1. TREATMENT PLANNING PROTOCOL FOR COMPLEX PROSTHODONTIC CASES
Soraya C. Villarroel, D.D.S., M.S.

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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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)

12. 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)

13. 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

16. 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

17. 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: mm
Land area width: 3-4 mm

18. Diagnostic Casts*
*Comprehensive Care Patient Presentations, , Dr. Mary Baechle 

19. 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

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

21. 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

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

23. 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

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

25. Altercast Impression Procedure

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

27. 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

28. 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

29. 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

30. 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

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

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

33. 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

34. 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

35. 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

39. 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

40. 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

41. 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

42. Clinical Case

43. Clinical Case I: Immediate Denture

47. Clinical Case II: Fixed-RPD

49. Clinical Case III: CD/Fixed-RPD

50. Clinical Case IV: Immediate Partial-Denture

52. 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

53. 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

54. References
Clinic Manual ; 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

55. Thank You!

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