TREATMENT PLANNING FOR RESTORATIVE DENTISTRY, EXAMINATION AND DIAGNOSIS

Dr. Paul Quinian

How to avoid failure?

• Formulate a treatment plan:
Examination -----à ​Diagnosis -------à ​Treatment Plan

EXAMINATION
• Presenting Concern – what does this patient want?
• Histories
- Medical

E-
- Social
- Dental
• Clinical Exam
- Oral Cavity
- Site in question
it
• Radiographic Exam Google
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• Special tests

MEDICAL HISTORY
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• ASA Classification I-VI
• Common things occur commonly
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• Bleeding issues
• Reflux (Gerd) and acid attack of teeth (restorative)
0
0Diabetes:
• ( surgery)

- Periodontal disease
- Implants & Bone Grafting
• Medication taken impact )
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tx

• Ref: medical problems in dentistry, Cawson

 • ASA 1: A normal healthy patient. Example: Fit, nonobese (BMI under 30), a nonsmoking patient with
good exercise tolerance.
• ASA 2: A patient with a mild systemic disease. Example: Patient with no functional limitations and a well-
controlled disease (e.g., treated hypertension, obesity with BMI under 35, frequent social drinker or is a
cigarette smoker).
• ASA 3: A patient with a severe systemic disease that is not life-threatening. Example: Patient with some
functional limitation as a result of disease (e.g., poorly treated hypertension or diabetes, morbid obesity,
chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, implanted
pacemaker).
• ASA 4: A patient with a severe systemic disease that is a constant threat to life. Example: Patient with
functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly controlled
COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke.
• ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not
expected to survive beyond the next 24 hours without surgery. Examples: ruptured abdominal aortic
aneurysm, massive trauma, and extensive intracranial hemorrhage with mass effect.
• ASA 6: A brain-dead patient whose organs are being removed with the intention of transplanting them into
another patient.
The addition of “E” to the ASAPS (e.g., ASA 2E) denotes an emergency surgical procedure. The ASA defines an
emergency as existing “when the delay in treatment of the patient would lead to a significant increase in the
threat to life or body part.”
SOCIAL HISTORY
• Impact on treatment
• Habits
- Alcohol

:-#
=
- Smoking
• Smoking
- Immunological effects: smoking suppresses polymorphonuclear leukocytes
- Bacteriological effects
- Small vessel healing post surgical treatment
• Smoking has an effects on:
- Periodontal disease
:- Bone grafting and implants
DENTAL HISTORY
• Trauma
• Past treatment
- Orthodontic – may have an effect on the tissue morphotype which in turn have an impact on:

= o Recession (may cause problem if you are placing crowns in areas of high aesthetic demand)
o Root length (can change prognosis for tooth abutment for fixed partial denture)
- Periodontal
o Refractory
o Recurrent
-0Prosthetic (a patient with a whole lot of different denture more than likely won’t be satisfied by the
treatment you do for them)
• Insight into patient
- Does patient have a reasonable expectation that can be satisfied, or is it best to refer patient to someone
else

CLINICAL EXAMINATION
Extra Oral
• Pathologies
• TMJ
- ROM (range of motion)
- Joint pathologies – can the patient open there mouth long enough to undergo procedure to be executed,
nd
can they open wide enough for placement of an implant in a 2 molar site
• Asymmetries – can have an impact on placement of crowns in the anterior maxilla especially in
 highly visible areas
• Functional & tissue analysis
- Occlusal plains
- Centre lines
- Soft tissue support

Exam question: Identify some features seen on this photography? Are these anatomical features well
supported by the patient’s denture?

Intra Oral
• Pathologies
• Restorative space
• Soft tissue
- Periodontal exam
• Hard tissue
- Caries
- Teeth and restorations
- Occlusion
RESTORATIVE SPACE – is the space available for the proposed restoration. It can be:
• Measured
- Mesio-distally
- Coronogingivally
- Intra arch
• Options limited - when there is a lack of restoration space and may require additional treatment.
 • Additional treatment
• Wax up
For

example, if a patient is going to have a 2 implant restorative denture, the question is, is there enough support or
is there enough room for the attachments on top of the implant. In this case, if we take the top blue line as being
the occlusal plane, we need a minimum of about 2mm thickness for acrylic. We need a certain thickness
depending on the attachment we use, and depending on how the implants are placed, how much space would
they occupy above the tissue. If that dimension is greater than what we have, then we won’t be able to
successfully place an implant supported overdenture.

PERIODONTAL EXAMINATION
• Tissue morphotype
• Recession
• Keratinized tissue
• Inflammation
- Tissue color
- Bleeding on probing
• Hygiene
- Plaque score

TISSUE MORPHOTYPE
Tissue morphotypes can be described as: thin, average or thick.
Tissue morphotype is dependent on underlying bone.
 For example: a thin tissue morphotype
might be more prone to recession, while a
thicker tissue morphotype may not. In this
case, if the patient was to be flapped, you
would find that there were dehiscence and
fenestration on the facial aspect of these
teeth. A lack of underlying bone would
result in a thin tissue morphotype, and the
patient will be more susceptible to
recession. A crown was placed, then
subsequent recession occurred.

A thick tissue morphotype is the reverse.

When it is flapped, you will find a thick
amount of bone on the facial aspect of teeth,
which are not prone to recession, and may
require crown lengthening surgery if they
are to be restored.

Exam question?
How would you determine the difference between someone with a thick or thin tissue morphotype?
A simple test described by Houchmand, 2013, which involves placing the periodontal probe into the gingival
sulcus, and if you can see the probe through the tissue then the patient is deemed a thin tissue morphotype.
PERIODONTAL DISEASE
• Probing depths
 - PSR (periodontal screening report)
- Full mouth charting
• Record
- Plaque
- Bleeding
- Probing
- Mobility
- Furcation
- Recession
What do the above indicate? Example: someone with a high Plaque but low bleeding score may have just
missed their brushing last night and the night before. Example: someone with a high bleeding score and high
plaque score may just have poor hygiene
• Interpret

HARD TISSUE EXAMINATION

• Caries – are caries present and are they controlled?
Trying to put a 3 or 4 crowns in a mouth with active caries is pointless. The disease process has to be controlled
st
1.
 • Teeth – the number of teeth present and their position. The crown root ration is also important, is this
tooth a bearer of abutment because of how much of the crown is above the level of the alveolar bone

• Restorations – how would you restore a tooth with temporary restoration if it was root treated or not.
• Occlusion
Difference between OCCLUSION AND ARTICULATION
OCCLUSION – is the static relationship between the incising or masticating surfaces of the maxillary or
mandibular teeth or tooth analogues.
ARTICULATION – is the static and dynamic contact relationship between the occlusal surfaces of the teeth
during movement and function.

OCCLUSION CONCEPTS
• CMMR (Centric MaxilloMandibular Relation or Centric Relation) vs MIP (Maximum Intercuspation
Position)
What we want in either of these concepts are even, simultaneous, point contacts.
 • Fixed restoration – we want:
- Anterior guidance – the mandibular incisor teeth are running off the back of the maxillary incisors
- Canine guidance
- No interferences
• Results of interferences may be:
- Pain in TMJ
- Broken restorations
RADIOGRAPHIC EXAMINATION
• Intra Oral – can show bone levels around the necks of teeth, apical pathologies present, and condition of
restorative margins
- Bitewings
- Periapical
• Pan Oral or Panorex – shows us location of IAC, location of sinuses and whether they are pneumatized or
not
• Cone Beam CT – gives us 3D view, we can see thickness of alveolar ridge
Cone beam CT scan are usually done for implant assessment.
Exam question: How much bone does one need to place a dental implant?
• Height: 8mm or greater, however there is a controversy in relation to short dental implants
• Width: 6 – 7mm for a 4mm diameter implant interproximally
• Depth: +2mm x 2 (this is changing since the bone depth of implants are changing). So we can say a
reasonable bone depth is the diameter of the implant for example 4mm plus 1 ½ mm on either side
• Density: Hounsfield scale
Hounsfield units (HU) are a dimensionless unit universally used in computed tomography (CT) scanning to express CT
numbers in a standardized and convenient form. Hounsfield units are obtained from a linear transformation of the
1
measured attenuation coefficients . This transformation (figure 1) is based on the arbitrarily-assigned densities of air and
pure water:

• radiodensity of distilled water at standard temperature and pressure (STP) = 0 HU

• radiodensity of air at STP = -1000 HU
5
STP: standard temperature is 0 °C and pressure is 10 pascals (i.e. sea-level).
SPECIAL TESTS
i. Vitality test
Exam question: what is the next step? Ans: take a radiograph or test vitality of tooth with cold spray (Endo
ICE), which can tell us or give us some indication of the pulpal status of that tooth.
ii. Make study casts
This can gives us much more detail than what we can see intraorally.
But the greatest diagnostic yield can be harvested if the casts are
mounted, therefore you should be aware of jaw records need to place
dental casts in an articulator.

JAW RECORDS
Consists of:
a) Face bow record
b) Interocclusal record

a) FACE BOW RECORD relates:

- Hinge axis to maxilla, in other words, it positions maxillary cast in the articulator.
• Face bow have 2 types:
i. Kinematic – very accurate face bow but not used frequently
ii. Average – what you learnt with in dental school

The arbitrary face bow, although it is based on averages, it is quite accurate. Most indivisuals are with 1-2mm of
 nd
the hinge axis. If there is a 5mm recording error, it results in a 0.2mm error at the 2 molar. Using semi-
adjustable articulators in practice may require a small adjustment of the restorations when they are placed, but
that is within the margin of error and doesn’t require much adjustment once they are placed. These can be used
for both Removable Prostheses and Fixed prosthesis.

b) INTER-OCCLUSAL RECORD
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In an inter-occlusal record, he 1 thing we need to do is:
• Decide position – where are we placing the position of the mandible
• Conformist – if we are placing 1 or 2 units we may conform with the patients occlusion and we can
mount it in MIP
-Single/few unit
• Reorganization

- Reconstruction – we can reorganize the patient’s dentition, therefore we might use CJR (centric jaw
relation)
• Repeatable – whatever position we use should be repeatable and measurable
- MIP (maximum intercuspation position)
- CJR (centric jaw relation)
DIAGNOSTIC WAX UP
Once the casts are mounted, as part of the diagnostic evaluation, we may require that we need a diagnostic wax
up. A diagnostic wax up can determine the end result of a treatment by showing us thing like:
- Restorative space
- Occlusal design
- Tissue deficiency - Not only can it be used for multiple cases or larger reconstruction, it can also be
used for single restoration
- Aesthetics

Patient present with a large diastema between her central incisors, the dentist’s treated it by placing a 3 unit
bridge on her incisors, which was very unattractive. The patient was about to undergo orthodontic treatment to
close the space after that bridge was removed. She was presented with 3 different options that could be achieved
using various combinations of restorative dentistry and orthodontic treatment.

DIAGNOSIS
Once we have our diagnostic information, you should be aware of the concept of a differential diagnosis and
then finally arriving at a diagnosis.
Differential Diagnosis – is the process of identifying a condition by comparing the signs and symptoms of all
pathologic processes that may produce similar signs and symptoms.
Diagnosis – is the determination of the nature of a disease.

Example question: what is your differential diagnosis?

Examination showed 11mm periodontal probing depth (ppd), bleeding on probing (BOP), tooth is non vital with
some bone loss, and has some pocketing on the other teeth.
Differential Diagnosis:
- Localized periodontal disease
- Endo lesion
- Vertical root fracture
Diagnosis:
- Endo-perio lesion

In terms of periodontal treatment, you should be able to analyze a periodontal charting.

Example: on examination we have a 47 year old male, non smoker, high plaque score (PS) = 65%, bleeding on
probing (BOP) = 54%, generalized periodontal pocket depth (PPD) = +++, along with interferences during
excursive movements.
Diagnosis:
 - Chronic, generalized, adult onset periodontal disease with trauma from occlusion as a possible co-
factor

CONCLUSION
• Examination and diagnosis are essential element in patient care.
• ‘Common things occur commonly’. So if you are in the exam and you are asked for an opinion, it may be
very exciting to give a diagnosis that occurs rarely, however it is probably unlikely that it is going to be
occurring with your patient, so remember, common things occur commonly.
• Be familiar with reading test results, radiographs and other diagnostic tests
st
• Give a differential diagnosis as opposed to the 1 thing that pops into your head.
• Plan your work, then work your plan!