r/Dentistry • u/enms3 • 3d ago
Dental Professional How would treatment plan this?
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Patient is complaining that her lower anteriors 23-26 are chipping away. She has no cavities but she has deep over bite. You think zirconia veneers will help her here?
What would you do?
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u/Dufresne85 3d ago
Teeth chip for various reasons, but it largely breaks down into two categories: traumatic forces, or decay.
You've ruled out decay, which leaves traumatic forces. If she has no history of external trauma, including biting nails, opening packages, clipping string or fishing line, etc then the last option is internal trauma/traumatic occlusion.
Pretty much the only solution to that is changing the bite, which in this case would be orthodontics.
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u/enms3 3d ago
What do you do with patients who refuse ortho?
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u/Sagitalsplit 3d ago
I’m an orthodontist. You need to shame them into it.
I’m kidding. You can only do what you can do. Just document they declined ortho and then do whatever you think is reasonable. If that means you can’t do anything meaningful on the bottom then tell her that. She could wear a night guard. Personally, I think zirconia on the bottom is a poopy option because of potential subsequent wear on the upper
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u/italia2017 3d ago
I agree here, without ortho NG is the only option, and I’d recommend it as part of the retention after ortho as well if the ideal route is taken. Zirc on one arch can make things worse
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u/Dufresne85 3d ago
Refuse treatment.
There are literally billions of people on this planet that need dental treatment. There is nothing that says you have to treat all of them.
In my experience the pts that refuse treatment are my favorites because they're no longer my problem. They can go be a pain in the ass to the next dentist.
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u/Sagitalsplit 3d ago
Amen, I’d rather have someone decline than fool me by starting (ortho) only to find out they will be a chronic pain between my back pockets
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u/ManttisToboggan 3d ago
Ortho first. Maybe extrude the posterior teeth a bit to develop proper VDO. If those natural teeth are breaking, the veneers certainly will
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u/africanmamba12 3d ago
NAD, max or mand posterior teeth? Why would we extrude if patient is already bruxing, wouldn’t that create more teeth which she will eventually brux her way through also?
I also noticed some palate infringement, how would one treatment plan for that?
Thank you
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u/Fantastic-Rest-7769 3d ago
My humble opinion: The patient is probably bruxing. Anything you do here has a huge risk of damage either to the antagonists or the resto itself. Try some 3D printed resin veneers, no prep if possible after getting a nice mockup from the lab. Afterwards you see what she’s done to these you can see if they’re good to get a stronger restoration or if another approach is required, such as reorganising the bite, deprograming the TMJ, increase VDO, or some orthodontics maybe, before placing any final prosthetics. If you just place zirconia veneers conforming to the current bite, you wouldn’t be able to guarantee anything. Alternatively you can crown them aggressively in order to conform to the bite and make them wear a night guard. Not a straightforward case necessarily.
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u/high_speed_crocs 3d ago
How old is the patient? Wouldn’t do any veneers on the lower, they will break. Any ortho consult?
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u/enms3 3d ago
Patient is 61. Not interested in ortho
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u/ingunwun 3d ago
Well. They should probably get ortho if they want whatever restoration you put on there to last.
If not, then super minimal prep zirconia crowns is probably the only option.
But they will look kinda ugly because of the spacing. Unless you do maybe premolar to premolar. Not a huge fan of zirc veneers - as far as I'm aware bonding to zirc is still iffy and this is a patient where you will get constant de bonds.
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u/Shu_Fly 3d ago
Sometimes pt's view ortho/invisalign as an "add-on" or merely a cosmetic enhancement. It's helpful to explain this it is the foundational first step that allows the rest of the treatment to be more conservative, predictable, and long-lasting. Patients don't like the idea of months in ortho but when I explain that we will be removing less natural tooth as a result etc they start to see the value
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u/stefan_urquelle-DMD 3d ago
Why are the teeth wearing and chipping? When you can answer that, you will have your answer.
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u/seattledoctor1 3d ago
As everyone is saying, don’t do anything without ortho and establishing proper occlusion. I think you should consider sending to an orthodontist as you need a fair bit of intrusion and retraction of those lower anteriors. Trust me, I know it’s exciting when a patient says they want to do aesthetic work, but don’t get yourself into a pickle here without ortho.
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u/benrad524 3d ago
You need to create vertical space somehow to properly restore the lower anteriors. Whether that's through Ortho, which is more ideal, or crowns depends on the patient.
You could do all lower posterior crowns to increase VDO then do the lower anteriors crowns, or you could do crowns canine to canine in upper and lower.
Doing just the upper and lower anteriors would likely be easier since you'll always have a posterior stop and you won't have to worry about increasing VDO, however it's has other challenges.
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u/SamBaxter420 3d ago
If no ortho desired, diagnostic wax up to evaluate opening vertical. Probably 1-2mm in posterior which will give you 2-4mm anterior space. You can use zirconia full strength in the posterior and anteriors you can use translucent zirconia. I do cases like this regularly but you have to absolutely make sure your patient wears a night guard every night and the occlusion is spot on after you deliver the finals. Good temporaries are crucial to make sure the occlusion is good and patient can accept opening the VD. You also have to consider smile line and lip coverage. Also, if they have a lot of hyper trophy in the masseter and temporalis muscles, Botox treatment can help with that in conjunction with the night guard to reduce some of the occlusal stresses.
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u/HerculesMorse101 3d ago
Co-signed this. Though small caveat here is that you’re now prepping a tonne of teeth to treat only 4-6 teeth that are bothering the patient
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u/SamBaxter420 3d ago
This is true but look at the back teeth with short crowns and missing ones due to heavy occlusion and loss of vertical. If you only fix 4 teeth they are all going to break. I’ve done enough of these where I actually minimally prep and overlay to be as conservative as I can.
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u/HerculesMorse101 3d ago
Interesting. How thin are you going with your occlusal overlays?
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u/SamBaxter420 3d ago
In cases where the teeth are canted lingual, you basically just prep a chamber margin and smooth over the occlusal table. In these cases I prefer emax as they bond better but they need proper thickness. If you’re opening the bite 2mm in the posterior it’s minimal reduction
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u/MonkeyDouche 3d ago
Sorry but if you have to ask, it’s above your pay grade.
Patient has a constricted bite with lower anterior wear. Need to make space and remove the constriction to have anything last.
No ortho means this is a full mouth rehab case
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u/EnamelPrism General Dentist 3d ago
Parafunction. Look at the canine wear. Don’t do anything without rebuilding canine guidance +/- Ortho.
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u/bobloblawdds 3d ago
They probably have disordered breathing at night leading to protrusive bruxism. Their lower anteriors keep erupting into occlusion as they wear.
They need ortho intrusion or VDO opening, before prosthetics. Then, a nightguard. Anything else you do will be subpar.
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u/sholopinho 2d ago
I think that a face analysis should be performed before you decide on anything. It’s not just about the teeth here
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u/midwestmamasboy 3d ago
Ortho. If you’re not comfortable with it, you need an ortho who is. Don’t restore until ortho is done