Phased Treatment for Complete Dentistry

Comprehensive dentistry can be accomplished in stages, and there are multiple reasons why it is often appropriate to phase complete treatment over a period of years. The patient may not be psychologically or financially ready to proceed with full treatment. Optimal restoration may require the patient to undergo periodontic, endodontic, orthodontic, and/or surgical treatment that takes significant time and resources to accomplish. The dentist may also be concerned about stabilizing the patient’s masticatory system prior to planning full treatment. Stabilizing the patient’s masticatory system early in the process provides the patient with improved comfort and function, minimizes further damage, and allows the patient and dentist more time to explore options regarding how much treatment will be done and over what period of time.

EUBANK’S FOUR STAGES OF PHASED TREATMENT

Stage 1: Stabilization. The goal of this stage is to establish stability so that further damage does not occur. Elements of stabilization could be treatment of periodontal disease or dental caries, appliance therapy, balancing the bite, transitional bonding, and/or other forms of trial therapy that are especially useful in cases of heavy wear. Trial therapy allows the dentist and patient to test the proposed functional and aesthetic treatment plan before final restorations are done to ensure longevity, comfort, and a smile that the patient will wear with pride.

Stage 2: Referral. During this stage, the patient is referred for any indicated endodontic, orthodontic, periodontic, and/or oral surgery treatment. Prior to the beginning of phased treatment, the lead dentist and interdisciplinary team of specialists consult to determine the procedures that will be necessary to help the patient achieve his or her goals. The patient approves the treatment plan and sequencing so that the treatment fits into his or her life and budget. Stabilization of the patient’s oral health and function first provides the time and optimal conditions for the specialist to achieve an excellent result.

Stage 3: Restorative. After any necessary endodontic, orthodontic, periodontic, and/or surgical treatment is completed, the restorative stage can be implemented in segments over a period of time that meets the patient’s desires, budget, time requirements, and/or other limitations.

Stage 4: Protection and Monitoring. A specific system for protection and monitoring is performed on an ongoing basis throughout recare to ensure that the patient experiences maximum longevity and comfort in the restored masticatory system.

CASE REPORT

Figure 1. Preoperative full smile. Note reverse smile line.	Figure 2. Uneven wear patterns from parafunctional habits. Note lack of end-to-end harmony.

Figure 3. Chipped enamel and wear into dentin.

In this example of phased treatment involving trial therapy, a 51-year-old male expressed his desire to stop his teeth from wear and breakage, to stop his jaw muscles from hurting, and to improve the appearance of his smile. The patient presented as a severe grinder with large chewing muscles and high bite force (Figures 1 to 3). He reported waking up with sore muscles, periodic jaw pain, and clenching during the day as well as during sleep. He had been told that his teeth were “worn and bro-ken down like those of a 70-year-old man.” In the past, he had lost teeth due to fractures and replaced them with bridges. Because of porcelain fractures the bridges had been replaced several times with a stronger material each time. At the time of diagnosis, fractures were present. He also had insufficient reveal and a reverse smile line with a black triangle between teeth Nos. 8 and 9.
For personal reasons, the patient decided to restore teeth Nos. 5 to 12 and teeth Nos. 21 to 28 immediately. He would then have the maxillary and mandibular posterior teeth restored over the next 2 to 3 years. Between these stages he agreed to wear an E-appliance (a patented, full-arch appliance available through Esthetics Unlimited Laboratories) to ensure stability, which would be monitored at recall visits. This plan would stop deterioration, fit his life circumstances, and ultimately meet his treatment goals.

STABILIZATION

Figure 4. This is a blueprint model of functional and aesthetic changes. A putty matrix was used to transfer the blueprint to the mouth using composite. This is called transition bonding, a method of trial therapy.	Figure 5. The matrix allows precise and efficient transfer of the blueprint to the mouth. In this case, Renamel Hybrid Composite (Cosmedent) was used for transitional bonded restorations.
Figure 6. Finished transitional bonding, which is an excellent method of trial therapy. Notice end-to-end harmony is established.	Figure 7. Anterior guidance was worked out on the articulator (blueprint) and transferred to the mouth via the matrix. Posterior centric stops were established with composite in the mouth, using the anterior centric stops to establish vertical dimension. Note lines in the front and dots in the back.

The patient’s stabilization treatment begins with appliance therapy using an E-appliance. Once a stable and comfortable joint position is verified, bite balancing and transitional bonding is implemented to test the new functional and aesthetic plan.
The patient was in “trial therapy” (transitional bonding) for 3 months. Trial therapy normally lasts 3 months without the benefit of an appliance. After 3 months, the patient is checked for wear and/or breakage of the transitional composites, chipped or broken teeth, movement of teeth, mobility, sensitivity, and any tissue changes. The patient reports that he no longer wakes up with pain. The tightness of his jaw is gone, and he has stopped grinding his teeth during the day. The patient also approves the aesthetics of the changes made.
We used transitional bonding as our method of trial therapy along with a transitional bridge on teeth Nos. 23 to 25. The new functional relationships were first established on an articulator then precisely transferred to the mouth (Figures 4 to 6). In this patient’s case, we needed to change the vertical dimension, centric stop placement, plane of occlusion, angle of disclusion, and envelope of function to achieve his functional and aesthetic goals (Figure 7).
The patient was ready to proceed with restorative treatment after the Stage 1 transitional bonding had been tested and demonstrated stability in the occlusal scheme. If it had been necessary, referral to an appropriate specialist(s) would have been done as a part of the referral phase. Before we began the following restorative process, it was documented that the patient was happy with the aesthetic changes, comfort, and function of the transitional bonding.

PREPARING THE MAXILLARY ANTERIOR TEETH

Figure 8. Maxillary “taco shell” veneer preparations on the anteriors and occlusal buccal veneers on the bicuspids.

The initial cut on tooth No. 8 was made with a red-stripe round diamond bur (8801014 [Brasseler]) in the marginal area. This allowed us to control the thickness of the restoration and take advantage of a contact lens effect, if appropriate. We utilized a “taco shell” veneer preparation design, where the distal interproximal contact is preserved (Figure 8). (The lingual was covered because the cingulum had been built up with composite during trial therapy to establish proper centric stops at a vertical dimension that had been verified as correct for him. An anterior guidance that discluded his posterior teeth and was in harmony with his envelope of function had also been previously tested.) Next, the mesial contact was broken and something similar to a 360-degree veneer was created, allowing us to close the black triangle between teeth Nos. 8 and 9. Following this, the margin at the gingival area was first prepared to the tissue and then extended one-half millimeter into the sulcus. This preparation conserved tooth structure while achieving the desired aesthetic results and facilitated an optimal impression. Minimal incisal edge reduction was required because the patient’s past bruxism had shortened the teeth. Next, the facial was reduced so that the restorations will have the same thickness of porcelain, facial 0.6 to 1 mm and incisal 1.5 to 2 mm (KS1012 [Brasseler]). It is important for the ceramist to have an even thickness of porcelain on the facial of each restoration because different thicknesses cause varying aesthetic results.
Most of the composite that had been placed to build up the cingulum and lengthen the teeth during trial therapy was removed in the preparation phase. We wanted to save as much of the cingulum as possible, since approximately 60% of an anterior tooth’s strength comes from the cingulum itself. Any time the cingulum is removed, the strength of the crown-tooth unit is reduced. Clearance was checked so the dental technician would have enough room to provide the proper thickness of restorative material. Finally, the preparations were smoothed with a Ceramiste Point (Shofu). As previously noted, during the transitional bonding stage, the angle of disclusion and the envelope of function were worked out and verified to be correct for the patient. This information was captured and transferred to an articulator for the fabrication of a preparation putty matrix and incisal guide table so the lab could duplicate what has been perfected in the mouth.

IMPRESSIONS OF THE MAXILLARY ANTERIOR PREPARATIONS

Impression preparation was done using a radiosurge technique rather than a retraction cord. The lining of the sulcus was removed with a varitip in a radiosurge (Dento-Surg 90 F.F.P. [Ellman International]), but the tissue height was not shortened. Superoxol (30% hydrogen peroxide [Henry Schein]) was placed on the tissue for 10 seconds and rinsed to produce a sulcus that did not weep. The specific technique is demonstrated in a video from National Dental Network, The Functional Requirements of Esthetic Success, an excerpt of which is available by clicking on the “Read and Watch” logo at dentistrytoday.com.
Four sets of impressions of the prepared teeth were taken using reversable hydrocolloid (DUX Dental). Each model had a specific purpose. The first was a solid model that we mounted with an aesthetic face-bow and a centric relation bite record that had been verified as correct. We take responsibility for a correct mounting, and the laboratory is held accountable to make everything fit and function properly on this model. The laboratory used the second set of models to section for dies and mount with the same relationship as the solid model we provided. The third set of impressions was used to fabricate the prototypes. The fourth set is the “hold-back” model. This is an unaltered original that the final restorations are tried on to verify proper fit. This is done because sometimes dies become abraded in the dental laboratory.

FABRICATION AND PLACEMENT OF THE MAXILLARY ANTERIOR PROTOTYPES

A clear stent of thermoplastic coping material of 0.5 mm using a Biostar unit was fabricated over the patient’s approved transitional bonding model. A fast-setting Snap-Stone (Whip Mix) occlusal key was also fabricated. Renamel Flowable Microfill (Cosmedent) of the proper colors was layered inside the stent to create a veneer on the facial. Each layer was cured separately.
The body of the prototypes (custom-fabricated provisionals) was made from a mixture of Triad 11 (DENTSPLY) and Renamel Flowable Hybrid. This mixture was warmed in a water bath and injected inside the stent and placed over the mock-up model of the preparations. The occlusal key was placed and held firmly in place for approximately one minute or until all excess material had flowed out. The key and model were secured with a rubber band and cured in a Triad 11 curing unit (DENTSPLY Ceramco) for 10 minutes. The prototypes were then removed, trimmed, and finished. The occlusion was perfected on the prototypes, and they were cemented.

LOWER ANTERIOR PREPARATION FOR VENEERS AND BRIDGE

Figure 9. Mandibular preparations.

During the transitional bonding phase, a transitional bridge had been fabricated on teeth Nos. 23 to 25. The patient was anesthetized, and this bridge was removed. On teeth Nos. 22 and 26 the preparation on the mesial was extended through the contact to the lingual line angle, and on the distal, the contact was preserved. Note that gingival margins on the lowers were left slightly above the tissue to conserve tooth structure, since they were not in the aesthetic zone. The other preparations were finalized, and impressions along with a face-bow were taken. Bite records were taken at the vertical established through the transitional bonding and maintained by the centric stops on the unprepared teeth. We normally take bite records at the vertical that has been verified as correct for the patient.
After the mandibular anterior teeth were prepared (Figure 9), they, and previously the maxillary teeth, were sealed with a self-etching, dual-cure primer (Clearfil Liner Bond 2V [Kuraray Dental]). We did this first to protect the pulp and seal the tooth in order to minimize sensitivity and the growth of chromogenic bacteria that sometimes grow underneath an open or leaking margin. Sealing the tooth and having well-fitting prototypes prevent the bacteria from growing and forming a black area.

FINAL PROTOTYPE APPROVAL

After the patient had worn the prototypes for 2 weeks, he came in for a prototype approval appointment and authorized us (by his signature) to send his case to the dental laboratory for fabrication of the final restorations. We took impressions and photographs of the approved prototypes to document what the patient approved. We also took bite records so that the approved prototype models could be cross-mounted with the preparation models. We fabricated 3 matrices (an incisal matrix, a lingual matrix, and a facial matrix) that helped the lab verify that the restorations duplicated the patient-approved prototypes. This was an important accountability step because the approved prototype models contain the functional and aesthetic information that had proven to work for the patient. The models, photographs, and matrices were sent to the dental laboratory. The prototype models were mounted to be interchangeable (cross-mounted) with the preparation models, and the patient even went to the laboratory to verify the aesthetics and to further familiarize the dental ceramist with the case.

TRYING IN THE CROWNS

Figure 10. Our system of retrofitting hold-back models to verify a proper fit when we receive restorations from the lab.	Figure 11. Verifying the thickness of a “taco shell” veneer after the functional platform has been perfected.

After the crowns were received back from the dental laboratory, they were checked and adjusted on the hold-back models for proper
fit (Figures 10 and 11). When we determined the crowns were ready to be permanently bonded, the mandibular prototypes were removed and the restorations were tried in for marginal fit and functional relationship to the maxillary prototypes. The lower try-in was done first because if any functional changes were needed, the adjustments could be made on the mandibular restorations, and/or the lingual of the maxillary teeth, without changing the aesthetics of the maxillary anterior teeth.

PLACING THE E-PONTIC BRIDGE

An E-pontic bridge was used to replace the patient’s existing Maryland bridge. An Epontic has an internal metal framework that does not show metal on the facial, lingual, or gingival. The bottom of the pontic is flat, not ovate, so that the facial and the bottom of the pontic come together to form a sharp angle at the facial-gingival line angle. This will butt right into the tissue. The sharp angle puts a slight amount of pressure on the tissue, which causes the tissue to roll up over the facial-gingival line angle, creating a probable sulcus.
When placing the restoration, the teeth are lightly sandblasted, which removes cement residue, stains, or anything that will interfere with a strong bond. The inside of the restorations is sandblasted with 50-µm aluminum oxide at approximately 15 pounds of pressure and etched with Super Etch (Chameleon Dental Products) to prepare them for the bonding process.
The E-pontic bridge was bonded in first. Because metal was involved, dual-cure Panavia (Kuraray Dental) was used. The other restorations were bonded with a mixture of hybrid and flowable composite that is described below. The other restorations were bonded in, one at a time, so that marginal fit and interproximal contacts could be perfected. If multiple restorations had been placed at the same time, a tight interproximal contact could have caused restorations to shift while opening up margins.
To prepare the bonding cement, a mixture of Renamel Hybrid Composite (80%) and Renamel Flowable composite (20%) was created. The 80/20 mixture is the right consistency for reliable handling and strong enough to withstand occlusal forces. The goal is to produce a resin material that is thick enough (not runny) for easy clean up and thin enough to allow the restoration to go to place with light pressure. This consistency keeps the restoration from moving and sucking air under the margin once it is seated.
The high-strength dentin bonding agent used was Clearfil Liner Bond 2V, a dual-cure, self-etching primer that has water as a solvent and produces zero sensitivity when used properly. The dentin primer was placed, agitated on the surface of the tooth for 20 seconds, allowed to set for 20 seconds, and then lightly air-dried until nothing moved. Then the primer was light-cured. Next, a thin coating of Clearfil Photo Bond (Kuraray Dental) mixed with activator was placed over the surface of the tooth and inside the restoration. After excess was blown off, the bonding resin was placed in the restoration (Panavia in the case of the bridge and the 80/20 mixture in the other restorations). The restoration was placed by holding some pressure on it, but not forcing it, and letting the cement flow. While holding firm pressure, the marginal fit was verified in three places. Once we were sure the restoration was properly seated with sealed margins, excess cement was cleaned up carefully, staying away from the margins. While holding firm pressure, the cement was light-cured. After thorough light-curing, excess resin was cleaned off using a No. 12 scalpel, Horico Ribbon Saw (Pfingst) and appropriate strips. (A more detailed step-by-step bonding sequence is available from the author. Other cleaning methods may be used. Care should be exercised to reduce the chance of bleeding.)

BONDING THE MAXILLARY AND MANDIBULAR PORCELAIN VENEERS

Figure 12. Full-face smile. Finished case at 9 months.	Figure 13. Retracted photo. Finished case at 9 months.

After the first restoration was bonded in place we needed to verify that the interproximal contacts were correct with the next restoration before repeating the bonding process. Shim stock (Artus) of 8-µm thickness was used. The Artus paper was placed in the contact. Holding the next restoration firmly in place, the Artus paper was pulled through. If the contact was proper, the Artus paper pulled through the contact without tearing while feeling resistance. If the Artus paper tore, the contact was too tight and had to be adjusted until the paper pulled through with resistance but without tearing. This process was repeated for each restoration. After all the restorations were placed, the occlusion was perfected and an engineering check was done to ensure the patient had no working or balancing interferences. A T-Scan III (Tekscan) was also used to perform an occlusal analysis and verify that all of the teeth hit at exactly the same time with the proper inclusion time in centric relation. The anterior guidance and envelope of function were checked to make sure that they duplicated the prototypes. Figures 12 and 13 are photos of the completed case 9 months after the restorations were bonded.

CREATING AND FITTING E-APPLIANCE

Figure 14. An E-appliance provides stability for the masticatory system.	Figure 15. E-appliance functional movements. The appliance is self adjusting and does not require doctor manipulation or equilibration of the appliance.

Single-arch appliances have advantages and disadvantages. One disadvantage is that the teeth, as they wear into the appliance over time, can move and shift. The appliance accommodates for the movement because of the wear, but when the appliance is removed during the day, the bite is again unbalanced because the teeth have shifted. The single-arch appliance must be continually updated and adjusted. An appliance that is improperly adjusted can have interferences that stimulate muscle activity and cause problems.
An E-appliance (patented and patents pending [Esthetics Unlimited Laboratories]) covers and stabilizes both upper and lower arches (Figure 14). The E-appliance allows the patient’s own muscles and anatomy to place the joint in its most natural position, and as a result, doctor manipulation is not required. The E-appliance is also self-adjusting as the appliance wears.
The E-appliance had an upper flat plane behind the centrals while the lower was like a thin bleaching tray with a bearing point placed just behind the lower centrals. The bearing point was placed so it could not get off the flat surface during any excursive movement; thus, the patient’s lower jaw could “skate” around on a slick surface, which is passive and kind to the entire masticatory system (Figure 15). This appliance does not have to fit as tightly as a single-arch appliance since all the forces are within the upper arch and tend to seat the appliance. The E-appliance will be worn until the next restoration segment is done in approximately one year. Long term, the patient will sleep in the E-appliance and bring it to each recall visit as part of our stability monitoring system.

CONCLUSION: THE IMPORTANCE OF THE FOUR STAGES

It is the author’s belief that in general we see 2 categories of patients. The first is the limited dentistry patient who only wants a broken tooth fixed. The second is the complete dentistry patient who needs all aspects of the masticatory system addressed. The patient in our case report had been trying to solve complete dentistry issues with limited dentistry, and it had not been working for him. These patients in the second category require different approaches, more knowledge, and supportive office systems. The truth is, most of us have both types of patients in our practices, and we need to be able to handle both types of patients.
The 4 stages and their proper implementation give us a system to treat complete cases predictably and with confidence in a manner that fits patients’ needs. The stabilization stage allows us to stop progressive breakdown while using trial therapy to test treatment plans if needed. Sometimes, all that a patient needs is bite balancing and an E-appliance. The specialist appreciates the referral stage because the patient is stabilized, and the specialist’s results are thus more predictable. The restorative stage allows us to make the dentistry more affordable by spreading the treatment over a period of years, if necessary. I have patients that have been in different phases of their restorative phase for many years, which is fine because they are not losing any ground. The protection and monitoring stage is essential to longevity and is ongoing. It has 4 main elements implemented at each recall visit: 1) the E-appliance, which is worn every night to maintain stability, 2) a centric relation Blumouse (zero-flash) bite is taken to verify centric stop harmony and position, 3) an “engineering check,” which will identify any working or balancing interferences, and 4) a sequential Tekscan record is also kept. The E-appliance keeps upper and lower teeth from moving, reduces muscle activity, protects from grinding, and maintains the joint in its most supported position. Once stability is established, little or no adjustment is required.

Dr. Eubank is an international authority in cosmetic dentistry and occlusal rehabilitation, and is accredited by the AACD as both a dentist and laboratory technician. He founded the Eubank Institute in Plano, Tex, and is a faculty member and director of the postgraduate Esthetics Continuum at Louisiana State University School of Dentistry. He has co-directed advanced postgraduate programs at LSU, UCLA, the University of Minnesota, and SUNY-Buffalo. He is a fellow of the AAED, AACD, and the AGD, and is past accreditation chairman of the AACD and received its President’s and Humanitarian awards. He designed the E-appliance, E-pontic, E-tab, and Eubank Bridge, all manufactured at Esthetics Unlimited Laboratories in Plano. He can be reached at dr.eubank@therightfitdentist.com or (888) 596-1811.

Disclosure: Dr. Eubank owns patents on the E-appliance and owns Esthetics Unlimited Laboratories. He has taught for and been a consultant for Cosmedent. He is also director postgraduate programs at LSU & UCLA.