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prosthodontics

Prosthodontics

Prosthodontic Consultations


Consult Requests/Responses

We are now asking everybody who requests a Pros consult to type up the entire “consult response” page prior to us seeing your patient, from “findings/observations” all the way to the “treatment recommendations” section. (See Pros Consult Template) This is to simplify and expedite the process of the consult session. What do you write down? Everything you think a prosthodontist would say regarding the case, including Phase 1 and Phase 2 treatment sequencing and alternatives. Basically, we want you to think like a prosthodontist. This also gives us a chance to evaluate your thought process when treatment planning Pros cases. Do not worry, we won't laugh at your responses ☺ (or at least I'll try to hide it.)

We will also stop entertaining consult requests 30 mins from the end of clinic session to help students finish ongoing pros procedures, so that patients are off the chair 15 mins from the hour - remember this rule? I know it frustrates many of you who wait 1-2 hours for a consult but at least this can give you an early estimation on whether we would still be able to see your patient or not. This way, you can release your patient early instead of contemplating on the possibility of getting that consult. Unfortunately, with the small faculty number we currently have in the department, problems such as this will arise and it is our hope that we can get to as many students as possible during a session.


Mounted Casts

See Clinic Manual Section 21.5.6.4

It is REQUIRED of each and every one that casts be mounted prior to requesting a Pros consult. We have seen many students acquire consults with casts in hand. Every case needs to be mounted, ideally with record bases and rims. If you do not have mounted casts, a consult will not be granted until it is accomplished.

EXCEPTIONS:

  1. Cases that do not need mounting for consult presentation is when one or both arches are ALREADY edentulous (CD cases). We can give you a consult for edentulous cases and then let you know further down the line if mounting is necessary for pre-prosthetic surgery.
  2. Consults can also be given on teeth undergoing caries removal for restorability requests.

Preliminary/Non-Definitive Consultation or Pre-Prosthodontic Consult

Acquired during the OD appointment or “buff-sheet” phase. This consult is not always needed to formulate a tentative treatment plan.

Casts are not necessary when obtaining pre-prosthodontic consults.
Response should already be filled in by student prior to approaching an instructor.

It is often difficult to give a definitive consult at the first examination of the patient. Some of the difficulties may include the following: Patient in denial about disease, patient not ready or able to understand the time and financial commitments required, complexities exist that are beyond scope of the 10-20 minute limit available, group leader unavailable, or any other reason closure is difficult at first contact.

The Preliminary Consult describes issues unresolved, a restorative problem list, and what steps may be needed for resolution. The faculty member must state on the consultation sheet, “consult not definitive, final consult required when issues resolved.” Remember that the response written for this type of consult does not constitute the “definitive” plan for the patient nor should this time be used to “fish” for answers when formulating the definitive Pros consult request or treatment plan.

In fact, faculty SHOULD NOT make any input on possible treatment options during this consultation phase.

There are only two indications/questions that this consult should address, namely:

  1. Question on a case’s candidacy for undergraduate dental treatment or if it is too complicated and must be referred to a resident or to faculty practice (severely resorbed maxillary ridges that may require implant options, medical complications, TMJ problems, changing the patient’s VDO, etc.)
  2. Questions on whether teeth may be salvaged and thus would need to undergo periodontal probing and diagnosis. Otherwise, a complete denture would be the treatment of choice. In other words, obtain a preliminary consult to determine whether the teeth are worth probing or not.

Definitive Consultation

REQUIRED after the OD appointment or treatment planning phase. The aim of this consult is for faculty to give their “blessing” on your treatment plan and not to dictate it.

Mounted casts are necessary when obtaining definitive prosthodontic consults, except when one or both arches are already edentulous.
Response should already be filled in by student prior to approaching an instructor.

The student presents medical and dental history, medications, and chief complaint. The consultant reviews the periodontal chart (checking dates), radiographs (checking dates), examines the patient, and discusses patient expectations. Consultants must look at all the issues, rather than focusing on a specific question from the consultation request. Financial issues must be included in the considerations. Insurance? Self-pay? Medicaid?

Consult Template

The consultation will read as follows:

  1. Findings/observations should record what you see, or think you are seeing.
    This section preferably includes:
    1. Overall dentate condition – “partial or complete edentulism on one (please specify) or both arches”, or “full complement of teeth” if there are no missing teeth
    2. Caries risk assessment – low, moderate, or high, followed by “Phase 2 may proceed” or “not be rendered until risk improves to low”
    3. A discussion of the status of all teeth in question on the consult request, including but not limited to:
      1. status of existing restorations or crowns
      2. status of proposed abutment teeth for fixed or removable partial purposes
      3. extent of existing decay or tooth structure loss
      4. status of periodontal support, or include periodontal diagnosis and radiographic findings or summary
    4. A discussion of anything else (except teeth) related to the request, including but not limited to:
      1. status of interarch space, tuberosities
      2. presentation of residual ridge
      3. presence of exostoses, tori, or bony undercuts
      4. muscle attachments that may complicate the treatment process
      5. questionable oral lesions affecting planned treatment
      6. patient habits – bruxism, etc.
      7. presence of TMD
      8. patient wishes and expectations
    5. Include important medical issues related ONLY to the planned treatment. No need to repeat the entire medical history.
  2. Diagnoses, or differential diagnoses should list the diagnosis or clinical impression.
  3. Prognosis should present your opinion regarding the prognosis. This subjective judgment may be listed as good, fair, poor, or hopeless. Prognosis should be based on the future treatment outcome or no treatment.
  4. Recommended treatment and treatment alternatives. All options which meet the standards of care, including patient referrals, phase I maintenance only, or other options that might be available.
    It is best to sequence Phase 1 and Phase 2 treatment procedures separately in an outline format as such:

    Phase 1:
    1.
    2.
    3. and so on…

    Phase 2:
    1.
    2.
    3. and so on…

    Alternative treatment plan:
    1.
    2.
    3. and so on…

    If the patient is not a candidate for treatment in the undergraduate clinic for any reason, this must be stated.
  5. Risks and benefit of treatment vs. no treatment. Informed consent requires documentation of the presentation of risks/benefits.
  6. Additional tests/information needed. These must be listed.
  7. Final comments. Disclaimers about relines, questionable teeth, plans for pre-prosthetic surgery, insurance/payment issues, other.

The consultation must be shown to your group leader that day for consensus in the DS3 clinics. It must be shown to the faculty member requesting the consultation, or if unavailable, the group leader, in the DS4 clinics.

Restorability Consults

The request should be approved by the requesting faculty.
Response should already be filled in by student prior to approaching an instructor.

Historically, the Prosthodontic faculty was responsible for responding to these consults. Recently, Operative and Patient Management faculty have been given authority to determine if a tooth can be restored. However, students are expected to fill the response form to the best of their abilities prior to approaching an instructor. Faculty would like to evaluate the student’s decision-making process.

Please remember that the restorability of a tooth should include a macroscopic view of the whole oral status and its proposed treatment plan, and not examined through a microscope concentrating on the tooth and its surrounding structures alone.

When a consultation asks about a specific tooth or teeth regarding restorability, the following questions must be addressed:

  1. How much tooth remains?
  2. What is the caries risk of the patient?
  3. What is the tooth’s periodontal status? Any bone/attachment loss?
  4. Does the existing restoration need to be removed to answer the question?
  5. Is crown lengthening or endodontics required? Is information from other specialists required to answer this question? Include biologic width considerations in relation to the proposed position of the future finish line for a planned crown procedure.
  6. What is the tooth’s role in Phase 2 treatment? Is the tooth planned as an abutment for an RPD or FPD? Or will it need a crown?
  7. How is the occlusion? Where does the tooth lie in the whole occlusal scheme? Supraerupted? Consider interach space issues.
  8. What is the prognosis/predictability/practicality?
  9. Can the patient afford to save this tooth? What are other options?
    If the tooth has been deemed restorable with pins, post, cores, etc., please make sure to inform patient of the added expenses to get their approval and add these codes to your treatment plans PRIOR to patient departure.
  10. Consideration of other issues which place the response in context.

For example, if there are many other teeth with caries waiting for treatment, a definitive plan for a single tooth may not be possible, until all the rest of the caries has been removed and disease control has been established. The consultant must state what would be required if the tooth were to be restored, so that when caries removal is complete, there is a record of what each tooth will need for restoration.


Sample Consultations

Sample #1

Consult Request:

Please evaluate pt for maxillary and mandibular RPDs. There is lack of interarch space on left side with possible extraction of tooth #17 and enameloplasty on tooth #18; lack of interarch space on right side with possible tuberosity reduction on right side. Also, hypererupted tooth on #29 - either extraction or survey crown on #29. Tooth #12 heavily restored - may need survey crown as well.

Consult Response:

1. Findings/Observations

Patient presents to the clinic with partially edentulous maxillary and mandibular arches. She is a moderate risk for caries. No phase 2 may be rendered until risk improves to low.

Clinical exam reveals all her dentition to be periodontally stable. No mobilities observed.

Tooth #12 has several restorations including an MOD amalgam and a faciocervical composite, hypererupted and tipped teeth #17, #18, and hypererupted tooth #29 making her occlusal plane non-ideal. Both 20 and 29 are rotated. All proposed RPD abutment #s 6, 12, 18, 20, and 29 are all stable.

Further exam reveals insufficient interarch space bilaterally along her posterior arch areas. She has enlarged right maxillary tuberosity with a moderate buccal undercut. Her left tuberosity is slightly enlarged with a palatal undercut.

The patient is interested in partial removable dentures.

2. Diagnosis or Differential Diagnosis
Hypererupted tooth #17, #18, and #29
Enlarged right maxillary tuberosity
Heavily restored tooth #12
Partial edentulism
Insufficient interarch space
Moderate caries risk

3. Prognosis
Good prognosis for RPD/RPD

4. Recommended Treatment and Treatment Alternatives
Recommend:

Phase 1:

  1. One-stage surgery
    1. extraction of tooth #17
    2. bilateral tuberosity reductions (STENT REQUIRED)
      1. right tuberosity - buccal and vertical reduction to improve occlusal plane, interarch space, and reduce buccal undercuts
      2. left tuberosity - vertical and palatal reduction to improve occlusal plane, interarch space and reduce palatal bony undercut.
  2. interim partial dentures upon request.

Phase 2:

  1. enameloplasty #18 (DB cusp and maybe DL as well)
  2. survey crowns on teeth #12 and 29
  3. definitive RPD/RPD

Alternative treatment:

  1. do nothing
  2. implant restorations for missing areas

5. Risks and Benefits of treatment vs. No Treatment
Yes

6. Additional tests/information needed
None

7. Final comment


Sample #2

Consult Request:

The patient made it through screening, and OD with 2 failing FPDs on the lower arch. She is mainly concerned about the R side; this has come out a few times. #20 is failing. She may be interested in implants, but we need to come up with a short term solution. According to OD, the maxillary crowns are in reasonable shape.

Consult Response:

1. Findings/Observations
Patient presents with a failing 3-unit FPD (29-x-31) with a history of it falling off frequently. The patient is interested in replacing this bridge. She is a moderate risk for caries. No phase 2 may be rendered until risk improves to low.

After removal of the FPD, clinical exam reveals tooth #29 to be stable with a small discoloration on its composite-tooth interface on the facial aspect. At this moment, it seems arrested but a better determination can be done during crown preparation. The rest of the tooth is stable with only physiologic mobility.

Tooth #31 however, has an extensive subgingival carious lesion almost 3 mm into the tooth when measured with a perio probe. Radiographic evidence of this tooth shows the same findings. This tooth is deemed non-restorable.

Further exam reveals FPD #18-x-20-21 is intact but #20 is severely decayed under the retainer. The bridge will be recommended for removal prior to making a decision.

2. Diagnosis or Differential Diagnosis
Extensive recurrent decay abutment #20 and 31.

3. Prognosis
Prognosis is hopeless for #20 and 31.

4. Recommended Treatment and Treatment Alternatives
Recommend:

Phase 1:

  1. section both mandibular FPDs to extract teeth #s 20 and 31.
  2. retain sectioned crowns #18, 21 and 29 to serve as temporary crowns.
  3. pros consult for FPD 18-21

Phase 2:

  1. crown/survey crown on #s 18, 21 and 29
  2. option of implant or FPD for missing 19 and 20; and implant for #30 and 31

Alternative treatment includes a mandibular RPD.

5. Risks and Benefits of treatment vs. No Treatment
Yes

6. Additional tests/information needed
None

7. Final comment
The patient is hesitant in receiving anything removable. She is leaning toward implants at this point.


Undergraduate Implant Cases

Many are still unsure on what implant cases are accepted in the undergraduate clinic. As much as we would love for everyone to have experience in implant therapy, there are cases that require advanced treatment planning and procedures that are outside the boundaries of undergraduate dental training. Our policy states that undergraduate students are allowed to treat the following cases:

  1. One to three individual posterior implant crowns – any more will have to be approved by Pros faculty, and
  2. Two implant-retained mandibular complete overdentures

Anterior tooth implant cases that involve esthetic management are complex treatments that will have to be handled by a specialist and thus are usually referred out.

Implant Evaluation Procedure

Protocol states that the patient should first obtain a Pros consult (general overview) that includes implants as an option among other things. This is then followed by an “implant evaluation” screening attended by a Pros faculty and a surgeon (Perio or OS) to work out the fine details.

Should we get an implant screening anyway even if the patient is unsure but all other factors are positive (health, finances, caries risk, etc.) for this treatment? NO. Please ask for an implant screening only if the patient is decided on this treatment procedure – not “just in case” the patient decides on it later. The Pros consult should determine if implants are an option or not.

Can we ask for implant screening now even if the patient has a long list of Phase 1 treatment to undergo? Prefer postponing the implant screening after evaluation of Phase 1 treatment because outcomes do vary, and the necessity for implants may not be as applicable after Phase 1 treatment is accomplished. If the patient is still interested in implants after Phase 1, we can revisit the case and decide then.

2013/06/08 23:05

Dr Lim's Alginate Impression Technique

TRAY SELECTION AND PREPARATION: “Use the appropriate tray size.”

Proper tray selection is key to capturing good anatomy.

  1. Make sure you choose a tray that is approximately 5 mm or a quarter inch larger than the arch or anatomy being captured.
  2. To check for proper depth/length:
    1. Insert the tray in the mouth and seat the distal end of the tray to cover the most distal anatomy you want captured including maxillary tuberosities and mandibular retromolar pads.
    2. Without moving its seated distal section, try to seat the anterior portion of the tray to check for room. Anterior structures (teeth or ridge) should still be about 5 mm inside the tray wall
  3. To add or to not add rope wax? That is the question.
    1. Maxillary tray
      In most cases, adding rope wax to the maxillary tray is not necessary except for the following situations:
      1. A hypererupted tooth that prevents sufficient seating of the tray – tray borders end up being way too short of the vestibule providing insufficient support for the future alginate border;
      2. A very tight distobuccal space preventing the migration of alginate even with the mandible in an elevated/closed position; or
      3. Tray borders are more than 5 mm from the vestibular fold
    2. Mandibular tray
      I ALWAYS recommend adding rope wax to the mandibular tray – regardless of the presentation, i.e. fully, partially, or completely edentulous. A good distolingual extension will always benefit you or the patient one way or another.
      Technique:
      1. Prepare the mandibular tray by adding one rope of wax bilaterally along the distolingual borders leaving the lingual frenum area free of wax. Use two ropes for flat mandibular ridge.
        Advantage:
        1. You lengthen the distolingual walls which pushes the floor of the mouth inferiorly. This exposes more distolingual alveolar ridge anatomy and would benefit complete and partial denture patients in giving more stability to their prostheses.
        2. By lengthening these walls, the tongue gets isolated in the center of the tray minimizing the possibility of its entrapment during tray seating.
        3. You may apply wax posteriorly if increasing the distal extension of the tray is necessary to capture the retromolar anatomies. I prefer NOT applying wax on these locations: lingual frenum or anywhere along the buccal borders.
  4. Patients with deep palatal vaults
    If the palatal vault is deep, capturing this depth is oftentimes difficult and usually leaves a huge void in the center of the impression.
    Two techniques may be employed:
    1. Add a mound of rope wax on the palate area of the tray for added support as well as to avoid using more alginate material. Make sure though that the wax does not contact the palatal tissue by trying it in the mouth; or
    2. You may also fill the palate area with the alginate mix using a finger before seating the tray for the impression.

MIXING THE ALGINATE: “Always measure.”

  1. Use less water to increase hydrocolloid viscosity. There’s two advantages to this:
    1. it slows or prevents the advancement of hydrocolloid material down the patient’s throat or air passage, and
    2. it pushes all peripheral soft tissues (lips, cheeks, and tongue) aside to emphasize the needed anatomy, namely teeth and alveolar ridges
  2. Recommended water-alginate powder ratio:
    1. When using the graduated cylinder, try using 43-44 cc per pack of alginate. This water-powder ratio will give you a dry mix which will also have a short working time. So some practice is necessary. You may use cold or warm water to increase or decrease working time, respectively.
    2. Always add the powder into the water, never the other way around. This decreases air entrapment in the mix.
    3. Swipe or strop the mixture vigorously against the side of the mixing bowl in a figure-eight fashion to wet the powder (like an old style razor on a leather strop). It should have a smooth consistency at the end.
    4. Press and spread the mixture onto the sides of the bowl in a rolling motion. This breaks out big bubbles that may have been trapped during mixing.
    5. Gather the mix together and scrape off the needed amount to load the impression tray.
    6. Load the impression tray.
  1. Loading technique for the maxillary tray:
    1. Fully load the maxillary tray by sliding the mixing spatula down the rim of the tray at an angle forming a summit of alginate material in the middle of the tray. This added height will help capture the depth of the palatal vault and minimize bubble entrapment or voids in this area.
  2. Loading technique for the mandibular tray::
    1. Load the mandibular tray one side at a time using a slice-n-slide technique. Slice a roll of alginate using a mixing spatula and load this alginate roll onto one side of the tray while sliding the spatula down the rim of the tray while advancing in an anterior or posterior direction. Repeat process for the contralateral side.
  3. Pour water onto the alginate. No smoothing of the alginate is necessary, but can be done if you wish.
    Advantage:
    This layer of water serves as an automatic surface smoothing agent during the impression procedure. Water also prevents the alginate from sticking to gloves.

IMPRESSION TECHNIQUE: “Practice makes perfect.”

Maxillary Impressions

For MAXILLARY IMPRESSIONS, remember this tray seating sequence: BACK-TO-FRONT first.

Details: “half back - half front - thumb push - full front - full back with mandibular closure”.

  1. Half back - half front
    Seat the back of the tray halfway up followed by the front, also halfway up, making sure the incisal edges or alveolar ridge enters the alginate material about half an inch from the anterior wall of the tray.
    Advantages: By seating the back area first, you force excess alginate material to flow in an anterior direction rather than posteriorly which may induce a gagging reflex.
    By allowing a half inch of space upon anterior seating, you assure yourself of less or minimal anterior tray burns as you attempt to fully seat the front by following through with the arc of motion.
  2. Thumb push
    The anterior migration of excess alginate material can benefit you in capturing more anatomy by lifting the patient’s upper lip, pushing the alginate back into the anterior vestibule, and draping the upper lip over the retreated alginate.
  3. Full front - full back with mandibular closure
    After draping the upper lip over the alginate, fully seat the anterior part of the tray; then instruct the patient to bring his/her mandible up as you finish off by fully seating the back of the tray.
    Advantage: By asking the patient to close while fully seating the back of the tray, this brings the coronoid process superiorly providing more room for alginate migration buccal to the tuberosity areas.

Mandibular Impressions

For MANDIBULAR IMPRESSIONS, remember this sequence: FRONT-TO-BACK.

Details: “tongue up - full front - full back - vestibular molding

  1. Tongue up
    Insert the tray, then instruct the patient to raise their tongue to contain it in the center of the tray and rope wax. Do not begin seating the tray if you do not see the tongue contained in the middle; otherwise, the tongue will be part of the impression.
  2. Full front - full back
    Pull the lower lip out and seat the front of the tray fully followed by the back of the tray. NO HALFWAY SEATING REQUIRED.
  3. Vestibular molding
    To really capture good vestibular shape on the mandibular impression, I find it necessary to mold the soft alginate myself by pushing down the material with a finger to fill the space from posterior to anterior and moving the cheek to mold it. I do the same on the contralateral side and the anterior area.

HOPE THIS HELPS!

2013/06/09 10:44

Minimizing Immediate CD Tx Plans

Some of you may know this already but for those who are not yet aware, we are minimizing the treatment planning of immediate CDs, and possibly some RPDs, due to the nature of this beast. Those who have made them in the past know that it is a lot of work and frustration on the student’s part that requires a tremendous amount of faculty supervision to produce a prosthesis that will not be up to par with patient expectations. There's more downside to this treatment than many patients realize, esp. when alveoloplasties need a second round of surgeries.

It is recommended to place this treatment option in the back burner so to speak. I have begun offering only conventional interim CD and RPDs only after all surgeries have been undertaken, including extractions and pre-prosthetic surgeries. This means that I offer patients the following: do all the planned surgeries (all extractions and alveoloplasties) first, wait for 4-6 weeks or 6 months of healing followed by the interim and/or definitive prosthesis.

Are we eliminating “immediate” prostheses? No. If patients are insistent on receiving nothing but immediate prostheses, you will need to get the approval of Dr. Gurun, Dr. Lim, or Dr. Mansour who will evaluate the case to see if the minimum requirements are there to ensure a good prognosis. Please review Dr. Lim’s lecture notes on immediate CDs (yes, you have them). As always, informed consent on the limitations of this treatment should be stated, accepted by the patient, and noted on axiUm. If the patient understands and accepts possible outcomes, then the treatment may proceed.

Just remember not to offer or promise immediate prostheses on the first round. This should be offered as a last choice. I try not to mention it as much as possible.

2013/06/08 22:23

Note about Implant Supported Overdentures

As undergrads at UDM, we don't do implant-supported maxillary overdentures. They require 4 implants and are more complicated than they'd like us handling.

2013/06/26 15:52

Prosth Progress Notes

Crown Prep:

2750 - Preparation and impression
Patient reported for crown preparation and temporization #29. Performed PFM preparation on tooth #29 with deep chamfer. Temporized with acrylic temp. Placed retraction cord 000 and 001 with ViscoStat ® hemostatic agent. Removed the 001 cord and took PVS impression. Took acrylic bite registration for #29. Removed second cord, adjusted temporary, and cemented with temp bond.
NV: crown delivery.

Crown Delivery:

2750 - Delivery
Pt presents for crown delivery. RMH - no changes. Vitals taken. Removed temporary and removed excess cement. Adjusted contacts, margins, occlusion and polished. BW radiograph taken to evaluate closed margins. Cemented crown with Fuji Glass Ionomer Luting cements. Cleaned excess cement and checked occlusion. Pt is satisfied with esthetics.
NV:POE

2013/10/25 22:38
prosthodontics.txt · Last modified: 2013/06/27 23:42 by brent