贋 Dec 贋 p.60 p.84 p.90 廣泛性齒質磨耗的診斷治療架構美學協同治療中的藝術 2015 年會心得及照片 / / / / / / / / / (02) / (02)

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2 贋 Dec 贋 p.60 p.84 p.90 廣泛性齒質磨耗的診斷治療架構美學協同治療中的藝術 2015 年會心得及照片 / / / / / / / / / (02) / (02) / / 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 Contents 理事長的話彭玉秋 02 小編的話劉閔結 03 病例討論專欄臨床病例討論報告 : 前牙區咬合面傾斜報告 / 曹博竣 04 臨床病例討論報告 : 上顎全口假牙與下顎局部活動假牙報告 / 馬偲紜 18 臨床病例討論報告 :Computer-guided Implant Surgery & Fixed Prostheses 報告 / 游傑名 36 專題討論廣泛性齒質磨耗的診斷治療架構陳逸陽醫師 60 治療藝術美學協同治療中的藝術盧家正醫師 74 贋復年會花絮 2015 年會緣起許綺真醫師年會的序曲奇美博物館的文化饗宴張瑞忠主任年會心得王少君醫師年會心得林靖傑醫師 95 展望許綺真醫師 96 : 贋 1

4 2 贋贋彭玉秋

5 贋劉閔結贋 3

6 臨床病例討論報告 : 前牙區咬合面傾斜 General Information Name: Gender: Female Age: 40y/o Occupation: Accountant Time factor: Poor Co-operation: Good Financial condition : Fair Chief complaint: I want to have my teeth problems solved 4 贋 PMH Denied any systemic disease Denied any food drug allergy Wry Neck PDH Extraction OD RCT FPD Personal habit Alcohol drinking (-) Betel nut chewing (-) Cigarette smoking (-) Bruxism or clenching (-) Chief Complaint

7 Frontal view: Facial asymmetry Gummy smile Occlusal plane canting Lateral view: Straight profile Nasolabial angle: 90o Extraoral Examination Arch form Upper: ovoid Lower: ovoid TMJ Palpation: no tenderness No clicking sound on mouth opening Canine relationship Occlusion Analysis R't: Class I L't: Class I Molar relationship 贋 5 R't: Unknown L't: Class

8 Occlusal plane canting Spacing between 13, 14 Mesial tilting: 48 Working side: Right 6 贋 Eccentric Movement Group function: 13, 14 contact to 43, 44, 45 Working side: Left Group function: 23, 24, 25 contact to 33, 35 Supraeruption: 16 Missing: 25, 38, 46, 47 Ill-fitting FPD: Clinical Finding Caries: 45 Gingiva swelling Mobility II: 14, 48 Mobility III: 37 Lichen planus over bilateral buccal mucosa Gumboil: 12, 22 12: through crown opened Radiographic Examinations & Periodontal Charting Data

9 Tooth PD(D) PD(P) Mobility WNL WNL Tooth PD(D) PD(P) Mobility WNL WNL WNL WNL WNL WNL Furcation Generalized mild to moderate horizontal bony destruction Angular bony destruction: 14, 15, 36 Calculus deposition Missing: 25, 38, 46, 47 Caries: 45 Incomplete RCT: 21, 22 Apical radiolucency image: 12, 22, 24 Residual root: mesial tilting FPD with marginal gap: 13 Occlusal plane canting Generalized mild to moderate chronic periodontitis Supraeruption: 16 Missing: 25, 38, mesial tilting Residual root: 24 Ill-fitting FPD: Caries: 13, 45 Incomplete RCT: 21, 22 Chronic apical periodontitis: 12, 22, 24 Lichen planus over bilateral buccal mucosa Diagnosis 贋 7

10 Periodontal phase I & OHI OD: 45 RCT: 12, 13, 21, 22 11, 13 clinical crown lengthening procedure 16, 18, 37 ext temp. FPD fabrication Lower: Class II mod. 1 wrought wire RPD Definitive Treatment Plan-Option 1 Open flap debridement: 12, 14, 15, 17 Clinical Crown lengthening procedure: 11, 13 Ext: 16, 37, 48 Prosthodontic plan: , , 23XX26 Implant:16, 37, 46, 47 8 贋 Tentative Treatment Plan Definitive Treatment Plan-Option 2 Open flap debridement: 12, 14, 15, 17 Clinical Crown lengthening procedure: 11, 13 Ext: 16, 37 Prosthodontic plan: 17X15, , , 23XX26 Lower: Class II mod. 1 RPD

11 Finding: 13 decay to even gingiva level Clinical and Lab Procedure Upper FPD Removal Temporary Prosthesis Ant. Teeth Analysis 贋 9

12 10 贋 Tooth Length Width Proportion 84% 73% 77% 75% 75% 76% Tooth Length Width Proportion 76% 75% 78% 78% 75% 76% After Periodontal Phase I Treatment

13 3M after CLP of 13 Working Cast for Provisional Fabrication Incisal Edge Correction 贋 11

14 12 贋 Wax Up for Provisional Prosthesis Provisional Prosthesis Fabrication Provisional Prosthesis Delivery

15 Post and Core Fabrication and Preparation Index Status for Impression 贋 13

16 14 贋 Full Contoured Wax Up

17 Cut Back Metal Framework Try In Check Occlusion of Final Prosthesis 贋 15

18 16 贋 Tr y In

19 Before and After Q1? A1 group function 13 ferrule group function 23XX26 FPD group function FPD Q splinting? A2 21 ferrulec Q3? A3 Q4 14 definitive? A4 14 grade II angular bony defect14 guidance 13 guidance guidance 14 guidance 13 flap OP splinting group function 贋 17

20 臨床病例討論報告 : 上顎全口假牙與下顎局部活動假牙贋 General data General Data Name: X Gender: male Age: 89 y/o Occupation: retaired Date of first visit: 103/11/13 Chief complaint "I want to have a new denture." Extraoral Examination Past medical history No facial asymmetry Gummy smile (-) Straight lateral profile Mentalis strain: (-) Lip incompetence: (-) Nasolabial angle: 110 Upper lip to E line: retrude Lower lip to E line: on No TMJ problem Stroke for 30 years Past dental history: Extraction, OD, endo, RPD

21 Intraoral Examination Poor oral hygiene Arch form Upper: ovoid Lower: square Missing: Caries: Retained root: Palatal throat form (House): class I Lateral throat form (Neil): Class I Tongue classification position (Wright): Class II Radiographic Finding Localized moderate to severe horizontal bony destruction Missing: Caries: Retained root: Tooth L(PD) L(AL) B(AL) B(PD) Mobility WNL WNL 贋 19

22 Localized moderate chronic periodontitis Problem List Right side paralysis Posterior support loss Financial limitation 20 贋 Diagnosis Missing: Caries: Retained root: Periodontal phase I treatment, OHI RCT: 43 Extraction: Maxilla: interim complete denture Mandible: Surveyed provisional crown: Kennedy Class I mod. 1 interim RPD Tentative Treatment Plan Diagnostic Mounting

23 CO (Diagnostic Wax Up) CO (Provisional RPD) Protrusion L'T working side R'T working side 贋 21

24 22 贋 Definitive Treatment Plan Maxilla Complete denture Border Modeling and Final Impression Mandible FPD: RCT Kennedy Class I mod. 1 RPD

25 abutment Wax Rim Try In and VD Determination 贋 23

26 24 贋 Bite Registration Wax Denture Set Up Full Contour of Surveyed Crown

27 Guiding Plane Wrought Wire Clasp Undercut Cutback 贋 25

28 26 贋 Metal Coping

29 Bisque Try In Surveyed Crown Fabrication 贋 27

30 28 贋 Surveyed Crown Try In and Delivery Border Modeling and Final Impression (Mandible)

31 Metal Framework Design and Wax Pattern Metal Framework Try In Bite Registration 贋 29

32 30 贋 Wax Denture Try In Extraoral View

33 Wax Denture Lab Remouting 贋 31

34 32 贋 Clinical Remount

35 Clinical Delivery (CO) 贋 33

36 Before 34 贋 Provision After

37 Q1 provisional RPD permanent stage permanent CD reline A1 provisional RPD resin teeth chewing efficiency permanent prosthesis maxillary complete denture permanent denture denture teeth provisional denture denture teeth occlusion Q2 permanent vertical dimension provisional stage A2 1mm VD provisional stage preparation endodontic therapy endo Tx VD 1mm PFM restoration space Suggestion case supraeruptionvd display combination syndrome 贋 35

38 臨床病例討論報告 : Computer-guided Implant Surgery & Fixed Prostheses CT + Gender: male Age: 60y/o Occupation: business Time factorgood Co-operationgood Financial : good Chief complaint I feel my teeth are not rigid as before. I also want to restore my missing teeth. 36 贋 Basic Information PAST MEDICAL HISTORY Hypertension under control (130/80) Denied food or drug allergy PAST DENTAL HISTORY General dental therapy: composite resin filling, endodontic treatment, extraction, crown and bridge PERSONAL HABITS Alcohol drinking: (-) Betel nut chewing: (-) Cigarette smoking: (-) Bruxism(-) Clenching sign(-)

39 Extraoral Examination Low to medium smile line Asymmetry upper teeth display Smile width: small Restricted orbicular muscle MMO:50mm Heavy calculus deposition Gingival redness and swelling Exostosis Poor teeth proportion Ill-fitting FPD : 17X15,21X23,24, 34X36, 45X Intraoral Examination Mobility grade I: 12,21X23 Mobility grade II:18,27,38,45 IRM filling: 25,27 Missing: 26,28, 37, 47, 48 贋 37

40 Arch form Upper: Ovoid to square Lower: Ovoid to square Overbite: 2mm Overjet : 2mm Protrusion: Incisor guidance Lateral movement: R: Canine+1st premolar L: Canine guidance 38 贋 Occlusal Analysis Gag reflex Clinical Finding Gingival swelling and redness, heavy calculus deposition Ill-fitting FPD : 17X15,21X23,24,34X36,45X Caries:11,25,27 Supraeruption:18 Mesial tilting:38, Distal tilting:12 Spacing:12,11 Rotation:13 Attrition Missing: 16,22,26,35,37,46,47,48 Restricted orbicular muscle Gag reflex: strong

41 Radiographic Examination Tooth PD(B) Furcation involvement Mobility Tooth PD(B) Furcation involvement Mobility 贋 39

42 Radiographic Finding Previous endodiontic treatment : 24,27 Ill-fitting FPD :17X15,21X23,24,34X36,45X Missing: 16,22,26,35,37,46,47,48 PDL widening:45 Furcation involvement: 36,38 IRM filling:25 Old resin filling:11 Problem List Unstable periodontal condition Poor posterior support Asymmetry Anterior teeth display Restricted orbicular muscle Gag reflex Disease control Periodontal therapy Tooth11:Composite resin filling 40 贋 Diagnosis Generalized moderate chronic periodontitis Ill-fitting FPD :17X15,21X23,24,34X36,45X Caries:11,25,27 Supraeruption:18 Distal tilting:12, Mesial tilting:36,38 Spacing:12,11 Rotation:13 Attrition Tentative Treatment Plan Removal of ill fitting FPD: 17 15, 21 23, 24, 34 36, 45 Extraction:18,27,36,38,45 Missing: 16,22,26,35,37,46,47,48 Prosthetic treatment Diagnosis wax up Temporary FPD: 17 15, 21 23, 24, 34 CBCT

43 Redistribution of Posterior Teeth 贋 41

44 42 贋 Diagnosis Wax Up

45 Removal of Ill Fitting Crown Periodontal Phase I Finished Tooth PD(B) Reevaluation PD(B) Recession Mobility 贋 43

46 barium sulfate mixed with clear acrylic resin 44 贋 Central Incisors Management Mounting without Prosthesis Radiographic Guide (Image Guide)

47 Check CT 贋 45

48 Gingivectomy:11,21 Crown:17,15,12,11,21,23,24,34 Veneer:13 46 贋 Definitive Treatment Plan 1 Implant supported FPD:16,22,26,27,35,36,37,45,46,47 Gingivectomy:11,21 Definitive Treatment Plan 2 Crown&bridge:17X15,12,11,21X23,24,34 Veneer:13 Implant supported FPD: 45X47,35

49 Treatment Sequence Provisional stage ( Now finished) Computer generated surgical guide Implant placement Establish the posterior support Correct anterior display Final stage Posterior prosthesis delivery Anterior prosthesis delivery Occlusal splint Computer Generated Surgical Guide Advantages(2013 Journal of pharmacy & Bioallied Sciences Manikandan Ramasamy "Implant surgical guides: From past to the present") Time saving Precise positioning Implant Plan from CT and virtual 3D model Digital data is easily to restore and sent 3D printing for the final guide Less post-operative strain on dentist and patient Cast Digitalization CT Image Superimposed with Cast and Radiographic Guide 贋 47

50 3D 3D 48 贋 Superimposed Image Implant Plan Designing 3D 3D 3D

51 Computer Generated Surgical Guide Fabricated Surgical Guide Try In Anchor Pin Inserted 贋 49

52 Lower Right 50 贋 Upper Right Flap Elevation Drilling Upper Left Implant Inserted Lower Left

53 22 GBR (Bio-oss+ FDBA + Collagen Membrane) Radiographic Examination Post OP 1 Week Post Surgery (2 Weeks) 贋 51

54 52 贋 Establish the Posterior Support SOLID ABUTMENT: 35Ncm Impression for early Loading (Post Op 6 Weeks)

55 Facebow Transfer Working Cast 贋 53

56 54 贋 Provisional Prosthesis Anterior Wax Up: Redistribution

57 Post op 8 weeks 贋 55

58 protrusion R't working L't working 56 贋 Posterior Provisional Prosthesis Delivery

59 Bone regeneration Implant Inserted 3 Months Correct Anterior Display 贋 57

60 Delivery 58 贋 Gingivectomy Mock Up Treatment Course First visit, 26extraction Data collection Treatment plan discussion Removal of ill fitting prosthesis: ~ Extraction:18,45,27,36, Check CT ~ Periodontal phase I therapy CT guide fabrication Implant placement in room Suture removed Check Ostell Solid abutment torqued, Impression Posterior prosthesis delivery Mock up try in Anterior teeth replacement Follow up

61 Q1 CASE implant supported bridge? A1 implant supported bridge implant supported single crown prognosis CASE Q2 A2 implant neck 1~1.5mm Drill drill sizenobel Guide drill size implant site preparationsimplant Tooth support Tooth-tissue support Tissue support anchor pin 3D Milling Bur drill 3D 贋 59

62 廣泛性齒質磨耗的診斷治療架構 Thinking Process for Management of Generalized Tooth Wear 60 贋 tooth wear Eric-Jan Muts 2014 attrition vertical dimension / /

63 Loss of tooth structure Carious defects Non-carious defects 5abutment tooth secondary cariescement wash out PDL widening trauma from occlusion (2) 影響區域大小 (3) 誘發因素 (4) 複雜程度 multiple factors erosionattritionabrasion abfraction (1) 磨耗速率 Developmental Traumatic 贋 61 Wear Fracture Avulsion Amelogensis imperfecta Dentinogenesis imperfecta Enamel hypoplasia Physiological/Pathological Localized/Generalized Mechanical/Chemical related Single/Multiple factors

64 (1) 齒腐蝕 (erosion) scooped out depression regurgitation / 贋 Belser 贋 (2) 咬耗 (attrition) / matching wearing facet Class III malocclusion parafunction

65 贋 retention form resistance form metal reinforcement part / trauma from occlusion (3) 刷耗 (abrasion) V (4) 裂耗 (abfraction) V enamel rod 贋 63

66 Turner vertical dimension 64 贋 Monitor/Preventive care / Monitor/preventive careactive restoration intervention Esthetics consideration Remained tooth structure Restorative space analysis Material chosen Date collection Primary management Diagnosis Interim phase Definitive phase Maintenance phase Evaluation restorative space Active restoration intervention Remained tooth structure Restorative material selection Esthetics consideration

67 Turner profile phonation freeway spaceswallowing Dawson dental-alveolar compensating mechanism Turner Fradeani material ageing overjet 贋 65

68 Rate of tooth wear Dental-alveolar compensating mechanism Restorative space availability? 66 贋 Enough space Limited/No space Restore under current VDO Check CO-CR discrepancy from MIP to CR Turner Orthodontic related therapy/surgery May face rick of insufficient retention/resistance form Restore under raised VDO Testing by reversible/adjustable material or appliance Space reorganized Restoration type(fixed/removable) Design new occlusal scheme Monitor profile change A B C Dawson 贋 X

69 Intral-oral Findings attrition#14,15 super eruption#36,37 ulceration #12,13 #43,44 #27 8mm 12mm #11,23,24 # 贋

70 1999/3 Pano 2002/9 second stage Missing teeth: 16,17,18,23,24,26,28,35,36,37,38,45,46,47, ,13,21,22 surveyed crown; 15: cut down and endodontic treatment crown restoration Healing abutment: 11,23,24 Lower Kennedy Class I RPD 贋

71 #12,13,21,22,43 surveyed crown 2002 #11,23,24 healing abutment #12,13 #44 rest 2003~ # #21,22 #44 #21,22, #43 12 #15 cemental tear #12,13,14,25 immediate overdenture clenching 贋 69

72 2012/ 贋 2012/6 extraction 44 horizontal root fracture 44 bleeding on probing, 5mm probing depth over distal side #44

73 2012/11 43 fracture extraction Suggest immediate upper overdenture fabrication and 43,44 implant evaluation #43,15 Immediate 2012 denture and splint delivery 2012/11 15 fracture/cemental tear extraction 44 #11,23,24 bar attachment 12,13,14,25 #44 ERA attachment incisal rest 2014 贋 71

74 2013 Tx plan Upper: Overdenture with bar attachment; Lower: Kennedy Class I partial denture with LOCATOR attachment Splint protection Definitive restoration and splint delivery 72 贋

75 2014 case 15 / clenching 贋 73

76 美學協同治療中的藝術 Interdisciplinary Treatment in Aesthetic 74 贋 Invisalign 2011 APAID 2012 TAO 2014 ICOI Dentistry GP

77 total patient care GP missing teeth syndome tooth shiftvd loss periodontal problem rehabilitaion pink and white prosth OD compromised outcome Interdisciplinary Treatment Planning: Principles, Design, Implementation Cohen Peri Koisortho Kokich Interdisciplinary treatment cover designer 贋 75

78 temporary crown X CT total patient care Interdisciplinary treatment 76 贋 Know How crown - cost down

79 powerpoint cost down Always Sync Full HD ppt ppt ppt template GP Powerpoint and Keynote powerpoint Apple keynote Mac PC keynote Alpha powerpoint 2013 Dolphin Manager 贋 77

80 keynote powerpoint 2013 keynote powerpoint powerpoint powerpoint X powerpoint Non-verbal system dolphin manager non-verbal system 78 贋 dolphin manager dolphin manager ppt dolphin manager ppt powerpoint ppt ppt

81 non verbal system ppt ppt DSD (Digital Smile Design) What's New --DSD concept DSD DSD workflow concept DSD Keynote powerpoint SKYN concept 3d cadcam DSD team DSD DSD 贋 79

82 - - CTGroot coverageclp superimposition DSD and temporary crowns DSD waxup DSD DSD waxup waxup 80 贋 mockup mockup preparationgingivoplasty waxup try-in DSD DSD mockup emotional link mockup mockup 2d waxup mockup DSD

83 20 Microscope enhancement preparation congress hands-on surface texture 11, 21 3M LAVA 贋 81

84 Microglaze and ceramic furnace try-in try-in 8 15 microglaze VITA 6000m 82 贋 pad VITA VITA enamel opaquedentin ZirconiaEmax Metal GC Initial IPS Emax IPS

85 EYE-Fi -- Eye-Fi pro 200 ^^ app try-in ,22,23 tetracyclin stain value unit unit Always Sync Eye-Fi 贋 83

86 Flickr eye fi unit Mobi pro Mobi 84 贋 Dropbox DSD DSD keynote dropbox google drive dropbox 4K

87 My interdisciplinary workflow of aesthetic treatment case case ill-fitting PFM crown Data collection DSD (Mk1) Curve of Spee smile curve Interdisciplinary Communication Interdisciplinary Treatment Arrangement Fabrication of MK1 Provisional Crownfor ortho Re-endo treatment under microscope by Dr. Endodontic specialist 贋 85

88 86 贋 Ortho treatment Invisalign ortho tx by Dr. (orthodontic specialist) space closureintrude lower ant. Curve of Spee DSD (Mk2) thin biotype perio Waxup and mockup Gingvoplasty 11 gingivectomy by Dr. (Periodontal Specialist) Fabrication of MK2 provisional crown Cementation of fiber posts and preparation under microscope CTG of Lower ant. by Dr. (Periodontal Specialist)

89 Communication with the patient Take impression Try-in Clinical Morphology Adjustment, Stain and Glaze temporary cementation 2-6 贋 87

90 Deliver Initial and Final 88 贋

91 贋 89

92 年會緣起 90 贋

93 贋 91 贋

94 500 4F 贋 1

95 2015 年會的序曲奇美博物館的文化饗宴贋贋贋贋 93

96 2015 年會心得贋 11/2122 facebook DM coffee break 11/21 94 贋

97 2015 年會心得...zZZ meeting 贋贋 95

98 展望 96 贋贋

99 中華民國贋復牙科學會活動快訊春季繼續教育預告主題時間內容 Pedo- Endo- Pros- 105 年度病例討論會年度專科醫師筆試年度專科醫師口試

100

Loss of tooth structure Carious defects Non-carious defects 5abutment tooth secondary cariescement wash out PDL widening trauma from occlusion (2) 影響區

廣泛性齒質磨耗的診斷治療架構 Thinking Process for Management of Generalized Tooth Wear 60 贋 tooth wear Eric-Jan Muts 2014 attrition 1 2 3 4 vertical dimension / / Loss of tooth structure Carious defects Non-carious

贋 Dec 贋 p.60 p.84 p.90 廣 泛 性 齒 質 磨 耗 的 診 斷 治 療 架 構 美 學 協 同 治 療 中 的 藝 術 2015 年 會 心 得 及 照 片 / / / / / / / / / (02) / (02)

贋 Dec 贋 p.60 p.84 p.90 廣泛性齒質磨耗的診斷治療架構美學協同治療中的藝術 2015 年會心得及照片 / / / / / / / / / (02) / (02)