CASE REPORT

The use of indirect composite

veneers to rehabilitate patients with
dental erosion: a case report
Ramn Asensio Acevedo, DDS, MSc
Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

Jos Mara Suarez-Feito, MD, DMD, MClinDent, PhD

Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

Carlota Surez Tuero, DDS

Postgraduate student, Department of Restorative Dentistry and Endodontics, International
University of Catalonia, Barcelona, Spain

Luis Jan, MD, DMD, PhD

Department of Restorative Dentistry and Endodontics, International University of Catalonia,
Barcelona, Spain

Miguel Roig, MD, DMD, PhD

Chairman, Department of Restorative Dentistry and Endodontics, International University of Catalonia, Barcelona, Spain

Correspondence to: Ramn Asensio Acevedo

Department of Restorative Dentistry and Endodontics Josep Trueta s/n, 08195 Sant Cugat del Valls; Barcelona, Spain; Tel: 93 504
20 00; Fax: 93 504 20 01; E-mail: ramon@uic.es

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Abstract

and function has to be restored. Even

though there is no clinical evidence of

The evolution of restorative dental ma-

the appropriateness of indirect compos-

terials has led to the development of

ites in these treatments, the latest gen-

more direct or indirect conservative

eration of composites used indirectly in

techniques to solve both functional and

the anterior teeth exhibits some interest-

esthetic problems in anterior and poster-

ing characteristics: it supports mechan-

ior teeth. Several authors have conclud-

ical stress adequately, has an excellent

ed that indirect restorations are the tech-

esthetic result and can be repaired in-

nique of choice in complex cases where

traorally.

shape and colour are difcult to achieve

(Eur J Esthet Dent 2013;8:414431)

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Introduction

of treatment could be considered as

one part of a functional and esthetic

The dietetic habits and parafunctions as

rehabilitation of patients with a certain

a consequence of modern-day lifestyles

level of parafunction.14

have increased dental wear from a nonbacteriological origin (abrasion, erosion

and attrition).1

Case presentation

This has led to a loss of hard dental

tissue structure that can have biological

A 62-year-old woman with a gastric

(sensitivity, pulp exposure), functional

esophageal reux disease diagnosis

(loss of canine and incisal guidance)

came to the dental ofce for a second

and esthetic consequences.2 Accord-

opinion on her dental wear. The clin-

ing to the traditional protocols of restora-

ical examination revealed that the pa-

tive dentistry, the rehabilitation of such

tient had severe and generalized den-

clinical cases will involve numerous full

tal wear involving both the anterior and

crowns and root canal treatments, a pro-

posterior teeth. According to the ACE

cess that is both costly in biological and

classication, the patient was consid-

time-consuming terms.3-8 Nevertheless,

ered ACE class IV since the palatal den-

there is no scientic evidence as to the

tin was largely exposed and the clinical

biological consequences and biome-

crowns were more than 2 mm shorter,

chanics of these

treatments.9

while the facial enamel and the pulp vi-

The improvement of adhesive tech-

tality were still preserved.19 Some old

niques allows the use of restorations that

defective restorations and missing teeth

do not sacrice the dental structure.10

were also observed. No temporoman-

Depending on the efcacy of the adhe-

dibular joint pain was referred. The man-

sive procedures and the possible bio-

dibular range of movement was within

logical and mechanical complications

normal physiological parameters. Oc-

that traditional extensive procedures

clusal analysis showed that maximum

involve, minimally invasive alternatives

intercuspation was not coincidental with

using adhesive restorations have been

centric relation, as well as a reduced oc-

proposed.2,11-12

clusal table with unstable occlusal con-

Long-term studies have shown that

tacts. An absence of canine guidance

porcelain laminate veneers show excel-

with group function on the six upper an-

lent biocompatibility and chemical sta-

terior teeth and rst bilateral premolars

bility, as well as the ability to reproduce

during lateral movements was also pre-

the structure and translucency of nat-

sent. Interferences during excursive

teeth.13

The newly manufactured

movements were not found. Dental hy-

micro-hybrid composite, with improved

giene and periodontal conditions were

physical and mechanical properties,

not optimal, so the patient was referred

seems to allow the use of indirect com-

to the periodontist for a hygienic phase

posite veneers as an alternative to ce-

prior to restorative treatment and was

ramics.14-18 While there is no clinical ev-

instructed to maintain her oral hygiene

idence to support their use, this choice

post treatment (Figs 1 and 2).

ural

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Fig 1a

Fig 2

Initial situation frontal view.

Fig 1b

Initial occlusal view.

Periodontal

examination.

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Objectives
Since the patient rejected previous conventional restorative approaches offered
by other dentists (due to the invasive nature of the treatment and cost), the aim
was to restore the patients dental health,
function and esthetics with minimally invasive rehabilitation. Reparability of the
restorations and the cost were also taken into consideration. After discussion
of the restorative options, the patient
Fig 3a

Study casts frontal view.

and clinician opted for the treatment of

choice, which combines direct and indirect composite restorations for the teeth,
and implants in the edentulous areas.

Treatment sequence
Root canal treatment of tooth 1.2, followed by reconstruction using a ber
post to increase the adhesive surface
for the nal restoration.
Incisal edge reconstruction with a direct composite resin restoration in the
mandibular anterior teeth. Composite
resin restorations can provide a simpler but conservative and efcient
Fig 3b

Study casts left lateral view.

way to restore the worn mandibular

anterior dentition.20
Direct composite reconstruction of the
palatal surfaces of the maxillary anterior teeth to the established new vertical dimension of occlusion (VDO).
Gulamali et al have shown that the
use of direct composite resin restorations to treat localized tooth wear at
an increased VDO is a viable restorative option over a period of 10 years.21
Placement of indirect composite overlays in the posterior teeth. Indirect restorations permit a better control of the
anatomy, however, the literature has

Fig 3c

Study casts right lateral view.

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not shown a major clinical advan-

ASENSIO ACEVEDO ET AL

tage of composites over ceramics. It

seems that the material of choice is
more dependent on personal experience and belief than scientic or clinical evidence.22
Indirect restorations with composite
veneers on the vestibular faces of
maxillary anterior teeth. Current ne
micro-hybrid composites have improved chemical and physical properties offering better wear resistance
and optical results. Composites are
also

more

elastic

than

ceramics.

Fig 4a

Wax-up at an increased vertical dimen-

sion.

Thus, composites can be indicated in

patients with parafunctions.14

Planning the reconstruction

Upper and lower alginate impressions
were taken to mount a set of study casts
in a semi-adjustable articulator by means
of a face bow and a centric relation record
(Fig 3). A diagnostic wax-up was performed by previously increasing the VDO
in the articulator pin to enhance patient
incisal display and esthetics (Fig 4).23,24
By increasing the VDO, occlusal restorative space for the anterior and posterior

Fig 4b

Wax-up left lateral view.

Fig 4c

Wax-up right lateral view.

restorations will be gained, thus avoiding

the need for crown lengthening procedures and/or elective root canal treatments.
Moreover, the unfavorable overjet-overbite relationships of the anterior teeth developed in this type of patient will also be
modied, allowing the creation of a much
shallower anterior guidance with a noticeable reduction of the horizontal forces
acting upon them.25 Silicon indexes were
obtained from the wax-up to guide the
direct composite resin restorations of the
incisal edges of the mandibular anterior
teeth and the palatal and incisal edges of
the upper anterior teeth (Fig 5).

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Fig 5a

Upper silicon index for direct composite

Fig 5b

Lower silicon index for direct composite

resin restoration.

resin restoration.

Fig 6

Fig 7

Posterior indirect composite overlays.

Frontal view after direct restorations of an-

terior teeth and indirect overlays of posterior teeth.

Following the direct restorations of the

was created by a lower implant support

anterior teeth, the posterior teeth were

xed partial denture and some occlusal

restored by means of indirect compos-

adjustments of the uppers. Anterior guid-

ite overlays maintaining the new vertical

ance with a more favorable overjet and

dimension (Figs 6 and 7). Left posterior

overbite was performed to separate the

occlusion was established with indirect

posterior segments of the occlusion and

composite overlays on top of the occlusal

to promote the distribution of the forces

surfaces of the upper metal ceramic xed

over the anterior restorations.

partial denture and over the worn lower

Impressions were taken again, and

natural dentition. Right posterior occlusion

a new diagnostic wax-up of maxillary

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Fig 8

Diagnostic wax-up.

Fig 9

Preparation of the mock-up.

Fig 10a

Labial reduction using the mock up and

calibrated round diamond burs.

anterior teeth was made to reevaluate

Tooth preparation and impression

the occlusal plane, the contour and

taking

the emergence prole of the future indirect composite resin veneers (Fig 8).

Another mock-up was fabricated specic-

A mock-up with polimethylmethacrylate

ally to be used as a reduction guide for the

resin was made with the help of a new

preparations (Figs 9 and 10).28-30 The re-

silicon index taken from the nal wax-

duction was conrmed by a silicon index,

up.26,27

The aforementioned aspects

as recommended by Magne30 (Fig 11).

were directly tested in the oral cavity and

The nal impressions were taken using a

accepted by the patient.

polyvinylsiloxane material (Fig 12).

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Fig 10b

Fig 10d

Reduction grooves are marked with a pencil.

Incisal reduction with a donut bur.

Fig 10c

Incisal reduction grooves.

Fig 10e

Finishing and polishing of the margins

and axial surfaces.

Fig 10f

Polishing of the axial surfaces.

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Fig 10g

Final preparations.

ASENSIO ACEVEDO ET AL

Fig 11a

Assessment of the icisal reduction.

Fig 11b

Assessment of the labial reduction of

the gingival third.

Fig 11c

Assessment of the labial reduction of

Fig 12a

Polyvinil siloxane impression.

the middle third.

Fig 12b

Detail of the impression without removal

the retraction cord.

Fig 13

By using the same silicon index of the

diagnostic mock-up, direct acrylic provisional restorations were made.

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Fig 14a

Indirect composite resin veneers in

Fig 14b

Indirect composite resin veneers in

ADORO Ivoclar Vivadent.

ADORO Ivoclar Vivadent.

Fig 14c

Fig 15

Indirect composite resin veneers in

Color assessment of the veneers with a

ADORO Ivoclar Vivadent.

medium value try-in paste.

Fig 16a

Fig 16b

Sandblasting with aluminum oxide.

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Silanization.

ASENSIO ACEVEDO ET AL

Provisionalization
The provisional restorations were made
with the same silicon index used in the
mock-up, lled with polymethylmethacrylate provisional material (Fig 13).

Laboratory phase
The nal reinforced micro-hybrid composite resin restorations (Adoro Ivoclar)
were manufactured by a dental technician using a layering technique (Fig 14).

Fig 17a

Cementation was carried out under

complete rubber dam isolation.

Try-in
The try-in was performed with variolink
veneer try-in (Ivoclar Vivadent) pastes
to match the desired nal value of the
restorations (Fig 15).

Preparation of the restorations

and the tooth
Previous to the cementation, the restorations were sandblasted with 50 m
aluminium oxide particles for 3 seconds
at a distance of 5 mm and 2 pressure
bars, followed by the placement of two

Fig 17b

Etching with 35% phosphoric acid.

layers of silane dried for 1 minute under

hot air (Fig 16). The enamel was etched
with 35% orthophosphoric acid and the
composite resin was previously sandblasted as described before (Fig 17).
Then, a layer of silane was applied to
the composites and nally bonding was
placed (Fig 18).

Fig 18

Bonding application.

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Fig 19a

Bonding agent application.

Fig 19b

Photocure of the restoration.

Fig 19c

Photocure of the restoration.

Fig 19d

Aspect of the cemented restoration.

Cementation

Follow-ups

The veneers were then cemented, under

One week after nishing the treatment,

rubber dam isolation with photo-cured

an occlusal relief stent was given to the

resinous cement (Fig 19).

patient to control the possible consequences of attrition (Fig 20). A 9-month

Finishing and polishing

follow-up was set to evaluate the stabilization of the occlusion and the patients

The restorations were nished and pol-

capacity to maintain the oral environ-

ished with a no. 12 surgical blade and

ment free of bacterial plaque (Fig 21).

interproximal strips. The occlusion was

adjusted with laminate tungsten carbide
burs, rugby-ball 40 m diamond burs,
and silicon polishers.

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Fig 20a

Frontal view eight days after the cemen-

tation note the biological integration between the

Fig 20b

Intraoral frontal aspect of the newly ce-

mented restorations in occlusion.

restorations and the soft tissues.

Fig 20c

Left lateral view.

Fig 20d

Right lateral view.

Fig 20e

The palatal view shows the blending

Discussion
Treatment of patients with tooth wear currently represents a challenge from the restorative point of view due to increased
life expectancy, making it necessary to
maintain the natural dentition for a longer period of time. This has meant that
in the last decade, some authors have
begun to question the invasive nature of
conventional restorative treatments that
were carried out in these patients. Consequently, clinicians began to search for
more conservative alternatives based

between the direct lingual composite resin and the

labial indirect composite resin veneers.

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Fig 21a

Nine-month follow-up.

Fig 21b

Nine-month follow-up right lateral view.

Fig 21c

Nine-month follow-up left lateral view.

on dental adhesion that would extend

Since our patient demanded a more

the life of restored teeth. Although some

conservative restorative treatment plan

short- and medium-term studies have

as an alternative to other more invasive

been conducted on the use of such pro-

options offered by another professional,

cedures, there is still insufcient scientic

we considered the possibility of provid-

information to support their routine use.

ing a treatment based solely on adhe-

A series of cases have recently been

sive procedures.

published describing the use direct and

After explaining to the patient the lack

indirect composite resin and ceramic

of scientic evidence that would justify the

adhesive restorations.

use of adhesive procedures compared

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to conventional protocols, and consider-

Recommending the use of an occlusal

ing the minimally invasive nature of the

splint for night use after treatment in these

restorative procedure and the possible

patients does not guarantee its use rou-

biological and biomechanical complica-

tinely, neither would it control parafunc-

tions of the conventional treatment, the

tional forces that could be generated dur-

patient accepted the most conservative

ing the day. All this information has been

option and the risks it entailed.

considered when choosing the compos-

It is often difcult to establish the eti-

ite as a restorative material in this patient.

ology of dental wear, due to its multifac-

Some degree of composite discolora-

torial origin (attrition, erosion, abrasion,

tion and loss of surface luster can be

abfraction). Likewise, at times, it is also

observed in the 9-month follow-up pho-

difcult to determine the attrition de-

tographs. However, the age of the pa-

gree of involvement in the origin of tooth

tient and the potential advantages of the

wear.31 However, in this particular patient

mechanical performance of the material

the presence of poor occlusion with a

can compensate for such drawbacks.

reduced masticatory surface may have

In young patients with high esthetic de-

contributed to the presence of attrition.

mands, the use of this type of restoration

It is important to note that the greater

would be questionable.

the attrition as an etiological factor in the

Regarding the use of indirect com-

origin of tooth wear, the poorer the re-

posite resin veneers in this case, their

storative prognosis from the biomech-

low elasticity modulus and high capacity

anical point of view. Because the patient

to absorb functional stresses would re-

was diagnosed with gastro-esophageal

quire less reduction of tooth structure

reux, erosion was established as the

during preparation,33 which is an im-

main etiologic factor in tooth wear, but

portant issue when considering tooth

attrition was a secondary etiological fac-

structure loss through erosion. Besides

tor, due to the presence of wear facets

the advantages of biomechanical be-

compatible with attrition.

haviour, Mangani mentioned the follow-

The presence of attrition was one of

ing positive indications concerning the

the reasons we decided to use com-

use of indirect composite resin veneers

posite resin as a restorative material

versus ceramic:

since its elastic modulus is higher than

They allow for better absorption of the

that of ceramics.32 Thus, the compos-

polymerization stresses generated by

ite would allow for greater absorption

the cement during cementation pro-

of occlusal forces that could be gen-

cedures.

erated during possible parafunctional

The nishing and polishing proced-

movements. Additionally, while the new

ures are easier than with ceramic ve-

micro-hybrid composite is more wear-

neers.

resistant, the ceramic is even more

The laboratory procedures are easier,

resistant and can lead to increased

thus lowering the manufacturing cost.14

wear of the antagonists enamel. Furthermore, intraoral repair of composite

Composite resin veneers involve easier

resin restorations is easier.

laboratory procedures than ceramic ve-

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CASE REPORT

neers, even though veneers built with

and offers more favorable biomechan-

the refractory cast technique take less

ical conditions. However the technique

time than those manufactured with other

proposed in the case report should be

techniques. Generally, indirect restor-

taken into consideration as a possible

ations require a greater amount of time

alternative to conventional protocols.

and involve more technical difculties,

which explains the higher overall cost of
ceramic restorations.14

Conclusions

It is sensible and benecial to maintain pulpal vitality, prevent endodontic

The need for root canal treatment and

treatment, and avoid the need for a post

full-coverage crowns used by the trad-

and core restoration, because these

itional treatment protocols in patients

more invasive approaches violate the

with dental wear could create a bio-

biomechanical balance and compro-

logical and biomechanical compromise

mise the performance of restored teeth

of the restored teeth in the medium or

over time.34

long term. This has led to the develop-

A recently published case report ad-

ment of new minimally invasive restora-

vocates the use of monolithic lithium di-

tive procedures based on adhesion. With

silicate restorations in the rehabilitation

this approach, indirect composite resin

treatment of a patient with tooth wear.35

veneers may represent a further treat-

Although the author stresses the con-

ment option as part of a treatment plan

servative approach of the treatment

to rehabilitate patients with tooth wear.

(0.8 mm reduction) and the resistance

The use of such veneers also provides

to exion from 360 to 400 MPa, it is the

the advantages of esthetic properties,

authors belief that this approach still re-

biomechanics and economical cost for

quires less sacrice of tooth structure

the patient.

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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 8 NUMBER 3 AUTUMN 2013

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