Clinical Treatment Planning Treating Clinician: Dr’s.

The plans where useless, but the planning was indispensable The plans where useless, but the planning was indispensable. Dwight Eisenhower, WW2

Treatment Planning Case Presentation. Introduction and Background. Patient Name: Gender: Date of Birth: Age: Marital Status: Race: Date of Initial Examination: Occupation: Personality Type:

Introduction-Background Chief Dental Complaint: Reason for Initial Visit: Oral Image and Expectation:.

Medical History ASA: Medications: Allergies: Smoker: Systemic Diseases:

Dental History Previous Dental Treatment History: What does the patient desire?

Diagnostic Findings ( Head and Neck) Nodes: TMJ/Mandibular: Range of Motion: Functional: Joint sounds: Tenderness to musculature palpation: Myofacial pain: Headaches:

Extra-Oral - Face/Profile/Symmetry

Extra-Oral : Lips/Smiles

Combination Charting

Status of Dentition - Occlusal Views

Periodontal Chart GI – PI – Gingival Status: Recession: Inflammation:

Intra-oral Images: (Periodontal) Recession – Gingivitis – Periodontitis – MG aberrations.

Intra-oral, Anterior – (Soft Tissue)

Intra-oral - Occlusal Views

L Radiographs - FMX R

L R Radiographs

Radiographs - Anterior L R Radiographs - Anterior

Radiographs - Panoramic L R Radiographs - Panoramic

L Radiographs – Misc. R

Casts - Facial R R L

Casts - Lingual R R L

Composite – Images, Casts, Radiographs L R

Composite – Images, Casts, Radiographs L R

Composite – Images, Casts, Radiographs L R

Occlusal Notes Class occlusion: Class: IG/CG: NW interferences. CO/CR/MIP: Slide/s:

R L Occlusal Images

Abrahamson – Tooth Wear

Esthetic Analysis (Chiche) Incisal Plane Incisal Profile Incisal Length Smile Line Tooth Proportion

Esthetic Analysis (Chiche) Gingival Outline Tooth Shades Intrinsic Characteristics Buccal Corridors Lip support

Treatment Planning Kois

Risk Factor - KOIS Periodontal Biomechanical: (Tooth structure) Functional: (Joint, Bite Chewing) Dento-Facial: (Esthetic)

Diagnostic Opinion - Kois RISK PROFILE PERIODONTAL BIOMECHANICAL FUNCTIONAL DENTOFACIAL MEDICAL PRECAUTIONS Low Moderate High

Diagnostic Opinion: Perio - Kois PERIODONTAL (Gum and Bone)   Risk Assessment __Low __Moderate __High General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosis: most teeth are in this category Specific: Individual Teeth Excellent Good Fair Poor Hopeless Please List

Diagnostic Opinion: Biomechanical   Risk Assessment __Low __Moderate __High General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosis: most teeth are in this category Specific: Individual Teeth Excellent Good Fair Poor Hopeless Please List

Diagnostic Opinion: Functional - Kois   Risk Assessment __Low __Moderate __High General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosis: most teeth are in this category Specific: Individual Teeth Excellent Good Fair Poor Hopeless Please List

Diagnostic Opinion: DentoFacial.   Risk Assessment __Low __Moderate __High General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosis: most teeth are in this category Specific: Individual Teeth Excellent Good Fair Poor Hopeless Please List

Risk Profile Summary - Kois PERIODONTAL BIOMECHANICAL FUNCTIONAL DENTOFACIAL MEDICAL PRECAUTIONS Low Moderate High

Guidelines - Kokich Creating Overjet/Overbite

Kokich Guidelines Creating Overjet/Overbite Procline/Retrude Maxillary Incisors Intrude Maxillary/Mandibular Anterior Teeth Retract Mandibular Incisors: (Facial of mandibular incisors should be over chin – see Ceph.) Uneven gingival margins, intrude or extrude. Maxillary Incisors should be parallel relative to lower lip – see Ceph) Maxillary Facial Incisal Inclination should be vertical to the Incisal plan for good light reflection – See Ceph

Guidelines - Spear Vertical wear (Rat) Constricted envelope of function. Need greater Overjet. Horizontal and incisal wear – (Cow) Need greater Centric Freedom

Frank Spear Worn Dentition Most cases do not require VDO opening. Check if posterior teeth are worn or missing; if no, need to get space in the anterior with modest opening prn.

Spear – Worn Dentition-Contd. Set 8UAS; check for wear, gingival margins, vertical uprightedness. Should it be proclined, retruded, intruded, APF or combination. For vertical check anterior facial angulation relative to occlusal plane. Usually a space problem so ortho is valuable. Apply same parameter to LAS

The Gummy Smile - Robbins Five questions. 1 Face height: Repose, from Glabella (mid-brow) to base of nose = Base of nose to inferior border of chin. (Middle third of face should equal the lower third of face. DX: Lower third of face longer – VME Tx: Orthognathic surgery.

The Gummy Smile – Robbins Five questions 2 Lip length: Repose from base of nose to inferior border of the maxillary lip In young adult: Females 20-22 mm In young adult: Males 22-24mm Dx: Short or hyperactive upper lip Tx: Behavior modification / Botox. LIP Mobility 6-8mm

The Gummy Smile - Robbins Five questions. 3 Gingival Line: Draw from Canine to Canine. Should engage centrals and cuspids. Dx Concave – Dentoalveolar Extrusion. Tx. Orthodontic, intrusion, Esthetic Crown Lengthening, Segmental osteotomy.

The Gummy Smile – Robbins Five questions 4 Length of the maxillary central incisor: 10-11mm Dx Less than 10mm Microdontia, Wear, APE In repose “Emma” 3-4mm of incisal edge of maxillary centrals in young female and 2mm in young males.

Bill Robbins DDS The Gummy Smile. Five questions 5 Feel the CEJ in the sulcus: DX: Cannot feel CEJ – APE Tx: Esthetic Crown lengthening Surgery.

Bill Robbins DDS-Esthetic Evaluation Face Height _______________________ Lip Length _______________________ mm Lip Mobility _____mm Dental / Facial Midline _____________ R/L Central Exposed in Repose _________ mm Gingival Line to Upper Lip in Full Smile _______________ +/- mm Distal Extent of Smile (Tooth#) ___________ R _________ L Incisal Edges to Lower Lip (Follows Smile Line, Covered by Lip)___ Buccal Corridors – Negative Spaces Y/N _ Length of Maxillary Anteriors – (Chart) Tissue Levels – (Chart) Angle of Incisal Plane – (Chart) Incisal Wear – Y/N Tooth #’s _____________________________ CEJ Located Y/N ______________________________________ Posterior Occlusal Plane (OK, Step Up, or Step Down) _________ Tooth Color ___________________________________________ Tooth Alignment (Spacing, Overlap) ________________________ DR. NOTES

Problem list

Summary of Concerns Interesting issues related to this case that warrant discussion prior to treatment? Wear Expectation Are there phasing issues? Depending on treatment plan chosen, see treatment outline below. Are there conflicts between what is best and what the patient wants or will tolerate? Possible cost, depending on treatment plan chosen

Diagnosis and Prognosis AAP Type: AAP Hopeless: #’s Guarded: #’s See risk factors. Good: The rest, assuming homecare improvement, and patient pursues prescribed treatment.

Comprehensive Dental Care includes Disease control Caries, Endodontic Periodontal and gingival infection Reconstructive Dentistry Tooth/Teeth, Bridges, partials, crowns, implants Periodontal: pocket reduction, regeneration, normal periodontal architectural configuration Esthetic enhancement Maintenance Professional and patient

Facilitating a Patient’s Choice for Better Dentistry Determine patient’s desired expectation Complete a comprehensive exam to delineate risk factors Educate patient – how their risk factors affect their desired expectations (communication) Discuss means to reduce risk factors – treatment needed and alternatives, plus timing and staging Determine if patient can accept the price of treatment and work with them in this regard.

A comprehensive result includes: Class 1 Occlusion No Pockets Normal skeletal relationship No recession No missing teeth Adequate KT Good tooth position Normal positive soft tissue architecture Normal occlusal landmarks CRO – No occlusal interferences No caries Stable anterior guidance Normal dental anatomy No mobile teeth Good sealed margins Stable healthy TMJ’s Good crown form Adequate bone support.

A Comprehensively Treated Case Should be: The easiest to Maintain The easiest to restore The most esthetic And produce the most predictable long term result.

Function and Esthetics. Comprehensive Care Periodontics Periodontics Restorative Dentistry Predictability Function and Esthetics.

Delivering a Successful Outcome includes: Comprehensive Exam Diagnosis Comprehensive Ts Planning Case Presentation Team Tx planning Long-term predictable Tx and Results.

Treatment Planning Work Sheet. Additional consultations requested: Disease control, aka. Initial Therapy, Phase 1 Therapy, Restorative: Periodontal: Endodontic: Oral Surgical: Other: Reconstructive Dentistry Orthodontic: Prosthodontic: Esthetic enhancement: Functional: Maintenance Professional: Patient:

Treatment Plan Break out time - 30 min Group A Ideal, costs are not a factor Group B Ideal, costs are a factor Group C The best you can do, costs and time are major factors. Outline Goals/Objectives of Treatment

Doctors Proposed Treatment Plan

Phase I: Disease control. Includes: Periodontal: HCI; PROPOSED

Phase II PROPOSED

Phase III PROPOSED

Phase IV Definitive treatment

Phase IV PROPOSED

Phase V PROPOSED

Phase VI:

Maintenance q 3 months, alternating Phase VII Maintenance q 3 months, alternating with the Periodontist. PROPOSED

Actual treatment provided

Actual treatment provided Disease Control: Caries/SRP/Endo/Etc

Actual treatment provided Orthodontic/Oral surgery/Orthognathics

Actual treatment provided Restorative

Actual treatment provided Reconstructive

Actual treatment provided Maintenance

Actual treatment provided Supplemental over time/

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