How to develop a complete treatment plan for every patient

Dr. Glenn DuPont outlines what clinicians should consider with each case to ensure every patient gets their mouth to optimal health.

One of the most enjoyable and rewarding aspects of being a dentist is developing a well thought out treatment plan for a patient.

When I joined the practice of Dr. Peter Dawson and Dr. Reuben Roach in 1979, they immediately impressed upon me the importance of a thorough exam, a well thought out treatment plan and an efficient treatment sequence. As I heard back then, and you can still hear Pete say today, “Every patient deserves to know the one best way to get their mouth comfortable, healthy, stable and maintainable.”

If after conducting a thorough exam on a new patient and following the process for developing a complete treatment plan the only requirements for getting the mouth totally healthy and maintainable are a prophy, sealants and homecare instructions, the principles of “Complete Dentistry” are fulfilled.

While a new patient with a severe lack of stability from years of wear presents a significantly more challenging case, the same systematic process of evaluation, diagnosis and treatment planning is used. These complex cases are also approached conservatively, not just treatment planned for restorations on 28 teeth, which I see all too often. I explain to patients that together we will decide the best, most conservative way to solve their problems. This is why at the Dawson Academy we use checklists for every case, regardless of the degree of perceived difficulty.

Where to begin?
There are three basic questions to answer about every patient-new patients as well as recall patients:

• Are the temporomandibular joints stable and maintainable?

• Are the periodontal structures stable and maintainable?

• Are the teeth stable and maintainable?

Answering these questions requires evaluation of the temporomandibular joints, the muscles of mastication, range of mandibular motion, the periodontal condition through probing and radiographs, the occlusion and the teeth themselves.

In cases of severe anterior wear, I cannot expect to restore the the teeth and have long-term stability if all aspects of the system are not stable. Similarly, in patients who may need orthodontic or orthognathic surgery, the position and condition of the temporomandibular joints must be evaluated and determined to be stable before proceeding. The occlusion must be monitored and adjusted to prevent a hit and slide from centric relation to maximum intercuspation that would drive into the anterior teeth and create undue stress on the entire system.

With all of this in mind, let’s look at a patient. Karl Wundermann, who is an excellent and knowledgeable lab technician, referred this patient. The preamble was that he was not happy with his smile and he had been told he would probably need orthognathic surgery to correct his occlusion, profile and smile (Fig. 1).

I could immediately see that his maxillary incisors were in need of help esthetically (Fig. 2) and that he had a very prognathic, Class III profile (Fig. 1). My assistant, Jennifer, took four initial photos: retracted 3:1 anterior teeth apart, unretracted 3:1 smile, upper and lower occlusals (Figs. 2-5) after reviewing his medical history.

As his chief complaint was purely esthetic, it would be easy to get tunnel vision and not do a complete exam. As I evaluated Curt’s temporomandibular joints through history, palpation, Doppler, load testing, and range of motion, it became evident that both joints were in good condition with no problems. This is somewhat typical of Class III occlusion but never can be assumed without an evaluation. Muscle palpation and history of headaches also proved negative. His periodontal probings were very good and gingival recession was almost non-existent throughout his dentition.

Evaluating his teeth for any signs or symptoms of instability (wear, breakage, mobility, displacement, non-carious Class V lesions or sensitivity) also proved negative. The anterior composite bonding was old, worn, cracking and discolored.

When a patient has a totally stable and maintainable stomatognathic system, no treatment needs to occur unless an esthetic change is desired. His esthetic concerns then were the only problem that I needed to solve.

It is critically important that this thorough evaluation take place on every patient to rule out problems in the entire system.

In discussing his desires and reviewing his profile and full series of diagnostic photos, it became clear he did not desire an esthetic change that would require orthognathic surgery, but simply wanted his front teeth to look better.

At this point I spent time going through the Functional-Esthetic 2D Checklist using my clinical notes and photos. With my study models mounted on the Denar Mark 320 articulator from Whip Mix, I then followed the 10 Step 3D Treatment Planning Checklist. I proceeded quickly to Step 5, which is the maxillary anterior incisal edge position. That was because Step 1 is to choose the correct joint position, which needed no change; Step 2 is to go tooth-by-tooth to identify all needs, and only the maxillary four incisors needed any treatment; Step 3 is determined by the Functional-Esthetic 2D Checklist; and Step 4 is the lower incisal edge position, which with Curt did not need to be altered.

As in all anterior cases, the vertical and horizontal position of the incisal edges is critical. In this case the horizontal position was exceptionally important to ensure it would not interfere with the Functional Matrix (Fig. 6). I did not want Curt’s maxillary edge to interfere at all with his mandibular arch of closure or his neutral zone. The force of the lips and tongue are an important component of the overall stability of the anterior teeth.

After completing a preliminary wax up (Fig. 7) at his existing vertical dimension of occlusion and with all of the above in mind, I decided veneers would be the best treatment option. Curt also desired a slightly lighter color so together we decided to include the cuspids to accomplish this result.

I prepared the maxillary six anterior teeth (Fig. 8), took final impressions and used some AccuFlow bite registration material by Great Lakes. Dentin and enamel shade photos were taken after which I placed and adjusted the Protemp Plus by 3M ESPE provisionals (Fig. 9) and took an impression for an APM (Approved Provisional Model) for the lab. The previously face-bow mounted lower opposing was added and everything was sent to the lab.

I called the patient a week later to be sure that the length, contour of the provisionals and his speech were acceptable, and they were. More extensive cases would necessitate a visit one week later to check for acceptable function, esthetics and phonetics.

I then tried in and, after approval, immediately placed the Ivoclar Vivadent e.max porcelain veneers made by technician Jim Free.

As with all anterior restorations, it is critical to re-check all function and phonetics. Because of the anterior overbite, the envelope of function and arch of closure were involved (Fig. 10). How would you know if they interfered? The patient may tell you, but also by checking for fremitus. I cannot emphasize enough the importance of checking for fremitus with ANY anterior restorations.

I placed my fingernails on the mandibular incisors and asked the patient to close, bite and tap his teeth together. I quickly realized the left maxillary central was interfering and banging the mandibular incisors too hard as seen marked with articulating paper (Fig. 11). I adjusted and polished this area and rechecked to be sure there was no further interference or fremitus occurring.

This turned out to be a very successful result with minimal dentistry and a very happy patient (Figs. 12-13).

I hope this communicates the importance of following the process of evaluating the three areas for stability, understanding the patient’s desires, and using the various checklists to arrive at a conservative but ideal treatment for all your patients.