TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES

Soraya C. Villarroel, D.D.S., M.S.
June 8, 2004

Outline
1. 2. 3. 3. Objective Developing Treatment Options Complex Treatment Planning Protocol RPD, Fixed and Immediate Dentures Clinical and Lab Procedures 4. 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*

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*C. Bain, Treatment Planning in General Denta1 Practice, 2003

Complex Prosthodontic Cases Factors to be considered:       Four or more fixed restorations (crowns. 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 . FPD) CD/RPD.

 Local factors: occlusion. etc.Developing Treatment Options Diagnosis:       Dental and medical history Clinical examination Radiographic films Diagnostic pictures Diagnostic casts Diagnostic wax-up Prognosis:  General factors: age. access for oral hygiene . oral environment.

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 .

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

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 .

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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 . 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.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.

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 .

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

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. etc. preliminary RPD design.  Help to explain intended procedure to patient . surgical stent (surgical procedures).

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

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 .

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 .

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

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 .

Contemporary Fixed Prosthodontics.. 2001 .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.

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.. 2001 . Contemporary Fixed Prosthodontics.

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

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

1999 .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.

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 .

Immediate Partial/Denture Clinical/Lab Procedures Immediate Denture  Examination and Diagnosis  Single Phase Surgical Schedule  Final Impression  Facebow. Jaw Records  Double Phase Surgical Schedule   Extract all posterior teeth Wait 6 weeks of healing  Final Impression  Facebow. AG Wee . Jaw Records       Marking ³Esthetic Indicators´ Wax Try-in Laboratory Procedures Extractions and Delivery Maintenance Fabrication of Definitive  Intra-oral Modifications  Final Impressions  Facebow. Jaw Record Immediate Partial Courtesy of Dr.

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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     .

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 .

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 .

Clinical Case .

Clinical Case I: Immediate Denture .

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Clinical Case II: Fixed-RPD .

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Clinical Case III: CD/Fixed-RPD .

Clinical Case IV: Immediate Partial-Denture .

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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. faculty.Summary  The patient should be considered as a human being  Successful accomplishment of dental treatment is the result of a multidisciplinary team effort: students. and Clinic  Improve OSU Clinic/College reputation . staff.

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 .

. The Ohio State University Department of Primary Care  Boucher¶s Prosthodontic Treatment for Edentulous Patients. 2004  Contemporary Fixed Prosthodontics. M. van Putten. 2001  Complex Denture Fabrication.. 11th Edition. 2000 .References  Clinic Manual 2003-2004. Rosenstiel et al. Zarb et al.

Thank You! .

Complex Fixed Tx Sequence *Rosenstiel et al.. Contemporary Fixed Prosthodontics. 2001 .

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