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Inside Dentistry
April 2021
Volume 17, Issue 4
Peer-Reviewed

A Transitional Full Mouth Rehabilitation

Injectable composite offers cost-effective, conservative solution to stabilize function and improve esthetics

Sandra Hulac, DDS

High-strength injectable composites are designed to be very durable, exhibiting excellent fractural strength, wear resistance, and gloss retention. Their material properties make them suitable for all classes of restorations, and they are increasingly being employed as a transitional restorative material for complex wear or erosion cases using an injection molding technique with clear matrices obtained from a diagnostic wax-up. This technique, which historically used only one such matrix per arch and required time-consuming isolation of the individual teeth to prevent them from becoming bonded together, has since evolved into an "alternating teeth" technique involving two matrices per arch. This permits a full mouth rehabilitation to be carried out in a single appointment, producing instant cosmetic and functional results. Typically, a few short follow-up appointments are required to fine-tune the occlusion and esthetics.

Transitioning a case with composite can immediately stabilize an otherwise deteriorating situation in a cost-effective way. This approach allows patients to address the realities of financial or time constraints and then change to more durable porcelain restorations in a timeframe that is appropriate for them. The transition to porcelain can be carried out either tooth by tooth as the composite restorations are failing or, preferably, in sections to obtain a more cohesive esthetic look, particularly in the anterior region.

Because composite is a more "forgiving" material for bite alterations, it is ideal for "road testing" occlusal changes. Furthermore, an entirely additive approach is the most responsible way to address the needs of patients, especially younger ones, and the constant changes in porcelain technology may permit the use of thinner restorations in the future, necessitating less tooth reduction.

The 21-year-old patient featured in this case came to the office with a chief complaint of having recently noticed more rapid wear of her upper front teeth. According to the patient, her teeth had always been "tiny," but after looking at recent photographs, she was shocked to realize that they had become significantly shorter during the past 6 months. Her previous dentist had told her that the wear was due to nighttime bruxism and fitted her with a hard maxillary arch splint. She wore the splint consistently; however, it failed to stop the progression.

An intraoral examination revealed significant attrition compounded by severe erosion on the palatal surfaces of her upper anterior and upper left posterior teeth. Her maxillary central incisors measured 4 mm in length, but the average length of a female patient's maxillary central incisors is approximately 10 mm. Compensatory overeruption had led to a loss of restorative space. In addition, moderate attrition and erosion were found on the lower anterior and lower left posterior teeth. Several carious lesions were present. When the patient's mouthguard was inspected, track marks could be seen.

These findings lead to a provisional diagnosis of parafunction accompanied by gastroesophageal reflux disease (GERD). When compared with that of bulimia, GERD typically produces a different erosion pattern in which the posterior teeth on one side of the mouth (ie, the patient's preferred sleeping side) are more affected than those on the other side. The patient confirmed that she had indeed noticed experiencing gastric reflux. After the presence of GERD was confirmed by a physician, the patient was treated with a short course of proton pump inhibitors and changed her dietary habits. Because any treatment solution, particularly those involving composite, will have an extremely poor prognosis in a consistently acidic oral environment, treatment was allowed to commence only after her symptoms had resolved.

Due to the young age of the patient, after initial caries removal, the decision was made to treat this case with injectable composite, opening the vertical dimension of occlusion to create restorative space to cover all of the eroded surfaces and permit appropriate lengths of her upper anterior teeth. Once the treatment was finished, she was fitted with a new hard splint for nighttime use.

About the Author

Sandra Hulac, DDS
Private Practice
Hong Kong, China

Preoperative smile view showing small teeth with severe wear in the upper anterior region.

Fig. 1

Preoperative retracted view with teeth apart showing moderate erosion on the lower anterior teeth. Note that the tissue levels of teeth Nos. 8 and 9 show some degree of compensatory overeruption.

Fig. 2

Preoperative maxillary occlusal view demonstrating severe erosion on the patient’s upper anterior teeth with additional erosion on her upper left posterior teeth.

Fig. 3

Preoperative mandibular occlusal view showing moderate erosion on the lower anterior teeth with more severe erosion on the lower left posterior teeth. A zirconia crown was present on tooth No. 30.

Fig. 4

Facially generated treatment planning with digital smile design to achieve correct tooth proportions and tissue levels.

Fig. 5

Closed crestal contouring was carried out with a Wedelstaedt chisel to the levels determined by the digital smile design. Before carrying out this procedure, it is mandatory to sound for the cementoenamel junction to avoid exposing any root surface. Please note that this kind of flapless crown lengthening should only be performed on patients with thin or normal gingival biotypes and a on limited number of teeth.

Fig. 6

The wax-up of the upper arch was duplicated, then every second tooth was removed from the duplicate. The same procedure was carried out on the wax-up of the lower arch.

Fig. 7

The wax-up of the upper arch was duplicated, then every second tooth was removed from the duplicate. The same procedure was carried out on the wax-up of the lower arch.

Fig. 8

Alternating tooth matrices were produced using clear bite registration paste that was placed into more rigid trays (Essix® Ace Plastic, Dentsply Sirona). These were then placed into a pressure pot while setting. Having a well-fitting matrix is paramount to reduce the overflow of injectable onto neighboring teeth. After the holes are placed to allow for injection of the material, it is important to check their patency several times from both directions with the tip that will be used for injection. Obstructions can result in small particles of the bite registration material blocking the tip.

Fig. 9

At the start of the appointment, any existing restorative material was removed from the teeth and they were thoroughly cleansed with pumice. Next, the alternating teeth to be restored in the first round of injections were individually etched and bonded. Avoiding etching and bonding the adjacent teeth in order to be able to separate them after the first round is more important in cases involving wide contact points, such as the those for the full coverage “injection crowns” in this case.

Fig. 10

View of the first matrix placed on the model demonstrating placement of the injection tip. To avoid the formation of bubbles, it is important to insert the tip as far cervical as possible before starting to inject, and then slowly withdraw the tip while injecting.

Fig. 11

The completed first round of injections.

Fig. 12

The sprues were polished off, and the contacts were easily separated with an interproximal saw (Ceri-Saw™, DenMat).

Fig. 13

Immediate postoperative retracted facial view with teeth apart. Following all four rounds of injections, the cervical margins and interproximal areas were finished with a No. 12 scalpel blade and polishing strips. Some gum irritation is to be expected; therefore, it is advisable to slightly anesthetize the tissues before finishing and polishing procedures. In areas where the material is thin, like it was on the lower left central in this case, “show through” may occur. This can be remedied by cutting the material back and overlaying the area with a slightly more opaque shade of composite.

Fig. 14

Close-up retracted view of the upper anterior teeth after healing of the soft tissues. Note how the variations in the thickness of the material and the color differences of the underlaying tooth structures result in restorations that exhibit natural polychromaticity. If desired, the incisal edges of the upper central and lateral incisors can be cut back slightly, and a more translucent material or a small amount of azure stain can be added to create more translucency.

Fig. 15

Postoperative smile view exhibiting harmonious tooth proportions.

Fig. 16

Postoperative retracted facial view with teeth apart demonstrating soft-tissue health. One of the advantages of choosing composite is that it does not require a waiting period of 3 months after crown lengthening because any possible biologic width violation can be easily remedied, and the soft tissue generally reacts favorably to a well-polished composite surface.

Fig. 17

Postoperative maxillary occlusal view of the upper arch showing that all eroded surfaces are protected.

Fig. 18

Postoperative mandibular occlusal view of the lower arch. Note that the existing crown on tooth No. 30 has been replaced.

Fig. 19

Close-up “glamour shot” photograph highlighting surface texture and luster.

Fig. 20

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