Esthetic Diagnosis and Treatment Planning

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Esthetic Diagnosis and Treatment Planning

by Allison Watts, DDS

We are walking through the steps of a  full – mouth reconstruction.  I enjoy learning all the parts of something and putting it all together and presenting it in a meaningful, easy-to-understand way. That is my goal here. The trick is whether it comes across in print…. and whether I’ve included enough detail…

Here’s what we’ve covered so far:

  1. Phone call/First encounter
  2. NP experience/First appointment
  3. Data collection/Records
  4. Treatment planning and sequencing
  5. Setting fees – I just want to add quickly that much of fee-setting is mindset—how comfortable are we with the value of what we do and do we believe that what we do is a commodity or a highly valuable service (the more training and skill we have, the more valuable).

Back to diagnosing and treatment planning Esthetics:

Remember diagnosis comes from information we get from the examination and records.  We want to gather information first, identify the condition (make a diagnosis), decide on the desired outcomes and then decide how to get to the desired outcome (treatment plan and sequence). You may need to do the following in order to make an excellent diagnosis (and treatment plan):
Mock-up/Trial smile – I find it helpful to do this, not only for the patient to see what’s possible, but for me to see what’s possible and help clarify the plan.
Mounted models – We get so much information from mounted models. From esthetic information to occlusal information, most cases I treat require and benefit greatly from mounted models. Full mouth rehabilitation definitely requires mounted models.
Waxup – Usually when doing large cases, I will do a mockup in the mouth and take impressions of it. I will sometimes mockup the models and sometimes I will just give the lab the parameters, such as length of upper and lower incisors, overjet, overbite, steep or shallow guidance, broaden the buccal corridors, etc. Any, some or all of the above in any combination are good. Leaving it up to the lab is usually not a good idea.
Urgent care may need to be done in order to make a correct diagnosis and decide the treatment plan for questionable teeth.
Specialist consultations may help in the diagnosis and treatment planning phase as we try to decide whether orthodontics, periodontics, endodontics and oral surgery can get us where we want to go.
Considering all of the above, let’s go through esthetic diagnosis and treatment planning. Remember, EFSB is the facially-generated model taught by Frank Spear.  Esthetics, Function, Structure, Biology is the order used for treatment planning. Many say reverse the order when working through the diagnosis: Biology, Structure, Function, Esthetics. We need to make the diagnosis BEFORE we treatment plan.  This system is based on the idea of treatment planning from the outside in, using the face to determine where the teeth go. If you’d like a copy of my diagnosis and treatment planning form, please contact me at insights@allisonwatts.com.
Much of esthetic diagnosis and treatment planning is done from the photos. Again, let me say, photography is a must for excellent diagnosis, treatment planning, patient education/case acceptance, and case documentation… especially the esthetic portion. 
Esthetic diagnosis (most of this is a la Frank Spear)
The key photographs are the full face smile, the close up smile, lip at rest and the retracted teeth apart photos.
Maxillary tooth position
  • Evaluate maxillary central incisal edge to face (excessive or inadequate tooth display)
  • Maxillary incisor facial inclination
  • Maxillary incisal midline location
  • Maxillary midline alignment
  • Maxillary occlusal plane (compare to inter-pupillary line, lower lip and posterior teeth)
  • Arch form(buccal corridors)
  • Alignment of teeth
Maxillary gingival levels
  • Amount of gingival display
  • Gingival margin levels
  • Papilla symmetry and papilla levels after changing gingival margins
  • Black triangles
Mandibular tooth position- Choose the mandibular tooth position based on esthetics and providing correct occlusion
  • Mandibular central incisor to face
  • Mandibular incisor inclination
  • Mandibular occlusal plane
  • Mandibular gingival levels
Besides EFSB, I have an adjunctive tool that is phenomenal. It’s Bill Robbins and Jeff Rouse’s CORE global diagnosis form. It is mostly used to make a diagnosis when the patient has a gummy smile and is quite useful. They have simplified esthetic treatment planning in some ways by giving us measurements and a “formula” for figuring out the diagnosis and often the treatment plan. 
Esthetic diagnosis is only part of the whole picture and once you have all the information you need, you will sit down to talk about treatment with the patient. When discussing findings and collaborating on the treatment plan, find out the patient’s current level of awareness about their dental needs, why they came to you, what they are most concerned about, and anything specific they would like evaluated. Use the photographs to communicate with the patients and increase their awareness:
1. What you see vs what is ideal/appropriate
2. What they need vs what they may want to do
3. What they could do to improve their smile
4. Condition of teeth and gums
5. What happens if they do nothing? (show photos of someone that is more broken down than them)
6. Outcomes and benefits of treatment (show similar cases)
7. Risks of treatment, options for treatment (don’t give them too many—start with the best one and if they decide that’s not what they want, go to plan B)
 
When I help dentists with treatment planning, there is often a tendency to treatment plan the way we were taught in school—phase 1, phase 2, etc. This works sometimes, but not very often unless the big picture has been accounted for first. It is very important to look at the big picture of what the patient wants and needs for the long-term so they don’t waste their time and money on things that do not take them in the right direction.
I hope this helps…. I felt like we needed to back track a little. Maybe it’s because learning happens in layers and I keep seeing the layers I need to go back and add so this information will be truly useful for you.   That is my intention—to have this be highly useful for you. Let me know if there’s something you want to hear more about.  You can leave a comment or question below, or connect with me on my Facebook Page. I will be more than happy to assist in any way that I can!
Go delight your patients!