Treatment Planning & the Diagnostic Wax-up

Treatment Planning & the Diagnostic Wax-up Walt Richardson, CDT

Tuesday, July 16, 13

The Diagnostic Wax-up . . . is the 3D architectural model which brings into reality the 2D blueprint, fulfilling the fundamentals of foundational and occlusal stability.

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network 4. the teeth

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network 4. the teeth • what they look like

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network 4. the teeth • what they look like • the role they play in mastication

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network 4. the teeth • what they look like • the role they play in mastication • the role they play in speech

Tuesday, July 16, 13

The Diagnostic Wax-up Before beginning, one must fully have a good knowledge base of the entire masticatory system:

1. the boney structure 2. the musculature 3. the nerve network 4. the teeth • what they look like • the role they play in mastication • the role they play in speech • how they work together

Tuesday, July 16, 13

ALL THE COMPONENTS OF THE MASTICATORY SYSTEM MUST WORK IN HARMONY WITH ONE ANOTHER TO PROVIDE OPTIMUM COMFORT TO ANY GIVEN INDIVIDUAL. Tuesday, July 16, 13

TREATMENT PLANNING IS THE TWO DIMENSIONAL PLAN FULFILLING ALL THE REQUIREMENTS OF OCCLUSAL STABILITY.

Tuesday, July 16, 13

1. STABLE HOLDING CONTACTS ON ALL TEETH WHEN THE CONDYLES ARE IN CENTRIC RELATION. THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

2. ANTERIOR GUIDANCE IS IN HARMONY WITH THE ENVELOPE OF FUNCTION.

THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

3. IMMEDIATE DISCLUSION OF ALL POSTERIOR TEETH WHEN THE MANDIBLE MOVES FORWARD FROM CENTRIC RELATION. THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

4. IMMEDIATE DISCLUSION OF ALL POSTERIOR TEETH ON THE NON-WORKING SIDE…

THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

5. NON-INTERFERENCE OF ALL POSTERIOR TEETH ON THE WORKING SIDE WITH EITHER THE LATERAL ANTERIOR GUIDANCE OR THE BORDER MOVEMENTS OF THE CONDYLES (IMMEDIATE DISCLUSION IS IDEAL IF ACHIEVABLE).

THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

ALWAYS DETERMINE IF THE PATIENT HAS: 1. ELIMINATED THE NEED FOR THE UNSATISFIED REQUIREMENT THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

ALWAYS DETERMINE IF THE PATIENT HAS: 1. ELIMINATED THE NEED FOR THE UNSATISFIED REQUIREMENT 2. SUBSTITUTED FOR THE UNSATISFIED REQUIREMENT THE FIVE REQUIREMENTS FOR OCCLUSAL STABILITY FROM FUNCTIONAL OCCLUSION BY PETER E. DAWSON, DDS Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions 5. if the patient has any removable prosthetics or present restorations

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions 5. if the patient has any removable prosthetics or present restorations 6. are there any teeth not in contact

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions 5. if the patient has any removable prosthetics or present restorations 6. are there any teeth not in contact 7. are the teeth showing signs of wear

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions 5. if the patient has any removable prosthetics or present restorations 6. are there any teeth not in contact 7. are the teeth showing signs of wear 8. are there mobile teeth

Tuesday, July 16, 13

To satisfy all five requirements, one must first determine the current situation and consider:

1. if the joint is healthy 2. the overall periodontal health 3. if any oral lesions exist 4. are there any carious lesions 5. if the patient has any removable prosthetics or present restorations 6. are there any teeth not in contact 7. are the teeth showing signs of wear 8. are there mobile teeth 9. does the patient bite their lip or cheeks

Tuesday, July 16, 13

1. RELIEVING THE PATIENT OF ANY EXISTING PAIN

A SYSTEMATIC APPROACH TO TREATMENT PLANNING MUST BE ADHERED TO Tuesday, July 16, 13

2. COMPLETELY ELIMINATING ANY INFECTIONS

A SYSTEMATIC APPROACH TO TREATMENT PLANNING MUST BE ADHERED TO Tuesday, July 16, 13

3. MAKE SURE ALL SOFT TISSUE IS COMPLETELY HEALTHY AND MAINTAINED

A SYSTEMATIC APPROACH TO TREATMENT PLANNING MUST BE ADHERED TO Tuesday, July 16, 13

4. RESHAPING TEETH, SUBTRACTIVELY OR ADDITIVELY OR REPOSITIONING TEETH ORTHODONTICALLY OR REPOSITIONING ALVEOLAR BONE OR REPOSITIONING THE SKELETAL BASE A SYSTEMATIC APPROACH TO TREATMENT PLANNING MUST BE ADHERED TO Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are:

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working)

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What are “well impressed” models?

• Use a material that will obtain detail • Capture all possible anatomical features • Provisional matrices and prep guides will fit • Vastly shorten chair time

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow

Tuesday, July 16, 13

What is a facebow?

A facebow is an instrument used to record the maxillary arch with the horizontal axis of the mandible . . .as well as the maxilla to the horizontal or Bonwill plane of the articulator.

Tuesday, July 16, 13

What is a facebow?

There are two basic types of facebow:

1. earpiece facebow

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2. hinge axis transfer facebow

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite 6. xrays appropriate for the situation (full mouth, panoramic, cephlometric, cone beam/CT scans, MRI)

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite 6. xrays appropriate for the situation (full mouth, panoramic, cephlometric, cone beam/CT scans, MRI) 7. periodontal probing chart

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite 6. xrays appropriate for the situation (full mouth, panoramic, cephlometric, cone beam/CT scans, MRI) 7. periodontal probing chart 8. noted observations of the TMJ

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite 6. xrays appropriate for the situation (full mouth, panoramic, cephlometric, cone beam/CT scans, MRI) 7. periodontal probing chart 8. noted observations of the TMJ 9. noted observations of the muscles

Tuesday, July 16, 13

The records needed to properly create a specific treatment for the patient are: 1. well impressed models (two sets: archival and working) 2. facebow 3. CR bite 4. maximum intercuspation (MI) bite 5. protrusive bite 6. xrays appropriate for the situation (full mouth, panoramic, cephlometric, cone beam/CT scans, MRI) 7. periodontal probing chart 8. noted observations of the TMJ 9. noted observations of the muscles 10. diagnostic photographs

Tuesday, July 16, 13

FULL-FACE SMILE shows the relationship of the smile to the face

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

PROFILE determines skeletal tendencies

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

FACEBOW VERIFICATION

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP SMILE captures relationship of the upper smile line to the lower lip

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP HIGH SMILE LINE provides information on embrasures, symmetry of gingival heights, lip hypermobility, and margin placement.

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP “E” POSITION shows relationship of upper incisors to upper lip

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP REST POSITION shows display relationship of incisal plane of lower teeth to lower lip

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

SMILE TEETH APART (CLOSE-UP) displays the silhouette of the upper and lower incisal plane

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

SMILE, HEAD TIPPED DOWN (CLOSE-UP, SHOT FROM THE TIP OF THE NOSE) shows the relationship of the arch form to lower lip

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP PROFILE shows the upper incisal edge position to the inner vermillion border of the lower lip

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

CLOSE-UP MI OCCLUSION (RETRACTED) shows front to back progression

REQUIRED DIAGNOSTIC PHOTOGRAPHS Tuesday, July 16, 13

Articulators - there are two types. . .

ARCON an instrument that maintains a constant relationship between the plane of occlusion and the representation of the condular assembly or arcon guides at any position of the upper member, thus making possible the replication of mandibular movement.

- can either be semi-adjustable or fully adjustable.

Tuesday, July 16, 13

Articulators - there are two types. . .

NON ARCON an instrument with equivalent condylar guides on the lower member and a hinge axis on the upper member.

- can be a simple hinged or average valve articulator.

Tuesday, July 16, 13

Articulators - there are two types. . .

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Articulators - why use them. . .

DIAGNOSIS • occlusal and joint relationships TREATMENT PLANNING • diagnostic wax-up • trial equilibrations - subtractive, additive, or a combination FABRICATION OF PROSTHETIC DEVICES

Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

THE TOOLS NEEDED FOR CREATING THE THREE DIMENSIONAL TREATMENT PLAN OR DIAGNOSTIC WAX-UP Tuesday, July 16, 13

model evaluation Verify CR bite and determine if CR is the desired restorative position.

The foundation must be stable.

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model evaluation Assess any skeletal abnormalities and/or asymmetries of facial features.

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model evaluation Assess the plane of occlusion, both the maxillary and mandibular, and verify with the photos.

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model evaluation Determine if the mandibular incisors are positioned correctly as they relate to the plane of occlusion and alveolar bone – both horizontally and vertically.

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model evaluation Assess the position of the maxillary anteriors – both horizontally and vertically – as they relate to the smile line, inner vermillion border, as well as their position in the alveolar bone.

Tuesday, July 16, 13

model evaluation Assess the occlusal contacts on all teeth and determine if there are any balancing or working interferences present.

Tuesday, July 16, 13

model evaluation Assess maxillary and mandibular anteriors as they relate to all anterior guidance functions: lateral, lateral protrusive, protrusive, end-on function, and crossover.

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model evaluation Determine if recontouring teeth, orthodontically moving teeth, restoring teeth, surgery, or a combination options are necessary.

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THE BASIC WAX-UP shows display relationship of incisal plane of lower teeth to lower lip GENERALLY THERE ARE FOUR TYPES OF WAX-UPS Tuesday, July 16, 13

THE FULL CONTOUR WAX-UP used when improved esthetics and contours are integral in the treatment plan GENERALLY THERE ARE FOUR TYPES OF WAX-UPS Tuesday, July 16, 13

THE CASE PRESENTATION WAX-UP generally used to show the patient the end result of the personalized treatment plan GENERALLY THERE ARE FOUR TYPES OF WAX-UPS Tuesday, July 16, 13

THE ORTHODONTIC WAX-UP helps to visualize the possibilities, available or necessary, when repositioned teeth are an integral part of obtaining optimal results in a given case GENERALLY THERE ARE FOUR TYPES OF WAX-UPS Tuesday, July 16, 13

FIVE ACTION STEPS

the wax-up Before starting – set the pin at the desired VDO.

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FIVE ACTION STEPS

the wax-up 1. Add to or reduce teeth in order to establish the ideal plane of occlusion and arch form.

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FIVE ACTION STEPS

the wax-up 2. Develop the incisal edge positions both horizontally and vertically.

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FIVE ACTION STEPS

the wax-up 3. Develop and maximize centric stops on all possible teeth being restored or repositioned.

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FIVE ACTION STEPS

the wax-up 4. Develop and maximize all anterior guidance function – verifying and eliminating any or all balancing and working interferences.

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FIVE ACTION STEPS

the wax-up 5. Complete wax-up by developing proper tooth contours and anatomy.

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Treatment planning and the diagnostic wax-up integrate all three aspects of dentistry.

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Questions?

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Thank you.

Special thanks to Harriet and Bay View Dental Lab.

Tuesday, July 16, 13