Does the thought of preparing a bunch of teeth, particularly on a young person, give you trepidation? Sure it does.
While sometimes we need to prepare teeth, it is safe to say the less we can prepare teeth (yet still meet the patient's goals), the better. In this article, I will discuss some methods you can use to not prepare teeth at all yet still deliver fantastic restorations.
The first key to making this possible is that the teeth you are dealing with must be smaller than the desired final size once they are restored. This could be due to a genetic condition such as peg laterals like you see here:
Or a case that involves excessive wear, like you see here:
Yes, you could consider placing crowns on all the latter patient's teeth and restore him that way. He is very young and clearly had significant functional issues, so I don’t know about you, but that makes me really nervous, and not only due to the fact that I feel there would be a high risk of him breaking porcelain. Think about it: he is destroying his teeth and he is also destroying his wear guard, as we can see here.
So why would we think it would be any different with crowns? Think about what a nightmare broken crowns would be for both you and him. Crowns are starting to sound really bad, right? Now add the fact that he is not even 30; crowns are starting to sound even worse, aren't they?
What are the chances that if you place crowns on all this patient's teeth, he is going to make it his whole life with all his teeth? My bet is that he would not. Sure, he might if you took the functional issues out of the equation; but if you can't eliminate those (which, by the way, we have been unable to find a way to do so) then chances are he won’t.
So what do you do? Well, in a case like this, when pretty much all the teeth are worn (yet still in the right position), you can add to them all, thus restoring what has been worn away and at the same time adding a protective layer.
Yes, you would prepare the teeth lightly to gain defined margins, but I would argue that if you pick the right restorative materials, you do not even have to do that in this case.
So what are the right materials? For me, is it either resin or a hybrid ceramic. If you are not familiar with hybrid ceramics, these are typically CAD-CAM materials that, while classified as all-ceramics, have a resin component to them.
Examples of these materials are Vita’s Enamic, 3M’s Lava Ultimate and GC's Cerasmart. One big factor that will influence your material choice will be your access to using CAD-CAM processes. If you or your lab do not have this ability, then you will be limited to using composite resin. So what did I use?
Given I have a CEREC in my office and I wanted to be efficient as possible in treating the case, my decision was to use my CEREC and Vita’s Enamic. I picked Enamic due to the fact that you can etch it for bonding and the fact I have used it many times before and I know it can mill very finely (in fact, less than 0.3 mm thick). Going this route allowed me to pre-mill my no-prep onlays, as you see here:
And then bond them to the teeth, as you see here:
Which saved me a TON of chair time and really made things much more efficient.
The anterior teeth were then done chair-side with direct composite. Could this entire case have been done with direct composite? Yes, for sure! Would it have been a TON more and taken WAY more time? You bet!
Oh and by the way, I did the anteriors with direct composite, and yes, it was a bunch of work!
If you are saying to yourself, “that’s great, but what if the teeth are not in the right place and/or not all of the teeth are undersized or have excessive wear, like the peg lateral case above, yet I still don’t want to prepare the teeth?” Never fear - there is a solution for that too!
The problem is it involves orthodontics. Name your last adult patient that was excited, in a positive way at least, about doing orthodontics...they don’t exist, do they? The good news is that, as we know, if our patients really want the best solution and we do a good job of communicating with them, then most of the time they will do the orthodontics. Once they are committed, the first step is to have the orthodontist move the teeth into the proper position and then, if needed, take the brackets off as you see here:
And send them to you so you can resize the teeth, as you see here:
One super important thing to note is that these teeth have been re-sized, BUT they are still not aligned correctly. That is because the bonding to re-size them was done according to the root angulation and desired final size, not the current position.
We do NOT expect it to look perfect here; all we want is the right size and shape. We do not care about alignment, and in fact, if the roots are still tipped, our bonding must follow that. It is then the orthodontist’s job to finish alignment of the teeth and make things look right, as you see here:
It is important to note that this is the same bonding you saw in the photo above; the difference is that the teeth are in the right place now. If you are by chance saying, “why don’t I just have my orthodontist stick the teeth where they belong, take all their stuff off, and then I will do the bonding?” ... that's a topic for next time. Let’s just say things will almost always, or should I say just plain always, end up compromised. Stay tuned and I will go into that more next time.