Phasing the Definitive Restorative Procedures

The key to success when treating patients is to follow a systematic approach to diagnosis and treatment planning. In my June article I discussed the initial phase of treatment, the completion of a comprehensive assessment. In this article, I will outline the steps I would take when sequencing treatment for a patient that requires restoration of all the teeth in both arches. 
Assuming that the comprehensive assessment has been completed; the clinician and patient have agreed upon a timeline driven by the patient’s needs or preferences and/or the clinical treatment-driven sequencing. The initial phase of restorative treatment may include direct bonding of teeth based on a diagnostic wax-up to establish the definitive length and shape of the teeth. 

Unfortunately, there is little current literature on this subject that reflects clinical and material advances, but that is a topic for another discussion. The following is the sequencing of treatment I suggest. The phases may be combined depending on the timeline that has been established:

 

• Initial Phases of Treatment (described in my last article)
• Phase 1 - Preliminary Procedures
• Phase 2 - Six Maxillary Anterior Teeth
• Phase 3 - Six Mandibular Anterior Teeth
• Phase 4 - Maxillary Posterior Teeth
• Phase 5 - Mandibular Posterior Teeth

 Phase 1: Preliminary Procedures

1. Complete a diagnostic wax-up of all teeth at the desired vertical dimension of occlusion. (Click this link for the steps on producing a diagnostic wax-up.) The wax-up is based on clinical decisions following FGTP Guidelines; the key is to level the occlusal planes in both arches. Depending on the complexity of the case, a decision needs to be made on how the wax-up is made. If there are minor to moderate tooth morphology changes, an additive only wax-up may be best to allow for direct composite transitional restorations to be made intraorally by the clinician. If there are extensive changes in tooth morphology, a reduction of the stone teeth may be required before the wax-up. This may require the clinician to do long-term provisionalization of some teeth if treatment will be phased. 

 Phase 2: Restore the Six Maxillary Anterior Teeth

1. Prepare the teeth based on silicone reduction guides produced from the diagnostic wax-up. 
2. If there is no change in the vertical dimension:
   1. Take the final impression of the prepared teeth.
   2. Fabricate the provisional restorations based on the diagnostic wax-up.
   3. Equilibrate or add composite to the anterior mandibular incisal edges to re-establish function with the newly designed maxillary anterior teeth.
3. If the vertical dimension is increasing:
   1. Fabricate the maxillary anterior provisional restorations based on the diagnostic wax-up.
   2. Establish posterior occlusion on the maxillary teeth by direct bonding using a copyplast stent made from the diagnostic wax-up. I recommend using the every-other-tooth technique to create individual tooth restorations.
   3. The mandibular anterior and posterior teeth may need to be transitionally restored to establish the occlusal scheme designed in the diagnostic wax-up. Equilibrate the occlusion to establish stable/solid contacts and intercuspation. 
   4. Take the final impression of the prepared anterior teeth and newly-transitionally restored maxillary posterior teeth.
4. Take an impression of the mandibular arch, which has either been adjusted or modified with transitional restorations.
5. Take a bite registration of the maxillary anterior preparations to the mandibular anterior teeth¹. (Click this link for bite registration tips.)
6. Cement the maxillary anterior provisional restorations.
7. Take an impression of the provisional restorations after any esthetic and/or functional changes have been made.
8. Take a facebow transfer of the maxillary provisional restorations.
9. The laboratory mounts the cast of the maxillary provisionals with the facebow.  The mandibular cast is mounted to the maxillary cast by hand articulation. This can only occur if there has been a stable occlusion established. The laboratory then cross-mounts the cast of the maxillary preparation to the mandibular cast using the bite registration.  The mounted provisional cast and photographs of the provisionals are used to confirm the esthetics of the case and a level of the occlusal plane.
10. The laboratory fabricates the maxillary six anterior teeth.
11. Insert the maxillary restorations.
12. Equilibrate the mandibular anterior teeth if necessary. 

 Phase 3: Restore the Six Mandibular Anterior Teeth

1. Prepare the teeth based on silicone reduction guides made from the diagnostic wax-up. 
2. Take the final impression of the mandibular teeth.
3. Take a bite registration record of the prepared mandibular teeth to the maxillary anterior teeth.
4. Make the provisional restorations and cement.
5. Take an impression of the mandibular provisional restorations.
6. Take an impression of the maxillary arch.
7. Take a facebow transfer.
8. The laboratory mounts the casts and fabricates the mandibular anterior teeth.
9. Insert the mandibular restorations.
10.  Equilibrate the occlusion if necessary.

Phase 4: Restore the Maxillary Posterior Teeth

When restoring the posterior teeth, it can be done on a tooth-by-tooth basis, in quadrants, one arch at a time, or all the posterior teeth at once.  The following example describes the process of doing one arch at a time.

1. Prepare the maxillary posterior teeth based on the silicone reduction guides made from the diagnostic wax-up.
2. Take the final impression of the maxillary arch.
3. Take a bite registration record of the maxillary posterior preparations to the mandibular posterior teeth.
4. Take a facebow of the maxillary arch with posterior preparations. (Click this link for more on facebows.)
5. Provisionalize the posterior teeth.
6. Take an impression of the mandibular arch.
7. The laboratory mounts the casts. The cast of the mandibular posterior teeth may need to be altered to idealize the final restorations to be fabricated for the maxillary teeth. The cast may be altered by equilibration or by creating a new diagnostic wax-up. The key is to establish a level maxillary arch to create the ideal morphology for the maxillary restorations. This allows for planning the occlusal design of the mandibular posterior restorations in order to create ideal morphology and a level occlusal plane.
8. The laboratory fabricates the maxillary posterior restorations.
9. Insert the maxillary posterior restorations. 
10. Equilibrate only the mandibular posterior transitional restorations or modify them with composite to establish appropriate cusp-fossa relationship and stable occlusion.

 Phase 5: Restore the Mandibular Posterior Teeth

1. Prepare the mandibular posterior teeth based on the silicone reduction guides made from the diagnostic wax-up.
2. Take the final impression of the mandibular arch.
3. Take a bite registration record of the maxillary posterior teeth to the mandibular prepared teeth.
4. Take a facebow of the maxillary arch.
5. Provisionalize the prepared teeth.
6. Take an impression of the maxillary arch.
7. The laboratory fabricates the mandibular posterior restorations.
8. Insert the mandibular posterior restorations.
9. Equilibrate the occlusion if necessary.

Phasing treatment can give the patient and the clinician the opportunity to achieve the outcome that is desired.  To meet this goal, it is important to apply a systematic approach such as the one above, to the planning and treatment process.

(If you enjoyed this article, click this link for more by Dr. Bob Winter.)

Bob Winter, D.D.S., Spear Faculty and Contributing Author

References:

1. Squier, RS. Jaw relation records for fixed prosthodontics. Dent Clin North Am. 2004 Apr;48(2):vii, 471-86.