Patient in distress




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From: Dr Sanjay Nayak
To: ROOTS
Sent: Thursday, May 31, 2007 7:25 PM
Subject: [roots] Patient in Distress !!! help !!!




Got this case  a couple pf days back and i do not know where to start
the main complaint was  'GAP" not of the designer T Shirt kind , she is 29 years old
An Acclaimed Endodontist of the city had done a few Root Canals and crown and Bridge work on her three years ago .....
two years back she underwent orthodontic treatment at the age of 27  because she felt her teeth were slightly in front
.... now she wants to do something about the GAPS !!!!
on careful examination
1) the lower right first molar  has grade 2 or 3 mobility .... with a pocket in the distal
2) Distal caries on the same tooth
3) The premolar also has grade 2 mobility
4) she has already lost four premolars 9 sacrificed For ortho) and also has a "wonderful " bridge on the left side
Now she is paranoid about visiting a dentist and she is justified after all the Hell she has gone through
what would your treatment paln be regarding this case  .. atleast the  molar and premolar ?
i would need as many responses i can get .. you would not only be helping a patient in distress
Impalnts is UNAFFORDABLE  ....attached some intra oral pictures and a pic of the rad ..... Kindly comment
sanjay 


        

my opinion:
second molar: fix caries
first molar:
(1) remove crown,
(2) distal root: extraction,
(3) mesial root: re-evaluate for mobility, perio and restorability, then extract or premolarize

premolar:
(1) occlusion: is it the reason for the mobility? hyperocclusion? anocclusion? is it fixable?,
(2) remove crown, excavate distal decay and re-evaluate mobility and assess restorability;

restorative plans for lower right queadrant (depending on whether you are saving the premolar
and regardless of whether you save the M root of the fisrt molar):

(1) bridge from second molar to canine
(2) bridge from second molar to premolar

(of course, appropriate endod tx on premolar and M root of 1st molar, if you opt to keep'em)
- Marcos Arenal JL

Whew! What a challenge.
My first thought would be to do a full-mouth series of radiographs, record perio probings,
and face-bow mount models in centric relation, probably using a leaf gauge to record centric
(a la Spear).  I bet her crown/bridges are not in harmony with her centric.
Then you will understand what stands in the way of occlusal stability, which will be challenging
to obtain with the ortho result she is presenting.
Extracting her lower right molar and periodontal therapy are next.
Then you will have as healthy a platform to work from as possible.  I would consider long-term
provisionals on the lower right as well as in other areas where her crowns prevent occlusal harmony.
I think better shade matching would diminish her dissatisfaction with the spaces.
She deserves to  know the big picture and that possibilities exist to restore her to health even
if it takes years.  Ultimately, its her choice. Best wishes, and keep us posted on your progress.- Peter