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CASE REPORT

The use of indirect composite


veneers to rehabilitate patients with
dental erosion: a case report
Ramón Asensio Acevedo, DDS, MSc
Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

José María Suarez-Feito, MD, DMD, MClinDent, PhD


Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

Carlota Suárez Tuero, DDS


Postgraduate student, Department of Restorative Dentistry and Endodontics, International
University of Catalonia, Barcelona, Spain

Luis Jané, MD, DMD, PhD


Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

Miguel Roig, MD, DMD, PhD


Chairman, Department of Restorative Dentistry and Endodontics, International University of Catalo-

nia, Barcelona, Spain

Correspondence to: Ramón Asensio Acevedo


Department of Restorative Dentistry and Endodontics Josep Trueta s/n, 08195 Sant Cugat del Vallès; Barcelona, Spain; Tel: 93 504

20 00; Fax: 93 504 20 01; E-mail: ramon@uic.es

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Abstract and function has to be restored. Even


though there is no clinical evidence of
The evolution of restorative dental ma- the appropriateness of indirect compos-
terials has led to the development of ites in these treatments, the latest gen-
more direct or indirect conservative eration of composites used indirectly in
techniques to solve both functional and the anterior teeth exhibits some interest-
esthetic problems in anterior and poster- ing characteristics: it supports mechan-
ior teeth. Several authors have conclud- ical stress adequately, has an excellent
ed that indirect restorations are the tech- esthetic result and can be repaired in-
nique of choice in complex cases where traorally.
shape and colour are difficult to achieve (Eur J Esthet Dent 2013;8:414–431)

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Introduction of treatment could be considered as


one part of a functional and esthetic
The dietetic habits and parafunctions as rehabilitation of patients with a certain
a consequence of modern-day lifestyles level of parafunction.14
have increased dental wear from a non-
bacteriological origin (abrasion, erosion
and attrition).1 Case presentation
This has led to a loss of hard dental
tissue structure that can have biological A 62-year-old woman with a gastric
(sensitivity, pulp exposure), functional esophageal reflux disease diagnosis
(loss of canine and incisal guidance) came to the dental office for a second
and esthetic consequences.2 Accord- opinion on her dental wear. The clin-
ing to the traditional protocols of restora- ical examination revealed that the pa-
tive dentistry, the rehabilitation of such tient had severe and generalized den-
clinical cases will involve numerous full tal wear involving both the anterior and
crowns and root canal treatments, a pro- posterior teeth. According to the ACE
cess that is both costly in biological and classification, the patient was consid-
time-consuming terms.3-8 Nevertheless, ered ACE class IV since the palatal den-
there is no scientific evidence as to the tin was largely exposed and the clinical
biological consequences and biome- crowns were more than 2 mm shorter,
chanics of these treatments.9 while the facial enamel and the pulp vi-
The improvement of adhesive tech- tality were still preserved.19 Some old
niques allows the use of restorations that defective restorations and missing teeth
do not sacrifice the dental structure.10 were also observed. No temporoman-
Depending on the efficacy of the adhe- dibular joint pain was referred. The man-
sive procedures and the possible bio- dibular range of movement was within
logical and mechanical complications normal physiological parameters. Oc-
that traditional extensive procedures clusal analysis showed that maximum
involve, minimally invasive alternatives intercuspation was not coincidental with
using adhesive restorations have been centric relation, as well as a reduced oc-
proposed.2,11-12 clusal table with unstable occlusal con-
Long-term studies have shown that tacts. An absence of canine guidance
porcelain laminate veneers show excel- with group function on the six upper an-
lent biocompatibility and chemical sta- terior teeth and first bilateral premolars
bility, as well as the ability to reproduce during lateral movements was also pre-
the structure and translucency of nat- sent. Interferences during excursive
ural teeth.13 The newly manufactured movements were not found. Dental hy-
micro-hybrid composite, with improved giene and periodontal conditions were
physical and mechanical properties, not optimal, so the patient was referred
seems to allow the use of indirect com- to the periodontist for a hygienic phase
posite veneers as an alternative to ce- prior to restorative treatment and was
ramics.14-18 While there is no clinical ev- instructed to maintain her oral hygiene
idence to support their use, this choice post treatment (Figs 1 and 2).

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Fig 1a Initial situation frontal view. Fig 1b Initial occlusal view.

Fig 2 Periodontal
examination.

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Objectives
Since the patient rejected previous con-
ventional restorative approaches offered
by other dentists (due to the invasive na-
ture of the treatment and cost), the aim
was to restore the patient’s dental health,
function and esthetics with minimally in-
vasive rehabilitation. Reparability of the
restorations and the cost were also tak-
en into consideration. After discussion
of the restorative options, the patient
and clinician opted for the treatment of
Fig 3a Study casts frontal view.
choice, which combines direct and indi-
rect composite restorations for the teeth,
and implants in the edentulous areas.

Treatment sequence

„Root canal treatment of tooth 1.2, fol-


lowed by reconstruction using a fiber
post to increase the adhesive surface
for the final restoration.
„Incisal edge reconstruction with a di-
rect composite resin restoration in the
mandibular anterior teeth. Composite
resin restorations can provide a sim-
pler but conservative and efficient
Fig 3b Study casts left lateral view. way to restore the worn mandibular
anterior dentition.20
„Direct composite reconstruction of the
palatal surfaces of the maxillary anter-
ior teeth to the established new ver-
tical dimension of occlusion (VDO).
Gulamali et al have shown that the
use of direct composite resin restor-
ations to treat localized tooth wear at
an increased VDO is a viable restora-
tive option over a period of 10 years.21
„Placement of indirect composite over-
lays in the posterior teeth. Indirect res-
torations permit a better control of the
anatomy, however, the literature has
Fig 3c Study casts right lateral view. not shown a major clinical advan-

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tage of composites over ceramics. It


seems that the material of choice is
more dependent on personal experi-
ence and belief than scientific or clin-
ical evidence.22
„Indirect restorations with composite
veneers on the vestibular faces of
maxillary anterior teeth. Current fine
micro-hybrid composites have im-
proved chemical and physical prop-
erties offering better wear resistance
and optical results. Composites are
Fig 4a Wax-up at an increased vertical dimen-
also more elastic than ceramics. sion.
Thus, composites can be indicated in
patients with parafunctions.14

Planning the reconstruction

Upper and lower alginate impressions


were taken to mount a set of study casts
in a semi-adjustable articulator by means
of a face bow and a centric relation record
(Fig 3). A diagnostic wax-up was per-
formed by previously increasing the VDO
in the articulator pin to enhance patient
incisal display and esthetics (Fig 4).23,24
By increasing the VDO, occlusal restora-
tive space for the anterior and posterior Fig 4b Wax-up left lateral view.
restorations will be gained, thus avoiding
the need for crown lengthening proced-
ures and/or elective root canal treatments.
Moreover, the unfavorable overjet-over-
bite relationships of the anterior teeth de-
veloped in this type of patient will also be
modified, allowing the creation of a much
shallower anterior guidance with a no-
ticeable reduction of the horizontal forces
acting upon them.25 Silicon indexes were
obtained from the wax-up to guide the
direct composite resin restorations of the
incisal edges of the mandibular anterior
teeth and the palatal and incisal edges of
the upper anterior teeth (Fig 5). Fig 4c Wax-up right lateral view.

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Fig 5a Upper silicon index for direct composite Fig 5b Lower silicon index for direct composite
resin restoration. resin restoration.

Fig 6 Posterior indirect composite overlays. Fig 7 Frontal view after direct restorations of an-
terior teeth and indirect overlays of posterior teeth.

Following the direct restorations of the was created by a lower implant support
anterior teeth, the posterior teeth were fixed partial denture and some occlusal
restored by means of indirect compos- adjustments of the uppers. Anterior guid-
ite overlays maintaining the new vertical ance with a more favorable overjet and
dimension (Figs 6 and 7). Left posterior overbite was performed to separate the
occlusion was established with indirect posterior segments of the occlusion and
composite overlays on top of the occlusal to promote the distribution of the forces
surfaces of the upper metal ceramic fixed over the anterior restorations.
partial denture and over the worn lower Impressions were taken again, and
natural dentition. Right posterior occlusion a new diagnostic wax-up of maxillary

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Fig 8 Diagnostic wax-up.

Fig 9 Preparation of the mock-up. Fig 10a Labial reduction using the mock up and
calibrated round diamond burs.

anterior teeth was made to reevaluate Tooth preparation and impression


the occlusal plane, the contour and taking
the emergence profile of the future in-
direct composite resin veneers (Fig 8). Another mock-up was fabricated specific-
A mock-up with polimethylmethacrylate ally to be used as a reduction guide for the
resin was made with the help of a new preparations (Figs 9 and 10).28-30 The re-
silicon index taken from the final wax- duction was confirmed by a silicon index,
up.26,27 The aforementioned aspects as recommended by Magne30 (Fig 11).
were directly tested in the oral cavity and The final impressions were taken using a
accepted by the patient. polyvinylsiloxane material (Fig 12).

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Fig 10b Reduction grooves are marked with a pencil. Fig 10c Incisal reduction grooves.

Fig 10d Incisal reduction with a donut bur. Fig 10e Finishing and polishing of the margins
and axial surfaces.

Fig 10f Polishing of the axial surfaces. Fig 10g Final preparations.

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Fig 11a Assessment of the icisal reduction. Fig 11b Assessment of the labial reduction of
the gingival third.

Fig 11c Assessment of the labial reduction of Fig 12a Polyvinil siloxane impression.
the middle third.

Fig 12b Detail of the impression without removal Fig 13 By using the same silicon index of the
the retraction cord. diagnostic mock-up, direct acrylic provisional res-
torations were made.

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Fig 14a Indirect composite resin veneers in Fig 14b Indirect composite resin veneers in
ADORO Ivoclar Vivadent. ADORO Ivoclar Vivadent.

Fig 14c Indirect composite resin veneers in Fig 15 Color assessment of the veneers with a
ADORO Ivoclar Vivadent. medium value try-in paste.

Fig 16a Sandblasting with aluminum oxide. Fig 16b Silanization.

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Provisionalization
The provisional restorations were made
with the same silicon index used in the
mock-up, filled with polymethylmeth-
acrylate provisional material (Fig 13).

Laboratory phase

The final reinforced micro-hybrid com-


posite resin restorations (Adoro Ivoclar)
were manufactured by a dental techni-
cian using a layering technique (Fig 14).
Fig 17a Cementation was carried out under
complete rubber dam isolation.

Try-in

The try-in was performed with variolink


veneer try-in (Ivoclar Vivadent) pastes
to match the desired final value of the
restorations (Fig 15).

Preparation of the restorations


and the tooth

Previous to the cementation, the res-


torations were sandblasted with 50 μm
aluminium oxide particles for 3 seconds
at a distance of 5 mm and 2 pressure
Fig 17b Etching with 35% phosphoric acid.
bars, followed by the placement of two
layers of silane dried for 1 minute under
hot air (Fig 16). The enamel was etched
with 35% orthophosphoric acid and the
composite resin was previously sand-
blasted as described before (Fig 17).
Then, a layer of silane was applied to
the composites and finally bonding was
placed (Fig 18).

Fig 18 Bonding application.

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Fig 19a Bonding agent application. Fig 19b Photocure of the restoration.

Fig 19c Photocure of the restoration. Fig 19d Aspect of the cemented restoration.

Cementation Follow-ups
The veneers were then cemented, under One week after finishing the treatment,
rubber dam isolation with photo-cured an occlusal relief stent was given to the
resinous cement (Fig 19). patient to control the possible conse-
quences of attrition (Fig 20). A 9-month
Finishing and polishing follow-up was set to evaluate the stabili-
zation of the occlusion and the patient’s
The restorations were finished and pol- capacity to maintain the oral environ-
ished with a no. 12 surgical blade and ment free of bacterial plaque (Fig 21).
interproximal strips. The occlusion was
adjusted with laminate tungsten carbide
burs, rugby-ball 40 μm diamond burs,
and silicon polishers.

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Fig 20a Frontal view eight days after the cemen- Fig 20b Intraoral frontal aspect of the newly ce-
tation note the biological integration between the mented restorations in occlusion.
restorations and the soft tissues.

Fig 20c Left lateral view. Fig 20d Right lateral view.

Discussion
Treatment of patients with tooth wear cur-
rently represents a challenge from the re-
storative point of view due to increased
life expectancy, making it necessary to
maintain the natural dentition for a long-
er period of time. This has meant that
in the last decade, some authors have
begun to question the invasive nature of
conventional restorative treatments that
were carried out in these patients. Con-
Fig 20e The palatal view shows the blending
sequently, clinicians began to search for between the direct lingual composite resin and the
more conservative alternatives based labial indirect composite resin veneers.

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Fig 21a Nine-month follow-up.

Fig 21b Nine-month follow-up right lateral view. Fig 21c Nine-month follow-up left lateral view.

on dental adhesion that would extend Since our patient demanded a more
the life of restored teeth. Although some conservative restorative treatment plan
short- and medium-term studies have as an alternative to other more invasive
been conducted on the use of such pro- options offered by another professional,
cedures, there is still insufficient scientific we considered the possibility of provid-
information to support their routine use. ing a treatment based solely on adhe-
A series of cases have recently been sive procedures.
published describing the use direct and After explaining to the patient the lack
indirect composite resin and ceramic of scientific evidence that would justify the
adhesive restorations. use of adhesive procedures compared

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to conventional protocols, and consider- Recommending the use of an occlusal


ing the minimally invasive nature of the splint for night use after treatment in these
restorative procedure and the possible patients does not guarantee its use rou-
biological and biomechanical complica- tinely, neither would it control parafunc-
tions of the conventional treatment, the tional forces that could be generated dur-
patient accepted the most conservative ing the day. All this information has been
option and the risks it entailed. considered when choosing the compos-
It is often difficult to establish the eti- ite as a restorative material in this patient.
ology of dental wear, due to its multifac- Some degree of composite discolora-
torial origin (attrition, erosion, abrasion, tion and loss of surface luster can be
abfraction). Likewise, at times, it is also observed in the 9-month follow-up pho-
difficult to determine the attrition de- tographs. However, the age of the pa-
gree of involvement in the origin of tooth tient and the potential advantages of the
wear.31 However, in this particular patient mechanical performance of the material
the presence of poor occlusion with a can compensate for such drawbacks.
reduced masticatory surface may have In young patients with high esthetic de-
contributed to the presence of attrition. mands, the use of this type of restoration
It is important to note that the greater would be questionable.
the attrition as an etiological factor in the Regarding the use of indirect com-
origin of tooth wear, the poorer the re- posite resin veneers in this case, their
storative prognosis from the biomech- low elasticity modulus and high capacity
anical point of view. Because the patient to absorb functional stresses would re-
was diagnosed with gastro-esophageal quire less reduction of tooth structure
reflux, erosion was established as the during preparation,33 which is an im-
main etiologic factor in tooth wear, but portant issue when considering tooth
attrition was a secondary etiological fac- structure loss through erosion. Besides
tor, due to the presence of wear facets the advantages of biomechanical be-
compatible with attrition. haviour, Mangani mentioned the follow-
The presence of attrition was one of ing positive indications concerning the
the reasons we decided to use com- use of indirect composite resin veneers
posite resin as a restorative material versus ceramic:
since its elastic modulus is higher than „They allow for better absorption of the
that of ceramics.32 Thus, the compos- polymerization stresses generated by
ite would allow for greater absorption the cement during cementation pro-
of occlusal forces that could be gen- cedures.
erated during possible parafunctional „The finishing and polishing proced-
movements. Additionally, while the new ures are easier than with ceramic ve-
micro-hybrid composite is more wear- neers.
resistant, the ceramic is even more „The laboratory procedures are easier,
resistant and can lead to increased thus lowering the manufacturing cost.14
wear of the antagonist’s enamel. Fur-
thermore, intraoral repair of composite Composite resin veneers involve easier
resin restorations is easier. laboratory procedures than ceramic ve-

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neers, even though veneers built with and offers more favorable biomechan-
the refractory cast technique take less ical conditions. However the technique
time than those manufactured with other proposed in the case report should be
techniques. Generally, indirect restor- taken into consideration as a possible
ations require a greater amount of time alternative to conventional protocols.
and involve more technical difficulties,
which explains the higher overall cost of
ceramic restorations.14 Conclusions
It is sensible and beneficial to main-
tain pulpal vitality, prevent endodontic The need for root canal treatment and
treatment, and avoid the need for a post full-coverage crowns used by the trad-
and core restoration, because these itional treatment protocols in patients
more invasive approaches violate the with dental wear could create a bio-
biomechanical balance and compro- logical and biomechanical compromise
mise the performance of restored teeth of the restored teeth in the medium or
over time.34 long term. This has led to the develop-
A recently published case report ad- ment of new minimally invasive restora-
vocates the use of monolithic lithium di- tive procedures based on adhesion. With
silicate restorations in the rehabilitation this approach, indirect composite resin
treatment of a patient with tooth wear.35 veneers may represent a further treat-
Although the author stresses the con- ment option as part of a treatment plan
servative approach of the treatment to rehabilitate patients with tooth wear.
(0.8 mm reduction) and the resistance The use of such veneers also provides
to flexion from 360 to 400 MPa, it is the the advantages of esthetic properties,
author’s belief that this approach still re- biomechanics and economical cost for
quires less sacrifice of tooth structure the patient.

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