Restoration of Severely Bulimic Patient Using Direct Composite

by Terry Shaw, DDS

Dentistry is evolving constantly in terms of treatment options and with acid etch techniques we can restore teeth that a few years ago were considered hopeless. In April 2006, a 31-year-old female education student presented for another opinion on her teeth. She had been bulimic for a long time but said she was not any longer. She had been offered dentures and a conventional full mouth rehab as options. Since she was a student she had limited funds. I explained we could try to restore her teeth with composite and expect 10 years plus longevity based on my experience with this type of treatment. My big concern was the lack of enamel as I had never done this many large restorations on one person with so little enamel remaining on the teeth. I told her we might have to repair the occasional lost restoration every year and she was comfortable with that. About 20 years ago, I started doing single arch rehabs with composite and have found the treatment lasts many years, so about 10 years ago I started full mouth rehabs with direct composite and again have been impressed with the results. In April, 2006 we restored the maxillary anterior and premolar teeth at the first operative appointment. 3M’s Z-250 in shade A2 was used. AllBond 2 has been my bonding system for the past 20 years. Some of the advantages of using composite are ease of use, ability to shape and finish restoration limited by only your artistic talents and it is easily repaired. Porcelain usually needs complete replacement when it fails.

The first three figures (Figs. 1-3) show her severely eroded teeth as she presented for treatment. I sandblasted (Danville Engineering with aluminum silica 50 micron particle size) the teeth to remove the stain (she drinks 5-6 cups of coffee daily) from the dentin as a bur would remove more tooth than necessary. There was a small amount of enamel all around the margins and this enabled me to bond to enamel and not just dentin. I use an Ivory 90N clamp for all my full labial surface bonding. This clamp is similar to a 212 but much stiffer and does not move on a tooth. It allows me to lift the gingiva and place my labial margin sub gingival for a nice emergence profile. I finish all my labial margins with a MW7901 finishing carbide that is slightly dull so I do not cut the tooth surface. The tip has no cutting flutes and can be placed under the gingiva as it is very small and you can finish to a feather edge sub gingival and in fact have an undectable margin.

Figures 4 & 5 show the 90N clamp in place with a Premier contoured matrix band in place. This band has been trimmed for use on anterior teeth. Composite is added first to the palatal part of the matrix band. I sometimes do the whole tooth at once, but often it is easier to do the palatal half separately and then the labial half next or in several increments. Much depends on the shape I am trying to replicate, matrix band curvature and tooth length as to the number of increments. The alignment of the midlines is critical for good esthetics so I do the centrals first. With these bands it is much easier to remove excess from the labial and palatal than the interproximal so I concentrate on getting my width correct and don’t worry as much about labial and palatal excess. I use the MW7901 for labial finishing and a 30 fluted ultrafine 7408 carbide which produces a highly polished surface. I use 3M Soflex superfine discs for labial polishing. These Premier bands can also be used for posterior teeth held in place by tofflemire retainers. The mesial and distal are deep and produce a contact too high for normal use so I cut these level with the rest of the band for normal use. As they arrive in the packaging they are excellent for deep interproximal restorations. I add 2mm at the gingival and cure my composite then add more pressure to my wedge to produce a good contact and add more composite.

Figures 6 & 7 show a band without a retainer simply held in place by the wedge and the lip of the band is under the rubber dam and friction helps keep it there. The band can be placed on the buccal for the buccal half of the restoration and then flipped to the lingual for the other half of the restoration. These bands again give a nice emergence profile from the buccal and lingual with very little finishing necessary.

Figures 8 & 9 show top anterior and premolars immediately after restorations were completed. I left the teeth slightly thicker at the first appointment as I wanted the extra thickness for strength and to have room to for adjustments when I did the lower teeth later. I adjusted the occlusion after the ten anterior teeth were restored and simply used articulating paper until the occlusion was even on the lower teeth. I have found these cases where the occlusion is opened to be amazingly free of occlusion difficulties and the patients do very well with their new occlusion. The maxillary ten teeth required four hours to complete. She returned six weeks later in June, 2006 for the lower teeth to be restored and these took six hours as we restored thirteen lower teeth with the exception of the 4-6 as it had a crown placed previously.

Figure 10 was taken when she returned for the lower teeth to be restored and shows the upper teeth with excellent gingival healing.

Figures 11, 12 & 13 show the lower teeth being restored while Figures 14 & 15 show the lower teeth completed.

Two months later Figures 16-18 were taken in August, 2006.

Figures 19 & 20 were taken May, 2007 when she came in for restorative work on her maxillary molars (13 months post-op for her maxillary teeth). The panorex was taken June, 2006 after her restorative work. Panorex (Fig. 21) should have been taken at first appointment but she declined because of funds. I wanted to help this young lady get her smile back and we accomplished this. I replaced her lower right first premolar restoration in February 2011 which failed probably due to lack of bulk and the other restorations were satisfactory. I have included six pictures to show the procedure for restoring a single tooth.

Figures 22-27 show restoration of tooth.

Figure 23 shows the tooth with the 90N clamp, rubber dam and matrix band in place.

Figure 24 an occlusal view.

Figure 25 shows palatal composite in place.

Figure 26 shows occlusal view.

Figure 27 shows all composite in place and Figure 28 shows bands. Having used this technique for many years I can restore teeth esthetically, quickly and with the expectation they will function for many years. I have included pictures of Premier Cure Thru matrix bands.

Figures 29 & 30 show burs. The top one is a 30 fluted ultrafine size eight football shape. It is excellent for the palatal curvature and highly polishes at the same time. The 7901 comes regular and the slightly larger MW7901 (mid west). These are excellent for removing excess at the labial margin and interproximal as well. Figure 31 shows maxillary teeth in February, 2012.

Some dentists use a template for bonding but I have done these restorations this way for so long I don’t feel it necessary for myself. This type of restorative treatment can be a part of many dentists’ armamentarium, for many people cannot afford conventional full mouth rehabilitation. As our population ages, composite can provide a large part of our treatment for broken dentitions.OH

Dr Terrence Shaw graduated from Dalhousie University in Halifax, N.S. in 1976 and practices in Perth-Andover, NB. He is currently Continuing Education Chairperson for the Atlantic Academy of General Dentistry.

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