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Treatment Plan Presentation

ตั�วอย��งตั�วอย��ง

Personal Data

เพศ หญิ�งสั�ญชาติ ไที่ยอายุ 73ป!ศาสันา อ�สลุ่�มภู�มิลำ�าเนา นำนำที่บุ ร�สัถานภูาพ หย��อาช�พ แม�บุ$�นำ

Socioeconomic Status

ไม�ได$ที่��ง�นำ ม�บุ ตัรที่��ง�นำร�ฐว�ส�หก�จเบุ�กค่��ร�กษ�พย�บุ�ลุ่ได$หย��ร$�งก�บุส�ม� ป(จจ บุ�นำอ�ศั�ยอย*�ก�บุหลุ่�นำ เจอลุ่*กที่ กส ดส�ปด�ห�

Medical history

โรคประจำ�าติ�ว

- ไม�ได$พบุแพที่ย�เป+นำประจ�� ในำอด�ตัร�กษ�โรค่ภู*ม�แพ$ที่�� รพ.ศั�ร�ร�ช

1. Allergy (แพ$อ�ก�ศัเย0นำ ผู้*$ป2วยจะม�อ�ก�รนำ�3�ม*กไหลุ่แลุ่ะจ�ม)

1. Allergy (แพ$อ�ก�ศัเย0นำ ผู้*$ป2วยจะม�อ�ก�รนำ�3�ม*กไหลุ่แลุ่ะจ�ม)

Medical history

Vital signs

ปฏิเสัธการแพ!ยุา อาหารแลำะสัารเคมิ�

BP 123/75 mmHgPR 72 beats/min

29 พ.ยุ. 54

BP 123/75 mmHgPR 72 beats/min

29 พ.ยุ. 54

Chief complaint

อย�กม�ฟั(นำหลุ่�งเค่�3ยวอ�ห�ร

Dental history

ม�ประว�ตั�ร�กษ�ที่�งที่�นำตักรรมที่�� ค่ณะที่�นำตัแพที่ยศั�สตัร� มห�ว�ที่ย�ลุ่�ย

มห�ดลุ่ ป! 2554 ที่��ก�รร�กษ�โรค่ปร�ที่�นำตั�อ�กเสบุ

แลุ่ะร�กษ�ค่ลุ่องร�กฟั(นำซี่�� 4344

รอค่�วก�บุนำ�กศั�กษ�หลุ่�งปร�ญิญิ�เพ7�อที่�� ค่รอบุฟั(นำแลุ่ะฟั(นำเที่�ยมบุ�งส�วนำถอดได$ ป(จจ บุ�นำใช$ฟั(นำหนำ$�เค่�3ยวแที่นำฟั(นำหลุ่�ง

AD (2554)

CT (2554 )

Referral Source

Lifestyle

ของหวาน , ขนมิกร บกรอบ

ของทอด , ผั�ก , ผัลำไมิ!

Oral hygiene practice

แปรงฟั(นำถ*ไป-ม� ในำแนำวนำอนำ ว�นำลุ่ะ 2 ค่ร�3ง(เช$�แลุ่ะก�อนำเข้$�นำอนำ) โดยใช$ย�ส�ฟั(นำผู้สมฟัลุ่*ออไรด�

ไม�ใช$ไหมข้�ดฟั(นำ

Clinical Examination

Extraoral Examination

Facial appearance Symmetry

Facial profile Concave

Lip morphology Competent

TMJ WNL

Lymph node WNL

Muscle of mastication WNL

WNL- within normal limit

Intraoral Examination

Intraoral examination

Torus palatinus

Exostosis

Impingement from 37

Intraoral Examination

Generalized attrition and some erosion

Partial edentulism

14-17 , 25-27 , 35-36, 45-47

Intraoral Examination

•21 D has 5 mm pocket depth and second degree mobility•22 and 23 first degree mobility, no pocket formation

•13 (I) erosion tooth•21, 22, 23 1

◦traumatic

occlusion•24 (O) erosion tooth

Intraoral Examination

37(O) Amalgam filling

43, 44 previously treated tooth with adequate root canal filling

43 Hx of RCT for 5 years .

44 Hx of RCT for 1 year

Occlusion

•Molar relationship : Rt & Lt unclassified

•Canine relationship :Rt Class III Lt Class III

•Overbite : 80%

•Overjet : 5mm

Occlusion

•Protrusive movement-21/31•Protrusive movement-21/31

•Right lateral excursion-1141/-1242/-1344/

•Right lateral excursion-1141/-1242/-1344/

•Left lateral excursion -2131/

•Left lateral excursion -2131/

Periodontal Examination

CAL

332

212

232325

333

233

235

CEJ-

GM

110

000

010000

000

000

023

PD222

212

222325

333

233

212

Upper archUpper arch

B

L

PD212

212

211215

212

111

111

CEJ-

GM

000

000

000000

000

000

012

CAL 21

2212

211215

212

111

123

1

I

2 1

Periodontal Examination

CAL

211

111

110

011

223

212

232

222

433

CEJ-

GM

010

000

00-1

-100

112

101

121

011

110

PD211

111

111

111

111

111

111

211

323

Lower archLower arch

B

L

PD112

111

111

111

111

111

112

111

323

CEJ-

GM

110

010

100

011

111

111

100

011

010

CAL 22

2121

211

122

222

222

212

122

333

Periodontal Diagnosis

Localized severe chronic periodontitis

สัมิาคมิปรท�นติวทยุาแห,งประเทศไทยุ 2007

ม�ฟั(นำเอ�ไว$ใช$เค่�3ยวอ�ห�รได$ด�

Patient’s Expectation

Dentist’s Expectation

1 .ม�ส ข้ภู�พร��งก�ยแข้0งแรง2. ม�ฟั(นำปลุ่อมที่��แข้0งแรง ใช$เค่�3ยวอ�ห�รได$

อย��งม�ประส�ที่ธิ�ภู�พ3. ส�ม�รถด*แลุ่ส ข้ภู�พช�องป�กข้อง

ตันำเองได$ด�แลุ่ะสม���เสมอ

1 .ม�ส ข้ภู�พร��งก�ยแข้0งแรง2. ม�ฟั(นำปลุ่อมที่��แข้0งแรง ใช$เค่�3ยวอ�ห�รได$

อย��งม�ประส�ที่ธิ�ภู�พ3. ส�ม�รถด*แลุ่ส ข้ภู�พช�องป�กข้อง

ตันำเองได$ด�แลุ่ะสม���เสมอ

Behavioral Evaluation

ม�ร�บุก�รร�กษ�ตั�มนำ�ดที่ กค่ร�3ง ไม�เค่ยม�ส�ย ม�ส�วนำร�วมในำก�รตั�ดส�นำใจแผู้นำก�รร�กษ�

Problem Lists

Loss of VD (no posterior teeth support) Torus palatinus and bony exostosisTraumatic occlusion at 21,22 and 2343,44 Previously treated with adequate root canal

fillingGeneralized attrition with some erosion

Areas of Concern

Loss VD

Tooth wear

No posterior teeth

Pulpal diseas

e

Traumatic

+/-

+/-

Loss of VD

จ��เป+นำตั$อง raise หร7อไม� หลำ�กการ : raise ให$นำ$อยที่��ส ดเที่��ที่��จ��เป+นำ ค่7อให$ม�space พอที่��

จะrestorationraise เที่��ไหร�raise ได$หร7อไม� อย��งไร

จ��เป+นำตั$อง raise?ด*จ�ก... ก�รสบุฟั(นำข้องผู้*$ป2วย---Space available for restoration Determination of OVD---Loss of VD ?

Loss of posterior support History of wear ( physiologic wear VS acclerated

wear) Phonetic evaluation ( the increased space alters /s/

sound to/∫/ Interocclusal rest space ( greater than 2-4 mm.) Facial appearance ( Wrinkles and drooping

commissures around mouth)

Loss of VD

5 mm

Loss of VD

Raise เที่��ไหร� หลุ่�กก�ร RVD – OVD = 5 mm. = Freeway space แลุ่$ว

ที่��ก�ร raise bite ข้�3นำม�ใหม� เพ7�อสร$�ง Freeway space ประม�ณ -23 mm.

Loss of VD

Raise อย��งไร ประเม�นำจ�กอะไร Turner’s classification of occlusal wear

Category 1 : Excessive occlusal wear with loss of vertical dimension with space available to restore the vertical height.

Category 2 : Excessive occlusal wear without loss of vertical dimension with space available.

Category 3 : Excessive wear without loss of occlusal vertical dimension with limited space

Loss of VD

Treatment options Overlay denture Crown & RPD Implants with crown

Areas of Concern

Loss VD

Tooth wear

No posterior teeth

Pulpal diseas

e

Traumatic

+/-

+/-

Generalized attrition with some erosion

3 4 4 3 2 1 1 2 3 3 4 4 3 2 1 1 2 3

Areas of Concern

Generalized Attrition with Some Erosion

Etiology Congenital anomalies

AI, DI Habit

Parafunctional habit Diet

Sour Hard

Loss of posterior teeth support

Diet advice

Prosthesis

oTreatment

Generalized Attrition with Some Erosion

Treatment options Diet advice Prosthesis

Areas of Concern

Loss VD

Tooth wear

No posterior teeth

Pulpal diseas

e

Traumatic

+/-

+/-

Traumatic occlusion at 21, 22, 23

Etiology Parafunctional habits >>> Nightguard High spot >>> Remove some Missing enough teeth >>> Removable

prosthesis, Implant-supported crown-

bridge Tooth mobility >>> bone graft

Areas of Concern

Loss VD

Tooth wear

No posterior teeth

Pulpal diseas

e

Traumatic

+/-

+/-

43,44 Previously treated with adequate root canal filling

Etiology Severe attrition

Treatment options of this area Post & core crown Enameloplasty for supporting overlay denture

EtiologySevere attrition

Treatment options of this area

Tentative Treatment Plan

Pre-treatment Phase

Dental consultation Prosthodontist, Endodontist

Dentist patient discussionPreliminary APD design

Systemic Phase

Patient management (ระว�งไม�ให$ผู้*$ป2วยเก�ดก�รแพ$อ�ก�ศัเย0นำ )แนำะนำ��ผู้*$ป2วยตัรวจส ข้ภู�พร��งก�ย

Acute Phase

The Disease Control Phase of Treatment

Torectomy and alveoloplasty Oral hygiene instructionScaling and root planning and polishing full

mouth13(O) Resin composite filling

The Definitive Phase of Treatment

Upper : APDLower : Overlay denture

The Maintenance Phase of Treatment

Recall 3 months Evaluate oral hygiene and periodontal status Evaluate all restorations and prostheses

Recall every 6 months Scaling and root planning

X-ray 6 months, 1 year and every year until 4 years

Review

Full mouth rehabilitation of the patient with severely worn dentition Treatment by occlusal overlay splint, interim fixed

restoration and the permanent reconstruction. Regular check-up for the occlusal adjustment and RPD fitting.

Resulto In this clinical report showed successful full mouth

rehabilitation.

Mi-Young Song, DDS, MSD, Ji-Man Park, DDS, MSD and Eun –Jin Park, DDS, MMsc, PhD Department of Prosthodontics,School of Medicine, Seoul, Korea

Overlay Denture

Definition “Overlay removable partial dentures, a subset of

overdentures, are often referred to as an RPD that has part of their components covering the occlusal surface of the abutment teeth to restore them into a functional occlusion.”

Overlay Denture

Advantages Psychological benefit

Patient still has his teeth Proprioception

Periodontal mechanoreceptors allow a finer discrimination of food texture, tooth contact, and levels of functional loading more control over mandibular

Movement and chewing food Effect on ridge resorption

Preserve the edentulous ridge, by reducing the amount of resorption

Overlay Denture

Advantages Improve stability and retention

Mechanical retention Minimizing horizontal forces on the abutment

teeth Correction of occlusion and aesthetics

VDO is maintained

Overlay Denture

Disadvantages Protecting the bacteria from mechanical wash and

the chemical activity of the saliva that can help in the teeth protection chance for dental caries is going to increase

It might initiate periodontal disease Considerable space or height is required. Difficult

to use in a short interocclusal situation

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

APD/Overlay Denture

Implant & Bridge RPD/RPD & Crown

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

Pre-treatment phase•Dental consultation:

ProsthodontistPatient-dentist discussion Preliminary prostheses design

Pre-treatment phase•Dental consultation:

ProsthodontistCT ScanPatient-dentist discussion Preliminary prostheses design

Pre-treatment phase•Dental consultation:

ProsthodontistPatient-dentist discussion Preliminary prostheses design

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

Systemic phase•Medical consideration•แนำะนำ��ให$ผู้*$ป2วยตัรวจส ข้ภู�พ•Patient management (ระว�งไม�ให$ผู้*$ป2วยเก�ดก�รแพ$อ�ก�ศัเย0นำ )

Systemic phase•Medical consideration•แนำะนำ��ให$ผู้*$ป2วยตัรวจส ข้ภู�พ•Patient management (ระว�งไม�ให$ผู้*$ป2วยเก�ดก�รแพ$อ�ก�ศัเย0นำ )

Systemic phase•Medical consideration•แนำะนำ��ให$ผู้*$ป2วยตัรวจส ข้ภู�พ•Patient management (ระว�งไม�ให$ผู้*$ป2วยเก�ดก�รแพ$อ�ก�ศัเย0นำ )

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

Acute phase• -

Disease control phase•Torectomy

•Oral hygiene instruction•Scaling and polishing•13(O) Resin composite filling•Treatment denture for edentulous area

Acute phase•Torectomy•Treatment denture (Overlay)

Acute phase•Torectomy•Treatment denture (Overlay)

Disease control phase•Oral hygiene instruction•Scaling and polishing•13(O) Resin composite filling

Disease control phase•Oral hygiene instruction•Scaling and polishing•13(O) Resin composite filling

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternative

Treatment IITentative

Treatment Tentative

Treatment

Definitive phase

• Treatment denture (Overlay)

• 43,44 PFM crown• 42,41,31,32,33

crown• Implant & Bridge

Definitive phase Definitive phase

• 34-44 crown• RPD/RPD

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

Maintenance and recall •Recall 3 months

Evaluate oral hygiene and periodontal statusEvaluate all restorations and prostheses

Maintenance and recall •Recall 3 months

Evaluate oral hygiene and periodontal statusEvaluate all restorations and prostheses

Maintenance and recall •Recall 3 months

Evaluate oral hygiene and periodontal statusEvaluate all restorations and prostheses

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

Maintenance and recall •Recall every 6 months

Scaling and root planinngEndodontically treated teeth 43,44X-ray 6 months, 1 year and every year until 4 years

Maintenance and recall •Recall every 6 months

Scaling and root planningEndodontically treated teeth 43,44X-ray 6 months, 1 year and every year until 4 yearsX-ray (+bite guide) check implant 6 months, every 1 yr. until 5 yrs. and every 5 yrs.

Maintenance and recall •Recall every 6 months

Scaling and root planningEndodontically treated teeth 43,44X-ray 6 months, 1 year and every year until 4 years

Treatment PlanAlternativeTreatment IAlternativeTreatment I

AlternativeTreatment IIAlternativeTreatment II

TentativeTreatment Tentative

Treatment

12,130 บาท 172,130 บาท

4,130 บาท

Review

Traumatic occlusionrepeated excessive force in closure of the

teeth that injures the teeth, the periodontal tissues, the residual ridge, or other oral structures. The closure extends beyond the reparative ability of the attachment apparatus (cementum, periodontal ligaments, and alveolar bone).

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

Traumatic occlusion

Clinical sign and symptoms - Tooth migration

- Pain - Wear facets

Traumatic occlusion

Type of traumatic occlusion

1. primary traumatic occlusion2.secondary traumatic

occlusion

Traumatic occlusion

Primary occlusal trauma - occurs when greater than normal

occlusal forces - parafunctional habits ,various

chewing ,or biting habits , biting fingernails and pencils or pens

- will occur when normal periodontal attatchment ,no periodontal disease.

Traumatic occlusion

Secondary occlusal trauma- occurs when normal occlusal

forces are placed on teeth with compromised periodontal attachment

Traumatic occlusion

Etiology and treatment

• Parafunctional habits >>> nightguard• Higth spot >>> remove some• Missing enough teeth >> removable prosthesis, implant-supported crown-bridge• Tooth mobility >> bone graft

The effects of occlusion on periodontitis.

Gher ME.

Despite volumes of publications on the theory of occlusion,

occlusal design, and equilibration techniques, there have been few well-designed human studies directed at answering the question does occlusal trauma modify the progression of attachment loss in periodontitis. The articles reviewed indicate that occlusal forces can cause changes in the alveolar bone and periodontal connective tissue both in the presence and in the absence of periodontitis. These changes can affect and clintooth mobility ical probing depth. Although occlusal forces do not initiate periodontitis, results are inconclusive as to if or how these forces affect attachment loss owing to plaque-induced inflammatory periodontal disease. Although some studies reported a relationship between increased attachment loss and tooth mobility, others found no relationship between attachment loss and abnormal occlusal contacts. Tooth mobility results from a variety of factors, including alveolar bone loss, attachment loss, disruption of the periodontal tissues by inflammation, widening of the PDL in response to occlusal forces (physiologic adaptation), PDL atrophy from disuse, and other processes that effect the periodontium.

PMID: 9597338 [PubMed - indexed for MEDLINE] 1998 Apr;42(2):285-99.

Review

Examination for signs of trauma from occlusion, such as fremitus test, presence of wear facets and mobility.

Dent Res J (Isfahan). 2009 Autumn; 6(2): 71–74.

Torectomy

Indication Large/Middle torus Extension/Retention of prosthesis Traumatic ulcer Undercut Speech/Swelling problem Mental problem

Complication Hemorrage Hematoma Perforation of the floor of the nose Fracture of palate Slough of the palatal mucosa

Examination for older women

1. Physical examination2. Chest X-ray3. Ultrasound whole

abdomen4. Digital Mammogram5. PV & ThinPrep Pap test6. EKG7. Exercise stress test

(EST) orEchocardiography

8. Bone densitometry

9. FBS10. CBC 11. Creatinine12. SGPT, SGOT, alkaline

phosphatase13. Total cholesterol,

Triglyceride, HDL-C, LDL-C direct

14. Anti HBs, HbsAg15. Uric acid16. Urine analysis

Occlusal Wear

Generation of interocclusal space Adhesive resin Overlay splint Cobalt chromium device

Evaluation of patient adaptation Teeth comfort Muscle tenderness Temporomandibular comfort Phonetics