1. Recurrent Procedures
PROCEDURE RATIONALE
-Easy to use, quick and is of low cost
-Adequate accuracy for diagnostic value if
Alginate - Irreversible they are poured within fifteen minutes of
Diagnostic impressions impression taking
hydrocolloid
-Should be stored in a humid environment
if there is a delay before pouring stone
-Accurate, tasteless, odorless, dimensionally
stable impression material
-Allows for accurate multiple pours
Final impressions of fixed -Triad custom tray fabricated from
prosthodontic treatment diagnostic casts used to produce a uniform
Vinyl Polysiloxane utilizing a
(crowns/fixed dental thickness of VPS material and increasing
custom tray
prostheses) material conservation
-VPS adhesive applied to the tray aids in
material retention an decreases distortion of
the material
The Hanau Wide Vue ARCON Articulator
is a semi-adjustable articulator
-Arbitrary 110mm distance between the
Hanau Wide Vue ARCON vertical components of the lower member
Articulation of casts
Articulator -Vertical members represent the patient’s
(AR-ticulating CON-dyle) ascending ramus
-ARCON articulator because the upper
member houses the condylar guidance
-The Spring Bow transfer system records
the relationship of the patient’s maxilla to
the anatomic terminal hinge axis
Facebow Transfer Record Hanau Spring-Bow Facebow -Used to relate the maxillary cast to the
upper member of the Hanau articulator and
indirectly relate the mandibular cast to the
articulator’s terminal hinge axis.
-Topical ester anesthetic
20% Benzocaine Topical -Applied to dry gingival tissue for 1 minute
Anesthetic -Decreases initial pain from anesthetic
injection
Local Anesthesia -Amide anesthetic with low allergenicity
-Epinephrine is used in conjunction with the
2% Lidocaine with 1:100,000 anesthetic, primarily to increase the
Epinephrine duration of analgesia
-Up to 1.5hrs pulpal analgesia and 3.25 hrs
soft tissue analgesia
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2. Systemic/Diagnostic Phase
PROCEDURE DESCRIPTION/RATIONALE
A planned, methodical and systematic approach including patient questioning and objective
clinical tests to evaluate the overall health of the patient
Comprehensive Intra/Extra oral i. Chief Complaint - relates patient needs, desires and expectations
Exam ii. Medical/Dental history - establishes current overall health of the patient
Hard/Soft Tissue Exam iii. Oral Cancer Screening - allows visualization/palpation of the entire oral cavity to include
floor of mouth
Radiographs (Full mouth series, Bitewings, Panoramic and Cephalometric)
Enables identification of:
- Hard tissue pathology
- Alveolar bone levels
- Root configuration
Radiographs
- Peri-radicular lesions
- Root to crown ratios
- Interproximal carious lesions
- Potential sites for endosseous implant placement
Intra/Extra oral photographs Photos for study and presentation purposes
Comprehensive Endodontic Percussion/palpation - to determine areas of peri-radicular inflammation
Exam Thermal cold testing - to establish pulp vitality
Assess the health of the patient’s periodontium and aid in developing a periodontal diagnosis
and treatment plan. Examination to include:
-Probing depths
Comprehensive Periodontal -Clinical attachment level
Exam -Function involvement
-Tooth mobility
-Bleeding on probing
-Presence of calculus/plaque (PASS)
Medical Consult for HTN Medical consult regarding the patient’s Stage 1 Hypertension
Alginate impressions for the
fabrication of diagnostic casts
See Recurrent Procedures Description
Utilize a Facebow transfer
record to mount casts on a
Hanau ARCON articulator
A 3D guide to assist in treatment planning
Diagnostic Waxup Aids in developing an occlusal scheme, final restoration contours and esthetics
Used to fabricate a stent for tooth reduction, provisional fabrication and implant radiographic
and surgical guide
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3. PROCEDURE DESCRIPTION/RATIONALE
To inform the patient of the planned treatment and discuss any alternative treatment plans
Explain goals, advantages, disadvantages, and complications for each proposed plan
Discusses the rationale and sequencing of each treatment, and the proposed time required to
complete treatment
Present treatment plan to patient Allows the patient the opportunity to participate with an informed decision on his treatment
outcome
Emphasis has been and will continue to be made on the patient improving and maintaining an
acceptable level of oral hygiene throughout the treatment and maintenance phase
Monitor vital signs before each To obtain baseline signs and identify any changes during treatment to ensure vital signs are
procedure and continuously within acceptable limits
during any surgery Any deviation from normal will receive an appropriate referral
Preparatory Phase
PROCEDURE DESCRIPTION/RATIONALE
Control the etiology of caries and periodontal disease
Improve prognosis for comprehensive treatment
Oral Hygiene Instruction
Evaluate compliance and reinforce effective OH
Goal: 85% plaque free surfaces (PASS)
Educate the patient on the effects of frequent sugar intake
Diet Counseling Explain how sugar indirectly affect the pH in the mouth and, when combined with poor OH,
can increase the risk of new and recurrent caries
a. Removal of caries and defective restorations and restore with a Glass Ionomer restorative
material
b. Sealant placement
Initiation of the
c. CHX Rinse/Fluoride Varnish
Anderson Medical Model
d. Xylitol Gum
e. At home fluoride rinse (ACT 0.05% NaF)
f. Re-eval/bacteriologic testing
Periodontal Diagnosis: Generalized Slight Chronic Periodontitis
Initial non surgical periodontal therapy removes basic etiological factors
i. Pre-rinse with 0.12% CHX for 30 seconds
Initial Non Surgical Periodontal ii. Generalized scaling removes calculus, plaque, and stains
Treatment iii. Site specific root planing of sites ≥ 3.0mm with local anesthesia if required (see
Recurrent Procedures Description)
Oral hygiene reinforcement - reinforce hygiene technique and standards
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4. PROCEDURE DESCRIPTION/RATIONALE
Re-evaluation of initial non surgical Re-evaluation is the diagnostic appointment to evaluate the effects of non surgical
periodontal therapy: periodontal therapy
A. Periodontal charting Plaque disclosure will show the patient areas of poor plaque control and reinforce areas of
B. Decide to perform open flap success
debridement to areas which do Goal: 85% plaque free surfaces (PASS)
not respond to initial therapy
Decision Point
By bettering his home care and diet compliance, I anticipate Patient S will display acceptable bacteriologic testing levels and attain a
PASS score of 85% plaque free surfaces and <100,000 CFU of S. Mutans. Arresting Patient S’s caries process and periodontal disease
will enable us to continue with the Preparatory Phase of treatment. Immediately following a successful re-evaluation, I will replace
all posterior GI provisional restorations with definitive amalgam restorations. Subsequently, orthodontic treatment will continue for
12-18 months. The patient will be placed on 3 month periodontal recalls to ensure compliance with oral hygiene. However, if the
patient does not attain a PASS score of 85% plaque free surfaces and <100,000 CFU S. Mutans, I will replace all provisional Glass
Ionomer restorations with definitive restorations, and fabricate Mx and Md treatment partial dentures.
Definitive Amalgam restorations will be placed in teeth #’s 3,4,5,14,21,28,31
Replace posterior provisional GI -high compressive strength
restorations with definitive
amalgam restorations -long history of clinical success
-will act as cores for crowns
Previously endodontically treated tooth #9
-Asymptomatic
Endodontic Retreatment -Previously large mesial carious lesion on tooth
Tooth #9 -Apical radiolucent lesion
2 appointment endodontic retreatment
-Increase the probability of a successful endodontic outcome
Initial fabrication of a Md treatment partial to assist in closing Md diastemas (particularly
mesialization of tooth #21)
Fixed Ortho Appliances Goals:
Maxillary and Mandibular Arches i.Correct OB/OJ
12-18 months ii.Correct Midlines
iii.Dev functional occlusion
iv.Close diastemas
Patient S will be on 3 month periodontal recalls to reinforce his oral hygiene
1 Stage Implant Placement
Implant (opposing tooth #14) to serve as:
i. Orthodontic anchorage (if required)
1 x Nobel Biocare Replace Select
ii. Locator abutment for distal extension RDP
Wide Platform
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5. PROCEDURE DESCRIPTION/RATIONALE
Orthodontic treatment will be considered complete when the following goals are achieved:
1. 1mm OJ
Removal of Orthodontic fixed 2. 10% OB
appliances
3. Intrusion of tooth #14 (≥3mm)
4. Md diastemas closed
Alginate impressions for the Fabrication of Essix retainer(s)
fabrication of diagnostic casts Diagnostic Waxup
Diagnostic Waxup
-Enables visualization of proposed treatment
Diagnostic restorative waxup
-Establishes proper occlusal plane and tooth forms
-Aids in CCL evaluation
1. Functional crown lengthening: Teeth #’s 14,21,28
-Prevent violation of the biologic width (2.04mm)
Clinical Crown Lengthening -Provide adequate exposure of tooth structure for crown placement
Ant Mx Teeth 2. Esthetic crown lengthening: Teeth #’s 6-11
FDP Tooth #14 -Will reestablish the gingival margin at the desired level for an optimal esthetic result
RDP abutment teeth #‘s 21 & 28 -Provide adequate exposure of tooth structure for crown placement
Preparation of the teeth for PFM crowns/FDP will proceed 6 weeks following CCL if
uncomplicated healing occurs
Re-evaluation of the CCL procedure (s) will occur 1 week, 4 weeks and 6 weeks post op
Re-evaluation of
Preparation of the teeth for PFM crowns/FDP can proceed 6 weeks following CCL if
Clinical Crown Lengthening
uncomplicated healing occurs
Corrective Phase
PROCEDURE DESCRIPTION/RATIONALE
Type III gold casts accurately and is readily finished before and after cementation
Tooth #9 cast post/core restoration
using Type III gold Zinc phosphate has reduced expansion, good retention, and high compressive and tensile
strength
Luted with zinc phosphate cement
The cast post will serve to retain the crown core
PFM reduction criteria:
-Labial: 1.3mm shoulder margin
Prepare teeth #‘s 3,6,7,8,9 & 10 for -Incisal: 2mm reduction
PFM crowns and temporize with -Palatal: 1mm reduction with 0.5mm chamfer
MMA temporary material using a
VPS putty stent MMA provisional material:
-excellent esthetics
-easy to manipulate (easy addition to voids/marginal discrepancies)
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6. PROCEDURE DESCRIPTION/RATIONALE
PFM reduction criteria:
-Labial: 1.3mm shoulder margin
Prepare teeth #’s 11,14 for PFM -Occlusal:
crowns as FDP abutments Functional cusps: 1.5mm reduction (metal)
Non-functional cusps: 1.5mm (porcelain)
-Lingual: 0.5mm chamfer
Survey of diagnostic waxup of RDP abutment crowns to develop:
-Sufficient height of contour for retentive elements
Prepare teeth #‘s 21, 28, 31 as
surveyed PFM crowns to act as -Guide planes
abutment teeth for Md RDP -Rest seat preparation
Survey of wax up directs lab to proper contouring of PFM crowns as RDP abutments
PFM crowns:
-High esthetics
-High wear and fracture resistance
-High marginal integrity
Deliver PFM crowns/FDPs and lute
with Resin-modified glass ionomer Resin Modified Glass Ionomer Luting agent
cement.
-Good marginal integrity
-Low film thickness
-Good retentive adhesive properties
-Fl release
Primary Impression for RDP
Primary impression for fabrication of a custom tray
fabrication
Border molding and secondary Please see Recurrent Procedures Description for VPS impression
impression of Md arch using VPS. -Border molding accurately captures the buccal vestibule and edentulous ridge in order to
Use Locator impression coping for ensure optimal seal and distribution of forces of the denture
impression -2 impressions allow for fabrication of master cast and subsequent RDP fabrication
RDP intaglio surface adjusted using Pressure Indicating Paste
-Occlusal evaluation and adjustment
-Male locator placement utilizing chair side “pick-up” method
Md RDP denture processing, chair -Male locator attached to female attachment and captured in seated Md RDP with cold cure
side male Locator attachment acrylic
placement and RDP delivery -Eliminates necessity of lab-work involved in indirect method of male attachment
placement
-Allows for quick eval of attachment retentive properties
- Denture will be polished and post insertion care and instructions reviewed
24 hr and 1 week denture re-call Occlusal and “sore-spot” adjustment and locator retention evaluation
appts. Re-appoint as necessary
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7. Maintenance Phase
PROCEDURE DESCRIPTION/RATIONALE
Three month periodontal recall to eval periodontal stability and reinforce
Periodontal Re-eval oral hygiene.
-After one year of successful recalls, SPC will be placed on 6 month recall
Prosthodontic/restorative recalls at three months, Verification of stability and retention of RDP and Locator attachments
nine months, then yearly Check integrity of restoration
Endodontic Re-eval Yearly clinical and radiographic evaluation of endodontically treated teeth
Treatment Prognosis Statement
With adequate restoration of carious and defection teeth, the long term prognosis for this patient is
good. Patient S is highly motivated and very receptive to treatment options. He will be in the Army at Fort
Hood for at least two years and should be able complete treatment. In order for the prognosis to improve, the
patient must maintain excellent oral hygiene and diet compliance, and report for recall appointments.
Alternate Treatment Plan
If Patient S were to deploy within 30 days, his treatment would consist of the following:
Urgent - None
Systemic - Med referral for Stage 1 HTN
Preparatory
A. Initial periodontal therapy (SRP) and OHI
B. Application of a Modified Anderson Medical Model to include:
i. Removal of carious lesions in teeth #’s 4,6,7,8,9,10 & 31 and placement of an RMGI provisional
restorative material
ii. Defective restorations in teeth #‘s 3,5,14,21 & 28 would be removed and replaced with new amalgam
restorations
iii. CHX 0.12%, Fl Varnish, Xylitol gum, Fl rinse (home)
Decision Point
i. >85% plaque free surfaces and <100,000 CFU S. Mutans
ii. Sufficient time prior to deployment
Corrective
C. Provisional restorations would be replaced with definitive restorations
D. Fabrication of maxillary and mandibular treatment partials
E. Fabrication of a bruxism splint
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