Restoration of severely worn teeth

Modern treatment approaches together with the adhesive bonding technique and state-of-the-art restorative materials enable dental practitioners to significantly reduce the removal of healthy dental hard tissue. This case report describes the complex restoration of several defects in the tooth structure of a young patient using all-ceramic and composite materials. In this case, the patient, dentist and dental technician collaborated very closely in order to draw up a detailed treatment plan which was fastidiously implemented. A wax-up and a diagnostic template as well as modifiable temporary restorations immensely facilitated communication, decision-making and the subsequent preparation work.

Pre-operative situation

A 28-year-old patient wished to improve the appearance of his front teeth. He complained about hypersensitivity while eating. In addition, he had noticed that his teeth were showing increasing wear. In fact, the damage was so severe that the function of the dentition was already impaired (Fig 1).

Treatment plan

Before the treatment plan was finalized, all the old fillings were replaced with composite restorations (Tetric EvoFlowR/Tetric EvoCeramR, Syntac) using the adhesive bonding technique. Furthermore, the severely damaged endodontically treated tooth 11 was built up with a glass-fibre post (FRC PostecR Plus, VariolinkR, Syntac). This enabled the treatment team to obtain a clear picture of the size of the defect, the condition of the abutments and the amount of remaining enamel.

After the technical and clinical analysis as well as the evaluation of alternative restorative options, the treatment team and the patient decided on the following treatment plan:

1. Fabrication of an analytical wax-up for the reconstruction of the aesthetics and function as well as for the creation of a diagnostic template

2. Determination of the most suitable restorative materials (direct or indirect) and the corresponding preparation forms

3. Transfer of the information about the required increase of the vertical dimension gained with the waxup to an occlusal appliance (wearing time of at least four weeks)

4. Preparation of the affected teeth using the diagnostic template as a guide and recording of the maxillo-mandibular relationship (split registration) as well as placement of the temporary restoration fabricated according to the wax-up in one appointment

5. Trial wearing of the temporary restorations and application of any adjustments

6. Impression-taking and prompt lab-fabrication of the restorations

7. Try-in and permanent placement of the all-ceramic restorations

8. Restoration of the lower front teeth with composite materials

Preliminary treatment and preparation

The pre-treatment phase started with the patient having to wear an occlusal applicance in the lower jaw for a four-week period. In this step, the vertical dimension was adjusted in accordance with the information gained from the wax-up. The correct relationship between the length and width of the upper anterior teeth was restored.

Furthermore, the diagnostic template which had been fabricated on the basis of the wax-up enabled the patient to obtain a first impression of the treatment goal (Fig 2).

This template served as a guide throughout the treatment and as an orientation aid during the preparation phase. As a result, very little of the tooth structure had to be removed, in accordance with the intended outer contours of the restorations. All the teeth were prepared and the maxillomandibular relationship was recorded in the same appointment. A crown (11) and several veneers had to be placed in the upper anterior jaw. The treatment team decided to useglass-ceramic occlusal veneers (also called “tabletops”) to restore the posterior teeth (Figs 3to5). All the all-ceramic restorations were fabricated with materials from the IPS e.maxR system. The minimum thickness for the pressed lithium disilicate ceramic “tabletops” was defined as 1mm. These restorations were fabricated with highly translucent ingots (IPS e.max Press HT) using the staining technique.

Temporary restorations

The temporaries were fabricated chairside with the help of the multi-use diagnostic template and a Bis-GMA-based temporary restorative material. In order to enhance the aesthetics of the upper anterior temporaries, a light-curing translucent composite (Tetric EvoCeramR, Shade T) was loaded in the incisal edge area of the template. In the posterior region, the minimally retentive temporary onlays were left splinted. The chairside temporaries were placed with a bonding agent (Heliobond), without prior etching of the tooth structure.

Try-in and incorporation

The restorations were tried in with a tooth-coloured glycerin gel (Try-in Paste, VarionlinkR Ⅱ and Variolink R Veneer) to inspect their shape and shade. The marginal seal was examined and the static and dynamic occlusal contacts were carefully checked for the first time with the help of a Low-viscosity addition silicone.

Prior to their permanent placement, the inner surfaces of the glass-ceramic restorations were etched with hydrofluoric acid (＜5% IPS Ceramic Etching Gel) for 20 secondsand subsequently conditioned with silane (Monobond-S). The Syntac dentin adhesive system was used on the teeth. The glass-ceramic anterior crown on tooth 11 was seated with a dual-curing, low-viscosity luting composite (Variolink Ⅱ Base and Variolink Ⅱ Catalyst, Shade 110). All the veneers and the prepared onlays were placed with either Variolink Ⅱ Base or Variolink Veneer and the luting composites were light cured. A high-performance curing light (new bluephaseR with ＞ 1200 mW/cm2 was used for the final light-cure(Figs 6 and 7).

After the glass-ceramic restorations had been placed and the fine adjustment of the occlusion made, the lower anterior teeth were built up with a highly aesthetic matching composite system (ArtemisR Professional Set) (Figs 8 to 11 ). The result of the restorative work fully satisfied the aesthetic expectations of the patient (Fig 12).

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