Clinical Continued »
Managing for success The goal of any treatment plan should be to achieve the patient’s wishes, while addressing their dental needs in order to achieve long-term success. Decision making is often
made easier when each episode of treatment is prescribed on an ‘as required basis’, with cause and effect clearly visible and acceptable to patient and dentist alike. But we also need to meet
the patient’s expectations and the best time to find out if we are going to fall short is before we start treatment. What is the patient’s
perception of how long a restoration is going to last? If it is five years, for example, then this is a much better prospect for a challenging restoration than if they expect it to last forever. That said, should we really
be advising, as the most predictable option, any treat- ment that is not going to last 10 years? If we are aiming at 10 years’ survival for our resto- rations, then we need reliable information to determine under what circumstances we can achieve this. For the recently qualified, and those that move practice
regularly, you can’t rely on your own experience and therefore have to look to the literature for best practice and evidence. Root canal treatment,
for example, is predictably successful, if carried out correctly: rubber dam isola- tion, correct preparation, smear layer removal and delivery of disinfectant to the apex for the required period of time, etc. Similarly, post-crown
restorations are also predict- ably successful if: • The post is kept narrow and extends to the correct length • The post is made of the correct material – cast posts when there is only the ferrule remaining, fibre posts when there is plenty of dentine. You may not need a post anyway • The crown preparation has to extend over a minimum of 1.5-2mm of dentine (ferrule) • They are not used as bridge abutments. Apicectomies, meanwhile,
can be predictable if, again, certain criteria are met: • The root canal filling should be sound. (i.e. You know it has been carried out correctly) • The coronal restoration (most usually a post-crown) has also been carried out to
“If we are aiming at 10 years’ survival for our restorations, then we need reliable information”
the ideal criteria • The surgical procedure is carried out in accordance with current best practice, including sterile field and magnification (Fig 6).
Other criteria There are many other factors which may or may not influence pre- dictable success. For example, these include: • Does the patient have a history of caries and peri- odontal susceptibility? Advanced restorations should be advised against in patients that cannot demonstrate an ability to maintain them (Fig 7). • Occlusal factors – how many teeth remain within the arch? Is the patient a bruxist? Is the tooth going to have to carry more weight than it may in an otherwise intact arch? • Aesthetics – does the patient have a high smile line and show the gingival margins of the lateral incisor? What is their gingival biotype
and susceptibility to reces- sion (Fig 8) ? Failure to address and meet
any of the required criteria is, of course, a compromise: this is the key to successful management of any situation – knowing the compromises and addressing them.
Drawing up a plan To formulate the correct plan which addresses, in as far as possible, all potential prob- lems, it is necessary to: 1. List all the potential compromises 2. Outline how they may be managed 3. List all potential alterna- tives and their compromises 4. Discuss your findings with the patient so that they have the opportunity to make as fully an informed decision as possible. This can sound a lot
more complicated that it is, but should be really no more than having a conver- sation about what we have
Continued »
Fig 2
Opaque UL2 crown with dark shine through at gingival margin from RCF
Fig 3
Does the patient know how unpredictable these restorations are?
Fig 4 North American smile design
Fig 5
Patient having had new veneers and crowns has subsequently fractured UR2 and requires xla or re-restoration (temporary crown in place)
48 Scottish Dental magazine
Fig 6 Apicectomy and post-crown
Fig 7
Caries should preclude further advanced restorative work, unless it can be controlled
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