Full-Mouth Rehabilitation of A Severe Tooth Wear Case: A Digital, Esthetic and Functional Approach

CLINICAL RESEARCH
Full-mouth rehabilitation of a severe

tooth wear case: a digital, esthetic
and functional approach
Carlo Massimo Saratti, Dr med dent, MAS

Senior Lecturer, University Clinics of Dental Medicine, Division of Cariology and
Endodontology, University of Geneva, Switzerland
Carl Merheb, Med dent, MAS

Lecturer, University Clinics of Dental Medicine, Division of Cariology and Endodontology,
University of Geneva, Switzerland
Leonardo Franchini, CDT

Private Practice, Florence, Italy
Giovanni Tommaso Rocca, Priv-Doz Dr med dent

Senior Lecturer, University Clinics of Dental Medicine, Division of Cariology and
Endodontology, University of Geneva, Switzerland
Ivo Krejci, Prof, Dr med dent

University Clinics of Dental Medicine, Division of Cariology and Endodontology,
University of Geneva, Switzerland
Correspondence to: Dr Carlo Massimo Saratti

University of Geneva, University Clinics of Dental Medicine, Division of Cariology and Endodontics,
rue Lombard 19, Geneva 1205, Switzerland; Tel: 022 / 379 41 00; Email: carlo.saratti@unige.ch
242 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
SARATTI ET AL
Abstract these kinds of treatments. This article provides a step-

by-step documentation of a full-mouth rehabilitation
The proliferation of digital technology is progressively performed with a digital approach and additive CAD/
changing dentistry. Thanks to continual improvements CAM composite resin restorations. An innovative func-
in CAD/CAM devices and dental materials, it is possi- tional evaluation is also documented and discussed.
ble nowadays to carry out a treatment plan for oral The initial situation was assessed and compared with
rehabilitations with fully digital approaches and nonin- the rehabilitation project through a snap-on device.
vasive concepts. The availability of digital resources After the intraoral adjustment and validation, the final
allows clinicians to increase the predictability of en- rehabilitation was performed according to the infor-
hanced esthetics and good functional results. There is mation obtained in the provisional phase and digitally
an increasing number of patients today who are af- transmitted to the laboratory.
fected by excessive tooth wear and may benefit from (Int J Esthet Dent 2020;15:242–262)
The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020 | 243
CLINICAL RESEARCH
Introduction ade.7-12 Such protocols guide the clinician to

obtain a predictable result and a high suc-
Tooth wear is a multifactorial phenomenon cess rate in terms of esthetic and functional
due to the interaction of mechanical, chem- benefits for the patient. Moreover, the rapid
ical, and tribological factors that provoke ir- development of digital technologies in re-
reversible loss of dental hard tissue.1 Tooth cent years has increasingly opened up new
wear is commonly considered a physiologi- treatment modalities. This allows for better
cal process that occurs throughout life, but predictability and more trust in the analysis
in some cases it can accelerate and be- of the esthetic and functional aspects of the
come the cause of various patient com- case.
plaints such as tooth sensitivity or poor es- Case reports on full-mouth rehabilita-
thetics. tions that follow a fully digital workflow have
The etiology of the loss of hard dental been published.13,14 They present different
tissue may be multifactorial, combining dif- types of in-lab, chairside or mixed work-
ferent processes2 such as erosion (due to flows, proposing models of rehabilitation
acids), abrasion (a mechanical process in- with many clinical advantages. Although
volving foreign substances or objects), attri- knowledge of digital dentistry is still limited,
tion (defines wear through direct tooth-to- it is continually increasing in conjunction
tooth contact, and generally relates to with the evolution of digital technologies.
parafunctions such as bruxism), and abfrac- The same is true for CAD/CAM materials in
tion (loss of hard tissue in the cervical tooth the form of blocks or blanks that, from a
area due to tensile or compressive stress). mechanical point of view, are generally
Due to its etiology, excessive tooth wear is more resistant than their manually manu-
considered challenging by practitioners: it is factured counterparts.15-17
difficult to determine and eliminate its caus- This article presents a clinical case where
es successfully and permanently, especially a full-mouth rehabilitation was planned and
in the case of parafunctions.3,4 executed with an adhesive and no-prep ap-
Recently, a European consensus was proach using a fully digital workflow.
published on the management of severe
tooth wear cases.5 Although conventional Clinical report
prosthodontic treatments such as full
crowns with or without root canal treatment A 46-year-old male patient (Fig 1a to c) con-
(RCT) followed by post and cores still remain sulted with a group of microinvasive esthet-
the standard treatment, minimally invasive ic dentists at the dental clinic of the Univer-
or noninvasive approaches, complemented sity of Geneva as he suffered from a
by preventive measures, are recommended severely worn dentition. His main desire was
in this consensus. The treatment should be to improve his esthetic appearance as his
simple, stepwise, adjustable, repairable, and teeth were no longer visible when smiling.
cost effective. Contemporary adhesive tech- The patient also complained of biting diffi-
niques in conjunction with composite ma- culty due to his worn anterior teeth (Fig 1d
terials meet the requirements stated above to f). He reported good general health but
and allow for maximum preservation of the mentioned a past history of acidic alimenta-
remaining tooth structure.6 tion. A detailed discussion with the patient
Different minimally invasive and adhe- about his dietary habits revealed that the
sive clinical techniques have been well doc- dental hard tissue loss was mainly due to a
umented and described over the past dec- combination of abrasion, erosion, and attri-
SARATTI ET AL
a b c
d e
Fig 1 (a to f) Extraoral preoperative photographs.
CLINICAL RESEARCH
a b
c d
Fig 2
tion resulting from a history of bruxism. The ed fillings on teeth 17, 16, 15, 14, 24, 25, 26,
intraoral examination revealed a generalized 36, 37, and 45 as well as one old infiltrated
excessive loss of dental hard tissue, particu- amalgam restoration on tooth 27. The pa-
larly in the maxillary anterior teeth (Fig 2). tient was classified as having a high-risk level
The diagnosis of decay was also confirmed of decay (DMFT > 12). He did not show any
by radiographic analysis (Fig 3). The exces- signs of temporomandibular disorders and
sive tooth wear led to the exposure of den- did not complain of orofacial pain. Palpation
tinal tissue. The patient had previously had and auscultation of the temporomandibular
RCT on tooth 24 as well as caries activity: joints (TMJs) did not reveal any signs of
nine decayed primary teeth and old infiltrat- clicking.
SARATTI ET AL
Fig 3 Diagnosis of decay confirmed by the radiographic analysis.
Planning phase First, the patient received a professional

tooth cleaning and oral hygiene instructions.
The patient was classified as ACE class IV, All cavities were treated and the infiltrated
since there was extended dentin exposure fillings replaced. The exposed dentin was
on the palatal aspect and a loss of tooth covered following the principle of immedi-
length (> 2 mm), although there was a pres- ate dentin sealing (IDS). For these adhesive
ervation of facial enamel.18 The European procedures, the dentin was slightly ground
consensus guidelines for severe tooth wear5 with a multiblade tungsten carbide bur to
state that monitoring is the primary man- expose the fresh dentin. Then, an etch-and-
agement strategy in this situation, unless the rinse adhesive system (OptiBond FL; Kerr)
patient requests treatment. Preventive was applied, following the manufacturer’s
measures were given to the patient prior to instructions. A microhybrid composite resin
the treatment, and arrangements were (Tetric EvoCeram; Ivoclar Vivadent) was
made for monitoring. However, due to the used to cover the entire dentin area and fill
stabilization of the patient’s wear condition the mayor undercuts without provoking any
and his request for an esthetic and function- change to the occlusion (Fig 4). The irregu-
al rehabilitation, it was decided to imple- lar margins of enamel were then smooth-
ment restorative measures. ened.
CLINICAL RESEARCH
Following a fully additive approach, the

teeth were not prepared at all.
The digital collection of data started with
jaw movement tracking that was performed
with a kinesiographic computerized system
(BIO-key; Bioket) (see Figs 15 and 16). Opti-
cal impressions were taken with a Trios 4
(3Shape) intraoral digital scanner, and the
exported open STL files were transferred to
the dental technician.
A digital wax-up was planned with la-
boratory CAD/CAM dental design software
(Trios Design Studio; 3Shape). The main
planning guideline was to treat the case as
conservatively as was reasonably achievable
(Fig 5). Therefore, a no-prep approach was
Fig 4 Clinical session of caries treatment and immediate dentin sealing
procedure.
chosen, and an increase in the vertical
Fig 5 Digital impression and modelization (top); digital wax-up (middle); project analysis (bottom).
SARATTI ET AL
a b
Fig 6 (a to c) Milled snap-on tried on 3D-printed casts. (d) Anterior

view.
dimension of occlusion (VDO) was per- facial aspects, smile lines, gingival level, and
formed. The VDO augmentation was car- dental contours were checked. The inter-
ried out by increasing the incisal tip by 4 mm pupillary line was used as a reference to es-
on the digital articulator. This allowed for tablish the horizontal plane. Next, the mid-
the design of the anterior restorations to facial line was drawn, based on facial
obtain a correct natural width-length ratio. references such as the glabella, nose, and
Once the digital wax-up was accepted, it chin. The patient’s face was assessed and
was decided to test it in the mouth with an the length of the upper lip in a forced smile
additional mock-up and in the form of a was checked to determine the gingival
snap-on, which is a double-milled remov- characteristics. After this primary facial
able orthodontic appliance made of an elas- analysis, the occlusal plane, interocclusal
tic resin material (Multistratum Flexible A3; distance, and static and dynamic occlusion
Zirkonzahn) (Fig 6). were checked and adjusted.
The prosthetic project was evaluated A second jaw-tracking examination with
and the usual phonetic, functional, and es- the snap-on in place was performed (see
thetic analyses were carried out, as with a Figs 15 and 16) and the results were com-
traditional diagnostic mock-up (Fig 7). The pared with the initial situation. A few occlu-
CLINICAL RESEARCH
a b
Fig 7 (a to c) Mock-up performed with snap-on in mouth.
sal modifications were made on the snap- CAM composite resin blocks (Lava Ultimate,
on to obtain a jaw-tracking path as similar as 3M) were used to fabricate all the restor-
possible to the initial situation during the ations. After milling, their adaptation was
protrusive and lateral excursions without al- tested and verified on 3D-printed casts
tering the esthetic result. (Fig 8a to c). The anterior restorations (teeth
The patient went home with the snap-on 13, 12, 11, 21, 22, 23, 33, 32, 31, 41, 42, and
in place in order to try out the rehabilitation 43) were modified to improve their esthetic
from an esthetic and functional point of outcome, following the technical protocol
view. This was possible because such a de- described by Magne.19 The technique con-
vice can be used during mastication. The sists of a cutback of the buccal surface of
patient kept and used the snap-on for the anterior restoration (Fig 8c) and subse-
1 month. After validation, a new optical im- quent customization by manual stratifica-
pression was taken to transmit all the infor- tion of composite resin materials of varying
mation to the laboratory. shades and translucencies (Inspiro SW and
Following the validation of the digital blue effect; Edelweiss DR) (Fig 8e). A per-
project, full-coverage tabletops in the pos- sonalized characterization of the buccal
terior area and V-shaped or traditional ve- surface of tooth 36 was also proposed to
neers in the anterior area were milled. CAD/ the patient (Fig 8f).
SARATTI ET AL
a b
c d
e f
Fig 8 Laboratory phase: milled restoration from the occlusal view. (c) Milled restoration from the anterior view. (d) View of the
buccal cutback of the anterior restorations. (e) Final result after the procedure of stratification of the esthetic composite resin on the anterior
teeth, from teeth 13 to 23 and teeth 33 to 43. (f) Characterization of tooth 36.
CLINICAL RESEARCH
a b c
Fig 9 Step-by-step adhesive luting

procedure of posterior restoration on
quadrant 2.
d e
Restorative phase step of the procedure consisted of protect-

ing the adjacent teeth with metallic strips.
In the restorative phase, each quadrant was The surface of the tooth was first cleaned
treated separately. It was decided to rehabil- by sandblasting with 27 μm Al3O2 (Fig 9a). In
itate the posterior teeth first to obtain a sta- the next step, the enamel was etched with
ble occlusion. 37% orthophosphoric acid gel for 30 s
First, the overlays were tried in the pa- (Fig 9b). Thereafter, bonding resin was ap-
tient’s mouth to check the proximal contact plied to the conditioned surface with a mi-
surfaces and marginal fit. Next, adhesive crobrush for 15 s and spread with air for 5 s
conditioning of the restorations began by without light curing (Fig 9c). A sufficient
sandblasting the inner surface of each over- amount of preheated restorative light-cur-
lay with 27 μm alumina powder, followed by ing hybrid composite resin (Tetric EvoCer-
the application of silane (Monobond Plus; am) was spread on the entire surface of the
Ivoclar Vivadent) for 60 s, which was dried preparation. The composite overlay was set
with compressed air. Finally, bonding resin manually and then pressed into the defini-
adhesive (OptiBond FL) was applied for 20 s tive position with an ultrasonic plastic tip
and thinned out without being polymerized. (Fig 9d). Excess luting composite was re-
The restorations were kept away from ambi- moved with a periodontal probe and floss
ent light to avoid the premature curing of (Oral-B SuperFloss; Procter & Gamble) in
the bonding resin. the interdental area. Full polymerization was
After isolation of the operatory field with achieved by light curing with a powerful
rubber dam, adhesive procedures were per- LED unit for at least 60 s per cured surface
formed on each tooth separately. The first (occlusal, buccal, and palatal). Once the lut-
SARATTI ET AL
a b
c d
Fig 10 (a to d) Adhesive luting phases of the anterior restorations.
ing was completed, the restoration margins (Fig 10). Major undercuts were previously
were finished and polished. Next, the rubber filled during the IDS procedure (see above).
dam was removed from the quadrant being The remaining minor undercuts were man-
treated, and the same luting procedure was aged and filled during the adhesive phases
followed to restore the remaining three using composite resin as a cement. The
quadrants (Fig 9 e). Once all the posterior same procedure and strategy were per-
restorations were luted at the end of the ap- formed on the mandibular anterior teeth.
pointment, the static and dynamic occlu- The restorations were finished and pol-
sion were checked. After some minor ad- ished and the occlusion checked. After
justments, the patient went away with stable some minor adjustments, the rehabilitation
posterior contacts and an open anterior phase was completed. Three months after
bite. the end of the treatment, final intraoral
The digitally milled snap-on used as a (Fig 11) and extraoral (Fig 12) photographic
mock-up was modified to be used as a pro- documentation and radiographic control
visional by slicing it distally to the canines. (Fig 13) were performed. Finally, an optical
The same luting procedure was applied impression was taken, according to the pre-
on the anterior restorations the following viously mentioned European consensus
day. After rubber dam isolation, luting start- management guidelines for severe tooth
ed with teeth 11 and 21 in order to obtain a wear,5 and the patient was given a protec-
correctly positioned midline. Luting was tive night guard. Due to the high caries risk
then applied to the neighboring teeth in a that had been assessed, the patient was in-
symmetrical manner until all the maxillary structed and motivated in correct dental hy-
restorations were adhesively bonded giene procedures (brushing and flossing).
CLINICAL RESEARCH
a b
c d
Fig 11 (a to e)
Posttreatment
intraoral photo-
graphs.
SARATTI ET AL
a b c
d e
Fig 12 (a to f) Posttreatment extraoral photographs.
CLINICAL RESEARCH
Fig 13 Posttreatment radiographs.
He also entered a 6-month recall program sult obtained was stable from a functional
with a dental hygienist for regular cleaning and an esthetic point of view.
and interproximal and palatal/lingual fluor- Since the patient did not stop smoking,
ide (Duraphat; Colgate) varnish application. some staining appeared in time, but this was
A last jaw-tracking examination was per- easily removed during standard professional
formed (Figs 15 and 16), which was then cleaning. Figure 14 shows the 15-month
compared with other registrations. The re- postoperative control.
SARATTI ET AL
a b
c d
Fig 14 (a to e)
15-month postopera-
tive control.
CLINICAL RESEARCH
Fig 15 Kinesiographic evaluation of open/close and protrusive movements: pretreatment (left); with the snap-on (middle); and post-
treatment (right).
Discussion ical context and the financial affordability of

the rehabilitation for the patient. The avail-
This clinical case of a full-mouth rehabilita- able clinical studies and case reports indi-
tion was performed by applying minimally cate that modern composite resins perform
invasive concepts and using no-prep adhe- well in patients affected by severe tooth
sive restorations that allowed for the preser- wear.21,22 When compared with other CAD/
vation of the natural dental hard tissue. CAM resin blocks, Lava Ultimate showed
The choice of the most appropriate re- the highest mechanical properties in terms
storative material in rehabilitations of severe of tooth wear and flexural strength.23,24
tooth wear cases is still an open discussion Moreover, Wendler et al25 recently reported
in the literature. A recent systematic review unexpected data about this material: even
concluded that there is no strong evidence though its mechanical properties evaluated
to suggest that any one material is superior in a static test were lower than the ceramic
in cases of severe tooth wear.20 In these cas- equivalents, its stress tolerance to dynam-
es, the choice is made according to the clinic loading was surprisingly high and at the
SARATTI ET AL
Fig 16 Kinesiographic evaluation of lateral movements: pretreatment (top left); with the untouched snap-on (top right); with the modified
snap-on (bottom left); and posttreatment (bottom right).
same level as that of a disilicate-reinforced sults from their intrinsic monochromaticity.

ceramic. This mechanical aspect is particu- Even though the level of translucency is
larly interesting for treating a parafunctional high in the material chosen for the present
patient with severe tooth wear in view of restoration, that alone might not have been
the high level of cyclic stress that occurs enough to achieve a natural tooth appear-
due to repeated episodes of parafunction. ance in the anterior region.27 This problem
Another advantage of this material resides was overcome by manually stratifying com-
in its reparability: parafunctional cases may posite resins of different shades and translu-
require interventive maintenance care, eg, cencies on the labial area of the anterior
the repair of chipping in the esthetic area. restorations, thus improving the esthetics
Such interventions are easily realizable with without affecting the mechanical resistance
a composite resin material.26 of the incisal area of the restorations.
The main problem with CAD/CAM To date there is no clear evidence sup-
blocks, whether composite or ceramic, is porting a possible pathological conse-
the unnatural esthetic appearance that re- quence of VDO augmentation, even if some
CLINICAL RESEARCH
authors have expressed concerns about this 4. No pain was evoked during maneuvers
procedure.28 A recent review by Abduo29 of palpation of any masticatory or neck
showed that an increase in VDO of up to muscles.
4 mm is predictable and safe. In cases of
severe tooth wear, VDO augmentation cre- The functional analysis of the rehabilitation
ates space, allowing the clinician to adopt a was supported by kinesiography before the
noninvasive approach to save as much nat- treatment, during the planning phase, and
ural dental hard tissue as possible. at the end of the restorative phase (Figs 15
To avoid any doubts in the present case, and 16). Kinesiography is a 3D tracking and
the new jaw position was tested for 1 month reconstruction analysis of jaw movement
with a snap-on, which turned out to be a that is both qualitative and quantifiable and
useful device to test this type of additive re- which expresses the muscular coordination
habilitation. A snap-on is prepared for both during mastication.30 Modification of the
jaws, maxilla and mandible, and is held in VDO automatically results in a variation of
place by the natural undercuts of the tooth dental guidance, which consequently
anatomy. This simple retention is possible changes the patterns of protrusive and later-
thanks to the elastic properties of the select- al movements. However, on the basis of the
ed material. Given its higher flexibility, it is pretreatment functional considerations, and
less susceptible to fracture and more resist- following the principles of minimally inva-
ant to flexural stress. Also, it can be milled sive dentistry, the kinesiography was intend-
following a very thin design. The main bene- ed to maintain the mandibular motoric
fit of a snap-on is its ability to meet esthetic scheme as closely as possible to the initial
and functional expectations, both in terms situation.
of practicability for the clinician and comfort Maximum open/close movements did
for the patient. Snap-ons, which are modifi- not undergo radical modifications, but a late
able with simple adjustments and adhesive right deviation present in the initial situation
procedures, allow for corrections to be disappeared after the end of the treatment.
made to shade, shape, and tooth position. A minor reduction of the maximum extent
In the present case, the snap-on allowed for of the movement of 0.5 cm was considered
the testing of the new VDO for a period of to be related to the space occupied by the
time, which achieved a high level of predict- thickness of the restorations. Thanks to the
ability for the permanent rehabilitation. restored length of the anterior teeth, the
Despite severe tooth wear, the patient protrusive movement found a new anterior
presented in good health from a functional guidance that had been lost for many years.
point of view: The marked deviation on the left side that
1. He did not complain of any masticatory was present before the treatment com-
problem; despite not being able to bite pletely disappeared at the end of the treat-
with his anterior teeth due to the lack of ment, most probably thanks to the aug-
contacts, his jaw movements were free mented proprioceptive sensibility that
with large extensions. resulted from the new anterior guidance. In
2. He neither showed nor complained of laterotrusion, the dental guidance angle
any kind of symptom, orofacial pain, (visible on the frontal plane of the kinesiog-
headache or neck muscle pain. raphy) looked almost flat from the frontal
3. No clicking was noticed during ausculta- plane before the treatment and presented a
tion of the TMJ, nor was any anatomical symmetrical pattern between the right and
anomaly noticed. left sides. As the snap-on reproduces the
SARATTI ET AL
occlusal contours of the digital wax-up, it sive component during the first third of the
reflects not only the newly defined bite but lateral’s excursions. The clinical feedback
also the newly designed dynamic occlu- from the patient was that he found the flat-
sion, allowing for an interactive functional ter lateral guidance configuration more
examination. Slight modifications were per- comfortable.
formed on the lateral guidance of the snap-
on to obtain a flatter angle that was closer Conclusions
to the initial situation. The canine guidance
became a group guidance function (the sit- The available literature on the restorative
uation before the treatment), and the es- management of severe tooth wear lacks a
thetic outcome of the canines was slightly robust body of high-level evidence. This
sacrificed by reducing their length. Interest- case report shows that a complex clinical
ingly, an immediate modification of the pat- situation of severely worn dentition can be
tern of movement in the horizontal plane managed with a fully digital workflow,
(ie, not only in the frontal plane) was no- which simplifies the clinical procedure and
ticed: lateral movements were more anteri- allows for good, predictable functional and
orized, with flatter lateral guidance com- esthetic results. Further clinical studies and
pared with deeper angled guidance. There monitoring should be conducted to deter-
is scarce information in the literature on the mine both the long-term prognosis of this
clinical interpretation of kinesiographic kind of treatment and the clinical relevance
analyses. However, observations in the pres- of the kinesiographic analysis. Deeper in-
ent case concord with the results of a study vestigation in this regard should provide in-
by Papini et al,31 where an increased inclina- formation that would allow this type of
tion on the frontal plane of the lateral guid- analysis to be better interpreted and under-
ance corresponded to an augmented retru- stood.
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Full-Mouth Rehabilitation of A Severe Tooth Wear Case: A Digital, Esthetic and Functional Approach

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CLINICAL RESEARCH

Full-mouth rehabilitation of a severe

Carlo Massimo Saratti, Dr med dent, MAS

Carl Merheb, Med dent, MAS

Leonardo Franchini, CDT

Giovanni Tommaso Rocca, Priv-Doz Dr med dent

Ivo Krejci, Prof, Dr med dent

Correspondence to: Dr Carlo Massimo Saratti

Abstract these kinds of treatments. This article provides a step-

Introduction ade.7-12 Such protocols guide the clinician to

Fig 1 (a to f) Extraoral preoperative photographs.

Fig 3 Diagnosis of decay conﬁrmed by the radiographic analysis.

Planning phase First, the patient received a professional

Following a fully additive approach, the

Fig 6 (a to c) Milled snap-on tried on 3D-printed casts. (d) Anterior

Fig 7 (a to c) Mock-up performed with snap-on in mouth.

Fig 9 Step-by-step adhesive luting

Restorative phase step of the procedure consisted of protect-

Fig 10 (a to d) Adhesive luting phases of the anterior restorations.

Fig 12 (a to f) Posttreatment extraoral photographs.

Fig 13 Posttreatment radiographs.

Discussion ical context and the ﬁnancial affordability of

same level as that of a disilicate-reinforced sults from their intrinsic monochromaticity.

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