Why is the planning phase important? Is this a part of all treatments?
An initial planning phase is a must for any treatment that has a cosmetic/aesthetic element. But this is also a helpful tool in multi-restoration cases or cases that require a change to the occlusion.
This is a helpful tool for understanding the patient requirements, limitations of a particular treatment and for effective communication between the dentist and the patient and the dentist and the lab.
The perception of beauty is different for everyone - and although there are golden proportions and ideals been calculated, not everybody would be happy with a result we think as perfect and so the patient’s perception is very crucial in the planning stage. This eliminates many misunderstandings and has a tremendous impact on maintaining expectations.
The patient and the dentist already knows the result and will work backwards to achieve an already known/agreed end result.
Can pick up other treatment requirements like gum correction or whitening.
What does the planning phase involve?
We take impressions of the mouth to make study models and record the bite, they used this information in the lab to articulate /mouth the models to recreate the way the teeth meet in the mouth.
A Diagnostic wax-up is prepared by adding wax to the desired shape on these lab articulated models to understand how the teeth can be improved in shape/size/length/proportion.
‘Mock up’ is to transfer the information on the wax-up to the patient mouth . This is usually achieved by making a mould of the planned wax-up and filling it with white restorative material, and transferring it to the mouth to recreate it in the mouth.
This helps to get the full visual impact of the expected change in the teeth, and also to the surrounding structures like the lips and cheeks.
This helps in communication and understanding and agreeing on the end result and formulating plans to work towards it.
This may not always be possible in the mouth, if the mock-up is a subtractive one wherein wax-up is planned after removing some of the, it can be fully appreciated only after preparing the teeth adequately or removing old restorations.
Figure 1: This patient was unhappy with his smile, we planned for changing the bite and to correct the esthetics for all the upper teeth, wax-up done on study models and then transferred to the mouth as a mock-up for patient information and consent. With this step we realised that only veneers will make the teeth very long to correct the patients reverse bite, so we have proceeded with orthodontics (braces /Invisalign) to align the teeth first before proceeding to the restorative phase. This helped us really avoiding disappointment at the end of treatment and pre-empting problems.
What other parameters are taken into consideration at the planning phase?
We also have to consider in detail regarding
Colour of teeth - to assess if any whitening is needed and if patient is happy with the colour of the teeth.
Position of teeth - can the position be improved with pre-restorative orthodontics so there is minimal preparation needed or we can improve the bite to a more favourable one to protect the veneers and increase their longevity. As in the case shown in Fig.1
Level of the gum if they are visible in the smile line. If the levels of the gum are not symmetrical, or if a patient is bothered about it then it will require some gum corrective surgery - called gingivoplasty (reshaping gum) or gingivectomy (removing some gum tissue). If there is a gummy smile or real small teeth, it may need a procedure known as crown lengthening (removal of some bone around teeth and repositioning the gum).
If crown lengthening is required, we may need to re-do the wax-up once the gums have healed, usually after 6 months for the gums to mature for assessing and consenting for final restorations.
The presence of old restorations will need to be assessed after removing the old restorations before making definitive plans to ensure the teeth under these restorations are restorable and do not need any further treatment like a root canal treatment. Sometimes after removing old restorations the teeth under will be deemed unrestorable and have to be planned to be extracted and replaced.
Assessment to see if the number and plan is suitable for the chosen patient.