Chasing the bite is when a dentist has done restoration work, the patient has pain or discomfort afterwards, the clinician makes adjustments to resolve the complaints, and it becomes a repetitive process. This process can go on indefinitely and often results in decreased productivity for the doctor and increased frustration for the patient.

When I sense that I am starting down this road, I follow this simple rule: If I make more than two adjustments and the problem persists, I put down my handpiece and utilize other strategies. To avoid chasing the bite, dentists need:

1. A systemic awareness of the problem
2. Tools to rectify the problem
3. A clear-cut strategy

A SYSTEMIC AWARENESS

In everyday practice, dentists can become hyper-focused on the tasks at hand, and sometimes they stop seeing the oral cavity as a system of interrelated parts.When this becomes habitual, dentists stop being physicians of the oral cavity and relegate themselves to the role of tooth mechanics. If this happens, a dentist may tweak minor issues on a patient without achieving the optimal outcome of a system in balance.

Especially with large cases, dentists should be cognizant of the context of the musculature and processes of the mouth and head. Failure to do so can result in a seemingly endless series of adjustments that never seem to resolve the patient’s original complaint.

For example, I often observe dentists taking a patient’s bite with the patient lying back in the dental chair. This is usually a recipe for disaster. The musculature of the mouth and jaw change when a patient is in a supine versus an upright position.

When taking a bite, the ideal position for the patient is sitting upright. Many cases are compromised from the outset because a dentist fails to ensure that the jaw, muscles, and tissues are in the optimal position for taking a bite.

Another problem can happen when dentists use a diamond bur for occlusal adjustments. The muscular systems of the human jaw can sense a change of up to 7 microns of pressure. Yet many dentists use a diamond bur, which can remove several hundred microns with a single pass. The sensitivity of the musculoskeletal system requires a less aggressive bur.

A final example is when clinicians misread articulating paper. As the lead instructor for The Dr. Dick Barnes Group (DDBG) seminars, I’ve had the opportunity to train dentists with a wide range of experience. Regardless of how long they have been practicing, many dentists misread articulating paper and make adjustments that further complicate the bite. Articulating paper is not a sufficient indicator for a clinician who seeks precision in their work. It is a dental tool, but it cannot accurately communicate timing and force in an actionable manner.

In dental school, students are taught to look for “donuts” or “smudges,” and to make alterations to mitigate the large marks made by articulating paper. Doing this is counterproductive because large marks are most likely deflection and possibly even a minor force. The more important, and often overlooked, indicators are pinpoint marks.

Think of a wood floor in a house: What is the most damaging type of shoe to a hardwood floor? A high-heeled shoe with a tiny heel. Why? Because the force of the individual’s weight is transmitted to the floor in a very focused manner as opposed to a more traditional shoe, where the force is spread out across a greater surface area.

With articulating paper, the pinpoints represent areas where force is concentrated onto a small surface area. The force results in the patient feeling pain and discomfort. By ignoring the small pinpoints and adjusting the big smudges, a patient’s complaint can easily go unresolved.

I always advise dentists to focus on the pinpoint marks on the articulating paper, and to give secondary importance to the larger smudges. The mouth is a Class III lever, so thinking of the overall system allows dentists to better interpret what the articulating paper indicates.

TOOLS TO USE

It doesn’t matter if you are the best dentist in the world—with the wrong tools, the outcome will be suboptimal. Too often, dentists limit their abilities by only using the tools they used in dental school, or those that they are comfortable with. For dentists who want to avoid chasing the bite, I recommend the following tools:

T-SCAN by tekscan

As noted, without information about timing and force, it is nearly impossible to accurately understand what is happening with a bite.

We’ve all experienced this: a patient comes in with a complaint that they are hitting hard in one place, so we adjust it, and then they report that the problem has moved to a different area. Without a T-Scan to show timing and force, dentists will chase the bite.

I have used a T-Scan for more than 18 years. It has been invaluable, particularly for large and complex restoration cases. The chairtime it saves more than covers the cost of the device.

With a T-Scan, a digital bite sensor transmits the timing and force of each tooth to a digital screen. The dentist doesn’t have to try reading smudges, because he or she has the exact information about where to adjust. Interestingly, the true problem area is seldom the area that the patient identifies.

A T-Scan allows dentists to make targeted adjustments and resolve problem areas definitively. Using the T-Scan to adjust orthotics works extremely well and can help balance the bites of patients with temporomandibular disorder (TMD) issues.

THE Dialite® Blue POLISHING CUP

A major cause of bite-chasing is over-adjusting one area, which then causes an additional adjustment in another area. I recommend that dentists relinquish the use of a diamond bur for occlusal adjustments.

With information from the T-Scan, I use the Dialite® Blue Porcelain Polishing Cup to make precise alterations. If dentists use a bur that takes off hundreds of microns at a pass, they can get stuck with over-adjustments that will have them chasing the bite, and may even compromise the outcome of the entire case.

TENSING: A SYSTEM RESET

An appropriate TENSing unit can help a patient’s muscles relax and get into the true resting position. Muscles are key kinetic elements of the mouth, and how they function when a dentist takes or adjusts a bite is critical.

Imagine a patient who is over-closed or stuck in a habitual malocclusion. The patient’s muscles have become unbalanced or strained because they have been trying to compensate for a less-than-ideal position. The worst thing a dentist can do is make adjustments while the musculature of the mouth is compromised or strained.

A TENSing unit subjects a patient’s muscles to a slight electric shock. The shock allows muscles to break out of the normal placement and find a natural position and tension. Once this state is achieved, taking or adjusting a bite becomes more accurate.

Not all tensing units are appropriate for dental use. Therefore, I recommend that dentists use a QuadraTENS unit with ultra-low frequency from BioRESEARCH Associates, Inc. This unit is specifically designed for fifth and seventh cranial nerve stimulation.

A BITE JIG

A bite jig is a great tool to use when dentists are changing the vertical on a large case. Its purpose is to maintain the patient’s new VDO during the sequential prepping process.

Arrowhead Dental Laboratory in Sandy, UT, includes a bite jig with a white wax-up for cases that are increasing the vertical of a bite. Using this tool ensures that dentists don’t lose proper VDO as they open the bite.

A bite jig works as follows:

1. Take full mouth impressions of the patient. VDO increases are determined by evaluating crown-to-root ratios, periodontal supporting structures, and desired occlusal schemes. Typically, VDO increases are 3–4 mm in the anterior region from maxillary central incisor to the corresponding mandibular incisor. This measurement from CEJ of the upper incisor to CEJ of the lower incisor is called the “Shimbashi” measurement. A normal Shimbashi reading is in the 16–18 mm range for Class I occlusions. The bite registration for VDO increases is called a “swallow bite.” The dentist will determine the new VDO and measure the increase with a Boley gauge.
2. A dental laboratory will mount the case and models to the new VDO with the use of the swallow-bite registration. The patient is over-closed (as shown in Image 1, below), and the lab will open the bite to the patient’s new VDO (as shown in Image 2, below).
3. The lab then fabricates a bite jig that will keep the patient’s new VDO during the prep phase (as shown in Image 3, below).
4. At the time of prepping, dentists should reline the bite as necessary to maintain new contact stops inside the jig (as shown in Image 4, below) and ensure the dentist doesn’t introduce inaccuracies that create a bite-chasing scenario. This bite jig will hold the postural position and relationship of the dentition in a 3D relationship of the determined VDO.
5. Each time a section is relined, the dentist must verify the new, determined VDO to make sure the patient is positioned properly in it. Once dentists have a systemic awareness of the mouth and the proper tools to help the patient, they then need a sound and replicable strategy to avoid chasing the bite. Here is the strategy I use on every case in which I open the bite on the upper arch:

STEPS TO OPEN A BITE

1. Try in the bite jig to verify fit; write the VDO on the bite jig and mark the midline.
2. Try in the reduction guide to evaluate reduction needs.
3. Determine the new tissue height on the gingiva to achieve symmetry from tooth numbers 5 to 12. Utilize a tissue laser (CO2) to contour the gingival margins. If tissue corrections are done, re-measure for a new tissue-corrected VDO.
4. Prep tooth numbers 3 to 6 (keep the most distal posterior teeth and anterior four incisors as holding stops in the jig). Verify with the reduction guide. Cut retention grooves into the bite jig to help retain the bite registration and then reline the jig with bite registration paste on tooth sites 3 to 6. DO NOT OVERFILL. Verify the new VDO with a Boley gauge every time the reline procedure is done (i.e., tooth numbers 8 to 25).
5. Repeat and prep tooth numbers 11 to 14. Verify with the reduction guide and then reline the bite jig. Verify VDO (tooth numbers 8 to 25).
6. Prep tooth numbers 2 and 15, and verify with the reduction guide.
7. The bite jig now has crossbite stabilization holding stops at the new VDO.
8. There is no need to reline the bite jig again unless you can ensure that the bite registration material will not seep into the already relined bite. This can distort the bite and cause the VDO to increase.
9. Prep tooth numbers 7 to 10, then verify with the reduction guide.
   • Follow mesial inclination of the teeth
   • Save the cingulum, if possible
10. Cut a retention groove into the facial wall of the bite jig.
11. Add the bite registration material on tooth numbers 8 and 9, and capture with a horizontal bite stick record that is parallel to a true horizontal. Once the restorations return from the lab, do a try-in before bonding or cementing.
12. During the try-in of the restorations, do the following:
    • Try-in the posterior molars and second bicus-pids on both sides.
    • Ask the patient to gently close, and watch the occlusion bilaterally to confirm that the teeth contact simultaneously.
    • Verify the new VDO with a Boley gauge. It’s better to be above the new VDO goal than below it. Adjusting the posterior segments will reflect a rapid decrease in the anterior measurement (a 1:2 ratio change).
13. Continue the try-in of the anterior segment and verify long centric parameters (anterior/posterior direction or “freeway” space).
14. Get final approval from the patient, and go to the cementation sequence. Once the restorations are secured, only light occlusal adjustments should be done. Wait 48 to 72 hours to take more defined occlusal refinements using the T-Scan. For the first occlusal refinements, clear the anterior segment (tooth numbers 6 to 11) and establish freeway space in an anterior/posterior direction. This can be done with shim stock or Accufilm®. The dentist should pull the material through when the patient bites in their new centric bite (also called centric occlusion).
15. Next, check the posterior segment. Look to see if timing and force are balanced left to right. The centric stops should be on the cusp tips, the marginal ridge, in the valleys, and the upper lingual and lower buccal cusp tips. Occlusal contacts on any incline slopes is not a centric stop—those are typically deflections that must be adjusted.
16. Use the T-Scan to verify how both sides are coming in as the patient bites. The goal is to come within 5 percent left to right or .04 of a second, left to right. Total occlusal forces should be close to a 50:50 balance. Once in that range, any adjustments should be done with a polishing cup (Dialite® Blue Polishing Cup).

Dentists must have a strategic approach that they follow, no matter how comfortable they become with large-case dentistry.

CONCLUSION

I regularly get calls from clinicians who have done the work to foster a systemic awareness and who have acquired the right tools, only to lose a patient’s bite because they took a shortcut or skipped a step. This is why dentists must have a strategic approach that they follow no matter how comfortable they become with large-case dentistry. A choreographed routine is a must. Chasing the bite is something that nearly every dentist encounters but doesn’t need to keep repeating. With sufficient knowledge, the right tools, and a foolproof strategy, chasing the bite can become a thing of the past. Sink your teeth into that!

The past few years have tested our collective strength, but they have also served as a catalyst for transformation and growth. As we return to print publication, we would like to share a bit about the journey that led us here, as well as eagerly anticipating the opportunities that lie ahead.

The decision to pause print publication during the pandemic was not taken lightly. It allowed us time to reevaluate our mission, reassess our content strategies, and rededicate ourselves to communicating the principles that are at the heart of the Dr. Barnes philosophy. We seized the moment to redefine our identity, ensuring that the return to print publication would also be marked by a renewed commitment to delivering meaningful, relevant, and engaging content. Our goal is simply, in the words of Dr. Barnes, “to help dentists become better and more productive.”

In the words of Dr. Dick Barnes, our goal is simply “to help dentists become better and more productive.”

To those who have been avid readers of Aesthetic Dentistry magazine in the past, welcome back! You might notice a change in our format. Rather than covering a range of industry-relevant topics, we’ve focused the magazine’s content primarily on the types of large-case dentistry that Dr. Barnes said “walk through the doors of every dental practice on a daily basis.”

Going forward, and on an annual basis, Aesthetic Dentistry will share the stories and outcomes from dentists who are practicing the comprehensive dentistry that is at the heart of everything Dr. Barnes did and believed in.

Our return is a celebration of the power dentistry has to change the lives of practitioners and patients alike. In this issue, the stories reflect the struggles, insights, and triumphs of dentists like you, who strive to provide the best outcomes for your patients. The narratives demonstrate the importance of building a support structure of mentors, working with a skilled dental laboratory, and enrolling in continuing education training that empowers dentists to constantly evolve their skills in pursuit of excellence.

From tales of personal progression to narratives about the challenges of helping patients understand the value of comprehensive dentistry, each page contains a testament to the strength and vitality of the dental profession.

To honor him, we are committed to telling the stories of dentists like you.

As the executive editor of Aesthetic Dentistry, I invite you to join us in rediscovering the joy of dentistry and the shared experiences that make this a rewarding profession.

The return of Aesthetic Dentistry magazine is an affirmation of Dr. Barnes’ core belief that every patient deserves the best dentistry, regardless of their perceived ability to pay for it. The life and philosophy of Dr. Barnes has been a beacon of hope for many dentists who felt trapped by the limitations of their circumstances.

As such, we felt it would be appropriate to feature our founder on the cover of this issue, to remind those who knew him of his legacy and to introduce him and his ideas to the new dentists who are the future of this industry. To honor him, we are committed to telling the stories of dentists like you, who push beyond the confines of their limiting beliefs to create dental practices that deliver life-changing dentistry every day. We sincerely thank you, our readers, for your patience and support during our hiatus. Together, let’s embrace the future with optimism and a commitment to becoming better at what we do each day. Welcome back to a revitalized and re-imagined magazine! We’re ready to embark on this journey with you.

At Mile High Smiles, my practice in Lakewood, CO, we held a contest in which the winning entry received a total smile makeover. We made the contest available to entries from anyone in our surrounding area.

A SUCCESSFUL MARKETING CAMPAIGN

The first thing we did was get the word out—we needed to attract the most candidates possible. We reached out to a popular local morning radio show in our area, whose disc jockeys were patients at our office. They helped promote our contest on the air. We also sent out email blasts and posted the contest on social media outlets.

Ideally, we wanted a patient who truly needed a makeover. We stipulated that candidates could
nominate themselves or someone else who was deserving of a smile makeover as long as they completed an application and explained why the applicant needed it.

Candidates submitted applications through our practice’s website. Our web designer set everything up online, so it was easy to enter. Ultimately, we received more than 250 applications, which was a great response. We then asked an independent panel of judges to narrow down the candidates to five finalists.

I asked each finalist to visit our practice and submit to a health assessment so that we could ensure they were healthy enough for treatment. The candidates came in not only for a dental assessment, but also a medical one. Fortunately, all the finalists were healthy enough for dental treatment and we administered a full, comprehensive dental exam and X-rays on each finalist.

Afterwards, we posted stories about each of the five candidates on our website. Then we asked the local radio station to drive interest by asking people to vote for their favorite candidate on our website. We also publicized our contest on our social media channels and via an additional email blast to garner as many votes as possible. The period of voting was held for about two weeks, the votes were tallied, and the winner received a $50,000 smile makeover from our office.

THE WINNING PATIENT

The winner was a young man in his mid-twenties (see photos on page 12). While he was growing up, this particular young man encountered some difficulties that affected his dentition. He was in a bike accident at a young age, and he hit the ground and knocked out (or at least severely chipped) his front teeth.

At the time, his parents weren’t able to afford dental care to fix his teeth, so the patient was bullied about them. He didn’t take care of his teeth very well because he was so ashamed of them. He had several untreated cavities.

As a result of his embarrassment, the patient didn’t smile, and he tried to hide his teeth. In the past, whenever he visited a dental office and learned how much work needed to be done, it was overwhelming, so things kept deteriorating.

TURNING THINGS AROUND

At the initial visit, we did a thorough assessment, which included evaluating the patient’s teeth, periodontium, occlusion, and temporomandibular joint (TMJ). Due to extensive decay, poor periodontal health, and missing teeth, a comprehensive approach to treatment was crucial. We took radiographs, intraoral photos, full mouth perio charting, and an occlusal analysis with the iTero intraoral scanner and T-Scan to assess the patient’s dental health.

After gathering this information, we developed a treatment plan and presented it to the patient. I consulted with Arrowhead Dental Laboratory in Sandy, UT, to ensure the results were predictable and possible. Together, we discussed what types of materials to use for the restorations and our goals for the occlusion.

To help establish a better plane of occlusion (over time, the patient’s occlusion had changed significantly due to missing teeth and some anterior teeth that had broken off at the gumline), a full mouth reconstruction was warranted. The patient opted for individual crown and multi-unit bridges to replace missing teeth and establish a better occlusion. In addition to this plan, we gave the patient options for dental implants.

Because his front teeth had been knocked out, other teeth grew into that space, and it affected his bite. I worked to re-establish the bite before working on anything aesthetic.

I have taken several continuing education (CE) classes on occlusion, including Everyday Occlusion with the Dr. Dick Barnes Group. Therefore, I knew to begin the patient’s treatment by taking specific measurements and finding his current Shimbashi measurement. I felt fortunate and confident when discussing his occlusion with the experts at Arrowhead before making any final decisions.

Throughout the process, we used Arrowhead’s white wax-up, prep guide, and putty matrix for the custom temporaries. After treatment-planning the case, I communicated my expectations to Arrowhead’s lab technicians.

Once the preliminary work was healed on the patient, we prepped his teeth for a full mouth rehabilitation. We decided to do all the work in one day. It was a long day. The patient came in early, and we started work around 7 a.m. We worked for more than 12 hours on his mouth. We decided to use oral conscious sedation to help the patient tolerate being in the dental chair for so long.

 I did extractions of tooth numbers 7, 8, 9, 10, 20, and 29. Then I did bone grafts in the extraction sites to help preserve bone in that area and to try to maintain a good architecture for the pontic teeth once they were restored.

About midday, we took a break and gave the patient a protein shake to keep his blood sugar levels up. Then we went back to work and continued until about 8 p.m. By the time we finished, we had completed extractions, bone grafts, root canal therapy, and crown and bridge preparations. The patient had a new set of temporaries on his uppers and lowers, and his bite was in the correct position.

A PERMANENT NEW SMILE

For the first time in his life, the patient could smile proudly. We took a video of his wife looking at him immediately after the procedure. She held his face in her hands with tears in her eyes. Of course, everyone else in the office teared up too. Even though the patient just had on temporaries, it was rewarding to see him with a full set of beautiful, functioning teeth.

The next day, we called the patient to ensure that he was feeling okay. Somewhat surprisingly, he responded that his mouth was not sore, and he was not in any pain. The only pain he felt was “because of smiling so much.”

We did the work on a Friday, and we asked the patient to return to the office the following Monday, after the anesthesia had worn off, so we could verify his occlusion. We used articulating paper to check his occlusion and ensure everything worked properly. We planned on taking a T-Scan of his bite after the permanent restorations were seated and his bite settled in. But with the temps, we just wanted to make sure he was touching evenly and that nothing was off in terms of margins, contacts, or occlusion.

The patient remained in temps for about six to eight weeks. He wore the temporaries a little longer than we normally recommend because we wanted his soft tissue to heal as much as possible. We didn’t want him to end up with shrinkage after the final seating—where he’d get gaps or spaces between the pontic. We were patient and waited about three months before proceeding. This time allowed the patient’s soft tissue and bone to heal.

Finally, the patient returned to our practice, and we seated his finals. It was a great day and there were no surprises. My team and I went about our work, taking our time, and everything went smoothly. I give credit to Arrowhead because a lot of the pre-operative details (getting good wax-ups, measurements, and planning) were essential to the success of this case. The team at Arrowhead were a big help throughout the treatment.

We seated the patient step-by-step using the protocol that I learned from Dr. Jim Downs in the Full Arch Reconstruction course, and it all went smoothly. I had done full mouth cases before, but never the way that Dr. Downs recommended. Now that I follow his method, it’s a lot easier and more predictable.

CONCLUSION

After the makeover, the local radio station invited the patient on the air to talk about his experience. It was fun to hear him tell the audience all about it. The patient said he felt so much more confident after receiving his new smile. He kept thanking us over and over again—telling us what a blessing it was to have a smile that he could be proud of.

Since that time, the patient has been coming in regularly for his cleaning and maintenance. My team and I educated the patient that nothing would last unless he took good care of it. The team spent a lot of time explaining the importance of home care. It’s been a great experience to see the transformation in this patient’s teeth and in his life. And personally, it was nice to help someone in need. I’d love to be able to do it again someday.

THE IMPORTANCE OF PLANNING

We started Lauren’s case by taking a complete set of 11 photos and upper/lower vinyl polysiloxane (VPS) impressions to use for diagnostics and treatment-planning. For me, photos are a critical component for achieving a predictable result. Photos help not only in planning the most ideal smile proportions, but also in communicating more effectively with the dental lab.

Our photo series includes:

• Full face, smile
• Full face, retracted
• Full face, repose (slightly open with lips relaxed)
• Close-up, smile
• Close-up, repose
• Close-up, retracted front view with teeth together
• Close-up, retracted from right with teeth together
• Close-up, retracted from left with teeth together
• Upper occlusal view (using mirror)
• Lower occlusal view (using mirror)
• Profile view

Over the years, I’ve heard many opinions about ideal smile proportions, such as the “Golden Proportion” or the “Recurring Esthetic Dental (RED) Proportion.” I’ve concluded that no one proportion works for all patients all of the time. Examining photographs with calibrated measurements allows me to better customize proportions to each individual patient’s facial profile, skin tone, gender, and age.

For years, I used templates in Keynote or PowerPoint to design a patient’s smile. While this approach has worked well, some newer applications for digital smile design (DSD), such as SmileFy (which we use), have streamlined the process and also provide a way for improved patient communication and increased case-acceptance. DSD photos show patients what is possible and allow for patient input.

THE TWO ESSENTIAL PHOTOS

Although I encourage taking a full set of diagnostic photos, the two photos I use most often are: full face, retracted and full face, smile. These two photos can quickly be taken at a patient’s initial exam and later be imported into DSD to begin a preliminary 2D smile design. Existing tooth proportion measurements can be acquired intraorally, or from models that were taken at the initial diagnostic appointment.

With some basic training and practice, most 2D smile designs can be completed in about 10 to 15 minutes. Training sessions are available through the DSD app. After completion of a 2D smile design, I usually ask the patient to return to the practice to review a proposed treatment plan that includes a summary of procedures, timeline, and cost. The patient is also shown a before-and-after smile design proposal.

The proposed treatment plan creates excitement and builds value for the patient by showing what is possible. Patients often acknowledge that we have already invested time in their case before they have even committed to treatment. The preliminary DSD demonstrates our commitment and builds patient confidence, which ultimately results in a high case-acceptance rate.

My only word of caution is to avoid presenting a smile design that is not possible to achieve within your dental practice. On a computer screen, it’s easy for a general dentist to cover over diastemas, misaligned teeth, and severe gingival irregularities in order to create the “perfect smile.” However, such results may not be possible without orthodontics or additional specialized treatment.

When used properly, DSD can help determine when additional treatment such as orthodontics or crown-lengthening may be indicated prior to reviewing the case with a patient. This helps dentists avoid unwanted surprises down the road and establishes realistic expectations for the patient.

Lauren had seen many digital smile designs, but it was exciting for all our team members to see her possibilities for treatment. While we knew that she would need aesthetic crown lengthening, DSD allowed us to determine how much we would need to modify her gingival contours and request that it be incorporated in the white wax-up. We also realized that although her front teeth were short, her incisal edges were in approximately the correct position.

I took Lauren’s measurements and put them on the final screen of the DSD app. I then took screen shots of the image for communication with Arrowhead Dental Laboratory. This enabled us to clearly demonstrate that her central incisors needed to be lengthened in a gingival direction by about 3 mm, and her lateral incisors by about 1.5 mm. Her central incisal edges would only be lengthened by <0.5 mm and contoured ideally.

LAUREN’S TREATMENT

Once the diagnostic wax-up was completed with the requested proportion changes shown in DSD, Lauren was scheduled for aesthetic crown lengthening. The clear preparation guide that Arrowhead provides with each white wax-up is an excellent way to measure and mark the proposed gingival heights prior to the initial gingivectomy.

In Lauren’s case, due to the extent of gingival recontouring, I knew she would require bone recontouring in order to preserve a 3.0 mm biologic width. After six to eight weeks of healing, Lauren was ready for preparation of her veneers. However, due to an extremely busy time in our practice, we waited almost a year before prepping her Elite porcelain veneers.

During that time, we preserved her biologic width during the crown lengthening so the tissue would remain in the desired position until we were ready to begin our prosthetic plan. We would have seen significant tissue rebound of the gingiva if we had not respected the ideal 3 mm biologic width through bony recontouring.              

When prepping Lauren’s teeth for veneers, I used a diode laser to make minor refinements for gingival contours. I also used a
Sil-Tech® matrix to place a bisacrylic temporary material onto the unprepared teeth as a mockup. This process enabled us to verify that our provisional was similar to the previously planned DSD. This step is a predictable one because we carefully plan our cases using the DSD process, and we always verify the proportions when the wax-up returns from the dental lab.

The mockup gave us a matrix to make 1.5 mm incisal and 0.5 mm facial depth cuts through (see above). The depth cuts were marked, and the teeth were prepped through the mockup material until the marks were gone. This helped prevent over-prepping and ensured that the majority of the preps remained in enamel and therefore had a stronger bond for the final restorations. At that point, adequate reduction was also checked using the clear reduction guide for crown lengthening. A full arch impression was taken using Indentium® (polyether siloxane).

Provisionals were fabricated using the Sil-Tech® matrix from our white wax-up. It is extremely important to ensure that the matrix is seated on the palate without applying firm pressure over the incisal edges because this can result in over-seating and shortened anterior teeth.

Once Lauren was 100 percent sure that she was satisfied with her provisionals, we took a VPS impression. The lab was instructed to use this impression to index the provisional incisal lengths and positions for the final Arrowhead Elite e.max® restorations.

In less than a month, the final Elite e.max® restorations were delivered to our office. As Lauren’s preps were kept primarily in enamel, we were able to use minimal local anesthesia, which allowed her to smile and view and approve her new restorations prior to bonding.

We also took photos of the restorations tried in with Variolink try-in paste. This allowed the patient to take a second look without the concern of a veneer falling out. Once Lauren confirmed that she was fully satisfied, the preps were isolated and cleaned with Consepsis and GLUMA was placed for desensitization. The final restorations were placed using Variolink Esthetic LC.

THE RESULTS

For years, our dental practice has been fine-tuning its systems in an effort to provide the highest quality care in a predictable, streamlined, and highly profitable manner. Digital smile design has been one of the most significant contributions to this ever-evolving challenge. It has enabled us to improve our communication and increase our case-acceptance with patients. Patients now have the opportunity to communicate their input prior to our office sending out materials for the diagnostic wax-ups, helping to ensure that we achieve the patient’s desired smile. With DSD, the results are more predictable.

Having one of our own team members experience this process personally has further affirmed the value of an organized and predictable protocol for delivering a smile design and makeover. Lauren felt that she was truly a part of the treatment process and had the opportunity to give her input along the way.

I encourage anybody who is interested in enhancing their cosmetic results to consider trying a few cases using a DSD application. Additionally, consider giving one of your committed team members the opportunity to have his or her smile redone at a reduced cost. Not only will it give you a chance to refine your smile design system, but it will speak volumes to your patients about the confidence your team has in your work. Most importantly, have fun! When results become more predictable, dentistry becomes more enjoyable. Watching Lauren’s case from start to finish was fun for our entire practice—and we were happy to see her beautiful new smile.

Although I didn’t know exactly what to do, I knew something would eventually have to be done. After dental school graduation, I recognized that I still didn’t quite have all the knowledge I needed to fix my issues. So I went to work and started actively pursuing additional educational opportunities.

LEARNING NEW SKILLS

About six months out of dental school, I met Hernan Varas, who is a Practice Development Executive at Arrowhead Dental Laboratory and the Dr. Dick Barnes Group (DDBG) in Utah. Hernan invited me to attend the Full Arch Reconstruction course. While I was there, I also met Dr. Jim Downs, the course instructor. During that class, I learned a process for restoring severely worn cases.

After the course, I was able to help my patients with full arch dentistry. My dad was the first full mouth rehabilitation case I ever did. It was gratifying to be able to offer additional treatments that helped my patients with severe dental conditions.

In the meantime, I knew my own dentition was worsening, but like many patients, I put off treatment. At the time, I was only 30 years old, and I was busy. For 10 years, I toyed with the idea of going to Dr. Downs’ practice in Colorado and having my teeth restored, but it didn’t happen.

About five years ago, I hired Dr. Heston Farnsworth as an associate in my dental practice, and Dr. Downs said, “You should ask Dr. Farnsworth to restore your teeth.” But somehow it still didn’t happen.

As time went by, my symptoms kept getting worse. I had headaches every day. And jaw pain and neck pain too. I even started to have some vision changes. When I had those headaches, I would lose some peripheral vision. It was a battle every day.

MAKING THE DECISION

Early in 2022, I visited Arrowhead and chatted with Kent Garrick, Director of Technical Services, about my symptoms. He said, “Doc! It’s time for you to do this.” Then Peggy Nelson, Arrowhead’s Director of Business Development, overheard our conversation and said, “Dr. Tomlinson, why are you waiting?” In all honesty, I wondered if I really deserved it or if I wanted to spend the money. But after I left Arrowhead, I kept thinking about what Peggy and Kent had said.

Not surprisingly, my symptoms got progressively worse. Each day, I took medication to get through the day. In April of 2022, I decided to have my impressions taken. I talked to Dr. Downs and said I was finally ready to get the work done.

I decided to get my treatment done during the August 2022 DDBG Clinical Hands-On course. During the class, Dr. Downs mentored Dr. Farnsworth throughout my treatment. It wasn’t Dr. Farnsworth’s first full mouth rehabilitation case. He had actually worked on his dad too.

Dr. Downs suggested that we do the full mouth in two days. Typically in the Clinical Hands-On course, they don’t do a patient’s uppers and lowers in the same course. But we decided that Dr. Farnsworth would prep my upper arch on the first day, and prep the lower arch on the second day.

OPENING MY BITE

When Dr. Farnsworth looked at my impressions and mounted the models, he noted that I had a Shimbashi of about 11 mm. In other words, my bite was collapsing. So the team at Arrowhead made an orthotic for me to wear prior to the course, which opened my bite to a Shimbashi of about 16 mm.

When I first inserted the orthotic, it felt huge. I put it in in the morning and just tried to get through the day with it. I worried that if I wore it at night, I might pull it out. The first day I wore the orthotic, I spoke with a lisp all day. The lisp lasted for about three weeks, but I didn’t care. I was determined not to give up.

After two full days with the orthotic, I noticed my headaches starting to fade away. Soon, I was no longer taking medication for my headaches. My jaw pain was also beginning to diminish. After about three weeks, I no longer had any jaw or muscle pain.

I never managed to eat with the orthotic in place—that was too difficult for me. So I removed it to eat, and by the end of the meal, I inevitably started to feel muscle and jaw pain. I was always anxious to put the orthotic back in when I finished eating. In total, I wore the orthotic for just over three months before the Clinical Hands-On course.

I was concerned that opening my Shimbashi 5 mm might make my teeth look awkward or that it would permanently affect my speech. But after I became comfortable in that position, I didn’t want to go back to anything less. I didn’t mind if my teeth looked different because it felt so good to be out of pain.

PLANNING THE CASE

When planning for my restorations, I relied on the team at Arrowhead. I wanted a natural look. I mentioned some cases that I liked, and the lab took it from there. They made my laterals a bit bold, and Kent said, “Take a look—we can soften them if you want.” But I liked the look and I knew it would turn out great.

THE PATIENT EXPERIENCE

I flew to Denver, CO, for the Clinical Hands-On course on August 26, 2022. The first day, there was a morning class for the doctors and Dr. Downs included me in that instruction. Then, as Dr. Downs often says, it was “go-time.”

I had 3D X-rays taken to confirm the plan. After everything checked out, Dr. Farnsworth began prepping. He prepped the upper arch first and then fabricated the temporaries. After the temps set for two minutes, he pulled them off, sectioning them into three sections.

He did the posterior right, posterior left, then the anterior segments, and trimmed it all up so that it would fit onto my preps. To hold everything in place, Dr. Farnsworth put them on with Vaseline®, which worked with suction and allowed me to eat dinner that evening. The next day, the upper temps were easily removed.

When we got to the course, Dr. Farnsworth numbed me up on the lower arch but didn’t numb anything on the upper arch. And then he prepped the lower sections, just like he did the uppers. Dr. Farnsworth pulled the temporaries off the upper and relined my bite with the bite registration from the previous day. And then he put the temporaries back in to protect my teeth from the sensitivity of the hand piece and the air piece.

Dr. Farnsworth then prepped the next section. Once the preparation was done on the lower arch, he took the final bite with the temporaries off. He cemented the temps with Telio® Link on the uppers and used the shrinkwrap technique that he learned at the Dr. Dick Barnes Group’s Full Arch Reconstruction course (with the Sil-Tech® matrix) on the lowers.

Throughout prepping, I felt no pain. I didn’t take any medication for the procedure, and I didn’t need any. About 15 minutes into the procedure, I felt so comfortable, I fell asleep! As a patient, it was much easier not to have the upper and lower arches done in one long day. I came in, they numbed me up, they left the temps on until the end and then took them off to capture my bite, and that was it! It took about six hours to prep the upper arch on Friday and four hours to prep the lowers on Saturday.

As a dentist, I’ve done both arches in one day for patients, but it makes for a really long day. Splitting up the treatment over two days is a great alternative.

THE FIRST REVEAL

When all the prepping was done, Dr. Downs asked me to look at the temps in the mirror. Seeing my new smile was surreal. It exceeded all my expectations! As I looked in the mirror, I felt like I could see all the hard work from everyone who contributed to my case—I felt like I could see all the effort, planning, and experience that went into my treatment.

I felt grateful to the technicians at Arrowhead because they took a lot of pride with my case. I was also thankful to Dr. Downs for making an exception so that I could get both upper and lower arches done in the same course. Of course, I felt gratitude for Dr. Farnsworth because he was willing to do my work. We had two dental assistants there, and one of the assistants has been with my practice for 14 years. It was fun to watch them work from a patient’s perspective.

I knew my new teeth were going to look good, but I didn’t know they were going to look that good—and it was just the temps! They looked like the best version of my smile that I’d ever had.

After the class, I went back to the hotel and FaceTimed my wife, who I’ve been married to for 23 years. I was so excited to show her the temps. She said, “Who are you? You don’t even look like my husband!”

With the temps, I felt better overall and had better chewing capability. Eliminating the headaches was the biggest change, but other things improved too. I had more energy and even started a workout regimen!

THE PERMANENT RESTORATIONS

In October of 2022, Dr. Farnsworth and two of our dental assistants (Chey Lynn Long and Shaylin Vincent) returned to Denver, CO, for the second part of the Clinical Hands-On course—seating the permanent restorations.

On the first day of this seminar, Dr. Farnsworth administered the anesthesia and then immediately removed my temporaries. He went through the process of sectioning the uppers and removing them carefully so that none of the gingival tissues were nicked.

I took good care of the temporaries at home because some of my patients have not been so diligent with that. And I know that it’s much harder (if not impossible) to seat a case if the home care hasn’t been stellar.

My permanent restorations are made from all zirconia—e.max® Prime in the posterior and ZirCrown aesthetic in the anterior. The cement was Ivoclar ZirCAD resin-modified glass-ionomer cement. Dr. Farnsworth was able to cement everything (no bonding required), and he worked quickly. He was done cementing in about three hours.

I’m so happy with my permanent restorations! Roy Petersen, Arrowhead’s ceramics supervisor, made them, and they are amazing! When I saw the restorations for the first time, I could sense how much work, training, and years of experience were involved in my case. Roy was at the seminar, and I even got to meet his wife, so that made it a special experience.

The next day, Dr. Farnsworth took a T-Scan of my mouth. Tooth number 15 was hitting a little early. It was interesting because as a patient, I sensed the force in the tooth number 5 area, but the scan indicated tooth number 15. Dr. Farnsworth did a minor adjustment, and I could feel that my muscles weren’t quite ready for that. So he made some small adjustments on my teeth later.

LIFE WITH MY NEW SMILE

The response that I’ve gotten from people who know me is usually longer-than-normal stares. I can tell from their expressions that they’re trying to figure out what’s different about me. Only close family members and colleagues noticed my new smile immediately. I’m glad for that reaction because it’s exactly what I wanted. I wanted my restorations to look natural.

Another benefit of having my teeth restored is that I can speak to my patients with conviction about the process of a full arch case. I can say, ‘I know what you’re going through because I’ve been there too.’ I can better empathize with my patients about all of it—the uncertainty about the outcome, the worry about finances, and even the pain from leaving the dental work untreated. I can tell my patients with a surety that the procedure will change and improve their lives. It certainly changed and improved mine.

Not surprisingly, it wasn’t just the front teeth that were a problem. He had severe bruxism, which contributed to much of his dentition breaking down. He also had a collapsed bite, and the patient’s facial structure was brachiocephalic.

Having a less-than-ideal smile affected his everyday life. He was an outgoing person, but because of his broken teeth, he became very self-conscious and would not smile. He finally decided he was tired of feeling embarrassed about his smile. He said, “I’m sick and tired of looking and feeling like this. I want the best treatment for me.”

When I met the patient, I had just completed three continuing education (CE) courses with the Dr. Dick Barnes Group—the Everyday Occlusion course, the Beyond the Basics course, and the Full Arch Reconstruction course. After each class, I was able to implement new things into my daily practice immediately. The language I used to speak with my patients was different, and I looked at treatment in a new way. So when I met the patient and he was ready to move forward, I was grateful I had the knowledge and access to the best resources to help.

After a thorough exam and looking at the patient’s measurements, I knew that a comprehensive treatment plan would include a full mouth restoration. I was concerned about how he could get the finances for such a large case. But I presented the plan anyway, knowing it was what he needed for optimal care.

In their CE courses, the Dr. Dick Barnes Group teaches that every patient should receive the best treatment plan, regardless of their perceived ability to pay. They also teach that dentists never know when a patient’s financial circumstances may change, and as it happens, my patient had recently received money from an inheritance. Without hesitation, the patient told me that the first thing he wanted to do with his windfall was to get a permanent solution for his dental issues. We were able to move forward immediately with treatment.

STARTING TREATMENT

A full mouth case with implants is not a simple appointment. I explained to the patient that it would be a several-months-long process to get things done right. The patient’s concerns were primarily aesthetic, but we needed to address the functional aspects of his dentition as well.

The patient still had his wisdom teeth, but they were not a hindrance. We agreed to do work on his uppers and lowers, second molar to second molar. The patient accepted the entire treatment plan.

I worked with Arrowhead Dental Laboratory throughout the process and sent them the patient’s scans for a white wax-up. While Arrowhead worked on that, I tackled tooth number 30, which already had a root canal that was failing. I extracted the tooth and eventually placed an implant. The extraction was challenging because the patient had dense bone, but everything turned out great. After the implant healed, I showed the patient the wax-up and we were able to approve the direction for his new smile.

Next, I turned my attention to his severely collapsed bite. The patient’s bite had a Shimbashi measurement of about 12 mm, so I knew we had to open his bite fairly significantly—about 4 mm. Arrowhead made a removable orthotic to stabilize the patient’s bite and make sure the measurement of the opening was comfortable. I told the patient to wear the orthotic all the time for about six weeks. He also needed to adhere to a soft diet while wearing the orthotic. This process would test his muscles and make sure that we would restore him to the right opening, which ended up being a Shimbashi measurement of 16 mm.

The patient was compliant with wearing the orthotic and following the soft diet protocol. Soon afterwards, he explained that he was no longer waking up with headaches. He was comfortable with the position of the bite and even ate with the orthotic in. It took a couple of months to test everything before we could move on and work on the upper arch.

When it came time for treatment, I started by prepping the upper arch and placing the temporaries. I followed the sequence that I learned in the Full Arch Reconstruction class from Dr. Jim Downs. I printed out the sequence of what I learned from the class and placed it on the counter so it was visible to me throughout the procedure.

Treatment went smoothly. All the tools that Arrowhead provided, from the white wax-up to the temporary matrix and the reduction guide, helped the process go seamlessly.

After placing the temps, the patient was so happy with the upper arch, he was anxious to move on with more treatment. I asked him to wear a new orthotic on the lowers because I wanted to test his bite with the temps.

He came back to the office 72 hours after we placed the upper temps so that we could check the bite and make minor adjustments. A month later, we received the permanent restorations for the upper arch and seated them. Everything went well.

WORKING ON THE LOWERS

The week after seating the permanent restorations on the uppers, the patient returned to start work on the lower arch. At the time, I suggested doing a bridge with Snowcaps (temporaries made from Radica®) on the lowers, which would hold him for several months if needed. [Arrowhead now uses PMMA for a similar product]. But the patient didn’t want to wait, so I temporized the lowers. We tested the temps on his lowers for about a month.

About a week after cementing the temps, the patient experienced pain on tooth numbers 31 and 32, so I referred him to an endodontist. He needed endo treatment on tooth 31 and an extraction of tooth 32. The endodontist was able to do the root canals through the temps. Afterwards, I did the extraction on tooth number 32. After the tooth healed, I was able to cement the permanent restorations on the lowers.

The lowers were a bit more time-consuming than the uppers because a patient’s tongue is always a factor. But everything fit perfectly, just like pieces of a puzzle. The patient is now completely restored. We used Arrowhead’s e.max® Prime for the posterior restorations and traditional IPS e.max® for the anterior restorations.

I had a nocturnal orthotic made for the patient to wear to protect his permanent restorations. I also suggested he work with a physician to address some of the health issues that may have contributed to the breakdown of his original dentition.

RESULTS

As mentioned, the patient has worked at the same job for several years. After he returned to work with his new smile, he said, “People think I look so much younger and healthier.” He also said, “This was the wisest investment I have ever made for myself. Everyone has said that I am so lively now and back to my old self. I feel comfortable talking to people without being embarrassed and hiding my teeth. I haven’t felt like this in a really long time.” He was very emotional when voicing his appreciation. Overall, he is much happier, and it shows.

RECOMMENDATIONS

For any doctor considering a complex case, I recommend setting yourself up for success by double-checking that you have everything you need ahead of time. The week before I started working on the case, I made sure everything was fully in place for the large treatment. By taking time to ensure that everyone on the team knew their part and what needed to happen for the optimal outcome, we avoided any problems, and the process was easier for us and for the patient. On the day of treatment, I didn’t have to scramble to find anything; everything was set up exactly the way I wanted. In addition, everything Arrowhead provided made my job much less stressful and helped so much. I couldn’t be happier with the results and for my patient’s new smile

In December of 2020, when Bethany first visited the practice, she mentioned that she wasn’t happy with the appearance of her teeth, and she wanted to have everything checked out. During the exam, I discovered several cavities, and large fillings on nearly all of her teeth, and significant wear overall. Bethany had a tendency towards clenching her teeth, so there was attrition. On the lingual of her upper interiors, there was little to no enamel on the back due to erosion. Furthermore, because of the way her lower teeth were positioned against her upper teeth, there was no space to create aesthetic harmony without changing the vertical dimension. It would require enough treatment that we needed to talk about her function at the same time as the aesthetics that she was hoping to improve.

When discussing any large treatment with a patient, I try to be sensitive to the fact that it may be complicated for them to understand. I try to gain a patient’s trust by getting to know them, and then I move on to what they hope to accomplish with their teeth. It’s never about “just” aesthetics, or “just” function, or “just” health. It’s all of those goals together in a comprehensive plan. I love being conservative with my patients when I can, but that’s not what we encountered with Bethany.

When I mentioned my findings, Bethany was surprised. So I showed her some before-and-after work that I had done with Arrowhead Dental Laboratory. I started working with Arrowhead in 1999. I remember being introduced to the lab at a seminar that Dr. Dick Barnes held in Little Rock. After the event, I started using the lab, especially for large and complex cases.

With Arrowhead as part of our team, we are able to produce the positive outcomes that I want to offer to my patients. I am always pleased with the cooperation I get from the lab and the level of aesthetics we create for patients. For the past three years, I’ve worked with Jordan Johnson, a technical consultant at Arrowhead, and it’s a great relationship. I’ve always found the people at Arrowhead to be genuinely interested in getting the best results for each patient.

After seeing the before-and-after images, Bethany said, “Let’s do it.” So we figured out the financing and scheduled treatment.

GETTING STARTED

I started treatment on Bethany in July of 2021. Before prepping and placing the temps on a large case, I work closely with the lab and get a cosmetic and functional wax-up. I use that as my guide for making the temporary work, which makes it much easier on the day of the procedure. With a wax-up as a guide, I don’t have to create something freehand. It also gives the patient the ability to see where we’re headed with their smile.

I discussed smile selection with Bethany and mentioned that I typically use the Las Vegas Institute (LVI) smile guide, so she had a general idea about the direction for her smile.

With Bethany, I did all the preps for the uppers and the lowers in one appointment. During that appointment, she requested IV sedation, so we had a nurse anesthetist administer it. The team and I prepped tooth numbers 3 to 15, and tooth numbers 18 to 31. I used a technique with a leaf gauge to assess and capture the patient’s vertical. I opened her anterior vertical about 2.5 mm.

I also contoured Bethany’s gingiva in the anterior, approximately 1 mm of her gingival tissue, with a CO₂ laser to create more length. I usually plan for gingival contouring on the cosmetic wax-up. Even after the wax-up is done, I expect some areas to be adjusted so that when I make the temporaries, they’re based on where I expect the gums will be after gingival contouring.

I was able to prep Bethany’s teeth without any problems. The appointment lasted about six hours. And she was happy with the way everything turned out—even with just the temps.

LIVING WITH THE TEMPS

After the temporaries were in, I asked Bethany to return for a follow-up appointment so we could make any adjustments if needed. Whenever possible, I make changes directly on the temporaries. I might say to the patient, “We’d like to shape this back,” or “We could make this canine a little less pointed,” etc. When I fine-tune all the details on the temps, the permanent restorations go in much more smoothly.

I also checked Bethany’s bite and made sure that she was comfortable. It’s easier to check the bite on the follow-up visit rather than immediately after placing the temps when the patient is likely still groggy from sedation. I made two adjustments on tooth numbers 18 and 31 and had to take additional impressions for those two teeth. Otherwise, every-thing worked well. I generally always expect to make a couple of minor adjustments when treating a patient’s entire mouth.

Finally, we talked about what tooth shade Bethany wanted for her new smile. Bethany chose a shade of OM3, with a gradient. She stayed in the temps for about six weeks.

SEATING THE PERMANENTS

For Bethany’s permanent restorations, we used Arrowhead Elite restorations, which is why they look so awesome. She did not do IV sedation for the seating appointment (usually patients opt not to use full sedation for that appointment because there isn’t as much “heavy” work on the mouth).

The patient reported no problems with her temporaries, so we proceeded to prepare to seat her permanent restorations. For seating full mouth cases, I follow a protocol that I’ve used for a long time. It’s basically the standard protocol that I learned from the Dr. Dick Barnes Group (DDBG) Clinical Hands-On course.

I proceeded with treatment as follows:

BETHANY’S SEATING PROTOCOL

1. Take the temporaries off, section by section
2. Clean the dentin with Consepsis
3. Etch the teeth
4. Apply Telio® desensitizer
5. Use Adhese®
6. Prepare the restorations for bonding
7. Clean out the inside of the crown with Ivoclean
8. Use a ceramic etchant if it requires more etching
9. Try-in the crown and make any light contact adjustments as needed
10. Use OptiBond adhesive inside the restorations
11. Use Variolink® Esthetic cement to bond the crowns in place
12. Do an initial cure to get the cement to a gel state
13. Clear off any excess material and then floss and use an interproximal saw to remove any cement that doesn’t come off with floss
14. Finish the margins with a series of fine diamond burs, if needed

THE FINAL RESULTS

When the finals were placed and Bethany saw her new smile, she was as happy as can be! She loves everything about it! And now when she comes into the practice, she tells me that people constantly make comments about her beautiful smile.

Currently, Bethany wears a nocturnal occlusal splint to protect her dental work, and she maintains her new smile with regular hygiene appointments. Even though I don’t use social media often, within days finishing Bethany’s work, I noticed that she was posting photos of herself with her new smile. It gave her a new level of confidence that she couldn’t get from basic dentistry. As a dentist, it’s rewarding to hear positive remarks from your patients and to see them enjoying their new smiles.

Taking a smile from good to great is one of the most challenging cosmetic cases that dentists can encounter. It’s relatively easy to please a patient who has a terrible smile by taking that smile to “good.” But taking a case from good to great means the patient has higher expectations, which can make things more difficult.

With Aimee, she didn’t think her veneers “fit” her face. She said they seemed bulky and didn’t “fill in” her smile. From my perspective, I noticed that the veneers didn’t fill in her buccal corridors. She had a narrow arch and wanted a fuller and more symmetric smile proportionate to her face. Aimee mentioned that prior to veneers, she had undergone three sets of braces trying to “fix” her smile.

A SOCIAL MEDIA INFLUENCER

Aimee’s smile is especially important because her full-time career is on social media (AIMEE@planesandprettythings). She travels frequently and has a large Instagram following. She takes multiple photos of herself every day and overall, she didn’t feel good about her smile.

Aimee found me through Instagram. I had just started posting before-and-after cases on the networking app. I post on social media to attract new patients with virtual consult requests, and Aimee reached out for a consult.

In a virtual visit, dentists can show potential patients the possibilities with before-and-after photos of other patients and talk about prices, and then when the patient comes in, they are usually already sold. I’ve found the acceptance rate from virtual consults to be high. And that’s just what happened with Aimee. During a virtual visit, we discussed what might be possible for her, and she decided to return for an in-person consult, despite the fact that she lives in another state.

STARTING OUT

During the initial exam, I noted that Aimee’s teeth were functionally healthy—they weren’t breaking, they weren’t causing any issues, and there was no decay or anything like that. Her case was purely an aesthetic one. I realized that the case might be tricky because taking a patient from good to great means the dentist has to get it right and nail it.

After the exam, I recommended a few more veneers to widen the arch (10 new veneers in total) instead of just replacing the 6 she currently had. Her veneers went from canine to canine, and I suggested adding the premolars on both sides. It would fill out her arch and we could make things brighter and whiter like she wanted.

We also looked at different smile designs, including natural, Hollywood, and some other options. I wanted to make sure that my team understood what Aimee wanted. Like many patients, she said, “Oh, I didn’t know we had all these options.” I tried to set realistic expectations for what the process would involve. I also explained how I would work closely with Arrowhead Dental Laboratory throughout the procedure.

PHOTOS, COMMUNICATION, AND TESTING

To take a patient from good to great, it’s important to have good photography, excellent communication with the lab, and the patient’s approval after a “test drive” of the smile with temporaries. A lab with expertise in highly aesthetic cases is vital to the outcome.

With every full arch case, I start by taking good records. I take either alginates or a scan with our iTero to send to Arrowhead for an aesthetic white wax-up. The wax-up shows us what’s possible for the smile. With Arrowhead, I know they’re going to pay attention to the details, and they offer advice on getting everything exactly right. For example, on the alginate impressions, Arrowhead asked about gingival recontouring for Aimee and marked exactly where it should go.

Using digital photography and a photo application was helpful because I could draw on the pre-op photos to show the lab what they needed, based on the patient’s wishes. Another option for good-to-great cases is to use light-cured, unbonded flowable composite and create the smile chairside on the patient. To do so, place the flowable, then cure, shape, and smooth to the desired aesthetic result. Then take photos and an impression to communicate the expectations of the wax-up. 

Once the lab receives the preliminary models and/or a digital scan and photos, it is important to review the case with a technical representative at the lab. This step is a must for challenging cases in order to communicate the desired results in detail and problem-solve any potential issues. 

PREP DAY

When Aimee came in for the treatment, I was able to place the temps without any unexpected issues. I used the putty matrix that was provided by Arrowhead to place the temporaries. I like to add my final touches to perfect the smile with flowable composite and polishing discs. I also pack cord for almost all my crown/veneer preps. During the impressions, I place Kerr 2a GingiBRAID+ retraction cord. With this extra step, I know I can give Arrowhead a perfect impression with a 0.5 mm cervical margin, so that I can receive a perfect-fitting restoration in return. And I mean perfect—with zero adjustments. 

I like to prep the margin to the gumline exactly, then place cord, and finally re-prep to lower the margin 0.5 mm so it will be subgingival. I also take prep shade photos. Lastly, I ask the patient to return one week after they are in the temps to give them ample time to try them out. This ensures satisfaction is met. If something is unsatisfactory and changes need to be made, then at the one-week follow-up appointment I’ll add flowable composite and reshape chairside until expectations are met by both the patient and me.

If any changes are made, I take a new scan/impression along with digital photos and send everything off to the lab with the case. If significant changes from the wax-up are required, then a second phone consult with the technical rep is helpful. 

I recommended that Aimee spend a little more time in the temps than usual so she could get used to the new restorations and really contemplate any changes she might want for the final restorations.

With Aimee, because we wanted everything to be perfect, there were a couple of minor things she wanted to change on the temps. So, when she returned to the office a week after we placed the temporaries, I made a few adjustments: we changed the length on a few teeth and made a couple of teeth slightly larger using composite to widen the smile even more. I used the Luxatemp® bleach shade for the temporaries, and she loved that.

Aimee tried out the adjusted temporaries for another week to ensure she was happy with everything. When aiming for the highest outcomes, it’s beneficial to have patients in the temporaries for a trial run—they can try them out in their everyday life and show them to their friends and family for feedback.

Once Aimee was thrilled with everything, we took an alginate of the adjusted temps, poured it up, and took photos to send to Arrowhead so they knew exactly what the patient was looking for.

About a week prior to the seating appointment, I asked Aimee to use chlorhexidine as prescribed to help maintain her healthy gingiva and limit the potential of a bloody environment. If a patient uses chlorhexidine any longer than that, I find the temps begin to stain. 

THE FINAL REVEAL

When she came in to have her case seated, everything went smoothly. At delivery appointments, if any bleeding is present once the temporaries are removed, cleaning the teeth with chlorhexidine is my preferred treatment. I use peroxide on a cotton pellet or GINGI-PAK®.

With highly aesthetic cases, I typically try-in on the patient without using try-in paste. I ask the patient to approve everything first, and then I bond the restorations on using Monobond and Variolink® Esthetic light-cured adhesive cement with DeOx barrier from Ultradent. This prevents formation of the oxygen-inhibition layer of the surface of the resin material when polymerized. 

Aimee’s final shade was an OM1 with some incisal translucencies. During the last step, I sit the patient upright and look at them straight on to ensure symmetry. If something is off, I’ll use polishing discs to reshape the final veneers.

After the seating appointment, Aimee returned to the practice to make sure everything was dialed in. I asked Arrowhead to make a nocturnal orthotic to protect her veneers. The results were great. She was floored with how her smile looked! She kept smiling a big smile. She said she loved everything about her new smile and hugged all our team members. I think it exceeded her high expectations, which was the best result of all.

When discussing treatment with my patient, I discovered that he is a third shift (late-night) nurse and a beta-tester of table games. He had developed poor sleep and diet habits due to his professional lifestyle, and he reported persistent acid reflux, grinding, and fatigue. We discussed the limitations of Invisalign® and also alternative treatment options. During this visit, I performed a comprehensive exam and reviewed digital photos and X-rays.

THE PROBLEMS

After studying the patient’s case, I observed significant mandibular occlusal and buccal posterior attrition and erosion. This resulted in decreased vertical dimension, reverse Curve of Spee, and deep anterior overbite. To further complicate the case, the patient had a congenitally missing tooth number 7, and in 2007, he had an implant placed at that site. I noted asymmetrical tissue formation of the implant restoration. The patient had 1 to 2 mm diastemas between all teeth, from canine to canine.

Given the patient’s entrapped bite and anterior implant, I determined that Invisalign® therapy may not fully achieve his goals. With that treatment, spaces would result somewhere in the upper arch given the constricted bite, and the anterior implant would limit the movement possibilities and aesthetic symmetry. Furthermore, Invisalign® could not correct his deep, entrapped bite, or rebuild the lost enamel that resulted in the loss of vertical dimension.

The patient returned to the practice for his diagnostic review. We discussed his desire to improve his smile by closing the spaces between his front teeth. I displayed his photos and discussed the extensive enamel loss to his lower posterior teeth, and I explained the significance of the erosion at such a young age. The patient understood that his bite was collapsing and shrinking his airway space. We talked about how his lower teeth were “trapped inside the garage” of the upper teeth and would cause forces that would contribute to further breakdown over time.

Although the patient had presented for an Invisalign® consultation, we talked about the limit-ations of that treatment in his case. I gave him multiple options to achieve his aesthetic and oral health goals. The patient chose to restore his entire lower arch and his upper teeth from premolar to premolar. He was absolutely determined to keep his teeth for a lifetime. The patient secured financing for treatment through personal funds and a loan from a family member, so he accepted treatment on the same day that it was presented.

GETTING READY

The most important factor in setting this case up for success was capturing the patient’s bite in the desired raised vertical dimension. I used a swallow-bite technique for this record—the patient swallowed and slowly closed on wax cubes until he achieved the desired Shimbashi measurement.

Communication with Arrowhead Dental Lab, our chosen lab, was also crucial to a successful outcome. We planned the case so that height was added to the lower teeth only, for a few reasons. First, the lower teeth had shortened over time from acid erosion and grinding. Adding porcelain to the worn teeth would rebuild them to their natural shape and correct the reverse Curve of Spee, allowing for proper occlusion and function. Second, the patient’s maxillary tooth lengths were pleasing within his smile, so we did not want to lengthen them.

PREPPING AND SEATING

At the first appointment, I prepped tooth numbers 4 through 13. I spent extra time recontouring the patient’s gingiva to improve symmetry. I used a laser to mold the facial tissue around the implant at site number 7 and by all the diastemas, so the emergence of the crowns would mimic natural teeth.

I then made the provisionals using a putty matrix. Arrowhead fabricated the matrix off the diagnostic wax-up. I love delivering temporaries in the desired shape and position to really allow patients to “test-drive” their smiles. I then overlayed the provisionals on the patient’s lower teeth. By doing this, I confirmed a balanced occlusion and protective eccentric function. We used a combination of Elite e.max® press veneers and crowns for this case.

At the seat appointment, I tried in all the restorations dry to confirm marginal fit and interproximal contact tightness. I then placed the Elite e.max® restorations with a try-in gel so the patient could stand and look at his teeth in a mirror for consent to the permanent cementation. I cleaned the Elite e.max® with Ivoclean Monobond® Primer and then bonded with the Adhese® Universal VivaPen® by Ivoclar.

Next, I isolated the patient’s upper teeth with a rubber dam. We then pumiced the prepped teeth, cleaned with Consepsis, etched and bonded again with Adhese®. I seated the e.max® restorations with Variolink® Esthetic LC.

The patient returned to the practice 48 hours later, when we checked his phonetics, occlusion, and eccentric contacts. Because minimal changes were needed, we proceeded with treatment on the lower arch.

Three weeks after placing the maxillary e.max® veneers, I prepped the patient’s full lower arch. For this process, the blueprint was laid by the diagnostic wax-up and provisionals, so the final restorations required minimal occlusal adjustments, and the patient reported that they felt natural immediately.

AN UNEXPECTED SURPRISE

One complication arose in the middle of the case. After the lower final impression was sent to the lab for the restorations, a possible distortion was discovered. I discussed how to remedy the situation with a lab technician, and we collaboratively decided to take a new final impression. This was somewhat frustrating and inconvenient for both the patient and me. Our patient was very understanding, however, and everyone wanted the best final outcome. So the patient returned to my office to fully remove his lower provisionals and get a new final lower impression.

In general, bonding a full arch of porcelain in one sitting is challenging. Moisture, bleeding, and multiple tiny restorations are some of the factors that make it tricky. My preferred technique is to use an Isodry® device to isolate and seat only the molars, so the restorations can be bonded in a dry field. Once those are fully cured, I place a rubber dam to isolate the teeth from the second premolar forward. The same materials and process were used to bond the lower teeth as I used for the upper teeth.

A SUCCESSFUL OUTCOME

I attribute the success of this case to two things—first is an education in full arch dentistry. Through the Dr. Dick Barnes Group and other continuing education (CE) courses, not only did I learn how to physically complete this case, but I also learned what to look for so I could properly diagnose and treatment-plan for a successful, long-lasting result.

 Initially, this patient came to my practice with spacing concerns and requested Invisalign®, which we could have given to him. But by digging deeper into the patient’s lifestyle and oral changes, we agreed that Invisalign® would not accomplish the patient’s goals. Instead, porcelain restorations were a better treatment option for his health and smile.

Second, Arrowhead Dental Lab has extensive experience with complex cases, including full arch dentistry. I provided them a detailed prescription and digital photos, and Arrowhead fabricated the tools I needed to complete the case successfully. With an experienced lab, I know the product I’m delivering to my patients will have minimal adjustments and my seat appointments will be stress-free. Arrowhead is truly elite.

This patient’s health and life have changed due to the treatment we delivered. He is a raving fan and a fervent referral source for our practice. His new smile has helped him in many areas in his life—he’s mentioned that he’s sleeping and breathing better. The patient is taking better care of his overall health, his eyes are brighter, and he’s more vivacious. He absolutely loves his smile and feels much more confident. It is so gratifying as a dentist to see such a positive result. While I love providing Invisalign® treatment, I am thankful for the CE training I’ve completed so that I can recognize when it will not be the best treatment modality.

SYMPTOMS OF OCCLUSAL ISSUES

The patient originally visited us because she broke the crowns on tooth numbers 19 and 30. She takes good care of her teeth overall, so she wondered why the breakage was happening. None of her teeth had ever broken before, but she mentioned that she had a root canal on one of the broken crowns.

Previously, she had some composite veneers placed, and since then she seemed to have more difficulty bringing her lower jaw into a comfortable position. The patient had worn those veneers for two years. She said that during that time, she felt like her front teeth were “hitting harder” than usual. But her foremost concern was her lower back teeth breaking down.

To understand the situation more clearly, I asked the patient a set of questions, including, “Do you feel like your lower jaw is being pushed back when you bite down?” And then I asked, “Do you feel like you have multiple bites?” She answered yes to both. From her answers, it became clear that she had an occlusal issue. The patient’s responses, her symptoms, and the clinical signs from a thorough exam led me to a diagnosis of anterior entrapment. After the exam, I did a diagnostic review to discuss her options for keeping her teeth for a lifetime.

The options included the optimal treatment of opening up her bite to give her lower jaw the freedom that it needed to function. The goal would be for her to eliminate her teeth continuously searching, clenching, and trying to push the jaw forward—resulting in a breakdown of the natural teeth. We talked about the jaw joint, the muscles, and the teeth, and how to get them all into harmony.

I noted that the previous dentist had added about 2 mm of tooth length in composite material with the veneers. Without that, the patient’s central incisor was 10.5 mm, an average length.

I put the patient in splint therapy for about two months to allow her jaw joint and muscles to settle into a comfortable position. If the jaw joint is not in the correct position and the muscles aren’t where they’re supposed to be, the bite will always be problematic.

THE IDEAL PLAN

I presented the patient with a treatment plan for full mouth rehabilitation that included full upper and full lower porcelain and zirconia crowns. I initially gave her an “ideal” plan, as Dr. Jim Downs recommends in the Dr. Dick Barnes Group (DDBG) continuing education courses. In general, if a patient can’t commit to an ideal plan due to finances or other constraints, I offer a segmented plan. However, this patient was able to proceed with the ideal plan immediately.

The first thing I planned for was opening the patient to the correct bite measurement. Her Shimbashi (length of CEJ to CEJ) was 12 mm. I planned to open it to 17 mm because of a favorable crown-to-root ratio.

I was adding vertical dimension, so the old composites were removed from her natural teeth and all the temporary restorations were able to be added without any tooth preparation. Temps over unprepped teeth were a great way for the patient to view her new smile before getting started. They were also used as a preparation guide.

THE FIRST FOUR APPOINTMENTS

During the first appointment, I prepped tooth numbers 4 through 13, we kept the molars in her overlayed provisionals for posterior stops, and then I re-temporized the front ten teeth. She returned a week later for the second appointment, during which I prepped tooth numbers 2, 3, 14, and 15 and took a final impression.

The upper arch took two appointments to prep, and during a third appointment I delivered the upper restorations. For the fourth appointment, I did the same process on the lowers: I prepped tooth numbers 20 to 29 and left the molars in the overlayed provisionals. When the patient returned to the office, I prepped tooth numbers 18, 19, 30, and 31, took an impression of everything, and re-temporized the entire arch.

Splitting up preparation appointments into multiple visits is a great way to help the patient if they are unable to sit in the chair for long periods of time. This patient preferred this method of treatment. We spent about three hours during each appointment. Asking some patients to stay in the chair for longer than that can be too difficult.

It is important to spend time making perfect provisionals, not only for tissue healing and the protection of the teeth, but also to provide the patient with a visible change from their original smile to the new one. Dentists can also use provisionals as a “test-drive” for functionality and aesthetics.

This patient stayed in her provisionals while Arrowhead Dental Laboratory in Sandy, UT, worked to get the final restorations done perfectly. Some colleagues wondered if the patient had orthodontics for this case, because some of the premolars were lingually inclined in comparison to the rest of her arch. The technicians at Arrowhead did a wonderful job of building out the crowns in zirconia and matching them with Elite e.max®.

For complex cases, it’s important to use a lab like Arrowhead. A great lab should not only have incredible ceramists, but they should also understand the pros and cons of different materials and have an expert knowledge of aesthetics and occlusion. This helps the lab provide beautiful, natural, and most importantly, properly functioning restorations.

SEATING THE FINALS

I seated the finals for the upper arch on one day and the lower arch on another day. I kept the patient in her temporaries on the lowers without prepping. I didn’t want the lab to build the uppers to her natural teeth; I wanted them to build them to the dimensions of the finals of her new lower teeth. So I put all of the temporaries on the bottom, then I took a scan of her lower arch with the temporaries on, and I took another scan with her final restorations on the top.

Once the occlusion was idealized with the lower overlayed provisionals, the patient returned to the practice, I took the temporaries off, prepped the lower arch, took an impression, and sent that information to the lab. With that information, the lab built the lower final restorations to the dimensions of the upper arch.

As mentioned previously, this case involved a large increase in vertical dimension. Therefore, the case was all additive, and there were many areas I did not have to prep because there was enough space for the restorative material. With the overlaid provisionals and Arrowhead’s reduction guide, I was able to see exactly which area of each tooth needed to be reduced and by how much. A reduction guide is such a valuable tool.

A LITTLE HELP FROM FRIENDS

The dental lab was extremely involved in this case, especially Arrowhead’s Technical Support Department. I always discuss my full mouth cases with technical reps, and they provide invaluable feedback on material choices and on how I can provide data to the technicians to help the case proceed smoothly. I’ve found that if I provide Arrowhead with quality information, they always exceed my expectations.

After the final restorations were placed, the patient was beyond grateful for everything. She’s my biggest advocate now! In the after photos, her facial shape seemed to change. If you look closely, you can see that her muscles of mastication relaxed, and she looks less tense.

With the knowledge provided by the Dr. Dick Barnes Group, the amazing lab technicians, and a great support team, dentists can provide an outstanding service to their patients. Not only is my patient happy with the aesthetics of this case, but she is functioning better than ever.