The 10:10 Sequence

Longevity is an underappreciated measure of success. I’d say that’s as true in dentistry as it is in any industry. As burnout shortens the careers of more dentists every year, the ability to withstand both the physical and mental trials of our profession has never been more important. Mental resilience and the attainment of career satisfaction are as equally valuable to today’s dentists as the ability to restore teeth correctly. In addition, the longevity of our patients’ dentition is more important than ever before. Patients are living longer, and a healthy dentition is vital to their systemic and nutritional health later in life. The reality of these scenarios is why I believe that learning to successfully complete a full-mouth rehabilitation is the greatest thing that you can do for your career. Full-mouth rehabilitations provide both long-term stability and predictability for our patients as well as tremendous pride in the work itself for the practitioner.

Full-mouth rehabilitations integrate all aspects of restorative dentistry, including evaluation, occlusion, smile design, preparation, materials, adhesive principles, case management, and effective communication with patients and laboratories. Because the process is so multifaceted, it became essential in my practice to establish a repeatable process for such treatment. My objectives were twofold: to achieve exceptional outcomes in my rehabilitations and to execute the process predictably and efficiently. From these goals, countless hours of education, and varied experiences with rehabilitations, I developed what I now refer to as the 10:10 Sequence.

The 10:10 Sequence is a structured 10-step framework designed to assist dentists in navigating the complexities of full-mouth rehabilitation. As its name indicates, it involves 10 steps in which 10 teeth (upper then lower, excluding the molars) are treated at a time. This protocol not only provides a strategic process for treatment but also assists the dentist in identifying outlier cases that may pose challenges and/or necessitate referral to specialists. In short, this is the protocol to follow to complete an exceptional, stress-free rehabilitation as well as to spot the cases that you’re better off passing on.

Step 1: Evaluation

Evaluation of the case is the most critical step of the entire sequence. The information gathered helps to both initiate a thought process for the final result and uncover any red flags that may give pause to the case or require referral to a specialist. During the evaluation stage, clinicians should concentrate on five specific areas: dental analysis, airway assessment, muscle activity assessment, joint condition appraisal, and medical history consideration.

Dental Analysis

The dental analysis focuses on the biologic health and structural stability of the dentition. Full-mouth rehabilitations are most commonly performed because of worn dentition or occlusal instability. However, any periodontal disease or gross caries should be treated, and stable health should be maintained for at least 12 months prior to the initiation of comprehensive treatment.

It is not indicated to gather records or formulate a treatment plan during the dental analysis; rather, you are simply conducting a thorough evaluation of the dentition. One of the most important considerations is the presence of wear patterns on a patient’s anterior teeth. These demonstrate ongoing muscle activity that is likely to persist after rehabilitation. The primary goal is not to alter the patient’s muscle activity but to create a resilient foundation that facilitates predictable long-term success.

Airway Assessment

For the airway assessment, it is preferred to utilize a straightforward approach. Inquire if the patient snores or experiences unrestful sleep. If signs of airway restriction are present, recommend an at-home sleep study to determine if there is a need for a posttreatment appliance, understanding that rehabilitations in which the vertical dimension is increased can improve the patient’s existing airway issues. Orthodontic/surgical options for improved airway health should also be considered and presented to the patient, if indicated.

Muscle Activity Assessment

When evaluating the patient’s muscle activity, look for pain points because discomfort most often originates from the muscles, not the joints. If the patient’s discomfort does not improve after the deprogramming step, the case either becomes one to consider referring or one to provide splint therapy for. The patient should be pain free for 6 months before beginning treatment.

Joint Condition Appraisal

Understanding joint diagnostics based on sounds as well as range of motion will assist in determining if you should proceed with caution or if the case should be referred. Conditions such as a late opening pop or click, a vertical range of motion of less than 40 mm, a lateral range of motion of less than 8 mm, or lower jaw deflection upon opening are all considered to be red flags, and these cases should be considered for referral.

Medical History Consideration

Patients’ medical histories should be taken into consideration, including an assessment from a psychological standpoint. Patients with conditions such as gastric reflux as well as patients who are taking selective serotonin reuptake inhibitors (SSRIs) for anxiety or depression are at increased risk of grinding and may have restorative implications that need to be considered. However, a greater concern should be a patient with unrealistic expectations. It’s important to remember that you are not obligated to treat everyone, and it’s very important that patients take ownership of their condition and realize that you as the clinician are trying to provide them with a better path forward.

Step 2: Deprogramming

Deprogramming is a pivotal step that serves as both a diagnostic and preparatory measure. This step helps alleviate muscle discomfort, allowing the practitioner to determine the patient’s muscle-neutral bite position. The use of a Kois deprogrammer is very effective in reducing muscle activity and allows for adjustments tailored to the desired vertical dimension, facilitating a clearer understanding of the patient’s joint health and ideal occlusal relationship.

Step 3: Acquisition of Records

After 2 weeks of wearing the deprogrammer, the patient should return for records, where detailed scans and photographs are acquired. Comprehensive photography should capture the patient’s smile from various angles and include occlusal images and full-face images with facial reference glasses. It can also be helpful to acquire short videos that record lip dynamics. Measurements of the anterior teeth as well as the existing and desired dimensions of occlusion are also recorded to guide the design.

Step 4: Design

The design phase emphasizes collaboration with a dental laboratory that is skilled in handling comprehensive cases. It is essential to provide detailed instructions based on evaluation data, including desired outcomes for facial volume, incisal edge positions, gingival margin levels, and an occlusal scheme that accommodates the patient’s unique grinding patterns and esthetic goals. A crucial directive is to limit the design focus to the upper and lower 10 teeth, excluding the molars, to facilitate accurate molar control bites.

Step 5: Crown Lengthening or Orthodontics

Crown lengthening is ideally performed 2 to 3 weeks in advance of the preparation appointment. This timing allows for adequate healing and minimizes inflammation during the final restorative stages. If orthodontic treatment is required, it should be executed after the design is approved to ensure that the orthodontist’s goals are aligned with the restorative goals of the case.

Step 6: Preparation of the Upper 10 Teeth

Although you are only preparing the 10 most anterior maxillary teeth, you should deliver mock-ups of both arches, 10 teeth on each, to verify the design and ensure that the correct vertical dimension is achieved. The lower mock-up will stay in place during the procedure and throughout the temporary phase of treatment.

The mock-ups serve as essential guides for the initial preparations. Any adjustments made to the design need to be noted and repeated on the temporary restorations. Once adjustments to the bite or design have been made, molar bite records are acquired. These bite references are of the patient’s existing molars and will serve as the posterior bite references once the upper 10 teeth have been prepared. After the maxillary preparations have been completed, the molar control bites are placed, and an anterior bite record is acquired to establish a stable tripod bite. In addition, digital or analog records of the maxillary preparations in reference to the mandibular temporary overlay should be acquired.

Once all of the preparation records have been collected, including shade pictures of the maxillary teeth, maxillary temporary restorations are fabricated, incorporating any changes that were made to the design, and an ideal bite equilibration is performed. The preferred occlusion in these cases is a mutually protected occlusion with bilateral, simultaneous posterior contacts and immediate posterior disclusion when moving into anterior or lateral guidance. Records of the temporary restorations should be captured for the laboratory to replicate in the final restorations.

Step 7: Delivery of the Final Upper Restorations

During the delivery phase, the restorations should be individually checked for marginal adaptation and then all together to verify the overall design, color, and interproximal contacts. The bonding protocol used is dependent on the material choice and restorative design. It’s imperative to follow manufacturers’ instructions when performing bonding protocols and to understand how the ceramic was treated by the laboratory prior to the case being sent to you.  Isolation is a crucial element of the delivery process. Using a split dam technique is a great way to ensure adequate isolation while maintaining the ability to place all of the restorations at once. Following the cleanup of any excess resin cement, all bite adjustments should be made to the mandibular temporary overlay.

Step 8: Repeat Steps 6 and 7 for the Lower 10 Teeth

If the initial shape of the lower mock-up has been maintained, it can be utilized as a preparatory guide. If not, it is recommended to place a new lower mock-up. The same protocols followed for restoration of the maxillary arch are followed for the mandibular arch, including the use of molar control bites and equilibration of the temporary restorations.

Step 9: Completion of the Molar Restorations

Because an ideal occlusal scheme and vertical dimension have been established, restoration of the molars can now be approached as “single tooth dentistry,” which allows for tremendous flexibility in treatment. This may involve addressing two opposing teeth at a time or restoring all of the molars simultaneously. The sequence also gives practitioners greater flexibility regarding material selection when restoring the molars. Ensure that the occlusal contacts on the molars are appropriate and balanced and avoid any excursive contacts. In general, it is preferred to have slightly less contact on second molars, with a single-central contact point.

Step 10: 3-Month Bite Equilibration

This step aims to evaluate how the patient’s bite has settled posttreatment and arrive at a final equilibration to ensure the long-term success of the case. The equilibration protocol mirrors the initial process, ensuring that any adjustments made to the restorations are polished to perfection to maintain esthetic and functional integrity.

Satisfaction for All

The 10:10 Sequence stands as a comprehensive protocol designed to facilitate successful full-mouth rehabilitation while minimizing risks and enhancing patient outcomes. By adhering to this methodology, dentists can effectively manage complex cases and offer an improved overall treatment experience for their patients. This approach not only promotes clinical excellence but also fosters tremendous confidence and satisfaction for patients and dentists alike. Patients who are treated comprehensively are set up for success far beyond the dentistry that has been provided, and the dentists who provide such comprehensive treatment can expect a career arch that provides both fulfillment and longevity.

About the Author

Mitchell Hopkins, DDS, is a fellow of the American College of Dentists and maintains a private practice in Kansas City, Missouri.