How to sequence optimum dentistry

Today’s dental patients present great challenges to the restorative practice. People are highly educated, with huge expectations about how their dentistry will look and feel upon the completion of their care. They are living longer than ever before, leading stressful lives, seemingly putting increased forces on their dentitions. Visualising a treatment plan that will correct all of the aesthetic and functional issues is difficult enough, but with financial pressures increasing, many patients need to be able to sequence their care.

The error most of us make is we stop treatment planning comprehensively. As dentists we feel the concerns of our patients, hear the negativity on the television, and that affects how we see our patient. Instead we begin to fall into a pattern of fixing problems that only have symptoms.
We have to remember that even in a down economy, we have an ethical responsibility to completely evaluate our patients so we can isolate any factor that could break down their dentition, as well as review any elective procedure they may be interested in.

This requires us to look for ‘signs’ of breakdown as well as any associated symptoms. This requires a comprehensive examination process that will look for caries, periodontal issues, occlusal problems (affecting the TM joints, muscles or teeth), or any other pathology that could affect the long-term health of the patient.

A complete examination will allow the dental team to gather the necessary information to develop a treatment plan that will become the patient’s road map to optimum health. While treatment planning comprehensively is an art form in itself, learning to break up large treatment plans into affordable segments is an extremely important skill in any economy.

Case report
Patricia is a 46-year-old patient (Figures 1-6) who was interested in changing her smile. She had had regular dental care her entire life, and reported losing one tooth from a fracture in her twenties. In recent years she had noticed her front teeth chipping and getting shorter. Her goal was simple: to have a beautiful smile, and keep her teeth for the rest of her life. It also came out in conversation that she was aware of the cost, and that it was unlikely she could afford to do it all at one time. If treatment could be done in phases over a series of years, it would be appreciated.

A comprehensive examination including a full series of photographs, X-rays, mounted diagnostic study models (mounted in centric relation), restorative examination, periodontal probing, TMJ-occlusal examination and oral cancer screening was conducted. After the records were
gathered, time was set aside to do the case work-up and the patient was rescheduled for a consultation.

During the course of the examination, Patricia was found to be periodontally healthy (no probings greater than 3mm, with excellent home care) and to have no active carious lesions. She did, however, have some large older fillings that would need to be restored.

Here, primary problems were occlusal, leading to the aesthetic issues that she did not like. Irregular lower incisors combined with habit enduced acid erosion of the maxillary incisors (in her teenage years), created very poor occlusal contacts anteriorly. A CR-MI discrepancy was also driving the mandible forward. The anterior crossbite on tooth 10 was also problematical both aesthetically and functionally.

When working up a case it is important to use a programmed approach, following  the same sequence every time. Our goal at The Dawson Academy is to teach our students how to use photographs and mounted models to visualise where the teeth need to reside in space for optimum aesthetics, optimum function and long-term stability.

Only then can we think about the materials and procedures we will be utilising to restore the mouth. It is important to understand that it is impossible to appropriately choose a sequence of care, unless we first visualise the finish line.

The following is the ten-step process that The Dawson Academy utilises to create the three-dimensional vision.

Step 1: Choose your treatment position
Patricia presented with a discrepancy between centric relation and maximum intercuspation, which in itself is not a problem. She had healthy temporo-mandibular joints, minimum muscle discomfort, but obvious signs of wear well into the dentin.

While she had no symptoms of occlusal disease, the sign of wear is something to take seriously. An ideal occlusal scheme, to minimise the stress to the system, will be one of our primary goals for Patricia. Therefore, restoration in centric relation is a necessity. By mounting the casts in centric relation (Figure 7), we will be able to evaluate the best way to create equal intensity contacts with an ideal condylar position.

Step 2: Go tooth-by-tooth
Using the photographs (Figures 4 and 5), models, X-rays and information for the restorative examination, make a list of each tooth that will require a restoration.
This could be for restorative purposes, or to satisfy the aesthetic desires of the patient. This was our list: veneers 4, 5, 12, 13; crowns 7-10; restorations (crown or veneer) tooth 6 & 11; veneers 21-28; onlay 2; crown 3; onlay 14, 15; crowns 19, 30, 31.

Step 3: Evaluate maxillary and mandibular occlusal planes, facial asymmetries as well as skeletal abnormalities
Utilise the mounted models, photographs (Figures 1 and 6) and information from the TMJ-occlusal evalation to look for major facial assymetries, or problems with the occlusal plane. The only problem with Patricia is the supra-eruption of tooth 15 due to the loss of tooth 18. While this is not a major functional issue, it can create an issue aesthetically (reverse smile).

Step 4: Choose vertical and horizontal position of the mandibular incisal edge
The lower incisal edge position is the functional starting point after the treatment position of the condyle. Reviewing models and photographs (Figures 2, 8 and 9) helps determine the position. The four options of treatment are reshaping, repositioning, restoring and surgical correction – in that order. One of the goals of the Dawson Philosophy is to do the least amount of dentistry to solve the problems of the patient. In this case, teeth
22-27 were repositioned on the diagnostic models to the ideal tooth position and arch form.

Step 5: Choose vertical and horizontal position of the maxillary incisal edge
The maxillary incisal edge position sets up the aesthetics for the entire case. The vertical and horizontal position of the maxillary incisal edge is also critical for phonetics and function. Utilising key photographs and mounted diagnostics models, it was determined that the incisal position needed to be lengthened 1.5mm and brought forward to round out the archform. These changes were waxed onto the diagnostic casts. Once the incisal edge is established, the gingival contours can be checked for optimum position, and a correct crown length of 10-12mm (Figure 10).
Step 6: Choose vertical dimension of occlusion
Occasionally extra vertical can be helpful in worn dentitions, and other restorative situations. Looking at the articulator with the casts mounted in centric relation, the posterior interference creates an anterior open bite. There are two ways to resolve this situation.
One, to do a traditional equilibration where the teeth are reshaped until all teeth touch with equal intensity contact are in centric relation. The second option is if the teeth are moved or restored in the new open relationship. In Patricia’s case, a simple equilbration was all that was required to get to centric (Figure 11).

Step 7: Provide equal intensity stops (or acceptable substitute)
One of the important tenants of a stable occlusion is equal intensity contacts (Figure 11). Having the ability to equilibrate to centric relation (which can only be determined on mounted diagnostic casts) is one of the keys to predictable sequential treatment.

Step 8: Eliminate balancing and working interferences
After equal intensity contacts, we want to make sure no posterior teeth bump in any excursive movement. After marking the models with blue paper in centric relation, excursive interferences are marked in red. All red marks on the posterior teeth are removed, being careful to preserve the blue marks.

Step 9: Harmonise anterior guidance
The lingual contours of the anterior teeth are harmonised so that a smooth protrusive and lateral anterior guidance exists (Figure 12). This may involve reshaping stone, or adding wax. In Patricia’s case, full crowns will be required to idealise the stops as well as the guidance on teeth 6-11.

Step 10: Final functional-aesthetic check

The last step in the process is to carefully evaluate the diagnostic wax-up for ideal aesthetics and function. Final contouring is the last step prior to the restorative phase. This wax-up will generate preparation and provisional matrices. The better the wax-up, the better the preparations and provisionals. The better the preparations and provisionals, the better the final restorations. Do not underestimate the importance of this process, it sets up the entire case.

The treatment plan and sequence:
1. Prophy
2. Essix removable orthodontic appliance to align 22-27
3. Occlusal equilibration
4. Crowns 6-11, Veneers 4, 5, 12, 13
5. Veneers 21-28
6. Onlay 2, Crown 3
7. Onlay 14, 15
8. Crowns 30, 31
9. Crown 19.
Patricia was able to afford the first four steps of the treatment plan. The hygienist cleaned her teeth, getting the tissues optimally healthy. 

Then we used an Essix Orthodontic Aligner with interproxial stripping to reposition the lower anterior teeth into the proper position. In the third stage we equilibrated the teeth, providing equal intensity contacts incentric relation. It should be noted that while the teeth were being moved and adjusted, this gave the patient time to arrange her finances for restorative phase.
In the fourth step, teeth 4-13 were prepared for crowns (6-11), and veneers (4,5,12,13). Figures 13-17 illustrate where the patient is at this point in her treatment. She is periodontally healthy, occlusally stable and caries free.

Our goals as we move forward are to veneer 21-28, to match porcelain work of the maxillary restorations, and proceed with the posterior work a quadrant at a time. It should be noted that a great deal of freedom now exists with this treatment plan. If one of the sextants should break down faster than expected, we simply direct our attention to this area. Stages 5-9 could literally be completed in one-year intervals. Patricia and I will make that determination as she returns for her re-care visits.

Even with a slow economy, patients still present with wants and needs. Their ability to pay for these services will, however, be varied. The key is to always do a comprehensive examination.
This is the only way the restoring team can determine an ideal course of treatment, as well as help the patient understand what treatment must be done, and what can be deferred.
This empathetic approach will help you treat each patient as an individual, customising how the care is delivered based on their wants, needs, and financial capabilities. This win-win approach will help keep the practice busy during slower economic times, and set you up for explosive growth when the economy turns back around.

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