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How to Sequence Optimum Dentistry

Issue: Fall 2009
By John C. Cranham, Clinical Director-The Dawson Academy

 Managing your treatment plans in tough economic times

They are living longer than ever before, leading stressful lives, seemingly putting increased forces on their dentitions. Visualizing 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 in tough economic times is that we stop comprehensive treatment planning. As dentists, we feel the concerns of our patients and hear the negativity through the media—and that affects how we see our patients. We begin to fall into a pattern of only fixing problems with overt symptoms. As dental professionals, 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 factors 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. A comprehensive examination should check for caries, periodontal issues, occlusal problems (affecting the TM joints, muscles, or teeth), or another pathology that could affect the long-term health of the patient.

Case Report:

Patrica is a 46-year-old patient (Figures 1–2) who presented as interested in changing her smile. She has had regular dental care her entire life, and reports losing one tooth from a fracture in her twenties. In recent years, she has noticed her front teeth chipping and becoming shorter. At one point in her life, her best asset was her beautiful smile. She is also concerned that whatever is causing the breakdown, could also cause her to loose her teeth. Her goal was simple: To have a beautiful smile, and keep her teeth for the rest of her life. During our conversation, she noted that she was aware of the cost of dentistry, 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.

Figure 1
Figure 2

A comprehensive examination, including a full series of photographs and X-rays and mounted diagnostic study models (mounted in centric relation), restorative examination, periodontal probing, TMJ-occlusal examination, and oralcancer screening was conducted. After the records were gathered, time was set aside to do the case workup 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 3 mm, with excellent home care) with no active carious lesions. She did, however, have some large older fillings that would need to be restored. Her primary problems were occlusal, leading to the aesthetic issues that she did not like. Irregular lower incisors combined with habit-induced acid erosion of the maxillary incisors (in her teenage years), created very poor anterior occlusal contacts. A CR-MI discrepancy was also driving the mandible in a forward direction. An 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 visualize 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 utilizing to restore the mouth. It is important to understand, that it is impossible to appropriately choose a sequence of care, unless we first visualize the finish line.

The Treatment Plan & 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, making the tissues optimally healthy. Then we used an Essix Orthodontic Aligner with interproximal stripping to properly reposition the lower anterior teeth. In the third stage, we equilibrated the teeth providing equal intensity contacts in centric relation. It should be noted that, while the teeth were being moved and adjusted, the patient had time to arrange her finances for the restorative phase.

In the fourth step, teeth 4–13 were prepared for crowns and veneers. Figures 3–5 illustrate where the patient is in her treatment schedule. She is periodontally healthy, occlusally, stable, and caries-free. Our next set of goals are to veneer teeth 21-28 to match the porcelain work of the maxillary restorations, then 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 sextants should break down faster than expected, we simply direct our attention to this area.

Treatment plan stages 5-9 could be completed at one-year intervals. Patricia and I will make that determination as she returns for future visits.

Figure 5



Even when the economy is slow, patients still present dentists with wants and needs. Their ability to pay for these services will be varied. The key is to always do a comprehensive examination. This is the only way the dental team can determine an ideal course of treatment and help the patient understand what treatment must be done and what can be deferred. This empathetic approach will help you customize each patient’s treatment, ensuring that 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 around.