If you asked most of your patients if they would fix their teeth if money were no object, the vast majority would say yes. We all have patients in our practice that need our services and want to have the best that dentistry can do for them.

Patient's bottom row of teeth that are broken and worn flat on tops.

With the current economic trend more people are being frugal with their discretionary income. I don't know about you but I don't have a ton of patients with a bunch of cash set aside to fix their teeth.

How can we make it possible for them to have the quality care they want and make it feasible financially?

For the patient that wants the best but cannot afford complete restorative care at this time it's necessary to stage their therapy over time. Long-term provisionals with composite are an ideal way to accomplish this objective.

Patient's restored bottom row, from the front.

Once the patient's restorative needs are determined an ideal wax up is created. The wax up is then duplicated in stone and a Vacuform matrix is created. The matrix is trimmed to the gingival margin to make easier clean up. Caries removal is done on diseased teeth. Restorations can either be left or removed depending on their condition. For metal crowns retention grooves can be cut into their surface. Crowns with a porcelain surface can be abraded and then conditioned to bond to the resin.

Once this is done the patient is isolated and the proper bonding protocol followed for the underlying structure. The matrix is then filled with composite and seated on the arch. The gross excess is trimmed away and the whole thing is cured. The teeth are then sectioned if so desired with fine finishing burs, cera-saws and finishing strips. The same is then done for the opposing arch if needed.

Patient's restored bottom row, from the top.

There are a number of benefits to staging a patient's therapy in this way. It allows the patient to have the crown and bridge work done over the course of years if necessary. If the patient is insurance-minded, they can rest assured that their plan will cover one or two of their crowns a year. It's also a great way for the patient to test-drive their new occlusion and pathways of function.

Darin O'Bryan, D.D.S., Spear Education Visiting Faculty www.onemorereasontosmile.com


Commenter's Profile Image Wayne Lyn
May 2nd, 2012
Darin, great article on shedding some insight on how to stage comprehensive care for our patients that are aware of problem, understands what happens if nothing is done, and wants the comprehensive treatment but can't quite afford the care. My question to you would be how to best set a fee for this service? To do this on a full arch is a lot of work and not easy. A follow-up question would be what I would hear from my patients, "How long will this last until we can do the real crowns?" And playing devil's advocate for a little, but how do you handle the patient when they love these long term provisionals and are happy enough and do not want to move forward with the final restorations? Thanks again for this great article! Wayne
Commenter's Profile Image Darin O'Bryan
May 3rd, 2012
Wayne, Thank you for the kind words. In regards to fees. I usually charge them out as four surface composites. You can charge them as build ups, but if the patient has insurance some insurance companies won't cover build ups unless a root canal has been performed. The only downside to this would be if the crowns are done within two years of the placement. I just make sure the patient is aware of this so it does not come as a surprise. So if we take the case shown above it was 11 teeth. If the average fee is around $300 you are looking at over $3000 for a case that took around three and half hours. Also by charging them out as composites later when you want to crown them the insurance company looks at the large composite and does not deny payment like they do for and erosion case. As to how long it will last I tell them it depends on what they do to them. If their hygiene is good and they don't try to open beer bottles or crack pistachio nuts it can last a few years if we need to stage the treatment over that long of a period. If they break one then it is time to crown that tooth. Once in a blue moon I get someone that loves their temporaries so much they don't want to continue with therapy. The good thing about this technique is they have a definitive restoration so from a liability stand point you are covered. I keep track of them and make sure they are coming in for recare visits. Then I can discuss with them that we do need to move forward with final treatment at some point. Eventually one of the restorations will fracture, chip or get recurrent caries on them. At which point the patient is generally willing to at least move forward with definitive care on that tooth. It's not ideal, but a heck of a lot better than leaving things as they were. Darin
Commenter's Profile Image Arnie Mirza
May 4th, 2012
I agree ,the patients usually love such kind of treatment. The patient will trust the dentist more. It is going to be an excellent test drive for the case or treatment plan( long or short term). I did a similar case just before 2 days, once I gave the patient a hand mirror she did'nt stop saying Wow and she gave me a hug.