PreProsthetic Treatment Planning For The Adult Ortho Restorative Patient Dr. Douglas J. Knight Summary by: Dr. Thomas Skafidas Dr. Knight defined interdisciplinary treatment planning as "the coordination of care amongst two or more disciplines of dentistry." The goal of interdisciplinary planning is to create a coordinated road map and develop a sequence and time line of treatment. Pre-prosthetic utilization of the orthodontist is needed in two (2) situations: 1. To Correct mal-alignment of teeth prior to restorations: A. Mal-alignment of the coronal tooth structure; B. Mal-alignment of roots, which could be either mesial, distal and/or buccal, lingual; C. Mal-alignment of the gingival architecture; D. Mal-alignment of the underlying and adjacent bone. The goal is to create a canvas for the restorative dentist to paint a picture and make it "paint by numbers." The objective is to eliminate the need for "restoradontics"; that is, instant orthodontics with a burr and without braces (undisciplinary treatment). Restoradontic cases do not finish as well as an interdisciplinary planned case. 2. For ridge development: A. Early Development of the ridge The example of the missing lateral incisor was presented. The objective is to allow the cuspid to erupt into the lateral incisor position. This will allow for proper ridge dimensions for future implant placement. Failure of the cuspid to erupt into the lateral site will cause a ridge defect. Another objective is to keep the central incisor on the side of the missing lateral, coordinated with the midline so that the cuspid erupts immediately next to the central incisor. This facilitates future space opening from distalization of the canine, not mesial movement of the central incisor. For a single tooth implant, there are two (2) specific needs: 1. Crown Space 2. Apex space Crown space factors include adjacent teeth and occlusion. A diagnostic set-up is needed, as tooth size is not determined by the size of the implant that will be utilized. Apex space includes root angulation and root inclination. B. Opposing Ridge Development Treatment options include intruding molars, occlusal equilibration, a combination of intrusion and equilibration, or extraction. Treatment options include the use of implants for anchorage to intrude teeth. When teeth were intruded, the bone followed the tooth. If the bone had not followed tooth eruption when extrusion had occurred, intrusion is not needed and equilibration can be accomplished. C. Orthodontic Extrusion The goal is to extrude the tooth to the point of extraction. This creates bone for future implants and gives the periodontist more tissue to manipulate. A discussion on ridge development regarding soft tissue aesthetic predictability using interproximal bone height to determine papillary height predictability was reviewed. The distance from the interproximal bone to the crest of the contact point determines soft tissue aesthetics. If the distance is less than five(5) millimeters, the papilla fills the space one hundred percent of the time. If the distance is six (6) millimeters, the papilla fills the space fifty-five percent of the time. With seven (7) millimeters distance, the papilla fills the space only twenty-five percent of the time. In regards to tooth and space positioning for implant placement, it was advised not to place two implants side by side in the anterior sextant of the maxillary arch. This will avoid compromise of the soft tissue and permit normal gingival morphology.