Composite Resin Rehabilitation of Eroded Dentition in a Bulimic Patient: a Case Report

Transcription

1 CASE REPORT Pulition Composite Resin Rehilittion of Eroded Dentition in Bulimi Ptient: Cse Report Roerto C Sprefio, DM, DMD Privte prtie, Busto Arsizio, Itly Correspondene to: Dr Roerto C Sprefio Vi Indipendenz, 6; Busto Arsizio, Vrese, Itly e-mil: roertospre@tisli.it 28

2 SPREAFICO Pulition Astrt Eting disorders suh s ulimi nervos n hve signifint impt on the struture of the teeth. Gstri id not only uses enmel nd dentin to dissolve ut lso uses progressive deteriortion of dentl helth, whih leds to funtionl estheti nd iologil onsequenes. Aording to the lssi onepts of restortive dentistry, the rehilittion of suh linil ses will involve numerous full rowns nd root nl tretments, proess whih is expensive finnilly, iologilly, nd in terms of time. However, the development of resin omposite nd dhesive systems hs mde it possile, tody, to reonstrut teeth with miniml dentl preprtion. This rtile will look t the dentl tretment of ulimi ptient who hd numerous serious erosions with signifint loss of dentl tissue. All teeth were reonstruted with nno-hyrid resin omposite nd, s very little preprtion ws neessry, the teeth s vitlity ws mintined nd did not require lortory ollortion. Furthermore, ll iologil, funtionl, nd estheti requisites were suessfully met in very short period of time. (Eur J Esthet Dent 2010;5:28 48.) 29

3 CASE REPORT Pulition Introdution Sutrtive-dditive dentistry nd dditive dentistry Eting disorders suh s norexi nervos, ulimi nervos, nd their vrints re growing onstntly in developed ountries. 1,2 Bulimi nervos, in prtiulr, is mentl disorder hrterized the onsumption of exggerted quntities of food prior to its expulsion from the ody, usully through vomiting or sometimes with lxtives. Moreover, it is hrterized pthologil ontrol of ody weight whih gives rise to the ptient hving wrped pereption of their own ody. From dentl viewpoint, the illness is hrterized loss of enmel nd dentin, without the involvement of teri. When the ptient vomits, the gstri ids ome in ontt with the teeth nd dissolve the enmel nd dentin, resulting in dentl erosion. The degree of suh erosions is diretly linked to the durtion of the disorder nd the frequeny of vomiting. The loss of dentl tiisue rings with it onsequenes of iologil nture (sensitivity, pulpl exposure) nd funtionl (loss of nine nd inisor guidne) s well s estheti onsequenes. There is some disussion s to whether the tretment should only e rried out one the illness hs een resolved, or whether it should e undertken while the ondition is ongoing. Some elieve tht if the disorder persists, the erosions my spred eyond the ervil limits of the restortions. However, if preventive tretment nd tive tretment re well omined, this n hve enefiil effets the ptient, even while the disorder is ongoing. 3 Trditionlly, fixed prosthesis is sed on totl rown preprtion with onsequent srifie of sound tissue not diretly linked to the pthology whih led to the need tretment. This tretment hs een justified essentilly the need to rete spe to ommodte the prosthesis nd to ensure its durtion over time. In the dys ee the existene of dhesive dentistry, this ws the pproh nd the retention of the tooth ws gurnteed mro-retention. A totl rown preprtion mens srifiing the sound tissue, nd in some irumstnes root nl tretment is required, t gret iologil ost. Furthermore, trditionl prostheti dentistry is lso very expensive from finnil point of view. Idelly, dentistry should e dditive nd not sutrtive. Theree, only the lost tissues should e repled with n dhesive mteril with sound tissues retined. Sine the 1990s, these mterils nd dhesive tehniques hve improved enormously, 4 llowing the restortion to e retined without the need to prepre retentive vity. On the sis of this onept, the uthor will present the orl rehilittion of ulimi ptient using n dditive tretment in omposite without dentl preprtion nd whih does not require lortory ollortion, exept dignosti wxups. 30

4 SPREAFICO Pulition Cse report The ptient, 28-yer-old femle with 12- yer history of ulimi treted with psyhotherpy, hd een delred free of the illness 2 yers previously. The ptient omplined of estheti nd funtionl dentl prolems (sensitivity to het nd old, pin when hewing). She did not omplin of musulr or temporomndiulr rtiultion pin. The mndile showed norml moility, with no restritions or devitions on opening. The nterior nd nine guides were sent. There ws ler evidene of diffused erosions with notle loss of sustne, espeilly on the mxillry nterior teeth nd the mndiulr molrs. The periodontl ondition nd hygiene ws good. There were some defetive restortions. The spe mong the nterior teeth ws insuffiient future reonstrutions (Fig 1). d Fig 1 to d Preopertive view of 28-yer-old ptient, who hs suffered from ulimi 12 yers nd hs een free of the disese 2 yers. Erosions, with differing degrees of tissue loss re evident throughout the dentition. 31

5 CASE REPORT Pulition Aims of tretment The ims of restortive dentistry re to restore helth, funtion, nd esthetis with less invsive tretment. In ddition, ll ojetives should e sustinle s long s possile nd the osts should e ontined in order the tretment to e fdle s mny ptients s possile. There re vrious wys of hieving these ims. Trditionl tretment this prtiulr se would require numerous full rowns nd endodonti tretments, resulting in lot of tissue eing srified. Moreover, the high ost of suh tretment would mke it unfdle mny ptients, espeilly ptients so young. There is no pulished dt on the lifetime or inherent omplitions of this type of tretment in ptients of this ge, nd mny uthors wonder how often in their lifetimes they will e ed to re-do these types of restortions. 5 Reently, lterntive tretments to these trditionl rehilittions hve een pulished. In ses where there re lolized nd generlized erosions or rsions, these lterntive tretments exploit the dvntges of dhesive dentistry nd keep dentl preprtion to minimum Tretment pln The tretment pln is designed round the reonstrution of teeth tht hve een ffeted the erosive pthology with omposite resins. In the present se, this will e pplied indiretly (omposite shell tehnique 7 ) on the mxillry nterior teeth nd on mxillry first molr (tooth 26, omposite only). The other teeth were diretly reonstruted. The sequene of tretment ws the following: 1) root nl re-tretment of tooth 26 nd omposite reonstrution with only 2) reonstrution of the mxillry nterior teeth t n inresed vertil dimension of olusion 3) reonstrution of the olusl surfes of posterior teeth 4) reonstrution of the inisor orders on the mndiulr nterior teeth 5) reonstrution of the vestiulr surfes of the teeth ffeted erosions. Reonstrution of the mxillry nterior teeth Evlution of new olusl nd estheti pln Susequent to the loss of dentl struture, n inrese in the vertil dimensions of olusion is neessry in order to mke spe future reonstrutions. This inrese is worked out on the sis of the dignosti wxup. A 2 mm inrese on the rtiultor pin is suffiient to provide good ntomi m. On the molrs, this inrese retes 0.5 to 1 mm spe, suffiient the reonstrution of posterior teeth nd not requiring tooth preprtion. A dignosti wxup is reted in order to evlute the estheti nd phoneti prolems nd work out the olusl pln (Figs 2 nd ). A silione mtrix is onstruted on the wxup nd this is loded with selfuring omposite nd pplied diretly in the ptient s mouth. 32

6 SPREAFICO Pulition Fig 2 nd Dignosti wxup of the superior front teeth. The vertil dimensions re lengthened 2 mm, thus reting spe funtionl ntomil m. After few minutes the omposite is polymerized nd the silione mtrix is removed. At this point the estheti results n e ssessed (Figs 3 to e). The entrl inisors were not dominnt nd ould e lengthened on the wxup. This new m ws reprodued in the finl restortions (Fig 3f). It is preferle to use speil self-uring omposite resin (Protemp, 3M ESPE, St Pul, MN, USA; Cool Temp, Coltene Whledent, Altstätten, Switzerlnd); due to its elstiity, it n e esily removed nd produes very little het during setting. Frition of the nterior restortions A trnsprent silione mtrix ws relized on the modified dignosti wxup (Memosil 2, Hereus Kulzer, South Bend, IN, USA) (Figs 4 nd ). The model, whih reprodued the ptient s sitution, ws isolted with ltex-sed insultor (Ruer Sep, Kerr L, Ornge, CA, USA) (Fig 4). The omposite is pplied to the silione mtrix t thikness of pproximtely 0.5 mm. A quntity of dentin mss is pplied to the pltl surfe while enmel mss is pplied on the ul surfe. The silione guide is then repositioned on the model nd the omposite light ured through the trnsprent silione (Figs 5 to e). At this point, the element is removed from the model, light ured gin 40 seonds on eh side seprtely (Figs 6 to ). The restortions re then dpted to the model. Their length is shortened to the level of the erosions nd finlly finished nd polished (Figs 7 to f). 33

7 CASE REPORT Pulition d e f Fig 3 The silione mtrix otined from the wxup is filled with self-uring resin omposite, repositioned in the mouth nd left to hrden 3 minutes (). One the silione mtrix hs een removed, it is possile to evlute the olusl plne, the estheti result, nd the phontion ( nd ). The redued thikness nd elstiity of this omposite mkes it esy to remove. The ptient ee, nd 3 minutes fter the omposite mok up (d nd e). In ddition to signifint improvement in her smile the fe itself ppers more relxed nd youthful. However, the entrl inisors were not dominnt nd were theree lengthened pproximtely 1 mm (f). 34

8 SPREAFICO Pulition Fig 4 An impression try () is filled with trnsprent silione nd positioned on the dignosti wxup to otin silione mtrix (). Menwhile, the plster model whih reords the ptient s sitution is insulted with ltex-sed liquid (). 35

9 CASE REPORT Pulition d e Fig 5 A mss of enmel of out 0.5 mm is positioned on the ul surfe of the mtrix (), mss of dentin is pplied to the pltl surfe (), the mtrix is then re-pplied to the model (), nd the omposite is ured 40 seonds per surfe, through the trnsprent mtrix (d). A digrm is shown of the plement nd thiknesses of the msses of enmel nd dentin (e). 36

10 SPREAFICO Pulition Fig 6 The ul () nd pltl () side of the restortions ee proximl seprtion; the restortions were seprted nd repositioned on the model (). 37

11 CASE REPORT Pulition d e f Fig 7 The omposite shells re shped with disks nd urs nd shortened s fr s the level of erosions ( to ). Using silione mtrix otined from the wxup, the position of the restortions nd their orrespondene to the wxup is evluted (d). The restortions re finished nd polished (e nd f). 38

12 SPREAFICO Luting proedures Bee eing emented, the restortions re tried size, dpttion, nd position (Fig 8). Any gps will e filled with the dhesive ement. Bee pplying the ruer dm nd proeeding with the ementing, it is neessry to selet the dentin to e used s ement nd to deide whether the olor nd sturtions re dequte (Figs 8 nd ). After pplition of the ruer dm, the teeth re lened with fluoride-free pste. No preprtion of the teeth is required. The dhesive proedure uses threestep eth nd rinse system. A lyer of onding is pplied to the internl prt of the restortion nd to the externl orders, without uring. The restortion is then generously filled with the hosen dentin nd pplied to the tooth. The exess omposite n e modeled on the tooth nd restortion so s to otin smooth trnsition from nturl tooth to restortion. Eh surfe is ured 40 seonds using high power irrdition method nd the sme proedures re then pplied to ll of the remining teeth. When ll restortions hve een luted, the teeth n e polished with rsive disks, rsive interproximl strips, nd ruer points (Fig 9). Pulition Fig 8 The restortions re tried on. Any gps will e filled during the dhesive ementtion (). Bee the luting proedures, the restortion is filled with dentin mss nd positioned onto the tooth (). It is now possile to see the finl spet nd, if neessry, mke hnges to the olor or sturtion of the dentin mss whih will e used ementing. Using the silione mtrix, the orret position of the restortion is heked (). The omposite is then refully removed from the restortion. 39

13 CASE REPORT Pulition d e Fig 9 After isolting the opertive field with ruer dm, the teeth re refully lened using ups, rushes, nd non-fluoride prophylxis pste (). The dhesion proedure ontinues using three-step dhesive system. A lyer of onding is pplied with rush to the inside of the restortion nd is not ured ut filled with mss of dentin (), nd positioned on the tooth (). Any exess of omposite is spred over the restortion nd tooth with sptul nd rush in order to otin smooth mrgins without gps (d). One the restortion hs een polished, the sme proedure is then rried out the other restortions. The restortions 2 dys fter ementtion (e). 40

14 SPREAFICO Pulition Restortion of posterior nd mndiulr nterior teeth Following the inrese in the vertil olusl dimension, the posterior teeth do not mke ontt (Fig 10). Two dys fter the mxillry nterior restortions hve een emented, work n egin on the posterior nd mndiulr nterior teeth. The olusl surfes nd some of the vestiulr surfes will need to e reonstruted For olusl surfes, this n e rried out ermi or omposite overly, either with the indiret method or pplying mtrix-guided omposite 8,9,11, or using trditionl diret tehnique. Severl uthors hve otined high suess rte in the medium term using the diret tehnique to reonstrut teeth tht hve een sujeted to erosions or rsions. 12,13 Yet nother reserh pper hs demonstrted tht miro-filled omposites pplied either diretly or indiretly re not suitle reonstruting posterior rded or eroded teeth. 14 In the present se, ll reonstrutions were rried out with nno-hyrid omposite pplied with the diret tehnique. Nturlly, the diret omposite reonstrution, hving no ntgonist referene, does present mjor diffiulties nd requires greter linil experiene. However, this tehnique is muh heper the ptient. Dentl preprtion is lso not neessry the reonstrution of premolrs. The omposite is pplied diretly nd reples the lost dentl tissue. Eh usp n e rereted with single lyer using smll mount of enmel mss (Figs 11 to f). Fig 10 nd Hving inresed the vertil olusl dimension, the posterior teeth re no longer in ontt. 41

15 CASE REPORT Pulition d e f Fig 11 Preopertive view of the mxillry premolrs (). The missing prt is repled with no preprtion; the restortion is retined through dhesion (). The pltl usp of the seond premolr is reonstruted with single lyer of enmel (). Reonstrution of the ul usp (d). The first premolr is then reuilt, using the sme proedure (e nd f). 42

16 SPREAFICO Pulition The molrs, due to the signifint loss of tissue, required greter numer of lyers (Fig 12). The erosions on the ul surfe of the posterior teeth were treted with no preprtion of the vities, ut rther simply pplying the resin omposite. The inisl mrgin of the nterior mndiulr teeth ws restored with diret omposite restortions (Fig 13). The olusion ws then djusted nd the ptient dismissed. Olusl hekups were rried out t 2 weeks, 1 month, nd 9 months (Figs 14 nd 15). d Fig 12 The qudrnt ee tretment (). The mesil surfe of the first molr is prepred euse of prtil frture of the mrginl ridge (). The dentin of the molrs hs een previously hyridized nd overed with lyer of flowle omposite to eliminte sensitivity. Adhesive proedures nd setionl mtrix in situ (). A thin lyer of flowle ompoite (d). A lyer of dentin (e). Lyering is ontinued with mss of enmel (f nd g). Lst enmel lyer (h). The restortions re now to e finished, nd polished. After removing the ruer dm, ny olusl djustments re mde (these will e very limited) (i nd j). 43

17 CASE REPORT Pulition e f g h i j 44

18 SPREAFICO Pulition d e f Fig 13 In order to void liquid pooling, whih ould mke the erosions worse, the nines nd inisors re treted with omposite resin (). After the dhesive proedures, the erosions re filled with mss of enmel ( to d). The result fter the removl of the ruer dm (e nd f). Olusl djustments re not needed. 45

19 CASE REPORT Pulition Fig 14 One-month hekup ( nd ). The restortions re esthetilly well-integrted with the ptient s fe (). Conlusions Non-rious pthologies, prtiulrly erosive lesions, re on the inrese in developed ountries nd tend to primrily strike young ptients. In the lssi order of events, tretment of these ptients would require the teeth to e reuilt using rowns, overlys, nd root nl tretment. This would involve gret loss of helthy dentl tissue s well s very high eonomi expense, whih young ptients n not lwys fd. Theree, there is need to investigte nd develop lterntive tretments tht n stisfy the iologil, funtionl, nd estheti requirements of these young ptients nd re oth relile nd long lsting. In reent yers, new strtegies the prevention nd tretment of erosive lesions hve een desried. 3,15 Improving dhesive mterils nd their reliility mkes it possile to provide lterntive tretments. At present, urrently ville resin omposites re muh improved from mehnil viewpoint nd, in ddition, offer exellent estheti qulities. These mterils re, in ft, le to reple missing tissue with very little dentl preprtion s hs een lerly shown in the present se history. The omposite shell tehnique treting upper nterior teeth, whih hs een doumented here, is not supported ny linil studies ut rises from personl experiene. 7 However, the tretment of posterior teeth with resin omposite or with porelin is something tht hs eome routine nd hs een proven to e relile lesions of rious nture. 46

20 SPREAFICO Pulition Fig 15 to e 9-month hekup. d e 47

21 CASE REPORT Pulition The tretment pplied to the present ptient, in short spe of time, met ll the requisites of restortive dentistry s well s the wishes of the ptient herself, nd ll in very few ppointments. Moreover, prt from the mnufture of dignosti wxup, ollortion with nother lortory ws not required nd the ost, oth iologil nd finnil, ws fr less thn it would hve een onventionl tretment. Moreover, ll of the desried tretment ws minimlly invsive nd llowed the possiility more invsive onventionl tretments in the future, should they e neessry. Nturlly, more time nd further studies will e required ee the positive shortterm permne desried here n e onfirmed. Aknowledgements The Author would like to thnk the lortory tehniin Mro Mntovn of Lortorio Odontotenio Grzini e Mezznzni the wxup presented in this rtile. Referenes 1. Beker AE, Grinspoon SK, Klinski A, Herzog DB. Eting disorders. N Engl J Med 1999;340: Hoek HW, Vndereyken W. Eting disorders; 25 yers of reserh nd tretment. Tijdshr Psyhitr 2008;50: Lussi A, Hellwig E, Gnss C, Jeggi T. Buonoore Memoril Leture. Dentl erosion. Oper Dent 2009;34: Vn Meereek B, De Munk J, Yoshid Y, Inoue S, Vrgs M, Vijy P et l. Buonoore Memoril Leture. Adhesion to enmel nd dentin: urrent sttus nd future hllenges. Oper Dent 2003;28: Vilti F, Belser UC. Full-mouth dhesive rehilittion of severely eroded dentition: the three-step tehnique. Prt 1. Eur J Esthet Dent 2008;3: Mgne P, Mgne M, Belser UC. Adhesive restortions, entri reltion, nd the Dhl priniple: minimlly invsive pprohes to lolized nterior tooth erosion. Eur J Esthet Dent 2007;2: Rotondo T. 4th Swiss Symposium on Estheti Dentistry, Montreux, Switzerlnd, My Vilti F, Belser UC. Full-mouth dhesive rehilittion of severely eroded dentition: the three-step tehnique. Prt 2. Eur J Esthet Dent 2008;3: Vilti F, Belser UC Full-mouth dhesive rehilittion of severely eroded dentition: the three-step tehnique. Prt 3. Eur J Esthet Dent 2008;3: Dietshi D. Optimizing smile omposition nd esthetis with resin omposites nd other onservtive estheti proedures. Eur J Esthet Dent 2008;3: Shmidlin PR, Filli T, Imfeld C, Tepper S, Attin T. Three-yer evlution of posterior vertil ite reonstrution using diret resin omposite se series. Oper Dent 2009;34: Hemmings KW, Drr UR, Vughn S. Tooth wer treted with diret omposite restortions t n inresed vertil dimension: results t 30 months. J Prosthet Dent 2000;83: Poyser NJ, Briggs PF, Chn HS, Kelleher MG, Porter RW, Ptel MM. The evlution of diret omposite restortions the worn mndiulr nterior dentition linil permne nd ptient stisftion. J Orl Rehil 2007;34: Brtlett D, Sundrm G. An up to 3-yer rndomized linil study ompring indiret nd diret resin omposites used to restore worn posterior teeth. Int J Prosthodont 2006;19: Lussi A, Jeggi T, Shffner M. Prevention nd minimlly invsive tretment of erosions. Orl Helth Prev Dent 2004;2(Suppl 1):

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