Tooth Wear of Lower Anteriors – Direct Partial Veneer Technique

The management of tooth wear necessitates a comprehensive understanding of various factors. When analyzing different forms of occlusal wear, particular attention should be directed towards the anterior teeth. Proper alignment of the posterior teeth between anterior and condylar guidance is crucial, ensuring they neither impede nor disrupt either guidance. Thus, the primary objective of posterior occlusion restoration is the establishment of stable occlusal contacts (1). For the conservative management of severe tooth wear without invasive preparation, increasing Vertical Dimension of Occlusion (VDO) emerges as a viable and predictable option (2, 3).

This article focuses on the treatment of lower anterior teeth utilizing an additive restorative technique and its pivotal role in functional envelope management. The Direct Partial Veneer Technique is elucidated as a significant component of the intricate direct rehabilitation of tooth wear. Illustrated through the case of a female patient exhibiting active tooth wear, affirmative responses to specific questions in the Kois dental history questionnaire, particularly in the Bite and JWA joint section (4), highlight the patient’s concerns and indicate potential dysfunction:

Q.23 Do you avoid or have difficulty chewing gum, carrots , nuts, bagels, baguettes, protein bars, or other hard, dry foods … ANSWER: YES (Concerns for TMJ or muscles, it shows that the chewing system is ineffective, indicates possible disfunction)

Q.24 In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed ….ANSWER: YES (That indicates that problem is active!)

Q 25. Are your teeth becoming more crooked, crowded, or overlapped ? ….ANSWER: YES

With a preference to maintain her aesthetic tooth appearance, the patient’s focus shifted towards functional restoration. Both the LOADING TEST and IMMOBILIZATION TEST yielded negative results (suggesting no muscular issues), leading to the recommendation of a Kois Deprogrammer (KD) for a period of 4 weeks (5).

Following the 4-week deprogramming period, verification was conducted. The initial contact point must be identified using articulating paper, ensuring it is singular, reproducible, and spontaneously achieved upon closure of the patient’s mouth, without mandibular manipulation. Consistency in this initial contact confirms successful deprogramming. The presence of Occlusal Dysfunction in the CR position was confirmed. Should the mandible retract and initial contact points appear on posterior teeth after deprogramming, it signifies occlusal dysfunction. During the process of avoiding premature contacts, the patient seeks a new, comfortable position, often resulting in horizontal wear patterns on other teeth. Subsequently, CR was recorded with the KD in the patient’s mouth and transferred to the laboratory for mounting the models in the articulator, maintaining the CR position.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano occlusal view of upper arch

Fig.1
Patient’s upper arch – occlusal view.

styleitaliano style italiano palatal tooth wear

Fig.2
Extensive tooth wear in palatal surface of palatal surface.

styleitaliano style italiano occlusal view of lower arch

Fig.3
Lower arch – occlusal view.

styleitaliano style italiano mounted models

Fig.4
The models were mounted in the articulator for functional analysis and to plan the new Vertical Dimension of Occlusion (VDO) and wax-up accordingly.

styleitaliano style italiano additive wax up

Fig.5
Wax up of the upper anterior teeth, which reveals additive restorative treatment plan in the upper arch.

styleitaliano style italiano wax up of the lower arch

Fig.6
The lower arch wax-up unveiled the additive restorative treatment plan. In the lower arch, the posterior teeth were restored using the Composite Ball Technique, as previously described in my article (6).

styleitaliano style italiano lower silicone index

Fig.7
In order to restore the anterior lower teeth, a silicone index was made based on the wax up (Zeta Labor, Zhermack, Italy).

styleitaliano style italiano surfaces cleaned with aquacare

Fig.8
The lower anterior teeth were isolated with the rubber dam and restorative tooth surface was prepared with 29 microns of aluminium oxide (Aquacare Twin).

styleitaliano style italiano chamfer buccal preparation

Fig.9
The dentin and enamel surfaces affected by tooth wear were air-abraded using 27-micron aluminum oxide. Subsequently, a delicate chamfer was created to enhance adhesive surface area and ensure improved aesthetic integration.

styleitaliano style italiano beveling buccal surface

Fig.10
Following the chamfer, a delicate “eggshell” finishing bevel was meticulously applied.

styleitaliano style italiano etching of enamel

Fig.11
Etching with 35% orthophosphoric acid (20 seconds).

styleitaliano style italiano bonding enamel

Fig.12
After thorough rinsing and gentle drying with an oil-free air flow (avoiding over-drying), GLUMA Bond Universal was dispensed into the mixing well and promptly applied to the dentin and enamel. It was then gently rubbed in for 20 seconds before being carefully air-dried with an oil-free air flow until the adhesive film remained stable.

Caution: Ensure the air flow is not too strong at the beginning to prevent thinning out of the bonding agent, which could lead to inadequate adhesion and potential post-operative discomfort.

styleitaliano style italiano bonded teeth

Fig.13
After applying GLUMA Bond Universal, the surface should exhibit a visibly glossy appearance. If the cavity surface does not appear uniformly glossy, apply GLUMA Bond Universal again as instructed. Subsequently, the adhesive was polymerized for 10 seconds using a conventional curing lamp with a wavelength range of 440 – 480 nm and a light intensity of at least 600 mW/cm2.

Caution: Ensure that the light power is sufficient to prevent inadequate adhesion.

styleitaliano style italiano restoring with composite in silicone index

Fig.14
The lingual surface of the lower anterior teeth was restored by cutting a silicone index and utilizing the high-strength nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany). The composite material was applied to the silicone surface of six lower anterior teeth and promptly placed intraorally. Subsequently, interproximal grooves were created using the Fissura instrument (LM Dental, Finland) to enable individual tooth separation.

Each tooth was then polymerized for 20 seconds.

Caution: In some parts of the world, the nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany) is marketed under the brand name Venus Diamond (Kulzer GmbH, Germany).

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano reinforcing lingual build up

Fig.15
To enhance the stability of the lingual wall during subsequent operative procedures, a “drop” of one-shade flowable Charisma Bulk Flow ONE (Kulzer GmbH, Germany) was carefully placed between the lingual surface of the restoration and dentin using the Fissura instrument (LM Dental, Finland).

Practical tip: Lingual walls built with a silicone index are often fragile prior to final restoration. Strengthening them immediately with a flowable composite that is easy to handle and does not compromise the final shade of the restoration is advantageous.

Caution: In certain regions, the nano-hybrid composite Charisma Bulk Flow ONE (Kulzer GmbH, Germany) may be sold under the brand name Venus Bulk Flow ONE (Kulzer GmbH, Germany).

style italiano styleitaliano kulzer venus Bulk flow ONE one-shade bulk filling composite
style italiano styleitaliano kulzer venus Bulk flow ONE one-shade bulk filling composite
styleitaliano style italiano transparent matrix and fissura instrument to prevent teeth from sticking

Fig.16
In order to separate the teeth that could have been connected by means of restorative lingual surface, it is practical to use Fissura instrument (LM Dental, Finland).

Practical tip: Place thicker part of Fissura instrument between the connected teeth and move the adjacent teeth gently left and right, and they will immediately separate from each other.

styleitaliano style italiano modeling the proximal walls

Fig.17
The approximal surfaces of the restorations were restored using the high-strength nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany), shaped with a single-use composite brush and the Blue View VariStrip Anterior Matrix (Garisson). Each approximal surface was then polymerized for 20 seconds.

Practical Tip: Be sure to round the angle between the approximal and buccal surface to create an adequate “Emergence Profile of the Contact Surface” and save time during restoration finishing. Alternatively, you can utilize the Applica Instrument (LM Dental, Finland).

styleitaliano style italiano outer restoration frames built to fill

Fig.18
The semi-profile view of the restored approximal surfaces with rounded “Emergence Profile of the Contact Surface”.

styleitaliano style italiano layering internal incisal anatomy

Fig.19
The dentin mamelons were performed with OM shade of nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany). The shaping strategy was carried out using the thick end of the Fissura instrument (LM Dental, Finland). Each of the tooth was polimerized for 20 seconds.

styleitaliano style italiano layering enamel mass

Fig.20
The final layer of the buccal surface was perfected using the A2 shade of high-strength nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany), applied with the Applica Instrument (LM Dental, Finland) to achieve a flat buccal surface. The composite resin was slightly overextended onto the central part of the buccal surface.

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano light curing composite

Fig.21
The final polymerization of each tooth was performed after applying layer of glycerin gel.

styleitaliano style italiano finishing composite partial veneers

Fig.22
The characterization of the buccal surface was conducted using a diamond bur (Style Finale Kit, bur no F4, Intensiv).

styleitaliano style italiano profin tip

Fig.23
The “Emergence Profile of the Contact Surface” was refined using the Profin® Reciprocating System (Dentatus Profin PDX, Sweden), which offers easy access and flexibility for shaping, contouring, and polishing.

Practical Tip: Adjust the angulation of the Profin® Reciprocating System to approximately 15-20 degrees relative to the contact surface of the tooth. Maintain a speed between 8000-10000 (max) rpm when shaping composite restorations. Always ensure significant air spray cooling with a dental air syringe. Take adequate breaks to prevent overheating of the Profin tip during use.

styleitaliano style italiano scaling excess composite away

Fig.24
To eliminate any excess polymerized composite, the no. 12 blade or the Eccesso Instrument (LM Dental, Finland) was utilized.

styleitaliano style italiano venus supra kulzer polishing kit

Fig.25
For the final polishing the Venus Supra Intro Kit 2 x 5 (Kulzer GmbH, Germany) was used.

styleitaliano style italiano twist polisher

Fig.26
Each surface of the restorations was initially pre-polished by pre-polisher of shape Twist Disc (66093899, Venus Supra Intro Kit 2 x 5; Kulzer GmbH, Germany).

styleitaliano style italiano high gloss twist disc polished

Fig.27
Then each surface of the composite restorations was polished with the high gloss polisher Twist Disc (66093900, Venus Supra Intro Kit 2 x 5; Kulzer GmbH, Germany).

styleitaliano style italiano polished composite partia veneers

Fig.28
Polished anterior restorations.

styleitaliano style italiano balancing occlusion

Fig.29
Once the palatal surfaces of the upper anterior teeth were successfully restored according to the planned wax-up, the final occlusal equilibration procedure was initiated. Utilizing the “Kois Chewing test,” functional chewing motions were replicated by the lower jaw while the patient maintained an upright seating position, using horseshoe-shaped thick blue occlusal paper (200 microns). Subsequently, all areas marked in blue were meticulously addressed using a diamond bur (Style Finale Kit, bur no. F4, Intensiv). This protocol was iterated multiple times to ensure thorough removal of all blue-marked surfaces from both the lower and upper anterior teeth.
Practical Tip: Gently remove all blue marked surfaces or transfer them into the delicate lines, in order to assure the adequate envelope of function.

styleitaliano style italiano finishing restoration with Intensiv STYLE FINAE kit burs

Fig.30
During the “Kois Chewing test,” using horseshoe-shaped thick blue occlusal paper (200 microns), the marked blue surfaces (chewing patterns) were meticulously addressed using a rugby ball-shaped diamond bur (size 012). Delicate red dots, occlusal points denoting the maximum intercuspal position (MIP), were left at the cingulum of the palatal surfaces of the upper anterior teeth, using thin (8 microns) double-folded articulating paper (2 x 8 microns = 16 microns, BK25 Bausch, Germany), to ensure proper stability. Concurrently, the Shimstock of 8 microns was to passively slide between the upper and lower anterior teeth in MIP without encountering any interference. This approach prevents overloading of the anterior teeth, thus ensuring the stability of composite restorations and maintaining an adequate functional envelope.

Practical Tip: Thoroughly removing all blue-marked surfaces is essential to ensure the establishment of an appropriate functional envelope.

styleitaliano style italiano direct partial composite veneers

Fig.31
Final view of the lower anteriors restored with “Partial Direct Veneer Technique” by means of nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany)

Caution: In some parts of the world the nano-hybrid composite Charisma Diamond (Kulzer GmbH, Germany) has another brand name – Venus Diamond (Kulzer GmbH, Germany).

style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
style italiano styleitaliano kulzer composite venus pearl and diamond long restorations
styleitaliano style italiano posterior occlusal check

Fig.32
During the equilibration procedure, the posterior teeth on the left side were restored using the Composite Ball Technique (6).

styleitaliano style italiano posterior occlusal check

Fig.33
Right side. It was essential to reduce all blue-marked surfaces while ensuring the red dots obtained in MIP remained adequately distributed.

styleitaliano style italiano before and after lower anterior teeth restoration with the “Partial Direct Veneer Technique”

Fig.34
Lower anterior teeth restored with the “Partial Direct Veneer Technique” within the Complex Direct Rehabilitation.

Conclusions

The article presents a comprehensive approach to rehabilitating tooth wear complexities using direct composite restoration, with a particular emphasis on restoring the lower anterior teeth.

  1. Today, complex rehabilitation of tooth wear can be achieved using a non-prep protocol, employing high-strength nano-hybrid direct composite resin.
  2. The restoration of worn anterior teeth holds significant importance in effectively managing the Envelope of Function.
  3. Rehabilitation of the Envelope of Function with high-strength nano-hybrid composite ensures the feasibility of safe and predictable occlusal equilibration, particularly in both lower and upper anterior teeth, especially when conducting dynamic functional tests like the Kois Chewing Tests.
  4. The Direct Partial Veneer Technique offers a safeguard for the restoration during ongoing professional hygiene, as the composite resin does not entirely cover the buccal tooth surface.

Bibliography

  1. Dawson PE. Evidence-based versus experience-based views on occlusion and TMD. Am J Orthod Dentofacial Orthop. 2005 Aug;128(2):150-1; author reply 151-2.
  2. Kois JC, Phillips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent. 1997 Dec;18(12):1169-74, 1176-7; quiz 1180.
  3. Calamita M, Coachman C, Sesma N, Kois J. Occlusal vertical dimension: treatment planning decisions and management considerations. Int J Esthet Dent. 2019;14(2):166-181.
  4. Kois JC, Filder BC. Anterior wear: orthodontic and restorative management. Compend Contin Educ Dent. 2009 Sep;30(7):420-2, 424, 426-9.
  5. Zarow M. Finding the Centric Relation – The Kois Deprogrammer – 2018 – styleitaliano.org
  6. Zarow M. “The Composite Ball Technique” and “Pre-Polymerisation Procedure” – the Simplification in VDO increase with direct composite – 2022 – styelialiano.org
  7. Manauta J. Polishing lifelike composite – 2011 – styleitaliano.org

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