CLINICAL APPLICATION Puliction Full-Mouth Adhesive Rehilittion of Severely Eroded Dentition: The Three-Step Technique. Prt 1. Frncesc Vilti, MD, DMD, MSc Senior Lecturer, Deprtment of Fixed Prosthodontics nd Occlusion School of Dentl Medicine, University of Genev Switzerlnd Urs Christoph Belser, DMD, Prof Dr med dent Chirmn, Deprtment of Fixed Prosthodontics nd Occlusion School of Dentl Medicine, University of Genev Switzerlnd Correspondence to: Dr Frncesc Vilti University of Genev, Deprtment of Fixed Prosthodontics nd Occlusion, Rue Brthelemy-Menn 19, 1203 Genev, Switzerlnd; e-mil: frncesc.vilti@medecine.unige.ch. 30
VAILATI/BELSER Puliction Astrct Trditionlly, full-mouth rehilittion sed on full-crown coverge hs een the recommended tretment ptients ffected severe dentl erosion. Nowdys, thnks to improved dhesive techniques, the indictions crowns hve decresed nd more conservtive pproch my e proposed. Even though dhesive tretments simplify oth the clinicl nd lortory procedures, restoring such ptients still remins chllenge due to the gret mount of tooth destruction. To fcilitte the clinicin s tsk during the plnning nd execution of full-mouth dhesive rehilittion, n innovtive concept hs een developed: the three-step technique. Three lortory steps re lternted with three clinicl steps, llowing the clinicin nd the lortory technicin to constntly interct to chieve the most predictle esthetic nd functionl outcome. During the first step, n esthetic evlution is permed to estlish the position of the plne of occlusion. In the second step, the ptient s posterior qudrnts re restored t n incresed verticl dimension. Finlly, the third step reestlishes the nterior guidnce. Using the three-step technique, the clinicin cn trnsm full-mouth rehilittion into rehilittion individul qudrnts. This rticle illustrtes only the first step in detil, explining ll the clinicl prmeters tht should e nlyzed ee inititing tretment. (Eur J Esthet Dent 2008;3:30 44.) 31
CLINICAL APPLICATION Puliction Fig 1 ( nd ) Severely eroded dentition in 27-yer-old ptient. Ptients ffected severe dentl erosion often present with n extremely dmged dentition, especilly in the nterior mxillry qudrnt. The verticl dimension of occlusion (VDO) my hve decresed, nd supreruption my hve occurred. If erosion is not intercepted t n erly stge, fullmouth rehilittion my e required. According to the ville literture (cse reports only), the recommended therpy comprises oth extensive elective root cnl tretment nd full-crown coverge of lmost ll teeth. 1 3 However, this pproch my e too ggressive considering tht the popultion ffected erosion is generlly very young (Fig 1). When 14-yer-old ptient receives full-mouth conventionl rehilittion, such s in recently pulished report, 2 the following questions should e considered: How mny times will these crowns hve to e replced in the future, nd wht will e the prognosis of such teeth? How mny of the teeth will remin vitl? How mny will ecome nonrestorle (Fig 2)? Fig 2 Pnormic rdiogrph of 70-yer-old ptient with hevily restored dentition. The ptient received his first full-mouth rehilittion t the ge of 50. 32
VAILATI/BELSER Puliction The current literture does not nswer these questions. No long-term follow-up studies of similr cses re ville. Consequently, ee proposing conventionl full-mouth rehilittion to young individuls ffected erosion, clinicins should consider more conservtive pproches. In this context, improved dhesive techniques my e vlid lterntive, t lest to postpone more invsive tretments until the ptient is older. 4 7 The dhesive pproch preserves more tooth structure nd voids elective endodontic therpy. In ddition, in the uthors opinion, the esthetic outcome of teeth restored with onded porcelin restortions is superior to tht chieved with cemented crown restortions. Further, gingiv seems to interct etter with the mrgins of onded veneers thn with the mrgins of cemented crowns, resulting in less inflmmtion or drk colortions. However, while severl uthors hve documented long-term follow-up conventionl fixed prostheses, 8 17 there is lck of comprle long-term dt on full- mouth dhesive restortions. Consequently, the dete is still open on whether possily less durle dhesive rehilittion is preferle to longer-lsting ut more ggressive conventionl tretment. For this reson, clinicl tril is underwy t the University of Genev. All ptients ffected generlized erosion re systemticlly nd exclusively treted with dhesive techniques, using onlys the posterior region nd onded lminte veneers the nterior region. The gol is to evlute the longevity of dhesive rehilittions ee proposing this tretment s the new stndrd of cre. The three-step technique To chieve mximum preservtion of tooth structure nd the most predictle esthetic nd functionl outcomes, n innovtive concept hs een developed: the threestep technique (Tle 1). Three lortory steps re lternted with three clinicl steps, llowing the clinicin nd dentl Tle 1 The three-step technique Lortory Clinicl Mxillry vestiulr wxup Step 1: Esthetics Assessment of occlusl plne Posterior occlusl wxup Step 2: Posterior support Cretion of posterior occlusion t n incresed VDO Mxillry nterior pltl onlys Step 3: Anterior guidnce Reestlishment of finl nterior guidnce 33
CLINICAL APPLICATION Puliction technicin to constntly interct during the plnning nd execution of full-mouth dhesive rehilittion. In the first lortory step, insted of full-mouth wxup, the technicin is instructed to wx up only the vestiulr spect of the mxillry teeth (estheticlly driven wxup). Afterwrds, the clinicin will check if the wxup is cliniclly correct using mxillry vestiulr mockup (first clinicl step). During the second lortory step, the technicin focuses on the posterior qudrnts, creting posterior occlusl wxup to determine new VDO. The second clinicl step is to give the ptient stle occlusion in the posterior qudrnts t n incresed VDO, closely reproducing the occlusl scheme of the wxup. With the use of silicon keys duplicting the wxup, ll four posterior qudrnts will e restored with provisionl posterior composites. Finlly, the third step dels with the reconstruction of the pltl spect of the mxillry nterior teeth (restortion of the nterior guidnce) ee restoring the vestiulr spect with onded porcelin restortions. In this rticle, only the first step is discussed. Tretment plnning Unrelistic ptient expecttions re often contrindiction to dentl tretment. However, wht seems to e n unrelistic expecttion my in fct e poorly expressed expecttion or n expecttion tht is misunderstood the clinicin. Even when there is seemingly perfect three-wy communiction (ptient/clinicin/technicin), there is lwys potentil misunderstndings, especilly when deling with ptients who re ccustomed to viewing themselves with smll, eroded teeth. The importnce of predictle result tht stisfies oth the ptient nd clinicin cnnot e stressed enough in tody s world of estheticlly demnding ptients. Surprisingly, mny clinicins still decide on the esthetic outcome their ptients, nd thus the result seldom meets the ptient s expecttions. A structured strtegy to minimize such n esthetic defet is to devote sufficient time to educte ptients out the tretment options nd expected results. The first step of this three-step technique is conceived to gurntee tht the clinicin nd technicin s vision the plnned restortion is reflection of the ptient s true desires. Step 1: Mxillry vestiulr wxup nd ssessment of the occlusl plne Generlly, t the eginning of full-mouth rehilittion, the clinicin will provide the lortory technicin with the dignostic csts nd request full-mouth wxup. Since ech prmeter, such s incisl edges, teeth xes, teeth shpes nd sizes, occlusl plne, etc, is esily controlled, wxing oth the mxillry nd mndiulr rches is not difficult tsk. Clinicins should relize, however, tht lortory technicins will often ritrrily decide on these prmeters without seeing the ptients nd with misleding lck of reference points (eg, djcent intct teeth). Untuntely, decision sed only on dignostic csts is extremely risky, since dentl restortion tht ppers perfect on the cst my e cliniclly indequte. One method to ensure tht everyone is on the sme pge is the use of mockup, technique tht mkes it possile to nticipte the finl shpe of the teeth in the mouth. Severl uthors hve lredy 34
VAILATI/BELSER Puliction Fig 3 Frontl () nd profile () views of 45-yer-old ptient ffected gstric reflux. e the severe generlized tooth destruction s result of the dentl erosion. c d Fig 4 Both trditionl mockup (covering only the mxillry nterior teeth) ( nd ) nd mxillry vestiulr mock-up (from second premolr to second premolr) (c nd d) were used to evlute esthetics. With the trditionl mockup, the nterior teeth ppered too long, nd the ptient disliked their length nd shpe. Once the mockup ws extended to the premolrs, the ptient rted the sme nterior teeth s estheticlly plesing. proposed the use of mockup veneer restortions of nterior teeth. 18,19 In cses of severe generlized destruction of the dentition, mockup of only the nterior teeth could e misleding, since the teeth will pper inhrmonious with the unre- stored posterior teeth. Insted, mockup tht involves ll mxillry teeth my e more pproprite pproch (Figs 3 to 5). To otin mockup of ll mxillry teeth is not necessry t this initil stge to hve full mouth wx-up. In fct, the three-step 35
CLINICAL APPLICATION Puliction c Fig 5 Fcil views ee () nd fter ( nd c) the mxillry vestiulr mockup. Fig 6 ( nd ) Mxillry vestiulr wx-up. e tht the cingul nd the pltl cusps re not included. In this ptient, the vestiulr spects of oth the first mxillry molrs were intct nd thus not included in the wxup. technique proposes tht the technicin should wx up only the vestiulr surfce of the mxillry teeth. To sve time nd fcilitte the next clinicl step, neither the cingul of the nterior mxill nor the pltl cusps of the mxillry posterior teeth re included. In situtions where the vestiulr spect of the first molrs ws not ffected the erosion, the technicin my stop the wxup t the level of the premolrs (Fig 6). The mxillry second molr is never included in the wxup. At the completion of the mxillry vestiulr wxup, the first clinicl step (mxillry vestiulr mockup) is introduced so tht the clinicin cn confirm the direction tken the technicin. The fctors tht should e considered during this ssessment will now e discussed. Incisl edges Ptients re often shocked the incresed length of the incisors selected the clinicin nd technicin. After yers of seeing themselves with compromised dentition, mny ptients cnnot immedi- 36
VAILATI/BELSER Puliction c Fig 7 ( to c) When n incresed VDO is plnned, the position of the occlusl plne is decided ritrrily the technicin. Often, the otined spce is shred eqully etween the two rches, with consequent chnge of position of the occlusl plne (lower position). This ritrry decision cn compromise the esthetic outcome in ptients with preexisting reverse smile. tely dpt to more voluminous teeth. Often, ptients will eventully gree to such chnge if they re llowed to test the new teeth; however, some ptients will never ccept it. Clinicins cnnot impose their personl opinions onto their ptients, ut they cn try to guide the ptient in mking n inmed decision. The mockup represents n excellent opportunity ptients nd clinicins to truly understnd ech other s points of view. The mockup covering the teeth cn e shortened or lengthened (using flowle composite), nd their shpe cn e modified. If mjor chnges re mde, n lginte impression cn e tken to guide the technicin. Occlusl plne The innovtive spect of the three-step technique is the extension of the mockup to the vestiulr spect of the mxillry posterior teeth. The inclusion of the four premolrs is crucil, not only to visulize their uccl spect in comprison with the nterior teeth (vestiulr hrmony), ut lso to relte the plne of occlusion to the incisl edges. Mxillry incisl edges nd the occlusl plne should e in hrmony n optiml esthetic nd functionl result. In frontl, smiling view, the cusps of the posterior teeth should follow the lower lip nd e locted more cerviclly thn the incisl edges. Otherwise, n unplesnt, reverse smile is generted. When n increse of the VDO is nticipted in full-mouth rehilittion, the question of how to divide the extr interocclusl spce is generlly nswered shring the spce eqully etween the mndiulr nd mxillry rches. However, such decision is completely ritrry nd my led to repositioning of the occlusl plne t lower level thn the originl. Untuntely, in cses of erosion, the loss of tooth structure is often compensted supreruption, especilly in the mxillry posterior region nd mndiulr nterior region. One gol of fullmouth rehilittion should e the correction of such sitution. The technicin must know to wht extent the incisl edges cn e lengthened ee deciding on the occlusl plne s position nd wxing up the posterior qudrnts. A mxillry vestiulr mockup, which visulizes oth the incisl edges nd the uccl cusps of the posterior teeth, cn help verify the orienttion of the future occlusl plne (Figs 7 nd 8). 37
CLINICAL APPLICATION Puliction c d e f Fig 8 ( to f) Bee nd fter views of 27-yer-old ptient with history of gstric cid reflux. The mockup reestlished the hrmony etween the occlusl nd incisl plnes. 38
VAILATI/BELSER Puliction Fig 9 ( to c) If crown-lengthening surgery is nticipted, the mockup cn help visulize the mount of ttchment to e removed. c Hrmony with the mxillry molrs If the wxup is stopped t the level of the mxillry premolrs, it will e possile during the mxillry vestiulr mockup to evlute how the unrestored molrs will lend in with the restortion plnned the premolrs. The lip disply will lso preview the visiility of the uccl mrgins of the future restortions (onlys) the molrs. Emergence profile nd gingivl levels At the time of the wxup, the clinicin nd technicin cn determine whether crown lengthening is needed (Figs 9 nd 10). To confirm if mucogingivl surgery is necessry nd to wht extent, the technicin should wx the cervicl spect of the future restortions overlpping the gingiv of the cst. Consequently, the teeth of the mockup will cover the gingiv of the ptient. Their emergence profile will e slightly ltered, ut they will still provide good sense of the finl outcome to oth the clinicin nd the ptient. 39
CLINICAL APPLICATION Puliction The mxillry vestiulr mockup is quickly nd esily fricted in the ptient s mouth nd offers the possiility to concretely visulize the finl outcome. A silicon key should e mde from the mxillry vestiulr wxup nd loded with tooth-colored mteril in the ptient s mouth (Fig 11). After its removl, ll vestiulr surfces of the mxillry teeth will e covered thin lyer of composite, reproducing the shpe selected the future restortions with the wxup. In our clinic, the mteril of choice is Protemp (3M ESPE), resin composite tht genertes limited exothermic rection nd is esy to dispense nd less suject to porosity thn polymethyl metcrylte. Since the cingul of the nterior teeth nd the pltl cusps of the posterior teeth re not included in the wxup, the silicon key will e stle in the mouth. It will lso e stilized on oth sides the unrestored second molrs (distl stops). Due to the key s close dpttion, excess mteril will e miniml nd esy to remove using sclpel or scler (Fig 12). It is not recommended to remove nd re Fig 10 ( nd ) After surgery, the mockup cn e used to evlute the outcome. Bsed on the lip disply, the teeth to e involved in the surgery cn e selected, nd the ptient cn mke n inmed decision whether to ccept the surgery. This presurgicl mockup cn e powerful tool to convince reluctnt ptients. In these cses, the compromised result could lso e visulized with nother mockup, this time without the gingivl overlp. Numer of teeth involved in the rehilittion Sometimes, ptients re not fully wre of the level of destruction of their dentition. Motivted primrily esthetics, ptients my elieve tht stisfctory result cn e chieved focusing only on the nterior teeth, nd thus they will not e interested in more comprehensive tretment pln. To void investing unnecessry time nd money, mxillry vestiulr mockup could e used. The mockup covering the posterior teeth could then e removed, leving the ptient with the mockup of only the six nterior teeth. While some of these ptients will still run wy s nticipted, others will e convinced to ccept the more extensive tretment. Clinicl steps the mxillry vestiulr mockup 40
VAILATI/BELSER Puliction Fig 11 ( nd ) A silicone key of the mxillry vestiulr wxup is fricted nd loded with tooth-colored provisionl resin composite. Fig 12 ( to c) Due to the key s close dpttion, very little excess will e present fter its removl. e the shortening of the cnines (c) The mockup cn e esily modified in the ptient s mouth. C cement the mockup, ecuse this my rek it or distort its ppernce. The mockup is stilized excess mteril in the retentive res (interproximlly). The clinicin, however, should py prticulr ttention to tht excess, since it cn interfere 41
CLINICAL APPLICATION Puliction c d e f Fig 13 ( to f) Bee nd fter views of 27-yer-old femle ptient. Without the mockup, it ws difficult to evlute her smile, since she ws uncomtle showing her dmged teeth. 42
VAILATI/BELSER Puliction with the ptient s norml orl hygiene procedures. The chllenge is to open the gingivl emrsures just enough to llow dentl floss (eg, SuperFloss, Orl B) to pss through without jeoprdizing the strength of the mockup. It is lso recommended to ccurtely remove the excesses t the level of the uccl gingivl sulci to etter understnd the emergence profile nd gingivl hrmony of the future restortion. The ptient cn leve the office wering the mockup short time to show it to fmily memers nd friends. Due to its miniml thickness, the mockup will eventully rek off, mking it esily removle the ptient. After evluting the mxillry vestiulr mockup in the ptient s mouth (Fig 13), ny chnges cn e mde the technicin, who will then progress with the second lortory step. Conclusions Ptients ffected severe dentl erosion often present severely dmged dentition. However, the trditionl restortive pproch (full-mouth rehilittion with crowns) my e too ggressive this generlly young ptient popultion. In the uthors opinion, n dhesive pproch should e preferred to preserve tooth structure nd postpone the more invsive tretments until the ptient is older. Even though dhesive techniques simplify oth the clinicl nd lortory procedures, restoring such ptient still remins chllenge due to the mount of tooth destruction. To chieve mximum preservtion of the tooth structure nd the most predictle esthetic nd functionl outcome, n innovtive concept hs een developed: the three-step technique. The threestep technique is simplified pproch tht emphsizes interdisciplinry collortion etween the clinicin nd lortory technicin. In this rticle, only the first step of the technique ws descried. By using simple mxillry vestiulr mockup, the lortory technicin cn gin precious inmtion, nd the tretment of severely eroded dentition cn egin in less ritrry wy. The time-consuming initil dignosis should not discourge the clinicin, since the ptient s full prticiption in ny decision-mking process is extremely vlule. Indeed, llowing ptients to visulize the finl result ee tretment egins oth ressures them nd helps them ccept more comprehensive tretments. Acknowledgments The uthors would like to thnk Dr Pierre-Jenne Loup, School of Dentl Medicine, University of Genev, his expertise in prodontology The uthors lso thnk the lortory technicins nd cermists, Sylvn Crciofo nd Dominique Vinci, School of Dentl Medecine, University of Genev, the excellent lortory support. References 1. Kvour V, Kourtis SG, Zoidis P, Andritskis DP, Doukoudkis A. Full-mouth rehilittion of ptient with ulimi nervos. A cse report. Int 2005;36:501 510. 2.Vn Roekel NB. Gstroesophgel reflux disese, tooth erosion, nd prosthodontic rehilittion: A clinicl report. J Prosthodont 2003;12:255 259. 3.Bonill ED, Lun O. Orl rehilittion of ulimic ptient: A cse report. Int 2001;32: 469 475. 4.Hyshi M, Shimizu K, Tkeshige F, Eisu S. Restortion of erosion ssocited with gstroesophgel reflux cused norexi nervos using cermic lminte veneers: A cse report. Oper Dent 2007;32:306 310. 5.Lussi A, Jeggi T, Schffner M. Prevention nd minimlly invsive tretment of erosions. Orl Helth Prev Dent 2004;2 Suppl 1:321 325. 43
CLINICAL APPLICATION Puliction 6. Sundrm G, Brtlett D, Wtson T. Bonding to nd protecting worn pltl surfces of teeth with dentine onding gents. J Orl Rehil 2004; 31:505 509. 7. Hstings JH. Conservtive restortion of function nd esthetics in ulimic ptient: A cse report. Prct Periodontics Aesthet Dent 1996;8:729 736. 8. Vn Nieuwenhuysen JP, D hoore W, Crvlho J, Qvist V. Long-term evlution of extensive restortions in permnent teeth. Dent 2003;31:395 405. 9. Wlton TR. An up to 15-yer longitudinl study of 515 metlcermic FPDs: Prt 1. Outcome. Int J Prosthodont 2002; 15:439 445. 10. Wlton TR. A 10-yer longitudinl study of fixed prosthodontics: Clinicl chrcteristics nd outcome of single-unit metlcermic crowns. Int J Prosthodont 1999;12:519 526. 11. Vlderhug J, Jokstd A, Amjornsen E, Norheim PW. Assessment of the peripicl nd clinicl sttus of crowned teeth over 25 yers. J Dent 1997;25:97 105. 12. Vlderhug J. A 15-yer clinicl evlution of fixed prosthodontics. Act Odontol Scnd 1991;49:35 40. 13. Krlsson S. Filures nd length of service in fixed prosthodontics fter long-term function. A longitudinl clinicl study. Swed Dent J 1989;13:185 192. 14. Wlton JN, Grdner FM, Agr JR. A survey of crown nd fixed prtil denture filures: Length of service nd resons replcement. J Prosthet Dent 1986;56:416 421. 15. Coornert J, Adriens P, De Boever J. Long-term clinicl study of porcelin-fused-togold restortions. J Prosthet Dent 1984;51:338 342. 16. Schwrtz NL, Whitsett LD, Berry TG, Stewrt JL. Unservicele crowns nd fixed prtil dentures: Life-spn nd cuses loss of serviceility. J Am Dent Assoc 1970;81: 1395 1401. 17. Pjetursson BJ, Brgger U, Lng NP, Zwhlen M. A systemic review of the survivl nd compliction rtes of llcermic nd metl-cermic reconstructions fter n oservtion period of t lest 3 yers. Prt I: Single crowns. Clin Orl Implnts Res 2007;18 Suppl 3:73 85. 18. Mgne P, Belser UC. Novel porcelin lminte preprtion pproch driven dignostic mock-up. J Esthet Restor Dent 2004;16:7 16. 19. Belser UC, Mgne P, Mgne M. Cermic lminte veneers: Continuous evolution of indictions. J Esthet Dent 1997;9: 197 207. 44
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