The patient presented with a chipped UL6 that he wanted repaired. He was a very anxious patient who attended the dentist on a ‘needs must’ basis.
Key clinical features included:
Decoronated LL6, retained root
Gingival recession upper posterior quadrants
Thick gingival biotype despite some volume loss
Generalised tooth wear and associated parafunction
Heavily restored dentition
This as a walk-in patient. He was a phobic patient who attended the dentist only when a problem needed a solution. He had fractured the LL6, most likely as a non-working side interference. The tooth had been sensitive prior to the fracture, but now was less so that the tooth had broken. He was concerned that there would be issues relating to tooth decay if he didn’t get it fixed. In addition, he was complaining about the rough edge left on the tooth and this was irritating his tongue.
The tooth was quickly repaired with some composite, despite the fact that he needed a more definitive restoration such as a crown. During the course of this appointment, discussion centred on the tooth wear and the aetiology of the tooth wear was explained to the patient.
The patient was a school principal under a lot of pressure and he noticed that his problems were more common towards examination times. The patient was advised about what was required to prevent further unpredictability, ie, stabilisation splint, and this led to him wanting to know what could be done for his teeth.
The utility of digital smile design was discussed to assess what a patient’s potential ideal smile could look like. The patient was interested in this as he had been getting ever more disillusioned about his teeth in recent times, and decried them as ‘old man’s teeth’.
The digital smile templates came back and a trial mock-up was carried out. Photos were taken to compare to the before and the after. The results were remarkable and immediately the patient emotionally connected with what was possible. Happily, this case would be an additive case, meaning that very little preparation of his teeth would be required to achieve an aesthetic result.
A Dahl appliance was used to increase the occlusal vertical dimension. To supplement the upper porcelain veneers and crowns that were required, further bite stabilisation was required by the provision of implants in the lower left first molar positions. Further full coverage crowns were placed on the LL6, LR6 and LL5.
Pre-treatment radiography, diagnosis and treatment discussion
Radiographs highlighted excellent bone health generally. None of the upper or lower teeth had any periodontal or apical issues. A CT scan highlighted the bone quality at the implant sites.
Diagnosis was as follows:
General tooth wear
Soft tissue recession
Missing LL6 and LR5
Loss of aesthetics
The patient had very low expectations and was just happy that he could be seen compassionately and if his function and aesthetics could be improved then he would be very happy. The treatment objectives were as follows:
Digital smile design
Porcelain veneers/crowns/bridge for UL6-UR6, LL5-LL7, and LR5-LR6
Implant for LL6
This patient was initially a difficult patient to treat due to his phobia and would require IV sedation to do anything dentally. Once he had seen his digital smile design mock-up, he was able to visualise the final result and he became emotionally connected to the treatment. The following aspects were considered and the following options for treatment were outlined to the patient:
Place fill/crown UL6 and provide a stabilisation splint full time, or
Porcelain veneers/crowns UL6-UR6, lower crowns LL5, LL7 and LR6, porcelain bridge LR5 and LR6
Implant placements on LL6
Maxillary soft tissue grafting to reposition the soft tissue.
The patient confirmed his desire to go for options one, two and three. The patient appreciated that the soft tissue grafting is an important part of the treatment plan, but now was not the correct time for him to do this. He was content that the margins of the posterior restorations would be left at the cemento-enamel junction. As his smile line was favourable, this was not a problem aesthetically either.