Protocols provide quality control and effective information management, ensuring that each critical point is verified and documented in the treatment plan. The completion of the treatment objectives and the longevity of the restoration reflect the precision exercised during each procedure and depend on the effort of all involved, including the interdisciplinary team, the dental laboratory technician (DLT), and the patient [Figure 3-01].

[Figure 3-01] Overview of the anamnesis, clinical examination, diagnosis, and treatment planning process. All the steps mentioned are interconnected and contribute to developing a complete and adequate treatment plan that consistently provides high-quality results.

TREATMENT PLANNING

Treatment planning is the systematic, rational, and dynamic act of establishing a logical sequence of steps to achieve a specific therapeutic objective related to the diagnosis such as, for example, eliminating or controlling disease, correcting structural deficiencies, improving masticatory function, and improving esthetics [Figure 3-02].

[Figure 3-02] To facilitate the organization of data from the anamnesis and clinical examination, to speed up communication with the interdisciplinary team members, and to prepare the treatment plan, patient data should be divided according to their esthetic, functional, structural, and biologic aspects.

Many treatments are performed from incomplete or nonexistent plans, and the results are inconsistent. According to Peter Dawson¹, approximately 90% of restorative treatment failures are related to treatment planning failures. Such failures are sources of stress and frustration. In addition, they waste time and finances and are detrimental to professional reputation.

Effective treatment planning makes it possible to organize the treatment steps progressively, allocate adequate time for each procedure, and determine the intervals between appointments, which optimizes the entire treatment process. It also allows problems to be anticipated and alternative paths to be considered according to different scenarios, minimizing the possibility of reintervention².

Barriers to Treatment Planning

The undeniable reality is that any procedure should be planned before execution to ensure consistent, predictable, and even profitable results. Large companies invest considerable sums of money to hire managers with planning skills to rationalize the steps and resources toward effective goals.

So why do dentists generally not devote time and attention to treatment planning? One reason is that most professionals did not have the proper training to plan clinical cases with varying degrees of complexity, perhaps due to a lack of time during their dental education period for developing this skill. Another concern is that, historically, the teaching of dentistry has occurred in a compartmentalized way through different fields throughout the curriculum. Thus, each domain presents its program and introduces specific techniques, demanding minimal requirements from the student to pass. As the different fields have different concepts and priorities, at the end of the course, the student does not necessarily understand the importance of each one in the context of the patient.

In daily practice, treatment planning requires comprehensive reasoning and demands knowledge and time to analyze different diagnostic information and treatment alternatives. It is recommended to avoid starting treatment without a defined treatment plan, or even to plan the case throughout the treatment according to priorities at a specific moment or the clinical time available for a particular session. Interdisciplinary and organized treatment planning through an efficient communication process is ideal, especially for complex cases.

In many cases, it is impossible to establish an absolute prognosis due to the presence of multiple risk factors observed in different clinical situations⁵. From a practical point of view, for a treatment plan to be viable, the prognosis of performing the treatment should be more favorable than allowing the natural course of the disease. It is necessary to consider the fact that the treatment prognosis is dynamic and may change according to tissue responses and the patient’s commitment to the proposed therapies.

Restorative Treatment Planning

Types of treatment

The process of elaborating the treatment plan requires a variable period, which depends on the treatment complexity and the knowledge and experience of the professional. One of the purposes of this book is to share the reasoning as it applies to most clinical situations, which allows customization according to individual needs.

For didactic reasons, the treatment plan is classified into four types [Figure 3-03]: interdisciplinary, esthetic, functional, and essential. As its name implies, the essential treatment plan is the foundation of any dental treatment, primarily relating to the structural and biologic health conditions of the stomatognathic system. It will be an integral part of the functional treatment plan, in which the patient’s concerns, signs, and symptoms indicate the need to solve occlusal issues. It is also the basis of the esthetic treatment plan when the patient’s concerns and wishes demand the improvement of the smile. It will be equally fundamental in the interdisciplinary treatment plan, as detailed later in this chapter.

[Figure 3-03] Treatment plans can be didactically classified into four distinct types: interdisciplinary, esthetic, functional, and essential. The essential treatment plan is related to structural and biologic aspects, constituting the foundation of the other treatments that can only achieve their goals if the patient’s oral health conditions are fully restored.

Interdisciplinary treatment plan (esthetic–functional)

In the interdisciplinary treatment plan (esthetic–functional), the patient presents a combination of esthetic and functional problems, accompanied, in most cases, by structural and biologic impairments with varying degrees of severity. In these cases, an integrated approach is recommended with a team of specialists to achieve an accurate diagnosis/diagnoses and effective solutions.

Within this team, the treatment manager or coordinator should have the knowledge and skills necessary to gather, summarize, and integrate all relevant information in a scientifically based and coherent manner to facilitate the team’s assessments and decisions. Ideally, but not necessarily, this person should be the dentist who consulted with the patient during the anamnesis and performed the clinical examination, as this professional will be familiar with the patient’s concerns, problems, and expectations.

In cases where the patient complains about their smile appearance or where the dentist has identified signs of esthetic disharmony regarding the shade, shape, arrangement, and position of the teeth or gingival tissue, it is recommended to carry out an esthetic smile project, as is detailed later. This project will define a potential esthetic therapeutic model, allowing the treatment coordinator to prepare a preliminary treatment plan containing a list of problems and a proposal for solutions to be discussed with specialists⁶. Thus, from the preliminary stages of treatment, all clinical actions will be carried out to contribute to the planned esthetic result^7,8.

The use of digital technologies considerably helps the treatment coordinator to gather and integrate the patient’s clinical data, complementary examinations, photographs, videos, digitized models (STL files), and the esthetic smile project. All patient-related data should be organized and made available in a shared folder, adequately identified, in a virtual and secure environment (“cloud dentistry”), to which only authorized team members have access at the appropriate time and place [Figure 3-04]. This information can be discussed (dental brainstorming) in person or through applications such as WhatsApp, iMessage, Skype, Zoom, or similar.

[Figure 3-04] The treatment planning flowchart shows an example of a shared folder “in the cloud” with relevant information, so that the interdisciplinary team can elaborate on the treatment plan and its execution. The treatment planning process occurs between appointments, in the time after the initial consultation and before the treatment plan presentation. The problems identified in the anamnesis and clinical examination are categorized into specialties to facilitate discussion with the different specialists.

The esthetic smile project is required whenever the patient has any esthetic concern or when the dentist identifies benefits in improving the smile. Specialists will be able to give their diagnosis and suggest treatment options asynchronously, i.e. at an opportune time. A preliminary treatment plan containing the treatment proposals should be documented.

This way, specialists can reassess the data, review individual diagnoses, analyze risks, establish prognoses, and decide on the most appropriate treatment option. This communication and treatment planning process needs to be cultivated and continuously improved by the interdisciplinary team to allow flexible and personalized decisions for each type of situation.

After discussing the advantages, disadvantages, limitations, risks, and time required to resolve the diagnosed problems as comprehensively as possible, the treatment coordinator will write the preliminary treatment plan and present it to the patient (more details in Chapter 5). Although there is a high degree of predictability when working in this way, minor changes in planning may occur throughout treatment, depending on the patient’s responses to the procedures or new clinical findings [Figure 3-05].

[Figure 3-05] The treatment plan may be modified based on the particularities of each individual at that moment in the patient’s life. It is designed to address all the relevant problems and can be classified into four different types for didactic purposes, with the essential treatment (i.e. the structural–biologic conditions) being the non-negotiable basis of them all.

In interdisciplinary cases [Figures 3-06A–V and 3-07A–Q], because the stomatognathic system is in a pathologic state or due to a large number of compromised teeth that require restoration, a reorganizing approach to the occlusion will be indicated, with the determination of a new therapeutic maxillomandibular relationship (see Chapter 7) as well as a change to the vertical dimension of occlusion (VDO) (see Chapter 11). These will need to be treated or controlled in situations where relevant functional signs or symptoms are present before any irreversible treatment is initiated.

[Figure 3-06A–V] The documentation required for interdisciplinary cases includes extraoral photographs of the patient’s face with the lips at rest and during smile, in addition to intraoral photographs and imaging examinations [A–I]. From there, the preliminary treatment plan will be prepared [J]. The esthetic smile project [K] will generate relevant information that will be transferred to the study model [L], allowing the fabrication of temporary restorations [M–O]. These will be installed, tested, and adjusted in the mouth until esthetic and functional approval [P,Q]. The final work will be developed by replicating the morphology validated by the temporary restorations in an analog or a digital manner [R–V].

[Figure 3-07A–Q] Documentation of this interdisciplinary case included extraoral photographs of the patient’s face with the lips at rest and during smile as well as intraoral photographs and imaging examinations [A–J] to develop the treatment plan [K]. The final restorations were developed by replicating the morphology validated by the temporary restorations in an analog manner [L–P]. The occlusal adjustment of the restorations and the bite plate should be performed with the utmost care for the adequate distribution of forces in the stomatognathic system [Q].

QR code linking to the Summary of the Diagnostic Evaluation and Preliminary Treatment Plan Form template that can be customized.

Esthetic treatment plan

The esthetic treatment plan takes place in response to patient concerns or when the dentist has identified problems in terms of tooth shade, shape, arrangement, position, or regarding the gingival tissue. The stomatognathic system is in a physiologic state, and any structural and biologic problems should be included in the treatment plan.

An esthetic treatment plan is required in cases in which the morphology or position of the maxillary and mandibular anterior teeth need to be modified, with a low risk of interference with the patient’s envelope of function [Figures 3-08A–S and 3-09A–P]. The most significant difference between the esthetic–functional treatment plan explained above and the esthetic treatment plan is that, in the case of the latter, a conformative approach may be adopted due to the absence of functional signs and symptoms (more details in Chapter 7).

[Figure 3-08A–G] To elaborate the esthetic treatment plan, it is necessary to acquire extraoral photographs and imaging examinations of the patient’s face with the lips at rest and during smile.

[Figure 3-08H–S] The esthetic smile project facilitates communication with other team members such as, in this case, the surgeon [H]. The implant was removed, and hard and soft tissue grafts were performed to enable the placement of a new implant with restored tissue levels [I–P]. (Surgical and periodontal treatment performed by the Implanteperio group.) After that, the soft tissue was conditioned with temporary restorations and the final restorations were completed [Q–S].

[Figure 3-09A–P] In this esthetic treatment plan, the esthetic smile project had the additional purpose of informing the patient about the limitations of a tissue reconstruction approach, given the significant tissue gap of 10 millimeters (mm) combined with the 10 surgical procedures already performed by other professionals in this area [A–I]. The work was carried out from tissue leveling through orthodontics (Dr. Juliana Romanelli), complemented with a connective tissue graft and dental implants [M] (Dr. Marcos Pitta). A dentogingival ceramic fixed prosthesis was performed in an attempt to achieve harmony between the white esthetics and adjacent teeth. The pink esthetics was optimized with the characterization of the ceramic gingiva with pigments and composite resin [N–P] (Anaxgum; Anaxdent, Germany).

However, if the preliminary treatment planning includes the need to change the position of the maxillary anterior teeth or the need for them to be elongated to achieve a significant increase in overbite, the anterior functional relationships should be reassessed for the risk of interfering with the trajectories of the mandibular movements. The functional conflicts resulting from the planned incisal relationships between the maxillary and mandibular anterior teeth may suggest alterations in the maxillomandibular relationships and VDO, which would transform an esthetic treatment plan into an esthetic—functional one.

Functional treatment plan

A functional treatment plan is required when the patient presents signs or symptoms of a stomatognathic system in a pathologic state such as pain or joint and muscle dysfunction, evident tooth wear due to attrition, fractured teeth or restorations, tooth hypermobility, tooth migration, resorption of the alveolar bone crest, noncarious cervical lesions (NCCLs), or dentinal hypersensitivity. During the clinical examination, structural or biologic problems may also be identified, which need to be included in the treatment plan [Figure 3-10A–P]. In this individual, esthetic problems were absent or limited to minor corrections of shade or shape of the restorations present, without the need to significantly modify tooth position and morphology or the maxillomandibular relationship.

[Figure 3-10A–P] The functional treatment plan may include the treatment of structural and biologic problems that should be treated beforehand or in conjunction with functional concerns. This treatment plan can range from controlling the clinical situation with medications to stabilizing interocclusal splints and careful occlusal adjustment, when necessary [A–C]. In the event of esthetic problems, this treatment plan may be transformed into an interdisciplinary one [D–P].

Due to the unpredictable nature of this case, it will require knowledge and experience in treating functional disorders of the stomatognathic system. When pain, discomfort, or occlusal instability are diagnosed, treatment can only start with conservative and reversible therapies, usually stabilizing interocclusal splints⁹. These will need to be adjusted, methodically and periodically, until pain relief, improvement in masticatory function, and stability of the occlusal contacts.

The definition of the subsequent therapeutic steps will depend on how the patient progresses. An anti-inflammatory and muscle relaxant medication may be prescribed to relieve symptoms. It is recommended that irreversible restorative treatments be started only after a significant and stable improvement of the clinical signs and symptoms, which can take weeks to months.

Severe cases of TMD may require an interdisciplinary approach specializing in the control of pain and dysfunction of these conditions with dentists, doctors, physiotherapists, and psychologists. Reports of sleep disorders should be referred for specialized evaluation and specific laboratory tests.

Essential treatment plan (structural–biologic)

The essential treatment plan is required when the patient presents structural or biologic problems such as gingival inflammation, carious lesions, endodontic problems, teeth with structural fragility, fractured restorations, missing teeth, etc. In such cases, the stomatognathic system is in a physiologic state, with esthetic problems that are either nonexistent or limited to minor corrections to the shade or shape of the present restorations, without the need to significantly modify the position and morphology of the teeth. The essential treatment plan is implemented in the most straightforward cases. It is a fundamental part of the more complex treatment plans because the health and stability of the hard and soft tissue are the foundation of all dental treatments [Figure 3-11A–F].

[Figure 3-11A–F] The essential treatment plan (structural–biologic) refers to treating structural and biologic problems. It should be based on the data from the anamnesis and clinical examination and should precede the other phases of more complex treatments such as esthetic, functional, or interdisciplinary ones.

The essential treatment plan aims to resolve or control diagnosed diseases, starting with urgent problems of infection, inflammation, pain, or discomfort. Careful prophylaxis of all the teeth is recommended, together with patient education and motivation regarding oral hygiene care, adapting the oral environment for restorative treatment (see Chapter 6).

As functional and esthetic references are maintained, the sequence of procedures in the essential treatment plan is not critical for the final result. It can be defined according to the professional’s preferred strategy or the patient’s comfort, performing the restorations one tooth at a time or by sectors. Due to the absence of functional signs and symptoms, with the stomatognathic system in a physiologic state, this treatment can be performed within a conformative approach, taking care not to introduce occlusal interferences in new restorations.

If, however, the structural or biologic problems involve multiple teeth, there is the possibility of loss or alteration of the present occlusal references, with the need to consider the possibility and advantages of reorganizing the existing occlusal scheme (more details in Chapter 7).

Treatment not indicated

The dentist must diagnose and document all problems in the patient’s stomatognathic system. However, it should be clear that not all of them require immediate treatment. When the risk or prognosis of the identified problem is unclear, it is preferable to establish a periodic control program with the patient for a future reassessment, waiting for the most opportune moment to intervene.

It is recommended to explain in detail to the patient the reasons for choosing the more conservative option or for not immediately indicating treatment. This conversation takes time and requires a cautious and confident approach, with enlightening and scientifically based explanations for the patient’s safety.

On the other hand, if, for personal reasons, the patient prefers to postpone a treatment that the dentist deems appropriate, the patient will need to be instructed as to the risks of this postponement and accept the responsibilities and consequences of their decision. All these guidelines should be documented in writing in the medical record. To avoid any future problems, the patient should sign an Informed Consent Form attesting to the fact that they are aware of the possible problems that may occur.

Decision making

The treatment planning process involves critical decisions that have implications for the scope, sequence, and results of the treatment. This process involves decision making based on the evaluation of present data and the prediction of possible future clinical scenarios according to the probable treatment evolution.

Several factors related to the dentist and the patient that can interfere with treatment decisions should be understood so that the process occurs in the best possible way.

Influencing factors in the decision-making process related to dentists

Current scientific knowledge and technical skills: With the advancement of science and technology, more diagnostic data can be obtained and incorporated into the treatment plan. This requires an up-to-date, experienced, and competent professional capable of sensibly integrating a vast amount of information. The dentist should be aware that many techniques or materials are indicated without proper scientific evidence.

Cognitive and emotional aspects: All specialists in the interdisciplinary team tend to interpret information according to their knowledge, values, and beliefs. The treatment coordinator should intelligently balance these different biases to build a treatment plan with a long-term view, anticipating alternative strategies in the case of possible complications.

Available technology: The availability of state-of-the-art equipment and materials as well as the possibility of working with skilled DLTs has a potentially significant influence on treatment planning.

Personal values: There should be a genuine commitment to the patient and their involvement with the process of excellence to achieve the best possible results and exceed the expectations of all involved.

Ethical aspects: The patient’s health, well-being, and needs must precede personal or professional interests.

Influencing factors in the decision-making process related to the patient

Age: Depending on the patient’s age, certain diagnostic aspects, such as tooth wear, become relevant. These aspects can be considered natural and physiologic in elderly patients but pathologic in young patients. The type of treatment will also depend on the patient’s age, with younger patients usually demanding preventive and minimally invasive treatments and those of a more advanced age often requiring more complex restorative treatments.

General health status and medications: These factors influence the patient’s motivation to undergo treatment, their ability to travel to the clinic and/or endure long-term consultations, their tissue responses to clinical procedures, etc. The treatment plan should be individualized in relation to such limitations.

Emotional behavior: This has a significant influence on the treatment. The experienced clinician needs to be able to detect behavioral aspects that can negatively influence the treatment such as difficulty understanding the limitations of the case, lack of motivation, lack of trust in the professional, lack of appreciation of the treatment, excessive concerns, and somatoform disorders. Some problems can be minimized through deliberate guidance by the professionals involved in creating the treatment plan.

Socioeconomic status: This has an important influence on the treatment plan. In addition to the treatment plan that is considered “ideal,” alternative and more affordable options should be suggested to enable the solution of the most relevant problems.

Time constraints: Many patients consider the lack of time in their schedule as an obstacle to undergoing dental treatment. Plan for longer and more efficient appointments – without compromising the final quality of the work – with the need for fewer patient visits to the clinic.

Distance from the patient’s home or workplace to the clinic: As with time constraints, for patients who come from far away, longer and more efficient appointments should be scheduled to solve more problems with fewer journeys to the clinic.

Fear of treatment: Many patients are afraid of treatment, although many are unwilling to report it. In reality, the fear of treatment is one of the main obstacles to starting or even finishing treatment. It can manifest differently and be related to fear of pain, discomfort, or not adapting to the treatment. This fear can only be minimized through empathy, by recognizing it and calmly explaining to the patient what can be expected from each appointment. Sometimes, this can be a long process, but reducing fear of treatment will be one of the most significant benefits the professional can provide to the patient.

Individual uncertainty factors: These factors are commonly present in different aspects of the treatment (esthetics, function, structure, and biology) and need to be carefully evaluated. Such decisions are not always straightforward and are directly related to the judgment of the risk involved; they may require immediate action or periodic control to minimize the risk of compromising the treatment prognosis. Examples of such situations include root canals with defective fillings but with no clinical or radiographic signs or symptoms of a periapical lesion; existing restorations with defective or leaking margins but with no clinical or radiographic signs of a carious lesion; or remaining tooth structure, presence of intraradicular retainers with inadequate length, absence of interproximal tooth contacts, impacted teeth, teeth with hypermobility, a discrepancy between the centric relation (CR) and maximal intercuspal position (MIP), staining of a tooth remnant in anterior teeth, among others. Regardless of the conduct adopted in these situations, they should be adequately documented on the patient’s Clinical Evolution Form, and/or an Informed Consent Form should be prepared.

Treatment Planning Sequence

The treatment planning process must be systematic and carried out according to a preestablished sequence and predetermined objectives. The order of stages and clinical procedures may vary according to the demands and complications of the case and the patient’s physical and emotional responses.

The following treatment planning sequence is recommended for all esthetic and esthetic–functional treatment plans. Depending on the clinical situation and the experience of the treatment coordinator, the suggested sequence does not need to be completed before the patient accepts the treatment plan because of the time and costs involved. However, the dentist needs to be aware that any failure resulting from incomplete treatment planning or incorrect information given to the patient may have unforeseen consequences for the solution of the case and the patient–dentist relationship.

A. Maxilla – Anterior

1. Three-dimensional (3D) position of the incisal edges of the maxillary central incisors in relation to the patient’s face

The incisal edges of the maxillary anterior teeth are related to esthetics and phonetics and establish the anterior limit of the envelope of function. Thus, defining where to position them in relation to the patient’s face and lips is the crucial point of rehabilitation treatment. Although not mandatory, this author recommends the use of specific software or applications for the esthetic smile project, such as the DSD Hands-On App, to guide, standardize, and even facilitate this intricate process [Figure 3-12].

[Figure 3-12] The DSD Hands-On App contains standardized tools that aim to facilitate the execution process of the esthetic smile project.

Stay updated, free dental videos. Join our Telegram channel

Join