Treatment Planning for Fixed Prosthodontics Flashcards
what is fixed prosthodontics
• The area of prosthodontics focused on permanently attached (fixed) dental prostheses
• Such dental restorations are also referred to as indirect restorations
because they are made in a lab mostly then cemented in
what are the types of fixed prosthodontic restorations
- Veneers
- Inlays and Onlays
- Crowns
- Bridgework
• Could maybe include posts and cores into this list as well
○ But this is kind of between fixed prosthodontics and endodontics territory
what is included in the history and examination
- Patient complaint (CO)
- History of presenting complaint (HPC)
- Past dental history (PDH)
- Past medical history (PMH)
- Social history (SH)
- Family history (FH)
- Extra-oral examination (EO)
- Intra-oral examination (IO)
what does the history and examination lead to
provisional diagnosis
what is included in the extra-oral examination
○ TMJ
○ Muscles of Mastication (MoM)
○ Lymph nodes
○ Symmetry
○ Lips - often over looked
what needs to be considered with regards to the lips
§ Vermillion borders
§ Commissures ~ corners
§ Smile line
what does a high lip line mean
□ High basically means you can see the zenith teeth and a bit of the gingiva is exposed
what does a medium smile line mean
□ Medium smile line means the vermillion border just touches the zenith of the teeth and can see a little bit of the interproximal gingival tissue as well between the teeth
what does a low lip line mean
□ Low lip line means the patient essentially hides the zenith of the teeth and hides a good chunk of the gingivae as well
what lip line is most beneficial in prosthodontics
In terms of prosthodontics a low lip line tends to be better as it hides a bit of the margins of the teeth as it can be quite tricky to get the margins of prosthetic teeth to look realistic so the more of that you can hide the better essentially
what is the gingival zenith
The gingivalzenithis the most apical aspect of free gingival margin
what is included in an intra-oral examination
○ Look at whole mouth first before individual teeth
○ Soft tissues
§ Buccal mucosa
§ Tongue
□ Lateral border
□ Dorsum
§ Sublingual tissues / floor of the mouth
§ Palate
□ Hard
□ Soft
§ Lips
what other examinations and tests would you do in when examining the patient
• Periodontal
○ BPE
• Dentition ○ Chart teeth § Present and missing teeth § Restorations § Caries
• Occlusion ○ Incisal relationship ○ Excursions of the mandible § Protrusion § Retrusion § Lateral ○ Canine guidance or group function?
• Inter-arch space
○ Want to make sure there is actually room to place these restorations
○ Look in both vertical and horizontal dimensions
• Inter-tooth space (mesio-distal)
what special investigations would you do
• Sensibility testing = to get an indication of the vitality of the teeth
○ EPT and thermal tests
• Radiographs
○ Caries ~ Restorability
○ Tooth fractures [root fractures]
○ Periapical pathology
○ Bone levels ~ Want to make sure the teeth are adequately supported as they are going to be subjected to more occlusal loads if a fixed prosthodontic is placed
○ Existing large restorations (direct or indirect)
○ Assessment of potential abutment teeth
• Study models
Allows you to further consider options (even if you have a pretty good idea of what you want to do)
• Facebow
○ Particularly if doing work on teeth that are involved in guidance (such as canines but then if the patient has group function then there will be several teeth involved)
○ Also want to get one of these if you are considering changing anything to do with the patient’s occlusion (such as contact points or even the occlusal vertical dimension [OVD])
• Diagnostic wax-up
○ Allows you to see what the finished result is going to look like
○ Also allows you to see how it may potentially function as you can look at the occlusal contact points
• Additional information
○ Diet diary
○ Plaque and gingivitis indices
○ Full mouth periodontal chart
§ Needed if the patient’s BPE chart comes back as 4 in any of the sextants
○ Clinical photographs
○ Microbiology, biopsy, haematology ~ more rare
§ If you get a patient and you are worried about any of these you would probably want to refer them to the oral medicine department
what are the 5 stages to think about in treatment planning
- Immediate
- Initial (disease control)
- Re-evaluation
- Reconstructive
- Maintenance
what is the immediate stage of treatment planning
- priority
○ Relief of acute symptoms
○ Consider endodontics and extractions
○ Consider immediate denture / bridge
want to sort out the pain
what is the initial (disease control) stage of treatment planning
○ Extraction of hopeless teeth
○ OHI and dietary advice
○ HPT
○ Management of carious lesions and defective restorations or provisional restorations
○ Endodontics
○ Denture design, wax up for fixed prosthodontics
what is the re-evaluation stage of treatment planning
○ Re-assessment of periodontal status, confirm denture / bridge design
○ Want to make sure our disease control stage worked
○ Check that there is no active disease so you are able to move on to doing the more complex dentistry
what is the reconstructive stage of treatment planning
○ Perio surgery
○ Fixed and removable prosthodontics
§ Shouldn’t be diving into these if the patient has poor oral hygiene and lots of carious lesions
what is the maintenance stage of treatment planning
○ Supportive periodontal care and review of restorations
○ Making sure treatment is a success
○ Making sure there is no new active disease
what are the different options in treatment planning driven by
- dentist
- patient
- medical factors
- costs
- time
- dental facts
how would the dentist and dental factors influence treatment planning
○ Has the knowledge about what is appropriate
○ Know what is most conservative
○ What is best and works long term
how does the patient influence treatment planning
depends on their preferences
how does medical factors influence treatment plannings
Might stop you from providing some of the options you would like to such an allergies to some materials
or maybe patient has medical problems that means certain treatments would not work as well for them or it would not be a good idea to carry out that treatment
how does time and cost influence treatment planning
○ Always factor into treatment planning
○ Fixed prosthodontics are more time consuming as they are made in a lab and need tooth preparations etc as well
○ Need more stages
○ Then if things don’t go to plan the treatment is prolonged again
what are some decisions that need to be made about teeth in poor conditions
- Keep the tooth or extract?
- If to be kept, what kind of restoration?
- What tooth preparation is necessary?
caries / fractures extending beyond where is the ultimate cut off point indicating the tooth is not restorable
beyond the alveolar ridge
Anything that fractures below or any caries extending beyond the alveolar ridge will not be able to be restored
Tooth needs extracted
if a tooth has a horizontal fracture running straight through the furcation of the tooth, is it restorable?
○ This cannot be restored, it will leak and cause the restoration to fail
○ Probably quite painful for the patient when they bite down on that tooth because the tooth will want to flex a little bit but it is now fractured
Needs extracted
if root canal treatment has left a tooth discoloured over time, what are the treatment options and what would be the best treatment?
Could opt for something like a veneer
- would still give a good aesthetic result
- Problem with a veneer is that it will eventually fail (after 5-10 years)
- After failure patient might have to opt for a crown then post crowns etc
= restorative sliding scale
)The longer you can avoid this sliding scale the better)
As this patient already has a root treated tooth the best option would be to do internal and external bleaching
- whitens the affected tooth - veneer treatment could be avoided
when can bridgework not be an option?
due to the degree of tooth loss
why place veneers?
○ Improve aesthetics
○ Change shape teeth and / or contour or colour
○ Correct peg-shaped laterals
○ Reduce or close proximal spaces and diastemas (especially in the midline)
○ Align labial surfaces of instanding teeth (if patient does not want orthodontic treatment)
what is a diastema
Diastema = space / gap between 2 teeth
what can the gurel minimal preparation technique help with
ideally want to remain in enamel when carrying out veneer treatment
This technique can help you to do this
what is involved in the gurel minimal preparation technique
○ Wax up
○ Stent
○ Intra-oral mock-up
§ Use the stent to create this using pro-temp
○ Preparation into mock up (can use depth cut burs)
§ Cut through the mock-up to the ideal veneer preparation you would want
○ Means any surfaces of the teeth that need prepared get prepared and any surfaces that don’t need preparation don’t get touched
= being more conservative
when should you not use veneers
○ Poor oral hygiene
○ High caries rate
○ Interproximal caries and / or unsound restorations
○ Gingival recession
○ Root exposure
○ High lip lines
§ Not absolute but proceed with caution
§ Work closely with technician to get good result
○ If extensive prep is needed
§ >50% of surface area no longer in enamel
○ Labially positioned, severely rotated and overlapping teeth
§ To try and align all of these teeth you would have to cut a lot of tooth tissue away to try and achieve the final result that you want
○ Extensive tooth surface loss / insufficient bonding area
§ Affects bonding
○ Heavy occlusal contacts
§ Not good for patients in class 3
§ Veneers will just fracture
○ Severe discolouration
§ Crowns might be better
§ Try bleaching first
if extensive prep is needed veneers are not a good option but what alternatives are available
Consider alternatives like: □ PJC □ DBCs □ MCCs Gives more mechanical retention Veneers rely heavily on a chemical bond to the tooth and this bond works best to enamel