A Full-Mouth Reconstruction With Responsible Esthetics
Elbow preparations facilitate conservative treatment for an excellent long-term prognosis
Zachary S. Sisler, DDS
When it comes to meeting patients' desires and managing risk, it can be difficult to know where to draw the line in the sand. There are many pivotal moments in clinicians' careers where a line is drawn and the ability to stand firm is a challenge. It is important for clinicians to advocate for their patients' best interests, and part of this involves keeping them from compromising long-term gains for short-term gratification.
A 32-year-old male patient presented to the office with maxillary and mandibular molars that were so severely worn that their occlusal surfaces resembled tabletops. Given his age, he was informed that it would be in his best interest to try to mitigate the risk related to this situation in order to achieve a more favorable long-term prognosis. If the patient were to continue without treatment, he could be in a high-risk category for further breakdown, which could lead to teeth becoming non-restorable and necessitate extraction.
Upon further inspection, it was noted that the patient displayed a large anterior open bite as well as areas of exposed dentin and flattened cuspal anatomy of the posterior teeth. The right side exhibited a posterior edge-to-edge bite, whereas the left side exhibited a posterior crossbite. Despite the severe posterior wear, the patient demonstrated a low caries risk and a healthy periodontium. His temporomandibular joints and muscles of mastication were asymptomatic and displayed good range of motion in all directions.
The recommended treatment plan consisted of clear aligner therapy (Invisalign®, Align Technology) followed by the placement of posterior overlay restorations to seal the posterior wear. It was explained that by utilizing Invisalign to correct the position of the teeth and obtain anterior occlusion, the subsequent canine guidance would facilitate posterior disclusion and, in turn, protect the posterior teeth from further degradation in a predictable manner to ensure a better long-term prognosis. The patient was also esthetically driven and desired a change in the shade and appearance of his anterior teeth as well. It was explained that minimal preparation veneers utilizing an elbow preparation could be placed to accomplish that goal and that they would ultimately help provide better guidance for posterior disclusion.
The patient's next question was whether or not his goals could be accomplished without the clear aligners by getting straight to the preparations. It was explained that given the crowding of his lower anterior teeth and the severe wear exhibited by his posterior teeth, aggressive preparations would be required, which would elevate the risk and compromise the long-term prognosis. He replied, "so it is possible?" This was the line in the sand. In order to obtain an ideal functional and esthetic result, minimize the risk of the new restorations failing, and keep the veneer preparation as minimal as possible, clear aligner therapy would be needed. Once the patient recognized the importance of clear aligner therapy to minimize the risk and allow for more conservative preparations, he chose to proceed with the recommended treatment.
About the Author
Zachary S. Sisler, DDS
American Academy of Cosmetic Dentistry