RestorativeDentistry
Anthony Roberts
The Use of Dentine-Bonded
Crowns in Anterior Tooth Surface
Loss: A Case Report
Abstract: This manuscript illustrates the management of a patient with anterior tooth surface loss. Specifically, the value of dentine-bonded
crowns in the restorative management of the case is discussed as well as demonstrating the aesthetic result that can be achieved.
Clinical Relevance: Dentine-bonded crowns may be appropriate in treating a patient with advanced anterior tooth surface loss.
Dent Update 2008; 35: 622-626
Dentine-bonded crowns are becoming
more widely used in dental practice1 and
may be considered useful in cases that
involve tooth surface/substance loss. These
crowns are all-ceramic crowns that are
bonded to the underlying tooth structure
by a low film thickness dentine-bonding
agent and a resin cement. There are several
advantages to dentine-bonded crowns
which include minimal tooth preparation,
excellent aesthetics and the good soft
tissue response following cementation.2 This
report presents a case which demonstrates
the management of anterior tooth surface
loss using direct composite placement,
periodontal surgery and, finally, dentine-
bonded crowns. Further, the double veneer
technique was used in the restoration of the
lower anterior teeth.
Case history
A 44-year-old male patient
Anthony Roberts, BSc, BDS, FDS,
FDS(Rest Dent) RCPS(Glasg), PhD, FHEA,
Senior Clinical Teaching Fellow and
Honorary Consultant in Restorative
Dentistry, Manchester Dental School,
Higher Cambridge Street, Manchester
M15 6FH, UK.
622 DentalUpdate
pg622-626 The use of dentine-bonded crowns.indd 1
attended the Restorative Department a
of Birmingham Dental Hospital in 2003
following referral from his General Dental
Practitioner. The patients complaint was
that his front teeth were wearing away
and he was unsure why this was the
case. Careful questioning revealed that
he suffered with gastric reflux and had a
high alcohol intake. Examination revealed
anterior tooth surface loss primarily b
affecting the upper anterior teeth (Figure 1),
although /1 and /2 were also affected. There
was no inter-occlusal space, carious lesions
were identified in 4/ and /6 teeth and a
lower acrylic prosthesis was worn to replace
5/, 2/ and 1/. A good band of keratinized
gingival tissue was observed anteriorly (57
mm) and periapical radiographs (Figure
2) of the upper anterior teeth revealed no
periapical pathology, good alveolar bone c
support and obvious pulpal anatomy. All
teeth tested positive for ethyl chloride and
electronic pulp testing and, in addition
to the caries and mild chronic gingivitis,
tooth surface loss (primarily erosion) was
diagnosed.
Aetiology
There were two components Figure 1. Initial appearance of patient: (a) anterior,
to this patients erosive load. The first was (b) upper occlusal and (c) lower occlusal views.
Note the advanced tooth surface loss affecting the
his high alcohol intake, which primarily
upper anterior teeth.
included alcopops drunk directly from
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 RestorativeDentistry

Figure 2. Periapical radiographs of patient taken at initial presentation.

Dietary advice
Referral to gastro-enterologist for specialist advice
c
Oral hygiene instruction and scaling
Caries stabilization and restoration of /6 and 4/
Composite additions to palatal aspect of 4/, 3/, 2/, 1/, /1, /2, /3 and /4 at an increased
occluso-vertical dimension
Review following occlusal re-equilibration to assess the necessity for surgical crown
lengthening and provision of provisional crowns
Definitive maxillary crowns with appropriate guidance copied from provisional crowns
d
Subsequent mandibular veneers and adhesive bridgework
Hard occlusal guard
Continued periodontal maintenance
Sequential study models to monitor tooth surface loss

Table 1. Itemized treatment plan.

e

the bottle. The patient admitted to
occasionally frothing the alcopop around
his teeth before swallowing. The second
erosive component was his gastric reflux
which correlated with periods of high
alcohol intake and stress.
Treatment objectives
One of the most important
aspects of this case was to halt the
progression of his tooth surface loss. This
was managed jointly following referral
to a consultant gastro-enterologist who
placed the patient on 400 mg Cimetidine
BD. Repeated dietary analysis and
sequential study models were invaluable
in establishing the lack of continued
tooth surface loss and continued control
of these factors was fundamental in the
management of this case.
The main concern in the
planning of this case was the extent of
the tooth surface loss already present.
Clearly, the main decision regarding
the tooth surface loss was to determine
whether a preventive regime would
be sufficient alone or whether an
interventional regime was required. The
patient was acutely concerned regarding f
the appearance of his dentition and,
following discussion of the treatment
options, an interventional approach was
deemed most appropriate. The patient
was already wearing a removable partial
denture, and was not enthused by the
prospect of another, no matter how well-
fitting. Figure 3. Crown lengthening surgical sequence
This case highlights the following composite additions and occlusal
importance of careful treatment planning, re-equilibration: (a) inverse bevelled incision; (b)
mucoperiosteal flap raised leaving tissue collar; (c)
a staged treatment provision and careful
tissue collar and bone removed; (d) closure with
interpretation of the aesthetic demands of
single interrupted sutures; (e) one week post-
the patient when no record of the initial operative; (f ) one month post-operative.
appearance of the teeth was available
(eg study models or photographs). The
case further highlights the necessity of
considering the soft tissues (gingival Treatment plan and treatment
dimensions with crown lengthening) progress
when planning and executing a The itemized treatment plan
restorative case. for this patient is shown sequentially in

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 RestorativeDentistry
Figure 4. Composite provisional crowns placed
during period of gingival healing.
Table 1. Once it had been established that
the progression of the tooth surface loss
was arrested, and the carious lesions dealt
with, directly placed composite additions
(Filtek Z250, 3M ESPE) were placed on the
palatal aspects of the upper anterior teeth.
These were placed at an increased occluso-
vertical dimension which, following an
occlusal re-equilibration period of 6 months
and a crown lengthening procedure,
created sufficient coronal tooth tissue for
the crowns (Figure 3). Provisional composite
crowns were placed in the immediate
post-surgery healing phase for 9 months
before the definitive crowns were placed
(Figure 4). Dentine-bonded crowns (Ivoclar
IPS Classic, Ivoclar Vivadent) were placed
at 2/, 1/, /1 and /2 and porcelain fused to
metal crowns (Ivoclar IPS Classic, Ivoclar
Vivadent) with V-Delta SF precious dental
alloy (Metalordental, Birmingham, UK) were
placed on the canines and first premolars
with palatal metal surfaces (Figure 5 ac).
In the anterior mandible, two
individual adhesive bridges were cemented
to replace 2/ and 1/ (using 3/ and /1 as
retainers, respectively) and labial veneers
were cemented to /1 and /2 (Figure 5 d and
e). Finally, a hard occlusal guard of Michigan
design was provided for night-time use.
Discussion and case assessment
This case demonstrates the
importance of prevention of further tooth
surface loss by stabilization of the intrinsic
and extrinsic erosive components, as well
as the value of crown lengthening surgery
and ultimate provision of dentine-bonded
crowns. The aesthetics of the final result was
excellent and the patient was extremely
happy with the result.
There are a number of
discussion points arising from this case. The
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pg622-626 The use of dentine-bonded crowns.indd 3
first was the choice to use a combination a
of dentine-bonded crowns and porcelain
fused to metal crowns. Examination of the
articulated pre-preparation study casts
revealed that establishing lateral guidance
on the canines alone would be difficult and,
therefore, lateral guidance was chosen to be
shared between both the canine and first
premolars. This would assist the restoration
of the posterior teeth if necessary in the
future, but required the additional strength b
of metal substructures. Clearly, any further
tooth surface loss may well necessitate
the restoration of the patients posterior
teeth and the importance of continued
contact with his gastro-enterologist has
already been, and will continue to be,
re-emphasized. Continued monitoring of
c
his toothwear with study models and/or
silicone indices will identify whether his
tooth surface loss is progressive or stable
over the forthcoming months/years.
The decision to use surgical
crown lengthening was to increase the
clinical crown height of the anterior
maxillary teeth achieved by the removal of
the coronal portion of the periodontium,
together with crestal bone, using a
standard periodontal flap procedure. In d
an attempt to determine the extent of
tissue removal, several factors required
consideration. The first consideration
was that the final restorations should not
encroach on the biological width widely
to be accepted as approximately 3 mm.3,4 e
A further consideration was the clinical
crown height necessary to restore the
tooth. Although there are no absolute
guidelines for preparation dimensions that
risk de-cementation,5 an in vitro study has
shown a significant increase in resistance
and retention as axial walls extend from
23 mm in height and recommended 3mm
as the minimum preparation height.5,6
Therefore, during the crown-lengthening Figure 5. Completed case demonstrating: (a)
procedure, a total distance in excess of 6mm labial; (b) upper anterior; (c) upper palatal; (d)
(3 mm biological width + 3 mm coronal lower labial and (e) lower lingual appearance.
tooth tissue) from the alveolar crest to the
incisal edge of the tooth was used as a
guide. Following surgery, the periodontal
tissues undergo continued dimensional recommendations suggest that time
changes as they heal.7 As a consequence, intervals in excess of 6 months should be
the placement of definitive crowns too soon standard.7
following surgery was contra-indicated. The dentine-bonded crowns
In this case, the time interval between the had the advantages of requiring minimal
surgery and the definitive restorations preparation and providing excellent
was 7 months, indeed, published aesthetics with minimal gingival irritation.2
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 RestorativeDentistry
The crown, veneer and adhesive bridgework
preparations were all minimal in nature so
that the patient is left with the broadest
range of treatment options should any
aspect fail. The restoration of worn teeth
using an indirect restoration labially, and
a further indirect restoration lingually or
palatally, often termed the double veneer
technique, is extremely valuable when
trying to preserve tooth tissue.8 This case
demonstrates a slight adaptation from the
technique whereby the lingual veneer was
the retainer for an adhesive bridge in the
lower arch.
Conclusion
This case illustrates the
management of a patient with anterior
tooth surface loss. Specifically, the value
BookReview
Clinical Periodontology and Implant
Dentistry 5th edition. J Lindhe,
NP Lang, T Karring (eds). UK: Wiley-
Blackwell, Munksgaard, 2008 (1340 pp.,
145.00). ISBN: 978-1-40516-099-5.
Over many years Clinical Periodontology
and Implant Dentistry has become
the definitive text in these areas of
dentistry. The latest fifth edition has
been significantly enhanced so that
those already familiar with previous
editions will not be disappointed, nor
will those who read the text for the
first time. The text is divided into two
volumes and, whilst initially a daunting
prospect for the reader, one soon
realises that the 15 new chapters offer
a truly comprehensive coverage of both
Basic and Advanced Clinical Concepts
of Periodontology and Implant
Dentistry. A total of 60 chapters
divided into 19 parts leads the reader
through the purer aspects of each
discipline and subsequently through to
their interfaces with other disciplines
within Dentistry. Previous editions of
this textbook have always been well
illustrated. The fifth edition continues
in this vain and offers an expanse of
clinical, radiological, diagrammatical
and histological figures that
complements the written text. Each
chapter is written by highly respected
626 DentalUpdate
pg622-626 The use of dentine-bonded crowns.indd 5
of stabilizing the tooth surface loss, crown dentogingival junction in humans.
lengthening surgery and dentine-bonded J Periodontol 1961; 32: 261267.
crowns in the restorative management of 5. Blair FM, Wassell RW, Steele JG.
the case is illustrated. Crowns and other extra-coronal
restorations: preparations for full
veneer crowns. Br Dent J 2002; 192:
References 561571.
1. Christensen GJ. Should we be bonding 6. Maxwell AW, Blank LW, Pelleu GB.
all tooth restorations? J Am Dent Assoc Effect of crown preparation height
1994; 125: 193194. on the retention and resistance of
2. Burke FJ, Qualtrough A, Hale R. The gold castings. Gen Dentistry 1990;
dentine-bonded ceramic crown: an May-June: 200202.
ideal restoration? Br Dent J 1995; 179: 7. Wise M. Stability of gingival crest
5863. after surgery and before anterior
3. Fugazzotto PA, Parma-Benfenati S. Pre- crown placement. J Prosthet Dent
prosthetic periodontal considerations. 1985; 53: 2023.
Crown length and biologic width. 8. Bishop K, Bell M, Briggs P, Kelleher M.
Quintessence Int 1984; 12: 12471256. Restoration of a worn dentition using
4. Gargiulo A, Wentz FM, Orban B. a double-veneer technique. Br Dent J
Dimensions and relations of the 1996; 180: 2629.
international clinicians
and researchers who
provide a thorough
and scientific approach
to the subject area
covered. Significant
improvements over
previous editions are
numerous and wide
ranging. For example,
this edition now
includes a specific and
detailed account of oral
hygiene techniques
and patient motivation
and, at the other
end of the spectrum,
recent innovations in
surgical management,
including contemporary
microsurgical
techniques.
In
summary, I would
highly recommended
this book to
undergraduates,
postgraduates, clinicians
and researchers,
indeed anyone with an interest in Dr Anthony Roberts
Periodontology and Implantology who Senior Clinical Teaching Fellow and
will no doubt refer to this text time and Honorary Consultant in Restorative
time again. You may have gathered Dentistry, Manchester Dental School,
that I like this book! University of Manchester, UK.
November 2008
5/11/08 14:30:06