Diagnosis and treatment planning – part 1

Bibin bhaskaran

Diagnosis and treatment planning – part 1

Index

Definition Objectives Purpose Patient interview Clinical examination Oral examination Diagnostic casts Face bow transfer Jaw relation records Recording centric relation Diagnostic findings Radiographic Interpretation. Periodontal considerations.

Definition of diagnosis & treatment planning.

• Diagnosis is defined as determination of nature of disease.

• Treatment planning is defined as the sequence of procedures planned for the treatment of a patient after diagnosis.

• Boucher –Diagnosis - Planned observation to

determine & evaluate the existing conditions, which lead to decision making based on the condition observed.

OBJECTIVES

Elimination of disease.

Preservation of oral tissues & remaining teeth.

Restoration of function and esthetics. Elimination of diseases

Purpose and uniqueness of treatment

Purpose – respond to patients needs.

Delineation of each pts uniqueness occurs through the pt interview and diagnostic clinical examination process.

Includes 4 distinct process-

Understanding pts desires or chief concerns/complaints regarding their condition thru a systemic interview process.

Ascertaining the pts dental needs through a diagnostic clinical exam.

Developing a treatment plan that reflects the best management of the desires and needs.

Appropriately sequenced execution of the Rx with planned follow up.

Patient interview

Patient comes for professional examination –

(1) an abnormality that requires correction (2) to maintain optimum oral health.

Fundamental objective of pt interview is to gain a clear understanding of why the pt is coming for examination.

Patient interview

Pt interview format-

1. Chief complaint and its history2. Medical history review3. Dental history review; especially related to

previous prosthetic experience.4. Patient expectations.

Infection Control –

Gloves.

Masks should be worn to protect oral and nasal mucosa

Eyes protected - blood and saliva.

Sterilization methods - autoclave, dry heat oven, chemical vapor sterilizers, and chemical sterilants.

Cleanup of instruments and surfaces in the operatory.

Contaminated disposable materials - discarded in plastic bags to minimize human contact.

The interview-to develop rapport –patient.

Involves listening to and understanding the patient's chief complaint or concern about their oral health.

Include clinical symptoms of pain ,difficulty with function, concern about their appearance, problems with an existing prosthesis, previous dental treatment.

Clinical examination

Objectives of prosthodontic Rx-

(1) the elimination of disease

(2) the preservation, restoration, and maintenance of the health of the remaining teeth and oral tissues

(3) the selected replacement of lost teeth for the purpose of restoration of function in a manner that ensures optimum stability and comfort in an esthetically pleasing manner.

Clinical examinationDiagnosis and treatment planning for oral rehabilitation

of partially edentulous mouths must take into consideration the following:

Control of caries and periodontal disease Restoration of individual teeth Provision of harmonious occlusal relationships and

replacement of missing teeth.

Diagnostic casts - designing and planning RPD treatment- definitive Rx is undertaken.

Clinical examination Failures of RPD - result in poor stability-from

inadequate diagnosis .

Complex treatment planning often require two appointments-

The first a preliminary oral examination ,a prophylaxis, full-mouth radiographs, diagnostic casts, and mounting records.

The follow up appointment includes mounting of the diagnostic casts ,review of the radiographs.

Oral examination

Include a visual and digital evaluation of the teeth and surrounding tissue.

Sequence of oral examination-

Visual examinationPain relief and temporary restorationRadiographs ,oral prophylaxisEvaluation of teeth and peridontiumVitality testsDetermination of floor of mouth position.

Relief of Pain and Discomfort and Placement of Temporary Restorations-

Advisable not only to relieve discomfort arising from tooth defects but also to determine -extent of caries and to arrest further caries activity until definitive Rx can be instituted.

By restoring tooth contours - temporary restorations, the impression -torn on removal from the mouth-accurate diagnostic cast .

A Thorough and Complete Oral Prophylaxis

An adequate examination can be accomplished best with the teeth free of accumulated calculus and debris.

Also, accurate diagnostic casts of the dental arches can be obtained only if the teeth are clean.

Complete Intraoral Radiographic Survey

To locate areas of infection and other pathosis

To reveal the presence of root fragments, foreign objects, bone spicules, and irregular ridge formations.

To display the presence and extent of caries.

To permit evaluation of existing restorations

To reveal the presence of root canal fillings .

To permit an evaluation of periodontal conditions.

To evaluate the alveolar support of abutment teeth.

Examination of Teeth, Investing Structures, and Residual Ridges

Consideration of caries susceptibility is of primary importance.

The No of restored teeth, recurrent caries and evidence of decalcification should be noted.

Gingival inflammation, the degree of gingival recession, and mucogingival relationships should be observed.

The presence of tori or other bony exostoses - detected-and evaluation -framework design.

Adequate relief of the palatal major connectors must be planned.

Occlusal relationship-opposing arch. Extrusion of a tooth or teeth-opposing edentulous

area-replacement of teeth in the edentulous area.

Determination of Height of the Floor of the Mouth to Locate Inferior Borders of Lingual Mandibular Major Connectors

Mouth preparation procedures are influenced by a choice of major connectors.

This determination must precede altering contours of abutment teeth.

DIAGNOSTIC CASTS-

A diagnostic cast should be an accurate reproduction of all the potential features that aid diagnosis.

These include the teeth locations, contours, and occlusal plane relationship; the residual ridge contour, size, and mucosal consistency.

Dental stone.

Purposes of Diagnostic Casts-

Diagnostic casts -permit view of the occlusion from the lingual and buccal aspects.

The degree of overclosure, the amount of interocclusal space available, and the possibilities of interference to the location of rests may also be determined.

Diagnostic casts are used to permit a topographic survey of the dental arch that is to be restored by means of a removable partial denture.

The principal considerations in studying parallelism of tooth and tissue surfaces of each dental arch -determine the need for mouth preparation.

Diagnostic casts are used to permit a logical and comprehensive presentation to the patient .

Occluded and individual diagnostic casts can be used to point out to the patient –

(a) evidence of tooth migration.

(b) effects of further tooth migration.

(c) loss of occlusal support.

(d) hazards of traumatic occlusal contacts. (e) cariogenic and periodontal implications of

further neglect.

Proposed fee.

Individual impression trays.

Diagnostic casts -reference as the work progresses.

location of rests, and the design of the removable partial denture framework.

Areas of abutment teeth to be modified may first be changed on the duplicate diagnostic cast.

Diagnostic casts should be duplicated, one cast serving as a permanent record and the duplicate cast used in situations that may require alterations.

Mounted Diagnostic Casts-

Supplement examination of oral cavity. Detailed analysis of pts occlusion. Aid in education of pt and presentation of Rx

plan. Provide a permanent dental record of pts

condition before Rx-avoids conflicts.

Objective-

Position casts of dental arches on an articulator -mand and max in pts skull-

3 distinct phases.

Orientation of max cast to condylar elements of articulator by means of facebow transfer.

Orientation of mand cast to max cast at the pt centric jaw relation.

Verification of these relationships by means of additional centric jaw relation records and comparison of occlusal contacts on articulator with those in the mouth.

Face bow transfer

Equipment and supplies-

Semi adjustable articulator Conventional face-bow and bitefork compatible

with articulator. Baseplate wax or red modeling compound. Marking pencil Accurate max cast Bunsen burner Dental stone, mixing bowl and spatula Separating medium Petroleum jelly.

Face bow transfer

Arbitary hinge axis- Depends upon the type of face bow and

articulator used. Several arbitary points have been described-

Beyrons point-13mm ant to post margin of tragus of ear on a line to the outer canthus of eye.

A line running through the marks placed on both sides of face or through ext auditary meatus is the arbitary hinge axis.

Face bow transferAnterior point of reference-

Position face-bow on pts face. Infraorbital notch-hanau face bow-hanau Wide

Vue articulator. Plane contacting ant reference point and ext

auditory meatus -parallel with Frankfort plane. Failure to use ant point of reference-errors in

analysis of eccentric occlusal interferences.

Technique

Preparation of bite fork-

One sheet of wax- softened over flame. Adapted on both sides of bite fork. Fork positioned in mouth with projecting

attachment arm to left side of pt and midline mark on fork to midline of the pt.

Imprints of teeth are accurately recorded.

Technique

Mand teeth allowed to close lightly into compound to stabilize the facebow- chilled with cold water.

Max cast seated in record to verify fit and stablilty.

If accuracy of record doubtful-Zno-eugenol paste.

Technique

Orientation of face bow to bite fork and reference points-

Bite fork -seated in max teeth supported by mand teeth.

Beyrons point – reference.

Spring bow held so that stem of bite fork enters the loose fork clamp on the bow.bow spung open-ear pieces will enter ext auditary meatus.

Orientation of face bow to the articulator-

Articulator adjusted-condylar guidance-30°-Bennett guide at 15°-incisal table at O°.

Ant elevator is attached to the transfer rod. Open the spring bow and attach earpieces. Attach orbitale indicator to undersurface of upper

member of articulator.

Use cast support attached to lower member to stabilize fork during mounting.

Seat max cast in occlusal index of the fork after base of cast been indexed and separating media applied.

Mix of dental stone

Jaw relation records for Diagnostic Casts-

Critical decision in RPD-horizontal jaw relationship.

Mouth preparations.

Failure – poor prosthesis stability,discomfort,resorption of ridges.

Correction of deflective contacts-max intercuspal and eccentric position-preventive measure.

Natural post teeth present, no TMJ problems, neuromuscular function or P.problems exist-restoration safely fabricated with max intercuspation.

Natural centric stops missing-prosthesis fabricated-max intercuspal position is in harmony with centric relation.

Regardless of method used –functional occlusion-evaluation of existing relationships with natural teeth-diagnostic casts.

Diagnostic cast-evaluate relationship of remaining oral structures-semi adjustable articulator-face bow, interocclusal records.

Necessary alteration – duplicates of mounted diagnostic casts.

Need for crowns or onlays for recontouring, repositioning or elimination of extruded teeth.

Max cast-articulator –facebow transfer-same relation max related to hinge axis and frankfort plane.

Centric relation record made in most retruded postn of mand.

A straight forward protrusive record made to adjust horizontal condylar inclines on articulator.

If occlusal rims necessary to correctly orient casts-centric relation –horizontal jaw relationship.

Materials and methods for recording centric relation

Wax

Modeling plastic

Quick-setting impression plaster

Metallic oxide bite registration paste

Polyether impression materials

Methods for recording centric relation

Mand cast -lower arm - articulator inverted Articulator locked - centric position. Incisal pin adjusted-ant distance b/w upper and

lower arms of articulator will be inc 2-3mm. Base of cast keyed and lubricated for future

removal. Articulator mounting-relates cast in centric

relation. Dentist –occlusal analysis. After occlusal analysis-casts removed-surveying. Indexed mounted ring record retained.

DIAGNOSTIC FINDINGS

Rx considered based on information-pt interview.

More than one Rx option considered.

Financial implications need to be considered – best decision.

Pt interview-medical considerations-prostheses.

Health conditions-(i.e. diabetes mellitus, Sjogren's syndrome, lupus, atrophic changes) -risk for pt comfort for a tissue-supported prosthesis and factor into-Rx decision.

Pt with previous experience of prosthesis-pt interview-additional information-Rx decisions.

The patient generally expresses concern about a symptom that can be related to support, stability, retention, or appearance.

Interpretation of examination dataRadiographic interpretation-

Disease validation-

Dental caries severity Periodontal disease risk and severity Bone lesions associated with jaws and teeth.

Tooth support-

Quality of alveolar support of abutment tooth. Abutment teeth adjacent to distal extension bases-

vert and horizontal forces. Design rigid connectors of Rpd. Understanding of bone density, index areas and

lamina dura.

Bone density-

Quality and quantity of bone. Height of bone and quality-importance. Interpreting bone height-lamina dura from apex

towards crown. Bone usually responds favorably to ordinary

stresses. Abnormal stresses-reduction in size of trabecular

pattern particularly in area of bone directly adjacent to lamina dura of affected tooth.

Dec in size of trabecular pattern-bone condensation.

Index areas-

Those areas of alveolar support that disclose the reaction of bone to additional stresses.

Reaction of bone to additional stresses in these areas—+ve or –ve.

+ve bone factor-ability to build additional support.

-ve bone factor-inability to respond favorably to stress.

Alveolar lamina dura-

Thin layer of cortical bone-lines sockets of all teeth.

Function-withstand mechanical strain.

Resorption occurs-pressure, apposition occurs-tension.

Bony trabeculations are often arranged at right angles to heavier lamina dura-build support.

Root morphology-

Teeth with multiple and divergent roots resist stresses better than teeth with fused and conical roots.

Forces distributed thru a greater number of periodontal fibres to a large amt of supporting bone.

Periodontal considerations-

Condition of gingiva,attached gingiva,presence or absence of periodontal pockets.

Mucogingival attachment,osseous defects or mobility patterns recorded-causes and potential Rx determined.

Oral hygiene habits determined-efforts to educate pt-plaque control.

Remaining teeth and prostheses will require meticulous plaque control after placement of

RPD.

Evaluation of prostheses foundation-teeth and residual ridge-

To ensure that an appropriately stable base of sound teeth/residual ridge is provided to maximize prostheses function and pt comfort.

Surgical preparation-

Need for preprosthetic surgery or Xns should be evaluated. Grossly displaceable soft tissue covering basal seat areas

and hyperplastic tissue-removed-firm denture base foundation.

Removal of mand tori,bone prominence.

Xn of teeth indicated for one of the following reasons-

If tooth cannot be restored to state of health Xn may be unavoidable.

A tooth may be removed if its absence will permit a more serviceable and less complicated RPD.

Another consideration for preprosthetic surgery involves the decision b/w use of RPD and implant supported prosthesis.

Short modification spaces-

For short spans less than 3 missing teeth-natural tooth, implant supported fixed prostheses and RPD can be considered.

Implants-adv-replacement of teeth – adjacent teeth.

Longer modification spaces-

Longer span modification spaces – greater challenge- F.P.D. RPD or implant supported prosthesis.

Distal extension spaces-

Without tooth support at end of missing teeth- RPD and implant supported prosthesis-primary consideration.

Implant therapy not elected frequently-pt medical factors,risks for surgical morbidity,inc time required,costs.

Residual ridge resorption-RPD.

Endodontic Rx-

Abutments for rpd-withstand forces.

Requirement for distal extension abutment(torsional forces) –different from tooth supported.

Bcos tooth support helps control prosthesis movt-need for endo RX should include assessment of overdenture abutments for RPDs.

Analysis of occlusal factors-

Mounted diagnostic casts. Improvements in natural occlusion-before

fabrication of prosthesis. Objective of occlusal reconstruction-occlusal

harmony of restored dentition. Decision whether to accept or reject the existing VD.

Fixed restorations-

Restore modification spaces with fixed prostheses-isolated abutment teeth.

FPDs-tooth bound spaces-unless space facilitates simplification of RPD.

Orthodontic Rx-

Occasionally ortho movt followed by FPD-better esthetic RPD design.

Need for determining type of mand major connector-

Oral examination Measuring ht of floor of mouth i.r.t lingual

gingiva-P.probe. Transferred to diagnostic cast.

Need for reshaping remaining teeth-

Paralleling of proximal tooth surfaces. Preparation of adequate rests. Reduction of unfavorable tooth contours. Failure to reshape unfavorable inclined tooth

surfaces-complicates design and location of clasps-failure of RPD.

Need for reshaping remaining teeth-

Unparallel proximal tooth surfaces-malaligned tooth-fail-needed guiding plane-excessive blockout.

Connectors placed far-food traps.

Amt of reduction-min-fluoride Rx.

Comprehensive analysis of diagnostic casts-surveyor

CONCLUSION

The treatment plan for an edentulous patient is simple.

The approach varies widely. Assembling all the diagnostic criteria

takes time, but it is time well spent to assure a successful result.

References

Carr A B, Mc Givney G P, Brown D T, Minor connector in McCraken’s Removable partial Prothodontics. 11th ed, st louis: Mosby; 2008, 35-53.

Stewart K L, Rudd K D, Kuebker W A, Minor connector in Stewart’s Clinical Removable Partial Prosthodontics. 2nd ed, 2004, 22-42.

Miller E L, Grasso J E, Major connector in Removable Partial Prosthodontics. 2nd ed, Baltimore: Williams & Wilkins; 1979, 175-94.