Fundamentals of Treatment Planning

Guidelines on How to Develop Plan

Write and Deliver a Prosthodontic Care
1st Edition Lino Calvani
Visit to download the full and correct content document:
https://ebookmeta.com/product/fundamentals-of-treatment-planning-guidelines-on-ho
w-to-develop-plan-write-and-deliver-a-prosthodontic-care-1st-edition-lino-calvani/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

How to Write a Marketing Plan: Define Your Strategy,

Plan Effectively and Reach Your Marketing Goals, 7th
Edition John Westwood

https://ebookmeta.com/product/how-to-write-a-marketing-plan-
define-your-strategy-plan-effectively-and-reach-your-marketing-
goals-7th-edition-john-westwood/

Questionnaire Design How to Plan Structure and Write

Survey Material for Effective Market Research 4th
edition Ian Brace

https://ebookmeta.com/product/questionnaire-design-how-to-plan-
structure-and-write-survey-material-for-effective-market-
research-4th-edition-ian-brace/

Write Your Business Plan The Staff Of Entrepreneur

Media

https://ebookmeta.com/product/write-your-business-plan-the-staff-
of-entrepreneur-media/

Shipping Go: Develop, deliver, discuss, design, and go

again 1st Edition Joel Holmes

https://ebookmeta.com/product/shipping-go-develop-deliver-
discuss-design-and-go-again-1st-edition-joel-holmes/
How to Write and Publish a Scientific Paper 9th Edition
Barbara Gastel

https://ebookmeta.com/product/how-to-write-and-publish-a-
scientific-paper-9th-edition-barbara-gastel/

How to Succeed on Primary Care and Community Placements

1st Edition David Pearson

https://ebookmeta.com/product/how-to-succeed-on-primary-care-and-
community-placements-1st-edition-david-pearson/

How to Manage Projects: Essential Project Management

Skills to Deliver On-time, On-budget Results, 2nd
Edition Paul J. Fielding

https://ebookmeta.com/product/how-to-manage-projects-essential-
project-management-skills-to-deliver-on-time-on-budget-
results-2nd-edition-paul-j-fielding/

How to Develop a Profitable Trading Strategy 1st

Edition Heikin Ashi Trader

https://ebookmeta.com/product/how-to-develop-a-profitable-
trading-strategy-1st-edition-heikin-ashi-trader/

Shipping Go: Develop, deliver, discuss, design, and go

again (MEAP V08) Joel Holmes

https://ebookmeta.com/product/shipping-go-develop-deliver-
discuss-design-and-go-again-meap-v08-joel-holmes/
 FUNDAMENTALS OF TREATMENT PLANNING

Calvani_Frontmatter.indd 1 3/10/20 9:28 AM

Calvani_Frontmatter.indd 2 3/10/20 9:28 AM
 FUNDAMENTALS OF
TREATMENT PLANNING
Guidelines on how to develop,
plan, write and deliver a
prosthodontic care project

Lino Calvani
Lino Calvani, MD, DDS, CDT, MSc, PhD
Adjunct Associate Professor
Department of Prosthodontics and Operative Dentistry
Faculty of Prosthodontics
Tufts University School of Dental Medicine
Boston, Massachusetts, USA

Fellow of the:
American College of Prosthodontists
Academy of Prosthodontists
Greater New York Academy of Prosthodontists
International College of Prosthodontists
International College of Dentists

III

Calvani_Frontmatter.indd 3 3/10/20 9:28 AM

 Library of Congress Cataloging-in-Publication Data

Names: Calvani, Lino, author.

Title: Fundamentals of treatment planning : guidelines on how to develop,
plan, write and deliver a prosthodontics care project / Lino Calvani.
Description: Chicago : Quintessence Publishing Co, Inc, 2020. | Includes
bibliographical references and index. | Summary: “This book helps
dentists, prosthodontists, and students form and organize their thinking
and formulate correct diagnoses and therapies that start with
appropriate treatment planning”-- Provided by publisher.
Identifiers: LCCN 2020010451 (print) | LCCN 2020010452 (ebook) | ISBN
9780867157925 (hardcover) | ISBN 9781647240332 (ebook)
Subjects: MESH: Dental Prosthesis | Patient Care Planning |
Prosthodontics--methods
Classification: LCC RK651 (print) | LCC RK651 (ebook) | NLM WU 500 | DDC
617.6/92--dc23
LC record available at https://lccn.loc.gov/2020010451
LC ebook record available at https://lccn.loc.gov/2020010452

©2020 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road
Batavia, IL 60510
www.quintpub.com

5 4 3 2 1

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or
otherwise, without prior written permission of the publisher.

Editing: Quintessence Publishing Co Ltd, London, UK

Layout and Production: ­Quintessenz Verlags-GmbH, Berlin, Germany
Cover illustration: Lino Calvani

Printed in Korea

Calvani_Frontmatter.indd 4 3/10/20 9:28 AM

 “Tristo Discipulo Qui Magister Non Superavit!”
“Bad is the student who won’t do better than his
teacher!”
University La Sapienza, Rome, Italy (founded in 1303)

“Great spirits have always encountered violent

opposition from mediocre minds. Imagination is
more important than knowledge. Knowledge is
limited; imagination encircles the world. Any fool
can know, but the point is to understand.
I didn’t arrive at my understanding of the fun-
damental laws of the universe through my rational
mind. I have no special talent; I am only passion-
ately curious.
Time is relative and its unique value is given by
what we do as it passes.
Only a life lived for others is a life worthwhile.”
Albert Einstein (1879–1955)

Calvani_Frontmatter.indd 5 3/10/20 9:28 AM

 Dedication

As science teaches, the concepts

expressed in this book were not
written as a point of arrival of
learning, but rather as a continuous
progression of learning. This book is
dedicated to all my beloved teachers
who inspired me and who still enrich
my life as I remind my students that
knowledge always follows when you
have passion and commitment.

Lino Calvani

VI

Calvani_Frontmatter.indd 6 3/10/20 9:28 AM

 Table of Contents

Foreword XIII Prosthodontists: Who we are and what we

Acknowledgments XV do XIX
Organization of the book and how to use it XVI Literature XX

Chapter one
Past, present, and future of treatment planning _________________________________________ 1

The distant past 2 ‘Hyper-science’ and the future 4

20th century to the present 3 References 7

Chapter two
Treatment planning management ___________________________________________________________ 9

Some definitions and basic premises 10 || Costs in the face of disease 14

Professionalism: four human factors 11 || Transparency and politeness 14
|| 1. Proper communication and dialogue with the Informed consent 15
patient 11 || Consent 15
|| 2. Motivating patients 11 || Informed consent 15
|| 3. Patient management 12 || We are not obliged to treat all patients 15
|| 4. Positive professional characteristics 12 || In case of emergency 16
Priorities 12 || The use of the informed consent 16
The ideal treatment plan 12 || Essential aspects of the informed consent
Compromise 13 document 16
Prosthodontic economics and patient treatment || Digital technology and informed consent
costs 14 documents 17
|| Affordability of the treatment plan 14 References 18
|| The patient’s occupation 14

Chapter three
Prosthodontic tools for treatment planning ______________________________________________ 21

How prosthodontists can help their patients 22 Removable overdentures 24

Aims and requirements of all prostheses 22
Current main prosthodontic tools 22
Fixed restorations 22
Removable partial dentures 23
Complete dentures 23
Full-arch implant-retained fixed prostheses 25
Bioinformatics and the digital prosthodontics
paradigm shift 25
Computerized chairside and laboratory
technologies 25

VII

Calvani_Frontmatter.indd 7 3/10/20 9:28 AM

 Table of Contents

|| Digital software treatment revolution 25 || 3D virtual articulators 26

|| In the clinic 26 || Facially driven dentistry 26
|| Digital treatment planning 26 || Computerized laboratory technologies 27
|| Cloud dentistry 26 Holographic prosthodontics 27
|| Computer-guided implant-positioning software The day after tomorrow 27
and hardware 26 References 28

Chapter four
Data, findings, and dental semiotics ________________________________________________________ 33

Data 34 || Simultaneous symptoms and signs 36

Findings 34 || Main symptoms and signs in dental medicine 37
|| Symptoms 34 Semiotics and dental semiotics 43
|| Signs 36 References 45

Chapter five
The first visit – diagnostics ___________________________________________________________________ 49

Approaching and meeting the patient 50 || Emergency examination 53

|| Professionalism 51 || Screening examination 53
|| Attitude 51 || Comprehensive examination 54
|| Kindness 51 The first professional appraisal 54
|| Empathy 52 The important basic information 54
Where we meet our patients for the first visit 52 Chief complaint 55
How to communicate with patients during the || The histories 56
first visit 52 Clinical examinations 60
Professional office techniques to gather || Radiographic examinations 60
information 53 References 64

Chapter six
Diagnosis and prognosis ______________________________________________________________________ 69

Diagnosis 70 || New predictive technologies 71

|| Differential diagnosis 70 || Prosthodontic prognoses 71
Prognosis 71 References 79

Chapter seven
Physical examination – Part I: extraoral examination ___________________________________ 85

Clinician qualities 86 || Prepare the environment 87

Steps of the physical examination 86 || Make the patient feel at ease 87

VIII

Calvani_Frontmatter.indd 8 3/10/20 9:28 AM

 Table of Contents

|| Check the evaluation questionnaire with the Nerves 97

patient 88 || Neurologic examination 97
Physical examination checklist 88 || Trigeminal nerve (sensory component of the
Physical inspection of the body, auscultation, and nerve) 98
odor examination 89 || Facial nerve (sensory and motor components of the
|| General appearance 89 nerve) 99
|| Body posture 89 Muscles 100
|| Movements and muscle coordination 89 || Masticatory muscles 102
|| Nails, skin, and hair 89 || Muscles of facial expression 103
|| Breathing patterns 90 Temporomandibular joints 104
|| Odors 90 || Neurological examination 104
|| Speaking ability 90 Lymphatic system 106
|| Speech peculiarities 91 || The lymph nodes and their importance 106
|| Understanding ability 92 Salivary glands 114
|| Vital statistics 92 || How to palpate the salivary glands 114
Head and neck inspection – examination 92 Thyroid gland 116
|| Face 92 || Shape 116
|| Eyes 92 || Inspection 116
|| Ears 95 || Palpation 117
|| Nose 95 || Health status 118
|| Mouth 95 || Function 118
Head and neck inspection – palpation || Clinical relevance 118
examination 96 || Absence 118
|| Static and dynamic possibilities 96 References 119
|| Palpation techniques 96

Chapter eight
Physical examination – Part II: intraoral examination ___________________________________ 121

Intraoral examination procedure 122 || Anatomy 132

Intraoral examination checklist 122 || Examination of the tongue 133
Vestibular area 123 Floor of the mouth 135
|| Lips 123 Salivary glands 137
Vestibules 126 || Submandibular salivary glands 137
|| Cheeks 126 || Sublingual salivary glands 137
|| Parotid (salivary) glands 126 || Minor mucous salivary glands 138
|| Floor of the vestibules 128 || Von Ebner’s glands 139
Oral cavity 128 || Clinical conditions of salivary glands 139
|| Palate 128 Alveolar arches and teeth 140
Oropharynx and isthmus of fauces 129 Occlusion 140
|| Pharyngeal tonsils 131 || Radiographic examination 141
Tongue 132 References 149

IX

Calvani_Frontmatter.indd 9 3/10/20 9:28 AM

 Table of Contents
Chapter nine
Main clinical examination assessment questions ________________________________________ 153
Clinical extraoral examination 154
Clinical intraoral examination 156
|| Oral mucosa evaluation 156
Chapter ten
The type and structure of prosthodontic treatments ____________________________________ 163
Prosthodontic treatment algorithms 164
Treatment planning and predictable results 164
|| Clinical priorities 164
|| Presence of an infectious disease and its healing
time 165
|| Need for additional clinical collaborators 165
|| Consequentiality of procedures 165
Treatment planning of complex cases 165
|| Concept of the ‘initial phase’ 166
|| Concept of customization 166
|| Expectations: a danger zone 166
|| ‘Not enough time’ 167
|| Balance of time commitment 167
|| Posttreatment care commitment 167
|| The clinical result should not be equal to or worse
than the problem itself 167
Chapter eleven
Treatment planning analysis of complex rehabilitations
Phase I: Diagnostics, consultations, and emergencies ___________________________________ 173
Some preliminary remarks 174
|| Treatment variations and alterations 174
|| Time for communication and
explanations 174
Diagnostics 175
|| Initial diagnostic screening questionnaire 175
|| Second updating questionnaire 175
|| Initial interview and first visit 176
Consultations with other specialists 178
|| Dental specialties and other areas of
consultation 179
Calvani_Frontmatter.indd 10
|| Case assessment occlusal evaluation 158
|| Clinical oral and tooth assessment questions 159
References 161
Classification of prosthodontic treatments 168
|| Class I: Prosthodontic treatments – full
reconstructive rehabilitations 168
|| Class II: Prosthodontic treatments –
interdisciplinary improving rehabilitations 169
|| Class III: Prosthodontic treatments –
interdisciplinary healing rehabilitations 169
Prosthodontic treatment phases and their
algorithms 169
Predictability, sequence of work, and consent 171
|| Predictability 171
|| ‘Red line’ concept 171
|| Emergencies and priorities 172
References 172
|| Diagnostic digital dental technology 180
Emergencies 181
|| Preprosthetic emergencies, priority treatments, and
initial disease control 181
|| Preferential route medical priorities 181
|| Oral cancer control 182
|| Maxillofacial emergencies 183
|| Periodontal emergencies 183
|| Endodontic emergencies 184
|| Tooth extraction emergencies 184
|| Caries emergencies 184
3/10/20 9:28 AM
 Table of Contents

|| Professional oral hygiene emergencies 184 References 185

|| Relining and rebasing of complete and partial
dentures 185

Chapter twelve
Treatment planning analysis of complex rehabilitations
Phase II: Prosthetic and restorative treatment ___________________________________________ 189

Some preliminary remarks 190 || Long-term fixed provisionals 195

|| General factors that may affect the planned
treatment sequence 190
|| Complications that may affect the planned
treatment sequence 191
Orthodontic therapy 191
Periodontal and oral surgery therapies 192
Endodontic therapies 192
Mutilated roots and teeth 193
Post and cores 193
Provisional restorations 194
|| Planning the lifespan of provisionals 194
|| Analog or digital provisionals? 195
Implant placement 195
|| Implants are a sensitive rehabilitation to plan 197
|| Implant postsurgery instructions for patients 198
Maxillomandibular registration 199
Final impressions 199
Final prosthesis try-in and delivery 200
|| Relining and rebasing of RPDs and CDs 200
Bite guards 201
References 206

Chapter thirteen
Treatment planning analysis of complex rehabilitations
Phase III: Posttreatment care and recalls __________________________________________________ 211

Planning for Phase III 212
|| Periodic recalls for maintenance 213
|| Patient compliance and special maintenance
holding programs 213
Basic prosthodontic maintenance checklists 214
|| Fixed prosthesis maintenance checklist 214
|| Removable partial denture (RPD) maintenance
checklist 214
|| Complete denture (CD) maintenance checklist 215
Reinforcing oral hygiene at recall visits 216
|| Educating patients about personal oral
hygiene 216
Treatment planning fluoride 219
Treatment planning prophylactic therapies 220
Treatment planning the improvement of the
patient’s diet 221
Making patients more aware of dangerous
habits 222
References 223

Chapter fourteen
Treatment planning for the elderly and those with challenging health
conditions _______________________________________________________________________________________ 227

Some medical statistics 228 Prosthodontic treatment planning for elderly and
Patient awareness and communication 229 geriatric patients 230

XI

Calvani_Frontmatter.indd 11 3/10/20 9:28 AM

 Table of Contents
|| Some basic statistics 230
|| Treating elderly people 231
Prosthodontic treatment planning for patients
who are addicted to drugs 232
Signs and symptoms of the most common
drugs 235
|| Prescription analgesics 235
Chapter fifteen
How to write a prosthodontic treatment plan ____________________________________________ 241
I. How to write a prosthodontic treatment plan for
your patient 242
II. How to write a prosthodontic treatment plan
for a professional case presentation 243
III. Main text and writing guidelines 243
IV. Prosthodontic case presentation
narratives 247
|| Examples and scenarios 247
Case 1 Perioprosthetic treatment 248
|| Phase I diagnostics – case narrative 248
Case 2 Perioprosthetic treatment 252
|| Phase I diagnostics – case narrative 252
Case 3 Perioprosthetic treatment 255
XII
Calvani_Frontmatter.indd 12
|| Sedatives, anxiolytics, and antidepressants 235
|| Marijuana 236
|| Cocaine 236
|| MDMA and ecstasy 236
|| Methamphetamines 236
|| Heroin 237
References 237
|| Phase I diagnostics – case narrative 255
Case 4 Perioprosthetic treatment 259
|| Phase I diagnostics – case narrative 259
Case 5 Perioprosthetic treatment 263
|| Phase I diagnostics – case narrative 263
Case 6 Maxillary complete dentures and
mandibular fixed/removable partial denture 266
|| Completed case narrative 1 266
Case 7 Rehabilitation of complete dentures 277
|| Completed case narrative 277
Case 8 Fixed and removable combined
rehabilitation 282
|| Completed case narrative 282
3/10/20 9:28 AM
 Foreword
What we know and do today creates the premises
of our tomorrow.
A scientific book is like a mosaic, a complex of
many chapters or tiles, each one with its color and
meaning and specific position in the whole. How-
ever, when you look at a single tile you only see that
particular color, whereas if you look at all the tiles
you see the overall final composition. This book it-
self is a humble tile that is part of a much larger
mosaic – medical care.
The specialty of prosthodontics was born almost
two centuries ago in the United States of America,
where it still evolves at a pace and level of complex-
ity that is unknown anywhere else. Prosthodon-
tic science is not an easy matter to deal with. It is
probably the field of dental medicine that deals with
the largest amount of medical, dental, clinical, and
laboratory data. But even though it is complex, it is
beautiful and requires humble passion and commit-
ment to know it well. Recent discoveries and tech-
nological advances have increased the amount and
quality of new treatment modalities. This may some-
times be misinterpreted as ‘heavier’ procedures, but
in fact it is not. While the increasing wealth of in-
formation may appear to be overwhelming or very
complex, it is really only a matter of putting in the
constant effort of learning how to handle it. For-
tunately, there are many new digital technologies
available today that are helping us to achieve this.
The entire preliminary before-treatment assessment
that professionals in all fields of medicine and den-
tal medicine have to commit to before they begin to
care for a patient can be summarized in two simple
words: treatment planning.
I wrote this book because while lecturing on the
topic of prosthodontic treatment planning over the
years I was asked to organize my notes and make
them easily access­ible to all students. The complex-
ity of the topic and the enormous body of existing
literature engaged me in a great effort of synthesis
Calvani_Frontmatter.indd 13
to rationalize and select the fundamentals. It was
a challenge to avoid dipping too deeply into the
var­ious more philosophical ideas and notions that
comprise this complex field, although some of these
are touched upon in the text when necessary. How-
ever, analysis and description are the backbones of
the book, and treatment planning is the basic scaf-
folding on which I have constructed the text. Treat-
ment planning is the investigative and diagnostic
phase where the clinician plans a well-structured,
rational sequence of care steps in order to best treat
each individual patient. And this aspect naturally
expands in the book into defining and discussing
many other aspects of prosthodontic work as well
as possible collaboration with other related dental
medical specialties that contribute to the rehabil­
itation of patients such as periodontics, orthodon-
tics, endodontics, maxillofacial surgery, and other
specialties.
Although the book primarily addresses pros­
thodontic specialists, it also explains basic mat-
ters relevant to all medical fields. Therefore, grad-
uate and postgraduate students as well as general
practitioners and specialists in other fields besides
prosthodontics will hopefully find useful explana-
tions and outlines that will make them aware of
the various aspects and possibilities of medical and
prosthetic treatment planning as it exists today. Af-
ter all, medical and dental medical treatment plans
have the same basic origin and structure.
I strongly believe that treatment planning should
be elevated to the same level as other scientific medical
fields such as anatomy and physiology and afforded
the same respect and dignity. It should be taught and
evaluated as a subject in its own right. Furthermore,
in the study, discussion, and formulation of a treat-
ment plan, practitioners should never place their
own professional pride or economic interest be-
fore the best interests of the patient, whose health
should always be the paramount issue. The needs of
XIII
3/10/20 9:28 AM
 Foreword
every patient should be treated with ­respect. Every
case deserves to be rehabilitated in full agreement
with the patient.
Winston Churchill is credited with saying: “He
who fails to plan is planning to fail.” This refers to the
logical premise that planning is essential in order to
achieve success in human endeavor. Knowledge and
organization are the main keys to success and make
all the difference between professionalism and in-
competence. For this reason, success in prosthodon-
tics (as in most other human activity) depends on
the amount and quality of our knowledge and how
we plan to carry out the work we face – the detail of
the where, when, and how of it – in order to predict
and then achieve the best possible results.
The topic of this book is deeply rooted in medical
ethics. As a board-certified physician, dentist, dental
technician, and prosthodontist, over time I have
become convinced that our professional duties go
way beyond the limits of the teeth and the oral
cavity.
Who we are is expressed by what we know and
what we do, which is largely a matter of conscious-
ness and awareness. The physical health of our pa-
tients is our primary goal; it is for this reason they
seek our help. Apart from how patients take care of
themselves, once they are in our offices their phys-
ical health largely depends on how well we perform
our examinations, and how attentive and clever
XIV
Calvani_Frontmatter.indd 14
we are in detecting their condition/s and realizing
how other physical ailments may be manifesting as
dental problems. It is for this reason that we need
to know our patients better from a broader med-
ical perspective. A deeper understanding of how
to conduct a physical examination of the head and
neck area may be helpful and improve the way we
work. The eyes, ears, nose, hands, and brain of the
dental medical professional can not only help peo-
ple to chew, speak, and look better, but also to live
better, safer, and longer lives; in some cases, they
may even save lives. As professionals we have to
be conscious and aware of this because we work in
the same medical field as physicians and surgeons,
and we should all be able to perform a careful phys-
ical examination of the head and neck. The more we
know and practice, the better able we are to take
care of our patients.
I respectfully bring this book to the attention of
all my young colleagues, both national and inter-
national, who may find the text helpful in order to
form and organize their thinking and to formulate
correct diagnoses and therapies that start with ap-
propriate treatment planning. I will derive a little
satisfaction if, with my effort, I am able to help cli-
nicians and patients to improve their work and live
better lives.
Lino Calvani, 2020
3/10/20 9:28 AM
 Acknowledgments
Thank you to my parents, Mario and Jole, beloved
knowledgeable pediatrician and dentist. Your
­superb example and loving memories are always
with me. You taught me to commit my profession to
the exclusive interest of the patient and of science.
Thank you to my daughter, Ludovica, ortho-
dontist, for your invaluable contribution, and to
my son, Gianluigi, actor and playwright, for your
Calvani_Frontmatter.indd 15
helpful sensitivity and brainstorming capabilities.
Thank you, dearest Francesca, for your love. I hope
you will forgive me for all the private time I took
from your lives. Thank you dear Avril, unique editor
and friend, you are always able to teach me a lot.
Thank you to my endless list of teachers who
have been beacons for me. I will always be your
humble student.
XV
3/10/20 9:28 AM
 Organization of the book and how to use it
The book is divided into 15 chapters that describe
different aspects of prosthodontic treatment plan-
ning, from the first meeting with the patient to the
delivery of the final prosthodontic treatment plan.
As you will see, each chapter describes a specific
topic. Due to the complexity of the subject mat-
ter, many topics appear in more than one chapter.
The reader is therefore provided with an index at
the back of the book as well as cross-referencing
throughout in order to reinforce the understanding
of treatment planning.
Progressive explanations lead the reader to the
last chapter, which contains a number of examples
of how to write and describe a treatment plan.
The structure of the book is learner-friendly and
will hopefully help readers to understand and memo-
rize both the concepts and their functional rationale.
The following paragraphs present a short de-
scription of what you can expect from each chapter.
Chapter one: Past, present, and future of
treatment planning
This introductory chapter, born from a curiosity to
better understand how medical treatment planning
came to be conceived, highlights the scientific as-
pects related to the development of treatment plan-
ning. Only the information that seems to have an
obvious connection to the topic is discussed. The
data show the clear growth trend of treatment plan-
ning in the western world. Possible future perspec-
tives to date and in the foreseeable future are also
touched upon. Due to the obvious restraints of the
size and nature of this publication, much informa-
tion has had to be omitted.
Chapter two: Treatment planning
management
The purpose and aims of any treatment plan are ex-
plained and discussed in this chapter. Also discussed
are the basis of respect for all patients; the priorities
XVI
Calvani_Frontmatter.indd 16
to be considered; the importance of clearly under-
standing the chief complaint/s that lead to patients
seeking help; patients’ understanding of their actual
condition/s; the possibility of achieving an ideal
treatment plan; the sometimes inevitable compro-
mises that need to be clearly explained to patients
to gain their understanding, awareness, and final
approval; and the importance and possible limita-
tions of the informed consent, which is the neces-
sary final step before treatment begins.
Chapter three: Prosthodontic tools for
treatment planning
This chapter describes the main restorative treatment
options that exist in prosthodontics, which can be
used as care tools to plan any type of rehabilitation.
The chapter also includes a discussion of the rapid
development of digital technologies and the impact
of this on the field of prosthodontics, including the
way in which our work has to be continually updated.
Chapter four: Data, findings, and dental
semiotics
The topic of data and findings is discussed in the
next chapter, including how, when, and why to col-
lect and interpret their meaning. Signs and symp-
toms such as pain, fever, and hyperthermia are also
defined and their diagnostic importance described.
The semiotic clinical analysis is explained with re-
gard to investigating the clinical signs that lead to a
more complete diagnosis.
Chapter five: The first visit – diagnostics
The aims and significance of the first visit are elab-
orated upon in this chapter. A description is given
of the different types of practical techniques that
are used to gather information about patients. Also
delineated is the diagnostic information that needs
to be gathered and assessed during the first visit
such as the patient’s chief complaint/s; personal,
3/10/20 9:28 AM

medical, dental, and prosthodontic history; and psy-
chologic profile. The development of the initial part
of the treatment plan, the management of emergen-
cies, and the restorative planning are also described.
Chapter six: Diagnosis and prognosis
The meaning of the diagnosis, the differential diag-
nosis, and the prognosis are detailed in this chapter
as well as their importance to the positive outcome
of the prosthodontic treatment. The pretreatment
and posttreatment prognoses are analyzed, and the
periodontal, prosthodontic, and orthodontic eti-
ology and risk factors that may impact the timing
of the prognoses are also described.
Chapters seven and eight: Physical
examinations
These two chapters on the medical examination
present a step-by-step description of the basic pro-
cedures and methods that need to be applied when
examining patients, starting from the first moment
of engagement with the patient and following with
the chairside examination at the first visit. Useful
descriptions of all the most important extraoral and
intraoral anatomical features are provided, together
with their clinical and prosthodontic relevance and
importance. The semiotic possibilities of these ex-
aminations are also evaluated.
Chapter nine: Main clinical examination
assessment questions
This chapter continues the topic of examinations. It
details the clinical intraoral and extraoral examina-
tions and their importance in evaluating and assess-
ing patients’ health status and possible past and ongo-
ing conditions. This can be considered an important
juncture in the clinician–patient relationship, which
can decide whether we gain patients’ trust or lose
them as patients; the procedures and suggestions in
this chapter are therefore crucial.
Chapter ten: The type and structure of
prosthodontic treatments
This chapter describes, analyzes, and proposes a
new and original classification for prosthodontic
Calvani_Frontmatter.indd 17
Organization of the book
treatment types according to the three main possi-
ble clinical variables: pure prosthodontic rehabilita-
tions, those in collaboration with other specialists,
and the presence of disease.
Chapters eleven, twelve, and thirteen:
Treatment planning analysis of complex
rehabilitations
The timing and organization of the different
phases comprising a prosthodontic treatment
plan are described and analyzed in these three
chapters. Each of the three phases is explained
with a view to understanding the priorities and
to better organize the sequence of the phases in
order to simplify the analysis and narrative de-
scription of a treatment plan. Also explained is
the importance of integrating the radiographic
and cone beam computed tomography (CBCT)
diagnostic examinations to better define the final
diagnosis.
Chapter fourteen: Treatment planning
for the elderly and those with challenging
health conditions
This chapter deals with the topic of treatment plan-
ning for elderly patients and those with drug addic-
tions. Included are observations on how the body
and oral cavity age, and how medicines and drugs
influence and affect patients and, in turn, the effect
this has on medical or dental treatment plans. Also
shown is how the changes of aging can significantly
affect a prosthodontic treatment, so that alternative
solutions need to be planned according to the pa-
tient’s needs. Discussed too is how transitory or
chronic major conditions may modify a patient’s
capability to withstand an oral rehabilitation. A
description and analysis are given of the most im-
portant drugs and how they may cause addiction as
well as how they affect and influence oral treatment
choices.
Chapter fifteen: How to write a
prosthodontic treatment plan
The final chapter describes why and how treatment
plans can be presented for in-office purposes or for
XVII
3/10/20 9:28 AM
 Organization of the book

PowerPoint or Keynote presentations. A number

of useful clinical case narratives are presented as
practical treatment planning examples that could
be used for the purposes of university case pres-
entations and examinations, meetings, congress
presentations or lectures. The ‘narrative frame-
works’ of all the narrative reports explain the ra-
tionale behind why certain decisions have been
made while other choices have been avoided, and
how this rationale can be explained to patients, to
other professionals or to students during seminars.

XVIII

Calvani_Frontmatter.indd 18 3/10/20 9:28 AM

 Prosthodontists: Who we are and what we do
“The world moves in front of them who know
where to go and what to do.”
Lino Calvani
I approached this profession and specialty with in-
finite humbleness, respect, curiosity, and commit-
ment, and this is what still pushes me forward with
passion. Prosthodontics is a beautiful, complex, and
very demanding specialty in terms of knowledge
and commitment. I have been moved to see in the
literature how many have dedicated so much of their
lives to its development and success. The list of lit-
erature that follows (in alphabetical order) is a small
but highly representative sample of the significant
writings dedicated to the growth and development
of prosthodontics. The amazing professionals who
have written these articles, papers, and books, and
the many others who are not included in this list for
reasons of space, have set a standard of passion and
professionalism that is difficult to match.
The specialty of prosthodontics was originally
recognized in 1948 by the Commission of Dental
Accreditation (CODA), an independent agency of
the American Dental Association (ADA), which
is an independent organization recognized by the
United States Department of Education.
The ADA defines prosthodontics as: “the den-
tal specialty pertaining to the diagnosis, treatment
planning, rehabilitation, and maintenance of oral
function, comfort, appearance, and health of patients
with clinical conditions associated with missing or
deficient teeth and/or oral and maxillofacial tissues
using biocompatible substitutes.”
During the three years of training in all United
States postgraduate prosthodontics specialty pro-
grams, students must become knowledgeable in the
Calvani_Frontmatter.indd 19
comprehensive treatment of clinical cases for miss-
ing or deficient teeth and oral and maxillofacial tis-
sue in order to competently find solutions and cures
using biocompatible substitutes. The focus is on the
following areas:
1. Patient assessment (both medical and dental
history).
2. Extraoral and intraoral examination.
3. Radiologic assessment and occlusal analysis.
4. Temporomandibular joint (TMJ) assessment.
5. Systemic, infectious, and neoplastic disease
screening (education for prevention).
6. Diagnosis.
7. Risk assessment and prognosis.
8. Treatment planning.
9. Comprehensive treatment.
10. Outcomes assessment and delivery.
11. Follow-up and maintenance.
As professionals, we ‘profess’ to believe in who we
are and what we do. As the Mission Statement of the
American College of Prosthodontics states: “Prost-
hodontists are specialists in the restoration and re-
placement of missing teeth and oral/facial structures
with natural, esthetic, and functional replacements.
This includes surgical implant placement, the simple
to most complex implant-supported restorations, lab-
oratory and clinical training in esthetics/cosmetics,
crowns, bridges, veneers, inlays, removable complete
and partial dentures, dental implants, TMD-jaw joint
issues, traumatic injuries to the mouth’s structures,
congenital or birth anomalies and/or teeth, snoring
and sleep disorders, as well as oral cancer, prosthetic
reconstruction, and continuing care. Prosthodontists
are experts in treatment planning.”
XIX
3/10/20 9:28 AM
 Literature
1. American Board of Prosthodontics. History, information,
and examination requirements of the American Board of
Prosthodontics. J Prosthet Dent 1984;52:281–287.
2. American College of Prosthodontists. Reframing the
Future of Prosthodontics: An Invitational Leadership
Summit, 2006:11–12.
3. American College of Prosthodontic. Mission Statement,
2018.
4. American Dental Association. Report of the ADA-Rec-
ognized Dental Specialty Certifying Boards, 2012;2.
5. Atwood DA. Practice of prosthodontics: past, present,
and future. J Prosthet Dent 1969;21:393–401.
6. Boucher CO. Trends in the practice and philosophy of
prosthodontics in the United States. J Prosthet Dent
1966;16:873–879.
7. Boucher LJ. The role of research in prosthodontics.
J Prosthet Dent 1965:15;962–966.
8. Boucher LJ, Wood GH. Workshop on advanced prostho-
dontic education: a preliminary report. J Prosthet Dent
1969;21:433–442.
9. Boucher LJ. Advanced prosthodontic education. J Pros-
thet Dent 1976;35:29–30.
10. Carlsson GE, Omar R. Trends in prosthodontics. Med
Princ Pract 2006;15:167–179.
11. Chalian VA, Dykema RW. Minimal clinical require-
ments for advanced education in prosthodontics.
J Prosthet Dent 1976;35:39–42.
12. Garfunkel E. The consumer speaks: how patients select
and how much they know about dental health care per-
sonnel. J Prosthet Dent 1980;43:380–384.
13. Hardy IR. History of the specialty of prosthodontics.
J Prosthet Dent 1965;15:946–948.
14. Johnson WW. The history of prosthetic dentistry.
J Prosthet Dent 1959;9;841–846.
15. Jones PM. Advanced education in prosthodontics – cur-
riculum content. J Prosthet Dent 1976;31:31–33.
16. Kelsey CC. Survey of income of prosthodontists as
assessed by the American College of Prosthodontists.
J Prosthet Dent 1975;34:120–124.
17. Knutson JW. Research and the future of prosthodontics.
J Prosthet Dent 1961;11:375–381.
18. Koper A. Minimal clinical requirements for advanced
prosthodontics education. J Prosthet Dent 1976;35:
34–36.
19. Koper A. Advanced prosthodontic education: a ra-
tionale for a curriculum which integrates fixed and
XX
Calvani_Frontmatter.indd 20
removable prosthodontic education. J Prosthet Dent
1979;41:576­–578.
20. Laney WR. History of the American Board of Prostho-
dontics. J Prosthet Dent 1972;28:655–656.
21. Laney WR. American Board of Prosthodontics. J Pros-
thet Dent 1975;34:675–693.
22. Laney WR. Limitation of clinical practice to prostho-
dontics. J Prosthet Dent 1976;35:57–61.
23. Love WB. Prosthodontics – Past, present and future.
J Prosthet Dent 1976;36:261–264.
24. Lytle RB. Criteria for evaluating candidates or the
American Board of Prosthodontics. J Prosthet Dent
1969;21:417–422.
25. Mann WR. What dentistry expect of the prosthodontist.
J Prosthet Dent 1965;15:949–955.
26. Morse PK, Boucher LJ. How 274 prosthodontists ranked
four methods of advanced education in prosthodontics.
J Prosthet Dent 1969;21:431–432.
27. Morse PK, Boucher LJ. What a prosthodontist does.
J Prosthet Dent 1969;21:409–416.
28. Nagle RJ. The role of the specialty of prosthodontics in
service to the public and to the profession. J Prosthet
Dent 1965;15:956–961.
29. Ortman HR. Meeting the challenges facing prosthodon-
tics. J Prosthet Dent 1980;43:586–589.
30. Payne SH. Knowledge and skills necessary in the prac-
tice of prosthodontics. J Prosthet Dent 1968;20:255–257.
31. Payne SH. The future of prosthodontics. J Prosthet Dent
1976;35:3–5.
32. Taylor TD, Bergen SF, Conrad H, Goodacre CJ, Piermatti
J. What is a Prosthodontist and the Dental Specialty of
Prosthodontics? American College of Prosthodontics,
Position Statement, 2014.
33. The Academy of Denture Prosthetics. Principles, con-
cepts and practices in prosthodontics. J Prosthet Dent
1968;19:180–198.
34. Travaglini EA. Prosthodontics and the single-concept
film. J Prosthet Dent 1973;30(4 Pt 2):640–641.
35. Wiens JP. Leadership, stewardship, and prosthodontic’s
future. Int J Prosthodont 2007;20:456–458.
36. Wiens JP, Koka S, Graser G, et al. Academy of Prost-
hodontics centennial: The emergence and develop-
ment of prosthodontics as a specialty. J Prosthet Dent
2017;118:569–572.
37. Young JM. Prosthodontics in general practice residency.
J Prosthet Dent 1974;31:615–627.
3/10/20 9:28 AM
 CHAPTER ONE

Past, present, and future of

treatment planning

Calvani_Ch_1.indd 1 12.02.20 12:04

 1 Past, present, and future of treatment planning
“Those who do not learn from history are
doomed to repeat it.”
George Santayana (1863–1952)
“The past should be read with the eyes of present
time.”
Charles Darwin (1809–1882)
“The past is never dead. It’s not even past.”
William Faulkner (1897–1962)
The distant past
The author believes it is important to understand
history not so much as a chronicle of events but
in terms of the value we attach to and derive from
these events. In this way, we arrive at the signifi-
cance of the events. When we look back, we under-
stand that for long millennia our civilization was
not able to conceive or understand much about sci-
ence, as we know it today. Certainly, in the distant
past, people had absolutely no idea what they were
doing when treating physical disease and illness.1-4
But once in a while, a gifted individual with a ‘beau-
tiful mind’ sensed something new, and in this way
our knowledge was carried a step or two forward.
Slowly there developed the understanding and ac-
knowledgment that the causes of illness and disease
were not so much ‘divine’ as they were natural or
human-made, and this understanding was the route
to healing them. Of course, the first medical treat-
ments were simple natural herbal remedies, primi-
tive bandages and cream prototypes, coupled with
attempts of a philosophical or religious nature to
explain and justify all incomprehensible events by
relating them to the will of a moody God.5-7
In more recent history, after the ‘static’ middle
ages (from a medical point of view), an increasing
awareness of scientific evidence over the past five
centuries has allowed for a better understanding of
the mechanics of our nature and of the ‘innate con-
sciousness’ and ‘self-awareness’ that distinguishes
us as a species.8-10 However, compared with other
sciences, the development of medicine, including
Calvani_Ch_1.indd 2
dental medicine, was more difficult because those
bright-minded individuals who became involved
had to face not only the extreme complexity and
difficulty of the subject matter of the human body
and mind, but also the limitations imposed by the
endless short-sighted and ignorant doctrines of the
time.11-13 The intelligent nature of humans means
that we need to trust in order to understand; ­trusting
in science means that in time science will explain
everything, whereas trusting in a religious sense
(having faith) means believing that God will take
care of everything. Historically, the development of
medical treatment planning has been strongly in-
fluenced by this.14,15 Nevertheless, over the last two
centuries, science finally gained its autonomy from
religion, and today the two areas of human endeavor
are separate, to the obvious advantage of medicine.
An important aspect of the renaissance of med-
ical science was the contribution scientists made to
laying the anatomical foundations for the under-
standing of the cause-and-effect relationship that
exists in the human body, and how the various parts
of the body function and malfunction in relation to
each other. This had profound implications for the
development of clinical and surgical therapies. This
cause-and-effect relationship can be seen as the
initial basis for the current treatment planning ra-
tionale. Nevertheless, despite all efforts, ignorance
about medicine among the general public was rife
because society was disconnected and disorganized,
and it was difficult and often impossible to teach
and impart new medical knowledge and trends. At
that time, medical treatment planning was largely
unknown, and to the extent that it did exist, it was
very primitive and poorly understood. Therefore,
due to almost no true medical understanding, epi­
demics, traumas, infections, and cancers indiscrim-
inately killed hundreds of millions of people. It
took other two centuries before anatomy, physio­
logy, and pathology became actual sciences, and the
word ‘treatment’ became a medical term.
So, regardless of all the clever minds, poor trans-
port and communication meant that people were
isolated and led an insular way of life. Medicine it-
self was still largely based on old, inaccurate, and
12.02.20 12:04

often imaginary notions. Medical practitioners were
on the whole pompously dressed, incapable igno-
ramuses, trying to describe nonexistent diseases
with useless Latin words. Original paintings of this
medical class show images of fantastic methods and
therapies full of enemas, leeches, ointments, and
draught potions that were invented and concocted
to ‘cure’ all ailments and diseases.4,16
Only during the 17th and 18th centuries did
physicists and chemists boost the curiosity of many
people, so that people started to believe that they
could follow in the footsteps of these scientists in all
scientific matters, driven by their then brand-new
practice of scientific research methods and the pur-
suit of evidence of reality theories. This indirectly
contributed to the speeding up of the understand-
ing of medical science and treatment planning. In-
deed, probably without realizing it, physicists and
chemists at that time were changing the way people
thought about medical science.
It can therefore be said that medical treatment
planning has its origins in scientists attempting
to prove that formulas could explain all scientific
elements and, indeed, the world. Over time, it be-
came clear that signs and symptoms were useful
and necessary to make a correct diagnosis of illness
and disease. In fact, medical treatment planning is
entirely based on scientific methodology and evi-
dence. However, while physics, astronomy, math-
ematics, and biology were progressing at a rapid
pace, scarce technologies and immature methods
limited people’s knowledge of the human body, no
matter how curious they were. Also, the slow pace
of life and very limited social contact meant that it
was difficult to spread news, which created many
problems.4,16,17
During the 19th century, medical scientists
looking for scientific evidence and using the new
scientific instruments of the time discovered more
ways to heal and cure, which were perfected with
time and passion, although many essential notions
were lacking, and there was still no precise under-
standing of treatment planning.13,18 Universities
and medical and dental medical schools began to
open and flourish in the USA and in other parts of
Calvani_Ch_1.indd 3
 20th century to the present
the developed world, for example, the Baltimore
College of Dental Surgery was founded in 1840,
the Philadelphia College of Dental Surgery in 1842,
Tufts Dental School in 1852, Harvard Dental School
in 1867, and the University of Michigan in 1875.
Passionate researchers and clinicians started to cre-
ate the basis of actual medical and dental medical
scientific treatments.19 So, by the turn of the 20th
century, official medical and dental medical sci-
ence was starting to be oriented toward what we
know today as ‘assessed methodology.’ The study
of anatomy was acknow­ledged as the basis for un-
derstanding medicine, and investigations into the
body’s functions and malfunctions started to drive
more organized and critical laboratory research and
clinical practice.18,20 Scientists’ curiosity and eager-
ness for clarification drove them to begin to look
for ‘evidence’ as the starting point. The worst of the
religious influence on medicine was part of the past.
20th century to the present
While the 20th century gifted us with geniuses such
as Albert Einstein (1879–1955), it also plagued us
with two devastating world wars, which had a sig-
nificant influence on the development of treatment
planning in the west. About 20 million lives were
lost in the First World War (1914­–1918), and about
68 million in the Second World War (1939–1945).
Apart from the death toll, war means all kinds of
terrible injuries, physical and psychologic, created
by all types of weapons. It means traumas, wounds,
burns, disfigurements, and epidemics.
The world wars profoundly changed the lives of
our grandparents and parents, and forced medical
science to find surgical, clinical, and pharmacologi­
cal solutions to address the sudden, terrible, and ur-
gent traumas they caused. The wide range of inju-
ries and infections, many of them never seen before,
meant that the understanding about how to plan
the treatment of patients accelerated, both during
emergencies on the battlefields and in the clinic.
In addition, the 1918 influenza epidemic (known
as the Spanish Flu), largely brought on by the un-
12.02.20 12:04
 1 Past, present, and future of treatment planning
hygienic conditions of the First World War, left
roughly 50 million dead worldwide. Therefore, the
total death toll in the almost 50-year period span-
ning both world wars was about 125 million peo-
ple, not to mention the millions more who were
seriously injured in these wars and who died pre-
maturely later on. On top of this, other local wars
and epidemics followed, bringing the death toll to
some 13% to 14% of the entire world population at
that time.21,22-24
Due to these events, and thanks to the increased
number of dedicated medical scientists and facili-
ties, improved communication and media, and the
growing body of scientific and medical knowledge
that had been slowly accumulating over centuries,
medical science made a great leap forward in the
first part of the 20th century. The level of aware-
ness and consciousness regarding medical treat-
ment and its planning increased rapidly during
that time, bringing a deeper understanding of the
importance of knowledge about medical proce­
dures and being well organized in the planning of
treatment (this includes dental medicine and pros-
thodontic treatment planning, even though the lat-
ter is not always that well defined).25-27
Population growth is another important factor
in the development of treatment planning. Over
the last three millennia, the human population has
increased from about 50 million to 7.5 billion peo-
ple. Parallel to this is the increase in the number
of ­scientists and thinkers who have dedicated their
lives to solving medical problems, which has esca-
lated the number of possibilities for furthering med-
ical and dental medical science.28,29 Inventions and
discoveries that make possible the forward move-
ment of science and medicine are not made so much
by specific individuals as by the collective know-
ledge and awareness that accumulates over time.30-
34 This is known as ‘collective intelligence,’ which
expands exponentially all the time, thereby increas-
ing the possibility of more and more discoveries that
lead to better medical understanding. For instance,
about a century ago there would have been few, if
any, physicists who properly understood Einstein’s
theories. Today, hundreds of thousands of students
Calvani_Ch_1.indd 4
easily do, and thanks largely to the internet, their
contributions to science are easily and quickly
spread throughout the world. Just a century ago,
only a few physicians knew what an antibiotic was,
and thousands of people died of bacterial infections.
Today, most people know about antibiotics and mil-
lions of people take them, often autonomously and
without careful prescription (which has unfortu-
nately also resulted in an alarming and increasing
physiologic resistance to them).
This ties in with another important factor in the
understanding of the development of treatment
planning, which is communication and the media,
particularly the internet and smart phones.17,35-37
Since the two world wars (and therefore in less
than a century), information about medical sci-
ence has rapidly increased, and has been shared
among millions of medical and dental profession-
als. This means that the panorama of clinical plan-
ning and treatment is continually changing and
evolving.
‘Hyper-science’ and the future
When the famous physicist Niels Bohr (1885–1962)
was asked to make predictions about the future, he
said humorously: “Predictions are very difficult, es-
pecially about the future.” Every small scientific step
forward changes our understanding of how to plan
and treat medical conditions. However, despite how
technology today allows for easy online access for
most people to medical research, data, literature,
and information, human endeavor remains crucial
and necessary.
Currently, data acquisition and processing
speeds seem to depend on a number of disruptive
‘innovation platforms’ that cut across sectors and
markets and converge on each other on the medical
stage, such as:
1. 5G and 6G internet connections.
2. Micro and macro energy storage for industry,
farming, transportation, cities, etc.
3. Plasma and quantum computers; liquid, nano-­
magnetic, and graphene transistors.
12.02.20 12:04

4. Artificial intelligence (AI), artificial narrow
intelligence (ANI), artificial general intelli-
gence (AGI), deep-learning software (DLS), and
self-learning software (SLS).
5. Collaborative robotics and humanoids.
6. Computer-aided design/computer-aided manu-
facturing (CAD/CAM) and 3D printing.
7. DNA sequencing and CRISPR therapeutic
­genome editing.
8. Nanotechnologies.
‘Hyper-science’ (author’s own word) seems an ap-
propriate composite word for these revolutionary
technologies and the current rapid growth of sci-
entific knowledge. As never before, the progress of
science is accelerating, and capabilities and possibil-
ities are increasingly opening up. Which is why the
medical progress indicators predict that medical and
dental schools will structurally change in the near
future under the pressure of digital innovations.38-44
A clear example of the above is the new, cheaper
DNA sequencing and CRISPR genome editing that
is enabling scientists to develop new types of diag-
nostic screens, tests, and therapies. Computational
techniques are changing our schools and educa-
tional programs constantly, with the three-dimen-
sional resources of virtual reality (VR) and aug-
mented reality (AR) changing the way students
and faculty interact, including the interaction with
robots.45-54 Nanotechnology is increasingly being
used to treat patients. Predictions made on solid sci-
entific bases foresee that, two or three decades from
now, well-programmed super-intelligent ANI, and
well-instructed human-dependent or independent
AGI machines as well as AGI humanoid robotized
digital doctors and caregivers will clinically treat
patients suffering from an increasing variety of dis-
eases and will also feature in the laboratory. These
machines will be able to handle programmable and
Calvani_Ch_1.indd 5
 ‘Hyper-science’ and the future
injectable chemotherapeutical nanorobots and na-
nocarriers. They will be much faster and, in many
ways, more capable than humans to do the job of
medical care providers.25,41,55-58 We will refer to
them with trust when we are ill or wounded.
Knowledge, consciousness, and indeed our entire
way of living and working are being revolutionized.
One only has to attend medical and dental medical
meetings, conferences, and expos all over the world
to see where the market is now and where it is
heading, and how much money is involved. Human
history has always demonstrated that whatever we
are capable of imagining, we are capable of achiev-
ing. Digital science has come a long way, being
completely free today of any religious constraints
that might prevent it from progressing.
Currently, there is much hyper-scientific intel-
ligent curiosity and imagination at work.59 An ex-
citing example is the newest IBM Watson Machine
Learning, which harnesses machine learning and
deep learning in a way that enables the manage-
ment of an infinite amount of data. It gives flexible
answers, insights, and possible solutions in many
different fields of human endeavor, and is already
useful to medical professionals in various fields of
health care. For treatment planning, for instance, it
can be used for collecting and reading scientific lit-
erature published in many languages. When asked
about a specific disease or illness, it can promptly
give one or more answers, propose a fitting diag-
nosis, and suggest various treatment options ac-
cording to clinical facts, scientific evidence, and sta-
tistics. It can also design program interventions.60
However, despite all future AI digital capabilities
and skills, the logic of treatment planning, with its
basic and complex algorithms, will always consti-
tute the common scientific foundation of medical,
dental medical, and prosthodontic treatment and its
planning.
12.02.20 12:04
 1 Past, present, and future of treatment planning

2000–present
AI, ANI, AGI,
and beyond ...

b. 1800–2000
Skoda, von Hebra, von
Helmholtz, Pasteur, Osler,
Bourdet, Kemperer, Muller,
Frugoni, Müller, Valdoni

b. 1600–1700
Sydenham, Locke, ­Lancisi,
460–359 Hippocratic Corpus 1163 – Edict of Tours ­Boerhaave, Fauchard,
428–347 Plato 1225–1274 Saint Thomas ­Morgagni, Bounon
384–322 Aristotle Aquinas
b. 1700–1800
129–216 Galen of b. 1300–1600 Auenbrugger, Pinel, Pfaff,
­Pergamon Chauliac, Da Vigo, Bichat, Corvisart, Laennec,
354–430 Saint Augustine Da Vinci, Paracelsus, Andral, Welsley
3600–1000 BC AD Paré, Vesalius, Harvey

ANCIENT AGE of GODS MIDDLE AGE of GOD MODERN AGE SCIENCE AGE DIGITAL AGE

Fig 1-1 The birth and growth of medical examination, diagnosis, and treatment planning in western civilization.
The first real scientific impulse occurred in 1500, with curiosity for the unknown and for medicine following
until the end of 1700, when scientific evidence changed the schools and universities and gave birth to empirical
knowledge and scientific research.

Calvani_Ch_1.indd 6 12.02.20 12:04


References
1. Garrison FH. An Introduction to the History of Medi-
cine. Philadelphia: W.B. Saunders, 1921:508.
2. Heidel WA. Hippocratic Medicine: Its Spirit and
Method. New York: Columbia University Press, 1941.
3. Crone HD. Paracelsus: the man who defied medicine:
his real contribution to medicine and science. Mel-
bourne: Albarello Press, 2004.
4. Major RH. A History of Medicine. Springfield: Charles
C Thomas, 1954.
5. Nutton V. Ancient Medicine. Taylor & Francis, 2004.
6. Phillips ED. Greek Medicine. London: Thames and
­Hudson, 1973.
7. Temkin O. Galenism. Ithaca: Cornell University Press,
1973.
8. Klein R. Anatomy, Behavior, and Modern Human Ori-
gins. Journal of World Prehistory 1995;9:​167–198.
9. Kording KP, Tenenbaum JB, Shadmehr R. The dynamics
of memory as a consequence of optimal adaptation to a
changing body. Nat Neurosci 2007;10:​779–786.
10. O’Neal JC. Auenbrugger, Corvisart, and the perception
of disease. Eighteenth Century Stud 1998;31:​473–489.
11. Durant W. The Age of Faith: A History of Medieval Civ-
ilization – Christian, Islamic, and Judaic – From Con-
stantine to Dante, A.D. 325–1300. MJF Books, 1993.
12. French R. Medicine before Science: The Business of
Medicine from the Middle Ages to the Enlightenment.
Cambridge University Press, 2003.
13. Grant E. A Source Book in Medieval Science. Harvard
University Press, 1974:807.
14. Buck AH. The Growth of Medicine from the Earliest
Times to about 1800. Yale University Press, 1917.
15. Prioreschi P. A History of Medicine, Volume 5: Medie-
val Medicine, ed 2. Lewiston, NY, USA: Edwin Mellen
Press, 1996.
16. Johnson DA, Schaffer D. Learning from the Past – The
History of Planning: Introduction. Journal of the Amer-
ican Planning Association 1985;51:​131–135.
17. Loudon I. Western Medicine: An Illustrated History.
Oxford University Press, 2001.
18. Adams FD. Physical Diagnosis, ed 14. Baltimore: Wil-
liams & Wilkins, 1958.
19. Gillis J. The history of the patient history since 1850.
Bull Hist Med 2006;80:​490–512.
20. DeGowin EL, DeGowin RL. Bedside Diagnostic Exam-
ination. New York: Macmillan, 1965.
21. McCallum JE. Military Medicine: From Ancient Times
to the 21st Century. ABC-CLIO, 2008.
22. Porter R. The Cambridge Illustrated History of Medi-
cine. Cambridge University Press, 2001.
Calvani_Ch_1.indd 7
 References
23. Tallett F. War and Society in Early Modern Europe
1495–1715. Routledge, 1997.
24. Rutkow IM. History of Surgery in the United States,
1775–1900: Periodical and Pamphlet Literature. Nor-
man Publishing, 1992:98.
25. Byrne D. Complexity theory and planning theory; a ne-
cessary encounter. Planning Theory 2003;2:​171–178.
26. Walker HK. The origins of the history and physical
examination. In: Walker HK, Hall WD, Hurst JW (eds).
Clinical Methods: The History, Physical, and Labora-
tory Examinations, ed 3. Boston: Butterworths, 1990.
27. Ellis H. A History of Surgery. Cambridge University
Press, 2001.
28. Rosling H. Why the world population won’t exceed 11
billion. TGS.ORG, 2016. YouTube lecture.
29. Haub C. How Many People Have Ever Lived on Earth?
Population Reference Bureau (PRB), 2011.
30. Goodman ND, Tenenbaum JB, Feldman J, Griffiths TL.
A rational analysis of a rule-based concept learning.
Cogn Sci 2008;32:​108–154.
31. Gopnik A, Tenenbaum JB. Bayesian Networks, Bayesian
learning and cognitive development. Dev Sci 2007;10:​
281–287.
32. Jaynes J. The Origin of Consciousness in the Breakdown
of the Bicameral Mind. Toronto: University of Toronto
Press, 1976.
33. Tenenbaum JB. Griffiths TL, Kemp C. Theory-based
Bayesian models of inductive learning and reasoning.
Trends Cogn Sci 2006;10:​309–318.
34. Zimmerman LM, Veith I. Great Ideas in the History of
Surgery. Norman Publishing, 1993.
35. Heisenberg W. The Physical Principles of the Quantum
Theory. New York: Dover, 1949.
36. Selin H (ed). Encyclopaedia of the History of Science,
Technology, and Medicine in Non-Western Cultures.
Springer, 2016.
37. Rosa H. Social acceleration: ethical and political conse-
quences of a desynchronized high-speed society. Con-
stellations, 2003;10:​3–33.
38. Albuha AI-Mussawi RM, Farid F. Computer-based tech-
nologies in dentistry: types and applications. J Dent
(Tehran) 2016;13:​215–222.
39. Al-Thobity AM, Farooq I, Khan SQ. Effect of software
facilitated teaching on final grades of dental students in a
dental morphology course. Saud Med J 2017;38:​192–195.
40. Lake BM, Salakhutdinov R, Tenenbaum JB. Human-level
concept learning through probabilistic program induc-
tion. Science 2015;350:​1332–1338.
41. Chang AC. How artificial intelligence will transform
medicine. Lecture on: History of Artificial Intelligence,
2017.
12.02.20 12:04
 1 Past, present, and future of treatment planning
42. Connell DJ. Planning and its Orientation to the Future.
International Planning Studies 2009;14:​85–98.
43. Goodacre CJ. Digital Learning Resources for Prost-
hodontic Education: The Perspectives of a Long-Term
Dental Educator Regarding 4 Key Factors. J Prostho-
dont 2018;27:​791–797.
44. Greene CC. How to educate millennials. J Calif Dent
Assoc 2018;46:​359–362.
45. Aerbersold M, Voepel-Lewis T, Cherara L, et al. Interac-
tive Anatomy-Augmented Virtual Simulation Training.
Clin Simul Nurs 2018;15:​34–41.
46. Bacca J, Baldiris S, Fabregat R, Graf S, Kinshuk. Aug-
mented reality trends in education: a systematic review of
research and applications. Educ Tech Soc 2014;17:​133–149.
47. Garg AX, Norman G, Sperotable L. How medical stu-
dents learn spatial anatomy. Lancat 2001;357:​363–364.
48. Hu J, Yu H, Shao J, Li Z, Wang J, Wang Y. Effects of
Dental 3D Multimedia System on the performance of
junior dental students in preclinical practice: a report
from China. Adv Health Sci Educ Theory Pract 2009;14:​
123–133.
49. Huang TK, Yang CH, Hsieh YH, Wang JC, Hung CC.
Augmented reality (AR) and virtual reality (VR) applied
in dentistry. Kaohsiung J Med Sci 2018;34:​243–248.
50. Kell HJ, Lubinsky D, Benbow CP, Steiger JH. Creativity
and technical innovation: spatial ability’s unique role.
Psychol Sci 2013;24:​1831–1836.
51. Piromchai P, Avery A, Laopaiboon M, Kennedy G,
O’Leary S. Virtual reality training for improving the
Calvani_Ch_1.indd 8
skills needed for performing surgery of the ear, nose or
throat. Cochrane Database Syst Rev 2015;(9):CD010198.
52. Radu I. Augmented reality in education; a meta-review
and cross-media analysis. Pers Ubiquit Comput 2014;18:​
1533–1543.
53. Walsh CM, Sherlock ME, Ling SC, Carnahan H. Virtual
reality simulation training for health professions train-
ees in gastrointestinal endoscopy. Cochrane Database
Syst Rev 2012;6:CD008237.
54. Wright EF, Hendricson WD. Evaluation of a 3-D inter-
active tooth atlas by dental students in dental anatomy
and endodontics courses. J Dent Educ 2010;74:​110–122.
55. Allmendinger P. Planning Theory. New York: Palgrave,
2002.
56. Bergdaà M. Temporal Frameworks and Individual Cul-
tural Activities: Four typical profiles. Time & Society,
Sage, 2007;16:​387–407.
57. EmTech Next. AI and robotics are changing the future
of work. Are you ready? MIT Technology Review. On-
line publication, 2018. https://events.technologyreview.
com/emtech/next/19/.
58. Reiser SJ. Medicine and the Reign of Technology. Cam-
bridge, New York: Cambridge University Press, 1978.
59. Alexander ER. Approaches to Planning: Introducing
Current Planning Theories, Concepts and Issues. Lux-
embourg: Gordon and Breach Science Publishers SA,
1992.
60. IBM – Watson Machine Learning. https://www.ibm.
com/cloud/machine-learning. Accessed 29 June 2019.
12.02.20 12:04
 CHAPTER TWO

Treatment planning
management

Calvani_Ch_2.indd 9 12.02.20 12:04

 2 Treatment planning management
We often take our knowledge for granted, which
in the medical field is a dangerous thing. While
good sense and innate wisdom drive the profession,
things are changing so quickly in our technological
age that we need to constantly keep ourselves in­
formed about new terms, concepts, rationales, pro­
cedures, and ideas in order to offer our patients the
best treatments possible. The science is not static but
must be constantly learned, understood, reviewed,
and remembered. Only then are we in a position to
formulate the best treatment plan.
So, what is the goal of a prosthodontic treatment
plan? In most cases, patients come to us because
they have an esthetic and/or functional problem in
their oral cavity. It is understandable that they are
not concerned about the physiology of the entire
oral system and how all aspects of it are interrelated.
What is not so understandable is how many dental
medical professionals think it is sufficient to treat
the teeth only, ignoring the overall context in which
the masticatory system works. Considering the part
as inseparable from the whole is the basis of the ho­
listic approach to medical and dental practice.
Prosthodontists need to solve problems in the
oral cavity, but that is not just a matter of teeth.
Indeed, they need to find the best possible way of
healing the oral cavity and its potential clinical
problems, taking into account all the structural and
biomechanical issues. They then need to rehabili­
tate the patient’s oral health in its entirety, focusing
on the dentition and its compromised or lost func­
tions, while also taking into account the patient’s
needs, wishes, and expectations. Prosthodontists
are called upon to improve the function of the den­
tition as well as the patient’s comfort and quality
of life so that both physical and psychologic health
are restored.
Prosthodontists should be equipped to manage
treatment planing with understanding, expertise,
and professionalism. This entails a sound know­
ledge of patient management, organization, and
what is available in terms of clinical therapies that
can be suggested to the patient.
Therefore, after the diagnosis, treatment plan­
ning is the moment where all the various aspects
10
Calvani_Ch_2.indd 10
of education, knowledge, understanding, expertise,
experience, observational capabilities, reasoning,
dexterity, skills, ethical awareness, responsibility,
communication, and critical thinking are distilled
into one focus. From this focal point, treatment
plans are conceived and presented to the patient.
At this moment, professional values such as clarity,
precision, and accuracy are key.
What follows are some basic concepts, defini­
tions, and suggestions related to this aspect of the
topic. Some may feel that their professional experi­
ence means they will not benefit from this level of
basic analysis. But for those who humbly approach
this subject with an open mind, these basic concepts
will hopefully be useful to tune in, so to speak, to the
matter of prosthodontic thought in order to enhance
their knowledge and understanding. It should also
be borne in mind that, unfortunately, the speciality
of prosthodontics still does not exist institutionally
in many parts of the world outside of the USA.
Some definitions and basic
premises
The three cornerstone definitions are:
● Treatment: According to the Cambridge
Dictionary, the word ‘treatment’ is defined as
“the way in which somebody behaves towards
or deals with somebody or something.” 1 In
the sense of medical treatment, it refers to the
care given to a patient in response to an illness
or injury, and in the case of dental medical
treatment, in response to an issue or issues
concerning the oral cavity.
● Plan: A plan has been defined as “an indivi­
dual or collaborative enterprise that is carefully
planned to achieve a particular aim.” 2 Indeed, a
plan is what results after:
● all the appropriate data have been acquired;
● the situation has been carefully studied;
● all the details are understood;
● appropriate conclusions have been drawn;
● one or more solutions necessary to solve the
problem/s have been formulated.
12.02.20 12:04

● Purpose: The purpose of treatment planning
in prosthodontic and restorative dental medi­
cine has been analyzed by many authors.
According to Rosenstiel et al,3 the purpose is to for­
mulate “a logical sequence of treatment designed to
repair existing damage and restore the patient’s den­
tition to good and maintainable health, with optimal
function and appearance.”
A treatment plan will only be successful and effec­
tive if it is:
● Organized: This important concept may seem
obvious but often it is not, so it is emphasized
here again that any treatment plan must be
well organized and clear, first in the prostho­
dontist’s mind and then transferred as such to
the patient. Only then can the plan be properly
understood by the patient.
● Explicable: During treatment planning, we
have the chance to understand the prosthodon­
tic rehabilitative course in detail and foresee its
possible final results. We then need to organize
our conversation with the patient. Indeed, the
treatment plan that is well understood and
then accepted by the patient is the tipping
point after which the clinical treatment may
begin.
● Predictable: Predictability of the clinical results
is the highest aim of treatment planning. In­
deed, during the planning, prosthodontists need
to consider all possible variables in order to reduce
the likelihood of surprises or pitfalls during the
clinical treatment and after the delivery of the
prostheses.
Professionalism: four human
factors
There are a number of positive characteristics that
the prosthodontist (or any clinician) should ideally
cultivate and develop in order to grow as a profes­
sional. These characteristics are further described in
Chapter 7. What follows is a brief description of the
Calvani_Ch_2.indd 11
 Professionalism: four human factors
main desirable qualities and skills necessary for us
to succeed in clinical practice:
1. Proper communication and
dialogue with the patient
The ability to communicate clearly is a primary skill.
Clear, open communication leads to trust, which is
not a given but is something that is earned. Trust is
the key to successful patient management and treat­
ment. However, it is not always possible to achieve
trust during the first appointment, unless we are
able to immediately tune into our patient’s state
of mind. Trust often results when we successfully
transfer to the patient through optimal communi­
cation skills a positive sense of our ability and pro­
fessionalism from the outset. This entails the ability
to clearly explain each step of the procedure and
to motivate patients to trust us, to recognize our
professionalism and capability, and to feel confident
that we are able to solve their problems.
2. Motivating patients
Often, patients must be motivated to be cured. Natu­
rally, a patient’s personality, character, previous ex­
periences, expectations, and other factors may influ­
ence this process (this important aspect is discussed
later in the book). Clinical experience shows that a
number of impediments to communication can be
identified when approaching patients such as:
1. Lack of trust or agreement.
2. Stress due to patients’ personal problems.
3. Lack of communication and understanding.
4. Lack of constancy to care.
5. An exacting, fussy, and/or controlling patient.
6. Special physical issues or needs patients may
have.
7. Demanding patients, and special psychologic
attention they may require.
However, no matter what past experience or per­
sonal problems patients may have that could result
in a negative attitude on their part, we need to know,
understand, and remember to behave professionally
11
12.02.20 12:04
 2 Treatment planning management
at all times in order to inspire trust in our patients
and communicate effectively with them.
3. Patient management
This is one of the most important skills we need
to develop for success in the clinic. Patient man­
agement depends mainly on us, and according to
psychology is based on two personal qualities of
the clinician that should be carefully nurtured and
developed: the ability to take responsibility and our
freedom of choice (free will).
Some patients have demanding personalities or
suffer from complex psychologic problems. These
factors could affect our ability to manage their
cases.4 For this reason, when we are dealing with
difficult patients, we need to pay even more careful
attention to our interpersonal management skills
because problems with these challenging patients
may arise at any time.
Psychologic studies suggest that we should be
professionally confident and capable and should
take responsibility for everything we say and do.
The more we transfer positive feelings to our pa­
tients, the more they will trust us and the easier it
will be for them to accept the treatment we offer
them. A number of psychologists have studied pa­
tient–clinician behavior and the kind of relations
that should be established from the first visit. It has
been noted that if we succeed in our intentions, our
self-esteem increases, which in turn increases the
positive attitude of our patients and the mutual abil­
ity to communicate and collaborate.4
Psychologic studies also highlight the impor­
tance of knowing how to evaluate patient feedback
when we start to create a bond with our patients.4
According to the Oxford English Dictionary defi­
nition, feedback is “the information about the result
of a process or action that can be used to modify or
control a process or system.” It is therefore important
to learn how to listen to our patients so that we are
better able to help them. That is patient manage­
ment in a nutshell.
12
Calvani_Ch_2.indd 12
4. Positive professional
characteristics
Patient management is not an easy task to perform.
To achieve success, we should always behave in an
impeccable and appropriate professional manner –
from the moment we first meet our patients, through
the first dataset acquisition and case assessment, the
explanation of the diagnosis and prognosis, the de­
livery and discussion of the proposed treatment plan,
and finally throughout the entire clinical treatment
and follow-up process. Professionalism in our ap­
pearance, our manner of speaking and listening, our
body language (non-verbal communication), and our
general attitude and demeanor is essential to the pro­
fessional and respectful relationship we build with
our patients. Every action has a reaction or conse­
quence. Actions we take as professional caregivers
are directly related to how our patients perceive us
from the beginning and will have an impact on how
much respect and trust they have in us – and ulti­
mately in the success of the treatment. We need to
listen carefully, be flexible in our approach, be adapt­
able to our patients’ needs, and respond with respect
and empathy to their questions, requests, and concerns.
Priorities
Simply put, when patients seek our help, they do
so according to their own personal priorities. These
priorities will differ for each patient. For some, the
priority will be pain relief, which can be seen as an
emergency. For others, it may be relief from discom­
fort, or perhaps unhappiness with the appearance
of their smile or teeth. Our role is to assess these
priorities and solve the case in such a way that the
patient’s priorities are respected.
The ideal treatment plan
Is there an ideal treatment for all patients? First
and foremost, the Latin phrase ‘primum non nocere’
(above all, do no harm) – included in the Hippo­
12.02.20 12:04

cratic Oath – should be the medical principle that
guides our minds and hands. In this respect, the
ideal treatment plan is one that achieves the best
possible long-term prognosis with the minimum of
necessary intervention, and which addresses all the
patient’s concerns and problems.5-7
Can this ideal treatment plan be achieved with
every patient? There are many answers to this ques­
tion, and this book explores them in some detail. A
guiding principle could be the KISS rule. KISS is an
acronym for ‘keep it simple, stupid’ or ‘keep it simple
stupid,’ which was a design principle of the US Navy
in 1960. The KISS principle states that most systems
work best if they are kept simple rather than made
complicated; therefore, simplicity should be a key
goal in design, and unnecessary complexity should
be avoided. Basing a treatment plan on this princi­
ple means that we seek out a simplified course of
action and solution to avoid the complications that
may arise when things become more complex, both
during the treatment and in the long term. How­
ever, it is not as simple as this. Due to today’s dig­
ital technological environment and more sophisti­
cated prosthetic rehabilitation options, simple may
not always be the best option. Perhaps KISS should
therefore be amended to ‘keep it simple, sometimes.’
Therefore, while the rule of simplicity when con­
ceiving a treatment plan is a sound notion, it is not
always entirely possible, nor is it always necessarily
the best option. Again, flexibility is required in our
thinking. We also need to bear in mind that with in­
creasing complexity comes increasing compromise.8-19
Compromise
Perfection should be the ultimate goal in treatment
planning, although it is seldom possible to achieve.
Despite our best intentions, we are usually forced to
compromise. Experience tells us that even when the
outcome is clear from the start, we need to propose
more than one possible solution.
Furthermore, we should remember that there
is no ideal treatment plan that fits all cases. Each
patient is unique. We therefore need to be open-
Calvani_Ch_2.indd 13
 Compromise
minded and knowledgeable enough to treat our pa­
tients using a range of possible treatments and pros­
thetic tools. Moreover, there is not one treatment plan
for each patient, but possibly many. This depends on
variables such as evidence, clinical factors, pros­
thetic limitations, and patient preference. It also
depends on what is objectively possible and what
we can imagine and plan within the context of the
specific case.
Also, despite the number of treatment options
that we devise and customize for each patient, there
is usually one treatment plan that we particularly
prefer for that patient. And then it sometimes hap­
pens that for a number of reasons the patient prefers
a treatment other than the one we prefer.
Indeed, to restore and rehabilitate a patient’s
mouth we usually have to agree to one or more
compromises that we hopefully have foreseen. We
then need to inform our patients of the final treat­
ment plan in such a way that they properly under­
stand it, agree to it as the best treatment for them,
and willingly approve it.18-30
Therefore, we need to search for the best com­
promise that will achieve the ideal outcome for that
particular patient, always taking into account the
following four patient realities:
1. Chief complaint.
2. Health status.
3. Motivation/will.
4. Financial situation.
Prosthodontic treatments are never easy and are
usually time consuming, both clinically and tech­
nically. Therefore, considering the high expecta­
tions of most patients, we would do well to heed
Bolender’s advice: “Communication to avoid frus­
tration!” 31,32 The right compromise can be reached
only if both parties, the clinician and the patient,
clearly communicate and agree. That is why it is
so important for us to carefully pay attention and
listen closely to our patients. It is also crucial to
clearly and carefully explain to our patients what
we can do for them (possibly in front of witnesses
in cases where it is considered necessary) so that
13
12.02.20 12:04
 2 Treatment planning management
they clearly understand the limitations in terms of
the clinical and technical realities. In this way, their
expectations will not exceed what is feasible and
possible in the circumstances and in terms of our
professional capabilities.13,16,20-25,29,33,34-36
Prosthodontic economics and
patient treatment costs
Prosthodontic treatments are usually expensive due
to the:
● costly and ongoing dental office expenses;
● duration of the treatment;
● cost of dental materials;
● laboratory fees;
● services of other collaborating specialists, if
any;
● clinical and prosthodontic complications that
sometimes occur despite our professional ex­
perience and capability to foresee them;
● treatment follow-up;
● any relevant taxes that need to be paid.
Affordability of the treatment plan
The financial resources available for treatment will
differ for each patient, who will only be able to af­
ford a certain type of treatment. This is potentially
a serious limiting factor in treatment planning and
selection. We therefore need to know the financial
situation of our patients before we begin planning
an appropriate course of treatment for them. In
many cases, we need to propose multiple solutions
for the same restorative problem in order to provide
as many available options as possible for successful
treatment and rehabilitation.37-39
The patient’s occupation
From the start, it is wise to gently investigate to
what extent patients are able to cope with the costs
of the restorative care we may propose (including
the follow-up maintenance costs) so that we com­
pletely understand their unique financial situation.
14
Calvani_Ch_2.indd 14
This is a responsible course of action that would be
acceptable to the majority of patients. To do this,
we need to politely ask our patients what their pro­
fession, job or occupation entails. Indeed, this in­
formation should be recorded as part of the initial
examination. This is not the same as asking outright
about a patient’s income, which can be construed as
rude even if we ask in a kind and confidential man­
ner. Moreover, what we know about the occupation
of our patients will throw light on their level of ed­
ucation, which has a bearing on how well they are
able to understand the theoretical and practical in­
formation we need to transfer. However, we should
always carefully explain why some treatment plans
are more technical, time consuming, and/or expen­
sive than others. It is our duty to help our patients
to understand, and it ought to be a pleasure for us
to take all the time necessary to do this in the best
possible way. At the same time, we need to treat this
issue with sensitivity because some patients may be
embarrassed if certain prosthodontic solutions are
too expensive for them to afford.37-39
Costs in the face of disease
If an infectious disease exists in the oral cavity, we
have the duty as dental medical professionals to assess
it and to find the best way to explain the gravity of
the situation to the patient, together with the related
treatment costs. Disease is a priority that needs to
be resolved before any prosthodontic solution can
be performed, especially if sensitivity, discomfort,
and/or pain exist.37-39
Transparency and politeness
It is crucial to plan the treatment costs as comprehen­
sively as possible and to be honest about them with
the patient in the interests of a good clinician–pa­
tient relationship. This will avoid surprises later on. If
we anticipate additional service costs, we need to let
the patient know about them from the outset. Treat­
ment planning is not an easy task, and explaining a
demanding prosthodontic plan is not like selling a
product; we need to be truthful and transparent as we
12.02.20 12:04

explain and advise about the solution/s that are in
our patients’ best interests. At the heart of this aspect
is having and showing respect for the patient.37-39
In the same vein, we need to be kind and polite
and treat our patients with empathy and gentleness
in order for them to view us as concerned profes­
sionals with integrity, as opposed to being only in­
terested in the money we will make from treating
them. We need to bear in mind that the decision
regarding which treatment to choose lies with both
the patient and the clinician, and not with the clin­
ician alone. In some instances, patients are happy
to allow us to make the decision, and may request
us to do so on their behalf. The rule of thumb is to
be polite and respectful at all times, an attitude that
will reward us and our dental office with the trust
and respect of our patients. This has a bearing on
our business too, because every patient could po­
tentially refer family and friends to our office.
Informed consent
The basic difference between the terms ‘consent’ and
‘informed consent’ is the degree of patient know­
ledge behind the consent decision. The amount of
information required to make consent informed
may vary depending on the complexity and risks of
treatment as well as the patient’s wishes. In terms
of our professional responsibilities and liabilities,
it is important to understand the exact meaning of
these terms.
Consent
Except in rare cases where we need to help patients
immediately such as in an urgent clinical emer­
gency or in the case of symptoms of severe pain,
a patient’s consent to be treated is always required
before the start of treatment.
Informed consent
Informed consent refers to a doctrine that was es­
tablished in the 1950s and has been continually re­
Calvani_Ch_2.indd 15
 Informed consent
vised over the years. What is established with in­
formed consent is that a clinician can only treat a
patient if and when the clinician is sure that the
patient is fully aware of and understands the type
of treatment being proposed to solve the problem.
Apart from the more ethical aspects outlined above,
an informed consent is a necessary document for us to
obtain to ensure control of our risk management and
to try to avoid legal problems that may arise later on
with some patients.
The House classification (see Chapter 5) was a
practical, organized attempt to define the personal­
ity of the edentulous patient. It may also be helpful
for other patients (ie, those who are not edentulous),
and may indeed be useful to give us some idea of the
complexity of patients and their idiosyncrasies. This
allows us to be better equipped to avoid unpleasant
surprises later on during the treatment.
Therefore, the treatment planning discussion or
initial diagnostic phase is the first ‘filter’ that as­
sists us to get to know a new patient, and it is the
point from which all further decisions are taken.
This sensitive phase is therefore very useful to our
understanding of the personality and psychology of
a patient. It colors the type of treatment plan we de­
vise that is most likely to be accepted by the patient;
in some rare cases, we may even see no chance to
treat a particular patient at all.25,27,40,41
We are not obliged to treat all
patients
There will be instances where, already at the first
treatment plan discussion (initial diagnostic phase),
we realize that we are not in a position to treat a
given patient in a manner that is agreeable to us.
In these cases, we may feel that, for a number of
reasons, it is better not to start any treatment at all.
Some of these reasons may be immediately evident,
but unfortunately others may not. Obviously, it is al­
ways our duty to try to help, but if the situation does
not feel right, or we are in serious doubt about whether
we should commit to treating a particular patient for
whatever reason, we need to heed that warning voice.
If we conclude that we will not be able to help a
15
12.02.20 12:04
 2 Treatment planning management
­ atient properly, we have the right and the duty
p The use of the informed consent
to suggest without prejudice from the outset – as
kindly as possible and with the appropriate humil­
ity and politeness – that there may be more capable
professionals who will be better able to help. It is
therefore much better to spend more time initially
with new patients, speaking clearly to them and
carefully analyzing them and their situation.
Prosthodontics is often a matter of invasive and
extremely complex treatments that go on for a long
time, treatments that may dramatically change the
esthetics and functionality of a patient’s mouth,
teeth, and face. Therefore, we need to be sure that
we will be able to work with the patient’s full com­
pliance and understanding about the often difficult
challenges that may lie ahead in the course of the
treatment.15 The longer the treatment, the greater
the need for clinician–patient understanding and
trust. If during the first visit or during the treat­
ment plan discussion we cannot communicate
properly, or if patients are unable or unwilling
to communicate properly with us, this may indi­
cate the possibility that we will end up working
under great stress or tension, with the possibility
of misunderstandings. This, in turn, could result
in the failure of the treatment, with further deep
frustration as well as possible legal problems and
consequences.16
In case of emergency
If an emergency occurs and our diagnosis is clear
and precise, we have a duty to explain to the patient
what the emergency is, how and why it should be ad­
dressed, and what the costs of the procedure will be.
In that case, always ask for written permission to
treat the patient and request the patient’s full com­
pliance and signed agreement before you proceed
with the treatment. This applies even in a situation
where we know the patient well. It is important to
understand that even in the case of an emergency we
require a patient’s full compliance via an informed
consent document, if possible signed by themselves
or, if not possible, by another responsible adult such
as a parent or guardian.
16
Calvani_Ch_2.indd 16
The informed consent document needs to be very
accurate and even customized in some cases. 6,27,41-
50 There are various examples of informed consent
forms and formats to be found on the internet.
However, as every patient is an individual whose
data will differ from the next patient, you will find
in later chapters many suggestions about what to
remember to include in the informed consent doc­
ument. Please bear in mind that these suggestions
are made from the vantage point of many years of
experience.
Another thing to bear in mind is that dentistry
and prosthodontics do not deal with an immediate
threat to life. Therefore, patients can take all the time
they need to listen to our proposals for solutions to
their problems. They can then ask all the necessary
questions in order to understand exactly what we
are suggesting. They will then hopefully agree to a
treatment plan and sign the informed consent form
that we submit to them.17,30,34,51-55,57
Essential aspects of the informed
consent document
All informed consent documents pertaining to a
specific treatment plan should contain at least the
following elements:
1. The patient is fully informed about all
the characteristics of the entire treat­
ment.24,29,30,42,45,47,58-61
2. The patient has a full understanding of the
treatment plan in terms of its diagnosis, prog­
nosis, anticipated benefits, therapy, timing,
certainties, risks, consequences, and the need
for future controls.17,30,34,51-53,56,57,59-61
3. The patient has been informed of alternative
treatment courses and associated risks.42,62
4. The patient is fully aware of the risks associ­
ated with refusing the recommended proce­
dures.17,30,34,51-56,59-61­
5. The patient is fully aware of any possible tem­
porary incapacitation that may occur during
the course of treatment.17,30,34,51-56,59
12.02.20 12:04

6. The patient is fully aware of what information
the patient is rewriting in front of witnesses
(see later), freely accepts the treatment plan,
and fully intends to be treated by the clinician
in full respect of the professional rules of the
dental office.17,30,34,51-56,59-61
7. The patient has read and discussed the
informed consent document sufficiently to
know and understand its entire contents and
is fully aware of what it contains. If this is
the case, the contents of the informed con­
sent document should ideally be rewritten
clearly in the patient’s own handwriting
(see later).2,18,28
8. If the patient is unable to fulfill the above point
(7) for any reason, another person should be
appointed in the patient’s stead to do so in
front of witnesses; this person should be able
to take responsibility for the patient’s situation
and health.3,7,11,29,39,49,50,58
9. Finally, the informed consent form should be
signed, together with the signatures of one
or more witnesses such as a relative of the
patient, an office secretary or a chair assis­
tant.2,6,30,39,41,52,56
If all these aspects of the informed consent docu­
ment have been honored, the intellectual honesty,
professional integrity and empathetic intentions of
the clinician will be immediately clear to anyone
who may consult the document later in the event
that they may want to prove negligence in some
way.2,6,14,15,19,30,36,39,41,52,55,56
It is important to note that any procedure
performed in the absence of informed con-
sent is liable to prosecution in a court of law
and could be construed as intentionally in-
flicting physical harm on a patient.
Calvani_Ch_2.indd 17
 Informed consent
Therefore, it is strongly advised that an informed con­
sent for any prosthodontic treatment plan should be
rewritten in the patient’s handwriting. In other words,
the document should be copied out in full by the
patient. The reason for this is that it has transpired
on a few occasions that simply signing an informed
consent without rewriting it is not sufficiently se­
cure. Instead, asking patients to rewrite it in their
own handwriting is a better guarantee for the dental
office (or a court of law) that they have understood
it, are completely conscious of the treatment details,
and are willing to be treated without further doubt.
Finally, the patient should sign the informed con­
sent document in front of one or more witnesses, who
will countersign it afterwards. After the document
has been signed by all the relevant parties, one copy
must be given to the patient. The original document
must remain in the safekeeping of the dental office
where it is stored as a confirmation and a warranty
for both the clinician and the patient.
Digital technology and informed
consent documents
Although the advent of computerized technologies
and the digitization of dental office documents has
optimized the storage and management of patient
documents and data, in the case of the treatment
plan and informed consent it is still strongly advis­
able to retain hard copies of all original documents.
This eliminates any possible questions that may
arise later concerning possible alteration of these
documents (ie, if they exist only as computer files),
and eliminates any possible legal doubts about the
honesty of the professionals and the dental office
staff, which may create problems in a court of
­law.2,6,14,15,19,30,39,41,52,55,56 Therefore, when it comes
to signed treatment plans and informed consent
documents, it is still better to have the original hard
copies on file in our dental offices.52,56
17
12.02.20 12:04
 2 Treatment planning management
References
1. Cambridge Dictionary. Cambridge University Press.
https://dictionary.cambridge.org/dictionary/english/
treatment/. Accessed 15 March 2019.
2. Öwall B, Käyser AF, Carlsson GE. Prosthodontics:
Principles and Management Strategies. London: Mos­
by-Wolfe, 1996.
3. Rosenstiel SF, Land MF, Fujimoto J. Contemporary
Fixed Prosthodontics, ed 3. Mosby Elsevier, 2001:59–76.
4. Kluger AN, DeNisi A. The effect of feedback interven­
tions on performance: a historical review, a meta-anal­
ysis, and a preliminary feedback intervention theory.
Psychological Bulletin 1996;119:254–284.
5. Brecker SC. A practical approach to extensive restora­
tive dentistry. J Prosthet Dent 1954;4:6:813.
6. Nazarko L. Consent to clinical decisions when capacity
is absent. Part 1: Making decisions. Nurs Manag (Har­
row) 2004;10:18–22.
7. Rich B, Goldstein GR. New paradigms in prosthodontic
treatment planning: a literature review. J Prosthet Dent
2002;88:208–214.
8. Allen PF, McMillan AS, Smith DG. Complications and
maintenance requirements of implant-supported pros­
theses provided in a UK dental hospital. Br Dent J
1997;182:298–302.
9. Bowley JF, Stockstill JW, Attanasio R. A preliminary di­
agnostic and treatment protocol. Dent Clin North Am
1992;36:3:551–568.
10. Hemmings KW, Schmitt A, Zarb GA. Complications
and maintenance requirements for fixed prostheses
and overdentures in the edentulous mandible: a 5-year
report. Int J Oral Maxillofac Implants 1994;9: 191–196.
11. Kazis H. Functional aspects of complete mouth rehabil­
itation. J Prosthet Dent 1954;4:833–841.
12. Lewis S. Treatment planning: teeth versus implants. Int
J Periodontics Restorative Dent 1996;16:366–377.
13. Milgrom P, Weinstein P, Getz T. Treating Fearful Den­
tal Patients. A Patient Management Handbook. Seattle:
University of Washington, 1995
14. Oxford Dictionary. Oxford English Dictionary. https://
en.oxforddictionaries.com/. Accessed 20 March 2019.
15. Palmer R, Palmer P, Howe L. Complications and main­
tenance. Br Dent J 1999;187:653–658.
16. Philips Z, Ginnelly L, Sculpher M, et al. Review of
guidelines for good practice in decision-analytic mod­
elling in health technology assessment. Health Technol
Assess 2004;8:1–158.
17. Vollmann J. Mental competence and informed consent.
Clinical practice and ethical analysis [in German]. Ner­
venarzt 2000;71:709–714.
18
Calvani_Ch_2.indd 18
18. Whyman RA, Rose D. Informed consent for people with
diminished capacity to consent. N Z Dent J 2001;97:
137–139.
19. Wilson WH. Practical application of oral physiology.
J Prosthet Dent 1956;6:1:53.
20. Barsh LI. Dental Treatment Planning for the Adult Pa­
tient. Philadelphia: WB Saunders, 1981.
21. Brehm TW. Diagnosis and treatment planning for fixed
prosthodontics. J Prosthet Dent 1973;30:876–881.
22. Cohen LA. Integrating treatment procedures in occlu­
sorehabilitation. J Prosthet Dent 1957;7:511.
23. Gill JR. Treatment planning for mouth rehabilitation.
J Prosthet Dent 1952;2:230–245.
24. Goldberg R. Medical Malpractice and Compensation
in the UK. Chicago-Kent Law Review. Symposium on
Medical Malpractice and Compensation in Global Per­
spective. Part II, 2011;87:131–161.
25. Hall WB, Robert WE, LaBarre EE. Decision making in
dental treatment planning. St. Louis: Mosby-Year Book,
1994.
26. Jacobson A, Sadowsky PL. A visualized treatment ob­
jective. J Clin Orthod 1980;14:554–571.
27. Miller LL. Lecture Series. Presented at Tufts University
School of Dental Medicine, 1989–1991.
28. Newton T. Involving the ‘consumer’ in the evaluation
of dental care: a philosophy in search of data. Br Dent J
2001;191:650–653.
29. Schwabel ST. Informed consent: medical, legal, and ethical
implications. Physician Assist 1986;10:108–110, 113–115.
30. Stauch MS. Medical Malpractice and Compensation in
Germany. Chicago-Kent Law Rev 2011;86:1139–1168.
31. Bolender CL, Swoope CC, Smith DE. The Cornell Med­
ical Index as a prognostic aid for complete denture pa­
tients. J Prosthet Dent 1969;22:1:20–29.
32. Ebel HE, Adisman IK, Bolender CL, Preston J, Ebel H;
Principles, Concepts, and Practices Committee. Princi­
ples, concepts, and practices in prosthodontics – 1982.
The Academy of Denture Prosthetics. J Prosthet Dent
1982;48:467–484.
33. Bain CA. Treatment planning in general dental prac­
tice: case presentation and communicating with the
patient. Dent Update 2004;31:72–76, 78–80, 82.
34. Greening P. Capacity, Consent and Dentistry – Who De­
cides and How Do They Do It? Prim Dent J 2015;4:67–69.
35. Mann AW. Examination, diagnosis, and treatment plan­
ning in occlusal rehabilitation. J Prosthet Dent 1967;
17:1:73–78.
36. Zitzmann NU, Krastl G, Hecker H, Walter C, Waltimo T,
Weiger R. Strategic considerations in treatment plan­
ning: deciding when to treat, extract, or replace a ques­
tionable tooth. J Prosthet Dent 2010;104:80–91.
12.02.20 12:04

37. Barber JA, Thompson SG. Analysis and interpretation
of cost data in randomised controlled trials: review of
published studies. BMJ 1998;317:1195–1200.
38. Graves N, Walker D, Raine R, Hutchings A, Roberts JA.
Cost data for individual patients included in clinical
studies: no amount of statistical analysis can com­
pensate for inadequate costing methods. Health Econ
2002;11:735–739.
39. Schweitzer JM. A conservative approach to oral rehabil­
itation. J Prosthet Dent 1961;11:119–123.
40. Burris S. Law and ethics and the decision to treat. In:
Glick M (ed). Dental Management of Patient with HIV.
Chicago: Quintessence, 1994;25–50.
41. Adeyemi AT, Kosoko JO, Ifesanya JU. Dentists’ knowledge
and attitude towards informed consent taking in a Nige­
rian teaching hospital. Odontostomatol Trop 2011;34:5–10.
42. Bal BS. An introduction to medical malpractice in the
United States. Clin Orthop Relat Res 2009;467:339–347.
43. Braly BV. Occlusal analysis and treatment planning for
restorative dentistry. J Prosthet Dent 1972;27:2:168–171.
44. Choctaw WT. Avoiding Medical Malpractice: A Physi­
cian’s Guide to the Law. Berlin: Springer Science and
Business Media, 2008:1–17.
45. CNA Dental Professional Liability, 2016 (Claim Report).
46. Kakar H, Gambhir RS, Singh S, Kaur A, Nanda T. In­
formed consent: corner stone in ethical medical and
dental practice. J Family Med Prim Care 2014;3:68–71.
47. Lal S. Consent in dentistry. Pac Health Dialog 2003;
10:102–105.
48. McCabe MS. The ethical foundation of informed consent
in clinical research. Semin Oncol Nurs 1999;15:76–80.
49. Pruden WH 2nd. Problems in oral re-rehabilitations.
J Prosthet Dent 1973;30:4:558­–559.
50. Sculpher MJ, Pang FS, Manca A, et al. Generalisability in
economic evaluation studies in healthcare: a review and
case studies. Health Technol Assess 2004;8:191–192.
51. Chate RA. An audit of the level of knowledge and un­
derstanding of informed consent amongst consultant
Calvani_Ch_2.indd 19
 References
orthodontists in England, Wales and Northern Ireland.
Br Dent J 2008;205:665–673.
52. Hein IM, De Vries MC, Troost PW, Meynen G, Van Gou­
doever JB, Lindauer RJ. Informed consent instead of as­
sent is appropriate in children from the age of twelve:
Policy implications of new findings on children’s com­
petence to consent to clinical research. BMC Med Eth­
ics 2015;16:1:76.
53. Holden AC, Holden NL. How many of our patients can
really give consent? A perspective on the relevance
of the Mental Capacity Act to dentistry. Dent Update
2014;41:46–48.
54. Medical Legal Handbook for Physicians in Canada. Ver­
sion 8.2. Ottawa: Canadian Medical Protective Associ­
ation, 2016;3–15.
55. Morris RB. Principles of Dental Treatment Planning.
Philadelphia: Lea & Febinger, 1983.
56. Stuart CE, Stallard H. Principles involved in restoring
occlusion to natural teeth. J Prosthet Dent 1960;10:304.
57. Martone AL. The value of “I don’t know”. J Prosthet
Dent 1957;7:4:541.
58. Regan LJ. The dentist and malpractice. J Prosthet Dent
1956;6:259.
59. Dimond B. The Mental Capacity Act 2005 and deci­
sion-making: advance decisions. Br J Nurs 2008;17:
44–46.
60. Ackerman JL. Bioethics and informed consent: applica­
tions to risk management in orthodontics. Presentation
made to the Annual Meeting of the American Associ­
ation of Orthodontics, Toronto, 1993.
61. Graziele Rodrigues L, De Souza JB, De Torres EM,
­Ferreira Silva R. Screening the use of informed consent
forms prior to procedures involving operative den­
tistry: ethical aspects. J Dent Res Dent Clin Dent Pros­
pects. 2017;11:66–70.
62. Bogdan J. Medical Malpractice in Sweden and New
Zealand: Should their systems be replicated here? New
York: Center for Justice and Democracy 2011;21:1–9.
19
12.02.20 12:04
Calvani_Ch_2.indd 20 12.02.20 12:04
 CHAPTER THREE
Prosthodontic tools for treatment
planning

21

Calvani_Ch_3.indd 21 12.02.20 12:04

 3 Prosthodontic tools for treatment planning
How prosthodontists can help
their patients
From the start of its existence in the USA at the
beginning of the last century, the specialty of den-
tal prosthodontics has involved the study of the art
and science of restoring broken or decayed teeth
and mouths in various states of edentulism. Much
research as well as clinical and laboratory experi-
ence and verifiable procedures have resulted in the
publication of numerous scientific articles, books,
manuals, photographs, films, webinars, and online
lectures on the topic of prosthodontics.
The Glossary of Prosthodontic Terms, an im-
portant and useful resource currently available as a
free download from the Academy of Prosthodontics
website, was created to define words and concepts
necessary to clarify and share a common prostho-
dontic terminology for the practice and scientific
reporting of the specialty.1-3
The outcome of all of this evidence-based science
and practice is a number of clinical and laboratory
therapeutic prosthodontic tools available on the
market today. These tools are intended for practical
therapeutic solutions capable of restoring oral es-
thetics and function in patients whose mouths are
in need of restoration.
As it is impossible to outline here all the clinical
and laboratory prosthodontic reconstructive tools
and procedures in use today, this chapter looks at
the main categories of tools currently available to
show the most common prosthodontic esthetic and
functional rehabilitative possibilities, as reported in
the literature.
Aims and requirements of all
prostheses
The following are the main rehabilitative goals of
any prosthesis. It should:
● replace the lost dentition and improve on it as
much as possible;
● satisfy the patient’s needs/desires/requests;
● guarantee the patient’s comfort;
22
Calvani_Ch_3.indd 22
● help to prevent further problems;
● improve the patient’s oral health;
● help to give the patient a better quality of life.
To achieve these goals, the prerequisite of all pros-
theses should be that they:
● are minimally invasive;
● protect the remaining dental and periodontal
structures;
● are made from biocompatible materials;
● are esthetically, phonetically, and functionally
effective;
● are accessible to excellent oral and dental
hygiene;
● are simple and easily repairable;
● last as long as possible;
● cost the least amount of money.
Current main prosthodontic
tools
Table 3-1 outlines the main categories of prostho-
dontic tools in use today. This should be seen in
light of the recent progress that has taken place in
the prosthodontic field due to the modern techno-
logical revolution.
Fixed restorations
Fixed prostheses such as crowns and bridges are
termed fixed partial dentures (FPDs) or fixed com-
plete dentures (FCDs), depending on their extension
and abutment involvement.2
Fixed prostheses are considered a dream tool for
prosthodontists because they are the best and most
natural restorations.3 The naturalness of the final
result depends on a number of clinical and techni-
cal factors such as laboratory materials, technical
possibilities, professional skills, and artistic dexter-
ity.4-8 Fixed prostheses are used all over the world
and are fabricated from various materials, including
gold, depending on factors such as culture and es-
thetics.5,9 Their manufacture follows rules imposed
12.02.20 12:04

Table 3-1 Outline of the most important prosthodon-
tic tools currently in use today
Fixed restorations
1. Inlays, onlays
2. Veneers
3. Crown, bridges, post and cores
4. Full-arch fixed complete prostheses
Removable par­tial dentures
1. Tooth-borne prostheses
2. Tooth- to ­muc­osa­-bor­ne pros­thes­es
Complete dentures
1. Immediate prostheses
2. Final prostheses
Over­den­tures
1. On some remaining portion of roots
2. On well-positioned implant
Fixed implant-retained prostheses
1. Partial implant prostheses
2. Following the prolonged use of complete dentures
(CDs)
3. Following extractions, immediate CDs, and delayed
implant placement
4. Following extractions and immediate implant place-
ment
Bioinformatics and digital prosthodontic tools
1. Computer-aided implantology
2. Computer-aided prosthetic designing and planning
3. Precise guided implant positioning
by ongoing research, especially that which is occur-
ring in the field of digital technology.
The use of fixed restorations for endodontically
treated teeth depends on the amount of the remain-
ing tooth structure and on well-established princi-
ples of tooth preparation.5,6,8,10-12,19 Even though
great improvement has taken place in this respect
with resin adhesive rehabilitations,11-13 cast post
and cores still show superior physical and biomech-
anical capabilities to withstand vertical and lateral
loads as well as decementation.5,6,8,12,14-25
Calvani_Ch_3.indd 23
Complete dentures
Nowadays, other new fixed prosthodontic meth-
ods, born as a result of and crafted with the help
of new digital technologies, are revolutionizing the
clinic and laboratory. And this is just the beginning,
as much more is expected with the current speed of
exponential progress and growth in this field.26
Today, in the case of edentulism where there is
one or more missing teeth, implants are usually con-
sidered as the first option during treatment planning
for fixed restorations, unless physical, biological,
biomechanical, psychologic or economic limitations
and/or contraindications are present.27-33 Where
implants are not indicated due to their negative bio-
logical, functional, and esthetic possibilities or the
chance of predictable short- or long-term complica-
tions,34 tooth-borne FPDs and FCDs are considered
the secondary restorative tool, with pontic elements
replacing the edentulous areas.
Removable partial dentures
Removable partial dentures (RPDs) are generally
considered the third restorative option in the west-
ern world. However, in many other countries world-
wide they are considered to be the first choice. RPDs
can be very helpful in various partially edentulous
cases, depending on the patient’s chief complaint, de-
sire, and financial situation.35-37 The relatively lower
cost of these prostheses is a major factor of choice,
despite the difficulty in planning them biomechani-
cally and the inevitable clinical limitations that their
unnatural composite structure introduces into the
masticatory environment.38-48 This fact should spur
us on to deliver a biomechanically well-conceived
project in order not to damage the remaining denti-
tion and to preserve it for as long as possible.
Complete dentures
Due to decades of success and their helpfulness in
innumerable edentulous cases, CDs have been called
the mother of all dental prostheses.49 According to
studies on oral health in the USA, even though there
23
12.02.20 12:04
 3 Prosthodontic tools for treatment planning
has been a relative decline in complete edentulism
over the past 30 years due to a corresponding de-
cline in caries, the need for complete dentures to
treat edentulism is still high due to the increase in
the aging population.28,50 Furthermore, edentulism
still depends on infectious disease conditions and
related health problems that involve both the young
and the elderly worldwide, even today.51
Although there is a large body of scientific lit-
erature about them, clinical experience shows that
in many instances CDs still remain very difficult to
create and craft properly. However, if the literature
is carefully studied and scientific engineering rules
are strictly followed, the construction of CDs can
result in a successful restoration. Experience shows
that the obvious weakness in these prostheses is
their mobility.52,53 In this respect, they must neces-
sarily rely on the remaining available maxillary and
mandibular primary and secondary bearing areas
and on the characteristics of the hard and soft tis-
sue comprising these areas. Their success also relies
on a number of other biological, physical, chem-
ical, and subjective factors that have been widely
described in the literature. Regardless of whether
they are created in an analog or digital manner,
the nature of CDs makes these prostheses biome-
chanically lacking in terms of stability, retention,
and support compared with other fixed prostheses.
Nevertheless, many patients lack the economic re-
sources for fixed implant treatments, and many in
fact do live with CDs satisfactorily and sometimes
more than satisfactorily, which compensates for
their biologic limitations.52-70
In cases where up-to-date, three-dimensional (3D)
digital technologies can be used to virtually plan the
rehabilitation of edentulous cases with immediate
implant-supported fixed prostheses, CDs can be used
as excellent interim prostheses, as useful verification
jigs, and as surgical guides to position implants prop-
erly to recreate final full-arch implant restorations.
In fact, when all anatomical dental reference
points are lost, CDs are a precious source of anatom-
ical information and can be used to recover most of
these points in any edentulous mouth. In these cases,
lip and cheek support, dental esthetics, phonetic and
24
Calvani_Ch_3.indd 24
functional landmarks, and all occlusal parameters ne-
cessary to properly guide the oral rehabilitation with
excellent approximation can be retrieved both in the
mouth and on the working casts. This also depends
on the knowledge and clinical skills of the clinician
and the laboratory technician to replace the lost den-
tition with final fixed implant-supported prostheses.
Removable overdentures
Indeed, the advent of implants helped to improve
this unstable situation. However, if structurally valid
roots still remain in strategic positions in the mandi-
ble (ie, canines or first premolars), they can be recon-
structed and utilized to support, retain, and stabilize
any complete denture prosthesis. This possibility is
cheaper than the use of implants, and biomechan-
ical improvement can be better achieved by means
of fixed attachments, as they may limit the number
of biomechanical degrees of freedom to the mobility
of the overlying CDs both at rest and during func-
tion. Certainly, the choice to save and use the roots
is limited by a number of structural and biomechan-
ical parameters that must be carefully evaluated dur-
ing the first visit and during treatment planning.71-82
Mandibular implant overdentures can be obtained
with two implants positioned in strategic positions. In
these cases, the further use of bars or attachments as a
means of anchoring may greatly enhance the stability,
retention, and support of these types of prostheses.83-94
This combination has been defined as optimal and as
the standard of care for mandibular CDs.95-97
In the maxilla, usually the greater extension
and the quality of the bearing surface guarantee
better support, stability, and retention. However,
in the following instances implants might also be
proposed to create maxillary implant overdentures:
when the amount of alveolar ridge bone is poor;
when the palate is particularly flat and induces in-
stability; when the posterior palatal seal cannot be
properly achieved and is not enough to aid the re-
tention; and when the patient is suffering from xe-
rostomia, which induces instability, inflammation,
and poor retention of the denture base.30
12.02.20 12:04
Another random document with
no related content on Scribd:
31 , [Verwijderd] 1
34 huilgento huilgenot 2
67 stonden stomden 1
118, 125,
344, 358, ouê ouë 1/0
386
146 prechtig prêchtig 1/0
171 Limmers Limmer 1
184, 277 ouên ouën 1/0
189, 132,
d’rop d’r op 1
160, 186
206 aange loopen aangeloopen 1
283 zachjes zachtjes 1
331 ” [Verwijderd] 1
44 aardbeiën aardbeien 1/0
56 furiende furiënde 1/0
68 ver-zuchtt ein ver-zuchtte in 2
71, 284,
[Niet in bron] , 1
343
105 [Niet in bron] - 1
107, 108 geen gèèn 2/0
127 éen één 1/0
137, 359 [Niet in bron] ” 1
182 woor voor 1
184 ikkke ikke 1
192 snoeptaèlel snoeptoàfel 3
204 doezelzakte doedelzakte 1
215 zn z’n 1
220 . 1
227 drieen drieën 1/0
spannend- spannend-
234 2/0
plooïige plooiïge
245 ’m ’n 1
248 Wierelandch Wierelandsch 1
253 aèmechtig aêmechtig 1/0
268 bange lijker bangelijker 1
270 vermoeïing vermoeiïng 2/0
272 lijveu lijven 1
274 boeren Boeren 1
275 lekaar elkaar 2
276 spaansche Spaansche 1
278 ontblooten ontblootten 1
292 bijeéngegroeid bijééngegroeid 1 / 0
300 betatoëerde betatoeëerde 1
312 mallemoletje mallemolentje 1
313 mallenmolen mallemolen 1
314 lainte laintje 1
415, 422 van Van 1
422 [Niet in bron] „ 1
431, 431 maìn màin 2/0
445 rot rat 1
 *** END OF THE PROJECT GUTENBERG EBOOK
MENSCHENWEE ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the

United States and most other parts of the world at no
cost and with almost no restrictions whatsoever. You may
copy it, give it away or re-use it under the terms of the
Project Gutenberg License included with this eBook or
online at www.gutenberg.org. If you are not located in the
United States, you will have to check the laws of the
country where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.
 1.E.5. Do not copy, display, perform, distribute or redistribute
this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must, at
no additional cost, fee or expense to the user, provide a copy, a
means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original “Plain Vanilla ASCII” or other
form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
 about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all
copies of the works possessed in a physical medium and
discontinue all use of and all access to other copies of Project
Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite
these efforts, Project Gutenberg™ electronic works, and the
medium on which they may be stored, may contain “Defects,”
such as, but not limited to, incomplete, inaccurate or corrupt
data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other
medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES -

Except for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU
AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE,
STRICT LIABILITY, BREACH OF WARRANTY OR BREACH
OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH
1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER
THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR
ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE
OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF
THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If

you discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person or
entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.
If the second copy is also defective, you may demand a refund
in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set

forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’,
WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS
OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR
ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this
agreement violates the law of the state applicable to this
agreement, the agreement shall be interpreted to make the
maximum disclaimer or limitation permitted by the applicable
state law. The invalidity or unenforceability of any provision of
this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the

Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and
distribution of Project Gutenberg™ electronic works, harmless
from all liability, costs and expenses, including legal fees, that
arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project
Gutenberg™ work, (b) alteration, modification, or additions or
deletions to any Project Gutenberg™ work, and (c) any Defect
you cause.

Section 2. Information about the Mission of

Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new
computers. It exists because of the efforts of hundreds of
volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project
Gutenberg™’s goals and ensuring that the Project Gutenberg™
collection will remain freely available for generations to come. In
2001, the Project Gutenberg Literary Archive Foundation was
created to provide a secure and permanent future for Project
Gutenberg™ and future generations. To learn more about the
Project Gutenberg Literary Archive Foundation and how your
efforts and donations can help, see Sections 3 and 4 and the
Foundation information page at www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-
profit 501(c)(3) educational corporation organized under the
laws of the state of Mississippi and granted tax exempt status by
the Internal Revenue Service. The Foundation’s EIN or federal
tax identification number is 64-6221541. Contributions to the
Project Gutenberg Literary Archive Foundation are tax
deductible to the full extent permitted by U.S. federal laws and
your state’s laws.

The Foundation’s business office is located at 809 North 1500

West, Salt Lake City, UT 84116, (801) 596-1887. Email contact
links and up to date contact information can be found at the
Foundation’s website and official page at
www.gutenberg.org/contact

Section 4. Information about Donations to

the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission
of increasing the number of public domain and licensed works
that can be freely distributed in machine-readable form
accessible by the widest array of equipment including outdated
equipment. Many small donations ($1 to $5,000) are particularly
important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws

regulating charities and charitable donations in all 50 states of
the United States. Compliance requirements are not uniform
and it takes a considerable effort, much paperwork and many
fees to meet and keep up with these requirements. We do not
solicit donations in locations where we have not received written
confirmation of compliance. To SEND DONATIONS or
determine the status of compliance for any particular state visit
www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states

where we have not met the solicitation requirements, we know
of no prohibition against accepting unsolicited donations from
donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot

make any statements concerning tax treatment of donations
received from outside the United States. U.S. laws alone swamp
our small staff.

Please check the Project Gutenberg web pages for current

donation methods and addresses. Donations are accepted in a
number of other ways including checks, online payments and
credit card donations. To donate, please visit:
www.gutenberg.org/donate.

Section 5. General Information About Project

Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could
be freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose
network of volunteer support.

Project Gutenberg™ eBooks are often created from several

printed editions, all of which are confirmed as not protected by
copyright in the U.S. unless a copyright notice is included. Thus,
we do not necessarily keep eBooks in compliance with any
particular paper edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg
Literary Archive Foundation, how to help produce our new
eBooks, and how to subscribe to our email newsletter to hear
about new eBooks.