Composite palatal veneers to restore a case

of severe dental erosion, from minimally to non

invasive dentistry: a 5-year follow-up case report
Francesca Vailati, MD, DMD, MSc

Private practice, Senior Lecturer, Department of fixed prosthodontics and occlusion, School of dental medicine,
University of Geneva, Switzerland

KEYWORDS ABSTRACT

Conservative approach, Dental Aim In this case report a conservative approach for the management of dental erosion is
erosion, Veneers. described. The restorations are based only on adhesive techniques.
Case report A 46 years-old patient presented at the Geneva Erosion Study at Geneva University
for diffused dental erosion of intrinsic etiology. The treatment plan was based only on adhesive
technique and six palatal veneers were necessary to restore the very compromised front
teeth. Moreover, the palatal veneers restorations did not require any tooth preparation, and
the teeth kept their vitality. The clinical results at the five year follow-up, confirmed esthetic,
biological and mechanical success.
Conclusion The adhesive technique described proved to be the most appropriate therapy.
and also the overall treatment was more affordable for the patient.

Introduction In the author’s opinion, the dental community should

Frequently patients affected by dental erosion are not stress more the importance of the tooth preservation
immediately treated, since tooth wear still represents (biological success), rather than aim for the “10
an overwhelming challenge. Some clinicians consider guarantee” of their work. A vital tooth restored for the
erosive wear as a physiological process related to age, first time with a crown could last 10 years, but if the
rather than a pathology that should be immediately same tooth looses the vitality and the remaining tooth
treated. Other dentists, instead, recognize the problem, structure becomes compromised (insufficient ferule),
but they are not comfortable to propose a full-mouth can the “10 year deal” still be guaranteed for the new
rehabilitation to their patients, especially at the early restoration? The clinician’s capacity to communicate
stage of the disease, waiting for more tooth destruction the switch in paradigm (biological success versus the
to happen to justify the treatment. Nowadays, thanks mechanical success) is fundamental, before proposing
to the adhesive techniques, dental erosion could be these extremely conservative treatments, because
immediately addressed, the tooth destruction slowed patients must accept that the restorations are now
down, with minimal to no additional tooth loss during weaker and eventually will fail over time; however, the
the delivering of the restorations (1-22). restored teeth will keep their integrity and a repair or
The key factor that allows this extremely conservative a replacement with a similar restoration will always
approach is the increase of the vertical dimension of be possible. This is not always the case, for example,
the occlusion (VDO), necessary in almost all cases when a devitalized tooth, restored with a crown, fails
to obtain enough interocclusal space to avoid tooth because of root fracture.
preparation. The new philosophy, “add not remove”, In this article, the treatment based only on adhesive
proposes weak restorations, which may need more techniques of a patient affected by several dental erosion
frequent maintenance, but which preserve intact the is illustrated. His maxillary anterior teeth were supposed
underlying original tooth structure. In addition, these to be devitalized in order to be restored with full-crown
restorations are cheaper, since they do not require restorations. The patient refused this aggressive option
root canal therapy or crown lengthening, and their and sought consultation in the Geneva Erosion Study at
maintenance is also not expensive (especially when Geneva University. A new treatment plan was proposed,
dealing with composite resin) (Figure 1). based only on adhesive technique; six palatal and six

24 ItalIan Journal of Dental MeDIcIne vol. 2/1-2017

 Figure 1 Occlusal view of the posterior
teeth of a patient affected by severe dental
erosion.
The first molar was restored with a direct
composite restorations. After 4 year the
composite worn down and it was replaced
by a new direct restoration. The patient
did not complain about this failure, since
he considered it as normal part of the
maintenance of his restored dentition

Figure 2a, 2b Initial status. The patient was very uncomfortable about showing his teeth, and only after several attempts,
a forced smile was obtained. Note the accentuated translucency at the level of the two central incisors, indicating the
severe thinning of the incisal edges

facial veneers (Sandwich approach) were considered to first consultation, the patient was very uncomfortable
restore his maxillary anterior teeth and to preserve to a to show his teeth, since he felt very guilty about the
maximum the remaining tooth structure. However, the status of his dentition. He was not fully aware that he
final treatment became even more conservative than was also affected by dental erosion and he thought
expected, since only six palatal veneers were necessary that the degradation of his dentition was related only
to restore the very compromised teeth. The clinical to poor oral hygiene (Figures 2a-2b). During the
results (esthetic, biological and mechanical success) investigation for parafunctional habits, grinding teeth
at the five year follow-up, confirmed that the adhesive was excluded, but clenching was confirmed, not only
approach chosen was the most appropriate therapy. by the patient himself, but also by the size of his very
Not only the palatal veneers restorations did not require developed masseters. The patient presented with a
any tooth preparation, and the teeth kept their vitality, deep bite, which, most probably, was aggravated by
but also the overall treatment was more affordable for the loss of contact on the palatal surfaces, damaged
the patient. by the dental erosion, and the supereruption of the
teeth. Despite the severe tooth structure loss, all the
Case presentation maxillary anterior teeth were still vital, indicating a
A 46 year old patient presented to the University very slow acid attack, most probably with an intrinsic
of Geneva, school of Dental Medicine, with the chief etiology (Figures 3a-3b). Since he also denied any
complaint that “his teeth were deteriorating at a high excessive consumption of acidic food or beverages, he
speed and he finally wanted to do something about was referred to a gastroenterologist to investigate the
it”. At the anamnesis, the patient remembered that status of the digestive system. Even though the patient
his dentist proposed to restore his dentition by means did not complain to this request, his dental treatment
of crowns and that he was not convinced by this started without knowing if the erosion was still active
treatment plan. Since then, he had sought dental in his mouth. Considering the maxillary anterior teeth,
treatment on an irregular basis. After several years the patient was an ACE Class III, because, even though
of neglecting his mouth, he was finally addressed to the incisal edges were extremely thin, the length of the
the Geneva Erosion Study, to investigate if other types clinical crowns was only reduced of a small amount
of treatments than crowns were available. During the (less than 2 mm) (23). Since at the time of the first

ItalIan Journal of Dental MeDIcIne vol. 2/1-2017 25

Figure 3a, 3b Occlusal and lateral views of the initial status. The palatal destruction was very advanced and the
teeth undermined, but due to the patients’ deep bite, the incisal edges fractured very little. The palatal enamel was
present only at the cervical level. Interproximal caries weakened the teeth furthermore, nevertheless, they all were
still vital. The posterior teeth were also very compromised and the clinical crowns were very short

Figure 4a, 4c Analyzing the lingualized position of the two central incisors, an additive mock-up was considered possible.
The laboratory technician slightly bulked the vestibular aspects of the maxillary teeth to reduce the need of tooth
preparation, while delivering the facial veneers

Figure 5a, 5b Following the classic three step technique, a maxillary vestibular mock-up was done, which extended up to
the first molars (I clinical step). The incisal edges and the occlusal plane were slightly lengthened. The esthetic outcome
was of course improved, but the tooth preparation for placing the facial veneers and the veneer/ onlays for the posterior
teeth would have been conspicuous, since the vestibular surfaces were almost intact

consultation in the Geneva Erosion Study, however, the and expensive, not only for the additional six facial
ACE classification had not been developed jet, it was veneers, but also for the veneer/onlays considered to
planned to restore his maxillary anterior teeth not only restore all the maxillary and mandibular premolars.
with palatal, but also with facial veneers (Sandwich This plan was, however, simplified, while the treatment
approach). As a result, the initial treatment plan for his was progressing. The case started following a classic
full-mouth adhesive rehabilitation was more invasive three step technique approach (24-26). Two alginate

26 ItalIan Journal of Dental MeDIcIne vol. 2/1-2017

 the second molars) should have been included in the
treatment. Consequently all the vestibular surfaces
were covered by wax and slightly bulked. At the same
time, the incisal edges and the occlusal plane were
also slightly lengthened (I laboratory step) (Figures 4a-
4c). A silicon key was prepared from this waxed up
cast and the patient was scheduled for the maxillary
vestibular mock-up visit (I clinical step). The patient
liked his new smile, but the clinician already felt that
the patient esthetic request was not the major driving
force to seek treatment (Figures 5a-7b). After the I
step, the casts, mounted in MIP were analyzed by the
clinician. An arbitrary increase of the VDO was decided
Figure 6 3/4 View of the maxillary vestibular mock-up in place. to obtain an interocclusal space necessary, not only to
With the teeth covered by the mock-up the patient did not feel restore the palatal aspect of the anterior teeth, but also
the necessity to hide his smile any longer. Very striking was the to cover the exposed dentin on the occlusal surfaces
difference in color with the antagonistic teeth. External bleaching of the posterior teeth.
was considered after the protection of the exposed dentin The increase of the VDO was limited by the necessity
not to set apart the anterior teeth excessively and
loose the possibility to recreate the anterior contact
afterwards with normal-size palatal veneers. Both
maxillary and mandibular arches had to be involved in
this rehabilitation (double arch distribution).
The laboratory technician waxed up the surfaces of
the posterior teeth (2 premolars and the first molar in
each sextant), and the casts returned to the clinicians
who fabricated 4 transparent keys out of them (Elite
Transparent, Zhermack, Badia Polesine, RO, Italy)
(II laboratory step). After 2 weeks, the patient was
scheduled for a 2-hour appointment for the fabrication
of the provisional posterior composite restorations
directly in the patient’s mouth (II clinical step). Without
anesthesia, the keys were loaded with warmed up
composite resin (Enamel Plus, HRi Micerium spa,
Avegno, GE, Italy) and placed in the mouth (Figures 8a-
8b). Since no anesthesia was delivered, the patient was
fully collaborating during the control of the occlusion.
After 1 week, another control was done, where the
patient reported to be comfortable, even though he
was functioning at an increased VDO and an open bite
was present at the level of his anterior teeth (Figures
9a-9c). According to the classical Geneva Erosion
Study’s protocol, the increase of VDO should be tested
for one month. During this time, the patient was seen
to remove the caries and to protect the pulp at the level
Figure 7a, 7b Esthetics was improved, but during a long
conversation with the patient, the clinician realized that he of the palatal aspect of the maxillary anterior teeth.
did not really want to change his look dramatically During this visit, the exposed dentin on the palatal
aspect of the maxillary anterior teeth was roughened
with a very course diamond round bur, and
immediately sealed with Optibond Fl (Kerr, Orange,
impressions were taken and the casts articulated in CA, USA), following the manufactures’ instructions.
maximum intercupidation (MIP), using a face bow. A To reinforce the hybrid layer, a final application of
maxillary vestibular waxup was requested. flowable composite (Tetric flow T, Ivoclar Vivadent,
Looking at the patient’s smile, the laboratory technician Schaan, Liechtenstein) was placed on the dentin, and
decided that to achieve satisfactory esthetics, all the polimerized for 40 seconds (20 seconds covered with
vestibular aspects of the maxillary teeth (excluded glicerine) (27-31).

ItalIan Journal of Dental MeDIcIne vol. 2/1-2017 27

Figure 8a, 8b Four transparent keys were fabricated out of the waxed up casts, loaded with warmed up composite resin
and placed in situ. After the removal, 12 provisional posterior composite restorations were bonded to the posterior teeth,
without any tooth preparation. No anesthesia was necessary (II clinical step)

Figure 9a, 9c Initial status and after the II step with the
improvement of the vertical overlap and the creation of the
open bite in the anterior quadrants for the presence of the
provisional posterior composite restorations

margin with the future veneer at the cervical level, since

the acid had already created the perfect chamfer and
there was no need to weaken the band of enamel next
to the gingiva (Figures 10a-10b). After the impression
for the palatal veneers, no provisional restorations were
delivered. The reason was related to the difficulty in
eventually cleaning the excesses of the provisional
material at the palatal level, which would have inflamed
the gingiva, and complicated the moisture control at
Thanks to the open bite creation, the caries’ removal the time of the bonding of the palatal veneers. Another
and the dentin sealed, these teeth became mechanically reason was the danger of breaking the very thin incisal
and biologically stronger. edges, while removing the provisional restorations,
After 1 month from the II step, the patient was and finally due to the lack of tooth preparation and the
scheduled for a 1-hour appointment where a polyvinyl immediate sealing of the exposed dentin, the patient was
siloxane impression of the maxillary arch was taken asymptomatic and did not require any tooth protection,
(Express 2 3M ESPE, Seefeld, Germany), to fabricate as in case of full coverage.
the palatal veneers. Since the patient was supposed The laboratory technician received the maxillary
to receive also the facial veneers, the interproximal impression and an alginate impression of the mandibular
contacts between teeth were slightly opened by means arch. Thanks to an anterior jig, he mounted the two
of a metallic strips. No attempt was made to remove the casts in MIP. Six composite palatal veneers were then
unsupported enamel at the incisal edges, nor to create a fabricated (Miris, Coltene, Whaledent, Altstatten,

28 ItalIan Journal of Dental MeDIcIne vol. 2/1-2017

Figure 10a,10b After caries removal and sealing of the exposed dentin, a final impression was taken, without
any additional tooth preparation. Enamel is present at the level of the cervical margins. No provisional
restorations were delivered

Figure 11a, 11b Six composite palatal veneers on the cast (III laboratory step). The cervical margins did not need to extend
behind the cervical enamel, and thanks to their supragingival margins, the bonding procedures were facilitated

Figure 12a, 12b Try-in of the palatal veneer before rubber dam placement. For ACE Class III patients, where the facial
veneers are not previewed, essential is the color match between the remaining facial surface and the incisal edges added
with the palatal veneers. Note that all the non supported enamel was left intact and no effort was made to make a chamfer
on the facial surface. This conservative attitude saved the original length of the tooth, but made it more difficult to blend the
joint with the palatal veneers

Switzerland) (III laboratory step) (Figures 11a-11b). The Surprisingly, the extremely transparent color was
patient was scheduled for a 2-hour appointment. No very nicely masked by the palatal veneers without
anesthesia was needed. Before the placement of the giving an opaque or too translucent aspect to the new
rubber dam, the palatal veneers were tried in the mouth, incisal edges (Figures 12a-12b). The palatal veneers
to verify the color match at the level of the facial junction. were bonded, one at a time, using the rubber dam.

ItalIan Journal of Dental MeDIcIne vol. 2/1-2017 29

Figure 13 After the rubber dam’s placement, the palatal Figure 15 After the bonding of the palatal veneers, the
veneers were bonded two at the time. Two hours were incisal hooks are removed. It is recommended to make
necessary to complete the procedure. No anesthesia was the hook in a different color (e.g. dark dentine color) to be
delivered (III clinical step) more visible, while being removed

The composite veneers were sandblasted (Cojet)

and cleaned in alcohol with ultrasound. Three coats of
silane were applied (Mondobond plus, Ivoclar Vivadent,
Schaan, Liechtenstein). A final layer of bond (Optibond
FL, Kerr Orange, CA, USA) was used without curing,
the warmed-up composite was then applied to the
restoration (Enamel Plus, HRi Micerium S.P.A., Avegno
GE, Italy) before placing them one at a time on the
teeth and light cured (Figures 13-14b). Thanks also to
the presence of a composite “hook” at the level of the
incisal edges of the veneers, it was easier to achieve
a correct positioning, even on the “slippery” palatal
surfaces. The hooks were subsequently removed
during finishing and polishing (Figure 15). After two
weeks, the patient returned to complete the restoration
of the maxillary anterior teeth with facial veneers, and
he expressed his satisfaction with the result already
obtained (Figures 16a-16b). He reported that his wish
was to save and strengthen the incisal edges and not
to completely change his look.
Even the patient’s tooth color was not an issue
anymore, and he decided not to bleach his teeth. He
did not mind the difference of color at the level of the
incisal edges (especially the canines), where the palatal
veneers were made lighter to give some luminosity to
the patient’s teeth. The clinician, who had assumed
Figure 14a, 14b The interproximal contacts were adjusted, that whither and bigger teeth were not necessary,
but there was not an effort to close them tightly, since agreed with the patient that the vestibular aspect of
facial veneers were also considered. Since these latter the restored maxillary anterior teeth had already a very
restorations were not delivered, some of the interproximal pleasing aspect and there was no need to deliver the
contact points were slightly open. Note the incisal hook to
facial veneers. Consequently, it was decided to wait,
stabilize the veneers on the slippery palatal surfaces
and to see if the composite veneers alone could have
strengthened the very compromised incisal edges in
The palatal sealed dentin was sandblasted (Cojet, this patient, who was used to clench his teeth. After
27μm, 3M, Espe, Seefeld, Germany), the surrounding 1 year of stand-by, the patient was still very satisfied
enamel was etched (37% phosphoric acid), and the with the palatal veneers, and it was decided together
bond (Optibond FL, Kerr, Orange, CA, USA) was with the patient to change the treatment plan also for
applied but not cured yet. the posterior teeth that would have been restored with

30 ItalIan Journal of Dental MeDIcIne vol. 2/1-2017

Figure 16a, 16b When the patient returned for the facial veneer preparation, the color match was very pleasing at the level
of the incisors, and questions arised on the necessity to restore the patient with the Sandwich approach

Figure 17a, 17b 3-year follow-up, the restorations were aging very nicely. The patient did not want to do the bleaching to
better match the color at the level of the canines, and he was very satisfied with the overall treatment. The only negative
comment on the aging of the restored teeth was the opening of a diastema between the two central incisors. Most
probably the initial contact point was not strong, since facial veneers were also previewed. Nevertheless no food impaction
or esthetic problem were reported by the patient

composite onlays, instead of ceramic veneer/onlays. At the 3 and 5 year follow-ups the palatal veneers
This new treatment plan was related to the decision not were aging very well. Not only all the restorations did
to deliver the facial veneers on the anterior teeth, which not present discolorations or sign of mechanical failure,
would have bulked these teeth, allowing also to bulk but also all the teeth maintained their vitality (Figures
the facial aspect of the posterior teeth. Keeping the 17a-18b). The clinical unexpected success of the
facial surfaces of the patient as they were, more tooth palatal veneers to restore these very compromised teeth
preparation would have been necessary to deliver the confirms the tennis racket’s theory. According to this
facial/onlays on the posterior teeth. In agreement with theory, the maxillary anterior teeth affected by dental
the patient, it was preferred to restore his posterior erosion present a framework of enamel which make
teeth with composite than ceramic onlays, since the them still very strong. This framework, composed by the
occlusal thickness was limited (less then 1.5 mm), cervical, mesial and distal and all vestibular enamel of
being a double arch distribution, and tooth preparation the remaining tooth structure, is responsible for a tooth
to obtain thicker restorations was not considered as an rigidity where even very undermined and unsupported
option. enamel could be preserved and strengthened by a
The new treatment plan was very welcome by the very thin composite palatal veneer. Finally, in case of
patient, also because the cost was reduced. At the end these compromised teeth, the potential for a vitality
of the treatment an occlusal guard was delivered to loss could be anticipated. The endodontic access
the patient, who entered in the Geneva Erosion Study could be easily made through the palatal veneer and
follow-up program. closed afterwards with a direct composite.

ItalIan Journal of Dental MeDIcIne vol. 2/1-2017 31

Figure 18a, 18b Occlusal view at the 3 year and 5 year follow-up. No margin discolorations or failure of the palatal veneers
were noticed, and all the teeth maintained their vitality

reverse curve of Spee), in order to help the laboratory

Discussion technician to gain more clinical information before the
The treatment of this patient was driven by the wax up of the posterior quadrants. This patient had a
maximum tooth preservation objective, which pushed very compromised dentition, but the facial aspects of
the clinicians to take several unusual decisions. One his teeth were almost intact, except the incisal third,
of them was to start the dental treatment before the and no major tooth supraeruption was evident. He was
cause of dental erosion was discovered and treated. an ACE Class III (Figure 19).
The urgency to start the treatment, even before the When the tooth destruction is less severe and the
diseases is arrested, is related to the preservation of anterior teeth can be restored only by means of palatal
the pulp vitality and the remaining undermined tooth veneers (ACE Class II and III), there is no need to do
surfaces. a mock-up to determine the plane of occlusion; the
As it often happens, asymptomatic patients, where laboratory technician can, in fact, easily visualize it in
an intrinsic cause of dental erosion is suspected, do relation to the future incisal edges’ position, just looking
not complain to clinician’s request to look into the at the articulated initial models and the photos of the
functionality of their digestive system, and if they patient’s smile.
do, after the first consultation and the first year of Consequently after the first consultation, ACE Class
treatment, they tend to disconnect the relationship with III patients directly proceed to the II step of the three
the gastroenterologist. step technique (increase the VDO and delivering the
Thus it is difficult for a dentist to determine if the provisional posterior composite restorations on the
cause of dental erosion is still present and if it will posterior teeth). The I step is not necessary.
be present again in the future. Especially in case of In this patient, the first step, the maxillary vestibular
patients affected by gastric reflux, the author strongly mock-up, was unnecessarily done. Another aspect of
recommends to start the dental treatment, regardless this case that could have been done better was the
if the cause of dental erosion will be treated or not. delivering of the palatal veneers, thinking that the
The initial treatment plan was more complicated patient would have also received the facial ones.
and expensive, since facial veneers for the anterior When the maxillary anterior teeth are meant to be
and veneer/onlays for the posterior teeth were also restored by the Sandwich approach (both palatal
considered. At the beginning of the treatment, the and facial veneers), it is not necessary to restore the
clinician was driven by the assumption that the patient interproximal contacts with the palatal veneers, since
wanted to change completely his look. these contacts will be removed, when preparing the
However, after obtaining the preservation and teeth for the facial veneers. In the specific case, the
strengthening of the remaining tooth structure, the wrong planning about the facial veneers led to a more
patient was already very satisfied, and additional superficial adjustment of the contact points between
treatment was not longer necessary. Following the the palatal veneers, which were not so tight.
classic three step technique, it has been recommended At the 3 and 5 year follow-ups a diastema between
to start with a maxillary vestibular mock-up, to the two central incisors became apparent, probably
determine the plane of occlusion (I step). This option is, related to the interproximal instability. However, no
however, limited to the very compromised cases, where clinical or esthetic consequences were reported by the
the position of the teeth is particularly altered (e.g. patient.

32 ItalIan Journal of Dental MeDIcIne vol. 2/1-2017

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