1) This document presents a comprehensive treatment plan for an 63-year-old retired veteran with a history of back surgery and arthritis.
2) The plan addresses numerous carious and defective restorations, periodontal disease, missing teeth, and a lesion in the floor of the mouth.
3) The proposed treatment involves multiple phases including emergency extractions, restorative and endodontic work, fixed and removable prosthodontics, and periodic maintenance to improve the patient's oral health.
4. Historical Notes
Retired from USAF in
1984 as a MSgt
Married with 6 kids and
8 grandchildren and 2
great-grandchildren
States that he is in good
health and somewhat
active
Lived in San Antonio
area since 1982
5. Subjective Findings
Chief Complaint: “I have a bunch of
problems I want to fix.”
Denies any history of smoking
Sporadic dental tx. at a civilian dentist.
Other major concern is missing crown
from tooth # 7
7. Medical / Systemic
History of back surgery to replace 2
cervical disks. Undergoing Physical
Therapy at WHMC
Seen at WHMC for Arthritis and high
B.P. which is controlled by medication
B.P. average: 138 / 88
Reports no known drug allergies
28. Mand Left Sextant
20 – 2 small pit occlusal amalgams
21 – missing
22 – No Treatment
29. Mand Anterior Sextant
23 – no treatment
24 – no treatment
25 – no treatment
26 – no treatment
27 – no treatment
30. Mand Right Sextant
28- Existing Gold crown over 42 years
29- Existing MODL Amalgam with 2 pins
31. Mand Right Sextant
30- Defective MODFL Amalgam restoration
with a pin and associated periapical
pathology and sinus tract and furcation
involvement
32. Mand Right Sextant
31- Defective MODFL Amalgam restoration
with 2 pins
32- Existing occlusal Amalgam restoration and also is
supraerupted and not in occlusion
33.
34. Endodontic Findings
3- defective restoration
● Asymptomatic
● No positive findings to palpation, percussion
● Endo Ice and EPT response WNL
● Recurrent Caries
● Periradicular Dx: Normal
● Pulpal Dx: Normal
35. Endodontic Findings
7- crown missing since June 2003
● Obturation radiographically and clinically
acceptable
● No contamination noted
● Asymptomatic- No positive responses
● Gutta Percha short about 2 mm
● May require retreatment for adequate post
length
● Periradicular Dx: Normal
● Pulpal Dx: Pulpless
36. Endodontic Findings
14 and 15
● Supraerupted
● Asymptomatic
● Re-establish Occlusion
● Calcified Canals beginning
to form
● Periradicular Dx: Normal
● Pulpal Dx: Normal
37. Endodontic Findings
29- Asymptomatic
● No positive findings to palpation, percussion
● Endo Ice and EPT response WNL
● Abutment tooth for a 3-unit FPD
● Periradicular Dx: Normal
● Pulpal Dx: Normal
38. Endodontic Findings
30- asymptomatic
● Sinus Tract present with sensitivity to palpation
● Subgingival Caries extending into pulp
● Class II Furcation involvement
● Periradicular Dx: Chronic Apical Periodontitis
● Pulpal Dx: Pulpal Necrosis
● Nonrestorable: to be extracted
39. Endodontic Findings
31- Defective restoration
● Recurrent decay
● No positive findings to palpation, percussion
● Asymptomatic
● Endo Ice and EPT response WNL
● Abutment tooth for a 3-unit FPD
● Periradicular Dx: Normal
● Pulpal Dx: Normal
42. Periodontics: Prognosis
Short term:
● Overall: Fair
● Individual: #30 and 32- Hopeless
Long term:
● Overall: Fair
● Individual: Questionable # 3 and 15
Perio Maintenance: Every 3-4 months
43. Orthodontics
Mand Ant. crowding about 3 - 4mm
Midline discrepancy: mand 2 - 3mm to the left
Pt. states he is not interested in Orthodontic Tx.
44. Occlusion
Angle class I molar on right side
Class I premolar on left side
Loss of VDO due to missing # 17, 18, 19 and 21
Supraerupted # 14, 15, 32
TMJ: Asymptomatic
51. Treatment Plan by Phase
I. Emergency Care
● Extract # 30 & 32
● Biopsy lesion in F.of M.
II. Medical / Systemic
● Consult with Physician for Contraindications
● High Caries Protocol and Dietary Counseling
52. Treatment Plan by Phase
III. Diagnostic / Initial Therapy
● Medical Model and Caries Control
● OHI- Brushing & Flossing
● Extract Hopeless teeth
● Endo- Retreat RCT # 7prn and other RCT prn
● Sc/RP- site specific # 3,11-15, 28-32
● Operative/Restorative
53. Treatment Plan by Phase
1 & 2: No Treatment – not to be replaced
3: Possible RCT with Full Gold Crown & Crown
lengthening prn
4: No Treatment
5: Replace with Occlusal amalgam
6: Replace with Glass Ionomer or composite
7: Retreat RCT prn for post length, Cast Post & Core and
PFM crown
8: Replace with Composite
9: Replace with Composite
10: Replace with lingual composite
54. Treatment Plan by Phase
11: Replace with Glass Ionomer or composite
12: Replace with MOD amalgam with enameloplasty
to adjust occlusion prn Class V abrasion, replace
with Glass Ionomer or composite
13: Replace with occlusal amalgam
14: Intentional RCT prn to allow for crown (Full Gold)
due to supraeruption and re-establish occlusion
15: Intentional RCT prn to allow for crown (Full Gold)
due to supraeruption and to re-establish occlusion
16: No Treatment
55. Treatment Plan by Phase
17: No Treatment
18: Replace with Denture tooth from RPD
19: Replace with Denture tooth from RPD
20: Abutment tooth for a 3-unit FPD &
Wrought wire clasp and distal rest
21: Replace with pontic from 3-unit FPD
22: Abutment tooth for a 3- unit FPD &
Cingulum Rest for RPD 23: No Treatment
23: No Treatment
24: No Treatment
25: No Treatment
56. Treatment Plan by Phase
26: No Treatment
27: No Treatment
28: Mesial Rest for RPD
29: Abutment tooth for a 3- unit FPD with a mesial rest for
an RPD & possible RCT prn
30: Extract and replace with Pontic from 3-unit FPD
31: Abutment tooth for a 3- unit FPD & Cast ½ round clasp
from distal and distal rest with possible RCT prn
32: Extract and not to be replaced
57. Treatment Plan by Phase
IV. Re-Evaluation
● Check O.H. and Pt. Compliance
● Re-chart 935
● Assess Key Teeth # 20, 22, 29 & 31
V. Corrective Surgical
● Ridge Augmentation prn
● Orthodontics: which pt. does not desire
● Prosthodontics
58. Treatment Plan by Phase
Single Crowns
● #3, 14 and 15- Full Gold Crown
● #7- Porclein Fused to metal
3-unit Fixed Partial Denture
● #20 – 22: Pier Abutment Survey Crowns
● #29 – 31: Pier Abutment Survey Crowns
59. Treatment Plan by Phase
Mandibular Partial Denture
● Kennedy classification II, modification I
● Major Connector: Lingual Plate
● Clasp Assembly # 20 and 31
● #20: Wrought wire clasp and distal rest
● #22: Cingulum Rest (indirect retainer)
● #28: Mesial rest
● #29: Mesial rest
● #31: Cast ½ round clasp from distal and distal rest
● Denture Teeth replacing # 18 and 19
60. Treatment Plan by Phase
Nightguard / Occlusal Guard
VI. Maintenance
● Re-evaluation
● Perio Recall every 3-4 months
61. Alternative TX. Plan #1
Maxilla
● Extract teeth # 14 and 15
Mandible
● Do NOT fabricate an RPD
● Keep the pt. in only 2nd premolar occlusion
on the left side
62. Alternative TX. Plan #2
Maxilla
● Extract teeth #3, 14 and 15
● Fabricate RPD replacing teeth # 3, 14 & 15
Mandible
● Single unit Survey crowns for teeth #29, 31
● Fabricate an RPD to replace teeth # 18, 19
and 30
63. Alternative TX. Plan #3
Extract # 30 and fabricate a bilateral
distal extention removable partial
denture if we are not able to save # 30.