This is the second in a three part series from the Chesapeake Dental Education Center (CDEC) covering the topic of treating the worn dentition. Treating the Worn Dentition – Part I” reviewed the etiology of tooth wear and problem of aberrant tooth position that often occurs as a result of the adaptive changes with wear. In fact, the solution to most wear cases is determining the ideal tooth position. And the two factors involved in determining ideal tooth position are esthetics and function (occlusion and phonetics). In “Part II”, the systematic process for developing a comprehensive treatment plan will be covered.
At the CDEC, we have developed STEP™ – a Systematic Treatment Evaluation Protocol consisting of 5 distinct sequential “STEPS” that allows for an efficient and predictable process to determine the ideal esthetic and functional tooth position for any patient (figure 1). STEP 1 is the thorough assessment of the patient that gathers all necessary history and information associated with the case. STEP 2 ensures that a comprehensive diagnosis is made and risk assessment is determined. In STEP 3.1, which is the first sub-step in Step 3 – Analyze, a two-dimensional esthetic plan is developed by applying esthetic parameters to patient photographs using PowerPoint. STEP 3.2 then converts the two-dimensional plan – the “blueprint” – into three dimensions – the diagnostic wax-up – by applying occlusal principles to the case (figures 2a and 2b). STEP 4
Communicates the plan to the patient and STEP 5 deals with the Implementation of the treatment plan.
The discussion will now focus on developing the esthetic plan (STEP 3.1).
First, In order to use patient photographs and PowerPoint to develop an esthetic plan, it should be understood that precision dental photography must be employed. Incorrect angulation of the camera will result in distorted perceptions of the patient’s true condition (figure 3a, 3b and 3c). It should also be understood that patient photographs will be used to demonstrate to the patient the potential treatment options to solve their problems. Clean, in-focus photographs void of retractors and mirror edges are important, as the subliminal message the patient receives is almost as important as the dental information relative to their case acceptance. Photographs can be fine-tuned – cropped, straightened and exposure adjusted. At CDEC, “Windows Live Photo Gallery” is used; however, nothing takes the place of capturing a great image with the digital camera.
Once captured and fine-tuned, the photographs are loaded into PowerPoint 2010. Esthetic determinants are applied to the photographs to determine the ideal two-dimensional position of the teeth. Esthetic determinants are applied first to the full face view photographs (facial thirds, facial midline, incisal plane – figure 4), then to the dento-facial photographs (desired incisal edge position relative to lip at rest and high smile, incisal plane to occlusal plane – figure 5) and finally to the dental photographs (tooth proportions, gingival position and contour – figure 6).
It must be understood that a two-dimensional plan can be done other ways – simply drawing on tracing paper taped over patient photographs or by computer imaging. However, there are distinct advantages in the dentist’s ability to understand the esthetic components of the case by building it in PowerPoint as well as the patient’s ability to visualize their treatment options. The latter can dramatically improve case acceptance.
Using a template of ideal teeth provides an expeditious way to complete an esthetic plan in PowerPoint. The plan then becomes a communication tool for the patient and allows the dentist and patient to determine the scope of treatment prior to commencing a much more involved diagnostic wax-up. With this protocol the dentist, patient and laboratory technician have the ability to visualize the desired outcome (figure 7) before commencing treatment.
Treating the Worn Dentition – Part III will cover the next STEP™ (3.2 – Evaluate the occlusion to determine how to accomplish the two-dimensional blueprint in three dimensions).