There are numerous ways to restore someone’s smile, and a one-size-fits-all solution is almost impossible. Thus, the following addresses the common dilemma of clinicians in restoring a “borderline” case and how effective communication between patient, dentist and lab ceramist is crucial in achieving the desired results.
By Dr Mansingh Patil
Minimally invasive restorative treatments have become a rule more than an exception in today’s modern dental practice. In fact, it is not only restricted to restorative dentistry but also other treatment modalities like extractions and implants.
In cases of failed orthodontic or borderline cases, restorative procedures also produce excellent results, particularly for patients who do not want to go through the orthodontic treatment again and prefer a quick fix remedy. The results are predictable and achieved in shorter duration as compared to conventional orthodontics. For this instance, the patient plays a huge role in deciding what they want, irrespective of what the clinician thinks is the ideal.
The following discusses a similar case that hovered around the borderline of whether to treat the issue with conventional orthodontics or minimally invasive prosthetics. After the explanation of the pros and cons, the patient chose the latter procedure.
A 27-year-old female dentist approached our practice with a chief complaint of hating her right-side smile, as seen when she takes a selfie. She was also conscious of her unilateral open bite to the extent that she wanted immediate rectification of the situation (Fig. 1).
As a result of a relapsed orthodontic treatment done a few years ago, the patient flatly refused to undergo the same procedure again.
Intraoral examination revealed a unilateral open bite on the right side and an absence of occlusal contacts between maxillary and mandibular canines.
The frontal view presented a canted midline to the right side (Fig. 2). The right lateral incisor (tooth 12) was positioned palatally, and the right canine (tooth 13) and left central incisor (tooth 21) are on off-the-arch form as seen in occlusal view (Fig. 3). Mandibular canine (tooth 43) was deficient in height and short of the occlusal plane like tooth 13.
The patient was warned that the canines will need aggressive preparation, which might jeopardise the pulpal health and necessitate endodontic therapy (Figs. 4-5, 1:1 Figs. 6-7b)
The decision to treat the case prosthetically without mutilation of dental tissues and safeguarding the dentin-pulpal complex was paramount. Hence, before doing any irreversible tissue destruction, it was decided at the first appointment to do a direct free-hand composite mock-up to assess if the case fits into the restorative domain or not.
Without etching or bonding enamel, an old, unused composite was sculpted onto teeth 13, 12, 11, 21, and 43. The patient was happy with how far the desired result could be achieved. She took some selfies using her mobile phone to seek her parents’ and friends’ opinions.
Upon the patient’s approval of the direct composite mock-up, an appointment was scheduled to take a set of impressions in alginate for diagnostic casts. The casts, along with the entire preoperative photographs and related information, were sent to the ceramist to do the wax-up of the model (Figs. 8a-b).
Three silicone indices (full-contour L/P, labial and palatal) were obtained from the wax-up to transfer it to the mouth and facilitate the preparation stages.
Protemp 4 temporisation material was loaded in the full-contour index (Fig. 9) to create a mock-up or Aesthetic Pre-evaluative Temporaries (APT), a term coined by Dr Galip Gurel, founder and the honorary president of EDAD (Turkish Academy of Aesthetic Dentistry).
Aesthetic and phonetic analysis of the APT was done to check the suitability of the additions done. The APT is modified to the desired functional and aesthetic parameters by adding or subtracting resin. (Figs. 10-11).
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