Tooth Wear - Unlocked

Didier DIETSCHI
DIETSCHI T O O T H W E A R
Carlo Massimo SARATTI
Serge ERPEN
Interceptive treatment approach
TOOTH WEAR
with minimally invasive protocols
ISBN 978-1-78698-115-8
www.quintessence.publishing.com
Success is not final, failure is not fatal; it is the courage to continue that counts.
― Winston Churchill
TOOTH WEAR
Interceptive treatment approach with minimally invasive protocols
Didier DIETSCHI
Serge ERPEN
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TOOTH WEAR
Interceptive treatment approach with minimally invasive protocols
Didier DIETSCHI
DMD, Privat-Docent, University of Geneva, Switzerland
PhD, Academic Centre for Dentistry in Amsterdam (ACTA), Netherlands
Honorary Professor, Ukrainian College of Medicine
Private Education Center & Clinic, The Geneva Smile Center, Geneva, Switzerland
Coauthors
Lecturer, Department of Cariology and Endodontics, School of Dentistry,
University of Geneva, Switzerland
Serge ERPEN
CDT
Oral Pro Dental Laboratory, Geneva, Switzerland
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Contributions by
Tony ROTONDO
DMD, University of Queensland, Brisbane, Australia
Certificate of Prosthodontics, UCLA, Los Angeles, California, USA
Rotondo Clinic and Education Center, Brisbane, Queensland, Australia
Roberto SPREAFICO
MD, University of Torino, Italy
DMD, University of Geneva, Switzerland
Honorary Professor, University of Buenos Aires, Argentina
Private practice, Busto-Arsizio, Italy
Romain CHERON
DMD, University of Paris, France
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Contributions by
Leonardo FRANCHINI
CDT
Dental Laboratory, Florence, Italy
Renan BELLI
DDS, MSc, PhD, Federal University of Santa Catarina, Brazil
DMD, Privat-Docent, Friedrich-Alexander-University Erlangen-Nuremberg, Germany
Associate Scientist at Laboratory for Dental Biomaterials Research, Friedrich-Alexander-University
Erlangen-Nuremberg, Germany
Stefano ARDU
DMD, Privat-Docent, University of Geneva, Switzerland
Senior Lecturer, Department of Cariology and Endodontics,
University Clinics of Dental Medicine, University of Geneva, Switzerland
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VI
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Author
Didier Dietschi
Dr Didier Dietschi graduated from the University of Geneva Dental School, Switzerland, in
1984, where he completed specialty training in periodontology and restorative dentistry.
He held the positions of assistant, lecturer, and senior lecturer at the same university,
where he received his doctoral title in 1988 under the supervision of Prof Jacques Holz
and a Privat-Docent degree in 2004. He earned his PhD in 2003 at the Academic Centre
for Dentistry in Amsterdam, Netherlands, under the guidance of Prof Carel Davidson. In
1990, he started a part-time practice in a private clinic in Geneva limited to esthetic re-
storative dentistry with a focus on soft tissue management and implantology. Since 2005,
he has held the position of adjunct professor at Case Western Reserve University (USA)
and maintained his part-time senior lecturer position at the University of Geneva in the
Department of Cariology and Endodontics headed by Prof Ivo Krejci.
Dr Dietschi has won numerous awards for his contributions to adhesive restorative
dentistry. He is an active lecturer author, journal reviewer, and industry consultant and
has contributed to significant improvements in the field of composite shading with
the development of the so-called “Natural Layering Concept.” He coauthored the book
Adhesive Metal-Free Restorations, edited in 1997 by Quintessence and translated into
seven languages. Dr Dietschi is internationally acclaimed for his theoretical and practical
teaching programs focused on adhesive and esthetic restorations with the integration
of scientific evidence and implementation of new technologies in the field of minimally
invasive esthetic dentistry applied to the restorations of anterior and posterior teeth.
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My Coauthors
Dr Carlo Massimo SARATTI

There are encounters that make you feel like you met someone special in the very first
instance … Massimo SARATTI is such a person! When this happens, building a productive
team is a spontaneous and natural process that eases cooperation, as it not imposed
by the environment or hierarchy. I got to know him as a candidate of our Master on
“Minimally Invasive Esthetic Dentistry”; he became a tutor and shortly thereafter the
clinical head of the same program, demonstrating very early special clinical skills and
capacities for teaching. Sharing the same professional values and aims, as well as being
a hard worker and curious scientist with solid common sense, Massimo has been a great
contributor and partner along the way to complete this book project; his special interest
in function and occlusion in particular proved highly valuable to related sections as well
as his contribution to clinical content thanks to his great technical skills and growing
experience. Massimo, your friendly and constant support and relentless positive attitude
have been a highlight in my career and I also look forward to continuing this collaboration
toward more shared successes! ...
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X
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MDT Serge ERPEN
Among a few outstanding dental technicians, Serge Erpen has accompanied me along a
great part of my investigations in tooth wear treatments, from diagnosis to realization. His
technical competence has no equivalent but his passion and dedication to the profession. I
found in Serge a true partner to share the many difficulties in treating sometimes complex
cases and reaching the best possible results for any patient. Flexibility and availability are
other virtues he has expressed in every aspect of our cooperation … and every dentist
understands how important it is to know we will respect deadlines, whatever the difficulty
and the unexpected. Serge has also shown an extraordinary curiosity and interest in
exploring new technologies to find the best balance between analog and digital solutions,
which proved to be an incredible asset to embrace together, and for the best, with the
evolution of dental technologies. Last but not least, we developed a mutual respect,
which is the essence and condition of a successful teamwork; as it should, authority
or professional position were never part of our friendly relationship. Thank you, Serge,
for having been by my side for so many years; wishing us still to continue this fruitful
cooperation much further ahead! ...
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Why this book?...
One of my most desired projects was to create a place to

share my experience as well as stories about successes and
failures with my peers. This became a reality in 2006 when
we had our first program at the Geneva Smile Center, where I
built my own education center. The driving force behind this
adventure was to offer an optimal environment dedicated
to the learning and practice of adhesive dentistry. This is
about being minimally invasive, even often with a no-prep
approach … what has become a lot more than a trend over
the last two decades. An instrumental cooperation that
made this dream become a complete reality was to have
Prof Pascal Magne joining me as an Edudent International
regular teacher. I am privileged to have Pascal as a close
and dear friend and a contributor to our teaching center; he
brings his invaluable scientific expertise and unique clinical
talent to our visiting colleagues … what a MUST for this place!
A repeated request from many visiting peers has been
to have a comprehensive presentation of the concepts and
procedures demonstrated in our courses … this has now
been completed, and its content is also dedicated to them in
appreciation of their attention and trust.
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XIII
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A journey
A 35-year-long journey within both the

academic and clinical dentistry worlds
opened my horizons while it also
turned many certainties into doubts,
dogmas into more sensible consider-
ations, and ultimately led me to con-
sider that science without clinical ex-
perience, common sense, and strong
ethics is a useless exercise. Let me then
explain below to the reader which fun-
damentals other than those of a tech-
nical nature underlie the concepts de-
veloped in this book.
Freshly graduated, my first years as a
full-time academic taught me the value
of research both in fundamental bio-
materials science and university-based
clinical dentistry. It took me however a
while to understand the frailty of many
in vitro protocols and thus their limited
clinical relevance. In regard to clini-
cal studies conducted at universities,
how could we interpret results after
having eliminated many of the con-
straints prevailing in the other areas of
our dental world? My daily work in the
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in academic and clinical dentistry
private sector made me increasingly wonder why the reality life as well. Like everyone, I have been tempted to listen to
of this environment was occasionally loosely fitting with so- the siren songs, to take the easy path to overtreatment, using
called “evidence-based” treatment recommendations and monotherapy applied to nearly every patient for the sake of
outcomes. For example, I realized the impact of relatively productivity and simplicity … and even “worse” the quest for
young and often inexperienced university fellows (as I was impeccable iconography to impress congress crowds or so-
at the time of my clinical doctoral thesis) performing treat- cial media followers. As a group of authors and contributors,
ments with somehow suboptimal results, seemingly inferior dentists, scientists, and technicians, we aimed then to share
to those obtained in an ideal private practice; conversely, here with the reader knowledge and clinical expertise to en-
failure rates for treatment performed under social system hance the patient’s health as an absolute priority.
guidelines proved factually superior, next to the issue of sub- This journey also brought me to meet amazing profes-
optimal treatment concepts. In brief, I progressively learned sionals and human beings who all share the same passion
to weigh both the impact of “nonnatural and realistic” labo- for dentistry and show the utmost respect and compassion
ratory conditions and the many different treatment environ- for patients; I realized over time how important those com-
ments and to confront the results of academic research to bined qualities are to drive our efforts toward just aims. The
the infinite confounding factors conditioning successes or above sounds obvious but in fact it is not, and this is why
failures in our daily activity. This long personal experience in we tried here to challenge the lasting trend of commercially
academics and private dentistry ultimately led me to better driven dentistry and overtreatment. The latter consideration
contemplate the complexity of research data analysis and actually is of prime importance when we consider the in-
how to generate useful, clinically oriented information. finite variations in the extent of tooth wear, localization, and
I have been privileged to travel extensively to share my interaction with preexisting individual biomechanical and
experience but above all to receive generous feedback from functional conditions; how then could monotherapy applied
many researchers as well as private and university clinicians. to the whole mouth be the correct answer to such clinical
This altogether shaped my vision of dentistry and how I variability? Ultimately, this challenge triggers our medical
could, hopefully, bring a modest contribution to improve the and technical creativity and makes this domain of dentistry a
way we treat and help patients to heal from certain patholo- highly stimulating and motivating one. We truly hope you will
gies, recover function, and improve esthetics and quality of have a stimulating, fruitful, and enriching reading experience.
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XVI
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Dedication
I dedicate this book first to my wife Manuela
for having transformed my life into a sunny
fairy tale and for her unconditional support
in many of my professional projects. She
provided the serene atmosphere needed
to work so intensively on this manuscript
and has been a critical reader and first
reviewer to select its most appropriate
graphic options and clinical content. Thank
you, Manuela, for your patience and for
being by my side with a smile, whatever the
circumstances …
I also dedicate this book to my brother

Jean-Michel, my lifelong private dentistry
partner, and his wife Beatrice, who have
tirelessly headed our two clinics since their
inception. Thank you both for all the love
and support you have given me throughout
the years, from the opening of our first
dental office in our small hometown of
Bernex to the bigger project of the Geneva
Smile Center. Achieving many of my
professional dreams happened thanks to
your trust and efforts on my side; without
you, my life journey wouldn’t have been so
beautiful! ...
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In gratitude of
I would also like to dedicate this book to all the mentors, colleagues, and industry partners who gave me confidence to
concretize my professional projects. Without colleagues reading our publications and following our teaching, all our efforts
would be meaningless. Special thoughts are indeed addressed to my first academic mentor, Prof Jacques Holz, who sadly
passed away very recently; he gave us an example of the utmost professional engagement and taught us something that has
not been impacted by technologic changes, namely rigor, dedication, and respect for our patients with a desire to deliver the
best treatment to them. In other words, he has given us a proper aim in everything we do. I am also profoundly grateful to Prof
Carel Davidson for his scientific guidance and for having accepted to be my PhD thesis supervisor. He is one of the most vi-
sionary and ingenious researchers I have ever met; he brought to adhesive dentistry totally innovative thinking and concepts
from his previous professional activity as an airline industry engineer. After all, it might be because he wasn’t a dentist that he
was so brilliant!?... Thank you to both of these men who guided me along my professional and academic paths. I would also
like to express my gratitude to Prof Ivo Krejci, head of the department of Cariology and Endodontics at the University of Ge-
neva, who took over its direction after Prof Holz’s retirement. He is not only an exceptional and recognized academic leader,
but as a member of his team, I had the privilege to receive his continuous support and guidance in many of my scientific and
educational projects. Last but not least, I want to express my sincere gratefulness to my Bis-GMA brother, Dr Roberto Spreaf-
ico, for having shared many dental dreams and for accompanying me on countless projects and courses around the globe. I
was blessed to meet him.
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Table of Contents
Chapter 1 Diagnosis and Prognosis of Tooth Wear 1
Chapter 2 Treatment Strategies 26
2.1 Treatment Strategies 28

2.2 Restorative Materials 100
2.3 Treatment of Interfaces 112
Chapter 3 Occlusal and Functional Factors, Vertical Dimension of

Occlusion 120
Chapter 4 Direct Techniques 176
4.1 The Natural Layering Concept 180

4.2 Freehand Anterior Restorations 202
4.3 Strategies for Direct Posterior Restorations 242
4.4 Freehand Posterior Restorations 254
4.5 Partial Molding for Posterior Restorations 310
4.6 Full Molding Technique 330
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Chapter 5 Shell Techniques 382
Chapter 6 Indirect Techniques 428
6.1 Adhesive Procedures 430

6.2 Indirect Protocols 448
6.3 Luting Procedures 530
Chapter 7 CAD/CAM Techniques 540
Chapter 8 Longevity and Maintenance 584
8.1 Longevity and Follow-up 586

8.2 Maintenance and Renewing 626
8.3 Maintenance and Replacement 722
8.4 Nightguards 786
8.5 Literature Review Longevity 794
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XXII
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Foreword
I met Didier in the early 1980s when both of us were young education of our pregraduate and postgraduate students, as
university assistants. He started his impressive career in the well as to the rich research output of our division.
French part of Switzerland at the University of Geneva; I was Didier is not only a gifted clinician. He is also a highly
at that time in the German part of Switzerland at the Univer- skilled author of several books and numerous scientific
sity of Zurich. Already, Didier was a highly charismatic per- publications and clinically oriented articles, many of which
son, and I was immediately fascinated by his extraordinary quickly became essential references in the field. However, I
gift for the highest quality esthetic dentistry. We became consider the present book the culmination of his splendid
friends and colleagues, and I have always admired Didier’s professional career and a masterpiece of dental art and sci-
outstanding clinical skills and his never-ending passion for ence. It features the highest quality clinical documentations
our profession. and besides being esthetically overwhelming, it is a com-
As time went by, Didier became a world-renowned leader prehensive source of the latest evidence-based procedures
and a highly competent and experienced teacher in the in the field of the restorative treatment of noncarious loss
field of adhesive esthetic dentistry. When I was appointed at of hard dental tissue. It is a milestone in adhesive esthetic
the University of Geneva, I was extremely happy that Didier dentistry and I am sure that it will remain for many years an
agreed to continue to working in my division and to dedi- outstanding source of knowledge and inspiration for all col-
cate an important part of his time to university teaching and leagues who aim to provide the best and most modern treat-
research. Since then, we have worked together side by side, ments to their patients.
and he has contributed in a very important way to the clinical
Prof Dr Ivo Krejci (Head of the Department of Cariology and Endodontics, University of Geneva)
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Introduction
Already more than a decade ago, Bardsley (2008) concluded evidence-based treatment rationale. Rushing treatments
in his review that “tooth wear is considered an ever-increas- (especially with an invasive and costly indirect approach)
ing pathology.” One could argue it is nothing else than the and simplifying the nature of tooth wear unfortunately is a
consequence of a progressive decrease of the other main sure way to fail globally to prevent progression and suitably
pathologies, namely carious and periodontal diseases; while treat tooth wear, following proper biomechanical and con-
this incidence drop is a fact in so-called “developed coun- servative principles.
tries”, two theories afront each other in regard to a possible Additionally, a common denominator behind the major-
true increase in erosive and attrition pathologies. One sug- ity of severe tooth wear cases is likely a failure of the dental
gests that our attention and actions were fully focused on team to install early enough preventive or interceptive mea-
pockets and decays, then “ignoring” tooth wear, while the sures. Again, because the restorative approach based on in-
other presents our modern “more stressful” lifestyle as the direct/CAD/CAM techniques was so frequently and wrongly
main trigger for this incidence outbreak. Sorting here the proposed as the only option, a large number of patients re-
true from the false is a useless exercise, but it is a fact that no nounced or delayed their treatment simply because of its
one can practice dentistry today without paying some atten- cost, letting wear pathology evolve until no other solution
tion to tooth wear, its diagnosis, its prognosis, and its many became feasible. This is a very critical reality, and this pub-
implications on the long-term dental health of our patients lication aims to present the conservative, cost-effective, and
in all age categories. Tooth wear is a multifactorial pathology evidence-based alternatives to “classical prosthodontics” to
with various degrees of intensity, fluctuating over time. This stabilize and treat tooth wear.
multifaceted, complex pathology doesn’t make it easy to This publication will ignore dogmas and short-sighted
obtain a precise etiologic diagnosis and subsequently clear statements or concepts that poorly fit with the individual na-
treatment plan in all cases. Complexity relates in particular ture of function/occlusion and the way each patient responds
to combined erosion and attrition phenomenon (probably to various pathologies, risk factors, and our treatments. We’ll
the majority of cases), and it is therefore important to give also try to apply wisely the concept of “evidence-based den-
us time to observe and analyze, one by one, the various con- tistry,” which in its early days strongly opposed the drive
ditions that did and do act synergistically to induce hard and motto of clinical opinion leaders, namely “I do it and it
tissue loss. Unfortunately, too many clinicians with sizeable works”! In fact, common sense brought things into a much
social media audiences have promoted a “monotherapy” better perspective today!
for tooth wear with either full-mouth CAD/CAM or indirect Would research be of quality (in vivo trials succeed in
high-strength ceramic restorations, in the absence of any minimizing the effect of confounding factors and in vitro
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studies apply protocols relevant enough to clinical reality), a
practitioner’s daily observations and treatment performance
should largely be supported by research. If not, it simply
means that for a given treatment, our specific environment
(type of patient and the techniques/materials used) impacts
its outcome differently; in other words, the “scientific evi-
dence” is valid only for a given environment. In fact, results
of clinical trials usually vary when reporting the performance
of a treatment in different environments, such as private of-
fices or social or university clinics. Then, the evidence-based
dentistry has strict limits, and common sense and detailed
observation have been the central thread of this work and
the recommendations given thereafter.
This publication doesn’t pretend to be a textbook but
rather a review of clinical procedures that can help the prac-
titioner find a proper protocol and select a suitable material
to more selectively treat the various forms of tooth wear. It is
based on more than 20 years of interest in this (apparently)
ever-increasing pathology. In a certain sense, it is a “cook-
book” with a main focus on preventing tooth wear progres-
sion, using in proper time noninvasive and affordable proce-
dures, keeping in mind that comprehending this pathology
will be a lifelong endeavor. If we miss the opportunity to in-
tervene early enough, you will also find the recipes to prop-
erly use indirect and CAD/CAM bonded restorations.
We wish you an informative and stimulating reading
experience.
Didier Dietschi & the author’s team
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Cases directory of
Direct protocols for posterior restorations
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Free-hand
Chapter 2: pages 48–53 Chapter 4: pages 298–309 Chapter 8: 628–645 Chapter 8: pages 724–745
Chapter 2: pages 66–77 Chapter 5: pages 386–401 Chapter 8: pages 646–663
Chapter 4: 262–279 Chapter 8: pages 588–605 Chapter 8: pages 664–677
Chapter 4: 280–297 Chapter 8: pages 606–625 Chapter 8: pages 702–721
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Cases directory of
Direct protocols for anterior restorations
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Free-hand
Chapter 2: pages 48–53 Chapter 4: pages 210–241 Chapter 4: pages 336–380 Chapter 8: pages 588–605
Ch 2: p 56–63 / 6: p 506–529 Chapter 4: pages 262–279 Chapter 5: pages 386–401 Chapter 8: pages 628–645
Ch 4: p 204–209 / 6: p 454–471 Chapter 4: pages 314–327 Chapter 6: pages 488–505
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Cases directory of
Molding protocols
XXX
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Direct molding Indirect molding
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Cases directory of
Digital & CAD-CAM protocols
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Treatment Planning Partial workflow Full workflow
Chapter 3: pages 156–173
Chapter 2: pages 78–91 Chapter 7: pages 546–563
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Cases directory of
Indirect protocols
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Posterior restorations Anterior restorations
Ch 2: p 56–63 / 6: p 506–529 Chapter 8: pages 724–745 Chapter 2: pages 66–77 Chapter 6: pages 506–529
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Cases directory of
Hybrid protocols
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Direct / CAD-CAM / Indirect
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XXVI
1
CHAPTER
1
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1
Diagnosis and Prognosis
tw
of Tooth Wear
Diagnosis and Prognosis of Tooth Wear 1

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2
Diagnosis and Prognosis of Tooth Wear for the Clinician
No proper preventive or therapeutic measures can be in- Erosion

stalled before a diagnosis is performed; tooth wear is of Erosion originates from extrinsic and intrinsic acid sources;
course no exception to this basic rule, in particular due to extrinsic sources include beverages (carbonated drinks,
its multifactorial nature. We need first to analyze the basic fruits juices, salad dressing, spicy liquid condiments), many
mechanisms (erosion, abrasion, and attrition) and then con- of them with low pH values (2.0–3.5), food (typically fruits
sider risk factors (eg, diet, occlusion, function and parafunc- and some vegetables like tomatoes and chilies), and a few
tions, anatomy, patient’s physical and psychologic health) medications (eg, chewing vitamin C). People who consume
and co-factors (eg, patient’s age, compliance, socioeconomic abnormal quantities of the aforementioned acidic products
conditions); this is important due to the complex interaction will then develop dental erosion. Unbalanced diet and food
that occurs between the aforementioned risk factors and compulsive behavior have unfortunately become common
co-factors, leading to various degrees of hard tissue loss. Un- problems in our modern society. If this etiology is identified,
derstanding basic tooth wear mechanisms and related cri- a basic approach is to ask the patient to monitor daily food
teria of diagnosis will help clinicians to safely and efficiently and beverage intake; the dentist or nutritionist can then ana-
manage patients affected by tooth wear. lyze the patient’s weekly reports and recommend impera-
tive changes. Needless to say, the dentist is not always in a
Wear mechanisms and their incidence very strong position to control food behavior. A final cause
The first basic mechanism of tooth wear, erosion, is induced for dental erosion, although of lesser incidence, is the de-
by extrinsic and intrinsic acids, fragilizing hard tissues mainly creased salivary flow and dehydration resulting from athletic
through mineral loss; fragilized surfaces then become prone or strenuous physical activities, with added risk from regular
to loosening during occlusion, mastication, and brushing. consumption of sweetened sport drinks.
The second basic mechanism, abrasion-attrition (mechan- There is only one intrinsic source of erosion: the gastric
ical-frictional), is due to abnormal forces and contacts acid produced by our stomach (main constituent being hy-
on hard tissues (through shear, flexural, and compressive drochloric acid), with a pH varying from 1 to 3. Apart from let-
strains), which lead to microscopic, structural disruption of ting food enter the stomach, the lower esophageal sphincter
enamel or dentin structures. Both phenomena happen from (LES) normally prevents gastric acid from entering the eso-
physiologic to various pathologic levels. Moreover, both phagus toward the mouth.
mechanisms often appear to act synergistically, worsening If the LES doesn’t close all the way or if it opens too often,
and accelerating tooth wear. Clinically, both mechanisms in- gastric acid can move up into the esophagus. An abnormal
duce typical wear patterns while when acting concomitantly, acid reflux is called gastroesophageal reflux disease (GERD),
atypical lesions with hybrid patterns are observed. inducing symptoms like pain and heartburn, and if untreated
1 Diagnosis and Prognosis of Tooth Wear
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3
for too long, a Barrett’s esophagus can develop with an ele- (psychopharmacologic and psychosocial treatments) is highly
vated risk of adenocarcinoma. It of course also causes dental recommended as untreated patients likely worsen their con-
erosion, which contributes to diagnose the underlying conditions and can even put their life at risk.
dition. A common cause of acid reflux is related to a malfunc-
tion of the LES called hiatal hernia. The other conditions of Attrition and abrasion
abnormal gastric acid production and increased reflux epi- Semantically, attrition is related to the wear process result-
sodes are linked to poor dietary habits like eating large and/ ing from tooth-to-tooth contacts, while abrasion results from
or heavy meals, particularly before bedtime, and drinking in the effect of a foreign object on dental tissues. Both phe-
excess fizzy drinks, alcohol, coffee, and tea. Other physical nomena lead to tooth wear by direct mechanical disruption
and medical conditions such as obesity, pregnancy, or med- of enamel and dentin. Attrition is physiologic up to a certain
ications like pain killers, muscle relaxers, and blood pressure level but can be significantly elevated by abnormal occlusal
medications can also trigger acid reflux. The critical period in forces and functional movements such as sleep and awake
case of reflux is during sleep as salivary flow and swallowing bruxism. Bruxism (parafunctions) is extremely complex as it
are reduced. In case of suspected reflux, proximal esopha- involves not only the masticatory system itself and its regu-
geal pH-metry and/or upper GI endoscopy (gastrointestinal) lation by the central nervous system but seemingly further
or EGD (esophagogastroduodenoscopy) are recommended musculoskeletal structures as well. Sleep bruxism is seen
to, respectively, monitor the frequency, duration, and pH today as a sleeping disorder (rhythmic body movements ac-
drop of reflux episodes and assess any anatomical anoma- tually involve many other zones than the jaws), while awake
lies or mucosa alteration. bruxism seems mainly a reaction to stress and anxiety. The
The last causes for severe dental erosion are bulimia and role of occlusion still remains unclear, apart from the logical
anorexia (bulimia nervosa and anorexia nervosa); patients role of stress distribution by dental contacts; the more occlu-
suffering from bulimia are known to eat excessive amounts of sal contacts, the more evenly functional stresses are distrib-
food in a short amount of time, then purge the consumed food uted on teeth, and vice versa.
through vomiting or the use of laxatives, diuretics, or stim- In light of recent evidence, occlusion seems neither re-
ulants. With anorexia, on the contrary, patients restrict their lated directly to the incidence nor the severity of parafunc-
food intake but apply the same purge methods to lose weight, tions; this however remains a highly controversial topic that
next to compulsive physical exercise. Bulimia and anorexia are necessitates further research to confirm the complex inter-
frequently associated with depression and anxiety, with a dis- actions between occlusion and the many systems involved
torted self-image. Apart from the severe dental implications in parafunctional activities (read more on this in chapter 3).
of these diseases (rapidly evolving erosion), psychotherapy Apart from the minor contribution of regular, proper personal

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4
dental hygiene, the causes of atypical abrasion include ag-

gressive tooth brushing (using too much force and wrong
movements, stiff toothbrush, and abrasive toothpaste), bit-
ing nails (onychophagy), and chewing on a smoking pipe
mouthpiece or pen, to cite the most common damaging
habits. Again, the simultaneous interplay of various causes
of wear (erosion, abrasion, and attrition) is a very common
situation that creates a vicious cycle for hard tissue integrity
and also makes it more intricate for the dental team having
to act against several risk factors.
Abfraction
Abfraction lesions are non-carious cervical lesions (NCCLs)
that result from tooth flexure arising from repeated, eccen-
tric function. Tooth deformation deteriorates the thin cer-
vical enamel prism structure, leading to dentin exposure
above the cementoenamel junction (CEJ); this localization
actually allows a differential diagnosis with other NCCLs,
such as root abrasion induced by brushing in the presence
of gingival recession. Abfraction lesions are likely to happen
conjointly with other lesions like erosion and abrasion, low- Interplay of wear mechanisms, risk factors, and co-factors
ering the occurrence of “mere” abfraction decays. However,
the etiology and biomechanics of abfraction remain contro-
versial in the literature. In fact, supposed abfraction lesions
are not frequently observed.
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5
Unlikely scenarios suggesting an absolute predominance of one wear mechanism
Abrasion
Erosion
Most frequent and likely scenarios showing various levels of predominance or combinations of the two wear mechanisms
These diagrams suggest that the respective contributions of the contrary develop parafunctional activities if some un-
both wear mechanisms can greatly vary and are frequently derlying anxiety and stress factors are not controlled; the
associated; clinical observations confirm that this later tooth same “scenario” can obviously be reformulated with an in-
wear model is prevailing on the one of single mechanism. finite number of variations. Then, having to decide how to
Moreover, risk factors are likely to vary over time while an al- treat tooth wear while not knowing the true dynamics of the
ternate prevalence of wear mechanism and intensity is to be disease is a limiting factor for success. This is why an inter-
expected; this has a major implication in selecting the cor- ceptive treatment approach using simple no-prep, chairside
rect treatment approach. For instance, a patient can suffer procedures with composite is best indicated for moderate
from compulsory food behavior for a while and then, after and intermediate tooth wear, considering indirect restora-
controlling his diet, will return to a normal risk factor or on tions only for severe cases.

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6
wear patterns
wear rate
time
Incidence and prevalence of tooth wear

The incidence and prevalence of tooth wear seem to have Kitasako et al found a prevalence of 26% tooth wear in
increased over the last few decades, although not all au- Japanese adults; in another review by Van’t Speiker et al,
thors agree on this hypothesis. Studies in various age groups the prevalence of severe tooth wear appeared, logically, to
and regions have however reported high incidence of tooth increase from the ages of 20 years (3%) to 70 years (17%).
wear in all groups. Kreulen et al in their systematic review Jaeggi and Lussi, when analyzing some literature data, also
on tooth wear confirmed that lesions exposing dentin in confirmed the high, increasing prevalence of tooth wear in
deciduous teeth had a prevalence ranging from 0% to 82%, younger age groups (mainly linked to the consumption of
with significant correlation to age; in a systematic review and acidic drinks) and a correlation of tooth wear with age.
meta-analysis study, Salas et al estimated that the overall From a practitioner’s perspective, it seems rather unques-
prevalence of tooth erosion in permanent teeth of children tionable that the occurrence of wear defects has increased in
and adolescents was 30.4%; Bartlett et al reported a 29% in- all age groups during recent decades.
cidence of substantial tooth wear in young European adults
(age 18–35 years).
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7
Dental wear patterns and tooth wear diagnosis

Depending on the type erosion process (extrinsic or intrin- • Flattening of occlusal surfaces, starting with cusps
sic), one can observe a number of typical lesions: • Flattening and chipping of incisal edges and cuspid tips
• Occlusal hollows • Flattening and indentation on palatal surfaces
• Smoothing of enamel surfaces, with prevalence in areas in
direct contact with acidic food or beverage In combined cases (erosive and mechanical tooth wear), hy-
• Complete loss of thin cervical enamel brid patterns or so-called “atypical forms” of tooth wear are
observed. This is a very common finding, when one cause
For attrition and abrasion, loss of tooth structure appears is not dominating, again because the majority of patients
more specifically in the form of wear facets or localized tooth are exposed alternatively or simultaneously to both wear
fractures (enamel chipping) in these areas: mechanisms.
DIAGNOSIS/WEAR PATTERNS Severity

Primary
Moderate
Severe
PROGNOSIS PARAMETERS
Erosion:
Hollowed occlusal pits
Lingual and facial e/d flattening Patient’s age
Young
Attrition-abrasion: Adult
Elderly
Occlusal/lingual facets
Incisal edge shortening and chipping
Cervical abfraction and abrasion Compliance
Poor
Limited
Good

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8
The extent of tooth wear considered physiologic and at Various wear indices have been recommended to study
what age related progression brings tooth structure damage the incidence and severity of tooth wear at enamel and den-
to a pathologic level has been vastly and controversially dis- tin levels; however, these indices are usually too detailed and
cussed in the literature. Common sense and medical ethics then inappropriate for the general practice. Such research
however suggest to prevent wear as much as possible and tools can be advantageously replaced by a simpler approach
install interceptive measures when prevention only is not involving three prognosis parameters, next to the identified
enough to stop tooth wear progression. A few simple guide- risk factors (see lower diagram of previous page). The first
lines are then sufficient to help the practitioner toward the parameter is wear severity (locally or globally), and the other
right decision between “acting” or just “observing.” The diag- two relate to the patient’s age and known (or expected) com-
nosis and prognosis parameters summarized in the previous pliance with treatment and risk control recommendations.
diagram provide a simple base for monitoring and treating The relationship of tooth wear severity to the patient’s age
tooth wear cases. In short, when tooth wear impacts tooth and compliance are good indicators of potential risk factor
esthetics or the biomechanical integrity of an individual or control, treatment complexity, and its likely outcome.
group of teeth or a full arch or mouth, our action is needed,
involving preventive measures (in any case) up to more com-
prehensive restorative procedures.
Multifactorial wear risk factors with combined patterns and varying, localized extent is a highly common finding (right page).
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9
This 60-year-old patient had only the chief complaint of discoloration and unesthetic smile appearance. Clinical examination revealed
moderate generalized tooth wear with evident signs of bruxism (shortened incisal edges and canine tips) and clenching (concave occlu-
sal anatomy of molars with mesiodistal cracks). Such findings call for preventive/interceptive measures, despite the patient’s age, which
suggests a physiologic wear extent.

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10
Early onset of attrition
Young male patient (aged 17 years) showing advanced tooth wear from parafunctional activities; attrition is clearly the main wear mech-
anism involved here with flattening of cusps and wear facets. The risk factor (correlation between patient’s age, wear severity, and poten-
tial progression) is considered high due to the patient’s age.
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Early onset of erosion 11
Young female patient (aged 19 years) with localized erosion of the four maxillary incisors due to compulsory consumption of fruits. Note
the smooth edges of worn incisal edges, in contrast to attrition induced by bruxism that triggers enamel chipping. The risk factor is con-
sidered moderate as it is controllable with proper patient guidance and awareness.

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12
Erosion
Male patient (aged 40 years) with typical hollowed occlusal lesions; erosion appears to be the predominant wear mechanism, although
wear facets (attrition) are also present and suggest combined risk factors. The risk factor is moderate to intermediate.
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13
This female patient (aged 39 years) consulted because of the esthetic impact of tooth wear on her smile appearance (flattening of the
smile line). The overall buccal examination revealed significant erosion of the palatal enamel of all anterior teeth and occlusal surfaces
of mandibular and maxillary posterior teeth. This wear pattern is typical for erosion, keeping in mind the likely contribution of the addi-
tional attrition co-factor. The risk is considered intermediate for a middle-aged adult.

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14
Severe erosion
Male patient (aged 36 years) showing extensive signs of tooth wear with predominant erosion pattern; the contribution of attrition to the
rapid loss of tooth structure was likely for this case. The patient is showing typical dental impact of bulimia nervosa.
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15
Some additional carious risk factor is present. The overall risk factor is extremely high in such cases (ie, bulimia and anorexia).

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16
Attrition
The two cases presented here (above, male patient aged 55 years, and below, female patient aged 48 years) show similar wear patterns
induced mainly by attrition (bruxism); note the irregular, chipped incisal edges. Depending on the overbite extent, wear will involve more
or less of the maxillary palatal surfaces. The risk factor for both cases is intermediate.
Chapter_1.indd 16 11.04.23 16:37

Combined erosion-attrition 17
Male patient (aged 41 years) presents combined wear patterns with occlusal hollowed lesions and wear facets, as a result of excessive
acidic beverage consumption and moderate parafunctions, without any protective means (ie, mouthguard). The incidence of combined
erosion/attrition is very high and makes it the most prevalent condition. The risk factor is considered moderate to intermediate.

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18
Abfraction
Abfraction is conceptually a mechanical disruption of cervical enamel through the action of excessive tooth flexure due to bruxism.
Enamel prisms are then progressively lost either spontaneously or during tooth brushing of fragilized enamel (abrasion). As soon as
dentin is exposed, erosion and abrasion can worsen hard tissue loss.
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19
The anatomical peculiarity of abfraction (which still remains a controversial mechanism) is the localization of lesions, namely cervical
enamel above the CEJ; this makes it possible to differentiate abfraction from abrasion of root dentin in case of gingival recessions.
Abfraction lesions tend to affect teeth overloaded by excursive movements in bruxers (see here all maxillary anterior teeth, up to pre-
molars). The nature of forces induced by parafunctional movements might explain why facial surfaces of maxillary teeth (submitted to
compressive/shear forces) are more affected than mandibular teeth (submitted to tensile/shear forces).

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20
Tooth wear progression
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21
Evolution of erosive tooth wear in a male patient (aged 32 years) at the first visit (left page, upper left); the 8-year (left page, upper right)
and 12-year (left page, lower image and above) follow-up visits show significant progression of the tissue loss. The patient denied having
any abnormal diet and did not consider our suggestion for consultation with a gastroenterologist. As the wear more severely involves
the facial aspect of the teeth, the extrinsic acidic origin was the privileged diagnosis, with likely contribution of attrition and abrasion (ag-
gressive brushing). Without the patient’s proper compliance, wear pathologies will likely evolve toward significant progression of tissue
loss. Clinicians must be aware that patients occasionally refuse even any preventive or interceptive measures to stabilize their problem.

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22
Age-related tooth wear
Time is a crucial factor to assess tooth wear severity and prognosis as evidenced in these intraoral images of elderly patients. Without any
preventive measures, attrition and erosion will lead to significant, damaging effect on natural or restored dentition, even without exceed-
ing “physiologic” levels of erosion, attrition, and abrasion. This deleterious effect on tooth structure is unavoidable without preventive
measures (see following chapters).
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23
Tooth wear is a common term to describe a multifaceted pathology; despite

the fact a few patients present lesions linked clearly to a predominant wear mechanism,
there is only a low prevalence of this condition. On the contrary, the vast majority of
patients affected by tooth wear suffer from a combination and effects of multiple risk
factors and co-factors, leading to various localizations, severity levels, and dynamics of
hard tissue loss.
A detailed oberservation of existing wear lesions and monitoring, if

appropriate (mild and moderate severity), with the help of the patient’s medical history,
allows us to comprehend or at least approach more closely the globality of risk factors.
Again, one should not forget the time dynamics and interplay of identified risk factors;
with analogy to financial investment strategies, former and current results (clinical
findings) are not always predictive of future outcomes (progression and mechanisms of
tooth wear)!

Chapter_1.indd 23 11.04.23 16:37
24
Recommended Readings
1. Bartlett DW, Fares J, Shirodaria S, Chiu K, Ahmad N, Sherriff 8. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological
M. The association of tooth wear, diet and dietary habits in mechanisms involved in sleep bruxism. Crit Rev Oral Biol
adults aged 18–30 years old. J Dent 2011;39:811–816. Med 2003;14:30–46.
2. Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bourgeois 9. Lee AL, Goldstein RS. Gastroesophageal reflux disease in
D. Prevalence of tooth wear on buccal and lingual surfaces COPD: Links and risks. Int J Chron Obstruct Pulmon Dis
and possible risk factors in young European adults. J Dent 2015;10:1935–1949.
2013;41:1007–1013. 10. Linkosalo E, Markkanen H. Dental erosions in relation to lac-
3. Hellstrom I. Oral complications in anorexia nervosa. Scand J tovegetarian diet. Scand J Dent Res 1985;93:436–441.
Dent Res 1977;85:71– 86. 11. Litonjua LA, Andreana S, Bush PJ, Cohen RE. Tooth
4. Huysmans MC, Chew HP, Ellwood RP. Clinical studies of den- wear: Attrition, erosion and abrasion. Quintessence Int
tal erosion and erosive wear. Caries Res 2011;45(suppl 1): 2003;34:435–446.
60– 68. 12. Loomans B, Opdam N, Attin T, et al. Severe Tooth Wear: Eu-
5. Imfeld T. Dental erosion. Definition, classification and links. ropean Consensus Statement on Management Guidelines.
Eur J Oral Sci 1996;104:151–155. J Adhes Dent 2017;19:111–119.
6. Kitasako Y, Yoshiyuki Sasaki Y, Takagaki T, Sadr A, Tag- 13. Lussi A, Schlueter N, Schmalz G, et al. Consensus Report
ami J. Age-specific prevalence of erosive tooth wear by of the European Federation of Conservative Dentistry. Clin
acidic diet and gastroesophageal reflux in Japan. J Dent Oral Investig 2015;19:1557–1561.
2015;43:418–423. 14. Lussi A, Ganss C (eds). Erosive Tooth Wear: From Diagno-
7. Kreulen M, Van ’t Spijker A, Rodriguez JM, Bronkhorst EM, sis to Therapy, vol 25, Monographs in Oral Science. Basel:
N.H.J. Creugers NHJ, Bartlett DW. Systematic review of the Karger, 2014.
prevalence of tooth wear in children and adolescents. Caries
Res 2010;44:151–159.
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25
15. McGuire J, Szabo A, Jackson S, Bradley TG, Okunseri C. Ero- 21. Schlossman M, Montana M. Preventing damage to oral hard
sive tooth wear among children in the United States: Rela- and soft tissues. In: Spolarich AE, Panagakos FS (eds). Pre-
tionship to race/ethnicity and obesity. Int J Paediatr Dent vention Across the Lifespan: A Review of Evidence-Based
2009;19:91–98. Interventions for Common Oral Conditions. Charlotte, NC:
16. Meurman JH, Vesterinen M. Wine, alcohol, and oral health, Professional Audience Communications, 2017:97–120.
with special emphasis on dental erosion. Quintessence Int 22. Schlueter N, Amaechi BT, Bartlett D, et al. Terminology of
2000;31:729–733. Erosive Tooth Wear: Consensus Report of a Workshop Or-
17. Okunseri C, Wong MC, Yau DT, McGrath C, Szabo A. The re- ganized by the ORCA and the Cariology Research Group of
lationship between consumption of beverages and tooth the IADR. Caries Res 2020;54:2–6.
wear among adults in the United States. J Public Health 23. Sovik JB, Skudutyte-Rysstad R, Tveit AB, Sandvik L, Mulic A.
Dent 2015;75:274–281. Sour sweets and acidic beverage consumption are risk indi-
18. Reddy A, Norris DF, Momeni SS, Waldo B, Ruby JD. The cators for dental erosion. Caries Res 2015;49:243–250.
pH of beverages in the United States. J Am Dent Assoc 24. Wetselaar P, Manfredini D, Ahlberg J, et al. Associations be-
2016;147:255–263. tween tooth wear and dental sleep disorders: A narrative
19. Salas MM, Nascimento GG, Vargas-Ferreira F, et al. Diet in- overview. J Oral Rehabil 2019;46:765–775.
fluenced tooth erosion prevalence in children and ado-
lescents: Results of a meta-analysis and meta-regression.
J Dent 2015;43:865–875.
20. Salas MMS, Nascimento GG, Huysmans MC, Demarco FF.
Estimated prevalence of erosive tooth wear in permanent
teeth of children and adolescents: An epidemiological
systematic review and meta-regression analysis. J Dent
2015;43:42–50.

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26
2
CHAPTER
2.
Chapter_2_1.indd 26 11.04.23 16:37
Treatment Strategies
27
Sub-Chapters
2.1 Treatment Strategies
2.2 Restorative Materials
2.3 Treatment of Interfaces
Treatment Strategies 2
Chapter_2_1.indd 27 11.04.23 16:37
0 28
2.1
CHAPTER
With contribution by Dr Viviana Coto-Hunziker, Geneva Smile Center (CH),

for the Invisalign treatment of hybrid case 1.
2.1
Chapter_2_1.indd 28 11.04.23 16:37
29
Chapter_2_1.indd 29
ts Treatment Strategies 2
11.04.23 16:37
30
Preventive, interceptive, or restorative? the majority of our patients. The use of indirect and/or CAD/
CAM restorations should be limited to cases with severe tis-
Treatment of tooth wear (including preventive strategies) sue loss and progression, especially in absence of earlier,
mainly depends on the factors previously described in chap- proper management. There are various alternatives to the
ter 1, namely the causative mechanisms and wear severity, classic restorative (indirect) option, which is known as inter-
correlated to the patient’s age and expected compliance ceptive therapy, aiming to stop tooth wear progression, re-
with lowering known risks factors. There are co-factors such store the lost volume of tooth structure, improve esthetics,
as additional carious and periodontal risks, preexisting bio- and rehabilitate function, using composite. The interceptive
mechanical conditions of affected teeth, and the patient’s approach involves many protocols with chairside use of
socioeconomic status. This undeniably creates a complex composite, following basically a “no-prep approach.” These
equation that needs to be rationally addressed, keeping in substitutes to prosthetic restorations are not only effective
mind that no monotherapy will be suitable to all cases. and reasonably durable but also rapid, cost-effective, and
The modern philosophy of tooth wear management lies above all, evidence-based!
in earlier diagnosis and onset of preventive measures; many A final important general concept is to adapt material
severe tooth wear cases actually show that a frequent reason choice and technique to general as well as local factors; the
for the absence of treatment relates to the cost of classic indi- latter includes the wear extent of each individual, affected
rect or even modern CAD/CAM restorations, proposed too of- tooth (extent can actually greatly vary from one area to an-
ten as the only or best option! This clearly is a failure in tooth other) and its pretreatment biomechanical status. Once
wear management, related to insufficient experience gained again, because it is rather seldom to observe a generalized
during pregraduate education and also an overwhelming in- wear pattern and extent, a combination of clinical protocols/
fluence of misleading publications/case reports flourishing materials is the rule rather than the exception, this of course
in journals, social media, and congresses. Unfortunately, too within a global functional and occlusal scheme. This notion
much information about tooth wear is of limited relevance is crucial and can be seen as a true breakthrough in tooth
with few clinical protocols applicable to daily practice and wear treatment approach.
Chapter_2_1.indd 30 11.04.23 16:37

31
Restorative
Treatment approach Tooth wear
approach/material
Freehand and molding

Preventive Limited
composite
CAD/CAM
Interceptive Moderate
composite
Indirect, CAD/CAM
Restorative Severe
HS ceramics
Overall treatment strategy: A logical correlation exists between tissue loss severity plus relevant risk factors/co-factors and the restorative
strategies. Note that preventive measures are integrated in all wear conditions. Equally important is to have a flexible strategy for severe
tooth wear and adapt it, for instance, to the patient’s socioeconomic conditions and age; some compromises are possible in any tooth
wear category, with aim to stop or limit further progression of the pathology. Monotherapy is no option for treating tooth wear.
Chapter_2_1.indd 31 11.04.23 16:37
32
Comprehensive treatment sequence starting the restorative phase can also provide additional
information that is of great help to efficiently manage this
The treatment of tooth wear sensibly follows the rationale “pathology” in the long run! To this regard, interceptive treat-
applied to any medical or dental treatment, namely to proc- ments once again play a crucial role in tooth wear manage-
ced in three phases: diagnosis, treatment planning, and then ment as they delay more complex restorative solutions and
the treatment itself (preventive—interceptive—restorative). bring important feedback about risk factor evolution and
As said before, the diagnostic phase is the most crucial one, the patient’s compliance This can contribute to confirm-
as all further steps depend on an adequate observation and ing the need (or lack thereof) for complex, less conservative
interpretation of clinical findings; this is why some delay in treatments.
Diagnostic Phase Treatment Planning Treatment Options

Initial clinical status a a ete t e di ed Approach and materials
Wear mechanism(s) Tooth display

Wear severity Tooth proportions/dimensions Preventive
Other risk factors Tooth color (pH control, Botox, nightguards)
Esthetics Overbite and overjet Interceptive
Function and occlusion Anterior function (Direct and molded composite)
(TMD?) VDO** Restorative
Biomechanical tooth status Occlusion position and scheme (CAD/CAM and monolytic ceramics)
(vital, nonvital, CTS*) Restorative space
*CTS, cracked tooth syndrome; **VDO, vertical dimension of occlusion.
Comprehensive management of tooth wear integrates all relevant clinical findings, risk factors, and specific functional and biomechan-
ical parameters that support adequate treatment planning and corresponding, structured treatment approach and sequence.
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33
Knowing that the majority of patients consult because of the Owing to the later consideration, esthetics can’t be dissoci-
esthetic impact of tooth wear on their smile (while dentin hy- ated from anterior function and occlusion; then we logically
persensitivity, pain, and functional problems preoccupy or initiate treatment planning by correcting and optimizing the
affect a lesser proportion), a comprehensive esthetic analysis following:
has to be performed during the treatment planning phase. • Tooth display
Although esthetics can’t be considered a medical priority, it • Tooth proportions/dimensions
is an obvious concern and motivation for a vast number of • Tooth color and appearance
patients to undergo dental treatments. • Overbite and overjet
Objective esthetic parameters are schematized here. Smile attractiveness mainly depends on a harmonious interplay of the follow-
ing parameters: 1. Gingival profile and zenith’s position. 2. Full gingival embrasures. 3. Tooth axis (slight distal divergence). 4. Tooth
proportions and dimensions, with optimal proportions (80% to 85%). 5. Smile line, with incisal embrasures and stepped incisal edges.
6. Contact point location. Next to these general features, individual parameters like color, form, and texture are also important to the
overall smile appearance.
Chapter_2_1.indd 33 11.04.23 16:37
34
The esthetic impact of tooth wear on esthetics is schematized here (left drawing depicts normal smile and tooth display); the most
frequent and visible consequences of attrition and erosion are chipping and/or shortening of anterior teeth and a flattened smile line
followed by decrease in tooth display. This prompts smile aging and unattractiveness.
The second treatment step is to find the best occlusal pos- restorative needs, this basic position can be displaced pos-
ition and vertical opening to create adequate restorative teriorly (closer to centric relationship position [CRP]) or an-
space to limit or—even better—avoid any preparation at teriorly (anterior to maximal intercuspation position [MIP]) in
all! This requires traditional (hardstone) or printed models order to augment stability and reliability (seldomly needed)
mounted on the articulator (physical or virtual) to create or to augment restorative space without losing anterior guid-
an adequate project. Choosing an “ideal” occlusal position ance (excessive increase of overjet/overbite; see chapter 3
(or correcting identified occlusal troubles) is a controversial for more information), respectively. The basic approach for
matter that will be further developed in chapter 3. For the tooth wear is very similar to the long-standing one used for
sake of simplicity, we will consider here that the most com- edentulous patients; in absence of suitable preexisting den-
mon occlusal position to restore tooth wear cases is a func- tal reference, the first planning steps aim to recreate a pleas-
tionally neutral position that is repetitive, reliable, and as- ing smile/tooth display, an occlusion reference, and the ver-
sumes a maximal number of dental contacts. Depending on tical dimension of future restorations (formerly dentures).
Chapter_2_1.indd 34 11.04.23 16:37

Optional Treatment Strategies 35
Preventive strategies available, logically due to the complex nature of the pathol-
ogy. Actually, no occlusal treatment/equilibration (other
Prevention of tooth wear should target both wear mechan- than evenly distributing contacts between teeth) or change
isms. In regard to erosion, controlling food and dietary hab- in occlusal positioning has been proven to impact the se-
its and treating GERD (gastroesophageal reflux disease) and verity or frequency of parafunctional activities. By today,
hiatal hernia with proper medication (eventually surgery) there are only two “protective” approaches to lower the
are key elements, keeping in mind the difficulty in acting on dental consequences of bruxism. The first approach targets
common unbalanced eating habits. More severe eating dis- muscle activity by injecting botulinum toxin (ie, Botox) to
orders such as bulimia and anorexia are a lot more difficult reduce contraction forces and revert muscle hypertrophy.
to control and require psychotherapy and often pharmaceu- There are debates on the innocuity of long-term usage of
tical support as well. botulinum toxin, but as for now, the related literature has
Additional professional and personal measures were also remained inconclusive. The second approach, a simple and
discussed in the literature with the aim to protect the tooth effective one, is to physically protect teeth during parafunc-
structure from the action of acids or attempting to revert it. tional activities with a mouthguard. While many types of
For instance, some studies found that milk and unsweet- tooth guards were developed, some with a therapeutic aim,
ened yogurt could have a protective effect because of their clinical studies have suggested the protective effect being
calcium and phosphate content. Calcium supplemented to the common and only proven action (see chapter 8.4 for
acidic beverages and other calcium-enriched products could more information). The most effective and common tech-
also lower the erosive action of soft drinks and sports drinks, nique to produce mouthguards is heat-forming techno-
although their efficacy has not been well documented. Flu- logy. Compulsive, harmful oral habits such as aggressive
oride, amorphous calcium phosphate (eg, Tooth Mousse or tooth brushing, onychophagy, and biting on hard objects
MI Paste, GC), or calcium silicate associated to sodium phos- are probably easier to control through adequate patient
phate (NR-5 product line, Regenerate enamel science) may education.
be used regularly to remineralize enamel and protect it from It is finally important to involve other team members
further erosion, although efficacy varies according to prod- such as hygienists who can play an important role in install-
ucts and their active ingredient composition. ing, supporting, and monitoring preventive measures at all
When it comes to preventing the deleterious effect levels. Then, managing tooth wear involves multifactorial
of bruxism on tooth structure, no causal therapy is yet and team approach.
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36
Restoration Longevity, Risk Factors, and Tooth Wear Progression
How do we anticipate tooth wear progression in intervening with preventive measures as well as prema-
and restoration longevity? ture indication for complex and extensive prosthetic reha-
bilitations must be prevented; this is one of the profession’s
Success in tooth wear management depends first on a biggest challenges today, as tooth wear shows an increasing
proper identification and control of risk factors on a me- prevalence in nearly all age groups.
dium- to long-term perspective. As detailed in chapter 1, the The aforementioned consideration will then have a ma-
main decisional parameters to opt for a strategy (preventive jor influence on long-term tooth wear management and suc-
and/or interceptive and restorative) include causative wear cess, especially at the very beginning when selecting a treat-
mechanisms and severity as well as the patient’s age and ex- ment strategy. Put simply, installing preventive measures or
pected compliance with preventive measures. There are also at least applying interceptive protocols as soon as possible
co-factors such as carious and periodontal risks, preexisting allows tooth wear to be managed in a biomechanically con-
biomechanical conditions of worn teeth, and the patient’s servative way, which has the potential to limit long-term,
socioeconomic status. Again, the natural complexity of tooth overall breakdown of the patient’s dentition with likely high
wear pathology has to be judiciously managed, having par- financial cost exposure.
ticularly in mind that risk factors evolve (type of wear and pro- As explained in the diagrams on the following pages, the
gression) and also that no monotherapy can solve all cases. available treatment strategies will be applied not only (logi-
A modern approach to long-term tooth wear manage- cally) sequentially but also simultaneously with the possibil-
ment lies in the fact that for a large number of patients, the ity to apply them selectively, according to the specific pro-
team endeavor (including patient and practitioners) will gression of risk factors and tooth wear within different arch
most likely occur over a lifetime. Therefore, excessive delay zones.
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37
Conceptual management of tooth wear according to its progression and restoration aging and failures. The diagram depicts various sce-
narios of tooth wear progression and impact on dental structures; the concept actually applies to localized as well as generalized tooth
wear status.
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38
Tooth wear extent
Limited Moderate Severe
Preventive insufficient Interceptive & insufficient Restorative &

preventive preventive
measures measures measures
Stabilization Limited progression Stabilization Limited progression
Preventive Renewing & insufficient Replacement &

preventive preventive
measures measures measures
This second diagram introduces the idea of individualized clinical protocols and how they are adapted to the progression of tooth wear.
The treatment strategy then evolves according to risk factor development/changes together with the adherence of patients to erosion,
abrasion, and attrition preventive measures.
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39
P I
I R
This last diagram depicts the idea of selective, progressive application of interceptive and restorative protocols to adapt to individual
wear and biomechanical status of each tooth or area of the mouth. The central circle depicts the progressive number of teeth treated
with either interceptive or restorative approach (usually per arch or localized anterior sextant[s] in case of the Dahl approach). The sur-
rounded green circle suggests the continuous attempt to control risk factors.
P, preventive measures; I, interceptive procedures; R, restorative procedures.
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40
Which Treatment Strategy?
Preventive approach
Early signs of tooth wear were identified in a male patient

aged 35 years; note the flattened incisal edges and cuspid
tips, in both the maxillary and mandibular anterior teeth. Dis-
crete wear facets are also visible on posterior teeth. The pa-
tient reported intermittent episodes of temporal mandibular
joint (TMJ) pain and occasional limitations in the functional
envelope (restricted opening and lateral movements),
mainly in the morning. There was no report of conscious
awake bruxism and otherwise, no noticeable malocclusion
present. Clinical findings suggest moderate sleep bruxism,
which requested nightguard “therapy.” The patient was first
instructed to wear a thicker nightguard (Michigan splint) and
then after relief of temporomandibular disorder (TMD) symp-
toms (although it cannot be proven that improvement of
such symptoms would solely result from the nightguard ac-
tion), a thinner nightguard (1.5 mm, hard heat-formed tray)
was introduced. This type of nightguard, made especially
for the mandible, is a lot more comfortable than so-called
“therapeutic” appliances. It also has an interesting effect in
maintaining arch alignment and is proposed for both arches
in patients when “mesial drift” initiates crowding.
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41
The 25-year follow-up of this highly motivated patient shows only a slight progression of initial wear lesions, despite the obvious persis-
tence of the parafunction risk factor, as evidenced by a regular need to replace the nightguard.
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42
Interceptive and Restorative Strategies
When the wear extent, correlated to the patient’s age and common is a proper case study and planning through ad-
known (or supposed) compliance, does not allow mere pre- equate anatomical and functional wax-up (analog or digital).
ventive measures to be installed or when it was installed but It is not recommended to manage tooth wear with a direct
proved unsuccessful due to wear severity and progression (as approach without a detailed esthetic and functional plan; all
well as possibly a lack of patient compliance), restoring worn other usual diagnostic measures have to of course be per-
teeth becomes a necessity. Restorations will play multiple formed beforehand.
roles, including the replacement of lost tissues; functional,
anatomical, and esthetic enhancements; and, of course, pro-
tection of the dentition against further wear. The interceptive
strategy is based on the use of composite as the primary re-
storative material together with a no-prep approach. Severe
tooth wear might only occasionally mandate the recourse of
CAD/CAM or indirect restorations; the few indications for the
The upper three images (right page) show an alternative ap-
aforementioned treatment options as first intervention are
plication of the interceptive strategy; flowable composite
then severe bruxism (especially awake bruxism and insuffi-
was applied here on all anterior teeth to stop the wear pro-
cient nightguard compliance) and aggressive localized or
gression and support better esthetics until a suitable, com-
generalized erosion (mainly anorexia and bulimia).
prehensive treatment could be installed.
Interceptive protocols include the direct freehand ap-
proach and different molding techniques. Composite mold-
ing can be used to produce single (tooth-by-tooth) or mul-
tiple (sextant or quadrant altogether) restorations. Molding
can serve to restore any tooth surface but, as a general rule,
only for limited to moderate wear extent. A last option is to
use a molding technique in the laboratory, which is a sim-
plification of the method, when more space is available (in- The lower two images (right page) demonstrate the anatomi-
termediate wear severity) to fabricate “occlusal or palate-in- cal and esthetic improvement of worn maxillary teeth in an
cisal” shells that will be adhesively cemented as usual indirect elderly patient seeking for improvement with simple restora-
restorations. What all direct and molding techniques have in tive means.
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43
Chapter_2_1.indd 43 11.04.23 16:37
44
The Dahl Concept
The use of the “Dahl concept” has been largely promoted as The main indication to apply such a “social” treatment con-
a key strategy to treat anterior tooth wear. The original idea cept is on a localized scale when, for instance, single, existing
from Dr Dahl was to use a metal-based removable appliance indirect restorations can be left out of occlusion until they
covering worn anterior teeth, then to create a lateral/posterior return spontaneously to occlusion, based on the aforemen-
disocclusion; within a few months (depending on the space tioned principles; this prevents replacement of a few restor-
and patient), combined passive eruption of posterior teeth ations that are otherwise of satisfactory quality (anatomy,
and intrusion/displacement of anterior teeth would allow full- esthetics, and recently placed).
mouth occlusion to be reestablished at a new vertical dimen-
sion of occlusion (VDO). The obvious limitation of this concept
lies in the condition of posterior teeth; if the posterior teeth
are free of wear or decay, the Dahl concept is therefore a great Recommended Readings
approach to limit the need for a comprehensive, full-mouth
treatment. In the context of restorative techniques used in 1 Dahl BL, Krogstad O, Karlsen K. An alternative treatment
the 1960s (when this technique was first proposed), this was of cases with advanced localised attrition. J Oral Rehabil
a great contribution to the treatment of tooth wear, while it 1975;2:209–214.
seems less significant in today’s era of minimally invasive den- 2. Dyer K, Ibbetson R, Grey N. A question of space: options for
tistry. Then, when would the Dahl concept be indicated today? the restorative management of worn teeth. Dent Update
The best potential indications are deep-bite cases with brux- 2001;28:118–123.
ism and peculiar erosion cases, for instance, in patients with 3. Gough MB, Setchell DJ. A retrospective study of 50 treatments
compulsory consumption of fruits (acidic ones). In the first using an appliance to produce localised occlusal space by
case scenario, parafunctional lateroprotusive movements cre- relative axial tooth movement. Br Dent J 1999;187:134–139.
ate a natural disocclusion of posterior teeth due to the deep 4. Magne P, Magne M, Belser UC. Adhesive restorations, cen-
bite; however, in case of clenching, some wear facets might tric relation, and the Dahl principle: Minimally invasive ap-
also develop on posterior occlusal surfaces, hence suggesting proaches to localized anterior tooth erosion. Eur J Esthet
posterior teeth also be restored. In case of more severe erosion Dent 2007;2:260–273.
pathology such as reflux, bulimia, or anorexia, more general- 5. Poyser NJ, Porter RW, Briggs PF, Chana HS, Kelleher MG.
ized tissue loss is observed, which makes the Dahl concept in- The Dahl concept: Past, present and future. Br Dent J
appropriate. The Dahl concept has also been used for merely 2005;198:669–676
economic reasons in restoring anterior esthetics and function 6. Robinson S, Nixon PJ, Gahan MJ, Chan MF. Techniques for
without any consideration and treatment of worn posterior restoring worn anterior teeth with direct composite resin.
teeth; the later indication is of course highly controversial. Dent Update 2008;35:551–552, 555–558.
Chapter_2_1.indd 44 11.04.23 16:37

45
The case shown on the right page illustrates the trad-

itional indication for the Dahl concept in the context
of tooth wear. Here, however, posterior teeth were
treated with direct composite application to stabilize
occlusion and improve immediate functional stabil-
ity. See chapter 8 for detailed case presentation. Note
the Class II/2 occlusion with important overbite (in-
cisal edge level evidenced by the dotted line).
Chapter_2_1.indd 45 11.04.23 16:37
46
The modern vision of tooth wear is to observe the location and amount of tooth wear
that reveals the interplay of various risk factors (erosion, attrition, and abrasion) on
either natural tissues or restorative materials. Together with previous hard tissue decays
and related treatment, we can comprehend the biomechanical status and challenge of
individual teeth or groups of teeth. From this, a selective and individualized, etiology-based
treatment plan can be established that involves various protocols and the use of specific
restorative materials. The thinking that excessive wear will be resolved by monotherapy
is all but realistic and logical, apart from a few cases showing uniform wear extent. This
biomechanically oriented approach has recently challenged former, simplistic strategies
that have led to unnecessarily invasive and costly treatments. Interceptive strategy based
on various “no-prep” resin composite application protocols will then play a major role in
successful long-term tooth wear management.
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47
Interceptive Strategy
Chapter_2_1.indd 47
is Treatment Strategies 2
11.04.23 16:37
48
Interceptive strategy
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49
A female patient aged 42 years consulted due to frequent action of combined erosion and attrition, which is a highly
dentin hypersensitivity of her mandibular teeth. The overall common finding. There is a visible impact of attrition on
clinical evaluation revealed moderate, generalized tooth the smile (flattening of the smile line/shortening of incisal
wear of both arches, however with various levels of damage edges). However, the patient did not consider our proposal
among different areas. Lesions present in areas with for esthetic changes and in particular central incisor
higher sensitivity (mandibular posterior teeth) suggest the lengthening.
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50
The overall case management involved the three usual phases: (1) comprehensive clinical and medical anamnesis, including functional
and esthetic analysis; (2) treatment planning with help of a detailed anatomical and functional wax-up; and (3) placement of direct com-
posite restorations following the interceptive approach aiming to replace worn tissues, protect residual tooth structure, and improve
function. The mandible received a fuller anatomical remodeling, while in the maxilla, only hollowed lesions were filled up with compos-
ite. Maxillary palatal surfaces were also covered to restore worn areas and to maintain anterior contacts and guidance following increase
in VDO.
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51
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52
Posttreatment views following a fully no-prep approach, with freehand composite appli-
cation (wax-up driven). The 5-year recall views (right page) show the satisfactory behavior
of direct composite restorations despite a total lack of patient compliance with night-
guard protection.
In this particular case, despite a few identified esthetic deficiencies, no smile line correc-
tion was performed, as there was no patient demand for such enhancement. Detailed
protocols for the interceptive strategy are presented in chapter 4.
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5-year recall 53
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54
In case of more extensive wear lesions and especially when risk factors are not under
control, indirect or CAD/CAM restorations are logically indicated; we then comprehensively
follow more or less the so-called “restorative” strategy, which is by nature more complex
and also requires some tooth preparation, by convenience, to create prosthetic space or to
accommodate technical demands. Up to a certain extent, the indirect approach can be a
means to protect some vulnerable surfaces, such as in severe erosion cases (anorexia and
bulimia nervosa).
The need to apply a “restorative” strategy is a consequence of a lack of proper, timely
application of “preventive” and “interceptive” measures. In addition, it should not be
considered an alternative to the aforementioned strategies due to less conservative approach
and much higher treatment costs. Last but not least, maintenance of indirect restorations
is far more complicated than, for instance, renewing direct composite restorations, which
should be considered the first line of defense against tooth wear progression, together
with proper implementation of preventive measures. Needless to say, prevention should
accompany the patient throughout her or his dental life.
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55
Restorative Strategy
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rs Treatment Strategies 2
11.04.23 16:37
56
Restorative strategy
When the extent of tooth wear is really substantial (ie, severe indicated for severe tooth wear cases due to the number of
bruxism, especially awake bruxism [clenching] and limited restorations involved and need to proceed with a full-arch
patient compliance, bulimia, anorexia) a direct approach or approach; it is then much easier to have the patient receive
even molding techniques reaches its limits due to compos- all laboratory-made restorations on the same day.
ite mechanical properties and possibly the management of Another source of “complication” is the need to place
polymerization shrinkage in larger volumes. Next to material temporaries when teeth are being prepared; this is particu-
properties, another even more significant issue will be the larly imperative when Class I and II restorations are being
control of anatomy and function when using composite to integrated to the occlusal coverage (overlay or “veneerlay”
restore extensive portions of tooth structure; the latter limi- design). There are different options, but any form of tempor-
tation is of course related to the practitioner’s skills and the ary is critical when treating severe bruxers.
clinical protocol selected. Even if not ideal, a direct/molded 37-year-old patient showing severe tooth wear (image
approach might occasionally serve as long-term interim res- below and right page). See next double page for case anal-
torations to protect teeth from aggressive ongoing wear pa- ysis and description.
thology if the patient can’t afford a more complex and costly
treatment.
The main benefits of the “restorative” strategy (use of
CAD/CAM or indirect techniques) are the improved control
of restoration anatomy and function, together with the use
of stronger materials (CAD/CAM composite blocks or high-
strength monolithic ceramics); more detailed information
about the materials’ physicochemical properties will be pro-
vided in chapter 2.2. This unfortunately comes at a “price”
in terms of additional tissue removal and treatment costs;
It is practically impossible to place CAD/CAM and indirect
restorations without additional preparation (convenience
cavity design and minimum restorative space), which justi-
fies restricting this strategy to severe cases and makes the
interceptive approach the most widely indicated. Both the
CAD/CAM and indirect approaches involve contribution from
the laboratory; the CAD/CAM chairside option is basically not
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57
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58
This patient consulted upon referral for a second opinion in regard to the best treatment option for his severe tooth wear problem. The
rapid and extensive hard tissue loss (patient noticed the wear problem only a few years ago) reveals a bulimia problem, likely compli-
cated by parafunctional activities.
Unfortunately, the patient decided not to proceed with the needed rehabilitation due to financial reasons and returned only 10 years
later, seeking help after an extreme progression of his dental problems. The panoramic radiograph actually revealed the progression of
tooth wear, loss of vitality of several dental units, and the action of an additional carious risk factor. Such a dramatic evolution is unfor-
tunately not rare, underlying the value and importance of interceptive protocols. Comprehensive esthetic and functional analyses were
performed before proceeding with the urgent treatments, including extraction of the untreatable teeth (irrational to treat) as well as the
wisdom teeth. The mandibular second molar could not be maintained to due to recurrent endodontic infection and the extent of decay;
as the tooth was not considered strategic, additional treatment measures were unrealistic, and the tooth was extracted.
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59
The overall rehabilitation included several phases: (1) initial therapy with extractions and surgical crown lengthening where needed; (2)
treatment of decays and adhesive core buildups, maintaining the patient with the existing VDO; (3) esthetic treatment planning at the
new VDO, as defined by the wax-up, on articulated models; (4) placement of temporaries at the new VDO; (5) buildup of mandibular an-
terior teeth with a direct approach, at the new VDO; (6) reconstructing all other teeth/implants with monolithic lithium-disilicate restor-
ations (IPS e.max Press, Ivoclar Vivadent); and (7) close follow-up of risk factors and maintenance with a nightguard. A summary of the
aforementioned diagnostic and clinical steps is shown on the next double page.
For more details about the treatment protocols, see chapter 6.
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60
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61
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62
The rehabilitation comprised 22 monolithic lithium-disilicate restorations (overlays, onlays, and 360-degree veneers, stained and glazed)
over adhesive bases and 2 implants; 4 direct composite buildups (mandibular incisors) could be made on these teeth due to the protec-
tive effect of saliva. Such a restorative approach is complex and time consuming, leading to very high treatment costs; modern strategies
for tooth wear clearly aim to limit the use of complex, prosthetic rehabilitations (see chapter 6 for detailed presentation of this case).
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63
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64
The extent of tooth wear can greatly vary from one arch area to another; parafunctional
forces and erosion actually do affect tooth structure and restoration integrity in highly
different extents, this also in consideration of individual preexisting biomechanical status.
Therefore, a specific treatment approach should specifically answer local biomechanical
and clinical challenges.
For instance, bruxism, particularly clenching that triggers higher occlusal forces on molars
where the least space is normally available to restore worn tissues, creates different
material demands as compared to anterior teeth; it is then frequently advisable to use
high-strength bondable ceramics for the restoration of molars while using composite in
other areas. Similarly, taking into account the extent of occluso-anatomical corrections and
esthetic demands supports decisions based on criteria other than mere material strength;
this highlights the interest and need for hybrid treatment strategies, combining materials,
clinical protocols, and fabrication techniques.
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65
Hybrid Strategies
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hs Treatment Strategies 2
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66
Hybrid strategy: Case 1
The case presented here illustrates the frequent variability again, managing tooth wear is a lifetime challenge, and long-
in tooth wear extent within various mouth areas and also term maintenance and need for retreatment must be part of
the preexisting biomechanical status of worn teeth. In such our global thinking process, giving full priority to interceptive
cases, the restorative challenge will differ within the teeth to strategies or often “hybrid” restorative solutions as well.
be treated. Consequently, our treatment approach shouldn’t A female patient aged 38 years (tbc) presented for an es-
be driven by the widespread misconception that occlusal thetic consultation with a wish to replace maxillary anterior
or functional surfaces should all be restored with the same porcelain restorations (three-quarter crowns) placed about
material in order to “benefit” from a similar wear rate or ma- 10 years ago that did not satisfy her anymore. The initial clin-
terial hardness. The implication of such dogma would be to ical evaluation identified occlusal, functional, esthetic, and
consider a full-mouth prosthetic rehabilitation as soon as a anatomical deficiencies, in addition to the tooth wear prob-
few teeth require indirect restorations; on the contrary, we lem; overall findings suggested a global treatment approach.
must envision a selective approach and avoid unnecessary
tooth preparation for all surfaces that can be treated with a
no-prep approach. Owing to the passive eruption process
(which maintains teeth in occlusion despite tissue wear), it
is possible to combine ceramics (eg, lithium-disilicate, the
most common material used today for partial coverage)
with direct composite in order to minimize treatment com-
plexity and costs. Authors have actually been applying this
technique over 25 years with no evident contraindication,
whether from functional or material standpoints. Patients
with parafunctional activities receive a nightguard after
treatment, which greatly contributes to alleviating differen-
tial wear of dissimilar restorative materials. In our view, a safe
and conservative biomechanical approach (tissue preserva-
tion) should prevail over any other considerations. Another
factor emphasizes the interest of this “hybrid” approach,
namely to relate the treatment approach to the patient’s age.
As tooth wear affects young patients with a significant preva-
lence, it seems unrealistic to promote global prosthetic reha-
bilitations as the “gold standard” for such individuals. Once
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67
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68
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69
The treatment plan involved several aims and phases: (1) restorative) was selected to minimize invasiveness of the
correction of canted occlusal plane; (2) correction of over- overall treatment. Contrary to a widespread belief, there is
bite (mainly related to a supraeruption of mandibular ante- no evidence that a dual restorative material approach would
rior teeth); (3) correction of asymmetric gingival profile; (4) lead to any complication. Then, a combination of direct
increase of VDO; and (5) restoration of all worn teeth. Due composite buildups, pressed lithium-disilicate overlays, and
to the various biomechanical conditions of teeth requiring full crowns was used to adapt the various anatomical, me-
treatment, a hybrid approach (no-prep interceptive and chanical, and functional needs of this case.
The occlusal record made at the new VDO as set on the articulator The post-orthodontic situation shows an improved leveling of the
allows good visualization of the available interocclusal space; this mandibular occlusal plane; although the correction (intrusion) is
prevents unneeded preparation. not complete, it will provide suitable conditions when combined to
the planned posterior restorations; see next page for more details.
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70
In order to obtain a more even occlusal plane of the mandible and create restorative space to correct wear, mandibular anterior teeth
(canine to canine) were orthodontically intruded (using Invisalign) prior to covering the occlusal surfaces of posterior teeth to be recon-
structed. The combination of orthodontic intrusion of the anterior segment and occlusal buildup in posterior segments allowed the
levelling of inferior occlusal plane, with a correct curve of Spee.
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71
The rehabilitation of the mandibular occlusal surfaces involved a combination of ceramic

overlays (molars) and direct cusp buildup with composite (premolars). The use of stiff
and stronger monolithic lithium-disilicate restorations to overlay molars also proved ben-
eficial to stabilize central cracks, likely originating from previous amalgam restorations.
Such cracks actually require special attention in patients with bruxism. Note that dentin
buildup is assumed by resin composite, which has physical properties closer to natural
dentin. See chapter 6 for detailed information for tooth preparation prior to placement of
indirect restorations.
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72
Direct—No-prep cusp buildups
This clinical option is extremely effective from a technical

standpoint and helps reduce tissue involvement and treat-
ment costs; there would be no evidenced-based rationale to
use indirect restorations for these teeth!
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73
The maxillary posterior teeth exhibiting

minimal wear were restored with direct
composite to replace the existing, decayed
ones. This later treatment phase aimed to
increase VDO (contributing to reduce over-
bite while creating the needed restorative
space) and even maxillary and occlusal
planes.
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74
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75
The last restorative step for the mandible following the orthodontic intrusion was the direct buildup of the six mandibular anterior teeth,
according to the pretreatment functional wax-up. A silicone index helped to restore teeth at an optimal length, taking into consideration
the anatomical and volume changes to be applied in the prosthetic restorations for the maxillary anterior teeth.
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76
2.1 76 Treatment Strategies
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1-year recall 77
Prior to this last restorative phase, namely replacing the maxillary anterior three-quarter crowns, gingival surgery was performed to
correct the substantial gingival asymmetry; to this aim, a combination of coronally advanced flap surgery with connective tissue graft,
combined with a flattening of facial cuspid root profile, allowed for the creation of the needed, balanced soft tissue profile; the high tooth
display configuration mandated this procedure before the replacement of the maxillary anterior restorations. irconia-based crowns
(layered only facially) were made to minimize risk of fracture or chipping, as well as based on the patient’s request for more “dynamic”
forms. The last treatment step was to align corridors with a freehand application of composite on the facial surfaces of maxillary premo-
lars and molars; preexisting, slight canting of occlusal planes was then corrected by lengthening buccal cusps of the maxillary left teeth
during this procedure.
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78
Hybrid strategy: Case 2
A 62-year-old female patient consulted primarily because of highly disturbing dentin hypersensitivity resulting from attrition (bruxism)
and erosion (acidic diet). The patient had several aged and decayed posterior restorations that had to replaced. Some caries lesions were
also present on teeth nos. 15 and 17. Tooth no. 26 was extracted a long time ago and replaced with a porcelain-fused-to-metal bridge,
which also needed to be replaced. Radiographs are shown on the next double page.
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79
The second patient’s concern was about her “unsatisfactory” smile appearance, although tooth wear had here relatively limited impact
on esthetics. Loss of periodontal attachment (recession and open embrasures) and misalignment of maxillary and mandibular anterior
teeth were the main issues. As per the patient’s wish, the planned rehabilitation involved minimal invasive procedures and VDO aug-
mentation (covering simultaneously sensitive dentin surfaces) using a combination of direct and indirect bonded posterior restorations,
followed by orthodontics and direct esthetic restorations to fulfill esthetic expectations.
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80
The patient presented with an occlusal Class I with

group guidance and no signs of TMD. The kinesio-
graphic analysis performed with a computerized
system (Biokey, Bioket, San Benedetto del Tronto,
Italy) displayed quite linear movements of the man-
dible during voluntary tasks (opening/closing and
lateroprotusive movements) with wide range of
excursions.
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81
All decays were treated and amalgam restorations replaced. Exposed

dentin was sealed and covered following the principles presented
later in chapter 6.1, using an etch-and-rinse adhesive system (Opti-
Bond FL, Kerr) and a homogenous nanohybrid resin composite (In-
spiro Bi3, Edelweiss DR); composite served to create a thicker coat-
ing and to fill up undercuts. Then, digital impressions of both arches
were taken with an intraoral scanner (CS 3700, Carestream Dental).
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82
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83
A digital wax-up was performed with a VDO augmentation of 2 mm using a digital articulator. The selected restorative treatment plan
included nine veneerlays/tabletop veneers for all mandibular posterior teeth as well as tooth no. 16. For all other maxillary posterior
teeth, full occlusal corrections were planned (to be performed with direct, full molding technique). After designing the new occlusal and
anatomical scheme (left page), the CAD/CAM restorations were milled into composite resin blocks (Lava Ultimate, 3M) and presented
(possibly adjusted as well) on resin printed models. Veneerlays were adhesively cemented individually after rubber dam isolation, fol-
lowing the detailed protocols described later in chapter 6.3. and following conventional procedures.
Chapter_2_1.indd 83 11.04.23 16:38
84
3D-printed models of the new occlusal configuration were used to produce 2-mm-thick hard trays (Erkodur, Erkodent) needed to per-
form the full molding technique. Those trays were relined with a clear silicone (Memosil 2, Heraeus) to capture all the anatomical details.
On the maxillary right quadrant, direct restorations were first molded with the customized tray (right page) before cementation of the
overlay on tooth no. 16. Molding composite over the occlusal surfaces of the bridge of maxillary left quadrant bridge was used temporar-
ily, awaiting the completion of orthodontic corrections.
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85
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86
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Postoperative first treatment phase and Invisalign initial records 87
Posterior occlusion was checked, and minor adjustments were performed to obtain well-balanced contacts (see left page). After the pos-
terior restorative phase was completed, a small anterior open bite resulted from the VDO augmentation, freeing anterior teeth to allow
their realignment. The orthodontic treatment took place immediately, with new digital intraoral scanning and treatment planning with
Invisalign ClinCheck.
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88
Post-Invisalign corrective phase
After 9 months of treatment, the desired corrections were achieved and the outcome considered satisfactory apart from small black
triangles following anterior teeth alignment; this is common problem resulting from orthodontic alignment in adult patients with attach-
ment loss. As initially planned, some final esthetic restorations still had to be performed to level up lower incisal edges and create more
symmetric and harmonious forms. To this purpose, direct bonding will be used, following the Natural Layering Concept (see chapter 3.1)
and following a no-prep approach.
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89
2
Treatment Strategies89
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90
Replacement of the maxillary left bridge and direct composites
The maxillary left bridge replacement completed the treatment.

This case is another good illustration of the hybrid treatment ap-
proach, responding to different biomechanical needs with differ-
ent materials and protocols. The diversity of individual clinical sit-
uations imposes a specific and proportional restorative concept; it
also makes it possible to constrain treatment costs compared to a
classic full-mouth prosthodontic rehabilitation.
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91
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92
Basic Treatment workflow and sequence
PHASE 1 PHASE 2
Tt objectives (1)
Anterior esthetics
Laboratory Anterior function
Clinical examination (mounted models) (overbite/overjet)
igital ae Diagnosis:
• Risk factors
• Occlusal Analog or digital wax-up
• Functional and mock-up
• Esthetics
Analog/digital pH-metry and other • Biomechanical
documentation medical records
Tt objectives (2)
Occlusal position
VDO change
PHASE 3 PHASE 4 PHASE 5 PHASE 6
Maintenance and
Posterior restorations
Anterior restorations follow-up
Initial/intermediate • New VDO
• New Tooth Display • Repair
Preventive measures • (New) occlusal
• New Smile Line • New preventive
position
measures
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93
In the majority of patients, tooth wear will have an impact on long-term performance of restorations and individual tooth
their smile, with a flattened and irregular smile line as well as biomechanical status. The continuous implementation and
reduced tooth display in severe cases. The “visible” impact adaptation of preventive measures is another pillar of the
of tooth wear is known to be a major motivational factor for long-term management of tooth wear. A last consideration
seeking treatment, because dentin hypersensitivity, func- relates to the logical search for reliable, simple (especially
tional limitations, or any occlusal symptoms are less prev- with use of interceptive strategies to slow down tooth wear
alent and lead in some degree to the patient’s adaptation. progression), and time-effective restorative protocols. This
Then, esthetics will be a driving parameter next to function is why, for instance, we base our treatment planning first on
and occlusion in a modern approach to tooth wear. anterior function and esthetics (phase 2) while we usually in-
The overall treatment scheme comprises then six ba- itiate treatment with posterior restorations and then follow
sic phases: (1) diagnosis (clinical and functional, mainly up with anterior ones (phases 4 and 5); the logic behind this
on articulated models); (2) esthetic and functional-occlu- approach is that it is easier to adapt an anterior restoration’s
sal treatment planning; (3) implementation of immediate anatomy and function to the newly established occlusal pos-
and medium-term preventive measures; (4) restoration of ition and VDO rather than the other way around.
posterior teeth at the new VDO (typical concept in conserva- When it comes to defining an optimal VDO change, one
tive tooth wear treatments); (5) restoration of anterior teeth; has to take into consideration its implication on maintain-
and (6) maintenance and follow-up, including adaptation ing proper anterior guidance and esthetics (overjet and
of preventive measures and possibly restorations repair. In overbite), which are instrumental to a successful treatment
the long-term, a new treatment cycle will likely happen with outcome (phase 2, objective 1). Then, there is a strict limit
renewing and/or replacement of restorations with correc- to how much we can increase VDO within the known safe
tion-adaptation of preventive measures, based on tooth increase value (up to 5 mm at the incisor level) before sag-
wear risk factor and tissue loss evolution. ittal and transversal anatomical discrepancies will preclude
The imperatives of tissue conservation condition many proper posterior occlusion and functional stability to be at-
strategic concepts for the modern tooth wear approach, tained (phase 2, objective 2). This is why, understandably,
such a VDO increase, possible change of occlusal position, anterior function and esthetics drive overall treatment plan-
maximal use of no-prep additive protocols, selective use of ning, but not the restorative sequence, due to the aforemen-
restorative materials based on local biomechanical factors, tioned clinical and technical considerations.
and contribution of modern adhesive protocols to optimize
Chapter_2_1.indd 93 11.04.23 16:39
94
Treatment Sequence and Restorative Strategies
Lower R/L
Clinical examination restorations
Diagnosis and tt Photographic documentation

Functional
planning phases Radiographic documentation
check
Impressions/casts mounting
Upper R/L
Laboratory restorations
Diet analysis and Restoration
phases PH investigations Functional replacement/change
check
Direct Functional and
esthetic wax-up at Lower anterior
techniques new VDO and selected restorations
Repair/renewing
occlusal position
Indirect/CAD/CAM Functional
check
Functional test phase Yearly check-up/compliance
techniques (day-/night-guard, functional and risk factor follow-up
mock-up, temporaries) Upper anterior Functional check
restorations
Impressions Nightguard
Esthetic mockup Functional
check
W1 W2 W3
Timeline
Tt planning phase Treatment phase Maintenance and follow-up
Clinical examination
Lower R/L
Photographic
restorations
documentation
Radiographic
documentation Functional
Impressions/casts check
mounting
Upper R/L
Diet analysis and restorations
PH investigations Restoration
Functional replacement/change
Functional and esthetic check
wax-up at new VDO
and selected occlusal Lower anterior
Repair/renewing
position restorations
Functional
Functional test phase
check Yearly check-up/compliance
(day-/night-guard,
functional mock-up, and risk factor follow-up
Functional check
temporaries) Upper anterior restorations
Impressions Nightguard
Functional
Esthetic mock-up check
W1 W2 W3 W4-5
Timeline
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95
i ect tec ni ue nl u e le diag a treatment is completed, we normally allow about 2 weeks

to confirm the patient’s adaptation to the new occlusal and
The treatment sequence and especially its duration largely re- functional scheme. Provided VDO increase remains below
lates to the chosen restorative protocol(s); direct techniques the known adaptation range and the eventual occlusal po-
will of course allow a much shorter treatment time compared sition change is properly planned (see chapter 3 for more
to indirect CAD/CAM techniques. One principle, however, ap- information), it is very seldom to experience a true lack of
plies to all restoration techniques, which is to simultaneously functional adaptation. Worst case scenario, we might need
restore both the upper or lower quadrants in one step so that to allow the patient a little more time and/or to perform
we can grant minimum occlusal stability and functional com- some additional adjustments until we can confirm final inte-
fort. Anterior restorations can be slightly delayed if considered gration of the newly placed restorations. Then, impressions
beneficial to the patient’s comfort. It is not uncommon for the can be performed for nightguard fabrication (see chapter 8.4
patient to experience muscle tiredness and have difficulty for detailed information about tray fabrication).
maintaining a forced mouth opening during long sessions. The follow-up period involves periodic recalls (usually a
This is why we recommend that treatment sequences have a yearly occurrence) and repair or renewing procedures when
maximum of two daily sessions (lunch break for instance sep- needed until some or all restorations need to be replaced
arating both appointments) to provide sufficient muscle re- (see chapter 8 for maintenance and renewing phases). If
cuperation and relaxation; such sessions usually last 2 hours using direct techniques appropriately (limited to moderate
at most, unless a few small Class I and II defects are to be tooth wear severity), this follow-up period usually lasts from
restored simultaneously. In case there are more than one or 6 to 10 years before an overall renewing or restoration re-
two small occluso-proximal cavities to be treated, we strongly placement become necessary.
recommend having all decays restored before occlusal build-
ups and VDO increase. We also believe that first restoring the i ed e a ilitati n l e le diag a
new VDO and posterior occlusion with the selected occlusion
has a more sensible rationale than first restoring the anterior When some indirect restorations (commonly veneers in max-
teeth, next to some obvious clinical facilitation; it is also tech- illary anterior teeth) are indicated, the restorative time frame
nically much easier to restore anterior occlusion based on is augmented; 7 to 10 days are usually needed, followed by
a set VDO and occlusal positions rather than the other way the 2-week adaptation time until the final occluso-functional
around, especially when using a direct technique. corrections can be performed and the nightguard delivered.
Functional adjustments and occlusal contact equili- The follow-up strategy should otherwise be similar to the full
bration should happen after each restorative step. When direct treatment approach.
Chapter_2_1.indd 95 11.04.23 16:39
96
Basic treatment workflow and sequence
Lower R/L restorations
Photographic Functional
documentation check
Radiographic
documentation
Impressions/casts Upper R/L restorations
mounting
Functional
Diet analysis and check
replacement/change
Functional and esthetic Lower anterior Restorations
wax-up at new VDO
and selected occlusal
Functional Repair/renewing
position
check

Upper anterior restorations Yearly check-up/compliance
(day-/night-guard,
temporaries) Functional
check
Esthetic mock-up Impressions Nightguard
W1 W3-4
Timeline
When indirect and CAD/CAM restorations are indicated, the patient adaptation to ongoing occluso-functional changes
overall treatment time frame is significantly increased after while limiting the “stress” of an extensive rehabilitation.
the diagnosis and treatment planning phases are completed. In patients with good tolerance to long treatment ses-
No precise time frame is given for the latter procedures, as this sions, the alternative protocol is to proceed simultaneously
may require not only regular dental assessments but also the with either a full posterior (upper diagram, right page) or full
contribution of other physicians (eg, gastroenterologist, psy- arch (lower diagram, right page) rehabilitation approach.
chiatrist, dietician, physiotherapist, etc). As for direct restor- This restorative strategy has obvious advantages in terms of
ations, defining the new VDO and a proper occlusal position treatment duration but bears the aforementioned shortcom-
precedes the placement of anterior restorations. The overall ings of limited adaptation and recuperation time, next to the
time frame of the restorative phase largely depends on patient patient’s potential tiredness and stress. As for many other
and operator factors; each sector (maxillary and mandibular considerations, there is no universal treatment sequence; on
posterior, maxillary and mandibular anterior sextants) can be the contrary, we logically adapt our restorative approach to
restored individually (above diagram), allowing progressive optimize treatment outcomes and patient comfort.
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97

Photographic
documentation
Radiographic
documentation Lower anterior restorations
Impressions/casts
mounting
Functional
check
Diet analysis and
replacement/change
Upper R/L restorations
Functional and esthetic
wax-up at new VDO
Upper anterior restorations Repair/renewing
position
Functional
check Yearly check-up/compliance
(day-/night-guard,
check
W1 W2 W3 W4
Timeline

Photographic
documentation
Radiographic
documentation Upper L/R restorations
Impressions/casts
mounting
Functional
check
Diet analysis and
replacement/change
Upper anterior restorations
Functional and esthetic
wax-up at new VDO
Lower anterior restorations Repair/renewing
position
Functional
check Yearly check-up / Compliance
(day-/night-guard,
functional mock-up, Risk factor follow-up
check
W1 W2 W3 W4
Timeline
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98
Chapter_2_1.indd 98 11.04.23 16:39

Recommended Readings 99
1. Colon P, Lussi A. Minimal intervention dentistry: Part 5. Ul- restorative care 2: The management of generalised tooth
tra-conservative approach to the treatment of erosive and wear. Br Dent J 2012;212:121–127.
abrasive lesions. Br Dent J 2014;216:463-468. 11. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current con-
2. Dietschi D, Argente A. A comprehensive and conservative cepts on the management of tooth wear: Part 4. An overview
approach for the restoration of abrasion and erosion. Part I: of the restorative techniques and dental materials com-
Concepts and clinical rationale for early intervention using monly applied for the management of tooth wear. Br Dent J
adhesive techniques. Eur J Esthet Dent 2011;6:20-33 2012;212:169–177.
3. Dietschi D, Argente A. A comprehensive and conservative 12. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current con-
approach for the restoration of abrasion and erosion. Part II: cepts on the management of tooth wear: Part 1. Assessment,
Clinical procedures and case report. Eur J Esthet Dent treatment planning and strategies for the prevention and the
2011;6:142–159. passive management of tooth wear. Br Dent J 2012;212:17–27.
4. Gr tter L, Vailati F. Full-mouth adhesive rehabilitation in case 13. Mesko ME, Sarkis-Onofre R, Cenci MS, Opdam NJ, Loomans
of severe dental erosion, a minimally invasive approach fol- B, Pereira-Cenci T. Rehabilitation of severely worn teeth:
lowing the 3-step technique. Eur J Esthet Dent 2013;8:358–375. A systematic review. J Dent 2016;48:9–15.
5. Klink A, Groten M, Huettig F. Complete rehabilitation of com- 14. Milosevic A. Clinical guidance and an evidence-based ap-
promised full dentitions with adhesively bonded all-ceramic proach for restoration of worn dentition by direct composite
single-tooth restorations: Long-term outcome in patients with resin. Br Dent J 2018;224:301–310.
and without amelogenesis imperfecta. J Dent 2018;70:51–58. 15. Muts EJ, van Pelt H, Edelhoff D, Krejci I, Cune M. Tooth wear:
6. Klink A, Huettig F. The challenge of erosion and minimally in- A systematic review of treatment options J Prosthet Dent
vasive rehabilitation of dentitions with BEWE grade 4. Quin- 2014;112:752–759.
tessence Int 2016;47:365–372. 16. Oudkerk J, Eldafrawy M, Bekaert S, Grenade C, Vanheusden
7. Loomans B, Opdam N, Attin T, Bartlett D, et al. Severe Tooth A, Mainjot A. The one-step no-prep approach for full-mouth
Wear: European Consensus Statement on Management rehabilitation of worn dentition using PICN CAD-CAM res-
Guidelines. J Adhes Dent 2017;19:111–119. torations: 2-yr results of a prospective clinical study. J Dent
8. Lussi, A, Ganss, C (eds). Erosive Tooth Wear: From Diagnosis 2020;92:103245.
to Therapy. Monographs in Oral Science, vol 25, Monographs 17. Rees JS, Somi S. A guide to the clinical management of attri-
in Oral Science. Basel: Karger, 2014. tion. Br Dent J 2018;224:319–323.
9. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current con- 18. Vailati F, Vaglio G, Belser UC. Full-mouth minimally invasive
cepts on the management of tooth wear: Part 2. Active re- adhesive rehabilitation to treat severe dental erosion: A case
storative care 1: The management of localised tooth wear. Br report. J Adhes Dent 2012;14:83–92.
Dent J 2012;212:73–82. 19. Varma S, Preiskel A, Bartlett D. The management of tooth
10. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current wear with crowns and indirect restorations. Br Dent J 2018;
concepts on the management of tooth wear: Part 3. Active 224:343–347.
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0 100
2.2
CHAPTER
With contributions by Dr Renan Belli, Friedrich-Alexander-Universität Erlangen-Nuremberg (D).
2.2
Chapter_2_2.indd 100 11.04.23 16:39
101
Restorative Materials
Chapter_2_2.indd 101
rm https://dentalbooks.net/
11.04.23 16:39
102
Why Are Material’s Physical Data Really Important?

One of the core aims of dental materials science is to investi- structural complexity and associated stress variability cre-
gate the relationships between some mechanical properties ates unlimited confounding factors that also impact the sig-
and the clinical behavior of restorations and developing to nificance of clinical studies. The better standardized “single
this purpose the most appropriate testing methodologies. operator” studies or the less homogenous multi-operator
The mechanisms causing restoration degradation and ulti- and multicenter ones have their own limitations and justify
mately failure are rather complex due to, on one hand, the pursuing and improving in vitro trials, at least as preclinical
variability of stresses (combination of thermal, chemical, tests, and ultimately also reducing the need for time-con-
and mechanical strains) and on the other hand, the intricate suming and complicated clinical trials.
interactions between the aforementioned stresses and ma- The value of any material test lies in its ability to predict,
terial structure, microstructure, and ultra-structure at both describe, and analyze potential restoration failures, and the
material and natural tissues levels. A last crucial parameter process therefore starts with proper identification of clinical
(or group of parameters) relates to the substrate on which failure scenarios. An abundance of literature describes the
such restorations are placed and how they are cemented to multiple origins and mechanisms leading to restoration loss
it. One could then argue that the natural complexity of the and need for replacement, such as partial or bulk fractures,
oral cavity and masticatory function combined to specific restoration wear, loss of marginal and internal adaptation
biomechanical conditions of each restored tooth make it im- leading to interfacial fluid penetration, bacterial infiltration,
possible to emulate in vitro with a likely relevance, but this and superficial or deep tissue demineralization (decays and/
reasoning is only fragmentally founded because this same or pulpal pathologies).
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103
Logically, adhesive procedures play an important role prevalence is a prerequisite to suitable material selection in
because the resistance and stability of the restoration-tooth the context of tooth wear treatment where the environment
interface is as important as the intrinsic material properties; places restorations under unusual stresses. The information
restoration survival then largely depends on it. provided later in this section summarizes the current me-
The modern view on material and restoration perfor- chanical performances of various materials classes that are
mance and degradation is then based on the interaction of used routinely in restorative dentistry and prosthodontics.
dental restorations with cyclic chemo- and thermo-mechan- Some information about strength variability and the impact
ical stresses triggering (1) material surface and internal flaw of fatigue on material resistance will complete the usual “in-
growth and (2) interface aging and degradation. The occur- ert” strength values presented later.
rence of mechanical bulk failures following a unique, abnor- Although material mechanical data alone are not suffi-
mally high-stress incident is less relevant today due to its cient to select a material for tooth wear treatment, it is an
rare incidence; then, for instance, popular in vitro testing of important element to consider with other selection criteria
restored teeth loaded until fracture, especially without prior such as esthetics, fabrication process, cost, repairability, and
fatigue simulation, should receive less attention in the future. the possibility to use adhesive cementation procedures.
All restoration failures potentially also have consequences
on the biomechanical status of remaining dental structures,
increasing further tooth frailty or loss risk. This is why under-
standing and anticipating material failure mechanisms and
Chapter_2_2.indd 103 11.04.23 16:39
104
Basic material abbreviations: R, zirconia; Li-Si, lithium silicate; Li-Di, lithium-disilicate; Leuc, leucite; Feld, feldspar; PIGS, polymer infil-
trated glass scaffold; CADRC, CAD resin composite; DRC, direct resin composite. Note that direct composite exhibit significant variations
in their flexural strength values; for this material group, data from other studies are included.
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105
Left and right page: Data courtesy of Dr Renan Belli and co-workers, Friedrich-Alexander Universit t Erlangen Nuremberg, Germany. All
data (except the direct composite group) were obtained from the same experimental protocol which allow for meaningful comparisons.
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106
Polycrystalline Ceramics
Reliability
Fracture Toughness Cyclic Fatigue
Brand Name Material Class Young Modulus [GPa] Strength [MPa] (Weibull modulus
[MPa m] Susceptibility (n)
m)
IPS e.max ZirCAD MO

(Ivolcar-Vivadent)
3Y-TZP 212 1254 9.0 4.90
Lava Plus
(3M Oral Care)
3Y-TZP 214 1337 6.6 4.45 20.9
Cercon ht
(Dentsply-Sirona)
3Y-TZP 214 1246 18.6 4.87
Katana ML
(Noritake)
4Y-TZP 217 1249 12.1 4.27
17.9
IPS e.max ZirCAD MT
(Ivoclar-Vivadent)
4Y-TZP 215 754 5.9 3.45
Lava Esthetic
(3M Oral Care)
5Y-TZP 215 830 11.9 3.26
Cercon xt
(Dentsply-Sirona)
5Y-TZP 216 832 8.2 2.80 23.7
Katana STML
(Noritake)
5Y-TZP 214 744 13.9 2.64
irconia-based polycrystalline ceramics are represented here as three successive materials generations. The first one is the yttria-stabi-
lized tetragonal (80%–90%) zirconia, which was followed by two subsequent modifications with increased ytrria content (4Y and 5Y-T P)
and higher cubic phase (up to 50%). The higher the tetragonal phase, the stronger the material is, but to the detriment of its translucency.
Usually, 3Y-T P materials are used for bridge and large construction frameworks, while more translucent forms (4Y-T P and 5Y-T P) are
for smaller bridges or single crowns.
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107
Glass Ceramics
Reliability
Fracture Toughness Cyclic Fatigue
Brand Name Material Class Young Modulus [GPa] Strength [MPa] (Weibull modulus
[MPa m] Susceptibility (n)
m)
IPS e.max Press Lithium

101 467 16.6 2.25 33.0
(Ivoclar-Vivadent) disilicate
IPS e.max CAD Lithium

102 649 9.2 2.04 14.2
(Ivoclar-Vivadent) disilicate
Celtra Duo Lithium

107 627 5.2 1.51 19.4
(Dentsply-Sirona) silicate
Suprinity PC Lithium
103 611 5.2 1.39 15.5
(VITA Zahnfabrik) silicate
Vitablocks Mark II
(VITA Zahnfabrik)
Feldspar 72 119 18.7 1.23 14.4
IPS Empress CAD

(Ivoclar-Vivadent)
Leucite 65 199 17.6 0.99 28.4
The glass-ceramic group comprises various material generations; the oldest one is feldspar-based ceramics (eg, VITABLOCS Mark II, VITA),
followed by leucite-reinforced ceramics (eg, IPS Empress CAD, Ivoclar Vivadent). Modern lithium silicate and lithium-disilicate systems
have replaced the later materials in most of their indications, especially in tooth wear cases due to their improved mechanical perfor-
mances. The common characteristic of glass ceramics is to be easily etchable, a favorable feature to fabricate partial bonded restorations.
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108
Composites
Reliability Fracture Toughness Cyclic Fatigue
Brand Name Material Class Young Modulus [GPa] Strength [MPa]
(Weibull modulus m) [MPa m] Susceptibility (n)
Polymer-
Enamic
infiltrated glass 37 195 19.2 1.12 28.4
(VITA Zahnfabrik)
scaffold
Lava Ultimate Indirect resin

13 231 10.8 1.14 25.7
(3M Oral Care) composite
Cerasmart Indirect resin

10 262 6.2 0.99 9.9
(GC) composite
Brilliant Crios Indirect resin

11 275 5.9 1.22 13.6
(Coltène) composite
Grandio Blocs Indirect resin

14 353 12.4 1.42 20.8
(VOCO) composite
Grandio SO Direct resin

16 243 13.1 0.97 27.1
(VOCO) composite
The composite group comprises the new polymer-infiltrated glass scaffold (PIGS) Enamic system (VITA), CAD composite ma-
terials, and one direct composite (GrandioSO, VOCO). Overall, this class of materials exhibits rather similar strength values but
with significant variations in stiffness (Young modulus), structural homogeneity (Weibull modulus), and response to fatigue
(n). The PIGS Enamic system appears to be an interesting alternative to composite for indirect restorations due to its good
fatigue behavior and higher stiffness, a useful feature to restore biomechanically fragilized teeth. Note that the GrandioSO
composite performs best in its class and is not fully representative of this material type.
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109
How to Interpretate Those Data?

In vitro testing of dental materials involves various method- that the average inert strength values are in fact not met by
ologies, such as quasi-static (ie, flexural strength, fracture a significant number of samples. The second aspect consid-
toughness) and cyclic measurements, with combinations of ers the impact of chemical and mechanical stresses (fatigue)
them to increase overall relevance. In search of better clinical on material strength; in other words, how much strength
guidance, dental materials science has recently integrated will the material lose when submitted to short-, medium-,
more comprehensive additional “dimensions” to usual (in- and long-term oral strains (moisture, thermal, masticatory,
ert) strength values of restorative tooth-colored materials. and parafunctional stresses). The cyclic fatigue susceptibil-
For brittle materials such as composites and ceramics, one ity (n) reflects how fast cracks can grow when the material
relates to the variations or spread of measurements (values is subjected to loads that are lower than the load required
at which the specimens fail) around the characteristic num- for spontaneous fracture, following different fatigue phases
ber; the reliability of strength data is then weighted by the (ie, biaxial flexure cycles in moist environment), and simu-
Weibull modulus (m). The spread of strength values is ac- lating various periods of clinical service (ie, from 1 day to 50
tually to be essentially attributed to material internal and years). Then, the higher the n value of a material, the more
surface flaws where cracks initiate and ultimately lead to resilient it is to fatigue, indicating a lower degradation poten-
specimen failure; an important aspect of material behavior tial during clinical service (resistance to stress corrosion and
(intraorally and during in vitro testing) is logically material crack propagation). So, the later values (m and n) showing
homogeneity as well as the quality of specimen preparation next to nonfatigued material data should help to adjust the
(aiming to limit the formation of additional flaws). The m relevance of data usually presented in the manufacturer’s
values are considered “best” in the range of 15 to 20, “satis- documentation or clinical publications.
factory” from 10 to 15, and “suboptimal” below 10, meaning
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110
Which Material to Use?

As mentioned previously, modern tooth-colored materials direct approach or an indirect or CAD/CAM approach. When
consist of three categories, namely polycrystalline ceramics the direct approach is no longer feasible (extent of restor-
(3Y- to 5Y-T P zirconia); glass ceramics, which exist in various ations, presence of cracks, nonvital teeth, severe bruxism,
forms (feldspar, leucite-reinforced, lithium-silicate and -disil- and limited patient compliance), the use of resin compos-
icate); and finally, composite materials with two subclasses, ites or CAD composite blocks for indirect partial restorations
namely traditional resin composites and a new polymer-in- is considered overall less ideal than glass ceramics; in fact,
filtrated glass structure (PIGS). The traditional resin com- the latter material type would be preferred due not only to
posite formulation exists mainly today as a direct material its superior strength but also its higher stiffness, which is a
(which can be used also for indirect restoration fabrication) positive feature to restore biomechanically fragilized teeth or
or CAD composite blocks. to resist clenching forces with limited restorations thickness.
Zirconia is the strongest tooth-colored material with For all other indications (limited to moderate tooth wear),
however reduced performance of semitranslucent forms; the direct application or resin composite has multiple advan-
this material class is then the ideal material for prosthetic tages, such as application simplicity, total noninvasiveness,
restorations (crowns and bridges), mainly for replacement of repairability, low cost, and well-documented performance.
preexisting ones; restorations can be either cemented or ad- Although showing some improvements in their mechanical
hesively luted as all zirconia types exhibit good strength. For performance (as compared to direct materials), CAD com-
partial restorations, depending on the severity of parafunc- posite blocks show rather limited indications for the treat-
tional activities and the extent of tooth wear, either glass ment of tooth wear.
ceramics or resin composites can be selected, following a
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2
111.2
1. Heintze SD, Ilie N, Hickel R, Reis A, Loguercio A, Rousson V. 8. Wendler M, Belli R, Valladares D, Petschelt A, Lohbauer U.
Laboratory mechanical parameters of composite resins and Chairside CAD/CAM materials. Part 3: Cyclic fatigue param-
their relation to fractures and wear in clinical trials A sys- eters and lifetime predictions. Dent Mater 2018;34:910–921.
tematic review. Den Mater 2017;33:e101–e114. 9. Alamoush RA, Silikas N, Salim NA, Al-Nasrawi S, Satterthwaite
2. Lohbauer U, Belli R, Ferracane JL. Factors involved in me- JD. Effect of the composition of CAD/CAM composite blocks on
chanical fatigue degradation of dental resin composites. mechanical properties. Biomed Res Intl 2018;2018:4893143.
J Dent Res 2013;92:584–591 10. Wendler M, Stenger A, Ripper J, Priewich E, Belli R, Lohbauer
3. Belli R, Wendler M, de Ligny D, et al. Chairside CAD/CAM ma- U. Mechanical degradation of contemporary CAD/CAM resin
terials. Part 1: Measurement of elastic constants and micro- composite materials after water ageing. Dent Mater 2021;37:
structural characterization. Dent Mater 2017;33:84–98. 1156–1167.
4. Wendler M, Belli R, Petschelt A, et al. Chairside CAD/CAM 11. Belli R, Ignacio orzin J, Petschelt A, Lohbauer U, Tommaso
materials. Part 2: Flexural strength testing. Dent Mater Rocca G. Crack growth behavior of a biomedical polymer-ce-
2017;33:99–109. ramic interpenetrating scaffolds composite in the subcritical
5. Kirsten J, Belli R, Wendler M, Peschelt A, Hurle K, Lohbauer U. regimen. Eng Fract Mech 2020;231:107014.
Crack growth rates in lithium disilicates with bulk (mis)align- 12. Belli R, Hurle K, Schürrlein J, et al. A revisited relationship be-
ment of the Li2Si2O5 phase in the 001 direction. J Non Cryst tween fracture toughness and Y2O3 content in modern den-
Solids 2020;532:119877. tal zirconias unpublished preprint 17 February 2021 . Chem-
6. Belli R, Wendler M, Petschelt A, Lube T, Lohbauer U. Frac- Rxiv doi:10.26434/chemrxiv.14044205.v1.
ture toughness testing of biomedical ceramic-based ma- 13. Belli R, Lohbauer U. The breakdown of the Weibull behavior
terials using beams, plates and discs. J Eur Ceram Soc in dental zirconias. J Am Ceram Soc 2021;104:4819–4828.
2018;38:5533–5544. 14. Zhang F, Reveron H, Spies BC, Van Meerbeek B, Chevalier J.
7. Belli R, Wendler M, Cicconi MR, et al. Fracture anisotropy in Trade-off between fracture resistance and translucency of
texturized lithium disilicate glass-ceramics. J Non Cryst Sol- zirconia and lithium-disilicate glass ceramics for monolithic
ids 2018;481:457–469. restorations. Acta Biomater 2019;91:24–34.
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0 112
2.3
CHAPTER
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113
Treatment of Interfaces
ti Treatment Strategies 2
11.04.23 16:39
114
Treatment of Interfaces for Adhesion
Among many other factors, the quality and stability of adhe- within modern adhesives. A few general guidelines can be
sive interfaces contribute to the longevity of any restoration. drawn, such as first, the imperative need to etch enamel for
When rehabilitating worn dentitions, multiple interfaces a minimum of 30 seconds with phosphoric acid (H3PO4) to
have to be managed, either simultaneously or subsequently. provide an optimal etching pattern on both cut and uncut
It is then crucial to apply proper procedures on each surface enamel. In regard to dentin, both self-etching (self-etching,
and select the best products to optimize interfacial bond acidic, and hydrophilic primer) or etch-and-rinse (etching
strength. A flawless interface is the ultimate goal for adhesive dentin for 5 to 15 seconds with H3PO4 prior to hydrophilic
restorations, such as shown on the scanning electron micro- primer application) systems can be used with similar ef-
scope (SEM) images underneath. ficacy. Whichever approach is chosen, the highest bond
strength and stable interface will be attained with a separate
Dental substrates
hydrophobic bonding; nowadays, the two product groups
Procedures to be applied on dentin and enamel are rather considered the gold standards are the 2-step self-etching
well standardized, although many options are available and 3-step etch-and-rinse systems.
Both of these restoration sections show a perfect continuity

with enamel (left image) and dentin (right image) following a
fatigue test simulating 4 years of clinical function. To achieve
such stable bond between tooth structure and restorative ma-
terial is key to successful outcomes of interceptive and restora-
tive treatment protocols for tooth wear.
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115
Restorative material substrates coating with an uncured hydrophobic bonding agent (some
chairside procedures and non–post-cured material) or ap-
There are two ways for adhering to restorative materials, plication of a multifunctional monomer or silane. For in-
namely by creation of micro-retentions through sandblast- direct glass-ceramic restorations, the most common pro-
ing or etching and chemical bonding with the use of a chem- cedure involves first an etching with buffered hydrofluoric
ical coupling agent such as multifunctional monomers (eg, acid to create micro-retentions through vitreous matrix and
10-MDP) or silane. The silicoating (tribo-chemical silica crystal dissolution (NB: recommended etching time and HF
coating) aims to deposit a silica layer on some restorative concentration greatly varies between materials), followed
materials during sandblasting (using special silica-coated by silane coupling. For zirconia-based restorations, sand-
Al2O3) to enhance chemical bond achieved with silane. blasting is used to smooth machining grooves but without
Aforementioned procedures are usually used in combina- aiming to create micro-retentions. Chemical coupling with
tion to enhance bond strength and stability. For indirect multifunctional monomers and/or silane is otherwise the
or CAD/CAM resin composite restorations, generally a pre- only way to bond to zirconia, usually following sandblast-
treatment is made with sandblasting, followed by surface ing and silicoating.
Confocal images showing adhesive failure (left) and perfect in-

terface (right). Note the well-formed hybrid with good penetra-
tion of bonding agent into dentinal tubules (resin tags). Com-
posite cement particles are visible within luting cement. The
failed interface resulting from another product combination
led to imperfectly structured interface.
Chapter_2_2.indd 115 11.04.23 16:39
116
Surface preparation
1a. Etching of glass ceramics
NB: Etching time is HF concentration

and material dependent.
Leucite reinforced (IPS Empress, Ivoclar Lithium-disilicate (IPS e.max CAD, Ivoclar
Vivadent) Vivadent)
1b. Sandblasting of zirconia and resin composites
ircon 3Y-T P (Vita In-Ceram Y , Vita). Nanohybrid

Courtesy of Prof. A. Mainjot, Liège University (eg, Miris 2, Colt ne/Whaledent)
and Prof. J. Chevalier, Dr L. Gremillard,
Dr. T. Douillard, INSA, Lyon.
2.3
NB: Resin composites can also be sandblasted with
conventional Al2O3 powder (25 to 50 m).
Treatment of Interfaces
Chapter_2_2.indd 116 11.04.23 16:39

Coupling and adhesive procedures 117
2. Cleaning 3. Silane and/or 4. Adhesive

• Ultrasonic bath multifunctional monomer • Hydrophobic bonding
• Brushing with H3PO4* • eg, Monobond-S (Ivoclar Vivadent) • eg, Clearfil SE Bond
• Dedicated cleaning agent** • eg, Monobond Plus (Ivoclar Vivadent) • (no light-curing)
• Air spray • eg, Clearfil SE Primer (Kuraray) • Hydrophobic bonding
• eg, Mononbond-S
• Alcohol • eg, Monobond Plus (NB: no light-curing)

Not to be used with zirconia. • eg, Clearfil SE Bond Primer eg, Clearfil SE Bond
NB: An “all in one” product (eg,
Decontamination after trial in mouth. Monobond Etch Prime, Ivolcar Vivadent) can replace steps 1a to 3. A universal adhesive
(eg, Adhese Universal, Ivoclar Vivadent) can replace steps 3 and 4. The traditional protocol
with individual steps is however recommended.
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118
Tissue preparation
Etching of enamel
On the left image, enamel was conditioned

with a self-etching adhesive and shows
insufficient retentive features; on the con-
trary, etching for 30 seconds (effective both
on cut and uncut enamel) creates the etch-
ing pattern needed for optimal adhesion.
Enamel etching is then recommended with
any adhesive type.
Etching of dentin
On the left image, dentin was both over-

etched and dried before primer appli-
cation; collagen network collapsed, im-
peding penetration of the adhesive. This
“drawback” of etch-and-rinse adhesives
can be easily prevented by controlling
etching time (5 to 15 seconds maximum)
while keeping dentin slightly moist before
primer application; this results in open col-
lagen network, facilitating bonding resin to
fully penetrate porosities. This grants qual-
ity and stability of the hybrid layer.
Chapter_2_2.indd 118 11.04.23 16:39

1. zcan M. Adhesion of resin composites to biomaterials in dentistry: An evaluation

of surface conditioning methods thesis . Groningen, Netherlands: University of
Groningen, 2003.
The gold standards remain the
2-step self-etch (eg, Clearfil SE Bond) 2. Passos SP, Ozcan M, Vanderlei AD, Leite FP, Kimpara ET, Bottino MA. Bond strength
and 3-step etch-and-rinse (eg, Op- durability of direct and indirect composite systems following surface conditioning
tiBond FL, Kerr) adhesive systems. for repair. J Adhes Dent 2007;9:443–447.
In short, they create a more stable, 3. Belli R, Geinzer E, Muschweck A, Petschelt A, Lohbauer U. Mechanical fatigue
moisture-resistant interface (hybrid degradation of ceramics versus resin composites for dental restorations. Dent
layer) compared to the many simpli- Mater 2014;30:424-432.
fied, modern adhesive systems. 4. zcan M, Bernasconi M. Adhesion to zirconia used for dental restorations:
A systematic review and meta-analysis. J Adhes Dent 2015;17:7–26.
5. Belli R, Wendler M, de Ligny D, et al. Chairside CAD/CAM materials. Part 1:
Measurement of elastic constants and microstructural characterization. Dent
Mater 2017;33:84–89
6. Wendler M, Belli R, Petschelt A, et al. Chairside CAD/CAM materials. Part 2: Flexural
strength testing. Dent Mater 2017;33.99–109.
7. Sundfeld D, Palialol ARM, Fugolin APP, et al. The effect of hydrofluoric acid and
resin cement formulation on the bond strength to lithium disilicate ceramic. Braz
Oral Res 2018;32:e43.
8. Yue X, Hou X, JING Gao J, Bao P, Shen J. Effects of MDP-based primers on shear bond
strength between resin cement and zirconia. Exp Ther Med 2019;17:3564–3572.
For direct restorations, both adhe-
9. Carrilho E, Cardoso Marques Ferreira M, Marto CM, Paula A, Coelho AS. 10-MDP
sive types work equally well, while
based dental adhesives: Adhesive interface characterization and adhesive
for indirect restorations, the 3-step
filled adhesive (OptiBond FL) cre- stability A systematic review. Materials (Basel) 2019;12:790.
ates a thicker layer (immediate den- 10. Scaminaci Russo D, Cinelli F, Sarti C, Giachetti L. Adhesion to zirconia: A systematic
tin sealing) that protects exposed review of current conditioning methods and bonding materials. Dent J 2019;7:74.
dentin and provides many clinical 11. Van Meerbeek B, Yoshihara K, Van Landuyt K, Yoshida Y, Peumans M. From
advantages over a thinner adhesive Buonocore’s pioneering acid-etch technique to self-adhering restoratives.
layer (see chapter 6.1 for details on A status perspective of rapidly advancing dental adhesive technology. J Adhes
preparation procedures). Dent 2020;22:7–34.
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120
3
CHAPTER
With support from Dr Viviana Coto-Hunziker, Geneva

Smile Center (CH) for the Invisalign treatment
of the functional case.
3
Chapter_3.indd 120 11.04.23 16:39
121
oc
Occlusal and Functional Factors,
Vertical Dimension of Occlusion
Occlusal and Functional Factors, Vertical Dimension of Occlusion 3

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Introduction to Function and Occlusal Factors
Schematic representation of the relationships between the central nervous system, the body posture, and
the masticatory system. Interactions are multiple and complex; some of them have to be further explored and
confirmed.
3 Occlusal and Functional Factors, Vertical Dimension of Occlusion
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123
Oral health is a key indicator of overall health, well-being, Recommended Readings

and quality of life. The World Health Organization (WHO)
defines oral health as “a state of being free from chronic 1. Petersen PE. The World Oral Health Report 2003: Continuous
mouth and facial pain, oral and throat cancer, oral infec- improvement of oral health in the 21st century—The approach
tion and sores, periodontal disease, tooth decay, tooth loss, of the WHO Global Oral Health Programme. Geneva: World
and other diseases and disorders that limit an individual’s Health Organization, 2003.
capacity in biting, chewing, smiling, speaking, and psychoso- 2. Lund JP. Mastication and its control by the brainstem. Crit Rev
cial well-being.” Oral health care means dealing with a mul- Oral Biol Med 1991;2:33–64.
titude of psychologic and physical factors that influence and 3. Van der Bilt A. Assessment of mastication with implications for
are influenced by oral activities and function. Considering oral rehabilitation: A review. J Oral Rehabil 2011;38:754–780.
mastication as an example, there are many aspects of this 4. Farooq M, Sazonov E. Automatic measurement of chew count
vital activity that are known today; this basic rhythmic and and chewing rate during food intake. Electronics (Basel)
complex function is controlled by a central pattern generator 2016;5:62.
located in the brainstem and requires a high level of muscular 5. Moss S. The primary role of functional matrices in facial growth.
coordination with a high capacity of adaptation. Large differ- Am J Orthod 1969;55:566–577.
ences exist between individuals regarding the parameters of 6. Woda A, Pionchon P, Palla S. Regulation of mandibular pos-
mastication, such as masticatory performance, number of tures: Mechanisms and clinical implications. Crit Rev Oral Biol
cycles needed to prepare the food for swallowing, amplitude Med 2001;12:166–178.
and velocity of jaw movements, the amount of jaw muscle 7. Sessle BJ. Biological adaptation and normative values. Int J
activity, and the chewing rate. Considering that this action is Prosthodont 2003;16(suppl):72–73.
repeated thousands of times a day, it is expectable that the 8. Carlsson GE. Critical review of some dogmas in prosthodon-
way in which an individual chews directly influences mul- tics. J Prosthodont Res 2009;53:3–10.
tiple morphologic aspects of growth, maturation, wear, and
aging of our dental system.

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1. Basics of Static Occlusion and Gnathology intermaxillary relationship took the name of centric relation
occlusion or position (CRO/ CRP; lately referred to as centric
Gnathology is a term that was first proposed by Harvey Stal- occlusion [CO]), which corresponds to the concomitance of
lard in 1924; it described it as the science that analyzes and CR with the maximal intercuspation position (MIP), deter-
treats the stomatognathic system (SS) as a whole, embracing mining a rather mere rotation along the hinge axis during ini-
anatomy, histology, physiology, and pathology. The funda- tial jaw opening. Based on this concept, which soon became
mentals of gnathology include the concepts of centric rela- a strong dogma, observation of the differences between CR
tion (CR), vertical dimension of occlusion (VDO), anterior and MIP prompted various dental treatments. The correc-
and lateral guidance, the posterior occlusal contacts (OCs) tion of such discrepancy involved occlusal “equilibrations,”
scheme, and the relationship of the determinants of man- prosthodontic and orthodontic treatments, and even ortho-
dibular movements. gnathic surgery, also in patients free of any symptom.
The concept of centric relation has been given over 26 However, contradictory results were soon reported, and
different definitions throughout the history of dentistry, the interestingly, many subjects continued to close and function
first proposed by Rudolph L. Hanau in 1929. In that period, in their initial, more anterior position (MIP) after a full-mouth
dentistry was largely oriented toward edentulous patients, rehabilitation was accomplished to fulfill the CRO concept.
and practitioners were dealing to a large extent with the In the 1970s, controversy developed about the hinge axis
construction and maintenance of maxillary and mandib- and the true anatomical location of CR (condyle in relation to
ular complete dentures. It was then necessary to establish the glenoid fossa has actually undergone a translation from
a reliable method to identify and transfer the interarch rela- the most retruded position to the most superior one and
tionship onto a mechanical articulator to reproduce the then to the most anterosuperior one), generating significant
patient’s occlusion and the dynamics of jaw movements to confusion and debates that continue today. Many studies
fabricate prosthesis that would respond to both functional also challenged the techniques used to record CRP and their
and esthetic criteria. As prevention helped patients to retain repeatability, demonstrating the many flaws of this concept.
their teeth over much longer periods of time, some of former Thus, instead of referring to the condyle and glenoid fossa
CR concepts are no longer relevant. relationship, Jankelson (1975) referred to muscle balance to
The hinge axis model was adopted to describe mandib- determine the CRP; this different approach is defined as the
ular mobility. Having also in mind that an ideal physiologic muscular centric relation (MCR), a position induced by the
and biologic jaw position should be defined, the reference isotonic closure path of the mandible from a rest position
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125
after muscle relaxation. Recent research, including dig- convictions: (1) during rest position, a person determines an
ital modeling, lead to a new interpretation of jaw motions, interocclusal distance that is unalterable during our entire
which confirmed the significant influence of muscle activity life, and (2) if VDO is augmented over its physiologic limit, it
variations on the mandible rotation axis and physiologic may provoke muscle hyperactivity in attempting to reestab-
movements. lish the original IOD with possible elevation of bite force and
For dentate individuals, the VDO is the “distance between possible advent of TMDs or orofacial pain. However, a signifi-
two selected anatomic or marked points (usually one on cant variability of rest position was later reported, implicating
the tip of the nose and the other on the chin)” when in MIP. the role of multiple others factors like head posture, missing
Early clinical studies claimed that loss of tooth substance teeth, and the patient’s emotional state. In fact, undesirable
subsequent to wear or missing posterior teeth led to a VDO reactions, such as TMJ degeneration, tooth intrusion/extru-
collapse, potentially responsible for temporomandibular sion or mobility, durable muscular tension, and pain, proved
disorders (TMDs) and orofacial pain. Costen (1936) actually to occur only in case of extreme VDO increase, in conditions
assumed that in the absence or reduction of molar sup- clinically irrelevant. Finally, the general outcome of animal
port, the strong elevating mandibular muscles could push and human studies confirmed the potential adaptation of
the condyle upward and backward, compressing the deli- the masticatory system over time after increasing VDO. To
cate anatomical area situated between the condyle and the date, there is no compelling evidence contraindicating a
acoustic meatus rich in vessels and nerves, thus provoking technique that involves only a slight alteration of the VDO
TMDs. (up to 5 mm at the incisal level) to benefit from its many res-
Costen’s hypothesis led to promoting the treatment of torative advantages (see chapter 2 for more information).
many patients at an “increased” VDO to cure or even pre- The concept of disocclusion, referring to the separation
vent this pathology. However, the description of undesir- of antagonist posterior teeth during eccentric movements
able consequences appeared, suggesting that a noteworthy of the jaw (protrusive and lateral movements) dates back
VDO augmentation would presumably obliterate the inter- to the early 20th century. The resulting occlusal schemes
occlusal distance (IOD) during the postural rest position, were then described: (1) canine-guided occlusion (CGO), (2)
also known as the freeway space. Such interference was group function occlusion (GFO), and (3) bilateral balanced
presumed to increase activity of masticatory muscles as occlusion (BBO). Although each lateral occlusal scheme had
an attempt to recover the individual’s original interocclusal its promoters, there is no clinical evidence supporting the
clearance. These observations gave rise to two closely related superiority of one concept over another. Anterior guidance

Chapter_3.indd 125 11.04.23 16:39
126
is dictated by incisors when normal overjet and overbite appear to be minimally influenced by the lateral occlusal
(about 2 to 3 mm) are present. The BBO associated with a scheme. Long-term acceptance of a new occlusal scheme
posterior balanced occlusion during protrusion movements also appeared moderately influenced by the lateral guidance
was defined the “fully balanced” occlusion. Although initially approach even though immediately after treatment, patients
quite popular, this concept was soon challenged by gnathol- reported to be more comfortable with GFO compared to
ogists who suggested the “mutually protected occlusion” CGO.
theory. This theory suggested that anterior teeth acted as From an anatomical perspective, studies about the
protectors of posterior teeth from tangential forces while dental anatomy and interarch relationships served to create
posterior teeth played the role of shock absorbers for ver- a model to be attained in restorative dentistry, as a pre-
tical forces in MIP. It was then stated that unguided occlusion vention or correction of malocclusions. Then, the interarch
could lead not only to disruptive effects on the dentition, relationship was characterized by the existence of occlusal
but also to pathologic consequences for the TMJ. Another curves: the curve of Spee on the sagittal plane and the curve
aspect of this theory was that eccentric jaw movements and of Wilson on the frontal plane.
resulting sliding along cuspal curves discharge forces from Similarly, occlusal morphology and its determinants were
teeth to supporting structures in a uniform and controlled described in a detailed way that would be in harmony with
way. Therefore, abnormal forces due to the wrong guidance the eccentric movements of the mandible. For those willing
scheme might affect the physiologic status of the stomato- to attain a “fully balanced” occlusal scheme (BBO or GFO),
gnathic system. Research also initially showed that CGO the ideal design of posterior teeth had to involve a cusp
induces significantly lower electromyography (EMG) activity inclination and antagonist fossa correlated to condylar path-
than all other occlusion schemes, and that with GFO, the EMG ways; such anatomy was considered ideal to assume jaw and
activity was significantly less than in BBO for both abduction denture stability in dynamic movements. Conversely, when
and adduction jaw muscles. Overall, these observations sug- aiming for anterior disocclusion (CGO), an occlusal design
gested that CGO supported the integrity of posterior teeth with defined ridge and groove direction was considered less
and TMJ during functional but especially parafunctional critical due to posterior teeth disocclusion during eccentric
activities. However, recent studies have mitigated the afore- movements. In the pursuit of an ideal occlusal stability, the
mentioned concepts due to the significant variability found “tripodism” model was also proposed as an ideal design for
in the anterior guidance of healthy, nonrestored dentition, posterior teeth anatomy to evenly distribute axial functional
assuming that physiologic function and patient acceptance forces, stabilize jaw movements and occlusion, and provide
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127
the highest masticatory efficiency. However, the application satisfy the same basic criteria of oral rehabilitation, namely to
of this ideal concept proved to be a challenging clinical exer- promote an adequate function, content esthetic demands,
cise, often leading to unintended posterior interferences. and ensure durability of the prosthetic treatment.
Today, material properties are seen as a relevant factor in
selecting some of the aforementioned occlusion approaches 2. Present View of Occlusal Dynamics and Jaw
to favor a better treatment outcome; for instance, in the Motions
treatment of moderate tooth wear cases, CGO could be more Description of a model to represent physiologic mobility of
favorable to limit critical flexural and tensile stresses in thin the mandible has been used since the beginning of the 20th
composite layers placed on the posterior teeth, redirecting century, explained with mathematic methods and verified
forces on the anterior teeth where thicker layers can be used. with mechanical records. A simplified model of analysis was
With high-strength ceramics, CGO might be more favorable first proposed by Posselt that represents the jaw motion by
to create a young smile line, while in heavy bruxers, a more tracing the interincisor point motion in maximal excursion
balanced occlusion (GFO or BBO) might also be chosen of different jaw movements on three bidimensional planes
owing to the material’s high mechanical performance that (frontal, horizontal, and sagittal). In the sagittal plane, these
can adapt to any occlusal scheme. limits have a banana-like shape, known as the Posselt dia-
After reaching its greatest acceptance in the 1970s and gram: The superior diagram explicitly limits the protru-
80s, scientific research failed to confirm the veracity of sive movement in continuous tooth contact from the most
gnathologic concepts; this mainly mechanistic approach retruded to the most protruded position; anterior and pos-
did not gain further clinical acceptance, as many principles terior diagram limits show the maximum opening-closing
proved too difficult to be fulfilled in daily practice, resulting movements of the jaw starting from these two extremes. Jaw
in unnecessary technical complications and even more movements are not restricted to only the sagittal plane, and
importantly revealing undue reasons to promote global and similar functional envelops may be defined in other planes.
aggressive overtreatment. Despite several attempts to refor- More recently, 3D dynamic modelling has allowed a better
mulate some of its core principles, confusion and ambiguity description of jaw motions into the three space dimensions.
remained, and with a lack of scientific evidence to support The mandible is able to perform translation and rotation
gnathologic concepts, their golden years vanished away and movements; translations are performed along anteropos-
gnathology became an historical dogma. Consequently, sim- terior (X), mediolateral (Y), and superoinferior (Z) axes, while
plified models of occlusion developed in recent decades to rotatory movements are described by their roll (about the

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128
X-axis), elevation (about the Y-axis), and azimuth (about the mediated by the feedback of sensory receptors (mechano-
Z-axis). Each motion can then be obtained by a unique com- receptors of the periodontal ligament and muscle spindles);
bination of the six independent fundamental movements: then, food consistency impacts the muscular activity, the
the six degrees of freedom of movement of the jaw. number of chewing cycles until swallowing, and jaw mobility.
Jaw motion during function is influenced by the direct,
coordinated action of masticatory muscles, each able to 3. Occlusion, Neuroplasticity, and Neurocognition
induce a translation and a rotation of the jaw. However, the Available evidence today supports a dynamic and adaptable
action of every muscle is not homogeneous, because the model of occlusion rather than a preconceived, mechanical
fine neural control may activate single motor units individu- theory. The stomatognathic system has an extraordinary
ally. Furthermore, many jaw movements are relatively small, capacity to adapt to various physiologic and pathologic
posing stiff challenges to experimental systems designed influences and shows a considerable functional reserve
to record adequately function. For example, it has been inducing different responses, modulated by the central ner-
reported that muscles with rather vertical orientation are vous system (CNS). Such modifications are possible thanks
also responsible for fine horizontal movement regulation. to the neuroplasticity of the brain, a phenomenon that plays
Considering there are more than 20 muscles directly or a major role in the aforementioned adaptation processes.
indirectly involved in jaw mobilization, the combination of Neurocognitive and neurophysiologic processes control
simultaneous, coordinated muscular contractions is to be the afferent somatosensory signals (ascending regulation)
considered endless, determining the high degree of func- originating from dental and orofacial mechanoreceptors,
tional adaptability of the SS. Jaw motion is also influenced generating a “sensation.” The sensation is then interpreted
by multiples passive components; muscles themselves may by the somatosensory cortex, creating a “perception” and
represent a passive constrain when inactivated. TMJ struc- subsequent sensorimotor regulation activity by the primary
tures and ligaments guide and also impose limits to the jaw motor cortex (descending regulation). Sensation and per-
motion, however allowing an envelope of movements within ception are closely linked but also distinct phenomena; the
the aforementioned six degrees of freedom. sensation is triggered by sensory organs, while the percep-
Teeth and food also interfere with jaw movements as tion relates to a complex interpretation of the sensation by
a result of the reaction forces from the presence of food the brain. In certain cases, a normal sensation can trigger
bolus between opposing structures. Precise adjustments of a wrong perception through a dysregulated interpretation
motor output in response to changes in food resistance are and management of the afferent signal. Attention (elevating)
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and distraction (lowering) are also powerful modulators of like lasting discomfort or occlusal troubles after simple
somatosensations; attention regulates neuronal excitability dental treatments (acute tactile acuity). If the new occlusal
during and also in anticipation of stimuli, which generates scheme respects “accepted” standards, this lack of adapta-
difficulties in patients with occlusal hypervigilance. In such tion intervenes in the context of “occlusal hypervigilance” or
patients, an imbalance between perceptual and cognitive “occlusal dyesthesia,” leading to chronical symptoms even
processes is often present with an expectation or antici- in the absence of objective occlusal or functional dishar-
pation of negative treatment effects; this condition is fre- monies. These observations underline the complex nature
quently associated to contributing psychologic factors such of “occlusion,” which should no longer be considered local
as affectivity troubles, anxiety, or depression. Practically, we or locoregional phenomena governed “only” by dental con-
can measure the interocclusal tactility threshold (ITT) by tacts, jaws anatomy, and muscle movements, but on the
using foils of different thickness. Interindividual measure- contrary, should be placed into a more global framework,
ments have reported tactile thresholds varying from 8 µ to involving its regulation by the CNS and the influence of
60 µ. Patients having the lowest ITT are more prone to expe- many important psychosocial factors. Without this in mind,
rience oral and occlusal disturbances after occlusal changes it would be impossible to understand the slow or nonadap-
or major restorative treatments, considering once again the tive response of some patients to restorative treatments or
contributing effect of psychologic factors. significant wear conditions.
Considering the complex regulation of sensations and Several conditions have been indicated to be risk fac-
perceptions by the sensorimotor cortex (somatosensory tors predisposing to compromised adaptive response; they
cortex and primary motor cortex) and their interaction include aging, disease, genetic abnormalities, gender, psy-
with the patient’s psychologic profile, one should be cau- chologic stress and neurologic dysfunction, nutritional
tious when handling nonadaptive response to usual occlu- deficiencies, trauma, and overloading of tissues. Those risk
so-functional changes. After suitable occlusal equilibration, factors set limits to the adaptive potential of the SS and may
“corrective” measures such as additional occlusal equilibra- provoke pathophysiologic manifestations, including chronic
tion, splint replacement, or major restorative changes can pain (TMD or myofacial pain), damage and disease of TMJ tis-
reinforce the patient’s conviction that there is a technical sues (disc tear or perforation, osteoarthritis), and increased
fault, making them even more vigilant to oral sensations parafunctional activities (dental wear). Such serious dys-
and further reducing an already limited adaptive response. A functions of the masticatory system are critical, especially if
warning sign not to be ignored is unusual patient response, they become chronic.

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4. Occlusion and Parafunctions factors; pragmatically however, there is only this “exception,”
which partially supports the modern definition of bruxism.
As for occlusal dogmas, classifications and definitions of As on the contrary, because bruxism generally is a lasting
bruxism are numerous and have widely varied throughout condition, its harmful effects are certain, even without the
the years. In 2017, international consensus was obtained on contribution of co-factors. In our view, next to the question-
a practical definition of two different categories of bruxism able rationale behind such definition changes, its reading
and published in 2018: linked to the superficial understanding of many dentists
• Sleep bruxism is a masticatory muscle activity during sleep about bruxism (resulting also from years of controversy) has
that is characterized as rhythmic (phasic) or nonrhythmic the potential to limit the use of preventive or interceptive
(tonic) and is not a movement disorder or a sleep disorder methods that are already insufficiently implemented. In con-
in otherwise healthy individuals. sideration of tooth wear prevalence, this is all but desired!
• Awake bruxism is a masticatory muscle activity during Bracing could be interpreted as forcefully maintaining a cer-
wakefulness that is characterized by repetitive or sus- tain mandibular position and thrusting as forcefully moving
tained tooth contact and/or by bracing or thrusting of the the mandible in a forward or lateral direction, both activ-
mandible and is not a movement disorder in otherwise ities without the necessary presence of tooth contact. This
healthy individuals. changing of paradigm from “classical” bruxism activities
(clenching and grinding) is in agreement with the current
Is bruxism then not a functional disorder of the stomatog- view that bruxism is mainly regulated centrally, not peripher-
nathic system and has to be considered only as a risk factor ally, and consequently not caused by anatomical factors like
for developing muscle pain, TMD, tooth wear, and restorative certain characteristics of dental occlusion and articulation.
complications of failures? Owing to the everlasting contro- Moreover, both definitions begin with “masticatory muscle
versies about this topic, the present status of bruxism as a activity,” which emphasize the role of as the source of poten-
risk factor rather than a disorder is likely to be reconsidered tial clinical consequences.
at some point in time, due to the present confusing state- Early identification of this condition is a critical com-
ment, potentially misleading our profession! As bruxism ponent in preventing its consequences, but accurate diag-
can be triggered by psychologic conditions and then be of nosis can be a challenging task. Especially in its early stages,
momentary occurrence, one could anticipate little impact self-reported parafunctional activities and clinical inspec-
on dental structures or restorations in absence of other risk tions may not be sufficient diagnostic tools, and monitoring
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131
with polysomnography for sleep bruxism and electromyog- it was interpreted as not having been radical enough! Log-
raphy for awake bruxism could be recommended to assess ically, those theories were soon questioned as leading to
bruxism. A Standardized Tool for the Assessment of Bruxism overtreatment Schwartz was the first to consider that TMDs
(STAB) has been recently published in a first version and could result from abnormal activity of masticatory muscles
could possibly become a useful tool to better assess bruxism rather than being only an occlusal or joint problem. Psycho-
and his consequences. social background, stress, and anxiety were soon identified
In summary, parafunctional habits have to be care- as some causes of increased tension in the masticatory
fully evaluated in order to maintain dental health and their muscles and an additional cause for TMDs. However, mech-
biomechanical status and also increase longevity of oral anistic models proved somehow more “resistant” than
rehabilitations. Available knowledge confirms that dental expected and fueled long divergences and disagreements
treatments cannot influence or prevent bruxism. Therefore, among academicians, scientists, and clinicians. The first
clinicians should carefully evaluate the real needs of each attempt to provide an evidence-based diagnostic method
patient affected by tooth wear to prevent undesired con- for TMDs began in 1992 with the Research Diagnostic Criteria
sequences of avoidable complex restorative treatment and for Temporomandibular Disorders (RDC/TMD) reviewed
especially their implications for long-term maintenance. by Schiffman et al in 2014 with the most recent Diagnostic
Criteria (DC/TMD); this more scientific approach aimed
5. Occlusion and Temporomandibular Disorders to diagnose and as well define subtypes of chronic pain–
(TMDs) related TMDs. The purely mechanical and morphologic view
Since Goodfriend first defined temporomandibular disor- of TMDs then gradually evolved into a model of orthopedic,
ders (TMDs) in 1932, more than 22,000 studies have been musculoskeletal conditions being frequently associated
published about TMDs, making it one of the most studied with pain and jaw movement limitations, influenced by psy-
but also most controversial topics in dentistry today. As chological components affecting not only the etiology but
aforementioned, early theories for the origin of TMDs pro- also therapeutic TMD management. With a clearer diag-
posed by Costen received considerable attention from the nostic, it became also possible to generate better epidemi-
dental community; his model embraced a theory capable ologic data. The incidence of TMD stands around 3.9% per
of explaining the biomechanical causes of TMDs and pro- year with about the same distribution between different
vided specific treatment indications; if the occlusal treat- genders, while prevalence is between 10% to 15% with an
ment or restorative change did not give the desired effect, approximately 1:4 male-to-female ratio.

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132
Undoubtedly, remarkable progress has been made by the • Dental anatomy

dental community to frame the question of TMDs and its mul- • Vertical dimension of occlusion
tiples subtypes. TMDs were described, related to pain, such • Occlusion type (CGO, GO, BBO)
as myofascial pain and arthralgia, plus jaw movement dis- • Occlusion position (CRP, MIP, AMIP, MCR)
turbances and disorders associated with the TMJ, primarily
internal derangements and degenerative joint disease. More- Such alterations can lead to adaptation, or nonadaptation,
over, the biopsychosocial components were largely clarified, based on three levels of response by the stomatognathic
such as the impact of chronic pain on a person’s psychology system in its global, modern understanding:
as well as on other psychosocial aptitudes. Modern under- • Mechano-anatomical adaption phase that is directly
standing about the etiology of TMDs then indicates multiple related to proper occlusal and dental relationships,
aspects that predispose to initiation and maintenance of the allowing basic jaw movements to occur without any
dysfunction such as metabolic, systemic, social, structural, anatomical restrictions impairing function. This can be
traumatic, psychologic, and behavioral factors. Available evi- assessed immediately and of course relates mainly to the
dences also indicate a low influence of the occlusion on the quality and design of the dental work
etiology and treatment of TMDs. • Short-term muscular activity adaptation that allows the
However, from a clinical standpoint, a patient who pres- masticatory system to function in the new occlusal posi-
ents TMD symptoms and requires a full-mouth rehabilitation, VDO, and occlusion scheme. This can be described as
tion has to be approached with caution. Risk factors and an immediate neuroplasticity response.
symptoms connected to the functional disorder have to be • In case the new occlusal scheme integration is incomplete
investigated and treated in first intention and then, before following the first two phases, neuroplasticity can pro-
performing the final rehabilitation, reversible tests to vali- vide further adaptive power to control the perception of
date the new occlusal project are strongly recommended disrupted occlusion and function and generate progres-
due to decreased capacity of adaptation in such patients. sive adaptation to the new situation from perceptual and
functional standpoints, eliminating also any discomfort or
6. About Adaptation to Tooth Wear Treatments pain, if present. The extent of adaptation through neuro-
In summary, a change in the occlusion scheme (first fol- plasticity depends among other factors on the extent of
lowing tooth wear and then treatments) potentially involves anatomo-functional corrections and on the other hand,
one or all of the following elements: the patient’s psychologic profile and status.
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133
The above has obvious interesting implications. Clinical of teeth present, type of rehabilitation (fixed, removable, or
research has actually shown that the large majority of appro- implant), as well as the influence of food consistency. TMJ
priate corrective measures of tooth wear are well and rapidly pathologies (TMDs) also influence chewing forces, here in
tolerated, chiefly via the first two adaptation mechanisms the direction of a decrease. Keeping in mind that mandib-
and that only a few major occluso-functional changes will ular movements and resulting dental contacts relate to com-
involve neuroplasticity to a much larger extent and pro- plex movements and muscle recruitment according to the
longed time frame. This means that we logically don’t need functional task performed, it suggests caution in oversimpli-
to install routinely temporary restorations in case of limited fying the mechanics of “occlusion” as a global phenomenon
occlusal changes like in moderate tooth wear cases, while describing function and teeth interactions. Nevertheless, a
a more cautious approach is mandated for severe cases, basic, common sense–oriented analysis of published data
owing to the fact such patients have by nature a more suggests the following interpretation and guidelines for
fragile or stressed personality (ie, severe erosion pathology application in clinical dentistry:
or bruxism), potentially limiting neuroplasticity. Again, in • Closing forces distribute differently within dental arches
such cases, a test phase is usually recommended to assess with maximum strength at molar level and minimum
the potential patient’s adaptive response using an occlusal strength at incisor level; forces are also higher in case of
splint or temporary restorations. bilateral jaw contacts.
• Parafunctions (bruxism and clenching) are abnormal
7. Occlusal Biomechanics rhythmic movements occurring during deep sleep
In order to better understand how forces act on dental struc- phases (sleep bruxism/clenching) or abnormal dental
tures and restorations and distribute over jaws, teeth, and contacts or functional habits during the day (awake
dental contacts, a large number of studies were performed bruxism/clenching); throughout these periods, chewing
to gain knowledge and tentatively correlate wear process, and closing forces seem to be close to the maximum
restoration aging, and function. Measures of chewing and forces of the neuromuscular system, within of course
closing forces (alternatively forces in case of bruxism and individual variability.
clenching) are essential to foresee the restorative challenge • The literature provides only limited data on “normal”
and eventually decide which material to use when treating chewing forces (non-parafunctional forces), which are
tooth wear. However, one has to integrate individual vari- mainly influenced by food consistency. Actually, most of the
ability related to age, sex, craniofacial morphology, number available research is focused on maximum closing forces.

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134
• When forces are related to dental contacts (distribution contacts submitted to much higher strains (especially ten-
of chewing/closing forces), pressure levels seem rela- sile and flexural stresses), also moving this load to resto-
tively low, or at least compatible with the use of both ration areas with low restorative material thickness.
existing tooth colored, bondable restoratives (compos- • The increase of functional and parafunctional forces from
ites and ceramics); however, those numbers are related to the front to the posterior teeth, correlated to the usual
even forces distribution (such as in the MIP). Due to the limitation of interocclusal space opening when restoring
observed chipping and wear of composite (sometimes as patients at a new, increased VDO supports the concept of
well ceramics), one should not ignore the peculiarity of “hybrid rehabilitations” (ceramics to restore occlusal sur-
eccentric jaw movements leading to a limited number of faces of molars and composite to restore anterior teeth).
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Occlusal Biomechanics 135
10–229 N 25–190 N 50–521 N 221–885 N Closing force range
569 N NA NA 911 N Forces in bruxers
NA 38-50 MPa 40-48 MPa 38-41 MPa Pressure/contact
Unilateral closing forces: 171 to 878 N Bilateral closing forces: 246 to 1650 N

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136 8. Occlusion Position and Attrition Wear Patterns contribute to a younger smile line configuration. CGO could
also have some beneficial impact on chipping/wear prob-
Next to the bigger “picture” previously described, under- lems in patients treated with direct composite within the con-
standing the interplay of function and parafunction with text of an interceptive approach: actually, canine guidance
occlusion is of interest for intervening on wear problems from (and concomitant posterior disclusion) created with thicker
a restorative standpoint; it can also bring a great contribution composite restorations (thickness of material actually aug-
to install appropriate preventive, interceptive or restorative ment from posterior to anterior areas when treating tooth
measures based on the location and extent of tooth wear. wear patients at an increased VDO), then limiting functional
Clinical observation here plays a critical role in daily prac- stresses on thinner posterior restorations. Conversely, when
tice as function/parafunctions monitoring is not a routine using stronger materials (eg, monolithic glass ceramics such
process. Moreover, recording devices used for this purpose as lithium-disilicate), any occlusal scheme could be selected
have known, potentially physical or psychologic interfer- for moderate tooth wear cases, giving priority to esthetic or
ence with the measuring process, next to the patient’s lim- mere tissue conservation considerations.
ited ability to replicate normal or even more parafunctional Clenching relates to a more static closing movement
masticatory cycles when connected to such apparatuses. with abnormally long contact periods; this mechanism is
Modern technology has fortunately made such devices a lot the most common pattern for awake bruxism. Due to a pos-
smaller, partially wireless, and inconspicuous, thus reducing sible enhanced pressure feedback during conscious day
this limitation. Monitoring the parafunctional envelope bear time, forces applied to teeth might be significantly less than
anyway another critical limit in a dental practice because the during sleep bruxism but might last for much longer periods
awake functional envelope might significantly differs from of time, having then an equally dramatic action on teeth
what happens during sleep bruxism; actually, careful clinical integrity. Sleep bruxism relates typically to extended para-
observation shows that it is often difficult, if not impossible, functional envelope with various lateroprotusive movement
to have patients replicating sleep parafunctional mandible patterns. These periods of parafunctional activities during
trajectories that create the facets and groves seen on their sleep bruxism can be of higher intensity (due partially to an
nightguard. A relatively simple approach to this challenging absence of pressure feedback during deep sleep periods)
task is to localize wear areas in both dental arches, asses but last only for a short time, thus making sleep bruxism not
their severity, and correlate this to basic jaw movements necessarily more damaging than awake bruxism. It is also
(opening and closing, occlusal position(s), lateral and protu- more feasible to obtain nightguard compliance than with
sive excursions). This can confirm restorative challenges and dayguards, which the majority of patients decline to wear.
help in choosing restorative method(s) and material(s) (not One should of course not ignore the frequent combination
necessarily identical for all affected teeth). of awake and sleep bruxism (leading to less typical wear pat-
Then, the various occlusal positions might have some terns but even more severe wear), both parafunctional activ-
advantages from a mere aesthetic or material perspective ities being triggered by stress, anxiety, and various altered
and not necessarily from conceptual and holistic stand- psychologic conditions. The main effect of the aforemen-
points. For instance, CGO (canine-guided occlusion) could tioned forms of bruxism on tooth wear location and evolu-
be considered more esthetic, as “prominent” canines tion are reviewed thereafter.
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137
Typical localized wear pattern related

to the combination “sleep bruxism/
deep bite.”

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138
In Class I occlusion with “normal” overbite/overjet, function and parafunction wear patterns (attrition and combined attrition/erosion)
will concentrate on different dental arch locations depending on bruxism type and dynamics. Clenching will mainly affect the posterior
occlusal surfaces and as well as possibly palatal contacts with lower incisal edges (but to a moderate extent compared to sleep bruxism).
Typical example of clenching wear pattern (above) with no, or very limited, eccentric parafunctional movements as evidentiated by wear-
free incisal edges of maxillary anterior teeth and localized tissue loss in molars.
This female patient aged 28 years (right page) shows nearly no signs of attrition of her anterior teeth while she shows substantial attrition
lesions on molars, mainly on the right side, arguably linked to asymmetric clenching and parafunctional activities. Note the discrete
mesiodistal fissure on tooth no. 47, which triggered existing pain to pressure (cracked tooth syndrome).
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139

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140
In Class I occlusion, contrarily to clenching, which affects mainly the posterior occlusal surfaces and palatal contacts with lower incisal
edges, sleep bruxism involving lateroprotusive parafunctional movements will affect initially incisal edges and cuspid tips (shortening
and chipping of both maxillary and mandibular anterior teeth), and if left untreated, the progressive loss of anterior and canine guidance
will further trigger cusp wear of posterior teeth.
The 39-year-old patient (below and right page) shows the typical attrition pattern of bruxism (mainly sleep bruxism here) with progres-
sive, generalized tooth wear. Note a shortening of the anterior teeth and flattening of the smile line, which is the prevalent reason for
patients to consult a dentist due to the esthetic impact of tooth wear. Without proper preventive measures (nightguard and information
about dental erosion if concomitant to bruxism), generalized attrition will appear, with progressive loss of occlusal anatomy, dentin
exposure, and premature aging of dental restorations (ie, wear, marginal degradation, and possibly fractures as well).
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141

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142
In Class III tendency occlusion (edge to edge), clenching and bruxism will potentially affect both arches and a larger number of dental
surfaces. In this occlusal configuration, patients rarely had or could maintain canine guidance so that functional and parafunctional
activities involve more even dental contacts and wear. Nevertheless, asymmetric neuromuscular activities can always concentrate wear
in some specific areas. Here, wear extent and severity affect all teeth in case of bruxism and clenching.
A 56-year-old patient presented himself for a consultation with aim to resolve the esthetic impact of his parafunctional problems. He was
under nightguard “therapy” and was aware of consistent awake bruxism and subsequent, ongoing wear of his anterior teeth. The normal
occlusal position implied mostly edge-to-edge contacts of anterior teeth with the most significant and visible wear impact on his smile;
mandibular posterior teeth show also significant signs of clenching (loss of occlusal anatomy, mostly concave profile, central cracks on
second molars, cusp flattening) while maxillary teeth were more discretely affected.
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143

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144
In Class II/2 and deep bite occlusion (increased overbite), clenching and bruxism will affect teeth in a very different way. In case of
clenching, posterior teeth will be mainly affected while anterior teeth will be only moderately affected, as in Class I occlusion.
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145
This 55-year-old female patient consulted for esthetic and functional concerns; she wished to brighten her smile and did also seek advice
about hypersensitive occlusal areas on molars. She had a history of severe TMD, presently resolved after undergoing 2 years of physio-
therapy and wearing regularly a nightguard with significant elevation of vertical dimension (decompressing TMJ structures). She had
otherwise no complain about her deep bite or about residual functional limitation at the time of her initial consultation. The occlusal
surfaces of her molars show the typical attrition pattern of clenching with limited wear of her maxillary and mandibular anterior teeth;
this suggests a narrow parafunctional envelope, typical of this parafunctional activity.

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146
In Class II/2 and deep bite occlusion, the increased overbite produces an effective posterior disclusion, limiting and delaying very effi-
ciently posterior teeth wear in case of bruxism with extensive lateroprotusive movements. Then, attrition will concentrate mainly in
anterior teeth.
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147
This 39-year-old male patient was seen for a regular check-up, having no esthetic or functional complaints. During parafunctional activ-
ities, the deep bite results here in proper disocclusion of posterior teeth, as confirmed by the patient’s normal cusp profile (note inter-
occlusal space created by protusive and both lateral guidance (lower central and lateral images). In this specific situation, the attrition
pattern suggests an extended parafunctional envelope (bruxism). This condition is also confirmed by the tendency to move into edge-to-
edge position, for instance when asked to smile (left page).

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148
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149
9. The Geometry of VDO Changes restorative approach instead of the subtractive one followed
formerly in conventional prosthodontics. The advantages of
One of the basic “tissue conservation” principles applied to increasing VDO are multifold:
modern tooth wear treatments is to open the VDO and create • Creates space for the restorative materials without need
restorative space to replace worn tissues without any (or for additional tooth preparation (minimally invasive or
absolutely minimal) additional tissue removal resulting from even no-prep approach)
preparation features. The long-term and formerly contro- • Eliminates the need for additional, invasive procedures
versial considerations with this principle was the “fear” that such a crown lengthening or endodontic treatments in
any change in the natural VDO could trigger a “nonadaptive case of limited residual dentin thickness (severe wear
response” of the stomatognathic system such as parafunc- cases)
tional activities or TMDs (in case, triggering or worsening • Limits biologic risks (supports periodontal health and
such pathologies). Both clinical experience and research pulp vitality)
have shown that altering vertical dimension within given • Helps to restore normal tooth anatomy, esthetics, and
limits is unlikely to produce any permanent occlusal or func- function with less complex procedures
tional troubles, and on the contrary results commonly in a
positive “adaptive response.” These findings prompted a true Is nowadays an integral part of both interceptive and restor-
paradigm shift in treating tooth wear, supporting additive ative strategies.

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150
Class I occlusion and VDO opening in MIP
When maximal intercuspation position (MIP) and centric relationship position (CRP) coincides, an opening of VDO results in a small
rotation of the mandible. Then, the axis around which this movement occurs is what is considered terminal hinge axis. In a sagittal
plane, for a Class I occlusion, this opening/rotation induces a relative retrusion of all teeth (observable as increased anterior overjet and
a tendency to posterior cusp to cusp relationship); it also creates an interocclusal space that increases from posterior to anterior teeth.
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151
TW1
On a transversal plane, due to the open arch form (TW1 < TW2),
the mandible rotation generates concomitantly a disruption of the
TW2
cusp/fossa relationship, which with sagittal posterior cusp mis-
alignment and progressive loss of anterior guidance sets locally
the anatomical limits of a large VDO increase.

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152
An important consideration related to opening the VDO along Class I in MIP (Maximal Intercuspidation Position)
a rotation path is the varying differential interocclusal space,
which increases from the posterior to the anterior areas;
as a simple ratio, it can be said that a 1-mm opening at the
molar level is equal to 2 to 3 mm at the canine-incisor level.
Some anatomical discrepancies however result from a VDO
opening, this even within the known range of adaptation for
the stomatognathic system. This is a simple geometric con-
sequence of a mainly small rotation of the mandible during
the first opening phase, before the condyles are displaced
anteriorly and inferiorly. As said before, the opening move-
ment equals to a slight retromovement of the whole man-
dible, relative to the maxilla. Again, due to the open arches
form (inter-molar distance bigger than inter-canine dis-
tance), this relative displacement induces not only sagittal
but also slight transversal discrepancies (at least when main-
taining the original occlusal position). One of the corrective
measures to be applied during the restorative phase is the
tilting (red arrows) of incisal edges, canine tips and premo-
lars cusps as compensation of the sagittal discrepancies
Class I in MIP.
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153
Class II and I occlusion and VDO opening in CRP
When MIP and CRP don’t coincide, a VDO opening with simultaneous repositioning in CRP will create a more pronounced retrusion of the
mandible, which complicates the restorative work due to the aforementioned occlusal discrepancies. Similiarly, opening VDO in Class
II cases worsens the natural preexisting occlusal discrepancy. Then, using CRP as a preferred occlusal position limits the use of conser-
vative solutions and has been too often a “justification” to engage more tooth preparation, followed by traditional prosthodontic work.
In consideration of the lack of evidence-based rationale to restore tooth wear cases in CRP, this “occlusal reference” (formerly applied
to the treatment of patients with posterior edentulism) is no longer considered the *“gold standard” for interceptive or even restorative
strategies.

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154
Class I occlusion and VDO opening with MIP anterior relocation
Due to the geometric limitations imposed by a VDO opening in the preexisting MI or CR positions, the idea of an anterior relocation of
the MIP (AMIP) was suggested to allow the VDO augmentation to happen with nearly no anterior and posterior occlusion disruption. The
reasoning behind anterior MIP displacement is mainly to better preserve tooth structure during tooth wear rehabilitation. This position
can eventually coincide or come close to the muscular centric relation (MCR) that will favor a rapid adaptation to a new and then stable
occlusal position. There is however still limited scientific or clinical evidence about the long-term stability of the new AMIP and despite
the known capacity of the TMJ to adapt to certain functional needs, more research is needed to confirm the validity of this concept.
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155
Edge-to-edge anterior occlusion (Class III tendency) and VDO opening
In case of edge-to-edge position (anatomical or functional Class III occlusion tendency), the aforementioned limitations of VDO opening
and related occlusal discrepancies will help to recreate a more harmonious dental relationship; it then becomes possible to reestablish
proper anterior guidance (overjet and overbite) as well as more normal posterior occlusal relationship (close to or even back to a Class I
position). In case of anatomical edge-to-edge occlusion, MIP doesn’t need to be posteriorly displaced, while in functional edge-to-edge
occlusion, a posterior MIP relocation might spontaneously occur; both conditions however respond well to this strategy provided we
consider a larger VDO change for the first condition (anatomical edge-to-edge occlusion Class III occlusion tendency).

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156
Anteriorizing occlusion position and jaw movement recording
A 21-year-old female patient presented for a counseling con- occlusal relationship in Class I occlusion or 2-year treatment
sultation with complaint about function limitation and pain with conventional braces aligners to improve alignment of
to her TMJ. She presented an occlusal Class II/2 division, teeth and partially Class II and deep bite occlusion. In any
with deep bite and bilateral canine guidance. To solve the case, the orthodontist encouraged the patient to solve the
orthodontic problem, two treatment options were proposed TMD problem prior beginning orthodontics.
to the patient: orthognathic surgery to obtain a perfect
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Pretreatment recordings 157
Clinical examination highlighted multiple initial signs of

generalized tooth wear, with discrete wear facets in both pos-
terior and some anterior teeth with multiple initial fractures
on incisal edges. The patient was aware of awake clenching.
During the occlusal and functional analysis, she showed a
tendency to move her jaw in a more anterior position where
she felt more comfortable than in MIP. A diagnosis of disc
displacement with reduction associated with myalgia was
made based on the DC / TMD axis. Early and slight clicking
noises of the right TMJ were also detected during opening
movements; the intraarticular displacement of the disc was
confirmed later by magnetic resonance imaging (MRI).
A kinesiographic computerized system (Biokey, Bioket,
San Benedetto del Tronto, Italy) was used to analyze the
three-dimensional kinematics of the mandiblular interin-
cisal point. The records revealed an asymmetric opening
movement of around 42 mm, and limited protrusive and lat-
eral movements of 4 to 5 mm.
A combined and personalized therapeutic protocol was
designed with a combination of splint, manual mobilization
and jaw exercise in collaboration with a physiotherapist. The
stabilization occlusal splint was fabricated with hard acrylic
material in MCR, which followed the patient’s tendency to
move in a more protrusive position. The splint was adjusted
to have maximal contact in MRC, symmetric anterior con-
tact, and canine guidance with balanced contact up to the
second molar. It was also recommended that the occlusal
splint was used at night or both at night and during the day
to increase utility time, however without impact on routine
work or social activities.

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158 Post-therapeutic phase nt a e c n enti nal t d ntic t eat ent n et
The proposed therapy promoted encouraging results; pain gradually decreased until full relief and maximal range of movements tremendously
increased, especially looking at protrusive and lateral excursions, as confirmed by the kinesiographic records performed soon after the ther-
apeutic phase. Subsequently, the patient started the planned, conventional orthodontic treatment, but without orthognathic surgery, which
she denied. However, TMD symptoms relapsed a few times soon after the beginning of the orthodontic treatment. Six months later, the patient
preferred to interrupt the treatment due to new, progressing imitations of jaw movement as confirmed by the new kinesiographic analysis.
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Anteriorizing occlusion position 159
At that point, a new therapeutic concept was suggested, rhythmic contractions of the masticatory and facial muscles;
based first on a permanent stabilization of the jaw posture during the TENS stimulation, the patient was asked to bite
with additive resin composite overlays on posterior teeth. on two cotton rolls. After muscle relaxation, MCR could be
This could be followed by a “lighter” and shorter orthodontic identified from the isotonic closure path of the mandible de-
treatment. Such approach was also justified to protect teeth rived from the rest position (as obtained following the TENS
from wear, in consideration of the patient’s clenching habits. phase), at the VDO desired to perform the rehabilitation; this
MCR then had to be registered again; in order to facilitate renew intermaxillary position was then fixed with hard silicon
laxation of the mandibular elevator and depressor muscles, and registered with an intraoral scanner (CS3700TM, Care-
a transcutaneous electric neural stimulation (TENS) device stream Dental USA). This recording was first used to create
(Myomonitor, Myotronics-Noromed) was used prior to this a customized splint simulating the new jaw positioning (im-
registration. The system was set to deliver repetitive stimuli ages below) to analyize it with MRI and for pretreatment test-
at 1.5-second intervals for a period of 60 minutes to produce ing. Next steps could be initiated after stable TMD absence.

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MRI images in both positions (MIP [external images] and MRC) show a symmetric, anteriorized condyle position when compared to the
initial situation; interestingly, the right TMJ image showed a more centered positioning of the disc.
Following this validation phase, digital planning of the foreseen treatment was performed with a laboratory CAD/CAM dental design
software (CEREC inLab SW 18.0, Dentsply Sirona, Germany). The new occlusal position and VDO were obtained by designing six resin
composite additive overlays on the mandibular second premolars and molars. Once the digital wax-up was validated, restorations were
milled in CAD/CAM resin composite blocks (Lava Ultimate, 3M). After milling, their adaptation was tested and verified on 3D-printed
models.
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After isolation of the operatory field with spread over the entire occlusal surfaces.
rubber dam, adhesive procedures were The composite overlays were inserted
performed on each tooth separately, using manually and then perfectly seated with
stainless steel strips for proximal separa- an ultrasonic plastic tip. After completing
tion. The tooth surfaces were only cleaned cementation on both sides of the man-
by sandblasting with 27 m Al3O2 before dible and rubber dam removal, static and
enamel etching with 37% orthophosphoric dynamic occlusion was checked, and after
acid gel for 30 seconds. Then, bonding some minor adjustments, the patient was
resin was applied on etched surfaces, air- dismissed with stable posterior contacts.
thinned for 5 seconds, and left without Thanks to the planned anterior occlusal
light curing. A sufficient amount of pre- relocation and despite the significant VDO
heated restorative light-curing hybrid com- augmentation, new overjet and overbite
posite resin (Inspiro Bi3, Edelweiss DR) was were found to be correct (right page).
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After having established a stable interarch relationship, the final orthodontic alignment of anterior teeth could be planned with the
Invisalign system (Align Technology). The treatment objectives were to align the maxilla and the mandible, while adjusting or closing
interocclusal spaces where no tissue wear or anatomical deficiency had to be corrected (ClinCheck project is shown on the right page).
Pretreatment records
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Treatment time was estimated to be half of what would have been needed with the occlusal status before the restorative phase, VDO
increase, and new occlusal positioning.
Posttreatment simulation

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6 months post-Invisalign 167
After 6 months of alignment treatment without complaint of further pain (left page), small direct resin composite restorations were
performed to enhance esthetics, finalize maxillary and mandibular anterior alignment, and correct incisal edge factures as well as wear
facets. To this purpose, a mono- or bilaminar technique was applied, depending on restoration thickness (Inspiro system, Edelweiss DR).
See chapter 4.1 for detailed description of the protocol.

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Post-Invisalign therapy and direct composite enhancements 169
Detailed posttreatment views with static and dynamic occlusion views demonstrating the fulfillment of esthetic, anatomical, and func-
tional treatment objectives following overall a highly conservative, but not conventional, treatment approach.

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Postoperative
Final documentation shows a satisfactory result from both esthetic and functional perspectives. Static occlusion was observed stable
and repeatable in MIP, and the patient achieved comfort, satisfactory masticatory function, and total absence of TMD.
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Jaw dynamics drastically changed since the initial situation:

opening movement increased to 56 mm, despite the VDO
augmentation performed. Protrusive and lateral excursions
both extended over 12 mm long and lateralities appeared
symmetric. Posttreatment MRI (c) show the adaptation of
the TMJ to the selected rehabilitative position: both discs
appear well located with no disc displacement clinically or
radiologically detectable; both retrodiscal areas appeared
also cleared in the new MIP. The patient adapted well and
swiftly to MRC (despite a significant anterior relocation of
the occlusal position as compared to pretreatment MIP
[a] or MCRP [b], as simulated with repositioning tray). This
new intermaxillary relationship allowed an easier and faster
approach for the dental full-mouth interceptive treatment
and shows great potential for helping to treat tooth wear in
patients whose neuromuscular systems show suitable adap-
tive response.
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a b c
a b c
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Recommended Readings 12. Jankelson B, Sparks S, Crane P, Radke JC. Neural conduction
of the Myomonitor stimulus: A quantitative analysis. J Prosth
1. Abduo A. Safety of increasing vertical dimension of occlusion: Dent 1975;34(3):245- 253.
A systematic review. Quintessence Int 2012;43:369–380. 13. Klineberg I, Palla S, Trulsson M. Contemporary relevance of
2. Abduo J, Tennant M, McGeachie J. Lateral occlusion schemes occlusion and mastication. Int J Prosthodont 2014;27:411–412.
in natural and minimally restored permanent dentition: A sys- 14. Koolstra JH. Dynamics of the human masticatory system. Crit
tematic review. J Oral Rehabil 2013;40:788–802. Rev Oral Biol Med 2002;13:366–376.
3. Abduo J, Tennant M. Impact of lateral occlusion schemes: 15. Lindauer SJ, Sabol G, Isaacson RJ, Davidovitch M. Condylar
A systematic review. J Prosthet Dent 2015;114:193–204. movement and mandibular rotation during jaw opening. Am
4. Belser UC, Hannam AG. The influence of altered working-side J Orthod Dentofac Orthop 1995;105:573–577.
occlusal guidance on masticatory muscles and related jaw 16. Lobbezoo F, Ahlberg J, Raphael KG, et al. International con-
movement. J Prosthet Dent 1985;53:406–413. sensus on the assessment of bruxism: Report of a work in
5. Beyron HL. Characteristics of functionally optimal occlusions progress. J Oral Rehabil 2018;45:837–844.
and principles of occlusal rehabilitation. J Am Dent Assoc 17. Maxwell LC, Carlson DS, McNamara JA Jr, Faulkner JA. Adap-
1954;28:648–659. tation of the masseter and temporalis muscles following alter-
6. Bucci R, Koutris M, Palla S, Sepúlveda Rebaudo GF, Lobbezoo ation in length with and without surgical detachment. Anat
F, Michelotti A. Occlusal tactile acuity in temporomandibular Ret 1981;200:27–37.
disorder pain patients: A case-control study. J Oral Rehabil 18. Ogawa T, Koyano K, Suetsugu T. The relationship between
2020;47:923–929. inclination of the occlusal plane and jaw closing path. J Pros-
7. Carlsson GE. Critical review of some dogmas in prosthodon- thet Dent 1996;76:576–580.
tics. J Prosthodont Res 2009;53:3–10. 19. Okano N, Baba K, Igarashi Y. Influence of altered occlusal guid-
8. Chen J, Katona TR. The limitations of the instantaneous centre ance on masticatory muscle activity during clenching. J Oral
of rotation in joint research. J Oral Rehabil 1999;26:274–279. Rehabil 2007;34:679–684.
9. Feldman S, Leupold RJ, Staling LM. Rest vertical dimension 20. Palla S. Neurocognition and neuroplasticity: what does it
determined by electromyography with biofeedback as com- all mean for clinical practice? J Oral Facial Pain Headache
pared to conventional methods. J Prosth Dent 1978;40:216–219. 2015;29:113–114.
10. Goldstein G, Andrawis M, Choi M, Wiens J, Janal MN. A survey 21. Pameijer JH, Brion M, Glickman I, Roeber FW. Intraoral occlusal
to determine agreement regarding the definition of centric telemetry. Part V. Effect of occlusal adjustment upon tooth
relation. J Prosthet Dent 2017;117:426–429. contacts during chewing and swallowing. J Prosthet Dent
11. Hanau R. Occlusal changes in centric relation. J Am Dent Assoc 1970;24:492–497.
1929;16:1903–1915.
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22. Pokorny PH, Wiens JP, Litvak H. Occlusion for fixed prostho- 33. Solaberrieta E, Otegi JR, Goicoechea N, Brizuela A, Pradies
dontics: A historical perspective of the gnathological influ- G. Comparison of a conventional and virtual occlusal record.
ence. J Prosthet Dent 2008;99:299–313. J Prosthet Dent 2015;114:92–97.
23. Radu M, Radu D, Abboud M. Digital recording of a convention- 34. Truitt J, Strauss RA, Best A. Centric relation: A survey study to
ally determined centric relation: A technique using an intraoral determine whether consensus exists between oral and max-
scanner. J Prosthet Dent 2020;123:228–231. illofacial surgeons and orthodontists. J Oral Maxillofac Surg
24. Ramfjord SP. Dysfunctional temporomandibular joint and 2009;67:1058–1061.
muscle pain. J Prosthet Dent 1961;11:353–374. 35. Valenzuela S, Baeza M, Miralles R, Cavada G, Zuniga C,
25. Rief W, Barsky AJ. Psychobiological perspectives on somato- Santander H. Laterotrusive occlusal schemes and their effect
form disorders. Psychoneuroendocrinology 2005;30:996–1002. on supra- and infrahyoid electromyographic activity. Angle
26. Rief W, Broadbent E. Explaining medically unexplained symptoms Orthod 2006;76:585–590.
—Models and mechanisms. Clin Psychol Rev 2007;27:821–841. 36. Van Eijden TM, Klok EM, Weijs WA, Koolstra JH. Mechanical
27. Rinchuse DJ, Kandasamy S. Centric relation: A historical and capabilities of the human jaw muscles studied with a mathe-
contemporary orthodontic perspective. J Am Dent Assoc matical model. Arch Oral Biol 1988;33:819–826.
2006;137:494–501. 37. van Eijden TM, Koolstra JH, Brugman P, Weijs WA. A feed-
28. Rugh JD, Graham GS, Smith JC, Ohrbach RK. Effects of canine back method to determine the three-dimensional bite-force
versus molar occlusal splint guidance on nocturnal bruxism capabilities of the human masticatory system. J Dent Res
and craniomandibular symptomatology. J Craniomandib 1988;67:450–454.
Disord 1989;3:203–210. 38. Walther W. Determinants of a healthy aging dentition: Maximum
29. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria number of bilateral centric stops and optimum vertical dimen-
for Temporomandibular Disorders (DC/TMD) for Clinical and sion of occlusion. Int J Prosthodont 2003;16(suppl):77–79;
Research Applications: Recommendations of the International discussion 89–90.
RDC/TMD Consortium Network and Orofacial Pain Special 39. Wiens JP, Goldstein GR, Andrawis M, Choi M, Priebe JW.
Interest Group. J Oral Facial Pain Headache 2014;28:6–27. Defining centric relation. J Prosthet Dent 2018;120:114–122.
30. Schuyler CH. Fundamental principles in the correction of 40. Wiskott HW, Belser UC. A rationale for a simplified occlusal
occlusal disharmony, natural and artificial. J Am Dent Assoc design in restorative dentistry: Historical review and clinical
1935;22:1193–1202. guidelines. J Prosthet Dent 1995;73:169–183.
31. Schuyler CH. The function and importance of incisal guidance 41. Woda A, Pionchon P, S Palla S. Regulation of mandibular pos-
in oral rehabilitation. J Prosthet Dent 1963;13:1011–1029. tures: Mechanisms and clinical implications. Crit Rev Oral Biol
32. Sinclair PM, Little RM. Maturation of untreated normal occlu- Med 2001;12:166–178.
sions. Am J Orthod 1983;83:114–123.

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4
CHAPTER
4.
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Sub-Chapters
4.1 The Natural Layering Concept
4.2 Freehand Anterior Restorations
4.3 Strategies for Direct Posterior Restorations
4.4 Freehand Posterior Restorations
4.5 Partial Molding for Posterior Restorations
4.6 Full Molding Technique
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The Direct Composite Option
Restorative dentistry has entered a phase of deep concep- In fact, no 3D printing or any foreseen technology will allow
tual rupture, demarcating two camps: the traditional one, soon the intraoral fabrication of highly esthetic and strong
pursuing the tradition of human-comprehended and -fab- restorations in a simple, efficient, and cost-effective way. In
ricated restorations, and the modern one, celebrating new case of extraoral fabrication, tapered cavities or at least dif-
technologies in all aspects and steps of a restorative treat- ferent cavity designs will be required, generating undesired
ment, limiting tremendously the manual contribution of the complications and costs as well, not only financially but also
dentist or dental technician. However, even the most enthu- biomechanically.
siastic, modern professionals recognize that no technology Direct composite application consequently has unique
can meet the excellence and perfection of a powerful brain advantages, but one should also embrace its “limited” phys-
and agile hands acting in synergy, while the most conserva- icomechanical properties and impact on potential indica-
tive ones also admit that digital dentistry has potential to tions, especially in regard to tooth wear treatments. Another
elevate the level of general dentistry. What is the most rea- crucial decisional parameter is the clinical protocol, which
sonable attitude? Probably, as usual, a position between the has to be adapted on one hand to the tooth wear extent and
two extremes! Freehand direct bonding can then be looked on the other hand to the practitioner experience so that the
at from different perspectives as well; it should either soon selected protocol will bring optimal results in a given envi-
be abandoned and replaced by CAD/CAM and 3D-printed ronment. As seen in chapters 1 to 3, in case of limited/mod-
restorations or on the contrary, even further developed, erate wear severity and extent, various protocols are avail-
using new digital technologies to improve its outcome and able; their respective indications will be reviewed in detail in
practicality. this chapter.
A slowing down worldwide economy and growing quest As for the various protocols involving the chairside use
for ultraconservative treatment approach should also trigger of light-curing composites, the technical limits of the full
further use and development of direct techniques. Thus, the molding technique lie on the amount of tissue to be re-
vision of progressive abandon of “direct bonding” is far from placed and the material mechanical performance, in case of
being the most realistic one, as many restorations can’t be severe parafunctions (especially clenching). One condition
approached simply by new technologies due to the limits of for success relates to the magnitude of functional stresses
cavity or restoration geometries and the irrational complex- and the restoration thickness; for instance, severe clenching
ity, preparation imperatives, or technology immaturity of with limited vertical dimension of occlusion (VDO) opening
CAD/CAM and 3D-printing systems if applied unrestrictedly. is logically more likely to induce composite failures such as
4.
4 Direct Techniques
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material chipping, wear, and marginal degradation. Such 1. Colon P, Lussi A. Minimal intervention dentistry: Part 5. Ul-
failures are however considered “minor” ones, which usually tra-conservative approach to the treatment of erosive and
necessitate only a repair procedure. Owing to the simplicity abrasive lesions. Br Dent J 2014;216:463–468.
of the treatment and restoration maintenance, the use of 2. Dietschi D, Argente A. A Comprehensive and conservative ap-
no-prep partial direct restorations appears to have irrefut- proach for the restoration of abrasion and erosion. Part I: Con-
able advantages and promising outcomes in the interceptive cepts and clinical rationale for early intervention using adhe-
treatment of moderate abrasion and erosion. sive techniques. Eur J Esthet Dent 2011;6:20–33.
3. Dietschi D, Argente A. A comprehensive and conservative ap-
proach for the restoration of abrasion and erosion. Part II: Clinical
procedures and case report. Eur J Esthet Dent 2011;6:142–159.
4. Dietschi D. Interceptive treatment of tooth wear: “why and
how do composite restorations play a key role in the long-term
management of abnormal attrition and erosion.” J Cosmet
Dent 2022;38:30-43.
5. Dietschi D. Minimally invasive and comprehensive rehabilita-
tion of severe tooth wear & extensive decays: A conservative,
“hybrid” approach. J Cosmet Dent 2012:28:98–110.
6. Loomans B, Opdam N, Attin T, et al. Severe Tooth Wear: Euro-
pean Consensus Statement on Management Guidelines. J Ad-
hes Dent 2017;19:111–119.
7. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current con-
cepts on the management of tooth wear: Part 4. An over-
view of the restorative techniques and dental materials com-
monly applied for the management of tooth wear. Br Dent J
2012;212:169–177.
8. Milosevic A. Clinical guidance and an evidence-based ap-
proach for restoration of worn dentition by direct composite
resin. Br Dent J 2018;224:301–310.
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4.1
CHAPTER
4.1
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Natural Layering Concept

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Natural Esthetics
Dentin and enamel are complex tissues
both from structural and optical stand-
points. A proper shading and layering
approach couldn’t be implemented
without a profound analysis and study of
those two natural tissues. This endeavor
happened in the late 1980s, lasting for
at least a full decade, until a simpler
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layering approach was conceived, lead-

ing to much more predictable color in-
tegration and esthetic results. Then, the
NATURAL LAYERING CONCEPT
was born.
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Shading and Layering Concept
Overall, layering concepts evolved from a primitive approach concept named after nature’s original model (Natural Lay-
to emulate natural dental anatomy and optical properties to ering Concept) and source of inspiration. It resulted from a
more reliable protocols to match tooth color and its many comprehensive study of true natural dentin and enamel op-
dimensions. “Color” integration as perceived by the patient tical properties, recognizing the variations in tissue quality
implies a correct hue, opacity, opalescence, and fluores- related to tooth age and functional maturing. Related find-
cence in regard to optical determinants and also surface ings have logically drawn the lines of this new concept.
gloss and light reflection (mainly related to the restoration Then, a new concept was born, allowing the emulation of
microanatomy). An optimal result in terms of esthetic inte- practically all usual VITA shades by using a proper combina-
gration is feasible today, although it will rarely be achieved tion of universal dentin shades of a single opacity level and
without proper material choice and appropriate layering ap- presenting a wide chroma range that extends beyond Vita
proach and application, which are largely product specific. Classic shades and multi-tint/multi- translucency enamels
We normally classify composite systems in relationship (typical brands named after their development period: Miris
to the number of recommended layers and as well as some and Miris 2 (Coltène/Whaledent), ceram.x duo (Dentsply
selected optical properties, which allows for finer differenti- Sirona), Enamel Plus HFO and HRi (Micerium), and Inspiro
ation among brands. In parallel, filler technology also con- (Edelweiss DR).
siderably evolved, aiming to offer the practitioner various
options such as universal materials (microhybrids or homo- eci c c a acte i tic f L dentin
geneous nanohybrids) that can be used both for posterior Interestingly, spectrophotometric measurements (tristimu-
restorations, owing to their excellent mechanical properties lus L*a*b* color and opacity values) of natural teeth belong-
and wear resistance, and for esthetics or specific composite ing to various VITA shades (in particular the a* and b* dentin
formulations (spherical or mixed filler composites), some of values from “A,” ”B,”’ and “C” VITA shades) suggested that the
which aim to be used chiefly in anterior teeth due to lower use of distinct dentin colors, at least for a direct composite re-
mechanical performances. Our preference today is toward storative system, was not justified. These spectrophotometric
universal composites as far as material technology is con- measurements conveyed another finding, namely that en-
cerned and a bilaminar application approach, considered amel significantly influences overall tooth color, confirming
simple, reliable, and also highly esthetic. The use of a natural the need for enamel to present not only different value/opac-
tooth as a model has been a logical evolution of direct restor- ity levels but also different tints to emulate perceived color
ative materials, leading to improved shading and layering variations (formerly attributed only to dentin hue differences).
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Natural Layering Concept (NLC) 185
Likewise, the variations of the contrast ratio (opaci- • Young enamel: white tint, high opalescence, less
ty-translucency) within a single shade group did not support translucency
the use of different dentin opacities (ie, translucent, regular, • Adult enamel: neutral tint, less opalescence, intermediary
or opaque dentins). However, the concept of a large chroma translucency
scale covering all variations of natural dentitions, plus some • Old enamel: yellower tint, higher translucency
specific conditions like sclerotic dentin (as found under- • Enamel shades should then present different tints and
neath decays, fillings, or cervical lesions) proved justified. opacity levels, tentatively replicating all variations found
Therefore, the following recommendations in regard to opti- in nature; it then follows a multi-tint and -translucency
cal characteristics of an ideal material aimed to replace den- concept
tin were drawn:
• Single hue ige t f L duct tical e tie
• Single opacity In summary, in an NLC composite system, the specific ma-
• Large chroma scale (beyond the four or five chroma levels terial optical properties for dentin are a single hue, a single
of the VITA system) opacity, and an extended chroma range (ie, level “0” to “7”).
For enamel, three specific enamel types with age-related tint
These findings have logically designed the features of this are needed to mimic young, adult, and elderly enamel types.
new and improved shading concept. Dentin shades should Various levels of translucency complete the different tints,
ideally be available in one single hue (as an average of natu- forming a multi-tint/multi-translucency system that emu-
ral dentin hue) with a sufficient range of chroma levels (cov- lates most of natural enamel variations
ering at least the existing VITA shade range) and presenting
an opacity similar to natural dentin.
eci c c a acte i tic f L ena el

In regard to enamel, differences in tissue brightness and
translucency generally varied in relation with tooth age and
therefore confirmed the clinical concept of three specific
enamel types:
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Adult configuration
Young configuration Elderly configuration
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nat ical and tical a iati n acc ding t Adult configuration

t t age Due to tissue maturation (ongoing dentin calcification and
enamel mineralization), the dentin core shows an increasing
Special attention must be paid to the morphologic changes chroma level, usually between 2 to 4. Maturation of enamel
that affect the incisal edge structure due to tissue aging and creates a progressive shift toward intermediate translucency
functional wear. In addition to the increase in dentin chroma and value/brightness; typical shade coding is “White,” “Neu-
and enamel translucency/tint, the progressive thinning of tral,” or “Ivory.” Progressive incisal wear is also modifying the
the enamel layer and exposure of dentin structure at the in- relative position and thickness of enamel and dentin at the
cisal edge necessitates an adaptation of the layering tech- incisal edge; observation of neighboring teeth or comparison
nique; see also the next pages for additional information. with the desired esthetic rendering requires a specific den-
tin/enamel modeling to be performed. In tooth wear cases,
Young configuration however, we tend to use the young tooth configuration but
The dentin core has its full volume and anatomical details, respect the optical determinants of the teeth age group.
including incisal lobes; its chroma is generally low and on a
the NLC scale with a value between 0 and 2 (see next page). Elderly configuration
Enamel shows little or virtually no wear at the incisal edge, The aforementioned tissue maturation processes and in-
preserving the full natural tooth anatomy; enamel tint is cisal wear further impact the appearance and anatomy of
commonly whiter than in adult and elderly configurations, the whole smile, particularly the incisal edges of anterior
with minimal translucency and higher value/brigthness. Typ- teeth. The dentin core chroma is then logically higher than
ical enamel or shade coding is “Bleach,” “White,” or “Warm in the two previous configurations, with common values be-
white = Ivory,” according to the aforementioned multi-tint tween “3” and “5.” Note that in the cervical third, if required,
and -translucency concept. flowable shades with higher chroma levels (“6” and “7”) can
be used for the restoration bulk or as shade modifier on the
dentin core surface. For the enamel, we likely select masses
with slightly more tint and higher translucency, with typical
coding “Neutral, “Ivory,” and “Transparent.”
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4188
.1 ung teet c n gu ati n
Dentin
Usual chroma levels
No enamel or dentin incisal wear
Enamel
Usual tint and translucency
4.1 188 Natural Layering Concept
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189 .
1
Within the Natural Layering Concept, two dimensions have

to be analyzed, which leads to the proper choice of both
dentin and enamel shades and as well guides the clinician
about which respective form and thickness of material has
to be applied at the incisal edge to properly mimic the 3D in-
ternal anatomy of different tooth ages (young, adult, elderly).
In nature, myriad specific configurations occur between the
three schematic ones represented here.
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190 ic ne f ena el t e e licated it t e atu al La e ing nce t
Late al inci ent al inci
t t
t t
t t
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The impact on the aforementioned concepts and layering guidelines for direct composites has been a lot more than
just a conceptual change; it resulted in a true shift in the way we use composites, offering a simple and predictable way
to mimic natural tooth appearance using only two layers (dentin and enamel masses). A few modern materials have led
globally the market of direct composite systems with this completely new shading technology and concept (Miris and Miris 2,
Colt ne/Whaledent; Inspiro, Edelweiss DR).
atu al t ila inated ite e lica
Under various light conditions (reflected, transmitted, and UV). The best products behave similarly to natural tissues, what is another key
element to obtain optimal esthetic integration in any visual environment.
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192 nal gie et een t e la ic ading te and L a ac
Although the underlying concept of the VITA Classic shading system is unlike the NCL approach with multiple dentin hues
(A, B, C, and D) and value order varying between different chroma levels, the “chroma” steps are shared by both systems (the
chroma change from one dentin shade to the other is alike). Note, however, that the number of chroma levels is extended in
the NCL system and does not reproduce the same numbering (eg, A3.5 would correspond to chroma level 4).
atu al La e ing nce t t ical ade guide
L L L L L
NB: Not all NLC chroma shades are represented below.
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inati n f ingle dentin it a i u ena el ade it t e L te 193
chroma levels (CL) “2” and “3” of the VITA Classic system
Not only can all VITA Classic shades be reproduced with the NLC, but also others that are not covered by the VITA shading system. In fact,
proper NLC composite systems allow multiple combinations of dentin and enamel to emulate virtually any natural tooth shade.
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194 Dentin chroma selection (1) is made at the cervical third.

There is no need to choose hue or include value in the ob-
servation process which greatly facilitates the procedure.
 
Tint and
translucency
Step 2a: Tint Step 2b: Translucency (value)
Whitish Low: Bleach

Neutral Medium: Neutral/Ivory/White
Yellowish High: Translucent
The selection of enamel tint and translucency (2) is done first visually, in the incisal and proximal areas where only enamel is present.
The first choice relates to tint (whitish, neutral, or slightly yellowish) and then translucency level (low, medium, or high); the process is
done mentally and then confirmed by combining the selected dentin and enamel samples (3). Using only enamel samples for intraoral
comparison with reference tooth is not recommended.
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ade ec ding it L te 195
The quality of the final restoration depends on a correct white hypocalcifications, high chroma areas, or localized
shade recording. According to the natural layering concept, opalescence zones). In this situation, the application of
there are only three simple steps involved: (1) selection effect materials such as white, blue, or orange-gold might
of dentin chroma in the cervical area, where enamel is be recommended (see later section on polychromatic
the thinnest, using samples of the composite material; (2) restorations).
selection of enamel tint and translucency, performed by
simple visual observation; and (3) confirmation of shade Dedicated shade guide for the NLC composites (Inspiro
match (superimposed samples with the reference natural system)
tooth). In order to provide an accurate shade matching, The dedicated and special Inspiro shade guide allows for
glycerin gel must be placed between dentin and enamel precise and reliable color evaluation. It is manufactured with
samples to facilitate light transmission; glycerin has a more the real composite and has been developed as an integrant
suitable Refractive Index (RF = 1.47), compared to air (RF = tool of the NLC, involving the two distinctive restorative layers
1.00) and water (RF = 1.33), which is rather close to composite (body and skin). It has smaller dentin/body samples, which
materials (RF range 1.54–1.62). can be inserted into enamel/skin samples to demonstrate
In specific and less frequent cases, a third step might be any possible combination between the 8 dentin/body and
involved in the form of a visual or photographic mapping 5 enamel/skin shades; this concept is practically simpler
of the tooth to identify special optical effects (such as than having too many bilaminated shade samples.
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Simplicity and Predictability of the Natural Layering Concept
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 

The uncomplicated NLC protocol is ideal for tooth wear enamel shade (1) was placed with help of the silicone
treatments, which by nature require multiple teeth to be index, then restorative dentin mass (2) was applied as a
restored simultaneously; simplicity, however, does not mean single increment (sculpted to emulate natural dentin core
to compromise with the esthetic outcome. Also, when doing anatomy) before a final layer of restorative enamel (3). The
additive restorations, some systems even provide shade- postoperative central image shows a satisfactory outcome
coordinated flowable and restorative masses (eg, Inspiro) as result of a simple layering approach and use of a material
that further facilitate the application protocol, such as the with suitable optical properties.
case presented here. A first thin lingual increment of flowable
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e f ect ade it t e atu al La e ing nce t
lue u
entin ec atic c a
ite ce
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199 .
1
l c atic e t ati n and e ect ade
For teeth with richer color composition (strong opalescent visible; we then observe a soft blending between the more
halo, noticeable dentin mamelons, enamel opacities, etc), chromatic and opaque dentin and the natural enamel trans-
special effect shades produced in a flowable consistency are lucency, an optical property different from opalescence.
available in some NLS systems to unleash esthetic boundar- Some teeth might show dentin lobes more, often in combi-
ies (eg, Miris 2, Colt ne/Whaledent; Inspiro, Edelweiss DR). It nation with increased opalescence halo, and in such cases,
is common to relate the addition of effect shades between dentin lobes edges have orangish effects that can be simu-
dentin and enamel masses to a “polychromatic” layering, as lated with a high chroma dentin color modifier (eg, Inspiro
opposed to normo-layering, based on the strict use of the Chroma). In general, any area with higher chroma can be
bilaminar concept. characterized with a thin layer of such an effect shade.
Blue opalescent effect shade White tint effect shade

In “normo-chromatic” teeth, natural opalescence creates a Normo-chromatic teeth don’t show much whitish enamel
discrete, diffuse blue halo; such effect will be emulated by colorations. The most usual enamel whitish discoloration/
the composite intrinsic opalescence. When the opalescent dysplasia are fluorosis, congenital, or atypical idiopathic
halo is a lot more intensive, an opalescent, usually blue- enamel hypocalcifications. Some very discrete application
tinted resin or flowable composite (eg, Inspiro Azur) can be of a whitish resin or flowable composite effect shade (eg,
applied atop and around the dentin lobes to replicate such Inspiro Ice) can enhance the shade integration or create a
e ffe ct. more natural appearance.
Hyperchromatic dentin effect shade Cases presented on the next page and in the next section of
In “normo-chromatic” teeth again, the dentin core shows this chapter will provide detailed insight about the indica-
discretely below the incisal edge and dentin lobes are hardly tions and use of effect shades.
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Dentin Bi3
(Inspiro system)
Clinical application of effect
shades
As shown on this clinical ex-
ample, effects have to be
placed between the dentin
core/layers and the enamel
that covers it all; such layer-
ing approach grants the best
natural outcome.
Azur effect
White enamel
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1. Cook WD, McAree DC. Optical properties of esthetic restor- 5. Dietschi D, Fahl N Jr. Shading concepts and layering techniques
ative materials and natural dentition. J Biomat Mat Res to master direct anterior composite restorations: An update. Br
1985;19:469–488. Dent J 2016;221:765–771.
2. Demarco F, Collaresa K, Coelho-de-Souza F, et al. Anterior com- 6. Dietschi D, Shahidi C, Krejci I. Clinical performance of direct
posite restorations: A systematic review on long-term survival anterior composite restorations: A systematic literature review
and reasons for failure. Dent Mater 2015;31:1214–1224. and critical appraisal. Int J Esthet Dent 2019;14:252–270.
3. Dietschi D. Layering concepts in anterior composite resto- 7. Heintze S, Valentin R, Hickel R. Clinical effectiveness of di-
rations. J Adhes Dent 2001;3:71–80. rect anterior restorations—A meta-analysis. Dent Mater
4. Dietschi D, Ardu S, Krejci I. A new shading concept based on 2015;31:481–495.
natural tooth color applied to direct composite restorations.
Quintessence Int 2006;37:91–102.
Shade Selection for the Natural Layering Concept
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4.2
CHAPTER
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ANTERIOR
203
Free-Hand Techniques
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CASE SUMMARY
linical nding and ele ant fact

UF Awake and cleep parafunctions (bruxism and clenching)
Smoker and frequent coffee/tea consumption
Patient required a cost-effective treatment approach
a illa ante i
UP
Lab-made (indirect) palatal composite veneers
Freehand incisal composite restorations (lateral to lateral;
see chapter 6.2 for complete treatment presentation)
a illa te i
Freehand, direct occlusal composites restorations
LP andi ula ante i

Freehand, direct composites restorations with index
andi ula te i
LF Freehand, direct occlusal composites restorations
See chapter 6.2 for comprehensive case presentation.
4.2 Free-Hand Techniques
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Freehand and Indirect

Composite Restorations
Case 1
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Additive resin composite application is

a fundamental principle in interceptive
treatments for moderate tooth wear
extent or when financial constrains
are present. A pretreatment wax-up is
then the prerequisite to further restor-
ative steps (1); an index is usually made
for both arches to guide the clinician
for creating optimal length, form, and
function (2). Lengthening anterior teeth
with a no-prep approach necessitates
a correct shade selection to grant res-
torations an optimal shade integration
(3). After sandblasting of the surfaces to
be restored and adhesive application,
a lingual shell of enamel is first placed
with help of the silicone index. It can
be either a restorative or flowable com-
posite (4).
 
Preop Laboratory steps
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Restorative phase
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Restorative phase
The next step consists of applying dentin against the lingual enamel shell (4). Dentin lobes are molded with hand instruments and
brushes. Effect shades (5) if needed have to be placed over the dentin core before application of the last proximo-labial enamel layer (6).
The inclusion of one more component (effect shade) does not impact the basic anatomical layering approach and thickness of the main
dentin/enamel increments. Finished and polished restorations are shown on the lower right image.
  
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Chroma 3 dentin 209
Opalescent effect shade
Ivory enamel
Incisal edge build-up with direct technique
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CASE SUMMARY
UF linical nding and ele ant fact

Moderate to severe anterior tooth wear induced by bruxism
Slight crowding of anterior teeth
Wish for a simple, cost-effective restorative approach
UP
a illa ante i
Orthodontic alignment of maxillary anterior teeth
Freehand incisal composite restorations (first premolar to
first premolar)
a illa te i
Regular dental maintenance
LP
andi ula ante i
LF andi ula te i
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Freehand Composite Restorations
Case 2
Contribution of Dr. Tony ROTONDO
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This 42-year-old female patient presented wanting an es-

thetic improvement and seeking a “natural look.”
She was aware of the localized wear of her maxillary an-
terior teeth, and wear (although less so) of her mandibular
anterior teeth. The loss of tooth volume was thought to be
largely related to attrition associated with nocturnal brux-
ism. She was suggested a number of treatment solutions;
these included ceramic veneers or composite resin additions
to restore both loss of tooth structure and esthetic improve-
ments, with or with out the inclusion of orthodontic treat-
ment. We decided that the mandibular anterior teeth could
be left alone, provided preventive strategies were embraced.
The patient chose a treatment plan involving orthodon-
tics to align her moderately crowded anterior dentition, im-
prove the maxillary arch form, align gingival levels, and cre-
ate space for restorative material for the restoration of her
maxillary anterior teeth.
Once orthodontic treatment was completed, another
esthetic analysis was carried out utilizing conventional es-
thetic guidelines and 2D Digital Smile Design protocol, which
helped to provide clear direction so that an accurate diag-
nostic wax-up could be fabricated.
The midline and incisal edge position were determined
first, followed by positioning of the incisal plane. Pleasing
tooth proportions were of course considered when finalizing
the esthetic analysis.
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The diagnostic wax-up was fabricated on articulated

casts and is a direct result of the esthetic analysis and the
functional relationship with the mandibular anterior teeth.
The wax-up was used to fabricate a laboratory putty
(Coltene/Whaledent) key, which was used as a matrix in
the fabrication of the restorations.
The diagnostic wax-up had defined the palatal surface
and the incisal edge of the definitive resin restorations
and to that end must be accurate. It is important that the
palatal interproximal regions are well defined, as this will
prevent excess resin from finding its way to the proximal
regions and resultng in less time trimming.
In the same way, the lab putty key had also to be ac-
curate; this could be achieved either by ensuring it cures
under pressure (in a laboratory pressure pot) or by relining
the key with light-body silicone impression material. The
key was trimmed so that it would not interfere with the
rubber dam isolation. It extended distally to the second
premolars and material was removed from the palatal part.
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The accuracy and morphologic-functional integration of diagnostic wax-up was then verified by carrying out a direct mock-up. Because
the quality of the treatment outcome is so dependent on the wax-up configuration (forms and proportions, teeth arrangement), a sepa-
rate short appointment for the purpose of verifying the aforementioned parameters prior to treatment is routinely arranged as it allows
any corrections to be be made prior to the restorative appointments.
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216 Shade selection is carried out as an initial step. This was done using shade tabs (Inspiro, Edelweiss DR). Dentin shades were selected
based on the chroma in the cervical and middle third of the patient’s natural teeth (Bi2), with a slightly warmer shade for the canines
(Bi3). A brighter enamel shade (SB) was selected to lift the overall value of the teeth to be restored.
First, the teeth were cleaned, all old restorative material was removed, and proximal surfaces freed with abrasive strips. Gentle bevels
were also created along the incisal edges to soften the optical transition from tooth structure to restorative material. Finally, all teeth
to be restored were thoroughly cleaned with air abrasion after isolation with rubber dam; floss ligatures provide correct placement of
rubber dam along gingival architecture.
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The key was sectioned through the incisal edge, more Enamel shaded material was placed first in the key in the
specifically through the mid-incisal. This is important, as the usual way. Important points to consider are to keep the en-
palatal enamel layer will ultimately define the mid-incisal amel layer thin so that ultimately it does not interfere with
and will provide an accurate reference for the positioning of positioning of the dentin mass and to ensure there is little or
the dentin mass. Additionally, when enamel shaded com- no composite in the proximal regions. Then, the key is pos-
posite is positioned beyond the mid-incisal, it eliminates the itioned on the teeth and time is taken to further thin the en-
potential to place dentin shaded material up to and some- amel shaded material and ensure again there is little or no
times beyond the incisal edge and in doing so restricts the material in the proximal areas.
ability to create effects more appropriate for particular teeth, Some small increments of dentin composite can be
for example worn teeth. pushed between the enamel shaded material and the tooth
The silicone key was tried in to ensure accurate adap- on the palatal while the material is still un-set to ensure there
tion, and the teeth were etched, primed, and uncured bond is no porosity in this region. The composite can now be com-
placed on all etched tooth surfaces (Scotchbond 2, 3M). The pletely cured and the putty key removed.
bond was thinned uniformly with air and left uncured.
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Placement of the dentin mass

was carried out with the desired
final appearance of the teeth in
mind. In this case, a three mamelon
arrangement was chosen for the
central incisors and two mamelon
arrangement was chosen for the
lateral incisors. The mamelons are
carried to but not beyond the in-
cisal edge. Accurate placement of
the dentin mass is critical to the
final appearance of each individ-
ual tooth, as previously mentioned;
this is in turn is directly related to
the accuracy of the wax-up and key
and positioning of the enamel pala-
to-incisal wall.
The dentin mass is preferably
applied prior to the proximal wall
buildup so that nothing interferes
with the placement and position-
ing of the dentin mass.
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Once cured, each buildup has sufficient strength such that the contacts can be separated with a strip and possibly some proximal abra-
sion with strips to ensure the accurate adaption of proximal matrices (mylar strips).
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Some effect materials were added at this point. In the Inspiro system, there are a number effect materials conveniently packaged as
flowable materials. A white effect material (ice) with moderate opacity (similar to dentin) was selected to highlight the incisal halo.
A warm gold effect material (chroma) was selected to increase the level of chroma in the middle mamelon (central incisors and
canines) and the mesial mamelons of the lateral incisors. Finally, small amounts of blue/opalescent effect material (azur) were added
to the proximal and incisal regions to enhance the perception of translucency in these areas.
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In completing the final enamel layer, the proximal surfaces were completed first. This was done one by one, starting with the midline
and moving laterally. The midline addition is most important and will typically need to be trimmed with a Sof-Lex disc (3M) to ensure the
midline is positioned accurately referencing both its position and inclination relative to the facial midline. Once the proximal additions
are complete, the labial enamel is placed; positioning of this mass is the least critical and can be carried out relatively rapidly, always
being careful not to incorporate porosity. Light-curing of the composite restorations is completed at this stage, and the restorations are
refined with flame-shaped diamonds and Sof-Lex finishing discs. At this point, the restorations are not completely finished and polished.
This would typically be carried out at a later appointment, after the patient has experienced the new restorations.
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The advantages of finishing at a

second appointment are numerous.
The operator and patient are not tired
or anaesthetized, respectively. The
patient will have had time to develop
a more objective opinion about the
restorations; this is less likely to hap-
pen at the first appointment.
After listening to the patient’s
feedback, final gross alterations
may be made. These might include
refining the patient’s occlusion and
checking excursive occlusal contacts,
adjustments of form that are based
on the views of the patient and the
clinician.
Once gross or primary alterations
have been completed, secondary
anatomical features such as labial
grooves and gross surface topogra-
phy can be developed. It is helpful to
map theses features with a pencil so
they are developed in a more or less
symmetric and controlled manner.
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A rough-grit, flame-shaped dia-

mond bur can be used to develop
these features either in a high-speed
or reduction handpiece; care should
be taken not to create too much reg-
ularity to the features, and the study
of natural tooth forms is essential to
develop natural shapes. Once this is
completed, the secondary features
will need to be softened to look more
natural. A pre-polisher such as the
gray Astropol polisher from Ivoclar
Vivadent is useful for this purpose.
This bur will both polish and remove
material, so it can be used to soften
forms, complete the primary polish,
and shape anatomical features.
At this point, the perykymata (and
other tertiary features) are added us-
ing a red-band, flame-shaped dia-
mond bur with gently sweeping hori-
zontal movements across the facial
surface of the tooth.
The polish was completed using
the Kerr silicone polishers sequen-
tially. Note that all shaping and polish-
ing was done without irrigant so that
the operator can watch the changes
each bur and polisher is performing
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Postoperative views. Composite resin can provide an esthetic and functional solution for managing worn teeth; however, in a bruxing
patient, a nightguard is highly recommended, but not mandatory.
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3 years postoperative
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The 3-year findings demonstrated highly satisfactory behav- composite materials improved with their optical and physi-
ior of restorations both in terms of form integrity (meaning cal properties. It also has to be confirmed that regular use of
good resistance to function and parafunctions) and esthet- the nightguard is key to the success of the interpretive strat-
ics, apart from minor chipping of the right central incisor. egy. Patient compliance is one of the main factors to prevent
In particular, the selected material demonstrated excel- degradation of residual structure and restorations, whether
lent color and gloss stability, confirming how much direct resin composite or ceramics as well.
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CASE SUMMARY

Sleep and awake parafunctions (bruxism and clenching)
Erosion due to high consumption of fizzy drinks
Patient looks for conservative treatment wherever possible
UP
a illa ante i
Direct composite restorations on both palatal and facial
aspects
a illa te i
Direct composite and indirect ceramic restorations with one
implant-borne crown for tooth no. 16
LP
andi ula ante i
No treatment; only preventive measures (nightguard)
andi ula te i
LF
Indirect ceramic overlays
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Freehand Palatal Composite Restorations
Case 3
Contribution of Dr Romain CHERON
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This 52-year-old male patient consulted due mainly to es- to cold and heat next to regular tensions in his masseter and
thetic concerns. He expected tooth whitening and replace- temporal muscles, mainly in the morning after waking up but
ment of aged and stained umaxillary composite fillings; he admittedly also sometimes during the day. These clinical el-
otherwise had no awareness of either his wear problems or se- ements supported the diagnosis of tooth erosion related to
verely decayed posterior teeth. During a more detailed dental a high consumption of fizzy drinks and moderate to severe
anamnesis, the patient reported frequent overall sensitivity attrition due to sleep and awake bruxism and clenching.
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The proposed treatment was based on two phases, first the replacement of all decayed posterior teeth mainly with indirect ceramic
restorations, composite onlays (maxillary right premolars), and direct Class I and II composites fillings (maxillary left premolars). After
a first attempt to re-treat the maxillary right molar, residual decay distally made the tooth “irrational to treat”; it was then extracted and
replaced by an implant.
Indirect and direct posterior restorations were made at a new, increased VDO in order to create the needed space to restore attrition
and erosion lesions of the maxillary front teeth. A night home bleaching preceded the second treatment phase comprising only direct
composite restorations, following the patient’s initial request for this part of the treatment. As usual, when completing the treatment, a
nightguard was given to the patient, together with proper information to control his erosion risk factor.
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Full views of palatal sur-

faces show the pretreat-
ment (left) and post-prepa-
ration (right) conditions.
Note that some composite

was left on the maxillary
central incisors to support
the application of palatal
increments. The upper left
image shows the space
gained with the resto-
rations of posterior teeth
at an increased VDO. See
further pages for details on
this first treatment phase.
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This case demonstrates the

classical approach for re-
storing the palatal surfaces
of worn anterior teeth in the
 presence of proximal resto-

rations. First, proximal in-
crements (1) are placed with
help of metal strips inserted
alternatively in between
each contact. The metal
strip is then stabilized along
the mesio-cervical tooth
profile (2) before light-cur-
ing (3). After completing this
step both mesially and dis-
tally (4), the remaining pal-
atal anatomy is completed
with a single increment for

each tooth (5).
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Postoperative
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Direct facial and palatal restorations.
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3 years postoperative
4.2 Free-Hand Techniques Palatal build-up with direct technique
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The 3-year findings demonstrated satisfactory behavior of due to severe horizontal and vertical bone loss resulting
both direct and indirect restorations and direct palatal com- from previous extractions. The patient was otherwise com-
posites. Only a small area of debonding and microchipping pliant with the nightguard over the first 3-year observation
was found on the palato-distal aspect of the maxillary left period.
canine. The radiographic follow-up did not present any re- This case illustrates again the importance and interest of
current problem, either biologically or mechanically; the a “hybrid” approach that embraces more specifically the in-
implant integration is also satisfactory with a stable bone dividual and localized biomechanical and esthetic demands
level. The maxillary molars were not replaced at this stage of worn teeth.
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4.3
CHAPTER
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sdpr
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Strategies for Direct Posterior

Restorations
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Techniques for Posterior Teeth
efe ence int t c nt l ate ial t ic ne There are two types of anatomical references to be
and functi nal anat considered:
• Occlusal pits and grooves
Reference points are needed both as visual control and sta- • Proximal contacts and marginal ridges
bilization of indexes. Logically, the greater amount of tissue
missing, the more difficult the treatment will be, and this is Based on the number of reference elements present, the
why a proper analysis of the preoperative conditions is cru- clinican should be logically guided toward the most appro-
cial to the successful application of the selected protocol. priate clinical protocol, from a direct freehand application up
Another element previously discussed is the selection of the to indirect or CAD/CAM solutions. In regard to the use of di-
restorative material according to known risks factors, next to rect restorative composites, there are three options, namely
the occlusal and functional determinants. freehand, partial, and full molding.
When occlusal determinants are missing (red circles), the freehand technique becomes more difficult and molding techniques are
advocated.
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ee and a licati n It has the other advantage of requiring only a “simple” wax-
ing technique and also works very well with printed models.
When occlusal pits and fissures as well as occlusal embra- Here, the clinician builds up all buccal and lingual cusps
sures (although sometimes showing loss of enamel) are during a single step; the remaining occlusal anatomy is then
present, a direct freehand technique can be applied. The completed with a freehand technique similar to making sin-
composite application is then morphologically driven by the gle occlusal, Class I fillings. This method is recommended for
functional wax-up and controlled visually; the clinician uses limited to moderate tooth wear cases
the remaining occlusal anatomy as a reference to build up
missing cusp structure, protect marginal ridges from further ull lding tec ni ue
attrition or erosion, and establish the new VDO. The control The full molding techniques makes use of an index provid-
of material thickness is given by the wax-up as seen by the ing full anatomy and control of the new VDO. This technique
color difference between added material and existing anat- is feasible with analog and digital wax-ups. Although very
omy (conventional, analog waxing technique has a clear ad- simple in concept, this protocol requires very precise and
vantage). This method is recommended only for limited to detailed procedures to provide a perfect reproduction of the
moderate tooth wear cases. Experienced and skilled practi- new anatomy and VDO, limiting the time and effort required
tioners can however expand the indication of this very sim- to remove composite excesses. This method is recom-
ple method. mended for limited to moderate tooth wear, possibly slightly
more severe tooth wear cases as well.
a tial lding
This technique brings some additional control of cusp
buildup anatomy and VDO increase compared to the free-
hand approach.
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Freehand application
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Full molding
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In cases with advanced tooth wear, indirect and CAD/CAM

techniques are advocated because freehand and even molding
techniques become overcomplicated.
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A Wear only B Wear and restorations
Treatment of decays and replacement of defective restorations

Opening of occlusal embrasure in non decayed teeth
Opening of occlusal embrasures
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e a ati n f additi e f ee and and lded te i

e t ati n
Case preparation
The first workflow phase depends on whether teeth were previously re-
stored and with which material or if there is no hard tissue pathology
other than tooth wear. In the latter condition (A), proximal embrasures
are opened with an ultra-thin diamond disk (0.3 to 0.4 mm) to allow for
marginal ridge molding and shaping (freehand and partial molding tech-
niques) or contact point isolation (full molding technique). Proximal em-
brasures also help to properly shape restorations and facilitate excess
composite removal after composite molding; moreover, “opened” embra-
sures contribute to the stabilization of the tray or index during molding
processes.
The replacement of defective tooth-colored restorations and met-

al-based restorations, or the treatment of decays, is often made with a
direct approach (B). In this case, restorations are made at the preexisting
VDO; then, in a second treatment phase, occlusal corrections and VDO in-
Post-interceptive treatment using direct crease can be performed (left image).
freehand technique.
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VDO opening and restorative material thickness
Material thickness?
One of the main factors clinicians have to know is the amount of material to be applied for obtaining the needed anatomical, functional,
and esthetic enhancements. Practically, the material thickness is rather consistent when it relates to moderate tooth wear extent and a
direct restorative approach using composite (with freehand or molding techniques).
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As explained in chapter 3, a wax-up is needed to define the new functional, occlusal, and esthetic scheme, together with a VDO increase,
which is the rationale to achieve the aforementioned treatment objectives with a no-prep approach. The space that has to be created
between the maxilla and the mandible (VDO increase) is strictly defined by the maintenance of anterior guidance with proper overjet
and overbite, as well as satisfactory interarch occlusal and anatomical relationships based on the chosen occlusal position (CPR, MIP,
MCR). No matter the aforementioned occlusal position, there is a rather constant ratio in the interocclusal space created, with about
1 to 3 increase factor from the molars to incisor areas, as shown below. The only exception to this rule is when choosing AMIP/MCR
(anterior displacement of MIP, according to muscular adaptability and neuroplasticity potential); then, the interocclusal space might be
more consistent from molars to incisors.
3 2 1
2.5–3.0 mm ( 0.5 mm) 2.0–2.5 mm ( 0.5 mm) 1.5–2.0 mm ( 0.5 mm) 1 mm ( 0.5 mm)
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4.4
CHAPTER
With contributions by Patrick Schnyder, MDT, Oral Design Group, Montreux-CH (case 2).
4.4
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255
fht
Freehand Techniques
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Freehand Technique for Posterior Teeth
The direct composite option is logically indicated for all should be performed beforehand at the preexisting VDO. It
forms of limited to moderate tissue loss/destruction. The ad- is in a second operative step that the VDO increase will be
vantages of direct composite over indirect restorations are performed together with anatomical and functional correc-
manifold. Among other benefits, one can cite the highly con- tions (scenario B); this allows treatment sessions to remain
servative approach, the possibility to replace/reshape small comfortable for patients who have to go through a full oc-
portions of the tooth, the reparability, the simplified replace- clusal change mostly within only 2 days (normally one arch
ment, and the relatively limited cost. Conversely, it is more per day).
technique sensitive and might create thin layers of material When correcting the anatomy and function of teeth show-
over some surfaces, which are mechanically “at risk” so that ing truly minimal tissue loss, all types of composite technol-
proper case analysis is mandatory prior to treating the pa- ogies can be used (occlusal stops), including flowable ones,
tient. This includes understanding the individual functional because permanent anatomical modifications are then not
and parafunctional occlusal parameters as well as each mandatory (passive eruption will compensate wear); in such
tooth’s biomechanical status (cracks, vitality, or nonvitality). scenarios, composite stops are used only to equilibrate con-
As formerly described (see chapter 3), the incidence of pre- tacts in the short term; such an approach can be considered
existing as well as posttreatment occlusion position together a delayed application of the Dahl concept. Conversely, when
with the parafunctional status will impact the decision of anatomical correction and replacement of missing tissue
whether or not to exclusively use direct composite to restore aims to be permanent, using a stronger, wear-resistant ma-
all worn dental surfaces. terial is imperative; to this purpose, hybrid composites are
When small decayed fillings are present, they can be re- preferred (see chapter 2.2 for information about material
stored simultaneously to the VDO correction and anatomical, selection). The most frequently used composites are hybrid
functional enhancements with direct composite application or nanohybrid materials that also provide the “firm consis-
(scenario A). On the contrary, in the presence of medium to tency” needed to create freehand the desired, improved
large defective Class I and II restorations, their replacement anatomy and function.
4.4 Freehand Techniques
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A Small decays or Class I/II restorations B Medium-to-large-sized decays and Class I/II restorations
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
Pretreatment worn occlusal surfaces Single occlusal increment of enamel composite placed with a plugger/spatula instrument
 

Occlusal sculpting with sharp working tip Completed modeling Characterization with “fissure” effect shade

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Instrumentation for Freehand Sculpting 259
The freehand approach strongly relies

on adequate instrumentation to create
proper anatomy and function. How-
ever, “adequate” doesn’t mean a large
number of instruments but on the con-
trary to select only a few instruments
that are well designed to perform the
needed tasks.
One example of such instrument
set is the CompoSculp kit (Hu-Friedy),
which includes only five instrument
designs: one application instrument in
two sizes, one sculpting instrument for
posterior restorations, and two spatu-
las for shaping labial, palatal, and prox-
imal surfaces.
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General Indications for Composite Freehand Application
As for the various protocols involving the chairside use of

light-curing composites, the technical limits of the direct
composite application lie in the amount of tissue to be re-
placed and the material’s mechanical performance in cases
of severe parafunctions (especially clenching). In fact, one
condition for success relates to the magnitude of functional
stresses and the restoration’s thickness; for instance, severe
clenching with limited VDO opening is logically more likely to
induce composite failures such as material chipping, wear,
and marginal degradation. Such failures are however con-
sidered “minor” ones that usually necessitate only a repair
procedure. Owing to the simplicity of the treatment and re-
storation maintenance, the use of no-prep partial direct res-
torations appears to have irrefutable advantages and prom-
ising outcomes in the interceptive treatment of moderate
abrasion and erosion. See chapter 8 for maintenance and
long-term results with direct restorations.
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1. Colon P, Lussi A. Minimal intervention dentistry: part 5. Ul- 6. Loomans B, Opdam N, Attin T, Bartlett D, Edelhoff D, Franken-
tra-conservative approach to the treatment of erosive and berger R, Benic G, Ramseyer S, Wetselaar P, Sterenborg B,
abrasive lesions. Br Dent J; 2014: 463-468. Hickelk R, Pallesen U, Mehtam S, Banerjin S, Lussi A, Wilson N.
2. Dietschi D, Argente A. A Comprehensive and conservative ap- Severe Tooth Wear: European Consensus Statement on Man-
proach for the restoration of abrasion and erosion. Part I: con- agement Guidelines . J Adhes Dent 2017; 19: 111–119.
cepts and clinical rationale for early intervention using adhe- 7. Mehta SB, Banerji S, Millar BJ, Suarez-Feito JM. Current con-
sive techniques. Eur J Esthet Dent 2011;6:20-33. cepts on the management of tooth wear: part 4. An overview
3. Dietschi D, Argente A. Comprehensive and conservative ap- of the restorative techniques and dental materials com-
proach for the restoration of abrasion and erosion. Part II: Clinical monly applied for the management of tooth wear. Br Dent J.
procedures and case report. Eur J Esthet Dent 2011;6:142–159. 2012;212:169-77.
4. Dietschi D. State-of-the-Art Patient-Centered Treatment & 8. Milosevic A. Clinical guidance and an evidence-based ap-
Management of Tooth Wear. J Cosmetic Dent 2022; Spring proach for restoration of worn dentition by direct composite
2022, Vol. 38 Issue 1, p30-43. resin. Br Dent J. 2018 Mar 9;224:301-310.
5. Dietschi D. Minimally Invasive & Comprehensive Rehabilita-
tion of Severe Tooth Wear & Extensive Decays: A Conservative,
“Hybrid” Approach. J Cosmet Dent 2012:28:98-110.
Direct build-up for posterior teeth
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CASE SUMMARY

Early signs of tooth wear in maxillary and mandibular
anterior teeth
UF
Sleep bruxism
Patient expects an esthetic correction of discolorations
a illa ante i
UP Lab-made felsdpathic veneers on teeth nos. 11 and 21
Direct palatal composite restorations
Direct facial composite restorations (lateral incisors
and canines)
a illa te i
No treatment required
LP
andi ula ante i
Direct incisal composite buildups on incisors
Direct facial composites on all anterior teeth
LF andi ula te i
Direct occlusal composite stops to increased VDO
Direct facial composite restorations
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Case 4
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This 46-year-old female patient consulted for an esthetic concern related mainly to the discoloration of her maxillary central incisors. She
was also willing to remove the many dispersed facial enamel hypoplastic, discolored lesions. She however had no perception of an early
tooth wear problem. She otherwise had a healthy dental and oral status.
The differential diagnosis of generalized discolorations and enamel pits involved either a mild fluorosis or hypoplastic form of amelo-
genesis imperfecta; the absence of abnormal exposure to fluoride and prominent whitish or brownish dyschromia (typical of moderate
fluorosis) favored the amelogenesis imperfecta origin, however of unusually mild form. The precise diagnosis remained uncertain.
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The proposed overall treatment approach involved a first

interceptive step to correct localized tooth wear facets, com-
bined with a no-prep treatment of all facial lesions with the
exception of the two maxillary central incisors, which would
receive two feldspathic veneers.
The aforementioned treatment plan involved the follow-
ing steps:
• Brighten up the whole smile with a “home bleaching”
procedure.
• Create posterior occlusal stops to increase the VDO, allow-
ing for the no prep restoration of lower incisal edges and
palatal lesions of the maxillary anterior teeth.
• Fill up all facial lesions with no-prep direct composites
(combination of flow and restorative masses) and perform
form corrections on the maxillary lateral incisor incisal
edges.
• Place two indirect feldspathic veneers on both central
incisors.
• Deliver a nightguard as prevention of further attrition.
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Clinical protocol for interceptive strategy 267
In this case, no preexisting caries lesions of defective Class I and II have to be treated before or even simultaneously to the VDO correc-
tions using occlusal composite stops. This first option among the many variations of the interceptive approach is not uncommon. This
scenario simplifies composite placement and allows shorter treatment sessions. The preparation of surfaces for adhesion is limited in
such situations to either sandblasting or roughening of the enamel/dentin surfaces with diamond burs (40 to 80 µm).
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In order to restore the lower incisal edges and palatal inden- 269
tations of the maxillary anterior teeth, some slight increase
in the vertical dimension was performed with a combina-
tion of restorative and flowable composite enamel masses
applied on the occlusal surfaces of mandibular teeth only.
Due to the simplicity and limited amplitude of this VDO cor-
rection, it was performed freehand and without a predictive
wax-up. However, this treatment modality should be limited
only to such minor occluso-functional complexity and when
posterior teeth have virtually a normal anatomy, easing com-
posite placement control.
Restorative composite Flowable composite
The procedure involves only a few steps. After cleaning the

surfaces with sandblasting (see next pages) and applying a
bonding agent, occlusal stops elevating the cusps, following
their natural position and configuration, are placed, using a
single increment of flowable (molars) and restorative (pre-
molars) composites. The rationale for using flowable com-
posite on the molars is both simplification of the procedure
and the possibility to let the material wear off progressively,
taking advantage of a “progressive” Dahl concept (passive
4
eruption preserving contacts with the restorations until it
would eventually fully disappear).
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Flowable enamel (Inspiro Skin Bleach) was used for 271

the restoration of the facial lesions; a flowable consis-
tency enables small cavities to be filled precisely, lim-
iting excesses of material, which are time consuming
to remove and create unnecessary mechanical stresses
on the restoration margins. The material used here is a
true, so-called “achromatic” enamel shade. A layering
of material wasn’t then needed for such small defects.
Incisal edges of the mandibular central incisors were

restored together with facial lesions. Preparation was
limited to sandblasting (25 to 50 µm Al2O3) for sur-
face conditioning (removal of aprismatic enamel) and
cleaning of pits and discolorations; this procedure
also makes it possible to remove some decayed tissue
when needed.
The posttreatment views show the additive repair
made on both mandibular incisors and the rather uni-
form color and enhanced anatomy obtained with this
simple and effective restorative approach.
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Apart from both central incisors, facial lesions of the

maxilla were treated the same way as for the mandibular
teeth, with a no-prep additive approach. To this purpose,
preparation included, in addition to sandblasting, some
surface flattening with discs and the use of a fine flame
diamond to better access narrow and deeper lesions.
As for the mandible, flowable enamel composite was

used for facial lesions, while a restorative composite was
applied to enhance lateral incisor mesial edges.
The microrestorations were finished and polished using

a combination of finishing-polishing discs of decreasing
grain size (OptiDisc, Kerr; above) and polishing rubber
points and cups (Identoflex Minipoint, Kerr; below left;
and HiLuster, Kerr; below right).
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The upper left image shows the treatment

result after VDO correction, home bleach-
ing, and the placement of no-prep, additive
microrestorations in all facial hypoplastic
lesions. A freehand mock-up was then per-
formed on both central incisors as a refer-
ence for future preparations and fabrica-
tion of temporaries.
On the right, postoperative images show

the significant enhancement obtained with
this highly conservative treatment.
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Treatment outcome
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2-year follow-up
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2-year follow-up
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The 2-year follow-up shows no deterio-

ration of composite restorations as well
as an excellent stability of the composite
buildups made on the mandibular cen-
tral incisors. Composite surfaces remained
smooth and stain-free.
The left image series provides the explana-

tion for the microchipping observed on the
maxillary left lateral incisor. Notwithstand-
ing the minor impact of such mechanical
failure, it however shows the importance
of anterior and especially canine guidance
to minimize the functional and parafunc-
tional strains on the thin composite layers;
in fact, while resin-bonded composites sus-
tain compressive forces well (see findings
for mandibular central incisors), they are
less resistant to tensile or shear forces.
The small fracture could be simply repaired.
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CASE SUMMARY

UF
Awake and sleep parafunctions (bruxism and clenching)
Erosion due to frequent consumption of fizzy drinks
Patient’s first expectation is esthetics
UP a illa ante i
Home bleaching
Pressed lithium-disilicate ceramic veneers
a illa te i
Direct freehand occlusal composite restorations
LP andi ula ante i

Home bleaching
Direct freehand composite incisal edge buildups
andi ula te i
LF
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Freehand Posterior
and Indirect Veneers
Case 5
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This 41-year-old male patient requested advice about his basically of interceptive nature, using composite to restore
smile appearance, as he noticed a flattening of his smile line, posterior teeth and modify VDO, followed by home bleach-
chipped incisal edges, and an overall tooth shortening (max- ing. The overall treatment would then be completed with six
illa and mandible). Next to some frequent episodes of dentin ceramic veneers. Due to the moderate extent of tooth wear
hypersensitivity, the patient also complained about his dark observed in this case, one major interest in using direct res-
tooth color and discolored, stained anterior teeth. torations to restore posterior anatomy and occlusion is to
The clinical evaluation revealed a generalized but mod- observe the possible, future wear progression in relation to
erate tooth wear with erosion and attrition contributing fac- the patient’s compliance. In case of insufficient compliance
tors; the attrition appeared to be the most significant wear and steady parafunctional activities leading globally to a
phenomenon. The diet investigation did not suggest any rapid deterioration of composite restorations, a more inva-
particular imbalance, at least at the time the patient con- sive and expensive restorative treatment using an indirect or
sulted in our clinic; if signs of erosion persist, a more detailed CAD/CAM approach could then be justified.
anamnesis (including for gastroesophageal reflux disease The proposed treatment plan then involved the following
[GERD]) will be advised. Usual recommendations for acidic steps:
food control were anyway given as well as information pro- • Restore worn posterior teeth and incisal edges of man-
vided to recognize symptoms of reflux. No TMD or relevant dibular anterior teeth using a no-prep approach with a di-
functional-occlusal problem was identified. rect, freehand approach guided by the digital wax-up and
A full digital documentation was then performed to printed models.
evaluate esthetic, functional, and occlusal needs, including • Home bleaching treatment in a second step to avoid likely
the VDO increase extent. In consideration of the wear sever- dentin hypersensitivity.
ity and the patient’s expectation favoring anterior esthetics • Complete the treatment with six maxillary anterior lithium-
and looking otherwise for a rather simple treatment ap- disilicate veneers.
proach, the most suitable restorative strategy appeared to be
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Posterior views confirm a moderate tooth wear extent resulting

from attrition and to a lesser extent erosion. The selected restora-
tive approach first involves the enhancement of occlusal anatomy
and occlusion using a digital wax-up guided direct freehand ap-
proach. In a second step, the maxillary anterior teeth will be re-
stored with ceramic veneers.
Digital impression and occlusial record were then taken with an

intraoral scanner (eg, dental scanner CS 3700, Carestream Dental).
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Treatment planning and laboratory steps
  
The pretreatment digital models made from the optical impressions (CS 3700, Carestream Dental) were imported into a dedicated la-
boratory software (Ceramill Mind, Amann Girrbach) to design a new anatomy, enhanced esthetics, and improved function at a new ver-
tical dimension using the digital articulator. Practically, the contour of wear lesion must be determined (1) before the additive parts (2)
can be placed over those areas to recreate the desired anatomy and function (3). This modern workflow exactly replicates what is done
with conventional impressions, hardstone casts, and conventional wax-ups on a physical articulator. One remaining, obvious advantage
of the traditional approach is that it makes the changes made by the wax-up clearly visible when a colored wax is used.
Printed models were used to visually guide the freehand placement of posterior composite restorations at the new VDO; an alternative
protocol would be to fabricate partial or full indexes such as described in chapter 4.5 and 4.6 (partial and full molding techniques). Simi-
larly, printed models can serve as anterior indexes to build up mandibular anterior incisal edges and guide the preparation for maxillary
anterior veneers (see next pages).
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The existing restorations still presenting a satisfactory adaptation were modified after proper surface
preparation (sandblasting, followed by the four applications of a multifunctional adhesive (eg, OptiBond FL,
Kerr or Clearfil SE Bond, Kuraray). Teeth were separated with a stainless steel band.
Direct
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Mandibular treatment
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The same technique was

applied to the four posterior
sextants.
A dedicated, simple set of

instruments (CompoSculp,
Hu-Friedy) was used to
place and shape the com-
posite so that optimal anat-
omy could be produced.
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Maxillary treatment
The combined wear lesions (attrition and erosion) are clearly visible and show the sig-
nificant impact that the anatomical changes can have on the occlusal function and tooth
biomechanical integrity.
Restoring such worn teeth is mandatory and will prevent further severe tooth wear and all
its detrimental consequences from occurring.
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Left page: Postoperative view of the four posterior sextants showing enhanced anatomy and function, without exposed dentin; this
should reduce possible, further dentin erosion and abrasion. This first treatment phase allowed for the setup of the planned VDO in-
crease, which was also needed to reconstruct mandibular incisal edges.
Right page: After surface preparation using sandblasting (no other preparation was required as wear bevels naturally mandibular teeth),
the mandibular incisors and canines could be restored using a direct freehand technique guided by the digital wax-up and printed mod-
els. A combination of dentin and enamel (Inspiro Body i2 and Skin Ivory) was used to emulate the color, translucency, and opalescence
of natural teeth.
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The interceptive phase was then completed, making it possible to proceed as initially planned with home bleaching; following a suffi-
cient time for tooth color stabilization (6 to 8 weeks), the last restorative phase could be initiated (veneering maxillary anterior teeth).
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Situation after 2 weeks of home bleaching (16% oom Nite White, Phillips). Shade recording was made to match maxillary lateral teeth.
Preparations were made as conservative as possible in consideration of the enamel lesions and remaining discolorations; at least, they
remained fully intra-enamel, which will facilitate bonding procedures and also provide optimal adhesive interface stability.
Tooth display obtained with the temporaries was considered slightly in excess from the patient’s perspective; this “judgment” is very
common in tooth wear treatments. It was then agreed to reduce tooth length by about 1 mm for the definitive veneers.
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4.4 Freehand Techniques Lab work by Patrick Schnyder, oral design (Montreux-CH).
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As for most of attrition cases, lithium-disilicate (e.max MT A1, Ivoclar Vivadent) was chosen to grant both esthetics and strength. Color
integration was achieved by using additional facial, fired porcelain veneering (Creation LS, Creation Willi Geller); however, the veneering
material thickness remained thick enough to optimize veneers’ strength. The postoperative views show a satisfactory esthetic outcome
with harmonious anatomical and functional interarch relationships.
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CASE SUMMARY
UF
Mainly sleep parafunctions (bruxism and clenching)
Erosion due to high consumption of acidic and fizzy drinks
Patient looks for a conservative treatment
UP
a illa ante i
Direct palatal composite restorations (canine to canine)
a illa te i
LP andi ula ante i

No treatment
andi ula te i
LF
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Case 6
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This 40-year-old male patient was referred from another install preventive measures such as reducing consumption
dental clinic to investigate the possibility of an interceptive of acidic drinks and wearing a nightguard at completion of
treatment of tooth wear, considering that the wear sever- the treatment, with which in principle the patient agreed.
ity necessitated some restorative work but nothing “major,” Functional and occlusal clinical evaluation did not reveal
suggesting already a noninvasive approach. The patient re- any TMD symptoms or functional limitations. The foreseen
ported moderate dentin hypersensitivity and had concerns anatomical changes and VDO changes were then planned
for the visible loss of tooth structure, both on occlusal and on articulated study casts with full wax-up (see laboratory
facial-cervical areas. The risk factor analysis revealed a high steps further). The intermaxillary relationship was recorded
consumption of fizzy drinks and fruit juices, combined with in MIP; no significant CRP/MIP sliding was observed.
known sleep and awake bruxism. The awareness of a likely The suggested treatment plan then involved the follow-
progression of tooth wear prompted the patient to ask for ing steps:
possible intervention. • Restore worn posterior occlusal, cervical, and maxillary
Clinical examination showed a moderate loss of enamel palatal surfaces using a no-prep approach with a wax-up
on the mandibular occlusal surfaces, the maxillary anterior driven, freehand technique.
teeth palatal side, and the cervical surfaces of maxillary and • Increase the VDO to perform all anatomical corrections
mandibular posterior teeth (from canines to molars). Wear with merely additive technique, without any preparation
was limited to moderate on the occlusal surfaces of maxil- but the surface preparation for adhesive procedures, using
lary posterior teeth. Affected surfaces revealed logically typ- sandblasting.
ical erosion and attrition lesions, confirming common hy- • Provide the patient with a nightguard soon after treatment
brid pathology. The patient was informed about the need to completion.
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Treatment planning
on models
Like every tooth wear treatment follow-

ing the interceptive approach, an aug-
mentation of the VDO is first planned
on articulated models so that space
is created to restore anterior and pos-
terior teeth with a no-prep approach.
Likewise, this VDO elevation allows
for improvement of both function and
esthetics.
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The wax-up provided the visualization and the perception of the material thickness needed to attain the needed anatomical and func-
tional enhancements. Modifications of the overall occlusal anatomy were however of a lesser extent than in the mandible (see previous
2 pages). For the mandibular teeth, amalgams were also replaced and therefore, dentin and enamel restorative masses used for this
purpose (Inspiro Body and Skin shades); homogenous nanohybrids are among the appropriate composite technologies that can be
used for such treatment.
Exposed dentin surfaces and flattened palatal cusps were restored using only enamel. The concept of freehand bonding implies the use
of the wax-up as a continuous reference together with proper anatomical knowledge in order to achieve a good functional anatomy.
Surface “effect shades” (Inspiro Fissure and White effect shades) are used to characterize the occlusal anatomy and improve our control
of the composite sculpting and modeling.
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Treatment outcome
Postoperative views of the maxilla and mandible, smile and maxillary palatal composite reconstructions. The direct freehand restor-
ations allowed us to protect teeth from further wear, relieve discomfort resulting from dentin hypersensitivity, and restore proper anat-
omy and function, following a fully additive/no-prep approach. The simplicity and cost-effectiveness of this technique is unsurpassed.
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6-year follow-up showing a satisfactory medium-term result of the direct freehand approach. These good results were obtained despite
a nearly total lack of patient compliance; he actually did not wear the nightguard and only partially reduced his consumption of acidic
and fizzy drinks; as a consequence, some further wear occurred on maxillary palatal and mandibular facial cusps, as well as on the facial
surfaces of mandibular premolars where some erosion occurred occlusally to the cervical restorations.
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10-year follow-up
The 10-year follow-up shows satisfactory behavior of the composite restorations despite no further compliance with the nightguard.
Some restorative material wear and possibly microchipping are part of the concept; for moderate tooth wear cases, the interceptive
treatment modality makes maintenance uncomplicated and cost-effective.
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Freehand Technique (FHT): Key Points to Master the Protocol
• Have a detailed functional wax-up made on articulated • Control composite thickness visually or with a probe (for
models (better analog one for the visibility of modified the first steps with this technique).
surfaces).
• Replicate the wax-up anatomy with a slight excess at the
• Replace Class I and II defective restorations (except very cusp tip to facilitate occlusal equilibration.
small ones) at the preexisting VDO before proceeding with
occlusal/functional buildup. • Finish composite margins with discs and fine diamonds.
• Prepare surfaces for adhesion with either sandblasting or • Adjust occlusion.

diamond burs.
• Use a multifunctional adhesive that provides some

chemical adhesion to preexisting restorations (better
mutli- component two-step “self-etch” or three-step
“etch-and-rinse”).
• cclu al e uili ati n i e f ed in c n ecuti e
• Isolate proximal contacts with a metal strip if needed. te a e c leting eac a c e a ilitati n and
ef e ta ing t e i e i n f t e nig tgua d if
• Heat up the composite (depending on the material initial a lica le in uc ca e an inte edia e uili ati n
consistency). can e e f ed a e ee
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4.5
CHAPTER
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pm t
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Partial Molding Technique
Although the “freehand” protocol is highly effective, it is more The partial molding technique as introduced in section 4.3
challenging in cases of increased tooth wear or for clinicians relies on a few simple and proficient steps, following log-
who have limited experience with advanced direct bond- ically the usual case preparation approach (full posterior
ing protocols. Molding techniques were then developed to functional wax-up at a new, increased VDO and occlusal pos-
overcome these challenges and make it accessible to any ition, if indicated). Then, a full index made of putty silicone
practitioner. The basic, common principles of the intercep- (stiffer, the better) is prepared and then cut slightly outside
tive strategy do of course fully apply to the partial molding the contact area so that it can shape both labial and lingual/
technique, the first option within this group of alternative palatal cusp profiles. The contact area will then remain free
protocols; molding composite over worn surfaces is not a of any composite excess. The final step consists of placing
new technique but it received rather limited attention due and molding composite freehand, with guidance of the
to shared recurrent shortcomings of many molding proced- molded increments, to complete the full occlusal anatomy.
ures, such as the following: Note that using a translucent silicone is not needed due to
• Imprecise molding result due to index deformation their lower stiffness.
• Increased operative time when using single (tooth-by- This technique alleviates both the possible difficulties of
tooth) molding a fully freehand approach as well as the frequent, tricky, and
• Difficult and lengthy removal of excess in the proximal con- time-consuming removal of interproximal excess resulting
tact area and cervical embrasures (classical full molding) from a full molding technique. The latter technique can how-
• Suboptimal anatomy if a perfect wax-up is not available ever become effective and uncomplicated with some varia-
(all full molding procotols) tions of the basic protocols (see section 4.6 for detailed pre-
sentation of a revised and improved full molding technique).
4.5 Partial molding technique
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1. Ammannato R, Ferraris F, Marchesi G. The “index technique” in

worn dentition: A new and conservative approach. Int J Esthet
Dent 2015;10:68–99.
2. Ammannato R, Rondoni D, Ferraris F. Update on the ‘index
technique’ in worn dentition: A no prep restorative approach
with a digital workflow. Int J Esthet Dent 2018;13:516–537.
3. Dietschi D, Saratti CM. Interceptive treatment of tooth wear:
A revised protocol for the full molding technique. Int J Esthet
Dent 2020;15:264–286.
4. Mehta SB, Francis S, Banerji S. A guided, conservative approach
for the management of localized mandibular anterior tooth
wear. Dent Update 2016;43:106–108.
5. Ramseyer ST, Helbling C, Lussi A. Posterior vertical bite re-
constructions of erosively worn dentitions and the “stamp
technique”—A case series with a mean observation time of
40 months. J Adhes Dent 2015;17:283–289.
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CASE SUMMARY
UF
Moderate to severe generalized erosion due to multifactorial
origin; likely contributive role of bruxism
Patient expects a cost-effective treatment approach
UP
a illa and andi ula te i
Direct composite occlusal buildup/restorations using the
partial molding technique
a illa ante i
Direct freehand palatal, labial, and interproximal
LP restorations (closure of diastemas)
andi ula ante i

Direct freehand composite buildup of incisal edges with
index and diastema closure restorations
LF
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Partial Molding and Direct

Case 7
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The 48-year-old female patient presented to the office with anamnesis revealed a high consumption of acidic food and
multiple concerns. She wished first to improve her smile es- drinks, the patient was first informed about usual prevention
thetics (especially the inhomogenous tooth color) and the measures to limit further dental erosion. The medical history
discolored margins of old composite restorations and pos- also confirmed a difficult, stressful period with gastric trou-
sibly close diastemas. She was aware of progressive tooth ble; since, the patient has been under anti-acid medication.
wear and anticipated to stabilize and correct this problem; A more detailed functional and occlusal evaluation was
moreover, exposed dentin surfaces triggered moderate den- also performed on mounted study casts (see laboratory
tinal hypersensitivity. Finally, she hoped for a noninvasive steps). The intermaxillary relationship was recorded in u -
approach as suggested by a friend who beneficiated from cula cent ic elati n with a slight advancement of
such treatment. Due to financial limitations, the replace- the jaw in order to facilitate the restoration of anterior teeth
ment of the missing mandibular second premolar with an and preserve anterior function and guidance. The foreseen
implant was postponed. treatment plan involved the following steps:
Clinical examination revealed moderate, generalized • Restore worn posterior teeth using a no-prep approach
tooth wear in both anterior and posterior segments. Large with direct, partial molding technique as previously de-
exposed dentin zones were present on almost all functional scribed, with a VDO augmentation to create interocclusal
and some nonfunctional surfaces. The observed wear pat- space and allow restoration of maxillary and mandibular
terns suggested a combined etiology with predominating anterior teeth.
erosion, confirmed by the hollowed lesions generalized on • Restore palatal and labial surfaces of maxillary anterior
occlusal and palatal surfaces. Attrition was likely a contribut- teeth and simultaneously closing diastemas.
ing factor as revealed by many wear facets and palatal inden- • Restore worn incisal edges of mandibular anterior teeth
tations as well as the worn lower incisal edges. As the diet and close diastemas.
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Treatment Planning and Laboratory Steps
Like for every tooth wear treatment following the interceptive approach, an augmentation of the VDO is first planned on articulated
models so that space is created to restore anterior and posterior teeth with a no-prep approach. Likewise, this VDO elevation allows for
improvement of both function and esthetics.
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After completing the wax-up at the new, most suitable VDO, a full index is fabricated that covers buccal, occlusal, and lingual surfaces.
The index then has to be cut occlusally along buccal and lingual paths in order to maintain cusp tips and at least 1.5 to 2.0 mm of the
cusp profile so that proper guidance is provided during further molding of the central occlusal surfaces.
This technique necessitates a precise index cut to facilitate clinical procedures and restrict composite excess in the proximal areas; this
concept is advantageous in case the wax-up is not as detailed as seen on the pictures above. The wax-up–based index will then pro-
vide the cusp height and profile and set up the new VDO, leaving only small occlusal (Class I–like) direct freehand restorations to be
performed.
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An “etch-and-rinse” system was used after roughening den-

tin with burs and then sandblasting all surfaces to be re-
stored. Clear and metal strips were placed between the teeth
to avoid bonding contact points.
The insertion path is critical to avoid formation of large ex-

cess over the facial or lingual surfaces. Equally important is
to avoid overfilling the index with composite, which is an-
other motive to create composite excesses; both of those
“mistakes” impact the efficiency and otherwise simplicity of
the technique.
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The intraoperative views demonstrate the straightforwardness of this protocol. After the molding of facial and lingual cusp lines, mar-
ginal ridges and occlusal surfaces are to be finally restored with a direct freehand technique. If properly cut, the index will provide not
only cusp height but also the cusp occlusal inclination that greatly simplifies the next steps.
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This technique will then involve three increments per tooth (facial, lingual, and occlusal). It is important not to cut the index too close
to the central occlusal anatomy, as it could bring molded composite into the proximal contact areas; contact points should then not be
included into the molding areas to facilitate finishing procedures.
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Sectional matrices were placed to help shape the marginal ridges prior to the remaining Class I direct increments. Due to the extent of
VDO augmentation, a bilaminar incremental technique (dentin and enamel) was used for this case, which usually is not necessary. The
sequential restoration of four anatomical zones (buccal and lingual cusps, marginal ridges, and occlusal surface), together with the cor-
rect index preparation, ensures a good functional and anatomical outcome.
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The last treatment phase consisted of correcting the anatomy of maxillary and mandibular anterior teeth to replace the worn tooth struc-
ture and also compensate for the increase in VDO, resulting in improved anterior function and esthetics.
To this purpose, a second wax-up was performed to provide precise guidance while increasing tooth length and anatomy; the wax-up
also eases composite molding on the palatal surfaces of maxillary anterior teeth, using either an index or freehand application that was
performed on this particular case.
Posttreatment views show enhanced tooth alignment, more harmonious smile line, and proper anterior and lateral occlusal relationships.
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This protocol represents a simplification of the direct freehand approach in cases of more advanced wear, combined with the need of
using a conservative and cost-effective treatment approach.
A nightguard was fabricated to control the attrition risk factor. The functional and esthetic treatment outcomes obtained with freehand
and molded composite application fulfilled the patient’s known expectations. Following the interceptive treatment strategy appeared
fully justified here, even in cases of moderate tooth wear.
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Partial Molding Technique (PMT): Key Points to Master the Protocol

• Have a functional wax-up (analog or digital) made on articulated models.
• Create ideally mesial and distal stops (no wax on buccal or lingual cusp and incisors).
• Make a full index with a rigid, putty silicone (no need to use a translucent material).
• Make two cuts internal to the cusp tip line and external to proximal contact areas to create two indexes.
• Control positioning of both labial and lingual indexes when rubber dam is in place.
• Etch enamel 2 mm (max) beyond the wax-up outline.
• Insert controlled composite amount within the cusp spaces (avoid creating too much excess).
• Insert the index following a vertical path rather than bringing it laterally (avoid spreading composite).
• Remove excess composite precisely, particularly along the index cut (no excess over the index).
• Light-cure each tooth for 20 seconds before and after index removal.
• Repeat the procedures for the other side of teeth.
• Isolate contacts with transparent or metal strips.
• Finalize occlusal anatomy with one last freehand increment.
• Finish and polish as for a conventional direct posterior restoration.
Partial molding for posterior teeth
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4.6
CHAPTER
With contributions by Dr Viviana Coto-Hunziker, Geneva (CH), for the Invisalign treatment of case 1.
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fm t
Full molding technique
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Full Molding Technique
Like all direct techniques (from freehand to full molding impacted treatment acceptance by both the patient and the
approach), there is a need for occlusal and proximal refer- dentist. Another imperative requirement to be mentioned is
ences to guide composite sculpting or molding, ensuring a the need for proper cast mounting (analog or digital) preced-
more precise functional and anatomical outcome. This being the production of an optimal wax-up with ideal anatomy
ing granted, the overall steps to be considered additionally and function, which is instrumental to a successful and reli-
or instead of those applied with a basic molding technique able protocol outcome. The forthcoming case presentation
(clear index with no other specific feature) are the following: will illustrate the clinical application of this revised protocol.
• Have a good anatomical and functional wax-up, managing Again, an important condition for the successful applica-
mesial and distal stops to stabilize the future molding tray tion of the full molding technique is the persistence of some
(usually one or two incisors and distal occlusal surface of anatomical references (stabilization points/areas) that allow
second molars, if needed). the molding tray to be repositioned precisely in the mouth,
• Use of a heat-formed hard, thick plastic tray ( 2 mm) to without a significant risk of deformation of molded surfaces.
prevent index deformation; the tray has to be precisely Provided this condition is met, the technique can be said to
cut to facilitate full removal of composite excesses (about be simple, effective, and reliable, involving relatively short
1.5 to 2.0 mm further worn surfaces and/or the wax-up fa- chairside time, which is of paramount importance for the ac-
cial and lingual extension). ceptance of the method.
• The tray is relined with clear silicone on the wax-up for op- As for the other protocols involving the chairside use
timal detail reproduction. of light-curing composites, another obvious limit for using
• Slight opening of occlusal embrasures (if nonexisting) to the full molding technique relates to the amount of tissue
obtain precise and accessible margins of molded restor- to be replaced and the material mechanical performance.
ations and create space for application of an isolation The success of direct composite restorations is bound to the
material. magnitude of functional stresses and restoration thickness;
• Isolation of occlusal and cervical embrasures to limit com- for instance, in cases of severe clenching with limited VDO
posite penetration in those critical zones. opening, we can more likely observe failures such as mater-
• Precise etching and dental bonding agent (DBA) applica- ial chipping, wear, and marginal degradation. Such failures
tion around the worn surfaces (maximum 1 to 2 mm be- are however considered “minor” ones that usually necessi-
yond these areas) to limit adhesion of composite excesses tate only a simple repair procedure. Owing to the simplicity
and facilitate their removal after composite light-curing. of the treatment and restoration maintenance, the use of
no-prep partial direct restorations appears to have irrefut-
The aforementioned steps limit time-consuming finishing able advantages and promising outcomes in the interceptive
procedures or delicate occlusal adjustments, which formerly treatment of moderate abrasion and erosion.
4.6 Full molding technique
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1. Schmidlin PR, Filli T, Imfeld C, Tepper S, Attin T. Three-year 5. Ammannato R, Rondoni D, Ferraris F. Update on the ‘index
evaluation of posterior vertical bite reconstruction using direct technique’ in worn dentition: a no-prep restorative approach
resin composite--a case series. Oper Dent 2009;34:102-108. with a digital workflow. Int J Esthet Dent 2018;13:516-537.
2. Attin T, Filli T, Imfeld C, Schmidlin PR. Composite vertical bite 6. Dietschi D, Saratti M. Interceptive treatment of tooth wear: A re-
reconstructions in eroded dentitions after 5 5 years: a case se- vised protocol for the full molding technique. Int J Esthet Dent
ries. J Oral Rehabil. 2012 Jan;39(1):73-9. 2020;15:264–286.
3. Ramseyer ST, Helbling C, Lussi A. Posterior Vertical Bite Recon- 7. Hardan L, Mancino D, Bourgi R, Cuevas-Suárez CE, Lukomska-
structions of Erosively Worn Dentitions and the “Stamp Tech- Szymanska M, arow M, Jakubowicz N, amarripa-Calder n
nique” - A Case Series with a Mean Observation Time of 40 JE, Kafa L, Etienne O, Reitzer F, Kharouf N, Haïkel Y. Treatment
Months. J Adhes Dent. 2015 Jun;17(3):283-9. of Tooth Wear Using Direct or Indirect Restorations: A System-
4. Ammannato R, Ferraris F, Marchesi G. The “index technique” in atic Review of Clinical Studies. Bioengineering (Basel). 2022 Jul
worn dentition: a new and conservative approach. Int J Esthet 27;9(8):346.
Dent 2015;10:68-99. 8. Vailatti F, Belser U. 3Step additive prosthodontics. Edra Pub-
lishing, 2022.
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Workflow for improved full molding technique
Laboratory procedures: Study casts are produced from any material on the initial model with wax-up to obtain an accu-
clinical scenarios (with or without Class I/II restorations) (1), rate wax-up replication and molding outcome (4). The need
and an improved anatomy and function is determined with to duplicate the initial model/wax-up can be considered
a wax-up (preferably analog for this technique) at a new, in- cumbersome, but the advantage of the analog protocol is
creased VDO (2). Then, the model with wax-up is duplicated to facilitate a precise tray outline (1 to 2 mm maximum fur-
for the fabrication of a thick (2 to 3 mm) translucent tray (3). ther wax-up limits). With printed models, the tray must be
This tray is finally relined with a clear, low-viscosity silicone checked on a printed model of the pretreatment situation.
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Basic restorative sequence: The tray is tried intraorally to embrasures, those areas can also be filled up with Teflon
ensure proper positioning and the existence of composite tape to prevent possible composite excess there as well (7).
extrusion zones that will facilitate the molding process (5). The tray is to be filled with heated composite to facilitate
A small quantity of isolation material (eg, Rubber Sep, the molding; it is highly recommended not to place the
Kerr) or a thin band of Teflon tape is placed in the occlu- composite on the teeth to avoid air entrapment in cusp
sal embrasures to prevent composite penetration inside tips (8). The quality of wax-up reproduction will then be
the interdental contact (6). For cases with open cervical greatly enhanced.
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CASE SUMMARY

Wear related mainly to attrition with likely contributive
effect of erosion
UF
Esthetics is the patient’s main concern
Patient expected a cost-effective treatment approach
a illa ante i
UP Correction of misalignment with Invisalign
Direct composite restorations to harmonize to tooth forms
and smile line
a illa te i
LP andi ula ante i

Direct freehand composite buildups of incisal edges and
canine tips
LF andi ula te i
Full molding technique to compensate tooth wear and
increase VDO
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Full Molding
Posterior Composite Restorations
and i ect ite
Case 8
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This 35-year-oldfemale patient presented herself to a coun- functional and occlusal evaluation was also performed on
seling consultation to resolve esthetic and functional con- mounted study casts (see laboratory steps). Correction of
cerns; she was made aware of a progressive tooth wear prob- the misalignment and visible shortening of the anterior teeth
lem by the referring dentist. The patient lies within the 60% of as well as the irregular smile line was also considered even
patients made mindful of the esthetic impact of tooth wear though this was not the first complain of the patient.
on their dental situation while not reporting substantial den- The suggested treatment plan involved the following
tin hypersensitivity, pain, or functional problem. Clinical and steps:
functional examinations otherwise revealed a Class II/I occlu- • Restore worn posterior teeth using a no-prep approach
sion, with generalized tooth wear (moderate extent) in both with direct, full molding technique as described above.
anterior and posterior segments. The observed wear pattern • Free functionally anterior teeth to allow their orthodontic
suggested a main role of bruxism, with an apparent slight ero- realignment and restore proper anterior guidance using
sion contribution. Medical and diet anamnesis did not how- clear aligners (Invisalign).
ever reveal anything particular in regard to this risk factor, at • Complete the treatment with no-prep anterior direct com-
least at the time of consultation. The patient was as usual in- posite restorations to optimize esthetics and function.
formed about preventive measures (controlled consumption
of acidic food and beverage) to limit further, possible contribu- Note the irregular smile line, with the loss of canine guidance
tion of erosion as a risk factor for wear progression. A detailed due to lateroprotrusive parafunctions.
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Occlusal views show signs of erosion as suggested by the typical hollowed lesions, mainly visible in mandibular molars; flattening of
cusps both in maxillary and mandibular posterior teeth is also characteristic of the observed parafunctional movements.
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Treatment planning and laboratory steps
The foreseen treatment had first to be simulated and confirmed by a full posterior wax-up produced on mounted stone casts. To this
purpose, a 4-mm VDO increase at the incisal guide of the articulator was considered suitable to restore posterior tooth anatomy, improve
function, and provide enough space for the restorative material following a no-prep protocol. Such increase is considered safe and not
prone to create any functional disruption or TMD. The new VDO defined by the wax-up had to be confirmed with a setup of the maxillary
and mandibular anterior teeth to ensure it was adequate for the planned orthodontic corrections.
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After completing the wax-up, a 2-mm-thick

hard tray (Erkodur, Erkodent) was pro-
duced by heat-forming on the duplicate of
the mandible. It was cut into two parts (left
and right with section at the midline) and
then relined with a clear silicone (Memosil
II, Heraeus), directly on the wax-up to cap-
ture all anatomical details. The tray can
have mesial and distal stabilization points;
usually, part of the occlusal surface of the
second molar and anterior teeth also serve
this purpose.
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The molding technique was performed on the full arch in one involved only a slight roughening of dentin lesions with a
session, and to this purpose, the full inferior arch was initially round carbide (steel) bur, followed by full occlusal surface
isolated with the rubber dam. Before starting with adhesive sandblasting; the teeth not to be treated were separated and
and restorative procedure, the index key was tested in order protected by metal strips beforehand.
to control its precision and fitting. The tooth “preparation”
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A three-step etch-and-rinse adhesive sys- proximal embrasures (Rubber Sep, Kerr) stops (the tray should extend the nonwaxed
tem (OptiBond FL Kerr) was applied after to avoid penetration of the composite in surfaces or teeth for 1 to 2 mm maximum).
selective acid etching using 37% phos- those areas, which is tricky to remove af- Due to the appropriate tray design, excess
phoric acid (Ultra-Etch‚ Ultradent) for ter polymerization. Then, the heated com- composite could easily be removed on fa-
30 seconds and 10 seconds on enamel and posite (homogenous composite; Inspiro cial, lingual, and interproximal surfaces.
dentin, respectively; the adhesive system Skin White, Edelweiss DR) could be placed Light-curing was then performed occlu-
was subsequently polymerized for 20 sec- into the tray, applied over the teeth, and sally with the tray in place for 20 seconds
onds. A small amount of isolation mate- pressed with gentle pressure until reach- per tooth; after tray removal, 20 seconds of
rial was still placed in the occlusal and ing its final position, as checked on mesial/ curing is repeated on each surface.
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Removal of small excesses followed by finishing was performed with a no. 12 blade, discs, and fine diamond
burs (flame and football shapes, 40 microns). Polishing with rubber points (Identoflex Minipoint, Kerr) and
brushes (Occlubrush, Kerr) completed the process and provided a smooth composite surface and transition with
underlying tooth structure. The full process was repeated on each sextant. The limited wear lesions on the maxilla
was restored with a direct approach, as described in section 4.4. After rubber dam removal and completion of the
molding process for both sides on the mandible, a final occlusal check was performed. Additional checks and
occlusal adjustments also had to be done during the course of the next treatment steps.
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The interocclusal space created in the anterior area allowed for the orthodontic alignment to take place immediately after completing
the VDO increase. The planned esthetic and functional project included the realignment of maxillary and mandibular anterior teeth and
the creation of an adequate space to restore them to a more ideal length and anatomy, while providing a suitable overjet and overbite.
The orthodontic correction provided an anterior relationship (overjet/overbite) even more convenient than the one initially planned (as
defined with the ClinCheck, upper right image). It is assumed that this outcome resulted from an anterior shifting of the jaw position fol-
lowing the VDO augmentation and as well a significant reduction of the preexisting deep bite.
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When the new anterior teeth position was achieved, direct composite restorations were performed to restore incisal edges of mandibular
anterior teeth with a freehand approach using the height of teeth nos. 34 and 44 as references; although not used here, such buildup is
usually performed with the help of an index made from a second partial wax-up. The buildups comprised a first lingual/palatal enamel
layer (Inspiro Skin White), the dentin core buildup (Inspiro Body Bi3) at the tooth edge, and a last labioproximal enamel layer using the
same mass as for lingual/palatal increments. The same additive approach was performed in order to restore the palatal face of the max-
illary anterior sextant but using only an enamel mass.
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Posttreatment views showing a satisfactory front alignment, improved smile line/configuration, and proper anterior
and lateral occlusal relationships
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Posttreatment overjet and overbite showing normal anterior occlusal and functional relationship. Posttreatment occlusal views with
enhanced functional anatomy and balanced occlusal contacts following a no-prep treatment approach; restoration thickness varies
from zero at their margins and provides about 1.5 to 2.5 mm (from posterior to anterior areas) in functional surfaces, granting enough
mechanical stability to expect good compliance in such patients with nightguard preventive therapy.
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Kinesiographic analysis was performed before and after the restorative treatment. This 3D tracking of the jaw movements allowed for
monitoring of mandibular movements at the interincisal point with the aim to provide a qualitative and quantifiable analysis of the pa-
tient masticatory function and jaw movement patterns following treatment.
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It is of interest to assess the impact of any occlusal therapy on the masticatory function of patients with known occlusal disorders. When
looking at the maximum opening and closing movements after a VDO augmentation, an overall increase of 1 cm was noticed (raising
from 4.2 to 5.2 cm). Protrusive movements only slightly increased (from 3.3 to 3.6 cm) but showed a slightly straighter pattern following
treatment. Lateral excursive movements also slightly increased from 1.4 to 1.6 mm on the right side while remaining unaltered on the left
side; however, lateral movement patterns also appeared more symmetric after treatment on the frontal plane while being slightly more
asymmetric on the horizontal one. Overall, the patient rapidly adapted to the new jaw position after the VDO augmentation and did not
show or complain about any masticatory restriction, orofacial pain, or temporomandibular joint disturbance, suggesting again a good
tolerance of the treatment.
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1-year posttreatment views demonstrating adequate occlusal, mechanical, and esthetic stability of the composite
restorations. Such positive treatment outcome relies in part on good compliance of patients with nightguard
therapy.
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The 3D analysis documenting the general stability of the rehabilitation performed at the 1-year recall shows only a few wear points on
the maxillary right quadrant (red spots) due to predominant excursive movements on this side.
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CASE SUMMARY

Limited tooth wear of posterior teeth but moderate to
UF severe tissue loss of anterior teeth
Previous period of highly acidic diet
Known awake and sleep bruxism
UP a illa ante i
Direct composite restorations with palatal molding and
freehand application for facial veneering
a illa te i
No treatment
LP andi ula ante i

Direct freehand composite buildup of incisal edges and
canine tips with index
LF andi ula te i
Full molding technique to restore worn surfaces and
increase VDO
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Full Molding
Posterior Composite Restorations
and i ect/ lded ite
Case 9
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Initial view of a female patient aged 41 years showing mod- intervention until she made herself available for the applica-
erate to advanced tooth wear due to combined erosion and tion of an interceptive therapy.
parafunction pathology; she has an history of unbalanced The treatment approach as per a diagnostic wax-up was
diet, with combined awake and sleep bruxism, which led to augment the VDO using a full molding technique on man-
to moderate to severe loss of tissue in the anterior teeth dibular posterior teeth only; to this purpose, the same tech-
while posterior teeth presented only limited wear (mainly nique described before was applied. For the mandibular and
mandibular molars). The patient did however show excel- maxillary anterior teeth, a direct approach was also used
lent compliance with her Michigan splint, as confirmed by with the help of indexes to restore esthetics and function as
many years of observation during a long preventive phase; defined by the wax-up.
for personal reasons, many years elapsed without restorative
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Functional wax-up and tray fabrication
The classical wax-up technique confers a definite advan- visualized, which is of great help to guide the clinician during
tage by making modified contours and anatomy properly the application of any direct freehand restoration.
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Due to a limited loss of tissue in posterior segments, espe- performed in accordance with restorative objectives and to
cially in the maxilla, it was considered more suitable to re- provide guidance for the various direct techniques applied to
store only the mandibular posterior teeth wear lesions and to resolve this case. A chairside mock-up was performed prior
simultaneously increase the VDO, creating the needed space to treatment onset to confirm that the new planned VDO and
to restore maxillary and mandibular anterior teeth, affected especially change in overjet/overbite would suit the patient.
significantly by attrition and erosion. The wax-up was then
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The first step is to produce a hardstone duplicate of the is further trimmed with a diamond disc and margins finally
wax-up (alternative would be a 3D-printed resin model). adjusted with carbide burs to create the desired design. The
Then, a hard plastic foil (Erkodur 2 mm, Erkodent) is heat- tray should on one hand, fully cover worn occlusal surfaces
formed over the printed model or hardstone duplicate. Us- and on the other hand, provide full access to composite ex-
ing first a heated blade, the tray is cut along the cervical process removal in the proximal areas and embrasures. Note the
file to allow its removal; in a second step and according to a wavy tray borders outline. Finally, the tray is relined with a
visual reference (1.5 to 2 mm further waxup limits), the tray soft, transparent silicone material (eg, Memosil 2 , Kulzer)
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Direct
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Molding protocol
The trays have to be tried in, especially with rubber dam, as enamel shade) is placed over the teeth and pressed gently
it might, for instance, interfere with the clamp and should until full seating; it is important to create even pressure to
then be trimmed until a perfect fit is obtained. Embrasures avoid tray deformation and obtain an optimal, precise mold-
are filled with Teflon tape if needed and contact isolated ing, even if the 2-mm plastic plate provides good stiffness.
with proper medium (eg, Rubber Sep, Kerr) or possibly with Light-curing is performed first with the tray in place and
a thin piece of Teflon; the isolation material should indeed again for 20 seconds after its removal to grant full material
physically block the contact so that composite cannot pene- polymerization. The procedure is completed with margin fin-
trate between teeth and make its removal very difficult. The ishing and polishing using a combination of a no. 12 blade,
tray, filled up with heated enamel composite (normally only flame fine diamonds, and discs.
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The VDO change was achieved in one

molding step for each sextant. Following
the removal of excesses and finishing of
margins, the occlusal surfaces were dis-
cretely characterized with the usual brown
and white surface colorants (effect shades
“Fissure” and “Ice” from the Inspiro sys-
tem). Surface shine was achieved through
the rebonding procedure: both compo-
nents of a two-step self-etch adhesive (eg,
Clearfil SE Bond, Kuraray) are used as first
a surface cleanser (primer) and then mar-
gin and surface sealing (bonding resin); the
bonding is light-cured under glycerin gel to
prevent formation of an oxygen-inhibited
layer, followed by a soft brush cleaning to
remove any remnant of polishing instru-
ments or glycerin.
The full occlusal view on the mandibular right side shows the mandibular arch after treat-
ment completion, including the buildup of lower incisal edges, as shown on the next
2 pages.
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The mandibular incisors were restored with a direct, bilaminar technique (dentin and enamel layers only) with the help of an index made
on the wax-up or duplicate of the wax-up as seen on the upper left image. Such direct buildup on the incisal edges has proven its high
reliability, the material being mainly loaded in compression that limits early mechanical failures; in fact, very few complications are ob-
served with this technique.
Apart from restoration durability, the advantage of this protocol, as illustrated already in previous cases, is multifold; first, the incisal
length is well controlled and therefore function improved. It also provides good control of increment thicknesses and the resulting color
integration and, esthetic outcomes.
Restorations were made with Inspiro Body i3 and Skin Ivory shades.
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Completed incisal edges buildups, before restoring facial, erosion lesions.
The palatal and incisal edges were restored according to the functional scheme defined by the wax-up, also using a molding
technique. The key element for palatal molding is to produce an index that ensures a good separation of teeth; this will prevent
the composite from penetrating gingival embrasures. Embrasures can be filled up and isolated with Teflon tape to facilitate the
molding procedure.
On the right side, the palatal molding was done using an enamel shade, while on the left side, a dentin shade was used. The reason for
this change was to demonstrate the lack of impact that the material used to restore the palatal surfaces had on final tooth color from.
The only modification related to the edge molding with dentin was to create some space (about 1.5 mm) for the application of enamel.
Some blue-opalescent effect shade (Azur, Inspiro system) was applied over the dentin lobes to enhance the natural appearance of com-
posite additions.
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Treatment outcome
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1-year follow-up
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3-year follow-up
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The intraoral frontal views at 1 and 3 years show very few, limited instances of composite chipping (minor points on upper incisal edges).
In the mandible, there is no visible or significant degradation of the direct posterior restorations or the buildups of mandibular anterior
teeth. However, slight chipping and development of wear facets is an part of the treatment approach. Thus, the compliance of the patient
with the nightguard plays an important role, even on a short- to medium-term perspective.
The follow-up of this case is considered satisfactory in regard to the performance of the composite material selected (homogenous
nanohybrid) both in the posterior and anterior areas, despite the rather severe parafunctions that previously affected significantly max-
illary and mandibular anterior teeth. The choice of an interceptive strategy is finally judged particularly satisfactory in consideration of
the simplicity, conservativeness, and cost-effectiveness of the restorative approach. See chapter 8 for more information and examples of
long-term follow-up after different treatment strategies.
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3-year follow-up
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Full Molding Technique (FMT): Key Points to Master the Protocol

• Have a detailed functional wax-up (analog or digital) made on articulated models.
• Create mesial and distal stops (no wax on buccal or lingual cusp and incisors).
• Produce a wax-up duplicate (if analog).
• Use a thick and rigid plastic for the tray fabrication (2 mm).
• Cut the tray about 1 to 5 mm further than the wax-up limits.
• Open the tray to access easily access proximal embrasure.
• Reline the tray with clear semi-rigid silicone.
• Etch enamel 2 mm (maximum) beyond wear surfaces and lesions.
• Isolate proximal contacts with a physical barrier (eg, liquid latex).
• Isolate gingival embrasures with Teflon tape (depending on anatomy).
• Heat up the composite (depending on the material consistency).
• Distribute the composite evenly and without excess inside the tray (not on the teeth).
• Apply even pressure over the whole molding area (no excessive pressure in the middle).
• Remove excesses before light-curing the composite.
• Light-cure again each tooth for 20 seconds after tray removal.
• Clean excess with a scalpel, discs, and fine diamonds.
Full molding for posterior teeth
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5
CHAPTER
5
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Shell Techniques
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Shell Technique (In-Lab Molding): Selected Treatment Area
The direct composite options (freehand or molding proto- When decays or defective fillings are present, they have to
cols) have some limits in their application when more severe be restored before the impression for the fabrication of the
tooth wear is present, mainly due to the lack of references shell restorations (see case 1). Depending on the wear lesion
to build up the anatomy or stabilize an index. Some mater- morphology, a minimally invasive chamfer or finishing line
ial physicochemical boundaries also relate to the extent of can be prepared to help the laboratory find the most suitable
occlusal forces in severe attrition cases. In moderate wear restoration margins. The composite shells are light-cured and
cases, an interesting alternative to the direct approach is the possibly also post-cured using a dedicated post-curing com-
“in-lab” shell technique. posite oven (generating heat; 110°C to 130°C, eventually un-
The treatment planning relies on the same principles and der vacuum or nitrogen atmosphere to eliminate the oxygen-
treatment objectives as formerly described in direct tech- inhibited layer); this process provides slight improvement in
niques with selection of a new vertical dimension of occlu- mechanical properties and wear resistance. The shells without
sion (VDO), occlusal position, and improved smile esthetics; internal dentin buildup are to be cemented with a light-curing
the merely additive approach also remains a crucial aspect cement or flowable composites owing to their limited thick-
of this alternative, new technique (right page, drawing se- ness (prevent eventual fracture of the shell during cementa-
quence on the right). The principle is rather simple, namely tion); dual-curing cements are not recommended to avoid
to use a wax-up (1 and 2) to produce an index (3) and mold working time constraint. Shells that imply internal buildup are
composite (normally only enamel; 4 and 5) to replace the cemented with a dentin shaded restorative composite. Adhe-
worn hard tissues, protect exposed dentin, and recreate sive procedures, especially immediate dentin sealing (IDS),
proper anatomy and function. Proceeding with the molding are performed either before impression taking or at the time
extraorally has some practical advantages while significantly of cementation, although the IDS protocol is preferably done
reducing chairside time. It allows overall for a remarkable right after preparation (see chapter 6 for more information).
simplification of clinical procedures with limited cost of the This technique can be used as the only protocol (see case 2)
composite shells compared to their equivalent produced by or together with other restoration types, according to the se-
a classical indirect or CAD/CAM technique. lective treatment concept described in chapter 2.
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 
 
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CASE SUMMARY

Moderate generalized tooth wear due to combined erosion
and attrition
UF
Patient expects an esthetic enhancement of worn and
discolored maxillary anterior teeth
a illa ante i
UP Lab-made felsdpathic veneers on teeth nos. 11 and 21
a illa te i
Direct composite restorations
Direct composites in noncarious cervical lesions
LP andi ula ante i

Direct incisal composite buildups on incisors
andi ula te i
LF Direct occlusal composite restorations to replace amalgams
Direct composites in noncarious cervical lesions
In-lab composite shells
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Posterior “In-Lab” Shell

Composite Restorations,
Veneers, and Direct Restorations
Case 1
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This 42-year-old female patient consulted our clinic to evalu- The suggested treatment plan involved the following
ate esthetic improvement options but without any know- steps:
ledge of the underlying wear conditions. Dental and medical • Replace all defective amalgams and old anterior compos-
anamnesis revealed a history of high consumption of acidic ite fillings and restore some cervical lesions, maintaining
beverages, a short episode of frequent vomiting, and sleep the preexisting VDO.
and awake parafunctional activities. All occlusal surfaces • Based on models of the maxilla and the mandible made
proved to be affected by erosion and attrition, although after the initial restorative phase, a wax-up will determine
wear severity was more pronounced in the mandible. Next the new VDO, occluso-functional configuration, and smile
to attrition of all incisal edges, palatal surfaces of maxillary line.
anterior teeth revealed nearly complete loss of enamel and • Mold enamel composite shells for the mandibular pre-
deep dentin indentations. Some noncarious cervical lesions molars and molars, based on the wax-up, using a thick sili-
were also present on many posterior teeth, recently treated cone index.
in another practice. No temporomandibular disorder (TMD) • Lute the mandibular composite shells and set up the de-
symptoms or functional limitations was reported. finitive VDO with help of direct composite restorations for
However, the patient did not complain about dentin hy- all other teeth and worn functional surfaces.
persensitivity and was not aware of the impact of the afore- • Finish the treatment with two indirect ceramic veneers on
mentioned conditions on her overall dental status, being maxillary central incisors to create a more harmonious
only concerned by the flattening of her smile line and aging smile line.
of interproximal composite restorations. As usual, recom- • Produce a nightguard for the maxilla.
mendations were given to the patient in regard to preventive
measure having to be installed simultaneously to the forth-
coming restorative phase.
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
The first treatment phase involves replacing
all metal-based and defective restorations
and treating decays with direct composite
restorations (1 and 2) at the pretreatment
VDO. In order to facilitate further luting pro-
cedures and optimal wax-up configuration,
proximal embrasures are slightly reopened
(2) and smoothed using an ultra-thin dia-
mond disc (0.3 to 0.4 mm). This allows in
particular to cut the shells away from the
contact area and facilitate the cleaning and

removal of composite excess during adhe-
sive cementation (3).
If not performed before making the impres-

sions for the laboratory phase, this should
at the latest be done before cementation.
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A thick, semi-rigid silicone index was fabricated over the wax-up. The index thickness is important to avoid deformation during the
molding phase and ensures precision and occlusal stability of the shells. Then, the index filled with composite is placed back on the
isolated model (eg, Vaseline) made after the replacement of amalgams (central image below).
The shells were made only from an enamel shade (White Regular, Miris 2, Coltène/Whaledent). The thickness of the restorations varies
from about 0.5 to 1.5 mm, depending on varying wear extent among the occlusal surfaces; shells are polished or alternatively glazed with
surface sealant (eg, Optiglaze, GC America or Palaseal, Kulzer). The last fabrication step was post-curing (D.I.-500 oven, Coltène/Whale-
dent). Interestingly, the extent of the work required to produce such restorations in the laboratory is limited.
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The occlusal surfaces in the third quadrant are

seen after the replacement of amalgams, the
opening of occlusal embrasure, and smoothing
of residual tooth anatomy. Dentin surfaces were
already sealed with a filled adhesive system (Opti-
Bond FL, Kerr), following the concept of IDS. To
improve adhesion, all surfaces are cleaned with
gentle sandblasting (25 µm Al2O3) before etching
enamel as usual with 37% phosphoric acid. See
chapter 6.1 for more details on tooth preparation
for luted restorations.
A flowable composite was used for cementation

(eg, Inspiro, Edelweiss DR); the flowable consis-
tency facilitates placement while the absence of
chemical curing gives enough time to clean all ex-
cesses. Depending on the shell thickness, either
enamel or dentin shades can be used.
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Due to the irregular internal anatomy of the shells and use of flow-
able composite for cementation, the clinical protocol is made ex-
tremely simple.
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Maxillary posterior teeth were restored with a direct freehand approach to obtain the needed additional anatomical and occlusal correc-
tions, as well as to replace the small amalgam fillings (simultaneous approach). Note the use of the effect shade to characterize occlusal
grooves (Inspiro Effect Shade Fissure, Edelweiss DR); this allows a better visual perception of the anatomy and serves for treatment con-
trol and improving the operator’s skills.
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Single increment buildup approach The upper palatal surfaces and incisal edges of both central incisors were also restored
with a direct freehand technique. Palatal restorations were made of a single increment of
enamel composite (Inspiro Skin, Edelweiss DR). The same effect shade used for posterior
teeth was used to visualize anatomy.
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Initially, a correction of the mandibular incisors was not planned, but due to the discolored edges, the patient asked for an esthetic en-
hancement, which was also performed with a direct freehand hand approach (as it was no wax-up and index). For such small correction,
the procedure remains clinically simple (see chapter 4 for detailed information about the increment geometry and layering approach).
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After completing the restorative phase using direct composite and “in-lab” shell restorations (upper images), the last treatment phase
involved the placement of two ceramic veneers using feldspathic porcelain. This option was considered appropriate to enhance the de-
fective incisor form resulting from multiple restorative interventions on the Class III fillings and also tooth shortening resulting from wear.
Veeners were seated on composite buildups.
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3 years posttreatment
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The 3-year posttreatment status showed a

lack of risk factor control as evidenced by
the wear facets on the mandibular com-
posite shells, mandibular anterior teeth,
and also a partial loss of volume of the
rather thin direct occlusal restorations in
the maxilla. One cervical filling got also lost
on the mandibular right canine.
Although not considered optimal, this

short-to-medium-term result is the conse-
quence of an obvious lack of patient com-
pliance with the nightguard preventive
strategy, which the patient fully admitted.
This confirms the importance of the pa-
tient’s factor in the long-term performance
of restorations placed in the context of an
interceptive approach of tooth wear.
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CASE SUMMARY
UF
Moderate to severe erosion due to GERD
Patient expects esthetic enhancements
UP
a illa ante i
a illa te i
LP andi ula ante i

In-lab composite labial shells
andi ula te i
LF In-lab composite shells
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“In-Lab” Shell
Case 2
linical n
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Shell technique (in-lab molding) full-mouth approach
Traditional methods for completing full-mouth rehabilita- simply pretreatment situation of new configuration follow-
tion rely heavily on a diagnostic wax-up (both digital and ing restoration of decays and replacement of defective Class
analogue). Various methods have been described that in- I and II restorations). The volume of the wax-up is replaced
volve a diagnostic wax-up to facilitate completion of a direct/ by the composite material (4). After light-curing through the
semi-direct rehabilitation in composite resin. The enamel index first and thereafter a second time after index removal,
shell technique was developed in 2005 with this concept in the full-arch composite resin shell can be removed from the
mind. The goal of including optical stratification with both cast and sectioned tooth by tooth to create individual shells.
dentin and enamel shades (Natural Layering Concept) is also The last step is to hollow each restoration such that a
an integral component of this approach. The technique is true enamel shell is finally available; the shell/restoration di-
well suited to the management of cases where there is mod- mensions are in harmony with natural enamel dimensions,
erate to severe generalized loss of tooth volume. hence the initial protocol name: enamel shell technique (5).
Typically, when fabricating both direct and indirect res- The shells are cemented with conventional dentin shaded
torations, stratification is developed by “building up” layers composite, which completes both the stratification and re-
from the inside out, beginning with the deeper dentin shades storative process (6). Unlike conventional methods, the
and moving toward the more superficial enamel layers. In stratification begins from the outside first.
contrast, with the “shell technique,” layers are developed The benefit of this approach is an unparalleled efficiency
from the outside in. and much lower cost than indirect or CAD/CAM alternatives.
Practically, casts are made and articulated at the desired Actually, it uses the same initial treatment planning steps
VDO and occlusal position and a wax-up fabricated accord- with a wax-up but then allows a significant simplification of
ing to the specific functional and esthetic needs of the pa- the restoration-shell fabrication. The only “drawback” relates
tient (1). A translucent key is made of the wax-up using a to the finishing of the shell surface, which is traditionally
plaster duplicate (2), creating the needed restorative space done intraorally, although conceptually, it could also be per-
(3); then, this key is filed with enamel shaded composite formed in the laboratory.
and applied to the isolated cast of the worn dentition (either
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  



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This 24-year-old male presented for examination with con- patient selected the latter, and the enamel shell technique
siderable amounts of tooth structure loss relative to his age. was employed to fulfill the aforementioned objectives while
A diagnosis of GERD (gastroesophegal reflux disease) was keeping treatment costs as low as possible.
established in conjunction with the patient’s gastroenterol- The suggested treatment plan involved the following
ogist. Erosion lesions were actually present on all occlusal steps:
surfaces in maxillary and mandibular posterior teeth as well • Determine a new VDO and functional and occlusal deter-
as upper labial and palatal surfaces; some attrition of max- minants as well as improve smile esthetics, based on a full-
illary and mandibular anterior teeth was noticed. An inter- mouth wax-up and test with maxillary anterior mock-up.
ceptive restorative solution was then considered mandatory, • Restore all worn maxillary and mandibular teeth with
with the view to both restoring lost volume and protecting the shell technique, following a “no-prep” fully additive
the remaining tooth structure. approach.
Two restorative treatment options were presented, a • Provide the patient with a nightguard soon after treatment
more “conventional” rehabilitation with bonded ceramic completion and engage a close follow-up to prevent fur-
restorations and a rehabilitation with composite resin. The ther wear and monitor attrition and erosion risk factors.
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The first step in the restorative process is to prepare the teeth prior to taking accurate alginate impressions. This often involves the
placement of bevels to (1) soften the optical transition, (2) remove some undercuts, and (3) in some instances define a finish line. Tooth
preparation is usually relatively quick and completed without anesthesia with a fine-grit, flame-shaped diamond bur. Once complete,
accurate alginate or silicone impressions can be made.
The desired occlusal position and new VDO are recorded with intraoral resin indexes intraorally; study models of the patient’s teeth can
then be properly mounted in the perspective of producing the needed wax-up.
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It is critical that the diagnos-

tic wax-up is accurate. With
respect to achieving this goal,
when the casts are properly
articulated, only the eight
maxillary anterior teeth are
first waxed. The full wax-up
will be produced after a trial of
the maxillary anterior configu-
ration with help of a mock-up
(next page); this is to avoid
time-consuming corrections
would the initial VDO and oc-
clusal position chosen not be
optimal.
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In this case, the restorations looked a little too bulky and a little
long. With this information, the wax-up of the anterior teeth was
altered and the entire wax-up could be completed with the know-
ledge that it would be reasonably accurate.
At this stage, the shade selection can also be performed. For this
case, the material used was Empress Direct (Ivoclar Vivadent); the
dentin selected was A3 and the enamel shade L.
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The final anterior wax-up included all corrections suggested by the mock-up trial; then, the full-mouth wax-up was completed as per the
confirmed VDO and occlusal position. We can observe harmonious occlusal curves, proper teeth proportions, and satisfactory overjet
and overbite. This is now the reference to be copied and transferred to the mouth as composite shells.
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Basic elements of the “in-lab shell technique”
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Once the diagnostic wax-up is completed, duplicates were made in dental stone; this will facilitate the fabrication of a thermoplastic
translucent keys (Copyplast, Scheu-Dental) using a Ministar pressure molding unit (Scheu-Dental). Plaster indexes were also fabricated
over the Copyplast keys; their significant purpose is to maintain the dimensional stability of the Copyplast keys when used later to form
the enamel shells.
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Separating medium (Rubber Sep, Kerr) is first

placed on the original model; then, the clear Copy-
plast key can be filled with the selected enamel
shade of the aforementioned light-curing resin
composite Empress Direct. It is placed and pressed
over the isolated plaster duplicate with the help of
the plaster key to ensure precise forming; with the
plaster key in place, significant pressure can be ap-
plied to optimize the molding process.
The composite resin is finally cured (laterally first

and then also occlusally after removing the plaster
key).
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Hence the translucent key removed, the individual composite resin shells first have to be separated using fine diamond discs. Then,
shell margins are trimmed and hollowed using a variety of diamond burs. The enamel thickness should roughly mimic that of nature,
although variables such as the material selected, the operator’s artistic skill, and esthetic concepts will influence this dimension.
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While in a conventional buildup, dentin

shaded masses are typically built up
with a view to creating optical charac-
teristics similar to teeth, with this tech-
nique, it is the way in which the shells
are hollowed that creates these natural
optical effects.
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The enamel shells are tried in. The shells are cleaned and sandblasted to remove debris, and a coat of unfilled resin is placed on the
intaglio, followed by the placement of dentin shaded composite. The enamel shells are then “cemented” to the patient’s natural teeth
using a dentin mass, following conventional bonding techniques.
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Once the enamel shells are cemented, the composite resin restorations are trimmed and shaped to perfect their primary anatomy using
a combination of finishing/polishing discs (Soft-Lex Pop-on XT, 3M). Creating secondary anatomy and final finishing and polishing will
not be carried out until the review appointment, typically 2 weeks later. For this case, the detailed secondary anatomy was created chair-
side, but it could be also produced by the laboratory technician if desired.
Secondary anatomy (right page) was developed first with a preparation cylindrical and flame diamond bur to create horizontal and ver-
tical grooves. Then a pre-polishing of the labial surface was performed before finalizing tertiary anatomy (eg, perikymata) using a flame
diamond again; the final polishing phase comprised only two steps with silicone pre-polishers and polishers (Politip-P and Politip-F,
Ivoclar Vivadent).
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Postoperative status 421
Final postoperative status after functional and esthetic parameters were idealized in combination with adjustments that addressed the
patient’s esthetic concerns and needed functional-occlusal improvements.
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This patient is distantly located and has only had one recall at 8 years; during that period, he visited a dentist once and had no restora-
tive work carried out. Postoperative images were taken on the day of review before a hygiene visit and the following day after a hygiene
appointment. Overall, the restorations have performed well over this long period and in absence of any specific maintenance for the
restorations except scarce hygiene sessions at another practice.
There were three fractures, all in the premolar region; these were easily repaired at the review (see next 2 pages for the postoperative
status following repair). There were only limited signs of wear in this particular case, and this probably reflects the origin of tooth volume
loss, which was erosive more than abrasive in nature. Quite noticeably, much of the surface detail has been lost over the 8-year period.
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8 years posttreatment (post-corrections)
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In-Lab Shell Technique (LST): Key Points to Master the Protocol 427
• A model (actual or virtual) of the natural dentition (prepared or unprepared) is fabricated/recorded.
• Final/restored tooth position and VDO are determined.
• When both models are superimposed, the difference represents the restoration.
• Enamel thickness of the restoration is determined based on anatomical averages and the optical and physical properties
of enamel restorative materials.
• The restoration/enamel shells are produced based on steps 3 and 4.
• The enamel shell is either cemented with a dentin replacement material (reduced restorative space) or alternatively filled
with dentin (bilaminated shells) before being cemented (larger restorative space).
1. Bagis YH, Rueggeberg FA. The effect of post-cure heating on residual, unreacted monomer in a commercial resin composite. Dent
Mater 2000;16:244–247.
2. Cook WD, Johannson M. The influence of postcuring on the fracture properties of photo-cured dimethacrylate based dental compos-
ite resin. J Biomed Mater Res 1987;21:979–989.
3. de Gee AJ, Pallav P, Werner A, Davidson CL. Annealing as a mechanism of increasing wear resistance of composites. Dent Mater
1990;6:266–270.
4. Ferracane JL, Condon JR. Post-cure heat treatments for composites: Properties and fractography. Dent Mater 1992;8:290–295.
5. Shah MB, Ferracane JL, Kruzic JJ. R-curve behavior and toughening mechanisms of resin-based dental composites: Effects of hydra-
tion and post-cure heat treatment. Dent Mater 2009;25:76–770.
6. Spreafico R. Composite resin rehabilitation of eroded dentition in a bulimic patient: A case report. Eur J Esth Dent 2010;5:28–48.
7. Takeshige F, Kinomoto Y, Torii M. Additional heat-curing of light-cured composite resin for inlay restoration. J Osaka Univ Dent Sch
1995;35:59–66.
8. Yamaga T, Sato Y, Akagawa Y, Taira M, Wakasa K, Yamaka M. Effects of post-curing by light and heat on hardness and fracture toughness
of four commercial visible-light-cured dental composite resins for crown and bridge veneers. J Mater Sci Lett 1994;13:1494–1496.
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6
CHAPTER
6.
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Indirect Techniques
429
Sub-Chapters
6.1 Adhesive Procedures
6.2 Indirect Protocols
6.3 Luting Procedures
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6.1
CHAPTER
6.1
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Adhesive Procedures
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Adhesive Procedures
The most common clinical problems encountered with indi- Immediate dentin sealing
rect bonded posterior restorations are related to tissue con- The idea behind this procedure is to seal the dentin surfaces
servation (creating an appropriate cavity design may lead to with a full adhesive system while the cavity still is under rub-
significant loss of sound tissue), impression taking, adhesive ber dam, which prevents further tissue dehydration (mainly
cementation (deep proximal preparations are a challenge when treating serial cavities) and dentin contamination. It
and make working-field isolation more difficult), and interim also provides optimal tooth protection against sensitivity
restorations (the placement of conventional acrylic tempo- during the temporary phase and improves bond strength
raries is time-consuming and the cement contaminates the and adhesive interface stability.
interface, while simplified, “soft,” light-curing temporaries
are easily lost and trigger sensitivity after some time due to Cavity design optimization
leakage and dentin contamination). This concept was developed in parallel with IDS to overcome
A series of original ideas emerged in the 1990s to fully unnecessary tissue removal when adapting inner cavity de-
integrate adhesion into the preparation and cementation of sign to an indirect technique (parallel or slightly tapered).
tooth-colored restorations; these new concepts were pur- Following multifunctional adhesive placement (IDS layer), a
suing multiple objectives such as the sealing/protection of flowable composite liner is applied to fill in all undercuts and
dentin, the development of proper cavity geometry with- confer an ideal geometry to the cavity. An optimal material
out additional hard tissue removal, and optimal cohesion consistency should ensure the material’s stability within un-
between the restoration and the remaining tooth structure dercuts while self-leveling to avoid further preparation and
to achieve tooth reinforcement and restoration strength. finishing. For this reason, highly filled flowable composites
This major advance for treating large decays developed are recommended. The use of products with high viscosity
over three continents with the contribution of Inokoshi and (restorative composites) or very low viscosity (low-filled flow-
Tagami with “Dentin Coating,” Pashley and Paul with “Den- able composites) is feasible, although the application of these
tin Hybridization” and “Dual Bonding,” and Dietschi and products is less practical and not recommended in routine.
Spreafico with a global treatment concept including the
following: Cervical margin relocation
• Immediate dentin sealing (IDS; also know as dual bonding This procedure is considered for deep proximal preparations
DB ) (intrasulcular) that complicate impression taking and cavity iso-
• Cavity design optimization (CDO) lation during cementation. In the case of deep proximal prepar-
• Cervical margin relocation (CMR; also known as deep mar- ations, after proper positioning of a matrix in the cervical area,
gin elevation DME ) a first layer of flowable or restorative composite (or a combina-
• Controlled adhesive cementation (CAC) tion of these materials) is applied to reposition the margin.
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The use of a flowable composite is recommended only This successful application of this procedure is also facil-
up to 1 to 1.5 mm; if more material is needed, a combination itated by the CDO concept, which reduces and optimizes re-
of restorative and flowable composites is suggested. A highly storation thickness, favoring proper light transmission to the
filled flowable composite or a bulk fill flowable base are pref- luting interface.
erable for this procedure. Another critical prerequisite in or- An additional benefit of this new, advanced global clinical
der to achieve successful adhesive procedures is to perfectly approach is that due to the dentin remaining fully protected
isolate the cervical preparation; indeed, when respecting the by the base/liner, anesthesia during cementation proced-
true indication of this procedure (mainly intrasulcular), the ures is virtually no longer required as well as hypersensitivity
placement of a rubber dam together with a matrix is usually in case of temporaries being dislodged or lost. This revised
possible. protocol features the following clinical advantages:
• The absence of tissue removal for the sake of conve-
Controlled adhesive cementation nience, the properties of materials, or the limitations of
This refers to the use of a highly filled light-curing material technology
for cementation to ensure optimal working time and control • The gentle treatment of the pulpodentinal complex during
(which is not the case with dual-curing adhesive cement). the preparation (and eventually the temporary phase)
Another major advantage of CAC in complex cavity design, through the systematic use of a rubber dam and extensive
and in combination with the CMR technique, is it allows for water spray, and by isolating the dentin immediately after
visual margin sight, offering the unparalleled advantage of preparation with a thick layer of DBA and adhesive base/
facilitating removal excess cement. We recommend the use liner
of a fine microhybrid, the viscosity of which is reduced at the • The long-term function and resistance of the teeth due to
time of placement using a special ultrasonic or sonic cemen- the use of wear-resistant, strong, and rigid restorative ma-
tation tip to ease restoration insertion. More recent compos- terials (both restoration and cement)
ite resin formulations, such as inhomogenous nanohybrids, • Strong and durable adhesive interfaces between the ma-
are not recommended due to their firmer consistency and terials and substrate (dentin enamel to adhesive, adhesive
large particle size (prepolymerized particles or clustered to base/liner, base/liner to composite cement, and com-
nanoparticles). The results of research studies on the possi- posite cement to restoration)
bility of bringing sufficient light into the cementing space for
optimal composite conversion and mechanical properties
have shown that proper light polymerization is feasible, and
in some conditions even superior to what can be achieved
with a dual-curing material in the absence of light.
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Immediate Dentin Sealing (IDS) and Cavity Design Optimization (CDO)
Cut dentin IDS IDS and lining/CDO
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The dental surfaces are prepared first with a filled adhesive actually forms a
mechanically with burs (diamond or thicker layer, providing a more efficient
stainless steel depending on the op- physical and thermal protection than a
erator’s preference) and sandblasting. nonfilled adhesive; in case a nonfilled
Then, the IDS layer is placed using pref- adhesive is selected, a thin amount of
erably a filled adhesive system (three- flowable composite should be used to
6
step etch-and-rinse system such as thicken the layer and provide adequate
OptiBond FL, Kerr). The IDS layer made protection.
Indirect Techniques
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1 2
3 4A
4B Step1: IDS. Step 2: Restoration fabrication. Step 3: Adhesion

to enamel. Step 4: Restoration luting.
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Shallow, supragingival cavities 437
In such restorative configuration (overlays to elevate vertical dimension of occlusion (VDO) and stabilize the cracked tooth: no. 47), there
is no need and space for a composite liner; then, dentin is selectively sealed with a highly filled 3-step etch rinse adhesive.
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1 2
3 4A
Step1: IDS. Step 2: Restoration fabrication. Step 3: Adhesion

4B to enamel. Step 4: Restoration luting. NB: Cavities are supra-
gingival and don’t require a cervical margin relocation.
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Nonretentive, supragingival cavities 439
Three teeth required wear stabilization, and due to the

clenching risk factor, lithium-disilicate overalys were chosen
as the best option. Wear lesions did not create undercuts so
that exposed dentin was simply covered with the IDS layer or
remaining composite material.
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Retentive cavities
1 2
Step1: IDS. Step 2: CDO. Step 3: Adhesion to enamel, restor-

ation trial, and adhesive cementation. NB: Cavities are supra-
gingival and don’t require a cervical margin relocation.
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Lower image sequence: Following cavity margin finishing and 441

after IDS, the CDO is made with first a thin layer of flowable
composite, followed by application of restorative composite;
the use of restorative composite is mandatory when larger
volumes are to be filled.
The IDS/CDO layers provides not only an optimal cavity

geometry and eliminate undercuts, but also follows a proper
biomimetic approach using bonded composite as a dentin
replacement and for this case, ceramics as enamel replacement.
The enlarged view shows the resulting, smooth internal cavity
design (see chapter 2, hybrid strategy, for detail presentation of
this case).
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Subgingival cavities
The clinical situation depicted below relates to juxta- or no longer applied. As a clinical reference, being able to place
subgingival proximal margin locations, with margins only the rubber dam, possibly with help of a matrix, and obtaining
slightly violating the biologic width (normally intracrevicular a perfectly dry working environment is key to a safe treat-
or involving only the epithelial attachment). In case of cavity ment outcome of this procedure.
extension into the connective attachment, this procedure is
The traditional approach (strategy 1) was based

on a number of precarious, successive clinical
procedures, starting with suboptimal rubber
dam placement, potentially favoring saliva/
crevicular fluid leakage along cervical margins
and then difficult IDS layer placement. Then,
impression taking (conventional or optical)
as well as restoration fit control, cementation
in perfectly dry environment, and removal of
cement excesses would also be unnecessar-
ily complicated. This approach is no longer
recommended.
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Among the four restorations to be replaced, three have either juxta-gingival (nos. 44 and 45) or subgingival (no. 46) 443
proximal margins; such a configuration is considered critical for tooth-colored restorations with the aim of perfectly
controlled adhesive procedures.
This series of images perfectly illustrates the number of potential limits of the conventional treatment approach,
without using new, improved adhesive protocols, including in particular the CMR for such deep cervical margins
locations.
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Subgingival cavities
The “conventional” treatment approach was also based on this resulted in various complications and eventually justi-
the removal of hard tissue to obtain the desired cavity geom- fied more invasive procedures such as crown lengthening,
etry, the proximal preparation level managed as such, and even sometimes “prophylactic” endodontic treatment. Such
dentin being left unprotected until the cementation phase; difficulties are no longer to be faced.
The “modern” approach (strategy 2) is based on

a serial of measures that correct the procedural
drawbacks of the “conventional” treatment ap-
proach. As for other cavity configurations, the
IDS is applied first (usually with help of the ma-
trix), then the CDO serves to fill up all undercuts
and finally the cervical margin is occlusally re-
located (CMR) to displace it supragingivally and
make it accessible for all further steps. The over-
all revised protocol supports improved quality
of adhesive interfaces and protection of the pul-
podentinal complex.
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The completed sextant shows the combined application of IDS/CDO on the second molar (no. 47) and IDS/ 445
CDO/CMR combination on the other three cavities (nos. 44 to 46). The advantage of this revised approach and
its clinical benefits is clearly visible on this image. The cervical margin relocation can be performed with either
flowable, flowable bulkfill, or restorative composites, depending on the operator’s preferences. Due the very
limited material volume, polymerization shrinkage is not considered critical.
The use of a wedge is case-dependent because rubber-dam pressure is often sufficient to maintain the matrix
in close contact with the cervical cavity limit. Sectional or full matrix systems can be used depending on tooth
anatomy.
Matrix placement IDS, CDO, and CMR stratums Completed cavities preparation
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Clinical steps Conventional protocol Revised protocol

Preparation eci c i lati n n enati nal a ginal nde u e da tl unde ate a nl
and inte nal de ign i e ui ed ta e a ginal c n enient de ign e ui ed
DBA application At cementation u ta e e a ati n
Base/liner Optional Mandatory
Base/liner material Composite or glass ionomer(s) ite nl fl ainl
Provisional restoration Cemented provisional temporary Noncemented light-curing temporary
recommended
Luting material Dual-curing composite cement Light-curing restorative composite
Restoration insertion Manual Assisted with sonic/ultrasonic tip (eventually with
heated material)
Description and summary of the major differences between the conventional and the revised preparation and cementation protocols for
indirect adhesive Class II restorations (according to Dietschi and Spreafico, 1997 and 1998). Since its inception, strong scientific and long-
term clinical evidences have confirmed the validity of this comprehensive protocol, emulating superior long-term interfaces stability and
restoration longevity.
Surface treatment for indirect posterior restorations
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1. Inokoshi S. Temporary sealing Pulp and dentin protection 13. Dietschi D, Monasevic M, Krejci I, Davidson C. Marginal and
using low viscosity composite in Japanese . Adhes Dent internal adaptation of class II restorations after immediate or
1992;10:250. delayed composite placement. J Dent 2002;30:259–269.
2. Pashley EL, Comer RW, Simpson MD, Horner JA, Pashely DH, 14. Dietschi D, Olsburgh S, Krejci I, Davidson C. In vitro evaluation
Caughman WF. Dentin permeability: Sealing the dentin in of marginal and internal adaptation after occlusal stressing of
crown preparations. Oper Dent 1992;17:13–20. indirect class II composite restorations with different resinous
3. Sato M, Goto H, Inai N, et al. How to use “Liner Bond System” bases. Eur J Oral Sci 2003;111:73–80.
as a dentin and pulp protector in indirect restorations in Jap- 15. Besek M, Mormann WH, Persi C, Lutz F. The curing of com-
anese . Adhes Dent 1994;12:41–48. posites under Cerec inlays in German . Schweiz Monatsschr
4. Otsuki M, Yamada T, Inokoshi S, Takatsu T, Hosoda H. Es- ahnmed 1995;105:1123–1128.
tablishment of a composite resin inlay technique. Part 7. 16. Dietschi D, Marret N, Krejci I. Comparative efficiency of plasma
Use of low viscous resin in Japanese . Jpn J Conserv Dent and halogen light sources on composite micro-hardness in
1993;36:1324–1330. different curing conditions. Dent Mater 2003;19:493–500.
5. Dietschi D, Spreafico R. Indirect techniques. In: Adhesive Metal- 17. Dietschi D, Argente A, Krejci I, Mandikos M. In vitro perfor-
Free Restorations: Current Concepts for the Esthetic Treatment mance of Class I and II composite restorations: A literature
of Posterior Teeth. Berlin: Quintessence, 1997:139–167. review on nondestructive laboratory trials Part I. Oper Dent
6. Dietschi D, Spreafico R. Current clinical concepts for adhesive 2013;38:E166–E181.
cementation of tooth-colored posterior restorations. Pract 18. Dietschi D, Argente A, Krejci I, Mandikos M. In vitro perfor-
Periodontics Aesthet Dent 1998;10:47–54. mance of Class I and II composite restorations: A literature
7. Paul SJ, Sch rer P. The dual bonding technique: A modified review on nondestructive laboratory trials Part II. Oper Dent
method to improve adhesive luting procedures. Int J Peri- 2013;38:E182–E200.
odontics Restorative Dent 1997;17:536–545. 19. Roggendorf MJ, Kr mer N, Dippold C, et al. Effect of proximal
8. Dietschi D, Herzfeld D. In vitro evaluation of marginal and inter- box elevation with resin composite on marginal quality of
nal adaptation of class II resin composite restorations after ther- resin composite inlays in vitro. J Dent 2012;40:1068–1073.
mal and occlusal stressing. Eur J Oral Sci 1998;106:1033–1042. 20. Frankenberger R, Hehn J, Hajt J, et al. Effect of proximal box
9. Magne P. Immediate dentin sealing: A fundamental proced- elevation with resin composite on marginal quality of ceramic
ure for indirect bonded restorations. J Esthet Restor Dent inlays in vitro. Clin Oral Investig 2013;17:177–183.
2005;17:144–154. 21. Lefever D, Gregor L, Bortolotto T, Krejci I. Supragingival relo-
10. Magne P, Kim TH, Cascione D, Donovan TE. Immediate den- cation of subgingivally located margins for adhesive inlays/
tin sealing improves bond strength of indirect restorations. J onlays with different materials. J Adhes Dent 2012;14:561–567.
Prosthet Dent 2005;94:511–519. 22. Rocca GT, Gregor L, Sandoval MJ, Krejci I, Dietschi D. In vitro evalu-
11. Stavridakis MM, Krejci I, Magne P. Immediate dentin seal- ation of marginal and internal adaptation after occlusal stressing
ing of onlay preparations: Thickness of pre-cured Dentin of indirect class II composite restorations with different resinous
Bonding Agent and effect of surface cleaning. Oper Dent bases and interface treatments. “Post-fatigue adaptation of indi-
2005;30:747–757. rect composite restorations.” Clin Oral Investig 2012;16:1385–1393.
12. Magne P, Spreafico R. Deep margin elevation: A possible ad- 23. aruba M, G hring TN, Wegehaupt FJ, Attin T. Influence of a
junct procedure to immediate sealing. Am J Esthet Dent proximal margin elevation technique on marginal adaptation
2012;2:86–96. of ceramic inlays. Acta Odontol Scand 2013;71:317–324.
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6.2
CHAPTER
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Indirect Protocols
449
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Indirect Techniques
Although the “freehand” protocol is highly effective, it is more contact area so that it can shape both labial and lingual/pal-
challenging in cases of increased tooth wear or for clinicians atal cusp profiles. The contact area will then remain free of
who have limited experience with advanced direct bonding any composite excess. The final step consists of placing and
protocols. Molding techniques were then developed to over- molding composite freehand, with guidance of the molded
come those challenges and make it accessible to any prac- increments, to complete the full occlusal anatomy. Note that
titioner. The basic, common principles of the interceptive using a translucent silicone is not needed due to their lower
strategy do of course fully apply to the partial molding tech- stiffness.
nique, the first option within this group of alternative proto- This technique alleviates both the possible difficulties of
cols; in fact, molding composite over worn surfaces is not a a fully freehand approach as well as the frequent, tricky, and
new technique but it received rather limited attention due time-consuming removal of interproximal excess resulting
to shared, recurrent shortcomings of many molding proced- from a full molding technique. The latter technique can how-
ures, such as the following: ever become effective and uncomplicated with some varia-
• Imprecise molding result due to index deformation tions of the basic protocols (see section 4.6 for detailed pre-
• Increased operative time when using single (tooth-by- sentation of a revised and improved full molding technique).
tooth) molding Two conditions preclude the use of direct and moulding
• Difficult and lengthy removal of excess in the proximal con- techniques, namely severe tissue loss and high functional
tact area and cervical embrasures (classical full molding) strains; those conditions either make direct composite appli-
• Suboptimal anatomy if a perfect wax-up is not available cation unpractical or trigger excessive composite wear and,
(all full molding procotols) or chipping.
The first limitation is then of mere clinical nature and in
The partial molding technique such as introduced in section case of extensive erosion, indirect or CAD-CAM techniques
4.3 relies then on a few simple and proficient steps, following using composite or ceramics can be considered. There is
logically the usual case preparation approach (full posterior nevertheless an advantage to use composite as it can be
functional wax-up at a new, increased VDO and occlusal pos- easily repaired, especially when erosion risk factors are not
ition, if indicated). Then, a full index made of putty silicone fully controlled; in such circumstances, ceramics is even
(stiffer, the better) is prepared and cut slightly outside the contra-indicated unless there is a significant contribution of
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attrition. Actually, some forms of erosion pathology are as- for treating heavy bruxers and clenchers (see chapter 2.2 for
sociated to stress and anxiety, both contributing factors for more information). Interestingly though, traditional compos-
bruxism. ite show very rarely, not to say never, bulk fractures if restor-
Despite the remarkable qualities and performance of ations are well bonded and polymerized. But a strict limit
resin composites to treat limited to moderate wear cases or to their use must be respected, especially if having limited
to restore anterior teeth even in more critical conditions, se- space available to restore conservatively worn teeth (usually
vere tissue loss combined to high functional strains might molars); in such clinical conditions, substantial clinical evi-
demand the use of both an indirect approach and restorative dence supports the use of glass-ceramics which are by today
material of higher inner strength. Then, the use of bonded, our preferred choice in advanced attrition cases.
monolithic glass or polycrystalline ceramics is the best op- The basic philosophy of tooth wear treatment however re-
tion either locally or for one or two full arches. The use of mains which targets the most conservative treatment option
etchable materials such as lithium-silicate or di-silicate is based on a sector by sector or even tooth by tooth approach;
usually preferred for all partial restorations while zirconia undue to passive eruption which occurs in teeth submitted to
der its various forms (3Y-T P to 5Y-T P) is also indicated for wear, with or without restoration, the use of a single mater-
full crowns. Composite CAD-CAM blocks present an interest- ial over the entire arch or mouth has no solid rationale, de-
ing alternative to direct materials mainly as replacement of spite the application of this concept over many decades as
classical, hand-made indirect composite onlays and overlays result of limited understanding of dental biomechanics and
but certainly not in case of high functional stresses. Actually, function. This is why it is instrumental to integrate modern
their physico-chemical characteristics are markedly inferior restorative concepts also in the treatment of severe local or
to glass ceramics and have to our opinion limited interest generalized tooth wear treatment.
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452
1. Didier Dietschi, Olivier Duc, Ivo Krejci, AvishaiSadan. Biome- 6. Magne P, Magne M, Belser UC. Adhesive restorations, cen-
chanical considerations for the restoration of endodontically tric relation, and the Dahl principle: Minimally invasive ap-
treated teeth: A systematic review of the literature Part 1. proaches to localized anterior tooth erosion. Eur J Esthet Dent
Composition and micro-and macrostructure alterations. 2007;2:260–273.
Quintessence Int 2007;38:733–743. 7. Mainjot AKJ. The one step-no prep technique: A straightfor-
2. Didier Dietschi, Olivier Duc, Ivo Krejci, AvishaiSadan. Biome- ward and minimally invasive approach for full-mouth reha-
chanical considerations for the restoration of endodontically bilitation of worn dentition using polymer-infiltrated ceramic
treated teeth: A systematic review of the literature, part II network (PICN) CAD-CAM prostheses. J Esthet Restor Dent
(evaluation of fatigue behavior, interfaces, and in vivo studies). 2020;32:141–149.
Quintessence Int 2008;39:117–129. 8. Oudkerk J, Eldafrawy M, Bekaert S, Grenade C, Vanheusden
3. Klink A, Groten M, Huettig F. Complete rehabilitation of com- A, Mainjot A. The one-step no-prep approach for full-mouth
promised full dentitions with adhesively bonded all-ceramic rehabilitation of worn dentition using PICN CAD-CAM res-
single-tooth restorations: Long-term outcome in patients with torations: 2-yr results of a prospective clinical study. J Dent
and without amelogenesis imperfecta. J Dent 2018;70:51–58. 2020;92:103245.
4. Klink A, Huettig F. The challenge of erosion and minimally in- 9. Sierra D, Vailati F, Mojon P, Torosyan A, Sailer I. Biological out-
vasive rehabilitation of dentitions with BEWE grade 4. Quintes- comes and patient-reported outcome measures (PROMs) of
sence Int 2016;47:365–372. minimally invasive full-mouth rehabilitations of patients with
5. Magne P, Carvalho AO, Bruzi G, Anderson RE, Maia HP, Gi- erosions and/or abrasions by means of the “3-step technique”:
annini M. Influence of no-ferrule and no-post buildup design Part 2 of the 6-year outcomes of a retrospective clinical study.
on the fatigue resistance of endodontically treated molars re- Int J Prosthodont 2022; 35:152–162.
stored with resin nanoceramic CAD/CAM crowns. Oper Dent
2014;39:595–602.
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10. Torosyan A, Vailati F, Mojon P, Sierra D, Sailer I. Retrospective

clinical study of minimally invasive full-mouth rehabilitations
of patients with erosions and/or abrasions following the “3-
step technique”. Part 1: 6-year survival rates and technical out-
comes of the restorations. Int J Prosthodont 2022; 35:139–151.
11. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a se-
verely eroded dentition: The three-step technique. Part 1. Eur
J Esthet Dent 2008;3:30–44.
J Esthet Dent 2008;3:128–146.
J Esthet Dent 2008;3:236–257.
14. Varma S, Preiskel A, Bartlett D. The management of tooth
wear with crowns and indirect restorations. Br Dent J
2018;224:343–347.
.
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CASE SUMMARY
Class II and deep bite occlusion
Bruxism as main risk factor
Smoker and frequent coffee/tea consumption
UF Patient expects tooth wear stabilization following the most
conservative and “simple” treatment approach
a illa te i
Direct composites to replace worn tissues in premolars
UP Replacement of maxillary right porcelain-fused-to-metal
(PFM) with monolithic disilicate crown
Other molars restored with lithium-disilicate overlays
Slight VDO increase (limited due to Class II occlusion)
andi ula te i
Direct composites to replace worn tissues and increase VDO
LP (limited due to Class II occlusion)
Existing PFM on mandibular second premolar not replaced
a illa ante i
Indirect composite palatal veneers
LF
Direct composites on some restorations’ incisal margins
andi ula ante i

Direct incisal composite buildups
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Indirect Palatal Veneers

and Direct Composite Restorations
Case 1
it c nt i uti n ean ic el ene a ile ente f t e te i e a ilitati n
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This 55-year-old female patient observed progressively wors- “simple,” straightforward solution to her functional problem.
ening signs of tooth wear in her smile area and consulted for The “basic” strategy suggested was then to use a combina-
treatment options to resolve this problem. She otherwise tion of interceptive/restorative protocols that would combine
neither presented any temporomandibular disorder (TMD) patient’s search for noninvasiveness, biomechanical impera-
symptom nor complained about dentin hypersensitivity. The tives (especially for fragilized molars), and clinical effective-
main risk factor identified was bruxism with obvious clench- ness (managing significant palatal thickening of maxillary
ing habits; significant flattening of upper and lower smile anterior teeth). The latter restorative aspect relates the need
lines, combined to the typical, highly concave anatomy of to create better anterior relationship and anterior guidance
molars supported the aforementioned diagnosis elements. with the combination of slight forward shift of maximal inter-
Orthodontics was considered during the treatment planning cuspation position (MIP), VDO increase with mandibular an-
but was refused by the patient who was expecting a rather terior teeth composite buildups, and palatal indirect veneers.
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The first treatment step consisted of increasing the VDO and moving the MIP slightly forward to preserve anterior contacts and guidance;
this part of the rehabilitation is not presented here (see next cases for related, detailed clinical protocols). Direct composite restorations
were made on the mandibular posterior teeth to complete the new occlusal scheme (see the right page, upper images). As soon as this
preparation step was completed, a wax-up was produced to define the respective material thicknesses to be used on upper palatal and
lower incisal edges and as well to visualize an enhancement of patient’s smile line.
The treatment phase dedicated to anterior segments started with lower incisal edge buildups (right page). A bilaminar technique was
used (see chapter 3.1 for detailed concept presentation). The first step consists of selecting the basic dentin and enamel shades; the
shade selection imperatively needs to precede any other preparation step, including rubber dam placement, so that no surface tissue
dehydration occurred, optimizing shade selection accuracy.
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
 
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461
 
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462 Previous double page: The overall layering approach in- optical transition is obtained. Effect shades are applied be-
volves four steps for such a “polychromatic” version of the tween dentin and enamel layers and must be used as thin
NLC (Natural Layering Concept): 1. lingual enamel layer with increments to obtain natural effects. Then, finishing and pol-
flow consistency, 2. buildup of dentin lobes, 3. localized ef- ishing complete the restoration of mandibular anterior teeth,
fect shade placement (in this case the opalescent blue-tinted following the detailed protocol presented in chapter 4.2.
Inspiro Azur, Edelweiss DR), and 4. proximolabial enamel.
Note that the dentin increments are shaped in a way that Right page: Post-finishing, immediate, and delayed post-
they cover enamel partially (about halfway) so that a smooth treatment views.
Opalescent
effect shade
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463
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464
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465
Using indirect composite palatal veneers was considered advanta-

geous to control restoration thickness in this case. Composite restor-
ations were made of the same material used for direct restorations
(Inspiro, Edelweiss DR) but with a post-curing treatment (120 C for
5minutes) following normal light-curing process. Note the resin “hooks”
helping restoration proper placement during luting procedures.
Palatal surfaces were only sandblasted so that we could follow a

no-prep approach here too. Restorations were sandblasted and
then coated with silane (Monobond-S, Ivoclar Vivadent) before ce-
6
mentation. A restorative or flowable enamel shade can be used for
luting. A metal strip was placed between teeth to prevent luting ma-
terial excess to bind neighboring teeth. Indirect Techniques
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466
The separation of teeth with metal strips is instrumental to avoid adhesive materials blocking interproximal spaces. Resin stabilization
hooks must be made after restoration polishing so that they don’t bond too strongly to restorations and are easy to remove after
cementation.
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467
As the veneers appeared slightly too dark and translucent at the teeth edge after cementation, a correction was made before ending this
treatment session. To this purpose, some material was removed at the interface and the marginal area corrected with a direct approach;
then a less chromatic dentin shade was used and covered with less translucent (higher value) enamel mass. The post-correction view
can be seen at the top of the page.
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468
Posttreatment status
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469
The posttreatment views demonstrate a satisfactory color integration of veneers and color blending with the natural teeth edges, even
without placing any facial bevel or chamfer. The no-prep approach is actually applied as often as possible to lower the biomechanical
impact of restorative procedures.
Next double page: The 1.5-year follow-up shows a good mechanical behavior of composite restorations, although some surface material
staining is visible on facial margins; the palatal surface discoloration is of negliglble importance, although it underlines the limit of partial
composite restorations for smokers and patients with staining diet (ie, high coffee/tea or turmeric consumption).
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1.5-year follow-up
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471
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472
CASE SUMMARY
Limited to moderate tooth wear mainly due to attrition,
leading to highly concave molars anatomy
Deep bite and Class II/2 occlusion
UF History of severe TMD
Patient has specific and limited esthetic concerns (tooth
color and irregular lower smile line) and hopes for limited
occlusal changes
UP a illa ante i
One direct composite on incisal edge of maxillary left
central incisor
andi ula ante i

Direct composite buildups to correct canted lower smile
line and compensate for VDO increase
LP
andi ula te i
Lithium-disilicate overlays and a crown to restore worn
surfaces and stabilize occlusion
Direct composites to correct wear facets on premolars
LF
a illa te i
Composite inlays to replace decayed, aged restorations and
restore worn surfaces
Direct composites to correct wear facets on premolars
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473
Partial, Hybrid Indirect Rehabilitation

with Direct Composites
Case 2
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474
This 55-year-old female patient consulted for a tooth color improvement and enhancement of her lower smile line. She was aware of
her moderate tooth wear problem and had a period with severe TMD that was finally resolved with nightguard therapy, although it
took several years for the symptoms and functional issues to disappear. She was then extremely concerned by the risk of any occlusal
treatment or even anatomical change that couldd trigger a relapse of the very painful TMD she experienced the last few years.
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Function was checked with simple normal and maximal lateroprotusive opening exercise movements to evaluate the functional 475
envelope, which proved within normal parameters, with no detectable joint clicking, discomfort, or pain. The intraoral examination
revealed moderate wear of maxillary and mandibular molars (except no. 46, which was crowned) and mandibular anterior teeth. Limited
wear facets were also visible on premolars and her maxillary left incisor (no. 21). A mesiodistal crack was present on the maxillary second
molar, obviously related to the very concave anatomy of molars and the resulting, abnormal diverging forces.
The anatomical locations of wear lesions together with the deep bite occlusion (Class II/2) suggested bruxism and clenching as risk
factors. The localized, moderate wear of molar occlusal surfaces is typical of clenching habits that also contribute to incisal wear of man-
dibular anterior teeth due to slight bruxism. It was then considered that increasing the VDO without further extending the thickness of her
nightguard should be reasonably safe and would allow for proper conditions to restore her molars and create more ideal occlusal anat-
omy and function while limiting the risk of tooth wear progression; the maintenance of preventive strategy (nightguard) was mandatory.
Finally, a bleaching was planned to brighten tooth color. See also next page, showing functional and occlusion pretreatment conditions.
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476
To increase VDO and stabilize occlusion, lithium-disilicate full-contour overlays and crown (e.max A2, Ivolcar Vivadent) on mandibular mo-
lars were considered suitable to resist highly unfavorable clenching strains. The right page shows the preparations with minimal invasiveness
and application of the IDS/CDO protocol. Note that marginal finishing lines had to be created to meet technical and fabrication demands.
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477
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478
Overlays were luted with a restorative composite (Tetric T, Ivoclar Vivadent for both its clinical simplicity and superior mechanical
resistance; see chapter 6.3 for more details on the procedure); the crown on tooth no. 46 was luted with a composite cement (RelyX
Unicem, 3M).
As the patient was seriously concerned about ceramic-to-ceramic contacts, she requested to have a softer material opposing the e.max
restorations; the maxillary molars were then restored with composite inlays (Inspiro system). As cavities did not present undercuts and
were not particularly profound, dentin was only covered by the IDS layer, as explained in the beginning of this chapter.
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479
Postoperative views of the planned rehabilitation, which fulfilled the aforementioned objectives that included tissue conservation,
occlusal stabilization, and “comfortable” occlusion in a patient at risk for TMDs.
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480
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481
The pretreatment clinical analysis sug-

gested the possibility to correct the visu-
ally unesthetic alignment of mandibular
anterior teeth by creating a new smile line.
To the purpose of creating the illusion of
straighter teeth, form correction extended
slightly over the proximal surfaces. Adding
composite on the canine tips also contrib-
uted to creating a horizontal plane, leading
to a satisfactory alignment. The entire

procedure could be performed “no-prep,”
which is once again a major benefit of us-
ing an interceptive protocol for this area,
while using other materials/techniques
for posterior teeth following the “hybrid”
philosophy.
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482
Final restorative status, just prior to the placement of a last restoration to correct the worn/chipped incisal edge of the maxillary left central
incisor with a simple composite restoration, using only one enamel shade (Inspiro Transparent). Note that occlusal surfaces of mandibular
molars were made rather flat to limit the guiding and nonguiding contacts generating detrimental lateral forces as much as possible.
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Final direct restorative work 483
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484
Postoperative status
Postoperative occlusal views.
The 4-year follow-up (right page) shows very

little sign of wear progression or restoration
aging. It is assumed that an improved occlusal
stability, a reduced overbite (VDO increase), and
good compliance with nightguard protection
were the prerequisites for a stable, successful
treatment outcome.
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486
8-year follow-up
The 8-year follow-up shows very little change in the

restoration conditions, whether for the indirect mono-
lithic glass-ceramic or composite restorations, as well as
the direct buildup of anterior teeth. This very favorable
outcome is likely related to the patient’s good compli-
ance and possibly as well a “quieter” life period. The pa-
tient continued “home bleaching” at regular intervals;
she also requested a slight esthetic improvement (to
reestablish a younger central incisor length and smile
configuration). This was then achieved with two direct,
no-prep composite restorations. The change had to re-
main rather moderate due to the deep bite condition.
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487
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488
CASE SUMMARY
Moderate to severe generalized tooth wear due mainly to
attrition with varying impact, depending on parafunctional
excursive and nonexcursive movements
UF Class III tendency with edge-to-edge anterior occlusion;
patients tends to bite “naturally” in this position
Patient expects a stable and durable result due to
demanding professional activities that limit his availability
for dental treatments; regular “maintenance” treatments
have to be avoided
UP
a illa ante i
Indirect monolithic lithium-disilicate bonded restorations
(360-degree veneers)
a illa te i
Few direct composite additions to harmonize both arches
LP
andi ula ante i
Direct composite buildups to compensate for VDO increase
and restore appearance and length
LF
andi ula te i
Lithium-disilicate overlays and “tabletop” veneers to restore
worn surfaces, arrest extension of existing cracks, and
increase VDO while aligning buccal surfaces
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489
Partial Indirect Rehabilitation

and Direct Composite Restorations
Case 3
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490
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491
This 54-year-old male patient consulted about his known The patient had worn a Michigan splint for several years
tooth wear problem to receive an esthetic and functional but could not witness a stabilization of his wear problem due
rehabilitation. A clear demand was to have a solution that to awake parafunctions. Apart from attrition, he otherwise
provided optimal strength of the restorations to minimize did not show any obvious signs of erosion.
the need for maintenance (periodical or occasional in case The choice for monolithic lithium-disilicate material was
of mechanical failures) due to his profession limiting strictly judged appropriate for the wear risk factor and the patient’s
his availability to attend dental treatments. His parafunc- expectations; only the mandibular anterior teeth were con-
tional habits and spontaneous closure position with anter- sidered suitable for direct restoration because such an op-
ior edge to edge triggered two types of attrition lesions; the tion has proven its efficacy, even in case of stronger parafunc-
first and most severe ones were concentrated in his anterior tional forces. In this area, forces are mainly of compressive
teeth as a result of both sleep bruxism and awake bruxism nature, leading only to moderate and progressive wear, with
and involved not only the anterior teeth but also lower oc- rare mechanical failures such as chipping or fractures.
clusal surfaces due to clenching habits. Some cracks on the
mandibular second molars are present, confirming the diag-
nosis. Note that the patient presented a dental Class I but
skeletal Class III.
Chapter_6.indd 491 13.04.23 14:31
492
Due to the chosen indirect restoration as the main restorative solution, a “simplified” wax-up was prepared to confirm the new VDO and
smile configuration (tooth display, forms, and smile line). From a functional standpoint, it shows a clear improvement of anterior occlusal
relationship; an adequate overjet and overbite should actually contribute to a more stable occlusal position. Likewise, this step is man-
datory to assess precisely the vertical space to be created for the future mandibular posterior restoration and grant an optimal balance
between minimal restoration thickness and tissue conservation. This wax-up also demonstrates that proper posterior and anterior occlu-
sal relationships can be established, contributing to better occlusal stability. The occlusal positioning can be fine-tuned during this step
and transferred either directly to the new restorations or to the temporary solution if testing is needed (occlusal splint or temporaries).
Chapter_6.indd 492 13.04.23 14:31

493
Chapter_6.indd 493 13.04.23 14:31
494
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495
Treatment of mandibular left posterior teeth (above): A mesio-occluso-distal crack is clearly visible on tooth no. 37; such defects suggest
the use of a stiff restorative material to oppose diverging occlusal forces and prevent further extension of such defect; a more flexible re-
storative material like composite (even CAD/CAM blocks) isn’t ideal for a biomechanically fragilized tooth. After removal of aged, Class II
composite on the first molar, highly conservative preparation of occlusal (full sextant) and facial surfaces (nos. 34 to 36) were performed;
to this purpose, occlusal anatomical details were smoothed and subtle margins defined with a small, fine diamond conical bur. Finally,
the limited dentin surfaces exposed by wear were sealed (IDS) with the usual three-step, filled etch-and-rinse adhesive (OptiBond FL).
Treatment of mandibular right posterior teeth (left page): This image series illustrates the use of rubber dam to allow optimal cleanness
and dryness of the cementation surfaces to grant optimal adhesive interface quality and stability. An additional clamp (eg, Ivory no. 212)
is often necessary to expose cervical margins.
Both sets of images demonstrate how conservative, indirect protocols can be when applied within a modern, comprehensive treatment
approach.
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496
After building up the new VDO and stabilizing posterior occlusion, mandibular anterior incisors could be restored at the length defined
by the wax-up, following the protocols described in chapter 4.4 using the lingual flowable composite shell technique; then, restorative
dentin and enamel masses served to complete the direct restorations. The lower right image shows the high level of esthetic integration
that can be attained with modern composite systems (here, Inspiro system, Edelweiss DR).
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497
Chapter_6.indd 497 13.04.23 14:31
498
After completion of mandibular anterior (e.max TM, Ivoclar). Although slightly “lim-
restorations, anatomical and functional iting” the esthetic outcome, it has the ad-
determinants were in place, following the vantage of superior mechanical strength
pretreatment wax-up configuration. To due to the limited restorations thickness.
grant the expected mechanical strength, Lower right images show the bis-acryl tem-
it was planned to place 360-degree mono- poraries (Protemp A2, 3M).
lithic ceramic, stained and glazed veneers
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499
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500
Final laboratory work and postoperative status
Chapter_6.indd 500 13.04.23 14:31

501
The posttreatment views show more harmonious occlusal and

functional schemes as well as the satisfactory integration of mixed
composite and ceramic restorations. This new “hybrid” treatment
method makes it possible to combine functional, restorative, and
tissue conservation objectives.
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502
Chapter_6.indd 502 13.04.23 14:31

1-year follow-up control, showing the absence of any mechani-

cal complication. Patient also reported comfortable function and
has no complaint with the maintenance of preventive measures
(nightguard).
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504
Chapter_6.indd 504 13.04.23 14:31

The 4-year follow-up confirms the satisfactory behavior of this hy-

brid rehabilitation, due in part to the patient’s good compliance
with the nightguard. Note the excellent behavior of lower compos-
ite and upper cuspid buildups. This again confirms the value of
interceptive protocols.
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506
CASE SUMMARY

Bulimia pathology protective vs conservative strategy
a illa ante i
Indirect monolithic lithium-disilicate bonded restorations
UP (360-degree veneers)
a illa te i
Direct composite buildups to compensate for VDO increase
and restore appearance and length
andi ula ante i

Lithium-disilicate overlays and “tabletop” veneers to restore
LP
worn surfaces, arrest extension of existing cracks, and
increase VDO while aligning buccal surfaces
andi ula te i
LF Few direct composite additions to harmonize both arches
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507
Full-Mouth Indirect Rehabilitation

with Four Direct Composite Buildups
Case 4
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508
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509
When this male patient first consulted our clinic for a second opinion at 36 years old, he presented with a severe tooth wear pathology,
likely related to bulimia with contribution of bruxism, although he did not report any vomiting occurrence. We must however keep in
mind that very few persons affected by this illness admit it. The patient returned 10 years later, finally seeking a resolution of his problem,
aiming to preserve his remaining dentition and restore function and esthetics. The main reason for the patient to postpone any treat-
ment following his first consultation was financial, as is unfortunately the case for many people affected by severe tooth wear. Next to
some psychologic considerations, the initial cost and maintenance plus future replacement of complex full-mouth rehabilitations are so
extensive that many patients might simply refuse any intervention. This underlines once again the importance of early diagnosis, appli-
cation of preventive measures, and rapid treatment using interceptive strategies.
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510
Chapter_6.indd 510 13.04.23 14:31

The panoramic radiograph below shows the overall impact of bulimia, bruxism, and high carious risk factors following nearly 10 years of 511
emergency-driven strategy without any preventive or interceptive measures.
The initial therapy involved the extraction of three third molars (teeth nos. 18, 38, and 48), the mandibular left second molar (due to
furcation decay linked to unsuccessful treatment of the endodontic abscess), and the maxillary and mandibular right first molars. Some
conservative crown lengthening was also performed in quadrants 1, 3, and 4. Following a period of 4 months, implants could be placed
for the replacement of the right first molars (Wide Neck Tissue Level implants, Straumann).
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512
Esthetic treatment planning
FML
OP
Due to the esthetic impact of the extent of tooth wear, a first diagnostic phase was performed chair-
side with the patient to collect some basic information about the expected treatment outcome; this
can also serve as motivational tool if needed at the very beginning of the treatment. To this purpose,
a digital template was used; its use is extremely simple with either PowerPoint or Keynote standard
imaging software. These templates developed by the author exist in four different configurations and
allow each tooth to be separately manipulated to any shade reproduction and can even be made
translucent when needed to show the patient the part of tooth structure to be replaced. This 2D imag-
ing approach has a huge advantage over the 3D approach, which is a time-consuming process and in
principle not for chairside use. The configuration used here is the balanced one.
FML, facial midline; BHP, bipupillary line; OP, occlusal plane ; HP, horizontal plane.
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513
FML
Chapter_6.indd 513 13.04.23 14:31
514
Triangular
Usually, half of the template is used to limit the extent of the

work. Each tooth can be resized and tilted, and tooth forms can
be modified; for instance, to adapt to the gingival profile, use the
“point modifier” option from the dropdown menu in both afore-
mentioned software.
Oval
Squarish
Balanced
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6
515.2
The first wax-up was done according to the digital mock-up design; the patient did however suggest the incisors to be slightly rounder,
although the initial tooth configuration was conceptually the most appropriate to fit the patient’s facial morphotype.
Chapter_6.indd 515 13.04.23 14:31
516
Both upper images show the initial mock-up configuration and its smile integration. The lower images show the modified wax-up as seen
on the right page with a 1 mm increase in length for both central incisors as well as smoothed edges; although pleasing on the model,
the patient and dental team agreed facial integration was not ideal, and it was decided to make final restorations following a hybrid
composition, between wax-ups 1 and 2 (see further pages). Note that a moderate crown lengthening was also performed before this step
to level up the gingival profile.
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6
517.2
Chapter_6.indd 517 13.04.23 14:31
518
Full-arch preparation followed mainly a protective ap-

proach, that is, extending restorations until gingival
level to prevent erosion progression due to uncertain
pathology control in the forthcoming years.
All composite bases were made according to the

concepts described in part 1 of this chapter, namely
IDS, CDO, and CMR, following to the specific anatomi-
cal features of each abutment. On the right page, the
placement of composite proximally to relocate the
distal margins of the maxillary right premolar (CMR)
is shown. All luting procedures were performed under
rubber dam.
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519
Chapter_6.indd 519 13.04.23 14:31
520
The use of composite as a buildup material to retore esthetics and function of mandibular incisors proved highly successful, including
in moderate to severe wear cases. Then, the “typical protocol” (see chapter 4.4) was used again for this patient; teeth were sandblasted
before applying the adhesive and three-step sequential composite layering (1. lingual enamel shell with flowable enamel mass, 2. dentin
buildup with restorative mass, followed by 3. facial enamel layer; Inspiro system, Edelweiss DR).
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521
A slight amount of blue opalescent effect shade was applied over dentin to enhance opalescence effect in the proximal areas. Note that
the enamel extended further than the worn facets; this configuration was needed to meet functional demands in a severe bruxism con-
figuration and also to contribute to assumed anterior guidance, following the significant increase in VDO.
Final result shown on page 524.
Chapter_6.indd 521 13.04.23 14:31
522
All posterior restorations were made of pressed monolithic lithium-disilicate (e.max A2MT, Ivoclar Vivadent), stained and glazed. An etch-
able material is advantageous in such overall configuration with composite bases underneath each restoration (apart from implants),
providing a biomechanical continuum with fragilized remaining coronoradicular structures. Note that the maxillary left molar did not
receive an indirect restoration, as it had no antagonist; it was restored with a direct composite restoration.
Chapter_6.indd 522 13.04.23 14:31

523
Chapter_6.indd 523 13.04.23 14:31
524
Due to the severe bruxism, anterior restorations were made of the same pressed monolithic lithium-disilicate material. Although it
somewhat limits the esthetic outcome, the experience and ability of the technician allows some pleasing results to be achieved without
compromising on the “360-degree veneering” approach used to restore volume and function of the maxillary anterior teeth. Right page
images depict the amount of tissue that had to be replaced with ceramics; it emphasized once again the importance of applying earlier
preventive and interceptive strategies.
6.2 524 Indirect Protocols
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525
Chapter_6.indd 525 13.04.23 14:31
526
Chapter_6.indd 526 13.04.23 14:31

527
Postoperative status showing a satisfactory end result, following

a long, rather complex initial therapy and surgical and restora-
tive phases. Note that the teeth appear slightly shorter than ideal
due to the Class II occlusion, which has restricted the maximal
VDO increase; nevertheless, treatment objectives were fulfilled
with awareness of the limitations set by the late onset of the
rehabilitation.
The direct composite partial veneers on the mandibular incisors

integrated well with neighboring all-ceramic restorations; this
shows that modern composite systems allow such hybrid restora-
tive strategy to be successfully carried out.
A nightguard was provided to the patient immediately after treat-

ment completion; as in all wear cases, preventive measures are
implemented with any other reconstruction strategy.
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528
Chapter_6.indd 528 13.04.23 14:31

529
The final intraoral radiographs demonstrate the extent of tooth structure that had to be
reconstructed. Unfortunately, excessive tooth wear can finally impact vitality status and
consequently tooth biomechanics as well. Such treatments confirm how challenging the
lack of control of “tooth wear” risk factors can be for the patient’s future dental health.
Note that a few teeth (mandibular left premolars) received titanium posts due the absence
of a ferrule effect on more than 50% of the tooth circumference. Authors have noticed a
significant reduction of failures such as recurrent decay and core loosening in severely
compromised endodontically treated single-rooted teeth. The concept is based on the
fact that composite “relative” softness is critical; a bonded titanium post (using silicoat-
ing and adhesive cementation) will provide a stiffening of the cervical core/restoration-
tooth interface, allegedly a mandatory factor to preserve tooth-restoration integrity on
a medium-to-long-term perspective. This concept of course relies on optimal adhesive
procedures. In general, posts are to be avoided, and the concept of “no post, no core”
is followed. Authors do not otherwise recommend the use of fiber posts, the insufficient
stiffness of which largely questions their indication and benefits.
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530
6.3
CHAPTER
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Luting Procedures
Chapter_6.indd 531
lp Indirect Techniques 6
13.04.23 14:31
532
Clinical Options and Protocols
The luting of an indirect or CAD/CAM restoration is another ceramics) and a composite cement (or flowable composite),
crucial step, as it can impact both the strength and longevity the use of a highly filled restorative material is preferred to
of the restored tooth and the restoration itself. The following reduce the wear defect that forms over time along occlusal
aspects shall be considered to select the ideal luting material margins. For limited occlusal margin extent or overlays, an
and technique: LVC can then be used, although the removal of excesses is
Restorative material and restoration thickness: The stron- more delicate and even time consuming.
ger the material, the more likely a light-curing restorative Substrate type: The substrate dictates the adhesive pro-
composite (RC) will be used instead of an adhesive cement, cedures to be applied before cementation. It may include a
even for thin restorations following the concept of “con- light sandblasting of the IDS layer and enamel, the etching of
trolled adhesive cementation.” The use of a low-viscosity enamel or treatment of underlying restoration (etching and/
composite (LVC) for luting is limited only to ultra-thin com- or priming), and finally the placement of a multifunctional
posite restorations (such as on the right page image), mainly adhesive, left uncured before restoration insertion (see chap-
in the absence of occlusal margins (ie, overlays). ter 2.2 and below for further details).
Cavity design: Owing to the differential wear resistance Both restoration configurations below usually favor the use
between an indirect or CAD/CAM restoration (composite or of an RC for cementation due to inherent restoration strength.
Partial occlusal restoration (Composite inlay (Miris2, Colt ne/Whaledent)) Monolithic lithium-disilicate overlay (e.max, Ivoclar )
Chapter_6.indd 532 13.04.23 14:31

533
Controlled adhesive cementation and composite viscos- thickness, especially when applying the IDS/CDO protocols
ity: The rationale is to benefit from the unlimited working time that provide more regular restoration forms and thickness;
of the luting material and avoid the risk of composite excesses actually, the deepest areas and undercuts are being filled up
entering concavities and in general all areas difficult to access with composite before impression. The overall use of mere
for their removal. It was found that the hardening of mere light-curing composite for cementation of indirect or CAD/
light-curing materials isn’t problematic with usual restoration CAM restorations is definitely considered the gold standard.
1. Dietschi D, Spreafico R. Current clinical concepts for adhesive 3. Rocca GT, Rizcalla N, Krejci I, Dietschi D. Evidence-based con-
cementation of tooth-colored posterior restorations. Pract cepts and procedures for bonded inlays and onlays. Part II.
Periodontics Aesthet Dent 1998;10:47–54. Guidelines for cavity preparation and restoration fabrication.
2. Dietschi D, Spreafico R. Evidence-based concepts and proced- Int J Esthet Dent 2015;10:392–413.
ures for bonded inlays and onlays. Part I. Historical perspec- 4. Dietschi D, Spreafico R. Evidence-based concepts and pro-
tives and clinical rationale for a biosubstitutive approach. Int J cedures for bonded inlays and onlays. Part III. A case series
Esthet Dent 2015;10:210–227. with long-term clinical results and follow-up. Int J Esthet Dent
2019;14:118–133.
Composite overlays (Miris2, Colt ne/Whaledent) Indirect Techniques 6

Chapter_6.indd 533 13.04.23 14:31
534
Selection of Luting Material
Proper selection of the composite material used for cemen- In these cases, light-curing is mandated when using dual-
tation is important to ease this instrumental step. The ma- curing composite cements. Last but not least, resin-modified
terial viscosity type (high-viscosity restorative material or glass-ionomer cements are no longer recommended for par-
low-viscosity composite cement/flowable composite) is tial indirect restorations due to their lower chemical stability
chosen, as previously mentioned, according to the restor- and physicochemical properties.
ation thickness and design; then, next to its consistency, the The most common filler technologies used for the ad-
filler technology has to be properly selected to avoid difficult hesive cementation of partial restorations are either con-
restoration seating or increased cement layer. ventional microhybrids (MH; eg, Tetric, Ivoclar Vivadent) or
Together with the adhesive interfaces, the quality of the homogenous nanohybrids (HNH; eg, Inspiro, Edelweiss DR);
cement plays various central roles such as isolating the these two materials are largely preferred to inhomogenous
pulpo-dentinal complex from external strains and bacterial nanohybrids (NH; eg, Tetric EvoCeram, Ivoclar Vivadent),
leakage and being a mechanical bridge between a usually which contain clusters or prepolymerized particles whose
fragilized tooth structure and a protective/reinforcing res- size (some above 50 m) preclude optimal restoration seat-
toration. Then, physicomechanical stability and wear resis- ing. As some brands of microhybrids or homogenous nano-
tance are key factors for the long-term stability of the tooth- hybrids exhibit a higher viscosity, they require preheating
restoration interface; using a highly filled composite has been and sonic/ultrasonic activation to facilitate full restoration
proven to be crucial to meet the aforementioned objectives. seating (see next pages) .
In addition, when no restriction to light penetration is
granted (use of semi-translucent resin composites or ceram- HNH: Homogenous nanohybrid technology
ics), light-curing provides superior conversion rate (polymer- MH: Microhybrid technology
ization extent) as compared to chemical activation alone. INH: Inhomogenous hybrid technology
5000 4000 4000
Chapter_6.indd 534 13.04.23 14:31

535
inlay
onlay RC
overlay
LVC
The use of RC or LVC depends on cavity design, restoration thickness, and material selection. Restorations with occlusal margins and
enough thickness as well as monolithic ceramic restorations are preferably cemented with a restorative material (RC), while an LVC (com-
posite cement or flowable composite) can be also used for overlays or thin restorations made of composite (to avoid fracture during
luting procedure).
Chapter_6.indd 535 13.04.23 14:31
536
Preparation of dental surfaces for adhesion:

• Rubber dam placement
• Cleaning with soft air-abrasion, air-abrasion, or cleaning paste (eg, pumice)
• Etching of enamel (30 seconds; NB: dentin already treated with
IDS/CDO)
 • Adhesive application over entire preparation (no light-curing)

• Adhesive placement inside restoration (no light-curing)
Placement of luting composite:

• RC for all restorations but thin composite overlays
• Use of small-particle material recommended (homogenous nanohybrid or
microhybrid)

• Heating of restorative material advised (45 C to 55 C)
• Use of achromatic enamel or transparent shades usually preferred
Restoration insertion:
• First manual pressure for initial seating
• Ultrasonic or sonic assistance for luting with restorative composite
(cementation tip, EMS or Acteon)

• Only manual pressure for LVC
• Excesses removal with probe and floss
Light-curing composite cement:

• 40 seconds per restoration surface usually recommended (more if rather opaque material
is used)
• NB: Dual-curing cements are not recommended due to limited working time (risk of

leaving composite excesses in difficult proximal areas and concavities)
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537
3 to 5 40s
Chapter_6.indd 537 13.04.23 14:32
538
Indirect Techniques: Key Points to Master the Protocol
1. The use of indirect techniques must be considered tooth-by-tooth to meet individual biomechanical
demands or sector-by-sector, depending on tooth wear severity and anatomical-functional needs.
2. Convenience cavity features such as finishing lines and specific geometry should be limited as much as
possible to assume minimal invasiveness.
3. Specific procedures apply to teeth receiving indirect restorations with the aim to limit preparation intru-
siveness and enhance adhesive interface quality and stability. This includes IDS, CDO, and CMR.
4. Preferred occlusal position depends on the rehabilitation objectives; CR is not necessarily favored over
other, more anterior positions (eg, MIR).
5. Other basic principles such as increase in VDO and maintenance of anterior guidance are also imple-
mented in partial and indirect rehabilitations.
Surface treatment for composite ceramic restorations Luting of indirect posterior restorations
Chapter_6.indd 538 13.04.23 14:32

1. Aldryhim H, El-Mowafy O, McDermott P, Prakki A. Hardness of 7. Jang Y, Ferracane JL, Pfeifer CS, Park JW, Shin Y, Roh BD. Ef-
resin cements polymerized through glass-ceramic veneers. fect of insufficient light exposure on polymerization kinetics
Dent J (Basel) 2021;9:92. of conventional and self-adhesive dual-cure resin cements.
2. Cho SH, Lopez A, Berzins DW, Prasad S, Ahn KW. Effect of dif- Oper Dent 2017;42:E1–E9.
ferent thicknesses of pressable ceramic veneers on polymer- 8. Kesrak P, Leevailoj C. Surface hardness of resin cement
ization of light-cured and dual-cured resin cements. J Con- polymerized under different ceramic materials. Int J Dent.
temp Dent Pract 2015;16:347–352. 2012;2012:317509.
3. De Angelis F, Vadini M, Capogreco M, D’Arcangelo C, D’Am- 9. Kr mer N, Lohbauer U, Frankenberger R. Adhesive luting of
ario M. Effect of light-sources and thicknesses of composite indirect restorations. Am J Dent 2000;13(spec no):60D–76D.
onlays on micro-hardness of luting composites. Materials 10. Li Q, Lin HL, heng M, Ozcan M, Yu H. Minimum radiant ex-
2021;14:6849. posure and irradiance for triggering adequate polymeriza-
4. De Souza G, Braga RR, Cesar PF, Lopes GC. Correlation be- tion of a photo-polymerized resin cement. Materials (Basel)
tween clinical performance and degree of conversion of resin 2021;14:2341.
cements: A literature review. J Appl Oral Sci 2015;23:358–368. 11. Park SH, Kim SS, Cho YS, Lee CK, Noh BD. Curing units’ ability
5. Dietschi D, Marret N, Krejci I. Comparative efficiency of plasma to cure restorative composites and dual-cured composite ce-
and halogen light sources on composite micro-hardness in ments under composite overlay. Oper Dent 2004;29:627–635
different curing conditions. Dent Mater 2003;19:493–500. 12. Tango RN, Sinhoreti MA, Correr AB, Correr-Sobrinho L, Hen-
6. Gregor L, Bouillaguet S, Onisor I, Ardu S, Krejci I, Rocca GT. riques GE. Effect of light-curing method and cement activa-
Microhardness of light- and dual-polymerizable luting resins tion mode on resin cement knoop hardness. J Prosthodont
polymerized through 7.5-mm-thick endocrowns. J Prosthet 2007;16:480–484
Dent 2014;112:942–948.
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540
7
CHAPTER
7
Chapter_7.indd 540 11.04.23 16:48
CAD/CAM Techniques 541
Chapter_7.indd 541
cct 7
CAD/CAM Techniques
11.04.23 16:48
542
CAD/CAM Restorations
CAD/CAM technologies for the fabrication of dental res- In tooth wear treatment, data processing will mostly
torations have rapidly spread worldwide due to obvious happen at the laboratory, although some CAD/CAM expert
advantages and also simplification of the fabrication pro- clinicians contribute to the treatment planning phase by,
cess in some specific indications. CAD/CAM workflows turn for instance, defining the new smile line or even basic occlu-
around three steps, namely: (1) data acquisition, (2) data so-functional sketch and VDO change. Among many other
processing, and (3) manufacturing. The market is propos- advantages, the IoS software provides tools such as measure-
ing more and more open systems, a characteristic that al- ment of restoration thickness to ensure that minimal or regu-
lows for more flexible workflows while choosing the most lar thickness was created (taking of course into consideration
appropriate processes, materials, and fabrication tech- a likely VDO increase). For crowns and multiple preparations,
niques. Moreover, the continuous enhancement of com- parallelism can also be checked and correction performed
puting power has resulted in major advances in all of these immediately. Then, a new scan of the corrected tooth or zone
areas. can be done in a rapid and simple way without having to redo
The diffusion in dentistry of intraoral scanners (IoS) for the whole impression as with an analog approach.
the acquisition of digital impressions is steadily increas- To date, the most commonly used manufacturing meth-
ing. This phenomenon is primarily due to the multiple ad- ods in digital dentistry are subtractive, which have attained
vantages that this technology offers. For instance, IoS has a high level of sophistication. The main advantages of this
the following advantages: (a) generally faster and more methods result in rather short time to mill structures (as
comfortable impressions for patients; (b) digital impres- compared to analog fabrication methods), the production
sion are easily storable and sharable; and (c) in case of of precise restorations and the use of industrially prefabri-
defect, the impression does not need to be retaken com- cated monolithic blocks having fewer internal defects than
pletely but a simple deletion to the zone to be rescanned handmade restorations; the absence of such defects provide
is possible. superior strength.
7 CAD/CAM Techniques
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CAD/CAM Workflow 543
Despite all these advantages, subtractive processes are not withstand physiologic stresses, but in fact, they are less ef-
free of limitations: ficient than natural tissues at containing damage when it
1. Raw material waste and tools aging; the material milled occurs because of their homogenous internal microstruc-
from blocks is difficult to recycle and is often considered ture (isotropic). Such material structure actually does not
as lost. Moreover, milling tools wear rapidly and thus need necessarily equal and replicate toughening mechanisms
to be replaced frequently. found in natural tissues (anisotropic); as a result, partial
2. Milling procedures still require manual finishing, which is or bulk fractures remain one of the most common cause
inevitably time consuming. In fact, after manufacturing, of clinical failures in all kinds of metal-free restorations, in-
the raw surfaces of restorations need to be polished to re- cluding CAD/CAM materials.
move the roughness left by the burs. This factor should be
seen as critical, owing to the microscopic surface cracks In the light of these limitations and considerations, it seems
triggering restoration “vulnerability.” Material surface flaws opportune to think about future alternatives. Additive man-
are where more extensive cracks and failures may develop. ufacturing (AM) or three-dimensional (3D) printing are pro-
3. The monolithic shade of milled restorations may lead to cesses that enable production of three-dimensional objects
suboptimal esthetic results without additional color mod- from digital data using a layer-by-layer deposition of mate-
ification. Improved esthetic outcomes will then require rial. 3D printers are currently employed to fabricate a wide
either surface staining or “classical” porcelain veneering. array of dental appliances such as occlusal splints, surgical
Such post-milling processes are not only time consum- guides, diagnostic models, orthodontic set-ups and provi-
ing but can also produce further structural defects during sional restorations. However, the use of 3D printing doesn’t
manual procedures. allow yet the manufacturing of definitive, high-strength
4. Modern CAD/CAM ceramic and composite materials have restorations.
high mechanical properties, theoretically sufficient to
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Overall clinical approach and workflow
Based on the “selective treatment” rationale, the complex- When chosing CAD/CAM for the occlusal restorations,
ity, invasiveness, and treatment costs should be carefully preexisting defective class I / II cavities can be restored si-
weighed, including the likely maintenance interventions multanesously (A) or prior to the rehabilitation (B), aiming
and further, unavoidable restoration replacements. By first to a new VDO and occlusion. The simultaneous approach
analyzing the risk factors for coma; then the wear extent, pa- is preferred when treating small restorations (A); with larger
tient’s age, and expected compliance for coma; and finally cavities, dentin build-up will be assumed by the compos-
the patient’s financial means, the best treatment option can ite restorations previously made (B); this concept allows for
be selected. This approach implies not only to adapt and avoiding the placement of temporaries. As an alternative, a
individualize the restorative technique and material to each hard mouthguard relined with temporary resin can serve as
patient but also to each tooth based on its biomechanical temporaries and protection (see case 1), because thin resin
status. This novel philosophy in managing tooth wear treat- temporaries are unfortunately prone to frequent decemen-
ments brings us to consider CAD/CAM restorations chiefly tation or breakage.
for moderate to severe tooth wear extent, particularly when The CAD/CAM approach for full occlusal rehabilitation is
deteriorated occlusal, anatomical, and functional determi- preferably done in two steps (similar to indirect approach)
nants suggest augmenting “significantly” the VDO and as rather than performed chairside. The later option is consid-
well more extensive occlusal and anatomical changes. ered less practical due to the additional time needed for the
In regard to the ceramic option, pressed lithium-disilicate entire CAD/CAM process; if choosing the ceramics option, a
restorations are preferred to their CAD/CAM counterpart due chairside approach won’t be possible.
to superior mechanical properties; this is an important fea- The preparation, surface treatments and luting proce-
ture for thin occlusal restorations eventually. In this case, the dures are similar to those described in chapter 6 (“Indirect
restoration design can be CAD generated and then wax rep- Restorations”).
licas machined with a CAM unit before pressing restorations.
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545
A Small decayed class I/II restorations B Medium-to-large-sized decayed Class I/II restorations
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546
CASE SUMMARY
Moderate to severe generalized tooth wear due to
combined erosion and attrition.
UF Patient requires retreatment of posterior teeth restored
15 years before with direct composite, together with
mandibular ceramic veneers; maxillary veneers were placed
22 years before.
Patient has worn a nightguard regularly since the first
UP treatment in 1997; however, erosion and awake bruxism did
not allow prevention of tooth wear progression in posterior
teeth.
a illa and andi ula ante i

No change; only preventive measure with nightguard.
Direct palatal composite restorations to adapt to planned
VDO change.
LP
Direct composite restorations as base, including immediate
dentin sealing (IDS) and cavity design optimization (CDO)
procedures.
LF
Overlays on maxillary first molars and mandibular second
molars.
Veneerlays on maxillary premolars and mandibular first
molars and premolars in all teeth with marked wear.
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Partial Rehabilitation with CAD/CAM

Case 1
7
CAD/CAM Techniques
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This 50-year-old patient was monitored over a 23-year period, following initial ve-
neering treatment for esthetic and tooth wear motives. Initial risk factors were found
to be erosion and attrition, however without clear view on their time-related predom-
inance. The treatment developed in steps, first due to patient’s unavailability and
then the progressive worsening of attrition.
Over this long-term observation period, numerous repairs were needed to maintain
occlusal composite wear and chipping. Despite a good compliancee with nightguard
prevention, awake bruxism led to proposing replacement of all posterior restor-
ations with a stronger restorative material. No replacement of anterior veneers was
considered at this stage; adaptation to the planned, slight VDO increase will be per-
formed on the cervicopalatal surfaces of maxillary anterior teeth.
The initial treatment and 23-year observation period is presented in chapter 8.3.
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551
Occlusal surfaces have to be prepared ac-

cording to the principles described in chap-
ter 6.1. The first step consists of completely
removing aged restorative materials and
decayed tissue if needed; in this particular
case, restorations have been in place for
more than 15 years, and it was considered
appropriate to remove them all. No attempt
was made to create a defined cavity geome-
try during this initial step. Then, the IDS layer
was placed (preferably using 3-step etch-
and-rinse or 2-step self-etch adhesives),
followed by the application of composite
(flowable or restorative, depending on each
case specific needs); here, flowable mater-
ial was used to level up all occlusal surfaces
and thicken the protective layer wherever
necessary, while the proximal cavities were
filled up with restorative material (cavity de-
sign optimization). Proximal contacts were
established at this stage to facilitate further
steps. Additional preparations to allow
proper insertion path of future restorations
was performed as the last step prior to op-
tical impression. This preparation approach
facilitates luting procedures and also pro-
tects dentin surfaces throughout the pro-
visional phase and eliminates the risk for
thermal or physical sensitivity.
The same preparation steps were performed

on the other side during the same, single
session. In fact, when altering the VDO, both
sides of each arch have to be treated during
a single session or alternatively over two
sessions scheduled on the same day.
7
CAD/CAM Techniques
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552
As thin temporaries are difficult to stabilize in patients with parafunctions, a simple yet reliable solution for posterior restorations is to use
a hard tray made from the wax-up duplicate (or from the initial cast with some slight elevation where composite has to be applied (IDS/
CDO); then, the tray is relined with a resin temporary material (eg, Protemp, 3M). This eventually can serve as a first adaptation test for
the patient until he will receive final restorations at the new VDO. No hypersensitivity to mechanical and thermal strains normally occur
because all dentin surfaces are efficiently protected by the IDS/CDO layers.
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553
Raw optical impressions were first digitally

mounted according to the initial interarch
recording, then VDO was augmented to
create additional space as needed for the
fabrication of restorations. A minimum of
1 to 1.5 mm was considered for functional
areas. In order to facilitate trial and cemen-
tation of the restorations, 3D-printed mod-
els were produced such as shown in the
lower image series.
The “natural anatomy” design was selected

from the CEREC inLab software (Dentsply
Sirona). Composite CAD/CAM blocks (CER-
ASMART 270, A1 HT, GC) were selected as per
the patient’s request. He felt comfortable at
all times with the direct restorations and did
not wish to experience any other material
for posterior function due to his former, slow
adaptation to anterior ceramic veneers.
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Left page: The digital model section shows the differential thickness of restorations (from second molar to premolars), which is minimal
at the second molar level due to the primary rotation of the condyle following VDO increase (see detailed explanation in chapter 3). For
this reason, both maxillary and mandibular molars are not systematically restored if the wear level allows one side to be only maintained
through preventive measures.
While the anatomy of current CAD/CAM systems is rather satisfactory, the drawback of using monochromatic composite blocks is mini-
mized by the application of superficial stains; moreover, when used for posterior restorations, this factor has less impact on their esthetic
integration.
Right page: Design of maxillary restorations; both premolars were restored with a “veneerlay” approach, using a very thin layer of restora-
tive material to protect worn facial surfaces and enhance esthetic outcome
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555
7
CAD/CAM Techniques
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556
Maxillary and mandibular restorations are seen on the printed models that serve for controlling their overall anatomy and function and
facilitate handling during trial and cementation steps.
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557
The adhesive luting of restorations is done tooth by tooth, using an additional clamp if needed to facilitate access to cervical margins;
this eases restoration trial and excess removal. A metal strip is also often used to separate teeth during cementation. Depending on the
restoration thickness, either a restorative composite or flowable one will be used. See chapter 6.3 for detailed information on cementation
protocol.
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558
Left page: Cementation phase for the

mandibular right sextant. As shown
in both occlusal and frontal views, all
teeth were perfectly protected by the
IDS/CDO layers during the tempor-
ary phase that prevents pulp irrita-
tion and dentin hypersensitivity. The
separation provided by the proximal
preparation (opening of occlusal em-
brasures) facilitated first the optical
impression and the reading of prep-
aration margins by the CAD system.
Then, it also allows an easy restoration
insertion and luting composite excess
removal.
Right page: The same process was

repeated again in both maxillary
right and left sextants. The use of
no. 9 clamps (or also 212) helped to
displace the rubber dam and allow
proper access to cervical margins
on teeth receiving “veneerlay” res-
torations. Again, luting is performed
tooth by tooth for better control.
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559
7
CAD/CAM Techniques
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560
Views of maxillary restorations at completion of the cementation

phase. Restorations on both sides of the maxilla were placed during
the same session (or in a second session later on the same day) to
prevent the patient staying with unbalanced occlusion and function.
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561
7
CAD/CAM Techniques
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562
Final views of the retreatment of posterior occlusion for this pa-

tient, which took place 15 years following the initial treatment
phase using direct composite. Not withstanding the improved
physical properties of CAD/CAM composite blocks, the treatment
involves many more steps and higher costs. The monochromatic
appearance of such restorative material isn’t a true drawback for
the posterior zones. A nightguard was of course provided to the
patient for optimizing behavior and longevity of restorations.
Note that maxillary second molars did not receive full occlusal
restorations as tooth wear extent allowed it; this provided more
space for mandibular second molar restorations. This approach is
rather common, due the usual lack of space at the second molar
level.
The next case will present a protocol to enhance the appearance

of CAD/CAM composite restorations when used in the smile area.
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7
CAD/CAM Techniques
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CASE SUMMARY
UF
Severe tooth wear due to combined erosion and attrition
Few untreated caries lesions
UP Patient expects an esthetic and functional overall
enhancement

Treatment of the decays and placement of IDS/CDO layers
as only preparation steps on all teeth
Full-contour composite CAD/CAM restorations
LP
Treatment of the decays and placement of IDS/CDO layers
as only preparation steps on all teeth
Full-contour composite CAD/CAM restorations
LF
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565
Full Mouth Rehabilitation with CAD/CAM

Case 2
With contributions by Dr Carl Merheb, University
of Geneva, for part of the case 2 clinical work and
Leonardo Franchini, MDT, Florence, Italy, for case 2
laboratory work.
7
CAD/CAM Techniques
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567
A 46-year-old male patient consulted at the dental clinic at

the University of Geneva because he suffered from severely
worn dentition. His main desire was to improve his esthetic
appearance as his teeth were hardly visible when smiling and
speaking. The patient also complained of biting difficulty due
to his worn anterior teeth. He otherwise reported good gen-
eral health but mentioned a history of a highly acidic diet.
A detailed discussion with the patient about his dietary
habits revealed that his hard tissue loss was due to a com-
bination of abrasion, erosion, and attrition resulting from
bruxism. The intraoral examination confirmed a generalized,
excessive loss of dental hard tissue, particularly in the maxil-
lary anterior teeth.
Clinical examination also confirmed the presence of sev-
eral decays and of a few restorations having to be replaced.
The patient was classified as having a high-risk level of decay
(decayed, missing, and filled teeth DMFT 12). He did not
otherwise show any signs of temporomandibular disorders
and did not complain about orofacial pain. Palpation and
auscultation of the temporomandibular joints (TMJs) and
function did not lead to abnormal findings or pathology.
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568
The patient had been instructed about preventive measures prior to the treatment. Due to
the wear extent and patient’s request for a global esthetic and functional approach, reha-
bilitation of this worn dentition was mandatory. As a first step, all cavities were restored,
and decayed fillings replaced. Undercuts and cavities were filled with a microhybrid com-
posite resin (Tetric EvoCeram, Ivoclar Vivadent), respecting the pretreatment occlusion
and vertical dimension. Exposed dentin was also covered following the principle of IDS
(lower right images, right page). No additional preparation was performed, following a
strict “no-prep” approach.
Then, optical impressions were taken (TRIOS 4, 3Shape) to generate a digital wax-up using
the dedicated CAD/CAM software (TRIOS Design Studio, 3Shape). The VDO was augmented
4 mm at the incisal tip, which created the restorative space to fulfill the esthetic and func-
tional treatment objectives. Images on the right page show the digital project and superim-
position of pretreatment and posttreatment configurations with expected restoration extent.
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569
7
CAD/CAM Techniques
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Once the digital wax-up was validated, a mock-up in the form of a

snap-on was fabricated as a double-milled removable orthodon-
tic appliance made of an elastic resin material (Multistratum Flex-
ible A3, irkonzahn).
The prosthetic project was evaluated, and the usual phonetic,

functional, and esthetic analyses were carried out, as with a trad-
itional diagnostic mock-up. The patient was allowed to wear the
snap-on for about a month to confirm both esthetic and func-
tional changes prior to restoration fabrication.
https://dentalbooks.net/
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572
Following the validation of the digital project, posterior veneer-

lays (overlay-veneer) and full-coverage anterior restorations were
milled using CAD/CAM composite resin blocks (Lava Ultimate, 3M).
The material choice was made with aim to limit treatment costs.
Apart from their lower production cost, another advantage of this
material is its reparability. As parafunctional cases may require
maintenance (repair) following minor complications such as chip-
ping, reintervention is made very simple by using a direct restora-
tive material.
After milling, adaptation was verified and, if necessary, adapted

onto 3D-printed casts. Occlusal characterization was performed
with brown stain (Inspiro Fissure Effect). The anterior restorations
(teeth nos. 13 to 23 and nos. 33 to 43) were enhanced esthetically,
following a technical protocol described by Prof Pascal Magne
(see recommended reading). A cutback of the buccal surface of
the anterior restoration was performed prior to manual veneering
using a composite system offering various shades and translucen-
cies (Inspiro Skin White and Azur Effect, Edelweiss DR).
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7
CAD/CAM Techniques
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574
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575
Prior to intraoral luting procedures, restorations were prepared by sandblasting their inner surface with 27 m Al3O2, followed by the
application of silane (Monobond Plus, Ivoclar Vivadent) for 60 seconds. Bonding resin of the selected adhesive system (OptiBond FL)
was applied and thinned out without being polymerized; restorations were then kept away from ambient light until cementation. After
isolation of the operatory field with rubber dam, adhesive procedures were performed on each tooth separately.
The first step of the procedure consisted of protecting the adjacent area and then tooth surface cleaned by light sandblasting using 27 m
Al3O2. Next, enamel was etched with 37% orthophosphoric acid gel for 30 seconds and bonding resin applied and air thinned without
light-curing. Preheated restorative light-curing hybrid composite resin (Tetric EvoCeram, Ivoclar) was spread on the entire surface of the
preparation before restoration insertion; perfect seating was obtained with an ultrasonic plastic tip before 60 seconds of light-curing on
each surface (occlusal, buccal, and palatal). The same procedures were repeated for the anterior restorations.
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576
The restorations were finished and polished and

the occlusion checked. After some minor adjust-
ments, the rehabilitation phase was completed.
Three months after treatment completion, final
documentation was performed. The patient was
also given a protective nightguard.
One of the limitations of CAD/CAM blocks,

whether composite or ceramic, is their inferior
esthetic appearance (compared to traditional
layered ceramic restorations) due to their intrin-
sic monochromaticity. Even though the level
of translucency was satisfactory in the material
chosen for this rehabilitation, that alone might
not have been enough to achieve a natural tooth
appearance in the smile area. This material limi-
tation could however be compensated with a
freehand, simple layering of composite resin with
masses of different shades and translucencies on
the labial surfaces. The esthetic outcome proved
fully satisfactory to the patient, providing a good
cost-quality ratio, taking into consideration the
repairability of the restorations.
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577
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CAD/CAM Techniques
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578
Kinesiographic Recordings
The functional analysis of the rehabilitation was supported As a result of the restored length of anterior teeth, the
by kinesiography before the treatment, during the planning protrusive movement found a new anterior guidance that
phase, and at the end of the restorative phase. Kinesiography had been lost for many years.
is a 3D tracking and reconstruction analysis of jaw movement The marked deviation on the left side present before the
that is both qualitative and quantitative and which expresses treatment completely disappeared after the rehabilitation,
the muscular coordination during mastication. Modifica- most likely due to the augmented proprioceptive sensibility
tion of the VDO automatically results in a variation of den- resulting from the new anterior guidance. In laterotrusion,
tal guidance, which consequently changes the patterns of the dental guidance angle (visible on the frontal plane of the
protrusive and lateral movements. However, on the basis of kinesiographic recording) looked almost flat from the frontal
the absence of pretreatment functional and TMJ pathology, plane before the treatment and presented a symmetric pat-
the kinesiography was used to monitor possible treatment tern between the right and left sides. The canine guidance
effects on the mandibular function scheme, aiming to stay as originally designed with the snap-on was reduced to reinstall
closely as possible to the initial situation following the mini- a group guidance function (situation before the treatment);
mally invasive treatment approach selected. as a result, an immediate modification of the movement pat-
Maximum opening/closing movements did not undergo tern in the horizontal plane was noticed with lateral move-
major modifications, but a late, right deviation present in the ments being more anteriorized and flatter lateral guidance.
initial situation disappeared after the end of the treatment; a The clinical feedback from the patient was that he found the
minor reduction (0.5 cm) of the maximum movement extent flatter lateral guidance configuration more comfortable.
also was observed, likely related to the space occupied by
the restorations.
Recordings with snap-on
Opening movements Lateral movements Protusive movements
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Pre-treatment recordings Post-treatment recordings 579
Opening movements
Lateral movements
7
Protusive movements
CAD/CAM Techniques
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580
1.5 years posttreatment
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581
CAD/CAM Restorations: Key Points to Master the Protocol

1. Preparation involves the same principles applied in indirect restorations (IDS, CDO, CMR).
2. Final/restored tooth position and VDO are determined either intraorally or with the help of software.
3. Select material according to clinical needs, mainly (strength), reparability, and esthetics.
4. For anterior restorations, composite blocks are contraindicated, unless veneering labial surfaces with
esthetic direct composite.
5. For posterior restorations, composite blocks are well indicated in moderate attrition cases while in heavy
clenchers, thicker restorations are needed and lithium disilicate material is better indicated.
6. Cementation procedures are similar to indirect restorations, using a highly filled restorative composite for
normal-thickness restorations ( 1.5 mm) and low-viscosity composite (flowable or cement) for thinner
ones.
7. Nightguard is mandated for patients with severe bruxism, as for other interceptive or restorative protocols.
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583
1. Alghazzawi TF. Advancements in CAD/CAM technology: Options 7. Rocca GT, Bonnafous F, Rizcalla N, Krejci I. A technique to im-
for practical implementation. J Prosthodont Res 2016;60:72–84. prove the esthetic aspects of CAD/CAM composite resin restor-
2. Del Curto F, Saratti CM, Krejci I. CAD/CAM-based chairside re- ations. J Prosthet Dent 2010;104:273–275.
storative technique with composite resin for full-mouth adhe- 8. Saratti CM, Del Curto F, Rocca GT, Krejci I. Vertical dimension
sive rehabilitation of excessively worn dentition. Int J Esthet augmentation with a full digital approach: A multiple chairside
Dent 2018;13:50–64. sessions case report. Int J Comput Dent 2017;20:423–438.
3. Giachetti L, Sarti C, Cinelli F, Russo DS. Accuracy of digital im- 9. Saratti CM, Merheb C, Franchini L, Rocca GT, Krejci I. Full-mouth
pressions in fixed prosthodontics: A systematic review of clin- rehabilitation of a severe tooth wear case: A digital, esthetic
ical studies. Int J Prosthodont 2020;33:192–201. and functional approach. Int J Esthet Dent 2020;15:242–262.
4. Joda T, arone F, Ferrari M. The complete digital workflow in 10. Stanley M, Paz AG, Miguel I, Coachman C. Fully digital workflow,
fixed prosthodontics: A systematic review. BMC Oral Health integrating dental scan, smile design and CAD-CAM: Case re-
2017;17:124. port. BMC Oral Health 2018 Aug 7;18:134.
5. Lee H, Fehmer V, Kwon KR, Burkhardt F, Pae A, Sailer I. Virtual di- 11. Van Noort R. The future of dental devices is digital. Dent Mater
agnostics and guided tooth preparation for the minimally inva- 2012;28:3–12.
sive rehabilitation of a patient with extensive tooth wear: A val- 12. Yuzbasioglu E, Kurt H, Turunc R, Bilir H. Comparison of digital
idation of a digital workflow. J Prosthet Dent 2020;123:20–26. and conventional impression techniques: Evaluation of pa-
6. Magne P, Noninvasive bilaminar CAD/CAM composite resin ve- tients’ perception, treatment comfort, effectiveness and clin-
neers: A semi-(in)direct approach. Int J Esthet Dent. 2017;12: ical outcomes. BMC Oral Health 2014;30:10.
134-154.
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8
CHAPTER
8.
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Longevity and Maintenance 585
Sub-chapters
8.1 Longevity and Follow-up
8.2 Maintenance and Renewing
8.3 Maintenance and Replacement
8.4 Nightguards
8.5 Literature Review and Conclusions

Chapter_8_1.indd 585 11.04.23 16:50
586
8.1
CHAPTER
With contribution by Dr Viviana Coto-Hunziker, Geneva Smile Center (CH)

for the Invisalign treatment of Case 1
8.1
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Longevity and Follow-up 587
l&f Longevity and Maintenance 8
11.04.23 16:50
588
CASE SUMMARY
Generalized, moderate tooth wear in posterior zones and
mandibular anterior teeth due mainly to attrition with likely
contribution of erosion
UF More severe attrition of maxillary anterior incisors due to
edge-to-edge contacts in maximal intercuspation position
(MIP)
An esthetic improvement was also anticipated due
to missing lateral incisors and resulting uneven smile
configuration
UP
andi ula ante i
Alignment and intrusion of incisors with Invisalign to create
space for maxillary teeth restorations
Direct composite buildup of incisal edges and cuspid tips to
improve guidance and reduce overbite
LP a illa and andi ula te i

Replacement of defective Class I and II restorations
Occlusal corrections to fill-up wear lesions and slightly
increase vertical dimension of occlusion (VDO)
LF
a illa ante i
Direct composite restorations to restore proper teeth
dimensions, function, and esthetics
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589
Freehand Composite
Restorations
Case 1
Moderate tooth wear

8-year follow-up

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590
This patient aged 40 years initially consulted for esthetic con- was also considered to fulfill restorative objectives following
cerns due to severe localized wear of his maxillary left incisors a “no-prep” approach. Due to overall moderate wear extent,
due to an edge-to-edge contact in MIP (with possible contri- the potential compliance of the patient with preventive mea-
bution of a previous fracture); the lateral incisor aplasia also sures suggested for the posttreatment phase, and the desire
resulted in an uneven and unesthetic smile configuration. of a simple and cost-effective solution, it was decided to
The patient had no other chief complaint and was often was use direct composite restorations to achieve the aforemen-
unaware of his tooth wear problem. In order to restore smile tioned restorative objectives. Depending on the evolution
balance and improve anterior function, it was decided to re- of risk factors, this first treatment phase can lead to another
align the mandibular anterior teeth to free the edge-to-edge one with use of indirect restorations or on the contrary serve
contact between teeth nos. 21 and 31, reduce overbite, and as a permanent solution with help of maintenance/renew-
create space for the planned restorations. An increase of VDO ing procedures (see chapter 8.2).
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591

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592
The preoperative intraoral status shows failing Class I fillings (poor marginal adaptation) on both maxillary molars and a debonded one
(Class II) on the maxillary left premolar. Tooth wear is considered limited with involvement of a few cusp tips. Mandibular teeth show
moderate tooth wear with slight signs of erosion and wear facets due to attrition. The direct restoration on the mandibular second pre-
molar and the mandibular right molars will be replaced.
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593
The VDO change and realignment of mandibular anterior teeth was decided based on a pretreatment wax-up and setup. In relatively
simple cases, a partial wax-up is usually sufficient to determine the extent of VDO increase and confirm overall treatment strategy.

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594
The setup/wax-up served to plan the Invisalign correction of mandibular anterior teeth position (intrusion and alignment of incisors). While the
restorative space needed to restore maxillary anterior teeth with a “no-prep” approach was partially achieved through a VDO increase follow-
ing restorations of maxillary and mandibular posterior teeth (see next double page), the Invisalign treatment provided the missing volume to
restore maxillary anterior teeth, especially at the level of the left incisor. As the gingival profile of maxillary anterior teeth was judged satisfactory
and also because of financial limitations, the maxilla was not orthodontically treated, although it would have facilitated the obtention of a more
ideal smile configuration.
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595

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596
VDO correction of maxillary posterior sextants with direct composite restorations. Preparation consisted of tooth and restoration surfaces
sandblasting followed by application of a multifunctional adhesive. Aged direct Class I and II were simultaneously replaced (teeth nos.
17, 25, 27 and 35, 37, 46, 47).
Chapter_8_1.indd 596 11.04.23 16:50

597

Chapter_8_1.indd 597 11.04.23 16:50
598
Thanks to the VDO increase and mandibu-

lar anterior teeth alignment, worn edges of
teeth nos. 11 and 21 could be restored to
normal dimensions and canines and pre-
molars reshaped to more closely resemble
lateral incisors and cuspids, respectively.
To this aim, a direct technique was applied
using anatomical matrices (experimental
ones), following a bilaminar layering tech-
nique following the Natural Layering Con-
cept (Asteria, Tokuyama).
Chapter_8_1.indd 598 11.04.23 16:50

599
Chapter_8_1.indd 599 11.04.23 16:50

600
Postoperative
The postoperative status shows more harmonious forms and proportions of anterior teeth, which enhanced smile appearance. Next
to the esthetic benefit of this treatment, the satisfactory outcome results also in an improved function (better anterior guidance and
reduced overbite and leverage stresses on anterior teeth and restorative material) and protection of worn posterior teeth using only a
no-prep approach.
Chapter_8_1.indd 600 11.04.23 16:50

2 years posttreatment 601

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602
The 5-year status shows an overall satisfactory behavior of direct restorations in both the
anterior and posterior zones with no significant wear or marginal or mechanical degrada-
tion of restorations. Shortly after the 5-year evaluation, a fracture of the restoration on the
modified maxillary right cuspid (right page, central image) occurred due to the contact
in lateroprotusion (right page, upper right image); these contacts are difficult to avoid, as
lateral incisors aplasia round the maxillary anterior arch form in addition to the absence
of proper guidance from premolars, despite their anatomical alteration.
Chapter_8_1.indd 602 11.04.23 16:50

603

Chapter_8_1.indd 603 11.04.23 16:50
604
Chapter_8_1.indd 604 11.04.23 16:50

8 years posttreatment—Case analysis 605
The 8-year follow-up of this case shows an overall satisfactory behavior of direct composite restorations in an intermediate tooth wear
case with attrition as the predominant risk factor. With rather good nightguard compliance, the integrity of restorations was preserved,
apart from one minor failure (chipping) on the maxillary left lateral incisor due to the aforementioned arch and dental changes result-
ing from lateral incisor aplasia; the repair of this minor failure was the only restorative intervention needed over the entire observation
period.
e all a e ent f t e t eat ent ad antage /di ad antage and e f ance

• Highly conservative
• Pleasing, stable esthetic outcome
• Simple and effective
• Inexpensive (relative to an indirect or CAD/CAM approach)
• Nearly no complication
• Risk factors well controlled with nightguard
• No overall restorative maintenance needed up to 8 years
• Can be considered as an optimal and successful treatment approach

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606
CASE SUMMARY

UF Generalized, severe erosive tooth wear related to bulimia
nervosa; pathology was however stabilized at the time of
treatment onset
Enhancement of the significant impact of wear on smile
appearance was expected
UP Hypersensitivity to cold and heat
Impaired masticatory function
a illa ante i
Composite shell restorations
andi ula ante i
LP Direct composite buildups to correct anatomy and adjust to

new VDO

Direct composite restorations to correct occlusal anatomy
LF and function and augment VDO to adapt to the new VDO
set for anterior shell restorations
Composite onlay on tooth no. 26
Chapter_8_1.indd 606 11.04.23 16:50

607
Composite Shells and

Direct Composite Restorations
Case 2
Severe tooth wear

10-year follow-up
Clinical work by Dr, Roberto SPREAFICO

Chapter_8_1.indd 607 11.04.23 16:50
608
The patient, a 28-year-old female with a 12-year history of The treatment plan was designed around the reconstruc-
bulimia treated with psychotherapy, had been declared free tion of teeth that were affected by the erosive pathology
of the illness 2 years previously. The patient complained of with composite resin. In the present case, this was to be ap-
esthetic and functional dental problems (sensitivity to heat plied indirectly (composite shell technique) on the maxillary
and cold, pain when chewing). She did not complain of mus- anterior teeth and on a maxillary first molar (tooth no. 26,
cular or temporomandibular articulation pain. The mandible composite onlay). The other teeth were reconstructed with
showed normal mobility with no restrictions or deviations on a direct approach.
opening. Anterior and canine guidance were absent. There
was clear evidence of generalized erosions with a notable
loss of substance, especially on the maxillary anterior teeth
and the mandibular molars. The periodontal condition and
hygiene were good, but some restorations were defective.
The interarch space in the anterior zone was insufficient for
future reconstructions.
Chapter_8_1.indd 608 11.04.23 16:50

609
The sequence of treatment was the following:

1. Root canal retreatment of tooth no. 26 and composite reconstruction with onlay
2. Reconstruction of the maxillary anterior teeth at an increased VDO
3. Reconstruction of the occlusal and labial surfaces of posterior teeth
4. Reconstruction of the incisor borders on the mandibular anterior teeth
Subsequent to the loss of dental structure, an increase in the VDO was necessary in order to create space for future reconstructions. This
increase was defined by a pretreatment diagnostic wax-up. A 2-mm increase on the articulator pin was sufficient to provide good ana-
tomical forms and restoration thickness. On the molars, this increase created a 0.5- to 1-mm space, sufficient for the reconstruction of
posterior teeth and not requiring tooth preparation. The diagnostic wax-up also served to evaluate the esthetic and phonetic outcomes
as well as the overall occlusion needed scheme.

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610
Chapter_8_1.indd 610 11.04.23 16:50

Diagnostic mock-up and shell fabrication 611
Mock-up: A silicone matrix was made

on the wax-up; it was then filled up with
self-curing resin (Protemp, 3M) and applied
over worn teeth to simulate the new smile
configuration.
A transparent silicone matrix was also realized on the diagnostic wax-up (Memosil 2,
Heraeus Kulzer). The model, which reproduced the patient’s pretreatment situation, was
isolated with a latex-based insulator (Rubber Sep, Kerr), then the composite was applied
in the silicone matrix with a thickness of approximately 0.5 mm. A dentin mass was applied
to the palatal surface (Miris S3, Colt ne/Whaledent) and enamel mass (White Regular,
Miris) on the buccal surface.

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612
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613
The silicone guide was then repositioned on the model and the composite light-cured through the transparent silicone and then again
40 seconds after removing the index from the model. The restorations were then adapted to the limits of worn surfaces. Note that teeth
did not need to be prepared for this purpose. Discs were used to trim the shells to properly fit them at the erosion level. The surface
of restorations could thereafter be worked with regular and fine diamonds to complete primary and secondary anatomy. Finally, the
restorations we polished with silicone points and polishing paste. The image below shows the shells ready for insertion. A detailed
description of the shell technique is presented in chapter 5.

Chapter_8_1.indd 613 11.04.23 16:50
614
Prior to cementation, the restorations were tried in to ensure proper fit and positioning.
Before proceeding with cementation, the dentin shade to be used for both internal buildup
and cementation was tested (chroma level) to confirm a suitable color integration. After
rubber dam application, the teeth were cleaned and lightly sandblasted (AL2O3, 25 m)
before application of a three-step “etch-and-rinse” adhesive (OptiBond FL, Kerr). A den-
tin shade with medium chroma (Miris S3) was then used for the restoration buildup and
cementation. A hard silicone index served to control enamel shells positioning. Margins
were finally polished with discs and polishing rubber points to complete the procedure.
Chapter_8_1.indd 614 11.04.23 16:50

615

Chapter_8_1.indd 615 11.04.23 16:50
616
The placement of maxillary anterior shell restorations resulted in an increase of the VDO as planned with the wax-up and articulated
models; this has created space for the restorations of all other wear lesions (maxillary and mandibular posterior teeth and lower incisal
edges). The occlusal surfaces and some of the vestibular surfaces of maxillary posterior teeth had to be protected and reconstructed. For
this case, a direct approach was chosen to constrain treatment costs. The buildup of the maxillary posterior teeth was made simple as
some space had to remain for the treatment of the mandibular antagonists. Due to the limited extent of corrections in maxillary teeth,
cusps could be restored with one single enamel mass and very few increments (Miris White Regular, Colt ne/Whaledent).
Chapter_8_1.indd 616 11.04.23 16:50

617
The mandibular molars, due to the significant loss of tissue, required a multilayering approach. The dentin surface was then lightly
sandblasted before application of the same multicomponent adhesive used in maxillary anterior teeth (OptiBond FL). One or two dentin
increments were first placed (depending on the depth of erosion lesions), followed by another two layers of enamel shade to reconstruct
the occlusal anatomy of mandibular molars. Due to less extensive wear affecting premolars, only one enamel increment was needed to
buildup shortened labial cusps.

Chapter_8_1.indd 617 11.04.23 16:50
618
The occlusion was then carefully adjusted before the patient was dismissed. Occlusal checks were carried out at 2 weeks, 1 month, and
9 months following treatment completion to ensure that a proper functional treatment outcome was achieved and that the new esthetic
and occlusal configurations were fulfilling the patient’s needs. This also allowed to control patient compliance with nightguard preven-
tive measure and to confirm no new erosion lesion would be detected.
The incisal edges of the anterior mandibular teeth were also restored with a direct approach using a simple bilaminar approach (dentin
and enamel increments; Miris system), as described in chapter 4.4.
Chapter_8_1.indd 618 11.04.23 16:50

619
Chapter_8_1.indd 619 11.04.23 16:50

620
The final views show highly satisfactory esthetic, anatomical, and functional outcomes despite a rather simple and cost-effective treat-
ment approach using six shell restorations on the maxillary anterior teeth and direct composite restorations for all other teeth.
Chapter_8_1.indd 620 11.04.23 16:50

Postoperative 621
Following the former “standard of care” to treat severe erosion pathology, this patient would have been proposed a global prosthetic
rehabilitation with overlays and crowns, possibly requesting some root canal treatment. This would have involved a great loss of healthy
dental tissue as well as a very high treatment cost, not only at the time of the first rehabilitation but also during the subsequent lifetime
maintenance period. This is why such an alternative treatment approach merits attention, as it satisfies the same biologic, functional,
and esthetic requirements and seems better adapted to young patients, providing reliable and acceptable medium- to long-term results.
The lateral views show the correct Class I occlusal position following the treatment as well as adequate tooth size. An increase of VDO
was instrumental to allow such a result to be attained. Thanks to the edge-to-edge initial occlusal position, the treatment was facilitated,
as compared to an initial Class I occlusal relationship. In such cases, a significant increase in VDO might result in cusp-to-cusp posterior
contacts (Class II tendency), which precludes an ideal occlusal relationship to be achieved.

Chapter_8_1.indd 621 11.04.23 16:50
622
The posttreatment occlusal views show a complete restoration of The full facial view demonstrates the new, harmonious smile and
erosion lesions and proper functional anatomy. esthetic integration of shell restorations with seemingly better per-
sonal confidence as a result of enhanced biomechanics, function,
and smile appearance. The proper management of dental conse-
quences of severe of anorexia or bulimia nervosa is instrumental
to improve these patients’ lives.
Chapter_8_1.indd 622 11.04.23 16:50

The 5-year follow-up showed an overall satisfactory behavior of both direct and shell composite restorations, with only slight color
change and no primary anatomy deterioration; only some of the secondary anatomical features were lost due to abrasion. No further
signs of erosion were noticed, confirming that the initial risk factor (anorexia) has been alleviated.

Chapter_8_1.indd 623 11.04.23 16:50
624
10-year follow-up
Chapter_8_1.indd 624 11.04.23 16:50

Case analysis 625
The 10-year follow-up revealed slightly more visible surface degradation of the composite, with further loss of secondary anatomy of the
maxillary restorations, labial surfaces. On the contrary, palatal surfaces do not present similar loss of gloss and anatomy, suggesting that
the specific enamel material used for the labial surfaces of shell restorations likely had inferior physico-mechanical properties, as often
found in surface composite masses. Discrete new erosion and/or abrasion lesions are now visible on the occluso-palatal surfaces of max-
illary premolars and molars. In addition, the tips of mandibular canines wore off completely during the observation period, suggesting
minor, secondary functional risk factor (bruxism).

• Highly conservative with full no-prep approach
• Pleasing and acceptable medium- to long-term esthetic outcome
• Cost-effective (relative to an indirect or CAD/CAM approach)
• No complications
• Initial, primary risk factor is resolved and secondary risk factors partially controlled with nightguard
• Can be considered as a very effective treatment approach for an erosion caseus smile and esthetic integration of shell
restorations

Chapter_8_1.indd 625 11.04.23 16:50
8.2
CHAPTER
Chapter_8_1.indd 626 11.04.23 16:50

Maintenance and Renewing
mr https://dentalbooks.net/
11.04.23 16:50
628
CASE SUMMARY

Insufficient oral hygiene
UF Limited tooth wear due to attrition
Excessive overbite due to Class II/2 occlusion
Tooth wear mainly affected maxillary anterior teeth due to
the occlusion type
Need to increase slightly VDO
UP
a illa ante i
Incisal edge buildup and proximal fillings replacement
using a direct approach
a illa te i
Replacement of amalgams together with occlusal
LP corrections
Inlay on maxillary left premolar (tooth no. 25) due to
mesiodistal crack
andi ula ante i

LF Incisal edge buildup and leveling with direct composites
Mandibular posterior:
Direct composites to correct occlusal anatomy and increase
VDO
Chapter_8_1.indd 628 11.04.23 16:50

629
Case 3
Limited tooth wear

11-year follow-up

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630
Chapter_8_1.indd 630 11.04.23 16:51

631
This female patient, aged 42 years, consulted initially for an Note the Class II/2 occlusal relationship, with increased over-
improvement of her unesthetic, irregular smile line and pro- bite. In case of bruxism, this occlusal configuration leads to
gressive shortening of maxillary anterior teeth. She had no predominant anterior tooth wear, as explained in chapter 3.
other dental or functional complaint and was unaware of In absence of significant biologic and functional problems
her ongoing tooth wear problem. The clinical examination or other esthetic concerns, the patient’s expectation was for
revealed no active carious or periodontal pathology and no a simple and noninvasive solution to the aforementioned
temporomandibular disorder (TMD) either. deficiencies.

Chapter_8_1.indd 631 11.04.23 16:51
632
The examination of posterior arches shows a nearly normal anatomy with very
limited wear occlusal surfaces, which can be explained once again by the deep
bite that creates a rapid disocclusion of posterior teeth during lateroprotusive
movements.
Chapter_8_1.indd 632 11.04.23 16:51

633
Due to the limited overall extent of tooth wear, the functional and es-
thetic diagnostic wax-up was limited to the anterior teeth; this however
provides the new smile line configuration and the needed information
regarding VDO augmentation (thickness and localization of corrections
to be done in the anterior areas).

Chapter_8_1.indd 633 11.04.23 16:51
634
Chapter_8_1.indd 634 11.04.23 16:51

635
Apart from the maxillary left premolar

(tooth no. 25) treated with a composite
inlay to strengthen the cracked tooth, all
other posterior teeth were restored with
direct composites restorations (amalgam
replacement, anatomical enhancements
to harmonize occlusal scheme and slightly
increase VDO). Anatomical/occlusal cor-
rections were performed without remov-
ing previous restorations. The procedure
for surface corrections is detailed in the
chapter 2.1 treatment of interfaces and in
this chapter section presenting renewing
procedures.
The Class III maxillary restorations and inci-

sal edge leveling of upper and lower smile
line was performed also with direct com-
posites. A conventional inhomogenous
nanohybrid composite system (Miris 2,
Colt ne/Whaledent) was used for all those
direct and indirect (inlay) restorations,
using either merely enamel masses (small
corrections) or a bilaminar layering ap-
proach (dentin and enamel) for cavities.

Chapter_8_1.indd 635 11.04.23 16:51
636
The posttreatment views demonstrate an enhanced smile line and posterior tooth anatomy as well as reduced overbite, which is also
considered a positive treatment outcome; it lowers the flexural stresses on the incisal restorations that can contribute to restoration ag-
ing and chipping. Despite the nonideal color integration of the porcelain-fused-to-metal (PFM) restoration on the maxillary left first pre-
molar (tooth no. 24), the patient preferred not to replace it. The patient was given a nightguard to control the main identified risk factor.
Chapter_8_1.indd 636 11.04.23 16:51

Postoperative status 637
Chapter_8_1.indd 637 11.04.23 16:51

638
The 4-year follow-up status reveals overall an ideal result with no visible alteration of posterior composite additions. The 4-year, 6-year,
and 7-year anterior views also show excellent stability of incisal edge buildups and form corrections, with neglectable wear.
Chapter_8_1.indd 638 11.04.23 16:51

639
4Y
6Y
7Y
Chapter_8_1.indd 639 11.04.23 16:51
640
Chapter_8_1.indd 640 11.04.23 16:51

At 9 years, the anterior restorations further show excellent esthetic and anatomical stability. The posterior restorations remain satisfactory,
with only slight wear and softening of anatomical details in some teeth.

Chapter_8_1.indd 641 11.04.23 16:51
642
11 years following initial treatment, only minor color changes of incisal buildups (visible on maxillary lateral incisors, teeth nos. 12
and 22) are noticed. The nightguard was controlled at this stage and reveals improper fit; this confirms that the patient stopped wearing
it years ago.
Chapter_8_1.indd 642 11.04.23 16:51

643
The middle image on the left page shows the anterior guidance, which has been instrumental to limit functional stresses on posterior
teeth, next to the protective effect of the nightguard. However, its discontinued use resulted in some composite deterioration
(eg, mandibular right second premolar tooth no. 45 ).

Chapter_8_1.indd 643 11.04.23 16:51
644
Renewing 11 years posttreatment
Chapter_8_1.indd 644 11.04.23 16:51

Case analysis 645
After a successful application of an interceptive/preventive strategy, a partial renewing was considered better than waiting further and
having to proceed with some full restoration replacement (see second diagram at the beginning of this chapter). After renewing man-
dibular posterior teeth, some composite addition was done on the incisal edges of mandibular incisors and canines, as a compensa-
tion of the change in VDO. This strategy follows the concept of minimal invasiveness while having strong biomechanical and financial
advantages.

• Fully conservative
• Harmonious, lasting esthetic outcome
• Simple and cost-effective
• Practically no complications and no maintenance required
• Risk factors well controlled with nightguard (at least until last few years)
• Can be considered an optimal treatment approach

Chapter_8_1.indd 645 11.04.23 16:51
646
CASE SUMMARY

Generalized loss of enamel on occlusal surfaces of
UF maxillary and mandibular posterior teeth with moderate
hypersensitivity to acids and cold
Erosion appears as the main contributing factor
Patient’s chief concern is dark tooth color
UP
a illa ante i
Tooth color improvement with home bleaching
andi ula ante i

Direct incisal composite buildups of incisors
Tooth color improvement with home bleaching
LP
Replacement of Class I and II fillings, treatment of decays,
and direct no-prep composite restorations simultaneously
LF with VDO increase
Direct composite fillings to restore noncarious cervical
lesions in the mandible
Chapter_8_1.indd 646 11.04.23 16:51

647
Freehand
Case 4
Moderate tooth wear
9-year follow-up

Chapter_8_1.indd 647 11.04.23 16:51
648
This 40-year-old female patient consulted chiefly for a tooth shade The vital “home bleaching” was planned after the interceptive
enhancement and prevention of mild dentin hypersensitivity trig- phase to prevent more severe dentin hypersensitivity; the re-
gered by cold and acids. She was not aware of the underlying ero- placement of maxillary PFM crown on tooth no. 25 was logically
sion problem associated with an unbalanced diet that included planned as the last intervention.
high consumption of fruits and acidic drinks. Clinical observation
suggested erosion to be the main wear factor. Neither functional
or occlusal discomfort nor TMD symptoms were reported by the
patient. The extent of tissue loss suggested a conservative ap-
proach, implementing a combination of preventive/interceptive
protocols. The first step involved diet counseling, followed by a
comprehensive functional-occlusal analysis on articulated mod-
els and wax-up to set the new VDO allowing occlusal anatomy cor-
rections. Note that the wear extent is more pronounced in man-
dibular teeth.
Chapter_8_1.indd 648 11.04.23 16:51

649

Chapter_8_1.indd 649 11.04.23 16:51
650
The lower model shows the planned anatomical corrections and of course increase in VDO, which allows the foreseen restorations to be
performed using a no-prep approach. In addition to some smaller occlusal anatomy corrections, some palatal composite additions are
mandated to compensate for the planned VDO change.
Chapter_8_1.indd 650 11.04.23 16:51

651
The small Class I and II decays were treated together with the correction of wear lesions and VDO correction. The wax-up is visually guid-
ing the clinician to restore anatomy and function (for more detailed description of the technique, see chapter 4). Proximal restorations
were done one at the time to obtain tight contacts. When having to restore larger proximo-occlusal lesions, it is recommended to realize
these restorations before anatomical and VDO corrections. A sharp end-sculpting instrument is always used to carve the anatomical
details (eg, CompoSculp DD1/2, Hu-Friedy)

Chapter_8_1.indd 651 11.04.23 16:51
The sextant treatment was completed with application of sur-
face colorants to give restorations a more natural look and better
demonstrate anatomical outcome.
Chapter_8_1.indd 652 11.04.23 16:51

653
The exact same procedures were then repeated in the third sextant, also using a visual transfer of the modified anatomy and VDO. For a
freehand approach, a conventional, analog wax-up makes it easier to picture the occlusal areas to be modified and also to estimate the
thickness of material to be applied.

Chapter_8_1.indd 653 11.04.23 16:51
654
8.2
Chapter_8_1.indd 654 11.04.23 16:51
655
In the maxilla as well, interproximal decays were treated simultaneously to occluso-functional corrections. Metal strips serve to prevent
adhesive or slight increments of composite to penetrate the contacts and bond teeth together. Those simple procedures greatly facilitate
the application of this interceptive protocol.

Chapter_8_1.indd 655 11.04.23 16:51
656
Postinterceptive phase
The postinterceptive phase allowed the clinician to restore and protect worn occlusal and facial surfaces in all posterior teeth through a
fully additive, no-prep protocol using a visual transfer of enhanced occluso-functional pretreatment wax-up using a freehand protocol.
When using composite to restore functional posterior surfaces, a nightguard is provided to the patient; it serves first to assess the occur-
rence of bruxism and then will extend the longevity of restorations, also protecting wear-free surfaces form attrition and abrasion; in case
of erosion, the protective effect of the nightguard is unproven.
Home bleaching was performed after this first treatment phase, because large, exposed dentin surfaces would have likely triggered den-
tin hypersensitivity.
Chapter_8_1.indd 656 11.04.23 16:51

657

Chapter_8_1.indd 657 11.04.23 16:51
658
The 3-year status shows the improved tooth color obtained with
home bleaching. The behavior of direct restorations proved satis-
factory with nearly no anatomical change (material wear) or chip-
ping. Very discrete indentation on a mandibular incisor was noted.
The PFM crown on the maxillary left premolar was replaced with a
monolithic (but facial veneering) zirconia crown.
Chapter_8_1.indd 658 11.04.23 16:51

At 5 years, there is only little change as compared with the 3-year

situation. Very slight signs of material wear or fatigue (surface
roughening) are visible on a few occlusal contacts. The medium-
term clinical status is considered satisfactory with no reinterven-
tion needed.

Chapter_8_1.indd 659 11.04.23 16:51
660
Chapter_8_1.indd 660 11.04.23 16:52

661
The 8-year status demonstrates progressive wear and fatigue of

composite, particularly in surfaces with very thin layers of mater-
ial (molars). The patient wore the nightguard but admitted to re-
cently using it less than 50% of the time; this likely accounts for
the ongoing aging of restorations. Some staining and minor, fur-
ther erosion of facial surfaces in the mandible is visible. Despite
the aforementioned minor failures or the need for reintervention,
the treatment concept applied was considered overall successful.

Chapter_8_1.indd 661 11.04.23 16:52
662
9-year renewing
Chapter_8_1.indd 662 11.04.23 16:52

9 years posttreatment—Case analysis 663
The initial clinical findings and lesion types suggested a predominance of the erosion risk factor; attrition was not obvious while hidden
by the most active wear process. As explained in chapter 1, tooth wear is not necessarily a continuous process in terms of risk factor
impact and severity. While direct composite restorations behaved overall satisfactorily over the 8-year observation period, molar restor-
ation integrity proved affected by wear and material fatigue (especially second molars). Therefore, 9 years after the initial treatment, the
posterior restorations were renewed and the new VDO increase compensated on the palatal aspect of maxillary anterior teeth; wear of
mandibular anterior restorations was also corrected (left page). In such cases, retreating worn posterior molar occlusal surfaces with
lithium-disilicate overlays would have granted more stability (hybrid approach); however, due to financial limitation, the patient re-
nounced to this option.

• Simple and effective approach to restore lost tissues and protect wear lesion
• Minimal complications (wear and material fatigue on molars and mandibular anterior teeth)
• Attrition risk factor partially controlled with nightguard
• Can be considered a satisfactory treatment approach over the observation time

Chapter_8_1.indd 663 11.04.23 16:52
664
CASE SUMMARY
UF
Moderate tooth wear in lower posterior areas and limited in
upper posterior teeth, with likely contribution of erosion
Patient who is dentist requested functional and protective
restorative treatment
UP
andi ula te i
Direct composite class I restoration with simultaneous
build-up of occlusal anatomy and VDO increase
a illa te i
Replacement of amalgam class I restorations without
LP occlusal anatomy and VDO changes
a illa ante i
Direct palatal restorations to compensate for the new VDO
and maintain anterior guidance
LF
Chapter_8_1.indd 664 11.04.23 16:52

665
Case 5
Moderate tooth wear

11-year follow-up

Chapter_8_1.indd 665 11.04.23 16:52
666
The patient, a 36-year old male dentist, consulted for a known not present noticeable wear lesions and it was then decided to re-
erosion problem which affected mainly his mandibular molars store only lesions of the mandibular posterior teeth as well as the
and premolars. There was initially no obvious contribution of palatal surfaces of maxillary front teeth; this approach did actually
attrition or abrasion risk factors and the patient was free of TMJ ensure usual occlusal and guidance needs with contacts overall
symptoms or functional limitations. Apart from the two occlusal both arches. Note the persistence of both second, lower decidu-
fillings on upper first molars to be replaced, the maxillary arch did ous molars.
Chapter_8_1.indd 666 11.04.23 16:52

667
Due to the limited extent of wear, the restorations will be placed without pre-treatment diagnostic wax-up. The restorative strategy was
then to restore mandibular wear lesions with an ideal anatomy, controlling however the amount of VDO increase to obtain direct palatal
restorations which thickness would not feel uncomfortable; the new to maintain anterior contacts justify the placement of the upper
restorations on otherwise wear free surfaces. A nightguard will be made to assess at least for a few weeks or months the absence of ad-
ditional attrition risk factor.

Chapter_8_1.indd 667 11.04.23 16:52
668
Occlusal lesions were treated only with sandblasting (Al2O3 25 to

500 microns) before application of the adhesive (OptibondFL,
Kerr) and composite build up using a bi-laminar technique (Miris
dentin S3 and White enamel, Coltene-Whaledent), before final oc-
clusal characterization (Kolor Brown, Kerr). Due to the rather sim-
ple tooth wear condition, not pre-treatment wax-up was needed.
Chapter_8_1.indd 668 11.04.23 16:52

669
Chapter_8_1.indd 669 11.04.23 16:52

670
The post-treatment views demonstrate the satisfactory anatomical changes, related functional enhancements and effective protection
of worn surfaces in mandibular posterior areas. Note that the palatal surfaces of maxillary frontt teeth were restored with direct compos-
ite application to ensure the maintenance of anterior contacts and guidance.
Chapter_8_1.indd 670 11.04.23 16:52

Postoperative 671

Chapter_8_1.indd 671 11.04.23 16:52
672
The case was maintained with a nightguard over

11Y without any intervention needed. The hy-
gienist suggested however a control visit to as-
sess the need of repair and/or new VDO change.
Chapter_8_1.indd 672 11.04.23 16:52

11 years posttreatment and renewing 673
The renewing phase included a similar approach to the initial

phase, namely the “preparation” of surfaces to be restored or
corrected with sandblasting beforee the application of a mul-
tifunctional adhesive (eg: Optibond FL, Kerr or Clearfil SE Bond,
Kuraray). Fresh increments of micro-hybrid or nano-hybrid com-
posite are then applied to complete this new treatment. Note that
proper overall functional scheme and balanced occlusal contacts
have to be ensured.

Chapter_8_1.indd 673 11.04.23 16:52
674
Chapter_8_1.indd 674 11.04.23 16:52

675
The procedures described in the previous double page were performed on all mandibular posterior teeth, followed again by application
of composite on the palatal surfaces maxillary frontt teeth (next page); this procedures follows the same rationale applied during the first
treatment phase, namely to provide the needed anterior guidance and maintenance of contacts in the patient’s usual occlusal position
(MIP or any other chosen position).

Chapter_8_1.indd 675 11.04.23 16:52
676
Chapter_8_1.indd 676 11.04.23 16:52

11-year follow-up and case analysis 677
The 11-year follow-up demonstrate the excellent performance of composite when the predominant risk factor is not of mechanical na-
ture; even when a contribution of attrition is revealed, nightguard therapy can alleviate most of potential functional and parafunctional
wear. Medium to long-term clinical observation allows the dental team to confirm risk factors and the patient’s cooperation with pre-
ventive measures. When patients grant their compliance, tooth wear can be very successfully managed with no-prep techniques, using
direct or molding protocols. Needless to mention the advantages of such strategy.

• Pleasing, stable esthetic outcome
• Anatomical and functional aspects well controlled
• Nearly no complications over 10 years of function
• Risk factors well controlled with diet change and nightguard
• Can be considered as an optimal treatment approach in such moderate, localized wear case

Chapter_8_1.indd 677 11.04.23 16:52
678
CASE SUMMARY

Generalized, moderate tooth wear
UF
Evidence of erosion and attrition risk factors
Patient expects an esthetic correction of maxillary anterior
teeth
No functional problem or dentin hypersensitivity
UP
a illa ante i
Incisal edge buildup with direct approach
Diastemas closure with direct composites
Correction of palatal lesions with direct composites
a illa te i
LP Direct composites to correct tooth wear and increase VDO
andi ula ante i

Incisal edge buildup and leveling
LF andi ula te i
Direct composites to correct tooth wear and increase VDO
Chapter_8_1.indd 678 11.04.23 16:52

679
Case 6
Moderate tooth wear
13-year follow-up

Chapter_8_1.indd 679 11.04.23 16:52
680
This 37-year-old male patient, who was a dentist, presented himself for an esthetic and tooth wear consultation; this col-
league was fully aware of his high fizzy drink consumption and parafunctional activities. He also wanted to take the opportu-
nity of a smile enhancement while correcting and protection his posterior teeth with restorations.
Chapter_8_1.indd 680 11.04.23 16:52

681
The initial clinical examination revealed a shortening of both upper and lower incisal edges as well as generalized wear
facets and hollowed occlusal lesions on posterior teeth. Clinical findings confirmed the risk factors mentioned by the patient.
Neither TMD nor other functional problem was reported.
Having full knowledge of the biomechanical consequences of the indirect treatment strategy, the patient’s expectation
was to be treated following an interceptive approach. The moderate tooth wear extent, the patient’s age, and expected good
compliance with diet enhancement and nightguard preventive measures fully supported the use of a preventive treatment
approach.

Chapter_8_1.indd 681 11.04.23 16:52
682
Chapter_8_1.indd 682 11.04.23 16:52

1st treatment phase 683
As for all tooth wear cases, a pretreatment wax-up was performed to create the new smile line, VDO correction, and diastemas closure,
while simulating the overall correction of wear lesions. A silicone index was then used to guide the placement of composite for enhanc-
ing the smile line using the typical bilaminar layering approach (Dentin S2 and Enamel RW; Miris 2, Colt ne/Whaledent).
NB: The treatment of posterior teeth was not documented for this case.

Chapter_8_1.indd 683 11.04.23 16:52
684
After first treatment phase
The posttreatment status shows a new, improved smile line with better proportions and no diastema. The initial erosion lesions visible
on the cervical areas of maxillary central incisors (teeth nos. 11 and 21) were not restored at this stage, owing to a likely control of the
erosion risk factor. A nightguard was given to the patient.
Chapter_8_1.indd 684 11.04.23 16:52

8 years after first treatment phase 685
During a following 8-year period, the patient was checked at his own clinic and never returned to us until some maintenance work was
needed. The clinical examination conducted 8 years posttreatment revealed however good behavior of maxillary anterior restoration
owing to a complete failure in controlling risk factors; the patient admitted having not reduced his consumption of acidic drinks and did
not wear the nightguard during most of the last 8-year period. Repair of maxillary anterior teeth chipping was performed first and recom-
mendation to follow strictly preventive measures was given.

Chapter_8_1.indd 685 11.04.23 16:52
686
8 years after first treatment phase
A renewing of mandibular posterior restorations was also recommended due to more pronounced wear and degradation of composite
as well as some additional tooth structure loss.
Chapter_8_1.indd 686 11.04.23 16:52

First renewing 8 years after initial treatment 687
This localized renewing was performed under rubber dam in a single session for both right and left sextants (for more information about
the technique, refer to the second renewing session detailed in the next pages). Anterior contacts were then reestablished on the upper
palatal surfaces (not illustrated). A new nightguard was provided to the patient, insisting on its protective effect to counteract parafunc-
tional activities.

Chapter_8_1.indd 687 11.04.23 16:53
688
13 years after first treatment phase
13 years following the initial treatment

phase, the maxillary anterior restorations
further behaved rather satisfactorily, con-
sidering again the lack of compliance with
preventive measures, in particular wearing
the nightguard.
Chapter_8_1.indd 688 11.04.23 16:53

689
In fact, the wear increase in maxillary and mandibular posterior teeth and restorations placed 8 and 13 years ago confirmed the signifi-
cant impact of parafunctional activities with obvious signs of bruxism (wear facets of upper/lower incisal edges and palatal surfaces and
overall flattening of posterior anatomy) and clenching (moderate to severe indention lesions on second and third molars; note the sig-
nificant, typical occlusal wear of those teeth despite persistent anterior guidance). The patient’s wish remained however to be retreated
with an interceptive approach, although we advised him to restore maxillary and mandibular molars with a stronger material (eg, mono-
lithic lithium-disilicate restorations).

Chapter_8_1.indd 689 11.04.23 16:53
690
Renewing 13 years after initial treatment
Only little composite material remained in some erosion lesions, while tooth wear overall worsened. A partial crack is visible on the man-
dibular right second molar. The maxillary right premolar (no. 15) required treatment (endodontics and crown placement) due to symp-
tomatic cracked tooth syndrome (CTS). The neighboring tooth (no. 14) received a ceramic overlay (e.max, Ivoclar Vivadent); the crown on
the first premolar was performed at the patient’s own clinic. Pre- and posttreatment status of lower sextants under the dam is illustrated
in right page images. The step-by-step procedure is shown on the next 2 pages.
Chapter_8_1.indd 690 11.04.23 16:53

691

Chapter_8_1.indd 691 11.04.23 16:53
692
Second renewing
1 2 3 4
If some restorations are defective, they should be replaced before occlusal correction and VDO change are performed. Then, both dental
and restorations surfaces must be cleaned and micromechanically prepared (sandblasting) to enhance interaction with hard tissues and
create micro-retentive features as well (1). Enamel (“self-etch” or “universal” adhesive) and dentin etching (“etch-and-rinse” approach)
follows sandblasting (2). Primer (3) and bonding resin (4) (multi-step “self-etch” and “etch-and-rinse” adhesives) are further applied, and
then light-cured (5).
Chapter_8_1.indd 692 11.04.23 16:53

5 6 7
A single layer of adhesive would be an alternative approach (with “single step” or “uni-
versal” adhesives). Composite can finally be applied to restore all lesions and occlusal
morphology, one tooth at the time (6 and 7) until the full sextant is completed (right
image).
Chapter_8_1.indd 693 11.04.23 16:53

694
The same preparation and adhesives steps (1 to 5) are applied

to the renewing of anterior restorations. However, contrarily to
the main monolayer approach applied to posterior restoration
(enamel shades), a bilaminar technique is applied, especially for
restorations involving the incisal third.
Chapter_8_1.indd 694 11.04.23 16:53

695
Note the peculiar oblique/concave design of dentin increment (D)

ending close to the labial wear zone margin, which allows a
smooth optical transition between composite and tooth structure
after restoration completion. A last layer of enamel (E) completes
the buildup.
E
Chapter_8_1.indd 695 11.04.23 16:53
696
At completion of the restorations, under the dam (left page), as well as following full rehydration (right page), a smooth optical transition
is attained, without any need to create a marked chamfer or bevel.
Chapter_8_1.indd 696 11.04.23 16:53

After second renewing 697
The overall esthetic integration can be considered highly favorable, despite the use of a no-prep direct restorative approach. Such a
positive treatment outcome is made possible with modern composite technologies, thanks to their improved optical properties. The
lengthening of maxillary central incisors is key to smile rejuvenation and maintenance of anterior guidance, an important functional
factor contributing to lower lateral forces on posterior restorations.

Chapter_8_1.indd 697 11.04.23 16:53
698
Chapter_8_1.indd 698 11.04.23 16:53

699
The overall occlusal and functional outcome was also considered satisfactory despite the use of a direct approach. A crucial element
to counteract risk factors will be to motivate the patient to wear an occlusal splint; we provided him with both day- (thinner, 1 mm) and
nightguards (thicker, 1.5 mm) to protect restorations and teeth from a rapid wear relapse (next pages). The dayguard was used to evalu-
ate the contribution of awake bruxism and allow the whole team (patients and operator) to know about the most efficient prevention of
continued attrition.

Chapter_8_1.indd 699 11.04.23 16:53
700
13-year follow-up after second renewing
Chapter_8_1.indd 700 11.04.23 16:53

Case analysis 701
The 8-year and 13-year follow-ups with two renewing phases set relative limits for the interceptive strategy when confronted with moder-
ate to severe parafunctions and limited patient compliance. It also points out the highly individual response to restorative therapies as well
as compliance to preventive measures. The main reason to follow first the “interceptive” strategy was then to take the chance of stabiliza-
tion ongoing attrition and observe risk factor evolution. Worse-case scenario, we could have changed to the “restorative” strategy (partial
or comprehensive) in case of rapid wear worsening, triggering major restoration failures and more tissue loss; this fortunately did not truly
happen in this particular case. However, such treatment evolution was considered a partial failure.

• No-prep “interceptive” approach conceptually adequate to treat such tooth wear extent
• Pleasing esthetic outcome
• Simple and cost-effective
• Risk factors (attrition and erosion) not well controlled over the entire observation period
• Two phases of restorations renewing mandated by restoration wear and attrition progression
• Patient wished to stick to the “interceptive” strategy
• Although no dramatic failure occurred, a partial restorative approach for molars would have likely been more adequate to
treat this case

Chapter_8_1.indd 701 11.04.23 16:53
702
CASE SUMMARY

Moderate to severe tooth wear in posterior zones due
mainly to erosion with likely contribution of attrition
UF
Moderate to severe palatal tooth wear of anterior teeth due
to a combination of erosion and attrition of incisal edges
due to improper occlusal relationship
Crowding of maxillary anterior teeth with edge-to-edge
occlusion and palato-version of maxillary premolars
UP
Patient was proposed orthodontics to correct his smile
misalignment but denied this option
andi ula and a illa te i

Direct composite restorations to treat decays and
compensate for occlusal wear
Indirect composite onlay to restore the mandibular first
LP molar
Direct composite veneers on both maxillary first premolars
a illa ante i
LF Feldspathic ceramic veneers to even smile
andi ula ante i

No treatment
Chapter_8_1.indd 702 11.04.23 16:53

703

and Ceramic Veneers
Case 7
Moderate Tooth Wear

13Y FOLLOW-UP

Chapter_8_1.indd 703 11.04.23 16:53
704
Chapter_8_1.indd 704 11.04.23 16:53

705
This 40-year-old male was initially referred for an esthetic is- Next to the orthodontic issues, moderate to severe erosion
sue by the orthodontist the patient first consulted; he actually was noticed in all posterior teeth and palatal surfaces of max-
rejected the treatment proposal due to its foreseen duration illary anterior teeth, with a higher severity in maxillary pre-
and discomfort. As a first consideration, the patient was re- molars, whose palatal cusps were nearly totally worn down.
minded again the invasive nature of any restorative approach The presence of these lesions was related to former high
to solve his anterior crowding and in general any orthodontic consumption of fruits and juices. Also noticed were some at-
problem. The clinical examination revealed a Class I occlusion trition of maxillary incisal edges as well as posterior occlusal
on the right side and Class II tendency with a cusp-to-cusp surfaces with noticeable wear facets. The patient was once
relationship on the left side. A retroclined and edge-to-edge more not aware of his tooth wear problem, which did not
position of maxillary left incisors was also noticed as well as trigger any functional limitation or dentin hypersensitivity.
a palatal displacement of both maxillary first premolars. In There was an active decay on the maxillary right second pre-
regard to the mandibular anterior crowding, the patient was molar and the presence of two endodontically treated teeth
not concerned by the condition due to its limited visibility. (maxillary left central and first right molar).

Chapter_8_1.indd 705 11.04.23 16:53
706
First treatment phase
The treatment plan involved two phases, the first one aimed at treating tooth wear following an
interceptive strategy with direct composite restorations on posterior teeth and palatal surfaces of
maxillary anterior teeth. The right page sequence shows the treatment of maxillary posterior teeth
with reconstruction of worn surfaces, palatal cusps of premolars, and the second premolar decay
with direct techniques using a bilaminar layering (Miris 2, Colt ne/Whaledent).
Chapter_8_1.indd 706 11.04.23 16:53

707
Chapter_8_1.indd 707 11.04.23 16:53

708
Chapter_8_1.indd 708 11.04.23 16:54

709
Mandibular teeth were restored using an identical direct approach, apart from the mandibular left first molar, which received an indirect
composite onlay made of the same direct restorative material, submitted to heat and light post-curing (Miris 2). On the left page, the
onlay fabrication is depicted, showing the layering technique also used for direct restorations, consisting of a first layer of composite
reconstructing the tooth dentin core and a second layer of enamel, simulating altogether the natural tooth histoanatomy. The other clin-
ical views show the intraoral status following the first treatment phase; note that the palatal surfaces of maxillary anterior teeth still need
to be restored prior to engaging the second treatment phase aiming to correct the misalignment of the maxilla with direct and indirect
veneers.
Chapter_8_1.indd 709 11.04.23 16:54

710
Second treatment phase
The second treatment started with the direct veneering of the maxillary first premolars (upper images show completed restorations) and
palatal surfaces of the six maxillary anterior teeth (central image on right page) using the same universal NLC (Natural Layering Concept)
composite system (Miris 2). Then, facial surfaces of incisors were prepared and temporaries used to test the new smile alignment and
tooth display. Due to its discoloration, the endodontically treated maxillary left incisor was also slightly prepared cervically to allow for
good color matching with other veneers.
Chapter_8_1.indd 710 11.04.23 16:54

711
Chapter_8_1.indd 711 11.04.23 16:54

712
The veneers were made of feldspathic porcelain; some preparation was of course due to realign facial surfaces, which clearly is not ideal.
However, the preparation approach was as minimally invasive as possible with only the four incisors involved. The patient refused the
suggested correction of his irregular gingival profile, as cervical areas were not visible during speech and smiling. Keeping in mind the
known compromise of the selected treatment approach, the maxilla realignment had however a highly positive impact on the patient’s
smile and fulfilled his main esthetic expectations while simultaneously treating the tooth wear problem with a no-prep approach.
Chapter_8_1.indd 712 11.04.23 16:54

713

Chapter_8_1.indd 713 11.04.23 16:54
714
1 year posttreatment
Chapter_8_1.indd 714 11.04.23 16:54

715
The short-term 1-year follow-up demonstrated satisfactory biologic, esthetic, and functional results of the treatment performed using
a hybrid approach with a combination of direct and indirect restorations. The patient received a nightguard that granted protection
against attrition. As erosion was unlikely due to reflux, the controversial risk of the nightguard retaining acid, worsening potentially ero-
sion progression, was not considered in this case.

Chapter_8_1.indd 715 11.04.23 16:54
716
Chapter_8_1.indd 716 11.04.23 16:54

717
The 7-year posttreatment showed good integrity of restorations with only minor marginal degradation of some margins (eg, no. 46) and
discrete progression of erosive wear on a few maxillary tooth surfaces (eg, nos. 16 and 26) and mandibular premolar occlusal surfaces.
The latter teeth were actually not previously restored, as space was needed to reconstruct maxillary premolars. One decay also had to be
treated on the mandibular left second molar.

Chapter_8_1.indd 717 11.04.23 16:54
718
Chapter_8_1.indd 718 11.04.23 16:54

The 9-year follow-up revealed very little

change as compared to the 7-year findings
in regard to both anterior and posterior
restorations (four upper images). Maxillary
palatal surfaces of anterior teeth show rel-
atively little wear progression with mainte-
nance of the protective effect of composite
restorations.
It was decided to apply composite to re-

pair restoration margins where needed
and protect occlusal surfaces of mandibu-
lar premolars, which had not yet been re-
stored. Material was also added on the sur-
faces showing further erosion impact (four
lower images).

Chapter_8_1.indd 719 11.04.23 16:54
720
Chapter_8_1.indd 720 11.04.23 16:54

13-year follow-up and case analysis 721
The 13-year follow-up confirmed the success of this hybrid and selective treatment approach. Over such a medium- to long-term obser-
vation period, only two new decays had to be treated as well as one fracture of the distobuccal cusp of the maxillary second right molar
related to a former large cervico-buccal amalgam. The occurrence of new decays despite an overall satisfactory hygiene confirmed the
persistence of the erosion risk factor, even if of reduced severity.

• Successful individualized combination of direct and indirect restorations following interceptive and restorative strategies
• Only few new decays and slight progression of erosion confirming the persistence of risk factors, however largely under
control
• The selected treatment approach proved efficient in regard to identified risk factors, using a no-prep approach for all func-
tional surfaces and composite veneers, with only few microinvasive indirect veneer preparations
• Nightguard contributed to the stability of composite restorations

Chapter_8_1.indd 721 11.04.23 16:54
722
8.3
CHAPTER
With contributions by
Michel Magne, CDT, for the initial lab work in cases 2 and 3 and
Patrick Schnyder, CDT, for the second set of veneers/anterior crowns in case 3.
8.3
Chapter_8_2.indd 722 13.04.23 16:52
Renewing and Replacement
723
r&r Longevity and Maintenance 8
13.04.23 16:52
724
CASE SUMMARY
Poor oral hygiene
Generalized, intermediate tooth wear due to attrition
UF Several failing restorations
Endodontic lesion on tooth no. 47
Root recession on tooth no. 43
Class III occlusion
UP a illa ante i
Incisal edge buildup and decayed restoration replacement
with a direct approach
a illa te i
Direct composites to correct tooth wear and increase VDO
on non-crowned posterior teeth
Replacement of failing amalgams with direct composites
Extraction of tooth no. 25 (horizontal fracture) and
LP replacement of maxillary left bridge with implant-borne one
andi ula ante i

Incisal edge buildup and leveling with direct composites
LF andi ula te i
Direct composites to correct tooth wear and increase VDO in
all teeth but nos. 46 and 47 restored with indirect composite
overlays
8.3 Renewing and Replacement
Chapter_8_2.indd 724 13.04.23 16:52

725
Freehand Indirect Composite

Restorations
and PFM/Zirconia Bridge
Case 8
Moderate to severe tooth wear

12-year follow-up

Chapter_8_2.indd 725 13.04.23 16:52
726
Chapter_8_2.indd 726 13.04.23 16:52

727
This 42-year-old male patient consulted initially for a global While in principle he agreed with the idea of going through a
solution to resolve both esthetics (Class III occlusion) and comprehensive occluso-functional driven rehabilitation, he
parafunctions synergically affecting his smile appearance and requested to delay the orthosurgical phase until he would be
his biomechanical dental conditions. He additionally wished less occupied professionally. His initial wish was then to stabi-
to replace metal-based restorations with tooth-colored ones. lize his wear problem, improve esthetics as much as possible
The main consideration discussed during the initial consul- (remaining likely in his present occlusal position), and restore
tation was whether the patient would consider orthodontics several decayed posterior and anterior teeth. The main risk fac-
and orthognathic surgery to correct the Class III malocclusion. tors were presently attrition and formerly carious susceptibility.

Chapter_8_2.indd 727 13.04.23 16:52
728
Detailed clinical and radiographic examination revealed some endodontic problem on tooth no. 37. Otherwise, periodontal conditions
were good, apart from severe gingival recession on tooth no. 43 resulting from its extrabony position. Another two teeth were endodon-
tically treated (nos. 25 and 27). No TMD was reported.
Chapter_8_2.indd 728 13.04.23 16:52

729
A pretreatment wax-up was performed to

assess first the possibility to correct the
Class III together with VDO opening. This
proved unfortunately not possible.
The wax-up guided the rehabilitation and

provided the needed reference to improve
curve of Spee and interarch occlusal rela-
tionship, owing the limits of the preexisting
skeletal discrepancy.

Chapter_8_2.indd 729 13.04.23 16:52
730
After first treatment phase
Chapter_8_2.indd 730 13.04.23 16:52

731
The first treatment phase resulted in an improved, overall dental restorative status with a combination of indirect composite overlays for
teeth nos. 27, 46, and 47 and direct composites for all the other teeth presenting wear or failing restorations (Miris 2, Coltène/Whaledent).
On the maxillary left side, a screw-retained long-term resin temporary bridge was placed awaiting for no. 25 extraction socket healing.
This first treatment phase actually fulfilled the initial patient’s request, namely a stabilization of his occlusal and functional problems
while waiting for a more ideal and comprehensive rehabilitation. Note that the patient did not integrate its new occlusal position (tooth
to tooth anterior relationship) and due to the lack of neuro-muscular adapation, he maintained a class III anterior relationship.
Chapter_8_2.indd 731 13.04.23 16:52

732
Chapter_8_2.indd 732 13.04.23 16:52

733
The 3-year posttreatment status demonstrates acceptable behavior of the “interim” restorations; a few minor material failures were ob-
served, such as chipping (nos. 16 and 22) or fatigue cracks (nos. 47 and 27). The patient also confessed to having poor compliance with
his nightguard, which he used only seldomly.

Chapter_8_2.indd 733 13.04.23 16:52
734
Chapter_8_2.indd 734 13.04.23 16:52

735
After 5 years, a few more minor failures were observed (nos. 15, 47, and 42); such material chipping is however simple to repair by apply-
ing the same procedure as for renewing composite restorations (see previous section). Due to a vertical root fracture, the maxillary left
molar had to be extracted. Such severe complications result from both a lack of functional risk factor control (nightguard was not worn)
as well as the use of a “low-elasticity” restorative material (nanohybrid composite) that has an insufficient anti-diverging effect when a
biomechanically fragilized tooth is submitted to high occlusal load.

Chapter_8_2.indd 735 13.04.23 16:52
736
Complications in maxillary left sextant
Initial treatment 7 years posttreatment After implant removal
Next to previous minor (composite chipping) and major (no. 27 loss) complications, the integration of the second maxillary left implant
(no. 26) was lost, likely due also to functional overloading. Note that there was not cervical bone loss and only light radiotranslucency
visible around the whole implant body, a typical finding in such situation; implant removal then had to be performed. The patient pre-
ferred not to wear a partial denture during the retreatment in the second sextant.
Chapter_8_2.indd 736 13.04.23 16:52

737
The retreatment involved the placement of three implants to distribute occlusal load and tentatively prevent a new failure. For the same
reason, a larger implant was placed in the no. 26 site in combination with a sinus elevation procedure to augment bone-to-implant
contact. The buccopalatal diameter of the tooth was also reduced to limit eccentric implant loading.

Chapter_8_2.indd 737 13.04.23 16:52
738
Chapter_8_2.indd 738 13.04.23 16:52

739
10 years following the initial treatment phase, it appeared that the patient renounce to a resolution of his Class III malocclusion; he
was then offered two options, namely to (1) replace all “interim” restorations with the aim to achieve maximal mechanical and wear
resistance (“restorative” approach, using monolithic ceramics) or (2) partial replacement of extensive composite restorations, especially
nonvital teeth (nos. 46, 47, 14, and 15) and renewing of other composite ones, implementing further the “interceptive” approach. The
patient then decided for the continuation of the “interceptive” approach as much as possible, owing to the few severe complications
that occurred over a 10-year period.

Chapter_8_2.indd 739 13.04.23 16:52
740
Partial replacement and renewing 12 years posttreatment
The replacement of large restorations of maxillary right premolars and two mandibular molars was performed simultaneously with the
renewing of direct composite restorations to control VDO and obtain proper bilateral function and occlusal contacts. Procedures for both
treatment types follow the description in chapter 6 and a previous section in this chapter (renewing).
Chapter_8_2.indd 740 13.04.23 16:52

741

Chapter_8_2.indd 741 13.04.23 16:53
742
Partial replacement and 12 years after initial treatment
Schematic description of the overall restorative status

12 years post–initial treatment phase.
Chapter_8_2.indd 742 13.04.23 16:53

743
After renewing and partial replacement phase. The patient was logically motivated once again to regularly wear his nightguard, owing to
the complications encountered during the 12-year observation period; in addition to such preventive measure, the new indirect resto-
rations led to biomechanically strengthening of fragilized teeth to limit the occurrence of new failures.

Chapter_8_2.indd 743 13.04.23 16:53
744
12-year follow-up
The posttreatment radiographic status reveals the potential impact of persistent over-
loading of the implant on tooth no. 26, although bone remodeling did not progress sig-
nificantly over the last few years. Note the reoccurrence of an apical endodontic lesion
on the mesial root of tooth no. 47. Periodontal and restorative conditions are otherwise
satisfactory.
Chapter_8_2.indd 744 13.04.23 16:53

Case analysis 745
The Class III and resulting lack of anterior and canine guidance had to be considered an unfavorable situation and contributive risk
factor in a patient with extremely limited compliance with nightguard therapy and rather severe parafunctional activities. Nevertheless,
despite the aforementioned critical biofunctional environment, the interceptive approach proved partially successful over this 12-year
observation period.

• Highly conservative value of the first “interceptive” treatment phase
• Improved esthetic appearance, despite the persistence of Class III malocclusion
• Simple and effective treatment approach
• Lack of compliance with risk factor (attrition) resulted in frequent minor failures and a few major failures
• Loss of a nonvital tooth due to vertical root fracture (VRF) and one implant (overloading)
• Regular maintenance needed with restoration renewing up to 12-year follow-up
• Replacement of various restorations required at 12 years following a selective treatment approach (localized application of
“interceptive” and “restorative” strategies)
• Importance of patient’s compliance for failure prevention

Chapter_8_2.indd 745 13.04.23 16:53
746
CASE SUMMARY
UF

Attrition and erosion with main impact on maxillary anterior
teeth
UP Moderate tooth wear of posterior teeth
Edge-to-edge anterior occlusal relationship due to Bolton
discrepancy
High esthetic expectations

Orthodontic correction to obtain a Class I relationship,
normal and overjet/overbite
LP Porcelain veneers for teeth nos. 13 to 23

Preventive strategy with Michigan splint
LF
Chapter_8_2.indd 746 13.04.23 16:53

747
Ceramic Veneers and

Case 9
Moderate/severe tooth wear

23-year follow-up

Chapter_8_2.indd 747 13.04.23 16:53
748
Chapter_8_2.indd 748 13.04.23 16:53

749
This patient, aged 27 years, first consulted for an esthetic The postorthodontic views more clearly show the impact
concern with his maxillary anterior teeth shortening due to of erosion, seemingly related to a high consumption of fizzy
attrition and erosion; at this time, wear was predominantly drinks, which the patient agreed to reduce drastically. The
localized in this maxillary anterior area with less impact on importance of wearing a nightguard as a permanent protec-
posterior and mandibular anterior teeth. Due to the edge- tion against attrition was also clearly explained; however, the
to-edge anterior occlusal relationship, an orthodontic treat- patient reported frequent periods of awake bruxism impact-
ment was recommended to create more favorable anatomi- ing potentially an optimal control of risk factors.
cal conditions to restore the six maxillary anterior teeth with
porcelain veneers.

Chapter_8_2.indd 749 13.04.23 16:53
750
The preoperative intraoral status shows moderate tooth wear (combined risk factor due
to erosion and attrition) in mandibular anterior and posterior teeth, which the patient ini-
tially denied to restore following an interceptive approach; then, these areas were only
kept under “preventive strategy” with a nightguard (Michigan splint).
Chapter_8_2.indd 750 13.04.23 16:53

751
The six maxillary anterior teeth were prepared rather conservatively in consideration of the 1997 guidelines. Feldspathic porcelain ve-
neers were fabricated on refractory dyes. Teeth had to be slightly prepared interproximally to allow for the closure of diastemas resulting
from the orthodontic preparation.

Chapter_8_2.indd 751 13.04.23 16:53
752
Postoperative
Posttreatment views show a satisfactory esthetic outcome that fulfilled patient’s expectations. All preparation margins were kept at gin-
gival level to promote optimal gingival health.
Chapter_8_2.indd 752 13.04.23 16:53

The 2-year posttreatment situation shows logically a stable esthetic result and stable orthodontic alignment with help of the Michigan
splint, which served here also as post-orthodontic stabilization.

Chapter_8_2.indd 753 13.04.23 16:53
754
Chapter_8_2.indd 754 13.04.23 16:53

755
Due to professional relocation, the patient was unable to attend regular recalls and returned only 8 years after initial treatment. The left
images show the severe wear progression in mandibular anterior teeth. Awake bruxism with enamel/porcelain contacts could possibly
account for faster wear of natural tissues.
A second treatment phase was then initiated, implementing first an interceptive strategy for maxillary and mandibular posterior teeth
(direct composites with full molding technique; see chapter 4.7 for detailed clinical description); then, mandibular incisors could be
restored with porcelain veneers and canines with direct composite ones. Preventive measures were also maintained with further night-
guard use.

Chapter_8_2.indd 755 13.04.23 16:53
756
12 years/4 years posttreatment
The 4-year follow-up (post second treatment phase) revealed a visible

progression of attrition on maxillary molars and the development of nu-
merous fatigue cracks/chipping (nos. 26 and 47). The patient reported a
high exposure to professional stress and increased awake bruxism; how-
ever, he confirmed being completely compliant with nightguard.
Chapter_8_2.indd 756 13.04.23 16:53

17 years/9 years posttreatment 757
The 17-year/9-year posttreatments follow-ups showed further deteriora-

tion of direct posterior restorations; minor failures such as chipping and
loss of dentin protective layer conducted to a few repair sessions (same
protocol as renewing technique). Note otherwise the crack of no. 22,
staining of porcelain veneers, and color change of direct ones.

Chapter_8_2.indd 757 13.04.23 16:53
758
20 years/12 years posttreatment
The next observation period (20 years/12 years) showed a partial fracture
of a mandibular veneer (no. 42) and persistence of surface staining. The
color discrepancy of direct composite veneers also worsened while aging
of direct posterior composites progressed further. Note that the crack of
the no. 22 veneer was sealed as it became more visible. Hygiene improve-
ment was also recommended.
Chapter_8_2.indd 758 13.04.23 16:53

23 years/15 years posttreatment 759
At the 23-year/15-year posttreatment recall, the patient finally agreed to

replacement of worn and mechanically failing direct posterior composite
restorations, which had lost part of the protective effect at this time. The
patient was encouraged to receive stronger restorations, but he imposed
the further use of composite.

Chapter_8_2.indd 759 13.04.23 16:53
760
Post-retreatment
Chapter_8_2.indd 760 13.04.23 16:53

23-year/15-year follow-up—Case analysis 761
This case provided an interesting 25-year follow-up of traditional porcelain veneers and 15-year observation of direct occlusal buildups
in a moderate/severe attrition case with initial erosion contribution. Actually, erosion proved largely under control with diet change,
while on the contrary, parafunctional activities worsened (especially awake clenching). Overall, porcelain veneers behaved satisfactorily
with only minor complications (crack line on tooth no. 22 and partial fracture on no. 42), which could be simply repaired. While a progres-
sive deterioration of direct posterior composite was observed over this 15-year period, no major failure occurred; minor failures such as
fatigue cracks, chipping, and wear could be repaired and partially renewed when necessary.
See chapter 7 for a detailed presentation of posterior teeth retreatment.

• Partially successful combination of restorative and interceptive strategies
• Cost-effective approach during a long maintenance period
• Minor failures occurred in both direct and indirect restorations with repair as the only corrective measures
• Composite resins confirmed their mechanical limits in heavy bruxers/clenchers although never led to major complications
• Complications and reduced restoration longevity are to be expected in absence of risk factor control
• The treatment approach required by the patient proved acceptable although not ideal

Chapter_8_2.indd 761 13.04.23 16:53
762
CASE SUMMARY
UF
Generalized, moderate to severe tooth wear in related
mainly to erosion due to bulimia nervosa with possible
contribution of parafunctions
UP More severe erosion in maxillary and anterior teeth
Treatment mandatory due to functional and esthetic
discomfort
a illa ante i
Full crowns
andi ula ante i

LP Direct composite veneers

Partial indirect, bonded ceramic restorations
Crowns
LF One direct composite buildup (no. 34)
Chapter_8_2.indd 762 13.04.23 16:53

763
Indirect Restorations and Direct

Composite Veneers
Case 10
Moderate/severe tooth wear
23-year follow-up

Chapter_8_2.indd 763 13.04.23 16:53
764
This female patient consulted for the first time in 1992 at aged 24 years due chiefly to esthetic concerns related to moderate to severe
erosion lesions of anterior teeth and also to dentin hypersensitivity of some posterior teeth. The first, urgent (but temporary) phase fo-
cused on the protection of occlusal lesion on premolars and molars to satisfy functional needs (images on both pages reflect the status
following this initial therapy phase). The patient then consulted various medical specialists to tentatively arrest the very active erosion
process, affecting her full dentition. A precise diagnosis for the recurrent vomiting was never confirmed from the patient’s gastroenterol-
ogist, although dental findings strongly suggested bulimia nervosa pathology. Then, a comprehensive treatment plan was proposed to
conciliate patient’s esthetics expectations as well as medical, functional, and biomechanical needs.
Chapter_8_2.indd 764 13.04.23 16:54

765
Over the initial 2-year follow-up period with aim to install preventive measures, it became obvious that erosion was not under control
due to daily, multiple vomiting episodes. Then, the approach for which the patient gave her consent was following a “protective” strat-
egy to replace lost tissue, restored function, and esthetics and tentatively prevent further hard tissue damage. The initial treatment took
place between 1992 and 1995, while classical (rather invasive) prosthodontic principles were predominant.

Chapter_8_2.indd 765 13.04.23 16:54
766
Functional wax-ups provided the interocclusal space required to place the needed indi-
rect restorations in anterior and posterior teeth as well as the mandibular anterior direct
veneers.
8.33
8. Renewing and Replacement
Chapter_8_2.indd 766 13.04.23 16:54

767
Partial indirect restorations (overlays) and full crowns were produced with the In-Ceram
Alumina/Zirconia and In-Ceram Alumina (VITA), respectively. At this time, the aforemen-
tioned materials were considered the strongest base for full ceramic restorations; a coat-
ing of the overlay intrados with fired porcelain allowed for better micromechanical reten-
tion following etching and salinization.

Chapter_8_2.indd 767 13.04.23 16:54
768
First treatment phase
The above image sequence illustrates a few steps of the basic preparation and cementation procedures; note that the relative frailty of
the available materials mandates an approach more invasive than in today’s modern adhesive dentistry. The upper middle images show
the mandibular right sextant after cementation while antagonists are still under temporaries. The mandibular left and right images pre-
sent complete sextants with a combination of partial and full indirect ceramic restorations and one direct composite buildup on the first
left premolar (no. 34).
Chapter_8_2.indd 768 13.04.23 16:54

769
The maxilla was treated with a combination of ceramic overlays and direct composites on left molars (nos. 26 and 27) showing less ex-
tensive wear. The overall concept applied was pioneering with the use of different materials and techniques, aiming to individualize the
restorative approach to tooth wear extent, biomechanical status, and foreseen risk factor management.

Chapter_8_2.indd 769 13.04.23 16:54
770
A conservative apical repositioning flap was performed on the labial aspect of maxillary incisors. Eight weeks later, following the increase
of VDO achieved with the indirect and direct restorations of posterior teeth, anterior teeth were treated with a combination of direct ve-
neers on the mandibular incisors and canines and full crowns on maxillary anterior teeth. The central and upper right images show the
indirect resin temporaries. The material used for the fabrication of definitive full-ceramic crowns was the In-Ceram Alumina system (VITA;
right page).
Chapter_8_2.indd 770 13.04.23 16:54

771

Chapter_8_2.indd 771 13.04.23 16:54
772
The direct composite veneers behaved satisfactorily over the first 9-year period. Likewise, all other direct posterior composites, the
partial indirect and full crowns made of In-Ceram material, performed well even in absence of control for both erosion and attrition risk
factors. The first major failure happened just after 9 years, leading to the patient requesting the replacement of two overlays with two full
PFM crowns (lower central and right images).
Chapter_8_2.indd 772 13.04.23 16:54

9 to 12 years posttreatment 773
The upper left radiographs show the 9-to-10-year situation and on the right side the 12-year one; more restorations failures (fractures)
occurred, which required the placement of another PFM crown (no. 25). Over the next 2 years, all partial restorations also had to be re-
placed by PFM crowns (nos. 15 and 16, 46 and 47). The two maxillary left molars (nos. 26 and 27) restored with direct composites were
also finally crowned. The crowns on central incisors were replaced by new ones due to veneering material fractures. Note the wear and
progressive discoloration of direct veneers on the mandibular anterior teeth. Vitality of both maxillary right molars was also lost due to
biomechanical complications (cracked tooth syndrome on no. 17 and vitality loss of no. 16, following palatal cusp fracture).

Chapter_8_2.indd 773 13.04.23 16:54
774
9 years after the first treatment phase was completed (left sketch), the lack of patient
compliance with nightguard and the unsuccessful attempts to control frequent
vomiting made necessary the change from a “conservative” to a “protective” treatment
approach due to both porcelain fractures and peripheral erosion of previously intact
surfaces. Then, the direct composite veneers and buildup of mandibular left premolar
(no. 34) subjected to more wear and discoloration were replaced by indirect, porcelain
veneers and a crown (right sketch). Note however that the protective effect of the first
veneer generation proved effective until their replacement as shown on the right page,
with no additional tissue loss over the entire period.
Chapter_8_2.indd 774 13.04.23 16:54

20 to 23 years posttreatment 775
Following a 6-year period without new complications, three extractions were made in emergency due to one endodontic complication
(no. 27) and secondary untreatable decay following palatal cusp fracture (no. 16) as well as long-term periodontal consequence of im-
proper premolar positioning after orthodontics (no. 25) during the following period (20 to 23 years). During the overall 23-year follow-up
of this case, the preexisting deep bite worsened, suggesting opening the VDO again. Moreover, soft tissue recession and aging of crowns
placed 10 years before impacted the patient’s maintenance ability as well as esthetics. The unsatisfactory evolution of this case relates
to a highly unfavorable biomechanical environment and an absence of risk factor control. As confirmed by the literature and illustrated
here, full crowns or extended prosthetic restorations do not alleviate the risk for severe failures and even tooth loss when timely preven-
tive and interceptive measures cannot be implemented.

Chapter_8_2.indd 775 13.04.23 16:54
776
RETREATMENT STRATEGY

Aging of restorations placed over the previous 23 years
Worsening of the deep bite occlusion
Several restoration fractures
Patient is expecting brighter teeth with volume
improvement in the lateral corridors
andi ula ante i

Moderate surgical crown lengthening
New ceramic veneers

Replacement of aged crowns with high-strength monolithic
ceramic system
Slight VDO increase
a illa ante i
New, less polychromatic full-ceramic crowns
Less triangular forms and straighter lateral incisors
Right page: The new smile configuration was simulated using

a 2D digital mock-up, offering minor and moderate change in
tooth shade.
Chapter_8_2.indd 776 13.04.23 16:54

777
Chapter_8_2.indd 777 13.04.23 16:54

778
Chapter_8_2.indd 778 13.04.23 16:54

Retreatment of maxilla 779
The double page illustrates a more traditional prosthetic treatment approach applied to the maxilla as a consequence of the aforemen-
tioned repeated biomechanical failures over the 23-year observation period. The maxillary right first molar implant required a sinus
elevation augmentation, while the natural right sinus anatomy allowed to exploit more height in both premolar and second molars sites.
Crowns were made of monolithic lithium-disilicate, stained, and glazed (e.max Press, Ivoclar Vivadent).

Chapter_8_2.indd 779 13.04.23 16:54
780
Retreatment of mandible
This double page illustrates the mandibular retreatment with full crowns, using the same monolithic glass-ceramic system. The stained
and glazed approach confers good esthetic, especially in posterior areas where the superior esthetics of veneered restorations is not rel-
evant. Marginally, such fabrication method reduces workmanship and usually also the laboratory costs. Note that in presence of severe
parafunctional activities as observed in this patient, the CAD/CAM lithium-disilicate is less favorable due to inferior initial strength and
lower fatigue resistance in a moist environment (see chapter 2.2).
Chapter_8_2.indd 780 13.04.23 16:54

781

Chapter_8_2.indd 781 13.04.23 16:55
782
Retreatment of anterior teeth
Despite the multiple biomechanical failures having impacted maxillary posterior teeth,
the retreatment of the anterior teeth neither required additional tooth preparation nor
resulted in vitality loss at treatment time. The mandibular incisors and the right canine re-
ceived V-shaped restorations protecting eroded lingual surfaces. These veneers received a
very thin layer of veneering porcelain to emulate a lifelike appearance.
Chapter_8_2.indd 782 13.04.23 16:55

The maxillary anterior teeth received the same type of restorations as for the mandible, namely a monolithic base with minimal veneer-
ing porcelain on their labial surface. The patient desired not to have polychromatic restorations as those from the first generation. In such
critical environment, minimizing the thickness of veneering material is always favored, taking advantage of the enhanced translucency
and optical properties of new ceramic materials.

Chapter_8_2.indd 783 13.04.23 16:55
784
23-year follow-up—Case analysis
Chapter_8_2.indd 784 13.04.23 16:55

785
The long-term follow-up of this patient made it possible other hand, our attempt to protect teeth from the other risk
to observe various materials reacting to high chemo- factor, namely erosion. The persistence of the aforemen-
mechanical strains. Although the first partial full-ceramic tioned risk factors resulted in even more severe, major fail-
restorations failed relatively early, even natural teeth with ures with vertical root fracture of no. 27 (even without post
minimal, initial wear involvement required full coverage fol- placement) and cusp fracture and untreatable decay of no.
lowing a “protective” strategy against erosion. Loss of vitality 16, leading to extraction. In the absence of risk factor control
due to mechanical (cracked tooth syndrome on no. 27) and in severe tooth wear patients, a more invasive prosthetic ap-
biologic reasons (full crown preparation of no. 16) occurred proach should not be considered to necessarily have a better
due to on one hand uncontrolled parafunctions and on the prognosis, as evidentiated by the literature.

• Partially unsuccessful attempt to install preventive and interceptive strategies
• Successful use of composite in mandibular anterior teeth
• Failure in controlling risk factors (erosion and bruxism)
• Frequent replacement interventions with escalating biomechanical complications and costs
• Expensive tooth wear management over long-term period
• Confirmation that prosthetic restorations are also unreliable in largely uncontrolled biofunctional environment

Chapter_8_2.indd 785 13.04.23 16:55
786
8.4
CHAPTER
Chapter_8_2.indd 786 13.04.23 16:55

Nightguards 787
n g Longevity and Maintenance 8

Chapter_8_2.indd 787 13.04.23 16:55
788
Night-/Dayguards: Functions and Fabrication
The prevention of mechanical/frictional wear is a key factor is a significant contributing factor or not. For some patients,
to stabilize and control its progression in patients who have using the dayguard in circumstances favoring parafunctions
excessive parafunctional activities owing to the fact no cure can be of great benefit, although it is a difficult objective to
exists to reduce or eliminate the cause of parafunctions. Apart reach.
from injection of Botox (botulinum toxin), which lowers para- There are numerous mouthguard designs; while it was
functional forces and reduces muscle hypertrophy, no medi- suggested that some would have a possible therapeutic ac-
cation truly eliminates clenching and bruxism directly, apart tion, it has been now largely proven that those appliances
from anxiolytic or anti-depressive drugs to reduce stress, a don’t provide such benefit and are useful mostly due to their
common aggravating factor. Because compliance with regu- protective role. A placebo effect has also been described. In
lar night- and dayguard use remains a problem in nonsymp- short, the literature and clinical experience demonstrated a
tomatic patients (no temporomandibular disorders [TMDs] stress breaker effect, prevention of tooth-to-tooth contacts,
or functional disturbances), such protective appliances must and more even stress distribution protecting overall dental
be both unobtrusive and comfortable for obtaining patient’s structures and restorations.
acceptance; this latter consideration proved crucial to suc- The protective effect of mouthguards then plays an obvi-
cessfully implement the effect of attrition “preventive ther- ous and crucial role in the potential success of “preventive”
apy.” Mouthguards can also be regarded as a way to evaluate and “interceptive” strategies. When patient compliance is
the severity of sleep and awake bruxism and clenching. We not obtained, the alternatives are to (1) proceed with more
actually suggest patients with obvious, severe parafunctional frequent restorations renewing and repair; (2) replace restor-
activities to wear a dayguard during the pretreatment and/ ations with stronger material, if feasible, usually leading to
or posttreatment phases to confirm whether awake bruxism more invasive procedures; and (3) use Botox.
8.4 Nightguards
Chapter_8_2.indd 788 13.04.23 16:55

1. Dias A, Redinha L, Mendonça GV, Pezarat-Correia P. A system- 8. Jokubauskas L, Baltru aityt A, Pilei ikien G. Oral appli-
atic review on the effects of occlusal splint therapy on mus- ances for managing sleep bruxism in adults: A systematic
cle strength. Cranio 2020;38:187–195. review from 2007 to 2017. J Oral Rehabil 2018;45:81–95.
2. Ebrahim S, Montoya L, Busse JW, Carrasco-Labra A, Guyatt 9. Klasser GD, Greene CS. Oral appliances in the management
GH; Medically Unexplained Syndromes Research Group. The of temporomandibular disorders. Oral Surg Oral Med Oral
effectiveness of splint therapy in patients with temporoman- Pathol Oral Radiol Endod 2009;107:212–223.
dibular disorders: A systematic review and meta-analysis. 10. Manrriquez SL, Robles K, Pareek K, Besharati A, Enciso R.
J Am Dent Assoc 2012;143:847–857. Reduction of headache intensity and frequency with max-
3. Ebrahim S, Montoya L, Busse JW, Carrasco-Labra A, Guyatt illary stabilization splint therapy in patients with temporo-
GH; Medically Unexplained Syndromes Research Group. The mandibular disorders-headache comorbidity: A system-
effectiveness of splint therapy in patients with temporoman- atic review and meta-analysis. J Dent Anesth Pain Med
dibular disorders: A systematic review and meta-analysis. 2021;21:183–205.
J Am Dent Assoc 2012;143:847–857. 11. Shiau YY, Paradowska-Stolarz A. Reported concepts for the
4. Eliassen M, Hjortsjö C, Olsen-Bergem H, Bjørnland T. Self-ex- treatment modalities and pain management of temporo-
ercise programmes and occlusal splints in the treatment of mandibular disorders. J Headache Pain. 2015;16:106.
TMD-related myalgia—Evidence-based medicine? J Oral Re- 12. T rp JC, Komine F, Hugger A. Efficacy of stabilization splints
habil 2019;46:1088–1094. for the management of patients with masticatory mus-
5. Fern ndez-N ez T, Amghar-Maach S, Gay-Escoda C. Effi- cle pain: A qualitative systematic review. Clin Oral Investig
cacy of botulinum toxin in the treatment of bruxism: System- 2004;8:179–195.
atic review. Med Oral Patol Oral Cir Bucal 2019;24:e416–e424. 13. van der Zaag J, Lobbezoo F, Wicks DJ, Visscher CM, Ham-
6. Forssell H, Kalso E. Application of principles of evidence- burger HL, Naeije M.J Controlled assessment of the efficacy
based medicine to occlusal treatment for temporomandibu- of occlusal stabilization splints on sleep bruxism. Orofac
lar disorders: Are there lessons to be learned? J Orofac Pain Pain 2005;19:151–158.
2004;18:9–22. 14. Zhang SH, He KX, Lin CJ, Liu XD, Wu L, Chen J, Rausch-Fan
7. Grymak A, Aarts JM, Ma S, Waddell JN, Choi JJE. Wear behav- X. Efficacy of occlusal splints in the treatment of temporo-
ior of occlusal splint materials manufactured by various meth- mandibular disorders: A systematic review of randomized
ods: A systematic review. J Prosthodont 2021;31:472–487. controlled trials. Acta Odontol Scand 2020;78:580–589.

Chapter_8_2.indd 789 13.04.23 16:55
790
Mouthguard Fabrication
1 2 3
8.4 Nightguards
Chapter_8_2.indd 790 13.04.23 16:55

791
5 6
7 8
Models first have to be mounted and articulated in the with the thermoformed foil is removed from the device (4).
thermoforming unit (eg, Erkoform 3D, Erkopress, Erkodent), The foil needs then to be cut at or above the larger teeth
eventually with a bite registration if models are not fully stable diameter to allow for easy mouthguard insertion/removal;
in the desired occlusal position (1). After the thermoforming this is usually performed with diamond disc (5) and/or heat-
foil reaches proper temperature, it is molded over the lower ing blade (6), depending on the foil type and thickness. A few
(or upper) model (2), and immediately thereafter, the antag- cuts are made with heated blade to remove the foil excess
onist is brought into occlusion (3). After cooling, the model material in multiple parts to prevent appliance breakage (8).

Chapter_8_2.indd 791 13.04.23 16:55
792
8.4 Nightguards
Chapter_8_2.indd 792 13.04.23 16:55

793
The thermoformed mouthguard needs then to have its Depending on the intended use (eg, day- or nightguard;
sides cleaned and smoothed to avoid any soft tissue me- protective or test mouthguard; “delicate patient”), the foil
chanical irritation or discomfort. A heated blade will leave thickness and quality may be adapted. We then use three
cut sides a little smoother than discs used mandatorily for different foil qualities. The first one (A) is the standard option
thick foils. A soft, abrasive disc (1) serves this purpose, cre- with 1.5 mm thickness; for patients with occlusal hypervigi-
ating perfectly smooth edges. The tray can be finally tried lance or very “sensitive” ones, the hybrid foil is indicated as it
on the model to assess proper fit and retention (2). It should provides both comfort from the soft internal layer and good
normally feel slightly more retentive than expected in mouth, protection though external hard shell. The merely soft foils
due to the rougher and softer model surface. (C) are mainly used as short-term protection during tempor-
ary phases as they allow some small anatomical corrections
to be done on restorations without making mouthguard ad-
aptation or change necessary.
A. Monolayer rigid and resistant foil B. Bilayer foil with hard shell and softer C. Monolayer, softer foil with varying
with varying thicknesses (usually 0.8 internal part with varying thicknesses thicknesses (2 mm; eg, Erkoflex-95)
or 1.0 mm initially and then 1.5 up to (usually 1.0 or 1.3 mm initially and then
2.0 mm; eg, Erkodur) 2.0 mm; Erkolock-Pro)

Chapter_8_2.indd 793 13.04.23 16:55
794
8.5
CHAPTER
8.5 Nightguards
Chapter_8_2.indd 794 13.04.23 16:55

Literature Review Longevity 795
lrl Longevity and Maintenance 8

8
Chapter_8_2.indd 795 13.04.23 16:55
796
Direct Composites Restorations (Annual Failure Rates)
29% *
8.5 Literature Review Longevity
Chapter_8_2.indd 796 13.04.23 16:55

797
Clinical studies related to the performance of direct bonding “minor failure” relates to suboptimal restoration quality that
techniques to treat tooth wear are summarized on the left can however be corrected by repair or repolishing without
page according to the treatment areas (anterior, posterior, or the need for restoration replacement, contrary to a “major
combination of both zones [mixed]) and observation period; failure” such as a recurrent decay or bulk fractures, which ap-
it is of interest to differentiate failure or success rates accord- pear very seldom in the given range of observation periods
ing to short-, medium-, or long-term periods of clinical ser- (1 to 11 years). In some cases, reports relate only to anterior
vice. As for the majority of clinical trials, there is some lack of restoration, such as in the application of the Dahl concept.
standardization in regard to evaluation criteria as well as re- Even if unrestored posterior teeth do normally retrieve con-
porting failures types. Some studies include minor failures in tacts after a period of a few months (see chapter 2), such ap-
their success rates, while other studies do not. Among other proach might lead to occluso-functional compromises that
confounding factors, clinical environment, number, and ex- negatively impact restoration longevity. It must also be said
perience of operators as well as calibration of observers limit that the inclusion of data coming from social clinics have ob-
the value and interest of computing an “average” success/ viously potential to increase AFR values.
failure rate. On the contrary, the most appropriate way to Notwithstanding the disparity of the clinical data re-
analyze and use the available data is to report minimum and ported here, our own experience based on the observation
maximum AFR (annual failure rate) values that allow for com- of several hundred restorations over up to 25 years con-
paring studies with different observation periods. firms the seldom occurrence of “major” failures when us-
In regard to the short-term studies, two studies included ing direct composite for treating limited to moderate tooth
data for microfilled composites (Hemmings et al, 2000; Bart- wear cases. In fact, material wear and occasional chipping
lett and Sundaram, 2006), which proved to be contraindi- of thin composite layers is part of the “interceptive” con-
cated for the treatment of tooth wear due to their significantly cept, which can be limited with nightguard compliance; we
inferior mechanical properties and wear resistance. This is can consider composite as a mechanical switch that pre-
why AFR values are relatively high as compared to medium- vents damage to natural tissues when needed. This treat-
and long-term studies. We notice logically an increase of AFR ment modality can then be considered the “gold standard”
values in studies reporting long-term behavior of composite in aforementioned tooth wear severity levels, without how-
in treating tooth wear, especially in case of parafunctions. ever overlooking individual tooth biomechanical status and
The conclusions of all studies presented are otherwise in the other individual clinical parameters such as described
good accordance and report primarily minor failure types; a in chapters 2 to 3.

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798
Indirect Restorations (Annual Failure Rates)
/ i ed i ect ndi ect PFM enee and c n

enee enee
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799
Only a very small number of studies investigated the monolithic ceramic restorations using different materials;
behavior of indirect restorations in the specific, critical this reports deals with tooth wear and AI (amelogenesis
environment of tooth wear pathologies. Then, the very imperfecta) cases but detailed the outcome for both condi-
limited available data do not allow for drawing clear trends tions. The failures rates proved actually lower for AI (AFR =
in regard to various material behavior that would support 0.2% at 3 years to 1.5% at 10 years) as compared to tooth
evidence-based clinical recommendations. The first study wear patients (AFR = 5.2% at 3 years to 4.0% at 10 years);
(Oudkerk et al, 2020) reported the use of PIGS (polymer infil- only major failures (red columns) were reported in this study
trated glass system) to restore moderate to severe cases; the (core fracture, secondary caries, chipping grade 3, or tooth
2-year outcome demonstrated a satisfactory outcome (AFR fracture).
= 2.8%) and only minor failures (green column). The second Despite again the inherent variability of restorative proto-
study (Vailati et al, 2013) deals with full mouth rehabilitation cols and evaluation scoring, one major trend emerges from
of moderate to severe tooth wear using a hybrid approach these results, namely that more extensive restorations lead
(direct and indirect composite restorations to reconstruct to more severe complications, while with direct composite
posterior occlusion and palatal surfaces of anterior teeth restorations, only minor failures occur. This is fully in line with
prior to facial ceramic veneers); the observation time went our own observations and documented behavior of various
up to 6 years, with an average 4.2-year follow-up. The re- restoration types presented in this chapter. Nevertheless,
ported outcomes are highly positive with no major failures one should not ignore the obvious impact of pretreatment
(ARF = 0%); no minor failures were even reported (“charlie” biomechanical status of teeth restored with indirect res-
and “delta” scores following United States Public Health torations as compared to those that could be treated with
Service [USPHS] criteria). The third study (Smales and Ber- a simpler direct composite (such as in the study by Smales
ekally, 2007) compared after 10 years of clinical service the and Berekally); in addition, the severity of tooth wear condi-
performance of direct composite restorations and gold/PFM tions that led to indirect rehabilitation is another factor that
crowns; the results showed slight higher failure rate of di- can trigger more severe failures. However, and despite the
rect composites (AFR = 3.8%; see previous double page) as latter considerations, fragilizing tooth structure due to con-
compared to crowns (AFR = 2.5%). However, failures with venience or technical principles when preparing teeth for
composites were minor ones, while it proved to be major partial or full prosthetic coverage should be considered an
ones with full crowns (red column). The fourth study (Klink absolute contraindication, and this is why hybrid treatments
et al, 2018) followed up to 10 years of partial and full bonded represent the safest way to manage tooth wear cases.

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800
References of Direct Composite Restorations Longevity Overview
1. Aljawad A, Rees JS. Retrospective study of the survival and pa- 7. Hemmings KW, Darbar UR, Vaughan S. Tooth wear treated with
tient satisfaction with composite Dahl restorations in the man- direct composite restorations at an increased vertical dimen-
agement of localised anterior tooth wear. Eur J Prosthodont sion: Results at 30 months. J Prosthet Den. 2000;83:287–293.
Rest Dent 2016;24:222–229. 8. Loomans BAC, Kreulen CM, Huijs-Visser HECE, et al. Clini-
2. Al-Khayatt AS, Ray-Chaudhuri A, Poyser NJ, et al. Direct com- cal performance of full rehabilitations with direct compos-
posite restorations for the worn mandibular anterior dentition: ite in severe tooth wear patients: 3.5 years results. J Dent
A 7-year follow-up of a prospective randomised controlled 2018;70:97–103.
split-mouth clinical trial. J Oral Rehabil 2013;40:389–401. 9. Milosevic A, Burnside G. The survival of direct composite res-
3. Attin T, Filli C, Imfeld C, Schmidlin PR. Composite vertical bite torations in the management of severe tooth wear includ-
reconstructions in eroded dentitions after 5.5 years: A case se- ing attrition and erosion: A prospective 8-year study. J Dent
ries. J Oral Rehabil 2012;39:73–79. 2016;44:13–19.
4. Bartlett D, Sundaram G. An up to 3-year randomized clinical 10. Ramseyer ST, Helbling C, Lussi A. Posterior vertical bite re-
study comparing indirect and direct resin composites used constructions of erosively worn dentitions and the “stamp
to restore worn posterior teeth. Int J Prosthodont 2006;19: technique”—A case series with a mean observation time of 40
613–617. months. J Adhes Dent 2015;17:283–289.
5. Gulamali AB, Hemmings KW, Tredwin CJ, Petrie A. Survival 11. Schmidlin PR, Filli T, Imfeld C, Tepper S, Attin T. Three-year
analysis of composite Dahl restorations provided to manage evaluation of posterior vertical bite reconstruction using direct
localised anterior tooth wear (ten year follow-up). Br Dent J resin composite—A case series. Oper Dent 2009;34:102–108.
2011;211:E9. 12. Smales RJ, Berekally TL. Long-term survival of direct and indi-
6. Hamburger JT, Opdam NJ, Bronkhorst EM, Kreulen CM, Roet- rect restorations placed for the treatment of advanced tooth
ers JJ, Huysmans M-C. Clinical performance of direct compos- wear. Eur J Prosthodont Restor Dent 2007;15:2–6.
ite restorations for the treatment of severe tooth wear. J Adhes 13. Tauböck TT, Schmidlin PR, Attin T. Vertical bite rehabilitation of
Dent 2011;13:585–593. severely worn dentitions with direct composite restorations:
Clinical performance up to 11 years. J Clin Med 2021;10:1732.
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801
References of Indirect Restorations Longevity Overview
1. Klink S, Groten M, Huettig F. Complete rehabilitation of com- 3. Smales RJ, Berekally TL. Long-term survival of direct and indi-
promised full dentitions with adhesively bonded all-ceramic rect restorations placed for the treatment of advanced tooth
single-tooth restorations: Long-term outcome in patients with wear. Eur J Prosthodont Restor Dent 2007;15:2–6.
and without amelogenesis imperfecta. J Dent 2018;70:51–58. 4. Vailati F, Gruetter L, Belser UC. Adhesively restored anter-
2. Oudkerk J, Eldafrawy M, Bekaert S, Grenade C, Vanheusden ior maxillary dentitions affected by severe erosion: Up to
A, Mainjot A. The one-step no-prep approach for full-mouth 6-year results of a prospective clinical study, Eur J Esthet Dent
rehabilitation of worn dentition using PICN CAD-CAM res- 2013;8:506–530.
torations: 2-yr results of a prospective clinical study. J Dent
2020;92:103245.
Other Recommended Readings
Ahmed KE, Murbay S. Survival rates of anterior composites in managing tooth wear: Systematic review. J Oral Rehabil 2016;43:145–153.
Mesko ME, Sarkis-Onofre R, Cenci MS, Opdam NJ, Loomans B, Pereira-Cenci T. Rehabilitation of severely worn teeth: A systematic review.
J Dent. 2016;48:9–15.
Kassardjian V, Andiappan M, Creugers NHJ, Bartlett D. A systematic review of interventions after restoring the occluding surfaces of anter-
ior and posterior teeth that are affected by tooth wear with filled resin composites. J Dent. 2020;99:103388.
VajaniD, Tejani TH, Milosevic A. Direct composite resin for the management of tooth wear: A systematic review. Clin Cosmet Investig Dent
2020:12;465–475.

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802
Conclusions
Tooth wear is a complex phenomenon, as it results from long-term clinical experience and provide useful, successful
physiologic and pathologic conditions, implying intricate clinical strategies and protocols to help patients, whatever
interactions of physical, neurologic, and psychologic pro- the level of tooth wear initially found. The vision of long-term
cesses; it is then by nature a multifactorial problem. Con- tooth wear management is indissociable from any treatment
trolling risk factors (key to preventing worsening of tooth approach; preventive measures then have to preclude any
wear) is rather complicated, owing overall to the limited pos- rehabilitation and should support the patient all the way to
sibilities for fully controlling highly acidic diets, psychiatric the next reevaluation.
disorders, parafunctional activities, and harmful oral habits Tooth wear management is a lifelong and dynamic en-
that unfortunately often act in synergy to trigger rapid tooth deavor, supporting an ongoing, main change of the dental
structure loss. Even defining a “threshold” that describes the team’s role in “treating” patients; we actually evolve toward
amount of tooth wear above which it should be considered the “dental coaching” vision, giving a larger role to education
a pathologic phenomenon is a source of controversy among and prevention rather than only handling pathologies when
specialists and confuses the profession, leading eventually they arise.
to even less prevention or delay of needed conservative When it comes finally to placing restorations when pre-
treatments. When it comes to making clinical decisions to vention proves insufficient, tissue conservation by maximiz-
manage patients showing abnormal erosion or attrition, ing no-prep protocols is key to long-term success in tooth
the relative “irrationality” and “inconclusiveness” of science wear treatments, next to using appropriately basic dental
leaves practitioners with no other choice than to use ex- biomechanical principles. Last but not least, applying the
perience, common sense, and logic to choose a treatment correct clinical protocols with optimal precision and dedica-
strategy. The hopeful meaningfulness of this publication tion will ultimately optimize the success and longevity of any
is to merge in vitro and in vivo research findings regarding rehabilitation of eroded and abraded dentitions.
various treatment and restorative material choices with our
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803
"Success in managing tooth wear lies in a well balanced use of limited scientific evidences, clinical
experience and the search for operative excellence... with a good dose of common sense"

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Didier DIETSCHI

Interceptive treatment approach

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Quintessenz Verlags-GmbH Quintessence Publishing Co Ltd

Editing: Quintessence Publishing Co, Inc, Batavia, IL, USA

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Dr Carlo Massimo SARATTI

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One of my most desired projects was to create a place to

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A 35-year-long journey within both the

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I also dedicate this book to my brother

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Chapter 2 Treatment Strategies 26

2.1 Treatment Strategies 28

Chapter 3 Occlusal and Functional Factors, Vertical Dimension of

Chapter 4 Direct Techniques 176

4.1 The Natural Layering Concept 180

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Chapter 6 Indirect Techniques 428

6.1 Adhesive Procedures 430

Chapter 7 CAD/CAM Techniques 540

Chapter 8 Longevity and Maintenance 584

8.1 Longevity and Follow-up 586

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Didier Dietschi & the author’s team

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Direct protocols for posterior restorations

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Chapter 2: pages 66–77 Chapter 5: pages 386–401 Chapter 8: pages 646–663

Chapter 4: 262–279 Chapter 8: pages 588–605 Chapter 8: pages 664–677

Chapter 4: 280–297 Chapter 8: pages 606–625 Chapter 8: pages 702–721

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Direct protocols for anterior restorations

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Ch 4: p 204–209 / 6: p 454–471 Chapter 4: pages 314–327 Chapter 6: pages 488–505

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Chapter 2: pages 78–91 Chapter 4: pages 360–379 Chapter 5: pages 386–401

Chapter 4: pages 314–327 Chapter 4: pages 360–379 Chapter 5: pages 402–425

Chapter 4: pages 336–359 Chapter 8: pages 746–761 Chapter 8: pages 606–625

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