TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES Soraya C. Villarroel, D.D.S., M.S. www.egydental.com

Outline Objective Developing Treatment Options Complex Treatment Planning Protocol RPD, Fixed and Immediate Dentures Clinical and Lab Procedures Assorted Clinical Cases Summary

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

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

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

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

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

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

Treatment Plan by Phases Dental & medical history Clinical examination, Radiographic films Dx Casts, Dx photographs Dx Wax-up, Aesthetic evaluation Phase I Diagnosis Periodontal Therapy Endodontic Therapy (RCT) Removal of existing restorations Caries control Phase II Disease Control Crown lengthening/Implant surgery Gnathologic technique Long-term provisional restorations Cast restorations, Cast RPD’s Phase III Restorative Recall every 6 months Fluoride supplements Reinforce oral hygiene Improve diet Phase IV Maintenance

Complex Cases Protocol Diagnostic Phase (Complex D&T) Paperwork (Prosthodontic Component) Prosthetic or Reconstructive Phase

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)

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)

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

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

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

Diagnostic Casts* *Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle 

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

Diagnostic Wax-up* *Comprehensive Care Patient Presentations, 2003-04, Dr. Mary Baechle 

Diagnostic Wax-up 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

Complex Cases Protocol (Pros phase) Removable Partial Dentures (RPD) Fixed Prosthodontics (crowns/FPD) Immediate Dentures

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

RPD Clinical/Lab Procedures Altercast impression in case of distal extensions or Kennedy class I or II arch form Tray fabrication Border molding

Altercast Impression Procedure

RPD Clinical/Lab Procedures Wax-rim fabrication, CRR, Facebow (if required) Selection of denture teeth shape/shade Set up teeth

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

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

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

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

Fixed Pros Clinical/Lab Procedures* Try-in Crowns/FPD (Framework Try-in) *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

Fixed Pros Clinical/Lab Procedures* Placement of final restorations *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001

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

Immediate Denture 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 Partial/Denture Clinical/Lab Procedures 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 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 Partial Courtesy of Dr. AG Wee

Immediate Partial/Denture Advantages 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 Disadvantages 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 Denture Contraindications Patient in poor general health Uncooperative patient Patient with surgical risks: Radiation therapy Blood clotting Tissue regeneration/wound healing problems After surgery drainage required

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 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

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

References Clinic Manual 2003-2004; The Ohio State University Department of Primary Care Boucher’s Prosthodontic Treatment for Edentulous Patients, 11th Edition; Zarb et al., 2004 Contemporary Fixed Prosthodontics, Rosenstiel et al., 2001 Complex Denture Fabrication, M. van Putten, 2000

Thank You!

Complex Fixed Tx Sequence *Rosenstiel et al., Contemporary Fixed Prosthodontics, 2001