Chapter 1 SHAH

1

Why comprehensive diagnosis and treatment planning?

Comprehensive diagnosis involves subjective and objective evaluation of patient characteristics, including periodontal health, remaining teeth, tooth structure, pulpal health, temporomandibular joints, esthetic concerns, oral hygiene compliance, availability of restorative space, and medical history [1]. It includes evaluating all the factors that are relevant to formulating a diagnosis and treatment plan [1]. Integrated treatment planning involves developing a comprehensive treatment plan that collaboratively integrates various disciplines [2, 3]. The intent is to find optimal ways to treat patients, factoring in all the disciplines. When working with dental specialists, a collaborative approach with a common goal is vital to treatment success. There are two perspectives regarding comprehensive diagnosis and integrated treatment planning. The first one involves the patient, and the second one is relevant to the clinician; however, both have some common undertones.

Patient perspective

Many dental practitioners are concerned about the fact that some of the fastest-growing “dental practices” in North America do not have dental professionals practicing in them [4]. An individual can go online, order a do-it-yourself (DIY) impression kit, and start orthodontic aligner therapy without ever meeting with a qualified dentist [5, 6]! Some of the DIY orthodontic companies say they have clinicians evaluating the process prior to sending out the aligners. But what if the case would be better treated with conventional orthodontic brackets and wires? What if the patient also requires periodontal, endodontic and/or surgical procedures? Patients must understand the risks and compromises of forgoing those consultations and the lack of integrated care.

Why is it that an individual can walk into a mall or tanning salon and have random people perform teeth whitening with no dental training [7]? It is because most patients feel that

dental treatment is a commodity and not a true healthcare procedure [8]. Would they be able to go to the mall for medical treatments such as a biopsy, knee injury, or cancer treatment without seeing a physician or healthcare provider? What is it about dentistry that has led dental practitioners down the path of being a commodity, based on price rather than expertise? Did they do this to themselves or did the market do it to them? It probably is a combination of the two.

How often does a dental receptionist receive calls from patients asking the following questions?

 “How much is a crown?”

 “How much for a root canal?”

 “How much do veneers cost?”

 “How much is a cleaning?”

Most of the time, these calls are answered by quoting a price without even thinking about what the caller’s (patient’s) requirements/diagnosis would be. Would an orthopedic surgeon quote a fee for a knee replacement without knowing the condition of the knee and what treatment might actually be required? The more these types of behaviors are encouraged, the more they perpetuate the notion that all our training, knowledge, and skill boil down to very little. Most dental practitioners fear losing a patient to another office, which is the most likely reason for discussing pricing over the phone even though most practitioners understand that each procedure requires their expertise in diagnosing and treatment planning and may be associated with different clinical and patient-related factors [9]. Not all veneer restorations are the same, nor are all direct restorations. Some patients are happy with a restoration that looks “white” even if we use only one shade. Others want something natural and inconspicuous, which may require artistically blending three to four shades. The time required to complete each restoration is different, and therefore treatment costs and time will vary from one restoration to another.

Dental insurance companies further endorse patients’ perception of dental procedures as a “commodity” rather than a healthcare service. Although these companies allow patients to defray some expenses, all procedures are distilled down to a dollar value based on statistics and the proposed norms in the industry, with little to no regard for clinical judgment, expertise, and complexity of treatment [10]. Thus, many patients assume that the value of a procedure is based on the compensation they receive from the insurance provider.

Dental professionals in many ways have “lost” their way in connecting and communicating value for what they can provide as healthcare practitioners. They are so focused on wanting to do every treatment that they get lost as to what they are truly there for. For efficient time management, many dental practitioners appoint “treatment coordinators” for explaining and discussing the treatment plan with the patients [11]. The treatment coordinators often commoditize the treatment procedures during patient consultation appointments. Their lack of

training precludes them from efficiently discussing oral health problems and their possible solutions. Dental practitioners should minimize delegating these tasks as they are in the best position to help patients understand their problems and the available treatment options. If a treatment coordinator is appointed, the dental practitioner should discuss details of the treatment plan with the coordinator before it is presented to the patient.

Dental practitioners are in a healthcare profession, and for that reason, they should not compromise on the “care” part. Care ideally pertains to clinicians being involved in the treatment from start to finish and beyond. It is important to educate patients and make them understand the value of comprehensive dentistry in creating a more stable and long-lasting result as opposed to being reactive to a single problem. This can help change the perception of dentistry in the minds of their patients.

Dentist perspective

How can dental practitioners change the perception of dentistry from a commodity to value-based profession? This can be accomplished by using their minds, evidence, and expertise to create value in everything they do. Treatment planning is an integral part of any practice, but there are varying interpretations of what that might look like when you speak to different clinicians [1]. Often, there is a “disconnect” between what is seen and the actual “bigger picture” [12]. A dental school setting may present challenges in teaching students how to perform a comprehensive diagnosis and formulate an integrated treatment plan for patients [13]. There are so many disciplines to learn and requirements to complete that it is difficult for dental students to comprehend the benefits of comprehensive diagnosis and treatment planning [13]. The situation is further complicated by the presence of a variety of full-time and part-time instructors, each with his/her experience and biases [14]. Dental students are trained to fix teeth by treating caries, inflammation, and fractures. When a dental student sees a patient with a history of repeated fracture of a Class IV composite restoration, instead of thinking about the cause of the repeated fracture, the student most likely starts working on redoing the composite restoration. Most dental students are too focused on “what they can do” and not “why the condition arose” or “how it could be further prevented.” As a result, most young dentists are trained to provide adequate “single-tooth” dentistry for the average patient but not comprehensive care [15]. Their dentistry becomes mechanical as they are more focused on the reactive or reparative approaches rather than a preventive approach.

There is an increased incidence of periodontal disease, caries, wear, crowding, drifting, fractured or missing teeth, temporomandibular joint (TMJ), and muscle dysfunction in today’s patient population due to longer life expectancy [16-20]. Furthermore, people continue to want to look and feel younger, eat properly, and have a beautiful smile. Missing teeth, loose

dentures, and worn teeth are no longer acceptable to most patients. Part of the daily challenge is differentiating the “forest from the trees.” Dental practitioners often have blinders on and focus on what they recognize easily instead of looking at the bigger picture or asking, “Why did this condition arise?” Patients’ problems vary from missing teeth (Fig. 1.1) to lack of tooth display when they smile, excessive tooth wear (Fig. 1.2), and dissatisfaction with their smile (Fig. 1.3) [16, 19]. Most of these conditions cannot be treated with a “tooth by tooth” approach as it would force the practitioner to ignore the underlying problems that may have led to the current condition [12].

To understand the value of comprehensive diagnosis and integrated treatment planning, it is important to understand the terms unidisciplinary, multidisciplinary and interdisciplinary dentistry (Fig. 1.4) [21].

Unidisciplinary Dentistry

 Unintegrated Dx and Tx planning

 Ignorance of other disciplines

 Minimal collaboration

Multidisciplinary Dentistry

 Awareness of benefits of other disciplines

 Unstructured collaboration

 Separate goals

Interdisciplinary Dentistry

 Working common knowledge (“think alike”)

 Structured collaboration

 Common goals

Adapted from R. Roblee, DMD

Figure 1.4. Comparison of unidisciplinary, multidisciplinary, and interdisciplinary dentistry [21]

“Can you replace

Figure 1.2. Severe wear with several missing teeth and a collapsed bite

“I don’t show teeth when I smile”

Figure 1.3. Missing teeth and large interdental spaces affect the patient’s smile

“I hate my smile; I’d rather have a denture”

Unidisciplinary dentistry

Unidisciplinary dentistry implies primarily single-tooth dentistry or utilizing only one discipline to treat a condition, even when other disciplines might help to improve the outcome [21]. Integrated diagnosis and treatment planning are absent; other disciplines are not considered; and there is no collaboration among dental practitioners/specialists. Most young dental graduates start off practicing “single-tooth” reparative dentistry and unidisciplinary dentistry [21]. There is minimal or no involvement of other disciplines in the treatment plan, and collaboration among dental practitioners is non-existent. The following three cases are examples of unidisciplinary dentistry.

CASE 1 “How about a quick fix?”

Age: 29

Sex: Female

Chief complaint: “I don’t like my smile, but I don’t want braces”

Medical history: No significant medical history

Periodontal assessment: AAP type II, Grade A with some infl ammation and plaque. Gingival recession associated with lower anteriors

Function/TMJ: No clicks, no joint pain, no functional limitations, good range of motion. 2 mm overbite, 7 mm overjet, 44 mm maximum opening

Tooth structure: No restored teeth

Esthetics: Severe crowding, uneven smile

Clinical scenario: The patient was not happy with her teeth and her smile (Figs. 1.5a, 1.5b).

She wanted a conservative and quick treatment. She had declined an orthodontic consultation

Problem list:

1. Unattractive smile

2. Severe crowding

3. Excess overjet

4. Uneven gingival zeniths

5. Dark buccal corridors

6. Occlusal plane asymmetry

7. Gingival inflammation

8. Gingival recession on lower anteriors

Treatment plan: Direct composite veneers on teeth

7, 8, 9 and 10

Summary of treatment performed: A unidisciplinary treatment with four direct composite veneers was provided to correct the shape and alignment of the four maxillary anterior teeth (Figs. 1.6a, 1.6b, 1.7a, 1.7b)

This was primarily additive to preserve the remaining tooth structure. This fulfilled the patient’s desire to improve her smile and avoid orthodontic treatment.

Figure 1.5(a). Patient’s smile

Figure 1.5(b). Pre-treatment frontal view

There was minimal discussion of the benefi ts of orthodontics, but not soft tissue grafting, and other restorative procedures

Treatment analysis: The patient’s problem list indicated that many issues needed to be addressed, not just one. Not all the problems were of concern to her, and some were not even evident. However, it is important to address all the conditions on the problem list and explain the implications of not correcting them to the patient. Patient education through consultations with

specialists would have facilitated understanding the risks and benefits of treatment choices.

Since the patient’s main concerns were esthetics, it would be prudent to draw her attention to the way overall function, facial esthetics, and occlusion could be improved by straightening the teeth. She could be educated regarding the benefits of orthodontic treatment [22, 23]. It could also be explained that periodontal maintenance would be easier with well-aligned teeth. A periodontal consult would help address the gingival recession and the benefits of grafting [24] 

Figure 1.6(a). Post-treatment occlusal view

Figure 1.6(b). Post-treatment frontal view

Figure 1.7(a). Pre-treatment smile

Figure 1.7(b). Post-treatment smile

CASE 2

Age: 35

Sex: Male

Chief complaint: “I have Bugs Bunny teeth, and I’m getting married in two months”

Medical history: No significant findings

Periodontal assessment: AAP type II, Grade A with some inflammation and plaque. Gingival recession associated with lower anteriors

Function/TMJ: No clicks, no joint pain, no functional limitations, good range of motion

Tooth structure: Two direct composite restorations

Esthetics: Poor shape and form of maxillary anterior teeth, evidence of tooth wear, black triangles

Clinical scenario: The patient did not like the appearance of his smile and wanted a change before his wedding (in

two months.) He had undergone orthodontic treatment in the past and although he could benefit from retreatment, he was not interested. He was happy with the color of his teeth but did not like the shape of his central incisors and their dominance within his smile. He asked for veneers to change the shape of his two front teeth and wanted them to be less triangular and prominent

Problem list:

1. Unattractive smile

2. “Triangular” teeth

3. Prominent central incisors

4. Wear on multiple teeth (bruxer?)

5. Uneven gingival zeniths

6. Narrow buccal corridors

7. Occlusal plane asymmetry

8. Gingival recession in multiple areas

9. Black triangles (large interdental spaces) (Figs. 1.8a, 1.8b)

10. Poor root inclination (Fig. 1.9)

Treatment plan: Porcelain veneers on teeth 7 to 10 and direct composite bonding on the maxillary canines

“My big day is coming up soon!”

Figure 1.8(a). Pre-treatment smile

Figure 1.8(b). Pre-treatment smile

Summary of treatment performed: Porcelain veneers were fabricated and placed on teeth 7 to 10, and two direct composite fillings were placed on the maxillary canines to improve their shape and balance the smile (Figs. 1.10a, 1.10b) [25]. The treatment helped fulfill the patient’s desires and needs prior to his wedding

Treatment analysis: The patient’s chief complaint was related to the shape of his teeth and their prominence within his smile framework (Fig. 1.11). Orthodontics would have been the ideal treatment recommendation for this patient as it would have helped improve the overall smile, occlusion, and function [22, 23]

The narrow buccal corridors could have been addressed well with orthodontics (Fig 1.12). Temporary esthetic procedures, including teeth whitening and composite build-ups to change the shape of the teeth in the cervical region, could have been accomplished prior to the wedding. Before initiating orthodontics in this situation, it would be best to additively bond composite material to the teeth to optimize their shape so that the orthodontist would be able to move the teeth and roots into a more favorable position (Fig. 1.13) [26]. The bone support could be assessed using a cone-beam computed tomography (CBCT) scan [27]. A periodontal consult would help address the gingival recession and benefits of soft tissue grafting (Figs. 1.14a, 1.14b) [24]

Figure 1.9. Pre-treatment radiograph of anterior teeth. Notice the inclination of the roots

Large black triangle due to root inclination and crown shape

Figure 1.10(a). Post-treatment frontal view, retracted

Figure 1.10(b). Post-treatment smile

Figure 1.11. Superimposition of a radiograph showing root inclinations in combination with the shape of the clinical crowns. Note: The root inclinations led to a narrow contact area and the formation of black triangles

CASE 2 > continues

This approach would provide the optimal treatment and patient outcome. However, for some patients, if

they don’t have a gummy smile, this may not be an issue (Fig. 1.14b) 

Narrow buccal corridors

Figure 1.12. Retracted view highlighting narrow buccal corridors within the circles

Widen contact area by changing shape

Figure 1.13. Changing the shape of the teeth by additive restorative procedures

Gengival recession & uneven zenith heights

Figure 1.14(a). Retracted viewing showing one area of gingival recession and uneven gingival heights

Figure 1.14(b). View of unretracted smile shows that cervical areas of the teeth are not visible

CASE 3 “I never smile”

Age: 53

Sex: Female

Chief complaint: “I haven’t smiled since my wedding day”

Medical history: History of breast cancer, occasional consumption of anti-inflammatory medications

Periodontal assessment: AAP type III, Grade A with minimal inflammation, furcation involvement, and minimum plaque

Function/TMJ: No clicks, no joint pain, no functional limitations, good range of motion

Tooth structure: Restorative procedures were performed on many of her posterior teeth

Esthetics: Crowding, misaligned teeth, reverse smile line (Figs. 1.15–1.18)

Clinical scenario: Crowding and missing teeth

Problem list:

1. Unattractive smile

2. Severe crowding

3. Uneven gingival zeniths

4. Discolored teeth

5. Peg laterals

6. Dark teeth due to amalgam show-through

7. Occlusal plane asymmetry

Treatment plan: Porcelain veneers on teeth 6 and 11 and individual crowns on teeth 7 to 10

Figure 1.15. Pre-treatment full-face smile

Figure 1.16. Pre-treatment smile; reverse smile line and uneven occlusal plane

Figure 1.17. Pre-treatment frontal view in maximal intercuspal position (MIP)

Summary of treatment performed: Porcelain veneers placed on teeth 6 and 11 and individual crowns placed on teeth 7 to 10 [25]. The treatment instantly changed her appearance and made her very happy (Figs. 1.20-1.22)

Treatment analysis: Based on the problem list and the patient’s facial esthetics, orthodontic treatment would have been very beneficial for improving her smile [22, 23]. It would have helped conserve tooth structure and correct the reverse smile line, occlusion, and teeth alignment [22]. It would have allowed for staging treatment and replacing older alloy materials at a pace the patient would be comfortable with. The maxillary anterior teeth were vital and healthy. To accomplish the

restorative treatment, a large amount of their tooth structure was removed (Fig. 1.23). The final smile shows an improvement in the esthetics and proportions of the teeth, but there are still enhancements that could make the smile better. The arch is still narrow on both sides, which could be improved by orthodontics or additional restorative procedures (Fig. 1.24)

The treatments rendered in all three cases were perfect examples of unidisciplinary dentistry [21]. Their features included non-integrated diagnosis and treatment planning, no use of other disciplines, and no collaboration among dental practitioners. Patients with misaligned teeth, missing teeth, and esthetic concerns are seen very frequently in a dental practice. Most

Figure 1.20. Post-treatment smile

Figure 1.21. Post-treatment frontal view

Figure 1.18. Pre-treatment right lateral view in MIP

dental practitioners quickly choose a restorative option for treating these conditions, thereby overlooking other issues that may need attention [15]. However, it is important to consider other treatment options, including orthodontics, as they might contribute favorably to the outcome. It is important to perform a comprehensive diagnosis and formulate an optimal integrated treatment plan with more than one option for every patient [1, 15, 21]. It is critical to point out conditions that could negatively impact a patient in the future if they are not addressed. Dental practitioners should not only address missing teeth, misaligned teeth, and unesthetic smiles but also try to improve the overall oral health of their patients [28] 

Figure 1.24. Posterior buccal corridors are dark and lack symmetry

Figure 1.23. Anterior tooth preparations

Figure 1.22. Post-treatment full-face smile

Multidisciplinary dentistry

Multidisciplinary dentistry implies that multiple disciplines are utilized for treating a patient [21]. However, there is no integrated execution of the treatment plan. Collaboration among clinicians and the laboratory is unstructured and the goals of each discipline are not necessarily common [21]. The following two cases are examples of multidisciplinary dentistry.

CASE 4 “I want implants!”

Age: Over 50

Sex: Female

Chief complaint: “I don’t like my upper denture and want implants!”

Medical history: Non-contributory health history

Periodontal assessment: AAP type III, Grade A with minimal inflammation

Function/TMJ: No clicks or joint sounds

Tooth structure: Many large restorations

Esthetics: Chipped and discolored teeth, poor esthetics, missing teeth, evidence of tooth wear, large embrasure spaces

Clinical scenario: This patient presented with a desire to improve her smile by replacing her partial upper denture with dental implants (Figs. 1.25–1.27)

Figure 1.25. Pre-treatment frontal view of the teeth and partial denture

Figure 1.27. Pre-treatment left lateral view; note the discolored teeth, mismatched shade of partial denture, and unsightly clasps

Figure 1.26. Pre-treatment right lateral view; note the discolored teeth, mismatched shade of partial denture, and unsightly clasps

Problem list:

1. Unhappy with esthetics

2. Maxillary partial denture

3. Multiple missing teeth

4. Discolored teeth

5. Failing prostheses

6. Gingival recession

7. Large embrasure spaces

8. Lack of posterior occlusal stops

9. Misaligned teeth

Treatment plan: Six implants were planned in the maxillary arch to replace teeth 4, 7, 10, 11, 12 and 13. Individual non-splinted crowns were planned on the implants to enable the maintenance of oral hygiene [29]. Full coverage restorations were planned on teeth 5, 6, 8 and 9. A cast partial denture was planned to replace the posterior missing teeth of the mandibular arch

Summary of treatment performed: Because of the less than ideal positioning of the implants in the locations of teeth 10, 11, 12 and 13, the implant crowns were splinted to optimize the esthetics. Full coverage restorations were placed on teeth 5, 6, 8 and 9. A cast partial denture was made to replace the bilateral missing posterior teeth in the mandibular arch (Figs. 1.28, 1.29)

Treatment analysis: Limited communication between the surgeon, restorative dentist and lab technician was the major reason for suboptimal implant placement

[30], which resulted in the display of metal collars (Figs. 1.30, 1.31) and necessitated splinting of the implants (in the locations of teeth 10, 11, 12 and 13). The implant positions were more cervical compared with the remaining teeth because of bone resorption (Fig. 1.32). The unavailability of CBCT at that time made implant planning and placement very challenging. As a result, the implant restorations were not predictable and had suboptimal esthetics. However, the patient’s low lip line covered the display of the unesthetic areas when she smiled. There was a step in the occlusal plane after treatment which was not a concern to the patient (Fig. 1.33).

Dental practitioners must decide the type and design of the restoration prior to implant placement and plan the implant position and angulation based on the design of the definitive restoration [30]. A thorough clinical examination must be performed along with mounted diagnostic casts and interocclusal records. A diagnostic wax-up incorporating the proposed missing teeth should also be made. Surgical guides should be fabricated for optimal implant placement [30]. A CBCT scan should be taken to assess and plan the optimal implant positions [31]. It is important to educate surgeons to place implants not only based on the location of the bone but also based on the design of the definitive prosthesis [30]. After developing an appropriate treatment plan, it is prudent to convey the restorative goals to the laboratory and the surgeon. It is also critical to discuss the surgical or restorative concerns with the patient before initiating treatment [32] 

Figure 1.28. Definitive restorations

Figure 1.29. Post-treatment smile

Figure 1.30. Display of metal collar due to suboptimal implant placement

Implant angulation compared to natural teeth

Figure 1.31. Poor angulation of the implants created some restorative challenges

Implant positions in bone/arch

Figure 1.32. The implant positions were more cervical compared with the remaining teeth because of bone resorption

Figure 1.33. Step in the occlusal plane

CASE 5 “I don’t want to remove my teeth at night”

Age: 20

Sex: Female

Chief complaint: Missing teeth

Medical history: Non-contributory medical history

Periodontal assessment: AAP type II, Grade A, good oral care, no concerns

Function/TMJ: No clicks or significant functional issues

Tooth structure: Minimal restorative treatment done

Esthetics: Numerous congenitally missing teeth and over-retained primary teeth. Gingival zeniths were uneven and tooth proportions were unbalanced

Clinical scenario: The patient came in for a consultation to discuss dental implant placement. She did not have any esthetic concerns and was generally happy with her smile. She had several missing teeth

and a removable prosthesis that she did not like (Figs. 1.34a, 1.34b, 1.35). She did not desire fixed partial dentures because they would require the removal of vital tooth structure (explained to her by her previous dentist). Teeth 8 and 9 had a cant and divergent roots (Fig. 1.36). The patient reported that she had recently completed 4.5 years of orthodontic treatment, which had been initiated to position the teeth in optimal locations for implant placement. However, the clinical images and the radiographs demonstrated that there were retained primary teeth, and the some of the existing root positions were not conducive to implant placement (Figs. 1.37, 1.38)

Treatment plan: This case shows one of the great pitfalls of “multidisciplinary” dentistry: a lack of structured collaboration among various dental specialists/practitioners [21]. In this case, the lack of communication between the restorative dentist/oral surgeon and the orthodontist resulted in a less than ideal result. The tooth roots and teeth positions were not conducive to implant placement.

Figure 1.34(a). Initial smile with the prosthesis

Figure 1.34(b). Frontal view with the prosthesis

Figure 1.35. Smile without the prosthesis

Figure 1.36. Frontal view without the prosthesis; note the root trajectories of the central incisors

Figure 1.37. Occlusal views of both arches. Note the missing teeth and the over-retained primary teeth

Ratained primary teeth with no permanent underneath

The distance between the two roots is insufficient for an implant but acceptable for a pontic

Roots diverge

Figure 1.38. Root inclinations preclude optimal implant placement

To accomplish the desired treatment, consultations with an orthodontist and an oral surgeon were required to correct the tooth positions for optimal implant placement. In addition, the following factors were assessed and analyzed during the treatment planning stage:

1. Type of prosthesis (fixed or removable): In this case, the patient had stated that she did not want a removable restoration. She wanted to preserve the remaining teeth/tooth structure; therefore, she declined the option of fixed partial dentures. If she requested a fixed bridge, it would be prudent to discuss the risks and benefits of this treatment compared with dental implants. It is important to inform the patient regarding the need for tooth structure removal to fabricate a fixed partial denture. In addition to the conservation of tooth structure, other factors such as ease of oral hygiene maintenance, periodontal and restorative condition of the abutment teeth, and bone quantity and volume present in the edentulous area should also be considered in the decision on the type of prosthesis [30, 33].

2. Position of teeth and roots: It is important to evaluate whether the teeth and roots are in a favorable position to permit optimal restoration and/or implants. The roots must be located 1.5-2.0 mm

away from the implant body for an optimal result [34-36]. It is also critical to assess the prosthetic space availability prior to initiating prosthesis fabrication [37] The prosthetic space available appears adequate in the pre-treatment photos, but as shown in the radiographs, the spaces are not conducive to ideal implant placement (Fig. 1.39)

3. Bone quality and quantity: It is important to assess the bone quality and bone quantity prior to the placement of implants [38]. However, it should not be the only determining factor. All implant placements should be restoratively driven, i.e., based on the design, type, and position of the definitive prostheses [30]. Restoratively driven implant placement can be easily accomplished using CBCT, implant planning software, and a diagnostic wax-up [30].

4. Oral hygiene status and periodontal condition: It is important to focus on improving oral hygiene and/ or periodontal health before initiating restoration or implant placement [39]. It is critical to educate the patient regarding his/her oral hygiene status and periodontal condition.

5. Esthetic desires and treatment goals: This can be very subjective as each patient has his/her conceptions regarding esthetics. It is important to understand what the patient’s esthetic desires are and whether they can be fulfilled or not. A facially gen-

Figure 1.39. Retracted laterals views in MIP

erated treatment plan helps achieve an optimal esthetic solution [40]. The utilization of photos, videos, mock-ups, and digital designs helps patients visualize the treatment result.

6. Economics: Talking about cost can be awkward, but it is a reality for most people to consider finances [41]. If finances are an issue, asking the patient for an approximate budget can help structure the conversation and the treatment plan. Many patients cannot afford expensive treatment at one time, but they can manage it over a few years. Treatment options can be staged to treat the patient as per their needs. It is important to anticipate potential questions or scenarios and be ready to address them while dis-

cussing the treatment options with the patient. The presence of other specialists would also be very beneficial during the planning stage and the treatment discussion with the patient. When considering a combination of orthodontics, oral surgery, and restorative treatments, it is important to have a clear understanding of the desired result and discuss it with the specialists [30]

Summary of treatment performed: An interdisciplinary approach combining orthodontics, oral surgery, and restorative dentistry was selected for this patient to prevent the issues faced earlier and provide optimal care 

Interdisciplinary dentistry

Interdisciplinary dentistry implies a working common knowledge so that all providers have the same goal in mind [21]. There is structured collaboration and communication throughout the treatment. It entails having the awareness of the benefits of other disciplines. The specialists provide treatment with structured collaboration to ensure that the treatment goals are in alignment with those of the restorative dentist.

CASE 6 “Missing teeth” (continuation of multidisciplinary case 5)

Age: 20

Sex: Female

Treatment plan: An interdisciplinary approach was selected for this patient to prevent the issues faced earlier and provide optimal care

Treatment steps: In view of the patient’s concerns and desires, a diagnostic wax-up was fabricated for her (Fig. 1.40). It helped assess and address esthetics, tooth positions, prosthetic space availability, tissue heights, implant positions, the need for grafting, and the desired occlusion [42]. A periodontal consult was sched-

The first phase of treatment included initiating conventional orthodontic treatment (Fig. 1.41). The oral surgeon and the restorative dentist monitored the progress of the treatment to provide guidance on root positioning for the implant and restorative treatment (Figs. 1.42, 1.43) [35, 36]. Once the desired prosthetic spaces were achieved through correction of the root inclinations, the final phase of the orthodontic treatment was initiated (Figs. 1.44, 1.45). At this stage, all refinements in teeth position were made. Another diagnostic wax-up was created to help visualize the final position of the prosthetic teeth. This wax-up was used to fabricate a surgical guide that directed the implant placement (Figs. 1.46, 1.47)

uled to discuss correction of the gingival zeniths; however, the patient was not interested in correcting them

Keys to success: During the initial meeting with the oral surgeon and orthodontist, treatment goals were reviewed along with the diagnostic wax-up, images, and radiographs. The goal was to ensure that all the treating dental professionals would visualize the same endpoint and work in a structured and collaborative manner.

Figure 1.40. Diagnostic wax-up

Figure 1.41. Conventional orthodontic treatment

Figure 1.42. Initial root positions at the start of orthodontics

Figure 1.44. Final positioning of teeth prior to completion of orthodontics

Figure 1.45. Final position of teeth in maximum intercuspation before completion of orthodontics

Figure 1.46. Diagnostic wax-up created following orthodontic treatment

Figure 1.47. A surgical guide was provided to the oral surgeon to guide implant placement

Figure 1.43. Progressive radiographs used to assess root positioning

The implants were placed by the surgeon using the surgical guide [43]. Following 6 months to allow integration, the implants were uncovered, and restorative procedures were initiated. Implant abutments were tried in the patient’s mouth to verify fit, occlusal clearance, and symmetry (Fig. 1.48), followed by fabrication and placement of implant restorations in the patient’s mouth. The laboratory was instructed to fabricate another wax-up on the casts to idealize tooth proportions (Fig. 1.49). The wax-up was used to guide the placement of direct restorations on the natural teeth. The final restorations were a combination of composite and porcelain restorations (Figs. 1.50, 1.51)

Treatment considerations: Several factors, including the type of prosthesis, esthetic desires, oral hygiene, periodontal condition, quantity and quality of bone, the position of teeth and roots, and finances, must be taken into consideration to achieve a predictable treatment result [30, 34-41]. The restorative dentist is the architect of the treatment plan [15]. It is paramount that the restorative dentist constantly communicate with the other specialists and regularly monitor the patient to ensure that the treatment proceeds as planned [15] 

Figure 1.48. Implant abutments were tried in the patient’s mouth

Figure 1.49. Diagnostic wax-up created following orthodontic treatment

Figure 1.50. Frontal view of implant crowns, veneers, and direct composite restorations

Figure 1.51. Final smile

CASE 7

Age: 25

Sex: Female

Chief complaint: “I hate my smile. I’d rather have a denture!”

Medical history: Allergy to metabisulfites, otherwise non-contributory

Periodontal assessment: AAP type II, Grade A, healthy, good oral care

Function/TMJ: No clicks or functional problems

Tooth structure: Healthy, only one previously restored tooth

Esthetics: Missing maxillary lateral incisors, hates her smile

Clinical scenario: The patient was extremely con-

scious and unhappy with her smile (Figs. 1.52-1.55). She had numerous dental consultations and was even ready to have her teeth extracted and wear a denture. She was missing maxillary lateral incisors and had disporportional spacing between the teeth

Problem list:

1. Very unhappy with her smile

2. Misshapen teeth

3. Space appropriation issue

4. Missing laterals

5. Midline off

6. Mal-aligned teeth

7. Tooth wear

Treatment plan: Diagnostic impressions and interocclusal records were taken. The casts were mounted on an articulator using the interocclusal records. The photographs, radiographs, and mounted casts were used to formulate a comprehensive treatment plan for the patient. The optimal treatment option for this patient included orthodontics to align the teeth appropriately

“I’d rather have a denture”

Figure 1.52. Pre-treatment full-face smile

Figure 1.53. Pre-treatment close-up of smile

in the arch, followed by implant and restorative treatment [35, 36]. Orthodontic treatment would help optimize spaces for implants to replace the missing laterals, which could be followed with restorative procedures to improve esthetics. The patient did not wish to pursue orthodontic treatment and asked for quicker options like veneers. The patient was advised that her teeth were not spaced appropriately, and direct restorative/ implant treatment would lead to less than ideal results. She was also educated regarding the risks of significant tooth reduction and the possible need for endodontic treatment if restorative treatment was chosen without orthodontics. She was also told that proceeding directly with the restorations might not even correct the alignment completely.

During the treatment discussion, the patient noticed the wear on her teeth on the casts (Fig. 1.56). She was

advised that the wear would continue over time because of improper positioning of the teeth in the arch [44]; therefore, orthodontic treatment was recommended to correct the improper positioning of the teeth. Although she was hesitant to pursue orthodontic treatment, she eventually consented to it. She understood that the risks of not having orthodontic treatment included significant removal of tooth structure, risk of endodontics, less than ideal tooth positions, and possible esthetic compromise. The patient chose not to have dental implants to replace her missing laterals, but knew that it would be an option in the future. The final treatment plan included orthodontics to level and align the teeth in the arches and establish proper occlusion followed by restorative procedures. It is important to ensure that patients understand the risks, advantages, and disadvantages of all the treatment options offered to them. It is important to explain the risks and benefits of accepting treatment, and it is critical to explain the risks of not accepting the recommended treatment. An interdisciplinary approach combining orthodontics and restorative dentistry was selected for this patient

Summary of treatment performed: The orthodontic treatment was started for the patient (Fig. 1.57). During the orthodontic treatment, the orthodontist asked the restorative dentist to reshape the teeth with direct restorative materials to a more ideal proportions

Figure 1.55. Pre-treatment panoramic radiograph depicting lack of space for direct replacement of two lateral incisors

Figure 1.56. Lower arch cast highlighting wear on the lower incisor; note that it is out of alignment

Figure 1.54. Pre-treatment frontal view in maximal intercuspal position (MIP)

to permit proper spacing between the teeth (Fig. 1.58) [26]. The final position of the teeth and roots permitted ideal implant placement (Fig. 1.59). The final teeth positions and occlusion were perfectly aligned for replacing ideal-sized lateral incisors (Fig. 1.60) The patient was provided with a variety of options to replace her lateral incisors. She chose direct fiber-reinforced composite restorations to replace the miss-

ing laterals. They were conservative as they required minimal tooth reduction and provided her with eight years of service (Figs. 1.61, 1.62). They were later replaced with ceramic fixed partial dentures (Figs. 1.631.65). Despite being in treatment for several years, the patient was very happy with the treatment. She was placed on a regular periodontal maintenance intervals (Fig. 1.66)

Figure 1.57. Initial orthodontic records for patient

Figure 1.58. Mid-treatment bonding to help the orthodontist visualize the final shape of teeth for proper alignment of roots

Figure 1.59. Final panoramic radiograph showing space created for replacing optimally sized lateral incisors

Figure 1.60. Final position of teeth and arches in maximum intercuspation

Figure 1.62 Smile with direct composite fi ber-reinforced restorations

Figure 1.61. Direct composite fiber-reinforced restorations as a medium-term solution

Treatment analysis: Fixed partial dentures increase the biomechanical risk of healthy abutment teeth. Dental implants to replace the laterals and conservative veneers on the centrals and laterals would help preserve tooth structure. Alternatively, the laterals could be replaced with single-winged porcelain pontics, which could be bonded to the lingual surface of the central incisors 

Figure 1.64. Final restorations and treatment photos in MIP

Figure 1.65. Patient’s smile with the definitive prosthesis

Figure 1.66. Patient’s full-face image five years after treatment

Figure 1.63. Final restorations and treatment photos with teeth apart

Summary

The goal of this chapter was to show that comprehensive diagnosis and treatment planning can help dental practitioners provide an enhanced level of care for their patients [1, 15]. The types of cases presented in this chapter are situations that most dental practitioners will routinely see in their practices. Prior to initiating the fabrication of restorations, it is essential to prepare a thorough diagnosis and treatment plan in every case [1]. An “interdisciplinary” treatment approach helps us provide optimal care for our patients [15, 21]. There are different ways to treat every situation, but structured collaboration is paramount to achieve a predictable result.

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