Dr. Andrew Cobb

What may appear as a relatively simple treatment may actually be more than expected and a bit more complicated.

For better or worse, things aren’t always what they seem. Sometimes we find this out the hard way, especially in dentistry. What may appear as a relatively simple treatment may actually be more than expected and a bit more complicated. Changing treatment midstream or having a final treatment not meet expectations are not the best ways for us to relate to our patients. How do we know whether a proposed treatment is actually a straight forward procedure or more complicated?
	The answer starts with a thorough and complete examination of the patient prior to developing a treatment plan or starting definitive treatment. Does the patient appear stable or are there signs of instability? If signs of instability are present, trouble may be lurking if we proceed with treatment before we visualize all possible solutions. Once treatment is initiated we are committed and responsible for the outcome. A step-wise process from comprehensive examination to definitive restorations can ensure predictable success.1

As dentists we are taught first to focus on biologic problems, especially as they relate to decay and periodontal problems our patients may have. We go around the arches tooth by tooth looking for problems and making treatment decisions. For many of our patients this approach works out just fine. For others, who may have esthetic or underlying functional issues as well, looking at the patient tooth by tooth may not be the best option. In addition, once we start treatment on a patient, if things do not go as planned, or fail, it is now our fault in the eyes of our patient. Predictable care starts with a thorough and complete examination.

What is a comprehensive and complete examination? How does it differ from what we may normally do for our patients? A typical examination includes an oral cancer screening, periodontal examination with full probing, restorative charting (going tooth by tooth) and a full series of radiographs. In a comprehensive examination we also look for signs of functional problems by examining the TMJs, masticatory muscles and teeth. We can do this with a TMJ/occlusal examination looking for potential signs of instability in each of these areas. In essence we examine the masticatory system as a whole and not just teeth. Not evaluating the patient completely can lead to incomplete treatment and a myriad of potential problems including chipped or fractured restorations, sensitive teeth, broken teeth, loose teeth, mobility, migration, headaches and esthetic concerns.2

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If the exam process does not identify any functional issues, tooth by tooth treatment planning is fine. On the other hand, if the examination does reveal functional issues and there are esthetic concerns, a different approach may be needed. This may include additional records starting with mounted diagnostic models, a photographic series and a stepwise process to visualize an appropriate treatment plan.

A complete understanding of all areas of dentistry: biologic, structural, functional and esthetic, leads to complete treatment plans and ideal treatment. In identifying patients with instability we can create a treatment plan that addresses all of the diagnosed problems and offers a solution.

Complete dentistry does not mean every patient needs a full mouth rehabilitation. Complete dentistry simply means we take the time to provide our patients with a comprehensive examination looking for signs of instability and then creating a treatment solution that solves these problems with the least amount of dentistry.


	Rosalie’s case is a good example of the differences between a “tooth by tooth” treatment plan and a plan created after a complete examination with the indicated additional records needed to help develop a complete plan.

Rosalie initially presented for a consultation for esthetic dentistry to improve her smile. A comprehensive examination revealed the following:

Rosalie’s chief complaint was that she was unhappy with her smile and was concerned it was deteriorating over time (Figs. 1 and 2).

TM joints could accept loading and there was no history of joint problems.

Muscle palpation was negative and range of motion was within normal limits.

There was wear on the maxillary and mandibular anterior teeth into the dentin-tooth Nos. 7-10/22-27 (Figs. 3 and 4).

There were no areas of decay and periodontal probings were within normal limits.

Other existing restorations were adequate.

CR/MIP discrepancy of 2 mm with a first contact in CR on the maxillary left second molars-tooth Nos. 15/18. From first contact in CR the mandible slid forward 2 mm to MIP (Figs. 5 and 6).

A bruxing habit that contributed to premature wear of the anterior teeth resulting in both a functional and esthetic issues 3 was noted.

Moderate crowding of the mandibular anterior teeth.

In addition there were a number of global, macro and micro esthetic issues that needed to be addressed with proper smile design.4,5

A systematic approach was used to create the 3D pre-treatment wax-up, which enabled us to find the most conservative treatment options and solutions for all of the diagnosed problems (Fig. 7). It also was used as a guide for tooth preparation design and as a template for provisional prototypes.

The staged treatment plan was presented and discussed with Rosalie, and she accepted. The complete treatment plan addressed solutions for all problems noted in the comprehensive examination and differed from what may have been suggested in the tooth by tooth plan (Figs. 8a and 8b). The pre-treatment wax-up and imaging based on the wax-up was used as a visual aid during the treatment review discussion (Figs. 9 and 10). Restorative care proceeded as expected and was completed predictably as presented (Figs. 11 and 12).

Rosalie’s treatment was completed more than five years ago. Since then she has maintained her periodic periodontal maintenance at six-month intervals. The restorations are well maintained and Rosalie is still extremely happy with her smile. There have been no complications.

Predictable successful treatment outcomes are more likely when we identify problems and develop solutions before we treat. The only way to know if our patients have functional issues is if we identify them in the comprehensive examination.

In Rosalie’s case, what would have happened if we had only treated the maxillary anterior teeth and not identified the other functional and esthetic issues? In the absence of a comprehensive examination, it would have been tempting to schedule Rosalie to restore her four maxillary anterior teeth. Would the result have been as predictable and successful? Most likely not and I wouldn’t want to find out the hard way. 
	
	

References
	1. Cranham J, Dupont G., Cobb A. Treatment Planing Functional Esthetic Excellence. The Dawson Academy; St. Petersburg, FL.
	2. Dawson PE, Functional Occlusion: From TMJ to Smile Design. 1st ed. St. Louis, MO: Mosby; 1989:4.
	3. McIntyre F. Restoring esthetics and anterior guidance in worn anterior teeth. J Am Dent Assc. 2000;131 (9):1279-1283
	4. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2011:132(1):39-45.
	5. Chiche JC, Pinault A, Esthetics of Anterior Fixed Prosthodontics, Chicago, IL: Quintessence; 1994:33-73

Dr. Andrew Cobb

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