London Bridge Case Report Summary

French-speaking 65 year-old female, presents with c/c Id like to fix my broken bridge (points to lower left), and my tooth hurts when I chew (points to upper left). LDV spring 2012, annual visits, brushes 2x/day, flosses 2-3x/week. Hypertension controlled with Ramipril for 20 years. 51, 128 lbs, BP: 115/65. History of presenting illness (HPI): 46 extracted at age 14 due to caries, PFM bridge fabricated at McGill 25 years ago (age 40), porcelain fractured 4 years ago, RCT 25 done at McGill 25 years ago, apicoectomy by endodontist 3 years ago, spontaneous pain 2 years ago, now sensitive to percussion. Private dentist suggested extraction and implant. Intra Oral: Bridge 45-x-47 fractured porcelain, metal intact, 16 supra-erupted, 24 large composite restoration including lingual cusp, cold test negative, 25 sensitive to percussion, 26 large amalgam restoration Initial treatment plan included 18 MO (a) redo, extract 25, PFM bridge 24-x-26, PFM bridge 45-x-47 redo. Alternative plans include Remove 18 M (a) overhang with curette, 24 endo/post/core/crown or extraction, Retreat 25, PFM bridge 24-x-26 or 23-x-x-26, Implants. Treatment on lower right quadrant included removal of bridge because the preps were short. Bone sounding for biological width, lowered margins, prepared temporary with PMMA: lack of occlusal clearance 47D, reduced opposing cusps and prep height, considered CCL. Adjustments to the plan include distalizing 48 with separating elastic to increase interproximal root distance for future restorative work and/or CCL. To continuously distalize, add PMMA to distal and replace elastic on a weekly basis. Adjust occlusal interference 48, patient felt pressure for 2 days. PFM with metal occlusion Temporary de-cementing on a weekly basis. Some steps taken to improve R&R: Verified and adjusted centric and eccentric contacts, electro-cauterized encroached gingiva 47, added composite to increase height of mesial wall, created new temporary, created box within occlusal composite, surveyed model: decreased taper 45 B, used less cement, considered implant again. Treatment for the upper left side: Prepared 24, little tooth structure remaining. Previous restoration and pins fractured. Pulp cap with CaOH and GIC, composite build-up. No Ferrule, bone sounding. Considered CCL. Prepared 26, amalgam overhang removed, temporary bridge 24-x-26 with PMMA, Implant placement scheduled for 3 months later. Surgical guide with pontic and vaccu-shell. Restore with 2 crowns and implant crown once osseointegration is approved by OMFS 6 weeks post-op