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Dr. Foad Shahabian
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Treatment Planning Phases: Where Do You Start When a Patient Needs Several Different Procedures?

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Many patients coming to the office for the first time do not have just one problem. A full examination may turn up, all at once, several carious lesions, one or two teeth needing root canal treatment, calculus and gingival inflammation, a retained root, several extracted teeth that have left edentulous spaces, and crowding of the anterior teeth. Diagnosing each of these on its own is not difficult. What may be unclear is the order in which this work should be carried out, and what happens if that order is not respected.

In the treatment planning literature, the order of treatment is defined as a series of consecutive phases. Each phase provides the conditions required by the next one. If a phase is skipped or moved, the work of the following phase is usually either ruined or has to be repeated. The general rule is this: first resolve the acute problem, then carry out the surgery and periodontal therapy, then the restorative work, then build the fixed prosthesis, and finally the removable prosthesis.

∆ Emergency phase

If the patient has come in with pain, swelling, or acute infection, that problem must be dealt with before any planning. At this stage only what controls the pain or the infection is done: opening the canal of the painful tooth, draining an abscess, or extracting a tooth that is both painful and unsalvageable. If the patient has acute joint or masticatory muscle pain, an interim splint can also be made at this stage. None of these is treated to completion in the emergency phase; a tooth whose canal has been opened, for instance, has its root canal treatment completed in the restorative phase.

If the patient has no acute problem at all, we go straight to phase one.

∆ Phase one: surgery and periodontal therapy

In this phase everything requiring extraction or surgery is carried out:

The reason this work comes before restorative and prosthetic treatment is simple. The margin of every crown and every restoration is set relative to the gingival level. If a crown is made against inflamed gingiva, then once the periodontal therapy is done and the inflammation subsides, the gingival level drops and the crown margin ends up exposed. By the same logic, until it is settled which teeth stay and which come out, the prosthetic plan cannot be finalized.

After this phase ends, leave a few weeks and reassess the gingiva. If active pockets or bleeding are still present, do not move into the next phase — continue the periodontal therapy.

∆ Phase two: restorative

In this phase the remaining teeth are made sound:

By the end of this phase there should be no active caries and no unfinished root canal treatment left in the mouth. Only then can prosthetic work begin without concern.

∆ Phase three: fixed prosthodontics

In this phase the crowns and bridges are made. If an implant was placed in phase one, the implant prosthesis is also done at this stage.

∆ Phase four: removable prosthodontics

Removable partial dentures and complete dentures are always the last stage. The reason is that the design of a partial denture — rest seats, guide planes, and the contours of the abutment teeth — has to be worked out on the final shape of the teeth. If the partial is made first and a crown is then placed on one of the abutment teeth, the framework no longer seats on that crown and has to be remade.

The definitive occlusal splint is also made at this stage, that is, after the patient's occlusion has reached its final form.

∆ Where does orthodontics fit?

Orthodontics is carried out after phase two and before phase three. That is, it starts once the periodontal therapy is finished, all caries have been restored, and no unfinished root canal treatment remains, and it finishes before any crown, bridge, or partial denture is made. Orthodontics is not started on a tooth with caries or on gingiva that is inflamed.

There is one exception. Sometimes a tooth is so broken down that it cannot be rebuilt with a direct restoration and needs a crown before orthodontics. In that case the crown is made before orthodontics, but three points must be observed. First, the choice of crown material should be coordinated with the orthodontist beforehand, because a bracket will later have to be bonded to this crown and the bonding protocol depends on the crown surface. Second, this crown is in effect an interim crown and may need to be replaced after orthodontics is finished, because of the change in tooth position and occlusion. Third, this possibility of replacement should be explained to the patient from the outset and recorded in the chart. The reason is that the final position of the teeth determines the space available for a bridge, an implant, and a partial denture. If the patient needs orthodontics and accepts it, the prosthesis and the implant must wait until orthodontics is complete. If the patient declines orthodontics, that decision is recorded in the chart and the prosthesis is designed around the current position of the teeth.

∆ After treatment ends

Treatment does not end with the delivery of the last prosthesis. The patient has to come back for recall: periodontal examination every three to six months depending on the patient's condition, review of the restorations and prostheses once a year, and periodic radiographs. Without recall, periodontal disease and caries return and everything achieved in the earlier phases is put at risk.

∆ References

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