Clinical Treatment Planning

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Clinical Treatment Planning Treating
Clinician Drs.
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The plans where useless, but the planning was
indispensable. Dwight Eisenhower, WW2
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Treatment Planning Case Presentation. Introduction
and Background.

• Patient Name
• Gender
• Date of Birth
• Age
• Marital Status
• Race
• Date of Initial Examination
• Occupation Personality Type

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Introduction-Background Chief Dental
Complaint Reason for Initial Visit Oral Image
and Expectation.
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Medical History ASA Medications
Allergies Smoker Systemic Diseases
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Dental History Previous Dental Treatment
History What does the patient desire?
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Diagnostic Findings ( Head and Neck) Nodes
TMJ/Mandibular Range of Motion Functional
Joint sounds Tenderness to musculature
palpation Myofacial pain Headaches
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Extra-Oral - Face/Profile/Symmetry
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Extra-Oral Lips/Smiles
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Combination Charting
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Status of Dentition - Occlusal Views
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Periodontal Chart GI PI
Gingival Status Recession Inflammation
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R
L
Intra-oral Images (Periodontal) Recession
Gingivitis Periodontitis MG aberrations.
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R
L
Intra-oral, Anterior (Soft Tissue)
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R
L
Intra-oral - Occlusal Views
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L
Radiographs - FMX
R
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L
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Radiographs
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L
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Radiographs - Anterior
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L
R
Radiographs - Panoramic
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L
Radiographs Misc.
R
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Casts - Facial
R
R
L
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Casts - Lingual
R
L
R
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Composite Images, Casts, Radiographs
L
R
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Composite Images, Casts, Radiographs
L
R
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Composite Images, Casts, Radiographs
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R
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Occlusal Notes Class occlusion Class
IG/CG NW interferences. CO/CR/MIP Slide/s
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L
Occlusal Images
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Abrahamson Tooth Wear
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Esthetic Analysis (Chiche)
Incisal PlaneIncisal ProfileIncisal
LengthSmile LineTooth Proportion
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Esthetic Analysis (Chiche)

• Gingival OutlineTooth ShadesIntrinsic
  CharacteristicsBuccal CorridorsLip support

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• Treatment Planning
• Kois

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Risk Factor - KOIS Periodontal Biomechanical
(Tooth structure) Functional (Joint, Bite
Chewing) Dento-Facial (Esthetic)
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Diagnostic Opinion - Kois
RISK PROFILE PERIODONTAL BIOMECHANICAL FUNCTIONA
L DENTOFACIAL MEDICAL PRECAUTIONS
Low Moderate High
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Diagnostic Opinion Perio - Kois
PERIODONTAL (Gum and Bone) PERIODONTAL (Gum and Bone) PERIODONTAL (Gum and Bone)  
Risk Assessment Risk Assessment __Low __Moderate __High  
General Prognosis General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosismost teeth are in this category
Specific Individual Teeth Excellent Good Fair Poor Hopeless Please List  
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Diagnostic Opinion Biomechanical
BIOMECHANICAL BIOMECHANICAL BIOMECHANICAL  
Risk Assessment Risk Assessment __Low __Moderate __High  
General Prognosis General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosismost teeth are in this category
Specific Individual Teeth Excellent Good Fair Poor Hopeless Please List  
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Diagnostic Opinion Functional - Kois
FUNCTIONAL FUNCTIONAL FUNCTIONAL  
Risk Assessment Risk Assessment __Low __Moderate __High  
General Prognosis General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosismost teeth are in this category
Specific Individual Teeth Excellent Good Fair Poor Hopeless Please List  
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Diagnostic Opinion DentoFacial.
DENTOFACIAL DENTOFACIAL DENTOFACIAL  
Risk Assessment Risk Assessment __Low __Moderate __High  
General Prognosis General Prognosis __Excellent __Good __Fair __Poor __Hopeless Based on the specific prognosismost teeth are in this category
Specific Individual Teeth Excellent Good Fair Poor Hopeless Please List  
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Risk Profile Summary - Kois
PERIODONTAL BIOMECHANICAL FUNCTIONAL DENTOFACIAL
MEDICAL PRECAUTIONS
Low Moderate High
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Guidelines - KokichCreating Overjet/Overbite
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Kokich GuidelinesCreating Overjet/Overbite

• Procline/Retrude Maxillary Incisors
• Intrude Maxillary/Mandibular Anterior Teeth
• Retract Mandibular Incisors (Facial of
  mandibular incisors should be over chin see
  Ceph.)
• Uneven gingival margins, intrude or extrude.
• Maxillary Incisors should be parallel relative to
  lower lip see Ceph)
• Maxillary Facial Incisal Inclination should be
  vertical to the Incisal plan for good light
  reflection See Ceph

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Guidelines - SpearVertical wear
(Rat)Constricted envelope of function. Need
greater Overjet.Horizontal and incisal wear
(Cow)Need greater Centric Freedom
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Frank Spear Worn Dentition Most cases do not
require VDO opening. Check if posterior teeth
are worn or missing if no, need to get space in
the anterior with modest opening prn.
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• Spear Worn Dentition-Contd.
• Set 8UAS check for wear, gingival margins,
  vertical uprightedness.
• Should it be proclined, retruded, intruded,
• APF or combination.
• For vertical check anterior facial angulation
• relative to occlusal plane.
• Usually a space problem so ortho is valuable.
• Apply same parameter to LAS

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The Gummy Smile - RobbinsFive questions.

• 1 Face height Repose, from Glabella (mid-brow)
  to base of nose Base of nose to inferior border
  of chin. (Middle third of face should equal the
  lower third of face.
• DX Lower third of face longer VME
• Tx Orthognathic surgery.

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The Gummy Smile RobbinsFive questions

• 2 Lip length Repose from base of nose to
  inferior border of the maxillary lip
• In young adult Females 20-22 mm
• In young adult Males 22-24mm
• Dx Short or hyperactive upper lip
• Tx Behavior modification / Botox.
• LIP Mobility 6-8mm

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The Gummy Smile - RobbinsFive questions.

• 3 Gingival Line Draw from Canine to Canine.
  Should engage centrals and cuspids.
• Dx Concave Dentoalveolar Extrusion.
• Tx. Orthodontic, intrusion, Esthetic Crown
  Lengthening, Segmental osteotomy.

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The Gummy Smile RobbinsFive questions

• 4 Length of the maxillary central incisor
• 10-11mm
• Dx Less than 10mm Microdontia, Wear, APE
• In repose Emma 3-4mm of incisal edge of
  maxillary centrals in young female and 2mm in
  young males.

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Bill Robbins DDSThe Gummy Smile. Five questions

• 5 Feel the CEJ in the sulcus
• DX Cannot feel CEJ APE
• Tx Esthetic Crown lengthening Surgery.

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Bill Robbins DDS-Esthetic Evaluation Face Height
_______________________ Lip Length
_______________________ mm Lip Mobility
_____mm Dental / Facial Midline _____________
R/L Central Exposed in Repose _________
mm Gingival Line to Upper Lip in Full Smile
_______________ /- mm Distal Extent of Smile
(Tooth) ___________ R _________ L Incisal Edges
to Lower Lip (Follows Smile Line, Covered by
Lip)___ Buccal Corridors Negative Spaces Y/N
_ Length of Maxillary Anteriors (Chart) Tissue
Levels (Chart) Angle of Incisal Plane
(Chart) Incisal Wear Y/N Tooth s
_____________________________ CEJ Located Y/N
______________________________________ Posterior
Occlusal Plane (OK, Step Up, or Step Down)
_________ Tooth Color ____________________________
_______________ Tooth Alignment (Spacing,
Overlap) ________________________ DR. NOTES
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Problem list
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• Summary of Concerns
• Interesting issues related to this case that
  warrant discussion prior to treatment?
• Wear
• Expectation
• Are there phasing issues?
• Depending on treatment plan chosen,
• see treatment outline below.
• Are there conflicts between what is best and what
  the patient wants or will tolerate?
• Possible cost, depending on treatment plan chosen

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Diagnosis and Prognosis AAP Type AAP
Hopeless s Guarded s
See risk factors. Good The rest, assuming
homecare improvement, and patient pursues
prescribed treatment.
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Comprehensive Dental Care includes

• Disease control
• Caries, Endodontic
• Periodontal and gingival infection
• Reconstructive Dentistry
• Tooth/Teeth, Bridges, partials, crowns, implants
• Periodontal pocket reduction, regeneration,
  normal periodontal architectural configuration
• Esthetic enhancement
• Maintenance
• Professional and patient

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Facilitating a Patients Choice for Better
Dentistry Determine patients desired
expectation Complete a comprehensive exam to
delineate risk factors Educate patient how
their risk factors affect their desired
expectations (communication) Discuss means to
reduce risk factors treatment needed and
alternatives, plus timing and staging Determine
if patient can accept the price of treatment and
work with them in this regard.
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A comprehensive result includes Class 1
Occlusion No Pockets Normal skeletal
relationship No recession No missing
teeth Adequate KT Good tooth position Normal
positive soft tissue architecture Normal occlusal
landmarks CRO No occlusal interferences No
caries Stable anterior guidance Normal dental
anatomy No mobile teeth Good sealed
margins Stable healthy TMJs Good crown
form Adequate bone support.
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A Comprehensively Treated Case Should be The
easiest to Maintain The easiest to restore The
most esthetic And produce the most predictable
long term result.
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Comprehensive Care
Periodontics
Periodontics
Restorative Dentistry
Predictability Function and Esthetics.
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Delivering a Successful Outcome
includes Comprehensive Exam Diagnosis Comprehensi
ve Ts Planning Case Presentation Team Tx
planning Long-term predictable Tx and Results.
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Treatment Planning Work Sheet. Additional
consultations requested Disease control, aka.
Initial Therapy, Phase 1 Therapy, Restorative
Periodontal Endodontic Oral Surgical
Other Reconstructive Dentistry Periodontal Orth
odontic Oral Surgical Restorative Prosthodontic
Esthetic enhancement Functional Other Mainten
ance Professional Patient
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• Treatment Plan
• Break out time - 30 min
• Group A Ideal, costs are not a factor
• Group B Ideal, costs are a factor
• Group C The best you can do,
• costs and time are major factors.
• Outline Goals/Objectives of Treatment

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Doctors ProposedTreatment Plan
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• Phase I
• Disease control.
• Includes
• Periodontal HCI

PROPOSED
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Phase II
PROPOSED
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Phase III
PROPOSED
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Phase IV Definitive treatment
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Phase IV
PROPOSED
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Phase V
PROPOSED
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Phase VI
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Phase VII Maintenance q 3 months,
alternating with the Periodontist.
PROPOSED
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Actual treatment provided
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Actual treatment provided Disease Control
Caries/SRP/Endo/Etc
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Actual treatment provided Orthodontic/Oral
surgery/Orthognathics
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Actual treatment provided Restorative
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Actual treatment provided Reconstructive
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Actual treatment provided Maintenance
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Actual treatment provided Supplemental over time/
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Discard garbage
Cell Phone Time
Name Tags and CE sheets
Drive safely