Nothing Lasts Forever: Case Planning for Easier Future RetreatmentsBy John Carson on March 15, 2021 | 1 comment
If you could, would you choose to make your life harder or easier? Bear in mind, in life there are always challenges to overcome, which can lead to a sense of personal satisfaction and achievement.
Still, I bet no one would choose to make their life harder for the sake of self-punishment. Nevertheless, there are instances when we do not take the time to fully think through our decisions and we end up regretful. As dentists that could implicate our patients.
In treatment planning cases, there are two critical principles to incorporate into your plan that will help you and your patient avoid unnecessary challenges down the road and will make life easier on everyone.
Principle 1: Plan for re-treatment
The first key principle when treatment planning is to plan for future retreatment and to make it as easy as possible because at some point in your patient's life, nearly everything will need to be redone or retreated.
For example, is the post you are considering really needed? Don’t use a post just because you can. It may, among other things, make re-treating the endodontics much harder down the road.
Is keeping your tooth preparations and materials thicknesses as close to ideal as possible? Cutting off a 3-mm thick zirconia crown is a lot harder than one of an ideal thickness. A tooth preparation with crazy contours and/or other odd features will be a lot harder to section a crown off of than a preparation with more ideal contours.
Combine a crazy tooth preparation and a thick crown and you’ll have a tough situation waiting for you in the future.
Look at this abutment and implant crown in which some porcelain fractured off (Fig. 1). How much easier would life have been if the implant was positioned at an ideal angle at the time of placement? A lot.
What if the screw came loose? You would have to go though at the same angle. Instead of making an access to tighten the screw and close the access, you would have to make at least a new crown.
Now, I understand you can’t always have ideal angulation, but my point is when you can it’s best to take the time to achieve it. If you’re not placing your own implants, which I would venture to say is the case for most restorative dentists, it’s worth having a conversation about angulation and future access with the surgeons.
Place as much Teflon (or whatever you use) as you can over the implant screw to protect it from cement or composite and pack it tight. For example, in Figure 1 there was only a small amount of cotton over the screw.
When I dropped into the screw channel the piece was so small I had to dig out a lot of cement only to discover I wasn’t even close to being parallel to it. If a larger amount of Teflon or cotton had been used this would have been easier and faster to fix.
Finally, when removing bone for crown lengthening, consider how it will impact future implant placement if that tooth is lost.
Principle 2: Keep clear records and chart notes
If you have record of and know exactly what implants are where, then life is much easier than having to figure out what you are dealing with via radiographs alone.
It’s more important than ever to know if a screw is regular or angled to determine which driver to use. Beyond putting the details in your chart notes consider using colored Teflon tape over the screw to guarantee you will stop and think, “This is colored tape, so I need an angled driver.”
Keeping note of the kind of cement or bond used for a crown is also a good idea when it comes time to remove it. Always try to plan and prepare for future options, for instance:
- For fixed hybrids, think about what you would do if you had to remove a bunch of bone, used all the available implant sites, and/or an implant fails?
- If you crown lengthen that tooth, especially if you have to do a lot of crown lengthening, consider how it will affect the chances of doing an implant in the future?
- What happens when that large roundhouse bridge fails?
The point is the decisions we make in treatment planning today affect what we may have to deal with in the future. Often small investments in upfront planning can pay big dividends in the future.
John R. Carson, D.D.S., is a member of Spear Visiting Faculty and a contributor to Spear Digest.
March 24th, 2021