"Can You Put Back the Tops of My Canines?"

Sure we can!

And we don't have to take away half your tooth to do it, either. 

I was at a very international sort of symposium at my alma mater, Penn, recently. There were brilliant lecturers there to be sure. Some of these folks, though, have an inherent bias against utilizing the principles of dental adhesion. Rather than place something on a tooth, they removed significant tooth structure and sprayed porcelain about like it was Tom Sawyer's infamous whitewash. It was beautiful porcelain, to be sure, but that was beautiful human tooth enamel that went up in a slurry into the dental evacuation unit, too.

Let's have a look, then, at a rather extreme case of employing dental adhesion principles to accomplish an interesting patient goal.

Here's our gal:

Well, her teeth, anyway. She's a dear friend of ours who was about to start Invisalign therapy. She wanted to know if, besides aligning her teeth overall, we could replace the worn areas on her upper canine teeth, those third ones from the center with the straight edges.

Now, some people think their canines are too pointy. We gently level these when asked to, and these patients are always quite happy. My patient was making the opposite request. 'Fascinating!' As a certain science officer was known to remark from time to time...

Keep in mind, we can't do anything if there's no room against the lower teeth. Orthodontic treatment allows us to make room, which is nice.

For more on alignment and wear, see my recent post:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2011/12/orthodontics-proper-function-and-tooth-wear.html

So we aligned my friend's teeth and towards the end of Invisalign treatment we used sectional veneers to add porcelain just where it was needed on her canines, and also on her front right tooth, which was a bit too uneven to align orthodontically:

The onliest places her canines were touched with a drill was on the inner side. The physics of the situation gives us more strength if we place a small platform there that resists the forces of biting. Here are closer views:

Please note! That is all her own lovely enamel that you see there, with just an addition of porcelain that matches. Most of the European lecturers, and indeed most of the Yanks at that conference I attended, would have crowned these teeth entirely, removing all their enamel and then hovering obsessively over Hans-Ulrich or Massimo, their uber-skilled ceramists, as they labored to precisely match the hue, chroma, value, translucency, opacity and surface texture of the patient's adjacent teeth.

Snaps for Massimo and Hans, but isn't the patient's own natural enamel, assuming it's beautiful to begin with, the best substance to use here? I will stand by this concept until the day I hang up my dental mirror and retire.

Decisions like this all come from a failure to adopt innovations once they are proven. If interested in this sort of thing, see my post:

http://rickwilsondmd.typepad.com/rick_wilson_dmds_blog/2010/08/facts-versus-our-opinions.html

The point is, dental adhesion is a proven concept with a vast body of research to back it up. We can now bond to both enamel and dentin with enough strength to make carefully planned and executed adhesive restorations last a very long time in most people's mouths.

One of the great leaders in this field of dental adhesion is Ray Bertollotti, DDS, PhD. I did shoot him an email before this case concerning the specifics of the preps and here's what he said:

 "If you need to build in cuspid rise, then a lingual bevel and no incisal prep. If not, reverse this and leave a lingual butt joint and incisal bevel at about 45 degrees. The facial bevel will give better esthetics."

That quote was more for the dentists in the audience. Yet, if you're a patient reading this, isn't the minimally invasive gist of his advice comforting?

If a patient's teeth have fractures, extensive old fillings or decay, deep intrinsic stains or some other major issues, by all means, let's use some beautiful modern porcelain. But when everything is ideal except for some part of a tooth that's missing due to wear or fracture-

Let's just put back what's been lost!

Comments

[Dentists fan]

I do think it's impressive that you tried to use as much of the patient's own enamel instead of just crowning the whole thing. I wonder just how many dentists actually do that? What kind of adhesive are you using to put the porcelain on? It was really interesting looking into the detail of what goes into this procedure.

[Rae Screen]

You're right. Using dental adhesion can restore the natural pearly white look of the treated tooth. What's more, this procedure is less expensive than putting dental crowns, though it has limitations on strength and longevity compared with veneers and crowns. I hope that future adhesion procedures will be stronger and more permanent.

[Rick Wilson DMD]

Dentists fan, I meant to get back to you on this. I bonded these sectional veneers with Accolade PV from Danville Engineering:

http://www.danvillematerials.com/

Ray Bertollotti DDS PhD was one of the developers of this material. It's brilliant. The try-in pastes are the same as the real thing, but they lack an initiator. So they won't cure, even if intense light hits them. You can muck about (my usual method) with the veneers for half an hour and more, checking fit and shade and even letting the patient smile, since they're a bit sticky even though unbonded.

Then, when you're ready to bond 'em in, all you need is approximately 50% of the paste to be the real stuff with the initiator, since it will all polymerize with the light at that level.

Dentistry is a supremely exacting art and science. This is one of the few times that a superb product lets us be a little lax, in that we don't have to worry about getting ALL of the try-in paste out!

[Kelly Jones]

I am looking to have a similar procedure done. Since I just moved to Wisconsin I am looking for a dentist in Green Bay who I could go to not only for this procedure but for regular checkups as well. It is nice to know that this procedure is cheaper than a dental crown, which my former dentist recommended. I guess I will have to look at all my options before I make a decision.

[Rick Wilson DMD]

So glad I was able to make you aware of this then, Kelly Jones! Not only is the monetary cost a bit lower, but the cost in terms of your precious enamel is lower, too. Over our lifespans, that's so very important.