Treatment sequence

Diagnosis and treatment planning

Phase I therapy
presurgical restorative treatment, extraction of teeth with guarded prognosis
Periodontal therapy, endodontic,orthodontics
Alteration of OVD
Correction of occlusal plane
Preparation of surgical guide if oral condition is altered
Reconstructive osseous and soft tissue surgery
Surgical phase
Implant placement healing phase
Prosthetic phase
Progressive bone loading
Initial abutment preparation
Final abutment preparation
Try in
Initial delivery
Final delivery after occlusl adjustment
Maintenance phase
First year every 3 to 4 months
Radiograph every 6 months
Home care instructions
Fluoride application
Chlorhexidine mouth rinse
Initial appointment -1
Chief complain
Medical and dental history
Examination both intraoral and extraoral
X-ray examination IOPA, Occlusal
Diagnostic cast
Preliminary discussion of treatment
alternatives
Objectives of initial appointment
Is to assess patients need, motivation and
approach towards dental treatment
Find out any condition that may be risk factor
for the treatment
Educate the patient about the tooth loss and
the consequences
Treatment options
Cost of each treatment option

Patients Name , Age, Sex and occupation should be recorded.
Chronological age is no a contraindication but in case of older patient
decision should depend upon treatment necessity and ability to tolerate the
procedure.
Young adults requiring single tooth replacement in anterior region should be
postponed after the age of 25 years due to prolonged changes in anterior
face height and posterior rotation of mandible, particularly in women.
Occupation may dictate the patients ability to afford time and money for the
treatment. Special precaution to be taken for the patients involve in contact
sports. Esthetics and phonetics may be of prime concern for actors etc.
Chief complaint be recorded in patients own words. That may guide to asses
the cause of seeking treatment.
Aesthetics
Functional


Personal details and Chief complain
Dental history
Reason for tooth loss
Caries
Periodontal disease
Trauma
Others
High caries - need additional diet recommendation -
decisive factor whether to maintain or replace a
questionable abutment.
Patients with periodontal history are at higher risk for
peri-implantitis leading to failure.
Accidental trauma may present with advance alveolar
ridge defects
Dental and medical history
Previous prosthesis
Esthetic desire
Types of prosthesis
No of implants
Bone augmentation
Intra Oral examination
Evaluate natural teeth
Perio dontal condition
Soft tissue
Bone
Extra oral examination
Facial symmetry
Lip fullness
Smile lines
TMJ evaluation
Radiographic examination
Bone quality
Bone density
Study models
Diagnostic waxup
Transitionals
Medical History
Smoking and alcoholism
Diabetes
Hypertension
Use of corticosteroids
Use of anticoagulants
Use of bisphonates
Radiation therapy
Chemotherapy
Intraoral examination
A comprehensive intraoral examination must be completed, with special attention to a number of
general and site specific features as follows:
General:
primary disease
Maxillary anterior tooth position
Occlusal vertical dimension
Mandibular incisal edge
Maxillary posterior plane
Mandibular posterior plane
Parafunction
prognosis of remaining teeth
Existing prosthesis
Specific to site:
Lip lines
Maxillomandibular arch relation
Existing occlusion
space-interdental and inter occlusal (Crown Height Space)
Arch form
ridge thickness and shape
nature, thickness and condition of the soft tissues
availability of bone, taking account of features such as concavities
Temporomandibular joint status
Maxillary anterior tooth position
Importance
Maxillary tooth position should be corrected first Because proper position influences other aspects such as
Occlusal vertical dimension, mandibular anterior tooth position, posterior occlusal plane
Severe malposition may indicate vertical maxillary excess or other orthodontic problem. Further diagnostic
studies are indicated in those cases.
Lip support
A line is drawn perpendicular to FHP at the level of sub nasale
Upper lip should be 1-2 mm anterior to the line
Lower lip at the perpendicular level
Chin should be 2 mm behind the line
Vertical
position
Canine tip should be located approximately 1mm with the lip in repose. It is irrespective of age and sex.
Central incisors must be 1 to 2 mm longer than the horizontal line joining the tips of canines
Remedy

If maxillary tooth position is not desirable then orthodontic treatment or orthognathic surgery is indicated
Occlusal vertical dimension
Importance
Significantly modify the overall treatment
Cange in OVD will require at least one arch reconstruction
Alter the CHS affects the biomechanics of the support of a prosthesis
potential number, size and the angulation requirement of implant changes
Effect of
change
A line is drawn perpendicular to FHP at the level of sub nasale
Upper lip should be 1-2 mm anterior to the line
Lower lip at the perpendicular level
Chin should be 2 mm behind the line
Vertical
position
Canine tip should be located approximately 1mm with the lip in repose. It is irrespective of age and sex.
Central incisors must be 1 to 2 mm longer than the horizontal line joining the tips of canines
Remedy

If maxillary tooth position is not desirable then orthodontic treatment or orthognathic surgery is indicated
Extra oral examination
temporomandibular joints (TMJ) and muscles
of mastication
facial profile and lip support
smile line.
local factors should be considered
when contemplating possible implant
treatment ?
ACCESS
Room to insert the implants?
PROSTHETIC SPACE
Room to place a restoration?
DYNAMIC SPACE TO RESTORE THE IMPLAN T
Do occlusal interference s preclude superstructure placement?
SIZE OF SPACES
How many implants?
BONEVOLUME
Will it house a suitable implant ?
BONE CONTOUR
Will the implant penetrate a concavity?
BONE ORIENTATION
Can the implant be oriented correctly?
PROGNOSIS OF REMAINING TEETH?
Restore the mouth in its entirety
STATUS OF EXISTING PROSTHESES
Could they be improved up on? With implants ?
Soft tissue assesment
Soft tissues are further assessed for health and quality in terms of
being Keratinised or non-keratinised.
The presence of non-keratinised tissue Around an emerging
abutment is not Considered ideal, and may indicate the need for an
autogenous gingival graft to increase the peri-implant zone of
keratinised ussue.
An assessment of soft tissues should also determine their
thickness.
This can be done by measuring soft tissue Thickness with a
periodontal probe. It Is then possible to map out the soft tissue
thickness on a sectioned Duplicate cast, thus highlighting residual
ridge width.
Alternatively bony ridge thickness can be measured directly using
bone calipers. A This is referred to as ridge mapping.
Diagnostic cast
Extent and location of edentulous area
Relation of edentulous ridge with the opposing
arch and adjacent hard and soft tissue
Existing occlusion
Intraarch space
Occlusal plane
Opposing dentition
Gross morphology of the edentulous area
Asses the arch location of future implant and
abutments
Direction of forces in potential implant site
Position and morphology of potential natural
abutments


Initial appointment-2
Objectives

1. Determine the number of implants needed to
support the prosthesis
2. Determine the location of implants
3. Design of prosthesis
Additional clinical and lab procedure prior to
additional diagnostic record
Extra office diagnostic orders such as
specialized x-rays, medical evaluation,
consultation
Diagnostic wax up of final result on duplicate
casts
Initial appointment -3
Final treatment plan and alternatives
Medical and lab tests evaluated
Pre-operative prescription and post-operative
instruction
Consent form
Picture of the existing condition