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414
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
415
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
Fig 2 Periodontal
examination.
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
Fig 9 Preparation of the mock-up. Fig 10a Labial reduction using the mock up and
calibrated round diamond burs.
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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.
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
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
Try-in
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
CASE REPORT
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
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CASE REPORT
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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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
ASENSIO ACEVEDO ET AL
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 • NUMBER 3 • AUTUMN 2013
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