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:

peg laterals restorations

Or a case that involves excessive wear, like you see here:

pre-op tooth wear
pre-op tooth wear restoration

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.

tooth splint

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:

dental restoration model

And then bond them to the teeth, as you see here:

tooth bonding

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:

dental patient mid-orthodontics

And send them to you so you can resize the teeth, as you see here:

bonded orthodontic treatment

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:

final tooth restoration

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.

(Click this link for more dentistry articles by Dr. John Carson.)

John R. Carson, D.D.S., P.C., Spear Visiting Faculty and Contributing Author - www.johncarsondds.com

 


Comments

Commenter's Profile Image Jon H.
October 22nd, 2017
Fabulous case, brilliantly executed. You have done your patient a tremendous service by maintaining all of their natural remaining tooth structure. This is what I would want for me, my family and my patients. I consider this the gold standard of interdisciplinary care involving Restorative Dentistry. Thanks for posting this case. Very best wishes. Dr Jon Henley UK
Commenter's Profile Image John C.
October 22nd, 2017
Thanks for the nice words Jon!!
Commenter's Profile Image Arnie M.
October 22nd, 2017
Hi John, thank you for such an interesting article. I am wondering how much the occlusal reduction for the onlay preps? Thank you Arnie Mirza
Commenter's Profile Image John C.
October 23rd, 2017
Thank you Arnie, I am glad you enjoyed it. As far as the occlusal reduction in this case I did not do any, since I was using Enamic I could mill them super thin, less them 0.3mm at the margin in many places.
Commenter's Profile Image shweta G.
October 27th, 2017
Really nice !! How long can one expect these restorations especially in the posterior (break/ debond etc issues)?
Commenter's Profile Image John C.
October 28th, 2017
Thanks Shweta! When it comes to longevity I can say I have many cases out there where the anteriors have done really well for many years, I have cases our there that are 7-10 years old now and doing well. When it comes to posteriors as you referred today they get way different forces on them, so far this case is do well as far a I know (the patient lives in Phoenix now but his Dad is an Oral Surgeon I work with and reports no issues and when asked says all is well). The reason we did this case as we did is that he needed his teeth restored and as you can see he grinds like CRAZY so we can expect him to pretty much destroy anything we put in his mouth and doing it this way means we kept the maximum amount of tooth structure so we have as much as possible to work with in the future AND if he breaks stuff (which we, including him and Dad, expect) it is an easier less invasive fix than had we prepared the teeth and done crowns. I can also say I have other smaller cases our there I have with direct composite in the posterior that are many years old and doing well, so I expect doing them indirectly should hold up well too.
Commenter's Profile Image Amber A.
October 30th, 2017
Wondering how to put the margin in the interproximal of those posterior teeth.. just over the marginal ridge, not prepping at all?
Commenter's Profile Image John C.
October 30th, 2017
Thanks for another great question Amber! In this case I was able to do the margin as you described, just over the marginal ridge. It was great the anatomy and wear patterns let us do that in this case and as I am betting you are guessing, this would not be possible in all cases.
Commenter's Profile Image Sarah A.
November 7th, 2018
Great article ! Thanks for sharing. I have a similar case that I'm planning to do two onlays but I don't have CAD-CAM. What is your material of choice in my case? Also , did you have to break the contacts at all? Thanks in advance!
Commenter's Profile Image John C.
November 8th, 2018
Thanks Sarah! So if your lab has CAD/CAM you would have them make the onlays using the same material, if they do not have CAD/CAM then I would discuss with them what they think would work well. Things that jump to my mind if CAD/CAM is totally out would be to either have the lab make resin onlays or you could also consider doing them direct composite yourself. On the contact in my case I did not break them. That will of course be case dependent as will material selection-the more room your have (the thicker the restorations will be) the more options you will have. Does that help? Let me know! John.