Simplifying the complex

The difference between good results and great results is often directly related to the ability to bring all the disciplines in dentistry together for the benefit of our patients. Interdisciplinary cases, by definition, are those cases that require interdependence among the specialties.

The challenge in dentistry today, with the geometric explosion of knowledge, is to stay abreast of so many areas and restorative dentists, who aspire to excellence, must cultivate specialists with whom to work and plan their cases.

Interdisciplinary teams recognise that they must work in concert, always with the long-term interests of the patients at the forefront, and that each member of the team must bring leadership from their area of expertise.

For those of us on the restorative side, complex cases can be overwhelming at first glance. The myriad of challenges we see can muddy the outcome, unless we have a system to analyse and develop our cases. The purpose of this article is to discuss a system for evaluating a case prior to consulting with other specialties.

The job of the restorative dentist is twofold: to determine where the tops of the teeth should be placed for appropriate function, comfort and aesthetics, and to advocate for the patient and help co-ordinate specialty therapies. There are three goals for every restorative case that are basics:
1. Stable temporomandibular joints and co-ordinated muscle function
2. Aesthetics and anterior guidance in harmony with condylar guidance
3. Posterior teeth in harmony with anterior guidance.

In order to accomplish these goals, it is sometimes necessary to support our restorative treatment by moving teeth, adding roots (implants), treating inadequate soft tissue support, and even moving skeletal structure.

In order to completely analyse a case, it is imperative to begin with all the diagnostic data: an understanding of the patient’s desires and goals, a complete clinical exam, appropriate radiographs and/or cone beam CT scan, clinical photographs and diagnostic casts mounted on a semi-adjustable articulator.

Any emergent situations will have been managed, caries risk evaluated and controlled and, if appropriate, initial periodontal therapy may be underway.
Three questions can be asked to identify the difficulty of the case.
Is the problem at the: 1. Tooth Level, 2. Root Level, 3. Skeletal Level?

While this may seem elementary, it is a good way to begin to think about who should be involved in the case.

Porcelain restorations

Tooth level cases are those which have teeth that can be restored without needing to change the tooth position in order to gain the best result.

Soft tissue may need to be augmented or altered, but the case can be completed by the restorative dentist and, perhaps, with the help of a periodontist and ceramist. In the example, in Figures 1-3, the patient requested porcelain restorations to replace the older pressed ceramic crowns on the laterals and the facial composites on the centrals.
She also requested that, if possible, the shapes of the teeth be altered to give her more ‘robust’ centrals and better symmetry in her teeth. The final result was accomplished with a subepithelial connective tissue graft on the upper right lateral and four feldspathic restorations. The pre-treatment planning was done with photographs and email communication among the
periodontist, restorative dentist, and the ceramist.

The provisionals served as the final roadmap for tissue support, aesthetics, phonetics and occlusion. Root level problems occur in those cases where root position, length, condition, or not enough roots interferes with the preferred restorative solution. These challenges often require orthodontic and/or surgical intervention.

Root level cases often require a higher level of communication among the team and it is imperative to develop a system by which information is exchanged. Frequently, meeting as a group to discuss the case allows for a free exchange of ideas and solutions may be discovered which were not initially considered.

Think about root level cases from the apex first and coronal last. The cascade of root issues in order of difficulty:
• Endodontic lesions single teeth
• Endodontic lesions multiple teeth
• Malocclusion requiring minor ortho
• Single missing tooth
• Malocclusion requiring comprehensive ortho
• Multiple missing teeth
Root form and position dictate crown form and position and proper root position allows for appropriate force distribution as well as better aesthetics.
Involving our orthodontic colleagues in optimising root position can turn a complex restorative case into one that is straightforward and routine.
Our surgical colleagues can help us by augmenting soft tissue as well as adding root form with implants. The final outcomes are far better if everyone involved
understands the desired outcomes before treatment is started and if everyone is kept abreast of progress throughout the case.

The example in Figures 4-7 required gingival levelling by the orthodontist and repositioning of the peg laterals prior to feldspathic veneers being placed on the laterals.

The case in Figures 8-11 was solved with subepithelial connective grafting on the right lateral, minor orthodontics in the lower anteriors to correct an anterior guidance issues and then porcelain veneers on the maxillary anterior teeth.

Skeletal level problems may have some or all the components of tooth and root level challenges and are complicated by either skeletal malocclusion of developmental origin or from a breakdown in the temporomandibular joint. Joint surgery or orthognathic surgery may be
indicated to help solve difficult restorative or aesthetic challenges and must be carefully choreographed to achieve optimum outcomes.

Ultimate outcome
If the ultimate outcome is to have the bone and roots support the final preferred position of the tops of the teeth, then the entire inter-disciplinary team should be involved from the outset.
In the case in Figures 12-14, the patient had chronic orofacial pain secondary to chronic bruxing, occlusal instability, from wear and from a Class II malocclusion, as well as violation of biologic width around several teeth. She also had significant breakdown in her posterior teeth requiring full coverage restorations.

The restorative dentist, periodontist, orthodontist, and oral surgeon each had consultations with the patient and then met as a team to discuss their findings and finalise a treatment plan.
The team agreed that they would each email their progress notes to all the dentists involved at each visit so that everyone was apprised of her progress at each step. The treatment consisted of orthodontics to level and align the teeth so the maxillary and mandibular orthognathic surgeries could be performed. Following healing and final orthodontics, the posterior reconstruction was finished.

The total treatment time was three and a half years. Interdisciplinary cases can be the inspiring and rewarding for everyone involved, especially the patients who trust us with their care.
Finding a team with whom you can excel makes the process seamless!

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