Often when I participate in dental related events, whether it is participating in a study club, getting together with my dental colleagues, or teaching at the dental school, people I interact with know that I am a prosthodontist and they will come ask me about their cases. Often, they come ask me with similar cases: cases with anterior worn dentition requiring treatment to restore aesthetics and function.
I think these are always interesting cases. Patients notice their teeth don’t quite look the same as before and they ask their dentists what to do about them. There is no need to sell these cases. They come to you naturally. However, if you have not done a lot of anterior reconstruction and you are a relatively new dentist who may want to expand the scope of your services, you need to approach these cases cautiously. There is often a misconception that these cases are just few more crowns or few more veneers than your single units. If you can handle single units comfortably, you can treat these cases one crown at a time. In fact, as a dental student, that is exactly what an instructor once told me, who treatment planned a case of ten maxillary crowns in my fourth year. His intention was good, encouraging me to do more, pushing the limits. However, I never finished the case. I was clearly not ready for it.
Looking at what may appear to be just a few more crowns, there is actually a whole lot of diagnostic information I often ask myself before starting a case like this. When I see these cases, these are the things I look for:
1/ Is there adequate posterior support? Often times, when the anterior teeth are worn, chipped or uneven, the underlying cause may be due to inadequate posterior support. Your patient may be missing numerous teeth such that there are no posterior occlusal stops except on their anterior teeth. As a result, these anterior teeth are overused, leading to chipping and uneven wear, compromising aesthetics. Before you decide to provide the anterior reconstruction, you have to identify the cause with the patient. If possible, I would like to include the treatment plan of posterior replacement as part of a complete treatment. If posterior support is not restored, whatever treatment you provide for the anterior teeth may be at risk for continuing chipping. And your patient may blame you when problems arise. Be sure to address the root of the problem before providing a solution to the anterior teeth.
2/What is patient’s existing anterior guidance? Before I start, I like to evaluate how the mandible moves in protrusive, right and left excursive direction. It gives me a chance to appreciate how the front teeth interact in these movements and determine if I can work with the patient’s existing anterior guidance or not. The old adage of “form follows function” cannot be ignored. During this analysis, I may identify the possible need to re-shape some of the front teeth. Or I may determine the need to alter them intentionally to improve function and aesthetics. Whatever I decide to do, I always like to test them out in the form of provisional restorations. To me, it’s a test run to see whatever I want to establish does and can work. However your diagnostic/digital wax up may look good on the model or on your screen, may not work with your patients’ joints and muscles. Only have I transferred the wax up directly on the patient’s dentition in the form of provisional restorations, and evaluating the change aesthetically and functionally, can I finalize the prep design and start planning the definitive restorations.
3/How do you want to change the teeth? If the existing front teeth have been worn, chances are there are many elements that compromise the aesthetics. You need to find out exactly what the patients want to improve. Is it the colour? Is the shape of the teeth? How is the gum line looking? Often times, the front teeth are too short or they do not have ideal width height proportion. If you want to improve the aesthetics by improving the width height proportion, sometimes you may want to lengthen the teeth. You can lengthen the front teeth by increasing them incisally. Or you can consider increasing them gingivally by aesthetic crown lengthening. The decision of which one is appropriate for the patient depends on many diagnostic information you need to acquire. Some clinical information you need to evaluate will be tooth display at rest, tooth display at full smile, lip length, location of CEJ in relation to the bone and much more.
It is not my intention to re-teach these fundamentals here but to highlight that when you are considering numerous crowns for the anterior region, it is not treating them one crown at a time. When you are doing just one crown whether it is in the anterior or the posterior region, many of the aesthetic and functional parameters have been established and you are not in the position to alter them. But when you are considering doing numerous crowns/veneers, you have the power to improve both function and aesthetics dramatically if you know what to look for. Sometimes what may appear to be a simple aesthetic case may actually have an underlying occlusal issue. I really believe that the success of any anterior restoration lies in a good understanding of occlusion. I hope you find this information helpful.
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