Doc, can we do something about my worn front teeth ?

Doc, can we do something about my worn front teeth ?

After more than 20 years of profession , I admit that the most common issue I run into when visiting a new patient is how to address a prior insufficient treatment plan due to the lack of a correct diagnosis algorithm , while resolving the problem ,not being critical of the previous therapeutical point of view and also preventing highly expensive costs ( both financial and biological ) that the patient wont be able or willing to accept .

What I mostly experienced in cases where "the end result was not aligned "with what is the so called " predictable & long lasting outcome " was the lack of overview , the wrong approach in collecting the diagnostic data and the simplistic mode of resolving the problem.

I have often confronted myself with situation in which every dental maneuver " per se" that the prior clinician performed was accurate , and yet , the end result was far for what we can claim to be a Therapeutic Success.

Here is the case of a lovely female patient in her 60s, that came to see me worried about the fact that her front teeth ,both upper and lower ,were constantly chipping . She was upset with her apparence from an esthetic point of view but mostly she was afraid of the consequences that might lead to tooth fracture .

After a careful analysis and documentation of the case I came to the conclusion that approaching the case in the same range of VDO (which in this case was insufficient for an adequate function ) will take us to the same results ..

Here are my findings in pictures :

chipping of 12, 13,

lack of the cusp tips: 43, 33( with impaired canine function ),

incongruence of " reference lines "

WS interference

I decided that a diagnostic wax-up should be done in order to confirm the amount of change in the VDO that will do in order to regain the correct function .I think every dentist should be trained in order to be able to execute him/her-self a wax-up , because not always the lab will be available to do it for us in short notice .

The mockup has been tested ( functional requirements ) and approved ( from an esthetic point of view ) by the patient.

Since biological & financial costs were responsible taken into account ( there was an implant supported bridge that we decided not to touch ) , the decision led to the choice of increasing the VDO and restore with DIRECT ADDITIVE THERAPY done with the aid of the MOULDING TECHNIQUE .The eligible composite resin was GC -Injectable . The chosen shade was A1, since the patient would appreciate a small change of color in the end result .

A transparent silicone index that replicates the wax-up was created with the aid of Exaclear/GC according to the Moulding Technique .

The teeth were previously cleaned ( AirFlow ) , etched ( 60 sec ) &bond ( Futurabond-U/VOCO) .A teflon tape covering the untreated teeth was used in order to prevent excess flow . A nr.12 surgical blade was used in order to remove the unwanted composite excess.Further procedures of finish& polish were completed .Here are the results in images :

After re-establishing the anterior guidance , in order to provide the correct VDO to the posterior sectors we decided to redo only the bridge on natural teeth :45-47 and cover the tooth 44 with a single unit crown .To the occlusal surfaces of the implant-supported bridge (35-37) were bonded E-Max chips in order to accord the new established VDO .Here is the final result in images :

protrusion

mediotrusion left

mediotrusion right

note the improvement regarding the deep bite .

single crowns: 26, 27 should be soon replaced .

As a conclusion , I would stress the need for us clinicians to assess the GLOBAL CONDITION of our patients and to refuse to act punctually on the immediate need or request of the patient.In this case the need of increasing the VDO that wasn't addressed from the very start jeopardized the outcome despite the fact that all the medical acts performed individually were done in a satisfactory manner.There's no better prize than bringing back the simile on our patients face !While restoring it ,let's keep in mind also that function is mandatory .

" If you see someone without a smile give them one of yours "-Unknown