Treatment planning dental cases is the basis for designing outcomes, creating predictability and providing longevity of restoration. Whether it is necessary to design treatment for a few teeth or many, establishing a plan of action is key to success.
Establishing the plan is the most difficult part for many dentists. The difficulty arises from the inability or lack of confidence to know where to begin the plan.
Frank Spear has always emphasized that the greatest challenge and difficulty in treatment planning stems from problems with tooth position. When the teeth are no longer in a “normal” position, it becomes difficult to visualize where they belong and what is required to get them back to a “normal” esthetic and functional position. It is common for many dentists to examine patients, take study models and photographs and, yet, spend hours “scratching their heads” about how to begin the case and provide a solution.
The biggest obstacle for many dentists is fear. The fear of the restoration fracturing, fear of requiring too much dentistry, fear of not being successful with the outcome and fear of the fees being too great for the patient to accept. These feelings are normal and common.
Cases with tooth wear create the greatest concern for most dentists. Tooth wear is challenging because, in many cases, as the teeth wear, they move out of position. As the wear continues, greater movement occurs and more complexity for solution occurs. It is difficult for many dentists to “visualize” where the teeth need to go for correction.
In the pre-treatment photographs of the two patients included, the excessive wear has resulted in very short teeth. In each of these cases, tooth movement has occurred. Creating an acceptable solution requires that the treatment plan includes tooth re-positioning and restoration. The questions are: how? How much? What direction? Will the restoration last? These unknowns create significant turmoil for many dentists.
The process of Facially Generated Treatment Planning, as taught at Spear Education, is a tool or concept that may be applied to design and outline the overall treatment plan and approach in solving complex tooth wear cases such as these. FGTP involves applying evaluation of Esthetics, Function, Structure and Biology in creating solutions for patient care. Following the EFSB outline provides a structured approach to solving both simple and difficult treatment presentations. Each specific area (Esthetics, Function, Structure and Biology) is evaluated and assessed as being acceptable or unacceptable in each category. This outline is a comprehensive assessment of a condition and provides guidance and understanding to both the dentist and the patient. Facially Generated Treatment Planning is the key to providing long-term predictable dentistry.
But for dentists that may be “paralyzed” in developing a treatment plan for complex cases, there is a simple way, or point of view, to begin the planning process. The step-by-step process of FGTP is necessary for completeness in case planning. Definitive assessment and treatment direction are provided by the FGTP outline. But to establish “a big picture view” of challenging cases, it is helpful to think in terms of what the teeth looked like before the wear occurred.
If you were to replace the missing tooth structure as if no wear had occurred, the teeth contours, shape and size would be different. “Restoring” the teeth (using templates) provides a perspective that gives visualization to the correct contours. These new contours can give guidance and direction to treatment.
As seen in the images with tooth shape templates, the perspective and direction of treatment magically unfolds. The complexity of the cases is reduced and the dentist can now focus on how to re-position the teeth to gain treatment success. The templates and outlines of the teeth may remove the “fears” and difficulty with treatment planning.
The finished cases represented in this article appear below. Complete Facially Generated Treatment Planning protocols were used to plan and restore both cases. Each case was difficult because of the significant tooth wear and subsequent tooth movement. By simply visualizing the missing tooth contours, it reduced the “mental complexity” and provided guidance as to the direction of planning and restoration.
In the Restorative Design Workshop offered here at Spear Education, we discuss the importance of “outcome-based restoration.” This means visualizing the “end in mind” before treatment is initiated. “Simplified” treatment planning involves the same philosophy. Begin “with the end in mind” (establish tooth shape) to develop a plan of action. I hope this article provides a shift in viewpoint that eliminates some fear and procrastination around treatment planning.