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 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 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)

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 

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.

References

1. Sivakumar A, Thangaswamy V, Ravi V. Treatment planning in conservative dentistry. J Pharm Bioallied Sci. 2012 Aug;4(Suppl 2):S406-9

2. Brunton P. Integrated dental treatment planning: A case-based approach. Br Dent J: BDJ online 2005;199:120

3. Boon H, Verhoef M, O’Hara D, et al. From parallel practice to integrative health care: A conceptual framework. BMC Health Serv Res 2004;4:15

4. https://www.dentistrytoday.com/ news/todays-dental-news/ item/7289-warn-your-patientsabout-the-risks-of-diy-dentistry accessed 09.18.21

5. Townend GC, Misra S. ‘DIY orthodontics’ – ‘don’t do it yourself’! Dental Update 2021;48:451-6

6. Wadia R. DIY orthodontics. Br Dent J 2021;231:114

7. Kwon SR, Meharry M, Oyoyo U, et al. Efficacy of do-it-yourself whitening as compared to conventional tooth whitening modalities: An in vitro study. Oper Dent 2015;40:E21-7

8. Holden ACL. Consumer-driven and commercialised practice in dentistry: An ethical and professional problem? Med Health Care and Philos 2018;21:583-9

9. Grembowski D, Milgrom P, Fiset L. Dental decision making and variation in dentist service rates. Soc Sci Med 1991;32:287-94

10. Institute of Medicine (US) Division of Health Care Services. Public Policy Options for Better Dental Health: Report of a Study. Washington (DC): National Academies Press (US); 1980. Chapter 5, Dental care expenditures and insurance. Available from: https:// www.ncbi.nlm.nih.gov/books/ NBK222665/

11. Goodwin J. The Role of the treatment co-ordinator. Prim Dent J 2015;4:67-9

12. Booth N. The single-tooth Syndrome. https://www.dentaleconomics. com/practice/article/16387750/thesingletooth-syndrome

13. Hook CR, Comer RW, Trombly RM, et al. Treatment planning processes in dental schools. J Dent Educ 2002;66:68-74

14. Lanning SK, Pelok SD, Williams BC, et al. Variation in periodontal diagnosis and treatment planning among clinical instructors. J Dent Educ 2005;69:325-37

15. Rodrigues AHC. Treatment planning in restorative dentistry and implant prosthodontics. A rationale for developing the philosophy of Total Care. Quintessence Pub Co 2020:1-8

16. Chan AKY, Tamrakar M, Jiang CM, et al. Common medical and dental problems of older adults: A narrative review. Geriatrics 2021;6:76

17. Genco RJ, Sanz M. Clinical and public health implications of periodontal and systemic diseases: An overview. Periodontology 2020;83:7-13

18. Kassebaum NJ, Bernabé E, Dahiya M, et al. Global burden of untreated caries: A systematic review and metaregression. J Dent Res 2015: 94:650-8

19. Van’t Spijker A, Rodriguez JM, Kreulen CM, et al. Prevalence of tooth wear in adults. Int J Prosthodont 2009;22:35-42

20. Nadig RR, Usha G, Kumar V, et al. Geriatric restorative care - The need, the demand, and the challenges. J Conserv Dent 2011;14:208-14

21. Roblee RD. Interdisciplinary dentofacial therapy: A comprehensive approach to optimal patient care. 1st Edition, Quintessence Pub Co; 1994 Jan 15

22. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Misaligned teeth and jaws: Overview. 2020 Jan 16. Available from: https://www.ncbi.nlm.nih.gov/ books/NBK553375/