I met this patient a couple years ago as a new grad. He had extensive, generalized acid erosion and wear through his entire dentition. He also has a posterior cross bite, moderate to severe recession (generalized). At the time he had a handful of failing restorations that were bothering him. Our initial conversations involved his immediate needs but also bigger picture things like his wear, bite imbalance, acid insult, etc. He was not interested in comprehensive care at the time (I also did not have the clinical skills or experience to treat him) so I fixed a handful of the broken teeth that were bothering him with a mix of crowns and composites. He declined ortho consults, night guard, etc.

Fast forward a couple of years. I've retained him as a recurring patient in hygiene and have built a stronger relationship. With my encouragement, he has cut out the energy drinks and gotten his GERD under control with a physician. He came to me a few weeks ago and wanted to talk about addressing his front teeth that continue to chip. I don't think he yet realizes what would be required to properly fix his teeth, but I went ahead and had my assistants take a series of photos (I know our photos need some work, but we are learning) and scans so I could sit down and take a good hard look at it.

Here are my observations

He's medium risk cosmetically. He doesn't have outrageous expectations. He's more concerned with function than esthetics, but does have a bit of a hyper mobile upper lip.
He's very high risk functionally with all off the occlusion dysfunction and wear. He's lost some vertical dimension but not a ton. He has gotten the acid erosion under control and that appears to be stable. I don't have much airway/ sleep training but I would be shocked if there was an airway component to this as well.
I highly doubt he would consider ortho (doesn't mean I don't discuss just being realistic). I think he would maybe consider FMR with crowns, etc. But he really wants to protect his front teeth from further chipping and wear.

I'm two years out of school and have been fortunate enough to land in a practice where I have gotten more reps than most dentists with my tenure. I've done some 6-12 unit anterior cases on "green light" patients and have seen good results thus far. I've begun taking more CE around comprehensive care, occlusion, cosmetics, etc but I still don't feel 100% ready to take on a full mouth case. On top of all of that this seems like a high risk case functionally and not great for someone still getting started with comprehensive care, FMR, etc.

I obviously would love to be able to treat this person, but would also be ok with him landing with a local prosthodontist, etc if he was ready and that meant he got the care he was looking for. What I really want to be able to provide is a comprehensive, realistic plan for him. Whether that's me executing it in the future, another doc doing it now, or even him just deciding to roll with his current situation. I would love to hear everyone's thoughts, assessment on his current condition, response to my observations, and how they would treat this patient.

I attached some initial x rays from a few years ago (didn't have access to recent x rays remotely) and a recent set of diagnostic scans.

Looking forward to learning form others. Thanks!

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bitescan.bin

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lowerjawscan.bin

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upperjawscan.bin

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