Treament Planning and
treatment sequences
Dr. Mahmoud Al-Afandi
MSc. Degree in Fixed Prosthodontics
1 5:00 PM
Decision making process
1. Gathering Information & Defining a Diagnosis.
2. Predicting prognosis.
3. Deciding on a treatment option.
2 5:00 PM
Socrates
No diagnosis.. No
treatment
Gathering Information & Defining a Diagnosis.
3 5:00 PM
History
Chief compliant
Personal details
Medical history
Dental history
4 5:00 PM
Chief compliant
The inexperienced clinician trying to prescribe an "ideal"
treatment plan can lose sight of the patient's wishes..
Comfort (pain characteristics)
Function (difficulties in chewing)
Social aspect (bad oral taste or smell)
Appearance (unaesthetic appearance discoloration –
malposition – misshape may be the main cause seeking
dental tr.)
5 5:00 PM
Personal details
patient's name
Patient‟s age: relative size of pulp chamber determine type of restoration coverage – orthodontic treatment to creat/eliminate spaces in young ages.
Address: sometimes reveals area-related diseases such as fluorosis, vitamin D deficiency…
phone number
Gender
Occupation: carpenters, tailors, glass blowers, (discoloration and fractures of anterior teeth)
work schedule:
marital and financial status: ability to afford Tr. Cost.
6 5:00 PM
1- Medical history
Any disorders that necessitate the use of
antibiotic premedication.
Use of steroids or anticoagulants.
Any previous allergic responses to medication
or dental materials.
Conditions affecting tr. methods
7 5:00 PM
1- Medical history
Previous radiation therapy.
hemorrhagic disorders.
extremes of age.
terminal illness.
Conditions affecting tr. Plan
These can be expected to modify the patient's response to dental treatment and may affect the prognosis. For instance, patients who have previously received radiation treatment in the area of a planned extraction require special measures (hyperbaric oxygen) to prevent serious complications.
8 5:00 PM
1- Medical history
Diabetes.
Pregnancy.
The use of anticonvulsant drugs.
Gastro-esophageal reflux disease.
Oral manifestation of systemic conditions
Dilantin Phenytoin seizures
9 5:00 PM
medications
Gingival hyperplasia due calcium channels blocker
antihypertensive drugs nifedipine
10 5:00 PM
• the lingual surfaces are bare of enamel except for a narrow band at the gingival margin
Etching times & severity of fluorosis
(45 seconds)
11 5:00 PM
1- Medical history
Risk factors for dentist
Medically compromised patients (legal considerations
associated with malpractice)
patients who are suspected or confirmed carriers of hepatitis
B, acquired immunodeficiency syndrome
Pregnant at the first trimester.
12 5:00 PM
2- Dental History
1. Periodontal History
(current oral hygiene & patient education)
2. Restorative History
(reflect prognosis of future restorations)
3. Endodontic history
(periapical health should be monitored for any recurrent lesion)
In such situations it is recommended to make provisional restoration and periodical follow up radiographs to assure healing before going to the final restoration)
One patient refused calculus removal because it splints his teeth, such a patient actually need a lot of time to educate.
13 5:00 PM
4. Orthodontic history
(previous tr. Associated with root resorption & C/R ratio consideration, need for pre-prosthetic orthodontic intervention)
5. Removable prosthodontic history
(very helpful in assessing whether future treatment will be more successful)
Patient expectations:
“ A patient with a false eye cannot see, a patient with false legs cannot run, but many patients expect to look and function with dentures as well as, or better than, they did with their natural dentition”
14 5:00 PM
6. Oral surgical history
(any complication during tooth extraction)
7. Radiographic history
(helpful in determining the progress of periodontal
disease)
8. TMJ history
(pain, clicking, muscular symptoms, may be caused
by TMI dysfunction, which should normally be
treated and resolved before fixed prosthodontic
treatment begins)
15 5:00 PM
Examination
General Examination
(patient's general appearance, gait, and weight, skin color, vital signs…)
Extra-oral examination
Intra-oral examination
Radiographic examination
16 5:00 PM
Extr-aoral examination 1- Temporomandibular joints: bilaterally palpation during the
opening stroke.
(Asynchronous movement)
anterior disk displacement
Tenderness or pain
inflammatory changes in the retrodiscal tissues
Clicking
maximum mandibular opening
intra-capsular changes in the joints.
17 5:00 PM
2- Muscles of mastication
the masseter and temporal muscles, as well as other relevant postural muscles, are palpated for signs of tenderness
Palpation is best accomplished bilaterally and simultaneously. This allows the patient to compare and report any differences between the left and right sides
18 5:00 PM
3- Lips:
The patient is observed for tooth visibility during
normal and exaggerated smiling. This can be
critical in fixed prosthodontics treatment
planning, especially for margin placement of
certain metal-ceramic crowns.
19 5:00 PM
3- Lips:
Negative space
20
missing teeth, diastemas, and fractured or poorly restored teeth disrupt the harmony of the negative space and often require correction
5:00 PM
Intraoral Examination
1- Periodontal Examination:
• Gingiva
• Periodontium
• Clinical Attachment Level
Healthy gingiva is pink, stippled, and firmly bound to the underlying connective tissue. The free margin of the gingiva is knife-edged, and sharply pointed papillae fill the interproximal spaces.
It provides a measurement (in millimeters) of the depth of periodontal pockets and healthy gingival sulci on all surfaces of each tooth.
accurate information regarding the prognosis of an individual tooth.
21 5:00 PM
2- Occlusal examination: • Initial tooth contact
• General alignment
• Lateral and protrusive contacts
Centric relation: Maxillo-mandibular relationship in which the condyles articulate with the thinnest avascular portion of their respective disks with the complex in the anterosuperior position against the shapes of the articular eminences. This position is independent of tooth contact.
Centric occlusion: maximum intercuspation position anterior to centric relation.
Retruded contact position RCP
When the mandible closes on the retruded axis, its position when the first tooth contact occurs is referred to as the retruded contact position (RCP). Approximately 90 percent of the population have a discrepancy between the retruded contact position and the intercuspal position.
Occlusal examination is usaully oversighted by dental students and professionals as well. Occlusal scheme paly a vital role in determination the prognosis of any Fixed prosthesis treatment. Those are the three main aspect you have to take in your account: I’ll remind you with some occlusal concepts.
22 5:00 PM
23
CR: centric relation
5:00 PM
24
CO: Centric Occlusion
5:00 PM
Initial tooth contact
The relationship of teeth in both centric relation and the
maximum intercuspation should be assessed. If all teeth come
together simultaneously at the end of terminal hinge closure,
the centric relation (CR) position of the patient is said to
coincide with the maximum intercuspation (MI). The
patient is guided into a terminal hinge closure to detect where
initial tooth contact occurs. This is referred to as a slide from
CR to Ml.
Any collateral signs or symptoms should be recorded.
(elevated muscle tone, mobility on the teeth where initial
contact occurs, wear facets on the teeth involved in the slide).
The neuromuscular system possesses an adaptive capacity, enabling it to maintain rcp, despite tooth loss, wear and the placement of inadequate restorations . It develops habitual paths of closure and lateral movement, enabling it to guide the mandible away from interferences and bring the teeth together in rcp.
25 5:00 PM
• These casts reveal a large horizontal discrepancy between RCP and ICP with only a small vertical component.
26 5:00 PM
27 5:00 PM
28 5:01 PM
What is the clinical significance of this fact? • Simple restorations should not alter the RCP- ICP slide.
• this may lead to muscle hyperactivity causing bruxing, clenching and TMJ and muscle problems. These in turn may lead to the mechanical failure of restorations.
29 5:00 PM
Lateral and protrusive contacts
Excursive contacts on posterior teeth may be undesirable.
lateral excursive movements (the presence or absence of contacts
on the nonworking side)
Such tooth contact in eccentric movements can be verified with a
thin Mylar strip (shim stock)
30 5:00 PM
Lateral and protrusive contacts
Teeth that are subject to excessive loading may develop varying
degrees of mobility.
Tooth movement (fremitus) should be identified by palpation. If a
heavy contact is suspected, a finger placed against the buccal or
labial surface while the patient lightly taps the teeth together helps
locate fremitus in MI.
31 5:00 PM
General alignment
The teeth are evaluated for:
Crowding.
Rotation.
Supra eruption.
Spacing.
Malocclusion.
Vertical and horizontal overlap.
32 5:00 PM
Vitality tests
Vital teeth may commonly
give a negative response
following trauma.
33 5:00 PM
Radiographic/imaging assessments
34 5:00 PM
Crown root ratio
The optimum crown root ratio is 2/3
Optimum Acceptable
35 5:00 PM
What to do if there is acceptable C/R ratio:
Double abutments:
• A secondary abutment must have at least as much root
surface area and as favorable a crown-root ratio as the
primary abutment it is intended to bolster.
36 5:00 PM
Root Configuration
Teeth with widely separated roots are better than those with
converged or fused roots.
Roots that are broader labio-lingually than they mesiodistally are
preferable to roots that are round in cross section.
37 5:00 PM
Periodontal ligament area
"Ante's Law" The root surface area of the abutment
teeth had to equal or surpass that of the
teeth being replaced with pontics.
38 5:00 PM
Biomechanical Considerations
• BENDING : Bending or deflection varies
directly with the cube of the length
39 5:00 PM
and inversely with the cube of the occluso-gingival
thickness of the pontic.
Biomechanical Considerations
40 5:00 PM
What is risk imposed by long span FPDs?
Longer pontic spans also have the potential for
producing more torqueing forces on the fixed
partial denture, especially on the weaker abutment.
To minimize flexing:
1. increase occluso-gingival dimension of the
pontic, if possible.
2. use rigid alloys.
Biomechanical Considerations
41 5:00 PM
Arch curvature • has its effect on the stresses
occurring in a fixed partial denture.
• When pontics lie outside the inter-abutment axis line, the pontics act as a lever arm, which can produce a torqueing movement.
• The first premolars sometimes are used as secondary abutments for a maxillary four-pontic canine to- canine fixed partial denture
Biomechanical Considerations
42 5:00 PM
Diagnostic Casts
43 5:00 PM
1. Provide valuable preliminary information and a comprehensive
overview of patient‟s needs
2. examine the occlusal relationships and the relationship of
antagonist teeth to the edentulous area.
3. Treatment procedures can be rehearsed on the stone cast before
making any irreversible changes in the patient‟s mouth
4. Used for diagnostic wax-up, preliminary RPD design, surgical
stent (surgical procedures), etc.
5. Help to explain intended procedure to patient
Diagnostic Casts
44 5:00 PM
Predicting Prognosis
Prognosis: is an estimation of the likely course of a disease.
VIPs
WOMEN
ESTHETIC TREATMENT SEEKERS
45 5:00 PM
Prognosis of dental procedure is influenced by
General
factors
Local
factors
46 5:00 PM
General Factors
1. The overall caries rate of the patient's dentition
indicates future risk to the patient if the condition is
left untreated.
2. the patient's understanding and comprehension of
plaque control measures, as well as the physical
ability to perform those tasks.
47 5:00 PM
3. Systemic problems: Diabetic patients are prone to a higher incidence of periodontal disease, and special precautionary measures may be indicated before treatment begins.
4. Amount of occlusal forces: Some patients are capable of an extremely high occlusal force whereas others are not. (muscleman Vs frail 90-year-old)
48 5:00 PM
Local Factors
1. The observed vertical overlap of the anterior teeth has a direct effect on the load distribution in the dentition and thus can have an effect on the prognosis.
2. Individual tooth mobility
3. root angulation & root structure
4. crown/root ratios
5. Previous endodontic treatments:
49 5:00 PM
Patient-Dentist Relation
Patient knows nothing
about your procedures..
How honest you are?
50 5:00 PM
Ask questions like..
1. would I carry out this treatment on my own
family members‟ teeth?‟
2. „Would I have this treatment carried on my
own teeth?
51 5:00 PM
Design of prosthesis
If single tooth:
Direct or cast restoration?
1. Destruction of tooth structure
2. Esthetics
3. Plaque control
4. Financial considerations
5. Retention
52 5:00 PM
Fixed or removable?
Span length
Span configuration
Abutment alignment
Abutment condition
Occlusion
Ridge form
General features
Periodontal condition
53 5:00 PM
Span length
1. Posterior spans longer than
2 teeth
2. Anterior spans longer than
4 incisors
Fixed PD Removable PD
1. Posterior span: 2 or fewer
2. Incisors: 4 or fewer
54 5:00 PM
Span configuration
1. No distal abutment
2. Multiple or bilateral
edentulous spaces
Fixed PD Removable PD
1. Usually has distal abutment
but can be used with short
cantilever pontic
55 5:00 PM
Abutment alignment
Tipped abutments can be
tolerated
Fixed PD Removable PD
Less than 25° inclination can be
accommodated by preparation
modification
56 5:00 PM
Abutment condition
1. Short clinical crowns
2. Insufficient abutments
Fixed PD Removable PD
1. Good if abutments need
crowns
2. Nonvital teeth can be used
if there is sufficient coronal
tooth structure
57 5:00 PM
Occlusion
More adaptable to irregularities
in a healthy opposing natural
dentition
Fixed PD Removable PD
Favorable loading (magnitude,
direction, frequency, duration]
58 5:00 PM
Ridge form
Gross tissue loss in residual
ridge
Fixed PD Removable PD
1. Moderate resorption
2. No gross soft tissue defects
59 5:00 PM
General Features
1. Dry mouth poor RPD risk
2. Limited patient finances
3. Treatment simplification
4. Advanced age
5. Systemic health problems
6. More adaptable to dentition
in transition to edentulous
state
Fixed PD Removable PD
1. Large tongue
2. Exaggerated gag reflex
3. Unfavorable attitude toward
RPD
60 5:00 PM
Treatment sequence
When patient needs have been identified a
logical sequence of steps must be decided:
1. Treatment of Symptoms: a fractured tooth or teeth, acute
pulpitis, acute exacerbation of chronic pulpitis, a dental
abscess, acute pericoronitis or gingivitis, and myofascial
pain dysfunction.
61 5:00 PM
2. Stabilization of deteriorating conditions:
Treatment of carious lesions
Chronic periodontitis and plaque control
measures.
Treatment sequence
62 5:00 PM
3. Definitive Therapy:
1. Oral surgery (removing residual roots and
ridge contouring)
2. Periodontics (bisection, pocket removal,
gingivectomy, crown lengthening)
3. Endodontics (evaluation of RCT)
4. Orhtodontics (need for any tooth movement;
upright, tilt, intrude, extrude)
5. Fixed prosthodontics
Treatment sequence
63 5:00 PM
References
Contemporary fixed prosthodontics
Chapter 1 Pages: 3 – 22,
Chapter 3 Pages: 99 – 102.
Fundamental of fixed prosthodontics. 3rd
Ed (Chapter 7 Pages: 85-102)
64 5:00 PM
65 5:00 PM