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Diagnosis and rx planning


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Diagnosis and rx planning

  1. 1. Diagnosis and treatment planning – part 1<br />Diagnosis and treatment planning – part 1<br /> Bibin bhaskaran<br />
  2. 2. Index <br />Definition <br />Objectives<br />Purpose <br />Patient interview<br />Clinical examination<br />Oral examination<br />Diagnostic casts<br />Face bow transfer<br />Jaw relation records<br />Recording centric relation<br />Diagnostic findings<br />Radiographic Interpretation.<br />Periodontal considerations.<br />
  3. 3. Definition of diagnosis & treatment planning.<br /><ul><li>Diagnosis is defined as determination of nature of disease.
  4. 4. Treatment planning is defined as the sequence of procedures planned for the treatment of a patient after diagnosis.
  5. 5. Boucher–Diagnosis - Planned observation to determine & evaluate the existing conditions, which lead to decision making based on the condition observed.</li></li></ul><li>OBJECTIVES<br />Elimination of disease.<br />Preservation of oral tissues & remaining teeth.<br />Restoration of function and esthetics.<br /> Elimination of diseases<br />
  6. 6. Purpose and uniqueness of treatment<br />Purpose – respond to patients needs.<br />Delineation of each pts uniqueness occurs through the pt interview and diagnostic clinical examination process.<br />
  7. 7. Includes 4 distinct process-<br />Understanding pts desires or chief concerns/complaints regarding their condition thru a systemic interview process.<br />Ascertaining the pts dental needs through a diagnostic clinical exam.<br />Developing a treatment plan that reflects the best management of the desires and needs.<br />Appropriately sequenced execution of the Rx with planned follow up.<br />
  8. 8. Patient interview<br />Patient comes for professional examination –<br /> (1) an abnormality that requires correction <br /> (2) to maintain optimum oral health.<br />Fundamental objective of pt interview is to gain a clear understanding of why the pt is coming for examination.<br />
  9. 9. Patient interview<br />Pt interview format-<br /> Chief complaint and its history<br /> Medical history review<br /> Dental history review; especially related to previous prosthetic experience.<br /> Patient expectations.<br />
  10. 10. Infection Control –<br />Gloves.<br /> Masks should be worn to protect oral and nasal mucosa<br /> Eyes protected - blood and saliva.<br /> Sterilization methods - autoclave, dry heat oven, chemical vapor sterilizers, and chemical sterilants.<br />Cleanup of instruments and surfaces in the operatory. <br />Contaminated disposable materials - discarded in plastic bags to minimize human contact. <br />
  11. 11. The interview-to develop rapport –patient.<br />Involves listening to and understanding the patient's chief complaint or concern about their oral health. <br />Include clinical symptoms of pain ,difficulty with function, concern about their appearance, problems with an existing prosthesis, previous dental treatment.<br />
  12. 12. Clinical examination<br />Objectives of prosthodontic Rx-<br /> (1) the elimination of disease<br /> (2) the preservation, restoration, and maintenance of the health of the remaining teeth and oral tissues <br /> (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. <br />
  13. 13. Clinical examination<br />Diagnosis and treatment planning for oral rehabilitation of partially edentulous mouths must take into consideration the following: <br />Control of caries and periodontal disease<br /> Restoration of individual teeth<br /> Provision of harmonious occlusal relationships and replacement of missing teeth.<br />Diagnostic casts - designing and planning RPD treatment- definitive Rx is undertaken. <br />
  14. 14. Clinical examination<br />Failures of RPD - result in poor stability-from inadequate diagnosis .<br />Complex treatment planning often require two appointments-<br />The first a preliminary oral examination ,a prophylaxis, full-mouth radiographs, diagnostic casts, and mounting records.<br /> The follow up appointment includes mounting of the diagnostic casts ,review of the radiographs.<br />
  15. 15. Oral examination<br />Include a visual and digital evaluation of the teeth and surrounding tissue.<br />Sequence of oral examination-<br />Visual examination<br />Pain relief and temporary restoration<br />Radiographs ,oral prophylaxis<br />Evaluation of teeth and peridontium<br />Vitality tests<br />Determination of floor of mouth position.<br />
  16. 16. Relief of Pain and Discomfort and Placement of Temporary Restorations-<br />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.<br /> By restoring tooth contours - temporary restorations, the impression -torn on removal from the mouth-accurate diagnostic cast .<br />
  17. 17. A Thorough and Complete Oral Prophylaxis<br />An adequate examination can be accomplished best with the teeth free of accumulated calculus and debris.<br /> Also, accurate diagnostic casts of the dental arches can be obtained only if the teeth are clean.<br />
  18. 18. Complete Intraoral Radiographic Survey <br />To locate areas of infection and other pathosis<br />To reveal the presence of root fragments, foreign objects, bone spicules, and irregular ridge formations.<br /> To display the presence and extent of caries. <br />
  19. 19. To permit evaluation of existing restorations<br />To reveal the presence of root canal fillings . <br />To permit an evaluation of periodontal conditions.<br />To evaluate the alveolar support of abutment teeth.<br />
  20. 20. Examination of Teeth, Investing Structures, and Residual Ridges<br />Consideration of caries susceptibility is of primary importance. <br />The No of restored teeth, recurrent caries and evidence of decalcification should be noted.<br />Gingival inflammation, the degree of gingival recession, and mucogingival relationships should be observed. <br />The presence of tori or other bony exostoses - detected-and evaluation -framework design. <br />Adequate relief of the palatal major connectors must be planned.<br />
  21. 21. Occlusal relationship-opposing arch.<br />Extrusion of a tooth or teeth-opposing edentulous area-replacement of teeth in the edentulous area.<br />Determination of Height of the Floor of the Mouth to Locate Inferior Borders of Lingual Mandibular Major Connectors<br /> Mouth preparation procedures are influenced by a choice of major connectors.<br />This determination must precede altering contours of abutment teeth.<br />
  22. 22. DIAGNOSTIC CASTS-<br />A diagnostic cast should be an accurate reproduction of all the potential features that aid diagnosis.<br /> These include the teeth locations, contours, and occlusal plane relationship; the residual ridge contour, size, and mucosal consistency.<br />Dental stone.<br />
  23. 23. Purposes of Diagnostic Casts-<br />Diagnostic casts -permit view of the occlusion from the lingual and buccal aspects.<br />The degree of overclosure, the amount of interocclusal space available, and the possibilities of interference to the location of rests may also be determined. <br />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.<br />
  24. 24. The principal considerations in studying parallelism of tooth and tissue surfaces of each dental arch -determine the need for mouth preparation.<br />Diagnostic casts are used to permit a logical and comprehensive presentation to the patient .<br />
  25. 25. Occluded and individual diagnostic casts can be used to point out to the patient –<br /> (a) evidence of tooth migration. <br /> (b) effects of further tooth migration.<br /> (c) loss of occlusal support.<br /> (d) hazards of traumatic occlusal contacts.<br /> (e) cariogenic and periodontal implications of further neglect.<br />
  26. 26. Proposed fee.<br />Individual impression trays.<br />Diagnostic casts -reference as the work progresses. <br />location of rests, and the design of the removable partial denture framework.<br />
  27. 27. Areas of abutment teeth to be modified may first be changed on the duplicate diagnostic cast.<br />Diagnostic casts should be duplicated, one cast serving as a permanent record and the duplicate cast used in situations that may require alterations.<br />
  28. 28. Mounted Diagnostic Casts-<br />Supplement examination of oral cavity.<br />Detailed analysis of pts occlusion.<br />Aid in education of pt and presentation of Rx plan.<br />Provide a permanent dental record of pts condition before Rx-avoids conflicts.<br />
  29. 29. Objective- <br />Position casts of dental arches on an articulator -mand and max in pts skull-<br />3 distinct phases.<br />Orientation of max cast to condylar elements of articulator by means of facebow transfer.<br />Orientation of mand cast to max cast at the pt centric jaw relation.<br />Verification of these relationships by means of additional centric jaw relation records and comparison of occlusal contacts on articulator with those in the mouth.<br />
  30. 30. Face bow transfer<br />Equipment and supplies-<br />Semi adjustable articulator<br />Conventional face-bow and bitefork compatible with articulator.<br />Baseplate wax or red modeling compound.<br />Marking pencil<br />Accurate max cast<br />Bunsen burner<br />Dental stone, mixing bowl and spatula<br />Separating medium<br />Petroleum jelly.<br />
  31. 31. Face bow transfer<br />Arbitary hinge axis-<br />Depends upon the type of face bow and articulator used.<br />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.<br />A line running through the marks placed on both sides of face or through ext auditarymeatus is the arbitary hinge axis.<br />
  32. 32. Face bow transfer<br />Anterior point of reference-<br />Position face-bow on pts face.<br />Infraorbital notch-hanau face bow-hanau Wide Vue articulator.<br />Plane contacting ant reference point and ext auditory meatus -parallel with Frankfort plane.<br />Failure to use ant point of reference-errors in analysis of eccentric occlusal interferences.<br />
  33. 33. Technique <br />Preparation of bite fork-<br />One sheet of wax- softened over flame.<br />Adapted on both sides of bite fork.<br />Fork positioned in mouth with projecting attachment arm to left side of pt and midline mark on fork to midline of the pt.<br />Imprints of teeth are accurately recorded.<br />
  34. 34. Technique <br />Mand teeth allowed to close lightly into compound to stabilize the facebow- chilled with cold water.<br />Max cast seated in record to verify fit and stablilty.<br />If accuracy of record doubtful-Zno-eugenol paste.<br />
  35. 35. Technique <br />Orientation of face bow to bite fork and reference points-<br />Bite fork -seated in max teeth supported by mand teeth.<br />Beyrons point – reference.<br />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 auditarymeatus.<br />
  36. 36. Orientation of face bow to the articulator-<br />Articulator adjusted-condylar guidance-30°-Bennett guide at 15°-incisal table at O°.<br />Ant elevator is attached to the transfer rod.<br />Open the spring bow and attach earpieces.<br />Attach orbitale indicator to undersurface of upper member of articulator.<br />
  37. 37. Use cast support attached to lower member to stabilize fork during mounting.<br />Seat max cast in occlusal index of the fork after base of cast been indexed and separating media applied.<br />Mix of dental stone<br />
  38. 38. Jaw relation records for Diagnostic Casts-<br />Critical decision in RPD-horizontal jaw relationship.<br />Mouth preparations.<br />Failure – poor prosthesis stability,discomfort,resorption of ridges.<br />Correction of deflective contacts-max intercuspal and eccentric position-preventive measure.<br />Natural post teeth present, no TMJ problems, neuromuscular function or P.problems exist-restoration safely fabricated with max intercuspation.<br />
  39. 39. Natural centric stops missing-prosthesis fabricated-max intercuspalposition is in harmony with centric relation.<br />Regardless of method used –functional occlusion-evaluation of existing relationships with natural teeth-diagnostic casts.<br />Diagnostic cast-evaluate relationship of remaining oral structures-semi adjustable articulator-face bow, interocclusal records.<br />Necessary alteration – duplicates of mounted diagnostic casts.<br />
  40. 40. Need for crowns or onlays for recontouring, repositioning or elimination of extruded teeth.<br />Max cast-articulator –facebow transfer-same relation max related to hinge axis and frankfort plane.<br />Centric relation record made in most retrudedpostn of mand.<br />A straight forward protrusive record made to adjust horizontal condylar inclines on articulator.<br />If occlusal rims necessary to correctly orient casts-centric relation –horizontal jaw relationship.<br />
  41. 41. Materials and methods for recording centric relation<br />Wax <br /> Modeling plastic <br /> Quick-setting impression plaster <br /> Metallic oxide bite registration paste <br /> Polyether impression materials<br />
  42. 42. Methods for recording centric relation<br />Mand cast -lower arm - articulator inverted<br />Articulator locked - centric position. <br />Incisal pin adjusted-ant distance b/w upper and lower arms of articulator will be inc 2-3mm. <br />Base of cast keyed and lubricated for future removal.<br />Articulator mounting-relates cast in centric relation.<br />Dentist –occlusal analysis.<br />After occlusal analysis-casts removed-surveying.<br />Indexed mounted ring record retained.<br />
  43. 43. DIAGNOSTIC FINDINGS<br />Rx considered based on information-pt interview.<br />More than one Rx option considered.<br />Financial implications need to be considered – best decision.<br />Pt interview-medical considerations-prostheses.<br />
  44. 44. 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.<br /> Pt with previous experience of prosthesis-pt interview-additional information-Rx decisions.<br />The patient generally expresses concern about a symptom that can be related to support, stability, retention, or appearance.<br />
  45. 45. Interpretation of examination data<br />Radiographic interpretation-<br />Disease validation-<br />Dental caries severity<br />Periodontal disease risk and severity<br />Bone lesions associated with jaws and teeth.<br />Tooth support-<br />Quality of alveolar support of abutment tooth.<br />Abutment teeth adjacent to distal extension bases-vert and horizontal forces.<br />Design rigid connectors of Rpd.<br />Understanding of bone density, index areas and lamina dura. <br />
  46. 46. Bone density-<br />Quality and quantity of bone.<br />Height of bone and quality-importance.<br />Interpreting bone height-lamina dura from apex towards crown.<br />Bone usually responds favorably to ordinary stresses.<br />Abnormal stresses-reduction in size of trabecular pattern particularly in area of bone directly adjacent to lamina dura of affected tooth.<br />Dec in size of trabecular pattern-bone condensation.<br />
  47. 47. Index areas-<br />Those areas of alveolar support that disclose the reaction of bone to additional stresses.<br />Reaction of bone to additional stresses in these areas—+ve or –ve.<br />+ve bone factor-ability to build additional support.<br />-ve bone factor-inability to respond favorably to stress.<br />
  48. 48. Alveolar lamina dura-<br />Thin layer of cortical bone-lines sockets of all teeth.<br />Function-withstand mechanical strain.<br />Resorption occurs-pressure, apposition occurs-tension.<br />Bony trabeculations are often arranged at right angles to heavier lamina dura-build support.<br />
  49. 49. Root morphology-<br />Teeth with multiple and divergent roots resist stresses better than teeth with fused and conical roots.<br />Forces distributed thru a greater number of periodontal fibres to a large amt of supporting bone.<br />
  50. 50. Periodontal considerations-<br />Condition of gingiva,attachedgingiva,presence or absence of periodontal pockets.<br />Mucogingivalattachment,osseous defects or mobility patterns recorded-causes and potential Rx determined.<br />Oral hygiene habits determined-efforts to educate<br /> pt-plaque control.<br />Remaining teeth and prostheses will require <br /> meticulous plaque control after placement of RPD.<br />
  51. 51. Evaluation of prostheses foundation-teeth and residual ridge-<br />To ensure that an appropriately stable base of sound teeth/residual ridge is provided to maximize prostheses function and pt comfort.<br />Surgical preparation-<br />Need for preprosthetic surgery or Xns should be evaluated.<br />Grossly displaceable soft tissue covering basal seat areas and hyperplastic tissue-removed-firm denture base foundation.<br />Removal of mandtori,bone prominence.<br />
  52. 52. Xn of teeth indicated for one of the following reasons-<br />If tooth cannot be restored to state of health Xn may be unavoidable.<br />A tooth may be removed if its absence will permit a more serviceable and less complicated RPD.<br />
  53. 53. Another consideration for preprosthetic surgery involves the decision b/w use of RPD and implant supported prosthesis.<br />Short modification spaces-<br />Forshort spans less than 3 missing teeth-natural tooth, implant supported fixed prostheses and RPD can be considered.<br />Implants-adv-replacement of teeth – adjacent teeth.<br />Longer modification spaces-<br />Longer span modification spaces – greater challenge- F.P.D.<br />RPD or implant supported prosthesis.<br />
  54. 54. Distal extension spaces-<br />Without tooth support at end of missing teeth- RPD and implant supported prosthesis-primary consideration.<br />Implant therapy not elected frequently-pt medical factors,risks for surgical morbidity,inc time required,costs.<br />Residual ridge resorption-RPD.<br />
  55. 55. Endodontic Rx-<br />Abutments for rpd-withstand forces.<br />Requirement for distal extension abutment(torsional forces) –different from tooth supported.<br />Bcos tooth support helps control prosthesis movt-need for endo RX should include assessment of overdenture abutments for RPDs.<br />
  56. 56. Analysis of occlusal factors-<br />Mounted diagnostic casts.<br />Improvements in natural occlusion-before fabrication of prosthesis.<br />Objective of occlusal reconstruction-occlusal harmony of restored dentition.<br />Decision whether to accept or reject the existing VD.<br />Fixed restorations-<br />Restore modification spaces with fixed prostheses-isolated abutment teeth. <br />FPDs-tooth bound spaces-unless space facilitates simplification of RPD. <br />
  57. 57. Orthodontic Rx-<br />Occasionally orthomovt followed by FPD-better esthetic RPD design.<br />Need for determining type of mand major connector-<br />Oral examination<br />Measuring ht of floor of mouth i.r.t lingual gingiva-P.probe.<br />Transferred to diagnostic cast.<br />
  58. 58. Need for reshaping remaining teeth-<br />Paralleling of proximal tooth surfaces.<br />Preparation of adequate rests.<br />Reduction of unfavorable tooth contours.<br />Failure to reshape unfavorable inclined tooth surfaces-complicates design and location of clasps-failure of RPD.<br />
  59. 59. Need for reshaping remaining teeth-<br />Unparallel proximal tooth surfaces-malaligned tooth-fail-needed guiding plane-excessive blockout.<br />Connectors placed far-food traps.<br />Amt of reduction-min-fluoride Rx.<br />Comprehensive analysis of diagnostic casts-surveyor<br />
  60. 60. CONCLUSION<br />The treatment plan for an edentulous patient is simple. <br />The approach varies widely.<br />Assembling all the diagnostic criteria takes time, but it is time well spent to assure a successful result. <br />
  61. 61. References <br />Carr A B, Mc Givney G P, Brown D T, Minor connector in McCraken’s Removable partial Prothodontics. 11thed, stlouis: Mosby; 2008, 35-53.<br />Stewart K L, Rudd K D, Kuebker W A, Minor connector in Stewart’s Clinical Removable Partial Prosthodontics. 2nded, 2004, 22-42.<br />Miller E L, Grasso J E, Major connector in Removable Partial Prosthodontics. 2nd ed, Baltimore: Williams & Wilkins; 1979, 175-94.<br />