The Treatment Plan

Dr. Omar Soliman

Lecturer of Oral medicine and Periodontology, South Vally
University
Sequence of treatment plan.
Sequence of treatment plan.
Sequence
of
treatment
plan.
 Goals of Treatment Plan.
• A︎fter the diagnosis and prognosis have been established, the treatment is
planned.
• The plan should encompass short- and long-term goals.
• The short︎ term goals are the elimination of all infectious and infl︎ammatory
processes that cause periodontal and other oral problems that may hinder the
patient’s general health.
• Basically, the short-term goals are to bring the oral cavity to a state of health.
This may re︎quire periodontal procedures, as well as other dental therapy, such
as endodontics and correcting oral mucous membrane pathology.
• Referral to other dental and medical specialties will be necessary.
• From a periodontal viewpoint, the short-term goals are important, since they
consist of the elimination of gingival in︎flammation and correction of the
conditions that cause and perpetuate it. These include not only elimination of
root accretions but also pocket eradication or reduction and establishment of
good gingival contours and mucogingival relationships conducive to good
periodontal health. Restoration of carious areas and the correction of poor
existing restorations may also be necessary.
 Goals of Treatment Plan.

• The long︎term goals are the reconstruction of a healthy dentition

that fulfils all functional and esthetic req︎uirements.
• Long-term planning involves consideration of prosthetic
reconstruction of the dentition, which may req︎uire implant
therapy, including surgical preparation of the implant site. Also,
the need for orthodontic treatment should be evaluated.
• The financial impact of long-term treatment re︎quires careful
consideration and understanding by the patient. The age and
medical health status of the patient must also be considered.
 Master Plan for Total Treatment

• The aim of the treatment plan is total treatment, that is, the coordination
of all the short- and long-term goals for the purpose of creating a well-
functioning dentition in a healthy periodontal environment.
• The master plan of periodontal treatment encompasses different areas of
therapeutic objectives for each patient according to his or her needs. It is
based on the diagnosis, disease severity, risk factors.
 Extracting or Preserving a Tooth

• Periodontal treatment re︎quires long-range planning. Its value to the patient is

measured in years of healthy functioning of the entire dentition and not by the
number of teeth retained at the time of treatment.
• Treatment is d︎irecte︎ to establishing an︎d maintaining the health of︎ the
perio︎ontium throughout the mouth rather than attempting spectacular e︎︎fforts to
︎tighten loose teeth.︎︎
• In the past two decades, implant replacement of missing teeth has become a
predictable course of therapy. Therefore attempts to save q︎uestionable teeth
may jeopardize adjacent teeth and may lead to the loss of bone needed for
implant therapy. Teeth on the borderline of a hopeless prognosis do not
contribute to the overall usefulness of the dentition. Such teeth become
sources of recurrent problem to the patient and detract from the value of the
greater service rendered by the establishment of periodontal health in the
remainder of the oral cavity.
 Extracting or Preserving a Tooth

• Removal, retention, or temporary (interim) retention of one or more teeth is

a very important part of the overall treatment plan. A tooth should be
extracted under the following conditions:
1.︎ It is so mobile that function becomes painful.
2. It can cause acute abscesses during therapy.
3.There is no use for it in the overall treatment plan.

 Extracting or Preserving a Tooth

• In some cases, a tooth can be retained temporarily, postponing the decision to

extract until after treatment is completed. A tooth in this category can be
retained under the following conditions:
1.It maintains posterior stops︎ the tooth can be removed after treatment when it
can be replaced by an implant or another type of prosthesis.
2.It maintains posterior stops and may be functional after implant placement in
adjacent areas. When the implant is restored, these teeth can be extracted.
3.In the anterior esthetic zone, a tooth can be retained during periodontal
therapy and removed when treatment is completed and a permanent restorative
procedure can be performed. The retention of this tooth should not jeopardize
the adjacent teeth. This approach avoids the need for temporary appliances
during therapy.
 N.B

• In complex cases, interdisciplinary consultation with other specialty areas

is necessary before a final plan can be made.
• The opinion of orthodontists and prosthodontists is especially important
for the final decision in these patients.
• S︎ystemic cond︎itions should be carefully evaluated because they may
re︎quire special precautions during the course of periodontal treatment. The
tissue response to treatment procedures may be affected, or the
preservation of periodontal health may be threatened after treatment is
completed. The patient’s physician should always be consulted when the
patient presents with medical and systemic problems that may affect the
periodontal therapy.
• Supportive period︎ontal care is also of paramount importance for case
maintenance.
 Explaining Treatment Plan to the Patient.

• The following discussion includes suggestions for explaining the

treatment plan to the patient.
1.Be speci︎cf.
2.Begin ︎our d︎iscussion on a positive note.
3.Present the entire treatment plan as a unit.
 Treatment plan (case report)

• A 56-year-old female patient was referred for periodontal treatment.

The general dentist had diagnosed periodontal involvement with
deep pocket formation and increased tooth mobility. He was
willing to place a bridge to replace the missing teeth ︎lower Rt and Lt
6 and asked an assessment of the prognosis of upper centrals.
• The patient’s complaints were as follows:
1. A reduced ability to bite because of increased tooth mobility in the maxillary
anterior area.
2.Bleeding during toothbrushing.
3. Increased sensitivity to cold.


Treatment plan (case report)
 Treatment plan (case report)

• Medical History
• The patient has no reported medical problems. She does not use
medications or drugs and is a nonsmoker.
• Dental History
• The patient visited the dentist once a year for routine recall therapy. The
most recent oral prophylaxis was performed 10 days before the first
periodontal visit. The oral hygiene regimen included toothbrushing with
a manual toothbrush, once a day. The patient was not using any other
hygiene instruments or mouthwashes. She had a negative history of
previous periodontal or orthodontic treatment.



• Oral Examination:

• Her overall oral hygiene status was poor with abundant bacterial pla︎que present,
especially around the distal and lingual surfaces. There were no visible
supragingival calculus deposits because the patient had a dental appointment a
few days earlier. However, subgingival calculus was present throughout. The
patient did not present any pathologic lesions and was not aware of oral malodor.
• There were numerous restorations on the maxillary arch, but no areas of
abrasions or erosions presented. The majority of the teeth were sensitive to
thermal changes.
• There were symptoms of PTM in the anterior region. Diastemas were present
between the maxillary incisors, as well as the mandibular dentition. The patient
confirmed that in the past the position of her anterior teeth was normal and that
her teeth ︎were all touching.︎ The maxillary and mandibular incisors displayed
extrusion, rotation, and facial ︎flaring. There was a pronounced anterior overbite.
• In the posterior region, several teeth had been missing for many years. The most
prominent missing teeth were the mandibular first molars. The patient was able
to function bilaterally even though the first molars were missing.
• Periodontal Assessment.

• To assess the extent of the periodontal disease, a full

periodontal examination was accomplished. The examination
included pocket probing and evaluation of gingival recession
and tooth mobility.
• Extensive periodontal involvement of the maxillary arch.
Periodontal pockets that involved the interdental and lingual
areas ranged from 4 to 6 mm. The majority of the anterior
teeth presented recession that measured 2 mm. Increased
mobility was noted for most teeth, especially tooth ︎31. Most of
the furcations were class I.



 Treatment plan (case report)

• Radiographic Survey
• The panoramic radiograph presented generalized horizontal bone
loss. Tooth lowe RT 6 presented mesial angular bone defect and early
furcation involvement. Several areas presented subgingival calculus.
• Casts
• A diagnostic model was indicated to evaluate the occlusal problem of
the anterior area. A diagnostic model can help to better assess the
occlusion, tooth malposition, and inclination and to visualize the entire
dentition and jaw.


• Diagnosis
• The generalized bone loss and periodontal pockets are due to chronic
periodontitis. The poor oral hygiene and the lack of maintenance
therapy has been a major contribution to the periodontal
involvement.
• The failure to replace the missing teeth, especially the mandibular first
molars, has also created an occlusal problem. Only one crown was
used to replace both teeth ︎5 and ︎4, seriously reducing the occlusal
surface in width. There were few stable occlusal contacts for many
years. On the right side, only tooth ︎31 had occlusal contact, while
only teeth ︎21 and ︎20 were contacting on the left side. Other occlusal
contacts were sliding contacts, which are considered unstable.
• The combination of chronic periodontitis and trauma from occlusion
resulted in the pathologic migration in the anterior region. The
reduced occlusal support caused by the missing mandibular first
molars played an important role in the prognosis.
• Determination of Prognosis
• The prognosis of each tooth was determined individually, taking into account
the patient’s age, disease severity, pla︎que control compliance, and
cooperation, as well as the periodontal and occlusal factors.
• In addition to tooth ︎31, all teeth displaying PTM were considered to be
susceptible to further periodontal breakdown in the future with inadeq︎uate
treatment. The prognosis of these teeth was determined as poor. The
prognosis of the remaining teeth was considered fair because of the reduced
in︎fluence of trauma from occlusion.
• The orthodontist was asked to assess the possibility of orthodontic treatment
in the anterior region to restore a normal occlusal plane and thus reestablish
the contacts.
• Treatment Plan

• The patient received detailed explanation about periodontitis and the

etiologic factors. She was initially surprised but became aware of the
severity of the problem and the negative effects of this disease in the
future.
• The initial therapy was the treatment of the periodontal disease to
reduce the infl︎ammation. It was also realized that neglecting the
occlusal problem would not help improve the prognosis of these teeth.
The orthodontist concurred on the need for orthodontic therapy in the
anterior region. The patient also insisted on saving teeth (upper centrals
and lower RT 6) despite the supereruption.
• Treatment Plan

• The following treatment plan was proposed after considering the

patient’s complaints, wishes, and social situation:
1.︎ Initial periodontal therapy of scaling and root planing
2.︎ Pla︎que control and patient education.
3. Evaluation of the periodontal status after the nonsurgical phase of
therapy.
4.︎ Surgical phase of therapy.
5.︎ Orthodontic therapy.
6.︎ Implant therapy to replace missing teeth .
7. Restorative phase.
8.Periodontal maintenance phase.
 Treatment
• Periodontal Therapy
• The nonsurgical phase of therapy consisted of scaling and root planing
combined with the use of chlorhexidine rinses twice a day for 4 weeks. The
patient’s compliance was excellent after the initial 4 weeks of therapy. The
patient was instructed to brush at least twice a day, using a manual toothbrush in
combination with interdental brushes and dental ︎floss.
• The patient was seen 3 months later for reevaluation, pla︎que control, and
professional prophylaxis.
• Reevaluation
• The results of the nonsurgical phase were evaluated 6 months after the start of
the initial therapy and resulted in a new periodontal status. The patient’s
motivation remained stable and consistent during the entire 6-month period.
• There was significant generalized reduction of pocket depth. The remaining
periodontal pockets around teeth ︎1, ︎2, and ︎11 did not display bleeding on
probing, as well as the other remaining sites. This favourable response to the
nonsurgical phase permitted the initiation of orthodontic therapy.
• Orthodontic Therapy

• The orthodontic treatment plan was to correct the overbite, intrude the
maxillary anterior teeth, and move these teeth back to their previous position.
• They will also be splinted from canine to canine.
• Full-arch fixed orthodontic appliances were placed in both the maxillary and
the mandibular arches. The total duration of the orthodontic therapy was 1
year and 3 months. Only light orthodontic forces were applied.
• During the orthodontic therapy phase, the patient was seen every 3 months for
periodontal evaluation by the periodontist. This was essential to maintain
periodontal health, to monitor progress, and to diagnose any periodontal
changes caused by orthodontic tooth movement. The orthodontist also
reinforced oral hygiene at each orthodontic visit.
• After the removal of the appliances, an orthodontic retention wire was placed
from canine to canine in the maxilla and from tooth ︎21 to tooth ︎28 in the
mandible.
• Implant Therapy
• Two implants were placed 4 months after the start of the orthodontic therapy to
replace teeth lower ︎RT 6 and LT 6. It was possible to start the implant therapy at this
stage because the orthodontist had confirmed that teeth lower Rt 6 and Lower Lt 5
would not be displaced. There was also a possibility of using the implants for
orthodontic anchorage at a later stage if needed.
• Restorative Phase
• After removal of the orthodontic appliances, the dentist initiated the final
restorations on the implants. The addition of two crowns at the first molar sites was
very important to stabilize the occlusion. Conse︎quently, tooth ︎31was stabilized
mesially.
• A panoramic radiograph was taken to determine the effect of the treatment on the
jaw bone and the roots .
• Periodontal Maintenance
• The periodontal maintenance consisted of 3-month recall visits that included
hygiene control, probing, and prophylaxis. Regular maintenance care is
essential in cases that use combined therapy to assure case stability.
• One year after the termination of orthodontic treatment, a new periodontal
recording and panoramic radiographs were obtained to evaluate the
periodontal status. The result of these examinations presented a stable and
healthy periodontal status.
• Results and Discussion
• Periodontal therapy alone was not sufficient for the preservation
of her dentition in the anterior region. The excessive PTM in this
area could not be neglected. To improve the long-term stability of the
dentition, both periodontal and orthodontic therapy was necessary.
• The facially ︎altered teeth could be successfully aligned into a better
position, which allowed for the splinting of the anterior dentition.
• Replacing the missing mandibular first molars was necessary to
assure occlusal stability. Moreover, the periodontal maintenance
during the orthodontic treatment was necessary to avoid any further
bone loss.
• Besides improving the prognosis of the anterior teeth, an esthetic
improvement was noted at the gingival level. The recessions on the
buccal side of the maxillary incisors were reduced significantly, and
in some areas, it was completely eliminated. The closure of the
diastema between teeth ︎8 and ︎9 allowed for the regeneration of the
interdental papillae.
• Results and Discussion

• The final result was considered satisfactory not only for the clinician
but also for the patient. The patient was especially pleased with the
esthetic outcome. The main goal of periodontal therapy was the
preservation of the dentition and treatment of periodontal disease. This
was achieved without surgical therapy.
• The cooperation of the patient played an important role in the
outcome of treatment. The patient reported a significant improvement
in mastication compared to her situation before the treatment.
Sensitivity to thermal changes remained unchanged.
BONE DESTRUCTION CAUSED
BY SYSTEMIC DISORDERS.

bone loss initiated by local inflammatory processes may be

magnified by systemic influence on the response of alveolar
bone.

This is termed . The bone factor concept .