Treatment planning from Smile design to

Biofunction
Ahmed El Sayed

Outlines :
1) Importance of systematic treatment planning.
2) Consequences or errors of missing this treatment planning.
3) Data driven decision and it’s uses in treatment planning.
4) Systematic approach.
5) Personal data collection and it’s importance.
6) Facial driven and facial data collection.
7) Intra oral data collection (dentogingival, macrogingival, biopathological).
8) Analysis, design and planning phases of treatment planning
9) Interdisciplinary cases.
10) Facial driven treatment planning specially in implant planning
11) Gummy smile approach.
12) Cases involving occlusal consideration/modification and adjusting
alignment through DSD.
Importance of systematic treatment planning and consequences of errors:
*In treatment of class V, before restoration you should consider:
 Etiology: caries, erosion, abfraction.
 Occlusion.
 Substrate (Enamel, Dentin, Cementum).
 Technique of bonding and Isolation.
 Retention.
*Avoid teeth centered treatment planning; you should consider teeth, mouth,
face and person.
* Before changing old big amalgam restoration you should do more investigations
and take a bitewing radiograph; you may find that the tooth is non-restorable or
you may find a high pulp horn that upon changing the filling may cause pulpitis.

Consideration in treatment planning:

 Biological considerations : biomechanical.
biochemical.
biophysiological.
biopsycological.
structural integrity.

 Functional considerations : mastication.

phonation.
swallowing.
breathing.
facial expression.

 Esthetic considerations : Alignment.

form.
shade.
reflections.
esthetic relations.

Stages in decision making in dentistry :

1) Data collection.
2) Analysis.
3) Diagnosis.
4) Design (treatment design).
5) Planning.
Data collection :
1) Personal data.
2) Facial data.
3) Dentogingival structure.
4) Biological data.
5) Deeper ( microscopic ).
the more data you get, the better results you achieve and less risks you take
1)Personal data:
-Psychological condition and history.
-Medical condition and history.
-Dental condition and history.
-Presenting complain and history.
-Chief complain.
-Personality and personal preferences.

 Interview for 15 min to evaluate the psychological or psychiatric

condition which has large impact on the patient and treatment
planning.
 Bullemia(Anorexia nervosa ) : is a condition of repeated vomiting and
the acidity of the stomach leads to erosion of the palatal surface and
loss of enamel .. so you should determine the etiology and treat the
cause before proceeding for restoration of lost enamel.
 Pica syndrome : a condition of eating or chewing anything like hair,
nails, ice , …etc.
Ice chewing is known as “pagophagia” which was found to be
associated with iron deficiency anemia; any attempt to make a
restoration before treating the anemia and stopping the habit will
lead to leakage, cracks and failure of the restorations.
 GERD disease “ Gastro-Esophagial reflux disease” : Massive erosion
of the occlusal surface and complete loss of enamel and loss of
dentin.
PH may reach: 2 which is severely acidic.
  Depression : know that restorations won’t treat depression but
medications will.
-Note that depression medications cause xerostomia.
 Mouth breathing: tongue adapts to allow the air stream to reach the
lungs causing: infraocclusion mandibular premolars, supraocclusion
mandibular incisors, impacted condyle (back in position and the disc
is in front position) causing clicking sound ; high arched palate and
neuromuscular affection.
 Personal preferences : some patients reject orthodontic treatment so
you should either find an alternative or reject the case and refer for a
second opinion.
2)Facial and intraoral analysis:
 Biofunction : skin and extraoral tissues.
lymphnodes and salivary glands.
TMJ.
Muscles.
facial symmetry/ deviation.
Phonatics.
breathing.
swallowing.
facial expressions.

 Frontal view : proportions.

3 vertical lines (midline, canine line, buccal corridor line).
3 horizontal lines (Interpupillary line, commisure line, horizon).
Outline of the face ( rounded, tapered, trapezoid, squared).
Skeletal effect ( vertical maxillary excess) .

 Profile : proportions.
lip profile.
nose profile.
chin profile.
skeletal antroposterior ( soft tissue and lateral cephalometry).
 Smile arc.
  Smile extension.
 Dentolabial relations (upper lip with maxillary incisal edges, gingival
show).
 Lip competence ( competent, incompetent).
 Relation between maxillary and mandibular teeth (overjet , overbite).

3) Intraoral data :
 Radiogaraphs ( endo , pathology,….etc.).
 Dentogingival photos.
 Gingival biotype, health and colour.
 Papilla and black triangles.
 Proximal contacts ( 3-4mm in upper centrals).
 Embrasures (incisal , gingival).
 Inclination of the teeth.
 Teeth proportions and symmetry ( lengh, width and zenith point).
 Colour ( shade and translucency).
 form ( outline, line angles, texture of labial surface , gloss).
 Macrolevel.
 Digital map analysis (extent of enamel and dentin shades).
Form is better detected with black and white photos; while the texture better seen in
45 degrees photos.

Analysis Report:
Any deviation of normal functionality, biology and esthetics should be recorded
eg. Spacings , unsatisfactory shade, …..etc.
Design :
Digital or manual.

Treatment planning
1) procedure x Doctor.
2) Cost x installment.
3) Date x Duration.

Cases :
Phases : 1) Control phase : motivation ( show old cases , mock up).
gingival treatment.
caries removal.
proper root canal treatment.
2) Alignment: Orthodontic treatment.
teeth are aligned to the position determined by the design
and not necessarily in their ideal position.
3) mock up.
Facially driven implant planning:
1) Photos and videos.
2) Restore psychology and esthetics with temporary restoration.
3) CBCT and 3d positioning of the implant in the bone.
4) Dentogingival analysis with software.
5) Facially driven implant guide and implant placement.

Gummy smile approach :

Treatment of gummy smile :
 Skeletal : orthognathic surgery.
 Dental : orthodontic treatment.
 Gingival : crown lengthening.
 Short lip : surgical lip repositioning.
 Muscular : botulinum toxin-A “Botox”.

Points to be checked :
 gingival display and symmetry.
 lip length and dynamics.
 reveal at rest and on smiling.
 teeth length and proportions.
 bone amount and relations.
-Botox is reversible temporary treatment.

Loss of enamel ( tooth wear ) :

-Patient complains of a bit collapsed face and short teeth.
-Photos : closed , repose , smile , Duchene.
-Dynamic analysis : to determine type of occlusion , habits and etiology of the
condition.
-Increasing the length of the maxillary incisors by addition on the incisal edge will not
affect the bite , but addition on the lower incisal edges will raise the bite ; also addition
to the palatal surface of the maxillary incisors will raise the bite too.
-Upper teeth are face and facial expressions ; while lower teeth are vertical dimensions
and functionality.
-No prep prototype mock up : check bite, occlusion and take photos to check the
dentogingival and dentolabial analysis.