Introduction
Prosthodontic Treatment Planning: Current Practice, Principles, and Techniques
Roy T. Yanase, DDS
Roy T. Yanase, DDS, is a clinical professor of continuing
education and advanced prosthodontic education at the University of Southern
California School of Dentistry. He has been co-director of the USC Odontic
Seminar for 15 years and has a private prosthodontic practice in Newport
Beach, Calif.
Copyright 2003 Journal of the California Dental Association.
Treating the prosthodontic patient has its challenges and rewards. Prosthodontic
treatment planning has progressed from an emphasis on planning for immediate
dentures to immediate loading of implants. Even with today’s extended
average lifespans, patients expect to keep their teeth for a lifetime.
Dentistry has followed new technology into the future to provide excellence
in prosthodontics and restorative dentistry.
Concepts and materials have been developed to help simplify the treatment for esthetic procedures, implants, and removable and fixed prostheses. Selection of appropriate restorative materials requires knowledge of the latest techniques and options. It is the challenge of all dental journal editors to present the most current information to their readers.
The faculty of the University of Southern California New Odontic Seminar has selected the 25 years of documented dental treatment of patient "AK" (see following article) as a foundation on which to base discussion of the concepts and technology that have developed in prosthodontic treatment planning. Each of the contributing authors was asked, "What are your thoughts retrospectively if you were to treat the patient ‘AK’ in your practice today?" And, since all dentists are challenged with evidence-based treatment planning, each author was also asked "On what evidence in the literature do you base your treatment planning for patients who need prosthetic therapy?" While some references may seem redundant, they only reflect the effect of the current literature on applications of the principles reported. Dentistry’s experience with long-term success of endodontics, periodontics, and implant dentistry is expressed in the presentations discussing when an implant may be better suited for a prosthetic abutment than a restored tooth.
50 Years of Prosthetic Dentistry
The first guest editorial in the Journal of Prosthetic Dentistry more than 50 years ago cautioned future contributors and editors to be aware of the hazards of magic, work juggling, authority, and emotion.1 The Journal of Prosthetic Dentistry has used the power of progress to develop better problem-solving techniques for the prosthetic patient.
In that first issue, Hughes and Aseltine outlined mouth preparations for the transition from natural teeth to dentures.2,3 Swenson identified two factors important in complete denture service -- a favorable attitude and favorable oral and residual ridge conditions.4 Bliss identified psychological factors to consider for patients about to lose their natural teeth.5 Hardy outlined the development of various tooth forms,6 and Schultz offered cast gold as a method of increasing chewing efficiency with complete dentures.7 Pound emphasized that esthetics and the occlusal vertical dimension can be established by phonetics.8 Most importantly, Kyes called for more communication between the dental technician and dentist to produce excellent dentures.9
The U.S. Surgeon General’s Report on Oral Health identified the opportunities for dentistry on behalf of the nation’s oral health.10 With the acceleration of science into clinical practice, the report highlights the assessment of risks and benefits and the education of patients about oral health. The report makes it imperative for health professionals to ensure appropriate referrals to practitioners in various areas of health care. For the totally and partially edentulous patient, the introduction of the art and science of osseointegration has changed diagnosis and treatment planning with documented effective and successful treatment options.
From Implantology to Implant Dentistry
The use of implants in dentistry can be traced to Central and South America, Egypt, and even prehistoric times.11 Early implantology documentation began with surgical and restorative combination efforts to replace missing dentition with an immediately supported and stabilized restoration following the placement of implant forms. Gold screws, shaped forms, baskets, and blades had various rates of survival.12 The mandibular subperiosteal implant denture aroused the interest of implantologists to secure a prosthesis immediately after placement. Forty-year survival rates of 66 percent (41 patients)13 and 100 percent (20 patients)14 have been reported. There have been no long-term survival studies reported on bladed implants or subperiosteal implants in the maxillary arch. These survival results were among the best presented at the 1978 National Institutes of Health Harvard Consensus Conference.15
In 1975, Wilkie established the concept of specialists working together as a team. For preprosthetic success, "A mutually cooperative effort between the prosthodontist and oral and maxillofacial surgeon must exist during the diagnostic procedures, be maintained through the various stages of treatment, and prevail through the follow-up care of the patient. Each must be aware of both the objectives and possible limitations of the treatment the other will provide to ensure optimal care for the totally edentulous patient."16 A multitude of preprosthetic procedures that developed aimed at solving the problems of the edentulous mandible.17,18 The emphasis changed from one dentist being responsible for the ultimate success of implant surgery and implant restoration to that of a shared responsibility for surgical and restorative phases.
Having completed the first replication of Brånemark’s work and convinced of its scientific merits, in 1982, Zarb organized the first conference on osseointegration in North America.19 The conference underscored the intimate ties that linked research, education, and clinical practice; and the public was to receive the benefits of implant dentistry safely, predictably, and effectively. Since that time, a series of symposia has been organized to bring together the research, development, and applications that document continued benefits and success of implants in clinical dentistry.20-27
There are few, if any, outcome assessments that compare patient-mediated factors of success such as longevity combined with physiologic, psychosocial, and economic factors.28 With the complexities of multiple-implant-supported restorations, more time and study are required to standardize the benefits and minimize the risks. Clinical observation and careful long-term followup of treated patients gives valuable insights into the selection of an implant system (There are 55 currently available) and planning of the restorations, including the many risks of site development.29-31 Esthetic demands and biomechanical considerations complete the complexity of the treatment planning process.32
In many other countries, all dentists are required to complete all aspects of implant therapy and thus carry a heavy burden of responsibility for long-term success. To learn and practice with the latest techniques and information requires intense study and practice.
The team approach remains the mechanism for more surgeons and restorative dentists, studying together, to participate and provide a predictable and safe treatment modality for a greater number of patients.33 Advanced education is possible to allow single practitioners to train in both surgical and restorative disciplines and practice solo implant dentistry. During this process of education, the standard of care in restorative dentistry relies on the blend of fixed, removable, implant, and maxillofacial prosthetic dentistry principles and appliances. The standard care in surgical protocols requires a thorough understanding of prosthodontic treatment planning principles, placement, and the management of complications following implant placement. The new paradigms in treatment require a fresh look at the probability of short- and long-term complications of grafting and pre-implant procedures as well. A complete review of the available options and the benefits and risks of treatment is essential for informed consent or informed refusal of the proposed treatment.34-37
References
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To request a printed copy of this article, please contact/Roy T. Yanase, DDS, 1441 Avocado Ave., Suite 508, Newport Beach, CA 92660.
