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TREATMENT PLANNINGPROTOCOL FOR
COMPLEXPROSTHODONTIC CASES
Soraya C. Villarroel, D.D.S., M.S.
www.egydental.com
Outline
1. Objective2. Developing Treatment Options3. Complex Treatment Planning Protocol3. RPD, Fixed and Immediate Dentures Clinical
and Lab Procedures4. Assorted Clinical Cases 5. Summary
Objective
Provide a consistent teaching to train the student to sequence the necessary procedures to diagnose
and develop a treatment plan for complex prosthodontic cases in the Primary Care Clinics
Treatment Plan Purpose
Formulating a logical sequence of treatment designed to restore the patient’s dentition to good health, with optimal function and appearance*
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
What is an Ideal Treatment plan?
Treatment plan that achieves the best possible long-term outcomes for the patient, while addressing all patient concerns and active problems, with the minimum necessary intervention*
*C. Bain, Treatment Planning in General Denta1 Practice, 2003
Complex Prosthodontic Cases
Factors to be considered: Four or more fixed restorations (crowns, FPD) CD/RPD, RPD/RPD with or without crowns Immediate dentures Cases requiring a change in VDO Implant cases (Optional) Cases deemed complex by screening or clinic faculty
Developing Treatment Options
Diagnosis: Dental and medical history Clinical examination Radiographic films Diagnostic pictures Diagnostic casts Diagnostic wax-up
Prognosis: General factors: age, oral environment, etc. Local factors: occlusion, access for oral hygiene
Developing Treatment Options
Factors to be considered: Longevity Cost Patient’s expectations Invasiveness / reversibility Success rate Possible complications Time involved, both total treatment time and number of visits Influence on quality of life
Phase IIPhase IIDisease ControlDisease Control
Phase IIIPhase IIIRestorativeRestorative
Phase IVPhase IVMaintenanceMaintenance
Treatment Plan by PhasesTreatment Plan by PhasesDental & medical history
Clinical examination, Radiographic films
Dx Casts, Dx photographs
Dx Wax-up, Aesthetic evaluation
Periodontal Therapy
Endodontic Therapy (RCT)
Removal of existing restorations
Caries control
Phase IPhase IDiagnosisDiagnosis
Crown lengthening/Implant surgery
Gnathologic technique
Long-term provisional restorations
Cast restorations, Cast RPD’s
Recall every 6 months
Fluoride supplements
Reinforce oral hygiene
Improve diet
Complex Cases Protocol
Diagnostic Phase (Complex D&T) Paperwork (Prosthodontic Component) Prosthetic or Reconstructive Phase
Complex Cases Protocol (Dx Phase)
A series of diagnostic appointments should be scheduled to complete a thorough evaluation of
the patient dental condition: Diagnostic Impressions Diagnostic casts (duplicated twice for RPD Tx
cases and one for other treatments) Two sets of casts oriented identically on articulator in CR (Face-bow required)
Complex Cases Protocol (Dx Phase)
Diagnostic Wax-up:
Casts/waxing/set-ups (denture teeth) must be completed prior to beginning any reconstructive treatment (castings/prostheses or definitive Periodontal therapy)
Complex Cases Protocol (Dx Phase)
Prosthodontic Component of the Dental record
(green sheet): One for removable prosthodontics One for fixed prosthodontics/Occlusal analysis Must be completed and signed by Faculty and student
Complex Cases Protocol (Paperwork)
Outline a Tx-plan with an Instructor (Complex D&T) Review Tx plan with complex case managers (Dr. Villarroel
CCC2/CCC4 and Dr. El-Gendy CCC1/CCC3) Outline a definitive Tx-plan with sequence for clinical and lab
procedures by appointment Stamp the blue tx-plan working sheet Reach agreement: patient, student, faculty Get case manager signature after all previous steps are
accomplished and Phase II is completed Student should follow up the Tx-plan with any instructor Advanced complex cases may be referred to Grad Pros clinic
Diagnostic Impressions/Casts
Dx impressions: Irreversible hydrocolloid (alginate)/stock trays High quality with no voids A clinical instructor must authorize impressions pouring
Type III dental stone (buff) is used for Dx-casts pouring Dx casts evaluation criteria:
Accurate reproduction of teeth and tissue Base thickness: 15-16 mm Land area width: 3-4 mm
Diagnostic Casts*
*Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle
Diagnostic Casts
Provide valuable preliminary information and a comprehensive overview of patient’s needs
Treatment procedures can be rehearsed on the stone cast before making any irreversible changes in the patient’s mouth
Used for diagnostic wax-up, preliminary RPD design, surgical stent (surgical procedures), etc.
Help to explain intended procedure to patient
Diagnostic Wax-up*
*Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle
Useful to show proposed treatment to the patient
Used for fabrication of provisional restorations Fabrication of final restorations against the
diagnostically waxed cast allows establishing optimum contour and occlusion
Provides specific information about desired tooth length and form or occlusal arrangement: dentist-lab technician communication
Diagnostic Wax-up
Complex Cases Protocol (Pros phase)
Removable Partial Dentures (RPD)
Fixed Prosthodontics (crowns/FPD)
Immediate Dentures
RPD Clinical/Lab Procedures
Mount Dx Casts in CR Dx-wax-up (set denture teeth) Survey Dx cast (preliminary design) Complete Phase II Rest seats/guide planes preparation
(enameloplasty if required) Impression for framework
fabrication (Alginate) Framework try-in/adjustment
RPD Clinical/Lab Procedures
Altercast impression in case of distal extensions or Kennedy class I or II arch form
Tray fabrication Border molding
Altercast Impression Procedure
RPD Clinical/Lab Procedures
Wax-rim fabrication, CRR, Facebow (if required)
Selection of denture teeth shape/shade
Set up teeth
Wax try-in: Verify CR/Esthetic try-in
Approval: patient/faculty Lab form required for
processing Prosthesis Prosthesis placement Post-placement checking
appointments
RPD Clinical/Lab Procedures
Fixed Pros Clinical/Lab Procedures*
Mount Dx casts on articulator using facebow/CRR
Each set is mounted identically (cross-mounted technique)
One set of Dx cast is used for Dx wax-up One set of Dx casts is left unaltered (original)
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
Fixed Pros Clinical/Lab Procedures*
Definitive tooth preparation (one arch at a time) Fabrication of provisional restorations
Final impression
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
Fixed Pros Clinical/Lab Procedures*
Working cast/CRR/Mounting each step must be evaluated by instructor
Selection of shade (Patient/Instructor approval)
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
Fixed Pros Clinical/Lab Procedures*
Try-in Crowns/FPD
(Framework Try-in)
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
Fixed Pros Clinical/Lab Procedures*
Placement of final restorations
*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
Immediate Denture
Definition:
A complete denture or removable partial denture fabricated for placement immediately following the removal of natural teeth
The glossary of Prosthodontic terms, 1999
Examination and Diagnosis Diagnostic Cast What teeth need to be extracted? What is the final RPD design? An esthetic evaluation is necessary if tooth
position will be altered
Immediate Denture
Immediate Partial/Denture Clinical/Lab Procedures
Examination and Diagnosis Single Phase Surgical
Schedule Final Impression Facebow, Jaw Records
Marking “Esthetic Indicators” Wax Try-in Laboratory Procedures Extractions and Delivery Maintenance Fabrication of Definitive
Immediate Denture
Double Phase Surgical Schedule Extract all posterior teeth Wait 6 weeks of healing
Final Impression Facebow, Jaw Records
Intra-oral Modifications Final Impressions Facebow, Jaw Record
Immediate Partial Courtesy of Dr. AG Wee
Maintain patient’s appearance Serve to control hemorrhage and swelling Prevent tongue spread out as a result of tooth loss Serve as a guide for esthetic of the final denture Protect tissues at the sensitive extraction sites from
irritation from the tongue and food Hasten patient adaptation to dentures Maintain efficiency of mastication
Immediate Partial/Denture Advantages
More difficult and demanding procedure (more chair time/increased cost)
Dentist’s inability to try-in the prosthetic teeth in advance (limited evaluation)
Impressions and Maxillo-mandibular records more difficult to record
Immediate Partial/Denture Disadvantages
Patient in poor general health Uncooperative patient Patient with surgical risks:
Radiation therapy Blood clotting Tissue regeneration/wound healing problems After surgery drainage required
Immediate Denture Contraindications
Clinical Case
Clinical Case I: Immediate Denture
Clinical Case II: Fixed-RPD
Clinical Case III: CD/Fixed-RPD
Clinical Case IV: Immediate Partial-Denture
Summary
The patient should be considered as a human being Successful accomplishment of dental treatment is
the result of a multidisciplinary team effort: students, faculty, staff, other dental departments
Following complex case protocol helps to: Provide a higher quality dental treatment to patients Enhance students’ clinical learning experience and
knowledge Increase efficiency: save time/money to patients,
students, instructors, and Clinic Improve OSU Clinic/College reputation
Summary
The key of a successful dental case is the planning of the treatment at the beginning
Primary care department team approach: Combine the vast clinical experience of
general dentistry faculty with complex case training of specialists
Clinic Manual 2003-2004; The Ohio State University Department of Primary Care
Boucher’s Prosthodontic Treatment for Edentulous Patients, 11th Edition; Zarb et al., 2004
Contemporary Fixed Prosthodontics, Rosenstiel et al., 2001
Complex Denture Fabrication, M. van Putten, 2000
References
Thank You!