TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES Soraya C. Villarroel, D.D.S., M.S

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!