Transcript Definitive Treatment Phase

ODRP 726
Patient Diagnosis and Treatment Planning
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Objective is to rehabilitate the patient’s oral
condition
Includes procedures to improve function and
appearance
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Perio surgery
Ortho treatment
Occlusal therapy
Elective oral surgery
Replacement of missing teeth
Cosmetic or esthetic procedures
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Follows initial treatment (root planing)
May be indicated for residual diseased sites
◦ Surgical flaps to improve access and increase
visibility
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Close furcation – bone graft
Make furcation easier to clean – apical
repositioning
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Improve placement of crown margin
Reduce pocket depth
Increase biologic width
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Thorough scaling and root planing, and OHI
Re-evaluate
Gingivectomy – blade, laser, electrosurgery
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Healthy lifestyle
◦ Good nutrition
◦ Good control of systemic disease
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Use of tobacco products
Patient motivation for treatment
Willingness to follow through with treatment
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Comprehensive orthodontics
Limited orthodontic movement
◦ Forced eruption – compromised biologic width
◦ Molar uprighting
◦ Minor tooth movement – 6 or fewer teeth
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Orthognathic surgery
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Indications
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Severe attrition
Abnormal occlusal planes
Malposed teeth
Occlusion-related periodontal attachment loss
Parafunctional habits
Temporomandibular disorders
Participates in contact sports
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Selective grinding of teeth
Often an adjunctive therapy to
◦ alleviate symptoms of temporomandibular dysfunction
◦ Complement comprehensive prosthodontic
reconstruction
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Treatment goals
◦ Develop and acceptable centric relation contact position
◦ Provide for acceptable lateral and protrusive guidance
◦ Establish an acceptable plane of occlusion with adequate
interarch space to replace teeth
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Bite guard, bite splint, occlusal guard, night
guard
Indications
◦ Symptoms of TMD –
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provides a more orthopedically stable TMJ position
reorganizes the neuromuscular reflex activity
Relieves pain
Confirm diagnosis of TMD
◦ Prevent tooth wear caused by bruxism
◦ Assess the patient’s tolerance of increased vertical
dimension of occlusion
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Reversible and non-invasive
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Protect remaining tooth structure
After placement of large restorations (core
build-up)
◦ Caries control
◦ Fractures
◦ Replacement of large restoration
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Restoration after root canal treatment
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Gold or porcelain inlay
Intracoronal restoration
Used instead of amalgam or composite
Increased longevity
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Covers one or more cusps of posterior tooth to
strengthen remaining tooth
Onlay, MOD onlay, ¾ gold crown, 7/8 gold
crown, inlay-onlay
Can be gold or ceramic
Used to preserve unaffected tooth structure
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Full gold
◦ Best against natural teeth and gold
◦ Best longevity
◦ No likelihood of fracture
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PFM
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All-ceramic
◦ Best strength
◦ Esthetic
◦ Best esthetics
◦ Least strength
◦ Can be one-appointment
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Studies show decreased fracture resistance
with cast post
Cast post has added expense and added
appointment
Indications
◦ Multiple post and core restorations planned on the
same arch
◦ Smaller teeth (mandibular incisor) prefab posts
difficult to fit
◦ If the angle of the core relative to the tooth must be
changed
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How much tooth structure remains?
Horizontal forces applied
No existing restorations (except access prep)
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Less than 50% of crown is missing
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More than 50% of crown missing
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Fracture resistance = normal tooth
Access cavity restored with composite
No post required
May require bleaching as tooth discolors
◦ No post required
◦ Porcelain veneer (covering incisal edge and facial)
◦ Prepare tooth to determine if post is necessary
 Based on remaining resistance form
◦ Full crown is required
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Vertical forces
Fracture resistance decreases as amount of dentin
removed increases
Post is only recommended when more conservative
retention and resistance features are not possible
Amalcore is effective
◦ Amalgam placed in the entire pulp chamber area and in the
coronal 2.0 – 3.0 mm of each canal.
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Threaded pins
Adhesive materials
Post should be used if the tooth is to be used as an
abutment for an RPD – increased horizontal forces –
when placing and removing RPD
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Post should be used if there is inadequate
pulp chamber for retention of core
Posts are placed only in:
◦ Palatal canal for maxillary molars
◦ Distal canal for mandibular molars
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Never more than one post is required
Posts NEVER strengthen a tooth
Posts improve retention of crown
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Microabrasion
◦ Superficial stain removal
◦ Defective surface material is removed using
abrasion/erosion
◦ Bathed in fluoride gel
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Contouring teeth
◦ Minor alterations from fractured, chipped, extruded
or overlapped teeth
◦ Rotary instruments used to remove and polish teeth
◦ Contraindications – hypersensitive teeth, thin
enamel
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Vital bleaching
◦ Toothpaste and OTC bleaching strips
◦ Bleaching
 At-home bleaching – 4-6 weeks
 In-office – immediate results
 Pulpal sensitivity
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Bleaching devitalized teeth
◦ Endodontically treated teeth
◦ Gutta percha removed below the cervical level,
bleaching solution is sealed into the pulp chamber
◦ Laser activated bleaching
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Replacing amalgams for cosmetic purposes
or “medical reasons”
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Do the fillings need to be replaced?
Can the fillings be replaced with composite?
What are the patient’s expectations?
Risks vs benefits
Informed consent
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Veneers
◦ Change color, contour or size of tooth
◦ Composite chairside (direct) or lab processed
(indirect) – more conservative
◦ Porcelain lab processed
 0.3 – 0.7 mm enamel is removed from incisal and/or
facial surfaces
 Extreme discoloration (tetracycline or fluorosis)
 Strong and stable
 Contraindicated in bruxers
 Best on virgin teeth
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Insufficent tooth structure for veneer
Patient bruxes
Porcelain fused to metal crowns
All-ceramic crowns
◦ More natural
◦ More fragile
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Healthy patient
◦ Aged 19-25
 Repeated episodes of pain from pericornitis
 No reasonable prospect for erupted properly aligned
fully functional 3rds, and desire by patient to avoid
future problems
◦ Any age
 Poor periodontal and/or restorative prognosis and
patient is unmotivated
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Additional guidelines
◦ Younger, healthier patients have an easier surgery,
heal faster with more normal bony architecture
◦ When the risk of future caries, periodontal,
pericornitis is high – more weight to extraction
◦ When possibility for complications (dry socket,
parasthesias, fracture or infection) is high – more
weight to not extracting
◦ Reasonable probability that teeth may be needed in
future as abutments or to maintain occlusal plane –
weight to not extracting
Dr. Patrick Palacci
Brånemark Osseointegration Center Marseille
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Diastema closure
Removable dentures – can be for any frena
with attachment near or on the ridge
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Removable denture – helps retention
Esthetics under FPD
Implant placement
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Results from low grade trauma caused by
poor fit of denture flange or body
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Categorization
◦ Bounded edentulous space – tooth on either side of
space
◦ Unbounded edentulous spaces with some teeth
remaining – no distal or terminal tooth present
◦ Fully edentulous arch
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Implant supported prostheses
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Implant placed in bone and healing cap
screwed into place
Healing time
Abutment placed and impression taken
Crown, fixed partial denture or other
prosthesis is fabricated for the implant
Implant placed in bone at time of extraction
= immediate placement
Implant, abutment and provisional restoration
placed at time of extraction = immediate
loading
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Improved function
Preservation of remaining teeth and bone
Increased stability
Longevity
Realistic and esthetic appearance
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Cost
Length of healing period after extraction for
non-immediate and non-healing implant
◦ 8 weeks
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Length of healing period after placement of
non-immediate, non-loading implant
◦ 3 months to allow for osteointegration
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Immediate placement and loading
◦ Healing and osteointegration periods are eliminated
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Implant should be the primary option
Advantages (compared to FPD)
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Challenges
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Stability
Longevity
Easier cleaning/maintenance
Health tooth structure not sacrificed
◦ Esthetic zone placement in three dimensions
 Contraindications for placement in esthetic zone
 Inadequate bone density or volume
 Inadequate buccal-lingual width (perio surgery)
 Insufficient mesial-distal tooth replacement bone width
(ortho)
 Insufficient interarch space (ortho)
 Mobility of adjacent teeth
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Matching the soft tissue contours of adjacent
natural teeth to those around the implant
◦ Esthetic periodontal surgery may be needed before
at or after implant placement
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Evaluation for these problems must occur
before treatment planning so that patient is
aware of all contingencies
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It is preferred that ALL abutments be
implants rather than tooth/implant
◦ Fewer pontics and more retentive units
◦ Prosthesis conveys less stress to surrounding bone
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More implants needed where heavier occlusal
forces are expected
◦ Fewer needed in the anterior
◦ Fewer needed when opposing a removable
prosthesis
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FPD in esthetic zone have same challenges as
single unit
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Two options for non-removable
◦ Hybrid prosthesis
 Constructed of cast alloy framework with denture teeth
and resin – compensates for moderate bone loss and
missing soft tissue contours
◦ Metal ceramic restoration
 Used when there is minimal bone and soft tissue loss
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Advantages compared to conventional
removable complete dentures
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More stable
More retentive
Less food entrapment
No need for denture relines or denture adjustments
Far greater longevity
Fixed functions more like natural teeth
Disadvantages
◦ Cost – increases with each additional implant or
pontic
◦ Time and effort for process and surgery
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Good for patient with severe bone resorption
Complete denture is supported by but not
affixed to two or more implants
Connect to implants by bar or clips on
denture
Removed and inserted by patient
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Advantages
◦ Facial esthetics are enhanced by the support of the
labial flanges
◦ Removal at night facilitates daily cleaning
◦ Avoids destructive forces from nocturnal bruxing
◦ Fewer implants needed
◦ Less expensive option
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Systemic diseases that are contraindications
for implant placement
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Poorly controlled diabetes
Osteoporosis
Radiation therapy to head and neck
Immunocompromising conditions
Cigarette smoking
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Assessment of intraoral conditions
◦ Site evaluation for single implant
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Bone height, width, contour and density
Mesial-distal interdental space
Interarch space
Relationship to anatomic structures
 Maxillary sinus
 Mental foramen
 Mandibular canal
 Submandibular gland fossa
 Esthetic zone
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Lip line
Shade, form and alignment of the surrounding teeth
Facial gingival and bone architecture
Height and density of facial gingiva
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Assessment of intraoral conditions for
implant retained FPD, fixed complete
dentures or overdentures
All of the previous plus
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Lip support
Location and size of edentulous areas
TMJ evaluation
Maxillomandibular relationship, VDO, occlusal
plane, arch form and size, occlusal relationships,
guidance patterns in excursive movements
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For decades the best option for bounded
edentulous spaces
Cast metal or porcelain fused to metal or all
porcelain
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Advantages
◦ Replacement teeth are fixed in place and provide a
stable and natural looking alternative to a removable
prosthesis
◦ Good esthetics
◦ Good function
◦ Preservation of arch form
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Disadvantages
◦ Margins, along with poor oral health care increases
risk for recurrent decay and periodontal disease
◦ Difficult to keep clean
◦ FPD can compromise the abutment teeth increasing
risk for future root canal or tooth loss
◦ Is not indicated if restorative and periodontal
condition of abutment teeth are poor
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Notable indications for fixed partial denture
◦ Bounded edentulous space present and
 Abutment teeth are heavily restored and are good
candidates for full coverage restorations
 Medical challenges against surgery
 Financial challenges
 Patient does not want surgery
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Forces on the partial denture are transferred
to abutment teeth via framework and clasps
and to the ridges from the acrylic bases
Advantages:
◦ Relatively inexpensive and stable
◦ Provides a measure of function and esthetics
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Advantages:
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Disadvantages
◦ Relatively inexpensive and stable
◦ Provides a measure of function and esthetics
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Must be removed for cleaning
Visible portions of framework and clasps
Abutment teeth at risk for caries and periodontal disease
Can cause
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Traumatic ulcers
Stomatitis
Bone atrophy
Epuli formation
◦ Denture is prone to wear, fatigue of clasps, loss of denture
teeth, poor fit
◦ Significantly reduced function when compared with natural
teeth, FPD or implant retained prosthesis
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Removable acrylic replacement for teeth and bone
lost in an entire dental arch
Advantages
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◦ Relatively economical
◦ Easy to fabricate and repair
◦ Provide a level of esthetics and function compared to no
teeth at all
◦ Lack of denture retention and loss chewing ability
 Several teeth can be retained in an arch to serve as overdenture
abutments
 Endodontically treated teeth with a capping restoration
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Disadvantages
◦ Lack of denture retention and loss chewing ability
 Several teeth can be retained in an arch to serve as
overdenture abutments
 Endodontically treated teeth with a capping restoration (gold
or amalgam)
 Advantages
 Increases stability and proprioceptive “feel” with chewing
 Helps to preserve the residual ridge
 Disadvantages
 Susceptibility to caries and periodontal disease
 Implant overdenture is usually better option
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The objective is to prevent relapse and
recurrence of disease
More than a “check-up”
A personalized plan designed to maintain the
patient in optimum oral health
Periodic exam, periodontal maintenance, oral
hygiene instructions, risk reassessment
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Throughout examination you have been
communicating with the patient, developing
trust and rapport
With the Tx Plan Presentation, you must use
communication skills to reach a consensus
with the patient on the final treatment plan
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If handled well – you will be respected and
seen as a professional
If handled poorly – you may be perceived as
uncertain, lacking confidence, self-serving,
arrogant or incompetent.
You should NEVER
be here
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You must be prepared to discuss all aspects
of the case and be open to any questions or
concerns from the patient.
1. Educate the patient about their problems
and diagnoses
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Start with the chief complaint
Use mounted casts, photos, radiographs,
drawings, informational pamphlets
Use terminology the patient will understand
Encourage questions, periodically verify that the
patient understands what you have said
2. Discuss treatment options
Advantages and disadvantages of each option
Short and long-term prognosis for each
Outcome if now treatment is provided
The importance of patient cooperation on the
overall prognosis
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Plaque control
Smoking cessation
Reducing parafunctional habits
Returning for maintenance therapy
3. Cost of services, number of appointments,
length of time
• In practice you may have staff do most of this
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Argues that patients must hold four beliefs
before they will accept treatment for a
particular disease
1. That they are susceptible to the disease
2. That contracting the disease has serious
consequences
3. That the disease can be prevented or limited if the
patient engages in certain activities or receives
treatment
4. That engaging in treatment is preferable to
suffering from the disease
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This comes from a thorough discussion of the
patient’s problems
The patient must understand and believe in
the doctor’s diagnosis before treatment will
be accepted
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The patient must recognize that there is
some level of severity to his oral condition
Especially important if the patient has no
symptoms and has been unaware of the
problem
Emphasize what may happen if the patient
does NOT have the treatment
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The patient MUST believe that the treatment
plan will help solve his problems
Spend time discussing prognosis
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It may be necessary to convince the patient
that accepting the treatment plan is better
than living with the dental problems.
The most common barriers:
◦ Pain
◦ Cost
◦ Time
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The dentist should always address these
three issues
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Patients prefer to receive information in an
interaction in which they do not feel that the
dentist is attempting to dominate them
When the patient is calm, trustful, and free of
anxiety she is more likely to comply with the
dentist’s suggestions.
When treatment planning is shared with the
patient, the patient is more likely to perceive
that she has a vested interest in the process
and comply with the proposed treatment
Questions???