THE

Worn and Eroded Dentition:

ETIOLOGY, RISK ASSESSMENT, &
TREATMENT CONSIDERATIONS
Ali Tunkiwala, BDS, MDS, AAACD

Abstract
The multifactorial nature of tooth wear poses several challenges
when making a definitive diagnosis regarding its etiology. Attrition
and erosion can work at different points in time in the same
dentition to create severe tooth surface loss. When examining the
patient, the clinician must collect all the clinical data and then
make an accurate diagnosis and risk assessment. The treatment
philosophy in such cases is to remain minimally invasive if
possible. However, with moderate to severe erosion, protection of
the remaining tooth structure from acid dissolution is paramount
and may render minimally invasive partial-coverage treatment
options impossible. This article presents an overview of some of
the major causes of tooth wear and provides a systematic approach
to the rehabilitation of afflicted patients with a combination of
digital and adhesive protocols.

Key Words: tooth wear, attrition, erosion, parafunction,

adhesive dentistry, digital dentistry, full-mouth rehabilitation

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With the growing human

lifespan, dental professionals
have found it increasingly
necessary to employ
preventive or restorative
strategies to manage the
clinically alarming effects of
tooth wear.

Journal of Cosmetic Dentistry 51

Introduction
Cultural and societal trends influence universal
norms of beauty and esthetics. White, bright teeth are
considered an indication of good health and hygiene,
while discolored, chipped teeth reflect aging and
neglect.1 Lifestyle-related diseases and aging affect all
parts of the human body, including teeth. With the
growing human lifespan, dental professionals have
found it increasingly necessary to employ preventive
or restorative strategies to manage the clinically
alarming effects of tooth wear.2
Over the years, teeth are exposed to numerous
chemical and physical influences. Many of these in- Figure 1: Dentition afflicted predominantly by attritional wear. Shortening
fluences are detrimental and lead to various forms of of the upper and lower anterior teeth and flattening of the posterior teeth
are a typical clinical presentation.
tooth wear, categorized as attrition, abrasion, abfraction,
and erosion. The term biocorrosion encompasses abra-
sion, abfraction, and erosion, all forms of chemical,
biochemical, and electrochemical degradation.3
Tooth wear is multifactorial in nature, making its Attrition, Abrasion, Abfraction, and Erosion
specific etiology difficult to diagnose. A detailed pa-
tient history correlated with the study of clinical ap- Attrition
pearance and wear patterns is mandatory to deter- Attrition occurs from tooth-to-tooth contact without the presence of
mine likely etiology. It is important to recognize that food and typically is characterized by the presence of facets on the oc-
while each tooth wear pattern can progress indepen- clusal surfaces of teeth that match a corresponding facet on a tooth in
dently, in most circumstances, various types of wear the opposing arch. The exposure of dentin creates a flat surface with
contribute to the patient’s clinical presentation. For no cupping, as observed in erosion. In general, well-defined, shiny
instance, drinking acidic beverages from straws, which facets are a good indicator of active attrition (Fig 1). Attrition is con-
direct the liquid to the labial surfaces of the central sidered to be a physiologic phenomenon; however, it is important to
incisors, can cause erosion of the labial surface; noc- quantify the amount of wear that can be considered physiologic. Data
turnal grinding will lead to wear patterns of attrition on the typical wear of enamel of the occlusal surfaces of permanent
alone; and brushing the teeth with a highly abrasive teeth is scarce, but it has been reported to be around 15 to 20 μm
toothpaste or a faulty toothbrush can cause abrasion per year for premolars and 29 to 38 μm per year for molars.7 Other
alone. Most authors and researchers agree that the ad- authors have reported a decrease in mean crown length of maxillary
vanced tooth wear observed in most patients is the re- incisors from about 12 mm at the age of 10 years to about 11 mm at
sult of a combined effect of various etiological factors, the age of 70 years, yielding a mean decrease of about 1 mm (1000
although one type of wear may be dominant in its μm) over six decades.8 Any attritional tooth wear beyond these num-
expression and others secondary.4-6 The morphology bers may be considered pathological. In severe wear cases, there may
of the wear pattern and its severity will depend on the be rapid loss of enamel and exposure of dentin, leading to sensitivity,
most dominant etiology. lack of function, and diminished esthetics. Abnormal attrition may
be due to occlusal factors (load-mediated) or due to parafunction
(brain-mediated). It is imperative to diagnose the cause of abnormal
attrition and target treatment strategies toward eliminating dysfunc-
tion, constriction, and/or parafunction.

In day-to-day practice, the Abrasion

balance between the degree of Abrasion occurs from the friction of exogenous material forced over
tooth surfaces. Although a multitude of foreign bodies (including
intervention and the ethical need the toothbrush) can cause abrasion, the most common—yet most
overlooked—is food, which affects the whole occlusal surface with-
to be minimally invasive is always out creating defined facets. The action of abrasive food on enamel or
a difficult call, and a multitude of dentin may cause pitting, gouge marks, and/or other characteristics
of mechanical breakdown. In contrast to erosion, dentinal scooping
factors govern that decision. from abrasion is relatively shallow, following a relatively fixed depth-
to-breadth ratio that seems to remain constant as the wear progresses,
provided the diet remains the same.9

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Abfraction gression while providing a solution for hypersensitivity. Occlu-

Abfraction is a type of noncarious cervical lesion (NCCL) that sal equilibration/splints may be necessary. The involved teeth
is multifactorial in its etiology. Occlusal forces, tooth brush- must be conservatively restored, preferably with an adhesive
ing, biocorrosion, and dissolution from proteolytic enzymes direct restoration. Finally, if root is exposed, root-coverage
of the gingival sulcus are its most commonly attributed causes surgical procedures must be performed with or without restor-
today. There is no conclusive evidence to prove occlusion as ative intervention.
the sole cause of abfraction. To determine the etiology, a thor-
ough medical history—which should include an evaluation for Erosion
gastroesophageal reflux disease, eating disorders, and dietary Dental erosion is the loss of tooth surface produced by chemi-
contributors—is a must. Moreover, occlusion, parafunction, cal/electrolytic processes of nonbacterial origin, usually involv-
and oral habits must be evaluated, as well as patients’ occupa- ing acids.10,11 The source of the acid may be intrinsic (regurgi-
tional and ritual behaviors.3 The interaction between chemi- tated gastric acid due to bulimia, anorexia nervosa, or lifestyle)
cal, biological, and behavioral factors is critical and helps to and/or extrinsic (acidic industrial vapors or dietary factors,
explain why some individuals exhibit more than one type of such as carbonated beverages, pickles, or acidic fruits, etc).
cervical wear mechanism. The prevalence of NCCLs is greater Awareness of the erosive potential of various beverages and
in incisors and premolars than in canines and molars. Man- foods is crucial to understanding erosion, as is knowing the be-
dibular premolars are affected more often and more severely havioral and biological factors that can lead to erosion.11 Ero-
than maxillary premolars. sion causes loss of tooth material and makes the tooth material
Buccal surfaces are the most common locations for these le- more susceptible to further wear due to attrition or abrasion by
sions and typically appear wedge-shaped. In most cases the in- softening the tooth substrate. Early stages of erosive tooth wear
ternal and external angles of these lesions are sharp; however, present subtly, and the clinician must look carefully to identify
in several instances these may become C-shaped with rounded the signs. There is a loss of surface enamel and the perikymata
floors and walls, especially when erosion and abrasion become vanish, leading to a smooth and dull enamel appearance. A
additional contributing factors. Preventive strategies for abfrac- smooth, silky glazed appearance, cupping of occlusal surfaces
tion include counseling to effect changes in patients’ behavior, of teeth (Fig 2), abnormal thinning of teeth (Figs 3a & 3b),
such as diet and brushing technique. Nightguards or splints and subsequent changes in color are some definitive signs of
to reduce clenching or bruxism must be explored. The use of early erosion. Dental erosion in severe stages is characterized
chewing gum to increase salivary flow and medical treatment by large enamel defects with exposure of dentin accompanied
if there is a potential intrinsic medical or mental condition is by dentinal hypersensitivity. These also lead to esthetic issues
recommended. The activity of abfraction lesions needs to be and loss of vertical dimension, which can cause muscular pain
assessed and considered in the treatment-planning process. or temporomandibular joint (TMJ) disorders.
Dental treatment options include monitoring of lesion pro-

a b

Figure 2: A smooth, silky glazed Figures 3a & 3b: Erosion leading to loss of palatal enamel on anterior teeth may lead to shortening of
appearance and cupping of enamel incisors and to subsequent esthetic concerns. Palatal erosion may be due to acid reflux, bulimia, or
is characteristic of early erosion. anorexia nervosa. In this case, it was due to a lemon-sucking habit of several years.

Journal of Cosmetic Dentistry 53

 Figure 4: Preoperative facial view with social Figure 5: Preoperative Duchene smile view,
smile. displaying a high lip line and full range of teeth.

Figure 6: Preoperative retracted 1:2 view in Figure 7: Preoperative 1:1 view showing
maximum intercuspation. deteriorated incisal edges and unsightly resin
fillings.

Figure 8: Preoperative maxillary occlusal view Figure 9: Preoperative mandibular occlusal view
depicting severe loss of occlusal enamel on depicting severe loss of occlusal enamel on all
all posterior teeth. Facial enamel was also posterior teeth. Facial enamel was also affected.
affected, and there were multiple carious Again, the teeth least affected by erosion, #20
lesions and defective old restorations. It is and #30, had metallic full coverage.
noteworthy that the tooth that survived the
erosion, #15, had metallic full coverage.

Management may be the ideal choice. Preventive strategies, such as bonding,

The mechanisms of attrition, abrasion, erosion, and abfraction and, in severe cases, change in vertical dimension of occlusion
act together, each with a different intensity and duration, to (VDO) and/or full-coverage restorations, may be needed.
produce a multitude of different wear patterns. Management of In the quest to be minimally invasive, the teeth may be
such wear varies per the severity of its manifestations and the inadvertently subjected to further acid dissolution, thereby
patient’s reported symptoms of thermal and tactile sensitivity. increasing the risk for biomechanical failures. In turn, these
The management will also depend on the extent of the lesion teeth will later need larger restorations. In day-to-day practice,
intraorally as far as the number of teeth affected. If the erosion the balance between the degree of intervention and the ethical
is localized in the anterior zone with no posterior wear, ortho- need to be minimally invasive13 is always a difficult call, and a
dontics/restorative methods or the modified Dahl approach12 multitude of factors govern that decision.

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Case Report
Patient Complaint and History
A 55-year-old male presented with severe generalized Table 1. Preoperative Clinical Findings
sensitivity in the posterior teeth and food lodging. His
Clinical Examination Findings
immediate concern was the esthetic appearance of his
teeth and the inability to enjoy food. Facial analysis • maxilla canted to the right
The patient had undergone a cardiac bypass five years • occlusal plane uneven
earlier. He was a heavy smoker and consumed alcohol • canted dental midline
in moderation. A thorough dental history revealed the
presence of a large number of carious lesions and erosive Dentolabial analysis • high lip line
loss of tooth structure, mainly in the posterior quadrants. • full visibility of maxillary incisors
with uneven incisal edges
Sensitivity and food lodgement were ongoing issues, with
• wide smile displaying a large
the patient reporting several craters on the biting surfaces number of teeth
of the teeth. He stated that in the past five years, his teeth • incisal edges not conforming to
had become thinner and the upper front teeth were los- curvature of lower lip
ing their edge and their color had drastically changed for
the worse. He reported episodes of nocturnal grinding Dental analysis • unesthetic incisal embrasures
and clenching, and to prevent damage arising from this, • asymmetrical and uneven locations
he had been wearing a soft nightguard for several years. of gingival levels and zeniths
• uneven axial inclinations
Intermittent episodes of gastric reflux were present, but
• displeasing teeth proportions
did not require medical treatment (Figs 4-9). He report- • displeasing teeth color
ed that the episodes of gastric reflux, as well as nocturnal • large cup-shaped defects with silky
grinding, had become much less frequent recently. smooth appearance. detected on
most posterior teeth
Clinical Findings • caries in several posterior teeth
Clinical examination, photography, and preoperative • worn lower incisors, possibly due to
video analysis were carried out to chart the various extrinsic erosion
clinical findings, shown in Table 1.14 The musculature
and the TMJs were normal. The negative load test and the Phonetic analysis • “F” and “V” sounds revealed upper
incisal shortening
overall clinical picture and patient history confirmed that
• “S” and “M” sounds revealed
the TMJs were in a healthy state. adequate VDO
The radiographic examination (Fig 10) revealed over-
all good bone condition with no relevant pathology.
Multiple carious lesions were detected on posterior teeth,
and defective restorations with marginal concerns were
rampant on almost all previously treated teeth. Teeth
#15, #22, and #30 showed issues with previous end-
odontic intervention.
The lateral cephalogram revealed that most parameters
were within normal limits. However, it was observed that
there was no loss in VDO. Also, the facial proportions
revealed that the lower third of the face already had an
increased dimension. Phonetic analysis was in sync with
these findings (Fig 11 & Table 2).

Risk Assessment
Risk assessment is an important aspect of patient-cen-
tered, evidence-based decision making in contemporary Figure 10: Preoperative panoramic radiograph revealing the extent
dentistry.15,16 A detailed analysis of patient data allows of tooth wear, the defective endodontics, and the presence of
the clinician to assess risk and determine the prognosis. periapical lesions in several teeth.
Periodontally, the patient was at low risk, as the overall
gingival health and bone levels were within acceptable
limits. Biomechanically, he was categorized as high risk.

Journal of Cosmetic Dentistry 55

 Table 2. Preoperative Cephalometric Findings Functionally, the patient was categorized as high risk. The
functional diagnosis was parafunction (with erosion as the
Measurement Preoperative Normal Values
contributory factor). For a differential diagnosis, dysfunctional
SNA 82º 82° (+/- 3) occlusion and a constricted chewing pattern were considered16;
however, both of these were ruled out on the basis of the his-
SNB 79º 79° (+/- 3) tory and the unique wear patterns.
It is critical to understand that in such complex cases with a
ANB 3º 3° (+/- 2)
multifactorial etiology, it is difficult to determine what aspect of
U1-SN 107º 103° (+/- 6) the disease came first. Did the patient have abnormal attrition
and that made the worn teeth susceptible to dietary acids? Or
L1 to MP 88º 90° (+/- 5) did the acids soften the substrate of the teeth and make the
normal occlusal force attritional? Faced with such a dilemma,
SN-MP 32º 32° (+/- 5)
it is prudent to go to the next step of treatment with a tentative
Interincisal 128º 135° (+/- 11) working diagnosis. In most cases, after deprogramming, the
diagnosis becomes evident.
UAFH/LAFH 0.5 135° (+/- 11)
Treatment Plan
The treatment plan involved a detailed strategy to reduce the
risk of erosion by eliminating the etiological factors and to
restore the lost morphology of the teeth. Functionally, the
occlusion had to be resurrected, the esthetics restored, the
sensitivity reduced, and the teeth protected from further acidic
damage.
As the patient presented with hypersensitivity and proximal
carious lesions in the upper premolars and molars, endodontic
intervention was mandatory. The wisdom teeth were extracted.
The patient was advised to have #20 extracted, but as it was
asymptomatic, he chose to save it with a new restoration. The
patient was informed that this tooth would be at increased
biomechanical risk.
The patient had three treatment options: direct resin build-
up on all teeth; onlays on posterior teeth and veneers on an-
terior teeth, or full-coverage restorations on all teeth. The first
option was ruled out, as it would be technically difficult to
build direct resins on the entire circumference of the tooth
and maintain them over the years. Moreover, exposure of large
dentin areas on the occlusal and buccal aspects of most of the
posterior teeth meant that bonding would be compromised in
Figure 11: Preoperative lateral cephalogram. the long term.
The choice between full-coverage restorations and onlays for
posterior teeth with veneers for anterior teeth was pondered.
Considering the loss of occlusal enamel, the proximal carious
lesions, the facial loss of enamel on most posterior teeth, and
the incisal and palatal erosion on the upper and lower anterior
teeth, it was decided to restore the patient with full-coverage
Several teeth had structural issues, defective restorations, and lithium disilicate restorations with no change in VDO. It is im-
faulty previous endodontics. In addition, large areas of absent portant to understand that sometimes, in the quest to be mini-
enamel on the occlusal as well as the axial surfaces would re- mally invasive, the long-term prognosis of teeth as well as of
duce the restorations’ ability to be bonded well, thereby in- restorations may be jeopardized in cases such as this.13 Full-cov-
creasing the biomechanical risk of failure with time. From a erage restorations were chosen because they would protect the
dentofacial standpoint, the patient was at high risk due to the teeth from further acidic insults and utilize the isolated islands
strong esthetic expectations he had for the treatment and the of enamel to provide good bonding for the final restorations.
full display of teeth and gingival tissues of all upper teeth while
smiling.

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Treatment and the upper anterior face height/lower anterior face height
The treatment was divided into four distinct phases: (UAFH-LAFH) showed that the lower third of the face was al-
1. diagnostic wax-up ready larger in proportion. As analysis of facial esthetics and
2. provisional restorations phonetic tests revealed the same, it was decided to accomplish
3. tooth preparations and impressions the treatment without any major change to the VDO and to use
4. laboratory protocols and finalization. the mounted casts in CR to create a diagnostic wax-up. The cen-
Each phase had a definitive role in the treatment, and tric occlusion contact was on the right second molars, thereby
breaking down such complex work into organized steps enabled leading to a 1-mm increase in VDO. This contact was retained
treatment that was comfortable for the patient and allowed the and the rest of the teeth were made to contact uniformly with
clinician to accurately assess the outcome at each step. the wax-up. The wax-up gauge on the dento-facial analyzer’s
Diagnostic wax-up: Digital impressions of the upper and mounting platform was used to create the wax-up with an es-
lower arches were made (CS 3600, Carestream Dental; Atlanta, thetically oriented maxillary occlusal plane. Morphological ac-
GA). The patient was deprogrammed before the centric bite curacy in the diagnostic wax-up is paramount, and the wax-up
record to allow the jaw relation record to be taken in centric was done as a full coverage on all teeth. All smile design prin-
relation (CR). A bite wafer (Aluwax; Allendale, MI) was used ciples were followed as recommended19 (Figs 12-15b).
to record the CR using a custom-made Lucia jig (Pattern Res- Provisional restorations: There are several methods for
in, GC America; Alsip, IL)17 and a Kois dento-facial analyzer making provisional restorations for the full mouth. The ideal
(Panadent; Colton, CA)18 recorded the orientation relation requirement for these provisional restorations is that they be
for the upper arch. The upper and lower models were printed made without any tooth preparation. Indirect laboratory-fab-
in three dimension (3D). The upper cast was mounted on a ricated provisional restorations can be made in this manner,
semi-adjustable articulator using the bite tab from the dento- provided the dentition and teeth do not have large undercuts.
facial analyzer, and the lower arch was mounted using the Usually, these lab-fabricated, indirect provisional restorations
aluwax bite in CR. The sella-nasion to mandibular plane are made in the form of an overlay on the whole arch and
(Sn-MP) angle from the lateral cephalogram showed that the may tend to get bulky. Direct techniques, however, offer some
vertical dimension was almost as desired cephalometrically, advantages, as these provisionals can be bonded intraorally,

Figure 12: Digital scans of the preoperative Figure 13: Maxillary 3D-printed model mounted Figure 14: Mounted study casts depicting
dentition status in maximum intercuspation. on an articulator using the dento-facial analyzer. contact only on the posterior molars in
CR.

a b

Figures 15a & 15b: Diagnostic wax-up accurately conforming to the wax-up guide and
morphologically replicating the lost tooth anatomy.

Journal of Cosmetic Dentistry 57

Figure 16: Maxillary teeth etched with 37% Figure 17: Teeth showing islands of frosted Figure 18: Bonding agent application
phosphoric acid. enamel after being dried. and light-curing to initiate the creation of
adhesively bonded provisional restorations.

Figure 19: The full-mouth bonded provisional Figure 20: The provisional restorations must be
restoration must replace the lost morphology of teeth esthetically satisfactory and approved by the patient.
and achieve all the functional criteria of dynamic
occlusion.

a b

Figures 21a & 21b: Uniform contacts on cuspids and all posterior teeth in static occlusion in the maxilla and
mandible.

thereby allowing a perfect “test drive” for the final esthetics sive. Once the adhesive was cured, bis-GMA-based chemically
and occlusion. However, errors in placement of the matrix dur- cured resin (Protemp 4, 3M ESPE; St. Paul, MN) was loaded
ing fabrication of the provisional restorations can lead to an on the putty wash matrix generated from the diagnostic wax-
inadvertent increase in VDO and a subsequent mismatch in up. With a correct orientation, the putty matrix was seated
occlusion that may require intraoral corrections. It is advisable on the teeth. After the material was set, the putty matrix was
to measure the distance between the free gingival margins of removed and the gross excess material was cleaned from the
the upper and lower cuspids on the wax-up and to achieve that teeth. The procedure was then repeated on the opposing arch.
dimension after the provisional restorations have been made Fine-tipped finishing carbides and a number 12 blade (Swann-
and adjusted intraorally. Morton; Sheffield, UK) were used carefully to remove all excess
The teeth in one arch were isolated and etched with 37% material from the gingival sulci around all teeth. The connec-
phosphoric acid (Uni-Etch, Bisco; Schaumburg, IL) for 10 sec- tors between the teeth were shaped to have no overcontouring
onds, followed by drying and application of universal adhe- at the gingival embrasure (Figs 16-21b).

58 2020 • Volume 36 • Issue 1

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The smile’s overall esthetics were evaluated. Phonetics were

verified and the occlusion adjusted to achieve uniform equal-
intensity contacts on the cuspids and on all posterior teeth. Tips for Clinicians
Shimstock (Arti-Fol Metallic, Bausch; Koln, Germany) was
used to check the occlusal contacts (as the incisors must not Beginner
hold the shimstock). After adjustment of the static occlusion, • Develop robust data collection systems, including
the dynamic occlusion was checked using the protocol of path- photography, imaging, and study of occlusion on
way adjustments.20 Articulating paper (200-μm, Arti-Fol Metal- mounted models.
lic) was used, and the patient was asked to chew on it while in • Understand underlying causes to make a diagnosis
an upright position. All the dynamic contacts creating friction and risk assessment in all cases and for all types of
in the chewing pathway were removed, and the provisional res- treatments.
torations were then polished and coated with a surface sealing • Create a systematic approach toward comprehensive
agent (BisCover, Bisco) to prevent discoloration. treatment planning.
The provisional restoration phase is an important milepost • Develop a core competency in simple fixed
in full-mouth rehabilitation. It is the phase when all the deci- prosthodontics and esthetic treatment.
sions made in the early stages of diagnosis and risk assessment • Identify and establish rapport with a good progressive
that culminated in the diagnostic wax-up are tested intraorally. A lab and ceramist who will help you understand the
successful outcome in this phase will go a long way to achiev- technological advances in materials science and
ing a positive outcome with the definitive restorations. manufacturing processes.
Patients are advised to use the provisional restorations for • Read up-to-date textbooks and articles on various
approximately two weeks. If at the end of that period, there are clinical aspects of dentistry.
no negative signs reported in the musculature or the joints, the
phonetics are comfortable, and the esthetics are acceptable, the Intermediate
clinician must record the approved provisionals in the form of • Harness the potential of online education to decrease
digital data (Fig 22) or an analog impression that can be used the learning curve in esthetic dentistry and advanced
as guidance in the lab. restorative dentistry.
Tooth preparation and impressions: Once the patient be- • Subscribe to state-of-the-art journals and periodicals
came comfortable with the function and esthetics of the pro- and participate in mentored CE programs.
visional restorations, the next step was to accomplish all the • Use the systems developed at beginner level to take
foundation work on the teeth. Procedures such as endodontics, on complex cases with occlusal wear and advanced
fillings, and posts and cores were done as needed by quadrant. restorative needs.
The provisional restorations from one quadrant were removed • Apply digital protocols in all stages of treatment
by cutting them off, and new ones were made at the end of the planning and restorative work to increase accuracy
sitting when the foundation work was completed. In this way, and speed.
all the required teeth were treated and the patient was ready for • Increase the level of lab communication and
the definitive impressions. understand materials science to apply more
The final impressions for all teeth for full-arch restorations conservative methods to achieve the end results.
may be done at one time; the challenge is to ensure that the
approved VDO does not fluctuate. Advanced
To prevent any change in VDO, the upper and lower ante- • Become active in organizations or institutions that are
rior teeth were prepared first. Depth cuts (Brasseler; Savannah, larger than yourself. Practice with a sense of purpose
and give back to the profession.
• Evolve in the arena of interdisciplinary dentistry to
harness the potential of periodontal medicine and
orthodontics that can aid in patient-centered treatment
approaches.
• Build upon strategies to provide consistent excellence.
• Process the clinical data documented in your practice
to begin publishing and educating others. Teaching is
the best way to continue learning.

Figure 22: Digital scan of esthetically, phonetically, and

functionally approved provisional restorations.
Journal of Cosmetic Dentistry 59
 • Crown • Tooth prep
• Conventional prep • Knife-edged margin
for lithium disilicate

Figure 23: Deep cervical margin placement is Figure 24: Knife-edged margins allow
detrimental to the strength of the tooth and conservation of enamel and better bond
exposes dentin, thereby compromising bond strength with less sensitivity.
strengths.

GA) were made on the provisional restorations to control the After the anterior preparations were finalized, a Lucia jig was
preparation depth, allowing adequate room for the final res- constructed intraorally with the posterior provisional restora-
torations while at the same time enabling the conservation of tions still in place. Thereafter, the posterior teeth were prepared
enamel. At this point, it is crucial to finalize the material choice to receive the full-coverage restorations, again with knife-edged
and restorative design specifics, as each material will have dif- margins. The Lucia jig on the anterior preparations was used to
ferent tooth preparation requirements. Lithium disilicate (IPS maintain the VDO and to ensure adequate room for the final
e.max, Ivoclar Vivadent; Amherst, NY) was the material of restorations on the posterior teeth (Figs 25-27).
choice for this case and was fabricated using the pressing tech- Tissue management was done with a gingival retraction cord
nique, as marginal fits with pressing have shown to be better (Ultrapak, Ultradent; South Jordan, UT) soaked in aluminum
compared to milling.21,22 chloride (Viscostat Clear, Ultradent).27 Digital impressions of
The final preparations of the anterior teeth were done using the upper and lower prepared teeth were taken. The bite record
the bonded provisional restoration as a preparation guide.23,24 was done on the posterior teeth digitally while the Lucia jig
The anterior margins were placed equigingivally.25 The mar- held the vertical dimension as an anterior stop (Figs 28-30).
gin geometry was knife-edged to allow a conservative prepa- Laboratory protocols and finalization: After the digital
ration on all teeth, saving the residual enamel for bonding.26 scans were received in the lab, the scanned data of the approved
Increased depth of preparation at the margins (Fig 23) leads provisional restoration were superimposed onto the definitive
to removal of thin cervical enamel and moves the preparation preparations to allow the final restorations to be of the same
into the dentin, leading to increased sensitivity and reduced length. The occlusal plane was replicated from the scans of the
bond strengths. Preparing deep chamfers and creating a very approved provisional restorations and the labial and lingual
prominent horizontal margin geometry also weakens the tooth morphologies were modified to achieve a good surface texture
structure and leads to increased incidence of biomechanical and finish. The lithium disilicate allowed for a good translu-
tooth failures, mainly due to the decreased rigidity of the tooth cency in the final esthetic work and was used as a monolithic
structure.24 Leaving the margins knife-edged (Fig 24) allows for design with staining only for the posterior quadrants. The ante-
conservation of tooth structure; however, this has the potential rior teeth were minimally layered to achieve good incisal char-
to create an overcontoured restoration with a cervical ledge. acteristics and translucency. The upper and lower models were
The lithium disilicate restoration must be thinned down (up to printed in 3D to allow seating of all restorations and to adjust
0.3 to 0.5 mm in the cervical region) at the bisque stage to pre- the proximal and occlusal contacts, as well as accomplish the
vent this from happening. The restoration margin is then hand layering (Figs 31-37).
polished and acts as a scaffold for the gingival tissue without Trials were carried out and final checks were performed
creating a detrimental horizontal ledge or overhang. to verify esthetics and marginal fit. Proximal contacts were

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Figure 25: Approved provisional restorations acting Figure 26: A Lucia jig on anterior teeth was fabricated
as a preparation guide for the final restorative phase. while the posterior provisional restorations were still
in place.

The full-coverage restoration was

chosen because it would protect the
teeth from further acidic insults and
utilize the isolated islands of enamel
to provide good bonding for the
Figure 27: Lucia jig holding the VDO during
final restorations. finalization of posterior tooth preparation.

Figure 28: Tissue management of the maxillary arch Figure 29: Final digital impressions of all teeth at the
prior to digital impression-taking. desired VDO.

Figure 30: Digital impressions of the final preparations with knife-edged margins for lithium disilicate.

Journal of Cosmetic Dentistry 61

Figure 31: The designs of the final Figure 32: Milled full-contour wax copings, Figure 33: Strategic cutback of maxillary
restorations (yellow) were merged with which were invested and used for pressed anterior teeth for minimal layering with
the approved provisional scans (green) to lithium disilicate. incisal ceramics.
replicate incisal length and occlusal plane.

Figure 34: Facial surface of anterior lithium Figure 35: Final lithium disilicate Figure 36: The lost occlusal anatomy was
disilicate veneered with translucent ceramic restorations. recreated with lithium disilicate restorations.
powders.

performed to achieve uniform contacts of equal intensity on

all teeth with 40-μm articulating paper. Thereafter, the final
finishing of occlusal contacts was done with 8-μm articulating
paper (Arti-Fol), and uniform contacts of equal intensity were
achieved on all teeth from cuspids to molars. The incisors were
adjusted to not hold the shimstock. Pathway adjustments were
Figure 37: Morphology of the final then carried out as discussed for the provisional restorations.20
restorations, recreating the line angles, three All the surfaces that were adjusted after bonding were polished
planes, lobes, and natural esthetic layering using a dedicated system for intraoral finishing and polishing
of incisal edges. of lithium disilicate (CAD/CAM Intraoral Ceramic Polishing
Kit, Brasseler).28
The patient was educated throughout the treatment about
the need to implement a strict erosion management system
checked and occlusion was marked to verify that uniform and he was given a list of all the acidic beverages and mouth-
equal-intensity contacts were achieved, as discussed previous- washes to avoid, as well as lifestyle changes to prevent gastric
ly. After final glazing, the restorations were bonded using the reflux. Fluoride varnish (Fluor Protector, Ivoclar Vivadent) was
adhesive protocol. Since large parts of the occlusal surfaces of applied at the margins of all restorations, and the patient was
the posterior teeth were in exposed dentin, selective etching asked to monitor his oral hygiene with increased frequency.
was done, where the enamel was etched for 15 seconds with Since parafunction was a part of the initial reported history,
37% phosphoric acid and the dentin was etched for 5 seconds. the patient was given an equilibrated maxillary occlusal splint
Dual-curing resin cement (Variolink N, Ivoclar Vivadent) was to prevent any ceramic chipping due to detrimental forces. The
used on the silanated intaglio of the restorations. The excess final photography was done two weeks after treatment, and the
cement was carefully removed from the gingival sulci and all patient was very pleased with the results (Figs 38-45). The case
the interproximal areas. Radiographs were taken to confirm has been followed up for 18 months and appears stable at this
removal of all residual cement. An occlusion check was then point in time (Figs 46 & 47).

62 2020 • Volume 36 • Issue 1

 Tunkiwala

Figure 38: Postoperative smile showing a good harmony Figure 39: Postoperative retracted 1:2 view with a
between the teeth and the envelope of the lips. beautiful perio-restorative harmony evident.

a b c

Figures 40a-40c: Postoperative frontal, right lateral, and left lateral retracted 1:2 views in maximum intercuspation.

a b

Figures 41a & 41b: Postoperative maxillary and mandibular occlusal views. Figure 42: Emergence of the final maxillary
anterior teeth.

Figure 43: Final mandibular anterior teeth depicting healthy Figure 44: Maxillary equilibrated Figure 45: Postoperative
dentogingival esthetics. occlusal splint to protect the layered portrait.
ceramic from chipping.

Journal of Cosmetic Dentistry 63

Figure 46: Smile at 18 months postoperative. Figure 47: Retracted view at 18 months, showing a stable short-
term result.

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