Contingency, Priority and Risk Protocol For Treatment: Part II

Priority

Priority in treatment planning culminates in a practical approach to resolving a patient's problem and providing common sense treatments. This includes addressing the initial clinical situation, surgical plan, surgical phase and choice/design of implant and restorative materials. It also involves considering the patient's esthetic, financial, and time constraints, as well as any other limiting factors.

For example, consider the case of a 70+ (Fig 1) year-old man who had been inappropriately treated with an implant-supported restoration.

Although his lip position and mobility were satisfactory, the dentistry hidden beneath the restoration revealed the extent of poor implant placement and restoration design. (Fig 2)

Upon removal of the restoration, it was clear the implant was placed in the incorrect position from multiple perspectives: mesial-distal, buccal-lingual, apical-coronal and angulation. (Fig 3)

Assessing priorities in this case required consideration of potential alternatives for redesigning the implant-supported restoration.

Additional complications and considerations in this case - including removing the implant, grafting, possible multiple implants, orthodontics to optimize the space, and muccogingival correction - were addressed. From a practical perspective, driven partially by the patient's lip mobility, a traditional tooth-supported restoration with conventional tooth preparation and crown was the approach indicated. (Figs 4 and 5)

While the patient's mindset influenced the selection of different treatment options, an essential priority is an understanding of the patient’s risk. By carefully considering the biology of the interaction between the implant-prosthesis complex with the implant site, as well as harmony among the implant-supported restorations and the surrounding hard and soft tissues, clinicians are better prepared to achieve a predictable, esthetic, and practical result.

Priority also addresses a patient's finances, desires, and compliance. Costs - both in the time and financial commitment involved - play an important role in determining the type of treatment that is ideal for a given patient; beyond the monetary outlay, they include number of office visits and lengthy appointments. Today, many treatments are limited to what patients can afford, and finances can determine the type and extent of treatment they receive.

Risk

Risk is the potential that a chosen action or activity, including the choice of inaction, will lead to a loss or undesirable outcome. It includes any threat that the patient or clinician could potentially encounter. When assessing risks, examining the patient through several different risk filters provides a holistic view of the patient's condition. A patient's risk may be present in one or many of these filters.

The biological filter evaluates the patient's health and condition, including the presence of periodontal disease and the need for treatment. Periodontal disease can lead to bone loss and other complications with surgery. A health questionnaire can be used, as well as an oral examination, to determine whether patients are at higher risk for biological complications for healing and after-treatment due to underlying health conditions such as being systemically compromised.

The structural filter evaluates the stability of the restorations. A patient with high structural risk demonstrates extensive ill-fitting restorations, numerous endodontically treated teeth, active decay, aggressive preparations/large cast posts and cores, or lack of adequate ferule effect - all of which can also affect the structural integrity of the treatment. The structural filter can be affected by material selection, occlusion and wear.

High functional risk can be seen in patients with severe parafunctional activity, and while implants may be necessary, many patients’ parafunctional activity persists after implantation. Clinicians are tasked with over-engineering the restorative design (e.g., increasing the number of implants) and providing a system that will withstand the patient's susceptibility to fracture due to parafunctional activity.

Finally, the esthetic risk filter is more subjective. Patient satisfaction, tooth position, extractions, missing teeth, shade, and shape affect esthetics. Lip mobility is also a critical parameter when assessing the patient's esthetic risk. The restorative design, including implant distribution, number of implants, type of retention and material choice are affected by a combination of esthetic risk and other risk factors.

References:

• Holst S, Blatz MB, Hegenbarth E, et al. Prosthodontic considerations for predictable single-implant esthetics in the anterior maxilla. J Oral Maxillofac Surg. 2005;63(9 Suppl 2):89-96.
• Zadeh HH, Daftary F. Implant designs for the spectrum of esthetic and functional requirements. J Calif Dent Assoc. 2004;32(12):1003-1010.
• Shumaker ND, Metcalf BT, Toscano NT, Holtzclaw DJ. Periodontal and periimplant maintenance: a critical factor in long-term treatment success. Compend Contin Educ Dent. 2009;30(7):388-394.
• Spear FM. Treatment planning materials, tooth reduction, and margin placement for anterior indirect esthetic restorations. Inside Dent. 2008;
  4(1):4-13.
• DiMatteo AM. Pounding on the occlusion pulpit—wherein lies all the controversy? Inside Dent. 2008;4(3).

(Click this link for more dentistry articles by Dr. Ricardo Mitrani.)

Ricardo Mitrani, D.D.S., M.S.D., Spear Faculty and Contributing Author