This document discusses treatment planning and sequences. It begins by outlining the key steps in treatment planning: gathering information and defining a diagnosis, predicting prognosis, and deciding on a treatment option. It then provides extensive details on gathering patient information through medical history, dental history, clinical examinations, diagnostic imaging, and diagnostic casts. Factors that influence prognosis and the design of fixed or removable prostheses based on considerations like span length, abutment conditions, and ridge form are examined. The document concludes by discussing the importance of establishing a logical treatment sequence that addresses symptoms, deteriorating conditions, and definitive therapy.

1. Treament Planning and
treatment sequences
Dr. Mahmoud Al-Afandi
MSc. Degree in Fixed Prosthodontics
15:00 PM

2. Decision making process
1. Gathering Information & Defining a Diagnosis.
2. Predicting prognosis.
3. Deciding on a treatment option.
25:00 PM

3. Socrates
No diagnosis.. No
treatment
Gathering Information & Defining a Diagnosis.
35:00 PM

4. History
Chief
compliant
Personal
details
Medical
history
Dental
history
45:00 PM

5. Chief compliant
The inexperienced clinician trying to prescribe an "ideal"
treatment plan can lose sight of the patient's wishes..
 Comfort (pain characteristics)
 Function (difficulties in chewing)
 Social aspect (bad oral taste or smell)
 Appearance (unaesthetic appearance discoloration –
malposition – misshape may be the main cause seeking
dental tr.)
55:00 PM

6. Personal details
 patient's name
 Patient‟s age: relative size of pulp chamber
determine type of restoration coverage –
orthodontic treatment to creat/eliminate spaces
in young ages.
 Address: sometimes reveals area-related
diseases such as fluorosis, vitamin D
deficiency…
 phone number
 Gender
 Occupation: carpenters, tailors, glass blowers,
(discoloration and fractures of anterior teeth)
 work schedule:
 marital and financial status: ability to afford Tr.
Cost.
65:00 PM

7. 1- Medical history
 Any disorders that necessitate the use of
antibiotic premedication.
 Use of steroids or anticoagulants.
 Any previous allergic responses to medication
or dental materials.
Conditions affecting tr. methods
75:00 PM

8. 1- Medical history
Previous radiation therapy.
hemorrhagic disorders.
extremes of age.
terminal illness.
Conditions affecting tr. Plan
85:00 PM

9. 1- Medical history
 Diabetes.
 Pregnancy.
 The use of anticonvulsant drugs.
Gastro-esophageal reflux disease.
Oral manifestation of systemic conditions
95:00 PM

10. medications
Gingival hyperplasia due calcium channels blocker
105:00 PM

11. • the lingual surfaces are
bare of enamel except for
a narrow band at the
gingival margin
Etching times & severity of
fluorosis
(45 seconds)
115:00 PM

12. 1- Medical history
Risk factors for dentist
 Medically compromised patients (legal considerations
associated with malpractice)
 patients who are suspected or confirmed carriers of hepatitis
B, acquired immunodeficiency syndrome
 Pregnant at the first trimester.
125:00 PM

13. 2- Dental History
1. Periodontal History
(current oral hygiene & patient
education)
2. Restorative History
(reflect prognosis of future
restorations)
3. Endodontic history
(periapical health should be
monitored for any recurrent
lesion)
135:00 PM

14. 4. Orthodontic history
(previous tr. Associated with
root resorption & C/R ratio
consideration, need for pre-
prosthetic orthodontic
intervention)
5. Removable prosthodontic
history
(very helpful in assessing
whether future treatment will
be more successful)
Patient expectations:
“ A patient with a false eye cannot
see, a patient with false legs cannot
run, but many patients expect to
look and function with dentures as
well as, or better than, they did
with their natural dentition”
145:00 PM

15. 6. Oral surgical history
(any complication during tooth extraction)
7. Radiographic history
(helpful in determining the progress of periodontal
disease)
8. TMJ history
(pain, clicking, muscular symptoms, may be caused
by TMI dysfunction, which should normally be
treated and resolved before fixed prosthodontic
treatment begins)
155:00 PM

16. Examination
General Examination
(patient's general appearance,
gait, and weight, skin color,
vital signs…)
Extra-oral examination
Intra-oral examination
Radiographic examination
165:00 PM

17. Extr-aoral examination
1- Temporomandibular joints:
 bilaterally palpation during the
opening stroke.
 (Asynchronous movement)
anterior disk displacement
 Tenderness or pain
inflammatory changes in the
retrodiscal tissues
 Clicking
 maximum mandibular opening
intra-capsular changes in the
joints.
175:00 PM

18. 2- Muscles of mastication
 the masseter and temporal
muscles, as well as other
relevant postural muscles,
are palpated for signs of
tenderness
 Palpation is best
accomplished bilaterally and
simultaneously. This allows
the patient to compare and
report any differences
between the left and right
sides
185:00 PM

19. 3- Lips:
The patient is observed for tooth visibility during
normal and exaggerated smiling. This can be
critical in fixed prosthodontics treatment
planning, especially for margin placement of
certain metal-ceramic crowns.
195:00 PM

20. 3- Lips:
Negative space
205:00 PM

21. Intraoral Examination
1- Periodontal Examination:
• Gingiva
• Periodontium
• Clinical Attachment Level
215:00 PM

22. 2- Occlusal examination:
• Initial tooth contact
• General alignment
• Lateral and protrusive contacts
Centric relation: Maxillo-mandibular relationship in which the
condyles articulate with the thinnest avascular portion of their
respective disks with the complex in the anterosuperior position
against the shapes of the articular eminences. This position is
independent of tooth contact.
Centric occlusion: maximum intercuspation position anterior to centric
relation.
Retruded contact position RCP
When the mandible closes on the retruded axis, its position when the
first tooth contact occurs is referred to as the retruded contact
position (RCP). Approximately 90 percent of the population have a
discrepancy between the retruded contact position and the intercuspal
position.
225:00 PM

23. 23
CR: centric relation
5:00 PM

24. 24
CO: Centric Occlusion
5:00 PM

25. Initial tooth contact
The relationship of teeth in both centric relation and the
maximum intercuspation should be assessed. If all teeth come
together simultaneously at the end of terminal hinge closure,
the centric relation (CR) position of the patient is said to
coincide with the maximum intercuspation (MI). The
patient is guided into a terminal hinge closure to detect where
initial tooth contact occurs. This is referred to as a slide from
CR to Ml.
Any collateral signs or symptoms should be recorded.
(elevated muscle tone, mobility on the teeth where initial
contact occurs, wear facets on the teeth involved in the slide).
255:00 PM

26. • These casts reveal a large horizontal
discrepancy between RCP and ICP with
only a small vertical component.
265:00 PM

27. 275:00 PM

28. 285:01 PM

29. What is the clinical significance of this fact?
• Simple restorations should not alter the RCP- ICP slide.
• this may lead to muscle hyperactivity causing bruxing,
clenching and TMJ and muscle problems. These in turn
may lead to the mechanical failure of restorations.
295:00 PM

30. Lateral and protrusive contacts
Excursive contacts on posterior teeth may be undesirable.
lateral excursive movements (the presence or absence of contacts
on the nonworking side)
Such tooth contact in eccentric movements can be verified with a
thin Mylar strip (shim stock)
305:00 PM

31. Lateral and protrusive contacts
Teeth that are subject to excessive loading may develop varying
degrees of mobility.
Tooth movement (fremitus) should be identified by palpation. If a
heavy contact is suspected, a finger placed against the buccal or
labial surface while the patient lightly taps the teeth together helps
locate fremitus in MI.
315:00 PM

32. General alignment
The teeth are evaluated for:
 Crowding.
 Rotation.
 Supra eruption.
 Spacing.
 Malocclusion.
 Vertical and horizontal overlap.
325:00 PM

33. Vitality tests
Vital teeth may commonly
give a negative response
following trauma.
335:00 PM

34. Radiographic/imaging assessments
345:00 PM

35. Crown root ratio
The
optimum
crown
root ratio
is 2/3
Optimum Acceptable
355:00 PM

36. What to do if there is acceptable C/R ratio:
Double abutments:
• A secondary abutment must have at least as much root
surface area and as favorable a crown-root ratio as the
primary abutment it is intended to bolster.
365:00 PM

37. Root Configuration
Teeth with widely separated roots are better than those with
converged or fused roots.
Roots that are broader labio-lingually than they mesiodistally are
preferable to roots that are round in cross section.
375:00 PM

38. Periodontal ligament area
"Ante's Law"
The root surface area of the abutment
teeth had to equal or surpass that of the
teeth being replaced with pontics.
385:00 PM

39. Biomechanical Considerations
• BENDING : Bending or deflection varies
directly with the cube of the length
395:00 PM

40. and inversely with the cube of the occluso-gingival
thickness of the pontic.
Biomechanical Considerations
405:00 PM

41. What is risk imposed by long span FPDs?
Longer pontic spans also have the potential for
producing more torqueing forces on the fixed
partial denture, especially on the weaker abutment.
To minimize flexing:
1. increase occluso-gingival dimension of the
pontic, if possible.
2. use rigid alloys.
Biomechanical Considerations
415:00 PM

42. Arch curvature
• has its effect on the stresses
occurring in a fixed partial
denture.
• When pontics lie outside the
inter-abutment axis line, the
pontics act as a lever arm,
which can produce a torqueing
movement.
• The first premolars sometimes
are used as secondary
abutments for a maxillary four-
pontic canine to- canine fixed
partial denture
Biomechanical Considerations
425:00 PM

43. Diagnostic Casts
435:00 PM

44. 1. Provide valuable preliminary information and a comprehensive
overview of patient‟s needs
2. examine the occlusal relationships and the relationship of
antagonist teeth to the edentulous area.
3. Treatment procedures can be rehearsed on the stone cast before
making any irreversible changes in the patient‟s mouth
4. Used for diagnostic wax-up, preliminary RPD design, surgical
stent (surgical procedures), etc.
5. Help to explain intended procedure to patient
Diagnostic Casts
445:00 PM

45. Predicting Prognosis
Prognosis: is an estimation of the likely course of a disease.
VIPs
WOMEN
ESTHETIC TREATMENT SEEKERS
455:00 PM

46. Prognosis of dental procedure is influenced by
General
factors
Local
factors
465:00 PM

47. General Factors
1. The overall caries rate of the patient's dentition
indicates future risk to the patient if the condition is
left untreated.
2. the patient's understanding and comprehension of
plaque control measures, as well as the physical
ability to perform those tasks.
475:00 PM

48. 3. Systemic problems:
Diabetic patients are prone
to a higher incidence of
periodontal disease, and
special precautionary
measures may be indicated
before treatment begins.
4. Amount of occlusal forces:
Some patients are capable
of an extremely high
occlusal force whereas
others are not. (muscleman
Vs frail 90-year-old)
485:00 PM

49. Local Factors
1. The observed vertical overlap of
the anterior teeth has a direct effect
on the load distribution in the
dentition and thus can have an
effect on the prognosis.
2. Individual tooth mobility
3. root angulation & root structure
4. crown/root ratios
5. Previous endodontic treatments:
495:00 PM

50. Patient-Dentist Relation
Patient knows nothing
about your procedures..
How honest you are?
505:00 PM

51. Ask questions like..
1. would I carry out this treatment on my own
family members‟ teeth?‟
2. „Would I have this treatment carried on my
own teeth?
515:00 PM

52. Design of prosthesis
If single tooth:
Direct or cast restoration?
1. Destruction of tooth
structure
2. Esthetics
3. Plaque control
4. Financial considerations
5. Retention
525:00 PM

53. Fixed or removable?
Span length
Span configuration
Abutment alignment
Abutment condition
Occlusion
Ridge form
General features
Periodontal condition
535:00 PM

54. Span length
1. Posterior spans longer than
2 teeth
2. Anterior spans longer than
4 incisors
Fixed PDRemovable PD
1. Posterior span: 2 or fewer
2. Incisors: 4 or fewer
545:00 PM

55. Span configuration
1. No distal abutment
2. Multiple or bilateral
edentulous spaces
Fixed PDRemovable PD
1. Usually has distal abutment
but can be used with short
cantilever pontic
555:00 PM

56. Abutment alignment
Tipped abutments can be
tolerated
Fixed PDRemovable PD
Less than 25° inclination can be
accommodated by preparation
modification
565:00 PM

57. Abutment condition
1. Short clinical crowns
2. Insufficient abutments
Fixed PDRemovable PD
1. Good if abutments need
crowns
2. Nonvital teeth can be used
if there is sufficient coronal
tooth structure
575:00 PM

58. Occlusion
More adaptable to irregularities
in a healthy opposing natural
dentition
Fixed PDRemovable PD
Favorable loading (magnitude,
direction, frequency, duration]
585:00 PM

59. Ridge form
Gross tissue loss in residual
ridge
Fixed PDRemovable PD
1. Moderate resorption
2. No gross soft tissue defects
595:00 PM

60. General Features
1. Dry mouth poor RPD risk
2. Limited patient finances
3. Treatment simplification
4. Advanced age
5. Systemic health problems
6. More adaptable to dentition
in transition to edentulous
state
Fixed PDRemovable PD
1. Large tongue
2. Exaggerated gag reflex
3. Unfavorable attitude toward
RPD
605:00 PM

61. Treatment sequence
When patient needs have been identified a
logical sequence of steps must be decided:
1. Treatment of Symptoms: a fractured tooth or teeth, acute
pulpitis, acute exacerbation of chronic pulpitis, a dental
abscess, acute pericoronitis or gingivitis, and myofascial
pain dysfunction.
615:00 PM

62. 2. Stabilization of deteriorating conditions:
Treatment of carious lesions
Chronic periodontitis and plaque control
measures.
Treatment sequence
625:00 PM

63. 3. Definitive Therapy:
1. Oral surgery (removing residual roots and
ridge contouring)
2. Periodontics (bisection, pocket removal,
gingivectomy, crown lengthening)
3. Endodontics (evaluation of RCT)
4. Orhtodontics (need for any tooth movement;
upright, tilt, intrude, extrude)
5. Fixed prosthodontics
Treatment sequence
635:00 PM

64. References
Contemporary fixed prosthodontics
Chapter 1 Pages: 3 – 22,
Chapter 3 Pages: 99 – 102.
Fundamental of fixed prosthodontics. 3rd
Ed (Chapter 7 Pages: 85-102)
645:00 PM

65. 655:00 PM