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    • Soraya C. Villarroel, D.D.S., M.S.
  • 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 good health , 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. Phase II Disease Control Phase III Restorative Phase IV Maintenance Treatment Plan by Phases Dental & medical history Clinical examination, Radiographic films Dx Casts, Dx photographs Dx Wax-up, Aesthetic evaluation Periodontal Therapy Endodontic Therapy (RCT) Removal of existing restorations Caries control Phase I Diagnosis
      • Crown lengthening/Implant surgery
      • Gnathologic technique
      • Long-term provisional restorations
      • Cast restorations, Cast RPD’s
    Recall every 6 months Fluoride supplements Reinforce oral hygiene Improve diet
  • 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
  • 14.  
  • 15.  
  • 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.
    • 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
    Diagnostic Wax-up
  • 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.
    • 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 Denture
  • 35. Immediate Partial/Denture Clinical/Lab Procedures
    • 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 Courtesy of Dr. AG Wee
  • 36.  
  • 37.  
  • 38.  
  • 39.
    • 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 Advantages
  • 40.
    • 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 Partial/Denture Disadvantages
  • 41.
    • Patient in poor general health
    • Uncooperative patient
    • Patient with surgical risks:
      • Radiation therapy
      • Blood clotting
      • Tissue regeneration/wound healing problems
      • After surgery drainage required
    Immediate Denture Contraindications
  • 42. Clinical Case
  • 43. Clinical Case I: Immediate Denture
  • 44.  
  • 45.  
  • 46.  
  • 47. Clinical Case II: Fixed-RPD
  • 48.  
  • 49. Clinical Case III: CD/Fixed-RPD
  • 50. Clinical Case IV: Immediate Partial-Denture
  • 51.  
  • 52. Summary
    • The patient should be considered as a human being
    • Successful accomplishment of dental treatment is the result of a multidisciplinary team effort: students, faculty, staff, 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, and Clinic
      • Improve OSU Clinic/College reputation
  • 53. 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
  • 54.
    • Clinic Manual 2003-2004; The Ohio State University Department of Primary Care
    • Boucher’s Prosthodontic Treatment for Edentulous Patients, 11 th Edition; Zarb et al., 2004
    • Contemporary Fixed Prosthodontics, Rosenstiel et al., 2001
    • Complex Denture Fabrication, M. van Putten, 2000
  • 55.
    • Thank You!
  • 56. Complex Fixed Tx Sequence *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  • 57.  
  • 58.  
  • 59.