Transcript ตัวอย่ำง Treatment Plan Presentation นำ เ ส น อ โ ด ย ก ลุ่ ม .

ตัวอย่ำง
Treatment Plan
Presentation
นำ เ ส น อ โ ด ย ก ลุ่ ม . . . . . . . . . . . . . . . . . . . . . . . . .
อ ำ จ ำ ร ย์ ท ี่
ป รึ ก ษ ำ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Personal Data
 เพศ
ั
 สญชาติ
 อายุ
 ศาสนา
 ภูมล
ิ าเนา
 สถานภาพ
ี
 อาชพ
หญิง
ไทย
73ปี
อิสลำม
นนทบุรี
หย่ำ
แม่บ ้ำน
Socioeconomic Status
 ไม่ได ้ทำงำน
 มีบต
ุ รทำงำนรัฐวิสำหกิจ
 เบิกค่ำรักษำพยำบำลได ้
ั อยูก
ั ดำห์
 หย่ำร ้ำงกับสำมี ปั จจุบน
ั อำศย
่ บ
ั หลำน เจอลูกทุกสุดสป
Medical history

โรคประจาต ัว
1. Allergy (แพ ้อำกำศเย็น ผู ้ป่ วยจะมีอำกำรน้ ำมูกไหลและ
จำม)
- ไม่ได ้พบแพทย์เป็ นประจำ ในอดีตรักษำโรคภูมแ
ิ พ ้ที่ รพ.ศริ ริ ำช
Medical history

Vital signs
BP
PR

123/75
72
mmHg
beats/min
ปฏิเสธการแพ้ยา อาหารและสารเคมี
29 พ.ย. 54
Chief complaint
อยำกมีฟันหลังเคีย
้ วอำหำร
Dental history
มีประวัตริ ักษำทำงทันตกรรมที่
คณะทันตแพทยศำสตร์ มหำวิทยำลัย
มหิดล ปี 2554
 ทำกำรรักษำโรคปริทน
ั ต์อก
ั เสบ
และรักษำคลองรำกฟั นซ ี่ 43 44
ึ ษำหลังปริญญำเพือ
 รอคิวกับนักศก
่ ทำ
ครอบฟั นและฟั นเทียมบำงสว่ นถอดได ้
 ปั จจุบน
ั ใชฟั้ นหน ้ำเคีย
้ วแทนฟั นหลัง

Referral Source
CT (2554)
AD (2554)
Lifestyle
ของทอด, ผ ัก, ผลไม้
ของหวาน, ขนม
กรุบกรอบ
Oral hygiene practice
แปรงฟั นถูไป-มำในแนวนอน
้
วันละ 2 ครัง้ (เชำและก่
อนเข ้ำนอน)
้ ฟ
ี ั นผสมฟลูออไรด์
โดยใชยำส
้
ไม่ใชไหมขั
ดฟั น
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 Hx of RCT for 5
years .
44 Hx of RCT for 1
year
43, 44 previously treated
tooth with adequate root
canal filling
Occlusion
•Molar relationship : Rt & Lt unclassified
•Canine relationship :Rt Class III
Lt Class III
•Overbite
: 80%
•Overjet
: 5mm
Occlusion
•Right lateral excursion
-11/41
-12/42
-13/44
•Protrusive movement
-21/31
•Left lateral excursion
-21/31
Periodontal Examination
Upper arch
CAL
332 212 232
325
333 233 235
CEJ
-GM
110 000 010
000
000 000 023
PD
222 212 222
325
333 233 212
I
B
2
1
1
L
PD
212 212 211
215
212 111 111
CEJ
-GM
000 000 000
000
000 000 012
212 212 211
215
212 111 123
CAL
Periodontal Examination
Lower arch
CAL
211
111
110
011
223
212 232
222
433
CEJ
-GM
010
000
00-1 -100
112
101 121
011
110
PD
211
111
111
111
111
111 111
211
323
PD
112
111
111
111
111
111
112
111
323
CEJ
-GM
110
010
100
011
111
111
100
011
010
CAL
222
121
211
122
222
222
212
122
333
B
L
Periodontal Diagnosis
Localized severe chronic
periodontitis
สมาคมปริท ันตวิทยาแห่งประเทศไทย 2007
Patient’s Expectation
้ ย
มีฟันเอำไว ้ใชเคี
้ วอำหำรได ้ดี
Dentist’s Expectation
1. มีสข
ุ ภำพร่ำงกำยแข็งแรง
้ ย
2. มีฟันปลอมทีแ
่ ข็งแรง ใชเคี
้ วอำหำรได ้
ิ ธิภำพ
อย่ำงมีประสท
่ งปำกของ
3. สำมำรถดูแลสุขภำพชอ
ตนเองได ้ดีและสมำ่ เสมอ
Behavioral Evaluation
 มำรับกำรรักษำตำมนัดทุกครัง้
 ไม่เคยมำสำย
ิ ใจแผนกำรรักษำ
 มีสว่ นร่วมในกำรตัดสน
Problem Lists
 Loss of VD (no posterior teeth support)
 Torus palatinus and bony exostosis
 Traumatic occlusion at 21,22 and 23
 43,44 Previously treated with adequate root canal filling
 Generalized attrition with some erosion
Areas of Concern
Traumatic
Loss VD
Tooth
wear
+/No
posterior
teeth
+/-
Pulpal
disease
Loss of VD
 จำเป็ นต ้อง raise หรือไม่
 หล ักการ : raise ให ้น ้อยทีส
่ ด
ุ เท่ำทีจ
่ ำเป็ น คือให ้มีspace
พอทีจ
่ ะrestoration
 raise เท่ำไหร่
 raise ได ้หรือไม่ อย่ำงไร
Loss of VD
 จำเป็ นต ้อง raise?ดูจำก...
 กำรสบฟั นของผู ้ป่ วย---Space available for restoration
 Determination of OVD---Loss of VD ?



5
mm


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
 Raise เท่ำไหร่
 หลักกำร RVD – OVD = 5 mm. = Freeway space แล ้วทำ
กำร raise bite ขึน
้ มำใหม่ เพือ
่ สร ้ำง Freeway space ประมำณ
2-3 mm.
Loss of VD
 Raise อย่ำงไร ประเมินจำกอะไร
 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
Traumatic
Loss VD
Tooth
wear
+/No
posterior
teeth
+/-
Pulpal
disease
Areas of Concern
Generalized attrition with some erosion
3
4
4321 123
Generalized Attrition with Some
Erosion

Etiology
 Congenital anomalies
 AI,
oTreatment
DI
 Habit
 Parafunctional
habit
 Diet
 Sour
 Hard
 Loss
of posterior teeth support
Diet advice
Prosthesis
Generalized Attrition with Some
Erosion
 Treatment options
 Diet advice
 Prosthesis
Areas of Concern
Traumatic
Loss VD
Tooth
wear
+/No
posterior
teeth
+/-
Pulpal
disease
Traumatic occlusion at 21, 22, 23
 Etiology
 Parafunctional habits
 High spot
 Missing enough teeth

Tooth mobility
>>> Nightguard
>>> Remove some
>>> Removable prosthesis,
Implant-supported crownbridge
>>> bone graft
Areas of Concern
Traumatic
Loss VD
Tooth
wear
+/No
posterior
teeth
+/-
Pulpal
disease
43,44 Previously treated with adequate
root canal filling
 Etiology
 Severe
attrition
 Treatment
 Post
options of this area
& 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 discussion
 Preliminary APD design
Systemic Phase
 Patient management (ระวังไม่ให ้ผู ้ป่ วยเกิดกำรแพ ้อำกำศเย็น)
 แนะนำผู ้ป่ วยตรวจสุขภำพร่ำงกำย
Acute Phase
The Disease Control Phase of
Treatment
 Torectomy and alveoloplasty
 Oral hygiene instruction
 Scaling and root planning and polishing full mouth
 13(O) Resin composite filling
The Definitive Phase of Treatment
 Upper : APD
 Lower : 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.
 Result
o 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 Plan
Tentative
Treatment
Alternative
Treatment I
Alternative
Treatment II
APD/Overlay Denture
Implant & Bridge
RPD/RPD & Crown
Treatment Plan
Tentative
Treatment
Pre-treatment
phase
•Dental consultation:
Prosthodontist
Patient-dentist
discussion
 Preliminary
prostheses design
Alternative
Treatment I
Pre-treatment
phase
•Dental consultation:
Prosthodontist
CT Scan
Patient-dentist
discussion
 Preliminary
prostheses design
Alternative
Treatment II
Pre-treatment
phase
•Dental consultation:
Prosthodontist
Patient-dentist
discussion
 Preliminary
prostheses design
Treatment Plan
Tentative
Treatment
Systemic phase
•Medical consideration
•แนะนำให ้ผู ้ป่ วยตรวจ
สุขภำพ
•Patient management
(ระวังไม่ให ้ผู ้ป่ วยเกิดกำร
แพ ้อำกำศเย็น)
Alternative
Treatment I
Systemic phase
•Medical consideration
•แนะนำให ้ผู ้ป่ วยตรวจ
สุขภำพ
•Patient management
(ระวังไม่ให ้ผู ้ป่ วยเกิดกำร
แพ ้อำกำศเย็น)
Alternative
Treatment II
Systemic phase
•Medical consideration
•แนะนำให ้ผู ้ป่ วยตรวจ
สุขภำพ
•Patient management
(ระวังไม่ให ้ผู ้ป่ วยเกิดกำร
แพ ้อำกำศเย็น)
Treatment Plan
Tentative
Treatment
Acute phase
Alternative
Treatment I
Alternative
Treatment II
Acute phase
Acute phase
•Torectomy
•Treatment denture
(Overlay)
•Torectomy
•Treatment denture
(Overlay)
Disease control
phase
•Torectomy
Disease control
phase
Disease control
phase
•Oral hygiene instruction
•Oral hygiene instruction
•Oral hygiene instruction
•Scaling and polishing
•Scaling and polishing
•Scaling and polishing
•13(O) Resin composite
filling
•13(O) Resin composite
filling
•-
•13(O) Resin composite
filling
•Treatment denture for
edentulous area
Treatment Plan
Tentative
Treatment
Definitive phase
• Treatment denture
(Overlay)
Alternative
Treatment I
Alternative
Treatment II
Definitive phase
Definitive phase
• 43,44 PFM crown
• 42,41,31,32,33 crown
• Implant & Bridge
• 34-44 crown
• RPD/RPD
Treatment Plan
Tentative
Treatment
Maintenance and
recall
•Recall 3 months
Evaluate oral
hygiene and
periodontal status
Evaluate all
restorations and
prostheses
Alternative
Treatment I
Alternative
Treatment II
Maintenance and
recall
Maintenance and
recall
•Recall 3 months
Evaluate oral
hygiene and
periodontal status
Evaluate all
restorations and
prostheses
•Recall 3 months
Evaluate oral
hygiene and
periodontal status
Evaluate all
restorations and
prostheses
Treatment Plan
Tentative
Treatment
Maintenance and
recall
•Recall every 6 months
Scaling and root
planinng
Endodontically
treated teeth 43,44
X-ray 6 months, 1
year and every year
until 4 years
Alternative
Treatment I
Alternative
Treatment II
Maintenance and
recall
Maintenance and
recall
•Recall every 6 months
Scaling and root
planning
Endodontically
treated teeth 43,44
X-ray 6 months, 1
year and every year
until 4 years
X-ray (+bite
guide) check
implant 6 months,
every 1 yr. until 5
yrs. and every 5 yrs.
•Recall every 6 months
Scaling and root
planning
Endodontically
treated teeth 43,44
X-ray 6 months, 1
year and every year
until 4 years
Treatment Plan
Tentative
Treatment
Alternative
Treatment I
Alternative
Treatment II
12,130 บาท
172,130 บาท
4,130 บาท
Review
 Traumatic occlusion
repeated 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 occlusion
2.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
1.
2.
3.
4.
5.
6.
7.
8.
Physical examination
Chest X-ray
Ultrasound whole
abdomen
Digital Mammogram
PV & ThinPrep Pap test
EKG
Exercise stress test (EST)
or
Echocardiography
Bone densitometry
9.
10.
11.
12.
13.
14.
15.
16.
FBS
CBC
Creatinine
SGPT, SGOT, alkaline
phosphatase
Total cholesterol,
Triglyceride, HDL-C, LDLC direct
Anti HBs, HbsAg
Uric acid
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