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Today I had a patient of record come in with a single tooth that had begun to decay and then she fractured the buccal cusp. She and I decided to proceed with a veneerlay restoration, so I prepared an MODB onlay, reducing the buccal cusp. Then I incorporated a veneer prep down to the crest of tissue on the buccal for esthetic optimization.
With this single tooth prepared my assistant asked me whether we would be taking a triple tray or full arch impression. Fifteen years ago I took most of the final impressions in my practice with triple trays. As my practice began to evolve and I began my journey toward more comprehensive care I started taking more and more full arch impressions with facebow transfers. As Chelly asked me this question I began to ask myself the question why wouldn’t I take this with a triple tray?
Veneerlay Prep
Triple trays do several things very well. They are very effective at impressing the preparation, margins and adjacent teeth. In addition they capture the bite at the vertical dimension the restoration will be made at, so the lab can very accurately manage intercuspal position. The missing pieces are about how the teeth function against one another in excursive movements. A triple tray does not give the lab the ability to move the models through all of the movements the mandible can make and adjust the restoration. What it does transfer is the relative cusp height, fossa anatomy and cuspal inclines of the adjacent teeth. A technician that has been trained well, can follow these anatomic features through to the new restoration.
Triple Tray Impression
So I decided in this case, a single lower bicuspid restoration, where we are replicating the patients existing occlusal scheme, triple tray it is! I’m confident that my technician at The Winter Lab, will have the information to create an exquisite result, and I am prepared to check and finalize the excursive contacts at the seat appointment.
Have used them for ever on single tooth impressions. If I am careful to to have the occlusion and canine guidance correct and included in the impresson , it will be correct on this new one as well.
Thanks Charles!
Lee, can you discuss your decision to restore this type of lesion indirect vs. a direct restoration
Hi Bill,
The patient had decay on the cusp tip, at the gingival margin on the labial, and as it turned out on e we started the prep on the distal as well. The patient and i discussed the option of doing separate composite restorations on the labial and cusp tip. The risk for me in doing the composite is the tooth structure between the two restorations on the labial being undermined, as well as the longevity and retention of the composite on the cusp tip, with the benefit being less removal of tooth structure now. For the veneerlay the risk is more aggressive reduction now, with the benefit to me being the continuity of the restoration, porcelain replacing the cusp tip, and retention form. The patient opted for doing the veneerlay after our discussion. I think either approach would have worked and achieved a nice result.
Don’t u think u have too many margins doing it this way? Have seen a lot of teeth and in removing decay this sucker gonna be really deep. If u prepped for crown so much easier to see if u got all decay. I playing devil’s advocate but I am not a huge fan of composite inlays od porcelain inlays. Gold yes but esthetics would preclude. Some dentists incredibly talented but why do a 4 surface onlay vs. crown? Thanks.
Thanks Lee. Makes sense. I was not aware or the other areas of decay on the tooth.
Thanks Bill, how are things in WI? Did your daughter and mine ever connect on FaceBook?
Lee, I enjoy reading you blog very much. I missed your energy after you left Pankey, and I never made it to Scottsdale to take courses there. It is nice to get your insights again.
Thank you!
Good to hear from you, hope everything is going well.
A few observations.if this picture is exactly how it looks in mouth I’d say tooth needs rct but let’s say I’m wrong. Any only or composite is so inferior to well prepared semi precious crown plus when u prep u won’t miss decay. The area of margin is so much less with crown. U may save tooth structure but restoration will have much more chance of early failure. To prove point look at molar. Posterior composite that was placed yuck. If done for esthetics looks terrible as 95% I see after 4 years. Make dentistry easy. A pretty crown makes sense for dr. And patient. If patient questioned me I’d send for endo consult!!!!!!!!!!!