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Gracis S. a Simplified Method to Develop An CLINICAL RESEARCH A simplified method to develop an interdisciplinary treatment plan: an esthetically and functionally driven approach in three steps Stefano Gracis, DMD, MSD Private Practice, Milan, Italy Correspondence to: Dr Stefano Gracis Via Brera 28/a, 20121 Milan, Italy; Tel: +39 02 72094471; Email: [email protected] 76 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 GRACIS Abstract typically required. This article provides a practical step- by-step approach to planning comprehensive interdis- Many clinicians are unsure of how to develop a com- ciplinary treatment focused primarily on the teeth as prehensive plan of treatment for patients who present they relate to each other and to the structures that with multiple problems and pathologies. In order to surround them. The approach is based on the answers efficiently plan appropriate treatment for such com- to six questions that are grouped into three steps: 1) plex patient cases, the clinician needs to either have or evaluation of the teeth relative to the face and lips; develop the necessary knowledge of evidence-based 2) assessment of anterior tooth dimensions; and 3) information on the predictability of available clinical analysis of the anteroposterior and maxillomandibular procedures. The clinician also needs to understand relationships. The information obtained must then be the correct sequence in which such treatment is ap- related to the patient’s skeletal framework, periodontal plied, and perfect the skills required for carrying out status, caries susceptibility, and biomechanical risk as- that treatment. Since most clinicians have not ac- sessment in order to formulate a clear and complete quired all the knowledge and skills necessary for this plan of treatment. task, an interdisciplinary approach to treatment is (Int J Esthet Dent 2021;16:76–128) The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 | 77 CLINICAL RESEARCH Introduction on a referral basis. Some discussion of the treatment to be provided will likely take The goals of prosthetic treatment are to place, but there is no real coordinated ef- rehabilitate a patient’s stomatognathic sys- fort in planning or providing treatment for tem to be functionally sound, biologically a patient. In contrast, an interdisciplinary healthy, and esthetically pleasing while fol- approach takes into account all available lowing accepted principles and using de- patient-specific variables. It requires the pendable materials to ensure that the end knowledge and expertise of all the treat- result will serve the patient for as long as ing clinicians from the disciplines involved possible.1-4 To achieve these goals, it is im- and coordinated communication between portant to adopt a systematic approach that them, not only with respect to the treat- allows the clinician to identify the problems, ment involved, but also to the planning, establish specific treatment goals for each sequencing, and timing of such treatment. problem, determine which therapies will ac- It also requires knowledge of available ev- complish each goal, and develop an appro- idence-based information on the predict- priate sequence of treatment that will lead ability of the various clinical procedures to the envisioned outcome, based on the being considered as well as an understand- presenting conditions. ing of their correct sequence. In essence, Patients often present with a multitude interdisciplinary care is about teamwork of problems that pose varying degrees of – the interconnectivity and ongoing inter- difficulty to manage. These include, but are action between clinicians from various dis- not limited to, esthetic expectations, degree ciplines involved in planning and providing of periodontal compromise, tooth integrity, treatment. tooth position, number of missing teeth, The aim of this article is to provide a occlusal relationships, functional demands, relatively clear concept of comprehensive and levels of risk associated with the treat- interdisciplinary treatment planning for cli- ment of each problem (Figs 1 to 3). As the nicians faced with challenging clinical sit- complexity of a patient’s problems increas- uations, and to do so in a simplified way. es, the clinician may need to acquire further However, in applying this simplified ap- knowledge, develop additional skills, and proach, one should recognize that it is pri- know when to involve clinicians from oth- marily focused on the teeth and surround- er disciplines to provide expertise and care ing structures with respect to function and in order to design and execute a treatment esthetics. Additionally, some patients will plan that will achieve the therapeutic goals present with problems that will require a and the desired end result. This, then, would more definitive assessment in order to de- establish the need for an interdisciplinary sign a plan of treatment commensurate approach to providing optimal care for the with the number and/or extent of their patient. problems. Whether you use the simplified There is a significant, but often over- approach to treatment planning present- looked, difference between an interdisci- ed in this article, or a more traditional ap- plinary approach to managing a patient’s proach to comprehensive interdisciplinary problems and treatment compared with a treatment planning, it is important to real- multidisciplinary one. Multidisciplinary care ize that treatment planning is a process simply refers to multiple clinicians of differ- that should begin with a vision of the end ent disciplines providing some level of care result. As Stephen Covey put it, “Begin with or procedure in treating a patient, typically the end in mind.”5 78 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 GRACIS Whether you work alone or as part of compatible, structurally sound, and ac- an interdisciplinary team, it is essential that ceptable to both the clinician and patient a complete and thorough examination, re- in terms of overall dental health as well cords acquisition, and subsequent evalua- as functional and esthetic considerations. tion be completed and documented so an Diagnostic records to facilitate a proper accurate diagnosis of every problem and evaluation typically include extraoral and concern the patient presents is identified intraoral photographs, a thorough extra- and shared between all team members in- oral and intraoral examination, a complete volved in planning and providing care. The periodontal charting, periapical and vertical planned treatment should be based on bitewing radiographs, a panoramic radio- the expected outcome and be biologically graph, a lateral cephalometric radiograph, ab cd Fig 1 context of a reasonably healthy periodontium and intact posterior teeth in a 33-year-old female. (a and b) The patient displays a relatively high smile line with disproportionate exposure of gingival tissue posteriorly relative to the central incisors, which are, in turn, disproportionately greater in height than the other teeth. (c) The central incisors also show gingival recession of 2 to 3 mm that is not visible during smiling. (d) Her congenitally missing maxillary lateral incisors had been previously replaced by resin-bonded fixed partial dentures (FPDs; Maryland bridges), noticeably compromised on examination. (e) Radiographic examination shows compensatory convergence of the central incisor and canine roots toward one another into the edentulous spaces bilaterally, which negates the possibility of using implants to replace the missing teeth. The patient refused orthodontic therapy to e correct the root malalignment of these teeth so that appropriate space could be established at the coronal and apical level for implant-supported prosthetic teeth. The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 | 79 CLINICAL RESEARCH ab cde f g h i Fig 2 (a to c) The appearance of this 30-year-old female at the initial presentation gives the impression of a much older person. (d and e) The incisal edge position of the maxillary central incisors with respect to the lips during smiling and at rest deviates from the norm. (f to h) The intraoral views show devastating damage due to bulimia over many years, which has caused erosion nearly to the level of the pulp on a number of teeth. This contributes to a signifi cant reduction in the clinical crown height of the teeth, and compensatory overeruption of a number of teeth, particularly the maxillary central incisors. Considerable incisal and occlusal wear, caries, loss of cervical tooth structure, and occlusal dysfunction are also evident. (i) The complete series of intraoral radiographs shows a level of bony support consistent with the diagnosis of incipient periodontal disease (Stage 1, Grade C, according to the revised classifi cation of periodontal disease),45 failing restorations, endodontic treatment of teeth 36 and 17, and a periapical lesion associated with tooth 16. 80 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 GRACIS a b c de f g Fig 3 This 65-year-old male patient presented with severe pain associated with both the mandibular left canine and second molar. (a to c) Profi le and frontal view photographs are within normal limits and the amount of tooth display during a reserved smile seems acceptable considering the patient’s age. (d to f) Intraoral views show severe gingival infl ammation, plaque, calculus, failing restorations, and
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