By Zackary T. Faber, DDS, MS
No matter how long we have been practicing, we are all guilty of not seeing the forest for the trees. We all treatment-plan differently, from the perspective of our biases and experiences. This is why the question, If this was your son/daughter/mother/father/etc., what would you do? poses such a problem for us all. Emotion clouds judgment, and our diagnostic and problem-solving skills are much better from an objective perspective than a subjective one.
From the moment we walk into our new patient exams, we start formulating these treatment plans based on the problems that are presented. Even while patients describe their problems, most of us are trying to think of ways to solve them right then and there ... not really listening.
We need to listen to our patients and realize that they are telling us what they want and why they are in our chair. This changes just because of the type of dentist or dental specialist we might be, but overall, the experience is the same. Where you go from here can define success or problems in each and every case.
I believe that treatment planning is the core of what makes you an orthodontist. A common opinion among dental students (and most dentists) is that they feel like they get a poor orthodontic education. The general feeling is that orthodontists keep their knowledge to themselves and don’t let everyone in on the “secret.”
Here’s the real secret: There is no secret! Being able to comprehensively treatment-plan a case is the most important principle in dentistry.
What does a comprehensive treatment plan mean? What questions do you have to ask? What information do you need to be able to assess and process a treatment plan?
My first question is this. When you are remodeling a house, would you start without an architect or an interior designer? How would you know where the best place is to position everything? Where do the walls go? Where can you place the windows? The floors? ...
I believe that in order to start the process of treatment planning, you need information. You need to assess the patient from a global position. We all have GPS in our cars, and now on our phones. When using your GPS, you need to know your starting position and the destination. During single-tooth dentistry, we all can predict the dentistry that is involved, whether we are prepping a crown, an onlay, or even the simplest of restorations — an occlusal composite. However, when we are planning someone’s smile, we need a destination. This destination can be CBCT-generated (NobelGuide), an esthetic wax-up, photographs and photograph software, a denture, or some other form of Visual Treatment Objective (VTO). All of these processes allow the dentist to plan the smile, or the remodeled house from our analogy above.
You need to start from the outside and work inside. The typical routine for the orthodontist is to take orthodontic records, which allows this perspective. This is why I believe that the orthodontist’s role in treatment planning is akin to the architect from our construction analogy. The orthodontic records will define the patient’s structural limitations (the position of the existing structure/walls). The orthodontist can review the lateral cephalogram, panoramic images, and possibly a CBCT to describe the positions of the maxillary and mandibular incisors so that certain parameters can be defined.
In prosthetics and cosmetic dentistry, the maxillary central incisor position will dictate your treatment plan. Armed with information about the maxillary central incisor position from the orthodontist (or prosthodontist, oral surgeon, periodontist, etc.), we can then determine the positions of the lower incisors to create a normalized overjet and overbite for our restorations. Most traditional orthodontics is treatment-planned with the lower incisor in mind, because the lower incisor position has the most limitations.
Once the initial position of the maxillary central incisor is determined, this will serve as our starting point. Now we have to consider all of the various treatments that we can render for the patient to place those teeth into the final position so that we can develop a treatment plan or road map. This blueprint will determine what treatments are possible. We can also decide if there are several different treatment plans that will work. Once all of these various plans are thoroughly fleshed out with the appropriate team members, the patient needs to be included in the discussion to determine goals, finances, and other life limitations. From here, our treatment plans can be comprehensively completed with our patients included in the process so that they can have the best dentistry available.
I always advocate that in your most complex cases, working with a specialist or team of specialists will afford both the dentist (general practitioner or prosthodontist) and the patient the best treatment possible. Unfortunately, we are all guilty of looking at the trees without seeing the forest. Believing that dentistry is a team sport and that we are all working toward the same goal will make your dentistry more rewarding and special.
Zackary T. Faber, DDS, MS, followed his father, Dr. Richard Faber, and grandfather, Dr. Albert Reitman, to the Baltimore College of Dental Surgery at the University of Maryland. He completed his orthodontic training at the University of Connecticut. Dr. Faber is an active member and founder of several study clubs across Long Island that collaborate across dental specialties. As an assistant clinical professor, he teaches orthodontic residents at SUNY Stony Brook School of Dental Medicine and volunteers at the Dentofacial Deformities Clinic and the Pediatric Residency Program at Cohen's Children's Hospital. Dr. Faber maintains a private practice in Melville, N.Y. You may contact him at [email protected] or at www.faberortho.com.
By Zackary T. Faber, DDS, MS