TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES

1. TREATMENT PLANNINGPROTOCOL FOR COMPLEXPROSTHODONTIC CASES Soraya C. Villarroel, D.D.S., M.S. June 8, 2004

2. Outline • Objective • Developing Treatment Options • Complex Treatment Planning Protocol • RPD, Fixed and Immediate Dentures Clinical and Lab Procedures • Assorted Clinical Cases • Summary

3. 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

4. Treatment Plan Purpose Formulating a logical sequence of treatment designed to restore the patient’s dentition to goodhealth, with optimal function and appearance* *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

5. 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

6. 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

7. 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

8. 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

9. Treatment Plan by Phases Dental & medical history Clinical examination, Radiographic films Dx Casts, Dx photographs Dx Wax-up, Aesthetic evaluation Phase I Diagnosis Periodontal Therapy Endodontic Therapy (RCT) Removal of existing restorations Caries control Phase II Disease Control Crown lengthening/Implant surgery Gnathologic technique Long-term provisional restorations Cast restorations, Cast RPD’s Phase III Restorative Recall every 6 months Fluoride supplements Reinforce oral hygiene Improve diet Phase IV Maintenance

10. Complex Cases Protocol • Diagnostic Phase (Complex D&T) • Paperwork (Prosthodontic Component) • Prosthetic or Reconstructive Phase

11. 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)

12. 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)

13. 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

16. 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

17. 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

18. Diagnostic Casts* *Comprehensive Care Patient Presentations,2003-04, Dr. Mary Baechle 

19. 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

20. Diagnostic Wax-up* *Comprehensive Care Patient Presentations,2003-04, Dr. Mary Baechle 

21. Diagnostic Wax-up • 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

22. Complex Cases Protocol (Pros phase) • Removable Partial Dentures (RPD) • Fixed Prosthodontics (crowns/FPD) • Immediate Dentures

23. 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

24. RPD Clinical/Lab Procedures • Altercast impression in case of distal extensions or Kennedy class I or II arch form • Tray fabrication • Border molding

25. Altercast Impression Procedure

26. RPD Clinical/Lab Procedures • Wax-rim fabrication, CRR, Facebow (if required) • Selection of denture teeth shape/shade • Set up teeth

27. RPD Clinical/Lab Procedures • Wax try-in: Verify CR/Esthetic try-in • Approval: patient/faculty • Lab form required for processing Prosthesis • Prosthesis placement • Post-placement checking appointments

28. 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

29. 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

30. 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

31. Fixed Pros Clinical/Lab Procedures* • Try-in Crowns/FPD (Framework Try-in) *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

32. Fixed Pros Clinical/Lab Procedures* • Placement of final restorations *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

33. 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

34. Immediate Denture 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

35. 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/Denture Clinical/Lab Procedures Immediate Partial Courtesy of Dr. AG Wee

39. Immediate Partial/Denture Advantages • 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

40. Immediate Partial/Denture Disadvantages • 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

41. Immediate Denture Contraindications • Patient in poor general health • Uncooperative patient • Patient with surgical risks: • Radiation therapy • Blood clotting • Tissue regeneration/wound healing problems • After surgery drainage required

42. Clinical Case

43. Clinical Case I: Immediate Denture

47. Clinical Case II: Fixed-RPD

49. Clinical Case III: CD/Fixed-RPD

50. Clinical Case IV: Immediate Partial-Denture