restorative-dentistry

Treatment planning is an essential component of clinical practice. While some cases can be completed in one or two visits, there are several reasons that patients or clinicians may opt for phasing treatment over an extended period of time.

First, it may allow the patient to financially manage the ideal treatment plan. In the case presented here, the appropriate steps are planned and executed to ensure a predictable outcome.

Second, it may simplify treatment for patients that have physical or psychological limitations, which require appointments that are shorter in duration. Third, it may make it more manageable for the clinician if they are able to treat smaller sections of the mouth at a time.

The inclusion of other disciplines or specialties (orthodontics, periodontics, endodontics, oral surgery or implant placement) may impact the phasing or sequencing of treatment. Their participation in the planning process help to determine whether they participate in the initial phases in order to set up the restorative treatment, or whether their involvement is integrated with the restorative procedures.

A search of the literature reveals almost no research has been conducted in the area of phased or sequenced restorative dental treatment, nor has a clear systematic process to guide novice and experienced dentists been established. [1] With so little written about the proper way to phase or sequence treatment, it is not surprising that clinicians can be confused about how restorative treatment should be phased when it is necessary for any of the reasons listed above.

I have found that the key to success when treating patients is to follow a systematic approach to diagnosis and treatment planning based on the medical model of care. That model emphasizes effective patient-centered care that focuses on communication, shared decision-making and understanding the patient's needs. [2] Goals should be established that incorporate existing scientific evidence and the dentists clinical experience and expertise.

Thoroughly completing the initial phases of treatment will help you successfully achieve predictable outcomes for your patients. The initial phases of treatment include:

  1. Comprehensive Assessment: This incorporates subjective and objective information.
    1. Subjective information includes:
      1. The patient's chief complaint.
      2. The patient's desires and expectations including short and long-term treatment objectives.
      3. If phasing the treatment is anticipated or desired:
        1. Ascertain how committed the patient is to finishing the definitive treatment to determine how permanent you will need to make the transitional restorations.
        2. Clarify the cost implications for the transitional restoration and therapy.
    2. Objective information includes:
      1. Clinical examination
      2. Radiographic examination
      3. Photographs
      4. Diagnostic casts - articulated
      5. Diagnostic wax-up - will this be additive wax only or first stone reduction and then wax-up (allows for greater tooth morphology changes)
  2. Diagnosis: Identify the current condition and the etiology for each problem identified.
  3. Treatment Plan
    1. Identify the desired comprehensive outcome by following facially generated treatment planning concepts.
      1. Establish the maxillary tooth position, tooth proportion, level the gingival heights esthetically, and level the occlusal plane.
      2. Alter the mandibular tooth position to correct the occlusion and the esthetics.
    2. Prioritize the problems based on urgency. The acute problems (pain, infection, caries and TMD) need to be resolved first, but their treatment is based on the comprehensive outcome desired.
    3. Present the ideal or optimum treatment plan and outcome to the patient.
    4. Identify alternative treatment options and any limitations that exist, which would compromise the outcome.
    5. Determine if the treatment will be completed in one set of appointments or phased over a predetermined period of time. The timeline will determine if you do provisional restorations or definitive 'transitional' or 'interim' restorations (i.e. composite restorations that may need to last until treatment is scheduled to be completed).

The following is an example of the order treatment would be phased for a full-mouth rehabilitation:

  1. Initial phases of treatment (includes assessments and preparatory work)
  2. Preparation for restorative phases
  3. Maxillary 6 anterior teeth
  4. Mandibular 6 anterior teeth
  5. Maxillary posterior teeth
  6. Mandibular posterior teeth

In my opinion, any of these steps can be combined, as long as the sequencing remains the same.


restorative

This patient is in need of extensive restorative dentistry and periodontal root coverage.


treatment-plan

Transitional (interim) composite resin bonding on the maxillary 6 anterior teeth to establish the incisal tooth length and the labial contour, to the desired gingival level. This establishes the final crown length. The root area must not be covered with composite.


treatment-planning

Periodontal surgery is performed to coronally advance the gingival tissue over an AlloDerm graft, to cover the previusly exposed roots to the level of the pre-established tooth length.


dental-restorations

Teeth are prepared and provisional restorations made based on which teeth are restored in each phase of treatment.


dental-restorations

All the teeth are restored based on the initial treatment plan.


References:

  1. Tokedo O, Walji M, Ramoni R, White JM, Schoonheim-Klein M, Kimmes NS et al. Treatment planning in dentistry using an electronic health record: implications for undergraduate education. Eur J Dent Educ [Internet]. 2013 Jul; 213(1):15-9.
  2. Institute of Medicine reports composite summary [cited April 10, 2014]. Institute of Medicine [Internet]. Retrieved from http://www.acmq.org/education/iomsummary.pdf.

Robert Winter, D.D.S., Spear Faculty and Contributing Author