Knowing when, how, and why to utilize a particular indirect restorative material is crucial for the final outcome and longevity of a case. This is especially true when planning to use indirect composites and/or all-ceramic restorations.1,2 Restoration selection is driven by occlusion (function), preparation, and aesthetics, with the need to perform a complete diagnosis of the patient’s dental/medical health condition. This must take into account the patient’s physical, psychological (desires and expectations), and financial status, as well as the individual skill and knowledge of the doctor/technician team involved in the execution of the dental treatment solution.
To serve the patients’ needs best, a thorough discussion of the case with all potential care providers should be carried out before final treatment is commenced. To do this, a treatment-planning consultation (TPC) is an important concept to incorporate into any practice wishing to ensure optimal results. It is defined as a sharing between the doctor and dental laboratory technician(s) all relevant case information. This may, and often does, involve the contribution of one or more specialists. This co-discovery process is designed to harness the collective knowledge of the total dental team, leading to improved functional (longevity) and aesthetic outcomes for patients.3
The case presented in this article demonstrates a teamwork approach to solving a complex treatment dilemma. The clinician thoroughly explored treatment options before the final patient consultation and before any tooth preparations were begun.
PATIENT FINDINGS AND INITIAL DISCUSSION
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| Figure 1. Preoperative smile. | Figure 2. Preoperative retracted view showing effects of severe bruxism. |
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| Figure 3. Preoperative retracted view. |
This 44-year-old patient presented with the desire to improve the appearance of his anterior teeth. He works with the public and was becoming increasingly self-conscious of the condition of his teeth and smile (Figure 1). He expressed concern about the large space between his 2 central incisors. The patient could not afford the option of a full-mouth rehabilitation at this time. However, he was open to some form of conservative aesthetic treatment that would last a reasonable length of time. The effects of severe bruxism were readily apparent (Figure 2). Two retained mandibular primary second molars presented with gold crowns (Figure 3).
Due to the history of severe bruxism, the decision was made to proceed cautiously in formulating any treatment plan to ensure that it would be acceptable from both an aesthetic and functional standpoint. The patient was given explanations to educate him on the historical and ongoing effects of bruxism. The implications of continued bruxism on any future restorations placed were also covered, as well as the need to try to manage and control this condition better. He was informed that while closure of the diastema was probably possible, the end result might still include the presence of a small black triangle between the central incisors.
SHORT-TERM DIAGNOSTIC TREATMENT
Provisional treatment (revers-ible) at this point was considered to be conservative by both the patient and the doctor. The vertical dimension was opened approximately 1.0 mm, and cuspid guidance was improved via the application of Z1000 (3M ESPE) microhybrid composite on the molars and cuspids. The doctor decided that for the time being, disturbing the crowns on the mandibular primary molars could pose risks greater than any benefits gained. A composite resin mock-up was done on the anterior teeth using Point 4 (Kerr Sybron).
In proceeding to the next step of determining how to approach a longer-term solution, the history of severe bruxism could not be overlooked. The composite buildups remained stable over the following 6 months, and the patient was generally pleased with the appearance. This was helpful in determining a potential treatment solution in that a material failure while in function would have been diagnostic in itself.
Impressions and photos were taken of the approved direct composite mock-up. These were poured and sent to the dental laboratory. Laboratory-fabricated Siltech (Ivoclar Vivadent) putty indexes were made from these to be utilized in the eventual fabrication of the provisionals and as a laboratory communication tool for the final restorations.
THE TREATMENT-PLANNING CONSULTATION
The doctor began the TPC by having discussions with 2 highly respected prosthodontists to explore treatment and material alternatives. One suggested the removal of the primary molars followed by orthodontics and implants. However, the patient was dolichocephalic, and the orthodontics would most certainly result in an even longer face. A more stable occlusion might be achieved, but there was no guarantee it could be accomplished without potential complications. The other specialist agreed with the treating doctor’s more conservative approach of treatment. This would include the previous composite additions along with some type of full or partial coverage of the maxillary lateral and central incisors. IPS Empress (Ivoclar Vivadent) was considered for possible use in fabricating laminate veneer restorations. However, the overriding concern for irreparable material fracture secondary to bruxism remained.
The clinician decided it would be prudent at this point to have a consultation with her dental laboratory technicians. The reason for contacting the laboratory would be to find out what material might best suit her desired treatment objectives for this unique situation. The doctor shared the diagnosis and discussed the various material options. She stated a desire to avoid porcelain-fused-to-metal full-coverage crowns if at all possible. The doctor wanted to explore the possibility of a more conservative, aesthetic, nonmetal-based material. This material should ideally offer an acceptable range of strength and yet be reliably repaired in the likely event that fractures would subsequently occur in this patient.
All-ceramic materials can be a highly aesthetic choice and are very strong once bonded. However, the manufacturers state that they are contraindicated in patients with severe bruxism. An exception to this could be if the clinician and technician are highly trained and skilled in achieving a significant degree of stabilization of the occlusion and the associated eccentric habits. This also assumes that the patient is willing to undergo the necessary treatment and can afford to do so. The patient must show marked improvement in the effects of eccentric habits or perhaps be willing to wear an occlusal guard regularly to prevent further destruction of the dentition and restorations placed. In the end, it was decided not to choose from the family of all-ceramic dental materials, primarily because of the issue of strength as it related to potential porcelain repairs.
An aesthetic material that allowed for characterization and would be sufficiently strong, yet kind to the already severely worn opposing teeth was another prerequisite for the successful treatment of this patient. Indirect composites were brought up as a possible solution. After lengthy discussion between the doctor and laboratory, Cristobal+ (DENTSPLY Ceramco), a micro-filled indirect composite, was suggested and chosen as the best alternative for this patient. The low wear of opposing enamel against Cristobal+ was reported to be excellent.4 Based on their experience with the material in numerous other cases, the dental laboratory technicians felt that Cristobal+, with a very high flexural strength of 195.6 MPa, would be sufficiently strong if used over well-designed laminate preparations.5 This, as is the case with all-ceramics, must in-clude careful attention to preparation details, such as the need to round all of the line angles to prevent premature stress fracturing of the material under functional loading.2,6
Indirect composites also allow for easy and strong repairs using direct composites if needed. This was an important consideration, since all parties, in-cluding the patient, were cognizant of the history of bruxism and that any material used would carry with it a guarded prognosis for long-term success.
FINAL PATIENT PREPARATIONS
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| Figure 4. Model of the (hybrid) veneer preparations showing lingual margin placement. | Figure 5. Photos of stump shades sent to the laboratory. |
Local anesthetic was administered, and the doctor and patient approved a shade for the final restorations. Laminate veneer preparations, which included lingual hooding with reduction adequate for indirect composites, were performed on all 4 maxillary lateral and central incisors (Figure 4). Stump shades were recorded with photos (Figure 5).
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| Figure 6. Postoperative retracted view of the Cristobal+ veneers on the maxillary central and lateral incisors. | Figure 7. Note the characterization achieved with this indirect composite system. |
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| Figure 8. Postoperative smile. |
A VPS full upper impression, an alginate lower impression, and a bite registration were taken. Provisionals were placed and the case was sent to the laboratory for fabrication of the Cristobal+ restorations.
The final restorations were returned to the doctor and bonded in place with no reported complications. The patient was given postoperative instructions and once again warned of the guarded prognosis due to bruxism. The patient was immediately pleased with the aesthetic result and the function of his new indirect composite restorations (Figures 6 to 8).
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| Figure 9. Postoperative at 1.5 years after placement of restorations. |
Three months after the seat appointment, the veneer on the left lateral incisor debonded. One year after the seat, the right lateral veneer debonded and a small piece of palatal composite fractured off. In both cases, the veneers were rebonded/ repaired easily utilizing Renamel (Cosmedent) microhybrid and microfilled composites. The first incident involved biting into a bone while chewing. The second debond was caused by biting on a pencil. After the second incident, the patient also started to improve compliance in the use of his bite splint. No problems have been reported subsequent to these 2 debonds as of the writing of this article (Figure 9).
The doctor and patient goals for conservative, aesthetic, interim treatment were achieved. Of course, they will not be without continued maintenance. Vigilance will be required to encourage the pa-tient to comply with instructions to wear the bite splint as directed and to protect against any harmful (conscious) habits. In the end, the patient will most likely remain very satisfied with the outcome of treatment, since realistic expectations were articulated prior to the start of treatment.
CONCLUSION
Acknowledgment
References
1. Adams DC. The indirect composite resin restoration: an underutilized restorative choice? Dent Today. Jan 2004;23:62-67.
2. Adams DC. The ten most common all-ceramic preparation errors: a doctor/technician liaison’s perspective. Dent Today. Oct 2004;23:94-99.
3. Adams DC. The treatment planning consultation: the doctor/technician partnership. Dent Today. Jul 2004;23:92-95.
4. Suzuki S, Nagai E, Taira Y, et al. In vitro wear of indirect composite restoratives. J Prosthet Dent. Oct 2002;88:431-436.
5. Nash RW. Processed composite resin: a versatile restorative material. Compend Contin Educ Dent. 2002;23:142-148.
6. Shillingburg HT Jr, Jacobi R, Brackett SE. Fundamentals of Tooth Preparations for Cast Metal and Porcelain Restorations. Carol Stream, Ill: Quintessence Publishing Co; 1987:301-302.
Dr. Adams is an assistant professor at the Medical College of Ohio’s division of dentistry in the department of otolaryngology in Toledo, Ohio. He lectures nationally and internationally for many dental organizations and dental laboratories. In addition to his years in private practice, Dr. Adams has served as the doctor/technician liaison for a high-end commercial dental laboratory for more than 9 years. This unique combination of experiences has enabled him to bring clinically relevant discussions and practical solutions to the challenges facing the entire dental team. He has written numerous articles on clinical, laboratory, insurance, and marketing topics for Dentistry Today, Dental Insurance Today, Dental Economics, Spectrum, Dental Practice Management, the Journal of the Canadian Dental Association, and the Journal of Dental Technology. He is currently listed in Dentistry Today’s Leaders in Continuing Education. Dr. Adams is a member of the ADA, MDA, AGD, AACD, and ICOI, and a fellow of the International College of Dentists. He can be reached at (231) 946-8880 or damona11@hotmail.com.
Disclosure: Dr. Adams is a consultant and doctor/technician liaison for DH Baker Dental Laboratory, located in Traverse City, Mich.
