Prosthetically Driven Treatment Planning – Common Clinical Scenarios

What happens at the clinic?

Let me begin with a common clinical scenario…

A patient comes to you with a complaint of pain in lower right first molar, 46. You examine the patient clinically followed by a radiographic examination. The tooth is diagnosed with a peri apical infection. You then go ahead and follow the obvious treatment plan…

Root canal treatment >>>tooth preparation >>>crown of patients choice

Sounds familiar?

Next day, patient comes back to you with a dislodged crown. How many of you are guilty of encountering a similar situation at least once in your clinical practice? I know I have…

Now you start wondering, where you have gone wrong?

Trying to find the cause for the crown dislodgement, you realize that the reason for failure is a short clinical crown height. This important factor was neglected in the first appointment.

You went for the obvious route failing to take into consideration the prosthetic or the restorative aspect of your case leading to a compromised treatment outcome.

But why didn’t you think of that earlier…? How can you prevent this from happening again?

The answer is simple: Prosthetically driven treatment planning!

Prosthetically driven treatment approach for the case presented would be as follows…

Chief complaint >>> Examination >>> Diagnosis >>> Treatment goal (Consider factors like Restorability, periodontal issues, prognosis)>>> Managing the peri-apical pathology with RCT >>> Crown lengthening procedure >>> tooth preparation >>> best crown options suggested by the dental practitioner for the case (Monolothic crown; preferably sintered or milled crown for superior fit)>>> Occlusion check and adjustment at bisque stage>>>Crown cementation

Tooth Based Dentistry vs Patient Based Dentistry

We all have different ways to manage a case, mostly based on our knowledge and experiences. Treatment planning is the core of a successful dental practitioner. Being able to comprehensively treatment-plan a case is the most important principle in dentistry.

Traditionally, treatment was performed with the intent to solve a specific problem described by the patient of a specific tooth. This concept of treatment proved to be inefficient and, at times, detrimental to the patient, especially on a long-term basis as it simply offered a segmented type of care in which only one tooth, quadrant, or arch was treated without any concern for the patient as a whole.

However, our focus has now shifted to a more interdisciplinary comprehensive approach to treatment, always considering the patient as a whole. Prosthodontics helped me shift my perspective from a single tooth approach to to a more holistic and comprehensive approach, be it a simple case like the example above or a complex case requiring a full mouth rehabilitation. It helps you plan for any future complications that may arise. You may not be a prosthodontist, but you can definitely develop a prosthodontist’s way of thinking.

Prosthodontics as Architecture

Imagine you want to construct a house, what is the first thing that you would do, even before laying the foundation? PLAN and DESIGN a blueprint of your house. Correct?

That is the stage where you put down your vision on paper keeping in mind important things like the aesthetics, form, durability and the requirements of the residents.

Similarly, in dentistry, Prosthodontists develop treatment plans and synchronise treatment sequences with dental/medical specialists as well as with general dentists in order to provide the most comprehensive treatment plan to the patients. They are considered as the “architects” the oral cavity.

They don’t just worry about a single tooth; they consider and care for the entire mouth.

Top 6 Clinical Scenarios for Prosthetically Driven Treatment Planning

Continue reading if you would like to learn more about common clinical scenarios requiring pre-prosthetic correction or assessment prior to definitive treatment plan for predictable outcomes.

1) Endodontics

Endodontic therapy lays a foundation for the creation and maintenance of successful prostheses. From a prosthodontic perspective, root canal treatment is necessary not only for routine crown and bridge procedure but also for more complex removable prosthodontic options like tooth-supported overdentures. Timely execution of root canal therapy and prosthetic rehabilitation helps in improving the function, phonetics and esthetics promoting a better prognosis.

Fig. 1A represents a flowchart to consider for your endodontic cases, while 1B represents issues to consider for prognosis.

2) Periodontics

The principal purpose of periodontics is to create a sound foundation where the final prosthesis is placed. Of all disciplines within modern dentistry, periodontics and prosthodontics have the strongest and the most intimate connections.

3) Orthodontics

The factors governing the need for orthodontic treatment depend on position of missing and adjacent teeth, amount of space, amount of overjet and overbite, tooth morphology, type of malocclusion, facial pattern etc. As a clinician, evaluate if orthodontic tooth movement will improve the prosthetic treatment goals and outcome.

Fig. 3 shows common case scenarios in which pre-prosthetic orthodontic treatment would help achieve a successful prosthetic outcome.

In reverse, post-orthodontic prosthetic treatment may also be required in rare cases where perfection is priority. For example –

• minor occlusal adjustments which may prevent relapse (occlusal equilibration)
• minor diastema closures (lumineers/veneers)

4) Implant Dentistry

Implant-supported restorations have been widely accepted as predictable treatment modalities for partially or fully edentulous patients. Proper implant position and angulation facilitates the construction of an optimal restoration and is critical for its long-term success. Prosthetic-driven implant planning allows clinicians to surgically place implants more accurately, predictably, and efficiently.

Fig. 4 represents the steps involved in prosthetically driven implant placement using a simple surgical template while Fig. 5 shows a prosthetically driven implant approach using a more advanced and accurate surgical guide.

Fig. 4 – Steps for prosthetically driven routine implant placement using a simple surgical template.

Fig. 5 Prosthetically driven implant planning using a more advanced and accurate surgical guide.

5) Esthetic rehabilitation

A comprehensive esthetic treatment plan enables you to visualize the final outcome from biologic, functional, and esthetic perspectives. Given below are seven steps of esthetic treatment planning that ensure good biologic, functional, and esthetic outcomes.

Steps for predictable esthetic outcome.

1. Facially-generated esthetic treatment plan – Parameters involving facial midline, dental midline, interpupillary line, incisal edge position etc.
2. Diagnostic wax-up, mock-up, or trial smile (3-D visualization of the plan)
3. Interdisciplinary procedures- Orthodontic tooth movement/ Periodontal crown lengthening/ site development and implant placement
4. Controlled and conservative tooth reduction using preparation guides (APT concept), keeping the final outcome in mind
5. Creation of lifelike temporaries that provide functional and esthetic data
6. Use of the matrix and stents during fabrication of the restorations
7. Cementation of the restorations.

6) Occlusion

Occlusion plays a very important role in any restorative dentistry case, regardless of whether it involves a small Class I composite restoration, a single crown, multiple crowns, or veneers. The dentist should also consider whether the patient has undergone any form of orthodontic treatment. In all patients, look for signs of occlusal discomfort, like –

• Tooth wear
• Gingival recession
• Mobility
• Tooth sensitivity
• Tooth/restoration fractures
• Fremitus/vibrations
• Abfractions
• vertical bone loss secondary to generalised periodontitis
• Pain in Joint/facial muscles

Other jaw-related questions must be considered as well.

• Are there any airway issues?
• Does the person sleep well, or does he or she snore?
• Has he or she ever dealt with any TMJ related discomfort, pain, popping, locking, or noises?
• Does he or she suffer from frequent headaches?

During the treatment planning phase, a thorough occlusal analysis should be considered to determine if the occlusion needs to be altered to improve the forces on the teeth.

Conclusion

Prosthetically driven treatment workflows can be reliable tools to predictably solve the problems of each individual patient. Dental practitioners often become focused on the execution of the treatment without having treatment goals in place that are specific enough and without any clear end point. This leads to compromised treatment, with unpredictable results and unmet patient expectations.

When each discipline takes the time to understand the strengths and challenges of the other, together they can formulate a treatment plan that will culminate in a successful result.