Protocols for Predictable Aesthetic Dental Restorations

8 Protocols for Predictable Aesthetic Dental Restorations
Another  example  is  a  fractured  crown  at  the
cervical margin,  on  a  root-filled  premolar with
periapical  radiolucency  but  no  active  suppura-
ion (Figs. 1.10 & 1.11). The treatment options
are:
1) Re-RCT  with  intra-radicular  support  and
replacement crown:
! Benefits  –  established  clinical  protocols
for treatment modalities
! Risks – further trauma from re-RCT and
post placement to an already weakening,
delicate  root,  relapse  of  re-RCT,  com-
promised  retention  for definitive crown
and protracted treatment plan
(2) Apicectomy with intra-radicular support and
replacement crown:
! Benefits  –  retrograde  filling  without
inflicting  trauma  to  delicate  root  from
re-RCT
! Risks  –  shortening of  root,  resulting  in
poor root-to-crown ratio, compromised
retention  for  definitive  crown  and  pro-
tracted treatment plan
(3) Crown lengthening or orthodontic extrusion
to increase retention and resistance form for
definitive crown in conjunction with options
(1) or (2):
! Benefits  –  exposure  of  root  surface  for
definitive crown margin placement
! Risks  –  shortening of  root,  resulting  in
poor root-to-crown ratio and protracted
treatment plan
(4) Extraction and immediate replacement with
endosseous  implant  and  implant  supported
crown:
! Benefits  –  expedient,  predictable,  but
requires  surgical  experience  and
expertise
! Risks  –  surgical  involvement.  Local
anatomy must be suitable with sufficient
quality  and  quantity  of  soft  and  hard
tissue volume for success
The patient opted for the last proposal. Firstly,
the costs of all the options were similar. Secondly,
the bone and soft tissue anatomy were conducive
for  successful  immediate  implant  placement
with immediate temporarisation, including suffi-
cient bone apical to root apex primarily for sta-
bility,  adequate  mesial-distal  implant-to-tooth
distance of 1.5mm and occlusal clearance (Figs.
1.12–1.16).
Arriving  at  the  most  appropriate  treatment
plan  involves  clinical  findings  and  a  definitive
diagnosis,  risk  assessment,  followed  by  an
evidence-based  approach  (clinical  erudition,
sound scientific research and patients’ needs and
wants).  Using  evidence-based  decision  making
and  treatment  planning  maintains  professional
competence  and  competitiveness  for  delivering
high quality, predictable  treatment. When using
an  evidence-based  approach,  it  is  important  to
appreciate that this principle is not dogmatic but
igure  1.10 Fractured  crown  on  root-filled  second
premolar.
igure 1.11 Radiograph of  tooth  in Figure 1.10  showing a
hin root cross section and periapical radiolucency.

Treatment planning – assessment planning and treatment 9
pragmatic,  incorporating  clinical  experience  as
well  as  respecting  patients’  preferences  and
desires.
10
Presenting treatment plan proposals to
the patient
A  treatment  plan  is  a  proposal,  not  a military
procedure. In fact, treatment can change due to
a  myriad  of  reasons,  including  the  patient’s
ambivalence,  prevailing  clinical  presentations,
unforeseen complications, financial burdens, etc.
At  the onset,  it  is  the clinician’s duty  to convey
the  flexibility  and  fluidity  of  the  proposed
treatment,  indicating  that  as  treatment
Figure  1.12 Immediate  placement  of  implant  fixture
(Replace  Select,  Nobel  Biocare)  following  atraumatic
extraction.
Figure 1.13 Abutment with occlusal plug prior  to  immedi-
ate provisionalisation.
Figure 1.14 Four-month radiograph showing
osseointegration.
Figure 1.15 Impression with  implant analogue  for  fabrica-
tion of definitive crown.
Figure  1.16 Cemented  implant-supported  all-ceramic
crown (compare with Figure 1.10).