pulp exposures secondary to abrasion.
3. Patient has near pulp exposure #6.
4. Patient has accentuated Curve of Spee secondary to loss of mandibular teeth and over eruption of maxillary teeth with accompanying bone level.
5. Patient has periodontal disease with possible furcation involvement associated with #2, 5, 12 . Patient also has severe horizontal and vertical bone loss.
6. Did not see the white areas mentioned in the opening narrative of the case but assume they are localized hyperkeratosis secondary to ridge trauma from mastication.
7. Mandibular incisors appear to have good clinical height and although there is a lot of bone loss, will assume they are still not mobile, or at least not class 2 mobility or worse.

Treatment:

Extract all remaining maxillary teeth.

1. Furcation involvement #2, 5, 12 with very guarded prognosis. Horizontal and vertical bone loss associated with many of remaining maxillary teeth. Patient has loss of vertical dimension with loss of clinical crown height. Given periodontal condition and limited finances, easiest way to open vertical dimension is with a removable prosthesis (complete maxillary denture). During surgical procedure would ask the Oral Surgeon to do limited alveoloplasty in maxillary right and left quadrants to compensate for bone that has erupted down with over eruption of bicuspids.

Extract the following mandibular teeth:

1. #18 - has supraerupted and allows no room for opposing maxillary denture.
2. #21 - severe bone loss, not a good abutment for a mandibular RPD
3. #29 - severe bone loss, fulcrum for the post is above level of bone, not a good abutment.
4. #28 - severe bone loss, clinical crown would require a survey crown, not a good abutment, also would make it easier to maintain #27 with #28 removed

Periodontal treatment:

1. Evaluation of remaining mandibular teeth 22-27. If 23-26 are somewhat firm, then scaling and root planning with follow-up and prophy ever 4 months. Check periodontal pocket depth in this area and amount of remaining attached gingiva, not that a graft would be done because of expense but amount

Prosthetic Reconstruction:

1.  After extraction areas have healed for 6-8 weeks, fabricate maxillary complete denture and mandibular RPD at correct vertical dimension. Mandibular RPD major connector should be a lingual plate because of assumed loss of lingual attached gingival that correlates with bone loss of mandibular incisors and because as mandibular incisors are lost teeth can be added to mandibular RPD easier.
2. Although a mandibular complete denture may be less expensive, I feel that in reality this patient's transition to removable prosthesis will be easier with a more stable mandibular RPD.
3. Maintaining mandibular incisors will allow patient to retain ability to incise (will have to rotate object down instead of up) and will therefore, make the transition to a complete maxillary denture much easier.
4. Clinical crowns on #22 and #27 appear to have sufficient infrabulge area for a I Bar clasp and for a good lingual rest, therefore, surveyed crowns will not be needed.

Cost of proposed treatment:

• Extractions: 11 maxillary teeth x $25/tooth = $275
• alveoloplasty @ $30/quadrant = $60
• 4 mandibular teeth x $25 /tooth = $100
• (IV sedation if requested would be extra )
• Periodontics:Scaling and root planning= $50-100
• Prosthetics: Maxillary complete denture = $240
• Mandibular RPD = $390
• Total $1165

Discussion provided by Dr. Ronald Elvers, University of Iowa College of Dentistry, Department of Oral Pathology, Radiology and Medicine. ©1997 All rights reserved.