Conservative treatment of excessive wear in a young adult
By Kevin Winters, DDS
Adhesive dentistry and wonderful, modern-day materials allow today's practitioner to accomplish things never before possible in dental treatment. With a little imagination, a solid background in cosmetic fundamentals, and a mastery of adhesive techniques, solutions to many problems can really be quite simple. This article will explore an innovative technique to provide relief to premature occlusal wear in a female high school student.
Not long ago, a young lady in my practice was exhibiting signs of bruxism and premature wear of her canines and incisal edges. She admitted to being aware of both day and nocturnal bruxing. Although she was attempting to limit this as much as possible, I noticed some very aggressive wear patterns occurring. I have noticed a very similar pattern in young females, usually 18 to the mid 30s, with the early 20s being a very common time.
My first recommendation was for this patient to consult with an orthodontist. This was absolutely out of the question — again, a very common response from females in this age bracket. So what other options do we have? Certainly, at least the use of a nightguard to help with the nocturnal habit would be advisable. However, this patient also knows she bruxes during the day, so the nightguard is really an answer for only one-third of her day. Inevitably, her aggressive wear patterns would continue.
Observing the excursive movements of her occlusion, it was easy to see that all canine guidance had been lost, the tips of all canines were worn flat, and now the incisal edges were beginning to wear.
Utilizing my background and training in adhesive concepts, I devised a very simple plan to restore this guidance that had been lost. I wanted a very conservative plan since the patient was so young, but one that would restore the basic occlusal function that was missing — canine guidance. I decided to just replace that which was lost. By restoring the maxillary canine tips, creating a better contour of the mandibular facial surface, and establishing the centric stops to have porcelain-to-porcelain contact, the plan was coming along.
Preparations for the maxillary canines involved utilizing the wear facet that had developed as the outline for the porcelain restoration. By removing approximately .3 mm on the lingual surface and defining a landing and guiding area for the lower canine to occlude with, most of the preparation is complete. The edge of the wear facet on the facial-incisal surface serves as our natural margin for the restoration.
Preparations for the mandibular canines were consistent with a traditional, conservative veneer preparation. A .3 mm depth guide was used to define the facial reduction necessary. Again, utilizing the wear facet of the incisal edge, the lingual-incisal margin was already established.
At this point, impressions and a bite registration were obtained. Due to the conservative nature of the preparations, no temporaries were placed. The patient reported no sensitivity between appointments.
I planned this case using feldspathic porcelain. In this particular situation, Fortress porcelain was used. Fortress porcelain is manufactured to be stronger than traditional feldspathic porcelains.
Once the impressions were poured and the veneers were made, you can see what the lab accomplished. The veneers were quite conservative.
With the patient anxious to see the finished results, the restorations were inserted. After cleaning the surface with a chlorhexidine scrub, the entire prepared surface was etched with 37% phosphoric acid. After thoroughly rinsing, the surface was left slightly moist and Optibond Solo Plus (Kerr) was vigorously scrubbed onto the tooth. Since Solo Plus is a filled adhesive, aggressive air thinning is necessary to ensure complete seating. The Solo Plus is then light-cured.
Before the tooth preparation was begun, each restoration was cleaned by applying 37% phosphoric acid, rinsing, drying, then applying Kerr's Silane Primer. This silane is unique in that it has a resin component, thereby deleting the step of coating the surface with bonding agent.
With the tooth and porcelain restoration both prepared, I then added a translucent shade of Nexus 2 (Kerr). With positive seating pressure, excess luting cement was removed with a rubber tip. By placing a tacking tip at the middle of the tooth, the porcelain was secured. Detailed removal of excess cement can now be accomplished without fear of dislodgment. Once cleanup was completed, including interproximal flossing, the Demetron 501 curing light was used to cure the restoration. This same sequence was followed for each tooth.
Now it is time for the big test — the patient's occlusion. Centric is verified and even. Now, having the patient disclude to the right and left shows the pot of gold at the end of the rainbow — canine rise with complete disclusion of all other teeth. Eureka! The restorations are then polished and the procedure complete.
The final step was to construct a nightguard, which the patient has worn faithfully.
I feel this case was successful for several reasons:
- Esthetically — Looking at the result, one would be hard-pressed to notice any dentistry had been done. The restorations were integrated into the teeth as if they grew there. These restorations will last for many years.
- Functionally — With an imaginative and conservative approach, this patient now has a protective occlusal scheme re-established which will protect her from certain future wear and problems had this procedure not been done.
Sometimes "cosmetic dentists" get accused of just doing veneers on everything. True cosmetic dentistry, and dentistry in general, is actually about helping people who want our help. Nothing we do is necessary to sustain life; all dentistry is elective.
As such, we owe it to our patients to use our knowledge to help these people who desire it. It is unfortunate to waste your abilities by taking "cookie cutter" approaches to your treatment plans.
I think a great analogy for dentists is professional athletes. There are many, many athletes who have the ability to play at a professional level. They are strong enough, fast enough, shoot well enough, or hit the ball well enough. What you'll find though is that the athletes who make it to the professional level are the ones who can adapt to situations very quickly. Michael Jordan doesn't go in to a game saying he's going to dribble three times, fake left, and then shoot. He simply takes his ability and adapts to the situation with which he is presented.
What we as dentists need to do is take our knowledge and adapt. We need to apply our knowledge in ways that may seem somewhat unconventional. Be creative, but sound in your judgment. To use a cliché, "Think outside the box."
Hopefully this case has shown you an example of applying basic adhesive principles, combined with sound occlusal principles to arrive at a rather unconventional, outstanding result.
Dr. Kevin Winters graduated from the University of Missouri-Kansas City in 1989. After completing a GPR at the University of Louisville-Humana Hospital, he opened a general practice in Claremore, Okla. After developing a successful general practice and being awarded the Young Dentist of the Year award in 1995, Dr. Winters transitioned his general practice to one that concentrates on esthetics and reconstruction. Dr. Winters is one of the original clinical instructors at the Las Vegas Institute. He also lectures and conducts seminars across the nation. Dr. Winters may be reached at (918) 341-4403 or by e-mail at [email protected].