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.

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- 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