Ejed - 2013 - 03 - s0414 Pilihan

CASE REPORT
414
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 NUMBER 3 AUTUMN 2013
The use of indirect composite
veneers to rehabilitate patients with
dental erosion: a case report
Ramn Asensio Acevedo, DDS, MSc
Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain
Jos Mara Suarez-Feito, MD, DMD, MClinDent, PhD
Barcelona, Spain

Carlota Surez Tuero, DDS
Postgraduate student, Department of Restorative Dentistry and Endodontics, International
University of Catalonia, Barcelona, Spain
Luis Jan, MD, DMD, PhD
Barcelona, Spain

Miguel Roig, MD, DMD, PhD
Chairman, Department of Restorative Dentistry and Endodontics, International University of Catalo-
nia, Barcelona, Spain
Correspondence to: Ramn Asensio Acevedo
Department of Restorative Dentistry and Endodontics Josep Trueta s/n, 08195 Sant Cugat del Valls; Barcelona, Spain; Tel: 93 504
20 00; Fax: 93 504 20 01; E-mail: ramon@uic.es
ASENSIO ACEVEDO ET AL
415
Abstract
The evolution of restorative dental ma-
terials has led to the development of
more direct or indirect conservative
techniques to solve both functional and
esthetic problems in anterior and poster-
ior teeth. Several authors have conclud-
ed that indirect restorations are the tech-
nique of choice in complex cases where
shape and colour are difcult to achieve
and function has to be restored. Even
though there is no clinical evidence of
the appropriateness of indirect compos-
ites in these treatments, the latest gen-
eration of composites used indirectly in
the anterior teeth exhibits some interest-
ing characteristics: it supports mechan-
ical stress adequately, has an excellent
esthetic result and can be repaired in-
traorally.
(Eur J Esthet Dent 2013;8:414431)
415
CASE REPORT
416
Introduction
The dietetic habits and parafunctions as
a consequence of modern-day lifestyles
have increased dental wear from a non-
bacteriological origin (abrasion, erosion
and attrition).
1
This has led to a loss of hard dental
tissue structure that can have biological
(sensitivity, pulp exposure), functional
(loss of canine and incisal guidance)
and esthetic consequences.
2
Accord-
ing to the traditional protocols of restora-
tive dentistry, the rehabilitation of such
clinical cases will involve numerous full
crowns and root canal treatments, a pro-
cess that is both costly in biological and
time-consuming terms.
3-8
Nevertheless,
there is no scientic evidence as to the
biological consequences and biome-
chanics of these treatments.
9
The improvement of adhesive tech-
niques allows the use of restorations that
do not sacrice the dental structure.
10

Depending on the efcacy of the adhe-
sive procedures and the possible bio-
logical and mechanical complications
that traditional extensive procedures
involve, minimally invasive alternatives
using adhesive restorations have been
proposed.
2,11-12
Long-term studies have shown that
porcelain laminate veneers show excel-
lent biocompatibility and chemical sta-
bility, as well as the ability to reproduce
the structure and translucency of nat-
ural teeth.
13
The newly manufactured
micro-hybrid composite, with improved
physical and mechanical properties,
seems to allow the use of indirect com-
posite veneers as an alternative to ce-
ramics.
14-18
While there is no clinical ev-
idence to support their use, this choice
of treatment could be considered as
one part of a functional and esthetic
rehabilitation of patients with a certain
level of parafunction.
14
Case presentation
A 62-year-old woman with a gastric
esophageal reux disease diagnosis
came to the dental ofce for a second
opinion on her dental wear. The clin-
ical examination revealed that the pa-
tient had severe and generalized den-
tal wear involving both the anterior and
posterior teeth. According to the ACE
classication, the patient was consid-
ered ACE class IV since the palatal den-
tin was largely exposed and the clinical
crowns were more than 2 mm shorter,
while the facial enamel and the pulp vi-
tality were still preserved.
19
Some old
defective restorations and missing teeth
were also observed. No temporoman-
dibular joint pain was referred. The man-
dibular range of movement was within
normal physiological parameters. Oc-
clusal analysis showed that maximum
intercuspation was not coincidental with
centric relation, as well as a reduced oc-
clusal table with unstable occlusal con-
tacts. An absence of canine guidance
with group function on the six upper an-
terior teeth and rst bilateral premolars
during lateral movements was also pre-
sent. Interferences during excursive
movements were not found. Dental hy-
giene and periodontal conditions were
not optimal, so the patient was referred
to the periodontist for a hygienic phase
prior to restorative treatment and was
instructed to maintain her oral hygiene
post treatment (Figs 1 and 2).
417
Fig 1a Initial situation frontal view. Fig 1b Initial occlusal view.
Fig 2 Periodontal
examination.
CASE REPORT
418
Fig 3a Study casts frontal view.
Fig 3b Study casts left lateral view.
Fig 3c Study casts right lateral view.
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 patients 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
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 ber
post to increase the adhesive surface
for the nal 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 efcient
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
not shown a major clinical advan-
419
Fig 4a Wax-up at an increased vertical dimen-
sion.
Fig 4b Wax-up left lateral view.
Fig 4c Wax-up right lateral view.
tage of composites over ceramics. It
seems that the material of choice is
more dependent on personal experi-
ence and belief than scientic or clin-
ical evidence.
22

Indirect restorations with composite
veneers on the vestibular faces of
maxillary anterior teeth. Current ne
micro-hybrid composites have im-
proved chemical and physical prop-
erties offering better wear resistance
and optical results. Composites are
also more elastic than ceramics.
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
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
modied, 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).
CASE REPORT
420
Fig 5a Upper silicon index for direct composite
resin restoration.
Fig 6 Posterior indirect composite overlays.
Fig 5b Lower silicon index for direct composite
resin restoration.
Fig 7 Frontal view after direct restorations of an-
terior teeth and indirect overlays of posterior teeth.
was created by a lower implant support
xed partial denture and some occlusal
adjustments of the uppers. Anterior guid-
ance with a more favorable overjet and
overbite was performed to separate the
posterior segments of the occlusion and
to promote the distribution of the forces
over the anterior restorations.
Impressions were taken again, and
a new diagnostic wax-up of maxillary
Following the direct restorations of the
anterior teeth, the posterior teeth were
restored by means of indirect compos-
ite overlays maintaining the new vertical
dimension (Figs 6 and 7). Left posterior
occlusion was established with indirect
composite overlays on top of the occlusal
surfaces of the upper metal ceramic xed
partial denture and over the worn lower
natural dentition. Right posterior occlusion
421
Fig 9 Preparation of the mock-up.
Fig 8 Diagnostic wax-up.
anterior teeth was made to reevaluate
the occlusal plane, the contour and
the emergence prole of the future in-
direct composite resin veneers (Fig 8).
A mock-up with polimethylmethacrylate
resin was made with the help of a new
silicon index taken from the nal wax-
up.
26,27
The aforementioned aspects
were directly tested in the oral cavity and
accepted by the patient.
Tooth preparation and impression
taking
Another mock-up was fabricated specic-
ally to be used as a reduction guide for the
preparations (Figs 9 and 10).
28-30
The re-
duction was conrmed by a silicon index,
as recommended by Magne
30
(Fig 11).
The nal impressions were taken using a
polyvinylsiloxane material (Fig 12).
Fig 10a Labial reduction using the mock up and
calibrated round diamond burs.
CASE REPORT
422
Fig 10f Polishing of the axial surfaces. Fig 10g Final preparations.
Fig 10d Incisal reduction with a donut bur. Fig 10e Finishing and polishing of the margins
and axial surfaces.
Fig 10b Reduction grooves are marked with a pencil. Fig 10c Incisal reduction grooves.
423
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
the middle third.
Fig 12b Detail of the impression without removal
the retraction cord.
Fig 12a Polyvinil siloxane impression.
Fig 13 By using the same silicon index of the
diagnostic mock-up, direct acrylic provisional res-
torations were made.
CASE REPORT
424
Fig 14c Indirect composite resin veneers in
ADORO Ivoclar Vivadent.
Fig 15 Color assessment of the veneers with a
medium value try-in paste.
Fig 16a Sandblasting with aluminum oxide. Fig 16b Silanization.
Fig 14a Indirect composite resin veneers in
Fig 14b Indirect composite resin veneers in
425
Fig 18 Bonding application.
Provisionalization
The provisional restorations were made
with the same silicon index used in the
mock-up, lled with polymethylmeth-
acrylate provisional material (Fig 13).
Laboratory phase
The nal reinforced micro-hybrid com-
posite resin restorations (Adoro Ivoclar)
were manufactured by a dental techni-
cian using a layering technique (Fig 14).
Try-in
The try-in was performed with variolink
veneer try-in (Ivoclar Vivadent) pastes
to match the desired nal value of the
restorations (Fig 15).
Preparation of the restorations
and the tooth
Previous to the cementation, the res-
torations were sandblasted with 50 m
aluminium oxide particles for 3 seconds
at a distance of 5 mm and 2 pressure
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 nally bonding was
placed (Fig 18).
Fig 17b Etching with 35% phosphoric acid.
Fig 17a Cementation was carried out under
complete rubber dam isolation.
CASE REPORT
426
Follow-ups
One week after nishing the treatment,
an occlusal relief stent was given to the
patient to control the possible conse-
quences of attrition (Fig 20). A 9-month
follow-up was set to evaluate the stabili-
zation of the occlusion and the patients
capacity to maintain the oral environ-
ment free of bacterial plaque (Fig 21).
Fig 19d Aspect of the cemented restoration.
Fig 19b Photocure of the restoration.
Fig 19c Photocure of the restoration.
Fig 19a Bonding agent application.
Cementation
The veneers were then cemented, under
rubber dam isolation with photo-cured
resinous cement (Fig 19).
Finishing and polishing
The restorations were nished and pol-
ished with a no. 12 surgical blade and
interproximal strips. The occlusion was
adjusted with laminate tungsten carbide
burs, rugby-ball 40 m diamond burs,
and silicon polishers.
427
Fig 20a Frontal view eight days after the cemen-
tation note the biological integration between the
restorations and the soft tissues.
Fig 20b Intraoral frontal aspect of the newly ce-
mented restorations in occlusion.
Fig 20c Left lateral view.
Fig 20e The palatal view shows the blending
between the direct lingual composite resin and the
labial indirect composite resin veneers.
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-
sequently, clinicians began to search for
more conservative alternatives based
CASE REPORT
428
on dental adhesion that would extend
the life of restored teeth. Although some
short- and medium-term studies have
been conducted on the use of such pro-
cedures, there is still insufcient scientic
information to support their routine use.
A series of cases have recently been
published describing the use direct and
indirect composite resin and ceramic
adhesive restorations.
Since our patient demanded a more
conservative restorative treatment plan
as an alternative to other more invasive
options offered by another professional,
we considered the possibility of provid-
ing a treatment based solely on adhe-
sive procedures.
After explaining to the patient the lack
of scientic evidence that would justify the
use of adhesive procedures compared
Fig 21a Nine-month follow-up.
Fig 21b Nine-month follow-up right lateral view. Fig 21c Nine-month follow-up left lateral view.
429
to conventional protocols, and consider-
ing the minimally invasive nature of the
restorative procedure and the possible
biological and biomechanical complica-
tions of the conventional treatment, the
patient accepted the most conservative
option and the risks it entailed.
It is often difcult to establish the eti-
ology of dental wear, due to its multifac-
torial origin (attrition, erosion, abrasion,
abfraction). Likewise, at times, it is also
difcult to determine the attrition de-
gree of involvement in the origin of tooth
wear.
31
However, in this particular patient
the presence of poor occlusion with a
reduced masticatory surface may have
contributed to the presence of attrition.
It is important to note that the greater
the attrition as an etiological factor in the
origin of tooth wear, the poorer the re-
storative prognosis from the biomech-
anical point of view. Because the patient
was diagnosed with gastro-esophageal
reux, erosion was established as the
main etiologic factor in tooth wear, but
attrition was a secondary etiological fac-
tor, due to the presence of wear facets
compatible with attrition.
The presence of attrition was one of
the reasons we decided to use com-
posite resin as a restorative material
since its elastic modulus is higher than
that of ceramics.
32
Thus, the compos-
ite would allow for greater absorption
of occlusal forces that could be gen-
erated during possible parafunctional
movements. Additionally, while the new
micro-hybrid composite is more wear-
resistant, the ceramic is even more
resistant and can lead to increased
wear of the antagonists enamel. Fur-
thermore, intraoral repair of composite
resin restorations is easier.
Recommending the use of an occlusal
splint for night use after treatment in these
patients does not guarantee its use rou-
tinely, neither would it control parafunc-
tional forces that could be generated dur-
ing the day. All this information has been
considered when choosing the compos-
ite as a restorative material in this patient.
Some degree of composite discolora-
tion and loss of surface luster can be
observed in the 9-month follow-up pho-
tographs. However, the age of the pa-
tient and the potential advantages of the
mechanical performance of the material
can compensate for such drawbacks.
In young patients with high esthetic de-
mands, the use of this type of restoration
would be questionable.
Regarding the use of indirect com-
posite resin veneers in this case, their
low elasticity modulus and high capacity
to absorb functional stresses would re-
quire less reduction of tooth structure
during preparation,
33
which is an im-
portant issue when considering tooth
structure loss through erosion. Besides
the advantages of biomechanical be-
haviour, Mangani mentioned the follow-
ing positive indications concerning the
use of indirect composite resin veneers
versus ceramic:
They allow for better absorption of the
polymerization stresses generated by
the cement during cementation pro-
cedures.
The nishing and polishing proced-
ures are easier than with ceramic ve-
neers.
The laboratory procedures are easier,
thus lowering the manufacturing cost.
14
Composite resin veneers involve easier
laboratory procedures than ceramic ve-
CASE REPORT
430
neers, even though veneers built with
the refractory cast technique take less
time than those manufactured with other
techniques. Generally, indirect restor-
ations require a greater amount of time
and involve more technical difculties,
which explains the higher overall cost of
ceramic restorations.
14
It is sensible and benecial to main-
tain pulpal vitality, prevent endodontic
treatment, and avoid the need for a post
and core restoration, because these
more invasive approaches violate the
biomechanical balance and compro-
mise the performance of restored teeth
over time.
34
A recently published case report ad-
vocates the use of monolithic lithium di-
silicate restorations in the rehabilitation
treatment of a patient with tooth wear.
35

Although the author stresses the con-
servative approach of the treatment
(0.8 mm reduction) and the resistance
to exion from 360 to 400 MPa, it is the
authors belief that this approach still re-
quires less sacrice of tooth structure
and offers more favorable biomechan-
ical conditions. However the technique
proposed in the case report should be
taken into consideration as a possible
alternative to conventional protocols.
Conclusions
The need for root canal treatment and
full-coverage crowns used by the trad-
itional treatment protocols in patients
with dental wear could create a bio-
logical and biomechanical compromise
of the restored teeth in the medium or
long term. This has led to the develop-
ment of new minimally invasive restora-
tive procedures based on adhesion. With
this approach, indirect composite resin
veneers may represent a further treat-
ment option as part of a treatment plan
to rehabilitate patients with tooth wear.
The use of such veneers also provides
the advantages of esthetic properties,
biomechanics and economical cost for
the patient.
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