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Full-Mouth Adhesive Rehabilitation


of a Severely Eroded Dentition:
The Three-Step Technique. Part 1.
Francesca Vailati, MD, DMD, MSc
Senior Lecturer, Department of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva
Switzerland

Urs Christoph Belser, DMD, Prof Dr med dent


Chairman, Department of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva
Switzerland

Correspondence to: Dr Francesca Vailati


University of Geneva, Department of Fixed Prosthodontics and Occlusion, Rue Barthelemy-Menn 19, 1203 Geneva, Switzerland;
e-mail: francesca.vailati@medecine.unige.ch.

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Abstract
Traditionally, a full-mouth rehabilitation clinical steps, allowing the clinician and the
based on full-crown coverage has been laboratory technician to constantly interact
the recommended treatment for patients to achieve the most predictable esthetic
affected by severe dental erosion. Nowa- and functional outcome. During the first
days, thanks to improved adhesive tech- step, an esthetic evaluation is performed to
niques, the indications for crowns have establish the position of the plane of occlu-
decreased and a more conservative sion. In the second step, the patient’s pos-
approach may be proposed. terior quadrants are restored at an in-
Even though adhesive treatments sim- creased vertical dimension. Finally, the
plify both the clinical and laboratory pro- third step reestablishes the anterior guid-
cedures, restoring such patients still re- ance. Using the three-step technique, the
mains a challenge due to the great clinician can transform a full-mouth reha-
amount of tooth destruction. To facilitate bilitation into a rehabilitation for individual
the clinician’s task during the planning and quadrants. This article illustrates only the
execution of a full-mouth adhesive rehabil- first step in detail, explaining all the clinical
itation, an innovative concept has been de- parameters that should be analyzed before
veloped: the three-step technique. Three initiating treatment.
laboratory steps are alternated with three (Eur J Esthet Dent 2008;3:30–44.)

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Fig 1 (a and b) Severely eroded dentition in a 27-year-old patient.

Patients affected by severe dental erosion may be too aggressive considering that
often present with an extremely damaged the population affected by erosion is gen-
dentition, especially in the anterior maxil- erally very young (Fig 1).
lary quadrant. The vertical dimension of oc- When a 14-year-old patient receives a
clusion (VDO) may have decreased, and full-mouth conventional rehabilitation, such
supraeruption may have occurred. If ero- as in a recently published report,2 the fol-
sion is not intercepted at an early stage, full- lowing questions should be considered:
mouth rehabilitation may be required. Ac- How many times will these crowns have to
cording to the available literature (case be replaced in the future, and what will be
reports only), the recommended therapy the prognosis of such teeth? How many of
comprises both extensive elective root the teeth will remain vital? How many will
canal treatment and full-crown coverage of become nonrestorable (Fig 2)?
1–3
almost all teeth. However, this approach

Fig 2 Panoramic radio-


graph of a 70-year-old patient
with a heavily restored denti-
tion. The patient received his
first full-mouth rehabilitation
at the age of 50.

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The current literature does not answer mouth adhesive restorations. Consequent-
these questions. No long-term follow-up ly, the debate is still open on whether a pos-
studies of similar cases are available. Con- sibly less durable adhesive rehabilitation is
sequently, before proposing conventional preferable to longer-lasting but more ag-
full-mouth rehabilitation to young individu- gressive conventional treatment.
als affected by erosion, clinicians should For this reason, a clinical trial is under-
consider more conservative approaches. way at the University of Geneva. All patients
In this context, improved adhesive tech- affected by generalized erosion are sys-
niques may be a valid alternative, at least tematically and exclusively treated with ad-
to postpone more invasive treatments un- hesive techniques, using onlays for the
til the patient is older.4–7 posterior region and bonded laminate ve-
The adhesive approach preserves more neers for the anterior region. The goal is to
tooth structure and avoids elective en- evaluate the longevity of adhesive rehabil-
dodontic therapy. In addition, in the au- itations before proposing this treatment as
thors’ opinion, the esthetic outcome of teeth the new standard of care.
restored with bonded porcelain restora-
tions is superior to that achieved with ce-
mented crown restorations. Further, gingi- The three-step technique
va seems to interact better with the margins
of bonded veneers than with the margins To achieve maximum preservation of tooth
of cemented crowns, resulting in less in- structure and the most predictable esthet-
flammation or dark colorations. ic and functional outcomes, an innovative
However, while several authors have concept has been developed: the three-
documented long-term follow-up for con- step technique (Table 1). Three laboratory
ventional fixed prostheses,8–17 there is a lack steps are alternated with three clinical
of comparable long-term data on full- steps, allowing the clinician and dental

Table 1 The three-step technique

Laboratory Clinical

Maxillary Step 1: Assessment


vestibular waxup Esthetics of occlusal plane

Posterior Step 2: Creation of poste-


occlusal waxup Posterior support rior occlusion at
an increased VDO

Reestablishment
Maxillary anterior Step 3:
of final anterior
palatal onlays Anterior guidance
guidance

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technician to constantly interact during the The importance of a predictable result


planning and execution of a full-mouth ad- that satisfies both the patient and clinician
hesive rehabilitation. cannot be stressed enough in today’s
In the first laboratory step, instead of a world of esthetically demanding patients.
full-mouth waxup, the technician is instruct- Surprisingly, many clinicians still decide on
ed to wax up only the vestibular aspect of the esthetic outcome for their patients, and
the maxillary teeth (esthetically driven wax- thus the result seldom meets the patient’s
up). Afterwards, the clinician will check if expectations. A structured strategy to min-
the waxup is clinically correct using a max- imize such an esthetic “defeat” is to devote
illary vestibular mockup (first clinical step). sufficient time to educate patients about
During the second laboratory step, the the treatment options and expected results.
technician focuses on the posterior quad- The first step of this three-step technique is
rants, creating a posterior occlusal waxup conceived to guarantee that the clinician
to determine a new VDO. The second clin- and technician’s vision for the planned
ical step is to give the patient a stable oc- restoration is a reflection of the patient’s
clusion in the posterior quadrants at an in- true desires.
creased VDO, closely reproducing the
occlusal scheme of the waxup. With the Step 1:
use of silicon keys duplicating the waxup, Maxillary vestibular waxup and
all four posterior quadrants will be restored assessment of the occlusal plane
with provisional posterior composites. Generally, at the beginning of a full-mouth
Finally, the third step deals with the re- rehabilitation, the clinician will provide the
construction of the palatal aspect of the laboratory technician with the diagnostic
maxillary anterior teeth (restoration of the casts and request a full-mouth waxup.
anterior guidance) before restoring the Since each parameter, such as incisal
vestibular aspect with bonded porcelain edges, teeth axes, teeth shapes and sizes,
restorations. occlusal plane, etc, is easily controlled,
In this article, only the first step is waxing both the maxillary and mandibular
discussed. arches is not a difficult task.
Clinicians should realize, however, that
Treatment planning laboratory technicians will often arbitrarily
Unrealistic patient expectations are often a decide on these parameters without seeing
contraindication to dental treatment. How- the patients and with a misleading lack of
ever, what seems to be an unrealistic ex- reference points (eg, adjacent intact teeth).
pectation may in fact be a poorly ex- Unfortunately, a decision based only on di-
pressed expectation or an expectation that agnostic casts is extremely risky, since a
is misunderstood by the clinician. Even dental restoration that appears perfect on
when there is seemingly perfect three-way the cast may be clinically inadequate.
communication (patient/clinician/techni- One method to ensure that everyone is
cian), there is always potential for misun- on the same page is the use of a mock-
derstandings, especially when dealing with up, a technique that makes it possible to
patients who are accustomed to viewing anticipate the final shape of the teeth in
themselves with small, eroded teeth. the mouth. Several authors have already

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a b

Fig 3 Frontal (a) and profile (b) views of a 45-year-old patient affected by gastric reflux. Note the severe gen-
eralized tooth destruction as a result of the dental erosion.

a b

c d

Fig 4 Both a traditional mockup (covering only the maxillary anterior teeth) (a and b) and a maxillary vestibu-
lar mock-up (from second premolar to second premolar) (c and d) were used to evaluate esthetics. With the
traditional mockup, the anterior teeth appeared too long, and the patient disliked their length and shape. Once
the mockup was extended to the premolars, the patient rated the same anterior teeth as esthetically pleasing.

proposed the use of a mockup for veneer stored posterior teeth. Instead, a mockup
restorations of anterior teeth.18,19 In cases that involves all maxillary teeth may be a
of severe generalized destruction of the more appropriate approach (Figs 3 to 5).
dentition, a mockup of only the anterior To obtain a mockup of all maxillary teeth
teeth could be misleading, since the teeth is not necessary at this initial stage to have
will appear inharmonious with the unre- a full mouth wax-up. In fact, the three-step

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a b c

Fig 5 Facial views before (a) and after (b and c) the maxillary vestibular mockup.

a b

Fig 6 (a and b) Maxillary vestibular wax-up. Note that the cingula and the palatal cusps are not included.
In this patient, the vestibular aspects of both the first maxillary molars were intact and thus not included in the
waxup.

technique proposes that the technician illary vestibular waxup, the first clinical step
should wax up only the vestibular surface (maxillary vestibular mockup) is intro-
of the maxillary teeth. To save time and fa- duced so that the clinician can confirm the
cilitate the next clinical step, neither the direction taken by the technician. The fac-
cingula of the anterior maxilla nor the tors that should be considered during this
palatal cusps of the maxillary posterior assessment will now be discussed.
teeth are included.
In situations where the vestibular aspect Incisal edges
of the first molars was not affected by the Patients are often shocked by the in-
erosion, the technician may stop the wax- creased length of the incisors selected by
up at the level of the premolars (Fig 6). The the clinician and technician. After years of
maxillary second molar is never included seeing themselves with a compromised
in the waxup. At the completion of the max- dentition, many patients cannot immedi-

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a b c

Fig 7 (a to c) When an increased VDO is planned, the position of the occlusal plane is decided arbitrarily by
the technician. Often, the obtained space is shared equally between the two arches, with a consequent change
of position of the occlusal plane (lower position). This arbitrary decision can compromise the esthetic outcome in
patients with a preexisting “reverse” smile.

ately adapt to more voluminous teeth. In a frontal, smiling view, the cusps of the
Often, patients will eventually agree to such posterior teeth should follow the lower lip
a change if they are allowed to test the new and be located more cervically than the in-
teeth; however, some patients will never cisal edges. Otherwise, an unpleasant, “re-
accept it. Clinicians cannot impose their verse” smile is generated.
personal opinions onto their patients, but When an increase of the VDO is antici-
they can try to guide the patient in making pated in a full-mouth rehabilitation, the
an informed decision. question of how to divide the extra interoc-
The mockup represents an excellent clusal space is generally answered by
opportunity for patients and clinicians to sharing the space equally between the
truly understand each other’s points of mandibular and maxillary arches. However,
view. The mockup covering the teeth can such a decision is completely arbitrary and
be shortened or lengthened (using flow- may lead to a repositioning of the occlusal
able composite), and their shape can be plane at a lower level than the original.
modified. If major changes are made, an Unfortunately, in cases of erosion, the
alginate impression can be taken to guide loss of tooth structure is often compensat-
the technician. ed for by supraeruption, especially in the
maxillary posterior region and mandibu-
Occlusal plane lar anterior region. One goal of a full-
The innovative aspect of the three-step mouth rehabilitation should be the cor-
technique is the extension of the mockup rection of such a situation. The technician
to the vestibular aspect of the maxillary must know to what extent the incisal
posterior teeth. The inclusion of the four edges can be lengthened before decid-
premolars is crucial, not only to visualize ing on the occlusal plane’s position and
their buccal aspect in comparison with the waxing up the posterior quadrants. A
anterior teeth (vestibular harmony), but al- maxillary vestibular mockup, which visu-
so to relate the plane of occlusion to the in- alizes both the incisal edges and the buc-
cisal edges. Maxillary incisal edges and the cal cusps of the posterior teeth, can help
occlusal plane should be in harmony for verify the orientation of the future occlusal
an optimal esthetic and functional result. plane (Figs 7 and 8).

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c d

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Fig 8 (a to f) Before and after views of a 27-year-old patient with a history of gastric acid reflux. The mockup
reestablished the harmony between the occlusal and incisal planes.

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Fig 9 (a to c) If crown-lengthening surgery is antic-


ipated, the mockup can help visualize the amount of at-
c
tachment to be removed.

Harmony with the maxillary molars Emergence profile and gingival levels
If the waxup is stopped at the level of the At the time of the waxup, the clinician and
maxillary premolars, it will be possible dur- technician can determine whether crown
ing the maxillary vestibular mockup to eval- lengthening is needed (Figs 9 and 10). To
uate how the unrestored molars will blend confirm if mucogingival surgery is neces-
in with the restoration planned for the pre- sary and to what extent, the technician
molars. The lip display will also preview the should wax the cervical aspect of the future
visibility of the buccal margins of the future restorations overlapping the gingiva of the
restorations (onlays) for the molars. cast. Consequently, the teeth of the mock-
up will cover the gingiva of the patient. Their
emergence profile will be slightly altered,
but they will still provide a good sense of
the final outcome to both the clinician and
the patient.

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Fig 10 (a and b) After surgery, the mockup can be used to evaluate the outcome.

Based on the lip display, the teeth to be Clinical steps for the maxillary
involved in the surgery can be selected, vestibular mockup
and the patient can make an informed de- The maxillary vestibular mockup is quickly
cision whether to accept the surgery. This and easily fabricated in the patient’s mouth
presurgical mockup can be a powerful tool and offers the possibility to concretely visu-
to convince reluctant patients. In these cas- alize the final outcome. A silicon key should
es, the compromised result could also be be made from the maxillary vestibular wax-
visualized with another mockup, this time up and loaded with a tooth-colored mate-
without the gingival overlap. rial in the patient’s mouth (Fig 11). After its
removal, all vestibular surfaces of the max-
Number of teeth involved illary teeth will be covered by a thin layer of
in the rehabilitation composite, reproducing the shape select-
Sometimes, patients are not fully aware of ed for the future restorations with the wax-
the level of destruction of their dentition. up. In our clinic, the material of choice is
Motivated primarily by esthetics, patients Protemp (3M ESPE), a resin composite that
may believe that a satisfactory result can be generates a limited exothermic reaction
achieved by focusing only on the anterior and is easy to dispense and less subject to
teeth, and thus they will not be interested in porosity than polymethyl metacrylate.
a more comprehensive treatment plan. To Since the cingula of the anterior teeth and
avoid investing unnecessary time and the palatal cusps of the posterior teeth are
money, a maxillary vestibular mockup not included in the waxup, the silicon key
could be used. The mockup covering the will be stable in the mouth. It will also be
posterior teeth could then be removed, stabilized on both sides by the unrestored
leaving the patient with the mockup of on- second molars (distal stops).
ly the six anterior teeth. While some of these Due to the key’s close adaptation, ex-
patients will still “run away” as anticipated, cess material will be minimal and easy to
others will be convinced to accept the remove using a scalpel or scaler (Fig 12).
more extensive treatment. It is not recommended to remove and re-

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Fig 11 (a and b) A silicone key of the maxillary vestibular waxup is fabricated and loaded with tooth-colored
provisional resin composite.

a b

Fig 12 (a to c) Due to the key’s close adaptation,


very little excess will be present after its removal. Note
the shortening of the canines (c) The mockup can be C
easily modified in the patient’s mouth.

cement the mockup, because this may the retentive areas (interproximally). The
break it or distort its appearance. The clinician, however, should pay particular at-
mockup is stabilized by excess material in tention to that excess, since it can interfere

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a b

c d

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Fig 13 (a to f) Before and after views of a 27-year-old female patient. Without the mockup, it was difficult to
evaluate her smile, since she was uncomfortable showing her damaged teeth.

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with the patient’s normal oral hygiene pro- step technique is a simplified approach
cedures. The challenge is to open the gin- that emphasizes interdisciplinary collabo-
gival embrasures just enough to allow den- ration between the clinician and laboratory
tal floss (eg, SuperFloss, Oral B) to pass technician.
through without jeopardizing the strength In this article, only the first step of the
of the mockup. It is also recommended to technique was described. By using a sim-
accurately remove the excesses at the lev- ple maxillary vestibular mockup, the labo-
el of the buccal gingival sulci to better un- ratory technician can gain precious infor-
derstand the emergence profile and gingi- mation, and the treatment of a severely
val harmony of the future restoration. eroded dentition can begin in a less arbi-
The patient can leave the office wearing trary way. The time-consuming initial diag-
the mockup for a short time to show it to nosis should not discourage the clinician,
family members and friends. Due to its since the patient’s full participation in any
minimal thickness, the mockup will eventu- decision-making process is extremely
ally break off, making it easily removable by valuable. Indeed, allowing patients to visu-
the patient. After evaluating the maxillary alize the final result before treatment begins
vestibular mockup in the patient’s mouth both reassures them and helps them ac-
(Fig 13), any changes can be made by the cept more comprehensive treatments.
technician, who will then progress with the
second laboratory step.
Acknowledgments
The authors would like to thank Dr Pierre-Jeanne Loup,
School of Dental Medicine, University of Geneva, for his
Conclusions expertise in parodontology The authors also thank the
laboratory technicians and ceramists, Sylvan Carciofo
Patients affected by severe dental erosion and Dominique Vinci, School of Dental Medecine, Uni-
often present severely damaged dentition. versity of Geneva, for the excellent laboratory support.

However, the traditional restorative ap-


proach (full-mouth rehabilitation with
crowns) may be too aggressive for this
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CLINICAL APPLICATION
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Full-Mouth Adhesive Rehabilitation


of a Severely Eroded Dentition:
The Three-Step Technique. Part 2.
Francesca Vailati, MD, DMD, MSc
Senior Lecturer, Dept of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva
Switzerland

Urs Christoph Belser, DMD, Prof Dr med dent


Chairman, Dept of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva
Switzerland

Correspondence to: Dr Francesca Vailati


University of Geneva, Dept of Fixed Prosthodontics and Occlusion, Rue Bathelemy-Menn 19, 1203 Geneva, Switzerland;
e-mail: Francesca.vailati@medecine.unige.ch.

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Abstract
Traditionally, a full-mouth rehabilitation achieve the most predictable esthetic and
based on full-crown coverage has been functional outcome. During the first step, an
recommended treatment for patients af- esthetic evaluation is performed to estab-
fected by severe dental erosion. Nowa- lish the position of the plane of occlusion.
days, thanks to improved adhesive tech- In the second step, the patient’s posterior
niques, the indications for crowns have quadrants are restored at an increased
decreased and a more conservative ap- vertical dimension. Finally, the third step
proach may be proposed. reestablishes the anterior guidance. Using
Even though adhesive treatments sim- the three-step technique, the clinician can
plify both the clinical and laboratory proce- transform a full-mouth rehabilitation into a
dures, restoring such patients still remains rehabilitation for individual quadrants.
a challenge due to the great amount of The present article focuses on the sec-
tooth destruction. To facilitate the clinician’s ond step, explaining all the laboratory and
task during the planning and execution of clinical steps necessary to restore the pos-
a full-mouth adhesive rehabilitation, an in- terior quadrants with a defined occlusal
novative concept has been developed: the scheme at an increased vertical dimen-
three-step technique. Three laboratory sion. A brief summary of the first step is
steps are alternated with three clinical also included.
steps, allowing the clinician and the labora-
tory technician to constantly interact to (Eur J Esthet Dent 2008;3:128–146.)

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a b

Fig 1 (a to c) Clinical views of a 60-year-old patient


affected by generalized dental erosion. For years the
patient suffered from gastric esophageal reflux. At this
late stage a full-mouth rehabilitation is inevitable. De-
spite the advanced loss of tooth structure, all teeth are
c
still vital.

Traditionally, a full-mouth rehabilitation has University of Geneva. All patients affected by


been the recommended treatment for pa- generalized advanced dental erosion are
tients affected by generalized severe den- systematically and exclusively treated with
tal erosion. However, a restorative concept adhesive techniques, using onlays for the
comprising full-crown coverage of almost posterior region and a combination of facial
all teeth and extensive elective root canal bonded porcelain restorations (BPRs) and
treatment may be too aggressive for this palatal composite restorations for the ante-
generally very young population of pa- rior maxillary region. The goal of this
tients.1–3 With current improved adhesive prospective clinical study is to evaluate the
techniques, the indications for crowns have longevity of adhesive rehabilitations, before
decreased and a more conservative ap- proposing this treatment option as the new
proach may be proposed, to preserve standard of care.
tooth structure and to postpone more inva- Despite the tendency for adhesive
4–8
sive treatments until the patient is older. modalities to rather simplify the involved
In order to test the hypothesis that such a clinical and laboratory procedures, treat-
concept can predictably reach the specific ment of such patients still remains a chal-
treatment objectives, a clinical trial testing a lenge because of the significant amount of
fully adhesive approach is underway at the tooth destruction (Fig 1).

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Table 1 The three-step technique

Laboratory Clinical

Maxillary Step 1: Assessment


vestibular waxup Esthetics of occlusal plane

Posterior Step 2: Creation of poste-


occlusal waxup Posterior support rior occlusion at
an increased VDO

Reestablishment
Maxillary anterior Step 3:
of final anterior
palatal onlays Anterior guidance
guidance

To facilitate the clinician’s task during the tended rehabilitation. Traditionally, one of
planning and execution of a full-mouth ad- the first steps consists of providing the lab-
hesive rehabilitation, a structured, innova- oratory technician with diagnostic casts,
tive concept has been developed: the and requesting a full-mouth waxup. A full-
three-step technique (Table 1). Three lab- mouth waxup should guide the clinician in
oratory steps are alternated by three dis- planning the treatment so that the most es-
tinct clinical steps, allowing the clinician thetic and functional result is achieved by
and the laboratory technician to constantly respecting the principle of minimal inva-
interact and thus to achieve the most pre- siveness, ie, minimal tooth preparation.
dictable esthetic and functional outcome. Clinicians should realize, however, that
The first step of the concept has been technicians will often arbitrarily decide on
previously described in detail. The present
9
numerous important dental parameters
article focuses on the second step, explain- (eg, occlusal plane, incisal edge position)
ing all the laboratory and clinical steps nec- without seeing the patients, and with an of-
essary to restore the posterior quadrants ten misleading lack of reference points
with a defined occlusal scheme at an in- (eg, adjacent teeth). The fact that the result-
creased vertical dimension. A brief sum- ing final rehabilitations often do not reflect
mary of the first step is also included. the initial full-mouth waxups confirms this
statement.
Full-mouth waxup: a crucial or In the authors’ opinion, the most mis-
arbitrary tool in the determination judged parameter in a full-mouth waxup is
of the plane of occlusion? the position of the occlusal plane. In case
Patients affected by severe dental erosion of a full-mouth rehabilitation at an in-
often present with an extremely damaged creased vertical dimension of occlusion
dentition, not infrequently making clini- (VDO), the gained interocclusal space is
cians hesitate to undertake such an ex- generally shared equally between the

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mandibular and the maxillary posterior teeth. As a consequence, not all of them will
teeth, to minimize tooth preparation in both readily accept having their anterior teeth re-
arches. However, such a decision is com- stored with added incisal volume. Hence
pletely arbitrary, and the repositioning of communication with the patient becomes
the occlusal plane at a lower level than the of paramount importance to avoid esthetic
original may lead to a compromised es- misunderstandings.
thetic result. In order to achieve an optimal Before starting the full-mouth rehabilita-
esthetic outcome, both the maxillary incisal tion, it is recommended to determine to
edges and the occlusal plane should be in what extent the patient will accept a length-
harmony. In a frontal, smiling view, the ening of the anterior maxillary teeth, so that
vestibular cusps of the maxillary posterior the final esthetic outcome will be well de-
teeth should follow the lower lip and be lo- fined and the required amount of prepara-
cated more cervically than the incisal tion of the maxillary posterior teeth can be
edges of the anterior dentition. Otherwise, accurately planned.
an unpleasant, “reverse” smile is generat-
ed. Thus, to determine the correct distribu- Step 1: Laboratory and clinic
tion of the interocclusal space gained by The first step of the three-step technique
the increase of VDO, it is mandatory to de- is conceived to guarantee that both the
termine first the optimal position of the clinician’s and the laboratory technician’s
maxillary incisal edges of the planned final vision of the planned restoration is a re-
restorations. flection of the patient’s true desires. With
In patients where the maxillary anterior the introduction of the first clinical step, the
teeth cannot be lengthened sufficiently on technician will not complete a potentially
their incisal aspect to compensate for an incorrect full-mouth waxup. In fact, the first
excessively low occlusal plane, all the laboratory step proposes to wax up only
space obtained has to be used exclusive- the vestibular surfaces of the maxillary
ly for the restoration of the mandibular pos- teeth. At this stage, where much of the rel-
terior teeth, which in turn will require a more evant information is still missing, it is not
aggressive tooth preparation of the maxil- advisable to invest time in a more compre-
lary posterior teeth. hensive waxup.
Advanced generalized dental erosion Subsequently, the information repre-
frequently leads to supraeruption of both sented by the maxillary vestibular waxup
the maxillary posterior sextants and the will be picked up by means of a precise sil-
mandibular anterior segment, causing a icone key (Fig 3).
so-called reverse smile (Fig 2). Logically, in The patient is then scheduled for a clin-
these patients, the position of the occlusal ical appointment where a maxillary vesti-
plane cannot be further lowered, unless bular mockup is directly fabricated in the
there is certitude that the incisal edges of mouth (first clinical step). The clinician will
the maxillary anterior teeth will be sufficient- load the silicone key with a tooth-colored
ly lengthened to correct the reverse smile. autopolymerizing resin composite material
An additional problem inherent to this par- and position in the patient’s mouth. After its
ticular type of patient is that they are used removal, all vestibular surfaces of the max-
to perceiving themselves with “smaller” illary teeth will be covered by a thin layer of

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a b c

Fig 2 (a to c) An unpleasent reverse smile is present when the position of the incisal edges of the maxillary
anterior dentition is more cervical than the occlusal plane, as apparent in these three patients affected by severe
dental erosion.

a b c

Fig 3 (a to c) First laboratory step: Maxillary vestibular waxup. The technician is instructed to wax up only the
vestibular aspect of the maxillary teeth. Neither the cingula nor the palatal cusps of the maxillary posterior teeth
are included at this stage. A silicone key is then fabricated and will subsequently be loaded with tooth-colored
resin composite material and repositioned in the patient’s mouth for the fabrication of a maxillary mockup.

a b c

Fig 4 First clinical step: Maxillary vestibular mockup. Clinical views before (a) and after (b and c) completion
of the diagnostic mockup. Mucogingival surgery was performed to cover the marked gingival recessions on the
maxillary left canine and premolars. Note that the mockup covers only the incisal edges and the vestibular cusps
of the maxillary teeth.

composite, reproducing the shape defined the future plane of occlusion. Additional in-
for the future restorations by the laboratory formation is also obtained, as explained in
technician. a previous article,9 most importantly the pa-
The described, fully reversible recon- tient’s consensus regarding the planned fi-
struction of the vestibular cusps of the max- nal esthetic outcome (Figs 4 and 5).
illary posterior teeth and the incisal edges After completion of the first step, either
of the anterior teeth allows visualization of formal acceptance by the patient is ob-

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Fig 5 (a to d) These photographs present the same patient as shown in Fig 4. Owing to the maxillary vestibu-
lar mockup (b), the orientation of the future occlusal plane can be visualized, and the esthetic direction taken by
the technician agreed with the patient. Generally, patients appreciate the planned treatment objective being pre-
sented to them so clearly at an early stage and before any irreversible measures have been taken.

tained, or new guidelines for changes are segments of the dentition as well as ante-
forwarded to the technician, who can then rior guidance, the clinician faces the
progress with the complete waxup of the dilemma whether to restore the patient in
posterior quadrants. Before continuing any centric relation (CR) or in maximum inter-
further with the three-step technique, it is cuspation position (MIP). According to nu-
important to address two topics specific- merous classic articles published in the
ally, which in the case of a full-mouth re- field of Gnathology,10–12 CR is recommend-
habilitation are still controversial: centric re- ed as the only acceptable position when it
lation and vertical dimension of occlusion. comes to full-mouth rehabilitations, since it
is considered the only reproducible one.
Centric relation: This concept was developed for conven-
centric occlusion dilemma tional full-mouth rehabilitations, when all
In the presence of generalized advanced the teeth were going to be restored by
dental erosion, which often significantly af- means of full coverage (crowns or fixed
fects occlusal morphology in the posterior dental prostheses) and when working ex-

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Fig 6 Mounted study casts of a same patient articulated in MIP (a) and in
CR (b), after a complete full mouth waxup. While the CR position can be de-
sirable in patients with class III molar occlusion, in patients with a class II, as for
this particular patient, it poses an occlusal dilemma. The future restorations on
the anterior teeth would never be in contact (no anterior guidance) unless un-
natural oversized cingula were created. Note the excessive horizontal overlap
(b) generated by the combination of the CR position and the increase of VDO.

tensively on both arches at the same time occlusion, ie, VDO and interarch relation,
had an elevated risk of losing all inter- are constantly maintained by the contralat-
maxillary reference points. An additional eral side of the mouth, using CR as a land-
argument for CR was that patients treated mark reference of occlusion may not be so
under extended local anesthesia were un- crucial. Furthermore, in cases of severe
able to collaborate during the occlusal ad- dental erosion, the palatal aspect of the
justments. maxillary teeth is often compromised; after
Currently, there is an increasing trend the enamel is lost, the exposed dentin is
towards minimizing the necessity for com- subject to accelerated wear, which leads to
plicated, time-consuming clinical proce- a pronounced concave morphology and
dures on the one hand, and reducing the not infrequently to weakening and fracture
number of full crown restorations on the of the incisal edges.
other hand, particularly when treating To stop the progression of the described
young patients. Consequently, the new tooth destruction (erosion and attrition), the
clinical approach (full-mouth adhesive re- exposed remaining dentin should be effi-
habilitation) for the treatment of advanced ciently protected. Due to the supraeruption
generalized erosion consists exclusively of of the anterior quadrants, an increase of
posterior onlays and anterior BPRs, and is VDO is mandatory to restore the original
strategically planned in a way that allows tooth form. However, in patients with class
rehabilitation of patients quadrant-wise in- II molar occlusion, the combination of in-
stead of by restoring both dental arches si- creased VDO and CR position may set the
multaneously. anterior teeth significantly apart and this
In a dynamic rehabilitation process, can lead to an absence of anterior guid-
where two key parameters of a functional ance.

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Since it is not recommended to substantial- functional anterior interarch contacts re-
ly increase the incisal length of the quired for anterior guidance. Furthermore,
mandibular anterior teeth (generally the new VDO should always be tested clin-
supererupted in cases of advanced gener- ically, before irreversible treatments begin,
alized dental erosion), anterior contacts since it is selected arbitrarily on the articu-
can logically only be re-established by in- lator.
creasing the size of the maxillary cingula. In this context, a traditional and fully re-
In fact, several of the patients affected by versible approach consists of the use of an
severe generalized erosion treated at our occlusal guard, which requires compli-
clinic presented a class II molar occlusion ance of the patient. However, considering
with a major discrepancy between MIP and the active lifestyle of most people, it is
CR. Thus it was preferred to restore their rather naïve to expect that patients will
occlusion in MIP and to establish anterior wear such an occlusal guard 24 hours a
contacts without the necessity of creating day for several months. A more realistic
oversized maxillary cingula (Fig 6). approach may be the use of interim
Furthermore, to evaluate if under the pre- restorations. In the case of adhesive reha-
viously described conditions and strictly fol- bilitation, the dental technician could fabri-
lowing the three-step technique the use of cate provisional composite onlays, which
CR as the interarch relationship of reference would subsequently be bonded to the
is not a prerequisite, the decision was made teeth, including the palatal aspects of the
to restore all the patients affected by severe maxillary anterior dentition. There are sev-
erosion in MIP. From the preliminary data eral disadvantages to this method, such as
collected so far, no significant adverse ef- the associated additional lab fees. Further-
fects have been encountered that would more, it may in many instances not be a
question the choice of using MIP. truly reversible approach, since it could re-
quire some tooth preparation to assure
The “increased VDO” dilemma: minimal thickness of the onlays.
how much and how to test? The third possibility for clinical testing of
In patients affected by severe generalized the feasibility of an arbitrarily chosen in-
erosion, the question of whether VDO has crease of VDO is the use of direct compos-
eventually decreased during this patholog- ites. However, free-hand direct composites
ical process is difficult to answer, as sever- are very time consuming, particularly if the
al compensatory mechanisms, eg, super- clinician aims to duplicate exactly the oc-
eruption of the alveolar process, may have clusal scheme determined by waxup on
occurred. It is also clinically quite irrelevant. the mounted study casts.
An increase of VDO is always mandato- It should be repeated that not only the
ry, in order to reduce the need for substan- posterior, but also the anterior teeth should
tial tooth preparation and to avoid the ne- be involved in the treatment in order to in-
cessity of elective endodontic treatments. crease the VDO and to recreate adequate
However, any increase of VDO should be anterior guidance. The respective result
minimal so it is tolerated by the patient, and may be disappointing, especially if the cli-
guarantees at the end of the rehabilitation nician expects to position the mandible in
the preservation or re-establishment of CR and to establish simultaneously stable

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Fig 7 (a to c) Second laboratory step: Posterior oc-


clusal waxup. The laboratory technician waxes only the
occlusal surfaces of the premolars and the first molars
in each posterior quadrant of the maxillary and
mandibular casts. Based on this waxup, four independ-
c
ent translucent silicone keys will be fabricated.

occlusal contacts at the identical VDO that splinted composite onlays, directly fabri-
had been previously selected on the artic- cated in the mouth.
ulator, a task that is generally considered
almost impossible. Step 2: Laboratory – posterior
All the three of the above techniques occlusal waxup
that have been proposed to test an in- At the beginning of the treatment, the two
crease of VDO have some major draw- maxillary and mandibular casts are mount-
backs. The dilemma of how to transfer effi- ed on a semi-adjustable articulator with a
ciently and correctly the new occlusion facebow in MIP. During the first step, the
defined with the waxup remains. As a con- technician performed a vestibular waxup
sequence, the second step of the three- on the maxillary cast, and the position of
step technique proposes an easy and re- the plane of occlusion was subsequently
versible approach to establish a new validated clinically.
posterior support and to test the adaptation For each patient, the new VDO is decid-
of the patient to this new VDO. This ap- ed arbitrarily on the articulator, taking into
proach, combining the advantages of the consideration the posterior teeth, where the
abovementioned techniques, allows fabri- maximum increase is desirable to maintain
cation of a “fixed” occlusal guard, made of a maximum of mineralized tissue, and the

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c d

Fig 8 (a to d) Waxup modifications before the fabrication of the translucent silicone keys. It is necessary to re-
move the wax from the maxillary canines, so that the key will better be adapted in the patient’s mouth (canine as
a mesial stop).

anterior teeth, which should not be set too ance or group function). In more complex
far apart to jeopardize the recreation of an- cases (shallow future anterior guidance),
terior contacts and the related anterior the technician may be obligated to wax up
guidance. Once the increase of the VDO is all the cingula of the maxillary anterior teeth
established and the plane of occlusion val- as well, to verify the disclusion of the poste-
idated, it is easy for the technician to wax rior quadrants in protrusion. Generally, there
up completely the occlusal surfaces of the is no need to wax up the mandibular ante-
posterior teeth. rior teeth, since they are often only minimal-
The second laboratory step, however, ly affected by the erosion.
proposes only to wax up the occlusal sur- At completion of the posterior occlusal
faces of the two premolars and the first mo- waxup, the technician will fabricate for each
lar in each sextant (Fig 7). The palatal as- quadrant one key, made of translucent sil-
pect of the maxillary canines may also be icone (Elite Transparent, Zhermack). These
waxed at this stage to better select the cusp keys will be used in the second clinical step
shape and inclination in relation to the oc- intraorally to fabricate direct composites,
clusal scheme selected (eg, canine guid- reproducing the waxup very closely.

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Fig 9 (a to d) Intraoral preparation of a posterior maxillary sextant for a direct bonding procedure: The two
premolars and the first molars for each posterior quadrant are etched, and priming and bonding agents are ap-
plied. Care is taken to isolate the adjacent teeth with matrices.

Some modifications of the waxup are subse- Step 2: Clinical – posterior


quently carried out to facilitate the next clini- interim composites
cal step, before producing the keys (Fig 8): The second clinical step basically consists
! The wax is carefully removed from the of the fabrication of posterior composite
buccal and the lingual surfaces of the onlays, directly performed in the patient’s
posterior teeth of the casts, so that in turn mouth, thanks to the special transparent
each key will be in close contact to the keys duplicating the occlusal waxup.
cervical aspect of the teeth in the pa- The two premolars and the first molars
tient’s mouth. As a consequence, less of each quadrant are acid-etched, followed
excess resin composite may flow into by application of primer and bond (Opti-
the gingival sulcus and fewer intraoral bond FL, Kerr) (Fig 9). In the authors’ expe-
adjustments will be necessary. rience, even in cases of severe exposure of
! The wax should also be removed, if dentin, there is no need to anesthetize the
present, from the canines, since they will patient before applying the etching agent.
serve as a mesial stop to stabilize the The clinician will then load each translu-
key intraorally. cent key with composite, position it in the

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Fig 10 (a and b) Second
clinical step: interim posteri-
or composite. The translu-
cent silicone key, duplicating
the occlusal waxup, is load-
ed with resin composite and
positioned in the mouth. The
key is well stabilized by the
canine and the second mo-
lar (mesial and distal stops).
Owing to the translucency of
the silicone, the composite
can be polymerized through
a b the key.

a b

Fig 11 (a and b) The posterior provisional resin composite is easily and quickly fabricated, with minimal ex-
cess requiring removal. A composite shade that is slightly different from the remaining dentition should be se-
lected to facilitate the future removal of these provisional restorations. Note that in this patient the clinician has
filled the interproximal spaces with teflon to reduce excess resin composite in the embrasures.

a b

Fig 12 (a and b) Since the second molars are not Fig 13 Even though the occlusal access to the inter-
restored with interim resin composite, they serve as proximal areas is blocked by the splinted posterior in-
valuable indication of the increase of VDO, once the re- terim composites, the gingival embrasures are still
spective casts are articulated. open to allow cleaning with Superfloss.

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patient’s mouth, and polymerize the com- Implementation of this technique includes
posite through the key (Fig 10). Since the splinting the three posterior teeth involved,
keys, made of translucent silicone, are not thus blocking the occlusal access of two in-
as rigid as desired, it is crucial not to use terproximal contacts areas and preventing
too viscous a resin composite (such as Tet- the use of dental floss. Adequate oral hy-
ric EvoCeram, Ivoclar Vivadent), or to load giene, however, is possible since the gin-
the key excessively. To avoid distortion, the gival embrasures are kept open and Su-
composite should be pre-warmed, and a perfloss can be used with a lateral path of
minimal quantity of material should be insertion (Fig 13).
placed in the key, just enough for the new As stated above, the original models of
volume of the occlusal surfaces. the patient are mounted in MIP and the in-
At this stage, the second molars are not crease in VDO is decided on the articula-
included in the occlusal waxup, nor will tor. Despite the fact that the articulator's
they be restored with a provisional occlusal hinge axis is going to be different from the
composite due to the following reasons patient's, in our experience it does not
(Fig 12): generate sufficiently different occlusal con-
! to assure the presence of a stable distal tacts on the composite resin to require the
occlusal stop for accurate positioning of mounting of the casts in CR.
the translucent keys during the fabrica- Minor occlusal adjustments should be
tion of the posterior interim composites expected by implementing this technique,
! to acknowledge the fact that three pos- but normally, if the waxup is correctly per-
terior teeth are considered sufficient to formed, and the keys accurately fabricated
establish stable posterior support in and positioned in the mouth, the time re-
each sextant quired for the adjustment is limited (Fig 14).
! to have a reference indicating the In addition, since there is normally no need
amount of increase of VDO. to anesthetize the patient, control of the oc-

a b

Fig 14 (a and b) A different patient, before and after the second step of the three-step technique. Minimal oc-
clusal adjustments are expected if the previous steps are performed correctly (eg, posterior occlusal waxup,
translucent key fabrication, loading of the keys). Note that the composites do not extend to the cervical third of
the teeth, thanks to the respective modifications of the waxup before the key fabrication. The resulting visible tran-
sition step can be smoothed with a polishing rubber wheel.

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c d

Fig 15 (a to d) A 29-year-old patient before and after the second clinical step of the three-step technique.
Even in cases of extensive dentine exposure, dental anesthesia is not required during this step.

a b

Fig 16 (a and b) Close-up view of the previous patient. Existing amalgam restorations can be removed (tooth
36) or left in place and covered with the interim resin composite (tooth 26).

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clusion will be facilitated and consequent- cisal edge position, by modifying the
ly more accurate. vestibular cusps of the posterior provision-
This “fixed” occlusal guard has the ma- al composites. Finally, their presence will
jor advantage that the compliance of the facilitate the occlusal adjustments of the fi-
patient is 100% in terms of testing the in- nal restorations placed in the opposite
creased VDO. Since no tooth preparation quadrant. The laboratory technician could
is requested for the fabrication of the pos- decide to fabricate the latter to the perfect
terior occlusal composites, the treatment form and all the occlusal adjustments
can be considered completely reversible; could be carried out on the opposite pro-
if signs and/or symptoms of temporo- visional posterior composites.
mandibular dysfunction arise, the initial The second clinical step has been con-
status could be re-established by grinding ceived to simplify the clinician’s work, with-
off the occlusal composites. These com- out compromising the final outcome of the
posite onlays are meant to be provisional, full mouth rehabilitation.
and they will be replaced (with final com- In this case, it was decided not to at-
posite or ceramic onlays) after the anterior tempt to restore the anterior teeth with pro-
quadrants are definitely restored (step 3 of visional resin composite. In the authors’
the three-step technique) (Fig 15). This is experience the increase of VDO is well tol-
one of the reasons that the use of rubber erated (because minimal) by the patients
dam is not vital during this particular step, even when an anterior open bite is creat-
and the removal of existing functioning ed temporarily. Some speech impairments
restorations (eg, old amalgam restora- could be anticipated. However, patients in-
tions) is not strictly required. formed before treatment usually deal very
Another advantage of these interim well with this problem (Figs 17 to 19).
composites is their potential for modifica- Currently, there is no consensus of the
tion. After, for example, completion of the time necessary to test the comfort of the
restoration of the maxillary anterior teeth, it patient with respect to a new, increased
is still possible to adjust the position of the VDO, and each clinician appears to decide
occlusal plane with respect to the new in- based on personal opinion rather than on

a b

Fig 17 (a and b) Same patient as shown in Fig 12. After completion of the second clinical step the patient is
restored at an increased VDO (b). Note the slight anterior open bite that has been generated.

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a b

Fig 18 (a and b) Another example of a patient affected by severe dental erosion, restored according to the
three-step technique. At this stage the posterior quadrants (except the second molars) were restored with inter-
im posterior resin composite (second clinical step).

c d

Fig 18 (c and d) Frontal view at the new vertical dimension of occlusion shown in Fig 18b. Normally, patients
who were informed beforehand deal well with the resulting anterior open bite.

a b

Fig 19 Close-up view of the previous patient’s right side. Initial status (a) and after the second clinical step (b).
The patient underwent mucogingival surgery, which revealed distinct class V lesions, previously located slightly
subgingivally.

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scientific evidence. At the University of The three-step technique is a structured ap-
Geneva, the protocol suggests waiting one proach to achieve a full-mouth adhesive re-
month. This is a completely arbitrary and habilitation with the most predictable result,
experimental choice. Once the patient the minimal amount of tooth preparation,
feels comfortable and neither signs nor and the highest level of patient acceptance.
symptoms of temporomandibular dys- The goal of this technique is to temporarily
function appear, the acceptance of the restore a compromised dentition at a new
new VDO can be confirmed, and the third VDO, implementing directly bonded poste-
step (the creation of the anterior guidance) rior composite restorations. With a stable
can be undertaken. posterior support, the anterior teeth can
If the clinician is concerned about leav- subsequently be restored easily, again us-
ing the patient without anterior contacts ing exclusively adhesive techniques. Once
and thus without a functional anterior guid- the anterior contacts and an anterior guid-
ance during the testing phase of the new- ance are re-established, the replacement of
ly introduced, increased VDO, the third the posterior provisional resin composites
step could be initiated more rapidly. can begin. Owing to the presence of the
Finally, the technician will concentrate provisional posterior composites, the full-
on the anterior teeth. Based on the degree mouth rehabilitation can be planned ac-
of destruction, the palatal aspect of the an- cording to a quadrant-wise approach.
terior teeth will be restored (direct or indi- Restoring a patient by quadrants has enor-
rect resin composites), representing the mous practical advantages for both patient
third and last clinical step of the three-step and clinician, since fewer appointments are
technique. necessary. Neither multiple anesthetic injec-
At this point the patient will be stable tions nor difficult full mouth impressions are
from a point of view of occlusion. The required. Since the contralateral part of the
only definitive restorations are the palatal mouth guarantees a stable occlusion, pa-
reconstructions. The vestibular/incisal as- tients feel comfortable throughout the whole
pects of the anterior maxillary teeth, as active treatment phase up to the delivery of
well as the remainder of the posterior the final restorations.
teeth, still need to be treated by means of In this article, the second step of the
permanent restorations. three-step technique has been discussed
in detail, including the fabrication of the di-
rectly bonded provisional posterior com-
Conclusions posites.

The restorative therapy of dental erosion


should be based on a minimally invasive Acknowledgments
approach, even in the case of extensive
loss of tooth structure. Adhesive techniques The authors would like to thank the laboratory techni-
cians and ceramists Alwin Schönenberger, Patrick
can help the clinician in rehabilitating this
Schnider and Sylvain Carciofo for their enthusiastic
type of patient in the most conservative collaboration and meticulous execution of the labora-
manner. tory work presented in this article.

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References
1. Kavoura V, Kourtis SG, Zoidis 5. Aziz K, Ziebert AJ, Cobb D. 9. Vailati F, Belser UC. Full mouth
P, Andritsakis DP, Doukoudakis Restoring erosion associated adhesive rehabilitation of a
A. Full-mouth rehabilitation of a with gastroesophageal reflux severely eroded dentition: the
patient with bulimia nervosa. A using direct resins: case three step technique. Part I. Eur
case report. report. Oper Dent J Esthet Dent 2008;1:58–72.
Quintessence Int 2005;30:395–401. 10. Stuart CE, Golden IB. The His-
2005;36:501–510. 6. Lussi A, Jaeggi T, Schaffner M. tory of Gnathology. CE Stuart
2. Van Roekel NB. Gastroe- Prevention and minimally inva- Gnatological Instruments.
sophageal reflux disease, tooth sive treatment of erosions. Oral 1981;13–32,113.
erosion, and prosthodontic Health Prev Dent 2004;2(Suppl 11. Granger ER. Practical Proce-
rehabilitation: A clinical report. 1):321–325. dures in Oral Rehabilitation.
J Prosthodont 7. Sundaram G, Bartlett D, Wat- Philadelphia: Lippincott,
2003;12:255–259. son T. Bonding to and protect- 1962:66–74.
3. Bonilla ED, Luna O. Oral reha- ing worn palatal surfaces of 12. McCollum BB. Fundamentals
bilitation of a bulimic patient: a teeth with dentine bonding involved in prescribing restora-
case report. Quintessence Int agents. J Oral Rehabil tive dental remedies. Dental
2001;32:469–475. 2004;31:505–509. Items Interest, 1939.
4. Hayashi M, Shimizu K, 8. Hastings JH. Conservative
Takeshige F, Ebisu S. Restora- restoration of function and
tion of erosion associated with aesthetics in a bulimic patient:
gastroesophageal reflux a case report. Pract Periodon-
caused by anorexia nervosa tics Aesthet Dent
using ceramic laminate 1996;8:729–736.
veneers: a case report. Oper
Dent 2007;32:306–310.

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CLINICAL APPLICATION pyrig
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Full-Mouth Adhesive Rehabilitation sse nc e

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fo r

of a Severely Eroded Dentition:


The Three-Step Technique. Part 3.
Francesca Vailati, MD, DMD, MSc
Senior Lecturer, Dept of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva, Switzerland
Private practice, Geneva Dental Studio, Switzerland

Urs Christoph Belser, DMD, Prof Dr med dent


Chairman, Dept of Fixed Prosthodontics and Occlusion
School of Dental Medicine, University of Geneva
Switzerland

Correspondence to: Dr Francesca Vailati


University of Geneva, Dept of Fixed Prosthodontics and Occlusion, Rue Bathelemy-Menn 19, 1203 Geneva, Switzerland;
e-mail: Francesca.vailati@medecine.unige.ch.

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Abstract ss e n c efo r
Dental erosion is a frequently underesti- resin composite restorations in the anterior
mated pathology that nowadays affects an maxillary region.
increasing number of younger individuals. To achieve maximum preservation of
Often the advanced tooth destruction is the tooth structure and predict the most esthet-
result of not only a difficult initial diagnosis ic and functional outcome, an innovative
(e.g. multifactorial etiology of tooth wear), concept has been developed: the three-
but also a lack of timely intervention. step technique.
A clinical trial testing a fully adhesive ap- Three laboratory steps are alternated
proach for patients affected by severe den- with three clinical steps, allowing the clini-
tal erosion is underway at the School of cian and the dental technician to constant-
Dental Medicine of the University of Gene- ly interact during the planning and execu-
va. All the patients are systematically and tion of a full-mouth adhesive rehabilitation.
exclusively treated with adhesive tech- In this article, the third and last step of the
niques, using onlays in the posterior region three-step technique has been described
and a combination of facially bonded in detail.
porcelain restorations and indirect palatal (Eur J Esthet Dent 2008;3:236–257.)

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Introduction First step:

n
ss e n c e
fo r
maxillary vestibular waxup
Patients affected by severe dental erosion
often present with an extremely compro-
and the occlusal plane
mised dentition, especially in the anterior The first step of the three-step technique is
maxillary quadrant; the vertical dimension designed to ensure the clinician, the tech-
of occlusion may have decreased, and/or nician and the patient agree on the final
and supraeruption of the respective alveo- treatment objective outcome, before any ir-
lar process segments may have occurred. reversible therapy starts.
If erosion is not intercepted at an early The major goal is to validate the position
stage, full mouth rehabilitation, mostly im- selected for the plane of occlusion of the fi-
plementing conventional full coverage nal restorations, which is in the authors’
(crowns), may be required. Thanks to im- opinion the most frequently neglected pa-
proved adhesive techniques, the indica- rameter in a full-mouth rehabilitation.
tions for crowns have decreased and a During the first appointment with the pa-
more conservative approach may be pro- tient, photographs, radiographs and algi-
posed to preserve tooth structure, and to nate impressions are taken (as well as
postpone more invasive treatments until anamnesis and comprehensive clinical ex-
the patient is older. A clinical trial testing a amination). Finally, the visit is concluded
fully adhesive approach is underway at the with a facebow record.
School of Dental Medicine at the Universi- The laboratory technician articulates the
ty of Geneva. All patients affected by gen- two diagnostic casts on a semi-adjustable
eralized advanced dental erosion are sys- articulator by the mean of the facebow in
tematically and exclusively treated with the maximum intercuspation position (MIP).
adhesive techniques, using onlays in the As without the clinical validation of the po-
posterior region and a combination of fa- sition of the occlusal plane a full-mouth
cial bonded porcelain restorations (BPRs) waxup may be useless, the three-step tech-
and indirect palatal resin composite nique proposes that the technician initially
restorations in the anterior maxillary region. waxes up only the vestibular surface of the
As the first and the second steps of the maxillary teeth. At this time, neither the cin-
concept have been previously described in gula of the anterior nor the palatal cusps of
1,2
detail, this article focuses on the third and the posterior maxillary teeth should be in-
last step explaining the rationale behind the cluded. Inspired by the photographs of the
approach selected to restore the anterior patient, the technician concentrates exclu-
maxillary quadrant. sively on the esthetic appearance of the fa-
For better understanding, a brief sum- cial surfaces of the maxillary teeth, with
mary of the two previous steps is present- maximum freedom of creativity.
ed in the following paragraph. An intermediate clinical step is taken to
verify that the direction is correct, and the
duplication of the maxillary vestibular
waxup by the means of a precisely fitting
silicone key concludes the first laboratory
step.

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Table 1 The three-step technique. ss e n c efo r
Laboratory Clinical

Maxillary Step 1: Assessment


vestibular waxup Esthetics of occlusal plane

Posterior Step 2: Creation of poste-


occlusal waxup Posterior support rior occlusion at
an increased VDO

Reestablishment
Maxillary anterior Step 3:
of final anterior
palatal onlays Anterior guidance
guidance

During the first clinical step, the silicone key Second step:
is loaded with tooth-colored provisional
posterior occlusal waxup
resin composite and repositioned in the pa-
tient’s mouth. After its removal, all the buc-
and new occlusion
cal surfaces of the maxillary teeth are cov-
at an increased vertical
ered by a thin layer of resin composite that dimension of occlusion
reproduces the defined shape for the future The second laboratory step deals with the
restorations (maxillary vestibular mock-up). posterior occlusion, as at this stage, the
This fully reversible reconstruction of the waxup only involves the posterior quad-
vestibular cusps of the maxillary posterior rants of both the maxillary and mandibular
teeth and the incisal edges of the anterior casts.
teeth allows perfect visualization of both In case of a severely eroded dentition, an
the plane of occlusion and the overall increase of the vertical dimension of occlu-
esthetic appearance of the future final sion (VDO) is inevitable in order to reduce
restorations. the need for substantial tooth preparation in
Other different dental parameters, such general and to avoid the necessity of elec-
as the gingival levels, are also clinically as- tive endodontic treatments in particular.
sessed with the full participation of the pa- For each patient, the new VDO is decid-
tient, as described in a previous article.1 ed arbitrarily on the articulator, taking into
Thanks to the maxillary vestibular mock- consideration both the posterior teeth,
up, the patient is reassured at an early stage where the maximum feasible increase is
about the treatment objective, which, in turn, desirable to maintain a maximum of min-
normally means that the patient wishes to eralized tissue, and the anterior teeth,
immediately begin treatment. With the which should not be set too far apart as this
mock-up in place, new photographs are would jeopardize the reestablishment of
taken, and the technician can subsequent- anterior interarch contacts and the related
ly progress to the second laboratory step. anterior guidance. As the new VDO should

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always be tested clinically prior to its final especially in the case of an extremely ss e n c e
fo r
acceptance before any irreversible treat- aged anterior dentition. The worsening of
ment starts, the second step is devoted to their smile is due to the fact that the maxil-
testing that the patient can adapt to the new lary posterior teeth have been lengthened
therapeutic occlusion. by the posterior provisional resin compos-
As explained in the authors’ previous ar- ites, whereas the maxillary incisal edges
ticle2, the laboratory technician will wax up have not yet been restored (Fig 1).
only the two premolars and the first molar Some speech impairments can also be
in each sextant to recreate the occlusal expected, as the anterior teeth are set apart
scheme planned for the final restorations.2 and more air can escape during the pro-
Four translucent silicone keys are then nunciation of the letter ‘s’. However, pa-
fabricated, each duplicating the waxup of tients are generally so motivated after the
one posterior quadrant. The patient is sub- first clinical step that they do not find this
sequently scheduled for a next appoint- treatment phase particularly stressful or un-
ment. This time the clinician explains that bearable. The second clinical step has
another reversible treatment will be per- been conceived to simplify the clinician’s
formed. However, this will change the oc- work, without compromising the final out-
clusion of the patient. come of the full-mouth rehabilitation.
The translucent keys are loaded with Consequently, it was decided for all pa-
resin composite prior to placement in the tients not to attempt to simultaneously re-
patient’s mouth. Thanks to the described store the anterior teeth while restoring the
translucency, a light-curing resin compos- posterior quadrant with provisionals.
ite can be utilized. As previously mentioned, thanks to the
Without any tooth preparation (only etch- maxillary mock-up of the first clinical step,
ing and bonding), the occlusal surface of all patients are very trusting, as the planned
the premolars and the first molars are re- treatment objective has been visualized
stored with a layer of resin composite, re- and thoroughly explained beforehand.
producing the respective diagnostic waxup. Consequently, this transitional period is ac-
The three-step technique recommends cepted without major complaints, and
an arbitrary observation period of approxi- none of the patients enrolled in our study
mately 1 month to assess the patient’s requested an earlier reconstruction of the
adaptation to the newly established VDO. anterior teeth. The most frequent objection
The new occlusion obtained is peculiar in raised by colleague clinicians to this tech-
that the anterior teeth are no longer in con- nique is that without adequate anterior
tact. The degree of this transitional open guidance, a new occlusion at an increased
bite depends on the one hand on the VDO cannot be correctly assessed. How-
amount of increase of VDO required, and ever, to date, there is no robust scientific ev-
on the other hand on the patient’s original idence available to support this criticism. In
vertical overlap and the severity of the in- the authors’ experience, patients are able
cisal edge destruction. to function well for a short period of time
Patients should be informed that the es- without anterior contacts.
thetic appearance of their smile could Finally, according to the three-step tech-
worsen at this transitional stage of therapy, nique, all these patients enrolled for thera-

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a d

b e

c f

Fig 1a to f Three patients before treatment (left) and at completion of the second clinical step (right). As the
anterior teeth have not been restored at this stage patients lose anterior guidance and the esthetic appearance
is worsened. The more compromised the anterior teeth are, the more visible the reverse smile will get. However,
normally, patients do react very well to this transitional stage, as they undertook the mock-up session and, thus,
were reassured when it comes to the perspective of the planned final result of treatment.

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ot n

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py should undergo a consultation with a ening and fracturing of the ss e n c e
fo r
specialist in the field of temporomandibu- Following the guidelines for conventional
lar disorders prior to initiating treatment, in oral rehabilitation concepts, such struc-
order to assess the clinical status of their turally compromised teeth should receive
articulations. full crown coverage. In order to place the
As the second clinical step (provisional crown margins at the gingival level, the en-
posterior resin composites) is considered tire coronal tooth structure, mesially and
fully reversible, the transient occlusal resin distally, is removed to guarantee the path
composite restorations can be easily mod- of insertion of the crown (see Fig 2).
ified or completely removed from the un- The entire facial aspect will also be sub-
prepared posterior teeth if signs and/or stantially reduced in the process of prepar-
symptoms of temporomandibular dys- ing the 1.5 mm shoulder ceramic margins
function should arise. for porcelain-fused-to-metal crowns. Even
when the more conservative all-ceramic
crowns are adopted (eventually <1 mm of
Third step: chamfer preparation) the clinician still has
to eliminate the mesial and distal under-
the anterior guidance
cuts of the tooth and smoothen the sharp
At the completion of the second step, a sta- edges, leading to a highly invasive prepa-
ble posterior occlusal support is estab- ration of the axial walls.
lished. As mentioned previously, owing to Several studies have demonstrated the
the presence of the posterior provisional importance of the marginal ridges for pos-
resin composites, the anterior teeth are set terior teeth. Restorations that extend to the
apart. Consequently, the third and final
step of the three-step technique deals with
the restoration of the anterior quadrants
(reestablishment of an adequate, function-
al permanent anterior guidance).

Restoration of the maxillary


anterior teeth, a minimally
invasive treatment:
the ‘sandwich approach’
Generally, the palatal aspect of the maxil-
lary anterior teeth is severely affected by
Fig 2 Maxillary incisors are chisel-shaped teeth. In
the destructive combination of erosion and order to remove the retentive areas and to prepare mar-
attrition, which leads to a substantial loss of gin of at least 1 mm circumferentially, crown prepara-
tooth structure. After the loss of enamel, the tion cannot be considered conservative. Only veneer
preparation can guarantee to preserve the triangular
exposed dentin is subject to accelerated
shape of these teeth, thanks to the facial insertion path
wear, which leads to a pronounced con- of the restoration.3
cave morphology, and frequently, to weak-

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7-14
mesial and distal aspect, such as a MOD crowned teeth in very young patients.
ss e n c e fo r
restoration, greatly affect the strength of the However, the problems that arise when a
restored posterior teeth.4-6 tooth looses its vitality, such us periapical
In the authors’ opinion, the mesial and lesions, discolorations, root fractures, etc.
distal marginal ridges of the anterior teeth are well documented.15-17
may have a similar importance as de- To avoid aggressive treatments on the
scribed for posterior teeth in guaranteeing one hand and to keep teeth vital on the
structural strength, thus, representing a other hand, an experimental approach of
framework for enamel. Therefore, the re- restoring the maxillary anterior teeth of pa-
moval of these mesial and distal margin- tients affected by severe dental erosion is
al ridges of the anterior teeth could dra- currently under investigation at the Univer-
matically compromise the tooth flexibility sity of Geneva, School of Dental Medicine.
the (“tennis racket theory”), see Fig 3. The authors’ minimally invasive treat-
Preparing such teeth for crowns will com- ment concept consists of reconstructing the
plete the destruction initiated by the ero- palatal aspect with resin composite (direct
sive process. Not infrequently, elective en- or indirect, as will be explained later in this
dodontic treatment will be necessary, and article)18-19 and to restore the facial aspect
posts will then be used to assure retention with ceramic veneers.
of the final crowns. The final outcome is reached by the
Only a few articles have been published most conservative approach possible, as
that have aimed at investigating the sur- the remaining tooth structure is preserved
vival rate of single crowns on vital natural and located in the center between two dif-
teeth, and there are no long-term follow-up ferent restorations (‘the sandwich ap-
studies on the survival of devitalized and proach’) (Fig 4).

Fig 3 Even though these teeth have been severely Fig 4 The sandwich approach. Keeping tooth prepa-
structurally compromised, the enamel layer represent- ration minimal, the remaining tooth structure of the erod-
ing the remainder of the mesial and distal marginal ed maxillary anterior teeth is maintained in between two
ridges is still visible. Like the external frame of a tennis adhesive restorations, performed at two different mo-
racket, these bands of enamel may play a significant ments in time, i.e. first the palatal resin composite and
role in strengthening the tooth (“the tennis racket second the facial ceramic veneer.
theory”).

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entire palatal surface restored with ss e n c e
fo r
composite. Such an ultra-conservative ap-
proach cannot be matched by any type of
full-crown preparation.
For all patients involved in this prospec-
tive clinical study, a strict follow-up is sched-
uled to collect information on the survival
and eventually complication rates of such
novel anterior restorations. The detailed
protocol and the preliminary results of the
study will be the topic of another article.
Fig 5 At the completion of the second step, the pa-
tient has a stable posterior occlusion. To reconstruct the
palatal aspect of the maxillary anterior teeth before
restoring them with veneers, the clinician can select di- Palatal aspect: direct or
rect or indirect resin composites. In this specific case, indirect resin composites?
indirect resin composite restorations were preferred, as
it was judged that the interocclusal space was conspic-
After 1 month of functioning with the pos-
uous and that the anterior guidance could have been
better recreated in the laboratory.
terior occlusal interim resin composite
restorations, it is assessed whether or not
the patient feels comfortable with the new
occlusion. Subsequently, two alginate im-
A still experimental, but highly promising, ul- pressions and a new facebow record are
tra-conservative approach, implementing taken. In order to mount the casts in MIP,
both basic principles of biomimetics and an anterior occlusal bite registration is al-
adhesive technology, has recently been so required.
20-23
published by Magne et al. The laboratory technician verifies on the
Severely compromised anterior teeth mounted casts that the second step had
have been restored without following the been accurately executed. In other words,
classic rules of crown preparation, which he/she must check that the position of the
traditionally would require localization of the occlusal plane is actually located where it
restoration margins on sound tooth struc- was planned, and that the posterior teeth
ture. with the provisional resin composites look
To the contrary, teeth with extensive class similar to the original waxup. Thanks to the
3 defects were directly restored with adhe- presence of the non-restored second mo-
sive resin composite restorations before the lars, a precise verification of the amount of
facial veneer preparations were performed, increase of VDO is possible at any time.
treating the resin composite as an integral The type of restoration that is best indi-
part of the tooth. In other terms, a part of the cated to restore the palatal aspect of the
veneer margins were located on resin com- maxillary anterior teeth (i.e. direct or indirect
posite. Along these lines the three-step tech- resin composite) is then selected, Fig 5.
nique has pushed the limit of this innovative If the space is reduced (<1 mm), the
application, as the teeth to be restored with resin composites can be done directly
facial ceramic veneers had previously the free-hand, saving time and money (there

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Fig 6a to c Palatal onlay preparation. The only tooth preparation required is the slight opening of the inter-
proximal contacts, to provide the laboratory technician access during trimming of the dyes on the master cast.
The dentin will be subsequently cleaned, followed by removing the most superficial layer with a diamond bur.
Note that, due to the erosive process, a cervical chamfer-like preparation is already present.

is no laboratory fee for the palatal onlays palatal onlays of the six maxillary anterior
and only one clinical appointment is re- teeth. This preparation can be a quite an
quired). If the interocclusal distance be- easy and rapid procedure. In fact, in the
tween the anterior teeth is, instead, signifi- case of severe dental erosion, the palatal
cant, free-hand resin composites could aspect of the maxillary anterior teeth is
prove to be very challenging. generally the most affected of the entire
When the teeth present a combination of dentition. Under the described circum-
compromised palatal, incisal and facial as- stances, the erosion and the attrition
pects, it is difficult to visualize the optimal fi- processes have already created the space
nal morphology of the teeth, particularly necessary for the onlays, and no addition-
while restoring at this stage only the palatal al tooth preparation is required once an
side with rubber dam in place. Thus, the re- anterior tooth separation is generated by
sult may be unpredictable and highly time the increase of VDO.
consuming. In addition, at closer observation, the
Under such conditions, fabricating the cervical part next to the gingiva frequently,
palatal onlays in the laboratory clearly pres- presents a chamfer-like preparation con-
ents some advantages, including superior figuration, with a small band of enamel still
wear resistance and higher precision dur- present. Owing to the buffering action of
ing the creation of the final form.24 both the sulcular fluid and the plaque, this
thin layer of enamel is often preserved from
the acid attack and its presence will pro-
Palatal onlays: vide a superior quality of adhesion. As this
chamfer is located supragingivally and
tooth preparation
there is no need to extend the margins
In case the indirect approach is selected, subgingivally, the next restorative steps are
the clinician will schedule an appointment also facilitated (e.g. impression-taking and
to proceed to the preparation for the bonding of the final restorations).

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Fig 7a and b During the fabrication of the palatal resin composites, the technician and the clinician can de-
cide to reestablish the full length of the future veneers or to keep the incisal edges slightly shorter.

The only features required are to slightly stage, as the information on how to orien-
open the interproximal contacts between tate the casts to the hinge axis of the artic-
the maxillary anterior teeth by means of ulator is preserved by the previously
stripping and to smoothen the incisal mounted mandibular cast.
edges by removing unsupported enamel As the interproximal contacts have been
prisms. The palatal dentin is also cleaned removed before taking the impression, the
with a non-fluoride-containing pumice, and maxillary anterior teeth are already slightly
the most superficial layer removed with ap- separated from each other on the working
propriate diamond burs (Fig 6). cast, facilitating the trimming of the dyes.
Owing to this minimal tooth preparation, The laboratory technician is specifically
sensitivity does not develop. Consequent- instructed to focus on the shape of the
ly, no provisional restorations are required palatal onlays in view of:
during the time necessary for the laborato- 1. Establishment of an adequate function-
ry technician to fabricate the palatal onlays. al anterior guidance
After the final impression, the appointment 2. Optimization of the future transition be-
is concluded with an anterior bite registra- tween the palatal onlay and the veneer.
tion of the patient’s maximum intercuspida-
tion position. At this stage, the laboratory technician can
either directly fabricate the palatal onlays,
or decide to wax up completely the maxil-
Third laboratory step: lary anterior teeth in order to better visual-
ize the future junction between the palatal
the fabrication of
onlay and its corresponding facial veneer.
the palatal onlays
This is a demanding step, and each labo-
The maxillary master cast comprising the ratory technician, who has participated so
preparations for the palatal onlays is far in this project, has selected a slightly
mounted on the articulator in MIP. Another different approach.
facebow record is not necessary at this

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Fig 8a and b To facilitate the positioning during bonding of the palatal onlays, a small hook is fabricated. This
incisal stop will be removed easily during finishing and polishing. Note that in this patient the decision to restore
the full length of the teeth with the palatal resin composites was made.

During the fabrication of the palatal resin they do not consider this as a major draw-
composites, the technician and the clini- back.
cian can decide to reestablish the final It is very important that the laboratory
length of the future veneers or to keep the technician fabricates a kind of hook at the
incisal edges slightly shorter (Fig 7). level of the incisal edge (incisal stop),
In case of severe dental erosion, the fa- made of the same material as the restora-
cial aspect of the maxillary teeth may also tion, which will help to position and stabi-
be significantly involved and the layer of lize the onlay during the bonding proce-
enamel thinned, to the point that the teeth dure (Fig 8).
appear more yellow – the dentin itself, ex-
posed at the level of the incisal edges,
could also be stained. Consequently, pa- Third clinical step:
tients with advanced dental erosion fre-
reestablishment of
quently complain about the color of their
anterior contacts and
teeth, becoming victims – like many other
people – of the bleaching obsession of
the anterior guidance
modern times. If one has decided to in- When an indirect approach is selected, an
crease the length of the teeth before the additional appointment is necessary to de-
fabrication of the facial veneers by means liver the final palatal restorations.
of the palatal onlays, patients should be in- Whereas tooth preparation and final im-
formed that there may be a possible color pression for indirect palatal resin compos-
mismatch with the vestibular surfaces. The ites are simple procedures, bonding of
color of the palatal onlays will be different, these restorations may be a demanding
as it is meant to match the color of the fi- step, not only for the more difficult visibility
nal veneers, instead of the unrestored fa- of the operating field, but because of the
cial aspect of the teeth. necessity to guarantee moisture control.
Generally, patients are so happy to The posterior resin composites are
have their anterior teeth lengthened that provisional restorations and, thus, the use

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Fig 9 Bonding procedure of a palatal onlay. The use


of rubber dam is crucial. To expose the margin it is nec-
essary to place a clasp on the tooth receiving the on-
lay. Once the bonding of the restoration completed, the
clinician will remove the clasp and place it on the ad-
jacent tooth to bond the next onlay.

a b

Fig 10a and b Third clinical step. Clinical close-up views before and after bonding of six palatal resin com-
posite onlays. In this patient, the full length of the future veneers was reconstructed at this intermediate stage of
therapy by means of palatal onlays. This approach is clearly more demanding for the laboratory technician, see
Fig 7a.

a b

Fig 11a and b Third clinical step. Clinical close-up views before and after bonding of six palatal resin com-
posite onlays. In this patient the resulting orofacial dimension of the restored teeth seems unnaturally larger. This
is due to the fact that the teeth were not restored to their final length at this stage in the treatment, see Fig 7b.

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Fig 12 At completion of the third step, the patient is


scheduled for final diagnostic mock-up, which this time
will involve only the six maxillary anterior teeth. The
waxup of these teeth and the subsequent mock-up are
necessary steps, not only to confirm the final shape of
the veneers, but also to produce the silicone keys guid-
ing the veneer preparations and serving as template for
the provisional restorations

of rubber dam is not necessary, whereas Once the tooth is isolated by means of rub-
the palatal onlays are final restorations ber dam, the bonding procedure itself is
and the bonding conditions should be not complicated, as the incisal stops help
optimal. to position the palatal onlays, the interprox-
To ensure the best conditions for the ad- imal contact points are often not a concern,
hesive procedures, after the placement of and the margins are supragingival (Figs 10
rubber dam, every onlay is bonded once at and 11).
the time using hybrid resin composite (e.g.
Miris, Coltène/Whaledent), following the
protocol proposed by P. Magne for ceram- Facial aspect:
ic veneers. The only difference is that the in-
ceramic veneers
taglio surface of the resin composite palatal
onlays is microsandblasted (30 µm Cojet The restoration of the palatal aspect of the
sand, 3M Espe), and not treated with fluo- maxillary anterior teeth concludes the
ridic acid. To correctly isolate the margins, three-step technique. At this stage, the pa-
it is necessary to place a clasp on the tooth tient has reached completely stable oc-
receiving the onlay, otherwise the rubber clusal conditions (in the anterior and pos-
dam would overlap the margins (Fig 9). terior quadrants) so the clinician can
Considering that the substrate is mostly decide, without pressure, on the pace to
sclerotic dentin, and that the length of the adopt for the completion of therapy and on
final restorations is sometimes double of the type of restorations. Generally, the
the original length of the remaining tooth mandibular anterior teeth only need minor
structure, the task requested for the bond- treatment and can, in most instances, be
ing is major. restored with direct resin composites.
Success can only be ensured by opti- Before replacing the posterior provision-
mal bonding conditions on the one hand al resin composite restorations with ceram-
and by the presence of enamel at all mar- ic or resin composite onlays, it is preferable
gins of each onlay, except, of course, at the to complete the restoration of the facial as-
incisal level. pect of the maxillary anterior teeth.

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a b

Fig 13a to c Three sil-


icone keys are obtained
from the waxup of the six
anterior maxillary teeth:
one for the mock-up, an-
other for the facial reduc-
tion and a third one for the
incisal reduction. The in-
dex for the mock-up will
be used again after tooth
preparation of the ve-
c neers, to fabricate the pro-
visional restorations.

As the protocol followed at the University If the patient’s consensus on the final
of Geneva previews facial ceramic ve- shape of the maxillary anterior teeth is ob-
neers to be the permanent restorations, a tained, another two silicone indexes are
second mock-up of the six maxillary ante- fabricated based on the waxup, to guide
rior teeth is recommended (Fig 12). the clinician during veneer preparation (re-
While waxing up, the technician should duction keys) (see Fig 13).25–31
be guided by the maxillary vestibular The veneer preparation follows stan-
mock-up done at the beginning of the dard protocols developed and described
three-step technique, and adapt it to the in detail by other authors (Fig 14).24-30
new occlusion of the patient. The only difference between this nov-
As the position of the occlusal plane el concept and a more traditional veneer
and the increase of VDO may be slightly approach is that the palatal aspects of
different from what was initially planned, the maxillary anterior teeth are consid-
the length of the maxillary anterior teeth ered as integral part of the respective
should be reconfirmed during the second teeth and no particular effort is made to
mock-up session. place the preparation margins for the ve-
neers on tooth structure. In addition, the

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Fig 14a to c Initial clinical view of a 27-year-old


male patient before and after bonding of six maxillary
anterior ceramic veneers. Note both the gingival health
and the minimal tooth preparation. The rehabilitation
has been performed according to the principles of the
three-step concept. The next step will involve the re-
placement of the posterior provisional resin compos- c
ites.

a b

Fig 15a and b Two different typical clinical situations during the bonding procedure of the facial veneers. Note
that in Fig 15a the facial enamel has been preserved. However, in Fig 15b the erosive process had greatly affect-
ed the facial aspect of the tooth.

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Fig 16 Schematic drawing of the recommended preparation for the veneers at the level of the incisal edges.
The length added by the palatal onlay is completely removed. The ceramic veneer will later reestablish the final
length.

a b

Fig 17a to c Three different patients after veneer


preparation with the silicone key in place reproducing
the length of the final veneers. Following the protocol
c of the University of Geneva, all the tooth-length added
by the palatal resin composites had to be removed.

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rationale for this approach is to avoid tplac-
ot

n
described concept comprises an incisal
en
fo r
coverage in form of a butt joint, with the ing the margin of the veneers in the palatal
ceramic veneer margin placed in the vol- concavity of the tooth, by moving it more
ume of the palatal resin composite on- cervically (Fig 15).33 In addition, without the
lays (see Fig 15).32 layer of resin composite, the veneer fabri-
In a situation where the incisal length of cation is facilitated, as there is a more uni-
the maxillary anterior teeth is severely re- form color on the facial surface.
duced and the respective tooth volume Even in patients where almost three
has been subsequently reestablished by quarters of the original tooth length is
means of palatal onlays, the decision has missing, the guidelines preview not to
to be made whether or not to remove the preserve some of the length of the palatal
entire length added with the resin compos- onlay (Figs 16 and 17). As the sandwich
ite or to leave part of it before restoring the approach is still experimental, a strict fol-
teeth with the facial veneers. low up of all these types of restorations is
The authors’ preference is to complete- applied. By means of photos and impres-
ly remove the length added by the palatal sions the interface between the facial ve-
onlays, leaving only the original length of neers and the palatal resin composite on-
the tooth on the facial aspect (Fig 16). The lays is carefully evaluated. Time will show

a b

Fig 18a to c The two year follow-up of a patient


treated following the sandwich approach for the max-
illary anterior teeth demonstrated very encouraging re-
sults. The gingival health is remarkable, and all the teeth c
are still vital.

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if problems may arise. However, the initial Traditionally, extensive dental therapies
ss e n c e
fo r
data collected seemed very promising are previewed for these patients, and cli-
(Fig 18). nicians often prefer to wait until the tooth
After bonding of the maxillary anterior tissue loss is more conspicuous before
veneers, the rehabilitation can progress proposing a conventional full-mouth reha-
with the replacement of the posterior pro- bilitation. This hesitation founds its ration-
visional resin composites. ale in the aggressiveness of the conven-
In fact, owing to the presence of a func- tional therapies.
tional anterior guidance and optimized Owing to the described novel and high-
posterior support, the full-mouth rehabilita- ly conservative approach, the University of
tion can be, from this point on, planned ac- Geneva, School of Dental Medicine has
cording to a quadrant-wise approach, become one of the centers of reference for
which simplifies the therapy for both pa- patients affected by advanced dental ero-
tient and clinician. Based on individual, pa- sion.
tient-related criteria, the clinician and the In the past few years, a number of pa-
technician can decide at which quadrant tients suffering from severely eroded den-
to start. Furthermore, having the plane of titions have been treated according to this
occlusion established with provisional still experimental approach, which basical-
restorations still allows minor modifications ly features minimal tooth preparation and
to be made. The vestibular cusps of the maintenance of tooth vitality.
posterior provisional resin composites The new clinical approach (full-mouth
could be lengthened by adding new resin adhesive rehabilitation) for the treatment of
composite, or shortened by grinding. advanced generalized erosion, consists
One of the major advantages of the exclusively of posterior onlays and anteri-
three-step technique consists of the fact or BPRs, and is strategically planned in a
that the opportunity to make modifications way that allows rehabilitating patients
is maintained throughout the different quadrant-wise, instead of restoring both
treatment phases. Under such conditions dental arches simultaneously
it is not a surprise that the final esthetic out- Even though adhesive techniques sim-
come of this kind of full-mouth rehabilita- plify both the clinical and the laboratory pro-
tion is consistently pleasing (Fig 19). cedures, restoring such compromised den-
titions still remains a challenge due to the
often advanced amount of tooth destruction.
Conclusions To achieve maximum preservation of
tooth structure and the most predictable
Dental erosion is a frequently underesti- esthetic and functional outcome, an inno-
mated pathology, which affects an increas- vative concept has been developed: the
34-35
ing number of younger individuals. three-step technique.
Often the advanced tooth destruction is Three laboratory steps are alternated
the result, not only of a difficult initial diag- with three clinical steps, allowing the clini-
nosis (e.g. multifactorial etiology of tooth cian and the dental technician to constant-
wear), but also of the lack of a timely inter- ly interact during the planning and execu-
vention. tion of a full-mouth adhesive rehabilitation.

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b a

c d

Fig 19a to d 29-year old patient at completion of the adhesive rehabilitation. Thanks to the three-step tech-
nique, the occlusal plane and the incisal edge position are in harmony, as this was determined during the first
step maxillary vestibular mock-up and continuously improved by minor modifications along the treatment.

In this article, the authors describe the third ever, the increased demand for treatment
and last step of the three-step technique in has led to eliminating this exclusion crite-
detail. To reduce the risk of mechanical rion. The next challenge will be to treat this
overload on the bonded restorations, pa- population of patients and to document the
tients who present parafunctional habits long-term survival rate of their full-mouth
were not included in this clinical trial. How- adhesive rehabilitation.

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Acknowledgements ss e n c e
fo r
Treating the described complex cases is a team effort. Erpen and Sylvain Carciofo for their meticulous execu-
Consequently, the authors would like to thank all the tion of the laboratory work. Dr Giovanna Vaglio, Dr Fed-
laboratory technicians and clinicians who have con- erico Prando and Dr Tommaso Rocca for their enthu-
tributed to the final outcome of the different full-mouth siastic collaboration and excellent clinical work, and
rehabilitations, the laboratory technicians and ce- finally Dr Olivier Marmy for his expertise during the
ramists: Alwin Schönenberger, Patrick Schnider, Serge temporomandibular consultations.

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tic mock-up. J Esthet Restor 31. Garber D. Porcelain laminate
Dent 2004;16:7–16. veneers: ten years later. Part I:
26. Gürel G. The science and art Tooth preparation. J Esthet
of porcelain laminate veneers. Dent 1993;5:56–62.
Chicago: Quintessence Pub-
lishing, 2003.

257
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 • NUMBER 3 • AUTUMN 2008
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)

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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
the severity of the dental destruction References
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Moynihan PJ. Dental caries and its associ-
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TG, Okunseri C. Erosive tooth wear among
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NH. Prevalence of tooth wear in adults. Int
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6. Milosevic A. Gastro-oesophageal reflux
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erosion requires a distinct augmen- 2008;9:54.
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sion of occlusion to create the R, Sonis A, Brown JN, Gordon CM. Oral
necessary space to restore the max- health and bone density in adolescents
and young women with anorexia nervosa.
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posterior quadrants must also be wear in elderly people. J Am Dent Assoc
planned as an integral part of the 2007;138(suppl):21S–25S.
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© 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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10. Hinds K, Gregory JR. National Diet and 23. Jaeggi T, Grüninger A, Lussi A. Restorative
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Eating disorders. Part I: Psychiatric diag-
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29. Ali DA, Brown RS, Rodriguez LO, Moody
15. Vailati F, Belser UC. Full-mouth adhesive EL, Nasr MF. Dental erosion caused by
rehabilitation of a severely eroded denti- silent gastroesophageal reflux disease.
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J Esthet Dent 2008;3:236–257.
30. Sundaram G, Wilson R, Watson TF, Bartlett
16. Vailati F, Belser UC. Full-mouth adhesive D. Clinical measurement of palatal tooth
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tion: The three-step technique. Part 2. Eur system. Oper Dent 2007;32:539–543.
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31. Sundaram G, Bartlett D, Watson T. Bonding
17. Vailati F, Belser UC. Full-mouth adhesive
to and protecting worn palatal surfaces of
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tion: The three-step technique. Part 1. Eur Rehabil 2004;31:505–509.
J Esthet Dent 2008;3:30–44.
32. Tay FR, Pashley DH. Resin bonding to cer-
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Clin Oral Investig 2008;12(suppl 1):S65–68. 33. Panitvisai P, Messer HH. Cuspal deflection
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34. Reeh ES, Messer HH, Douglas WH.
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J Endod 1989;15:512–516.
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criteria for dental erosion? Clin Oral Investig
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22. Lussi A, Hellwig E, Zero D, Jaeggi T. Erosive
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inate preparation approach driven by a
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2004;16:7–16.

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572

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CLINICAL RESEARCH

CLINICAL RESEARCH

Treatment planning of adhesive


additive rehabilitations:
the progressive wax-up
of the three-step technique
Francesca Vailati, MD, DMD, MSc
Private practice, Geneva Dental Team, Geneva, Switzerland
Senior Lecturer, Department of Fixed Prosthodontics and Biomaterials,
University Clinic for Dental Medicine, Geneva, Switzerland

Sylvain Carciofo, MDT


Chief Dental Technologist,
University Clinic for Dental Medicine, Geneva, Switzerland

Correspondence to: Dr Francesca Vailati


Geneva Dental Team, Rue St-Léger 8, 1205 Geneva; Tel.: 022 310 74 56; Fax: 022 312 32 21; E-mail: francesca.vailati@unige.ch

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Abstract the diagnostic wax-up is progressively


developed to the final outcome through
A full-mouth rehabilitation should be the interaction between patient, clinician,
correctly planned from the start by us- and laboratory technician. This article
ing a diagnostic wax-up to reduce the provides guidelines aimed at helping
potential for remakes, increased chair clinicians and laboratory technicians to
time, and laboratory costs. However, become more proactive in the treatment
determining the clinical validity of an planning of full-mouth rehabilitations, by
extensive wax-up can be complicated starting from the three major parameters
for clinicians who lack the experience of of incisal edge position, occlusal plane
full-mouth rehabilitations. The three-step position, and the vertical dimension of
technique is a simplified approach that occlusion.
has been developed to facilitate the cli-
nician’s task. By following this technique, (Int J Esthet Dent 2016;11:XXX–XXX)

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Introduction to each other, a change to one neces-


sarily entails a modification to another.
When a dentition is severely compro- In this way, the wax-up may become
mised, a full-mouth wax-up is generally useless. For example, if a mock-up is
considered mandatory to reassure the made out of the full-mouth wax-up, and
clinician that the case is comprehen- the patient asks for the incisal edges to
sively analyzed. Unfortunately, at the be shortened, the occlusal plane must
end of the therapy, clinicians often real- also be modified to avoid an unesthetic
ize that the initial full-mouth wax-up did reverse smile; and if this latter aspect is
not correspond to the final outcome of modified, the occlusal wax-up should be
the rehabilitation, to the point that ques- remade. The full-mouth wax-up has then
tions arise as to its real clinical value. become useless.
The reason for this may be that clinicians The three-step technique prefers, in-
allow laboratory technicians to make in- stead, a partial wax-up that will progress
dependent decisions about several clin- after being evaluated and validated by
ical parameters, which increases the the clinician at several stages. In labora-
chance for error. tory step  I, the laboratory technician
An approach has been developed will wax up only the vestibular aspect
to simplify the full-mouth rehabilitation of the maxillary teeth, and the clinician
treatment plan – the three-step tech- will validate only the incisal edges and
nique – which considers three funda- the occlusal plane. In laboratory step II,
mental parameters: the vertical dimen- wax will be placed on the occlusal sur-
sion of occlusion (VDO), the incisal faces of specific posterior teeth, and the
edge position, and the occlusal plane clinician will approve the occlusal plane
position.1-7 Since the three-step tech- position and the increase of the VDO.
nique advocates the principles of mini- Finally, in laboratory step III, the wax-up
mally invasive to non-invasive dentistry, will recreate the palatal aspect of the
an increase of the VDO is strongly advo- maxillary anterior teeth, and the clin-
cated for every full-mouth rehabilitation ician will give an opinion on the incisal
to avoid the need for tooth preparation length and the increase of the VDO.
(additive dentistry). In addition, the in-
cisal edge position of the final restor-
ations is essential to satisfy the patient’s Step I
esthetic needs. Finally, the occlusal
plane position not only has an important
The esthetic
esthetic value, but also defines how to
share the interocclusal space obtained Since satisfying the patient’s esthetic
with the increase of the VDO at the level needs is a major objective, clinicians
of the posterior teeth. should take the time to really under-
In the authors’ opinion, a full-mouth stand what will be considered esthetic
wax-up where these three parameters for each patient. Trying to impose the
are considered at the same time is risky. clinician’s taste on the final restorations
Since the parameters are closely related may be highly risky. The risk of not ac-

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a b

Fig 1a and b In case of the destruction of the incisal edges, it is recommended to involve patients as
soon as possible in the important decision about the esthetic of their future smile, since not everyone is
ready to accept longer and wider restorations.

cepting the shape of the maxillary an- should be done as soon as possible, be-
terior teeth is higher in patients affected fore investing in an extensive wax-up of
by dental erosion, especially in severe the posterior teeth.
cases. Although these patients claim to Following the three-step technique,
be dissatisfied with their smile, they are the two casts (out of alginate impres-
often more accustomed to the look of sions) are articulated in maximum in-
their irregular, small, and yellowish teeth terocclusal position (MIP) on a semi-ad-
than they imagine, and drastic change justable articulator using a facebow. The
can be difficult for them to accept. first partial wax-up will cover only the
To avoid lengthy discussions and vestibular surface of the maxillary teeth,
costly remakes, it is advisable to identify sufficient to recreate the incisal edges
the shape and color of the final restor- and the occlusal plane at the level of the
ations as soon as possible. Larger, long- maxillary teeth (maxillary vestibular wax-
er, whiter teeth may be shocking for the up). Inspired by the photographs of the
patient, and the initial negative reaction patient’s smile, the laboratory technician
does not always change to an accept- will focus exclusively on the esthetic ap-
ance of the new proposed smile design. pearance, with maximum freedom of
A tridimensional mock-up, which also in- creativity (Figs 2 and 3).
volves the maxillary posterior teeth, may Since the rehabilitation is driven by
be more useful to communicate with minimally invasive to non-invasive den-
these patients (Fig 1).8 Consequently, tistry, laboratory technicians should
in the three-step technique, while a full- remember to always thicken the teeth
mouth wax-up is not considered nec- during this wax-up so that the vestibular
essary, a more extended mock-up is a aspect of the teeth can be left intact dur-
fundamental step for understanding the ing the preparation for the final facial ve-
patient’s esthetic wishes. This mock-up neers (additive wax-up). The use a dif-

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a b

Fig 2a and b Maxillary vestibular wax-up. Only the incisal edges and the vestibular cusps of the maxil-
lary teeth are reconstructed in wax, where needed. The antagonistic cast is not considered at this stage,
since before progressing to the occlusal wax-up, the esthetic occlusal plane should be validated clinically
with the patient.

a b

Fig 3a and b This simplified wax-up is then used to fabricate a vestibular mock-up. Thanks to the
limited wax on the palatal aspect, the mock-up key will be very stable on the teeth, limiting the presence
of excesses. Patients could also keep the mock-up and remove it themselves simply by pulling it in the
vestibular direction.

a b c

Fig 4a to c Lack of contrast between the stone and the wax did not allow for the evaluation of the thick-
ness of the future restorations. A silicon index was necessary to see the vestibular space occupied by the
wax, which in this specific case was insufficient for a non-invasive approach.

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a b

Fig 5a and b Maxillary vestibular mock-up. To avoid any occlusal preparation of the maxillary posterior
teeth, the additive wax-up lowers the position of the initial occlusal plane, worsening the existing reverse
smile. Thus, before waxing the occlusal surfaces of the posterior teeth, it is mandatory to confirm with the
patient the choice of longer anterior teeth to harmonize the new occlusal plane.

ferent color wax to allow the visualization case, the laboratory technician would
of its thickness is fundamental (Fig 4). be instructed to lengthen the maxillary
At the completion of clinical step I, while anterior teeth until their incisal edges
the patient expresses an opinion on the overlap the antagonistic teeth. The incis-
look of the maxillary vestibular mock-up, al edges of the waxed-up teeth should
the clinician should gather information have a minimal horizontal and vertical
for the restoration of the posterior teeth. overlap (at least 1.5 mm), and a minimal
In fact, the major goal in this mock-up thickness (1.5 mm), to guarantee the
visit is to validate the esthetic position strength of the final restorations. During
of the occlusal plane (eg, harmony with the mock-up visit, the clinician, in addi-
the incisal edges), so that the laboratory tion to evaluating the esthetic outcome
technician has helpful information on of the lengthened teeth, may also regis-
how to share the posterior interocclusal ter the patient’s occlusion at the new in-
space, which will be obtained with the crease of the VDO by asking the patient
increase of the VDO (Fig 5). to simply bite on the incisal edges of the
One of the variants of a classic clin- mock-up, and then inject bite registration
ical step  I occurs in cases where there material in the posterior sextants (Fig 6).
is an insufficient horizontal overlap of Another variant to the classic three-
the maxillary anterior teeth. Generally, step applies in cases affected by initial/
to fabricate the maxillary vestibular wax- moderate dental erosion where the tooth
up, waxing up the opposing arch is not destruction is not sufficiently severe to
considered, since the increase of the justify the need for facial veneers. When
VDO has not yet been decided. How- the vestibular aspect of the maxillary
ever, in case the mandible has a pro- anterior teeth is mostly intact, and the
trusive position, the maxillary vestibular patient can be restored only by means
wax-up could be used to also determine of palatal veneers, a mock-up visit is
the increase of the VDO clinically. In this not necessary, since the incisal edges

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a b c

Fig 6a to c A 23-year-old patient affected by severe dental erosion. The laboratory technician was in-
structed to also consider the position of the mandibular arch. During the wax-up, the maxillary incisors were
lengthened until a minimal overlap with the antagonistic teeth (1.5 mm) was achieved. During clinical step I,
with the maxillary vestibular mock-up in place, the clinician evaluated whether the length of the mock-up
pleased the patient. In addition, the bite was registered by asking the patient to bite on the mock-up while
registration material was injected into the posterior spaces.

and the occlusal plane of the final res- Which posterior restorations to use
torations can easily be visualized with during step  II (direct and/or indirect
the casts and the clinical photographs of restorations).
the patient’s smile. Step I (the maxillary
vestibular wax-up) is then skipped, and After having established the esthetic oc-
the laboratory technician can directly clusal plane in step  I, in order to com-
start the wax-up of the posterior quad- plete the occlusal surfaces of the pos-
rants, reducing the cost and speeding terior teeth it is necessary to determine
up the therapy (MODIFIED three-step the increase of the VDO. As already
technique).9 mentioned, in case of a severely worn
dentition, an increase of the VDO is in-
evitable to reduce the need for substan-
Step II tial tooth preparation in general, and to
avoid elective endodontic treatments,
in particular at the level of the anterior
The posterior support
teeth. Clinicians are generally afraid to in-
The aim of laboratory step II is to wax up crease the VDO, fearing consequences
the posterior teeth at an increased VDO. at the level of the temporomandibular
This wax-up will involve only the occlusal joints. On the contrary, the capacity to
surfaces of the two premolars and the adapt to the change of the VDO is gen-
first molars, and will be used to fabricate erally remarkable.10-14 However, while
direct composite restorations by means for the posterior teeth a conspicuous in-
of transparent keys. crease of the VDO is always favorable
At this stage, the clinician must be to deliver thicker restorations and avoid
prepared to answer three questions: tooth preparation, limitations exist in de-
How much to increase the VDO. livering too-bulky anterior restorations to
How to distribute the posterior inter- reestablish the contact points.
occlusal space obtained with the in- Consequently, the increase of the
crease of the VDO. VDO is more restricted by the risk of set-

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ting the anterior teeth too far apart than There are two extreme clinical choic-
by the patient’s poor adaptability to the es when considering the increase of
increase of the VDO. Since each patient the VDO (Fig 7). The first choice is to
presents a different scenario, a care- favor the anterior teeth with a minimal
ful evaluation of the articulated casts increase of the VDO, which will lead to a
should be considered before deciding rehabilitation with adequate final contact
on the increase of the VDO. The three- points in the anterior quadrants, but thin-
step technique suggests first making an ner and weaker posterior restorations.
arbitrary choice by looking at the initial In addition, it will be difficult to correct
casts mounted on the articulator. The the occlusal plane and/or the deep bite.
increase of the VDO should be guided The second choice is to favor the pos-
not only by restorative needs, such as terior teeth with a maximum increase
the type of restorative material selected of the VDO, which will obtain adequate
(eg, ceramic or composite), but also by thickness of the posterior restorations
occlusal considerations. While decid- without any tooth preparation. At the
ing on the increase of the VDO, atten- same time, it will be possible to harmo-
tion should be paid to harmonizing the nize the occlusal plane and improve the
curve of Spee and correcting the deep deep bite. However, the treatment will
bite, especially in erosive patients with lead to the creation of an anterior open
a reverse smile and supraerupted man- bite, which cannot be corrected only by
dibular incisors.15 To flatten the curve of means of palatal veneers. With the sec-
Spee without orthodontic therapy, a sig- ond choice, orthodontic therapy could
nificant amount of the space obtained be considered afterwards to restore the
with the increase of the VDO should be anterior contacts. The least-favorable
given to the mandibular arch, leaving solution with the second choice is to
less space available for the maxillary leave the patient with an anterior open
posterior teeth. bite. In this unstable occlusal situation,

Fig 7 The increase of the VDO should be related to the anterior and posterior teeth. While for the poster-
ior restorations a conspicuous increase is always auspicious, for the anterior teeth there is a limitation to
increasing the size of their palatal aspect.

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a b

c d

Fig 8a to d Progression of the wax-up to the posterior teeth. The esthetic occlusal plane had indicated
how much of the interocclusal posterior space could be given to the maxillary posterior teeth. To know how
much is left for the mandibular teeth, the increase of the VDO should be determined first. In this patient, the
ANTERIOR stop was touching the antagonistic teeth, and the posterior space obtained was considered
sufficient to deliver thick-enough posterior restorations.

a b

Fig 9a and b Maxillary vestibular wax-up and ANTERIOR stop. Thanks to the presence of the ANTER-
IOR stop, the posterior teeth were set apart. Their separation indicated the maximum possible increase of
the VDO, which still allowed for obtaining anterior contacts. The clinician should now decide if the interoc-
clusal space is sufficient for the posterior restorations selected. Note that the ANTERIOR stop in this patient
also included a mandibular incisor.

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a b

Fig 10a and b Progression of the wax-up shown in Fig 9, after taking the decision on the amount of
increase of the VDO.

a Michigan occlusal splint should be If the mandibular anterior teeth pre-


worn every night to stabilize the anterior sent exposed dentin, they should also
contact and avoid supraeruption. Since be included in the treatment and in the
the anterior teeth’s coupling is the limit- ANTERIOR stop. For the mandibular (as
ing factor in the increase of the VDO, well as the maxillary) anterior teeth, only
the laboratory technician should provide a few strategic teeth should be waxed up
an ANTERIOR stop by reconstructing in (ie, the most vestibular ones), to better
wax only the palatal aspect of the two visualize the clinical outcome. Thanks to
central incisors to the thickest clinically this partial wax-up, malpositioned teeth
acceptable shape. can be better identified, and the need for
Only two central incisors are neces- orthodontic therapy may be advocated.
sary to fabricate the ANTERIOR stop, While reconstructing damaged mandib-
since leaving the surfaces of the adja- ular teeth in wax, the laboratory techni-
cent teeth free of wax allows for a better cian should be careful not to lengthen
judgment on the clinical acceptability their incisal edges excessively, since
of the bulkier palatal surfaces. With the these teeth often already present a su-
models mounted on the articulator, the praerupted position. In addition, length-
clinician can visualize the interocclusal ening these teeth in the incisal direction
space obtained in the posterior sextants will worsen the curve of Spee and the
when the casts touch at the level of the vertical overlap (deep bite) (Fig 11).
reconstructed central incisors, since this To fabricate an ANTERIOR stop, three
represents the maximum amount of the points should be identified:
VDO possible to still reestablish anterior A – Incisal edge of the final restor-
contacts. The clinician should then de- ation.
cide if this increase of the VDO is suffi- B – New contact point with the anta-
cient for the restorative needs of the pos- gonistic tooth after an increase of the
terior teeth or not, and make the clinical VDO.
choice of favoring either the anterior or C – Most cervical margin of the final
the posterior teeth (Figs 8 to 10). restoration.

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Fig 11 Restoration of the anterior teeth and deep bite. To avoid worsening the deep bite, the clinician
and laboratory technician should resist the temptation to excessively lengthen the incisal edges of both the
maxillary and mandibular teeth. In particular, the mandibular incisors are often supraerupted, so instead
of lengthening their incisal edges, the contact point should be reached by thickening the palatal aspect of
their antagonistic teeth.

Fig 12 Three points could be identified in an ANTERIOR stop. A decision on the position of the B point
(new contact point at the increase of the VDO) should involve the clinician, since the final shape may be
bulkier than a natural tooth, to allow for a larger increase of the VDO. The clinician should determine whether
the new shape is clinically acceptable to the patient.

The union of these three points defines contact (mechanical strength) (Fig 12).
the palatal shape of the maxillary pala- It is recommended that the palatal wax-
tal restorations. The junction between B up be kept inside a vertical line passing
and C should be as straight as possi- through the C point (the C line), placed
ble to avoid phonetic impairments and on a frontal plane. This line defines the
plaque accumulation (cleansability), but most palatal limit where the occlusal con-
to still guarantee support to the occlusal tact (B point) could be placed (Fig 13).

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a b

Fig 13 and b Incorrect ANTERIOR stops. In both cases, the B point was more palatal than the C line,
and this shape for the final restorations would not have been tolerated by the patient. With just this minimal
wax-up, the clinician has gained valuable information on the increase of the VDO and the reestablishment
of the anterior contact points.

The three-step technique recom- bite registrations could be adapted on


mends the articulation of the models in the models (Fig 14).
MIP. However, for more complex cases While deciding on the increase of the
(eg, deviated mandible), it is possible to VDO, the clinician should also consider
reregister the position of the mandible at how to distribute the obtained interoc-
the increased VDO during the mock-up clusal space among the posterior teeth.
visit, thanks to the presence of the AN- This decision will mostly be based on
TERIOR stop, which could also be used the presence of exposed dentin (eg,
as an anterior jig. While the patient is bit- teeth to be restored), and the finances
ing on the ANTERIOR stop, the interarch of the patient. The authors believe that
posterior space is filled with registration it is also important to flatten the occlusal
material. The mandibular cast can then plane and reduce the deep bite when-
be remounted, since the occlusal aspect ever possible to promote more freedom
of the posterior teeth is partially not cov- to the lateral excursions of the mandi-
ered by the mock-up, and the occlusal ble.15

a b c

Fig 14a to c An ANTERIOR stop could become an anterior jig during the mock-up visit to rearticulate
the casts at a increased VDO (case completed with Dr. C Damardji).

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Fig 15 The best view to analyze articulated casts is from the palatal/lingual aspect. While laboratory
technicians are familiar with this view, clinicians are not, since it is impossible clinically. From this view it is
easier to visualize the occlusal plane, the curve of Spee, and the supraerupted mandibular anterior teeth.

The posterior interocclusal space increase of the VDO will not be shared
could be shared in three different ways: among antagonistic teeth. Conse-
1) one-arch distribution; 2) two-arch dis- quently, the increase of the VDO could
tribution; 3) mixed distribution (Fig 15). be kept smaller, and the open bite cor-
rected more easily by means of palatal
One-arch distribution veneers. Unfortunately, this option is not
With this option, the space is given to always possible due to clinical limita-
only one arch (mandibular or maxil- tions. For example, the posterior teeth
lary). The advantage of this option is of the unrestored arch should be intact
the reduction in the overall cost of treat- (no dentin exposure), and the existing
ment, since only one arch is restored. occlusal plane of the antagonistic teeth
In addition, the space obtained by the should be correct (Fig 16).

a b

Fig 16a and b One-arch distribution. The increase of the VDO required to repair the incisal edges was
minimal. Since the maxillary posterior teeth were intact, it was decided to increase the VDO, restoring only
the antagonistic mandibular teeth.

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a b

Fig 17a and b Two-arch distribution. A moderate to severe case of dental erosion. Both the arches
presented teeth with exposed dentin, so a two-arch distribution was necessary, requiring more space at
the level of the posterior teeth.

Two-arch distribution will be restored, but not all of them. This


This is the most common situation, espe- is often the case when there is an irregu-
cially in the case of severe dental wear, lar occlusal plane, with supraeruption of
since unfortunately the posterior teeth of some posterior teeth. To achieve a cor-
both the arches present exposed den- rect occlusal plane, the supraerupted
tin and need to be restored. The advan- teeth will not be restored, if of course
tage of this option is the possibility of their occlusal surface is intact. The ad-
changing the position of the occlusal vantage of this option is that it costs less
plane by modifying both the occlusal and has a shorter clinical time compared
surface of the maxillary and mandibular to the two-arch distribution (Fig 18).
posterior teeth. One disadvantage is the Before the laboratory technician starts
cost, since the patient has to pay for a the wax-up of the posterior teeth, the
full-mouth rehabilitation, with the restor- clinician should also have an idea about
ation of all the posterior teeth. Another which type of restorations will be deliv-
disadvantage is the necessity to share ered during step II – provisional and/or
the interocclusal space obtained with final – so that the wax-up can be modi-
the increase of the VDO. For example, if fied accordingly. In this article, only the
2 mm is available at the level of the first wax-up modifications in case of fabrica-
molar, the two antagonistic onlays shar- tion of provisional restorations are dis-
ing the available space equally will only cussed. When the dentition is particu-
have a 1-mm thickness, which may not larly compromised and/or a mandibular
be strong enough, especially in patients deviation is present, it is preferable dur-
with parafunctional habits (Fig 17). ing step II to deliver provisional poster-
ior composite restorations, fabricated
Mixed distribution directly in the mouth by means of trans-
This distribution means that both the parent keys. This treatment is compara-
maxillary and mandibular posterior teeth ble to an occlusal bite bonded for 24 h in

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a b

Fig 18a and b Mixed distribution. In this early case of dental erosion, the increase of the VDO was mini-
mal and necessary mostly to reinforce the thin incisal edges. To reduce the number of teeth to be restored
and to avoid sharing the limited posterior interarch space, only the mandibular molars and the maxillary
premolars were restored. It was possible to not include the remaining posterior teeth in the rehabilitation,
since they did not present dentin exposure. Note that the wax-up of the palatal aspect of all the maxillary
teeth was not necessary. The ANTERIOR stop could be done with only one or both central incisors.

the mouth (therapeutic white bite). This the white bite will be. The remaining wax
is also the fastest treatment to restore should be removed before the fabrica-
multiple teeth at the same time (eg, in tion of the keys to reduce the size of the
a two-arch distribution) for patients who provisional composite restorations and
do not have time or cannot tolerate long facilitate their future removal. In addition,
appointments. the interproximal areas should be clean
Following the three-step technique, of excess wax, to reduce the risk of inter-
these provisional restorations will be re- proximal excesses during the fabrication
placed after the rehabilitation of the an- of the composite restorations. A mesial
terior quadrants by the final restorations. and a distal stop should always be iden-
When the wax-up of the posterior teeth tified and left waxfree, to promote a bet-
is used for the fabrication of the provi- ter sitting of the transparent keys (ie, less
sional restorations, it should be modified occlusal adjustments). Damaged ves-
at four levels before the fabrication of the tibular and/or palatal surfaces may also
transparent keys: represent a dilemma during the wax-up.
1) interproximal areas; The laboratory technician should resist
2) mesial and distal stops; the temptation of fully reconstructing in
3) occlusal embrasures (marginal wax these damaged surfaces, since the
ridges); and clinician does not need to fabricate the
4) vestibular/palatal surface (one-third provisional composite so close to the
cervical). cervical aspect of the teeth (high risk of
excess) (Fig 19).
In general, the wax should be kept to a The only reason to extend the wax-up
minimum and placed only on the occlus- to the cervical aspect is if the support-
al surfaces where the contact points of ing cusps are very compromised (eg,

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a b

Fig 19a and b For a white bite, the wax should be limited to the occlusal surfaces only, even when the
teeth are not intact in the cervical third. This will guarantee better bonding conditions and easier removal
of the excesses.

a b

Fig 20a and b The posterior wax-up to fabricate the transparent keys should be very precise at the
level of the embrasures. Any excess of wax will lead to an excess of composite in the mouth. The marginal
ridges could be weakened with a scalpel to promote the opening of the contact points between the direct
restorations during mastication.

palatal maxillary cusps), and the oc- the clinician will use the contrast with
clusal contacts of the white bite need to the stone to get an idea of how much
be reinforced (ie, avoid shear failure). composite should be placed in the
One of the limits of the white bite is the transparent keys (Fig 21).
closed interproximal contact points. To At the end of clinical step II, patients
try to favor their opening during func- will present a stable posterior support
tion, the occlusal embrasures of the at an increased VDO and an anterior
wax-up could be weakened by accen- open bite. Thanks to this anterior space,
tuating the separation of the waxed-up the maxillary anterior teeth will then be
marginal ridges with a scalpel (Fig 20). restored without any tooth preparation
Finally, it is worth remembering to al- (maximum tooth preservation) by means
ways use a different color wax, since of palatal veneers (step III). To move to

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modified during step III. In case the la-


boratory technician realizes that the clin-
ical increase of the VDO was excessive
to reestablish the anterior contacts by
means of palatal veneers, he/she can
progress with the fabrication of the final
anterior restorations to the ideal shape,
which will have no contacts with the an-
tagonistic teeth. The clinician will then
bond these restorations and adjust the
occlusion on the posterior teeth until the
Fig 21 The use of a similar color between the wax anterior teeth are in contact (decrease
and the cast makes it very difficult to see the limits
of the VDO). It is also possible to correct
of the wax and its thickness. Note that the maxillary
canine is not free of wax, and if this is not removed, the opposite situation (increase of the
the transparent key will not have its mesial stop. VDO). In this scenario, the VDO will be
increased on the articulator by adding
wax on the posterior teeth, and the pala-
tal veneers will be fabricated according-
ly. Once bonded on the palatal veneers,
as expected, the posterior teeth will no
the next step, new impressions, an an- longer be in contact. To reestablish the
terior bite registration in MIP, and a face- posterior support, simple direct com-
bow are needed. posite will be delivered by adding ma-
terial on the previously roughened sur-
faces of the pre-existing contact points.
Step III To facilitate this second option, the direct
composite restorations should be made
The anterior contacts in only one arch. If major increments of
the VDO are necessary, new transpar-
In step III, the laboratory technician will ent keys could be used to speed up the
recreate in wax the palatal surfaces of treatment (Fig 23).
the maxillary anterior teeth before fab- Several authors have set fundamen-
ricating the palatal veneers. The shape tal guidelines for the reconstruction of
of the two central incisors was already the palatal surfaces of the maxillary
proposed with the ANTERIOR stop, and anterior teeth, especially considering
confirmed or changed by the clinician the envelope of function.16-25 However,
(Fig 22). following the three-step technique, the
As previously mentioned, one of the shape of the maxillary anterior final res-
advantages of the three-step technique torations is strongly dictated, not only
is the possibility of evaluating and, if by restoring the damaged palatal as-
necessary, correcting the outcome pect, but also by the need to establish
of previous steps. The increase of the the anterior contacts after the increase
VDO, obtained during step II, could be of the VDO. To achieve these contacts,

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Fig 22 Waxing up the central incisors to fabricate Fig 23 In this case, the increase of the VDO ob-
the ANTERIOR stop allows the laboratory technician tained with the white bite was not sufficient. Instead
to discuss the shape of the future palatal veneers. of rescheduling the patient, with the same impres-
At this stage, the clinician can ask for modifications sion for the palatal veneers, the laboratory techni-
or accept the proposed form. cian waxed up the occlusal surfaces of the maxil-
lary teeth and fabricated the palatal veneers at the
increased VDO. Two transparent keys were used to
increase the VDO before bonding the veneers.

there is no hesitation to restore teeth to aspect of these restored teeth should


a larger size than the natural dentition. not resemble the intact teeth, appearing
In addition, clinicians often have to face thicker even at the incisal edges, there
and solve dental/skeletal discrepan- are limitations to how much the size can
cies – improved or aggravated by the be increased.
increase of the VDO – by using restora- There are six major objectives dur-
tive means only, since this type of pa- ing step III (fabrication of the palatal ve-
tient accepts the therapy because of its neers):
simplicity (and rapidity), and frequently Re-establish anterior contacts points
refuses orthodontic therapy and even (B points), unless decided otherwise.
more frequently, orthognathic surgery. Supported B points (eg, not on sur-
Therefore, the laboratory technician will faces that are too inclined).
rarely be inspired by the natural denti- BC line straight (for cleansability and
tion for the anterior region of the mouth, phonetics).
and will recreate the perfect shape and Smooth palatal surfaces (no exces-
ideal contact points. sive anatomy).
Overall, the restored teeth will always Maximum effort to correct or not ag-
look wider in an anterior–posterior di- gravate deep bite (minimum length-
rection than the natural dentition, and ening of both the incisal edges of
laboratory technicians should not feel maxillary and mandibular teeth).
uncomfortable about delivering res- No steep anterior guidance (open in-
torations with an unusual shape. Even cisal angle).
though it is expected that the palatal

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a b

Fig 24a and b Palatal veneers with a palatal anatomy that is too accentuated, occupying space for the
tongue without any functional purpose. In addition, these veneers could be very uncomfortable for patients
who are accustomed to a concave shape of eroded teeth.

While defining the maximum thickness grooves and/or pronounced cingula. In


tolerated by each patient, laboratory addition, not only is more effort required,
technicians should bear in mind that but the surfaces of the final restorations
patients affected by dental erosion are will be more difficult to polish, and the
used to having very flat/concave palatal irregular texture will be very uncomfort-
surfaces, and that they have adapted able for the patient’s tongue (Fig 24).
the tongue to speak even with a con- During the fabrication of the ANTER-
spicuous loss of tooth structure, since IOR stop, the laboratory technician fo-
this loss has happened progressively at cused only on static occlusal contacts,
a very slow rate. mostly analyzing the shape of the palatal
Occupying the tongue space with surface between the B and C points for
bulky palatal veneers all at once will cleansability and problems with phonet-
be immediately considered uncomfort- ics. In this laboratory step III, the sur-
able by the patient, especially because face, comprised between the B and A
it would cause the impairment of the points, will also be considered, since
pronunciation of some letters (eg, D-T this is the area involved in the eccentric
sounds). In time, the tongue will even- movements (anterior guidance). Several
tually adjust, but there will be patients authors have given guidelines to corre-
who will struggle for longer, and who late the condylar inclinations with the
may panic in the meantime. As a gen- steepness of the anterior guidance, and
eral rule, since the final shape will be it is not the objective of this article to an-
bigger, the size of the palatal surfaces alyze the validity of the different methods
should be kept flat in the areas cervi- to achieve a correct occlusal scheme,
cally to the B point (straight BC line). especially when there is no evidence to
Complicated occlusal anatomy should support the superiority of one method
be avoided, such as very deep palatal over the others.26

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Fig 25 Incisal angle. This angle is defined by the AB line (from the contact point to the incisal edge) and
the facial surface of the antagonistic tooth. In the case on the right, the incisal edges are too thick. Redu-
cing their volume without compromising the mechanical strength of the future palatal veneers will open the
incisal angle and promote the freedom of the mandible in its functional movements.

Fig 26 To open the incisal angle (1), the A point is moved more vestibularly (2). The palatal veneer will
stop with a step (2), which will be filled by the composite used during the bonding procedure to smooth the
transition and improve the shade matching with the remaining tooth structure (3).

As a general rule, since a rigid articu- palatal veneers facilitates this task. The
lator cannot duplicate the sophisticated eccentric movements are simply tested
mandibular movement, the three-step with the patient sitting upright, not anes-
technique promotes the use of the pa- thetized, and chewing a small piece of
tient as the “final articulator” to test the gum. It is very surprising how patients
occlusion. Consequently, occlusal ad- know exactly which are the interfer-
justments in the mouth will always be re- ences during chewing when they are
quired and expected.21 The use of com- not anesthetized. Following the patient’s
posite for the therapeutic bite and the request, group function is often the pre-

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ferred choice over canine guidance, es- technicians, who are not experienced/
pecially in horizontal chewers.15 Since knowledgeable enough to choose from
the eccentric movements will be tested the different options and consider their
in the mouth, the laboratory technician clinical implications. As a result, the risk
is instructed to only reduce the steep- of remakes and misunderstandings in-
ness of the incisal guidance, adopting creases. The simplified approach that
an arbitrary condylar inclination of 30 has been developed – the three-step
degrees. technique – promotes an active inter-
One method to reduce the steepness action between the clinician and the
is to resist the temptation of rejuvenat- laboratory technician through the pro-
ing the smile, and to lengthen the teeth gressive development of the wax-up.
indiscriminately in every patient (without This technique fragments the wax-up of
considering the initial status and/or the the full-mouth rehabilitation into stages,
presence of parafunctional habits). To and allows the clinician to clinically vali-
help visualize the steepness of the an- date the laboratory technician’s choices.
terior guidance, an incisal angle could Thanks to the simplicity of the three-step
also be identified by tracing the AB line technique, critical parameters such as
and intercepting it with the vestibular the incisal edges, the occlusal plane,
surface of the mandibular antagonistic and the VDO can be correctly evaluat-
tooth (incisal angle) (Fig 25). To open ed, and the final treatment plan is visual-
the incisal angle, the laboratory techni- ized progressively with the progression
cian may also reduce the thickness and/ of the wax-up and the gathering of more
or move the position of the incisal edges clinical information.
facially. The palatal veneers will then join
the vestibular surface with a step, which
will be filled with the hybrid composite Acknowledgments
used to bond the veneers. In this man-
ner, not only will the anterior guidance The authors would like to thank Profes-
be less steep, but the color match will sor Irena Sailer for believing in and sup-
also be improved, without the need for a porting the concept of the three-step
chamfer preparation (Fig 26). technique at the University of Geneva.
Thanks to all the laboratory technicians
who have contributed with their pas-
Conclusion sionate work to the development of the
three-step technique and the creation
A full-mouth wax-up is considered a of this article, being: Sylvain Carciofo,
necessary step for the correct treatment Alwin Schonenberger, Patrick Schnider,
planning of a full-mouth rehabilitation. Pascal Muller, August Bruguera, Serge
Unfortunately, when asking for a com- Erpen, Vincent Locultre, Giuseppe Dol-
prehensive wax-up, clinicians delegate ce, Romeo Pascetta, and Giuseppe Ro-
important decisions to their laboratory meo.

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