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The Open Dentistry Journal

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CASE REPORT

Digital Full-mouth Rehabilitation for Complex Cases Involving Severe Deep

Overbite and Worn Dentition: A Case Report
Pooya Jannati1 , Kelvin I. Afrashtehfar2,3,* , Faranak Vakili1 and Marzieh Alikhasi4,*
1
Department of Prosthodontics, School of Dentistry, Bandar Abbas University of Medical Sciences, Bandar Abbas, Iran
2
Clinical Sciences Department, College of Dentistry, Ajman University, Ajman City, UAE
3
Department of Reconstructive Dentistry & Gerodontology, School of Dental Medicine, University of Bern, Berne, Switzerland
4
Dental Research Center, Dentistry Research Institute, Tehran University of Medical Sciences, Tehran, Iran

Abstract:
Introduction:
The demand for aesthetic restorations in dentistry has led to full-mouth reconstructions or rehabilitations (FMRs) as a viable solution for treating
patients with worn and altered teeth. This study presents a clinical case report of a middle-aged patient with severe tooth wear and deep overbite
with digital workflows.

Case Presentation:
The case report highlighted the successful application of digital technology in the comprehensive rehabilitation of a patient with worn dentition,
showcasing improved esthetics, function, and patient comfort. The case report demonstrated the potential benefits of this rapid approach in
achieving successful outcomes. Digital CAD/CAM technology is a solution for optimizing the prosthetic workflow, achieving time and cost
efficiency, and delivering high-quality dental restorations.

Conclusion:
Future primary studies with larger sample sizes and longer follow-ups can further validate the FMR digital approaches.

Keywords: Tooth wear, Tooth erosion, Vertical dimension, Computer-aided design, Computer-aided manufacturing, Digital technology.

Article History Received: May 19, 2023 Revised: July 24, 2023 Accepted: August 17, 2023

1. INTRODUCTION The management of worn dentition can range from

Tooth wear is a phenomenon characterized by tooth preventive and localized treatments to full-mouth rehabilitation
surface loss (TSL) without bacterial infection and can have (FMR) based on the severity of the condition [6]. FMR
either physiological or pathological origins [1]. While presents a significant challenge for dental practitioners,
physiological tooth wear occurs gradually with age, requiring a reliable and predictable workflow. Integrating
pathological wear, such as attrition, abrasion, abfraction, and computer-aided design/computer-assisted manufacture (CAD/
erosion, is often multi-factorial in nature and can be CAM) technology, advanced ceramic materials, and adhesive
challenging to isolate a single etiological factor in clinical cementation offers a reliable approach to FMR [7, 8].
presentations of worn dentition [2 - 4]. The term 'tooth surface Conventional FMR techniques are often time-consuming,
loss' was proposed by Eccles in 1982 to encompass all causes requiring numerous clinical appointments and laboratory
of wear regardless of their identification [2 - 4]. Severe tooth procedures, with the risk of errors in each step potentially
wear can result in both esthetic and functional problems, necessitating repeat treatment. Digital advances in intraoral
including decreased vertical dimension of occlusion (VDO) scanners (IoS) and laboratory scanning, as well as intuitive
[5]. software design, have greatly improved the speed and accuracy
of CAD/CAM fabrication processes.
* Address correspondence to these authors at the Artificial Center Research
Center (AIRC), Ajman University, Ajman City, UAE; and at the Dental Research The use of virtual on-screen designing and CAM with
Center, Dentistry Research Institute, Tehran University of Medical Sciences,
Tehran, Iran; E-mails: [email protected] (K.I.A.) and rapid prototyping options such as milling (s-CAM) or printing
[email protected] (M.A.) (a-CAM) allows for the efficient production of various

DOI: 10.2174/0118742106263229230926041533, 2023, 17, e187421062309130

2 The Open Dentistry Journal, 2023, Volume 17 Jannati et al.

restorations without physical models. The utilization of adjusted using a flowable composite (G-aenial, GC, Tokyo,
CAD/CAM technology enhances the predictability and Japan), where the reference was the lip level (Fig. 2A). To
reliability of FMR while reducing treatment duration and analyze vertical dimension, phonetics, facial profile, and
appointments/steps [9]. This clinical report outlines the interocclusal space were evaluated. The vertical dimension of
application of a digital approach in a full-mouth rehabilitation rest (VDR) was approximately 5 mm from the VDO. Lucia jig
procedure for a patient with severe deep bite occlusion and was made (GC Resin Pattern, GC, Japan). After several
extensive tooth surface loss. minutes and deprogramming of the muscles, the centric
relation (CR) was recorded by injecting posterior bite
2. CLINICAL CASE REPORT registration (Granit, Mueller Omicron Dental, Lindlar,
A 45-year-old male patient was referred to the Germany) in the newly defined vertical dimension (VDR –
Prosthodontics Department at the Dental College to treat his VDO = 2). The first impressions were made using one-step
worn dentition. The patient presented with chief complaints of putty/light-body silicon impression material (Speedex, Coltene,
tooth surface loss (TSL), reduced chewing ability, and mild Altstätten, Switzerland), which served as a diagnostic cast. The
esthetic concerns, particularly regarding shade. The medical ear-bow (Spring-bow Hanau earpiece facebow, WhipMixCorp,
history was unremarkable, with no indications of Kentucky, United States) record was determined for mounting
temporomandibular joint disorder (TMD), except for excessive on the Hanau semi-adjustable arcon articulator (Hanau Wide-
consumption of lemon and vinegar related to a pre-diabetes Vue Arcon 183-2, WhipMixCorp, Kentucky).
condition. Intraoral examination revealed a two-surface Based on the earbow record, the maxillary cast was
amalgam filling on the left second molar and composite resin mounted on the articulator (Hanau Wide-Vue Arcon 183-2,
fillings on the right first premolar, right second premolar, and WhipMix Corp, Kentucky, United States). Then, the
right first molar. Abfraction was observed in several teeth of mandibular cast was mounted against the maxillary cast using
varying severity, with mild abfraction in all posterior teeth the jig and the CR record (Fig. 2B). The Broadrick flag was
except for the right first and second molars, which showed used to estimate the posterior plane on each side. The wax-up
moderate abfraction. The patient's occlusion was classified as procedure was done based on the defined occlusal plane, and
Class II division 2 with a deep bite. All teeth displayed worn the putty index (Speedex, Coltene, Switzerland) was prepared
incisal/occlusal surfaces, exposing dentin in the maxillary intraorally for the mockup process.
central incisors, and limited to enamel in the maxillary
premolars and most areas of the mandibular premolars (Fig. 1).
The extraoral examination showed a square, symmetrical face,
a slightly shorter lower third, and competent lips. The pattern
of worn dentition did not match the opposing teeth, indicating
that the cause of TSL was not solely due to parafunctional
habits but may also have been a result of a chronic erosion
progression exacerbated by job-related stress.

Fig. (2). (a) Lower incisal plane is mock-up with flowable composite
and verified (b), Centric relation record using anterior jig.

The mockup was made with a bis-acrylic composite-based

temporary material (Teco, Tecodental, New York). Face
profile, smile, phonetics, and freeway space were examined
after occlusal equilibration and adjustments, and minor esthetic
modifications were made. Based on the mockup, the treatment
planning was designed (full-coverage crowns: teeth #6, 7, 8, 9,
10, 11, and 28; laminate veneers: teeth #22, 23, 24, 25, 26, and
27; vonlay: teeth #4, 5, 12, and 13; overlay: teeth #3, 18, 19,
20, 21, 28, 29, and 30). Teeth #2, 14, and 15 were excluded
from the treatment planning and were left intact since they
Fig. (1). Intraoral examination of the initial scenario displaying worn provided stable holding contacts after a slight enameloplasty.
incisal/occlusal surfaces. (a) Maxillary arch (b), Mandibular arch (c), Due to the presence of generalized TSL and the need to restore
Exposed dentin in most inciso-labial and occlusal surfaces of most posterior teeth to cover exposed dentin areas, establish
mandibular teeth. stable occlusal contacts, create appropriate buffer space, and
correct the deep curve of Spee, we were advised against
The incisal level of the mandibular anterior teeth was utilizing the Dahl appliance. Despite being recognized as one
Full-mouth Rehabilitation of a Complex Case The Open Dentistry Journal, 2023, Volume 17 3

of the most conservative approaches in full-mouth The STL (Standard Tessellation Language) and PLY
rehabilitation (FMR), its application was cautioned against in format (Polygon File Format) files were extracted and sent to
this particular case [10]. The mockup was removed from the the laboratory. The finish lines were determined. Then, the
patient’s mouth after he approved it, followed by finishing and mockup, occlusion, and preparation STL files were
polishing with discs (3M Sof-Lex, 3M, Minnesota, US). A superimposed on the corresponding prepared arch (Figs. 3B,
flowable composite (G-aenial, GC, Tokyo, Japan) was used for 3C and 3D). These data were used to assess the final smile line
cementing them as a temporary restoration for follow-up newly using digital smile design (DSD) software (Digital smile
established VDO. Then, the patient's condition was assessed design, Madrid, Spain). The restorations’ shape and
regarding the temporomandibular joint (TMJ) and muscle occlusal/incisal level were estimated and used for designing
comfort, phonetics, chewing ability, and esthetics for four
resin patterns (Detax, Ettlingen, Germany). Finally, resin
weeks.
patterns and Geller casts (Longer blue modeling resin,
The mockup of each jaw and the occlusion were scanned. Longer3d, China) were printed (a-CAM) (Asiga, Sydney,
The putty index was determined for tooth preparation. The Australia) (Figs. 3E and 3F).
anterior temporary restorations were removed. The maxillary
Resin patterns were assessed intraorally. After verifying
and mandibular anterior tooth preparations were performed
using a round-end cylindrical bur (Jota, Rüthi, Switzerland) the adaptation and proximal contacts, occlusion adjustment was
based on the putty index. The occlusal clearance was assessed made in eccentric and centric movements. Face profile, smile
considering the posterior temporary restorations. After line, phonetics, and freeway space were examined, and minor
completing the anterior preparation, a new anterior jig was esthetic modifications were made with the patient’s approval.
made as the anterior stop, maintaining the VDO. Retraction Resins were sent to the laboratory to fabricate injectable resin
cords #00 (EasyCord, Mueller Omicron Dental, Lindlar, patterns (Resione c01 transparent castable dental resin,
Germany) were used for gingival retraction for the crowns’ and Resione, Guangdong, China) and accomplish the heat-press
at the gingival vonlays’ finish-line preparations. Both prepared process (Programate p3010, Ivoclar, Vaduz, Lichtenstein). The
arches and occlusion with the anterior jig were scanned with contouring process and staining (Ivoclar, Lichtenstein) on the
IoS (Medit i500, MEDIT Corp., Seoul, South Korea) (Fig. 3A). Geller cast were done.

(a) (b)

(c) (d)

(e) (f)

Fig. (3). (a) Preparation scan (b), Maxillary prepared teeth and temporary restorations superimposition, using anatomic landmarks (c), Mandibular
prepared teeth and temporary restorations superimposition, using anatomic landmarks (d), Maxillary and mandibular superimposition (e), Resin
patterns design (f), Resin patterns printed and ready to try-in.
4 The Open Dentistry Journal, 2023, Volume 17 Jannati et al.

Pressed monolithic lithium disilicate glass-ceramic

(Ivoclar, Lichtenstein) with a staining technique was chosen for
all restorations. The A1 shade (VITA) was selected after
consulting with the patient in standard light conditions and
considering patient’s skin color and age. Based on the patient's
history and considering the comparative durability of dental
ceramics, we decided against using direct composite resin,
despite some studies advocating it as a conservative technique
[11, 12].

Fig. (4). (a) Intraoral frontal view of occlusion (before) (b), Intraoral
frontal view of occlusion (resin patterns try-in) (c), Intraoral frontal Fig. (5). (a) Smile view of patient profile (before) (b), Smile view of
view of occlusion (final restorations). patient profile (after).

How can a full-mouth rehabilitation (FMR) be done in few appointments for complex patient cases with severe
deep bite and extensive tooth loss?
Materials and Methods Findings

A MEDLINE search was conducted in 2023.

Clinical evaluation and diagnosis of the patients dental
Limited to English language articles published from 2016 condition.
to 2022.
Develop a comprehensive treatment plan.
Included reviews, guidelines, observational studies, and
case reports/series. Select monolithic lithium disilicate glass- ceramic
restorations.
Selection done by two reviewers with disagreements
resolved by a third. Use digital workflows (CAD/CAM) for accurate and
predictable fabrication.
Conclusion: FMRs of complex, severe tooth wear cases Reference: Jannati P, Afrashtehfar KI, Vakili F, Alikhasi M.
can be conservatively restored in 5 appointments thanks Digital Full-Mouth Rehabilitation in Severely Overlapped
to the available digital technologies. and Worn Dentition: A Five-Session Approach for
Complex Cases. The Open Dentistry Journal 2023.

Fig. (6). Graphical abstract of the article.

After assessing the restorations' adaptation, adjusting the Schaumburg, IL, USA), and 6th generation dentine bonding
proximal and occlusal contacts, and confirming the form and agent (Clearfil SE BOND, Kuraray, Tokyo, Japan),
shade with the patient, the adjusted areas for restorations were respectively, for teeth with dominant enamel and dominant
finished and polished, and the cementation process started. The dentin. Considering the restoration thickness, the light-cure
ceramics surface treatment was done with 20s hydrofluoric cement (Choise2 Trans, Bisco Schaumburg, IL, USA) was
acid 5% (Porcelain Etchant, Bisco Schaumburg, IL, USA), 30s
selected in the esthetic areas. A dual-cure cement (Duo-Link
phosphoric acid 37%, (Etch-37, Bisco Schaumburg, IL, USA),
Universal, Bisco Schaumburg, IL, USA) was selected where
and silane (Bis-Silane, Bisco Schaumburg, IL, USA),
respectively. Under isolation with a rubber dam (Nic Ton,
the restorations were thicker (Figs. 4 and 5). The STL file of
Bucharest, Hungary), surface treatment of the prepared tooth final restorations was used for stabilization appliance
was done with pumice powder (Kemdent, Swidon, United fabrication with clear resin (Detax, Ettlingen, Germany) and
Kingdom), Al2O3 air-abrasion (Parkell, New York) (5s, 3D printer (Asiga, Sydney, Australia) since there was no need
10mm, on exposed dentin), 20s phosphoric acid 37% (on to adjust the maxillary restoration during the occlusal
enamel), 5th generation bonding (All-Bond3, Bisco equilibration.
Full-mouth Rehabilitation of a Complex Case The Open Dentistry Journal, 2023, Volume 17 5

3. DISCUSSION HUMAN AND ANIMAL RIGHTS

This case report focused on the treatment procedure of a Not applicable.
patient who suffered from pathologic deep overbite (i.e.,
vertical overlap) and TSL in 5 appointments. Due to the CONSENT FOR PUBLICATION
presence of CAD/CAM technology for the clinician and Informed consent was obtained from the patient.
technician, these cases can be treated in fewer sessions with
more precise and predictive occlusion and esthetics [2, 13]. STANDARDS OF REPORTING
Patient’s comfort, ease of making and restoring working casts,
even Geller casts, superimposing details of confirmed mockup CARE guidelines were followed.
on prepared teeth, transferring the new determined VDO from
AVAILABILITY OF DATA AND MATERIALS
mockup to final restorations precisely with minimum occlusal
adjustments, facilities the treatment procedure and results in The data that support the discussion of this work are
fewer clinical and laboratory steps. available from the corresponding authors, [M.A. and K.I.A.],
upon reasonable request.
Obtaining esthetics in a monolithic restoration requires an
experienced technician for detailed staining. The final shade
FUNDING
and translucency of ceramic restorations can be significantly
influenced by the type of material, cement, and substrate. In the None.
present case, there was no discoloration in patient’s teeth and a
satisfying and vital final shade was obtained using translucent CONFLICT OF INTEREST
cement under monolithic restoration. From the perspective of The authors declare no conflict of interest, financial or
color stability, lithium disilicate is less susceptible [14 - 17]. otherwise.
By this pathway, omitting porcelain layering steps and multiple
and miscellaneous clinical try-in appointments, besides the ACKNOWLEDGEMENTS
optimal performance of monolithic restorations in an oral
Declared none.
cavity environment, make way for quick treatment procedure
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