A Transitional Full Mouth Rehabilitation
Injectable composite offers cost-effective, conservative solution to stabilize function and improve esthetics
Sandra Hulac, DDS
High-strength injectable composites are designed to be very durable, exhibiting excellent fractural strength, wear resistance, and gloss retention. Their material properties make them suitable for all classes of restorations, and they are increasingly being employed as a transitional restorative material for complex wear or erosion cases using an injection molding technique with clear matrices obtained from a diagnostic wax-up. This technique, which historically used only one such matrix per arch and required time-consuming isolation of the individual teeth to prevent them from becoming bonded together, has since evolved into an "alternating teeth" technique involving two matrices per arch. This permits a full mouth rehabilitation to be carried out in a single appointment, producing instant cosmetic and functional results. Typically, a few short follow-up appointments are required to fine-tune the occlusion and esthetics.
Transitioning a case with composite can immediately stabilize an otherwise deteriorating situation in a cost-effective way. This approach allows patients to address the realities of financial or time constraints and then change to more durable porcelain restorations in a timeframe that is appropriate for them. The transition to porcelain can be carried out either tooth by tooth as the composite restorations are failing or, preferably, in sections to obtain a more cohesive esthetic look, particularly in the anterior region.
Because composite is a more "forgiving" material for bite alterations, it is ideal for "road testing" occlusal changes. Furthermore, an entirely additive approach is the most responsible way to address the needs of patients, especially younger ones, and the constant changes in porcelain technology may permit the use of thinner restorations in the future, necessitating less tooth reduction.
The 21-year-old patient featured in this case came to the office with a chief complaint of having recently noticed more rapid wear of her upper front teeth. According to the patient, her teeth had always been "tiny," but after looking at recent photographs, she was shocked to realize that they had become significantly shorter during the past 6 months. Her previous dentist had told her that the wear was due to nighttime bruxism and fitted her with a hard maxillary arch splint. She wore the splint consistently; however, it failed to stop the progression.
An intraoral examination revealed significant attrition compounded by severe erosion on the palatal surfaces of her upper anterior and upper left posterior teeth. Her maxillary central incisors measured 4 mm in length, but the average length of a female patient's maxillary central incisors is approximately 10 mm. Compensatory overeruption had led to a loss of restorative space. In addition, moderate attrition and erosion were found on the lower anterior and lower left posterior teeth. Several carious lesions were present. When the patient's mouthguard was inspected, track marks could be seen.
These findings lead to a provisional diagnosis of parafunction accompanied by gastroesophageal reflux disease (GERD). When compared with that of bulimia, GERD typically produces a different erosion pattern in which the posterior teeth on one side of the mouth (ie, the patient's preferred sleeping side) are more affected than those on the other side. The patient confirmed that she had indeed noticed experiencing gastric reflux. After the presence of GERD was confirmed by a physician, the patient was treated with a short course of proton pump inhibitors and changed her dietary habits. Because any treatment solution, particularly those involving composite, will have an extremely poor prognosis in a consistently acidic oral environment, treatment was allowed to commence only after her symptoms had resolved.
Due to the young age of the patient, after initial caries removal, the decision was made to treat this case with injectable composite, opening the vertical dimension of occlusion to create restorative space to cover all of the eroded surfaces and permit appropriate lengths of her upper anterior teeth. Once the treatment was finished, she was fitted with a new hard splint for nighttime use.
About the Author
Sandra Hulac, DDS
Hong Kong, China