TREATMENT  PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES <ul><li>Soraya C. Villarroel, D.D.S., M.S. </li></ul><ul><li>...
Outline <ul><ul><li>Objective </li></ul></ul><ul><ul><li>Developing Treatment Options </li></ul></ul><ul><ul><li>Complex T...
Objective  <ul><li>Provide a consistent teaching to train the student to sequence the necessary procedures  to diagnose an...
Treatment Plan Purpose <ul><ul><li>Formulating a logical sequence of treatment designed to  restore  the patient’s  dentit...
What is an Ideal Treatment plan? <ul><li>Treatment plan that achieves the best possible  long-term outcomes  for the patie...
Complex Prosthodontic Cases <ul><ul><li>Factors to be considered: </li></ul></ul><ul><ul><li>Four or more fixed restoratio...
Developing Treatment Options <ul><ul><li>Diagnosis : </li></ul></ul><ul><ul><li>Dental and medical history </li></ul></ul>...
Developing Treatment Options <ul><ul><li>Factors to be considered : </li></ul></ul><ul><ul><li>Longevity </li></ul></ul><u...
Phase II Disease Control Phase III Restorative Phase IV Maintenance Treatment Plan by Phases Dental & medical history Clin...
Complex Cases Protocol <ul><ul><li>Diagnostic Phase (Complex D&T) </li></ul></ul><ul><ul><li>Paperwork (Prosthodontic Comp...
Complex Cases Protocol (Dx Phase) <ul><ul><li>A series of diagnostic appointments should be scheduled to complete a thorou...
Complex Cases Protocol (Dx Phase) <ul><ul><li>Diagnostic Wax-up: </li></ul></ul><ul><ul><li>Casts/waxing/set-ups (denture ...
Complex Cases Protocol (Dx Phase) <ul><ul><li>Prosthodontic Component of the Dental record </li></ul></ul><ul><ul><li>(gre...
 
 
Complex Cases Protocol (Paperwork) <ul><ul><li>Outline  a Tx-plan with an Instructor (Complex D&T)  </li></ul></ul><ul><ul...
Diagnostic Impressions/Casts <ul><li>Dx impressions:  </li></ul><ul><ul><li>Irreversible hydrocolloid (alginate)/stock tra...
Diagnostic Casts* * Comprehensive Care Patient Presentations,   2003-04, Dr. Mary Baechle 
Diagnostic Casts <ul><li>Provide valuable preliminary information and a comprehensive overview of patient’s needs </li></u...
Diagnostic Wax-up* * Comprehensive Care Patient Presentations,   2003-04, Dr. Mary Baechle 
<ul><li>Useful to show proposed treatment to the patient  </li></ul><ul><li>Used for fabrication of provisional restoratio...
Complex Cases Protocol (Pros phase) <ul><ul><li>Removable Partial Dentures (RPD) </li></ul></ul><ul><ul><li>Fixed Prosthod...
RPD Clinical/Lab Procedures <ul><ul><li>Mount Dx Casts in CR </li></ul></ul><ul><ul><li>Dx-wax-up (set denture teeth) </li...
RPD Clinical/Lab Procedures <ul><ul><li>Altercast impression in case of distal extensions or Kennedy class I or II arch fo...
Altercast Impression Procedure
RPD Clinical/Lab Procedures <ul><ul><li>Wax-rim fabrication, CRR, Facebow (if required) </li></ul></ul><ul><ul><li>Selecti...
RPD Clinical/Lab Procedures <ul><ul><li>Wax try-in: Verify CR/Esthetic try-in </li></ul></ul><ul><ul><li>Approval: patient...
Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Mount Dx casts on articulator using facebow/CRR </li></ul></ul><ul><ul><li...
Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Definitive tooth preparation (one arch at a time) Fabrication of provision...
Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Working cast/CRR/Mounting each step must be evaluated by instructor </li><...
Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Try-in Crowns/FPD  </li></ul></ul><ul><ul><li>(Framework Try-in) </li></ul...
Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Placement of final restorations </li></ul></ul>*Rosenstiel et al., Contemp...
Immediate Denture <ul><ul><li>Definition : </li></ul></ul><ul><ul><li>A complete denture or removable partial denture fabr...
<ul><li>Examination and Diagnosis </li></ul><ul><li>Diagnostic Cast  </li></ul><ul><li>What teeth need to be extracted? </...
Immediate Partial/Denture  Clinical/Lab Procedures   <ul><li>Examination and Diagnosis  </li></ul><ul><li>Single Phase Sur...
 
 
 
<ul><li>Maintain patient’s appearance </li></ul><ul><li>Serve to control hemorrhage and swelling </li></ul><ul><li>Prevent...
<ul><li>More difficult and demanding procedure (more chair time/increased cost) </li></ul><ul><li>Dentist’s inability to t...
<ul><li>Patient in poor general health </li></ul><ul><li>Uncooperative patient </li></ul><ul><li>Patient with surgical ris...
Clinical Case
Clinical Case I: Immediate Denture
 
 
 
Clinical Case II: Fixed-RPD
 
Clinical Case III: CD/Fixed-RPD
Clinical Case IV: Immediate Partial-Denture
 
Summary <ul><li>The patient should be considered as a human being </li></ul><ul><li>Successful accomplishment of dental tr...
Summary <ul><li>The key of a successful dental case is the planning of the treatment at the beginning </li></ul><ul><li>Pr...
<ul><li>Clinic Manual 2003-2004; The Ohio State University Department of Primary Care </li></ul><ul><li>Boucher’s Prosthod...
<ul><li>Thank You! </li></ul>
Complex Fixed Tx Sequence *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
 
 
 
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CLINIC CASE

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CLINIC CASE

  1. 1. TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES <ul><li>Soraya C. Villarroel, D.D.S., M.S. </li></ul><ul><li>www.egydental.com </li></ul>
  2. 2. Outline <ul><ul><li>Objective </li></ul></ul><ul><ul><li>Developing Treatment Options </li></ul></ul><ul><ul><li>Complex Treatment Planning Protocol </li></ul></ul><ul><ul><li>RPD, Fixed and Immediate Dentures Clinical and Lab Procedures </li></ul></ul><ul><ul><li>Assorted Clinical Cases </li></ul></ul><ul><ul><li>Summary </li></ul></ul>
  3. 3. Objective <ul><li>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 </li></ul>
  4. 4. Treatment Plan Purpose <ul><ul><li>Formulating a logical sequence of treatment designed to restore the patient’s dentition to good health , with optimal function and appearance * </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  5. 5. What is an Ideal Treatment plan? <ul><li>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* </li></ul>*C. Bain, Treatment Planning in General Denta1 Practice, 2003 
  6. 6. Complex Prosthodontic Cases <ul><ul><li>Factors to be considered: </li></ul></ul><ul><ul><li>Four or more fixed restorations (crowns, FPD) </li></ul></ul><ul><ul><li>CD/RPD, RPD/RPD with or without crowns </li></ul></ul><ul><ul><li>Immediate dentures </li></ul></ul><ul><ul><li>Cases requiring a change in VDO </li></ul></ul><ul><ul><li>Implant cases (Optional) </li></ul></ul><ul><ul><li>Cases deemed complex by screening or clinic faculty </li></ul></ul>
  7. 7. Developing Treatment Options <ul><ul><li>Diagnosis : </li></ul></ul><ul><ul><li>Dental and medical history </li></ul></ul><ul><ul><li>Clinical examination </li></ul></ul><ul><ul><li>Radiographic films </li></ul></ul><ul><ul><li>Diagnostic pictures </li></ul></ul><ul><ul><li>Diagnostic casts </li></ul></ul><ul><ul><li>Diagnostic wax-up </li></ul></ul><ul><ul><li>Prognosis : </li></ul></ul><ul><ul><li>General factors: age, oral environment, etc. </li></ul></ul><ul><ul><li>Local factors: occlusion, access for oral hygiene </li></ul></ul>
  8. 8. Developing Treatment Options <ul><ul><li>Factors to be considered : </li></ul></ul><ul><ul><li>Longevity </li></ul></ul><ul><ul><li>Cost </li></ul></ul><ul><ul><li>Patient’s expectations </li></ul></ul><ul><ul><li>Invasiveness / reversibility </li></ul></ul><ul><ul><li>Success rate </li></ul></ul><ul><ul><li>Possible complications </li></ul></ul><ul><ul><li>Time involved, both total treatment time and number of visits </li></ul></ul><ul><ul><li>Influence on quality of life </li></ul></ul>
  9. 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 <ul><ul><li>Crown lengthening/Implant surgery </li></ul></ul><ul><ul><li>Gnathologic technique </li></ul></ul><ul><ul><li>Long-term provisional restorations </li></ul></ul><ul><ul><li>Cast restorations, Cast RPD’s </li></ul></ul>Recall every 6 months Fluoride supplements Reinforce oral hygiene Improve diet
  10. 10. Complex Cases Protocol <ul><ul><li>Diagnostic Phase (Complex D&T) </li></ul></ul><ul><ul><li>Paperwork (Prosthodontic Component) </li></ul></ul><ul><ul><li>Prosthetic or Reconstructive Phase </li></ul></ul>
  11. 11. Complex Cases Protocol (Dx Phase) <ul><ul><li>A series of diagnostic appointments should be scheduled to complete a thorough evaluation of </li></ul></ul><ul><ul><li>the patient dental condition: </li></ul></ul><ul><ul><li>Diagnostic Impressions </li></ul></ul><ul><ul><li>Diagnostic casts (duplicated twice for RPD Tx cases and one for other treatments) </li></ul></ul><ul><ul><li>Two sets of casts oriented identically on articulator in CR (Face-bow required) </li></ul></ul>
  12. 12. Complex Cases Protocol (Dx Phase) <ul><ul><li>Diagnostic Wax-up: </li></ul></ul><ul><ul><li>Casts/waxing/set-ups (denture teeth) must be completed prior to beginning any reconstructive treatment (castings/prostheses or definitive Periodontal therapy) </li></ul></ul>
  13. 13. Complex Cases Protocol (Dx Phase) <ul><ul><li>Prosthodontic Component of the Dental record </li></ul></ul><ul><ul><li>(green sheet): </li></ul></ul><ul><ul><ul><li>One for removable prosthodontics </li></ul></ul></ul><ul><ul><ul><li>One for fixed prosthodontics/Occlusal analysis </li></ul></ul></ul><ul><ul><ul><li>Must be completed and signed by Faculty and student </li></ul></ul></ul>
  14. 16. Complex Cases Protocol (Paperwork) <ul><ul><li>Outline a Tx-plan with an Instructor (Complex D&T) </li></ul></ul><ul><ul><li>Review Tx plan with complex case managers (Dr. Villarroel CCC2/CCC4 and Dr. El-Gendy CCC1/CCC3) </li></ul></ul><ul><ul><li>Outline a definitive Tx-plan with sequence for clinical and lab procedures by appointment </li></ul></ul><ul><ul><li>Stamp the blue tx-plan working sheet </li></ul></ul><ul><ul><li>Reach agreement : patient, student, faculty </li></ul></ul><ul><ul><li>Get case manager signature after all previous steps are accomplished and Phase II is completed </li></ul></ul><ul><ul><li>Student should follow up the Tx-plan with any instructor </li></ul></ul><ul><ul><li>Advanced complex cases may be referred to Grad Pros clinic </li></ul></ul>
  15. 17. Diagnostic Impressions/Casts <ul><li>Dx impressions: </li></ul><ul><ul><li>Irreversible hydrocolloid (alginate)/stock trays </li></ul></ul><ul><ul><li>High quality with no voids </li></ul></ul><ul><ul><li>A clinical instructor must authorize impressions pouring </li></ul></ul><ul><li>Type III dental stone (buff) is used for Dx-casts pouring </li></ul><ul><li>Dx casts evaluation criteria: </li></ul><ul><ul><li>Accurate reproduction of teeth and tissue </li></ul></ul><ul><ul><li>Base thickness: 15-16 mm </li></ul></ul><ul><ul><li>Land area width: 3-4 mm </li></ul></ul>
  16. 18. Diagnostic Casts* * Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle 
  17. 19. Diagnostic Casts <ul><li>Provide valuable preliminary information and a comprehensive overview of patient’s needs </li></ul><ul><li>Treatment procedures can be rehearsed on the stone cast before making any irreversible changes in the patient’s mouth </li></ul><ul><li>Used for diagnostic wax-up, preliminary RPD design, surgical stent (surgical procedures), etc. </li></ul><ul><li>Help to explain intended procedure to patient </li></ul>
  18. 20. Diagnostic Wax-up* * Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle 
  19. 21. <ul><li>Useful to show proposed treatment to the patient </li></ul><ul><li>Used for fabrication of provisional restorations </li></ul><ul><li>Fabrication of final restorations against the diagnostically waxed cast allows establishing optimum contour and occlusion </li></ul><ul><li>Provides specific information about desired tooth length and form or occlusal arrangement: dentist-lab technician communication </li></ul>Diagnostic Wax-up
  20. 22. Complex Cases Protocol (Pros phase) <ul><ul><li>Removable Partial Dentures (RPD) </li></ul></ul><ul><ul><li>Fixed Prosthodontics (crowns/FPD) </li></ul></ul><ul><ul><li>Immediate Dentures </li></ul></ul>
  21. 23. RPD Clinical/Lab Procedures <ul><ul><li>Mount Dx Casts in CR </li></ul></ul><ul><ul><li>Dx-wax-up (set denture teeth) </li></ul></ul><ul><ul><li>Survey Dx cast (preliminary design) </li></ul></ul><ul><ul><li>Complete Phase II </li></ul></ul><ul><ul><li>Rest seats/guide planes preparation (enameloplasty if required) </li></ul></ul><ul><ul><li>Impression for framework fabrication (Alginate) </li></ul></ul><ul><ul><li>Framework try-in/adjustment </li></ul></ul>
  22. 24. RPD Clinical/Lab Procedures <ul><ul><li>Altercast impression in case of distal extensions or Kennedy class I or II arch form </li></ul></ul><ul><ul><ul><li>Tray fabrication </li></ul></ul></ul><ul><ul><ul><li>Border molding </li></ul></ul></ul>
  23. 25. Altercast Impression Procedure
  24. 26. RPD Clinical/Lab Procedures <ul><ul><li>Wax-rim fabrication, CRR, Facebow (if required) </li></ul></ul><ul><ul><li>Selection of denture teeth shape/shade </li></ul></ul><ul><ul><li>Set up teeth </li></ul></ul>
  25. 27. RPD Clinical/Lab Procedures <ul><ul><li>Wax try-in: Verify CR/Esthetic try-in </li></ul></ul><ul><ul><li>Approval: patient/faculty </li></ul></ul><ul><ul><li>Lab form required for processing Prosthesis </li></ul></ul><ul><ul><li>Prosthesis placement </li></ul></ul><ul><ul><li>Post-placement checking appointments </li></ul></ul>
  26. 28. Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Mount Dx casts on articulator using facebow/CRR </li></ul></ul><ul><ul><li>Each set is mounted identically (cross-mounted technique) </li></ul></ul><ul><ul><li>One set of Dx cast is used for Dx wax-up </li></ul></ul><ul><ul><li>One set of Dx casts is left unaltered (original) </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  27. 29. Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Definitive tooth preparation (one arch at a time) Fabrication of provisional restorations </li></ul></ul><ul><ul><li>Final impression </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  28. 30. Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Working cast/CRR/Mounting each step must be evaluated by instructor </li></ul></ul><ul><ul><li>Selection of shade (Patient/Instructor approval) </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  29. 31. Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Try-in Crowns/FPD </li></ul></ul><ul><ul><li>(Framework Try-in) </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  30. 32. Fixed Pros Clinical/Lab Procedures* <ul><ul><li>Placement of final restorations </li></ul></ul>*Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001
  31. 33. Immediate Denture <ul><ul><li>Definition : </li></ul></ul><ul><ul><li>A complete denture or removable partial denture fabricated for placement immediately following the removal of natural teeth </li></ul></ul><ul><ul><li>The glossary of Prosthodontic terms, 1999 </li></ul></ul>
  32. 34. <ul><li>Examination and Diagnosis </li></ul><ul><li>Diagnostic Cast </li></ul><ul><li>What teeth need to be extracted? </li></ul><ul><li>What is the final RPD design? </li></ul><ul><li>An esthetic evaluation is necessary if tooth position will be altered </li></ul>Immediate Denture
  33. 35. Immediate Partial/Denture Clinical/Lab Procedures <ul><li>Examination and Diagnosis </li></ul><ul><li>Single Phase Surgical Schedule </li></ul><ul><li>Final Impression </li></ul><ul><li>Facebow, Jaw Records </li></ul><ul><li>Marking “Esthetic Indicators” </li></ul><ul><li>Wax Try-in </li></ul><ul><li>Laboratory Procedures </li></ul><ul><li>Extractions and Delivery </li></ul><ul><li>Maintenance </li></ul><ul><li>Fabrication of Definitive </li></ul><ul><li>Immediate Denture </li></ul><ul><li>Double Phase Surgical Schedule </li></ul><ul><ul><li>Extract all posterior teeth </li></ul></ul><ul><ul><li>Wait 6 weeks of healing </li></ul></ul><ul><li>Final Impression </li></ul><ul><li>Facebow, Jaw Records </li></ul><ul><li>Intra-oral Modifications </li></ul><ul><li>Final Impressions </li></ul><ul><li>Facebow, Jaw Record </li></ul>Immediate Partial Courtesy of Dr. AG Wee
  34. 39. <ul><li>Maintain patient’s appearance </li></ul><ul><li>Serve to control hemorrhage and swelling </li></ul><ul><li>Prevent tongue spread out as a result of tooth loss </li></ul><ul><li>Serve as a guide for esthetic of the final denture </li></ul><ul><li>Protect tissues at the sensitive extraction sites from irritation from the tongue and food </li></ul><ul><li>Hasten patient adaptation to dentures </li></ul><ul><li>Maintain efficiency of mastication </li></ul>Immediate Partial/Denture Advantages
  35. 40. <ul><li>More difficult and demanding procedure (more chair time/increased cost) </li></ul><ul><li>Dentist’s inability to try-in the prosthetic teeth in advance (limited evaluation) </li></ul><ul><li>Impressions and Maxillo-mandibular records more difficult to record </li></ul>Immediate Partial/Denture Disadvantages
  36. 41. <ul><li>Patient in poor general health </li></ul><ul><li>Uncooperative patient </li></ul><ul><li>Patient with surgical risks: </li></ul><ul><ul><li>Radiation therapy </li></ul></ul><ul><ul><li>Blood clotting </li></ul></ul><ul><ul><li>Tissue regeneration/wound healing problems </li></ul></ul><ul><ul><li>After surgery drainage required </li></ul></ul>Immediate Denture Contraindications
  37. 42. Clinical Case
  38. 43. Clinical Case I: Immediate Denture
  39. 47. Clinical Case II: Fixed-RPD
  40. 49. Clinical Case III: CD/Fixed-RPD
  41. 50. Clinical Case IV: Immediate Partial-Denture
  42. 52. Summary <ul><li>The patient should be considered as a human being </li></ul><ul><li>Successful accomplishment of dental treatment is the result of a multidisciplinary team effort: students, faculty, staff, other dental departments </li></ul><ul><li>Following complex case protocol helps to: </li></ul><ul><ul><li>Provide a higher quality dental treatment to patients </li></ul></ul><ul><ul><li>Enhance students’ clinical learning experience and knowledge </li></ul></ul><ul><ul><li>Increase efficiency: save time/money to patients, students, instructors, and Clinic </li></ul></ul><ul><ul><li>Improve OSU Clinic/College reputation </li></ul></ul>
  43. 53. Summary <ul><li>The key of a successful dental case is the planning of the treatment at the beginning </li></ul><ul><li>Primary care department team approach: </li></ul><ul><ul><li>Combine the vast clinical experience of general dentistry faculty with complex case training of specialists </li></ul></ul>
  44. 54. <ul><li>Clinic Manual 2003-2004; The Ohio State University Department of Primary Care </li></ul><ul><li>Boucher’s Prosthodontic Treatment for Edentulous Patients, 11 th Edition; Zarb et al., 2004 </li></ul><ul><li>Contemporary Fixed Prosthodontics, Rosenstiel et al., 2001 </li></ul><ul><li>Complex Denture Fabrication, M. van Putten, 2000 </li></ul>References
  45. 55. <ul><li>Thank You! </li></ul>
  46. 56. Complex Fixed Tx Sequence *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

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