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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