When teeth are worn, and the patient has occlusal issues, the treatment planning process becomes much more complex and confusing. Any attempts at determining a treatment plan using the traditional tooth-by-tooth approach only leads to greater confusion and an unclear vision of the end results.

Facially Generated Treatment Planning
Since the early 1980s, I have called the treatment planning process that I use for more complex patients facially generated treatment planning (FGTP). This refers to the fact that tooth position must be planned first, as a key reference for tooth position is the face and lips, hence the name facially generated.^1,2

The FGTP process refers to the sequence of how we, as dentists, treatment plan complex patients; it is not the sequence in which we will treat the patient. The sequence of FGTP is very linear and can be applied to any patient; the sequence of treatment will vary from patient to patient and must be individualized.

The FGTP process consists of 4 separate phases of planning.

Phase 1. Aesthetics: To identify the desired maxillary tooth position, gingival levels, and papilla levels, including an assessment of the mandibular incisors’ position aesthetically as well. The aesthetic phase of planning is similar to the first phase of managing any edentulous patient—one has to position the maxillary teeth and gingiva before the occlusion can be developed.

Phase 2. Function involves developing the oc­clusion, which is now possible since the desired position of the maxillary teeth has been identified. The function component of FGTP involves the assessment of the temporomandibular joints (TMJs) and muscles, as well as any parafunctional patterns the patient may have. The occlusal development involves positioning the mandibular teeth to produce the desired occlusal relationships, overbite, and overjet, against the previously identified maxillary tooth position.

Phase 3. Structure consists of the restoration or replacement of teeth. For most restorative dentists, this is the phase with which they are most familiar, and the one they treatment plan every day in patients who don’t have complex problems. It is also the phase they try to plan first in patients with complex problems—such as severe tooth wear—and then get confused because there isn’t any room to perform restorations. That’s why the structural phase of treatment planning must come after the aesthetic phase and the function phase, because those 2 phases identify the corrections necessary in tooth position, which will then always provide the space needed for the restorations.

Phase 4. Biology incorporates the planning of any endodontic therapy, and any perio­dontal or oral surgery. This phase is evaluated last because the desired tooth position, tissue position, occlusal relationship, and restorative plan all need to be known before finalizing any endodontic, perio­dontic, or oral surgical planning.

Essentially the FGTP process consists of aesthetics, function, structure, and biology as the phases of the planning. Dentists who use the process routinely shortened it to AFSB (or EFSB) when referring to each of the phases.
In the following case example, a patient with significant maxillary and mandibular anterior tooth wear will be used to demonstrate the process.

CASE REPORT
In this patient, the maxillary centrals were retroclined, there was minimal overjet, and he had an almost end-to-end occlusal relationship between the maxillary and mandibular centrals. He had minimal posterior tooth wear and minimal canine wear. In addition, he had no TMJ or muscle issues, and needed no posterior restorations other than the replacement of a lower left first molar. The wear on the anterior teeth was from attrition, not erosion or abrasion, and occurred because he moved his mandible into a protruded position and then into lateral positions. He was aware of doing this during the day at work, and stated it had become a habit he used when stressed; a habit he would be unlikely to stop (Figure 1).

This patient presented the classic challenge for restorative dentists in that he wanted his anterior teeth restored but had no room to place the restorations. It is critical in any wear case to realize that if worn teeth are in occlusal contact with the opposing teeth, there are only 2 possibilities for how that could happen: either the worn teeth erupted, or the patient lost vertical dimension. When there is minimal to no posterior wear, it is unlikely the patient has lost any vertical dimension; therefore, in this patient, my dental team could assume that there had been anterior eruption following the tooth wear, and correcting the tooth position would regain space for restorations (Figure 2).

Figure 1. The patient presented with severe wear of the maxillary and mandibular incisors and minimal posterior or canine wear.	Figure 2. Due to the eruption that occurred as the teeth wore, they were too short, and there was no room to restore them.
Figure 3. The upper lip at rest showed no tooth display.	Figure 4. The proposed changes to the incisal edge position were drawn on a photo, adjusting the incisors to the correctly positioned canines and posterior teeth.

The Aesthetics of Phase 1
The first teeth evaluated in this phase were the same as the first teeth that are set in a maxillary denture: the central incisors. The central position was evaluated using photographs of the patient with the lip at rest, as well as in a full smile.

There is never just one acceptable incisal edge position. In general, it is desirable to show a range from 1.0 to 4.0 mm of the central incisors with the lip at rest. In patients with anterior tooth wear, it is not uncommon to see no anterior tooth display at rest (Figure 3).^3,4 Ultimately, the amount of tooth display at rest is not what determines the final incisal edge position; however, the largest factor impacting the smile is the amount the patient’s lip moves (lip mobility) from its rest position to its highest point in a full smile. For most patients, the range of lip mobility is between 6.0 and 8.0 mm.

In patients with worn anterior teeth, the teeth need to be lengthened, and the clinician can use the amount of tooth displayed at rest and the amount of lip mobility to determine how he or she will lengthen them—by adding to the incisal edge, apically positioning the gingiva, or both. This patient had additional guides for the central incisor position: unworn canines and posterior teeth. Placing the incisal edges so to be well aligned with the posterior teeth would likely also produce an acceptable display at rest and in a full smile.

It is very helpful for the clinician to draw the proposed tooth position changes on a photograph to visualize the planning process. This can be done very quickly on a computer with the patient’s images loaded into programs such as PowerPoint on a PC or Keynote on a Mac. In this case, pre-drawn templates of the anterior teeth were used which could be copied and pasted on the desired image, then resized for that particular photograph. This reduces the drawing process to a few minutes’ time but provides an excellent visualization of the end result. The same drawing can then be shown to the patient to help him or her visualize the changes being proposed.

Once the changes needed for the centrals have been identified, the new central position will now guide the changes necessary for the remaining maxillary teeth, starting with the laterals, then canines, premolars, and finally molars, creating a pleasing arch form and smile-line, determined primarily by aesthetics (Figure 4).

Following the identification of the desired tooth position, the gingival levels for all of the maxillary teeth can be evaluated. Again, starting with the central incisors, the identification of the desired gingival margins involves choosing gingival margins levels that create a pleasing width-to-length ratio for the centrals relative to the chosen incisal edge position. This is usually a ratio between 75% and 80%.5 Using the drawings, it is very easy to measure the width-to-length ratio that would exist after lengthening the incisal edges (in this case, 92% [Figure 5]). The clinician can now redraw the gingival margin levels to a more aesthetically pleasing perspective (in this case, 77%). The drawings gave both the clinician and patient the opportunity to visualize what was necessary, and what the desired outcomes for treatment would be (Figure 6).

Figure 5. Measuring the width-to-length ratio. After the incisal edge position was corrected on the photo, there was still a very short and square appearance to the teeth.	Figure 6. Altering the drawing to depict apically repositioning the gingiva showed the desired final result with a pleasing width-to-length ratio.
Figure 7. The patient’s preoperative smile demonstrated that a significant amount of his lower anterior teeth had worn, illustrating that they had hyper-erupted also.	Figure 8. The initial phase of orthodontics to procline the retroclined maxillary anterior teeth, improving the overjet.
Figure 9. The use of rectangular wire to intrude the maxillary and mandibular incisors.	Figure 10. After bracket removal, note the correct gingival levels and room that was created for the restorations.
Figure 11. The final maxillary and mandibular partial-coverage lithium disilicate (IPS e.max [Ivoclar Vivadent]) bonded all-ceramic restorations, from canine to canine.	Figure 12. Close-up view of the completed maxillary layered lithium disilicate restorations.
Figure 13. The completed lithium disilicate all-ceramic mandibular anterior restorations. Note the absence of incisal embrasures, allowing a smooth lateral movement to minimize chipping.	Figure 14. Final smile. Note the impact of intruding the maxillary and mandibular anterior teeth as compared to the initial smile.

The last part of the aesthetic phase is to evaluate the mandibular anterior position relative to the face. In this patient, the mandibular incisors were very short, yet quite visible in his smile, meaning that if restored to a normal length by adding to their incisal edges and leaving them in their existing position, they would be too tall in his smile, from an aesthetic standpoint. Here it was evident that the mandibular incisors had significantly erupted as they had worn, and like the uppers, would need the gingiva to be moved apically through orthodontic intrusion or crown lengthening surgery (Figure 7).

The Function in Phase 2
Upon completion of the aesthetic phase, the changes in maxillary tooth position and gingival levels have been identified. Alterations necessary in the occlusal relationship can be identified to allow the desired maxillary and mandibular tooth position to be achieved. In this case, increased overjet was needed.

Many times, in anterior wear cases, the teeth have erupted^6,7 but are in a good position in relation to facial lingual position and inclination, and they have an acceptable overjet relationship. In these cases, either orthodontic intrusion or crown lengthening surgery can be used to reposition the bone and gingiva, followed by restorations.

In individuals with minimal overjet, such as this patient, the use of crown lengthening will not correct the occlusal relationship. In this case, the ideal treatment plan to correct the functional relationship would be orthodontics to intrude and procline the maxillary incisors, and to also intrude the mandibular incisors.^8,9

The Structure in Phase 3
This phase is about deciding how to restore the worn teeth; ie, crowns versus veneers, and also what material to choose. In this patient’s case, following the orthodontics, there would be minimal need to reduce the incisal edges of the worn incisors for clearance during tooth preparation, as the orthodontics would have created the necessary space. The restorative plan for him was to use partial-coverage, bonded, all-ceramic restorations, made out of an aesthetic and yet high-strength material such as lithium disilicate (IPS e.max [Ivoclar Vivadent]) to resist his parafunctional behavior.

The Biology of Phase 4
With a clear picture of where this case was headed, the final questions would be whether there was a need for any endo­dontic treatment, periodontal sur­gery, or oral surgery. If the patient accepted the orthodontic treatment plan, there would not be a need for any of the above. If he did not accept ortho­dontic treatment, then crown lengthening would be necessary and, most likely, endodontic treatment as well on the over-erupted incisors so that adequate preparations could be done. However, it is important to recognize that the non-ortho plan could never correct the overjet to an ideal result, which was a significant problem in this patient’s case. The only other alternative would be crown lengthening and opening the vertical dimension of occlusion, meaning that posterior teeth that did not require restorations would need to be restored. In addition, the mandibular anterior teeth would end up significantly too tall in his smile.

Treatment Protocol
The patient accepted the orthodontic treatment plan as the best and most conservative way to go. Orthodontics was begun with straight-wire appliances to procline the maxillary anterior teeth and to start the alignment process (Figure 8). This progressed to rectangular wire to intrude the incisors, using the gingival margins of the canines as a guide for positioning the central gingival levels. The same approach was taken to intrude the mandibular incisors (Figure 9).

Following the removal of the ortho­dontic appliances, the gingival margin levels were now correct, and there was an anterior open bite across the incisors which would provide the necessary space for the restorative phase (Figure 10).
The final partial-coverage, bonded, all-ceramic restorations (IPS e.max) extended from canine to canine in the maxillary arch, and from the mandibular left canine to the mandibular right first premolar. It should be noted that extension to the canines in both arches and mandibular first premolar was done for aesthetic reasons (Figures 11 and 12).

Examination of the final mandibular anterior restorations showed minimal incisal embrasures. This is an alteration that allows patients with protrusive and lateral parafunctional habits to move across the maxillary incisal edges smoothly, with less risk of chipping or fracturing porcelain (Figure 13).

CLOSING COMMENTS
The goal of this article was to present an approach to treatment planning that can help interdisciplinary teams sequence the process of developing plans in a logical fashion for patients with complex problems. This process is particularly effective when used in group treatment planning sessions, such as a study club setting.

In my experience of using and teaching this approach for 3 decades now, FGTP provides an easy-to-follow, logical solution for otherwise challenging problems, particularly with patients who present with significant wear of their teeth (Figure 14).

References

1. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of dental esthetics. J Am Dent Assoc. 2006;137:160-169.
2. Spear FM, Kokich VG. A multidisciplinary approach to esthetic dentistry. Dent Clin North Am. 2007;51:487-505, x-xi.
3. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978;39:502-504.
4. Al Wazzan KA. The visible portion of anterior teeth at rest. J Contemp Dent Pract. 2004;5:53-62.
5. Sandeep N, Satwalekar P, Srinivas S, et al. An analysis of maxillary anterior teeth dimensions for the existence of golden proportion: clinical study. J Int Oral Health. 2015;7:18-21.
6. Craddock HL, Youngson CC. Eruptive tooth movement—the current state of knowledge. Br Dent J. 2004;197:385-391.
7. Ainamo J, Talari. Eruptive movements in teeth in human adults. In: Poole DFG, Stack MV, eds. The Eruption and Occlusion of Teeth. London, England: Butterworths; 1976:97-107.
8. Kokich VG, Spear FM. Guidelines for managing the orthodontic-restorative patient. Semin Orthod. 1997;3:3-20.
9. Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. J Am Dent Assoc. 2010;141:647-655.

Dr. Spear, a dual-trained periodontist/prostho­dontist, earned his dental degree and MSD in periodontal prosthodontics from the University of Washington. He is an affiliate professor in graduate prosthodontics at the University of Washington and maintains a private practice in Seattle limited to aesthetics and fixed prosthodontics with long-time practice partner Dr. Greggory Kinzer. He is the founder and director of Spear Education, and his memberships include the American Academy of Esthetic Dentistry, the American Academy of Restorative Dentistry, the American College of Prosthodontists, the Pierre Fauchard Academy, and the International College of Dentists. He is a former president of the American Academy of Esthetic Dentistry, and he can be reached at via email at info@speareducation.com or via the website at speareducation.com.

Disclosure: Dr. Spear is the founder and a shareholder and employee of Spear Education.

The purpose of this paper is to acquaint the reader, briefly, with the management of the overall sequencing of care and the role of dentistry in this care. The team required for ideal care includes many types of healthcare professionals, and through this case presentation, we will focus primarily on the demands on the dental and craniofacial approaches required. The good news is, given today’s knowledge and skills available to cleft patients, their final outcome can be surprisingly good. We will accomplish this through the presentation of a single patient from beginning to end. There is great variability of timing and treatment for each individual patient, and we will present one patient for illustration.

The early phases of treatment begin at birth, and the infant must reach a sufficient weight to undergo the first procedure: primary lip and palatal repair. This procedure is needed for the child to feed properly and, in addition, it is an important aesthetic step as well.

Figure 1. This 6-year-old boy was born with a unilateral cleft lip alveolus and palate with the characteristic nasal and lip deformities. He had already undergone lip and palatal repair as an infant, and presented with the nasal deformity frequently seen as a sequelae of the defect.

Figure 2. This results in either unilateral or bilateral crossbite. Interruption of the septal contribution to the anteroposterior development of the maxilla often results in in varying degrees of Class III malocclusion and crossbite.	Figure 3. The first phase of dental treatment included orthodontic treatment for posterior maxillary expansion and advancement of the premaxilla, which prepared the cleft site for placement of a bone graft and soft-tissue closure by his oral and maxillofacial surgeon.
Figure 4. The occlusal view before his orthodontic and surgical stage of treatment.	Figure 5. The occlusal view after the orthodontic and surgical stage of treatment. The palatal closure was not completely successful (and was to receive final repair later), but was obturated by his retainer that was worn full-time.

AGE 6 YEARS
Orthodontic Assessment, Expansion, and Bone Graft
This 6-year-old boy (Figure 1) was born with a unilateral CLAP with the characteristic nasal and lip deformities. Treatment in the initial phase for the cleft patient usually starts with posterior maxillary expansion, frequently required because of the compromise of normal transverse maxillary growth due to the absence of a midpalatal suture. This results in either unilateral or bilateral crossbite. In addition, interruption of the septal contribution to the anteroposterior development of the maxilla often results in diminished anteroposterior maxillary growth, resulting in varying degrees of Class III malocclusion (Figure 2); and, the naso-septal defect diminishes nasal growth and projection as well as asymmetry. Expansion of the maxilla is necessary for occlusal improvement, but it is also desirable for other reasons. The purpose of the posterior expansion (usually initiated at ages 5 to 7 years) is to prepare for alveolar bone grafting of the alveolar defect. The purposes of alveolar bone graft placement are for:

• Canine eruption. Bone should be in place as the emerging canine follicle to complete the normal eruption process into the alveolar ridge with adequate bone for reception of the tooth and its long-term maintenance.
• Alveolar continuity. The alveolar bridge is needed for completion of the canine eruption as well as lip support and lateral nasal base support. A desirable element of orthodontic expansion is to over-expand, so that once the graft undergoes healing with resulting loss of volume, the alveolar ridge has adequate height and width. This can be highly variable.
• Nasal base support. As in this case, the left side of the nose is flatter than the right and the nasal tip deviates to the left because of the lack of paranasal bony support as well as alveolar support (Figure 1).
• Sources of grafting materials. Sources of bone grafting materials can include the patient’s own bone harvested from the hip, or other sources such as “bank bone,” or freeze-dried bone, from donors.

Figure 3 reflects the outcome of the orthodontic treatment of posterior maxillary expansion and advancement of the premaxilla, resulting in improved occlusal relations and successful placement of the bone graft by his oral and maxillofacial surgeon (Figures 4 and 5). At this stage, our patient was placed into retention using a maxillary Hawley retainer. Patient compliance is obviously critical for maintenance of this stage of treatment.

Figure 6. By age 12, the patient had additional growth and maxillary constriction resulting in severe crowding with palatally displaced maxillary premolars. These teeth were removed as part of this phase of orthodontic treatment designed to align the teeth for cosmetic reasons, understanding that the Class III growth pattern was eventually going to require combined orthodontic/surgical treatment when growth was complete.	Figure 7. The patient was kept in retention until 19 years of age. At that point, we combined a last phase of orthodontics with orthognathic surgery. This was done to advance the maxilla and chin in order to correct open bite and Class III malocclusion while improving his facial aesthetics. Final palatal closure was also performed during this procedure.
Figure 8. The final occlusal relationships, shown after the final phase of orthodontics and surgery.	Figure 9. The maxillary arch at completion, reflecting palatal closure and arch form after bone grafting. The canine was substituted for the congenitally missing maxillary left lateral incisor.

Figure 10. After appliances were removed, the patient underwent final nasal and lip revision surgery with gratifying results. His smile was adequate; however, after a brief discussion, he was referred to his restorative dentist for porcelain veneers.

AGE 12 YEARS
Comprehensive Orthodontic Treatment
Comprehensive orthodontic treatment is required to achieve normalization of dental alignment for both functional and aesthetic reasons. In some cases, this is the final phase of orthodontic treatment, but in a percentage of cases, the skeletal growth pattern may be unfavorable and could result in a return of negative overjet. This is not because of “relapse,” but instead is a result of insufficient maxillary growth in both the anteroposterior and vertical planes of space. If this occurs, even another stage of orthodontic treatment is required to coordinate with an orthognathic surgical dentoskeletal correction. This arises more frequently in the bilateral CLAP case than the unilateral CLAP patient. In this particular case, severe maxillary constriction resulted in severe crowding, so the palatally displaced maxillary premolars were removed. Of course, this would place the first molar against the canine, but given the amount of treatment and travel required of the family to get to this point in treatment, we judged it to be unreasonable to undertake the amount of treatment required to incorporate of these teeth into the arch. The second phase of treatment was fairly successful, but growth was unfavorable with the patient having developed a Class III dental relationship. Therefore, the patient was again placed into retention (Figure 6) to await maturation, and then to proceed to final skeletal correction with orthognathic surgery.

AGES 16 to 19 YEARS
Further Orthodontic Treatment and Orthognathic Surgery
In this instance, it is important to follow the patient carefully, documenting craniofacial skeletal changes through superimposition of cephalometric head films. The accepted “gold standard” for documenting cessation of growth is to obtain 3 serial head films demonstrating no discernible growth changes before committing to further treatment.

After following this growth for the appropriate amount of time and with appropriate documentation, that growth was finished (Figure 7). After orthodontic alignment for 9 months, the maxillary LeFort I surgery was performed for both maxillary advancement and expansion for occlusal correction and midfacial augmentation. This procedure was executed in a multisegmental fashion to further expand the posterior maxilla and to improve midline alignment. On the left side, the canine was placed into the lateral position to be “lateralized.” The final occlusal relationships, after this final effort, are depicted in Figures 8 and 9.

Figure 11. Post-restorative occlusal view, showing change of tooth shapes (canine to lateral, premolar to canine, and molar to premolar).	Figure 12. Post-restorative retracted view demonstrating how the pressed lithium disilicate (e.max Press [Ivoclar Vivadent]) veneers were used to add incisal length, to alter tooth shape (ie, canine to a lateral), and to give the patient a lighter/brighter smile. Also note how the gingival scallop of tooth No. 9 was improved with minor recontouring.

Figure 13. The final successful functional and aesthetic outcome, reflecting an interdisciplinary effort that spanned during the 12 years of treatment.

Refinement of the Soft Tissue
Once the orthodontic and orthognathic treatments were completed, final nasal and lip refinement were performed by the patient’s plastic surgeon to improve the short upper lip (also referred to as a “whistle deformity”), the nasal asymmetry, and the nasal form (Figure 10).

Addressing and Finishing Smile Aesthetics
In our final assessment, the smile was adequate by many standards. Although the patient and his parents were very satisfied with the orthodontic, orthognathic, and surgical results, they were still interested in exploring further options to improve the aesthetics and overall appearance of the smile. Consequently, the final phase of his interdisciplinary treatment involved a consultation with his restorative dentist.

The clinical examination revealed a very acceptable aesthetic result, considering the difficulty in treating cleft cases, but nevertheless it was determined that some improvements could most likely be achieved. When developing the restorative treatment plan, it was important to establish the goals of treatment and to identify specific smile design characteristics that could be improved while still maintaining a conservative approach to tooth preparation.

The main area of concern involved the maxillary left side, from tooth No. 9 to tooth No. 15. Due to the missing maxillary left lateral incisor (No. 10), there was a midline shift to the left. The gingival architecture of the left central incisor (No. 9) gave the tooth a triangular appearance with an exaggerated mesial axial inclination, creating the appearance of a slight midline cant. The left canine (tooth No. 11) had been orthodontically placed in the missing lateral incisor position, and the first premolar (tooth No. 12) had been moved into the canine position. Since the second premolar (tooth No. 13) had been previously extracted, the first and second molars (teeth Nos. 14 and 15) were actually in the first and second premolar positions. A smile evaluation concluded that, while incisal display and the smile arc were aesthetically acceptable,^1,2 they could be improved by slightly increasing incisal length. Additionally, the color of the teeth was a concern to the patient and he desired a whiter, brighter smile.

The goals of treatment established from the information gathered during the consultation with the family, as well as the clinical exam, radiographs, photographs, etc, were to:

• Improve the gingival scallop of tooth No. 9 to correct the triangular appearance, exaggerated mesial inclination, and slight midline cant
• “Lateralize” the canine (tooth No. 11) to simulate a lateral incisor (tooth No. 10)
• “Cuspidize” the first premolar (tooth No. 12) to simulate a canine (tooth No. 11)
• “Bicuspidize” the first and second molars (teeth Nos. 14 and 15) to simulate first and second premolars (teeth Nos. 12 and 13)
• “Bicuspidize” the right first molar (tooth No. 3) to simulate a second premolar (tooth No. 4)
• Increase incisal display and improve the smile arc by adding incisal length
• Whiten and brighten the smile.

Studies have recognized that the dental midline can deviate by as much as 3.0 mm to the left or right and go unnoticed, as long as it is perpendicular to the horizontal plane.³ Attempting to move the midline to the right (in order to place it in the center of the smile) was not deemed to be necessary in this case and, therefore, was not included in the treatment plan.

Porcelain veneers were chosen as the restorative option because they are minimally invasive and require very little (if any) tooth preparation, while allowing the dentist to conservatively alter the size and shape of a tooth (ie, changing a canine to a lateral incisor) and to convert the natural tooth color to lighter shade. The actual teeth prepared were the maxillary right first molar, first premolar, canine, lateral and central incisor, and the maxillary left central, canine, first premolar, and first and second molars. The desired result was to simulate the appearance of second premolar to second premolar (teeth Nos. 4 to 13); made possible by tooth preparation and by the anatomical shape of the porcelain veneers (Figure 11). The restorative material chosen to fabricate the definitive restorations was pressed lithium disilicate (IPS e.max Press [Ivoclar Vivadent]). The lab team used a cut-back and microlayering technique to provide optimal aesthetics for our patient.

The treatment goals, as outlined, were all accomplished. Patient satisfaction was achieved with some subtle changes that further enhanced an already acceptable aesthetic result (Figures 12 and 13).

CLOSING COMMENTS
The final facial appearance and smile reflects the result of careful interdisciplinary planning and treatment during a 12-year period. This case involved careful planning and coordinated teamwork among the orthodontist, oral and maxillofacial surgeon, craniofacial surgeon, facial plastic surgeon, and the general dentist. What is clearly a most satisfying outcome is a tribute to the family, for their dedication and patience, and to the skill of all the doctors involved.

References

1. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
2. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111.
3. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311-324.

Dr. Dudney is a 1977 graduate of University of Alabama in Birmingham School of Dentistry. He is a member of the ADA, the Alabama Dental Association, and the American Academy of Cosmetic Dentistry; an accredited member of the American Society for Dental Aesthetics; and a Diplomate of the American Board of Aesthetic Dentistry. He has served as a past clinical director for Aesthetic Advantage, the hands-on programs taught by Dr. Larry Rosenthal at New York University and the Eastman Dental Clinic in London as well as the past clinical director for the California Center for Advanced Dental Studies live patient hands-on programs taught in the United States, Canada, and the United Kingdom. Presently, he is the clinical director for the newly formed Pacific Aesthetic Continuum hands-on programs. In addition to teaching hands-on programs, he has presented workshops and lectures at dental meetings and has authored several articles on aesthetic and restorative dentistry. He can be reached at (205) 663-6545 or via e-mail at tedudneydmd@aol.com.

Disclosure: Dr. Dudney reports no disclosures.

Dr. Sarver received his DMD from The University of Alabama School of Dentistry and MS in Orthodontics from the University of North Carolina in 1979. He is a Diplomate of the American Board of Orthodontics, a member of the Edward H. Angle Society of Orthodontists, and a Fellow in both the International and American Colleges of Dentists. In addition to his private practice, Dr. Sarver has authored or co-authored more than 60 scientific articles, 14 book chapters, and his book, Esthetics in Orthodontics and Orthognathic Surgery, was published in 1998. He is also co-author with Drs. William Proffit and Raymond White of the surgical text Contemporary Treatment of Dentofacial Deformity (Elsevier) and is co-author the 4th and 5th editions of Dr. Proffit’s classic textbook Contemporary Orthodontics. His 2-part article, coauthored with Dr. Marc Ackerman, on smile analysis won the 2004 B. F. Dewel Award for the best clinical article in the American Journal of Orthodontics and Dentofacial Orthopedics. He has given more than 300 professional presentations internationally, including both the Salzmann and Mershon Lectures at the American Association of Orthodontists. Dr. Sarver has been featured on NBC’s Today, ABC’s The View, and Fox national news. He can be reached via e-mail at sarverd@sarverortho.com.

Disclosure: Dr. Sarver reports no disclosures.

Factors for Success
When patients are evaluated for an implant restoration, many criteria are evaluated. Some of the factors that affect implant success rely upon patient health factors, which can be systemic or local. The cause of tooth loss can be indicative of the challenges that may present themselves in the surgical and restorative phases of implant rehabilitation. So, it is invaluable to carefully evaluate the existing dentition and assess the current occlusal scheme for canine guidance, group function, and parafunction. The etiology of tooth loss can be further broken down into categories, which may include periodontal pathology, occlusal traumatism, trauma, neglect, and failed dental restorations. Restorations that exceed 50% of the isthmus width may result in failure due to the challenges that forces of mastication pitted against extensive restorations, posts, and otherwise weakened tooth structure, can create.

CASE REPORT
Findings and Patient History
This male patient had a Class I malocclusion with a Class III tendency and an open bite in the bicuspid area. He had reported a Class III bite as a teenager and his orthodontic treatment improved the anterior sextant relationship, making his dental classification Class I, but skeletally he remained Class III (Figure 1).

The patient was an engineer, a large 6-foot-plus male, and he was capable of generating significant force factors due to his size and brachycephalic head and jaw structure. He had been in a car accident that resulted in fractured teeth, jaws, the death of his brother, and severe post-accident depression. Rather than save teeth that may have had a good prognosis, he opted to have these teeth removed. The subsequent edentulation and lack of orthodontic follow-up resulted in a jaw asymmetry, malocclusion, and a significant amount of bone loss in the lower right quadrant.

Figure 1. Retracted view in centric occlusion.	Figure 2. Occlusal view of mandibular arch preoperatively.
Figure 3. Right lateral view of virtual implant placement with abutments.	Figure 4. Occlusal view of planned implant placement.
Figure 5a. SimPlant (Materialise Dental) view of parallel-walled implant, axial and panoramic view of planned implant placement.	Figure 5b. SimPlant view of a smaller profile implant system for comparison.

In an ideal world, the patient should have undergone orthodontics to level and optimize his occlusion. Then, he should have undergone block grafting to allow for larger endosseous implant placement to withstand the forces of mastication his occlusion demanded. Due to the psychogenic factors related to his case, he refused to undergo substantial grafting and refused to wear a lower partial denture.

Is Compromise Acceptable?
If patients are made aware of their situation and the costs, advantages, disadvantages, benefits, and risks of treatment are explained, they are allowed to be a co-partner in the diagnosis and treatment of their situation. In this case, the idea of placing implants in the narrow ridge was discussed after a thorough evaluation of the bone via cone beam (CB) radiograph.

Overall Treatment Plan
A treatment plan was evaluated and agreed upon with the patient to place 3 implants on his lower right and one on the lower left. The 3 implants would be splinted together for strength, and they would be placed in a tripodized configuration, which would increase the strength, stability, and support of the bridge.¹ The patient agreed to nighttime wear of a bruxism appliance to decrease nocturnal parafunction. It should be noted that block grafting would have provided this patient with a more favorable foundation for implant placement, but the patient did not wish to undergo this procedure.

Records and Clinical Treatment Protocol
The records were taken, including study models, face-bow transfer, bite registration, Panorex, CBCT, reformatting by 3DDX (3D Diagnostix), photographs, and a lab-fabricated diagnostic wax-up.

Figure 6a. Implant No. 28 and distance to the nerve.	Figure 6b. Implant No. 29, and proximity to nerve and lingual concavity.	Figure 6c. Implant No. 30 and proximity to lingual concavity.

SimPlant software (Materialise Dental) was used to manipulate the images, which were reformatted by 3DDX. This would facilitate placement of different implant systems to see which design, length, and brand would best serve the patient in his reconstruction given his osseous limitations. The company receives the images from the scanning center, and they reformat the images so that different colors can be attributed to teeth, bone, and implants; masks can be fabricated to help isolate and plan the design of the case prosthetically and functionally. Then, surgical guides can be fabricated that are either for the pilot holes of implant osteotomy, full control Universal guides for 3-D placement of implants in the x, y, and z axes with depth control or bone reduction guides with one of the aforementioned guides. Next, the guides are ordered by 3DDX, and after they are fabricated and returned back to 3DDX for a quality control check, they mail the guide, instructions, and drilling keys (if needed) for the desired surgical guide.

Figure 7. Intaglio of tooth supported pilot drill surgical guide.	Figure 8. Intraoral occlusal view of seated surgical guide.
Figure 9. Permucosal extensions of implants after healing.	Figure 10. Uncovered implants Nos. 28 to 30 prior to master impressions.
Figure 11. Uncovered implant No. 19.	Figure 12. Radiographic verification of impression analogues.
Figure 13. Abutments on cast with soft-tissue model.	Figure 14. Entire arch showing abutments.

Figure 15. Gold fixed bridge and porcelain crown on cast.

Since the posterior mandible is triangular in shape, the base of the available bone will usually be wider than the coronal aspect. This may make the site amenable to ridge spreading, osteoplasty, or augmentation to create a proper foundation for implant placement. In this patient, there is a lack of bone in the buccal shelf area (Figure 2).

The reformatted image of the lower right quadrant shows the proposed implant placement and the abutments (represented by yellow extensions from the osseous crest) (Figure 3). The limited bone height and width, as well as parafunctional nocturnal bruxism, meant that several strategies would be implemented to offset the force factors present. First, utilizing a parallel-walled implant system with reverse buttressing threads, we would increase the bone implant contact, resulting in greater surface area of the implant in contact with the bone as compared to tapered implant designs with nonbuttressed threads.

Next, 3 implants would be used to replace 3 teeth (instead of utilizing 2 implants to support a 3-unit bridge). The implants would be offset in a tripod fashion (as space allowed), to further resist lateral forces (Figure 4). The implants would be splinted together to further increase strength, and the occlusal table would be narrowed to decrease occlusal load. Lastly, the material selection for the bridge chosen by the patient was a full-gold fixed partial denture (FPD). This was accepted to further decrease risk of porcelain failure and decrease occlusal forces and wear to the opposing dentition.

Figure 16. Intaglio of restorations.	Figure 17. Seated gold bridge intraorally with narrowed occlusal table.
Figure 18. Seated PFM crown with slightly narrowed table.	Figure 19. Final radiograph (Panorex) of the seated restorations.

The author placed virtual implants with several different implant systems to visualize their anterior-to-posterior spread as well as the distances to vital anatomy (Figure 5). Each implant was measured from the existing teeth, and distances were recorded to verify intraorally at the time of surgery. The individual implant screen shots were taken to appreciate the distance from the buccal and lingual plate as well as the inferior alveolar nerve and mental nerve and lingual concavity (Figure 6).

After the implants were evaluated for maximal surface area and positioning, a tooth-supported pilot surgical guide was ordered from 3DDX (Figure 7). The decision to utilize a pilot surgical guide was made due to the low tolerance for error, given the patient’s osseous limitations. A universal surgical guide could have been used, but was deemed unnecessary; this was because the pilot guide would provide the location, angulation, and depth of the pilot drill. These initial osteotomies could then be sequentially enlarged to allow for implant placement in a very specific orientation. The use of a universal guide may have increased the overall accuracy of placement, as it gives more specificity within the x, y, and z axes; this should be considered for clinicians who are more comfortable with the added precision this guide affords. The guide was verified for passive fit on the remaining teeth at the time of surgery and all 4 implants were placed precisely according to the Simplant guide (Figures 8 and 9).

A 4-month healing period was uneventful and the implants were uncovered and permucosal extensions attached to optimize soft-tissue healing (Figures 10 and 11). A master implant impression (BioHorizons External Hex Implants), utilizing an open-tray impression technique, was done to optimize the accuracy of the casting for the splinted fixed bridge. Once the impression analogs were affixed to the body of the implants, a radiograph was taken to ensure the analogues were fully seated and the implants had no bone loss or pathology prior to making the cast abutments and bridge superstructure (Figure 12).

The implant abutments were fabricated to optimize the triangular offset (by prescription), and they were delivered with a soft-tissue model and an abutment-seating jig (Figures 13 and 14). This jig was made out of pattern resin (Primotec USA); this resin demonstrates almost negligible shrinkage as compared to other comparable materials. The additional step of a resin try-in was not used, as the accuracy attained in the dental laboratory has allowed the author to forgo this step. It should be noted that a try-in at this stage would allow for sectioning and re-indexing the superstructure, if it were a concern.

Go for the Gold
The 3-unit gold FPD (all-gold bridge on custom cast abutments) and all-ceramic single-unit crown (a PFM bridge with Creation Porcelain) were fabricated with the abutments. At the delivery appointment, the UCLA custom cast abutments were tried in and verified radiographically prior to torqueing them to 35 NCm2 twice (with a 5-minute rest period in between torqueing). The abutment screw holes were covered with TempoSIL 2 (Coltene) prior to cementing the crowns with Smart Cem 2 (DENTSPLY Caulk) (Figures 15 and 16). Smart Cem 2 was chosen because it is a dual-cure resin cement with low-film thickness. The ability to very briefly light cure the resin allows it to be easily removed in a gel stage prior to its complete polymerization. This helps prevent cement from remaining in the sulcus which can lead to peri-implantitis.

Intraorally, it was evident that the occlusal tables were narrowed to decrease load on the implants in centric occlusion (Figures 17 and 18). The ability to utilize canine guidance provided an extra safeguard in this case, given the patient’s jaw asymmetry and lack of bicuspid coupling preoperatively. The final Panorex radiograph illustrates the splinted implants and the cemented prostheses (Figure 19).

CLOSING COMMENTS
While implant placement is a wonderful modality that is increasing in popularity, it should be realized that premature tooth loss (and accompanying bone loss) can and will lead to challenges in implant placement secondary to remaining osseous anatomy and proximity to critical anatomy. These implants should only be undertaken with a knowledge and discussion of the optimal foundational support required for these implants. Some clinicians are utilizing small-diameter implants and hybrid (2.9-mm) implants to address these limitations. Others are utilizing advanced ridge spreading, tent-screw, and block grafting, as well as bone morphogenic proteins with titanium mesh.

This case study illustrates one way to address implant restoration in an osseous compromised situation through the use of implant design, placement strategies, and restoration type and design to optimize this patient’s treatment within the given parameters of care.

Acknowledgement
The author would like to sincerely thank Leszek Rapa, master dental technician, for the technical laboratory work shown herein. It is through the work of dedicated laboratory technicians that doctors can provide optimal care for our patients in an efficient and cost-effective manner.

Reference

1. Bidez MW, Misch CE. Clinical biomechanics in implant dentistry. In: Misch CE, ed. Contemporary Implant Dentistry. 2nd ed. St Louis, MO: Mosby; 1999:303-316.

Suggested Reading
Anitua E, Errazquin JM, de Pedro J, et al. Clinical evaluation of Tiny 2.5- and 3.0-mm narrow-diameter implants as definitive implants in different clinical situations: a retrospective cohort study. Eur J Oral Implantol. 2010;3:315-322.
Baggi L, Cappelloni I, Di Girolamo M, et al. The influence of implant diameter and length on stress distribution of osseointegrated implants related to crestal bone geometry: a three-dimensional finite element analysis. J Prosthet Dent. 2008;100:422-431.
Balshi TJ, Hernandez RE, Pryszlak MC et al. A comparative study of one implant versus two replacing a single molar. Int J Oral Maxillofac Implants. 1996;11:372-378.
Bass SL, Triplett RG. The effects of preoperative resorption and jaw anatomy on implant success. A report of 303 cases. Clin Oral Implants Res. 1991;2:193-198.
Becker CM, Kaiser DA, Jones JD. Guidelines for splinting implants. J Prosthet Dent. 2000;84:210-214.
Blanes RJ. To what extent does the crown-implant ratio affect the survival and complications of implant-supported reconstructions? A systematic review. Clin Oral Implants Res. 2009;20(suppl 4):67-72.
De Boever AL, De Boever JA. Guided bone regeneration around non-submerged implants in narrow alveolar ridges: a prospective long-term clinical study. Clin Oral Implants Res. 2005;16:549-556.
Eckert SE, Wollan PC. Retrospective review of 1170 endosseous implants placed in partially edentulous jaws. J Prosthet Dent. 1998;79:415-421.
Elanchezhiyan S, Vennila K. Narrow ridge augmentation technique for improved immediate oral implant placement. Journal of Dental Implants. 2011;1:97-100.
Ganz SD. Restoring a unilateral edentulous space with an implant supported prosthesis. Implant Soc. 1993;4:2-6.
Ganz SD. Techniques for the use of CT imaging for the fabrication of surgical guides. In: Atlas of the Oral and Maxillofacial Surgery Clinics of North America. Philadelphia, PA: Elsevier Saunders; 2006: 75–97.
Jacobs R, Adriansens A, Verstreken K, et al. Predictability of a three-dimensional planning system for oral implant surgery. Dentomaxillofac Radiol. 1999;28:105-111.
Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with a diagnostic/surgical template and advanced radiographic imaging. J Prosthet Dent. 2003;89:611-615.
Mordenfeld MH, Johansson A, Hedin M, et al. A retrospective clinical study of wide-diameter implants used in posterior edentulous areas. Int J Oral Maxillofac Implants. 2004;19:387-392.
Romeo E, Lops D, Amorfini L, et al. Clinical and radiographic evaluation of small-diameter (3.3-mm) implants followed for 1-7 years: a longitudinal study. Clin Oral Implants Res. 2006;17:139-148.
Sahin S, Cehreli MC, Yalçin E. The influence of functional forces on the biomechanics of implant-supported prostheses—a review. J Dent. 2002;30(7-8):271-282.
Weinberg LA, Kruger B. Three-dimensional guidance system for implant insertion: Part I. Implant Dent. 1998;7:81-93.

Dr. Winter graduated from the University of Minnesota School of Dentistry in 1988. He is a Master in the AGD and a Diplomate in the International Congress of Oral Implantologists, and he holds Fellowships in the Academy of Dentistry International and the International College of Dentists. He has published numerous articles on implant and reconstructive dentistry emphasizing upgradeable dentistry and general dentistry as a specialty. He can be reached via e-mail at rick@winterdental.com for information about his lectures.

Disclosure: Dr. Winter received some material support from 3D Diagnostix.

Figure 1. Patient before treatment, showing 2 missing maxillary anterior teeth with a large bone defect. Figure 2. Periapical radiograph of the bone defect. Figure 3. Facial view of bone and the soft-tissue defect. Figure 4. Occlusal view of the bone and soft-tissue defect.

When reading the most prestigious dental implant publications, it appears that the solution to most of the difficult partial and completely edentulous situations with inadequate bone lies in grafting the defective sites, waiting for healing, placing dental implants, and restoring the defects. In such cases, significant amounts of autogenous bone (the patient’s own bone), allograft (human cadaver bone), alloplast (synthetic graft materials), or xenograft (animal bone) are placed into the defective site.
      There is no question that these procedures are desirable, and sometimes successful. However, the process can be extremely expensive. If the grafting material is autogenous, it is often painful at both the site from which the graft was taken and the site into which it was placed. Grafting large defects can be time consuming, often unpredictable overall, and can sometimes result in a less than perfect aesthetic result. We, as educated dentists, are the most knowledgeable clinicians concerning these situations. Are we providing adequate information to patients to allow them to make an educated and informed decision about their complex therapy? Is informed consent education providing all of the alternatives for such difficult situations being delivered to them? Often, patients see restorative dentists and prosthodontists after the grafting and implant placement has already been accomplished by a surgical specialist. At that late time, there are no alternatives except to proceed with whatever the surgical clinician accomplishing the grafting and implant placement envisioned. The clinical result may range from adequate to disastrous.
      In recent months, we have seen clinical examples that have caused concern about apparent overtreatment or mistreatment. In the following cases, more conservative plans would have been possible and potentially better than those planned:

• Older teenagers with partial anodontia and stable remaining primary teeth treatment planned for removal of all functional and stable primary teeth, extensive iliac crest bone grafting in to all 4 quadrants, placement of many implants into the edentulous jaws, and fixed restorations on both jaws. Each of the jaw restorative rehabilitations had the planned cost of a new automobile. The cost of an entire oral rehabilitation such as this often equals the cost of an average house in the United States.
• Partially edentulous patients with inadequate bone for standard-diameter implants (3 mm or larger in diameter), who were planned for extensive ridge augmentation using chin or ramus grafts; followed by implants, abutments, and crowns; when a simple, predictable fixed or removable prosthesis would satisfy the clinical situation from both a functional and aesthetic standpoint.
• Edentulous senior patients with inadequate bone for standard-diameter implants who were planned for major autogenous bone grafting into the anterior mandible and maxilla, before rehabilitation with removable overdentures; when placement of small, up to 3 mm in diameter, implants would have been ideal in the resorbed, mostly cortical bone that was present.
• Planning for the removal of functional and aesthetically acceptable 3-unit fixed prostheses; grafting of the single tooth edentulous site; and placement of an implant, abutment, and crown; under the guise that an implant in the edentulous single tooth areas would serve the patient better than the currently functional 3-unit fixed prosthesis.
• Planning for an active chemotherapy/radiation therapy patient to remove all remaining teeth, graft defective sites, place 4 implants on each arch; followed by a fixed prosthesis on each arch.
• Planning for placement of single implants between treated, previously periodontally involved mobile teeth. These patients are often in a maintenance stage, but the long-term prognosis for the teeth is questionable. These patients often have several remaining teeth on each arch, several implants between the teeth, and a full-mouth rehabilitation is planned. Removal of the remaining teeth and placing conventional complete dentures or implant supported dentures often satisfies such situations more adequately, less expensively, and with more predictability.
• Planning for 4 or more implants with flattening of the bone on the crest of the ridge, and placing several over 3 mm diameter implants and a fixed prosthesis, when numerous other more conservative treatment plans could be considered.
  The many more examples witnessed over our cumulative years in practice would only add to the anxiety that we have stimulated in you already. The questions related to this article are clear. Should grafting and placement of implants be planned for everybody? Or, should more conventional therapy be accomplished occasionally?

This article is a call for each of us to ensure that our patients are:

• Honestly informed of the numerous alternatives for their complex oral rehabilitation needs;
• Encouraged to consult with other practitioners for their clinical opinions in addition to our own suggestions;
• Convinced that the “best” treatment for their specific situation is eventually chosen in light of their health, aesthetic needs and concerns, financial ability, age, temperament, and psychological well being. They should know that their treatment plan is not based on the highest revenue-producing procedure or whatever may be the most technologically advanced procedure at the time.

It appears that the previously described patients did not have the opportunity to make educated decisions about their therapy, since many of the planned treatments were neither logical nor in the patient’s best interest. For some dentists, the excitement of treating a “big” case and the obvious financial rewards cast a shadow over the patient’s true needs.
      Both of the authors of this article are prosthodontists. And both of us graft defective bone sites and place implants. We agree that in many situations, grafting, healing, implant placement, and restoration constitute the best treatment. However, we also see many cases in which the treatment was excessive; ill-timed; too expensive for the patient or family, causing financial distress; or placed in situations where conventional oral therapy would have actually been better.

Figure 5. Build-ups, tooth extraction of maxillary canine, grafting of canine socket, and tooth preparation ready for healing and provisional restoration. Figure 6. One single-cast unit fixed prosthesis in porcelain-fused-to-noble-metal (John Archibald, CDT). Figure 7. Tissue side of fixed prosthesis. Figure 8. Anterior view with lips retracted. Figure 9. Maximum smile of patient, which does not show any objectionable abnormal gingival architecture.

TREATMENT PLANNING FACTORS: GRAFTING AND/OR IMPLANT PLACEMENT
We will use an actual patient to encourage you to think about treatment planning for difficult cases.
Figures 1 and 2 show the radiographs of a patient who came to us for a “second opinion.” According to the patient, a surgical dentist in our geographic area had removed a single upper anterior tooth, which led to removal of another apparently defective anterior tooth, an autogenous bone graft, and the eventual failure of the bone graft.
      Figures 3 and 4 show the resultant significant bone and soft-tissue defects. A surgical dentist had suggested another extensive bone graft into the defect, some implants and crowns. The patient, an educated and intelligent person, was concerned about more surgery, its expected success, the aesthetic result, and the time involved for the overall procedure. After considerable dentist and staff time expended for “informed consent” (Table), and evaluation of the potential for functional and aesthetic success, the patient decided to have a conventional fixed prosthesis. We agreed with the patient’s decision, feeling that grafting and the other procedures were not in the patient’s best interest, although we could have easily accomplished the other route with more grafting and restoration with implants.
      We agreed to do the therapy. A defective canine was removed and the socket of the extracted canine was grafted with an Alloplast (Bioplant by Kerr) to provide long-term socket and ridge stability for the soon-to-be-made pontic. The other remaining teeth were built up and prepared for the fixed prosthesis (Figure 5). The prosthesis was made in a one-unit casting using high palladium noble metal, with both tooth-colored and gingival-colored ceramic placed on the metal. It was fabricated as shown in Figures 6 and 7.
      The clinical result is shown in a lip-retracted view in Figure 8 and the patient’s highest natural smile is shown in Figure 9. Only the upper teeth including the premolars were included in the fixed prosthesis. The mandibular teeth and the maxillary molars were not restored due to their stability, their lack of aesthetic needs, and to control expense for the patient. Obviously, the gingival-colored ceramic as shown in Figure 8 will never show unless the lips are forcefully retracted, in spite of a relatively good aesthetic result. The patient was highly satisfied with the result.
      The following factors were considered and discussed in detail with the preceding patient before he decided to accept conventional dentistry instead of another large bone graft, a long healing period, significantly more expense, and an unknown clinical outcome.

EXAMPLE INFORMED CONSENT PROCEDURE
Alternatives for treatment:

• Leave his maxillary anterior teeth “as is,” repair the defective crown margins, and make an all-resin or metal-supported removable partial prosthesis;
• Place a fixed prosthesis, including the maxillary premolars and the remaining anterior teeth;
• Extensive grafting, implant placement, abutments, and crowns;
• The ultimate failure—remove all of the maxillary teeth and place a removable complete denture, with or without implants.

Advantages of each treatment: After discussing the advantages of each alternative, the patient rapidly elected to accept the fixed prosthesis. The advantages of the fixed prosthesis were:

• Three appointments only spread throughout a period of several weeks;
• After removal of the defective canine tooth and analysis of the other remaining teeth, the cost of the rehabilitation will be known;
• Significantly lower cost than grafting and implants;
• Known predictability for aesthetics and function;
• Relative lack of discomfort compared to the surgical approach.

Disadvantages and risks related to the fixed prosthesis:

• Higher cost than the removable prostheses options;
• Possibility for endodontic therapy need for some of the remaining vital teeth. However, some restorative dentistry would have also been needed if grafting and implants had been done;
• Unknown longevity of the fixed prosthesis, as with any restorative dentistry.
• Relative cost of the respective therapy: In this case, the grafting, implants, abutments, and crowns would have been at least 3 times the cost of the fixed prosthesis as shown.

IN CLOSING
Numerous treatment plans are present for most extensive, difficult cases, including missing teeth and significant bone loss. In light of the observed frustration of many patients, concerning how to best treat their complex oral conditions, it appears that many patients need more information before agreeing to their treatment plans. The treatment team (consisting of general dentist, dental specialist, and dental laboratory technician) needs to communicate better before committing patients with complex needs to extensive/expensive treatment plans. Although dental implants are highly desirable treatment when indicated, all possible treatments should be considered and explained to patients before proceeding with oral rehabilitation. Usually grafting and implant placement are the most adequate therapy. However, conventional treatment that doesn’t include implant placement and complex bone grafting may often be the best treatment choice.

Dr. Christensen is currently a practicing prosthodontist in Provo, Utah. His degrees include DDS, University of Southern California; MSD, University of Washington; and PhD, University of Denver. He is a Diplomate of the American Board of Prosthodontics, a Fellow and Diplomate in the International Congress of Oral Implantologists, a Fellow in the Academy of Osseointegration, American College of Dentists, International College of Dentists, American College of Prosthodonists, AGD (Hon), Royal College of Surgeons of England, and an Associate Fellow in the American Academy of Implant Dentistry. Drs. Gordon and Rella Christensen are co-founders of the nonprofit CR Foundation (previously CRA) and the Gordon J. Christensen CLINICIANS REPORT. He has presented more than 45,000 hours of continuing education throughout the world and has published many articles and books. He can be reached at (801) 226-6569 or at info@pccdental.com.

Disclosure: Dr. Christensen reports no conflicts of interest.

Dr. Child is the CEO of CR Foundation, a nonprofit educational and research institute (formerly CRA). He conducts extensive research in all areas of dentistry and directs the publication of the Gordon J. Christensen CLINICIANS REPORT, and other publications. Dr. Child graduated from Case Western Reserve University School of Dentistry, completed a prosthodontic residency at Louisiana State University, and maintains a private practice at the CR Dental Health Clinic in Provo, Utah. He is also a certified dental technician through National Board of Certification in Dental Lab Technology. Dr. Child lectures nationally and copresents the “Dentistry Update” course with Drs. Gordon and Rella Christensen. He lectures on all areas of dentistry, with an emphasis on new and emerging technologies. He maintains membership in many professional associations and academies. He can be reached at (801) 226-2121 or via e-mail at toni@cliniciansreport.org.

Disclosure: Dr. Child reports no conflicts of interest.

Figure 1. Sunflex partial denture.	Figure 2. IPS Empress all-porcelain bridge.

Figure 3. Porcelain-to-metal bridge.

Figure 4. Complete denture.	Figure 5. Clasped partial denture.

To be successful, a positive experience must carry itself through every aspect of the dental practice. To treatment plan successfully, we need to know which of the 5 senses this new patient uses most to interpret the surrounding world. We must ask questions that provide answers quickly. Is the person  seated before us “visual”? Is his or her interpretation of the world based strongly on what is seen? Is he or she an “auditory” person, one who interprets the world more by listening to what is said than by seeing? Most people tend to be visual, but many are a combination of both. It is important for us to identify the stronger of the two. Taste and smell are very important, and these senses can be easily addressed by the many products on the market that cater to them and make the dental visit more enjoyable. Lastly, touch is extremely important. It is incumbent on us to be gentle and be aware that we are treating a live person, not a mannequin or typodont model; these people are the lifeblood of our practice. Communication through the 5 senses is extremely important. It is difficult to communicate and demonstrate using visuals to a person who responds more to auditory communication. The same is true for the olfactory, taste, and touch communicators.
As we treatment plan our patients, we should also note how they respond to what we are telling them. Usual responses are by words, tone of voice, and physiology or body language. Studies have shown that 7% of people respond by words, 38% of people respond using their tone of voice, and 55% of people respond by body language. Paying close attention to the way people respond to what we tell them can ultimately relate to our treatment planning success. It is interesting to note how most people communicate without even saying a word!
One of the techniques we learned in dental school in dealing with pediatric patients is the “tell, show, and do” technique. Many of us practice this technique every day as we go about our dental lives. We simply tell patients what we plan to do, show them how we are going to do it, and then, with their permission, do it. Since it is very important for patients to be directly involved in their treatment, we must bring them into the treatment planning process.
In my office, treatment planning usually involves 3 visits. The first visit is for gathering information. A complete medical history, radiographs, study models, photographs, intraoral camera images, periodontal charting and assessment, soft-tissue health and the evaluation of hard tissues, and patient needs and wants are all part of the process. A treatment plan is formulated and, if necessary, an alternate plan. The plan (or plans) is presented at the next visit. At that time, I use the information gathered to communicate the necessary treatment to the patient. Since on the initial visit I already assessed how the patient intakes information, as well as how the patient responds using words, tone, and physiology, I am able to communicate better, as well as meet and exceed the patient’s expectations.
All of my treatment planning sessions involve explaining and showing the patient what he or she needs and then establishing what he or she wants. I start with study models of the patient’s mouth and then use patient demonstration models (Sun Dental Laboratory) to show what the mouth will look like and how it should function after I am finished. Sun Dental Laboratory offers a useful and reasonable set of models that demonstrate complete dentures, clasped partial dentures, Sunflex flexible partials, IPS Empress crowns (Ivoclar Vivadent), and porcelain-fused-to-metal crowns (Figures 1 to 5). I use them, along with other models, to show patients the nonmetal alternatives to crown and bridge. I allow them to take the bridges in their hands and compare the two (Figures 2 and 3). For those patients who would prefer to have their salvageable teeth removed rather than saved because they believe that extraction is a better alternative, I always hand them a set of complete dentures and allow them to hold them for a few minutes (Figure 4). I then ask them if they still think that dentures are a better alternative to natural teeth.
The aesthetic concerns of the clasped partial denture can be a source of consternation if the patient does not fully understand what he or she has agreed to in the initial treatment planning session. Using Sun Dental Laboratory’s clasped partial denture model along with study models of the patient’s mouth, all confusion and possible misunderstanding as to what the patient has agreed to become clear (Figure 5). An interesting aesthetic alternative to the clasped partial denture is the Sunflex partial denture, which can be fabricated in various ways, with or without metal. The key to the Sunflex partial denture’s success is the fact that the denture frame and clasps are made from a flexible rubber-like material, very much like Valplast (Valplast International), allowing for a new level of comfort (Figure 1). Using the model, I can demonstrate the differences between a rigid cast framework (Figure 5) and one that is flexible (Figure 1), thereby eliminating confusion. The models come conveniently and individually boxed, which saves significant time in initial setup.
Treatment planning does not have to be difficult.  Knowing how people gather information and make decisions enables us to communicate our various treatment alternatives clearly and effectively. The use of study models and other visuals, coupled with effective listening techniques, can result in finished treatment that meets and exceeds patients’ expectations. “Wow” is to be expected!

Suggested Reading

Davis M, Paleg K, Fanning P. How to Communicate Workbook: Powerful Strategies for Effective Communication at Work and Home. New York, NY: Fine Communications/MJF Books; 2004.

Schwartz S. It’s Your Choice! New York, NY: Jay Street Publishers; 2002.

McLeod Seminars Training Manual. Quest Intensive, Sonoita, Ariz: 1990.

Robbins A. Personal Power. San Diego, Calif: Robbins Research International; 1996. http://www.tonyrobbins.com.

Cornell AW. The Power of Focusing: A Practical Guide to Emotional Self-Healing. Oakland, Calif: New Harbinger Publications; 1999.

Cinotti WR, Grieder A. Periodontal Prosthesis Volume One & Two. St Louis, Mo: Mosby; 1968.

Cinotti WR, Grieder A, Springob KH. Applied Psychology in Dentistry. 2nd ed. St Louis, Mo: Mosby; 1972.

Dr. Bambara is a graduate and is on the faculty of the University of Medicine and Dentistry of New Jersey. He is past president of the Richmond County Dental Society and holds Fellowships in the American College of Dentists, the International College of Dentists, and the International Academy of Dento-Facial Esthetics. He is an adjunct assistant professor at the College of Staten Island and is on the attending staff at Methodist Hospital in Brooklyn and Seaview Hospital on Staten Island. He is a general practitioner with a private practice in Staten Island, NY, and can be reached at gbtatch@aol.com, (718) 356-9700, or by visiting the Web site gentledental-smiles.com.

The need to know when and how to use both well-established and new materials holds significant consequences for aesthetics, function, and longevity. It is vital to know in which clinical situations these materials will perform as expected, or perhaps when they may not. The mutual stress and loss of profits caused from preparing and sending cases to dental technicians before thoroughly understanding restorative materials and their respective preparations is still a problem observed in most of the nationís dental laboratories.

One way for doctors to help overcome the information overload is to develop closer working relationships with their dental laboratory technicians. Dental technicians can be valuable, contributing team members when it comes to the evaluation of-and clinical indications for-dental materials created in their laboratory. They can give crucial insight into preparation requirements and aesthetic considerations related to the materials they are fabricating. In addition, the majority of dental technicians are willing and eager to assist their doctors. Doctors simply need to ask for assistance and then be open and ready to listen.

A doctor/technician communication technique that has proven to be extremely useful in elevating the quality of laboratory-fabricated restorations, reducing mutual stress, and increasing mutual profits by reducing costly remakes is the Treatment Planning Consultation (TPC). In order for a TPC to be effective, all team players must have a clear definition of the process. They should also understand when and why it is being implemented. The TPC can be defined and described as follows: a sharing between the doctor and laboratory technician(s) of all relevant case information that is vital to the functional and aesthetic success of a case.

This teamwork approach to treatment planning is always done before the final patient consultation and before any restorative preparations are done. It may involve single-unit or multiple-unit cases, especially when new materials are being used or when complex aesthetic and/or functional challenges are present. This co-discovery process may often involve the referral of the patient to the dental specialist and subsequent discussion of the findings between all parties, including the dental technician. This is also to be done before the specialist(s) begins any procedure that may affect the restorative outcome. Preoperative fee quotes from the laboratory and/or specialist(s) can be included to assist in planning financial arrangements for complex or interdisciplinary cases.

Implementation of the TPC requires an allocation of time during the business day. It should be scheduled and treated with the same degree of importance as any other patient procedure, since the up-front planning will pay significant dividends in time and money saved. The TPC usually involves one or more phone conversations with the dental technician(s) and possibly with the specialist(s). It may occasionally require a doctor and/or patient visit to the laboratory when geographically feasible.

Once the TPC is routinely integrated into the doctor/technician relationship, one can expect a major shift in the level of care from ìprep-and-prayî to more predictable aesthetic and functional results. There will also be positive effects on the relationships involved. The degree of mutual respect between the doctor and technician will be raised to previously unexpected levels. Mutual stress will decrease significantly. The patient and doctorís staff will often perceive the higher level of communication and cooperation. They will not only benefit from more rewarding technical outcomes, but will observe a deeper sense of patient-centered integrity in the total team approach to care. By employing the skills and knowledge of the entire dental team, the TPC can be a powerful tool for increasing both mutual satisfaction and profits for the doctor and laboratory. As the late Walter Hailey once said, ìGet a group of successes in-sync and thinking together, and you will all be geniuses…so powerful and smart that you will amaze yourselves!î

PUTTING THE TPC TO WORK FOR OUR PATIENTS!

The following clinical case was done utilizing the TPC concept of doctor/technician communication. (Note: TPCs will vary depending on the case being considered.)

Findings at the Initial Appointment

This 17-year-old patient visited her restorative dentist accompanied by her mother. She presented with 2 congenitally missing maxillary lateral incisors (Figures 1 and 2). She had recently completed full-banded orthodontic treatment, resulting in a class I occlusion with an otherwise excellent anterior aesthetic appearance that was pleasing to both her and her parent. Her expressed desire to “fill in the spaces” with something “permanent” (non-removable) and “natural-looking” was noted. Oral hygiene assessment verified a need for continued attention to home plaque control. No evidence of bruxism or other occlusal pathology was observed.

Figure 1. Pre-op photo showing congenitally missing maxillary lateral incisors.	Figure 2. Pre-op photo (retracted).

Doctor’s First Call for Laboratory Assistance During the Patientís Initial Visit

The doctor called his laboratory to ask about possible restorative choices. He described the overall wishes of his patient. The dental technician asked him if implants had been considered. Implants were discussed as a potential long-term solution, and a consultation appointment with the specialist was offered. The parent was not in favor of this surgical procedure and was unwilling to seek an appointment with the specialist. (This was noted in the patient records.) This decision left only fixed crown and bridge options.

The restorative doctor asked his dental technician what restorative options might be best. PFM bridges? All-ceramic bridges? Standard Maryland bridges? Indirect composite Maryland bridges? He also noted that he felt the mesial contours of both cuspids were somewhat “deficient,” and wondered if this problem should be treated with direct composites. The dental technician, instead of hastily suggesting a possible solution over the phone with limited information, asked the doctor to consider taking some time for a more detailed analysis. The TPC definition and concept of communication was briefly introduced to the doctor. He agreed with this team approach and was willing to send models, a bite registration, and photos to the laboratory. He was then informed that a 10- to 15-minute phone call would be needed to discuss the case once the laboratory staff had a chance to review the information being sent. The dental technician sincerely thanked the doctor for involving the laboratory before making the final restorative choice and before starting the preparations. (Remember that the restorative choice dictates preparation design.) In turn, the restorative doctor informed the patient and her parent that he would like to send models and photos to his dental laboratory. He told them that he wanted to discuss the material options with his laboratory team members in more detail before presenting the best treatment options.

TPC Information Arrives for Discussion by the Laboratory Staff

The laboratory staff assembled the mounted models, photos, and notes from the initial conversation with the restorative dentist. All restorative options were discussed along with any potential positive and negative implications. If aesthetics were to be optimized, PFM or all-ceramic bridge preparations would be quite aggressive for this young patient. Standard metal-reinforced Maryland bridges, although done with conservative preparations, would exhibit an aesthetic challenge with metal show-through for the retainer teeth. For this laboratory, past experience with indirect composite, fiber-reinforced Maryland bridges resulted in a remake rate above its accepted standards. One material that has been achieving a higher degree of success for conservative, indirect, composite, single-pontic anterior bridges is Cristobal+ (DENTSPLY Ceramco).¹ It is uniquely indicated for use either with metal substructures or without substructure of any kind, including fiber reinforcement.² The low wear of opposing enamel against Cristobal+ was also a plus for this young patient.³ Since the patient had no current contraindications for the use of this material, the laboratory staff felt that Cristobal+, with the highest flexural strength of any indirect composite (195.6 MPa), used for Maryland bridges with no fiber or metal reinforcement, would be sufficiently strong if used over well-designed preparations.⁴ Since the indirect composite technician felt he would also be able to achieve the aesthetic goals required, including matching the hypocalcified areas of the adjacent teeth, the decision was made to present Cristobal+ as the laboratoryís recommended material of choice for this patient.

Laboratory Makes TPC Call to the Restorative Doctor

The laboratory called the doctor to discuss its findings and make its treatment recommendations based on the information shared. The pros and cons of the various options available were discussed. The thought process used by the laboratory technicians leading to the decision to recommend Cristobal+ was briefly summarized. Of course, these treatment options were made as suggestions from a laboratory perspective, since the responsibility for final treatment decisions rests with the doctor. The doctor asked again how to handle his concern with the “deficient” contour on the mesial aspect of both cuspids. If direct composite were to be utilized, ideally it would be best to do this before the preparations and impressions were done. Or, if the preparations were planned properly for the indirect composite bridges, the ìdeficientî contours might be remedied within the design of the bridges.

At this point, the doctor was asked if he would like a model with study preparations for “modified” Maryland bridges along with a diagnostic wax-up. These would allow pre-planning of the preparation variations needed to accomplish the structural and aesthetic goals of the case. They are also done to help eliminate the increased stress and money lost from potential re-preps and additional impressions. The restorative doctor agreed that this would be valuable information to assist him with his decisions and preparation of the case.

The Laboratory Completes Study Preparations and Diagnostic Wax-Up

The proposed preparations were first cut on the study model. Ideally, the same burs to be used by the doctor should be utilized in the mock-up procedure. (A Brasseler 5856-016 diamond chamfer bur was used for these preparations.) A ìreciprocal armî style preparation was cut into the interproximal and lingual aspects of both central incisors (Figure 3). A modified laminate preparation was then done, which covered approximately two thirds of the facial surface and extended distally to the distal transitional line angle (Figure 4). As in closing diastemas with laminate veneers, the cuspid preparations were carried through the interproximal surfaces to the mesio-lingual line angles. The margins were also placed approximately 1 mm sub-gingival to allow the technician to create natural interproximal emergence and contours. (Note: For anterior Cristobal+ bridges, the manufacturer recommends an interconnector size of 4×4 mm as ideal for strength.)

Figure 3. TPC study preparation of central incisors.	Figure 4. TPC study preparation of cuspids.

Final TPC Information Was Returned to the Doctorís Office

The diagnostic wax-up, along with a model of the suggested preparations, was returned to the doctor for examination (Figure 5). The doctor was informed that it is always prudent to give the patient a guarded long-term prognosis before beginning any treatment utilizing a new material and/or procedure. This was important information to be considered by the patientís mother before actual tooth preparation was begun, given her desire for no implants and an aesthetic fixed restoration. This was also to be balanced with the doctorís concern for conservative preparations due to the patientís young age.

Figure 5. Completed diagnostic wax-up over TPC study preparations.

Final Patient Consultation and Treatment

The restorative dentist reviewed all of the TPC findings, including a fee quote for the laboratory services, and scheduled a final patient consultation to discuss his treatment recommendations. The patient and her mother agreed to proceed as outlined. The preparations were then done as the laboratory had suggested and the doctor had accepted. A full-arch VPS impression (Aquasil Ultra; DENTSPLY Caulk) and VPS bite registration (Regisil Rigid; DENTSPLY Caulk) were taken. The case was sent to the laboratory with shade information that included preoperative photos that clearly demonstrated the enamel characterization needed for proper aesthetics.

The 2 Cristobal+ anterior bridges were created uneventfully as preplanned in the TPC and returned to the doctor. Instructions for the bonding procedure for indirect composites were included with the case by the laboratory. The restorations were tried in for fit and aesthetics. Once the doctor, patient, and parent were satisfied with the results, the restorations were deep-cleaned with 38% phosphoric acid gel for 20 seconds, rinsed, treated with fresh silane for 60 seconds, and bonded with Calibra dual-cured resin cement (DENTSPLY Caulk). The occlusion was then checked, adjusted, and polished. The patient was given postoperative hygiene instructions including the use of floss threaders.

Postoperative photos were then sent to the dental laboratory (Figures 6 and 7). Sharing post-op photos with the laboratory technician is a wonderful way to improve the quality and content of future TPCs. Postoperative photos can also be used to send praise for a job well done or to give immediate feedback to the laboratory for any technical changes that could have further improved the case. (For example, it was noted that the creation of aesthetic pontic sites, along with a more ideal relative gingival crest height of the lateral incisors as compared to the central incisors and cuspids, would have improved the aesthetic result. However, since the parent wanted a fixed, aesthetic solution without surgery for implants, this additional surgical treatment may not have been accepted.)

Figures 6 and 7. Cristobal+ nonfiber-reinforced anterior ìmodifiedî Maryland bridges. (Clinical work and clinical photos performed by Dr. Carl Meier; laboratory work created by Douglas H. Baker, CDT; laboratory photos courtesy of DH Baker Dental Laboratory.)

CONCLUSION

This article has defined and described a typical working example of the Treatment Planning Consultation as an effective doctor/technician communication tool. The use of the TPC as a co-discovery technique for discussing cases early in the diagnostic and treatment planning phases can lead to improved functional and aesthetic outcomes for our patients. Being willing to engage in a total team approach to cases can also decrease stress and increase profits by reducing needless remakes. In addition, it will build trust and respect between all the team members. It only takes openness to working together and a mutual understanding of the TPC concept, and everyone can benefit.

References

1. Leinfelder KF. Developments in indirect resin composite materials. Dent Today. 2000;19(3):58-61.

2. Kurdziolek S, Leinfelder KF, Delahaye A. Properties and characteristics of an indirect Bis-GMA/barium-glass polymer ceramic restorative system. Compend Contin Educ Dent. 2000;21:1031-1038.

3. Suzuki S, Nagai E, Taira Y, et al. In vitro wear of indirect composite restoratives. J Prosthet Dent. 2002;88:431-436.

4. Nash RW. Processed composite resinóa versatile restorative material. Compend Contin Educ Dent. 2002;23(2):142-148.

Dr. Adams is an assistant professor at Medical College of Ohio, division of dentistry, department of otolaryngology, in Toledo, Ohio. He lectures nationally and internationally for many dental organizations and dental laboratories. Dr. Adams’ lectures and hands-on seminars include “Excellence in Everyday Esthetics! Reduce Stress and Increase Profits Utilizing a Total Team Approach;” “Restorative Excellence…Problems and Solutions!;” and “Indirect Composites: Dentistry’s Best Kept Secret!” He is currently listed in Dentistry Today’s 6th annual Leaders in Continuing Education. He may be contacted for comments or seminar information at (800) 946-8880 or damona@dhbaker.com.

Disclosure: Dr. Adams serves as the doctor/technician liaison for DH Baker Dental Laboratory in Traverse City, Mich.