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ACE Class I

Thinning of palatal enamel


Treatment:
No restorative
treatment

ACE Class II
Dentin exposure on the palatal
aspect (contact areas), no
damage to incisal edges Treatment:
Direct or indirect
palatal composites

ACE Class III


Dentin exposure on the palatal
aspect, damage to incisal edges
(< 2 mm) Treatment:
2 mm Palatal veneers

ACE Class IV
Extended dentin exposure on
the palatal aspect, loss of tooth
length (> 2 mm), preserved Treatment:
2 mm
facial enamel Sandwich approach

ACE Class V
Extended dentin exposure on
the palatal aspect, loss of tooth
length (> 2 mm), loss of Treatment:
facial enamel Sandwich approach
(experimental)

ACE Class VI

Advanced loss of tooth structure


leading to pulp necrosis Treatment:
Sandwich approach
(highly experimental)

The International Journal of Periodontics & Restorative Dentistry

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559

Classification and Treatment of the


Anterior Maxillary Dentition Affected by
Dental Erosion: The ACE Classification

Francesca Vailati, MD, DMD, MSc* In modern society, dental erosion has
Urs Christoph Belser, DMD, Prof Dr Med Dent** become one of the major causes of
the loss of mineralized tooth struc-
ture. Several surveys have pointed
out a high and still increasing preva-
lence, especially among young indi-
viduals (eg, 37% of 14-year-olds in
the United Kingdom present signs of
Erosive tooth wear is a serious problem with very costly consequences. palatal enamel erosion).1–12 Signs of
Intercepting patients at the initial stages of the disease is critical to avoid signifi-
dental erosion that may be easily evi-
cant irreversible damages to their dentition and to benefit from still favorable
dent at an early stage include:
conditions when it comes to clinical performance of the restorative measures
“glossy” (smooth, glazed) enamel,
proposed. In this article, a new classification is proposed to quantify the severity
yellowing of the teeth from the under-
of the dental destruction and to guide clinicians and patients in the therapeutic
decision-making process. The classification is based on several parameters lying dentin, increased incisal translu-
relevant for both the selection of treatment and the assessment of the prognosis, cency, and cupping of the occlusal
such as dentin exposure in the palatal tooth contact areas, alterations at the level surfaces. While the presence of den-
of the incisal edges, and ultimately, loss of pulp vitality. (Int J Periodontics tal caries normally leads clinicians to
Restorative Dent 2010;30:559–571.) take action immediately, in the case
of dental erosion, many clinicians pre-
fer to postpone any dental treatment
until the patient is older, even though
literature confirms that direct clinical
observation is an unreliable method
for monitoring the rates of tooth
wear.13,14 To play down this problem
*Senior Lecturer, Department of Fixed Prosthodontics and Occlusion, School of Dental
is frequently the preferred approach,
Medicine, University of Geneva, Geneva, Switzerland; Private Practice, Geneva,
Switzerland. which is understandable since many
**Chairman, Department of Fixed Prosthodontics and Occlusion, School of Dental clinicians do not feel comfortable
Medicine, University of Geneva, Geneva, Switzerland. proposing an extensive dental reha-
Correspondence to: Dr Francesca Vailati, rue Barthélemy-Menn 19, Geneva, Switzerland
bilitation to young individuals who
1205; email: francesca.vailati@unige.ch. are still asymptomatic and unaware of

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560

the problem. What such clinicians are each patient and to subsequently incisal edge may result, which
not considering, however, is that relate it to the appropriate treatment. depends strongly on the original over-
these patients sooner or later will bite and overjet configuration and on
need to restore their jeopardized the location of the occlusal contact
dentition anyway. The debate over Maxillary anterior teeth and area. For example, in a patient with a
whether it is preferable to start earli- dental erosion slight vertical overlap (overbite), the
er with a lighter, less invasive rehabil- risk of incisal fracture is very high
itation or later with a highly Disease progression because of the destructive combina-
aggressive but eventually more resis- tion of erosion and the focal attrition
tant one is still open. In the case of dental erosion, the of the antagonist teeth. In fact, at an
The aim of this article is to con- palatal aspect of the maxillary anteri- early stage of enamel erosion, chip-
vince clinicians that in the specific case or teeth usually appears to be the ping is frequently visible in the form of
of dental erosion, hesitation in under- most affected portion of the denti- irregularities at the incisal edges. On
taking the adequate treatment will tion, particularly in patients with an the other hand, in patients with a
inevitably lead to further degradation intrinsic etiology (eg, gastric reflux, deep bite interarch configuration, the
of the patient’s dentition. To persuade psychiatric diseases). At an early stage, maxillary anterior teeth may present a
the patients and to obtain informed acid-caused destruction can be very pronounced concave morphology on
consent for treatment, it is necessary subtle and thus difficult to discover their palatal aspect before any effect
to quantify the dental destruction and because of the somewhat hidden on the length of the clinical crown
to make a prognosis on the future location of the palatal tooth surfaces, manifests. In extreme situations, the
progression of the disease if no treat- especially if the disease progresses loss of the tooth structure may
ment would be undertaken. It would slowly. Patients frequently do not pre- become so extensive that the pulp
appear that the existing erosion sent signs of tooth sensitivity, even in chamber (or its original extent) can be
assessment indices and classifications the presence of dentin exposure. identified on the palatal aspect.
have not led to a broad respective Often, the erosive wear will manifest Surprisingly, such teeth frequently
awareness among dental care too late, when irreversible damage keep their vitality; however, they may
providers to date. This may be has already taken place and costly respond less quickly to the vitality test.
because these tools are rather com- restorative treatments are required. In advanced stages, when the
plex and difficult to use in a daily prac- At the initial stage, only an atten- labial tooth structure has been under-
tice set-up, since they have been tive and trained eye can detect the mined too much, the facial surfaces
primarily designed for scientific pur- more yellowish color resulting from fracture and the clinical crowns sud-
poses. Furthermore, practical experi- the thinning of the enamel in the cen- denly appear reduced in length.
ence indicates that all relevant signs tral palatal portion of the clinical Finally, especially in deep bite
linked to the various progression crown. The cingula appear flatter and patients, the vertical overlap may be
stages of generalized dental erosion their surfaces are very shiny. aggravated by the supraeruption of
could be assessed clinically by main- The next step of erosive wear the anterior segments.
ly examining the anterior dentition. leads to a weakening of the incisal
This finding may help to simplify the edges, which is first noticeable by an
diagnostic process significantly. increase in translucency. Furthermore, Traditional reconstructive versus
Consequently, a new classifica- the presence of caries or Class III adhesive therapy
tion, the anterior clinical erosive clas- restorations may contribute addition-
sification (ACE), has been proposed ally to the weakening of the facial Following the guidelines for conven-
to provide clinicians with a practical aspect of the tooth. In extreme tional oral rehabilitation concepts,
tool to grade the dental status of instances, a complete loss of the structurally compromised teeth

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561

should receive complete crown cov- The type of restoration best indi- preparation for all-ceramic crowns
erage. To place the associated cated to restore the palatal aspect of could not achieve this level of tooth
restoration margins at the gingival the eroded maxillary anterior teeth preservation.
level, a significant amount of the (direct or indirect composite restora-
remaining volume of the clinical crown tions) is selected according to the
has to be removed during tooth amount of the anterior interocclusal ACE classification
preparation to provide the required space obtained after an increase in
vertical path of insertion for the crown. the vertical dimension of occlusion. If Assessment of the severity of dental
In other terms, preparing such teeth the space is limited (< 1 mm), the erosion is complicated because of the
for crowns will substantially aggravate composite restorations can be fabri- subjectivity of the methods of evalu-
the destruction of mineralized tissue cated free-hand, saving time and ation and the possible presence of
that was initiated by the erosive money (there is no laboratory fee for wear cofactors (parafunctional habits,
process. Not infrequently, elective the palatal onlays and only one clini- hyposalivation, wear resulting from
endodontic treatment will be neces- cal appointment is required). If the tooth malposition, aging, coarse diet,
sary, mostly accompanied by the use interocclusal distance between the inappropriate tooth-brushing tech-
of posts, to assure intraradicular reten- anterior teeth is significant, however, niques, abrasive toothpastes, etc). In
tion of the crowns to be cemented. free-hand resin composites could addition, the rating scales selected
To avoid these types of invasive prove to be rather challenging. by investigators may be somewhat
treatment modalities and to keep the When the teeth present a com- complicated to translate in a clinical
teeth vital, an experimental approach bination of compromised palatal, environment, and early alterations are
to restoring the maxillary anterior incisal, and facial aspects, it is difficult difficult to locate, even with the sup-
teeth of patients affected by severe to visualize the optimal final mor- port of photography, study casts, and
dental erosion is currently under phology of the teeth, particularly attentive clinical examination.18–26
investigation at the University of while restoring only the palatal Several authors have proposed
Geneva School of Dental Medicine aspect with rubber dam in place. classifications and indices addressing
(Geneva Erosion study) by the authors Thus, the results may be unpre- either tooth wear in general25 or
of this research. A minimally invasive dictable and highly time consuming. including diagnostic criteria for erosive
treatment concept that consists of Under such conditions, fabricating tooth wear specifically.26 Most recent-
reconstructing the palatal aspect with palatal onlays in a laboratory clearly ly, Bartlett et al18 published a new
composite restorations, followed by presents some advantages, including scoring system, termed basic erosive
the restoration of the facial aspect superior wear resistance and higher wear examination (BEWE), designed
with ceramic veneers, is promoted. precision during fabrication of the for both scientific and clinical purpos-
The treatment objective is reached definitive form. A series of articles es. It was the authors’ twofold objec-
by the most conservative approach on full-mouth adhesive rehabilitation tive to provide a simple tool for use in
possible, since the remaining tooth address this in detail.15–17 One of the general practice and to permit more
structure is preserved and located in criticisms to the sandwich approach scientifically oriented comparisons
the center between two different is the work and cost associated with with already existing indices.
restorations (the sandwich approach) the fabrication of two separate Furthermore, the BEWE aimed to
and performed at two different time restorations for each tooth. However, augment the awareness of tooth ero-
points. When it comes to the preser- only with two independent restora- sion among general practitioners and
vation of mineralized tooth structure, tions are two different paths of inser- to provide a respective guide for treat-
such an ultraconservative approach tion possible, and the tooth ment when indicated. Finally, the
cannot be matched by any type of preparation can therefore be kept BEWE was intended to stop the con-
complete crown coverage. minimal. Even the most conservative tinued proliferation of new indices, as

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562

Table 1 The ACE classification


Palatal Palatal Incisal edge Facial Pulp Suggested
enamel dentin length enamel vitality therapy
Class I Reduced Not exposed Preserved Preserved Preserved No restorative treatment
Class II Lost in contact Minimally exposed Preserved Preserved Preserved Palatal composites
areas
Class III Lost Distinctly exposed Lost 2 mm Preserved Preserved Palatal onlays
Class IV Lost Extensively exposed Lost > 2 mm Preserved Preserved Sandwich approach
Class V Lost Extensively exposed Lost > 2 mm Distinctively Preserved Sandwich approach
reduced/lost (experimental)
Class VI Lost Extensively exposed Lost > 2 mm Lost Lost Sandwich approach
(highly experimental)

Fig 1 ACE Class I: (left) Frontal and (right)


occlusal views. Very early detection of the
erosive problem. All the cingula lost their
microanatomical details. The enamel
appears very shiny. Even though there is not
yet dentin exposure, small chipping of the
enamel at the incisal edge is visible (minimal
vertical overlap). Considering the patient’s
age (25 years) and etiology (bulimia), this
patient has a high risk of deteriorating
toward a more severe stage in a short period
of time.

it was hoped to represent a consensus parameters and that guides the clin- the incisal edges, the length of the
within the specialized scientific com- ician in a logical and systematic way. remaining clinical crown, the pres-
munity. Nevertheless, there is still an As a consequence, these two funda- ence of enamel on the vestibular sur-
undisputable need for a classification mental paradigms have been instru- faces, and the pulp vitality.
that directly and specifically focuses mental in the development and
on the anterior maxillary dentition, finalization of the proposed ACE clas-
where loss of mineralized tissue sification (Table 1). ACE Class I: Flattened cingula
because of erosion, as minute as it The ACE classification is strictly without dentin exposure
may be at an early stage of the dis- related to the clinical observation of
ease, can be assessed easily. the status of the anterior maxillary Suggested therapy:
Clinicians not involved in epi- teeth, which are generally the most No restorative treatment
demiologic surveys clearly need the damaged. Patients are grouped into This is the earliest stage of dental
least complicated approach to clas- six classes, and for each class, a den- erosion. The enamel is present but
sify each patient rapidly and to tal treatment plan is suggested. The thinner. The palatal aspect of the
decide on the most appropriate classification is based on five para- teeth may appear more yellowish in
treatment plan. Thus, the prerequi- meters relevant for the selection of the central portion of the underlying
site for a precise and rapid assess- the treatment and the assessment of dentin and more white at the periph-
ment is a diagnostic instrument that the prognosis: the dentin exposure in ery with the presence of thicker enam-
is based on a limited number of key the contact areas, the preservation of el (Fig 1).

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563

Fig 2 ACE Class II: Pretreatment (left) frontal and (center) occlusal views and (right) posttreatment occlusal view. In this patient, the palatal
aspects present areas of dentin exposure at the level of the contact points. The incisal edges were still intact. An early conservative rehabilita-
tion was planned, and all maxillary anterior teeth were restored using an indirect approach (palatal veneers), while the posterior teeth
received direct composite restorations.

For patients in this category, no intact and act like chisels, damaging
restorative treatment is recommend- the maxillary anterior teeth in a very
ed. However, preventive measures aggressive manner (focal attrition).
(eg, occlusal guard, fluoride gel) are Since the occlusal contacts are now
mandatory. Most of all, the etiology composed of softer dentin, it is rea-
should be investigated and the cause sonable to anticipate that the loss of
of the dental erosion eliminated. tooth structure will worsen at a faster
Since the enamel layer is still intact, rate, especially if the cause of the ero-
100% recovery is possible at this sion is not under control. This is the
stage if the patient is capable of pre- reason why the dental status of
venting further tissue loss. patients affected by dental erosion
may deteriorate quickly after an initial
slow start (Fig 3). Nobody can predict
ACE Class II: Dentin exposure exactly how each patient will evolve;
on the palatal aspect (contact nevertheless, parameters such as age
areas), no damage to the incisal and etiology of the dental erosion
edges can guide the clinician to predict the
steepness of the curve of the disease
Suggested therapy: Direct or progression and to justify early inter-
indirect palatal onlays vention. A bulimic patient in his or her
In this group of patients, the enamel early 20s who already presents
at the level of the palatal aspect of the exposed areas of dentin (Class II) is at
maxillary teeth is more compromised a higher risk of deteriorating the den-
and small areas of dentin are tition compared to a patient in his or
exposed, generally related to the her 50s who suffers from gastric reflux
contact points of the opposing den- that is kept under medical control.
tition (Fig 2). Since the mandibular The first patient should be treated
anterior teeth are rarely affected by immediately, even though several
erosion, their incisal edges, com- authors recommend controlling the
posed of enamel, typically remain disease first.27–29

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564

Fig 3 Correlation between loss of tooth


structure and the patient’s age in cases of
dental erosion. The change in the steepness
Enamel
Adhesive therapy, ACE Class II patient of the curve is related to the loss of enamel
and the consequent dentin exposure in the
contact areas. Several factors can add to
Coronal the aggravation of the steepness of the
Adhesive therapy, ACE Class III patient
dentin curve (parafunctional habits, hyposalivation,
lack of erosion control, acidic diet, etc).
Tooth structure

Adhesive therapy, ACE Class IV patient

Loss of tooth vitality

No restorative treatment
Radicular
dentin
Conventional therapy

10 20 30 40 50 60 70 80 90 100
Age (y)

Since a psychologic problem is tive orthodontic treatment could be restoring so many teeth with so-called
not often resolved quickly, protecting advocated, which allows the posteri- ”weak” restorations is an overtreat-
the remaining enamel and the or teeth to be excluded from the treat- ment for which a sufficient longevity
exposed dentin from further dam- ment. However, not every patient would not be guaranteed. As a con-
age is recommended, even though accepts this possibility. A second sequence, many clinicians prefer to
the restorations may have a less option to obtain the anterior space wait until further damage has taken
favorable prognosis under these spe- needed consists of increasing the place to justify a full-mouth rehabili-
cific conditions.30–32 In the opinion patient’s vertical dimension of occlu- tation based on stronger restorations
of the authors of this paper, the sion. In this case, all the posterior (onlays or crowns). Unfortunately,
palatal aspect of Class II patients teeth, at least in one arch, are restored there are no clinical studies available
should be restored as soon as possi- with direct composite restorations to date showing which choice may be
ble, either by means of direct or indi- without any tooth preparation. Since the most beneficial in the long term to
rect composite restorations (early not the dental destruction is intercepted ACE Class II patients: an immediate
invasive rehabilitation). at an early stage, there is not enough rehabilitation with weaker direct com-
If the palatal wear has not yet space for thicker, indirect posterior posites and no tooth preparation, or
affected the strength of the incisal restorations; removing tooth structure a later treatment with more resistant
edges and the length of the facial sur- to create the space for thicker restora- restorations but a more compromised
faces of the teeth is still intact, restora- tions goes against the principles of dentition and more aggressive tooth
tion of the palatal aspect of the minimal invasiveness. This early and preparation. Thus, further clinical
maxillary anterior teeth could be the extensive rehabilitation based on research is needed.
only treatment required. To obtain the direct composites is not well accept- In the current investigation
necessary interocclusal space, adjunc- ed among clinicians, who think that being undertaken by the authors of

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565

Fig 4 ACE Class III: (left) Pretreatment


and (right) posttreatment views. In this deep
bite patient, a severe loss of tooth structure
at the level of the palatal aspect weakened
the vestibular surfaces (note the high
translucency), but the facial surface was
almost intact (shortening of the clinical
crown less than 2 mm). This patient
required only palatal onlays. No further
treatment was necessary to restore the
maxillary anterior teeth. Note that all teeth
were vital and maintained vitality after
treatment.

this research in Geneva, all patients ACE Class III: Distinct dentin
(ACE Class II) involved were treated exposure on the palatal aspect,
as early as possible. Since this damage of the incisal edge
prospective clinical study does not length ( 2 mm)
have a control group of patients who
were left untreated and restored Suggested therapy: Palatal veneers
later with conventional therapy, com- If patients are left untreated, erosion
parison between the two different and focal attrition will eventually lead
treatment plans is not possible. On to a weakening of the thickness of
the other hand, this clinical study will the incisal edges of the maxillary
provide the first set of data helping anterior teeth, especially if the verti-
to confirm (or reject) the clinical cal overlap (overbite) is not signifi-
validity of this ultraconservative cant (Fig 4). When the incisal edges
adhesive approach. are affected, attentive patients start
seeking help, driven mostly by esthet-
ic concerns. Patients in this category
are generally in their late 20s or early
30s. Since not all of them are willing
to receive orthodontic treatment to
create interarch space in the anterior
segments of their mouth, an increase
of the vertical dimension of occlusion

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566

Fig 5 When the enamel frame is still pres-


ent (mesial, distal, cervical, and vestibular
aspects), the tooth presents a higher resis-
tance to tensile forces. Adhesive restora-
tions restoring the palatal aspect are
subject to less bending forces, and their
clinical performance is enhanced (tennis
racket theory)

is necessary and involves the recon- veneers, since the horizontal flat junc-
struction of the posterior teeth, tion between the tooth and palatal
which, at this stage, may present veneers may be difficult in terms of
signs of erosion as well. The choice color blending. Shade modification
between indirect or direct composite could always be attempted later if
restorations is based on the severity necessary. The clinician should have
of the loss of tooth structure and a discussion with each patient to
sometimes on the financial status of determine if the patient could be sat-
the patient. isfied esthetically without veneers.
The final restorative choice for the Even though no long-term follow-
posterior quadrants (direct composite up data are available currently on the
restorations or onlays) must always longevity of palatal veneers used to
be driven by minimally invasive prin- replace damaged incisal edges, these
ciples. Following the three-step restorations have an acceptable prog-
technique to increase the vertical nosis for ACE Class III patients. Often,
dimension of occlusion, the anterior all the margins of palatal veneers are
maxillary teeth are restored with indi- bonded to enamel. Furthermore, the
rect restorations (composite palatal teeth involved still preserve their
veneers), especially if the anterior enamel frame. In fact, looking from
space created with the increase in the palatal aspect, this frame could be
the vertical dimension of occlusion is identified and comparable to the
more than 1 mm. Due to the minimal frame of a tennis racket (tennis racket
damage to the vestibular aspect of theory, Fig 5).
these anterior teeth, there is often no The mesial and distal walls of
need for further treatment. such erosion-affected teeth are gen-
If the vestibular surfaces of the erally still intact (unless Class III
maxillary anterior teeth are intact or restorations are present). The cervical
only slightly damaged at the level of palatal enamel is also mostly present
the incisal edges, facial veneers may as a band of 1 to 2 mm next to the
be considered an overtreatment since gingival margin. Finally, the enamel at
the length could be reestablished by the vestibular aspect of the tooth is
means of palatal veneers. An attempt almost completely intact in this class
should be made to match the color of of patients (less than a 2-mm loss of
the natural tooth with the palatal incisal edge length).

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567

According to the tennis racket (Figs 6a to 6d). At this stage, the pos- option, the technician should not be
theory, compromised teeth with an terior teeth are often involved, espe- concerned with the final esthetic
almost intact enamel frame will show cially the premolars. Since an increase result (as for the crowns), since these
surprisingly high resistance to flexure in the vertical dimension of occlusion teeth are generally still alive and their
during function (mastication or occlu- is mandatory to create the necessary original color should not need heavy
sion). As a consequence, palatal interarch space for the restorative modification.
composite restorations, subject to materials in the anterior and posteri-
less tensile forces, will last longer. or segments, the three-step technique
Several studies have demon- should be followed. ACE Class V: Extended dentin
strated the importance of the mar- To restore the anterior maxillary exposure on the palatal aspect,
ginal ridges for posterior teeth. teeth, the sandwich approach is rec- loss of the incisal length of the
Restorations that extend to the mesial ommended. After the restoration of tooth (> 2 mm), distinct reduc-
and distal aspect, such as mesial the palatal aspect with composite tion/loss of the facial enamel
occlusal distal restorations, greatly veneers, the treatment should be
affected the strength of the restored completed with ceramic facial Suggested therapy: Sandwich
posterior teeth.33–35 In the opinion of veneers. The veneers are necessary approach (experimental)
the current authors, the mesial and not only because palatal veneers Patients who are treated at this later
distal marginal ridges of the anterior often do not match the color of the stage, unfortunately, may not have a
teeth may have similar importance to natural teeth, but also because there favorable long-term prognosis if their
that described for posterior teeth. are no studies to document the long- maxillary anterior teeth are restored
Since their removal during palatal term performance of such a large using the sandwich approach (Fig 7).
veneer preparation could dramatical- composite restoration in case the In addition to the reduced length of
ly compromise the flexure resistance facial veneers are not placed. the remaining clinical crown, the lack
of the tooth, the interproximal contact Some patients in the ongoing of enamel on the facial aspect of the
point should be removed minimally Geneva study have decided not to teeth compromises the quality of the
by means of an interproximal dia- obtain facial veneers and are under bond of the definitive veneers and
mond strip or not be removed at all. strict monitoring. If the palatal the flexure resistance.
veneers degrade at a quick rate, There are no long-term clinical
ceramic facial veneers could be fab- studies reporting on the longevity of
ACE Class IV: Extended dentin ricated at a later date. On the other a sandwich approach in Class V
exposure on the palatal aspect, hand, the remainder of ACE Class IV patients. At the University of Geneva,
loss of the incisal length of the patients all received the two anterior patients in this category were treat-
tooth (> 2 mm), preserved facial restorations, and the preliminary ed following the adhesive technique
enamel results (up to 4 years of follow-up since the alternative option (conven-
without any clinical problems) are very tional therapy) would require devi-
Suggested therapy: encouraging (Figs 6e to 6h). While talization of all compromised teeth.
Sandwich approach preparing these damaged teeth for Preliminary data from the Geneva
Most patients in this category are facial veneers, attention should be Erosion study show very promising
aware of their dental problem since given to not remove the facial enam- results: the capacity of the sandwich
they have noticed the shortening of el and transform these patients into approach to keep the vitality of all
their clinical crowns and an increase in ACE Class V cases. Additive tech- treated teeth, all rehabilitations
the translucency of the incisal edges, niques (tested by the diagnostic achieved a very pleasing esthetic
even though they might not realize mock-up) or very thin veneers should result, and tooth preservation was
the extent of the tooth destruction be advocated. 36 For this second maximal. Nevertheless, patients

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568

Fig 6 ACE Class IV

Figs 6a to 6d (left) Pretreatment and


(right) postreatment views of an anterior
maxillary restoration. This patient required a
sandwich approach (composite palatal and
ceramic facial veneers).

Figs 6e to 6h (left) Pretreatment and


(right) posttreatment views. In this patient,
the combination of erosion and focal attri-
tion led to a complete loss of the incisal
edges (more than 2 mm). Composite
veneers were used to restore the palatal
aspect; even though ceramic facial veneers
were planned to complete the treatment of
these teeth, the patient decided to wait
since the difference in shade was not visible
at a normal communication distance (1-year
follow-up). Note that all teeth kept their
vitality after treatment.

should be intercepted and treated ACE Class VI: Advanced loss of compromised teeth surprisingly pre-
whenever possible for an optimal tooth structure leading to pulp serve their vitality, a result of the slow
clinical performance of their rehabil- necrosis progression of the erosive process.
itation. For a tooth to lose vitality because of
Suggested therapy: Sandwich dental erosion, a very severe and fre-
approach (highly experimental) quent acid attack (eg, bulimic or
Patients at this stage present a severe- anorexic patients) is necessary, which
ly compromised dentition (Fig 8). overcomes the capacity of the pulp to
Generally, even in the case of signifi- protect itself, or simply an extreme
cant loss of palatal tooth structure, destruction of its coronal dentin. In
the pulp has time to withdraw and both cases, treatment prognosis may

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569

Fig 7 ACE Class V: (left) Pretreatment and


(right) posttreatment views (2-year follow-
up). The dental destruction had involved
almost two thirds of the crown length and
the dentin was exposed on the facial
aspect. The sandwich approach is consid-
ered experimental in these cases, since the
ceramic facial veneers are bonded mainly to
a reduced surface of dentin.

Fig 8 ACE Class VI: (left) Pretreatment


and (right) posttreatment views. The dental
tissue destruction in this patient was so
severe that two teeth were not vital at the
time of the first consultation. Since the
alternative was the extraction of the four
maxillary incisors, the patient was treated
following the sandwich approach. The 2-
year clinical follow-up results are presented.
Note that the palatal composite restora-
tions were made directly in the mouth, and
the veneers were fabricated by a laboratory
technician selected by the patient for per-
sonal reasons (completed in collaboration
with Dr H. Gheddaf Dam).

be poor, especially if the erosion can- So far, in the Geneva Erosion in cases of a later loss of vitality is that
not be controlled. study, patients in this category have internal bleaching procedures could
In the authors’ opinion, adhesive maintained the vitality of all treated be done easily. On the contrary, in
techniques should still be attempted, teeth. If loss of vitality occurs as a cases with conventional therapy, the
even though long-term results are result of the severely affected pulp of option to change the shade of a dis-
lacking. The sandwich approach has these teeth, endodontic access will colored root visible after gingival
the advantage of preserving the be made easier through the palatal recession is not available because of
maximum tooth structure and, in veneer without damaging the facial the presence of the post cemented
most cases, the tooth vitality of the veneer. This would be more difficult in the root.
remaining teeth. in cases of full coverage. Another
. advantage of the adhesive technique

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570

Conclusion Acknowledgment

Dental erosion is a frequently under- The authors would like to thank the following
laboratory technicians and ceramists for their
estimated pathology that affects an
integral support in completing these complex
increasing number of young individ- cases: Alwin Schönenberger, Patrick Schnider,
uals. Intercepting patients at the ini- Pascal Müller, Serge Erpen, Sylvan Carciofo,
tial stages of the disease is critical to and Sophie Zweiacker. Finally, the authors would
like to acknowledge the collaboration of Dr
avoid irreversible damage to their Hamasat Gheddaf Dam, Dr Giovanna Vaglio, Dr
dentition and to guarantee a better Federico Prando, Dr Linda Grutter, Dr Tommaso
clinical performance of the restora- Giovanni Rocca, and Dr Julian Luraschi.
tions selected. In this article, a new
classification is proposed to quantify
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The International Journal of Periodontics & Restorative Dentistry

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