復科臨床病例報告二 - 中華民國贋復牙科學會26 中華民國贋復牙科學會／ the...

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China,Taiwan26

病例討論專欄

復科臨床病例報告二

時間：中華民國一○三年六月七日Instructor: 傅立志醫師、陸泰年醫師、沈嬿文醫師

報告／R4黃若婷

█ Chief complaint

█ Past medical history ● HTN under medical control ● N�

█ Personal habits ● Smoking (-) ● Alcohol : (-) ● Betel nut chewing (-)

█ General data

Name : 洪X池

Chart number : 16767959

Gender : Male

Age : 79 y/o

Marriage : married

Occupation : farmer

Attitude : cooperation and comprehensive

First visit : 102.06.13

Came for dental examination. Request for denture evaluation.

102.06.13

● Bruxism(-) ● Oral hygiene

● Brushing teeth: one time/day

The Academy of Prosthetic Dentistry, Republic of China,Taiwan／中華民國贋復牙科學會 27

病例討論專欄

█ Extra-oral examination




Frontal view ● Facial midline : on ● Face form : long ovoid ● Front facial view : symmetry

Frontal view (with retractor) ● Facial midline : on ● Facial to maxilla midline : shi� to right side about 1mm

Frontal view (smile) ● Facial midline : on ● Face form : long ovoid ● Front facial view : symmetry ● Gummy smile: no

Lateral view :45°

● Malar area: � at ● Paransal area: � at

102.07.15

102.07.15

102.07.15

102.07.15


病例討論專欄

█ Extra-oral examination █ TMJ-related examination

█ Intra-oral examination

█ Occlusal view

Lateral view :90°

● Pro� le: cave ● E-line: ● Upper lip: retrued ● Lower lip : on ● Nasolabial angle: 100°

● Maximum mouth opening :50 mm (edentulous ridge-41incisor edge)

● Clicking sounds: (-) ● Jaw deviation when opening mouth : (-) ● Muscle palpation pain(-) ● Joint palpation pain(-)

● A� er extraction for a week102.07.15

◆ Arch form : square ◆ Maxillary edentulous ridge ◆ Multiple extraction sockets ◆ Ulcer at incisive papilla

◆ Arch form : tapper ◆ Remaining teeth: 34, 33,

32, 31, 43 ◆ FPD:32-31-X, 43-X-X-X ◆ Caries:34

102.07.15


病例討論專欄

█ Study cast

█ Panoramic fi lm

◆ Shallow vestibular at bilateral posterior area

◆ No obviously bony under cut

◆ Multiple extraction sockets

◆ Lingual frenum to gingival line: > 8mm

◆ Very bulky of old LA FPD ◆ No tissue undercut at 34,

43 buccal area ◆ FPD:32-31-X, 43-X-X-X ◆ Caries:34102.07.15

● Maxillary edentulous ridge ● Missing:38,37,36,35,41,42,44,45,46,47,48 ● FPD:32-31-X, 43-X-X-X ● RCT:31,32

● Apical lesion at 34 ● Generalized moderate alveolar bone loss ● Normal TMJ, No obviously bony lesion

102.06.13


病例討論專欄

█ Periapical fi lm

█ Intra-oral Examination

102.07.15

102.07.15

Lower Left SextantCAL&BOPPD&plaqueCEJ.GM

Facial

Lingual

CEJ.GMPD&plaqueCAL&BOP


病例討論專欄

█ Intra-oral Examination

█ Charting data102.07.15

Lower Left SextantCAL&BOPPD&plaqueCEJ.GM

Facial

Lingual

CEJ.GMPD&plaqueCAL&BOP


病例討論專欄

Provisional Prognosis (1991 McGuire MK.)

Overall prognosis：Fair

Individual prognosis：

X X X X X X X X X X X X X X X X

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

X X X X X F X X Q Q F F X X X X

良好 Good 尚可 Fair 差 Poor 可疑 Questionable 放棄 Hopeless

■ Adequate remaining bone

■ Possibilities to control etiologic factors

■ Maintainable dentition

■ Patient cooperation

■ Less than adequate remaining bone support

■ Some tooth mobility ■ Degree I furcation-

involvement ■ Adequate maintenance

possible ■ Patient cooperation

■ Moderate to advanced bone loss

■ Tooth mobility ■ Degree I~II furcation-

involvement ■ Di� cult to maintain areas ■ Doubtful patient

compliance

■ Advanced bone loss ■ Degree II~III furcation-

involvement ■ Tooth mobility ■ Inaccessible area

■ Advanced bone loss ■ Nonmaintainable

area ■ Extraction indicated

█ Diagnosis

█ Problems list

● Generalized periodontitis ● Caries:34,33,32,31,43 ● Apical periodontitis :34 ● Missing teeth: 18, 17, 16, 15, 14, 13, 12, 11, 21, 22,

23, 24, 25, 26, 27, 28, 38, 37, 36, 35, 41, 42, 44, 45, 46, 47, 48

● Traumatic ulceration lesion at incisive papilla

● Poor oral hygiene ● Inadequate space of 41,42 ● Ill-� � ed old FPD: 32-31-X (patient refused remove

this FPD) ● Limited budget ● Gingival recession


病例討論專欄

█ Preliminary treatment options

█ Prosthetic treatment options

█ Prosthetic treatment options-I █ Prosthetic treatment options-II

● Oral hygiene instruction ● Full mouth scaling ● RCT: 33, 34 ● Remove FPD: 43-XXX,41 ● Provisional crown fabrication of 33,34, and 43 ● Interim maxillary CD and mandibular RPD

患者不想花太多錢,不想花錢做臨時活動假牙也不願意植牙和根管重新治療

Maxilla ● Complete denture

Mandible ● Kennedy class I RPD ● 33-43, 34 surveyed crown

Maxilla ● Complete denture

Mandible ● Kennedy class I modi� cation 1 RPD ● 33-34, 43 surveyed crown

患者選擇第二個治療計畫


病例討論專欄

█ Survey and RPD design

█ Design

█ Prosthetic treatment course

Defi nite treatment plans ● Maxilla: complete denture ● Mandible: Kennedy class I modi� cation 1 RPD

● Major connector : lingual plate ● Cingulum rest :33, 43 ● Occlusal rest: 34(M) ● Guiding plane :34(D), 31(M), 43(MD) ● I-bar clasp : 34, 43

● 102.07.15 : pre-treatment data collection ● 102.08.10 : 33,34,43 tooth preparation and provisional crown fabrication ● 102.09.11 : 33,34 post ● 102.09.19 : 33,34,43 impression ● 102.09.25 : border molding of maxilla ● 102.10.12 : VD and CR record ● 102.10.28 : Wax denture try in ● 102.11.16 : 33,34,43 deliver and cementation. OHI ● 102.11.21 : border molding of mandible ● 102.11.27 : framework try in and take CR bite ● 102.12.03 : denture try in ● 102.12.06 : deliver CD+ RPD ● 102.12.09 : follow up(3 days) ● 102.12.23 : follow up(2 weeks) ● 103.01.21 : follow up(1.5 M) 但沒來 ● 103.03.13 : follow up(3 M) ● 103.06 : follow up (6M)

I-bar clasp : 43 - 43 into mesio-buccal 0.01 inch

I-bar clasp : 33 - 33 into mesio-buccal 0.01 inch


病例討論專欄

█ Tooth preparation and provisional crown fabrication (33,34,43)

● Referred to endo dept. for 33 and 34 RCT. ● 43 keep follow up ● Deliver so� occlusal splint for prevention of the traumatic injury

102.08.10

█ Impression: 33,34,43102.09.19


病例討論專欄

█ Border molding of maxilla

█ Occlusal rim

102.09.25

102.10.12


病例討論專欄

█ VD and CR record

█ VD and CR record

102.10.12

102.10.12


病例討論專欄

█ Wax denture try in

█ Fully wax up

◆ Occlusal view

102.10.28

Profi le (frontal view) Profi le (smile) Profi le (frontal view) Profi le (lateral view)


病例討論專欄

█ Occlusal analysis

█ Cut back

█ Metal framework

W B B W

Lateral and protrusive movement

Right excursion Left excursion

R't L't

Protrusion


病例討論專欄

█ FPD delivery

33,34,43 deliver and cementation. OHI ● Occlusal view

102.11.16


102.11.16

W B

B

R't L't

W

Lateral and protrusive movementRight excursion

Left excursion

Protrusion


病例討論專欄

█ FPD delivery102.11.16

102.11.21

43 33,34Occlussion

OHICheck with PA fi lm

Study cast impression and plan to do border molding (one piece)

█ Border molding of mandible


病例討論專欄

█ Border molding of mandible

█ Framework try in

Before After

102.11.27


病例討論專欄

█ Take CR record

102.11.27


◆ Check CR and VD

102.12.03


病例討論專欄


◆ Check CR and VD

102.12.03


102.12.03

W B

B

R't L't

W


Left excursion

Protrusion


病例討論專欄

█ Denture try in

102.12.03Profi le (frontal view)

Before tooth extraction Now With retractor

Profi le (lateral view)

Before Nasolabial angle: 95°

NowNasolabial angle: 85°

█ Delivery

102.12.06組織面


病例討論專欄

102.12.06

Occlusal view

█ Delivery

102.12.06咬點


病例討論專欄


102.12.06

W B

B

R't L't

W


Left excursion

Protrusion

█ Delivery

102.12.06 102.12.06

102.12.06

Profi le (frontal view) Profi le (lateral view-45 °)

Profi le (lateral view-90 °)Before Before

Before

Now Now

Now


病例討論專欄

█ Delivery

102.12.06

Mounting cast

█ Follow up

● 102.12.09 : follow up(3 days) ● Ulcer at le� cheek

● 102.12.23 : follow up(2 weeks) ● No speci� c complaint

● 103.01.21 : follow up(1.5 M) 但沒來 ● No any complaint

● 103.03.13 : follow up(3 M) ● No speci� c complaint

● 103.06 : follow up(6 M)

◆ Overjet :1mm ◆ Overbite: 1mm


病例討論專欄

█ Follow up (3M)

103.03.13

Occlusal view

Mucosa103.03.13


病例討論專欄

Q1： 36有磨耗是否有考慮提高VD，則可以不必將34進行根管

治療？

A1： 36咬合面雖然有磨耗，但是磨耗的咬合面36往近心傾

斜，且34 elongation的狀況較為嚴重，故還是建議患者

34進行根管治療以建立較適宜的咬合平面和避免日後34如果牙髓神經發炎必須要重新製作一個34固定式假牙來

配合已經存在的下顎部分活動假牙之困擾。

Q2：有確認VD是否有loss？

A2：本Case只有以患者的臉型初略評估垂直高度沒有嚴重尚失和不足。日後如果遇到

類似的case將會製作上下顎的咬合蠟堤進行較準確的垂直高度是否合宜的確認。

Q3： 13和47為何要拔？如果不拔，可能會影響RPD的設計。

A3：臨床上，13的牙周狀況不佳、位置過度偏於頰側且齒槽骨過度突出，47的位置

過度偏於舌側，這2顆牙齒在以修磨牙齒型態的處置下是無法讓部分活動假牙獲

得適當的置入和取出路徑，故建議患者拔除。

Q4：如果預算不是問題，Orthodox. Tx.和植牙如何設計？

A4：如果患者沒有預算上的考量，進行全口重建時，Orthodox. Tx.和植牙是治療計畫

的選項之一，如果是製作固定式假牙步驟如下：

(1) 拔除牙周狀況預後不佳和影響決定人工牙根位置的牙齒。

(13的牙周狀況不佳故還是建議拔除，47的牙周狀況尚可，則可以考慮保

留。人工牙根位置預定在13, 11, 21, 23, 25, 37, 33, 31, 42, 45, 46)

(2) 製作符合初步美觀和功能的過渡性活動假牙。

(3) 進行Orthodox. Tx.。

(上顎和下顎如果要矯正都沒有足夠的牙齒當作anchorage，必須使用矯正用

的小植體來當作anchorage)

(4) 當牙齒的位置和角度調整後，重新製作第2個過渡性活動假牙，並重新評估

上述步驟(1) 預定的人工牙根位置是否要調整。

(5) 依據第2個過渡性活動假牙製作手術導引版。

(6) 進行軟硬組織的移植和植牙手術。

(7) 製作固定式假牙。

(Tooth-supported fixed bridge：16-14; 34-36。Implant-supported fixed bridge：13-11; 21-23-25; 37; 33-31-42; 45-46)


病例討論專欄

Case I和Case II結論：治療前，要先有diagnostic wax-up or denture確認VD and CR。如果有活動假牙要先

想好path of insertion和考慮力量的分配下設計rest and clasp的位置。

Case I 1. 如果可以重新製作，流程和設計該如何調整？

2. 沒有美觀問題，建議用metal collar

3. 牙齒顏色和形態可以調整符合患者年紀和個性

4. 拆除舊假牙之前上顎無牙，沒有辦法確認咬合平面，無法評估牙

齒要修多少，建議要先取VD、CR和預估舊假牙與RPD的path of insertion。

Case II 1. 36 有磨耗是否有考慮提高VD，則可以不必將34進行根管治療？

2. 是否有確認VD 是否有loss

3. 13和47為何要拔？可能會影響RPD的設計

4. 如果預算不是問題，Orthodox. Tx. 和植牙如何設計？上顎如果要矯

正沒有足夠的牙齒？

5. 植牙前是否有評估製作假牙的空間？

檢查graft 的質地、厚度和移動量、舌頭的移動度、假牙的穩定度決

定牙齒要排到哪裡？

治療後牙的固定補綴前，要先評估高速手機是否可以在正確的軸向

移動，也就是要確認張口度。

復科臨床病例報告二 - 中華民國贋復牙科學會26 中華民國贋復牙科學會／ the...

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