Lec 3 Diagnosis and Treatment Planning PDF

Diagnosis and Treatment Planning When pts present for dental care the process begins w: o Diagnosis o A problem list o Treatment Plan (sequenced) Importance of the Diagnostic Phase of Tx Many failures can be traced to inadequate diagnosis and incomplete tx planning A thorough, properly sequenced tx...

Diagnosis and Treatment Planning When pts present for dental care the process begins w: o Diagnosis o A problem list o Treatment Plan (sequenced) Importance of the Diagnostic Phase of Tx Many failures can be traced to inadequate diagnosis and incomplete tx planning A thorough, properly sequenced tx plan is essential to removable therapy Formulation of an appropriate tx plan requires careful evaluation of pertinent diagnostic data o Info from patient interviews, radiographic evaluation, oral examination, diagnostic mounting of casts, preliminary survey and design procedures, and appropriate consultations with medical and dental specialists. Steps in Evaluation, Diagnosis and Tx Planning 1. Health History 2. Chief Complaint 1. Health hx: Always have UTD health hx 3. Intraoral/extraoral Examination 2. Chief Complaint: Pt’s own words, “Why are they here?” 4. Radiographic Evaluation 3. Intraoral/Extraoral Exam 5. Oral Prophylaxis/Restorative needs o Visual exam depends on nature of CC 6. Vitality of remaining teeth § Caries susceptibility 7. Evaluation for Major Connector § Decayed/restored/missing/teeth 8. Impressions/Mounted Casts § Oral Hygiene 9. Psychological profile § Periodontal disease- inflamed gingiva, Recession 10. Prognosis § Periodontal charting 11. Case Presentation - Pocket depths - Attachment levels - Furcations (class III: advanced periodontitis) - Mobility 4. Radiographic exam o Complete series § Recurrent caries § “overhangs” § Endo treated teeth, good risk? § Tooth support/bone level/bone quality § Impacted or unerupted teeth Less tissue and bony attachments, are 5. Oral Prophylaxis/Restorative Needs sufficient to support partial denture § Cemental caries § Abfraction § Abrasion 6. Vitality of remaining teeth 7. Major connector evaluation o Measure floor of mouth to FGM-major connecter = 7mm 8. Impression/mounted Casts o Occlusal analysis o Ridge Relationships o Extruded teeth/space limitations Don’t put denture or base on 3rd molar, it will come o Survey cast: need for mouth prep? out o Pt presentation o Pt records Edentulous Jaws (Maxillary and Mandibular) CANNOT tolerate compressive forces over a long time o Pre-prosthetic sx (frenum, tori, redundant tissue) 9. Psychological Profile o Meet Mindset and Attitude of patient o 4 aspects: § Philosophic → good attitude; accepts Tx readily; cooperative § Exacting → scrutinizes every detail, difficult to please esthetically § Indifferent → doesn’t seem to care; can be trouble at Tx completion § Hysterical → everything is a crisis; unnerving 10. Prognosis: Good, Guarded, Poor? 11. Case Presentation + Feedback o Alternatives, economic considerations, physical limitations, esthetic considerations Data Influencing Tx Decisions Combination Syndrome o Dental condition in pts w completely edentulous maxillary arch and partially edentulous mandibular arch w preserved mandibular anterior teeth o Causes anterior maxillary resorption o Redundant pre-maxilla (flabby tissue) o Supra-erupted mandibular anteriors o Extruded tuberosities Extensive alveolar bone loss necessitating tooth replacement AND Alveolar Bone o Good indication for Kennedy Class IV. Impression Materials and Procedures for Removable Partial Dentures Impression Materials can be classified as: Rigid, Thermoplastic, Elastic Rigid o Plaster of Paris o Metallic Oxide Pastes (Zinc Oxide Eugenol) Thermoplastic o Modeling plastics (like red -cake compound) = gray or green stick used for border molding only due to temperature sensitivity and fragile nature o Impression waxes and resins Elastic * Rigid and Thermoplastic impression materials are NOT used for RPD primary or secondary impressions anymore * Types of Elastic Impression Materials Reversible Hydrocolloid Irreversible Hydrocolloid Elastomeric Impression Materials: exhibits elastic behavior after setting o Mercaptan “Rubber Base” – Polysulfide o Polyether o Silicone – Condensation silicone and Addition silicone (polyvinyl siloxane- PVS) Elastic Materials Only materials that can be withdrawn from tooth and tissue undercuts WITHOUT permanent deformation. The MOST used impression material for RPD Hydrocolloids o Derived from natural sources such as seaweed, seeds, roots, tree sap, fruit peels Reversible Hydrocolloid o Agar-agar- fluid when heated and when cooled reverts to a stiff like consistency o Few advantages over irreversible hydrocolloids Irreversible Hydrocolloid (Alginate) o Advantages: *Simple technique *Cost effective (Inexpensive) *Can be used in the presence of moisture *Pleasant taste – well…o.k. taste *Can be disinfected *Nontoxic, Nonstaining o Disadvantages: *Less surface detail than some materials *Must be poured in stone immediately unless stored in 100% humidity and then within 1 hour *Use room temperature water *** cold water slows setting, while warm water sets it faster *Use correct ratios when mixing Alginate or Stone Elastic Materials…cont… Mercaptan “Rubber Base” o 4 Types of Elastomeric impression Material: § Polysulfide § Polyether § Condensation silicone § Addition silicone o More often called “ Rubber Base” o A two-part dental impression material o It is widely used bc it gives an accurate impression in the presence of saliva and blood o Disadvantage: have to use another material if you border mold for customization of an impression Polyether Impression Material o Ex. Impregum o An elastomeric impression material that provides good detail o Can be used in border molding but NOT COMPATIBLE with siloxane impression materials o These materials flow well and have a long working time o Disadvantage § Absorbs moisture § Must be washed, disinfected and dried as soon as it is removed from the mouth § MUST be STORED DRY Silicone Impression Materials (2 categories) o Condensation silicones § Putty – may exhibit slightly more shrinkage over time § A two-part system that has to be manually mixed o Addition silicones § MOST accurate of the impression materials § Most expensive § Examples: Imprint, Express and Paradign Are Impression Materials phasing out? Computer scanning capable of gliding over arch and capturing digital image Lab Notes (Alginate Impressions and Stone Pour-Ups) Primary Impression and Model Alginate should NOT be left exposed to air for an extended time because dehydration will occur and result in shrinkage Impression should NOT be immersed in water OR disinfectant as some imbibition will result and accompanying expansion The impression, if not poured immediately, should be placed in a humid atmosphere or wrapping the impression in a damp paper towel until the cast can be poured (within 15 minutes after removing the impression from mouth) Impression Steps Select an appropriate perforated or rim-lock impression tray Tray large enough to provide 4-5 mm thickness of impression material between teeth, tissues and tray The palatal area of the maxillary impression (palatal vault) and the distolingual flange may need to be built up (to prevent tissues from the floor of the mouth from rising inside the tray) Place patient upright position with the arch to be impressed parallel to the floor When irreversible Hydrocolloid (Alginate) is used o Place measured amount of water (room temperature) in a clean dry rubber mixing bowl o Add the correct measure of powder. o Spatulate rapidly, against the sides of the bowl (1-2 minutes) Place the alginate material in the tray. Be careful not to trap air. Prior to placing tray in mouth, take finger and quickly place (rub) excess alginate material over critical areas (areas for rest preparations or abutment teeth) Use a mouth mirror or your index finger to retract the cheek on the side away from you as the tray is rotated into the mouth from the near side. Seat the tray first on the side away from you, next the anterior area, while reflecting the lip and then the side near you retracting the cheek with mouth mirror or index finger DO NOT place tray too deeply, we must leave room for a thickness of material over the occlusal and incisal surfaces. Hold the tray immobile for 3 MINUTES with light pressure in the right and left pre-molar area. Do not allow the tray to move until completely set. Remove the impression quickly in line with the long axis of the teeth to avoid tearing or distortion. Rinse the impression free of saliva, examine the impression, spray with disinfectant, and cover the impression with a damp cloth if not to be poured immediately. * Pour cast immediately into disinfected impression unless circumstances necessitate some delay (disinfectant). Do not delay longer than 15 minutes as a longer delay could result in dimensional changes. Stone Cast Making Materials needed: o Measured stone with measured room temperature water o Rubber mixing bowl o Spatula o Vibrator Procedure: o Pour measured water in rubber mixing bowl and add measured stone. o Spatulate thoroughly – 1 minute (weak and porous stone can result from insufficient spatulation) o Place rubber bowl on the vibrator and move the bowl back and forth to allow the escape of trapped air. o Remove damp paper towel if in place and gently shake out any moisture. o Hold the impression to the vibrator trying to only allow the handle to come in contact with the vibrator to prevent possible distortion of the impression. o With the spatula, add cast stone to the distal of the area away from you. Allow the first stone /material to vibrate around the arch from tooth to tooth from posterior to the anterior portion of the impression and to the posterior of the impression near you. Add stone/material from the same end you started pushing the stone ahead of it. o As you add stone/material in increments and push the material ahead of it around on the vibrator (this prevents trapping of air and pushes any moisture in the impression forward – discarding the moisture o When the impression of the teeth and all the teeth have been filled, continue to add stone in larger portions until the impression is completely filled. o The base of the cast , if possible , should be complete with the same mix of stone. o Any stone that interferes with separation must be removed as soon as the stone has developed sufficient body. o Allow the cast to set for 30 minutes in the impression before separation. o Clean the material out of the impression tray while the material is still elastic o Do not Trim the casts until the final set has occurred Kennedy I Design Major Connector o Lingual Bar o Must have 7mm from the FGM (free gingival margin) to the floor of the mouth o The Bar should be 4 mm in height (3 mm from the FGM) Use Red color of pencil for major and minor connectors Use Blue color of pencil for direct and indirect retainers Use #2 Lead pencil for flange areas. Major Connector o Kennedy Class I- Lingual Bar with framework (meshwork) o Denture base on Tooth #18,#19,#30, and #31 Minor Connectors o Mesial Tooth #21 and #28 o Indirect Retainers= mesial rests #21 and #28 – distal Rests #20 and #29. o Direct Retainer= Circumferential clasps (C-clasp) on tooth #20 and #29 o Retention arm –facial o Reciprocating arm –lingual