Partnering for Full-Mouth Reconstruction–An Interview with Steve Ratcliff, DDS, Lee Ann Brady, DMD, and Matt Roberts

Dentistry Today is pleased to present this interview with a dentist, Dr. Steve Ratcliff; patient Lee Ann Brady, DMD; and ceramist Matt Roberts, who partnered to meet the patient’s objectives and create an outstanding result. The interactive communication among them added to the diagnosis and treatment planning process. Because the patient was a dentist, there was the added dimension of the patient’s knowledge and the dentist’s experience of being the patient.

Steve Ratcliff, DDS	Lee Ann Brady, DMD	Matt Roberts

There are 5 parts to a comprehensive exam at The Pankey Institute, and we went through the full co-discovery process with Lee. First, we had a preclinical conversation, in which one of the objectives is creating an environment of partnership. In this conversation, we uncovered things that she had been thinking about. She was using a bite splint that she had made when she began participating in The Pankey Institute continuums. It had gotten rid of many of her symptoms, but not all. She knew that she had sore muscles and bruxed at night. When she was chewing, her canines sometimes “crashed.” She had restorative dentistry done in her mandibular arch to eliminate group function that she had developed, but it had returned. Tooth No. 8 was short, and even though she had had it restored several times, the composite always fractured off. She was aware of non-carious cervical lesions; she had gingival grafts done in dental school, and it was a very uncomfortable procedure that had to be redone because of poor healing.

The next step was the clinical examination. As Lee and I started to explore her mouth, we found muscles that were tender to palpation. She knew that her front teeth were “crashing” so we started looking at her anterior guidance and envelope of function. There was wear and cracks on posterior teeth, and we also discovered failing restorations and recurrent decay. Together, we observed the evidence of bruxing and clenching. We saw the poorly contoured gingival grafts and found some attachment loss. Aesthetic concerns started to surface as we talked about her mouth.
We completed radiographic imaging, articulated diagnostic casts, and took digital photographs (Figures 1 and 2). As we looked at them together, we decided it was important to address Lee’s chief complaint first, so we fabricated a bite splint to create a stable occlusion in plastic. Then we provisionalized symptomatic cracked teeth to evaluate our ability to eliminate the sensitivity. The muscle and joint symptoms went away and we worked out her anterior guidance on the top of the bite splint. At this point, the bite splint was not only therapeutic, but also diagnostic. Creating a stable occlusion on the splint allowed us to understand what had to be done to create a smooth, comfortable anterior guidance within the envelope of function for her teeth.
Lee played with her teeth a lot. She was very sensitive to nuances in her bite. We knew that whatever we did to the tops of the teeth would also have to be the equivalent to what we did on the bite splint. We needed stable centric stops and a shallow anterior guidance. It had to be smooth, meaning that she would be able to move in right and left lateral all the way past the canine into the crossover position and into protrusive crossover without interferences, without dragging, and without stuttering or hesitation. We spent significant time together evaluating and refining her occlusion on the bite splint. This partnership helped us to finalize what we needed to do restoratively to create Lee’s preferred outcome.
When Lee removed her bite splint, she felt like she only hit her anterior teeth. Because she had had 4 premolars extracted and the spaces closed orthodontically, we suspected that the upper anterior teeth were placed against the lower anterior teeth in such a way that her envelope of function was restricted. As we adjusted the splint, her lower jaw kept coming forward. When we achieved stability, her front teeth no longer had heavy contact with the lower bite splint, and that is when all of the pain went away. After remounting her models in this centric relation position, we noticed that the only place she hit in the centric relation arc of closure was her front teeth. We knew that we would have to change that relationship before she could have a healthy bite.

Figure 1. Maxillary anteriors pretreatment.	Figure 2. Maxillary arch pre-treatment.

During the time we worked on Lee’s splint, she learned a lot about her teeth, and her aesthetic goals. She asked questions, and together we thought about the answers. As she discovered what she was most concerned about, she was able to process what would be her best outcomes. In addition to stabilizing her occlusion and restoring damaged teeth, we would aesthetically correct any black triangles, incisal edge discrepancies, postortho discoloration from brackets, poorly contoured gingival grafts, and irregular gingival heights.

DT: Dr. Brady, what is your perspective on this initial phase of your bite-splint therapy?

Dr. Brady: I had discomfort that went away on the new bite splint. Sometimes it’s not until you feel better that you realize how bad you felt before! Living with the differences in my bite every day made it clear to me that I wanted my bite to be different. As we refined the bite splint, I had opportunities to talk with Steve about my case.
During the diagnostic phase, I clarified what I wanted to achieve in my own mouth and grew in commitment to do what was necessary. We were building a plan together for achieving the functional and aesthetic results that I wanted. At some point, I would move forward. Steve did not hurry me before I was ready. I reflect on this now with my own patients. Patients need time to prepare mentally and emotionally for changes in their mouths; to grow in trust and become secure with their outlined treatment.

Figure 3. Equilbration prior to final wax-up.

My treatment plan was somewhat complex. We did orthodontics to move the lower anterior teeth and open up the envelope of function. Once that was accomplished we would do an equilibration (Figure 3) and also treat some minor caries. We would have a consultation with the periodontist regarding restoration of adequate keratinized tissue, and the creation of symmetrical gingival margins. We’d ask the periodontist to recontour grafts and thin them out a little bit. We would do bonded porcelain restorations from first molar to first molar in the maxillary arch, feldspathic veneers on the 6 anterior teeth, and pressed ceramic crowns on the first molars and premolars. On the lower arch we would do pressed ceramic in the first molars and the second premolars. I wanted cast gold for the second molars because these were the teeth that had the most severe cracks. Aesthetically, this would be fine since they were not visible when I smiled. When everything was done, we would replace the bite splint.

DT: Does the patient’s involvement on this scale help the lab?

Mr. Roberts: Yes, it gives us more confidence going into a diagnostic wax-up knowing that the patient has been through a bite splint, and that the vertical dimension of occlusion (VDO) from which we are choosing to work has been validated by the patient. Otherwise, we are going through the time-consuming and expensive diagnostic wax-up process with faulty information. We start from a firmer foundation when we know the patient and dentist agree on the aesthetic and functional objectives.

DT: How did you collaborate with the patient as you proceeded with her case?

Figure 4. Wax-up 5-12 on new postequilbration models.	Figure 5. Bis-acryl mock-up.
Figure 6. Preparation guide over maxillary anterior preps.	Figure 7. Final preparations.

Dr. Ratcliff: I created a direct composite mock-up from Matt’s diagnostic wax-up (Figure 4). Lee wore this mock-up for a day to experience the length of the teeth and to experience how the bite felt. Lee wanted it thinned on the palatal surface be-cause it was interfering with her envelope of function. As the 3 of us talked, we decided that we could add 0.5 mm more to the labial of her central incisors. Matt accommodated this change on a new diagnostic wax-up. He made a putty matrix that was filled with Venus Temp (Heraeus Kulzer) and spot-bonded to the teeth (Figure 5). This would allow Lee to evaluate the new mock-up in her mouth. Since the wax-up was additive, I could apply Venus Temp over the facial surfaces of the teeth, and when I began the preparations, I was actually preparing teeth that were full contour. That allowed me to create ideal depth cuts and to preserve enamel in the preparations (Figures 6 and 7).
Lee was in provisionals 3 months. She gave us feedback on length, width, and position against her lips and tongue. We wanted to ensure that her speech and function were optimal. We had to work through some things with the bite, mostly with the steepness of the canines. This process takes several weeks, when done carefully.

Figure 8. Provisionals at 6 weeks.

Dr. Brady: When Steve delivered the provisionals, they felt comfortable. However, after having the opportunity to wear them for a while (Figure 8), I discovered some subtle things about function. I kept going to Steve and saying, “Can you adjust this a little here?” It usually took only a minute in the chair but it made a world of difference in my mouth.

Figure 9. Powder buildup on refractory dies.	Figure 10. Powder buildup against incisal guide matrix from provisionals.
Figure 11. Final bake on refractory dies.	Figure 12. Veneers on solid model to evaluate contacts.

Mr. Roberts: Once we knew where to build the teeth, the next step was to decide which restorative materials would be used. Both Lee and Steve indicated a preference for a refractory technique of powder-built porcelain on refractory dies, rather than a pressed ceramic (Figures 9-12). However, it was up to me to evaluate whether this would be best for her situation. Lee wanted her 6 veneers and 2 crowns to be in an A-1 shade range, with possibly an A-2 shade in her cuspid and bicuspid region.
We agreed to a very conservative preparation, as Lee is young and might need restorative work again later in life. Because much tooth structure was conserved, the darkness of the underlying tooth had to be brightened up about half-a-shade, and a little warm color was added to produce natural effects in her incisal edge.

Dr. Ratcliff: After removing the provisionals and seeing healthy tissue, we tried in the veneers with some glycerin. Lee and I evaluated them for shade, contour, and shape. Although Lee is a dentist, nondentist patients can also partner in a similar process. Patients appreciate knowing that their input is important—after all, it is their mouth!

DT: What photos does the lab need for a wax-up?

Mr. Roberts: We need to visualize what is going on with a case and to orient that to facial aesthetics. We need full-face photos, from chin to eyebrow. The patient should be looking directly at the camera with a full, natural smile. In this way, we can see how the gingival tissue relates to the upper lip and how the incisal edges follow the lower lip. We also need full-face lateral views of the smile, with the head slightly turned, so we can see anterior tooth inclination relative to lip structure. We want photos that are cropped right at the corners of the mouth. For more detail, again with the patient smiling, we need left and right lateral, and then retracted views. A stick-bite photo is valuable as a horizontal plane reference tool. The bite registration material is indexed on the lower incisal edge so it has a positive seat, and the stick is level to the horizon with the patient standing up looking directly at the camera.
A point and shoot camera will not provide the required images. Dentists should use an SLR camera like a Canon 40-D or 5D. I received photos from Steve and he received images from me as I did the wax-ups. For example, as I started the second wax-up, I pulled up an image and used the pentablet function to draw a little black line on the digital image that followed the incisal edge of what I thought would be appropriate. I e-mailed this to Steve, and the 3 of us talked on the phone. They agreed that we should open up the embrasure between teeth Nos. 9 and 10, and to shorten No. 10 a little bit. We went back and looked at our original mock-up, which was less square than the incisal of the provisional restorations. Lee liked the softer look, so I followed the provisional restorations for the length and position of the incisal edge. However, I modified the incisal shape back to what we had on the original mock-up.

DT: What photos does the lab need before you create the restorations?

Mr. Roberts: We need to see photos of the prepared teeth to know what color we are dealing with underneath; 60% to 70% of the final color of the restoration comes from the underlying dentin color. If it is a very nice color, we want to let it show through and to simply filter it. If it is a purple, brown, or gray color, we have to opaque it and create the illusion of depth by using opacified ceramics and relayering over the top with fluorescing material and translucent ceramics.

Dr. Brady: On the day that Steve prepped my teeth, he captured images and e-mailed them to Matt. He called Matt from the treatment suite, and we had a 3-way conversation. There was some back and forth with photos and calls while I was in the chair.

Mr. Roberts: We also need photos of the provisional restorations. We want to see a chin-to-eyebrow, straight-on facial shot. We also like lateral views of the patient smiling and looking away from the camera, so we can see the protrusive-retrusive position of the teeth. In addition, we want close-up views of one to two of the teeth at a time, from all 3 angles. Finally, we would like to have retracted views of the preparations, and a photograph of the patient with a stick bite.

DT: Dr. Brady, what was it like to be the patient?

Dr. Brady: Like other patients, I had lots of questions and concerns. Several years ago I thought about “maybe” changing my smile. Steve’s role in helping me think through what I wanted was enormous! The way he facilitated my process is something that I can take to my patients to help them make their own healthy decisions.
A big thing I took away is, understanding the commitment that it takes to go through this process as a patient. It’s a lot of procedures and much time in a dental chair. I wouldn’t have made it to the end if it hadn’t been for Steve’s support. He was always there, no matter how many times I asked a question. As a dentist, I’ve caught myself thinking, “I’ve already told them that. Don’t they remember that?” As a patient, it wasn’t always that I didn’t remember; I wanted to hear it again.
Now that we are done, I am proud of how it all looks (Figures 13 to 15), and I don’t worry about my teeth any more. I feel confident that everything is healthy and that it will be that way for a long time. I also want my patients to have this confidence and pride.

DT: Dr. Ratcliff and Mr. Roberts, what parting things would you like to say about your experience working together?

Figure 16. Final restorations, 1 year postoperatively.

Mr. Roberts: As a team we looked at what we could do with Lee to accomplish her needs and preserve tooth structure. Then, we chose a strategy that included the right techniques, preparations, and materials for long-lasting results. We worked together to choose what would be best in her specific clinical situation.
This was the first time that Steve and I have worked together. When I am working with a new client, I don’t know how conservative of an approach the client likes to take. I’d like to know it would be okay to verbalize thoughts like “I wish you had prepped that a little bit more aggressively.” When you start a relationship, you are cautious. Steve and I were able to speak our minds, and that is very good from my perspective.

Dr. Ratcliff: Matt raised the level of my dentistry. I was learning from him what materials would make the teeth look and function best in Lee’s situation. I learned about his techniques in the dental laboratory, and he helped me communicate what he needed from me to do his best. Because Matt is the ceramist, I didn’t prescribe what porcelain to use. I wanted him to use the porcelain that was going to make the teeth look most beautiful. I would like to conclude by saying that the way we all worked together allowed Lee to own her dental treatment. I always feel overwhelmed by the trust that my patients place in me. I think that accomplishing exquisite results together can happen, even when the patient is not a dentist. There are always ways to create a partnering experience.

Dr. Ratcliff is the Chairman of the Education Department of The Pankey Institute and practices in the Pankey Faculty Practice in Key Biscayne, FL. He can be reached by e-mail at sratcliff@pankey.org.

Dr. Brady is the clinical director at The Pankey Institute and practices dentistry in the Pankey Faculty Practice in Key Biscayne, FL. She can be reached at lbrady@pankey.org.

Mr. Roberts is founder of CMR Dental Laboratory in Idaho Falls, Idaho, and of Team Aesthetic Seminars. He is one of 13 accredited ceramists in the American Academy of Cosmetic Dentistry. He can be reached at CMR@ida.net.