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Inside Dentistry

November/December 2005, Volume 1, Issue 2
Published by AEGIS Communications


Clinical Decision Making: The Challenge of Isolated Anterior Teeth Requiring Restoration

Frank M. Spear, DMD, MSD

Patients’ desires to have beautiful, white teeth is widespread in our culture, and dentists routinely use procedures such as bleaching, bonding, veneers, and crowns to provide patients with the smiles they desire. When a patient presents who requires or desires restoration of multiple anterior teeth for structural or esthetic reasons, the usual decisions facing clinicians involve tooth preparation design, what porcelain to use, and the final position, form, and color of the restoration.1

Often, however, we are faced with the challenge of only 1 or 2 anterior teeth requiring restoration; the remaining teeth are in acceptable or even excellent condition. Or, the patient would like all of his or her teeth whiter and, for most of the teeth, bleaching would produce a perfectly acceptable result, leaving only 1 or 2 teeth to restore (Figure 1).

Now the dentist is faced with a new challenging decision: either restore only the problem teeth, attempting to match the bleached natural teeth that the patient likes, which can be very difficult; or restore all of the teeth, which is much easier and more profitable for the dentist, but which involves restoring teeth that don’t need any treatment simply for the sake of convenient shade matching. There is no easy answer to this dilemma. If the patient’s natural teeth are poorly shaped, worn, have large restorations, or some other condition for which they may benefit from restoration, then restoring all of the teeth makes sense.2 It’s when the natural teeth don’t need any treatment that restoring them—simply to match the shade of a problem tooth that is being restored—must be carefully examined. The pros and cons of restoring multiple teeth, versus getting one to match, must be presented to the patient.

My approach has always been to tell patients that if the natural teeth are acceptable—to the extent that the only reason to treat them is to match the color of the restoration being placed on another anterior tooth—then they are usually better off doing what is necessary to match the single restoration to the acceptable natural teeth3 (Figure 2). I also explain that matching a single anterior tooth is one of the most difficult things I do, and that less than 50% of the time does the first restoration match perfectly.4 I may need to make 2 or 3 restorations to achieve an ideal match and, because of this, the fee to treat a single anterior tooth is variable. Depending upon how many times it must be remade, it could cost as much as having 2 or 3 teeth done in order to make it ideal (Figure 3).

This difficulty is obviously magnified when treating maxillary central incisors. Getting laterals or canines to match acceptably is a much easier proposition. I also inform the patient that because the natural teeth are in good condition and esthetically acceptable, the most predictable long-term prognosis would be not to treat them.5

Conclusion

It is ultimately the dentist’s judgment and patient’s desires that determine whether it is better to proceed with restoring multiple teeth or just the isolated problem teeth. How adamant the patient is about what he or she wants, the competency of your dental laboratory, and your ability to communicate with the patient and the technician will ultimately influence your decision. In the end, as in many areas of dentistry, there is not one right answer.

References

1. Zappala C. Esthetics or cosmetics? Bleaching and how to choose the proper alloy for esthetic restoration. In: Romano R, ed; The body of The Smile: Integrating Prosthodontics, Orthodontics, Periodontics, Dental Technology, and Plastic Surgery in Esthetic Dental Treatment. Chicago: Quintessence Pub.; 2005:40-62.

2. Gürel G. Esthetic Dentistry. In: The Science and body of Porcelain Laminate Veneers. Chicago: Quintessence; 2003:19-58.

3. Garber D, Adar P, Goldstein R, et al. The quest for the all-ceramic restoration. Quintessence Dent Technol. 2000:27-49.

4. Chiche G, Pinault A. Communication with the dental Laboratory: Try-in procedures and shade selection. In: Esthetics of Anterior Fixed Prosthodontics. Chicago: Quintessence Pub. Co.;1994:115-40.

5. Gürel G. Failures. In: The Science and body of Porcelain Laminate Veneers. Chicago: Quintessence; 2003:345-68.

About the Author

Frank M. Spear, DMD, MSD
Founder and Director
Seattle Institute for Advanced Dental Education
Seattle, Washington

Affiliate Assistant Professor
University of Washington School of Dentistry
Seattle, Washington

Private Practice
Seattle, Washington


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Image Gallery

Figure 1 The patient presented unhappy with her anterior tooth color and the margin of the old crown. The dilemma: how many teeth to restore?

Figure 1

Figure 2 The decision was made that the anterior teeth, other than tooth #9, would be acceptable after bleaching. This view shows the teeth after bleaching, removal of the old crown, and re-preparation of the tooth.

Figure 2

Figure 3 View of the final restoration in this case—a metal-ceramic crown to block out the previously existing metal post and core. Achieving a match such as this with the adjacent natural dentition may require the fabrication of several crowns.

Figure 3