Dr. Stefano Gracis

Treatment planning exercise

1

CH

IEF

C

OM

PL

AIN

T• 65 y.o. male, just retired• no medical contraindication to treatment • no medications

“I cannot chew properly due to the removable prosthesis in the upper arch which I never accepted. I would like to eliminate it and replace it with a fixed restoration. Also, I am experiencing some discomfort in the lower right and upper left sides of my mouth”.

PA

TIE

NT

D

ATA

oral hygieneThe patient brushes his teeth twice a day with a manual toothbrush. He does not floss.

• The patient, prior to this time, had not seen a dentist for any treatment in approximately four years. In the past, he sought only emergency care. • The mandibular removable partial denture was

fabricated about 5 years earlier, after the left first premolar was lost and the fixed prosthesis that it was supporting had to be sectioned and removed.

dental history X X

XX XXX

XXX XXXXXX

X XXXXXX

XXXX XX XXX

X

X

extraoral exam23/05/06

40

XX

• Both TMJs within normal limits, no click and no pain, neither spontaneous neither upon palpation

• Maximum mouth opening within normal limits

• No muscle pain upon palpation

• No significant facial asymmetries• Flat to slightly concave profile with a

normo-divergent skeletal pattern• Asymmetric smile• Low smile line• Upper dental midline coincident with

facial midline

extraoral exam

• At repose, the upper incisor exposure is ∼ + 5 mm

extraoral exam

extraoral exam• The lower third of the face appears

proportioned to the other thirds• Lip length in the norm• Flat to slightly concave profile

occlusal analysis

occlusal analysis

Overjet: 0 mmOverbite: 0% Central incisors: 10-11 mmCanine relationship: on the right, tendency to Angle Class III; on the left, tendency to Angle Class II

mounting in CR

occlusal analysis

• In MI, only the anterior teeth contact• CR does not coincide with MI

(RC posterior to MI by about 1 mm)

17 16 15 14 13 12 11 21 22 23 24 25 26 2747 46 45 44 43 42 41 31 32 33 37

occlusal analysis

• No efficient canine guidance in either excursions

Right

Left

17 16 15 14 13 12 11 21 22 23 24 25 26 2747 46 45 44 43 42 41 31 32 33 37

17 16 15 14 13 12 11 21 22 23 24 25 26 2747 46 45 44 43 42 41 31 32 33 37

occlusal analysis

• In protrusion, disclusion of the molars

17 16 15 14 13 12 11 21 22 23 24 25 26 2747 46 45 44 43 42 41 31 32 33 37

occlusal analysis

• Flat curves of Wilson• Curve of Spee within normal limits

occlusal analysis

EXISTING PROSTHESES

IN BLUE

diagnosis✓Generalized marginal gingivitis✓Moderate to advanced loss of

periodontal support✓Inadequate endodontic treatments✓Defective restorations✓Missing teeth✓Class III malocclusion

prognosisdiagnosis✓Generalized marginal gingivitis✓Moderate to advanced loss of

periodontal support✓Inadequate endodontic treatments✓Defective restorations✓Missing teeth✓Class III malocclusion

HOPELESS

QUESTIONABLE

17, 24, 2747, 46

16, 13, 2645, 33, 37

What shall you do ?

9 questions to treatment plan

1. Is the apico-coronal position of the incisal margin of the upper anterior teeth (central incisors) at the correct level with respect to the lips, at repose and in a forced smile?

2. Is the clinical crown of the upper anterior teeth of the proper length? 3. Is the gingival margin of the upper anterior teeth at the correct level (with respect to

the lips and to the adjacent teeth)? If not, would you do something about it and, if so, what therapy would you recommend?

4. Is there enough overbite for an efficient anterior guide?5. If the maxillary teeth are too long and they were to be shortened, how will the

overbite be modified? Will it be enough to provide an effective anterior guidance?

6. If the upper teeth are short and they have to be lengthened incisally, is there a possibility to do it (at this VDO and at this inter-incisal relationship)?

7. Is the clinical crown of the mandibular anterior teeth of the proper length? Are they visible enough with respect to the lower lip?

8. When taking in consideration the posterior teeth, if indicated, is there the need/possibility to alter VDO (i.e., for lack of posterior space, or because all the teeth have to be crowned)?

9. If the VDO is altered (increased or decreased), how can the new overjet be managed?

Good luck!!