Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2012 39; 7379
Case Report
Composite vertical bite reconstructions in eroded dentitions
after 55 years: a case series
T. ATTIN, T. FILLI, C. IMFELD & P. R. SCHMIDLIN
Cariology, Center for Dental Medicine, University of Zurich, Zurich, Switzerland
SUMMARY In the following case series, we report on six
cases of erosive worn dentitions (75 posterior teeth),
which have been reconstructed using a template-
based technique with direct composite resin restora-
tions and already examined after 3 years in service. In
all patients either one or both tooth arches were
completely restored using direct resin composite
restorations. A wax-up-based template was used to
avoid freehand build-up techniques and to ensure
optimal anatomy and function. All patients were
re-assessed after a mean service time of 55 years
(mean 67  4 months) using United States Public
Health Service criteria. The overall quality of the
Introduction
Tooth substance loss in patients suffering from dental
erosions often needs to be treated by restorative
measures, especially, when extensive areas of dentin
are exposed or the aesthetic appearance of the patient is
compromised. The erosively induced loss of dental hard
tissue often leads to a reduction in the vertical dimen-
sion. Rehabilitation of a severely worn dentition with
loss of vertical dimension is often associated with many
difficulties for the practitioner as to follow an appro-
priate and stringent therapeutic strategy (1). Recently,
Jaeggi et al. (2) related possible treatment options
according to the dimension of the vertical loss and
proposed three categories. In category 1 (vertical loss
<05 mm), sealing of the eroded areas or direct com-
posite restorations was indicated. Direct composite
restorations were also recommended in category 2
(vertical loss <2 mm), whereas rehabilitation with
indirect ceramic veneers and overlays was judged to
be suitable for category 3 (vertical loss >2 mm).
2011 Blackwell Publishing Ltd
Clinic for Preventive Dentistry, Periodontology and
restorations was good with predominantly alpha
and bravo scores, respectively. However, the resto-
rations showed some deterioration with respect to
marginal quality, marginal discoloration, surface tex-
ture and anatomy as compared to the 3-year investi-
gation. The marginal impairments could be resolved
by polishing. It is concluded that this non-invasive
technique provides a possible treatment option at
least for the displayed observation period of 55 years.
KEYWORDS: composite resin, clinical, case series,
posterior, tooth wear
Accepted for publication 25 June 2011
Especially in patients with distinct vertical loss of
dimension, indirect restorations could be regarded as a
suitable means for comprehensive oral rehabilitation
(3).
Improvements in the composite restorative materials
make them suitable for direct restorative procedures to
rehabilitate worn dentitions (46). Using direct restor-
ative materials allows for a minimally invasive treat-
ment only replacing the dental hard tissue lost under
the erosive conditions. Additionally, using direct resto-
rations might be regarded as an expectative approach
allowing to render the patient familiar with the new
vertical dimension and to implement anti-erosive
strategies in the patients behaviour, before fabricating
indirect restorations at a later stage (79). Numerous
long-term studies document that composite restorations
in posterior teeth behave well under clinical conditions
(1015). However, most of the long-term follow-up
studies in posterior teeth have been performed in
more or less small cavities, thus respecting the tradi-
tional indications of using resin composites. Extensive
doi: 10.1111/j.1365-2842.2011.02240.x
74 T . A T T I N et al.
composite restorations with cuspal coverage showed
conflicting results in the literature (1619).
Recently, the results of a case series of seven patients
after an average of 3 years of follow-up were published.
In these patients, a vacuum-formed matrix template was
used for the reconstruction of the posterior vertical bite
with composite resins (20). The matrix was fabricated
based on wax-up models, allowing replacement of the
missing vertical dimension avoiding freehand forming.
The aim of the present investigation was to
re-evaluate the posterior vertical bite composite resin
reconstructions of these patients after a mean period of
55 years in function.
Material and methods
Patients and treatment
Of the seven patients investigated in the 3-year case
series, six returned to the present follow-up examina-
tion. One patient has moved abroad and could not be
motivated to come to Zurich to the examination. How-
ever, on to question, the patient did not report of any
problems with the restorations and they were still in situ.
The mean observation time of the patients examined
in the present recall was 67  4 months, with a range of
6067 months. The age of the patients at treatment was
35  6 years. A total of 75 posterior restorations could
be examined. Only patients suffering from mainly
erosively induced dental hard tissue loss with vertical
loss of about 23 mm were included. Before restoration,
in all patients, abolishment of the causative erosive
factors was achieved. Thus, nutrition control and or
medical and psychological treatment was applied,
where necessary, and patients were instructed about
measures how to prevent erosion (2125). The patients
did not show signs of craniomandibular dysfunctions.
The restorative procedure has already been described
in detail previously (20).
Full-arch sets of gypsum casts were made and
mounted on an articulator. A diagnostic wax-up of all
teeth was fabricated in a balanced occlusion giving the
intended vertical bite reconstruction. For this situation,
a stabilisation splint was completed, which was worn
by the patients for a period of four to 6 months to check
the response to the new vertical bite position prior to
the restorations (26). When the new position was well
accepted by the patient, the restorative treatment was
performed.
For five of the patients, a vacuum-formed template
was fabricated on a duplicate of the wax-up gypsum
model. This means that these templates showed up
with a space between the occlusal surface of the natural
teeth in the oral cavity and the inner aspect of the
template, namely in the dimension of the wax-up. This
space was later built up with composite by means of the
template. Thus, the teeth were restored in a balanced
occlusion scheme applied, which was the same as
waxed up before on the gypsum casts. Both the worn
front teeth and the most distally located tooth, which
had not been waxed up before, ensured support of the
template. The most distally located teeth were restored
free-handed, not using the template for giving shape to
the occlusal surface. The anterior teeth were restored in
a later appointment.
Prior to the appointment in which the vertical bite
reconstructions were performed, all metallic or defec-
tive restorations were replaced with composite restora-
tions using the adhesive system Syntac classic and the
fine hybrid composite Tetric* following manufacturers
instructions. For the vertical bite reconstruction, local
anaesthesia and a full-arch rubber dam were applied for
all restorative procedures. Surfaces of existing com-
posite restorations were conditioned by sandblasting
(Microetcher II and application of a silane coupling
agent (Monobond S*). Besides this, no additional
preparations of the teeth were made.
After conditioning of the tooth surfaces with the
adhesive system, the occlusal parts of the teeth were
reconstructed by means of the template. For better
understanding, a step-by-step documentation of this
procedure is given in Fig. 1af.
Every second tooth of each quadrant was conditioned
and built up at the same time, thus allowing interprox-
imal passage with floss afterwards. Separation between
the teeth was performed with small strips of a metal
matrix. Firstly, an about 05-mm layer of composite was
applied to the occlusal surfaces of the teeth and light-
cured for 40 s (Optilux 500). Then, composite was
filled into the template, which was insulated before
(Insulation Gel), and the template filled with the
uncured composite was re-positioned on the tooth
arch. The composite was shortly light-polymerised for a
*Ivoclar Vivadent, Schaan, Liechtenstein.
Danville Engenieering, San Ramon, CA, USA.
Demetron Inc., Danbury, CT, USA.
Haeraeus Kulzer, Hanau, Germany.
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 POSTERIOR COMPOSITE IN ERODED DENTITION 75

Table 1. Patients and teeth involved in the present study at

re-evaluation

Patient Observation
age Evaluated teeth period
(a) (b) Gender (years) (tooth number) (months)

1 Male 40 17,16,15,14,24,25,26, 65
27,37,36,35,34,44,45,47
2 Female 43 37,36,35,34,44,45,46,47 68
3 Male 36 17,16,15,14,25,26,37,36, 68
(c) (d) 35,34,44,45,46,47
4 Male 33 37,36,35,34,44,45,46,47 72
5 Male 46 17,16,15,14,24,25, 27,37, 67
36,35,34,44,45,46,47
6 Male 37 17,16,15,14,25,26,27,37, 60
36,35,34,44,45,46,47
(e) (f) 39  5 n = 75 67  4

with composite, so that contact and support between

(g) (h)
Fig. 1. Step-by-step documentation of the procedure on a man-
ikin plastic model with worn teeth. (a) View of the worn teeth.
(b) Fit of the template, which was made on a wax-up model,
showing the unfilled space between the occlusal surface of the
teeth and the inner aspect of the template. (c) Application of a first
thin increment on the occlusal surface. This layer is hardened
achieve proper bond strength of the composite to the tooth
already at this stage. (d) Filling of still missing amount of
composite into the template. (e) Placement of template filled
with uncured composite onto the teeth. (f) Light-curing of the
composite through the template for few second firstly. Then, the
template is removed from the teeth. (g) Removal of excess
composite before performing second light-curing. (h) Completely
reconstructed and polished occlusal surfaces. The most distally
located tooth, which served as a vertical support of the template,
has to be reconstructed free-handed or by use of a second
template.
few seconds to freeze the material. After careful
removal of the template, excess composite material
could be removed from the teeth with a scalpel and the
composite was completely light-cured for additional
60 s. Following finishing, the remaining teeth were
conditioned and built up in the same way. Finally, the
occlusion was carefully controlled. In one patient,
the reconstruction was performed free-handed without
the use of a template.
In Table 1, the jaws and teeth of the patients
treated and finally evaluated in this report are
illustrated. Few days after reconstruction of the
posterior teeth, the anterior teeth were also built up
upper and lower anterior teeth were re-established.
These restorations were not included in the follow-up
study, because most of them were restored with
indirect restorations.
The patients received acrylic splints to protect the
restorations. Regular recall appointments were agreed
with a maximum period of 6 months in between. If
manipulation or corrections of the restorations were
necessary at these appointments, the respective proce-
dure was noted in the patients record.
Evaluation
The posterior restorations were evaluated by three
investigators independently, who were pre-calibrated at
85% reliability. Consensus was achieved in case of
disagreement. The restorations were evaluated using
the modified United States Public Health Service
(USPHS) criteria (Table 2). Moreover, bitewing radio-
graphs were performed.
Results
Two exemplary situations of the posterior region after 3
and 55 years, respectively, are presented in Figs 2 and 3.
The case illustrated in Fig. 3 was rated as bravo scores
with respect to surface texture, anatomical form and
colour match. It was estimated as bravo for marginal
integrity and marginal discoloration, which could,
however, be improved by polishing of the margins.
All other items were scored as alpha.

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76 T . A T T I N et al.

Table 2. Modified USPHS criteria applied for the clinical evaluation of the restorations

Alpha Bravo Charlie* Delta

Surface texture Sound Rough

Anatomical form Sound Loss of material Loss of material Complete or partial
within the composite extending to the (>50%) loss of the bulk
tooth surface
Marginal integrity Sound Positive negative step, Negative step, not Strong negative step,
removable by removable by finishing not removable in
finishing major parts
Marginal None Slight discoloration, Discoloration, localised Strong discoloration
discoloration removable by not removable in many parts, not
finishing removable
Secondary caries None Caries present
Restoration colour No change Change in colour as
stability compared to baseline
Colour match Sound Non-perceptible at Perceptable at talking Total mismatch
talking distance distance
Post-operative None Moderate Severe
sensitivity (air)
Marginal None No pockets Slight No pockets Moderate pockets Severe pockets
inflammation >3 mm; no bleeding >3 mm; bleeding 45 mm; bleeding 6 mm; bleeding

*Treatment: repairable.

Needs complete re-restoration.

(a) (b)

(a) (b)
(c) (d)

(c) (d)
(e) (f)
Fig. 2. View of a lower jaw of a patient enrolled in the study. (a)
Baseline situation. (b) Situation at the reconstructive appoint-
ment, before placement of composite. (c) Situation at the 3-year
and (d) 5-year follow-up.

Because of the limited number of patients re-exam-

ined in the present investigation, only a descriptive
statistical analysis was indicated. Thus, the percentages
of the respective scores of the USPHS evaluation are
given (Table 3). For better estimation of the results,
values recorded at the 3-year follow-up are also
presented. At the 55-year follow-up, the restorations
were mostly scored as alpha or bravo for all items
evaluated according to the USPHS criteria. As compared
to the 3-year results, a decrease in alpha scores and an
increase in bravo scores were recorded for every item,
Fig. 3. Clinical performance of the posterior region of one of the
patients involved in the study after 3 years (a) and 55 years (b) of
service. At the 55-year recall, the margins showed up discolor-
ations (c), which could be removed by polishing (d). The surface
of the restoration of the first lower molar of the same patient (e, f)
scored as bravo for surface texture and anatomical form.
except for the occurrence of secondary caries, which
was only seen at the 3-year examination. An increase
in charlie scores was only recorded for the items
anatomical form, marginal integrity and marginal

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 POSTERIOR COMPOSITE IN ERODED DENTITION 77

Table 3. Percentage of respective scores (alphadelta) for the different categories of the USPHS evaluation at 30 years* and 55 years
recall examinations

Alpha Bravo Charlie Delta

30 years 55 years 30 years 55 years 30 years 55 years 30 years 55 years

Surface texture 100 72 0 28

Anatomical form 51 29 46 57 2 13 1 0
Marginal integrity 49 41 49 57 2 5 0 1
Marginal discoloration 59 39 38 51 2 11 1 0
Secondary caries 99 100 1 0
Restoration colour stability 100 97 0 3
Colour match 91 89 9 11
Post-operative sensitivity (air) 100 96 0 4 0
Marginal inflammation 91 41 8 59 1 0 0 0

*Values taken from Schmidlin et al. (20).

discoloration. The two latter events could be improved,
but not completely resolved by polishing in all cases. In
one case, a repair filling of a limited marginal area of
the restoration became necessary because of deficien-
cies in marginal integrity (delta score).
All patients had accepted the new vertical position
well, showing no signs of craniomandibular disorders.
Discussion
The present investigation is the 55-year follow-up of
vertical bite reconstructions performed with direct
composite materials, which has already been proved
to be successful in an examination conducted after
3 years of service (20). The investigators of the present
study found acceptable to excellent performance of the
restorations after the mean observation time of
55 years service using the USPHS criteria. These overall
judgements give support to the estimation that the
presented treatment approach is able to help clinicians
to restore the occlusal anatomy and function of eroded
teeth in a proper way. Thus, the proposed technique
may help to avoid more traditionally reconstructive
concepts for the severely worn dentition, which mainly
base on invasive methods, such as full-crown or partial-
crown coverage (3, 7, 27, 28). At least the method helps
to postpone a more invasive treatment to a later time
point or to allow the patient checking the new vertical
position for a longer period before other kind of
restorations are performed.
All patients were equipped with a mouthguard
for use overnight. However, we do not know how
consequent these mouth guards were worn by the
patients and in how far this procedure is necessary for
prevention of extensive wear of the applied composite
restorations.
The evaluation of the extensive restorations in the
present study showed deterioration of the fillings with
respect to anatomical form and surface texture at the
55-year evaluation as compared to the 3-year follow-
up. These findings correspond well to recent publica-
tions, in which it was stated that wear resistance of
composite resins is no longer a major concern unless
very large restorations in direct occlusal contact are
considered (29, 30). It should be noted that in the
present study the fine hybrid composite resin Tetric was
used, which presented state of the art as a resin-based
restorative material for posterior teeth, when the
restorations were performed in 2004 (3133). With
respect to wear, fine hybrid composite resins behaved
well in in vitro models as well as in clinical investigations
(3335). In this sense, it was recently shown in 3- and
5-year follow-up clinical studies that fine hybrid
composite materials exhibit wear similar to heavily
occlusally loaded enamel areas (34, 35). It is known that
composite resins with even finer filler particles, such as
mircofilled composite resins, showed even better wear
resistance than fine hybrid composites (33). However,
microfilled composite resins present low physical
properties, such as flexural strength, which are impor-
tant properties with respect to longevity of extensive
composite restorations under masticatory load (36, 37).
Thus, it might be conceivable that the latest generation
of composite resins with very small filler particles and
improved physical properties, namely the so-called
nanofilled composite materials, would offer a good

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78 T . A T T I N et al.
alternative to the fine hybrid composite resin Tetric with
respect to improvement in wear resistance with con-
comitant acceptable physical properties. This hypothesis
is based on own unpublished in vitro experiments, in
which we could show that nanofilled composites
showed improved wear resistance as a compared to a
fine hybrid composite for both composite-to-enamel
and composite-to-composite contact.
It might also be taken into consideration that the
patients did not completely refrain from their habits
inducing acidic impact on their teeth and restorations,
although they were instructed accordingly. This possi-
ble acidic impact might also have contributed to an
increased wear of the composite material, as shown in
previous studies (38, 39).
It was striking that some restorations exhibited
marginal discolorations at the buccal and lingual
enamel interfaces, although polishing could remove
most of them (Fig. 3). The adhesive system Syntac
classic was used, which is applied after phosphoric acid
treatment of the enamel in an etch and rinse approach
and which is therefore usually robust against marginal
discolorations (40, 41). Occurrence of the high prev-
alence of marginal discolorations in the present study
might be explained by the fact that the conditioning of
the teeth with the adhesive system was more or less
restricted to their occlusal surfaces and that the
restorations were placed without prior preparation of
the teeth. Thus, the transition of the restoration to the
tooth surface was not clearly defined, which led to
thin layers of excess material on unconditioned
enamel areas being prone to discoloration later.
Moreover, the technician who fabricated the wax-
ups and the templates tended to restrict the wax not
only to the occlusal parts but also applied a thin film
of wax to the adjacent buccal and lingual aspects of
the teeth. To get a better control over this, we now ask
the technician to use blue-coloured wax, which
renders it easier to identify the thickness and the
extension of the wax on the cast, thus facilitating
the correct amount of composite necessary for
reconstructing the tooth.
Finally, the described direct restorative technique
might be considered in terms of cost-benefit ratio.
However, it is difficult to provide a general estimation
on this aspect, because costs for dental treatment and
technician work may vary extensively between differ-
ent countries. It was calculated that on the basis of
Swiss tariffs, the initial costs for the described treatment
amounted to less than half as much as compared to an
indirect approach applying ceramic restorations.
This agrees with a previous study showing that in a
10-year-estimation, relative costs of restoration place-
ment for class-II cusp amalgam fillings are about half as
compared to cast onlays (42). For performing a reliable
estimation of a cost-benefit ratio, not only the initial
costs, but also the longevity of the restorations and
the supposed costs for maintenance (i.e. repair) of the
restorations should be considered. It is known that the
average annual failure rate for composite and ceramic
posterior restorations does not differ considerably,
although these data had been gathered mainly from
restorations, which were less extensive than those
evaluated in the present report (5). However, data for
extensive composite restorations are scarce and have
not been collected in long-term studies. This renders it
difficult to reliably extrapolate the cost-benefit ratio of
the described direct approach vs. an indirect procedure
including the initial costs, but also the future costs for
maintenance and replacement.
Overall, the results of the present case series allows to
conclude that the demonstrated non-invasive tech-
nique provides a possible treatment option at least for
the displayed observation period of 55 years.
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2004;196:639643.
Correspondence: Professor Dr Thomas Attin, Plattenstr. 11, CH-8032
Zurich, Switzerland. E-mail: thomas.attin@zzm.uzh.ch