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September 2008 | Dental Products Report
Everyday Dentistry

It’s all part of the plan

When it comes to treatment planning comprehensive prosthodontic cases, there’s plenty for general practitioners to consider.

By Dr. David A. Felton

This column is sponsored by Ivoclar Vivadent. Our goal is to provide you with information that will assist you with your everyday dental techniques.

It is critical that all dentists, dental specialists, and laboratory technicians work as a team to ensure their patients receive complication-free, expedited, outstanding treatment. For this reason, the prosthodontist or restorative dentist and dental laboratory technician must be involved in diagnosis and treatment planning from the beginning of the case, not after other treatment has been attempted or completed.

In terms of the overall “treatment care team,” the restorative dentist or prosthodontist should be the quarterback of patient care, collecting and providing sufficient diagnostic information for consultation with other specialists. This enables all parties to clearly identify the ultimate treatment goal and develop a plan to achieve that goal. This encompasses how to coordinate respective treatments and therapies among the various specialty groups.

Creating a road map

The complex patient’s three Treatment stages

  • Control phase of therapy (including caries control/periodontal therapy/pulpal therapy, extracting hopeless teeth, orthodontic treatment, and replacing missing/extracted teeth with transitional removable partial dentures as needed)
  • Reassessing the patient’s condition after control phase, developing the diagnostic wax-up as well as a definitive plan of care with proper treatment sequencing
  • Completing the definitive phase of care, consideration of providing a post-treatment occlussal guard and developing an appropriate recall interval for follow-up and maintenance care

The diagnostic wax-up should be considered all-important to this process, as it provides a “road map” for upcoming dental care. Before a diagnostic wax-up can be developed, the restorative dentist or prosthodontist must obtain accurate clinical records. These should include and may require the use of:

  • Charting
  • Periodontal probing
  • Assessing all aspects of edentulous ridges
  • Assessing the existing dentition (pulp health/status, periodontal and occlusal status, caries assessment, occlusal plane analysis, etc.).
  • High-quality clinical and intraoral photographs. These photographs provide all team members with good data for assessing cosmetics and occlusal plane orientation, as well as wear characteristics and other aspects that cannot always be ascertained from examining a cast on an articulator.
  • Preliminary impressions for development of diagnostic casts. This requires good impression trays and impression materials (Accudent for removable prosthesis/Virtual for fixed prosthesis).
  • Facebow and use of a semi-adjustable articulator. Using an adjustable and semi-adjustable articulator (Stratos) enables the clinician and/or laboratory technician to articulate the diagnostic casts in a way similar to what patients present with. This is critical to simulating actual functional jaw movements and assessing the patient’s ultimate goal of therapy—whether it’s single or multiple crowns (IPS Empress), implant therapy, a fixed or removable partial denture (BlueLine), or some other combination of restorations (IPS e.max).

Ultimately, the dentist needs to consult with the laboratory technician to discuss treatment goals so diagnostic waxing can be completed on the articulated diagnostic cast. However, a combination of records and considerations are required for treatment planning (e.g., using an articulator and a facebow; intraoral photographs; all other diagnostic information).

What to look for

Here are some patient parameters you should analyze when it’s time to make treatment decisions:

Occlusal characteristics. These dictate the types of materials that would or should be used when fabricating the patient’s restorations (porcelain-fused-to-metal, zirconia based). For example, are there sufficient pairs of opposing posterior teeth that can hold and stabilize an occlusion, or does the patient have “posterior bite collapse”? This is a real issue that can lead to premature wear of the anterior teeth.

Wear facets. These may indicate patient habits, such as bruxing or clenching, and may dictate the type of restorative material needed.

Beginning the planning process

How the planning process begins depends on your ultimate treatment goals for the patient, coupled with the patient’s desires and expectations. If you have a patient who needs one crown, the level of planning required will be significantly less than what is necessary for a comprehensive, full-mouth rehabilitation. If you have a patient who needs comprehensive therapy, more time and analysis will be required.

Analysis is key to differentiating one patient’s treatment from another’s. It is important to note that not every patient requiring comprehensive care will present with the same level of problems or complexity.

Exactly when in the process to bring in other specialists for consultation and treatment planning depends upon the patient’s condition. Typically, most clinicians treat periodontal disease early if it exists. In the case of prosthodontics, a periodontally stable oral environment helps determine which teeth are salvageable and which are not. This also is true in terms of the pulpal assessment. Non-salvageable teeth should be removed early in the treatment phase and replaced with transitional removable prostheses if esthetics is a concern. After the initial therapy has been completed and healing has occurred, the diagnostic waxing phase can begin. Clinicians also can arrange consultations regarding cosmetic, occlusal/orthodontic and other needs at this point in the process.

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