The use of extra-coronal restorations in the correction of malaligned teeth

The main aims of healthcare provision are generally to eradicate disease, improve health, prevent further disease and improve function. These ideals are seemingly in conflict with the cosmetic dental epidemic currently facing dentistry. Although some may argue that the provision of elective cosmetic treatment can improve well-being, this is often at the cost of the removal of sound tooth tissue. One aspect that may not be entirely apparent initially is damage to the adjacent periodontium.

Patients may complain of rotated, instanding, crowded or labially placed teeth with the desire to have a ‘perfectly’ straight alignment. For some dentists, the worrying apparent alternative to orthodontics, or simply accepting the tooth position, is the elective preparation of teeth to ‘align’ incisal edges and the bucco-palatal profile of the sound teeth. What follows is a critique of this ‘supposedly cosmetic’ technique.

When crowns and veneers are electively utilized to improve cosmetic appearance the co-morbidities are significant. One problem that requires specific attention is pulpal damage (Figure 1). Felton and colleagues, as long ago as 1987, recognized that, when crowning teeth, the greater the amount of tooth removed, the greater the likelihood of pulpal death.1 Where teeth in normal alignment are prepared for veneers or crowns, the vulnerable perimeter of the pulps may be encroached upon, depending on individual anatomy and the skill set of the operator. Unfortunately, these risks are magnified greatly where teeth are malaligned, especially when positioned towards the labial aspect (Figure 2). Somewhat futile attempts to overprepare teeth, not only to create space for the ceramic, but also to mask position, can be so aggressive that there will be a high probability of pulpal damage.