A patient recently came to my office after visiting several other practices. He lives in Florida, but he does a lot of business in Texas, which is where my practice, Stonebriar Smile Design,is located. Initially, my colleague saw him as a patient and knew that the case would be complex, so she referred him to me.
During the first consultation for all new patients, I usually spend time trying to get to know them and understanding what their goals are for their dentistry. This particular patient had been through a divorce and was ready to start dating again. He is also an entrepreneur and owns many businesses. He wanted a new smile to help him with his confidence, professionally and personally.
The patient mentioned that other dentists had recommended orthodontics. But he was hoping for a faster alternative than braces because orthodontics would take a long time for the results that he wanted.
After our conversation, I agreed the best scenario would include braces. However, I suggested another option that wouldn’t require such a long time-commitment. I said, “This option requires a full mouth reconstruction. Let’s take some impressions, take some photos, and do a digital mock-up. Then let’s look at what we can get from Arrowhead Dental Laboratory in terms of a cosmetic wax-up to see what can be done.” The patient was immediately on board with the plan. He paid for the wax-up that day and couldn’t wait to return.
He was hoping for a faster alternative than braces because orthodontics would take a long time for the results that he wanted.
Two weeks later, the patient returned and saw the white wax-up from Arrowhead. We presented him with the full treatment plan and the fee. He immediately said “Yes!” We talked about any minor adjustments that he wanted to make to the wax-up. We decided that the cuspids on the lowers could be cut in a little bit farther, but from an aesthetic standpoint, and for what the patient wanted and needed, the wax-up was 100 percent what he hoped for. The patient “signed on the dotted line” and made an appointment to start treatment.
In the past, I’ve taken a lot of continuing education with the Dr. Dick Barnes Group seminars, and I’ve worked closely with the lab, so I’m an Arrowhead alumnus. I’ve established a great relationship with them that works to get my patients the best results. For a patient wanting a total change like this, I knew that Arrowhead could give us the exceptional results we wanted.
MAKING THE PATIENT FEEL SPECIAL
When a patient agrees to a full mouth reconstruction, it’s undoubtedly an investment. Therefore, I work hard to make my patients feel special. I want them to feel important because they are! So I use the best lab to get exactly what the patient wants, and I do not schedule anything else while I’m working on their case. We have lunch brought in for them on a silver tray because we want them to know that we’re going above and beyond to make their experience the best it can possibly be.
I worked with a technical support rep at Arrowhead to ensure that we could deliver what the patient wanted.
Before prepping this gentleman, I worked with Dave Frost, a technical support rep at Arrowhead, to ensure that we could deliver what the patient wanted. Dave and I discussed the case in detail before I commenced treatment. I told Dave about the patient’s wants, desires, and values (what was important to him). I said, “Please give me a reduction coping for the space that you need.” And Dave asked for cut-back on the cuspids.
I let the patient know that there was a possibility that he might end up with root canals on those two cuspids. I don’t ever make promises to my patients and then call the laboratory and “ask for forgiveness.” Instead, I always talk to the lab before treatment, and they are honest with me about what’s possible. I use the laboratory to help me be a better dentist.
PREPPING DAY
The patient asked to be sedated during the prep appointment. At that time, I used a laser to recontour the gingival tissue where it was needed. Arrowhead is great with regards to the symmetry of the gingival tissue height—it is even included on the diagnostic white wax-up.
Prior to the procedure and the administration of the sedative drugs, I reminded the patient that on tooth numbers 22 and 27 there was a possibility for endodontic surgery because we cut them back so far. But fortunately, as of this writing, the patient has been asymptomatic.
I didn’t have to open the patient’s bite at all—it was a completely aesthetic case. The patient didn’t have any parafunctional habits. However, where his cuspids were, he didn’t have any range of motion and was locked in, which did not allow for any excursive movement. The patient had no other dental treatment issues and there wasn’t anything else I needed to do from a perspective of extracting, placing implants, or anything else.
For full mouth reconstruction appointments, I always have two dental assistants working at all times. We “tag team” the patient, meaning we prep one side, change dental assistants for the other side, and then we follow the same procedure for the lowers. I have the assistants pack cord if we’re doing gingival contouring, but we don’t have to pack a lot because the laser is very hemostatic and we don’t end up with a lot of bleeding.
After we finished prepping the patient, he had full cuspid motion, even with his temps. I took a full upper and lower iTero scan of all the preps, as well as full upper and lower VPS impressions for back-up. I then took a second bite with the iTero to confirm the patient’s occlusion as a function of both force and timing.
I fabricated the temporaries from the diagnostic matrix that Arrowhead provided. The temps all went in at once—they were a solid piece for the uppers and a solid piece for the lowers. Finally, I polished the temps and did any tweaking that was necessary.
A benefit of treatment for a patient of a more mature age is that the nerves retract a bit. Before the patient left the office, I gave him a temporary orthotic that we made for him to use while he was in the temporary restorations. The appliance protected the temps and helped him get accustomed to the new smile. After treatment, we always provide a bite guard for the final restorations to protect the patient’s investment.
We started the procedure at 7 a.m. and worked until about 2:30 p.m. with a break for lunch. When the patient left the office, he was so happy!
I always talk to the lab before treatment, and they are honest with me about what’s possible. The lab helps me be a better dentist.
A TRIAL RUN
Three days later, the patient returned to review anything he didn’t like about the temps from a size or a shape perspective. During this appointment, I always hand the patient the mirror and we review each individual tooth, one by one. I’ll ask, “What do you like about this one? What don’t you like about this one? How do you like the gum recontouring? Is that high enough?” We check the bite too, and everything else we can think of, so this post-op appointment can last anywhere from 30 minutes to an hour.
During the appointment, I’ll educate patients about dental symmetry and the golden proportion because I want them to be a part of the decision-making process. There is always a minor difference from one side and the other on the diagnostic wax-up, and I’ll always ask the patient for their preference. Then I make a note of whatever we’ve decided on the prescription for the lab in the notes section. I’ll write something like, “Patient likes right side,” or “Patient likes left side.” We send the details to the lab for the fabrication of the permanent restorations. I have learned that all communication, even over-communication, provides the best outcome possible.
SEATING THE FINALS
After six weeks, the patient returned to the practice for the seating appointment. As he sat in the chair, he said, “I’ve gotten so used to my temps, I hate giving them up!” I responded, “You may hate giving up your temps, but you haven’t seen what you’re going to end up with.” I knew the final results would exceed even his high expectations.
Normally, I don’t like to anesthetize the patients when I’m seating because it makes it difficult to ensure that the bite is correct. In this case, the patient opted to not be sedated in addition to not being numb. Some of his teeth already had root canals, so numbing was not necessary. Additionally, the patient opted for no sedation because he was taking a flight back to Florida that evening.
I’ll usually plan on three to three and a half hours to seat a full mouth case. For this gentleman, we were done in about two hours. The lab sent three reduction copings because, as noted, his canines protruded out quite far on the lowers, and I trimmed them back fairly significantly to get them in line as much as possible. The lab sent the reduction copings to give the patient a little bit more room, so I was able to prep that area without the patient being numb.
Arrowhead also provided a seating guide that indicated a preferred tooth to start with, and then the best way to work from there. I rely on the lab to give me the information I need to make the seating appointment a success. And everything fit like a glove! I seated the restorations with 3M™ RelyX™ and cleaned up everything afterwards.
When we finished, the patient looked in the mirror and was ecstatic! The crowns ended up being three different shades, from OM1 to OM3, because the patient didn’t want a monochromatic look. We were going for characterization, and it worked.
When he saw the final restorations, the patient started tearing up, and then I did too! He said, “I’m now ready to get back in the dating world.” He was smiling from ear to ear!
CONCLUSION
A case of this caliber, where a dentist makes a lifetime change for a patient, doesn’t come along every day. I’m lucky that I had the opportunity to help this patient change his life for the better.
Even though this case was primarily aesthetic, a full mouth reconstruction treatment not only enhanced the patient’s looks, but also the function of his mouth. If he had kept his teeth in their previous condition, the patient likely would have encountered serious dental issues later in life. By doing a full mouth reconstruction, we set the patient up for good health and dental function in his later years. He can conduct his business and personal life with the confidence of a beautiful smile. I feel blessed to be his dentist.
