Interdisciplinary

An Interdisciplinary Approach to Treatment Planning in the Esthetic Zone

Sajid A. Jivraj, DDS, MSEd, and Winston W.L.Chee, DDS

Authors

Sajid Jivraj, DDS, MSEd, is an assistant professor of clinical dentistry in the Division of Primary Oral Healthcare and co-director of Pre-Clinical Fixed Prosthodontics at the University of Southern California School of Dentistry. He also maintains a private practice limited to prosthodontics in Burbank, Calif.

Winston W.L. Chee, DDS, is the Ralph W. and Jean L. Bleak Professor of Restorative Dentistry, director of Implant Dentistry, and co-director of Advanced Education in Prosthodontics at USC School of Dentistry. He also maintains a private practice limited to prosthodontics in Pasadena, CA.

Copyright 2003 Journal of the California Dental Association.

The practice of prosthodontics requires a multidisciplinary approach that integrates the knowledge, skills, and experience of all the disciplines of dentistry into a comprehensive treatment plan. This article outlines a comprehensive interdisciplinary treatment philosophy designed for developing the foundation for optimal esthetics in fixed prosthodontics. Cases are presented to illustrate the utility of interdisciplinary treatment in which specialists are recruited to enhance and improve a patient’s dental function and esthetics.

The practice of prosthodontics requires a multidisciplinary approach that integrates the knowledge, skills, and experience of all the disciplines of dentistry into a comprehensive treatment plan. Fixed prosthodontic treatment can offer exceptional satisfaction to both the patient and dentist. It can transform an unhealthy, unattractive dentition with poor function into a comfortable, healthy occlusion with greatly enhanced esthetics.1

To obtain optimal functional and esthetic results from dental treatment, meticulous attention must be paid to myriad details. The process starts with the patient interview and meticulous treatment planning, then continues through active treatment and culminates in regular follow-up care.

The objectives of this treatment process are to improve oral health, establish proper occlusal function, and create the most ideal esthetic result possible. It is only through an organized and systematic approach that appropriate diagnoses can be made and, based on these diagnoses, functional and esthetic problems can be addressed predictably.

Interdisciplinary therapy involves the combination of diagnostic, treatment planning, and therapeutic procedures. It is imperative that the team leader appropriately select a team of practitioners. The selection process can have a great impact on the overall treatment. Each provider on the team must have an optimal level of skill in his or her area of expertise to positively contribute to the overall result.2 The complex nature of dentofacial problems necessitates a highly organized method of communication among the team members so that all aspects of treatment can be equally considered. It is through this communication that an interdisciplinary treatment plan can be formulated prior to generation of a joint treatment letter. This treatment letter should include a discussion of the aspects of treatment that will be provided by each team member, the time frame of the proposed treatment, the inherent risks involved, informed consent, and the financial responsibilities of the patient. The quality of treatment depends upon the quality of the communication. It is critical that the team leader maintain communication with the specialists both during treatment and once it has been completed. It is only through this approach that optimal care can be delivered and regular follow-up care can be implemented.

This article outlines a comprehensive interdisciplinary treatment philosophy designed for developing the foundation for optimal esthetics in fixed prosthodontics. Three cases are presented to illustrate the utility of interdisciplinary treatment in which allied specialists are recruited to enhance and improve a patient’s function and esthetics.

Case 1

A 49-year-old male disliked the appearance of his maxillary fixed partial denture and wanted to restore the teeth to more ideal esthetics (Figure 1). His particular concerns were the color and shape of the teeth as well as the size discrepancies among teeth Nos. 7, 8, 9, and 10.

Tooth No. 10 exhibited advanced bone loss and was deemed to have a poor prognosis (Figure 2). Probing to the osseous crest under local anesthetic at the midfacial aspect of tooth No. 7 exhibited a distance of 5 mm from the free gingival margin to the osseous crest. The soft tissue levels also exhibited a discrepancy, with the gingival level of No. 10 being apical to that of teeth Nos. 7, 8, and 9.

An analysis of the anterior teeth of this patient indicated a number of issues that could be corrected to improve their esthetics. These included balance of gingival levels, relative tooth dimensions, tooth characterization, surface texture, color, and smile symmetry.3 To confirm that the analysis matched the perceptions of the patient, a diagnostic wax pattern was formed and an acrylic resin template of the wax pattern fabricated. This template served to communicate the desired result to the patient4 (Figure 3). Approval from the patient was obtained and the treatment plan formulated and put into action.

From the esthetic evaluation, it was determined that the gingival contours required alteration. This objective would be achieved using a combination of orthodontic and periodontal treatment.

The treatment outline for Patient 1 was as follows:

1. Orthodontic treatment;

2. Provisionalization;

3. Periodontal treatment;

4. Definitive restoration.

Forced eruption of tooth No. 10 was initiated although eventual extraction of the tooth was planned. To augment the ridge contour of this area, this movement proceeded at a rate of 1 mm per week with a stabilization period of one month for each 1 mm of extrusion (Figure 4).5 Simultaneously with the extraction of tooth No. 10, the fixed partial denture (from Nos. 7 to 10) was removed and the abutments re-prepared. A provisional restoration was fabricated with ovate pontics in the region of teeth Nos. 8 and 10. The ovate pontic in the region of tooth No. 10 was positioned approximately 3 mm apical to the facial gingival margin inside the extraction site. This served as a tissue scaffold to guide the pontic site development.6

At a subsequent appointment, an excisional gingivectomy was performed around tooth No. 7 to harmonize the gingival level with that of the contralateral lateral incisor (Figure 5). The soft tissue was allowed to stabilize for six months prior to re-preparation of the abutment teeth and relining of the provisional restoration.7

The definitive restoration was a metal-ceramic fixed partial denture spanning teeth Nos. 7 to 10 with ovate pontics in the region of teeth Nos. 8 and 10 (Figure 6).

Without the participation of other specialties and a proper treatment plan, it would not be possible to achieve the result obtained.

Case 2

A 47-year-old female was unhappy with the appearance of her maxillary anterior teeth. She requested that they be restored to more ideal esthetics. Her specific complaint was the shape and color of the metal-ceramic crowns on teeth Nos. 8 and 9. The patient also commented that the position of the teeth were “a little out” (Figures 7 and 8).

The patient interview revealed that she had suffered trauma to teeth Nos. 8 and 9 when she was 9 years old. On clinical and radiographic examination, it was found that teeth Nos. 8 and 9 had been restored with cast post and cores and metal-ceramic crowns. The post and cores were of tapering design and appeared to have intimate adaptation with the canal walls (Figure 9).

The soft-tissue levels of the maxillary anterior teeth also exhibited a discrepancy, with the gingival level of tooth No. 10 being apical to that of teeth Nos. 7, 8, and 9.

Consultations with an orthodontist, periodontist, and endodontist proceeded; and an interdisciplinary approach was initiated.8

The patient was not exhibiting symptoms related to the existing endodontic treatment. Consequently, a decision was made to leave the existing post and cores in place. It was believed that attempted removal would incur greater risk to the teeth.

The treatment outline for Patient 2 was as follows:

1. Provisionalization;

2. Orthodontic treatment;

3. Periodontal treatment;

4. Re-provisionalization;

5. Definitive restoration.

The crowns on teeth Nos. 8 and 9 were removed and provisional restorations fabricated prior to referral of the patient to the orthodontist. The orthodontic treatment consisted of retraction of teeth Nos. 7, 8, 9, and 10 and extrusion of tooth No. 10 (Figure 10). The left lateral incisor was extruded to relocate the gingival margin more coronally to match the gingival margin of the left canine.

Prior to referral to the periodontist, diagnostic wax patterns were completed and used to fabricate a surgical guide for the crown lengthening procedure (Figure 11). Use of the surgical guide was necessary so the surgeon could identify the future location of the restorative margins and ensure that at least 3 mm of clearance would exist between the restorative margin and the crest of the alveolar bone9 (Figures 12, 13, and 14).

After waiting six months for healing and stabilization of the gingival margins,6 new provisional restorations were fabricated (Figures 15 and 16).

The definitive restorations included porcelain-fused-to-metal ceramic restorations on teeth Nos. 8 and 9 and small composite resin restorations on teeth Nos. 7 and 10 (Figures 17 and 18).

Case 3

A 22-year-old male disliked the appearance of tooth No. 8 and requested that it be restored to more ideal esthetics. This patient had suffered trauma to tooth No. 8; and, following endodontic treatment and orthodontic extrusion, it was restored with a metal-ceramic crown. In comparison to the contralateral tooth, tooth No. 8 exhibited an occlusogingival size discrepancy and a slightly shorter incisal edge length3 (Figure 19).

The treatment outline for Patient 3 was as follows:

1. Periodontal treatment;

2. Provisionalization;

3. Definitive restoration.

This patient presentation illustrates the need for all practitioners involved in treatment to understand that each phase of treatment will affect the next phase. The periodontal and restorative treatment plan was to perform crown lengthening of tooth No. 8 to achieve a similar gingival form to the contralateral tooth. However, due to a tapering root form of tooth No. 8 and a more palatal position of the facial aspect of the root, symmetry was difficult to achieve10 (Figure 20). Mesiodistally, the differing dimensions were compensated for by having deeper than normal mesiodistal margins while taking care not to violate the biologic width11 (Figures 21 and 22). It was not possible to compensate for the discrepancy of the root size faciolingually. This difference could only have been compensated for through the tooth being erupted more labially during the orthodontic phase (Figures 23 and 24). This treatment example illustrates the need for each participant in interdisciplinary treatment to visualize the ultimate form of the restoration.

Summary

This article illustrates the advantages of an interdisciplinary approach to the management of patients who require fixed prosthodontic care. Treatment planning must begin through visualization of the end result. By paying attention to details and systematically analyzing each factor that affects the esthetic result and recognizing inadequacies in crown contour and gingival margin levels prior to restorative intervention, the restorative dentist can take advantage of the benefits of orthodontic and periodontal treatment to enhance the esthetic and functional outcomes. Without an interdisciplinary approach, final outcomes can be compromised. With a team approach to the management of patients who require fixed prosthodontic treatment, fewer compromises will occur and more ideal restorations can be developed.

Acknowledgments

The authors would like to thank Dr. Tae Tha, Dr. Abdy Moshrefi, and Dr. Fernado Verdugo for surgical therapy in Cases 1, 2, and 3 and Dr. Joseph Zernik for orthodontic therapy in Case 2. The authors would also like to thank Yasuhisa Shimizu (National Ceramics) and Randy Ching for their technical support during the ceramic fabrication phase.

References

1. Rosenstiel SF, Land MF, Fujimoto J, Contemporary Fixed Prosthodontics. Mosby, St Louis, 1995, pp 46-64

2. Roblee RD, Interdisciplinary Dentofacial Therapy. A Comprehensive Approach

to Optimal Patient Care. Quintessence Publishing Co Inc, 1994, pp 17-43.

3. Magne P, Belser U, Bonded Porcelain Restorations in the Anterior Dentition. A Biomimetic Approach. Quintessence Publishing Co Inc, 2002, pp 57-99.

4. Cho GC, Chee WWL, Custom characterization of the provisional restoration. J Prosthet Dent 69:529-32, 1993.

5. Ingber J, Forced eruption: Part 1. A method of treating isolated one and two wall infrabony osseous defects -- rationale and case report. J Periodontol 45:199-205, 1974.

6. Mitrani R, Kois JC, Restorative dentistry using a multidisciplinary approach. Compend Contin Educ Dent 21(4):316-23, 2000.

7. Wise MD, Stability of the gingival crest after surgery and before anterior crown placement. J Prosthet Dent 53:20-3, 1985.

8. Kokich VG, Spear FM, Guidelines for managing the orthodontic-restorative patient. Sem Orthod 3(1):3-20, 1997.

9. Gargiulo A, Krajewski J, Gargiulo M, Defining biological width in crown lengthening. CDS Rev 88:20-3, 1995.

10. Kokich VG, Esthetics and anterior tooth position an orthodontic perspective. Part II Vertical position. J Esth Dent 5(4):174-8, 1993.

11. Preston JD, Rational approach to tooth preparation for ceramo-metal restorations. Dent Clin North Am 21(4):683-98, 1977.

To request a printed copy of this article, please contact/Sajid A Jivraj, DDS, USC School of Dentistry, 925 W. 34th St., Los Angeles, CA 90089-0641.

Legend

Figure 1. Fixed partial denture on Nos. 7 through 9. The patient’s particular concerns were color, shape, and size discrepancy among teeth Nos. 7, 8, 9, and 10.

Figure 2. Periapical radiographs of teeth Nos. 7 through 10, demonstrating advanced bone loss on No. 10.

Figure 3. Diagnostic wax pattern of teeth Nos. 7 through 10 to communicate desired end result.

Figure 4. Orthodontic extrusion of tooth No. 10, which proceeded at a rate of 1 mm a week with a stabilization period of one month for each millimeter of tooth extruded.5

Figure 5. Excisional gingivectomy to harmonize gingival levels with contralateral side.

Figure 6. Labial view of final restorations.

Figure 7. Labial view of metal-ceramic restorations on teeth Nos. 8 and 9. The patient’s particular complaint was color, shape, and size discrepancy between teeth.

Figure 8. Lateral view of metal-ceramic restorations. The patient’s specific complaint was the protrusion of the anterior teeth.

Figure 9. Periapical radiographs of teeth Nos. 8 and 9 demonstrating size and shape of cast posts.

Figure 10. The orthodontic phase included extrusion of No. 10 and retraction of teeth Nos. 7, 8, 9, and 10

Figure 11. The diagnostic wax pattern for crown lengthening template.

Figure 12. Initial incisions and scallop of gingiva following outline dictated by crown lengthening template.

Figure 13. Presentation prior to osseous surgery.

Figure 14. Presentation following osseous removal for crown lengthening.

Figure 15. Gingival crest was allowed to stabilize for six months.7

Figure 16. New provisional restorations fabricated for teeth Nos. 8 and 9.

Figure 17. Close up of metal-ceramic restorations on Nos. 8 and 9 and composite resin restorations on Nos. 7 and 10.

Figure 18. Lateral view of metal-ceramic restoration on Nos. 8 and 9 illustrating change in labial inclination of these teeth as compared to the preoperative situation.

Figure 19. Preoperative labial view of existing restoration and patient presentation.

Figure 20. Incisal view of preparation illustrating narrow root form and palatal position of root compared to contra lateral tooth.

Figure 21. Provisional restoration after crown lengthening -- note narrow cervical contours.

Figure 22. Provisional restoration after tissue maturation and re-preparation of the tooth and deep interproximal margins to allow development of more natural contours.

Figure 23. Close up of retracted smile.

Figure 24. Patient’s smile.