Contemporary Fixed Prosthodontics

C H A P T E R 3 Treatment Planning Treatment planning consists of developing a logical factor, and thus helps reduce the likelihood of further sequence of treatment designed to restore the patient’s dental caries. Such instruction also helps improve gingi- dentition to good health, optimal function, and optimal val health, and the resulting healthy tissue is more resist- appearance. The plan should be presented in writing and ant to disease. In such patients with extensive caries, discussed in detail with the patient. Good communica- additional preventive measures are necessary (e.g., tion with the patient is critical as the plan is formulated. mouth rinses, high-fluoride toothpastes, dietary analysis). Most dental problems can be solved in a number of dif- Restorative treatment replaces damaged or missing tooth ferent ways; the patient’s preferences and concerns are structure, but additional treatment is crucial to control paramount in establishing an appropriate treatment plan. the underlying causes. In appropriate proper planning, the patient is informed about the current conditions and problems, the extent of Prevention of Future Disease dental treatment that is proposed, the time and cost of treatment, and the level of home care and professional The likelihood of future disease can be predicted from follow-up necessary for success. Also, before any irrevers- the patient’s disease experience and from the prevalence ible procedures are initiated, the patient should under- of the disease in the general population. Treatment stand that some of the planned procedures may need to should be proposed if future disease seems likely in the be changed as treatment progresses and new information absence of such intervention. becomes available. One of the first phases of treatment is to stabilize This chapter outlines the necessary decisions in plan- active disease, which often includes replacement of defec- ning fixed prosthodontic treatment. Foremost among tive restorations and treatment of carious lesions. If a these is the identification of patients’ needs and their patient presents initially with poor oral hygiene, the preferences, which must be correlated with the range of dentist should monitor if improvement in plaque control treatments available. For long-term success, when a fixed results during the stabilization phase. If such does not dental prosthesis (FDP) is being considered, the abut- occur, renewed emphasis on proper oral hygiene meas- ment teeth must be carefully evaluated. Finally, the treat- ures is indicated. Subsequently identified limitations in ment plan must be properly sequenced as part of an the patient’s oral hygiene may justifiably affect the final ongoing program of comprehensive dental care. treatment plan. IDENTIFICATION OF PATIENT NEEDS Restoration of Function Although objective measurement can be difficult, the Successful treatment planning is based on proper identi- level of function is assessed during the examination. fication of the patient’s needs. If the dentist attempts to Treatment may be proposed to correct impaired function make the patient conform to the “ideal” treatment plan (e.g., mastication or speech). Prerequisite treatment rather than make the treatment plan conform to the may include mandibular repositioning through occlusal patient’s needs, success is unlikely. In many cases, several reshaping before fixed prosthodontic treatment (see plans are presented and discussed, each with advantages Chapters 4 and 6) and orthodontically repositioning and disadvantages. Indeed, failing to explain and present teeth in more favorable locations before missing teeth are available options may be considered legally negligent. replaced. Treatment is necessary to accomplish one or several of the following objectives: correcting an existing disease, Improvement of Appearance preventing future disease, restoring function, and improv- ing appearance. Patients often seek dental treatment because they are dissatisfied with their appearance. However, it is difficult Correction of Existing Disease to assess dental esthetics objectively (see Chapter 23). The dentist should develop expertise in this area and Existing disease is revealed during the clinical examina- should be prepared to appraise the appearance of the tion (see Chapter 1). Active disease can usually be halted patient’s dentition and listen carefully to the patient’s by identification and reduction of the initiating factors, views. If the existing appearance is far outside socially identification and improvement of the resistive factors, accepted values, the feasibility (and limitations) of cor- or both (Fig. 3-1). For example, oral hygiene instruction rective procedures should be brought to the patient’s helps reduce the amount of residual plaque, an initiating attention. Long-term dental health should not be 70 3 Treatment Planning 71 A FIGURE 3-1 ■ Poor plaque control with dental caries and tooth wear. compromised by unwise attempts to improve appearance. Patients should always be made aware of the possible adverse consequences of treatment. AVAILABLE MATERIALS AND B TECHNIQUES All existing restorative materials and techniques have limitations, and none exactly match the properties of natural tooth structure. Clinicians must understand these limitations before they can select the appropriate procedure. This helps prevent an experimental approach to treatment. Plastic Materials C Plastic materials (e.g., silver amalgam or composite resin) are the most commonly used dental restoratives. They allow simple and conservative restoration of damaged teeth. However, their mechanical properties are inferior to those of cast metal or metal-ceramic restorations. Their longevity depends on the strength and integrity of FIGURE 3-2 ■ A, The large amalgam restoration is hard to con- the remaining tooth structure. When the tooth structure dense and contour accurately. B, The complete cast metal needs reinforcement, a cast metal restoration should be crown is stronger and can be shaped by an indirect procedure fabricated, often with amalgam or composite resin as the in the dental laboratory. C, Although an esthetic crown is weaker foundation or core (see Chapter 6). than cast metal, it was used to restore this first molar. Large amalgam restorations (Fig. 3-2, A) are shaped or carved directly in the mouth. Because of the great degree of difficulty with this direct approach, defective contours and poor occlusion often result. The indirect function. Thus crowns must be fabricated to precise tol- procedure, used in making crowns (see Fig. 3-2, B and erances. Preparation design for cast metal restorations is C), facilitates the fabrication of more accurately shaped critical and is discussed in detail in Chapters 7 through restorations. 10 (Fig. 3-3). Cast Metal Intracoronal Restorations Cast metal crowns (see Fig. 3-2, B) are fabricated in the An intracoronal cast metal restoration (Fig. 3-4), or inlay, dental laboratory and are cemented with a luting agent. relies on the strength of the remaining tooth structure They fit over a prepared tooth, somewhat like a thimble’s for support and retention, just as a plastic restoration fitting on a finger. To minimize exposure of the luting does. However, greater tooth bulk is needed to resist any agent to oral fluids, a long-lasting crown must fit the wedging effect on the preparation walls (see Fig. 7-28). tooth well. Precise technique enables the routine fabrica- Therefore, this restoration is contraindicated in a signifi- tion of metal crowns with excellent marginal fit and pre- cantly weakened tooth (see Fig. 3-2, A). When fabricated cisely shaped axial and occlusal surfaces. Replication of correctly, intracoronal inlays are extremely durable optimal anatomic form in crowns helps maintain perio- because of the strength and corrosion resistance of the dontal health and good occlusal function. The internal gold casting alloy; however, in a tooth with a minimal dimensions of a crown must allow it to seat without proximal carious lesion, an inlay usually necessitates binding against the vertical preparation walls while greater removal of tooth structure than does an amalgam remaining stable and not becoming displaced during preparation. 72 PART I Planning and Preparation Fracture A A Inlay B Onlay C Complete crown Cuspal protection becomes more important as the B structural durability of the cusps is compromised. FIGURE 3-3 ■ A, An intracoronal cast restoration (inlay) can act as a wedge during cementation or function. If the cusps are weakened, fracture will occur. B, A cuspal-coverage onlay provides better protection but often lacks retention. C, A complete crown provides the best protection against fracture. It also has the best retention, but it can be associated with periodontal disease and poor esthetics. (Redrawn from Rosenstiel SF: Fixed bridgework—the basic principles. In Rayne J, ed: General Dental Treatment. London, Kluwer Publishing, 1983.) C FIGURE 3-5 ■ A, Complete cast metal crowns restore the molars. Occlusal (B) and buccal (C) views of two partial veneer crowns. With partial veneer crowns, more tooth structure is conserved. A Extracoronal Restorations An extracoronal cast metal restoration (Fig. 3-5), or crown, encircles all or part of the remaining tooth structure and the occlusal surface. Crowns strengthen and protect teeth weakened by caries or trauma. To provide the necessary bulk of material for strength, considerably more tooth structure must be removed than for an intracoronal restoration.

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