Treatment planning Flashcards
What are the 5 categories in the multidisciplinary tx plan?
- problem list by discapline
- tx objective and overview
- 6 phased tx plan & rationale
- prognosis
What are the problem list by discipline categories?
C MORE POOOPER
Chief Complaint
Medical/Systemic
Oral Path
Restorative
Endo
Perio
Oral surgery
Ortho
Occlusion
Prosth
Esthetics
Risk Factors
What should be discussed in the tx obje/overview?
statement of desired goals of tx- taking into account findings, pts situations and resources of the practitioner. — where you are headed with the case
What are the 6 tx plan phases?
- systemic phase
- emergency phase
- preparatory
- re-evaluation
- corrective restorative
- maintenance
What would you discuss during the prognosis?
a short and long term prediction based on an educated calculation ofthe response of heard and soft tissues planned treatment. Will take into account existing dental dn perio support, vulnerability to disease host resistance, pt adaptibility,
For the systemic/medical section? what might you be looking for?
med hx, ROS (how it might effect tx), Meds, Allergies, socail habits, labs, asa,
bleeding disorder
cardiac
repiratory
muscoloskeletal
GI, skin, endocrine
neurologic and genitourinary
What to look for during Oral Path?
review radiographs: note pneumitized sinus, RL/RO lesions,
Intra/extra oral photo review- lesions in the mouth, moles
Endo PARL
diffdx for everything!
What to look for during Restorative?
CD-PUNQ-C
Carious and fx teeth
Defective/unesthetic restorations
Prior endo (no cuspal coverage, GP exposure)
Underminded tooth structure or overhangs- like BW invasions,
Non- carious lesions (abfraction, attrition, erosion etc)
Questionable restorability- available restorative space, or perio considerations
Caries risk assessment– ICDAS, CAMBRA, low/med/high
Consider also: bac counts, OH status, Fl intake/exposure, salivary function, and dietary habits
What about Endodontics?
SP5 UP
Symptomatic teeth
PARL
Potential endo
Prior endo (comment on taper, density, length of obturation)
Parulis
Pre-Prosth endo
Unusual canal morphology (calcific metamorphosis, receded pulp_
*Pulpal and periapical dx!
Perio?
PBR2-MFO2-GSDP
Probing depths (>4mm, 5-6, >7mm, and CAL
BOP (and suppuration)
Recession (Cairo: RT 1-3)
Root Proximity
Mobility (miller 1-3)
Furcation (glickman grade 1-4)
O’Leary Plaque index (modified = 85% or higher is goal)
Open contacts (food impactions)
Gingival excess/discrepancy (5 reasons ***)
Systemic factors (smoking, DM, cardiac)
Diagnosis (Stage 1-IV, Grade A-C, localized, generalized or molar/incisor
Prognosis (Kwok-FQUH)
Other: cervical enamel projection and pearls
bifurcation ridges
palato-radicular grooves
marginak ridge discrepancy, 3rd molar angulation
Ortho?
R O3 M3AC
Rotated/crowding
Open contact
Over bite
Overjet
Missing teeth
Midline discrepancy
Mesially tilted molar/malpositioned teeth
Angle’s classification (Class I, II, Div 1, 2, 3) canine class
Crossbite
Skeletal profile?
Occlusion TMD
OW- CROP-IT
Occlusal scheme (mutually protected, group function, canine/ant guidance
Wear facets (attrition, erosion, abfraction)
Co/MI discrepancy
Rotated
Occlusal plane discrepancy (super-eruption, steep curve of spee/wilson
Parafunctional habits (nails, bruxism, chewing on non-food)
Interferences (excursive)
TMJ Status
Also: Vertical Dimension (Of occlusion, VDO- and Rest VDR)
Restorative space- tissue to bone/opposing,
for implants0 crown heigh space (misch)
Classification of oral facial pain
Prosth?
ABUM3 PRICE2 T3
Abutment status/length of edentulous span
Biologic width invasions (exisitng and new)
Undercuts (RPD)
Margins of crowns
Marginal ridge discepancies
Missing Teeth
P&C (existing, or needed)
Ridge (seibert 1-3) reiterate here to justify restoring with Implants, RPD, FDP
Inter arch and overall space considerations
Crown:Root (1:1 min, 2:3 ideal)
Estahtics
Endo without cuspal coverage
TMJ
Tori (if RPD)
Tuberosity (if RPD)
Esthetics
G2 TC SE
Gingival architecture (marins and papilla heights equal?)
Gingival display (is it excessive)
Tooth qualities: form, dicoloration, length, rotation
Crown qualities: margins, fx porcelain, stains
Smile disharmony
Expectations (via CC)
Risk Factors
CPC
Caries
Perio
Cancer
Treatment planning Phases
Emergent
Systemic
Preparatory Phase
Re-eval
Corrective Restorative
Maintenance
Emergent/Urgent Phase
CC- if it includes pain
Swelling
Oral path- if concerning
emergent esthetic concerns
systemic issues, if needed
Systemic Phase
DISCUSS TX MODS OR PRECAUTIONS
med consults as needed
Med list
Labs
Allergies
ASA
PMhx, ROS, meds, allergies, vitals, labs, asa, consultations
PREPARATORY PHASE
no crowns, preps, ortho
dx: work up (casts, O analysis, wax up, radiographs, photos)- rational for articuator selection, information obtained in anh of the above. why certian xrays, photos
Caries risk and charting- rationale for assessment and how it effects tx plan
What kind of articulator will be used? What is its class and why?
Whipmix- Celenza Class 3B, semi adjustable
Will accept an arbitrary facebow, and most lateral records (condylar/bennett angle)
helps reproduce simulated mand movement and resembles the anatomic structure of the pt.
can complete a custom incisal guide table to record ant guidance for prosthetic fabrication
When making an RPD- what do you need to do to the casts?
Make lab form
Tripod
Red: tooth modifications
Blue: Acrylic outlines
Brown: Metal outlines
For an RPD, what metal will I use and why?
Vitallium: alloy of 60% cobalt, 20% chromium, 5% molybdenum
Why: high MOE, high strength, relatively low cost
For an RPD- what teeth would i choose and why?
20 degree Portrait IPN
WHY: strong resin resists abrasion, balance of esthetics and function/chewing effeciency/cusp height, easy to adjust
When deliverying an RPD or CD, what do i do during the try in phase?
Verify occlusion and adjust as needed
Check and verify esthetics with the patient- natural light/light they are in most often
Phonetics-
P,B,M: Bilabial- lip support, A-P position, flange thickness VDO/lip closure
F V: labial dental- incisors in the post 1/3 of lip, too short max V=F, long max F=v
Th: 3mm tongue tip visible(unless class II div I) if not visible, teeth too forward
T,D: T=D if max too L, D=T is max too facial.
S (silibants): opening too small or post arch too narrow=whistle, Opening too big, lisp
OR: is S on mand–> whistle = mand too L, Faulty S, L flange too thick.
SCZ: too gret a VDO= teeth come together.
occlusal scheme: Why would I choose a mutually protected occlusion-
ideal
ant teeth protected during MIP
Post teeth protected during excursive
THUS: protecting my restore and improving overall prognosis of all definitive tx
occlusal scheme: Why would i choose group function?
if unable to have Mutually protected due to loss of cainine
done to distribute forces to as many teeth as possible
Why would i restore the pt in CO?
restoring multiple post teeth bilaterally on both arches
preparing teeth that act as 1st content
CO is most repeatable which helps the lab too
Why would I restore someone in MI
pt has stable occlusion in the post
(instability = hypermobility, excessive wear, migration of teeth, TMJ pain)
Diagnositic: What articulator do i use? and why?
Whip Mix Class IIIb- Arcon, smi adjustable, accepts arbitray facebow and lateral records, and I guide table fabrication
What facebow do i use and why?
arbitrary- Nasion for whipmix is external
related max cast to condylar hinge axis
What amalgam do i use and why?
Contour- admix- 30%lathe, 70 spherical
Contour: high copper (28%)- no gamma 2 (tin-mercury)
533mPa @24 hrs compressive
good condensability, ease to develop interprox contacts, good compressive strength, long hx of success.
or Spherical- Tytin
occlusal best, fast setting time, 608mPa @ 24 hr compressive
What composite do i use and why?
*Nanocomposite- Filtek supreme
-nanoclusters (zirconia/silica or silica nanomer sized particles) clusters are silate treated and crosslink to resins, broad filler distribution.
-Higher filler loading, increased strength, nanomer filler particles allow increased polish retention
Microfill-Venus
Esthetic, good polishability, lower MOE, flexes with the tooth Wears well. Use in class 3 or 5 only
What bond do i use? Do i etch and with what?
HOW do i use the bond?
Optibond FL- 4th gen 3 step (E, P, Adhesive)- highest strength
37% phosphoric acid- 15 secs
Prime: 15 secs, rub in. Gently air dry for approximately 5 seconds.
Bond: adhesive 15 secs, airthin 3s, light cure for 20
What is the primer in Optibond FL and what are common primers?
Primer in optibond: IDK
Common: HMEA, Polyalkenoic acid, aceton, ethanol, PENTA, water
What are common adhesives in bond?
Bis-GMA, HEMA/UDMA
Why might you use a 6th gen, and what is it and give an exampl
Because there is not etch, can use for deeper restorations to decrease sensitivity. no post conditioning rinse
6th gen: P and cond then adhesive, 2 step (no etch, or selective etch)
moderately high bond strengths.
Clearfil SE, Optibond XTR
What is glass ionomer, which one do i use and why?
How does GI bon?
Fuji II LC: dual cure, excellent retention to dentin (similar strength and CTE as dentin), moderate esthetics, fl release and recharge. Use on Class 5 lesions in high caries risk pt.
Bond: A/B rxn polyacrylic acid is the conditioner, 20 secs, remove smear
EQUIA Forte HT - hybrid filler is more susceptible to moisture and temperature cycling. Fuji II LC exhibits a smoother surface with reduced cracks, voids, and clumps compared to EQUIA Forte with and without a resin coating.
What is my endo procedure
Crown down, Protaper Gold- variable taper
Sx, S1, S2 (Y, P, W)- orifice shapers F1-5 (Y, R, B)= finishing files.
Irrigate with NaOCL 8%, and 17% EDTA
Endo activator use in canal
Continous wave- set plugger to 5-7mm from apex. Back fill and plug. Permaflow purple over orifice.
Use MTA for perfs or other probelms.
Close access- depends on plan with tooth.
What do i use for ridge preservation after ext?
70% FDBA/30%DFDBA (allograft):
Why: osteoinductive and conductive
Biomend (Bovine collagen)- resorable, prevents ET/CT down growth. Suture with PTFE (non-resorbable)
ABX 7-10 days
tryt o get 1 closure
For crowns, why would I use gold?
What is the prep?
What kind of gold?
durable, kind ot opposing, burnishable, minmal reduction.
Prep design: 1mm axial with chamfer or shoulder, 1.5mm for stamp, 1mm sheer
High noble metal (Type III, IV) such as Jelenko 7 or Firmilay
For crowns, why would I use MCR?
What is the prep?
tooth color, more durable than ACR
10-20* taper, 1.5mm axial, 2mm O, shoulder margin
0.3mm metal, 0.2mm opaque, 1mm porcelian
For crowns, why would I use empress?
What is the prep?
What is empress?
What is the strength?
Leucite filler particles- empress
80-160mPa
veneers
butt joint, 1mm at margin, 1.5 at incisa
For crowns, using emax?
What is the prep?
What is emax?
What is the strength?
lithium disilicate
500MPa
1mm reduction if bonded
treated with 5% acid etch for 20 second and a silane primer
esthetic and strong- single unit crowns
For crowns, why would I use zirconia?
What is the prep?
What are the types of zirconia
What is the strength?
3Y: 1000mPa, Lacal, emax zircad LT, bruxzir
4Y: 750MPa: Zircad MT, Katana ST/STML
5Y: 500MPa( lava ethetic, Katana UT.UTML)
strength, posible can be bonded, longer span bridges, can make more esthetic with less wear on enamel than emax when polished
Treated with Tribochemical silicates or 50um aluminum oxide and MDP
For an FDP, what are the connect sizes for LiDi and Zirconia
LiDi: 16mm^2
Zirconinia: 7mm^2 (ant) 9mm (post) 12mm(2pontics)
Which cements do i use and why?
No bonding- Fuji Cem- RMGI. chemical adhesion, F release, low leakage, high compressive strength
Resin bondng: least soluble, highest strengths, no need for retnetion, need bonding agents, deceases leakage.
Veneers: Variolink LC,
Variolink DC= dual cure
Self Adhesive Relyx unicem- use with pre-fab prosts.
What kind of temporary materials do I use for C&B?
Jet (PMMA)- long span FDP indirect
Low cost, strong enough, good color stability - high polymerization shrinkage, high heat,
Bisacryl (integrity) - single unit
chemically polymerized resin, good color stability, good strength, easy to report, low shrinkage,
Tempbond NE: zinc oxide, good retention, does not interfere with bond.
What kind of post do i use?
Prefab, parallel 0 WHY: dislodgement will leave salvagable tooth
resin cement to retain- self adhesive
Custom: one piece, increased resistence and retention, minimal loss of tooth structure, include core
For an RPD- what are the major connectors?
Max: A-P strap, Mand: L bar/plate
For an RPD what are the minor connectors?
guide plate, denture base connectors
For an RPD what do direct retainers must have?
R2,EPS2
Reciprocation
Retention
Encirclement
Passivity
Support
stability
What different types of Direct retainers?
Suprbuldge
Intrabuldge
Combo
What are the suprabulge retainers?
Circumfrential clasp (good for class 3, or mod spaces)
Ring- embrasure
RPA: when I bar cant be used, Class I or II
What are the infabulge retainers?
I bar- T, Y
RPI: clas I or II- has a mesial rest
IWhat kindo f unercut do you need for a combo clasp?
WW in 0.02” undercut
What is the material do I use for RPD framework?
Wironium- cobalt-chromium, or type IV gold
acrylic teeth
What kind of implants do i use? Describe them
3i Certain, osseotite parallel or tapered
Ossteotite: acid etched surface, increases clot/implant attachement, increases PLT activation an d RBC agglomeration to allow for increased rate and extent of bone healing
Internal connection
Tapered sizes: Length: 8.5, 10, 11.5, 13, 15
Width: 3.25, 4, 5, 6mm
Width at apex: 1.9, 2.4, 3.1, 4.1
Parallel
Length: 8.5, 10, 11.5, 13, 15, 18, 20
Width: 3.25, 4, 5, 6mm
Width at apex: 2.4, 2.6, 3.1, 4.1
screw retained, UCLA abutment waxed to full contour, and custom cast abutments
TiBase screw retained: cad/cam milled to full contour.
