Live Webinar: Terminal Dentition - where do we draw the line?

In this live webinar, Dr. Ricardo Mitrani addresses the question regarding terminal dentition and how to plan the rehabilitation. 

He opens the webinar by highlighting the point that there is a bit of confusion as far as what 
guidelines we should follow to decide when to remove teeth and when to place implants. He mentions that when diving into topics like the present one, the perspective can change, that includes the perspective of the patient, the clinical team, the technicians, and the industry. All are aiming to provide the best possible treatment for the patients. The most challenging process we all face every day is the process of communication, which also happens to be complex. We need to re-evaluate the perception of communication and if the message we want to convey is received as expected. Also, if the message we receive is how it was meant to be. All of this is connected to expectations. For example, what level of commitment do we expect from the patient when embarking on a treatment as complex as a full arch restoration and how do we handle disappointment and frustration when reality and expectation do not meet? According to Dr. Mitrani, one of the biggest lies that we, the society and the patients still believe, is that dental implant are forever. The oral cavity is a hostile environment, he says, with many microorganisms, there is thermocycling, and teeth are used for things they should not be used for. The susceptibility varies from patient to patient. When a patient comes to the office, years after receiving a successful restoration, and the restoration fractured (as in the shown example) we should ask ourselves if we treat, cure or manage patients and if this was to be expected and should have been communicated to the patient at the beginning of the treatment? Looking at other replacement parts for the body, e.g. prosthetic limbs, the expectations are not that they last forever. So why do we think dental restorations last forever, asks Dr. Mitrani. With the technologies we have available today, it is common to create very fancy restorations, but we cannot ensure that they will last forever. There is also a fine line between use and abuse. We need to understand where the patient is at, when the treatment starts, regarding behavior, cognition and emotions. These elements will influence the prognoses of any treatment. 

Dr. Mitrani continues to discuss the treatment plan we go through and the number of decisions we have to take each day, when coming up with a treatment plan. The fundamental questions we need to ask ourselves are: 

• Why are we choosing treatment X, Y or Z?
• What are the possible solutions we can offer?
• How do we achieve this, with which technology, what are the steps, how do we communicate with the treatment team?
• Which parts and pieces of the systems that we are going to be embarking on should be well thought of?

The webinar will mostly focus on the “Why”. Looking at clinical aspect, we would need to review location, etiology and condition. The other aspects would be compliance and finance. Within compliance, cognition, emotion, and behavior play an important role. When the patient presents to us, they present with either a “terminal” dentition, edentulous or – what we see more and more these days – with implants and a restoration that does not work anymore. Dr. Mitrani focuses on the patients showing a terminal dentition in his lecture. He mentions that the education we receive plays a critical part on how we approach a case. He reminds us that there is a very fine line between negligence and over-treatment. Most of the decisions we take daily is based on “prosthetic convenience” according to Dr. Mitrani. He shares some quotes of experts on how they approach the treatment planning process and what that says about their approach to rehabilitation. The quotes show a bit of a contradiction, no matter which option we chose, and there is a price attached to any prosthetic solution. He reminds us of the different perspectives involved, again. With a clinical case, he illustrates his previous points. The case shows a patient who had a significant bone reduction to have four implants placed and immediately loaded. According to Dr. Mitrani the patient had been edentulated but also mutilated for this rehabilitation, as the provided solution seems questionable, even without all context available.  Recalling his training, he shares that as a prosthodontist he was trained to placed implants but to save teeth by being as thorough and as conservative as possible. He continues to share one of his early cases, where he placed a removal prosthesis to save the existing teeth. He shares the case of a young patient coming for a second opinion as the first dentist told her that all teeth would need to be removed. He continues that he would do anything to save the remaining in a case like the presented one. When the risk of retaining the remaining teeth outweighs the benefits of keeping the teeth, that's where we potentially would think of removing them, he emphasizes. We should utilize prognostic indicators to help us making the decisions, but which indicators are those? First, we look at the periodontal damage and structural damage, and among these, there are specific parameters that need to be carefully investigated. All of these will allow us to come up with what we feel is a compelling argument to keep or to remove teeth. The three main aspects to look into are tooth positions, occlusal relationship, and strategic value. What about distribution? We see a slide with possible distribution patterns. For illustration purposes, he picks two patterns with the same number of teeth: patient A and patient B. From the shear appearance, one patient looks more appealing regarding keeping the teeth than the other. When thinking about possible prosthetic solutions, one option also seems more cumbersome than the other, from a pure distribution point of view, resulting on one being more favorable than the other. This has to do with the location in symmetry, unilateral versus bilateral distribution. Looking at the illustrations, one can build an argument to keep the teeth for one patient easier than for the other patient, meaning one distribution is more favorable than the other. Why should we keep the teeth? The first reason is proprioception and the second is contingency. If we give the existing teeth a chance but end up removing them at a later point in time, we still have the placed implants that can be incorporated in the new rehabilitation. Dr. Mitrani asks us to consider this aspect as well during the evaluation of a patient. The other aspect has to do with the dental gingiva or dental facial aesthetic potential outcome. In other words, we look very carefully at the gingival harmony of our patients relative to lip mobility. This strongly influences the success or failure of a rehabilitation. Looking back at the sample patients, one looks more symmetric than the other. This concludes the three things to look at irrespective of how those teeth are holding up structurally or biologically, because we often remove teeth even if their integrity looks salvageable from a structural and periodontal standpoint. The three variables are: the number, the distribution, and the aesthetic risk and we should look at them in a systematic approach. 
Dr. Mitrani shares the algorithm that he follows, and which includes all the previously discussed points. He uses a case to illustrate how to apply the approach, going through each point and discussing the present patient situation and his decision-making process. He reminds us to look at structure, function, biology, and aesthetics and how they correlate. The last element he is looking at is the patient condition, that means the lip-tooth-ridge (LTR) classification. He addresses multiple publications that are available, discussing potential scenarios when restoring full arche cases. There might be a little bit of confusion in many of these publications, says Dr. Mitrani. He presents the classification that allows us to see when we have a non-defect or an all-white restoration. This might look like Misch’s classification in the beginning, but this classification also takes the lip-tooth-ridge relation into consideration, allowing to visually see when to choose a fixed restoration or a removal restoration. He continues to illustrate the classification with different patient cases. An important aspect of the evaluation is the lip mobility, requiring videos of the patient instead of photographs. He emphasizes that we should be able to master not only one technique but several to offer different solutions to the patient, depending on their condition. The five aspects or elements to look at are: location, etiology, condition, patient’s compliance, and cost. Dr. Mitrani demonstrates the application of the algorithm with different patient cases. The webinar closes with questions from the live audience.