A clinical case by our Community member Dr. Sandra Hulac
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
This patient presented with with a worn dentition. Attrition compounded by moderate erosion and abrasion was present on most teeth.
The most likely reason for the attrition was a growth spurt of the mandible post orthodontic treatment, which is common in males, causing and edge to edge situation.
The patient’s medical history listed obstructive sleep apnea (OSA) which had initially been treated with a mandibular advancement device which failed to resolve the issue. With CPAP treatment he managed to reduce his AHI down to 2. A history of nighttime bruxism, GERD, and high blood pressure was also noted.
These pathologies often occurring alongside OSA, all improved after regular CPAP use.
The patient’s treatment plan involved creating restorative space to lengthen the worn upper anteriors by opening the occlusal vertical dimension (OVD) with an additive treatment to the entire upper arch.
As opening the OVD distalizes the mandible, it has a potential negative effect on Sleep Apnea. In order to enable “road testing” the opened vertical, its effect on the patient’s AHI readings and also to visualize the aesthetic changes, it was decided to transition this patient with injectable composite restorations.
Fig.1
Pre-treatment full smile.
Fig.2
Pre-treatment maximum intercuspal position.
Fig.3
Pre-treatment occlusal situation, showing attrition and moderate erosion.
Fig.4
Pre-treatment lip in repose image highlights insufficient incisal reveal.
Fig.5
Smile design included significant lengthening of anteriors.
Fig.6
Smile design also incorporated added volume to the facial aspect of the upper anteriors.
Fig.7
Occlusal smile design.
Fig.8
A centric bite registration using shims was deemed acceptable in this case as treatment would be initially carried out in composite, allowing for adjustment and adaptation. For porcelain cases the Author prefers the use of a Kois Deprogrammer.
Fig.9
Printed models for alternating matrix injection technique.
Fig.10
It is advisable to check patency of matrix injection holes for debris before commencing the procedure.
Fig.11
Treatment in progress after use of first matrix and finished treatment. This technique is extremely time efficient and usually an arch can be restored in less than 2 hours.
Fig.12
Using printed models, will necessitate more polishing to remove print lines. For this reason the Author prefers a traditional wax up for the technique.
Fig.13
Checking of functional envelope is essential to ensure no chipping of restorations will occur.
Fig.14
Smile with transitional composite restorations. The patient wore these uneventful for one year.
Fig.15
MIP with transitional composite restorations. The patient0s AHI did not increase, in fact, it dropped to 1 and has been stable.
Fig.16
New Smile Design before transfer of case into final porcelain restorations, addressing the shortcomings of the previous aesthetic result, namely a flared appearance of the anterior teeth and prominence of tooth 13. Axial inclinations and zenith positions need to be corrected particularly on centrals.
Fig.17
Conservative tooth preparations, consisting mostly of removal of previous composite restorations and creation of preparation margins.
Fig.18
Seating of the final restorations.
Fig.19
Postoperative smile.
Fig.20
Postoperative lip in repose.
Fig.21
Smile before, with transitional restorations, and with final restorations.
Fig.22
Retracted view of the porcelain restorations.
Fig.23
Smile, before and after.
Conclusions
Transitioning complex cases with injectable composite is a useful tool to ensure occlusal changes do not negatively affect patients, and to non-invasively ensure function and aesthetics of the future permanent restorations. Studies on the longevity of injectable composite restorations are lacking but, anecdotal evidence suggest they can last for 3-5 years, which is in line with other transitional restorative methods.
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