A 10-Year Follow-Up of an Approach to Restore a Case of Extreme Erosive Tooth Wear

Abstract

Background: In recent years, thanks to the improvement of adhesive techniques, patients affected by tooth wear, related to erosion and/or parafunctional habits, can undergo restoration by adding only what has been lost of their dentition (additive approach). However, since not all clinicians are convinced that dental rehabilitation should be proposed in the early stages of exposed dentin, several treatments are often postponed. It is important to emphasize that, in the early stages, the clinical approach should remain conservative, focusing on dietary counseling, the modification of harmful habits, fluoride application, and risk factor management. Only when these preventive and non-invasive strategies prove insufficient, and the condition continues to progress, should invasive restorative treatments be considered. Unfortunately, epidemiological studies are reporting an increase in the number of young patients affected by erosive tooth wear, and not intercepting these cases earlier could lead to a severe degradation of the affected dentition. In addition, parafunctional habits are also becoming more frequent among patients. The combination of erosion and attrition can be very destructive, and may progress rapidly once dentin is exposed and the risk factors remain unaddressed. The aim of this report was to present a conservative full-mouth rehabilitation approach for severe erosive lesions and to provide a 10-year follow-up assessing the biological, functional, and esthetic outcomes. Methods: In this article, the postponed restorative treatment of a patient, suffering from severe tooth wear, is illustrated. The patient had sought dental treatment in the past; however, due to the already very compromised dentition, a conventional but very aggressive treatment was proposed and refused. Four years later, when the patient finally accepted an alternative conservative therapy, the tooth degradation was very severe, especially at the level of the maxillary anterior teeth. The combination of three different approaches, Speed-Up Therapy, BOPT (Biologically-Oriented Preparation Technique), and the 3 Step Technique, however, improved the capacity to successfully complete the difficult therapeutic task. Results: The biological goals (maintenance of the pulp vitality of all of the teeth and the minimal removal of healthy tooth structure) were accomplished, relying only on adhesive techniques. Conclusions: The overall treatment was very comfortable for the patient and less complicated for the clinician. At 10-year follow-up, biological, functional, and esthetic success was still confirmed.

Keywords: full-mouth rehabilitation; mock-up; orthodontics; set-up; smile aesthetics; speed-up therapy.

Figure 1

Example of two patients affected by generalized tooth wear.

Figure 2

Patient’s profile and smile during the first visit. Due to the tight lips and the very damaged teeth, it was impossible for the patient to show his teeth upon smiling. Note the visible collapse of the lower third of the face when the teeth were in contact.

Figure 3

Occlusal view showing the severe loss of tooth structure, especially at the level of the maxillary anterior teeth and the mandibular left molars.

Figure 4

Intraoral view. Despite the generalized conspicuous loss of tooth structure, all the teeth (except one premolar) were still vital, confirming the slow progression of the disease. Note the deep bite and the very tight lips, which made it difficult to take intraoral pictures.

Figure 5

Initial radiographic status.

Figure 5

Initial radiographic status.

Figure 6

Comparison between the dentition of the patient photographed by another clinician and the dental degradation which occurred by leaving the patient without any dental therapy for four years. The severity of the tooth wear supports the authors belief in the early interception of patients affected by tooth wear.

Figure 7

Instead of following the partial wax-up of the 3 Step Technique, the laboratory technician was instructed to complete a full-mouth wax-up. The increase in VDO was arbitrarily decided on the articulator looking at the restorative needs of the specific case.

Figure 8

The maxillary anterior teeth were not devitalized but restored with a core build-up in composite fabricated directly in the mouth by means of a transparent key.

Figure 8

The maxillary anterior teeth were not devitalized but restored with a core build-up in composite fabricated directly in the mouth by means of a transparent key.

Figure 9

Following the Speed-Up Therapy, the mandibular arch was isolated and orthophosphoric acid applied on all the surfaces to retain the therapeutic mock-up, fabricated directly in the mouth by means of a silicon key.

Figure 10

Mandibular arch restored with the therapeutic mock-up and view of both arches immediately after removing the silicon keys. Minimal excesses were present, and the occlusion required very few adjustments, thanks to the modification of the wax-up at the cervical level and the rigidity of the keys.

Figure 11

Therapeutic mock-up and super floss. This picture shows the possibility for each gingival embrasure to be accessible and cleansable.

Figure 12

Teeth preparation (initial, abutments, final prep).

Figure 12

Teeth preparation (initial, abutments, final prep).

Figure 13

First provisional restoration made with a mock-up key directly in the mouth.

Figure 14

Laboratory-made provisional with BOPT emergency profile.

Figure 15

CAD/CAM composite crowns with minimal cutback.

Figure 16

Close view of the removal of the laboratory-made provisional restorations and the abutments ready to receive the final restorations. Note the status of the soft tissue.

Figure 17

Follow-up at 2 weeks after delivering the final restorations in the premaxilla. The treatment progressed with the replacement of the antagonistic provisional restorations and after with the posterior teeth by quadrant.

Figure 18

Initial radiographs and after bonding the anterior maxillary final restorations. Due to the different radio opacity, it is possible to see the size of the core build-up and the remaining monolithic CAD/CAM composite with the very little cutback.

Figure 19

Delivery of the composite facial veneers and follow-up 2 week later. The rehabilitation progressed then with the replacement of the posterior provisional restorations by quadrant.

Figure 20

Wax-up for the fabrication of the CAD/CAM restorations.

Figure 21

Delivery of the final restoration and 1-month follow-up.

Figure 22

Radiographs after delivery of the restorations. All the teeth kept their vitality.

Figure 23

Completion of the full-mouth adhesive rehabilitation.

Figure 24

A Michigan occlusal guard was delivered to the patient, in addition to an umbrella bite to re-mineralize the unrestored tooth surfaces (as the erosion risk is still present).

Figure 25

Dynamic occlusal adjustments and occlusal view of the static occlusion.

Figure 25

Dynamic occlusal adjustments and occlusal view of the static occlusion.

Figure 26

Follow-up at 2 years and at 4 years.

Figure 27

Re-bonding of the incisal edges on teeth: maxillary left central incisor, maxillary left lateral incisor, and maxillary left canine.

Figure 28

Extra-oral photos at Seven-year follow-up.

Figure 29

Seven-year follow-up.

Figure 30

Ten-year follow-up.

Figure 31

Ten-year follow-up.

Figure 32

Ten-year follow-up.