Fixing years of significant wear and tear by rebuilding upper
and lower teeth with composite over two appointments
The patient, John McDermott, a well-known Canadian tenor, was referred to me by a good friend, Jimmy Flynn. The two men entertain on the snowbird tour in the Southern states in February every year so they can escape the cold and snow. McDermott mentioned he needed some dental work, and Flynn recommended he give me a call. McDermott sent me some iPhone pictures of his teeth, followed by some X-rays. He came in June 2018 for his lower teeth and in September 2018 for his upper teeth—and as of October 2020, the patient reports things are still in great shape!
Procedure 1: Bottom teeth
Fig. 1: June 2018. Where did all the tooth structure go? Grinding in protrusion? There is serious wear and tear. This 63-year-old gentleman has been wearing out his teeth, especially in the past 10 years.
Fig. 2: Maxillary teeth.
Fig. 3: Lower incisors. The patient’s dentists in Ontario wanted to do ortho for 18–24 months and then restorative crowns with many elective root canals, to the tune of a nice luxury car.
Fig. 4: Panorex, part 1. Gold crowns on the lower left, PFM on right maxillary molar.
Fig. 5: Close-up of Panorex.
Fig. 7: Z250 A2 composite, AllBond 2 and Premier Dental Cure-Thru matrix bands were used.
Fig. 8: First tooth done, but not finished. I built up the incisors about 5mm.
Fig. 9: Right lower canine.
Fig. 10: Lower left lateral incisor being restored.
Fig. 11: Got the teeth all hitting with the same pressure. However, I kept the lower central incisors in lighter occlusion because they were worn more than the rest.
Fig. 12: I told the patient there was a chance that restoring his teeth could end his singing career.
(I was sort of kidding.)
Fig. 13: The first thing he did when he got out of the dental chair was go to the bathroom. He came back shortly to tell me he could still sing.
Fig. 14–16: It is hard to see, but the patient’s bicuspids nearly miss in occlusion because the upper bicuspids are buccal to his lower bicuspid.
One reason for ortho would have been to expand the lower arch to get more occlusion on the bicuspids.
Fig. 20: In protrusion, but I told him
not to bite like this.
Procedure 2: Top teeth
Fig. 21: September 2018. First picture from his second go-round. Not brushing the lowers well.
Figs. 22 and 23: Lowers fit palatal to the upper teeth.
Fig. 24: You can see the second left maxillary molar I restored in the June appointment to give him posterior support on his lower gold crown. Could have sandblasted his lower left crown and bonded to it, but it was easier to add to the upper left molar. On his lower right side, I did add to the lower right first and third molars for occlusion against his upper molars.
Fig. 25: End to end.
Fig. 26: Closed tight = MI.
Fig. 27: Starting the maxillary teeth with 90N, rubber dam and Premier Cure-Thru contoured matrix band. Incisal view.
Fig. 28: My first increment is Z250 to provide palatal support, and then I cover that with Renamel A1.5.
Fig. 29: I cut an increment off the end of my Renamel syringe, flatten it between my finger and thumb and place on the labial of the tooth. I apply a little bonding resin on the composite increment to reduce pull-back, then work it into the interproximal and cover the tooth. Takes some time, because it does not flow like Z250.
Fig. 30: Incisal of same as above.
Fig. 31: Ready to start finishing. I use a small diamond at first, then a 7901 for fine labial finishing. Use a 30 fluted 7408 for palatal surface. This bur polishes so smooth and shiny, you don’t need any more polishing on the palatal.
Fig. 32: Incisal view to see how much
or little I have added.
Fig. 33: Left lateral.
Fig. 34: Tooth is rotated a bit, but with composite we will solve and eliminate the rotation.
Fig. 35: Hard to see, but I am using a Bioclear matrix to add flare sideways at the gingiva. Reduces the black holes.
Fig. 36: All done adding my pound of composite.
Fig. 37: For the upper first bicuspids, I added to the buccal cusp and made them longer and more prominent for aesthetics using only Z250 A2.
Fig. 38: Right side and polished with 3M’s Sof-Lex Superfine disk.
Fig. 39: Left side, the same polish.
Fig. 40: Plaque.
Fig. 41: Occlusion being adjusted. I did not increase his vertical when I did the upper teeth.
Fig. 42: Marks show heavier contact in lateral and protrusive excursions. Again, light occlusion on the centrals because of the lack of support I was bonding to.
Fig. 43: Finished. If you have not tried Renamel, you really owe it to yourself and your patients to get a syringe and see how nice it looks. Dr. Buddy Mopper brought it to market well over 25 years ago.
Figs. 44–46: The patient smiling. Never really could see his teeth when he smiled before.
Fig. 47: Treatment.
Figs. 48 and 49: Before and after. This took four hours (top teeth only).
Fig. 50: He sent me a follow-up photo of his lower teeth over Spring Break 2020.