The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 19

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█病例特色：矯正合併全瓷牙冠 復重建

█口外觀：

█口外檢查1. No gross deformity or abnormality.

2. No palpable lymph node over the submandibular, sublingual and neck region.

3. No enlargement of salivary gland.

4. No lip incompetence

5. No gummy smile

6. Lateral pro� le : Mild convex of lip to E-line

7. Face : generally symmetry Her nose axis mild shi� ing to R''t the inter- pupil line mild down to L't

37歲女性職業教師主 訴：上顎左側臼齒不舒服，要求作檢查。牙科病史：不定期地洗牙、蛀牙填補、根管治療與假牙製作。醫療病史：無明顯病症與不良習慣。

夏季季病例討論會病例二

時間：中華民國一百年六月十八日地點：中國醫藥附設醫院

報告／中榮 宋博達 醫師

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China20

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█口內檢查與診斷 ● FM periodontitis with bone loss

● Caries :15,13(deep),23,37 with ill-� � ed crows/FPDs

● Gingival recession:14,13,12,21,22,23,24,35,32,31,41,42,44,45

● Missing:18,24,26,28,38,48 (or 46 early missing, then 47,48 mesial dri� ing )

● 15 R/O chronic apical periodontitis with previous RCT

● Lower crowding; Lower midline deviation to right

● Malocclusion of 14-17 to 44-47

● 14,15 rotation ( 14 disto-lingual rotation; 15 mesio-lingual rotation )

● 27,37 mesial tipping,

● Palatal Cross bite of 15 to 45

● 46,47 mesial lingual tipping

● 45 disto-buccally out tipping and infra-occlusion

● Dark triangle:45-47(46), Ant. dark triangle

● Dental class I Type I

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 21

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█全口X光片檢查

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China22

病例討論專欄

█ Periodontal probing data(I)

333 325 322 323 424 525 523 525 524 413 514 528 GM-BP (B)

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

433 335 324 443 525 535 533 525 425 525 425 527 GM-BP (P)

Ⅱ Ⅰ Ⅰ Ⅰ Ⅰ Ⅰ Ⅰ Ⅰ Mobility

327 426 423 424 323 323 323 214 323 325 323 327 435 GM-BP (L)

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

323 323 423 424 514 324 525 525 526 325 324 334 725 GM-BP (B)

Mobility

█ Tentative treatment plan ● FM Scaling & OHI, FM Periodontal treatment

● Remove ill-� � ed FPDs/re-evaluation :15,13-21,22-23,24-27,35-37,32-42

● Provisionalization of 15,13,12,11,21,22,23,25,27,35,37,32,31,41,42

● Remove post & endodontic re-treatment : 15

Ortho treatment with the control of periodontal condition

FM alignment and leveling

Forced eruption of 13

Up-righting of 37,46,47 and Correct 45-47 dark triangle

De-rotation of 14,15

● Re-evaluaiton

● Prosthetic phase

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 23

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Right excursion

Left excursion

Protrusion

The 39Ms-orthodontic treatment finished

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China24

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Lateral profile improvement : straight

█ TMJ examination1. No tenderness of masticatory , facial and neck muscles.

2. No tenderness of the TMJ region.

3. No limitation of the mouth opening, maximum opening : 45 mm interincisive

distance.

4. No clicking sound & no creptius while opening or closing.

5. No deviation of lower jaw during mouth opening.

█ Intra-oral examinationGeneral view:

1. Missing teeth: 24,26,36

2. Provisional crown: 13,12,11,21,22,23,25,27, 35,32,31,41,42

3. 12,21,22,23,27 provisional crowns with occlusal perforation with intact

internal permanent cement

4. Post-RCT : 15,13,12,11,21,22,23,25 with large casting posts and 27 with para-

post and resin core

5. Gingival recession:14,21,23,25,27,35,34,32,31,41,42,44,45

6. Mobility II: 31,41with ½ root exposure

7. AMF: 16(o),15(o),37(o),46(o),47(o)

8. CRF: 14B

9. Stain over grooves/ pits :15,33,34,43,44,45

10. Amalgam margin chip o� and arrested caries: #16,46,47

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 25

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█ Periodontal probing data (II)

323 332 323 322 323 222 323 312 213 313 323 433 GM-BP (B)

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

323 323 323 312 322 223 323 322 213 312 323 423 GM-BP (P)

Ⅰ Mobility

323 323 323 323 322 212 415 414 212 212 323 213 322 GM-BP (L)

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

223 323 322 223 323 212 514 514 212 212 233 323 323 GM-BP (B)

Ⅱ Ⅱ Mobility

█ X光片檢查

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China26

病例討論專欄

█Diagnosis 1. Missing teeth: 24,26,36

2. Gingival recession:#14,21,23,25,27,35,34,32,31,41,42,44,45

3. Periodontitis of #31,41 ,mobility II

█ Problem list ● 27 mesial tilting - if occlusion on its mesial occlusal table, trauma from occlusion cannot be avoided. space for 26 is

insu� cient.

● 13 to 23 labial gum level

● 31,41 poor prognosis

● 37 is vital, mesial tipping with mild super-eruption at distal side

● Missing teeth: #24,26,36

█ Final Treatment plan ● Full mouth ultrasonic scaling and OHI

● Replace previous provisional FPDs : 15,13,12,11,21,22,23-25,27,35-37,32-42

● 31,41 Extracted & socket preservation and pontic-relined at 31,41 region

● 15,13,12,11,21,22,23-27,35-37,32-42 full ceramic crowns/FPDs

● � e patient rejected the implant surgery, so dental implant option was excluded.

Removal of old provisional restorations and Extraction of 31,41

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

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Fabrication of new provisional crown /FPDs:#15,13,12,11,21,22,23-25,27,35-37,32-42 after removal of marginal and internal caries of 13,12,21,22,23,25 and Extraction of 31,41

Smiling view with new provisional FPDs

Occlusion adjustment until she felt comfortable and no interference

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China28

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Incisal, midline adjustment

Adjustment stage

After the occlusion was satisfied and the soft tissue became stable without bleeding on probing. . . Ready for final impression taken.

Re-check the space for crown/FPDs

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 29

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Final impression for master casts

Final impression for master casts

Full wax-up with resin-wax coping

Wax-up copings try-in and adjustment

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China30

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Duplicate the morphology of wax pattern and transfer to new provisional FPDs

Try in the new provisional FPD/crowns and adjustment

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 31

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Centric occlusion

Right excursion

Protrusion

Duplicate the anterior guidance to fabricated the customized incisal table

Left excursion

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China32

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Color matching

Fabrication of zirconia copings

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 33

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Zirconia copings try-in and check bite

Completion of FM all-ceramic FPDs

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China34

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Delivery of FM All-ceramic FPDs

Right excursion

Left excursion

Protrusion

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 35

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█完成後口外觀

Follow up 8 Ms later

Follow up 8 Ms later

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China36

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Follow up 15 Ms later

Follow up 8 Ms later

The Academy of Prosthetic Dentistry, Republic of China／中華民國贋復牙科學會 37

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Follow up 17 Ms later

█術前術後比較

中華民國贋復牙科學會／ The Academy of Prosthetic Dentistry, Republic of China38

病例討論專欄

Q

Q

Q

Q

A

A

A

A

＃21至＃23 gingival line 較高位，有考慮解

決方式？

#21牙齒是歪斜的，以臨時義齒改變牙齒型

態並求中線對正。前牙gingival line右低左

高，曾考慮牙周手術解決，但評估後因為

periodontal root coverage 效果不好故而沒有

考慮手術。

有無考慮請病人配戴咬合板？

基於保護 復物立場應該製作，但病人說有戴了會失眠經驗所以沒有

意願做，不過會密切追蹤回診。

＃25,＃27為何要splinting？不splinting會怎樣？

第一組臨時義齒是兩顆牙齒分開，但因為兩者之occlusal table會加長

而增加受力時的offset，牙齒因而產生mobility; 之後將兩者splinting，

mobility 減少故而最後選擇splinting。

主模送去scanning ＆ milling時die是切開狀態與否？會有何影響？

是切開的，不過每個die起碼有兩支pins。再則，另外將製作好的全瓷

牙冠copings 再置放回未切成die 的master cast上做recheck的動作。因

為矯正過後的牙齒仍會有位移的情況，這也可能是造成過程中#23-25-27牙橋重做的原因。