indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Interceptive treatment in worn dentition concept and treatment

Treating tooth wear is an ever increased topic. Young patient are as affected as older people , this is why every dentist has to pay attention to identify and treat in a proper way (ultra conservative) eroded dentition. It is a challenge, of course, but the clinician has to be ready to fix it. The purpose of raising the occlusal vertical dimension (OVD) is to reconstruct the occlusal morphology on worn dentition with the most minimally invasive possible tooth preparation, and to restore the smile line with an adequate thickness of restorative material. This will allow clinician and technician to have more freedom to recreate occlusal harmony, improve the bite, and reduce stress on the muscles. This creates a sufficient inter-occlusal space to restore proper anterior guidance and correct the occlusal anatomy. Increasing OVD is safe and well-tolerated by healthy patients. In most cases, recreating the ideal morphology and obtaining optimal aesthetic results with minimal preparation would be almost impossible without changing the OVD. This step is crucial to create the ideal aesthetic and functional project. In other words, the required space for anatomic reconstruction will dictate the new OVD recorded on the patient, giving the lab technician all the information needed to create the new design.

This article presents indirect approach for treating eroded dentition on a young patient.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.1

A 23 years old male patient came for a control visit, asking why he had some small cavities in the posterior region.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.2

Palatal view shows erosion with still a thin enamel layer.

Unfortunately the anamnesis reveals a high consumption of soft drinks.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.3

On this different view, the incisal edge thickness appears to be damaged and is getting thinner due to the erosion and abrasion.

This combination can explain the small breaks and cracks on the incisal edges.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.4

In posterior areas, occlusal enamel almost desappears exposing dentin and creating small cavities and cusps, which are typical of erosion pattern.

CAD CAM styleitaliano style italiano dmg

Fig.5

Treatment planning here is very simple and is customized according to the selective destruction. 1- For the upper arch the emergency is to protect the palatal anatomy . The posterior area does not need to be treated at the moment because of the existing anatomy.

CAD CAM styleitaliano style italiano dmg

Fig.6

For the lower arch only posterior anatomy is affected by erosion . The anterior zone still has good shape and morphology. This means that treatment plan is not always dedicated to the full arch and can be selective. But in all the case the final occlusion has to be stable with simultaneous contacts.

This automatically open a comprehensive discussion around material selection, considering the nature of the antagonist which will be natural enamel. In such a case dentist is looking for an “enamel like” material to get the same wear behavior.

Composite is the ideal material for this requirement and monolithic composite is even better . This is why LuxaCam Composite (DMG ) was selected for this case in order to fit with this clinical reality.

CAD CAM styleitaliano style italiano dmg

Fig.7

The advantages are:

– Easy to mill at 0,5 mm
– Soft and mimetic
– Wear behavior close to natural enamel
– Ideal in functional rehabilitation where antagonist are not included in the treatment . (CAD CAM restorations performed by Hilal KUDAY Bodrum)

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.8

Bonding sequences is always same as for veneers, using individual dam to go fast and precise.

sandblasting treatment styleitaliano style italiano aquacare

Fig.9

Sandblasting with alumina oxide (50 microns – Acquacare ) is used here to clean the surface and improve bond strength because almost no prep were performed, except for peripheral enamel in order to stabilize the table tops.

etching treatment styleitaliano style italiano dmg

Fig.10

Etching with phosphoric acid (37%) for 15 sec. When you see bubble inside the effect is already done.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.11

Universal adhesive is used for the bonding protocol (LuxaBond Universal DMG) . This Dual cure system offer a good flexibility and versatility for all the clinical application. It is important to pay attention to let the adhesive system penetrate 20 sec and apply a second layer , dry each layer with air syringe for 10 sec before curing for 30 sec with a high intensity lamp (Blue Phase G4 ivoclar vivadent).

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.12

LuxaCam Composite occlusal veneer is bonded with a light cure composite resin (Vitique veneer B1 DMG) to maintain the value of the restoration. Self adhesive resin cement are not recommended for such type of restoration with no retention, because bond strength are lower and tis can affect the mechanical behavior of the occlusal veneer . Surface treatment for occlusal veneer must follow : -sandblasting -etching with phosphoric acid 37% to avoid contamination -adhesive application without light curing with LuxaBond Universal.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.13

Important excess are removed with a brush and finishing and polishing are performed without rubber dam. This bonding procedure takes between 5 and 10 minutes all included, which fits with the dental economical reality.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.14

Comparison of the occlusal anatomy before and after the placement of table tops.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.15

Intraoral integration of occlusal veneer . Thanks to composite esthetic integration is nice.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.16

Other side.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.17

Occlusal view of the palatal veneers.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.18

Thanks to the bonded restorations, teeth are reinforced and protected.

indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.19

After 2 years in acidic environment the material resists well, but margin are a little discolored. Why? The patient got depressed and started to drink 2 bottles of Coke every day.

This acidity affects matrix resin, this is why the texture of the material became matte instead of shiny, but material still resists pretty well.

2 years indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.20

After 2 years you can note a small surface modification but a very good integration. With parafunctional habits, this type of material absorbs the occlusal stress during grinding. Of course in acidic environment resin matrix suffers more than lithium disilicate material, but can be a good option to stabilize and protect tooth.

Incisal view of indirect approach on a young patient with eroded dentition styleitaliano style italiano dmg

Fig.21

Incisal view of the new occlusion.

Conclusions

In today’s world of bonding, tissue preservation is critical (29, 30), and many clinicians often forget or bypass the strict rules of minimally invasive tooth preparation techniques and designs for fixed prostheses because of technical challenges, time constraints, or lack of training. Treating dental wear in younger patients is also an important challenge for clinicians. However, patients can be treated with a very low biological cost due to the performance of current materials. The difficult balance between biology, aesthetics and function can be achieved. The goal of this minimalistic approach is to simplify the procedures for clinicians and provide strict guidelines in order to make the treatment feasible, repeatable, and predictable.

BIBLIOGRAPHY

1-Koubi S, Gürel G, Margossian P, Massihi R, Tassery H. Aspects cliniques et biomécaniques des restaurations partielles collées dans le traitement de l’usure: Les table top. Réal Clin 2014 ; 25 (4): 327-336.

2-Koubi S, Gurel G, Margossian P, Massihi R, Tassery H. A Simplified Approach for Restoration of Worn Dentition Using the Full Mock-up

3-Concept: Clinical Case Reports. Int J Periodontics Restorative Dent. 2018 Mar/Apr;38(2):189-197

4-Vailati F, Belser U: full month adhesive rehabilitation of a severely eroded dentition: 3 step technique part 2 Eur J Esthet Dent. 2008 Summer;3(2):128-46.