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Function, Aesthetics and Biomimetics in the

Interdisciplinary Treatment: Concerning a Clinical Case

 

auther3

cheap pfizer viagracheap pfizer viagraDDS, MSc Periodontology
- Associate Professor, Faculty of Dentistry, Univ. of Oporto
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cheap pfizer viagracheap pfizer viagraDDS, MSc Esthetic Dentistry
- Teacher at Fernando Pessoa Univ.
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cheap pfizer viagracheap pfizer viagraDDS, MSc Orthodontics
- Teacher at Fernando Pessoa Univ.
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cheap pfizer viagracheap pfizer viagraCeramist, Lugo
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cheap pfizer viagracheap pfizer viagraOrthodontics
- Full Professor, Faculty of Dentistry, Univ. of Oporto
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The evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects.

An adult patient’s aesthetic and functional rehabilitation present an even more difficult challenge for the dental professional, particularly in those situations where the treatment involves an intimate collaboration between different specialties, demanding a critical planning.

We will present a clinical case which involved an interdisciplinary approach, where the operative sequence and the multidisciplinary approach exerted in this case illustrates the importance of specialised knowledge and professional communication.

cheap pfizer viagra Aesthetics, Periodontics, Implantology, Orthodontics, Interdisciplinary approach.

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An adult patient’s aesthetic and functional rehabilitation presents a challenge for the dentistry professional, particularly in those situations where the treatment involves an intimate collaboration between several specialties, demanding a critical planning. It is therefore important to define in what way aesthetic, periodontal, implantology and orthodontic specialists should connect in order to properly achieve the proposed goals.

As an example of an interdisciplinary treatment, we present a complex clinical case in an adult patient where periodontal, implantology, prthodontic and prosthodontic treatment were involved.

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A fifty-eight year old female patient consulted us to replace her missing teeth and to improve her smile’s appearance. This is a case of a patient with high expectations and a philosophical personality according to House’s classification.1

In medical terms, she was diagnosed as an ASA patient type 1,2 not presenting any associated pathology and not being under any kind of medication. She was non-smoker and had a moderately stressful life style.

Extra-orally, we can observe in cheap pfizer viagra that the patient presents a facial type with normal patterns and a straight profile. It is also obvious in cheap pfizer viagra that the patient presents a low smile line.


r11 r21  

cheap pfizer viagraInitial anterior profile

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During intraoral examination we could observe the presence of posterior bite collapse with decreased occlusal vertical dimension resulting from the loss of posterior teeth number 14, 15, 24, 25, 26, 46 and 36, and from the mesioversion of teeth 47 and 37, as well as the extrusion of tooth 16 cheap pfizer viagra. It was also possible to detect the presence of localized gingival recessions both in the upper and lower arches.

The intraoral examination also showed an increased overjet due to labial inclination of upper anterior segment with an increase of the horizontal overbite, which resulted in the absence of the anterior guide during protrusive movement. At the same time, we could observe the presence of a parafunction (bruxing habit), since there is a clear wear at the upper anterior teeth’s incisal edge cheap pfizer viagra.

After examination of the upper anterior segment, gingival asymmetry was observed, especially at teeth 11 and 21, as well as presence of interincisal diastema that might have been caused by the labial movement of these teeth cheap pfizer viagra and/or the loss of teeth posteriorly. The upper anterior teeth present themselves with an inadequate height – width proportion and the incisors show a somewhat triangular shape.

The periodontal examination showed moderate generalized chronic periodontitis, with Plaque index values of 80% and Bleeding of 48% (Dicotomic Index). One can verify, as mentioned earlier, the presence of multiple areas of gingival recession. The microbiological analysis allowed to observe the presence of periodontal pathogens of endogenous character,3 therefore not presenting an increased risk in terms of response to the periodontal treatment.

In the initial radiographic examination, it was possible to confirm the presence of periodontal pathology, with a moderate radiographic horizontal bone loss except for tooth 27, which presents a circumferential defect. The detected bone loss is worsened due to the mal-positioning of some teeth cheap pfizer viagra. We could also observe the clear buccalization of the antero-superior teeth in the lateral cephalometric projection cheap pfizer viagra.

 

r3 r4 r5

cheap pfizer viagraIntra-oral 1

cheap pfizer viagraIntra-oral 2

(cheap pfizer viagra  Intra-oral 3

 

 

r6 r7 r8

cheap pfizer viagraWear of incisal edges

cheap pfizer viagraPanoramic view

(cheap pfizer viagra Lateral cephalometric view

 

cheap pfizer viagraThe patient can be diagnosed with:
- Moderate Generalized Chronic Periodontitis.
- Bite Collapse Syndrome with buccal inclination of the anterosuperior teeth and presence of inter-incisive diastema.
- Extrusion and mal-positioning of several teeth as well as posterior edentulism.
- Bruxism.
- Asymmetry of the anterior gingival margins and incorrect width-length ratio of anterior teeth.

cheap pfizer viagraAfter the analysis of the presented case we can summarize our
treatment plan as follows:
cheap pfizer viagra- Treatment of the periodontal pathology.
cheap pfizer viagra- Alignment of the remaining molars and increase of the vertical dimension.
cheap pfizer viagra- Retrusion of upper incisors decreasing the horizontal overbite and reestablishment of an adequate anterior guide.
cheap pfizer viagra- Closure of the interincisal diastema and gingivoplasty.
cheap pfizer viagra- Reconstruction of the lost dental structure of the upper anterior segment.
cheap pfizer viagra- Replacement of the lost teeth.
cheap pfizer viagra- Treatment of the occlusal parafunction.

cheap pfizer viagraHence our treatment plan consisted of the following, according to the sequence we have described:
cheap pfizer viagra- Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatment.
cheap pfizer viagra- Placement of osseointegrated implants in the sites of 14, 15, 24 and 25.
cheap pfizer viagra- Setting of provisional fixed partial prosthesis over implants on 14, 15, 24 and 25 for orthodontic anchorage.
cheap pfizer viagra- Bimaxillary orthodontic treatment with fixed appliances.
cheap pfizer viagra- Extrusion of tooth 47.
cheap pfizer viagra- Placement of implant in the area of 46.
cheap pfizer viagra- Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26.
cheap pfizer viagra- Rehabilitation of the anterosuperior sector with ceramic veneer.
cheap pfizer viagra- Placement of centric relation occlusal splint.

cheap pfizer viagra Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatment
The goal of the periodontal treatment was to eliminate the opportunistic microorganisms that might impede, if not treated, any kind of interdisciplinary therapeutic approach.

The initial or hygienic stage aims to eliminate the etiologic cause of the periodontal disease; eliminating all the bacterial deposits, as well as the plaque retaining factors. During this stage, we proceeded with the patient’s motivation, instructing her on oral hygiene techniques.
Therefore, in theory, with the basic periodontal treatment we should get:
- A reduction of the Bleeding Index to values equal or inferior to 25%.
- A total elimination of gingival pockets with probing depth of over 5 mm.
- Reduction of the furcation lesions.
- The elimination of pain since the only pain that the patient had was due to periodontal problems.
- Starting to achieve the patient’s functional and aesthetic satisfaction.

At the same time, we must have the ability to effectively control the risk factors associated with chronic periodontal disease, such as bacterial plaque, tobacco and uncontrolled diabetes.4 In this particular case, the need to improve the used oral hygiene techniques was to promote a better plaque control. From the above mentioned risk factors, bacterial plaque was the only one initially present. In terms of active treatment, we proceeded with the root planing in the sites with probing depth of over 3 mm.

Forty-five days after the basic stage’s completion, we proceeded to the re-evaluation of the performed treatment.

Re-evaluation aimed to assess the results of the established treatment and to plan the need for additional periodontal treatment (surgical, for example) or supporting periodontal treatment. In the analyzed clinical case, and considering the good results obtained (plaque index values and bleeding inferior to 20%) with the initial treatment it was possible to move the patient to a supporting periodontal treatment program. The periodicity of the appointments relative to the program is dependent on the present risk factors, on the degree of initial bone loss presented and on the treatment’s complexity to be executed in interdisciplinary terms. For this patient periodontal supporting appointments with a 2-month periodicity5 were prescribed.

cheap pfizer viagra Placement of osseointegrated implants in positions 14, 15, 24 and 25
Considering the edentulous spaces and bearing in mind the orthodontic movement to be performed it was decided to proceed with the placement of osseointegrated implants in the position of teeth 14, 15, 24 and 25 in the maxilla and tooth 46 in the mandible. The decision was made in order to maintain teeth 27 and 47 as orthodontic anchorage and to re-evaluate their status after orthodontic treatment ends.

For both sides in the maxilla, the need to perform sinus elevation was verified, although on the right side such procedure was performed at the same time of the implant placement,6 as there was over 6 mm of residual bone cheap pfizer viagra,7 but on the left side, the necessity to perform a previous elevation of the maxillary sinus floor arose as we did not have sufficient alveolar bone to achieve primary stability, and afterwards (6 months) we proceeded with the placement of the implants cheap pfizer viagra.8


r9 r10 r11_copy

cheap pfizer viagraPre-operative, upper right quadrant

cheap pfizer viagraImplants placement in positions 14 & 15 with immediate sinus liftingcheap pfizer viagra

cheap pfizer viagra  Post-operative photo of implants in positions 14 & 15 after suturing


 

r12 r13 r14

cheap pfizer viagraIncision for upper left quadrant

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cheap pfizer viagra Sinus lifting

 

 

r15 r16 r17

cheap pfizer viagraBio-Oss application

cheap pfizer viagraSuturingcheap pfizer viagra

(cheap pfizer viagra Alignment of mandibular teeth

 


cheap pfizer viagra Setting of provisional fixed partial prosthesis over implants 14, 15, 24 and 25 for orthodontic anchorage After the implants’ osseointegration period (6 months), we proceeded with a casting and record registration for the fabrication of a fixed partial prosthesis, screwed in metal-acrylic, allowing, on one hand, the re-establishment of a suitable vertical dimension and on the other hand, an additional anchorage during the execution of the orthodontic treatment.

cheap pfizer viagra Bimaxillary orthodontic treatment with fixed appliances
The orthodontic treatment began with the alignment of mandibular teeth cheap pfizer viagra.
In a later stage, already with a steel rectangular arch, of a bigger gauge, the verticalization of tooth 47 was initiated, resorting to an open spring of nickel-titanium.

In a later stage, already with a steel rectangular arch, of a bigger gauge, the verticalization of tooth 47 was initiated, resorting to an open spring of nickel-titanium.

After tooth 47 verticalization, the alignment of maxillary teeth was initiated cheap pfizer viagra.

This arch being leveled and aligned, we proceeded with the recoil of the anterosuperior sector, with steel contraction arches and resorting to the anchorage provided by the implants previously placed in teeth positions 14, 15, 24 and 25 cheap pfizer viagra.

The canine neutroclusion was achieved and improved in an initial stage through the use of triangular rubber bands placed bilaterally cheap pfizer viagra.


r18 r19 r20

cheap pfizer viagra Initiation of maxillary teeth alignment

cheap pfizer viagraStainless steel contraction archescheap pfizer viagra

(cheap pfizer viagra Triangular rubber bands placed bilaterally


cheap pfizer viagra Extraction of tooth 47
As previously anticipated, tooth 47 extraction was decided due to its periodontal bad condition cheap pfizer viagra


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Periodontal chart: tooth # 47 had mobility grade II


cheap pfizer viagra Placement of implant in the position of 46
Besides the implant at the site of tooth 46 and since tooth 47 extraction was performed, the possibility of also placing an implant at the site of this last tooth was taken into consideration. Nevertheless, the bone availability was limited and it would imply the use of guided bone regeneration technique which was not accepted by the patient at this stage of the treatment. The risk that might exist from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment cheap pfizer viagra.

cheap pfizer viagra Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26
Right after the bimaxillary fixed orthodontic appliances removal (that were used for 18 months), as well as after the osseointegration period of the implants placed in the mandibular arch, we proceeded with the definitive impressions using an elastomeric material, as well as to the collection of intermaxillary registrations which allowed the elaboration of structures built in metal-ceramics, which were cemented over prefabricated intermediate abutments. As for the second quadrant, we decided for an implant-supported structure design over implants in positions 24 and 25 and a cantilevered pontic at the level of tooth 26 cheap pfizer viagra.

cheap pfizer viagra Rehabilitation of the anterosuperior sector with ceramic feldspar veneers
After the removal of the fixed appliances we also proceeded with the anterosuperior segment rehabilitation. In order to do so, we performed a previous waxing up, in order to be able to visualize the intended final result. This wax up also made possible the attainment of an in-mouth “Mock-up ” , as well as it functioned as a guide during all the dental preparation process, creation of temporary restorations and the execution of ceramic feldspar veneers cheap pfizer viagra.

rr22 rr23 rr24

cheap pfizer viagraImplant placement in the position of tooth 46

cheap pfizer viagra Fabrication of fixed partial dentures. Tooth # 26 replaced as a cantileverd pontic

cheap pfizer viagra Waxing up of the anterosuperior segment



The dental preparation based on the previous wax up insured a thickness of approximately 0,5 mm in buccal and 2 mm in the incisal 1/3 in order to assure a suitable thickness for the feldspar ceramic. The vestibular and palatal finish line was a deep chamfer to assure an easier positioning of the definitive restorations and to promote a higher marginal integrity after the definitive cementation cheap pfizer viagra.

In these areas in which the preparation included the exposure of dentin, we recommend the use of an immediate dentinal sealing technique by applying phosphoric acid and a dentinal adhesive (of fourth or fifth generation) on areas of exposed dentin, where after a first cycle of 20 seconds curing an oxygen inhibitor (glycerine gel) was applied in order to perform a second cycle of curing, assuring a total sealing of the exposed dentinal tubules. We also intended, by doing this, to increase final adhesion values during the cementation of the ceramic feldspar veneers.

After the dental preparation, we proceeded with the definitive casting as well as with the intermaxillary registrations, determining the vertical dimension of the occlusion to be used.

The cementation technique included the acid conditioning of both enamel and dentin with phosphoric acid and of the interior surface of the veneers with hydrofloric acid. We proceeded with the silanization of the interior surface of the veneers, placed an adhesive of fourth generation on the restorations and on teeth without curing, used a photo-curable micro-hybrid resin cement and performed the final cementation cheap pfizer viagra.

cheap pfizer viagra Placement of centric relation occlusal splint
Despite the thought that the incisal and canine guides’ re-establishment will solve the parafunction problem, we decided to produce an occlusal splint that will allow, on one hand, to reduce the parafunctional habits’ effects and that will simultaneously allow it to function as a retainer for the orthodontic treatment performed at the maxilla cheap pfizer viagra.


rr25 rr26 rr27

cheap pfizer viagra Preparation of the upper anterior teeth

cheap pfizer viagracheap pfizer viagraDeep chamfer vestibular & palatal finish line

cheap pfizer viagra Final cementation of ceramic feldspar veneers



rr28 rr29 rr30

cheap pfizer viagra Extra-oral view

cheap pfizer viagracheap pfizer viagraCentric relation occlusal splintne

cheap pfizer viagracheap pfizer viagraSplinting of lower anterior teeth



rr31 rr32 rr33

cheap pfizer viagracheap pfizer viagraPost-operative anterior view

(cheap pfizer viagra Post-operative lateral view

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After the clinical case treatment, the main discussion topics are:
cheap pfizer viagra no placement of implant at the site of tooth 26, cheap pfizer viagra the possible extraction of tooth 27 and the extraction of tooth 47.

As to what concerns tooth 26, no implant was placed because the initial planning foresaw the extraction of tooth 27, which would make the implants location to be at 24, 25 and 27. However, and since the tooth was maintained as a result of the periodontal treatment, a cantilever was made supported on the 24 and 25 implants. Obviously, and once the case was finished, we could claim that it might have been preferable to place them at the sites of the 24 and 26. Nevertheless, the performed treatment did not present any kind of problem as far as the long term predictability is concerned. 

Relatively, tooth 47 had to be extracted due to periodontal causes. The ideal would have been to also place an implant at that level. However, as above mentioned, the bone availability was limited and it would imply the use of guided bone regeneration technique, not accepted by the patient at this stage of the treatment. The risk that might derive from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment.

cheap pfizer viagra
The evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects. Naturally, the excellence of the results demands an interdisciplinary approach, consolidated in a close collaboration between the different protagonists where the patient’s motivation and availability is pivotal. The therapeutic planning, the operative sequence and the pluridisciplinarity exerted in this case illustrate the importance of specialised knowledge and professional communication.

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1. House MM. Full denture technique. In: Conley FJ, Dunn AL, Quesnell AJ, Rogers RM, editors. Classic prosthodontic articles: a collector’s item. Vol III. pp 2-24. Chicago: American College of Prosthodontists, 1978.

2. Keats, AS. The ASA classification of physical status--a recapitulation. Anesthesiology. 1978 Oct;49(4):233-6.

3. van Winkelhoff AJ, Rams TE, Slots J. Systemic antibiotic therapy in periodontics.
Periodontol 2000. 1996 Feb;10:45-78.

4. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Periodontol 2000. 2006;40:107-19.

5. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop. 1989 Sep;96(3):191-8

6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994 Feb;15(2):152, 154-6, 158 passim; quiz 162.

7. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants. 1998;13 Suppl:11-45.

8. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986 Apr;30(2):207-29.


 
 

What causes erectile dysfunction (ED)? Symptom-Specific Homeopathic Treatments for Erectile Dysfunction (ED) Sometimes several sessions of sexual counseling can be helpful to a man who is going to receive medical or surgical treatment for erectile dysfunction. A counselor can help guide a couple in agreeing on a treatment or help them improve their sexual communication and lovemaking skills. A single man may benefit from counseling on how to talk to his partner about penile injections or a vacuum constriction device, both treatments for ED. None of the volunteers reported any pain or side-effects from the treatment. Make you look fit and healthy. No reports on long-term use Erectile dysfunction. This image demonstrates the vacuum device in place (see Image 10). Note the presence of the constricting ring at the base of the penis. Many medical conditions result in more physical discomfort than erectile dysfunction. But ED may be as psychologically challenging as any. Coping with serious medical issues is always a challenge. It's difficult for some men to understand that ED is completely the result of an underlying physical condition, or that, even so, an act of choice alone will not cure it. They feel out of control. For a man, that's always hard. But coping with ED does not have to be just an exercise in keeping a stiff upper lip to compensate for the lack of a stiff penis. Coping with ED involves a range of actions, including getting proper diagnosis, understanding treatment alternatives and above all, being honest about the condition and potentail outcomes. Realism, is the first principle to observe in order to optimize coping with erectile dysfunction. Whatever the underlying causes - be they the consequence of recent prostate surgery or diabetes, or substantial psychological problems - denial never helps. Being sensible about the effectiveness of treatments is equally important. Pharmaceutical drugs are only about 90% effective and may also include side effects. That's a very encouraging number, but it means that 10% may need to seek other remedies such a Herbal Supplements. In a small percentage of cases there simply is no short term remedy. That's always unfortunate, but the psychological impact can be reduced only by facing facts squarely. Only on that basis can a patient deal with possible subsequent effects on one's relationships and self-esteem. Still, optimism is not only pleasant, it's also a constructive attitude for coping with ED. Far from necessarily being the choice to always live in a fantasy world, optimism can and should be based on facts. Optimism is valid when, as is usually the case these days, real options are available that encourage or produce real results. Optimism is not the same as stoicism, though the latter may be appropriate to some degree. Stoicism is simply accepting consequences as inevitable. Optimism goes beyond this and believes that good outcomes are achievable, even likely. One then has an incentive to find them, even if they're not immediately obvious or attainable. Coping with ED involves developing strategies for long term treatment, some of which may involve substantial life changes. Erectile dysfunction is more likely, the older a man becomes. That's not only because of elementary changes such as a decrease of testosterone. It's also because the possibility of disease and other conditions that can result in ED increase with age. Life is risky andgets more risky the older you become. Taking that fact into account can help develop those plans that call for significant change. Those adjustments can range from simple adjustments of diet and exercise, to opting for a different career, to embracing any of the number of typically permanent treatments such as Herbal Supplements or a prosthetic implant. They may involve adjusting one's attitude toward oneself, toward what's achievable in life and toward sex. None of those are easy adjustments. But coping with ED, like many conditions, is done best when one looks at the situation head on, then summons the courage to do what is required to achieve the desired goal. Herbal Boost(http://www.herbalboost.co.uk) promotes a range of safe, Herbal Supplements that are used as sexual enhancers to improve libido and increase sex drive. Medical diagnosis Click Diabetes mellitus You may be relieved to learn that the risk of breast cancer from taking the birth control pill is very small, as revealed in research from the Mayo Clinic. However, there are many other side effects associated with the pill and the birth control patch. Learn more about these risks so you can make better contraceptive choices and protect your health. I like Improve muscle tone and strength. The American College of Obstetricians and Gynecologists (ACOG) reassures that the birth control pill is safe and effective for most women. However, although today's pills have lower doses of hormones than pills from previous decades, they still cause side effects, and some are quite serious. Q. How does a VED device work? To block veins that drain blood from the penis. This test involves pumping fluid into the penis and measuring the pressure in the corpus cavernosum during an erection. This test will help establish how severe the venous leak is.Corpus Cavernosometry This is another test of venous leakage that involves infusing saline into the corpus cavernosum. The flow rate needed to maintain an erection indicates the degree of venous leakage. The leaking veins responsible may be visualised by infusing a mixture of saline and x ray contrast medium and performing a cavernosogram.

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