Full-Mouth Adhesive Rehabilitation of a Severely Eroded Dentition: The Three-Step Technique. Part 2.

Transcription

1 Full-Mouth Adhesive Rehilittion of Severely Eroded Dentition: The Three-Step Tehnique. Prt 2. Frnes Vilti, MD, DMD, MS Senior Leturer, Dept of Fixed Prosthodontis nd Olusion Shool of Dentl Mediine, University of Genev Switzerlnd Urs Christoph Belser, DMD, Prof Dr med dent Chirmn, Dept of Fixed Prosthodontis nd Olusion Shool of Dentl Mediine, University of Genev Switzerlnd Correspondene to: Dr Frnes Vilti University of Genev, Dept of Fixed Prosthodontis nd Olusion, Rue Bthelemy-Menn 19, 1203 Genev, Switzerlnd; e-mil: 128

2 VAILATI/BELSER Astrt Trditionlly, full-mouth rehilittion sed on full-rown overge hs een reommended tretment ptients ffeted severe dentl erosion. Nowdys, thnks to improved dhesive tehniques, the inditions rowns hve deresed nd more onservtive pproh my e proposed. Even though dhesive tretments simplify oth the linil nd lortory proedures, restoring suh ptients still remins hllenge due to the gret mount of tooth destrution. To filitte the liniin s tsk during the plnning nd exeution of full-mouth dhesive rehilittion, n innovtive onept hs een developed: the three-step tehnique. Three lortory steps re lternted with three linil steps, llowing the liniin nd the lortory tehniin to onstntly intert to hieve the most preditle estheti nd funtionl outome. During the first step, n estheti evlution is permed to estlish the position of the plne of olusion. In the seond step, the ptient s posterior qudrnts re restored t n inresed vertil dimension. Finlly, the third step reestlishes the nterior guidne. Using the three-step tehnique, the liniin n trnsm full-mouth rehilittion into rehilittion individul qudrnts. The present rtile fouses on the seond step, explining ll the lortory nd linil steps neessry to restore the posterior qudrnts with defined olusl sheme t n inresed vertil dimension. A rief summry of the first step is lso inluded. (Eur J Esthet Dent 2008;3: ) 129

3 Fig 1 ( to ) Clinil views of 60-yer-old ptient ffeted generlized dentl erosion. For yers the ptient suffered from gstri esophgel reflux. At this lte stge full-mouth rehilittion is inevitle. Despite the dvned loss of tooth struture, ll teeth re still vitl. Trditionlly, full-mouth rehilittion hs een the reommended tretment ptients ffeted generlized severe dentl erosion. However, restortive onept omprising full-rown overge of lmost ll teeth nd extensive eletive root nl tretment my e too ggressive this generlly very young popultion of ptients. 1 3 With urrent improved dhesive tehniques, the inditions rowns hve deresed nd more onservtive pproh my e proposed, to preserve tooth struture nd to postpone more invsive tretments until the ptient is older. 4 8 In order to test the hypothesis tht suh onept n preditly reh the speifi tretment ojetives, linil tril testing fully dhesive pproh is underwy t the University of Genev. All ptients ffeted generlized dvned dentl erosion re systemtilly nd exlusively treted with dhesive tehniques, using onlys the posterior region nd omintion of fil onded porelin restortions (BPRs) nd pltl omposite restortions the nterior mxillry region. The gol of this prospetive linil study is to evlute the longevity of dhesive rehilittions, ee proposing this tretment option s the new stndrd of re. Despite the tendeny dhesive modlities to rther simplify the involved linil nd lortory proedures, tretment of suh ptients still remins hllenge euse of the signifint mount of tooth destrution (Fig 1). 130

4 VAILATI/BELSER Tle 1 The three-step tehnique Lortory Mxillry vestiulr wxup Step 1: Esthetis Clinil Assessment of olusl plne Posterior olusl wxup Step 2: Posterior support Cretion of posterior olusion t n inresed VDO Mxillry nterior pltl onlys Step 3: Anterior guidne Reestlishment of finl nterior guidne To filitte the liniin s tsk during the plnning nd exeution of full-mouth dhesive rehilittion, strutured, innovtive onept hs een developed: the three-step tehnique (Tle 1). Three lortory steps re lternted three distint linil steps, llowing the liniin nd the lortory tehniin to onstntly intert nd thus to hieve the most preditle estheti nd funtionl outome. The first step of the onept hs een previously desried in detil. 9 The present rtile fouses on the seond step, explining ll the lortory nd linil steps neessry to restore the posterior qudrnts with defined olusl sheme t n inresed vertil dimension. A rief summry of the first step is lso inluded. Full-mouth wxup: ruil or ritrry tool in the determintion of the plne of olusion? Ptients ffeted severe dentl erosion often present with n extremely dmged dentition, not infrequently mking liniins hesitte to undertke suh n ex- tended rehilittion. Trditionlly, one of the first steps onsists of providing the lortory tehniin with dignosti sts, nd requesting full-mouth wxup. A fullmouth wxup should guide the liniin in plnning the tretment so tht the most estheti nd funtionl result is hieved respeting the priniple of miniml invsiveness, ie, miniml tooth preprtion. Cliniins should relize, however, tht tehniins will often ritrrily deide on numerous importnt dentl prmeters (eg, olusl plne, inisl edge position) without seeing the ptients, nd with n often misleding lk of referene points (eg, djent teeth). The ft tht the resulting finl rehilittions often do not reflet the initil full-mouth wxups onfirms this sttement. In the uthors opinion, the most misjudged prmeter in full-mouth wxup is the position of the olusl plne. In se of full-mouth rehilittion t n inresed vertil dimension of olusion (VDO), the gined interolusl spe is generlly shred eqully etween the 131

5 mndiulr nd the mxillry posterior teeth, to minimize tooth preprtion in oth rhes. However, suh deision is ompletely ritrry, nd the repositioning of the olusl plne t lower level thn the originl my led to ompromised estheti result. In order to hieve n optiml estheti outome, oth the mxillry inisl edges nd the olusl plne should e in hrmony. In frontl, smiling view, the vestiulr usps of the mxillry posterior teeth should follow the lower lip nd e loted more ervilly thn the inisl edges of the nterior dentition. Otherwise, n unplesnt, reverse smile is generted. Thus, to determine the orret distriution of the interolusl spe gined the inrese of VDO, it is mndtory to determine first the optiml position of the mxillry inisl edges of the plnned finl restortions. In ptients where the mxillry nterior teeth nnot e lengthened suffiiently on their inisl spet to ompenste n exessively low olusl plne, ll the spe otined hs to e used exlusively the restortion of the mndiulr posterior teeth, whih in turn will require more ggressive tooth preprtion of the mxillry posterior teeth. Advned generlized dentl erosion frequently leds to supreruption of oth the mxillry posterior sextnts nd the mndiulr nterior segment, using so-lled reverse smile (Fig 2). Logilly, in these ptients, the position of the olusl plne nnot e further lowered, unless there is ertitude tht the inisl edges of the mxillry nterior teeth will e suffiiently lengthened to orret the reverse smile. An dditionl prolem inherent to this prtiulr type of ptient is tht they re used to pereiving themselves with smller teeth. As onsequene, not ll of them will redily ept hving their nterior teeth restored with dded inisl volume. Hene ommunition with the ptient eomes of prmount importne to void estheti misunderstndings. Bee strting the full-mouth rehilittion, it is reommended to determine to wht extent the ptient will ept lengthening of the nterior mxillry teeth, so tht the finl estheti outome will e well defined nd the required mount of preprtion of the mxillry posterior teeth n e urtely plnned. Step 1: Lortory nd lini The first step of the three-step tehnique is oneived to gurntee tht oth the liniin s nd the lortory tehniin s vision of the plnned restortion is refletion of the ptient s true desires. With the introdution of the first linil step, the tehniin will not omplete potentilly inorret full-mouth wxup. In ft, the first lortory step proposes to wx up only the vestiulr surfes of the mxillry teeth. At this stge, where muh of the relevnt inmtion is still missing, it is not dvisle to invest time in more omprehensive wxup. Susequently, the inmtion represented the mxillry vestiulr wxup will e piked up mens of preise silione key (Fig 3). The ptient is then sheduled linil ppointment where mxillry vestiulr mokup is diretly frited in the mouth (first linil step). The liniin will lod the silione key with tooth-olored utopolymerizing resin omposite mteril nd position in the ptient s mouth. After its removl, ll vestiulr surfes of the mxillry teeth will e overed thin lyer of 132

6 VAILATI/BELSER Fig 2 ( to ) An unplesent reverse smile is present when the position of the inisl edges of the mxillry nterior dentition is more ervil thn the olusl plne, s pprent in these three ptients ffeted severe dentl erosion. Fig 3 ( to ) First lortory step: Mxillry vestiulr wxup. The tehniin is instruted to wx up only the vestiulr spet of the mxillry teeth. Neither the ingul nor the pltl usps of the mxillry posterior teeth re inluded t this stge. A silione key is then frited nd will susequently e loded with tooth-olored resin omposite mteril nd repositioned in the ptient s mouth the frition of mxillry mokup. Fig 4 First linil step: Mxillry vestiulr mokup. Clinil views ee () nd fter ( nd ) ompletion of the dignosti mokup. Muogingivl surgery ws permed to over the mrked gingivl reessions on the mxillry left nine nd premolrs. e tht the mokup overs only the inisl edges nd the vestiulr usps of the mxillry teeth. omposite, reproduing the shpe defined the future restortions the lortory tehniin. The desried, fully reversile reonstrution of the vestiulr usps of the mxillry posterior teeth nd the inisl edges of the nterior teeth llows visuliztion of the future plne of olusion. Additionl inmtion is lso otined, s explined in previous rtile, 9 most importntly the ptient s onsensus regrding the plnned finl estheti outome (Figs 4 nd 5). After ompletion of the first step, either ml eptne the ptient is o- 133

7 d Fig 5 ( to d) These photogrphs present the sme ptient s shown in Fig 4. Owing to the mxillry vestiulr mokup (), the orienttion of the future olusl plne n e visulized, nd the estheti diretion tken the tehniin greed with the ptient. Generlly, ptients ppreite the plnned tretment ojetive eing presented to them so lerly t n erly stge nd ee ny irreversile mesures hve een tken. tined, or new guidelines hnges re wrded to the tehniin, who n then progress with the omplete wxup of the posterior qudrnts. Bee ontinuing ny further with the three-step tehnique, it is importnt to ddress two topis speifilly, whih in the se of full-mouth rehilittion re still ontroversil: entri reltion nd vertil dimension of olusion. Centri reltion: entri olusion dilemm In the presene of generlized dvned dentl erosion, whih often signifintly ffets olusl morphology in the posterior segments of the dentition s well s nterior guidne, the liniin fes the dilemm whether to restore the ptient in entri reltion (CR) or in mximum interusption position (MIP). Aording to numerous lssi rtiles pulished in the field of Gnthology, CR is reommended s the only eptle position when it omes to full-mouth rehilittions, sine it is onsidered the only reproduile one. This onept ws developed onventionl full-mouth rehilittions, when ll the teeth were going to e restored mens of full overge (rowns or fixed dentl prostheses) nd when working ex- 134

8 VAILATI/BELSER Fig 6 Mounted study sts of sme ptient rtiulted in MIP () nd in CR (), fter omplete full mouth wxup. While the CR position n e desirle in ptients with lss III molr olusion, in ptients with lss II, s this prtiulr ptient, it poses n olusl dilemm. The future restortions on the nterior teeth would never e in ontt (no nterior guidne) unless unnturl oversized ingul were reted. e the exessive horizontl overlp () generted the omintion of the CR position nd the inrese of VDO. tensively on oth rhes t the sme time hd n elevted risk of losing ll intermxillry referene points. An dditionl rgument CR ws tht ptients treted under extended lol nesthesi were unle to ollorte during the olusl djustments. Currently, there is n inresing trend towrds minimizing the neessity omplited, time-onsuming linil proedures on the one hnd, nd reduing the numer of full rown restortions on the other hnd, prtiulrly when treting young ptients. Consequently, the new linil pproh (full-mouth dhesive rehilittion) the tretment of dvned generlized erosion onsists exlusively of posterior onlys nd nterior BPRs, nd is strtegilly plnned in wy tht llows rehilittion of ptients qudrnt-wise insted of restoring oth dentl rhes simultneously. In dynmi rehilittion proess, where two key prmeters of funtionl olusion, ie, VDO nd interrh reltion, re onstntly mintined the ontrlterl side of the mouth, using CR s lndmrk referene of olusion my not e so ruil. Furthermore, in ses of severe dentl erosion, the pltl spet of the mxillry teeth is often ompromised; fter the enmel is lost, the exposed dentin is sujet to elerted wer, whih leds to pronouned onve morphology nd not infrequently to wekening nd frture of the inisl edges. To stop the progression of the desried tooth destrution (erosion nd ttrition), the exposed remining dentin should e effiiently proteted. Due to the supreruption of the nterior qudrnts, n inrese of VDO is mndtory to restore the originl tooth m. However, in ptients with lss II molr olusion, the omintion of inresed VDO nd CR position my set the nterior teeth signifintly prt nd this n led to n sene of nterior guidne. 135

9 Sine it is not reommended to sustntilly inrese the inisl length of the mndiulr nterior teeth (generlly supererupted in ses of dvned generlized dentl erosion), nterior ontts n logilly only e re-estlished inresing the size of the mxillry ingul. In ft, severl of the ptients ffeted severe generlized erosion treted t our lini presented lss II molr olusion with mjor disrepny etween MIP nd CR. Thus it ws preferred to restore their olusion in MIP nd to estlish nterior ontts without the neessity of reting oversized mxillry ingul (Fig 6). Furthermore, to evlute if under the previously desried onditions nd stritly following the three-step tehnique the use of CR s the interrh reltionship of referene is not prerequisite, the deision ws mde to restore ll the ptients ffeted severe erosion in MIP. From the preliminry dt olleted so fr, no signifint dverse effets hve een enountered tht would question the hoie of using MIP. The inresed VDO dilemm: how muh nd how to test? In ptients ffeted severe generlized erosion, the question of whether VDO hs eventully deresed during this pthologil proess is diffiult to nswer, s severl ompenstory mehnisms, eg, supereruption of the lveolr proess, my hve ourred. It is lso linilly quite irrelevnt. An inrese of VDO is lwys mndtory, in order to redue the need sustntil tooth preprtion nd to void the neessity of eletive endodonti tretments. However, ny inrese of VDO should e miniml so it is tolerted the ptient, nd gurntees t the end of the rehilittion the preservtion or re-estlishment of funtionl nterior interrh ontts required nterior guidne. Furthermore, the new VDO should lwys e tested linilly, ee irreversile tretments egin, sine it is seleted ritrrily on the rtiultor. In this ontext, trditionl nd fully reversile pproh onsists of the use of n olusl gurd, whih requires ompline of the ptient. However, onsidering the tive lifestyle of most people, it is rther nïve to expet tht ptients will wer suh n olusl gurd 24 hours dy severl months. A more relisti pproh my e the use of interim restortions. In the se of dhesive rehilittion, the dentl tehniin ould frite provisionl omposite onlys, whih would susequently e onded to the teeth, inluding the pltl spets of the mxillry nterior dentition. There re severl disdvntges to this method, suh s the ssoited dditionl l fees. Furthermore, it my in mny instnes not e truly reversile pproh, sine it ould require some tooth preprtion to ssure miniml thikness of the onlys. The third possiility linil testing of the fesiility of n ritrrily hosen inrese of VDO is the use of diret omposites. However, free-hnd diret omposites re very time onsuming, prtiulrly if the liniin ims to duplite extly the olusl sheme determined wxup on the mounted study sts. It should e repeted tht not only the posterior, ut lso the nterior teeth should e involved in the tretment in order to inrese the VDO nd to rerete dequte nterior guidne. The respetive result my e disppointing, espeilly if the liniin expets to position the mndile in CR nd to estlish simultneously stle 136

10 VAILATI/BELSER Fig 7 ( to ) Seond lortory step: Posterior olusl wxup. The lortory tehniin wxes only the olusl surfes of the premolrs nd the first molrs in eh posterior qudrnt of the mxillry nd mndiulr sts. Bsed on this wxup, four independent trnsluent silione keys will e frited. olusl ontts t the identil VDO tht hd een previously seleted on the rtiultor, tsk tht is generlly onsidered lmost impossile. All the three of the ove tehniques tht hve een proposed to test n inrese of VDO hve some mjor drwks. The dilemm of how to trnsfer effiiently nd orretly the new olusion defined with the wxup remins. As onsequene, the seond step of the threestep tehnique proposes n esy nd reversile pproh to estlish new posterior support nd to test the dpttion of the ptient to this new VDO. This pproh, omining the dvntges of the ovementioned tehniques, llows frition of fixed olusl gurd, mde of splinted omposite onlys, diretly frited in the mouth. Step 2: Lortory posterior olusl wxup At the eginning of the tretment, the two mxillry nd mndiulr sts re mounted on semi-djustle rtiultor with feow in MIP. During the first step, the tehniin permed vestiulr wxup on the mxillry st, nd the position of the plne of olusion ws susequently vlidted linilly. For eh ptient, the new VDO is deided ritrrily on the rtiultor, tking into onsidertion the posterior teeth, where the mximum inrese is desirle to mintin mximum of minerlized tissue, nd the 137

11 d Fig 8 ( to d) Wxup modifitions ee the frition of the trnsluent silione keys. It is neessry to remove the wx from the mxillry nines, so tht the key will etter e dpted in the ptient s mouth (nine s mesil stop). nterior teeth, whih should not e set too fr prt to jeoprdize the reretion of nterior ontts nd the relted nterior guidne. One the inrese of the VDO is estlished nd the plne of olusion vlidted, it is esy the tehniin to wx up ompletely the olusl surfes of the posterior teeth. The seond lortory step, however, proposes only to wx up the olusl surfes of the two premolrs nd the first molr in eh sextnt (Fig 7). The pltl spet of the mxillry nines my lso e wxed t this stge to etter selet the usp shpe nd inlintion in reltion to the olusl sheme seleted (eg, nine guidne or group funtion). In more omplex ses (shllow future nterior guidne), the tehniin my e oligted to wx up ll the ingul of the mxillry nterior teeth s well, to verify the dislusion of the posterior qudrnts in protrusion. Generlly, there is no need to wx up the mndiulr nterior teeth, sine they re often only minimlly ffeted the erosion. At ompletion of the posterior olusl wxup, the tehniin will frite eh qudrnt one key, mde of trnsluent silione (Elite Trnsprent, Zhermk). These keys will e used in the seond linil step introrlly to frite diret omposites, reproduing the wxup very losely. 138

12 VAILATI/BELSER d Fig 9 ( to d) Introrl preprtion of posterior mxillry sextnt diret onding proedure: The two premolrs nd the first molrs eh posterior qudrnt re ethed, nd priming nd onding gents re pplied. Cre is tken to isolte the djent teeth with mtries. Some modifitions of the wxup re susequently rried out to filitte the next linil step, ee produing the keys (Fig 8): The wx is refully removed from the ul nd the lingul surfes of the posterior teeth of the sts, so tht in turn eh key will e in lose ontt to the ervil spet of the teeth in the ptient s mouth. As onsequene, less exess resin omposite my flow into the gingivl sulus nd fewer introrl djustments will e neessry. The wx should lso e removed, if present, from the nines, sine they will serve s mesil stop to stilize the key introrlly. Step 2: Clinil posterior interim omposites The seond linil step silly onsists of the frition of posterior omposite onlys, diretly permed in the ptient s mouth, thnks to the speil trnsprent keys dupliting the olusl wxup. The two premolrs nd the first molrs of eh qudrnt re id-ethed, followed pplition of primer nd ond (Optiond FL, Kerr) (Fig 9). In the uthors experiene, even in ses of severe exposure of dentin, there is no need to nesthetize the ptient ee pplying the ething gent. The liniin will then lod eh trnsluent key with omposite, position it in the 139

13 Fig 10 ( nd ) Seond linil step: interim posterior omposite. The trnsluent silione key, dupliting the olusl wxup, is loded with resin omposite nd positioned in the mouth. The key is well stilized the nine nd the seond molr (mesil nd distl stops). Owing to the trnslueny of the silione, the omposite n e polymerized through the key. Fig 11 ( nd ) The posterior provisionl resin omposite is esily nd quikly frited, with miniml exess requiring removl. A omposite shde tht is slightly different from the remining dentition should e seleted to filitte the future removl of these provisionl restortions. e tht in this ptient the liniin hs filled the interproximl spes with teflon to redue exess resin omposite in the emrsures. Fig 12 ( nd ) Sine the seond molrs re not restored with interim resin omposite, they serve s vlule indition of the inrese of VDO, one the respetive sts re rtiulted. Fig 13 Even though the olusl ess to the interproximl res is loked the splinted posterior interim omposites, the gingivl emrsures re still open to llow lening with Superfloss. 140

14 VAILATI/BELSER ptient s mouth, nd polymerize the omposite through the key (Fig 10). Sine the keys, mde of trnsluent silione, re not s rigid s desired, it is ruil not to use too visous resin omposite (suh s Tetri EvoCerm, Ivolr Vivdent), or to lod the key exessively. To void distortion, the omposite should e pre-wrmed, nd miniml quntity of mteril should e pled in the key, just enough the new volume of the olusl surfes. At this stge, the seond molrs re not inluded in the olusl wxup, nor will they e restored with provisionl olusl omposite due to the following resons (Fig 12): to ssure the presene of stle distl olusl stop urte positioning of the trnsluent keys during the frition of the posterior interim omposites to knowledge the ft tht three posterior teeth re onsidered suffiient to estlish stle posterior support in eh sextnt to hve referene inditing the mount of inrese of VDO. Implementtion of this tehnique inludes splinting the three posterior teeth involved, thus loking the olusl ess of two interproximl ontts res nd preventing the use of dentl floss. Adequte orl hygiene, however, is possile sine the gingivl emrsures re kept open nd Superfloss n e used with lterl pth of insertion (Fig 13). As stted ove, the originl models of the ptient re mounted in MIP nd the inrese in VDO is deided on the rtiultor. Despite the ft tht the rtiultor's hinge xis is going to e different from the ptient's, in our experiene it does not generte suffiiently different olusl ontts on the omposite resin to require the mounting of the sts in CR. Minor olusl djustments should e expeted implementing this tehnique, ut normlly, if the wxup is orretly permed, nd the keys urtely frited nd positioned in the mouth, the time required the djustment is limited (Fig 14). In ddition, sine there is normlly no need to nesthetize the ptient, ontrol of the o- Fig 14 ( nd ) A different ptient, ee nd fter the seond step of the three-step tehnique. Miniml olusl djustments re expeted if the previous steps re permed orretly (eg, posterior olusl wxup, trnsluent key frition, loding of the keys). e tht the omposites do not extend to the ervil third of the teeth, thnks to the respetive modifitions of the wxup ee the key frition. The resulting visile trnsition step n e smoothed with polishing ruer wheel. 141

15 d Fig 15 ( to d) A 29-yer-old ptient ee nd fter the seond linil step of the three-step tehnique. Even in ses of extensive dentine exposure, dentl nesthesi is not required during this step. Fig 16 ( nd ) Close-up view of the previous ptient. Existing mlgm restortions n e removed (tooth 36) or left in ple nd overed with the interim resin omposite (tooth 26). 142

16 VAILATI/BELSER isl edge position, modifying the vestiulr usps of the posterior provisionl omposites. Finlly, their presene will filitte the olusl djustments of the finl restortions pled in the opposite qudrnt. The lortory tehniin ould deide to frite the ltter to the perfet m nd ll the olusl djustments ould e rried out on the opposite provisionl posterior omposites. The seond linil step hs een oneived to simplify the liniin s work, without ompromising the finl outome of the full mouth rehilittion. In this se, it ws deided not to ttempt to restore the nterior teeth with provisionl resin omposite. In the uthors experiene the inrese of VDO is well tolerted (euse miniml) the ptients even when n nterior open ite is reted temporrily. Some speeh impirments ould e ntiipted. However, ptients inmed ee tretment usully del very well with this prolem (Figs 17 to 19). Currently, there is no onsensus of the time neessry to test the omt of the ptient with respet to new, inresed VDO, nd eh liniin ppers to deide sed on personl opinion rther thn on lusion will e filitted nd onsequently more urte. This fixed olusl gurd hs the mjor dvntge tht the ompline of the ptient is 100% in terms of testing the inresed VDO. Sine no tooth preprtion is requested the frition of the posterior olusl omposites, the tretment n e onsidered ompletely reversile; if signs nd/or symptoms of temporomndiulr dysfuntion rise, the initil sttus ould e re-estlished grinding off the olusl omposites. These omposite onlys re ment to e provisionl, nd they will e repled (with finl omposite or ermi onlys) fter the nterior qudrnts re definitely restored (step 3 of the three-step tehnique) (Fig 15). This is one of the resons tht the use of ruer dm is not vitl during this prtiulr step, nd the removl of existing funtioning restortions (eg, old mlgm restortions) is not stritly required. Another dvntge of these interim omposites is their potentil modifition. After, exmple, ompletion of the restortion of the mxillry nterior teeth, it is still possile to djust the position of the olusl plne with respet to the new in Fig 17 ( nd ) Sme ptient s shown in Fig 12. After ompletion of the seond linil step the ptient is restored t n inresed VDO (). e the slight nterior open ite tht hs een generted. 143

17 Fig 18 ( nd ) Another exmple of ptient ffeted severe dentl erosion, restored ording to the three-step tehnique. At this stge the posterior qudrnts (exept the seond molrs) were restored with interim posterior resin omposite (seond linil step). d Fig 18 ( nd d) Frontl view t the new vertil dimension of olusion shown in Fig 18. Normlly, ptients who were inmed eehnd del well with the resulting nterior open ite. Fig 19 Close-up view of the previous ptient s right side. Initil sttus () nd fter the seond linil step (). The ptient underwent muogingivl surgery, whih reveled distint lss V lesions, previously loted slightly sugingivlly. 144

18 VAILATI/BELSER sientifi evidene. At the University of Genev, the protool suggests witing one month. This is ompletely ritrry nd experimentl hoie. One the ptient feels omtle nd neither signs nor symptoms of temporomndiulr dysfuntion pper, the eptne of the new VDO n e onfirmed, nd the third step (the retion of the nterior guidne) n e undertken. If the liniin is onerned out leving the ptient without nterior ontts nd thus without funtionl nterior guidne during the testing phse of the newly introdued, inresed VDO, the third step ould e initited more rpidly. Finlly, the tehniin will onentrte on the nterior teeth. Bsed on the degree of destrution, the pltl spet of the nterior teeth will e restored (diret or indiret resin omposites), representing the third nd lst linil step of the three-step tehnique. At this point the ptient will e stle from point of view of olusion. The only definitive restortions re the pltl reonstrutions. The vestiulr/inisl spets of the nterior mxillry teeth, s well s the reminder of the posterior teeth, still need to e treted mens of permnent restortions. Conlusions The three-step tehnique is strutured pproh to hieve full-mouth dhesive rehilittion with the most preditle result, the miniml mount of tooth preprtion, nd the highest level of ptient eptne. The gol of this tehnique is to temporrily restore ompromised dentition t new VDO, implementing diretly onded posterior omposite restortions. With stle posterior support, the nterior teeth n susequently e restored esily, gin using exlusively dhesive tehniques. One the nterior ontts nd n nterior guidne re re-estlished, the replement of the posterior provisionl resin omposites n egin. Owing to the presene of the provisionl posterior omposites, the fullmouth rehilittion n e plnned ording to qudrnt-wise pproh. Restoring ptient qudrnts hs enormous prtil dvntges oth ptient nd liniin, sine fewer ppointments re neessry. Neither multiple nestheti injetions nor diffiult full mouth impressions re required. Sine the ontrlterl prt of the mouth gurntees stle olusion, ptients feel omtle throughout the whole tive tretment phse up to the delivery of the finl restortions. In this rtile, the seond step of the three-step tehnique hs een disussed in detil, inluding the frition of the diretly onded provisionl posterior omposites. The restortive therpy of dentl erosion should e sed on minimlly invsive pproh, even in the se of extensive loss of tooth struture. Adhesive tehniques n help the liniin in rehilitting this type of ptient in the most onservtive mnner. Aknowledgments The uthors would like to thnk the lortory tehniins nd ermists Alwin Shönenerger, Ptrik Shnider nd Sylvin Criofo their enthusisti ollortion nd metiulous exeution of the lortory work presented in this rtile. 145

19 Referenes 1. Kvour V, Kourtis SG, Zoidis P, Andritskis DP, Doukoudkis A. Full-mouth rehilittion of ptient with ulimi nervos. A se report. Int 2005;36: Vn Roekel NB. Gstroesophgel reflux disese, tooth erosion, nd prosthodonti rehilittion: A linil report. J Prosthodont 2003;12: Bonill ED, Lun O. Orl rehilittion of ulimi ptient: se report. Int 2001;32: Hyshi M, Shimizu K, Tkeshige F, Eisu S. Restortion of erosion ssoited with gstroesophgel reflux used norexi nervos using ermi lminte veneers: se report. Oper Dent 2007;32: Aziz K, Zieert AJ, Co D. Restoring erosion ssoited with gstroesophgel reflux using diret resins: se report. Oper Dent 2005;30: Lussi A, Jeggi T, Shffner M. Prevention nd minimlly invsive tretment of erosions. Orl Helth Prev Dent 2004;2(Suppl 1): Sundrm G, Brtlett D, Wtson T. Bonding to nd proteting worn pltl surfes of teeth with dentine onding gents. J Orl Rehil 2004;31: Hstings JH. Conservtive restortion of funtion nd esthetis in ulimi ptient: se report. Prt Periodontis Aesthet Dent 1996;8: Vilti F, Belser UC. Full mouth dhesive rehilittion of severely eroded dentition: the three step tehnique. Prt I. Eur J Esthet Dent 2008;1: Sturt CE, Golden IB. The History of Gnthology. CE Sturt Gntologil Instruments. 1981;13 32, Grnger ER. Prtil Proedures in Orl Rehilittion. Phildelphi: Lippinott, 1962: MCollum BB. Fundmentls involved in presriing restortive dentl remedies. Dentl Items Interest,