Indirect Veneer Composite

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CASE REPORT

414THE 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

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


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


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: [email protected]


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ASENSIO ACEVEDO ET AL



Abstract

The evolution of restorative dental ma-

terials has led to the development ofmore 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 difficult 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;8:414–431)




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Introduction

The dietetic habits and parafunctions as

a consequence of modern-day lifestyleshave 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 scientific 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 sacrifice the dental structure.10

Depending on the efficacy 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 reflux disease diagnosis

came to the dental office 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

classification, 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 first bilateral premolars

during lateral movements was also pre-

sent. Interferences during excursivemovements 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).


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

Fig 2 Periodontal

examination.


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CASE REPORT



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 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

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

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 atan 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-


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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 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

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

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).


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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

fixed 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 fixed

partial denture and over the worn lower

natural dentition. Right posterior occlusion


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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 profile 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 final 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 specific-

ally to be used as a reduction guide for the

preparations (Figs 9 and 10).28-30 The re-

duction was confirmed by a silicon index,

as recommended by Magne30 (Fig 11).

The final impressions were taken using a

polyvinylsiloxane material (Fig 12).

Fig 10a Labial reduction using the mock up and

calibrated round diamond burs.


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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.


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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

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.


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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



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Fig 18 Bonding application.

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).

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 µ 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 finally bonding was

placed (Fig 18).

Fig 17b Etching with 35% phosphoric acid.

Fig 17a Cementation was carried out under

complete rubber dam isolation.


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Follow-ups

One week after finishing 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 patient’s

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 finished and pol-

ished with a no. 12 surgical blade and

interproximal strips. The occlusion was

adjusted with laminate tungsten carbide

burs, rugby-ball 40 µ m diamond burs,

and silicon polishers.


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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


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on dental adhesion that would extend

the life of restored teeth. Although some

short- and medium-term studies havebeen conducted on the use of such pro-

cedures, there is still insufficient scientific

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 invasiveoptions 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 scientific 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.


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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 difficult to establish the eti-

ology of dental wear, due to its multifac-

torial origin (attrition, erosion, abrasion,

abfraction). Likewise, at times, it is also

difficult 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

reflux, 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 parafunctionalmovements. 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 antagonist’s 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 finishing 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-


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CASE REPORT



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 difficulties,

which explains the higher overall cost of

ceramic restorations.14

It is sensible and beneficial 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 flexion from 360 to 400 MPa, it is the

author’s belief that this approach still re-

quires less sacrifice 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 possiblealternative 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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C o p y r i g h t o f E u r o p e a n J o u r n a l o f E s t h e t i c D e n t i s t r y i s t h e p r o p e r t y o f Q u i n t e s s e n c e

P u b l i s h i n g C o m p a n y I n c . a n d i t s c o n t e n t m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r

p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s

m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r i n d i v i d u a l u s e .

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