I was hoping to get some thoughts and guidance on how people would treat this thirty year old patient who presented with severe generalized TSL. The chief complaints were that her teeth are worn, sensitive and yellow. She would like something done before her wedding in a years time but has a very limited budget. Orthodontics, crowning lengthening and indirect restoration are therefore not likely to be a viable option at this time. All of the teeth are vital apart from the root treated lower left first molar. The TMJ's and muscles are healthy and asymptomatic. There was no pain from the joints when load tested.

I have very limited experience in treating wear patients and have never treated a full mouth case like this before. However, the patient is unlikely to be accepted for treatment at the local teaching hospital and I would really like to offer her treatment as a 'training case'

We have established the main cause of the TSL is untreated GORD and previous high intake of carbonated soft drinks. The lower incisors appear to be relatively unworn suggesting attrition has a limited role in the TSL. My provisional treatment plan is:

1) Prevention - referral for treatment of GORD. Oral hygiene instruction, diet diary etc.

2) At home tooth whitening if patient accepts and tolerates

3) Mounted study models in CR and diagnostic wax up at slightly increased vertical dimension lengthening the upper anterior teeth 1-2 mm to achieve a more esthetic crown to width ratio

4) Gingivectomy to improve gingival esthetics as much as possible without surgical crown lengthening

5) Direct composite restoration of all of the teeth using matrices fabricated from the diagnostic wax up

6) Long term review potentially replacing the direct composites with indirect restorations when feasible for the patient

I have the following questions:

1) Is this a reasonable treatment plan given the limitations of the case?

2)How would you phase the restorative treatment? start with the six upper anterior teeth and then do the posterior teeth a side or a quadrant at a time? How long can you wait to restore the posterior teeth before the teeth are likely to over erupt?

3)What is the most efficient way to treat the posterior teeth? Tooth by tooth using a copyplast/memosil matrix directly or with mach-2 silicone dies 'semi-directly'? My main concern is how difficult it will be to clean up the restorations interproximally

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