Have you noticed that the patients who have been coming to you for a long time demonstrate less and less need for new restorative dentistry? It is likely that you have already crowned, filled, and refilled any molar or bicuspid that so much as revealed the slightest marginal ridge fracture. Well, that might be an exaggeration, but you know what I mean. This is particularly true of most of the baby boomer patients in your practice. If they’ve been with you long enough, they are often in the “stable” category, except for any potential breakdown of prosthetics that might have been done 10 to 20 years ago. Unless you are blessed by practicing in an area with a growing population that has not yet been invaded by corporate dentistry (in which case, new patients abound), the relative stability of your patients’ dentitions likely has resulted in more openings in your schedule than you may care to admit to. Practicing in an area whose economy has been shrinking and has, in fact, been invaded by corporate dentistry, I’ve found it helpful to refocus my dental vision on what might be thought of as the “last frontier”: the maxillary canine-to-canine sextant.
MORE ON REFOCUSING
Take a look at Figure 1, the “pre-op” view of the case that will be discussed here. Does this patient’s dental presentation look familiar? Of course it does! The clinician quickly recognizes the worn, chipped, thinning, translucent incisal edge enamel that is so typical of our bruxing patients who have long ignored our advice to wear a nightguard. To be sure, in some instances, this look is simply a result of long-term wear and tear, while in other cases it can be the result of a common anterior-posterior bruxism habit that has slowly taken its toll throughout time. In some patients, some canine guidance may still be evident and, in others, it has sometimes been lost. You might also be surprised to know that our patients are aware of the state of their smiles, as this is one of the few areas of their dentition that they can actually see and can also easily feel with their tongues. By and large, they have assumed that nothing could be done, other than major cosmetic revisions that are not covered by their dental insurance plans. Thus, they fail to bring up the subject. This is where you and your hygienist(s) can step in. You simply point out the anterior breakdown to patients by using a mirror or a photo, explaining how easy and affordable it is to repair their smiles. At this point, you should mention that there will likely be no need for a local anesthetic and that their restorations can be submitted to their carriers as restorative dentistry, which, in fact, it is!
The Clinical Protocol
You may now be thinking, “I’ve tried this before. Paste composite is a real challenge to manipulate around incisal edges. It is prone to voids and frequently pops off, making it more trouble than it’s worth.” At least, that’s what I used to think. Make it a porcelain veneer, or don’t bother. Did I mention that porcelain veneers are a tough sell in my neck of the woods? Well, they are! As it’s often said, “necessity is the mother of invention.” Alternatives needed to be explored. Let’s review how this upper anterior segment was restored, inclusive of the ingredients that have changed my way of thinking.
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| Figure 1. Pre-op view of case to be restored; note the worn and broken edges on teeth Nos. 7 to 10. Canines were still functioning in a protective occlusal scheme. | Figure 2. Labial-incisal tooth bevel preparation with Alpen diamond point (Coltene); 1.0 to 2.0 mm down the surface of the tooth. |
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| Figure 3. The completed labial bevel preparation. (Note: the prep was placed entirely in enamel.) | Figure 4. Lingual preparation that accentuates the worn lingual incisal shelf. |
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| Figure 5. All 4 incisors were etched with 35% phosphoric acid gel. | Figure 6. Application of universal bonding agent (Optibond XTR [Kerr]) to all 4 incisal edges. |
The preparation is what you would expect. As seen in Figure 2, a medium-grit diamond (Alpen 850-014-10 [Coltene]) was used to provide a gentle labial bevel that extended 1.5 to 2.0 mm down the labial surface (in enamel) (Figure 3). The lingual surface of the preparation served to create/refine the lingual shelf that, in most cases, had already been started by the patient’s bruxism habits (Figure 4). In most cases, all teeth are prepped simultaneously. Next, all preps were etched (Figure 5), then my team’s favorite bonding agent (Optibond XTR [Kerr]) was applied (Figure 6), making sure to clear away any interproximal bonding agent with a Mylar strip or floss before curing it.
A flowable composite (Shofu Dental’s Beautifil Flow Plus [BFP]) (Figure 7) was used in this case. This is not the flowable composite material of yesteryear that would be indicated only in nonstress-bearing surfaces. This particular resin restorative (comparable to your favorite hybrid composite) is rated for all classes of restoration, including incisal edge repair, and it is designed to take a beating. Yet, it retains the viscosity of a traditional flowable. The ease of application is where you get a sense that you are almost cheating, creating the feeling that “this is too easy.” In the case presented, a Mylar strip was used to re-establish the mesial incisal corner of No. 8. Once the strip was digitally (use your fingers) secured, a small amount of BFP was applied and light cured. Don’t worry about overbuilding the composite (Figure 8), as cutting it back is a breeze. Next, the BFP syringe was used to simply bead in the rest of the incisal edge, as if drawing the edge with a pen (Figure 9). The tip of the syringe can be used to manipulate the resin as it flows. If needed, additional layers can be added as well as fill-ins applied, particularly on the lingual surfaces. BFP will self-level quickly, allowing you to assess whether additional material is needed. The material is stackable, lending itself nicely to sculpting the new incisal edge. In this instance, shade A3 was utilized. Once all of the edges were applied, an 8-bladed carbide-finishing bur (ET9 [Brasseler USA]) was used to cut back and shape the freshly placed and cured resin (Figure 10). An abrasive cup (Enhance [DENTSPLY Caulk]) was then used for additional shaping (Figure 11) (particularly helpful on the lingual surface), followed by a medium-grit composite finishing disk (Shofu Dental) (Figure 12). The final restoration can be seen in Figure 13.
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| Figure 7a. Beautifil Flow Plus (Shofu Dental) flowable composite resin restorative material. | Figure 7b. Beautifil Flow Plus stat sheet, comparing this material to familiar composite resin paste restoratives. |
The entire procedure took no more than 45 minutes, required no local anesthetic, and was billed to the patient’s dental insurance (and to the patient) as four 3-surface composite resin restorations. My patient was absolutely thrilled, as are the majority of patients that receive this type of smile makeover. It’s fast, painless, inexpensive, and aesthetic.
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| Figure 8. Mesial incisal corner of tooth No. 8 was re-established. | Figure 9. “Drawing” in the incisal edge of tooth No. 8 with the flowable composite application tip. |
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| Figure 10. An 8-bladed carbide-finishing bur (ET9 [Brasseler USA]) was used to shape the final anatomy. | Figure 11. An abrasive cup (Enhance [DENTSPLY Caulk]) was then used for additional shaping. |
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| Figure 12. A medium-grit composite finishing disk (Shofu Dental) was used to place a final polish on the restorations. | Figure 13. The final aesthetic restorative outcome. Our patient was delighted! |
The Fine Print
There’s always the fine print. That is, stipulations that accompany most purchase decisions in life. And so it goes with 45-minute smile rehabs. To be certain, patients are told why the need for their dental work came about, and cautioned that there will likely be the need for future repairs. This, of course, could be mitigated by consistent use of a nightguard that hopefully becomes a part of the accepted treatment plan. Should they decline to purchase the more expensive lab-fabricated nightguard, I will often fabricate a chairside nightguard (Temp Tabs [All Dental Prodx]) made from a thermoplastic material. In many instances, I will do this gratis, as it takes only about 10 minutes to make the guard, and the material is inexpensive. Furthermore, and most importantly, it will dramatically reduce the need for premature repairs of the patient’s new smile. (A demonstration of the use of Temp Tabs can be viewed on YouTube, under the tag “Temp Tab Nightguard 3.”)
Should canine guidance no longer be present due to excessive wear, it is also recommended that the canines be “re-tipped” to re-establish a protective anterior guidance occlusal scheme. This is done for about the fee we charge for a 3- to 4-surface composite restoration, and is more easily accomplished with a paste-form hybrid composite resin. As you would guess, patients are also told that the re-tipping process will likely require replacement within a 2- to 3-year period (this prediction is experience-based) and that the restoration longevity would be prolonged by faithfully wearing a nightguard.
It is important to note that this approach works well for early to moderate anterior wear in which the posterior occlusion is stable and preferably canine guidance is still in play. It is not intended for advanced wear cases featuring inordinately heavy incisal contacts in multiple excursions.
CLOSING COMMENTS
The procedures and materials covered here offer much to the general practitioner seeking to remain productive while providing meaningful restorative care to an aging patient base. This treatment is minimally invasive and affordable. Since patients co-discover the need for any restorations, this eliminates the need for salesmanship. What has encouraged this author to offer restorations that, historically, would have seemed like more trouble than they were worth, is the ability of a modern and efficient-to-place material to have a reasonable expectation for longevity. This aspect cannot be overstated; new materials often afford new capabilities. (Think back to the days that use of composite in posterior restorations was considered heresy.)
One last thought. Once you’ve completed a 45-minute smile rehab, and you (and your patient) are pleased with the results, be sure to let your hygiene team know about the process and in which cases it may be appropriate. If you keep it a secret, opportunities will walk out the door on a daily basis.
Dr. Goldstein practices general dentistry in Wolcott, Conn. He is a Fellow of the International Academy of Dento-Facial Esthetics and of the AGD. Recognized as one of the Leaders in Continuing Education by Dentistry Today since 2002 for his expertise in the field of dental digital photography, he lectures and writes extensively on cosmetic topics and the integration of digital photography into the general practice. He has authored numerous articles for multiple dental periodicals both in the United States and abroad. He can be reached via email at martyg924@cox.net.
Disclosure: Dr. Goldstein reports no disclosures.
