ORAL & Implantology - Anno V - N. 2-3/201270

PROSTHETIC-RESTORATIVE APPROACHFOR THE RESTORATION OF TOOTH WEAR.VDO INCREASE, REHABILITATION OFANATOMY AND FUNCTION AND AESTHETICRESTORATION OF ANTERIOR TEETH. CASE REPORTM. GARGARI1,2, F.M. CERUSO2, V. PRETE2, A. PUJIA1,2

1 Department of Odontostomatological Sciences, University of Rome “Tor Vergata”, Rome, Italy2 Department of dentistry “Fra G.B. Orsenigo - Ospedale San Pietro F.B.F.”, Rome, Italy

SUMMARYProsthetic-restorative approach for the restoration of tooth wear. Case reportObjective. This article presents a case report of combined prosthetic-adhesive rehabilitation in a patient with a general-ized tooth wear. Methods. A combined treatment adhesive - prosthetic was proposed to a male patient of 65 years old having a clinicallysignificant tooth wear, with dentine exposure and with a reduction in clinical crown height. The erosive/abrasive worn den-tition have been reconstructed with direct resin composite restorations on the posterior teeth and with zirconia crown onthe anterior teeth. Results. Direct composite restorations have a number of distinct advantages. These restorations have proved durable andaesthetic, protect tooth structure and posterior occlusal contact is predictably re-established.Conclusions. A combinations of direct and indirect restorations, based on the new vertical dimension of occlusion (VDO),can help to reestablish anatomy and function.

Key words: VDO, tooth wear, resin restoration, full-mouth rehabilitation.

Introduction

Tooth wear represents a frequent pathology withmultifactorial origins. Behavioral changes, unbal-anced diet, various medical conditions and med-ications inducing acid regurgitation or influencingsaliva composition and flow rate, trigger tooth ero-sion, awake and sleep bruxism, which are wide-spread nowadays with functional disorders, induceattrition (1).It can be generalized throughout the dentition, butis often localized to the incisor and canine teeth (2).

Significant loss of tooth structure caused by attritioncan result in flattended occlusal surface with littleoriginal form remaining and significant proportionof exposed dentine (3).Tooth wear treatment consist of three fases: 1) eti-ological, clinical, functional and aesthetic valuationfor a treatment strategy based on etiology; 2) pre-ventive and restorative fase; 3) maintenance pro-gram (4).A diagnostic wax-up can help the determination ofocclusal plane and the evaluation of correct heightof vertical bite (VDO) that compensates for the lossof tissue and creates space for the anterior restora-

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tions with a better guide of anterior teeth (reducingthe potential excessive incisal overbite) (4).If the loss of dental tissue is small or moderate theincreasing of vertical bite (VDO) is obtainedthrough the application of resin direct restorations. The increase of vertical bite (VDO) is maintainedthrough anterior restorations made from a materialstrong and wear resistant (resin or ceramic). The wax-up is the guide of teeth restoration and asilicon guide is fabricate from the wax-up to trans-fer in the mouth the correct occlusal plane and thesmile line.The idea of increasing vertical bite for tooth wearrestoration was described and popularized by Dhal (4, 5).Is the state of the posterior teeth which determinesthe most appropriate restoration option: 1) in caseof limited loss of tissue and small fillings using onlydirect restorations; 2) in case of moderate loss of tis-sue and medium-sized restorations using a combi-nation of direct and indirect resin restorations; 3) incase of severe loss of tissue, loss of dental anatomyand large restorations using mainly indirect restora-tions (crows and veneers) (4, 5).Dental treatment improves the patient’s oral hy-giene, reduces thermal sensitivity, prevents pulpalinvolvement and further abrasion, and aesthetics areimproved (6).This paper presents a case report of combined pros-thetic-conservative rehabilitation in a patient with ageneralized tooth wear.

Methods

A combined treatment adhesive – prosthetic wasproposed to a male patient of 65 years old having aclinically significant tooth wear, with dentine ex-posure and with a reduction in clinical crownheight. He had a stable periodontal condition but apoor oral hygiene (Figs. 1,2). The patient is in good general health, he doesn’thave allergies to medications, he doesn’t smoke. In this case report, the erosive/abrasive worn den-tition have been reconstructed with direct resincomposite restorations on the posterior teeth andwith ceramic-zirconia crown on the anterior teeth1.1 - 2.1 and 2.2.

Before the treatment, the patient signed the in-formed consent and periodontal evaluation and pro-phylaxis were done for removing any signal ofplaque accumulation.After clinical exam, impressions of maxillary andmandible arches were taken with alginate to obtainpreliminary casts for diagnostic waxing from rightcentral incisor to left lateral incisors and fabricationof 3 provisional crowns in acrylic resin, and fromthe diagnostic wax-up were fabricated a siliconeguide masks (Fig. 5).The vertical bite (VDO) was increased by raisingthe bite of 3 mm on the articulator according to thegnathologic parameters. This has allowed the re-construction of the anterior elements through a fiberpin and the subsequent reconstruction using zirco-nium-ceramic crowns.

Figure 1Palatal view of the toothwear. 

Figure 2Lingual view of the tooth wear.

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Before the beginning of restoration procedures, thesilicone guide should be tested as to its adaptation. The teeth were isolated with a rubber dam (DentalDam, HYGIENIC, 6” X 6”, 152X152 mm,Coltène/Whaledent Inc., 235 Ascot Parkway, Cuya-hoga Falls, OH 44223 / USA) that is useful to keepthe operative field dry; the rubber dam was fixed oneach tooth with wires (Fig. 3).

A 35% phosphoric acid gel with BenzalkoniumChloride was applied for 20 seconds over the oc-clusal posterior tooth surface. The tooth was thenwashed with an air-water spray (Wet tecnique).Then the adhesive system (Tokuyama BondForce, Tokuyama Dental Corporation, 38-9,Taitou 1-chome, Taitou-kuu, Tokyo, Japan) wasapplied on the exposed dentine surface. The air-water spray has been used for 10 seconds to evap-orate the solvent before the light curing (30 sec-onds).Using a round-ended spatula a small ball of translu-cent enamel microhybrid composite (Estelite SigmaQuick, Tokuyama Dental Corporation, 38-9, Taitou1-chome, Taitou-kuu, Tokyo, Japan) was placed onthe silicone guide and spread over the silicone guidesurface; the composite was placed in layer ofenamel and dentine of appropriate color. The com-posite was aimed to cover all the exposed dentin atthe occlusal surface. Subsequently, the siliconeguide was placed into position and the entire layerof resin was polymerized for approximately 40 sec-onds (Figs. 4-6). Static and dynamic occlusion waschecked.The final polishing of restoration surface was car-ried out with silicon rubber.

The front teeth 1.1, 2.1 and 2.2, where the amountof tissue lost was greater, were reconstructed withfiberglass pins and ceramic-zirconia aestheticcrowns. The front teeth were prepared to adjust the tempo-

Figure 3Isolation of operative field with rubber dum.

Figure 4Occlusal surface built with aid of rubber dum.

Figure 5Diagnostic wax-up.

Figure 6Completed occusal built-up.

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rary crown. After a week was taken the precisionimpression with polyvinylsiloxane (Panasil, PuttySoft Type 0 and Initial Contact Light, KettenbachGmbH & Co. KG, Im Heerfeld 7, 35713 Eschen-burg, Germany) through single-step technique andtwo components with different viscosities.For the recording of the beyond preparation havebeen used 2 different sizes of wires retraction: size“00” more deeply in the gingival sulcus and size “1”more superficial. The first wire was moistened withferric sulfate at 25% of concentration and the secondwith aluminum chloride at 20% of concentration. Af-ter the test of the structure and the aestethic valuation,the crowns were cemented with adhesive resin ce-ment. Static and dynamic occlusion was checked.The complete treatment was carried out in 3 months(Fig.7).

The maintenance program includes a silicone nigth-guard to protect the remaining tooth structure andrestorations (4).

Discussion and Results

Traditionally, a full-mouth rehabilitation based onfull-crown coverage has been recommended treat-

ment for patients affected by severe dental erosion.Nowadays, thanks to improved adhesive tech-niques, the indications for metal-ceramic crownshave decreased and a more conservative approachmay be proposed (7).Direct composite restorations have a number ofdistinct advantages over indirect techniques for lo-calized tooth wear, particularly metal ceramiccrowns which are:• Minimally invasive;• May restore aesthetics and function;• Afford the clinician control over the final aes-

thetics;• Can reduce costs and treatment time for patient

and clinician by being performed over fewersessions;

• Tends to be more appealing to patient thancrown-lengthening surgery and crowns as dis-comfort is minimal (8).

These restorations have proved durable and aes-thetic, protect tooth structure and posterior occlusalcontact is predictably re-established (8).The direct technique involves intra-oral build-upwith composite in order to restore the lost crownheight and construct a balanced, protective anteriorocclusion.The results were very favorable, and the patientwas satisfied.

Conclusions

The treatment of eroded teeth, caused by sleep brux-ism, acid regurgitation and other factors, with directcomposite resin appears to be a conservative and aes-thetic procedure that is well accepted by patients.Based on the new vertical dimension of occlusion(VDO), combinations of direct and indirect restora-tions can then help to reestablish anatomy and func-tion. The use of adhesive techniques and resin com-posites has demonstrated its potential, in particularfor the treatment of moderate tooth wear (1).Tooth wear is an increasing problem and restoringworn teeth with composite resin is a viable and rel-atively straightforward option in a general practicesetting (8).

Figure 7 Composite build-up in a severe wear case: pre-operative andcompleted case.

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Further studies and research need to better definethe guidelines for a correct approach to increasingclinical cases of dental wear.

References

1. Dietschi D, Argente A.A comprehensive and conser-vative approach for the restoration of abrasion and ero-sion. Part I: concepts and clinical rationale for early in-tervention using adhesive techniques. Eur J EsthetDent. 2011 Spring;6(1):20-33.

2. Hemmings KW, Darbar UR, Vaughan S. Tooth weartreated with direct composite restorations at an in-creased vertical dimension: results at 30 months. JProsthet Dent. 2000 Mar;83(3):287-93.

3. Bartlett D, Sundaram G. An up to 3-year randomizedclinical study comparing indirect and direct resin com-posites used to restore worn posterior teeth. Int JProsthodont. 2006 Nov-Dec;19(6):613-7.

4. Dietschi D, Argente A. Un approccio globale e con-servativo per il restauro di abrasioni ed erosioni. ParteII: procedure cliniche e presentazione di un caso. EurJ Esteth Dent. 2011Summer; 6(2):144-161.

5. Dahl BL, Krogstad O. The effect of a partila bite rais-ing split on the occlusal face height. An x-ray cephalo-metric study in human adults. Acta Odontol Scand1982;40:17-24.

6. Higashi C, Loguercio AD. Re-anatomization of anterioreroded teeth by stratification with direct compositeresin. J Esthet Restor Dent. 2009;21(5):304-16.

7. Vailati F, Belser UC. Full-mouth adhesive rehabilitationof a severely eroded dentition: the three-step tech-nique. Part 2. Eur J Esthet Dent. 2008 Sum-mer;3(2):128-46.

8. Robinson S, Nixon PJ, Gahan MJ, Chan MF. Tech-niques for restoring worn anterior teeth with directcomposite resin. Dent Update. 2008 Oct;35(8):551-2,555-8.

Correspondence to:Marco GargariUniversity of Rome “Tor Vergata”Department of Dentistry “Fra G.B. Orsenigo - Ospedale SanPietro F.B.F.” Via Cassia 600 00189 Rome, Italy E-mail: marco.gargari@gmail.com