In treatment planning, the concept of phasing your treatment is not new. For example, in periodontics, after the initial examination and diagnosis, phase 1 therapy often involves a sanative phase of basic scaling and root planning, a review of oral hygiene and an identification and modification of risks factors. The goal is to remove all soft and hard deposits responsible of the periodontal inflammatory disease and modify risk factors that have played a part in this disease process. Then following phase 1 therapy, the algorithm is to re-evaluate the patient in 4-6 weeks to assess the periodontal health at that point. A decision will have to be made regarding whether the patient can be placed on maintenance/preventive phase or will require further treatment in Phase 2 therapy. Phase 2 therapy in periodontics may include pocket reduction therapy, guided tissue regeneration or more.
Similarly, in prosthodontics, in my mind, there is often a phase 1 for the prosthodontic treatment plan. I used the term “phase 1” figuratively to describe the concept that before definitive prosthodontic treatment can be implemented, there is often a need to evaluate and to correct something pre-existing in the dentition to improve the outcome of the prosthodontic treatment plan. The process of treatment planning involves the diagnostic phase, the goals setting phase and then choosing your treatment phase.
Choosing your treatment phase is often the part of what you learn in dental school. What is a bridge? What is a denture? What are the indications for each treatment option? Do I fabricate a bridge or a partial denture in this area? What are my treatment options for a completely edentulous patient? Or how do I improve the esthetics with veneers or crowns? These are all the final definitive treatment options you would consider.
But before you get there, there may be pre-existing conditions that should be addressed, corrected, or at minimum, discussed with the patient. Some of these conditions, if not corrected, can influence the outcome of your prosthetic treatment plan. Some common conditions requiring correction prior to definitive prosthodontic treatment plan may include but not limited to:
• Hyperplastic tissue due to ill-fitting dentures
• Occlusal trauma
• Inadequate inter-occlusal clearance for prosthetic replacement
• Uneven occlusal plane requiring correction
• Inadequate posterior support due to multiple missing teeth
Many people will focus on the definitive treatment plan of teeth replacement. While this is often a common treatment goal in prosthodontics, there are other prosthodontic goals that should be considered as well.
Some Common Prosthodontic Goals can be:
• Modify medical risk factors through multidisciplinary consultation
• Replace missing teeth
• Improve esthetics
• Provide stable posterior support
• Restore vertical dimension of occlusion
• Alter anterior guidance and occlusal scheme
• Improve occlusal plane orientation
For example, there may be a need to evaluate and modify the patient’s medical and social condition as they may play a role in the dental condition. An example of such a case would be people who have gastroesophageal reflux disease or bulimia along with a parafunctional habit resulting in the loss of tooth structure requiring reconstruction.
Another example of phase 1 therapy would be a process of evaluating pre-prosthetic orthodontic, surgical and/or endodontic options prior to finalizing the most suitable treatment option for the patient.
Or the procedure of planning and removing existing restorations to evaluate the restorative status of potential abutment teeth is also part of phase 1 therapy. Sometimes the final treatment plan cannot be finalized until the restorative status can be determined.
Finally, the procedures of stabilizing the patient’s posterior support and testing out the patient’s tolerance to the altered occlusal scheme are all part of phase 1 therapy to me.
Inadequate posterior support and interocclusal clearance for teeth replacement
With occlusal appliance
With provisional crowns and acrylic partial denture to provide posterior support
Slanting and unesthetic occlusal plane
Provisional crowns and acrylic partial denture to correct occlusal plane and to test out esthetics and occlusal relationship
Definitive crowns and partial denture in the maxilla
Some common procedures that can be planned in phase 1 therapy include:
• Referral to other dental specialists for evaluating or discussion of treatment options
• Diagnostic wax up
• Removing old crowns to determine restorability
• Provisionalization of existing teeth to ideal esthetics and occlusal scheme
• Provision of posterior support to minimize occlusal trauma to anterior teeth
• Removing non-restorable teeth
• Replacing old restorations/improving the core restorations
• Improving, correcting or re-establishing ideal occlusal plane
Phase 1 therapy is the process of identifying what prosthodontic goals you want to achieve. It is often a process that may evolve when new information becomes available. It must be a flexible one, where both the clinician and the patient have a better understanding of what options are available. It is also a phase of treatment that allows the patient to test out what works and what does not work in the mouth. And finally it may be a phase of treatment where pre-existing dental conditions are altered to facilitate the prosthetic treatment plan. Figuring out what to do in the phase 1 part of the prosthodontic treatment is the most challenging part of treatment planning. There are many factors to consider: medical, social, dental condition and the patient’s decision. But once the phase 1 part is properly planned and executed, carrying out the definitive phase of prosthodontic treatment becomes much more predictable and will likely leading to a more successful and favourable outcome.
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