Lecture 2. treatment planning & treatment sequences

Treament Planning and

treatment sequences

Dr. Mahmoud Al-Afandi

MSc. Degree in Fixed Prosthodontics

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Decision making process

1. Gathering Information & Defining a Diagnosis.

2. Predicting prognosis.

3. Deciding on a treatment option.

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Socrates

No diagnosis.. No

treatment

Gathering Information & Defining a Diagnosis.

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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.

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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.

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1- Medical history

Diabetes.

Pregnancy.

The use of anticonvulsant drugs.

Gastro-esophageal reflux disease.

Oral manifestation of systemic conditions

Dilantin Phenytoin seizures

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medications

Gingival hyperplasia due calcium channels blocker

antihypertensive drugs nifedipine

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• the lingual surfaces are bare of enamel except for a narrow band at the gingival margin

Etching times & severity of fluorosis

(45 seconds)

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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.

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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.

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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”

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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)

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Examination

General Examination

(patient's general appearance, gait, and weight, skin color, vital signs…)

Extra-oral examination

Intra-oral examination

Radiographic examination

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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.

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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

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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.

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3- Lips:

Negative space

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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.

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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.

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CR: centric relation

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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.

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• These casts reveal a large horizontal discrepancy between RCP and ICP with only a small vertical component.

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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.

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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)

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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.

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General alignment

The teeth are evaluated for:

Crowding.

Rotation.

Supra eruption.

Spacing.

Malocclusion.

Vertical and horizontal overlap.

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Vitality tests

Vital teeth may commonly

give a negative response

following trauma.

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Radiographic/imaging assessments

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Crown root ratio

The optimum crown root ratio is 2/3

Optimum Acceptable

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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.

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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.

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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.

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Biomechanical Considerations

• BENDING : Bending or deflection varies

directly with the cube of the length

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and inversely with the cube of the occluso-gingival

thickness of the pontic.

Biomechanical Considerations

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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

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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

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Diagnostic Casts

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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

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Predicting Prognosis

Prognosis: is an estimation of the likely course of a disease.

VIPs

WOMEN

ESTHETIC TREATMENT SEEKERS

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Prognosis of dental procedure is influenced by

General

factors

Local

factors

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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.

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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)

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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:

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Patient-Dentist Relation

Patient knows nothing

about your procedures..

How honest you are?

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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?

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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

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Fixed or removable?

Span length

Span configuration

Abutment alignment

Abutment condition

Occlusion

Ridge form

General features

Periodontal condition

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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

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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

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Abutment alignment

Tipped abutments can be

tolerated

Fixed PD Removable PD

Less than 25° inclination can be

accommodated by preparation

modification

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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

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Occlusion

More adaptable to irregularities

in a healthy opposing natural

dentition

Fixed PD Removable PD

Favorable loading (magnitude,

direction, frequency, duration]

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Ridge form

Gross tissue loss in residual

ridge

Fixed PD Removable PD

1. Moderate resorption

2. No gross soft tissue defects

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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

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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.

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2. Stabilization of deteriorating conditions:

Treatment of carious lesions

Chronic periodontitis and plaque control

measures.

Treatment sequence

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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

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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)

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