38 / 15 7 王巍穆

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2 贋第 18 卷第 1 期 September 目錄 / / / / / / / / / / (02) / (02) / / Case I Case II NTU Prostho G 56 Pros - 61 台灣郵政北台字第 3844 號執照登記為雜誌交寄行政院新聞局局版台誌第 8091 號

3 38 / 15 7 王巍穆

4 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 General data Name : X Chart number : Gender : Male Age : 44 y/o Marriage : married Occupation : Attitude : cooperation and comprehensive First visit : Chief complaint The patient was referred from LDC for evaluation of prosthetic rehabilitation due to malocclusion and severe exostosis. Past medical history Denied any major systemic disease Allergic historyallergic to some kind of anodyne Personal habits Smoking (-) Alcohol : (-) Betel nut chewing (-) Bruxism(-) Oral hygiene Brushing teeth:2 times/day 2 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

5 Extra-oral examination Occlusal view Arch form : square Crowding dentition Missing : : 18,22,23,28 Caries:16, 17 Malocclusion Severe deep bite Angle class II div. II Scissors bite:34, 36, 44, 47 Exostosis Uneven occlusal plane Arch form : tapper Crowding dentition Missing : 31, 35, 37, 38, 45, 46 Caries: The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 3

6 Study cast Overjet:1 mm Overbite: 15 mm Right Canine : Angle class II 1st molar: Left Canine : st molar: Angle class II 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

7 Panoramic film Horizontal impaction of 48 Missing18,22,23,28,31,35,37,38,45,46 Restoration16, 17, 47 RCT16 Maxillary sinus pneumatization Mesial tilting of 36 Generalized moderate alveolar bone loss Periapical film The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 5

Distal Buccal Mesial 18 17 16 15 14 13 12 11 A.L. 3 4 6 8 4 2 2 1 2 6 3 4 4 2 3 5 7 8 8 10 9 P.D. 3 3 6 8 4 2 2 1 2 6 3 4 4 1 1 4 2 5 4 6 7 P.

3 3 4 5 1 3 4 3 6 7 4 6 6 5 6 10 7 12 14 10 13 Mobility I I I III III F.I. Palatal 101.02.

D. 4 2 3 2 2 3 2 4 4 4 2 2 3 3 3 A.L. 4 2 3 5 5 6 4 5 5 4 2 2 3 3 3 Mobility III III F.I. Palatal 101.

8 Distal Buccal Mesial A.L P.D P.D A.L Mobility I I I III III F.I. Palatal Mesial Buccal Distal A.L P.D P.D A.L Mobility III III F.I. Palatal 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

9 Mesial Lingual Distal A.L P.D P.D A.L Mobility I I I F.I. Buccal Distal Lingual Mesial A.L P.D P.D A.L Mobility I II F.I. Buccal The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 7

Diagnosis Angle class II division II relationship Localized chronic severe periodontitis Dental caries16, 17, 47 Problem list Severe deep bite (15 mm) Scissors bite Elongation 11, 12, 21, 24, 32, 33,

10 Diagnosis Angle class II division II relationship Localized chronic severe periodontitis Dental caries16, 17, 47 Problem list Severe deep bite (15 mm) Scissors bite Elongation 11, 12, 21, 24, 32, 33, 41, 42 Distopalatal rotation12, 25 Severe exostosis Mobility Degree I15, 14, 13, 32, 33, 34, 42 Degree II24, 41 Degree III11, 12, 21 Treatment plans OD:16,17 Extraction:16, 14, 13, 12, 11, 21, 24, 25, 34, 33, 41, 42, 47, 48 Prosthetic treatment plans Implant FPD RPD Definite treatment plans Regular follow up of interim RPD Periodontal condition control deliver interim RPD Regular follow up( ~ ) Ask for RPD fabrication and repair broken interim RPD 8 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

After tooth extraction for 1.5 years 102.06.

view : symmetry Front facial view : symmetry Lower left lip : cave Lower left lip : cave Gummy smile: no Frontal view (smile) Lateral view :45 Facial midline

11 After tooth extraction for 1.5 years Extra-oral examination Frontal view Frontal view (smile) Facial midline : on Facial midline : on Face form : long ovoid Face form : long ovoid Front facial view : symmetry Front facial view : symmetry Lower left lip : cave Lower left lip : cave Gummy smile: no Frontal view (smile) Lateral view :45 Facial midline : on Malar area: convex Facial to maxilla midline: Paransal area: flat shift to right side about 2mm Lateral view :90 Profile: convex E-line: Upper lip: on Lower lip : retrued Nasolabial angle: 110 The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 9

After extraction (for 1.5 years) 102.06.

teeth: 17,15,26,27 Scissors bite: 27-36,15-44, 43

34 elongation and bite to maxilla ridge 102.06.

protrusive movement W B Left excursion 15,44 guide

guide R't L't 26-36 and15-44 guide 102.06.

12 After extraction (for 1.5 years) Occlusal view Arch form : square Remaining teeth: 17,15,26,27 Scissors bite: 27-36,15-44, 43 Arch form : tapper Remaing teeth: 36, 34, 43, elongation and bite to maxilla ridge Occlusal analysis Right excursion Lateral and protrusive movement W B Left excursion 15,44 guide Disocclusion B W Protrusion Disocclusion 26,36 guide R't L't and15-44 guide 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

13 Occlusal view Interim RPD Extraoral view The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 11

14 Study cast 34 elongation and bite to maxilla ridge Lingual frenum to gingival line: > 8mm Right: Canine : st molar: --- Left : Canine : st molar: Angle class II Panoramic film (After extraction 11 months) Extraction: 18, 16, 15, 14, 13, 12, 11, 21, 22, 23, 24, 25, 28, 38, 37, 35, 33, 32, 31, 41, 42, 45, 46, 47, 48 OD:17 Generalized moderate alveolar bone loss 12 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

Periodontal examination Re-charting Reduced but healthy periodontium 102.01.

) Overall prognosisfair Individual prognosis X F X F X X X X X X X X X F F X 18 17

36 37 38 X X X X F F X X X X X F X F X X 良好 Good 尚可 Fair 差 Poor 可疑 Questionable 放棄

Maintainable dentition Patient cooperation Less than adequate remaining bone

possible Patient cooperation Moderate to advanced bone loss Tooth mobility Degree

Advanced bone loss Degree II~III furcationinvolvement Tooth mobility Inaccessible

15 Periodontal examination Re-charting Reduced but healthy periodontium Provisional Prognosis (1991 McGuire MK.) Overall prognosisfair Individual prognosis X F X F X X X X X X X X X F F X X X X X F F X X X X X F X F 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 furcationinvolvement Adequate maintenance possible Patient cooperation Moderate to advanced bone loss Tooth mobility Degree I~II furcationinvolvement Difficult to maintain areas Doubtful patient compliance Advanced bone loss Degree II~III furcationinvolvement Tooth mobility Inaccessible area Advanced bone loss Nonmaintainable area Extraction indicated The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 13

Lower left lip collapse Prosthetic treatment options Maxilla Kennedy class III modification 1RPD Mandible Kennedy

16 Diagnosis Generalized periodontitis (reduced but healthy periodontium) Skeletal class II malocclusion Scissor bite: 15-44, Elongation: 34, 43 Problem list Skeletal class II malocclusion Scissor bite:15-44,27-36 Elongation:34,43 Lower left lip collapse Prosthetic treatment options Maxilla Kennedy class III modification 1RPD Mandible Kennedy class I modification 2 RPD 34 surveyed crown 14 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

Survey and RPD design Maxilla: Kennedy class III modification 1RPD

43 34 Crown reduction 5 mm maybe involve to pulp intentional RCT

plane : 17(M),15(MD), 26(M) Wrought wire clasp : 17,15 Casting clasp

disto-buccal 0.02 inch Casting clasp: 26, 27-26 into mesio-buccal 0.

17 Survey and RPD design Maxilla: Kennedy class III modification 1RPD Mandible: Kennedy class I modification 2 RPD Elongation teeth :34 and Crown reduction 5 mm maybe involve to pulp intentional RCT surveyed crown 43 Crown reduction 2 mm enamel plasty Design Maxilla Major connector : A-P strap with post. meshwork design Occlusal rest :17(D),15(D), 26(D), 27(M) Guiding plane : 17(M),15(MD), 26(M) Wrought wire clasp : 17,15 Casting clasp :26(D), 27(M) 15 and and 27 Wrought wire clasp: 15,17 - into disto-buccal 0.02 inch Casting clasp: 26, into mesio-buccal 0.01 inch - 27 into disto-buccal 0.01 inch The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 15

Design Mandible Major connector : lingual plate with meshwork design Cingulum rest :43

wire clasp : 36, 34, 43, 44 43 and 44 34 and 36 meshwork design Wrought wire clasp: 43

02 inch Notch at 44 mesial side Wrought wire clasp: 36 and 34-34 into disto-buccal 0.

18: pre-treatment data collection 102.08.

09.09: 43 deliver and tooth preparation of RPD 102.09.16: framework try in and VD and CR record 102.

18 Design Mandible Major connector : lingual plate with meshwork design Cingulum rest :43 Occlusal rest: 36(M), 34(D), 44(M) Guiding plane :36(MD), 34(MD), 43(M), 44(D) Wrought wire clasp : 36, 34, 43, and and 36 meshwork design Wrought wire clasp: 43 and into disto-buccal 0.02 inch - 44 into mesio-buccal 0.02 inch Notch at 44 mesial side Wrought wire clasp: 36 and into disto-buccal 0.02 inch - 36 into mesio-buccal 0.02 inch Prosthetic treatment course : pre-treatment data collection : 43 tooth preparation and provisional crown fabrication : 43 impression : 43 deliver and tooth preparation of RPD : framework try in and VD and CR record : wax denture try in : delivery Follow up 34 impression 34 deliver 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

19 Tooth preparation and impression Occlusal rest :17(D),15(D), 26(D), 27(M) Guiding plane : 17(M),15(MD), 26(M) Cingulum rest :43 Occlusal rest: 36(M), 34(D), 44(M) Guiding plane :36(MD), 34(MD), 43(M), 44(D) Framework try in The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 17

20 VD and CR record Framework try in Occlusal rim Occlusal plane VD CR Mounting Occlusal plane and face-bow transfer Mounting on articulator 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

denture try in Check CR and VD Intraoral

excursion B W Protrusion R't L't 102.09.

21 Denture try in Check VD and CR Lateral movement Wax denture try in Check CR and VD Intraoral photograph Extraoral photograph Occlusal analysis Right excursion Lateral and protrusive movement W B Left excursion B W Protrusion R't L't The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 19

22 Wax denture try in Check CR and VD Occlusal analysis Right excursion Lateral and protrusive movement W B Left excursion B W Protrusion R't L't 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

view) Before tooth extraction Nasolabial angle: 105 Now

23 Denture try in Profile (frontal view) Before tooth extraction Now With retractor Profile (lateral view) Before tooth extraction Nasolabial angle: 105 Now Nasolabial angle: 90 The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 21

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

25 Occlusal analysis Right excursion Lateral and protrusive movement W B Left excursion B W Protrusion R't L't Delivery Profile (frontal view) Profile (frontal view) Before tooth extraction Now Smile With retractor Profile (lateral view-45 ) Profile (lateral view-90 ) Before tooth extraction Now Smile With retractor The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 23

26 Delivery Mounting cast Follow up (post-delivery 3 day) Ulceration (2 weeks) Biting pain at 26, (1.5 months) No specific complaint (3.5M follow up) Sensitive to temperature at 26, (9.5Mfollow up) Regular follow up 24 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

27 Q1: 如果可以重新製作, 流程和設計該如何調整? A1: 如果患者不願意製作過渡性的上顎全口假牙和下顎部分活動假牙時, 步驟可以修正如下 ( 如果一切都順利的話 ): (1) 會先製作上下顎的咬合蠟堤來評估患者適合的咬合平面和垂直高度, 並將上下顎模型置位在咬合器上 (2) 在此咬合平面和垂直高度下, 先排好上顎全口假牙和下顎的牙齒位置, 必要時修磨掉下顎前牙區域牙齒的石膏, 排列出適當的上顎和下顎前牙區域的牙齒位置和角度 (3) 臨床上, 再次確認上顎前牙區域的牙齒位置和角度是否適當 ( 此時臨床上, 下顎前牙會接觸到上顎全口假牙的牙齒或 recording base, 可以先把干擾處修除 ; 或不要讓患者咬起來 ) (4) 以 Alginate 複製上述步驟 (2) 預估的下顎牙齒位置的模型, 以真空成型機和 Polypropylene thermoplastic sheet 製作透明的參考用模板 ( 以無牙嵴來定位參考用模板 ) (5) 拆除舊有假牙和修磨牙齒, 以上述步驟 (4) 製作的透明參考模板確認製作假牙的空間是否足夠, 製作 provisional crown fabrication (33, 34, 43) 些微修磨患者不願意拆除的 32, 31, 以讓上顎和下顎前牙區域的牙齒位置和角度協調與自然 ( 以上述步驟 (2) 垂直高度下排列的上顎全口假牙和下顎的部分活動假牙再度確認咬合平面和垂直高度是否合適 ) (6) 印模 (33, 34, 43), 以上述步驟 (5) 確認的咬合平面和垂直高度將上下顎模型置位在咬合器上 (7) 製作 surveyed crown (33, 34, 43) (8) 臨床上交付 surveyed crown (33, 34, 43) 之後印模製作下顎部分活動假牙的金屬架 ; 以上述步驟 (2) 排好的全口假牙進行上顎 border molding 和印模獲得上顎的主要模型 (9) 將上述步驟 (8) 的上顎模型置位到步驟 (6) 咬合平面和垂直高度的咬合器上在上顎的主要模型上重新製作 recording base 和咬合蠟堤 (10) Try-in 下顎部分活動假牙的金屬架再度確認上顎咬合蠟堤的位置和垂直高度 (11) Wax denture try-in (12) 交付上顎全口假牙和下顎部分活動假牙 (13) 告知注意事項和安排回診追蹤的時間 Q2: 下顎的固定式假牙的 margin 如何設計? A2: 在沒有美觀的考量下, 會建議患者用 metal collar 的固定式假牙 Q3: 活動假牙部分有甚麼是需要再改進? A3: 活動假牙的牙齒顏色和形態可以調整為較符合患者年紀臉型和個性的牙齒 The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 25

28 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 General data Name : X Chart number : Gender : Male Age : 79 y/o Marriage : married Occupation : farmer Attitude : cooperation and comprehensive First visit : Chief complaint Came for dental examination. Request for denture evaluation Past medical history HTN under medical control NKA Personal habits Smoking (-) Alcohol : (-) Betel nut chewing (-) Bruxism(-) Oral hygiene Brushing teeth: one time/day 26 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

Extra-oral examination Extra-oral examination 102.07.

15 Frontal view Frontal view (smile) Facial midline : on Facial midline : on Face form : long ovoid Face form : long ovoid Front facial view

29 Extra-oral examination Extra-oral examination Frontal view Frontal view (smile) Facial midline : on Facial midline : on Face form : long ovoid Face form : long ovoid Front facial view : symmetry Front facial view : symmetry Gummy smile: no Extra-oral examination Extra-oral examination Frontal view (with retractor) Lateral view :45 Facial midline : on Malar area: flat Facial to maxilla midline : shift to right side about 1mm Paransal area: flat The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 27

Extra-oral examination TMJ-related examination Maximum mouth opening :50 mm

mouth : (-) Muscle palpation pain(-) Joint palpation pain(-) Lateral view :90 102.

Upper lip: retrued Lower lip : on Nasolabial angle: 100 Occlusal view Arch form :

papilla Arch form : tapper Remaining teeth: 34, 33, 32, 31, 43 FPD:32-31-X,

30 Extra-oral examination TMJ-related examination Maximum mouth opening :50 mm (edentulous ridge- 41incisor edge) Clicking sounds: (-) Jaw deviation when opening mouth : (-) Muscle palpation pain(-) Joint palpation pain(-) Lateral view : Intra-oral examination After extraction for a week Profile: cave E-line: Upper lip: retrued Lower lip : on Nasolabial angle: 100 Occlusal view 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: 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

Study cast Shallow vestibular at bilateral posterior

old LA FPD No tissue undercut at 34, 43 buccal area

43-X-X-X RCT:31,32 Apical lesion at 34 Generalized

31 Study cast 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:34 Panoramic film 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 The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 29

32 Periapical film Intra-oral Examination Lower Left Sextant CAL&BOP PD&plaque CEJ.GM Facial Lingual CEJ.GM PD&plaque CAL&BOP 30 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

33 Intra-oral Examination Lower Left Sextant CAL&BOP PD&plaque CEJ.GM Facial Lingual CEJ.GM PD&plaque CAL&BOP Charting data The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 31

34 Provisional Prognosis (1991 McGuire MK.) Overall prognosisfair Individual prognosis X X X X X X X X X X X X X X X X 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 furcationinvolvement Adequate maintenance possible Patient cooperation Moderate to advanced bone loss Tooth mobility Degree I~II furcationinvolvement Difficult to maintain areas Doubtful patient compliance Advanced bone loss Degree II~III furcationinvolvement Tooth mobility Inaccessible area Advanced bone loss Nonmaintainable area Extraction indicated Diagnosis 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 Problems list Poor oral hygiene Inadequate space of 41,42 Ill-f itted old FPD: X (patient ref used remove this FPD) Limited budget Gingival recession 32 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

Preliminary treatment options Oral hygiene instruction Full mouth scaling RCT: 33, 34

and mandibular RPD Prosthetic treatment options, Prosthetic treatment options-i Maxilla

treatment options-ii Maxilla Complete denture Mandible Kennedy class I modification 1 RPD

35 Preliminary treatment options 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 Prosthetic treatment options, Prosthetic treatment options-i Maxilla Complete denture Mandible Kennedy class I RPD 33-43, 34 surveyed crown Prosthetic treatment options-ii Maxilla Complete denture Mandible Kennedy class I modification 1 RPD 33-34, 43 surveyed crown The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 33

Survey and RPD design Definite treatment plans Maxilla: complete denture Mandible: Kennedy class I modification 1 RPD Design Major connector : lingual plate Cingulum rest :33, 43 Occlusal rest: 34(M)

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.

36 Survey and RPD design Definite treatment plans Maxilla: complete denture Mandible: Kennedy class I modification 1 RPD Design 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 I-bar clasp : into mesio-buccal 0.01 inch I-bar clasp : into mesio-buccal 0.01 inch Prosthetic treatment course : pre-treatment data collection : 33,34,43 tooth preparation and provisional crown fabrication : 33,34 post : 33,34,43 impression : border molding of maxilla : VD and CR record : Wax denture try in : 33,34,43 deliver and cementation. OHI : border molding of mandible : framework try in and take CR bite : denture try in : deliver CD+ RPD : follow up(3 days) : follow up(2 weeks) : follow up(1.5 M) : follow up(3 M) : follow up (6M) 34 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

37 Tooth preparation and provisional crown fabrication (33,34,43) Referred to endo dept. for 33 and 34 RCT. 43 keep follow up Deliver soft occlusal splint for prevention of the traumatic injury Impression: 33,34, The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 35

38 Border molding of maxilla Occlusal rim 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

39 VD and CR record VD and CR record The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 37

40 Wax denture try in Occlusal view Profile (frontal view) Profile (smile) Profile (frontal view) Profile (lateral Fully wax up 38 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

41 Occlusal analysis Right excursion Lateral and protrusive movement Left excursion Protrusion W B B W R't L't Cut back Metal framework The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 39

42 FPD delivery 33,34,43 deliver and cementation. OHI Occlusal view Occlusal analysis Right excursion Lateral and protrusive movement Left excursion W B Protrusion B W R't L't 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

43 FPD delivery Occlussion 43 33,34 Check with PA film OHI Study cast impression and plan to do border molding (one piece) Border molding of mandible The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 41

44 Border molding of mandible Before After Framework try in 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

45 Take CR record Wax denture try in Check CR and VD The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 43

46 Wax denture try in Check CR and VD Wax denture try in Right excursion Lateral and protrusive movement Left excursion W B Protrusion B W R't L't 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

47 Denture try in Profile (frontal view) Before tooth extraction Now With retractor Profile (lateral view) Before Nasolabial angle: 95 Now Nasolabial angle: 85 Delivery The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 45

48 Delivery Occlusal view 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

49 Occlusal analysis Right excursion Lateral and protrusive movement Left excursion W B Protrusion B W R't L't Delivery Profile (frontal view) Profile (lateral view-45 ) Before Now Before Now Profile (lateral view-90 ) Before Now The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 47

50 Delivery Mounting cast Overjet :1mm Overbite: 1mm Follow up : follow up(3 days) Ulcer at left cheek : follow up(2 weeks) No specific complaint : follow up(1.5 M) No any complaint : follow up(3 M) No specific complaint : follow up(6 M) 48 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

51 Follow up (3M) Mucosa Occlusal view The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 49

52 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; Implant-supported fixed bridge:13-11; ; 37; ; 45-46) 50 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

53 Case I Case II 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 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 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 The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 51

54 作者 / 郭恬君醫師 (#10) 92.9% 1/3 crest bone 4mm 2mm , cuspal stiffness 5% 20% 63% 5 A B C 圖一 :(A,B) 根管適度修形保留齒質 (C) 牙髓過早壞死導致根管極寬大, 這樣的牙齒與前者相比, 抗斷裂強度較低 52 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

A B C 圖二 :(A) 齒質結構不佳的牙齒, 遠心牙根管壁內側過薄 (B) 牙釘位置偏移圖三 : 右上第二大臼齒 palatal

Post Zr post ferrule effect 1.5mm 2mm 7 RC Prep EDTA 8-10 NaOCl 0.

etch- and-rinse adhesivesself-etch adhesives Chlorhexidine Eugenol

55 A B C 圖二 :(A) 齒質結構不佳的牙齒, 遠心牙根管壁內側過薄 (B) 牙釘位置偏移圖三 : 右上第二大臼齒 palatal canal 置放 titanium post, 不容易由 X 光片中判讀 2mm 9mm 5mm 5mm crest bone Zr Post Zr post ferrule effect 1.5mm 2mm 7 RC Prep EDTA 8-10 NaOCl 0.5% 5.25% EDTAChlorhexidineChlorhexidine two-step selfetching adhesive etch- and-rinse adhesivesself-etch adhesives Chlorhexidine Eugenol The Academy of Prosthetic Dentistry, Republic of China,Taiwan / 中華民國贋復牙科學會 53

56 eugenol IRMZOE sealer Roth 801CANALS Eugenol eugenol total etching 12 total etching eugenol eugenol self-etching agent eugenol hybride layer Glass- Ionomer cement eugenol eugenol minocycline sodium perborate 2mm 30% 1. Chen SC, Chueh LH, Hsiao CK, Tsai MY, Ho SC, Chiang CP. An epidemiologic study of tooth retention after nonsurgical endodontic treatment in a large population in Taiwan. Journal of endodontics. 2007;33(3): Chen SC, Chueh LH, Hsiao CK, Wu HP, Chiang CP. First untoward events and reasons for tooth extraction after nonsurgical endodontic treatment in Taiwan. Journal of endodontics. 2008;34(6): Helfer AR, Melnick S, Schilder H. Determination of the moisture content of vital and pulpless teeth. Oral surgery, oral medicine, and oral pathology. 1972;34(4): Sedgley CM, Messer HH. Are endodontically treated teeth more brittle? Journal of endodontics. 1992;18(7): Panitvisai P, Messer HH. Cuspal deflection in molars in relation to endodontic and restorative procedures. Journal of endodontics. 1995;21(2): Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dental clinics of North America. 2010;54(2): Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and cores and complete crowns. The International journal of prosthodontics. 1995;8(2): Morris MD, Lee KW, Agee KA, Bouillaguet S, Pashley DH. Effects of sodium hypochlorite and RC-prep on bond strengths of resin cement to endodontic surfaces. Journal of endodontics. 2001;27(12): Ari H, Yasar E, Belli S. Effects of NaOCl on bond strengths of resin cements to root canal dentin. Journal of endodontics. 2003;29(4): Erdemir A, Eldeniz AU, Belli S. Ef fect of the g utta - percha solvents on the microhardness and the roughness of human root dentine. Journal of oral rehabilitation. 2004;31(11): Shuping GB, Orstavik D, Sigurdsson A, Trope M. Reduction of intracanal bacteria using nickel-titanium rotary instrumentation a n d v a r i o u s m e d i c a t i o n s. Jo u r n a l o f e n d o d o n t i c s. 2000;26(12): Peutzfeldt A, Asmussen E. Influence of eugenol-containing temporary cement on efficacy of dentin-bonding systems. European journal of oral sciences. 1999;107(1): 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China,Taiwan

57 作者 : 劉瑋禎 The Academy of Prosthetic Dentistry, Republic of China / 中華民國贋復牙科學會 55

58 ~ ~ NTU Prostho G 作者 : 許丹菁 Working Time Start! 5 Leisure Time Start! 5 56 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China

59 1. Prostho ~ case update 重複被 cast 攻占的技工桌趕末班車的留念照神來之手 2. meeting 7 meeting meeting 要用包容心和愛心看診用包容心和愛心教導小學生 The Academy of Prosthetic Dentistry, Republic of China / 中華民國贋復牙科學會 57

60 3. 3 各式各樣琳瑯滿目的聚餐 4. ~! ~! 老師們的慶生會 58 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China

61 5. ~! ~! bass ~ prostho 開心的郊遊和旅遊 The Academy of Prosthetic Dentistry, Republic of China / 中華民國贋復牙科學會 59

62 平日的休閒 : 游泳路跑與郭富城熱舞! prostho! treatment plan!!!!! prostho ~!! 臺大 Prosthetic Programme 20 年 (2013 年 3 月 3 日 ) 60 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China

work resin wax repeat lab Perioc or OS 1

63 Pros - 今日值班店員 : 林郁華略帶苦味的黑巧克力包裹著散發極致果香的君度橙酒, 就像黑夜裡獨行的貓女, 危險又充滿魅力 case case textbook 99 1 口味單純但製程繁複的巧克力是每位巧克力廚師 delay 下班的主因 lab work resin wax repeat lab Perioc or OS 1 technician The Academy of Prosthetic Dentistry, Republic of China / 中華民國贋復牙科學會 61

64 難以言喻的口感, 酥酥麻麻彷彿觸電般巧克力廚師人人喜愛, 但當你是製作者時, 一切就不好玩了 topic case photo fit checker fix removable 200 每間 Pros 巧克力專賣必備的基本款, 作用不明, 內容不明, 但是沒有它就是不行 trouble 早出晚歸頭髮上的屑屑 Temporon or denture resin Margin 差一點 FitChecker 差一點永遠在為那一點點而努力 That s my Pros Life!!! 62 中華民國贋復牙科學會 / The Academy of Prosthetic Dentistry, Republic of China

Intra-Oral Examination Dentition: Midline: on Occlusion : Canine Class I, R't molar- Class I Overjet: 3 mm, overbite: 3 mm Crowding over 31~44 24 mesi

Intra-Oral Examination Dentition: Midline: on Occlusion : Canine Class I, R't molar- Class I Overjet: 3 mm, overbite: 3 mm Crowding over 31~44 24 mesi 2 28 Personal habits 2 : No Smoking: No Alcohol: No Betel nut chewing: No Front facial view: Symmetry TMJ pain and click: No Facial profile: concave Jaw deviation: No Lip line: average Bruxism: No The