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The International Journal of Periodontics & Restorative Dentistry

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135

Esthetic Rehabilitation of a Severely


Worn Dentition with Minimally Invasive
Prosthetic Procedures (MIPP)

Mauro Fradeani, MD, DDS*/Giancarlo Barducci, MDT**


Leonardo Bacherini, DDS***/Myra Brennan, DMD**** It has been suggested that the de-
cision to rehabilitate the severely
worn dentition should be guided
by the patient’s stated and per-
ceived esthetic and functional
Restorative treatment of the severely worn dentition is typically indicated to needs and the severity of wear, as
replace deficient tooth structure, limit the advancement of tooth destruction, determined by the morphologic
improve oral function, and enhance the appearance of the teeth. Minimizing changes and the potential for pro-
removal of additional tooth structure while also fulfilling the desire of patients
gressive wear.1 The aims of therapy
to have highly esthetic restorations can present a prosthetic challenge when
are to restore the jaw and tooth
the existing tooth structure is already diminished. This article presents a
relationships essential for occlusal
comprehensive minimally invasive prosthetic treatment approach using
a lithium disilicate all-ceramic material for the esthetic rehabilitation of
harmony,2 whereby the joint posi-
a severely worn dentition for a female patient diagnosed with Sjögren tion is located in centric relation
syndrome. (Int J Periodontics Restorative Dent 2012;32:135–147.) and the anterior teeth protect the
posterior teeth in eccentric move-
ments and conversely have the
posterior teeth protect the anterior
teeth in centric occlusion without
any deflective occlusal contacts or
interferences during function3; to
reduce tooth sensitivity; and to en-
hance the overall esthetic appear-
ance of the patient. The prosthetic
challenge with restoring severely
    *Private Practice, Pesaro, Italy. worn dentitions is to preserve as
   **Private Laboratory, Ancona, Italy. much of the already diminished
  ***Private Practice, Firenze, Italy. tooth structure as possible for
****Private Practice, Hingham, Massachusetts, USA.
retention while also providing
Correspondence to: Dr Mauro Fradeani, Corso XI Settembre 92, 61121 Pesaro, Italy; enough interocclusal space for the
fax: +39(0)721 32796; email: info@maurofradeani.it. restorative material.

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136

Vertical dimension of Ceramic system to that for porcelain-fused-to-metal


occlusion restorations, varying in thickness
Though traditional metal-ceramic from 1.2 to 1.5 mm axially and 1.5
Clinical procedures to improve the restorations have predictable to 2.0 mm occlusally.11 Presently,
mechanical retention of restora- strength and reasonable esthetics,7 new all-ceramic systems require a
tions for severely worn dentitions all-ceramic crowns have been re- lesser amount of tooth structure
typically consist of devitalizing the ported to have better optical to be removed because of the in-
pulp with endodontic therapy, in- properties and a superior gingival creased strength and improved
sertion of a post-and-core resto- response.8 The desire for improved light transmission properties of the
ration, and removal of bone and esthetics has advanced the devel- material. This ability to minimize
soft tissue with crown-lengthening opments of all-ceramic systems overall crown tooth preparations
surgery. Historically, increasing the and core materials, such as lithium with the selection of an all-ceramic
interocclusal space by altering the disilicate, aluminum oxide, and zir- material promotes the preservation
vertical dimension of occlusion conium oxide.9 A review of the liter- of the enamel tooth structure and
(VDO) was not a commonly used ature on treatment considerations dentoenamel junction, which has
treatment modality because it was for esthetic restorations reported a significant role in redistributing
formerly thought that the rest posi- that longitudinal clinical studies stress and resisting enamel crack
tion of the mandible was fixed and evaluating glass-ceramic crowns propagation.12
not able to be altered.4,5 Moreover, have shown similar success rates to
sometimes it may not be possible conventional metal-ceramic crowns
to significantly alter the VDO be- of 94% over 10 years.10 There is no Silica-based ceramic system
cause tooth eruption can occur at evidence to support the selection and adhesive bonding
the same rate as tooth wear, and of only one ceramic system or ma-
the VDO of the patient can remain terial for all clinical cases. The se- With respect to the various core
unchanged. However, if the erup- lection of an appropriate ceramic material ceramic systems avail-
tion does not keep pace with tooth system, whether metal-ceramic or able, silica-based glass-ceramics,
wear, the VDO may decrease over all-ceramic, depends on several unlike alumina- and zirconia-based
time.6 Regardless, in the presence clinical criteria, such as the location ceramics, can be acid etched to in-
of a worn dentition with or without and type of the restoration, color crease the intaglio surface area and
signs of altered passive eruption, of the tooth preparation, the de- surface roughness and improve the
there is still the need to maintain as sired color of the restoration, con- mechanical interaction with adhe-
much of the remaining tooth struc- figuration of the remaining tooth sive resin cements.13 This results in
ture as possible and attempt to al- structure, design of the marginal a stronger resin bond for higher re-
ter the VDO to create space for the finish line, and the luting agent tention, better marginal accuracy to
restorative material prior to tooth and cementation technique. The prevent microleakage, and greater
preparation. This would be benefi- minimum amount of tooth structure fracture resistance of the restora-
cial to avoid the aggressive reduc- removed and the tooth preparation tion and tooth.14 Nevertheless, with
tion of tooth structure and preserve design required to achieve optimal bilayered all-ceramic restorations,
the maximum amount of enamel. physical and optical properties of cohesive fracture within the veneer-
the restoration also can vary be- ing porcelain and adhesive fracture
tween ceramic systems.9 The tooth of the ceramic core material have
preparation depth for most tradi- been the most commonly reported
tional all-ceramic systems is similar clinical complications.8

The International Journal of Periodontics & Restorative Dentistry

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137

Lithium disilicate disilicate ceramic needed to be in


occlusion with respect to fracture re-
A monolithic silica-based ceramic sistance? Is it possible to reduce the
material was introduced in 2005 as overall ceramic thickness to a range
IPS e.max (Ivoclar Vivadent), for- of 0.8 to 1.0 mm? The manufacturer
merly IPS Empress 2, with enhanced reports that a 0.8-mm thickness for
physical properties and translucen- the core and 0.7-mm thickness for
cy through a different firing pro- the veneering material are required
cess.15 It can be pressed or milled when using a bilayered modal-
using computer-aided design/ ity, or a minimum of 1.5 mm for a
computer-assisted manufacturing, monolithic lithium disilicate restora-
allowing for a traditional occlu- tion. However, if the final fracture
sal surface reduction of 1.5 mm,16 resistance is related to the use of
which can be reduced to 0.8 mm the lithium disilicate material (ap-
if additional veneering porcelain is proximately 400 MPa), it could be
layered over the coping.17,18 The re- hypothesized that the addition of
sults of an in vitro study comparing a veneering layer (approximately
the fracture frequency of monolith- 100 MPa) may not significantly in-
ic pressed crowns fabricated from crease the fracture resistance of
leucite glass (IPS Empress) and the overall restoration. As such,
lithium disilicate (e.max) and luted the use of the monolithic material
with glass ionomer or adhesive in occlusion with a full-contour de-
resin cements reported no fractures sign, even with reduced thickness
or cracks observed for the lithium (0.8 to 1.0 mm), may provide suffi-
disilicate crowns.19 cient strength, even in the posterior
areas.
Posterior occlusion on monolithic Is it possible to leave the lith-
lithium disilicate ium disilicate ceramic material in
According to the manufacturer, occlusion without causing exces-
there are two modalities used to sive wear of the antagonist tooth
fabricate e.max all-ceramic res- or restoration? The literature shows
torations: full-contour lithium di- that the behavior of dental materi-
silicate (monolithic ceramic) with als is associated with some specific
a 1.5-mm-thick occlusal dimen- factors and mechanisms that are
sion without the need for veneer- not yet well identified. However,
ing porcelain and fabrication of a recent clinical studies investigat-
lithium disilicate coping (minimum, ing the enamel wear of monolithic
0.8 mm) covered with veneering lithium disilicate demonstrate that
porcelain (maximum, 0.7 mm). it seems to be within the range of
More research is needed to normal enamel wear.20
investigate the potential capabili-
ties of this ceramic material. What
is the minimum thickness of lithium

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138

MIPP: Key elements Case presentation matrix was fabricated and the fi-
nal composite resin mock-up was
The minimally invasive prosthetic A 38-year-old woman presented performed prior to the initial tooth
procedure (MIPP) is a compre- to the first author’s clinic stating preparation to evaluate function
hensive treatment modality rec- that she was unhappy with the ap- and esthetics (Fig 3). Subsequent-
ommended especially in cases of pearance of her teeth and she ex- ly, an impression of the two arches
severely worn dentition involving perienced difficulty in chewing and with the composite resin mock-up
the following procedures: sensitivity to cold. She was diag- was taken using irreversible hydro-
nosed with Sjögren syndrome and colloid (Jeltrate, Dentsply/Caulk)
• Increase of the VDO. In exten- was being treated with cortisone to fabricate the provisional acrylic
sive rehabilitations, alteration and azathioprine. In the clinical in- resin restoration. Tooth preparation
of the VDO is possible if the terview regarding her expectations was performed with the appropriate
restorative treatment plan in- to improve her smile, she empha- burs to achieve overall reductions
volves at least one arch. The sized her desire to have highly es- of 0.8 mm occlusally and 0.4 to
interocclusal space gained en- thetic restorations without the use 0.6 mm axially (Fig 4). Tooth struc-
ables the clinician to reduce of metal. A thorough clinical oral ex- ture removal on the occlusal sur-
the occlusal tooth preparation amination and radiographic evalua- face was limited to only 0.3 mm in
depth and to maintain tooth tion were performed. There were no the posterior teeth because 0.5 mm
structure and vitality. adverse findings during the muscu- of space was gained in both arches
• Minimally invasive tooth prepa- loskeletal examination. Significant by increasing the VDO by 1 mm
ration. The goal is to reduce intraoral findings included gener- posteriorly. Therefore, 0.8 mm of
tooth structure removal, espe- alized moderate-severe erosion of occlusal clearance was achieved
cially in the occlusal area, to cre- the cervical, midfacial, anterior inci- for the use of the monolithic mate-
ate a restoration with a thickness sal, and posterior occlusal surfaces; rial. As a result, it was also possible
not exceeding 0.8 to 1.0 mm caries lesions; minimal plaque ac- to maintain most of the remaining
and to preserve more enamel cumulation; and low salivary flow enamel on the abutment previously
surfaces along the axial walls and (Fig 1). It was proposed to increase built with the composite resin re-
the light chamfer finish line for a the incisal length of the maxillary construction (Fig 5). The finish line
superior bond over dentin.21 anterior incisors, together with al- on the cervical area was positioned
• Monolithic lithium disilicate pos- teration of the VDO 3 mm anteriorly. in the sulcus (intracrevicular prepa-
terior restorations. It is hypoth- These modifications were evaluated ration) to optimize the esthetic re-
esized that a monolithic lithium with a direct mock-up in the anterior sult and to include any possible
disilicate material with a re- segment using a flowable composite existing tooth structure deficiency
duced thickness (0.8 to 1.0 mm) resin material (Systemp Flow, Ivoclar in the restoration design. The shell
can be used with a full-contour Vivadent) (Fig 2). The initial study of the provisional restorations was
design for partial- and full- casts were mounted at the new fabricated at the new VDO with the
coverage restorations without VDO on a semiadjustable articulator modified indirect technique, then
adding veneering porcelain. (Denar Mark II, Denar) using an ar- relined and cemented temporarily
• Bonding the restorations. Ad- bitrary facebow transfer and poste- with zinc oxide noneugenol cement
hesively bonding the restora- rior wax (Beauty Pink, Moyco Union (Freegenol, GC Dental). The pa-
tions, mainly in enamel with an Broach), and the diagnostic wax-up tient’s comfort, speech, and appear-
etchable ceramic material, is was completed in accordance with ance were reassessed after 1 month,
likely the key element for the the clinical findings. After duplicat- and the final impression was fabri-
success of this restoration. ing the wax-up, the transparent cated. After placement of double

The International Journal of Periodontics & Restorative Dentistry

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139

Figs 1a to 1c    Preoperative clinical


photographs of a 38-year-old woman with
Sjögren syndrome. Erosion and caries le-
sions with different degrees of tissue loss
were evident throughout the dentition.

Figs 2a and 2b    Anterior direct mock-up allowed the clinician to evaluate the amount of increase in VDO that would have to be performed
to fulfill the esthetic and functional needs of the patient.

cord in the sulcus (Ultrapack, Ultra- nique (Fig 6). Then, an intraoral
dent), the final impression was taken facebow and centric relation records
with a polyether material (Impregum were taken at the new VDO such
Penta Duo Soft, 3M ESPE) using a that the stone cast replicas of the
light-activated custom tray (Palatray provisional restoration were able to
LC, Haraeus Kulzer) and the single- be cross-mounted with the master
impression double-mixing tech- cast of the tooth preparation.

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140

Fig 3    Transparent matrix obtained from


the wax-up filled with light-curing compos-
ite resin.

1.5–2.0 mm

0.8–1.0 mm

1.5–2.0 mm

Figs 4a to 4c    Once the volume of the final restoration was defined by the complete mock-up, the preparation of teeth for the definitive
crown could be performed with calibrated burs to achieve an occlusal reduction of (a and b) 1.5 to 2.0 mm in the incisal aspect of the
anterior teeth and (c) 0.8 to 1.0 mm in the occlusal aspect of the posterior teeth.

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141

Figs 5a and 5b    A very light chamfer preparation was performed, slightly deepening the margin in the intrasulcular position. Note the
minimum preparation thickness and remarkable maintenance of enamel.

Figs 6a and 6b    Occlusal view of the final preparation. Note the minimum amount of tooth reduction performed.

Adhesive cementation vicular fluid and to act as a barrier onds, thoroughly rinsed with water,
for the penetration of the resin ce- and put in an ultrasonic bath with
Cementation followed a precise pro- ment to the base of the sulcus. The distilled water for 3 minutes. After
tocol. Retraction cords were placed inner surfaces of the restorations thorough air drying, the intaglio
in the sulcus of every abutment to were etched with hydrofluoric acid surface was silanized (Monobond-
minimize the humidity from the cre- 4.5% (Ivoclar Vivadent) for 20 sec- S, Ivoclar Vivadent) and dried for

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142

Figs 7a and 7b    Finished and polished lithium disilicate restorations.

Figs 8a and 8b    Occlusal view after cementation.

60 seconds (Fig 7). Tooth prepara- tions, and teeth were coated with
tions were cleaned with pumice and the adhesive system (Syntac, Ivo-
rubber burs (Opticlean, KerrHawe), clar Vivadent), and because of the
etched for 30 seconds on enamel reduced thickness of the ceramic
and 10 seconds on dentin with restoration, a light-polymerized
37.5% phosphoric acid (Ultra-Etch, composite resin cement (Variolink
Ultradent Products), rinsed, and II, Ivoclar Vivadent) was selected to
dried. Both fitting surfaces, restora- lute the restorations (Figs 8 and 9).

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143

b
Figs 9a and 9b    (a) Initial and (b) final full-mouth radiographs. The ultraconservative MIPP approach
guaranteed the maintenance of vitality of all the teeth.

Discussion calcium phosphate ions; less sa- is a complex and challenging condi-
liva predisposes patients to car- tion for the dentist to diagnose and
Sjögren syndrome has been proven ies, especially on smooth surfaces manage.22 There is no evidence in
to be a progressive disease, since that are usually well protected. Sa- the literature that suggests pros-
patients have shown deteriorat- liva contains antimicrobial proteins thetic treatment for this type of
ing lacrimal and salivary secretion and immunoglobulins that help to patient and no indication whether
over time. Saliva is protective of limit the adherence and growth of a complete-coverage restoration
enamel by its supersaturation with plaque bacteria. Sjögren syndrome design can reduce the incidence

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144

Figs 10a and 10b    The final result shows a satisfactory biologic, functional, and esthetic integration of the full-mouth rehabilitation.

Figs 11a and 11b    Anterior guidance shows a correct disclusion of posterior teeth.

of caries in long-term follow-up. case.23 It is sensible and beneficial with a reduced thickness (0.8 mm)
Since patients with this condition to maintain pulpal vitality and pre- was used for the posterior teeth.
are at a higher risk for caries, they vent endodontic treatment and the Monolithic glass-ceramic struc-
need to be seen more regularly need for a post-and-core restora- tures offer some distinct ad-
for examinations, given preventive tion because these more invasive vantages in that they provide
treatment such as home fluoride approaches violate the biome- exceptional esthetics without re-
regimens to follow, and maintain chanical balance and compro- quiring a veneering ceramic (Figs
excellent oral hygiene that should mise the performance of restored 10 to 12). Therefore, by eliminating
be regularly reinforced by the teeth over time.24 An all-ceramic the veneered ceramic and using
dental practitioner. layered material over a lithium di- only a 0.8-mm-thick core mate-
Maintenance of tooth struc- silicate coping (e.max Press) was rial with 360 to 400 MPa of flexural
ture is the approach that guides chosen to achieve high esthetics in strength, greater structural integrity
the dentist during treatment, es- the anterior teeth, and the mono- can be achieved with minimal re-
pecially in this particular clinical lithic form of this ceramic material moval of tooth structure.

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145

Figs 12a to 12d    Appropriate function helped maintain the integration achieved after 3 years of service.

There is a lack of data on the ence on the fatigue resistance of studies comparing different mate-
selection of the appropriate mate- such thin (0.8-mm thick), nonreten- rials suggest that lithium disilicate
rial, specifically regarding the influ- tive restorations. However, recent seems to be more effective when

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146

it is fabricated in its monolithic Wear of enamel caused by a References


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147

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