Treatment plan

Once you know you have a patient that is truly interested and motivated, then and only then take the next step in designing the case. I have done more than my share of treatment plans for patients that never wanted the treatment in the first place, which ultimately is a waste of my time and theirs.

The treatment plan starts with complete and accurate records. This is usually done at a time that is not the initial interview, although that occasionally exceptions to this in instances were a patient may have traveled significant distance. However, in these exceptional cases the relationship and trust have been developed either over the telephone or across the internet.

The records include a medical history with special emphasis on any maladies that will either compromise the patient during treatment or the result. We do a comprehensive clinical examination of the dentition, oral structures and hard and soft tissues of the head and neck with radiographs, periodontal and endodontic evaluation, photographs and accurate diagnostic models. An occusal analysis is critical to success in every case because form has to follow function. Violate the functional envelope and the form will not last. The occlusal analysis includes the dentition, the muscles and the tempromandibular joints. In the analysis factors that are important are:

Closed dimension of the cemento-enamal junction of the maxillary and mandibular central incisors termed the Vertical Index (a guideline is 15-19mm in clinically healthy patients).
Open dimension at the maximal effort between the maxillary incisal edges (usually around 50mm). Inability to open in this ranges or beynd may indicate muscles spasms or an intracapsular disorder in the TMJ.
The presence of wear facets on the dentition (indicates bruxing).
Pain that is chronic, acute, spontaneous or provocated. It may not be directly in the area of the teeth, but may be related to headaches, neck or upper back pain.

An extensive photographic series is very important to cosmetic cases, because a picture is worth a thousand words. With the advancements in digital camera technology, the ease of use and the immediacy of excellent clinical photographs becomes a cornerstone in documentation, treatment planning, laboratory communication and future marketing. A high quality digital camera that has proper lighting, depth of field and clarity for intra-oral and portrait use is as important as the handpiece.

Finally, discussing with the patient specifics about the shape and shade of the teeth they would like is worthwhile. Most patients want teeth that are lighter, straighter and display more than they presently do. What I have observed most patients seeing but unable to describe are asymmetries. In your smile design, if you can regain some semblance of bilateral symmetry then you are 80% on the way to a successful clinical result. (Figure 7)

Cosmetics and ethics can go together and establishment of a process can lead to an increase in case acceptance. In the end, success in a cosmetic case is only a success if the patient feels it is a success. Not only does the result need to be technically excellent, it has to be psychologically satisfying for the patient. It has to look good, feel good and last a long time. As the dentist or supporting staff, you opinions about the "beauty" of a case will always be secondary to what the patient feels. (Figure 8)

(Fig 7)

(Fig 8)

Dr Rhys Spoor DDS Aesthetic / Restorative Dentistry - Providing services in cosmetic and sleep dentistry to the area of Seattle, Washington.

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