How to effectively treatment sequence any case

One of the questions I get a lot from dentists who have been through our classes, and they really are treatment planning their cases well, is, how do I sequence their cases? And sequencing the case correctly can help with profitability and predictability. So let’s have a few thoughts about that.

How do I sequence in way to test this out?

This is David. He has a little bit of wear in from what he says, but we can see, and he really knows he has a lot of wear that he has to solve. We can see the wear and the breakage almost on every tooth, and so we’re really looking to restore most of his mouth. How do we sequence that so that we end up with a good result? He has a deep overbite. This is very important to realize because we’re not going to be able to move these teeth out horizontally with that strong lip. We’re going to have to be very careful of that neutral zone. So how do I sequence this in a way to test this out? We must create an ideal occlusion. We know what an ideal occlusion is, stops on all the teeth and anterior guidance. It starts with those centric stops. We have to develop an anterior guidance that’s in harmony with the muscles, which is the envelope of function. We want the back teeth to disclude in every excursion, and we want it in the neutral zone. So again, what I want you thinking about as you’re listening to me today is, “How do I sequence this so that it comes out this way?” These are not new. They’re time-tested and research-proven principles. We know we do everything in our mind first, then we put it on our study models, then we test it in provisionals, and then we finish.

The 2D and 3D Checklist

So we’re going to follow that process as we sequence this case. Use the checklist and plan every detail. We’re going to use the 2D checklist, the functional aesthetic checklist, the 10-step 3D checklist as we work on our models. But what I want to emphasize today is that sequencing checklist that comes in right there between the 3D model work and the provisional checklist. So we look at David. His profile’s okay. We go through the wizard. I’m not going to show you all of the wizard. I’m going to pick out some key ones. Notice his smile doesn’t show much at all. Look at his rest. Doesn’t show anything. So we’re looking at maybe lengthening his front teeth a little bit. We can look at the gingival levels. We can use some help there with some periodontal work. We look at the width-to-length ratio, so we know we want to lengthen it and raise the gum a little. And also we look at the position of those teeth, the angulation, and also the golden proportion was important when we planned this. But all that goes on our models. So we can see here the 3D plan. Now that functional matrix is critical for this type of patient.

Sequence into phases

So how do we sequence this? Well, stage one, stage two, stage three is the way I like to look at it and the way I’ve looked at it for years. Stage one, you can see, it’s eliminate pain, emergency concerns, initial scaling, root planing, home-care instruction, carries control, splint therapy for pain and discomfort. Splint therapy to be sure we have a good joint position and a healthy joint position. That’s stage one. And then refer to specialist for evaluation. Not so much for treatment if it’s an orthognathic/orthodontic case, but for evaluation. Stage two, you can see we might do splint therapy just for position of the joint. We have equilibration. So in stage two, we develop an ideal occlusion. We refer to specialists for treatment if it’s orthognathics, orthodontics, whatever, and we do provisional restorations. So in stage two, we’re testing it all out. Very important when we sequence cases. Stage three then becomes easy. We just have to match that. But sequencing in stage three is critical also in that it moves ahead smoothly. So we can see that I like doing the lower interiors first, and the upper interiors, and then the posteriors.

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