EJED2 Dietschi 329

CLINICAL APPLICATION
A Comprehensive and Conservative

Approach for the Restoration of
Abrasion and Erosion.
Part II: Clinical Procedures and
Case Report
Didier Dietschi, DMD, PhD, Privat-docent
Senior Lecturer, Department of Cariology & Endodontics, School of Dentistry,
University of Geneva, Switzerland
Adjunct Professor, Department of Comprehensive Care, Case Western University,
Cleveland, Ohio
Private practice and Education Center – The Geneva Smile Center, Switzerland
Ana Argente
Assistant, Department of Cariology and Endodontics and Lecturer,
Department of Prosthodontics, School of Dentistry, University of Geneva, Switzerland
Correspondence to: Didier Dietschi

Department of Cariology & Endodontics, School of Dentistry, 19 Rue Barthélémy Menn, 1205 Geneva, Switzerland
tel:+41 223 829 165/150; fax:+41 223 929 990; e-mail: [email protected]
142
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 • NUMBER 2 • SUMMER 2011
DIETSCHI/ARGENTE
Abstract ferred, and with extensive tissue loss

and large restorations, mainly indirect
This article proposes a comprehensive restorations will be chosen. The restora-
and conservative approach to the treat- tion of anterior guidance and a proper
ment of tooth wear, based on the appli- smile line are reestablished using ad-
cation of minimally invasive composite hesive restorations, including primarily
restorations to treat both anterior and direct composite buildups; in the pres-
posterior decay. Three treatment op- ence of more severe tissue destruction,
tions were considered, in relation to the loss of facial morphology or discolor
severity of tissue loss and size of ex- ation, veneers and possibly crowns can
isting posterior restorations. Posterior be considered.
tooth status actually will guide the cli- The driving force behind the concept
nician toward the most appropriate re- presented in this article is to intercept tis-
storative option. In the presence of lim- sue destruction and restore proper tooth
ited tissue loss and small fillings, only biomechanics, function, and esthetics
direct restorations are considered. With using adhesive restorations which do
moderate tissue loss and medium size not further invade hard tissues.
existing restorations, a mix of direct and
indirect composite restorations is pre- (Eur J Esthet Dent 2011;6:142–159)
143
Introduction Part II of this article will confirm the

indications of “minimally” invasive so-
As outlined in Part I of this article,1 the lutions, using mainly partial composite
incidence of tooth wear and related restorations, in the context of tooth wear.
pathologies are an increasing concern This section also aims to describe step-
for the dental profession and has multi by-step, related clinical procedures.
factorial causes. Behavioral changes,
unbalanced diet, and various medical
conditions including acid regurgitation Comprehensive treatment
or medications influencing saliva com-
outline
position and flow rate, trigger erosion.
In addition, awake and sleep bruxism The treatment of tooth wear systematic
are widespread functional disorders, ally includes three phases, which are:
which also induce severe tissue attrition. 1) a comprehensive etiological, func-
It is important to diagnose early signs tional, and esthetic clinical investigation
of tooth wear so that proper preventive, leading to an etiology-based treatment
and if needed, restorative measures can strategy/plan; 2) the preventive and re-
be taken. storative phase; and 3) a maintenance
In the previous article, a treatment program.
approach was presented which fo- The etiological investigation com-
cused on a comprehensive diagnostic prises the identification of general/
and the use of conservative, adhesive medical risks or disorders (ie, bulimia
restorations to re-create tooth anatomy nervosa, gastric reflux, hiatal hernia,
and esthetics and prevent further tis- medications), local risk factors such
sue destruction. Another important as bruxism (awake and sleep) and
feature of adhesive, direct or indirect other parafunctional habits, abnormal
tooth-colored partial restorations is to occlusal conditions, carious activity,
postpone the need for a more inva- periodontal diseases, susceptibility,
sive prosthetic rehabilitation, which will and saliva alterations (flow, buffer ca-
have a positive biomechanical impact pacity, and compositional changes).
on the long-term maintenance of these After taking any possible action to re-
patients.2-5 Actually, the use of adhe- duce risk factors, the treatment plan is
sive techniques and hybrid composite made, including a functional analysis
technology in particular has proven its on mounted casts which leads to a par-
potential in the treatment of moderate tial (moderate tooth wear) or full waxup
tooth wear.6-10 Other materials such (advanced tooth wear). The waxup
as lithium di-silicate are used today as helps planning and to establish a bet-
an alternative to resin composite due ter occlusal scheme, a suitable verti-
to their improved mechanical proper- cal dimension of occlusion (VDO) that
ties.11 Clinical reports have however compensates for tissue loss and cre-
yet to confirm their satisfactory clinical ates space for the anterior restorations,
behavior in such a demanding clinical and also a more ideal smile line with
environment. improved anterior guidance (reducing
144
DIETSCHI/ARGENTE
possibly excessive incisal overlap, see

Fig 1).1 Then, the restorative phase can
start with the indirect restorations (set
at the new VDO) and continue with all
direct posterior restorations, enabling
the placement of direct and indirect an-
terior restorations (Fig 1). The mainte-
nance phase systematically includes a
protective night guard or other “thera-
peutic appliance,” regular check-ups,
repair or replacement of restorations,
when needed.
The idea of increasing the VDO to treat
or restore patients with abnormal tooth
wear has been described and popular-
ized by Dhal.12 The rationale was for-
merly to use a metal appliance to elevate
occlusion and allow teeth to move pas-
sively until once again in occlusion, and
then create space for teeth, which were
stabilized by the appliance.13 The dental
movements occur by a supra-eruption
of “occlusally free” teeth, together with
simultaneous alveolar growth and also Fig 1 Anterior teeth: treatment approach – the
intrusion of teeth maintaining contacts. overall treatment is usually guided by the desired
anterior function and smile line. To fulfill these objec-
Such phenomena occur in a significant
tives, an increase in the vertical dimension of occlu-
proportion of patients treated according sion is expected; this will be defined on models and
to this concept after a delay of 4 to 8 fixed by an anterior or full mouth waxup, depending
months.14-16 on the extent of anatomical modifications required.
An index (resin or silicone) will help the clinician to
transfer this information to the mouth. After creating
the new posterior occlusion, the final anterior res-
Treatment strategies for torations can be placed. Here, a direct composite

solution is depicted; in this case, a minimal 1 mm
posterior teeth restoration thickness is mandatory to resist functional stresses.
Posterior teeth: treatment approach – the choice of
Even though the perceived treatment restorative material and technique is guided by the
need usually takes priority for the pa- amount of tissue wear and size of existing restora-
tions. Left column: with no tooth wear and decay,
tient with anterior teeth, the amounts of
direct composite restorations are preferred (any
tissue loss and restoration size in poster composite type). Middle column: in the presence of
ior segments guide the treatment plan. moderate tooth wear and small to medium size res-
Three conditions are possibly faced with torations/decays, direct composite restorations are
considered (hybrid composites). Right column: In the
regard to posterior teeth status:
presence of severe tooth wear and large decays/
minimal tissue wear and no restora- restorations, indirect tooth-colored restorations will
tion be used (composite preferably or ceramics as well).
145
moderate tissue wear and/or small to using a direct approach is obvious since
medium size restorations no marginal preparation or occlusal re-
advanced tissue wear and large/ duction are needed, and allow resto-
metal based restorations. rations to be placed in a limited inter-
occlusal space.
The treatment rationale and restorative The preoperative waxup will guide the
material choice is then based on the anterior and posterior teeth build-ups;
aforementioned conditions (Fig 1). With therefore, silicone indexes are used to
regard to the treatment of anterior teeth, transfer in the mouth, as accurately as
their biomechanical status will drive the possible, the intended occlusal scheme
clinician toward direct composite or in- and smile line (Fig 1). Figure 2 illustrates
direct ceramic restorations; treatment the clinical application of this treatment
rationale and options will be described option.
further below.
The conservative approach
The minimally invasive approach (direct and indirect partial
(direct composites only) restorations)
When more tissue wear occurred and/

In the first two conditions (minimal and or in the presence of large decays or
moderate tissue wear), the elevation of restorations (especially metal-based
VDO is usually achieved with the place- ones), a combination of indirect and di-
ment of direct composite restorations rect restorations is indicated (Fig 1: right
(Fig 1: left and central columns). When column). Existing tooth-colored restora-
no tissue loss is present, any type of tions showing satisfactory occlusal and
composite can be used (flowable or re- proximal adaptation, anatomy, and es-
storative composite) since occlusal cor- thetics can normally be modified after
rections could be only transitory; in this sandblasting and appropriate adhesive
case, the material’s wear would be com- surface treatment. Once again, the use of
pensated by passive eruption until the hybrid composites are preferred for the
reestablishment of direct tooth-to-tooth fabrication of onlays and overlays due to
contacts. The VDO increase will how a less demanding preparation protocol
ever be maintained through anterior res- (it is more feasible to use composite in
torations, made with a strong and wear thinner occlusal space than ceramics)
resistant material (composite or ceram- and because of their satisfactory behav-
ics). The most frequent condition how- ior and potential to be repaired.6-10
ever is when moderate tissue wear and The indirect restorations have to be
small restorations co-exist; then, direct fabricated first and inserted at the new
composite restorations are placed using VDO; then, all direct posterior restora-
a hybrid composite.6-7 Even though an tions are placed to complete the poster
indirect technique could be considered ior rehabilitation. Figure 3 illustrates this
to resolve such situation, the benefit of second treatment option.
146
DIETSCHI/ARGENTE
a b c
d e
f g
Fig 2 (a–c) The preoperative situation revealing moderate to severe tooth wear, mainly of erosive origin.
However, the amount of tissue loss does not speak in favor of a conventional prosthetic solution; thus, an
interceptive solution using direct composite restorations was used in this case. (d–g) Treatment of left quad-
rant. After rubber dam placement, amalgam fillings are removed and tooth surfaces prepared and cleaned
with sandblasting, before applying composite. A highly filled hybrid material was used and sculpted before
light-curing, enabling proper anatomy and function to be established. (h–i) A full mouth waxup is often
made prior to treatment to serve as a reference and establish the new vertical dimension of occlusion (VDO)
also when a direct restorative approach is followed. Silicone indexes can serve to buildup lingual and buc-
cal cusps at the right level, when needed. (j–m) The same treatment sequence is applied to the maxillary
quadrants. These views show that composite serves both to fill existing cavities and replace eroded or
worn tissues. (n–o) Completed functional restoration of both maxillary and mandibular posterior surfaces,
using only direct restorations; such an approach is highly conservative, comfortable for the patient due to
the short treatment time, and cost-effective.
147
h i
j k
l m
n o
148
DIETSCHI/ARGENTE
c d
e f
Fig 3 (a–d) Preoperative situation revealing severe erosion of the lingual surfaces of maxillary anterior
teeth as well as generalized tooth wear due to a combination of tooth attrition and erosion. The extent of
existing restorations on mandibular molars associated with the need to increase the vertical dimension of
occlusion (VDO) favors here a combined solution, using indirect ceramic and direct composite restorations.
(e–f) A full mouth waxup is also needed to establish the new VDO prior to treatment onset and serves
to plan all restorative steps according to a proper functional scheme and improved smile line. (g) When
indirect restorations such as onlays, overlays or crowns are needed, they must be fabricated at the new
VDO and inserted first; then, all direct restorations can be made accordingly. (h–j) All direct restorations
needed for both maxilla and mandible are made in two or three sessions to allow proper occlusal balance
and function to be re-established as quickly as possible. The rehabilitation of the smile line and new an-
terior guidance were made here with a direct approach, using a silicone index made from the waxup; this
enables this crucial procedure to be performed with precision and predictability. (k–n) These are occlusal
and frontal views of the mixed rehabilitation, using a combination of indirect ceramic restorations and direct
composites to reverse tooth wear impact on function, biology, and esthetics.
149
g h
i j
k l
m n
150
DIETSCHI/ARGENTE
a b
c d
Fig 4 (a–d) Preoperative situation showing a se-

vere erosion of the lingual surfaces of maxillary anterior
teeth as well as generalized erosion of occlusal sur-
faces. Several restorations were to be replaced due
to improper marginal adaptation and some other teeth
showed active decay. The patient was willing to correct
the significant crowding of the maxillary front teeth;
most of those teeth were in a reclined position, making e
an orthodontic solution rather difficult and time con-
suming, which the patient refused. A mixed approach
was selected: indirect and direct composite restor
ations were chosen to restore posterior teeth while
micro-invasive porcelain veneers were used to correct
the maxillary anterior teeth positions. (e–f) Indirect and
direct composite restorations allowed for the treatment
of decay and the restoration of proper tooth anatomy
and function at a new VDO, creating the space re-
quired to also restore the lingual surfaces of maxillary
front teeth. (g and h) Both maxillary and mandibular
posterior occlusal views showing improved tooth anat-
omy and function. (i and j) Porcelain veneers were
made to correct the buccal profile of teeth #12 to #22.
Preparations were minimally invasive on three of these
teeth, tooth #11 being the only one to be prepared
micro-invasively to correct rotation. Canines were left
untouched and the maxillary premolar buccal profile
was modified by direct composite veneers. f
151
g h
i j
k l
m n
152
DIETSCHI/ARGENTE
Fig 4 (continued) (k–n) Two-year postoperative

views demonstrating the satisfactory stability and per-
formance of composite restorations to correct the con-
sequence of tooth wear and to prevent further biome-
chanical impact of conventional prosthodontics. (o) A
vacuum formed, relatively thin night guard is prepared
for all patients at the end of the phase to protect both
the restorations and residual tooth structure from attri-
tion. The compliance of patients with such thin night
guards proved largely superior to conventional thicker
“therapeutic” splints.
Hybrid and indirect ceramic not a guarantee that no chipping or de-
rehabilitation tachment will occur. Of course, the night

guard will play an important role; it is fab-
In the case of severe tissue loss and ero- ricated for the arch, which received the
sion, or if abfraction lesions have signifi- more “delicate” restorations. In cases
cantly affected buccal and lingual sur- of erosion, this risk factor might not be
faces, the benefit of a partial restoration as predominant as in patients showing
is less obvious; therefore, full tooth cov- episodes of severe bruxism.
erage might be the more realistic and In the presence of eroded buccal
effective solution (Fig 4). surfaces, more severe tissue destruc-
tion and slight to moderate misalign-
Treatment of anterior teeth – ment, a veneering approach is re-
quired. On the lingual side however, a
rationale and various options
direct composite application is often
Whenever possible, the direct option chosen because of its simplicity and
is preferred in all cases of moderate efficacy. An alternative is the place-
anterior tooth wear (Figs 1 and 2). The ment of indirect lingual composite ve-
condition for applying a direct restora- neers, such those described by Vailatti
tion, or conversely, to avoid a veneering and co-workers.17-19 Figures 4 and 5
technique or full tooth preparation is the illustrate various combinations of ad-
persistence of an intact buccal anato- hesive, conservative restorative solu-
my and rather satisfactory alignment of tions for anterior tooth wear.
front teeth. It is only in the case of total, or near
A “biomechanical” rule, which is total, enamel loss and anatomy (or se-
based mainly on the author’s experi- verely decayed teeth) that full crowns
ence, is that a strict minimum of 1.0 mm would be appropriate. However the
of material is needed on the restored amount of additional tooth preparation
incisal edge to avoid mechanical fail- and the potential impact on tooth vitality
ures and the need for frequent repairs. and biomechanics are to be considered
Even if this guideline is respected, it is before choosing this option (Fig 6).
153
b c
d e
154
DIETSCHI/ARGENTE
f g
j k
Fig 5 (a–c) Preoperative situation revealing a Class III occlusion associated with severe tooth attrition.
Numerous large posterior restorations are present as well as two implants to replace teeth #24 and #26.
There is also positional attrition of the lingual surfaces of maxillary anterior teeth, as well as generalized
tooth wear due to a combination of tooth attrition and erosion. The extent of existing restorations on man-
dibular molars associated with the need to increase the vertical dimension of occlusion (VDO) favors here
a combined solution, using indirect composite and ceramic restorations and/or direct composite. (d–e)
Maxillary and mandibular front teeth were restored with direct composite restorations, after proper VDO
correction. (f–g) Occlusal views showing mixed rehabilitation using indirect (teeth #46 to #48 and #36) and
direct composite restorations as well as an implant-supported bridge (#24 to #26). (h–k) Two-year views
demonstrating the good performance of composite restorations despite the parafunctional environment;
the patient actually confirmed that he did not wear the night guard over this period. Some minor mechani-
cal degradation occurred on a few teeth (#22 and #16); such “failures” can be easily repaired with fresh
composite after proper surface treatment (sandblasting, silane, and bonding).
155
a b
c d
e f
Fig 6 (a–f) Preoperative situation showing generalized tooth wear due to a combination of tooth attrition
and erosion. In the absence of a few teeth and existing prosthetic restorations, a new prosthetic rehabilita-
tion was planned with an increased VDO. This case demonstrates the difference between an interceptive
adhesive approach and a classic prosthetic approach. (g–h) Indirect posterior mandibular restorations
and related working model showing that the space needed to fabricate indirect ceramic restorations that
exhibit proper mechanical strength is impacting residual tooth structure and tooth biomechanics. (i) The
mandibular incisors were restored with porcelain veneers. (j–m) Buccal and occlusal views of the finished
rehabilitation. The postoperative status shows improved functional balance, smile configuration, and VDO
through a full mouth prosthetic rehabilitation. Such a satisfactory result, however, was achieved at higher
biomechanical and financial costs.
156
DIETSCHI/ARGENTE
g h
j k
l m
157
Complications and repair what the more appropriate restorative

option is.
The more likely complications of a com- In the presence of 1) limited tissue
posite restoration are wear and chipping loss and small fillings, direct restora-
(partial failure) while full loss or detach- tions only are usually considered; 2)
ment (total failure) is an unlikely occur- moderate tissue loss and medium-size
rence.6-10 Figures 4k to 4n and Figures existing restorations, a mix of direct and
5f to 5k illustrate the satisfactory per- indirect composite restorations is then
formance of hybrid composites, even preferred; and 3) extensive tissue loss
in a critical biomechanical environment. and large restorations, indirect restora-
Composite chipping or limited fractures tions mainly will be selected. As regard
can be easily repaired. Then, surfaces the restoration of anterior guidance and
are sandblasted and fresh composite the restoration of proper smile line and
re-applied after proper adhesive proce- tooth proportions, adhesive restorations
dures (etching enamel and bonding all are also preferred, including primarily
surfaces). In fact, the worst-case sce- direct composite buildups. In the pres-
nario would be the full replacement of ence of more severe tissue destruction,
the restoration, normally a rather uncom- loss of facial morphology or discolora-
plicated procedure, implying moderate tion, then veneers and possibly crowns
cost in comparison with a conventional can be used.
prosthetic restoration. Finally, the driving force behind the
concept presented in these two arti-
cles is to intercept tissue destruction
Conclusions and restore proper tooth biomechanics,
function, and esthetics using adhesive
Parts I and II of this article have pro- restorations which do not further invade
posed a comprehensive and conserva- hard tissues.
tive approach to the treatment of mod-
erate tooth wear, based mainly on the
application of minimally invasive com- Acknowledgments
posite restorations to treat both anterior
and posterior decays. The combination We would like to thank Mr Serge Erpen (oral pro,
of appropriate preventive and mainte- Geneva, Switzerland) for the waxup and fabrication
of indirect restorations presented in Figures 2h to i,
nance measures has the best potential 4e and Figure 5. We would like to thank Mr Patrick
as a treatment concept to restore and Schnyder (oral design, Montreux, Switzerland) for
stabilize tooth biomechanics, and avoid the fabrications of veneers presented in Figures 4j
to k. We would also like to express our gratitude to
or postpone a more costly and invasive
the Dental School dental laboratory of the University
prosthetic solution. of Geneva (Switzerland) for the fabrication of the
Three treatment options were con- indirect restorations presented in Figures 3 and 6,
sidered, in relation to the severity of tis- as well as to Dr Claude Crottaz, senior lecturer at
the Department of Fixed Prosthodontics (University
sue loss and the extent of existing res-
of Geneva), for his support and supervision of the
torations in the posterior segments. In case presented in Figure 6.
fact, posterior tooth status determines
158
DIETSCHI/ARGENTE
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159

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CLINICAL APPLICATION

A Comprehensive and Conservative

Correspondence to: Didier Dietschi

Abstract ferred, and with extensive tissue loss

Introduction Part II of this article will confirm the

possibly excessive incisal overlap, see

Treatment strategies for torations can be placed. Here, a direct composite

When more tissue wear occurred and/

Fig 4 (a–d) Preoperative situation showing a se-

Fig 4 (continued) (k–n) Two-year postoperative

Hybrid and indirect ceramic not a guarantee that no chipping or de-

rehabilitation tachment will occur. Of course, the night

Complications and repair what the more appropriate restorative

References 8. Redman CD, Hemmings KW,

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