TRANSFER OF INFORMATIONFOR ESTHETIC ANDFUNCTIONAL PREDICTABiliTYIN SEVERE WEAR CASES

Tal Morr, DMD, MSDl

P rosthodontists are often called upon to re-construct the occlusion in patients with se-vere wear. There may be a multitude of is-

sues to address in such cases, including attrition,abrasion, and erosion, all of which contribute touneven wear and compensatory eruption through-out the arches. There may also be incisal wearand/or interproximal wear, and as a result, the oc-clusal plane may need leveling and lengtheningfor enhanced esthetics and to allow correctionand control of the occlusal relationship.Treating the edentulous patient requires the

fabrication of occlusion rims to allow evaluation ofcritical esthetic and functional information, mount-ing of the final casts, and fabrication of estheticand functional complete dentures.'-8The estheticand functional information includes determination

'Private practice, Aventura, Florida, USA.

Correspondence to: Dr Tal Morr, 20760 West Dixie Hwy,Aventura, FL 33019, USA. E-mail: tmprostho@yahoo.com

of the incisal edge position at rest, the occlusalplane, midline and angulation of the midline, lipsupport, facial plane of the incisors, arch form,and buccal corridors. In addition, the clinician canevaluate the vertical dimension of occlusion,check phonetics, and take a centric record.

CRITICAL ESTHETICoETERM INANTSAll comprehensive treatment planning shouldbegin with an esthetic evaluation. Evaluation ofthe face is essential in determining the ideal es-thetic orientation of the teeth from a horizontalperspective. The horizontal reference planes willhelp the clinician align the occlusal plane and thesoft tissue levels along with other related estheticdeterminants. The horizontal reference planesshould be evaluated from two perspectives: thefrontal and the sagittal. The frontal perspective isassessedby having the patient look out into thehorizon and choosing the ideally leveled plane.The most commonly used horizontal reference

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~~,,wI.,.::;:--=:;;:-: :'b- -:..::;:::::-1

., \....,'~ I~';'r"

.&Fig 1 Horizontal reference planes:ophriac, interpupillary, and commisuralplanes respectively,

Fig 3 Sample incisal plane,

planes include the ophriac line, interpupillary line,and commissural line (Fig 1).5,9-10 Most people areslightly asymmetric in these planes, and in thesecases,the floor is used as the horizontal referenceplane. From a lateral (sagittal) perspective, thepatient holds his or her head erect, again lookingout to the horizon. From the saggital perspective,the horizontal reference plane should again beleveled with the floor. Once the horizontal refer-ence plane is established, the critical esthetic de-terminants are established in relationship to thehorizontal reference plane.

The incisal edge position, incisal plane, and oc-clusal plane are the three most important estheticdeterminants in the development of the treatmentplan. These determinants enable the clinician totransfer information throughout the treatment,and are related in specific ways to other estheticcriteria. The first step in determining the positionof the teeth is evaluation of the incisal edge posi-tion at rest (Fig 2). Tooth exposure is consideredto be esthetic in the 1- to 5-mm range.a-" To

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Fig 2 Sample incisal edge at rest.

Fig 4 Sample occlusal plane,

achieve this range, tooth proportions can be ad-justed by either shortening or lengthening the an-terior teeth. For example, if crown lengthening isindicated on teeth that were previously ideallyproportioned, the incisal edge length can be re-duced. Maintaining a minimum of 1 mm of toothexposure at rest should be the goal. Once thefinal incisal edge position is determined, the in-cisal plane (a line from canine to canine in the an-terior portion of the occlusal plane) is evaluated(Fig 3). The incisal plane should be leveled to thechosen horizontal reference plane (the floor, inter-pupillary line, etc), and evaluated from the frontalperspective while the patient is smiling. The nextstep is to evaluate the occlusal plane from a sagit-tal view of the patient's smile. The occlusal planeshould be flat from the incisal edge of the centralincisor back to approximately the mesial of thefirst molar (Fig 4). The illusion of a radial relation-ship of the smile line to the lower lip derives fromthe cant of the maxilla in the frontal perspective(see Fig 3).

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 5 Casts mounted using the occlusalplane guide.

Fig 7 Evaluation of the incisal edge atrest with the occlusal plane guide.

The original occlusal planeguide technique

As with the edentulous patient, a method of trans-ferring critical esthetic and functional information isneeded to allow the technician to predictablyachieve the ideal esthetic orientation and occlusalrelationship of the teeth in the waxup. The originalocclusal plane guide technique'2 employed a vacu-form machine and acrylic resin to evaluate theideal esthetic determinants in the patient's mouth.The maxillary cast was mounted to the articulatorwith the occlusal plane guide using a facebow, anearbow, or a dentofacial analyzer.The mandibularcast was mounted at the evaluated vertical dimen-sion using the occlusal plane guide (Fig 5). Themandibular cast was removed, and a flat mountingplate was placed against the acrylic resin andmounted to the lower member of the articulator(Fig 6). When the occlusal plane guide was re-moved, the space between the original cast andthe flat plane indicated the exact amount the teethneeded to be lengthened. Unfortunately, therewere problems with delamination of the acrylic

Fig 6 Mounting plate mounted againstthe occlusal plane guide.

Fig 8 Evaluation of the occlusal planeusing the occlusal plane guide with thepatient smiling.

resin from the vacuform material, and the acrylicresinwas difficult to trim and shape.Wax is a moresuitable material for this technique due to its easeof trimming and shaping, and its ability to take acentric record at the appropriate vertical dimen-sion (Figs 7 and 8). The centric record should betaken at the appropriate vertical dimension withboth the ideal overjet and overbite relationship.This will minimize the negative effect of the arc ofclosure if the casts are not mounted in a direct re-lationship to the hinge axis of the articulator andthe vertical dimension is modified.

Diagnostic waxup fabrication

Step 1: Develop the occlusal planeMount the casts on the articulator at the correctvertical dimension and relative to the mountingplate, and remove the maxillary wax occlusalplane guide. The resulting space indicates theamount of wax to be added to reach the ideal oc-clusal plane (Fig 9). First, add wax to the incisaledges of the anterior teeth and the buccal cusp

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Fig 9 Maxillarycastwithout the oc-clusalplaneguide.

Fig 11 Evaluationof verticaldimensionwith the caststogether.

tips of the posterior teeth (Fig 10). If wax is addedto fill the space from the mounting plate distal tothe mesial cusp of the first molar, it will be impos-sible to close the casts together in the posteriorarea due to the axis of closure of the hinge.Therefore, the length of the wax distal to the firstmolar should be short of the mounting plate, butequal in distance from the flat plane on bothsides.

Step 2: Alter the vertical dimension of occlusion (ifneeded)Ideally, the casts should be mounted at or close tothe correct vertical dimension of occlusion basedon the restorative space needed to develop theideal anterior relationship, including the anteriorguidance and room for the envelope of function.If the casts are mounted at the ideal vertical di-mension of occlusion, the effect of the arc of rota-tion will be insignificant. If the casts are notmounted at the ideal vertical dimension, open orclose the articulator pin to develop the idealspace needed for the restorative material (Fig 11).If the casts do not close to the ideal position, ei-

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Fig 10 Waxisaddedto incisaledgesof anteriorteeth andbuccalcusptipsof posteriorteeth.

Fig 12 Lingualviewof waxupcreatinganteriorguidance.

ther shorten the maxillary posterior teeth, movethe maxillary buccal cusps facially, or move themandibular buccal cusps lingually. This is a purelysubjective process and can be refined during thenext step.

Step 3: Develop the anterior guidanceIf the mandibular anterior incisal plane is irregularand the treatment plan calls for restoration of themandibular anterior teeth, level the mandibular in-cisal plane with wax, followed by the lingual as-pect of the maxillary anterior teeth, to developthe correct anterior guidance relationship. If onlyone arch will be restored, add wax to the appro-priate teeth (Fig 12).

Step 4: Level the mandibular posterior planeIf the mandibular occlusal plane requires leveling,add wax to the mandibular occlusal surfaces tolevel the mandibular arch (Fig 13). It may not bepossible to level the mandibular posterior planewith the mandibular anterior plane because thismay require opening the vertical dimension toomuch. If this is the case, level as much as possible.

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 13 Evaluationof spaceto waxthe mandibularocclusalsurfaces.

Fig 14 Evaluationof spaceto waxthe maxillaryocclusalsurfaces.

Fig 15 Finalwaxup.

The level of the lower posterior plane can be eval-uated by opening the pin slightly and assessingthe space between the maxillary and mandibularposterior cusp tips. There should be equal spaceon either side of the arch.

Step 5: Add wax to the maxillary occlusal surfacesto develop the occlusal contactsOnce the mandibular teeth are ideal, add wax tothe maxillary posterior occlusal surfaces to fit intothe mandibular occlusal surfaces in the correct re-lationship (Fig 14).

Step 6: Refine the occlusion and perfect thecontoursAdd to or modify the occlusal surfaces to perfectthe occlusal relationship and to idealize the es-thetic contours (Fig 15). The final contours of thecentral incisors should be determined first, fol-lowed by the lateral incisors and canines, sincethe symmetry of these teeth is not as critical asthe central incisors.

Relationships to the critical estheticdeterminantsThere are certain relationships that can be devel-oped regarding the critical esthetic determinants.It has been established that the midline position isnot as critical as the midline verticality.13If the in-cisal plane has been idealized in the waxup, themidline should be perfectly perpendicular to theincisal plane. Ideally, the facial plane of the in-

cisors should be perpendicular or slightly acuterelative to the occlusal plane from a sagittal per-spective. The gingival plane should be parallel tothe incisal plane.

CASE PRESENTATIONAn 82-year-old man presented to the office inneed of a complex rehabilitation. He had noticedrapid wear on his anterior mandibular teeth in thelast couple of years, and that his maxillary andmandibular anterior teeth were "on top of eachother." Considering the severe occlusal wear andClass III malocclusion, a thorough esthetic evalua-tion was done to formulate a treatment plan. Theincisal edge position at rest was evaluated first.The patient showed approximately 2 to 3 mm oftooth structure with the lips in repose (Fig 16).Ac-cording to esthetic principles, this fell within thedesired range. When the patient smiled, the in-cisal plane also seemed adequate; however, a dis-tinct step between the anterior and posteriorplanes existed, indicating an esthetic need tolengthen the maxillary posterior teeth (Fig 17).Opening the vertical dimension of occlusionwould be beneficial in this case because this pa-tient was in need of a dramatic leveling of themaxillary occlusal plane and the mandibular incisaland occlusal planes to create room for develop-ment of a better functional relationship of the an-terior teeth (Figs 18 to 20).

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Fig 16 Initial incisal edge at rest.Note the good position of incisaledges and incisal plane.

Fig 17 Initial smile. Note the dis-crepancy in the posterior occlusalplane.

Fig 18 Initial right lateral view. Note the discrepancy between the anterior and posterior occlusal planes.

Fig 19 Initial intraoral view. Note the discrepancy of the mandibular anterior incisal plane.

Fig 20 Initial left lateral view. Note the discrepancy between the anterior and posterior occlusal planes.

Modified occlusal planeguide technique

In this case, the anterior occlusal plane was

deemed adequate at the esthetic evaluation, so

the wax was added to the posterior occlusal

plane. This occlusal plane guide was tried in the

mouth and shaped to the correct length corre-

sponding to the ideal esthetic plane. A centric

record was taken at the anticipated vertical di-

mension to aid in creating a better relationship in

the anterior region, as well as room to level both

the maxillary and mandibular occlusal planes.

Mounting the casts

Once the wax of the occlusal plane guide was ide-

alized, the maxillary cast with the occlusal plane

guide was mounted on the Kois dentofacial ana-

lyzer mounting plate (Panadent, Grand Terrace,

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CA, USA) by aligning the facial aspect of the in-

cisors with the line drawn on the platform (Fig 21).

The midline on the maxillary diagnostic cast was

aligned with the midline drawn on the platform.

The Panadent system mounting platform was de-

veloped using scientific data (unpublished re-

search, 2006), so there is no need to use the

dentofacial analyzer or an earbow leveled to the

horizontal plane with this technique (Figs 22 and

23). The incisal edge position on the mounting

platform that was used to align the cast is based

on a 100-mm measurement from the hinge axis of

the articulator (Fig 24). According to Kois and Kois

and others,'4-18this measurement is the average in

the population from the hinge axis to the incisal

edge position, with 80% of the population falling

within 1 standard deviation of the mean. The max-

illary cast was mounted relative to the hinge axis

using the mounting plate. By using the wax to

mount the cast, there was an ideal esthetic rela-

tionship of the cast to the mounting plate. Once

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Hinge Axis to Maxillary Central Incisor Edge Distribution

36

30

>, 24UcQJ

6- 18

~LL

12

85 90 95 100 105 110 115

Distance (mm)*Mean = 100.21 mm

Fig 21 Diagnostic cast mounted Fig 22 Diagram of findings in research conducted by Kois and Kois.14

on the dentofacial analyzer mount-ing platform using the occlusalplane guide.

Fig 23 Illustration of measurementin research conducted by Kois andKois.'4

Fig 24 Articulator with dentofacialanalyzer mounting platform.

Fig 25 Maxillary waxup on thedentofacial analyzer mountingplatform.

Fig 26 Final waxup. Note the per-pendicular relationship of the in-cisal plane to the interincisalangle.

Fig 27 Lateral view of final waxup.Note the perpendicular relation-ship of the facial plane of the in-cisors to the occlusal plane.

the maxillary cast was mounted, the mountingplate was removed and the mandibular cast wasmounted using the occlusal plane guide at the ap-propriate vertical dimension. The wax occlusalplane guide was removed and the diagnosticwaxup was fabricated as previously described, al-though the maxillary cast was waxed against the

dentofacial analyzer mounting plate rather than astandard mounting plate (Fig 25). Both archeswere leveled and aligned to the horizontal refer-ence plane, and other relationships, such as theinterincisal angle and the facial plane of the in-cisors, were also incorporated in the waxup (Figs26 and 27).

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Fig 28 Frontal view of the provi-sional prostheses.

Fig 29 Intraoral view of the provi-sional prostheses.

Fig 30 Maxillary preparations.

Fig 31 Mandibular preparations.

Figs 32 and 33 A different caserequiring crown lengthening. (left)Provisional prostheses prior tocrown lengthening. Note themeasurements given to the sur-geon prior to crown lengthening.(right) Provisional prostheses aftercrown lengthening. Note that thesoft tissue level is parallel to in-cisal plane.

Making the provisional prostheses

Once the waxup was complete, a provisional shell

was made by fabricating a matrix and painting in

both incisal- and dentin-colored cold-cure acrylic

resin. These prostheses were filled with acrylic

resin, relined in the mouth, trimmed, and equili-

brated slightly. It was difficult to visualize the es-

thetic aspect of the provisional prostheses while

the patient was anesthetized, so he was allowed

to leave and return 1 week later for further refine-

ment.There will almost always be a need to

slightly recontour the provisional prostheses to

achieve the desired esthetic outcome, but modifi-

cation of the incisal edge position and occlusal

plane is rarely needed when this technique is used

(Figs 28 and 29).

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Crown lengthening

This patient refused crown lengthening, but after

preparation there was enough tooth structure for

retention of the final restorations (Figs 30 and 31).

In a complex wear case, a surgical procedure is

often needed to level the soft tissue for esthetic

and/or structural reasons. Because the ideal incisal

edge position and incisal plane are developed in

the provisional stage based on the horizontal ref-

erence plane, it is easy to develop ideal soft tissue

levels. If the clinician has determined the proper

esthetic and structural length for the teeth, he or

she can ask the surgeon to measure from the in-

cisal edge up to the desired soft tissue height and

add 2.5 to 3.0 mm of length for the biologic width

to achieve the new bone level (Fig 32). Once the

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 34 Centric record of the maxillary provisional prosthesis to the mandibular preparations.

Fig 35 Centric record of the maxillary preparations to the mandibular provisional prosthesis.

Fig 36 Centric record of the maxillary preparations to the mandibular preparations.

bone level is idealized, the soft tissue is posi-tioned and sutured 2 to 3 mm more coronal thanthe bone. If the ideal tooth width has been devel-oped in the provisional prosthesis, the surgeonalso has the information necessary to scallop thebone so the gingival zenith will be in the correctposition (the height of the contour of the soft tis-sue, distal to the center of the tooth) (Fig 33).

Centric record and cross-mounting

Once the biologic width is redeveloped and theprovisional prostheses are relined, a final impres-sion is taken of at least one arch. This is thenmounted on the articulator using the dentofacialanalyzer to develop the correct relationship withthe face. The various centric records allow thetechnician to mount the casts of the provisionalprostheses and the preparations in identical 3-di-mensional positions. Four critical relationships(centric records) need to be taken if both archesare to be fabricated at the same time. The first is aprovisional prosthesis-to-provisional prosthesisrelationship (see Fig 29). There is no need to takean occlusion rim for this relationship if there is anideally generated occlusal relationship that showsbilateral simultaneous contacts in centric occlu-sion. The second and third centric records are

those of the preparations against the opposingprovisional prostheses in both arches (Figs 34 and35). The final relationship needed is the centricrecord of the preparations to preparations (Fig 36).If only one arch is undergoing restoration, the

provisional-to-provisional and provisional-to-preparation relationships need to be taken onlyfor that arch. These 3-dimensional relationships ofthe preparation casts to the provisional casts areessential in allowing the technician to duplicateboth the esthetic and functional relationships thatwere developed in the provisional prostheses.

Transferring informationin the laboratory

Once the castsare mounted and have become in-terchangeable, the technician must use the infor-mation from the provisional prostheses. One suchtransfer of information is the incisal guide table(Fig 37). This is fabricated by placing acrylic resin(GC America, Alsip, IL, USA)within the table thathouses the pin. When the acrylic resin is in thedoughy stage, the upper member of the articula-tor with the provisional cast is moved against theopposing cast in all directions to replicate theguidance. This movement creates a troughthrough the acrylic resin. After the acrylic resin

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Fig 37 Incisalguide table.

Fig 38 Maxillaryprovisionalcastwith incisalmatrix.

Fig 39 Porcelainbuildup usingthe incisalmatrix.

Fig 40 Finalrestorationsagainstthe incisalmatrix.

hardens, the trough will guide the lingual contoursof the restorations on the preparation cast tomatch the provisional cast.

The next transfer of critical information in thelaboratory is the fabrication of matrices. The mainmatrices used in the laboratory are the facial ma-trix, the lingual matrix, and the incisal matrix. Thefirst two allow verification or reduction of eitherthe waxup or framework, as well as comparison ofthe final prosthesis to the provisional prosthesisfrom a facial and lingual contour perspective. Thissaves time because the technician does not haveto remake the waxup. Because the provisionalprosthesis is the pattern for the final prosthesis, allthe esthetic and functional information is present.The next step is to open the pin by 1 mm and fab-ricate a matrix against the incisal edges and cusptips of the maxillary provisional cast (Fig 38).When the provisional cast is replaced with thepreparation cast, the laboratory technician knowsexactly how much material to add incisally in theframe to support the ceramics and for the finallength of the ceramics. This matrix can be used tofabricate the ideal porcelain buildup. If the techni-cian knows how much shrinkage will result, the pincan be opened by that amount, and after the first

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bake, the incisal edge will be nearly in the perfectposition (Figs 39 and 40). The final prosthesesshould fit intimately to the incisal matrix.

CONCLUSIONIt is evident that the transfer of information through-out the rehabilitation process is critical. Althoughit may take a bit more time in the diagnosticphase of treatment, accurate means of transfer-ring information throughout the rehabilitation pro-cess is paramount to predictability. In severe wearcases where the teeth are too short and need tobe lengthened, the incisal plane guide is an indis-pensable tool. By transferring the critical estheticdeterminants to the articulator, the process ofwaxing becomes easier and more predictable. Ifthe patient needs crown lengthening, all the infor-mation necessaryfor esthetic successis already in-corporated in the provisional prosthesis becausethe critical esthetic determinants were used forfabrication. Once the provisional prosthesis is ide-alized and the correct occlusal relationships aretaken to allow cross-mounting the casts, fabrica-

Transfer of Information for Esthetic and Functional Predictability in Severe Wear Cases

Fig 41 Final incisal edge atrest.

Fig 42 Final smile. Note thelevel maxillary occlusal plane.

Fig 43 Final intraoral frontalview. Note the level maxillaryand mandibular occlusal planes.

tion of the incisal guide table and matrices fromthese casts will guide the laboratory technician toensure esthetic and functional predictability in thefinal restorations (Figs41 to 43).

ACKNOWLEDGMENTSA special thanks to Drs John Kois and Dean Kois for the useof their diagrams and research findings. Also, a special thanksto Harald Heindle (Aesthetic Dental Creations, Mill Creek,Washington) for the beautiful ceramic work.

REFERENCES1. Frush F, Fisher R. How dentogenics interprets the sex fac-

tor. J Prosthet Dent 1956;6: 160-172.2. Frush F, Fisher R. How dentogenics interprets the person-

ality factor. J Prosthet Dent 1956;6:441-449.3. Frush F, Fisher R.The Age Factor in Dentogenics. J Pros-

thet Dent 1957;7:5-13.4. Frush F, Fisher R.The dynesthetic interpretation of the

dentogenic concept. J Prosthet Dent 1965;8:558-581.5. Lombardi RE.The principles of visual perception and their

clinical application to denture esthetics. J Prosthet Dent1973;29:358-382.

6. Lombardi RE.A method for the classification of errors indental esthetics. J Prosthet Dent 1974;32:501-513.

7. Tjan AH, Miller GD, The JG. Some esthetic factors in asmile. J Prosthet Dent 1984;51 :24-28.

8. Vig RG, Brundo Gc. The kinetics of anterior tooth display.J Prosthet Dent 1978;39:502-504.

9. Rufenacht CR. Fundamentals of Esthetics. Chicago:Quintessence, 1990:67-134.

10. Chiche GJ, Pinault A. Esthetics of Anterior FixedProsthodontics. Chicago: Quintessence, 1994:13-32.

11. Arnett GW, Bergman RT.Facial keys to orthodontic diag-nosis and treatment planning. Part I. Am J Orthod Dento-facial Orthop 1993;103:299-312.

12. Phillips K, Morgan R.The acrylic occlusal plane guide: Atool for esthetic occlusal reconstruction. Com pend ContinEduc Dent 2001 ;22;302-306.

13. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the per-ception of dentists and lay people to altered dental es-thetics. J Esthet Dent 1999;11 :311-324.

14. Kois JC, Kois D. Simplified facebow rationale and tech-nique. In press.

15. Bonwill WGA. The scientific articulation of the humanteeth as founded on geometrical, mathematical, and me-chanicallaws. Dent Items of Interest 1899:617-643.

16. Weinberg LA. An evaluation of basic articulators and theirconcepts. Part I: Basic concepts. J Prosthet Dent1963;13:622-644.

17. Weinberg LA. An evaluation of basic articulators and theirconcepts. Part II: Arbitrary, positional, semiadjustablearticulators. J Prosthet Dent 1963;13:645-663.

18. Monson GS. Occlusion as applied to crown and bridgework. JADA 1920;7:399-413.

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ZIRCONIUM OXIDE CAD/CAM-GENERATED RESTORATIONS: AN

ESSENTIAL OPTION IN CONTEMPORARYRESTORATIVE DENTISTRY

Ricardo Mitrani, DDS, MSD1Roberto Duran, DDS2

Eduardo Nicolayevsky, DDS3Joel Lopez, MDT3

Two of the most important characteristics ofmodern restorative dentistry are:

1. The ability to integrate an interdisciplinarytreatment plan

2. A full understanding of current restorative ma-terials and technology

'Affiliate Assistant Professor, Graduate Prosthodontics, Uni-versity of Washington, Seattle, Washington, USA; VisitingProfessor, Universidad Nacional Autonoma de Mexico; pri-vate practice, Mexico City, Mexico.

'Director, Nogales Implant Center, Nogales Sonora, Mexico;private practice, Nogales Sonora and Mexico City, Mexico.

'Private practice, Mexico City, Mexico.

Correspondence to: Dr Ricardo Mitrani, Paseo de losLaureles #458-302B, Bosques de las Lomas, Mexico City05120, Mexico. E-mail: ricardomitrani@hotmail.com

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The treatment planning phase unquestionablyrepresents the foundation of contemporary den-tistry.' Whether dealing with the restoration of asingle tooth, an implant, or a full-mouth reconstruc-tion, it is through this planning phase that thedental team must set the road map for therapy.While the final outcome may be reached througha variety of pathways, close communication be-tween specialistsis essentialto choose the ultimateroute of treatment.Indeed, there is no better investment than the

time spent during treatment planning. The inter-disciplinary team should not overlook even theslightest detail regarding the treatment options.The starting point for any therapy should be a

full understanding of the patient's needs, desires,and complaints. Clinicians should explore the pa-tient's mind before diagnosing his or her mouth,and devote as much time as necessary during