Combining Traditional and Adhesive Dentistry To Reconstruct The Excessively Worn Dentition

CLINICAL APPLICATION pyrig
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Combining Traditional and ss e n c e
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Adhesive Dentistry to Reconstruct

the Excessively Worn Dentition
Basil Mizrahi, BDS, MSc, MEd

Clinical Lecturer, UCL Eastman Dental Institute, London
Specialist in Prosthodontics and Restorative Dentistry, Private Practice, London
Fellow, American College of Prosthodontics
Correspondence to: Dr Basil Mizrahi

39 Harley Street, London, W1G 8QH, United Kingdom
phone: 44 (0) 20 7436-3194; fax: 44 (0) 20 7323-1679; e-mail: info@basilmizrahi.co.uk; website: www.basilmizrahi.co.uk
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 • NUMBER 3 • AUTUMN 2008
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Abstract ss e n c e
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Adhesive dentistry has changed the face of creasing trend of young to middle-aged
traditional dentistry and has the potential to patients presenting with advanced gener-
improve esthetics and reduce tooth prepa- alized tooth surface loss. These dentitions
ration. However, the materials and tech- are conducive to treatment that combines
niques used in adhesive dentistry are gen- traditional and adhesive materials and
erally more technique sensitive than those techniques. This article discusses guide-
used in traditional dentistry. It is, therefore, lines for treatment of these dentitions and
important that strict guidelines and proto- outlines the clinical treatment involved in
cols are followed to ensure long-term suc- the full-mouth rehabilitation of a worn den-
cess. Clinicians must be able to determine tition using a combination of all-ceramic
where adhesive techniques and materials crowns, porcelain and gold onlays, and
can be used and where traditional, biome- porcelain veneers.
chanically sound techniques and materials
should be used. There appears to be an in- (Eur J Esthet Dent 2008;3:270–289.)
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The advent of adhesive dentistry has rev- teeth, which is contraindicated in ss e n c e
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olutionized dentistry. As macromechanical ready worn down tooth surface. Alterna-
features are not as important as in tradi- tively, the vertical dimension of occlusion
tionally cemented restorations, tooth (VDO) can be increased, and this is usual-
preparation can be greatly reduced.1 How- ly the preferred method of treatment in
ever, there is a danger of placing exceed- dentitions with advanced generalized tooth
ingly high expectations on adhesive wear.
restorations and foregoing basic, sound To increase the VDO, traditional den-
biomechanical principles. Compromises tistry would require crowning of the poste-
can be made when carrying out simple rior teeth. However, adhesive onlays offer
dentistry on individual teeth. However, in a far more conservative approach. An
complex dentistry involving multiple teeth, added advantage is that despite the ex-
early failure of individual units may jeop- cessive wear, there is normally a wide rim
ardize the overall long-term success of the of enamel on the posterior teeth, which has
entire treatment. Having spent an exces- been shown to be important in long-term
sive amount of time, effort and money on success of bonded porcelain restora-
a complex treatment, long-term success is tions.5,6
a prerequisite for both patient and dentist Despite the fact that the VDO is being in-
satisfaction. creased, it is usually necessary to carry out
The optimal solution is to find the correct some minor occlusal reduction of the pos-
indications for adhesive restorations so that terior teeth to allow for adequate thickness
tooth reduction can be reduced without ex- of restorative material. In addition, unlike
cessively jeopardizing the longevity of the porcelain veneers, it is extremely difficult to
tooth/restoration. The success of adhesive create a totally invisible margin on the la-
restorations, in particular ceramic onlays, is bial surface of the tooth and patients
multifactorial and reasons for failure include should be made aware of this before the
secondary caries, fracture, marginal defi- start of treatment. The reason for this is the
ciencies, wear, and postoperative sensitivi- greater thickness of the onlay margin re-
ty. However, when used with the correct in- quired compared with the veneer margin.
dications and techniques, ceramic onlays This esthetic limitation is not normally a
can be a successful long-term restoration.2–4 concern on posterior teeth and is out-
Treatment of a dentition showing excessive weighed by the biologic advantage of re-
generalized tooth wear is one such indica- duced tooth preparation.
tion where a combination of adhesive and On second molar teeth, where esthetics
conventional macromechanical restora- is not usually a concern and space is at a
tions may offer an optimal solution. premium, metal adhesive onlays can be
In patients with excessive generalized used. Metal is able to better withstand the
tooth wear, the teeth are often caries free high occlusal forces generated in the pos-
with minimal or no restorations present. In terior area and requires less occlusal thick-
order to restore the worn tooth surfaces, ness than porcelain.
space needs to be created for the restora- On the maxillary anterior teeth, besides
tive material. This can be achieved by the aspect of controlling the occlusion and
preparing the occlusal surfaces of the increasing the VDO, esthetic considera-
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tions need to be taken into account. Un- cantly lower level than ss e n c e
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sightly appearance of the anterior teeth is sors.10 It, therefore, appears that 2 mm is the
usually a primary presenting concern of optimal incisal-edge porcelain that should
these patients, and although palato-incisal be present when building up mandibular
build up of these teeth7,8 would address the incisors.
aforementioned occlusal aspects, the
tooth–restoration junction high up along
the worn labial surface of the teeth would Case report
be esthetically unacceptable to most pa-
tients. For this reason, full-coverage crowns The following treatment illustrates the use
are normally the restoration of choice in of a combination of adhesive onlays,
treatment of advanced generalized tooth porcelain veneers and full-coverage
wear. Although this may appear to be an crowns to restore a dentition with ad-
aggressive option, the reality is that mini- vanced generalized tooth wear.
mal tooth preparation is required, as these The patient was a healthy 29-year-old
worn teeth usually need to be built up labi- male whose main complaint was the ap-
ally, incisally, and palatally. pearance of his worn front teeth, which he
Another reason for using full-coverage felt had been gradually getting worse over
crowns is that diagnostic provisional the years. He was also aware that his pos-
crowns can be used for an extended terior teeth were severely worn and were
period of time prior to placing the final becoming increasingly sensitive.
crowns. This is an essential requirement On examination there was evidence of
in these dentitions, where there is usually advanced tooth wear on the occlusal sur-
occlusal instability and many of the es- faces of the posterior teeth, the palatal and
thetic landmarks have been lost. A stable, incisal surfaces of the maxillary anterior
esthetic, and well-functioning anterior teeth, and the incisal edges of the
guidance needs to be established in pro- mandibular anterior teeth (Figs 1 to 6 ). The
visional restorations and tested prior to teeth showed signs of all three compo-
placing the definitive restorations. Long- nents of wear, as follows:11
term, diagnostic, modifiable provisional I Erosion – acid attack of tooth structure:
restorations are not possible with palato- – Saucerized cupping of palatal sur-
incisal veneers. faces of maxillary incisors, occlusal
On worn mandibular anterior teeth, and/or palatal surfaces of posterior
where the opposing surface is porcelain, teeth, and buccal surfaces of anterior
incisolabial porcelain veneers offer a good or posterior teeth
restorative solution. Wall et al showed that – Teeth appear shiny when erosion is
mandibular incisal length can be in- active
creased by 2 mm without significantly re- – Metal restorations protrude from
ducing the fracture resistance of either the tooth tissue.
tooth or the tooth–veneer complex. In a 9
I Attrition – excessive contact between
similar study, Wylie et al showed that occlusal surfaces of the teeth:
mandibular incisors restored with <1 mm – Mandibular and maxillary teeth
of incisal porcelain fractured at a signifi- affected simultaneously
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– Even contact between worn enamel, it was important that any treatment
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mandibular and maxillary teeth plan included coverage of the exposed
in excursive movements dentin surfaces, which would otherwise
– Flattening of the entire tooth surfaces. continue to be eroded at an increased rate.
I Abrasion – excessive contact between The secondary aims were to reduce the
tooth and a physical agent: tooth sensitivity and to improve the esthet-
– Wear on buccal aspect of teeth that ic appearance of the patient’s smile.
corresponds with agent, for example Following detailed clinical recording, it
toothbrush. was decided that the optimal way to
achieve these aims was to increase the
The teeth were generally not heavily re- VDO and restore the worn surfaces of all
stored, with small one- and two-surface the teeth except the wisdom teeth. Unfortu-
amalgams present. There was an existing nately, the patient would not consent to ex-
gold crown on tooth 36, and a large com- traction of the wisdom teeth prior to treat-
plex amalgam on tooth 26 that showed ev- ment and these were left untreated and
idence of marginal breakdown and leak- earmarked for extraction sometime in the
age (Fig 5). future.
A discrepancy was noted between cen- The treatment plan was carried out us-
tric relation and centric occlusion, with ing a combination of porcelain crowns, ve-
centric occlusion being slightly forward of neers and onlays, and gold onlays. The use
centric relation. There was no evidence of of adhesive onlays on the posterior teeth
anterior guidance or posterior disclusion offered a more conservative approach than
during excursive movements. traditional full-coverage crowns. Simple
On questioning, the patient admitted that placement of direct adhesive restorations
in the past he had a high intake of sugary over the exposed dentin surfaces would
soft drinks and alcohol, but he had adopt- not have allowed control of the occlusion,
ed a far healthier eating pattern in recent and because of their limited longevity,
years. He was also aware that he “ground would have required continual replace-
his teeth at night.” He was given dietary ment and caused ongoing occlusal insta-
counseling, instructed in correct tooth bility.
brushing technique, and advised that he
should wear a night-time occlusal splint Diagnostic build up
following treatment. An initial and simple waxup of the maxillary
The primary aim of treatment was to and mandibular anterior teeth at an in-
create a mutually protected occlusion creased VDO was carried out on study
where the posterior teeth would prevent casts mounted in centric relation. Only the
excessive contact of the anterior teeth in palatal and incisal surfaces of the maxillary
maximum intercuspation and the anterior teeth and the incisal edges of the mandibu-
teeth would disengage the posterior teeth lar teeth were built up.
12
in all mandibular excursive movements. At this early stage, the waxup was em-
This occlusal scheme is designed to pre- pirical and based on supposed restora-
vent further wear of the teeth. As the wear tive and esthetic requirements (Fig 7).
had already penetrated the protective This waxup was then duplicated in resin
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Fig 1 Anterior unretracted preoperative view. Fig 2 Anterior retracted preoperative view.
Fig 3 Right lateral preoperative view. Fig 4 Left lateral preoperative view.
Fig 5 Maxillary occlusal preoperative view. Note cup- Fig 6 Mandibular occlusal preoperative view.
ping of dentin and severe erosion of palatal surfaces of
anterior teeth.
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Fig 7 Initial waxup of anterior teeth at arbitrarily in- Fig 8 Light curing of resin composite inserted in a
creased VDO. clear silicone stent made on the waxup and seated
onto the maxillary anterior teeth.
Fig 9 Mandibular silicone stent in place prior to com- Fig 10 Completion of resin composite build up of
mencement of direct resin composite build up. maxillary and mandibular teeth. Note the separation of
posterior teeth.
Fig 11 Mandibular posterior bite splint worn by the Fig 12 Initial preparation of maxillary anterior teeth
patient. for initial chairside temporary crowns.
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composite directly in the mouth using ments are to be made over a period ss e n c e
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custom-made matrices of the waxup time.14 Further refinements of the esthetic
(Figs 8 to 10). A removable mandibular appearance and occlusal scheme were
posterior flat bite splint was given to the made over a period of time, and the maxil-
patient to wear for comfort and to main- lary anterior tooth preparations were final-
tain the space created between the pos- ized. The patient now had maxillary anterior
terior teeth (Fig 11). The composite temporary crowns opposing mandibular
buildups were adjusted to provide a anterior composite buildups and a mandi-
comfortable VDO and anterior guidance bular posterior bite splint (Fig 13).
as well as an esthetically pleasing maxil-
lary incisor length. The patient appeared Definitive waxup and
to tolerate this increased vertical dimen- anterior provisional crowns
sion and anterior guidance well over a Once the incisal edge position and VDO
period of about 2 months. had been established and the anterior
tooth preparations had been finalized,
Anterior tooth preparation and maxillary and mandibular, irreversible
initial chairside temporary crowns hydrocolloid impressions were made with
Following this early stage of assessment the temporary crowns in place. At the
and adaptation, the maxillary anterior teeth same appointment, a polyvinylsiloxane im-
were prepared for initial, chairside, acrylic pression was made of the six maxillary an-
resin, temporary crowns (Fig 12). These terior tooth preparations (Fig 14). Jaw rela-
temporary crowns were based on the com- tionship records (JRR) at the new VDO
posite buildups carried out in the previous and a facebow recording were made.
stage. The temporary crowns were made In the laboratory, a full-mouth definitive
from acrylic resin (methylmethacrylate), diagnostic waxup, based on information
which is the preferred material when adjust- obtained from the maxillary temporary
Fig 13 Maxillary initial temporary crowns opposing Fig 14 Maxillary polyvinylsiloxane impression for
mandibular composite buildups. laboratory processed provisional crowns.
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Fig 15 Maxillary definitive waxup. Fig 16 Mandibular definitive waxup.
Fig 17 Silicone putty preparation guide. Fig 18 Silicone putty matrix for fabrication of chair-
side temporary onlays.
Fig 19 Acrylic resin provisional restorations in place Fig 20 Palatal aspect of laboratory-processed provi-
on cast of tooth preparations. sional crowns.
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Fig 21 Laboratory-processed acrylic

resin provisional crowns in situ. Note
multichromatic layering and natural
morphology.
crowns and the mandibular composite The advantages of making a secondary

buildups, was carried out (Figs 15 and 16). set of definitive, laboratory-processed pro-
Two sets of silicone matrices were made visional crowns include strength, margin-
on these waxups. One set was sectioned to al accuracy, and occlusal and esthetic
be used intraorally for tooth preparation precision. These definitive provisional
guides (Fig 17). The other set was to be crowns are based on information ob-
used for making the posterior, chairside tained from the initial temporary crowns
temporary restorations (Fig 18). Definitive as well as the definitive diagnostic waxup,
acrylic resin, provisional crowns based on and should be blueprints of the final
this waxup were then processed on the crowns (Fig 21). Their precise marginal fit
preparations of the maxillary anterior teeth and contour allow for optimum gingival
(Figs 19 and 20). health, which, in turn, contributes to the
Fig 22 Existing amalgam restorations prior to Fig 23 Reinforced glass-ionomer bases were placed.
removal under rubber dam.
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success of the future final impression. worn teeth there is often a wide, long ss e n c e
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These provisional crowns were cemented tact area, stretching from the gingivae to
in place with a non-eugenol containing the occlusal surface, and breaking the con-
temporary cement (TempBond NE, Kerr, tact point would result in excessive tooth
USA). removal. If the contact point/area is not bro-
ken, care must be taken when making the
Posterior tooth preparation impression that the entire margin is cap-
and temporization tured accurately. One way of overcoming
Once the anterior provisional crowns were this is by placing a thin piece of mylar strip
in place, preparation and temporization of between the teeth when the impression is
the posterior segments was carried out. For made.16
reasons discussed earlier, the premolar In areas where there was exposed
and molar teeth were prepared for ceram- dentin and no glass ionomer was present,
ic onlays and the second molar teeth were immediate dentin sealing was carried out
prepared for adhesive gold onlays. Tooth as described by Magne.17 The silicone ma-
36 had a previous crown gold crown and trices were utilized for the provisional on-
was prepared for a new metal-ceramic lays, which were made from acrylic resin
crown. and cemented in place with a polycarboxy-
The existing amalgam restorations were late cement for additional retention (Figs 26
removed and replaced with a restorative and 27).
glass ionomer (Ketac Molar, 3M ESPE), The mandibular bite splint was modified
which would serve as a base for the defin- to maintain opposing tooth contact and
itive porcelain onlays (Figs 22 and 23). comfort between appointments.
The posterior sextants were prepared Preparation of the porcelain veneers on
and temporized over four separate appoint- the mandibular anterior teeth was delayed
ments with the help of the silicone matrices until the time the impression was taken to
prepared on the waxup (Fig 24). The tooth minimize the amount of time the patient
preparation for porcelain onlays allowed for would need to spend with provisional ve-
2 mm of occlusal porcelain and was neers, which are notoriously unpredictable.
smooth and rounded with no sharp angles At the end of this stage, the maxillary an-
to create internal stresses on the porcelain. terior teeth contained provisional crowns,
Definitive and smooth deep chamfer mar- the mandibular anterior teeth contained
gins of about 1 mm were prepared to pro- resin composite buildups, and the posteri-
vide an adequate bulk of porcelain for or teeth contained chairside provisional
strength.15 The preparations for the adhe- restorations (Figs 28 and 29).
sive gold onlays allowed for 1 mm of oc-
clusal gold. The margins were prepared Impression 1
with a 0.5 mm deep chamfer (Fig 25). For ease of management, it was decided to
When preparing occlusal onlays, better complete the full-mouth restoration in seg-
morphology and a more harmonious tran- ments rather than simultaneously.
sition between tooth and restoration can be The position and relationship of the an-
created if the preparation margins are car- terior teeth determine the esthetics and
ried below the contact point. However, in occlusal function, and are key factors in
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Fig 24 Utilization of silicone preparation guide. Fig 25 Porcelain and adhesive gold onlay prepara-
tions.
Fig 26 Silicone matrix filled with acrylic resin in place Fig 27 As yet untrimmed provisional onlays from sil-
over tooth preparations. icone matrix.
Fig 28 Maxillary arch with anterior provisional Fig 29 Mandibular arch with anterior composite
crowns and posterior provisional onlays. buildups and posterior provisional restorations.
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determining the posterior tooth morphol- gold onlays. The anterior provisional
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ogy and occlusal scheme. As such, the crowns, which were to be blueprints of the
establishment of the correct maxillary in- definitive crowns, were left in place for this
cisal edge position and incisal guidance impression (Fig 33).
should precede any definitive posterior JRRs were made at the desired VDO
18
restorations. provided by the anterior provisional
In this treatment it was decided to define crowns. Lateral and protrusive JRRs and a
the anterior guidance by completing the facebow recording were also made.
mandibular anterior porcelain veneers Despite the complexity of the treatment
against the definitive maxillary anterior pro- and the occlusal reconstruction, it was
visional crowns. A custom anterior guid- deemed acceptable to use a semi-ad-
ance table was used to replicate the ante- justable articulator as opposed to a fully
rior guidance created in the provisional adjustable articulator and pantographic
19
stage. In order to prevent loss of the VDO tracing for the following reasons:
occurring due to wear of the maxillary pro- I The anterior guidance had been deter-
visional crowns against the mandibular mined intraorally on the provisional
porcelain veneers, it was decided to fabri- crowns and could be replicated in the fi-
cate and cement the definitive gold onlays nal restorations using a custom anterior
on the four opposing second molar teeth guidance table.
at the same time. I The JRRs were taken at the desired
For the definitive impressions, a one- VDO and no change of VDO was re-
stage, two-phase impression technique quired on the articulator.
was used. Heavy-body (polyvinylsiloxane) I Lateral and protrusive JRRs allowed set-
impression material was placed in a cus- ting of the posterior elements on the ar-
tom tray and light-body material syringed ticulator.
around the preparations.
In the mandibular arch, the porcelain ve- In the laboratory, a feldspathic porcelain
neers were prepared and an impression (Vintage Halo, Shofu) on refractory dies
was made of the anterior six teeth and teeth was used for construction of the mandibu-
37 and 47 for bonded gold onlays. For the lar veneers. The porcelain onlays were fab-
veneers, tooth preparation with a bur did ricated using a leucite-reinforced glass ce-
not penetrate the contact points, but these ramic (IPS Empress Aesthetic, Ivoclar
were opened minimally with an ultra thin Vivadent). A cutback and layering tech-
diamond disk. This allowed accurate cap- nique was used (Figs 34 and 35).
ture of the marginal detail in the impression The gold used for the onlays was a type
(Figs 30 and 31). Following the mandibular 3 high-noble gold (Jensen JRVT, Jensen
impression, nonremovable shrink-fit bis- Industries). It was heat treated at 450°C for
acryl (PreVISION CB, Hereaus Kulzer) pro- 15 minutes to allow the formation of an ox-
visional restorations were made directly on ide layer and facilitate adhesive bonding.
20
the veneer preparations (Fig 32). It has been shown that heat treatment of
In the maxillary arch a definitive impres- the gold surface provides superior bond
sion was made of the bilateral posterior strength compared with sandblasting and
sextants for the adhesive porcelain and tin plating.21
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Fig 30 Mandibular anterior teeth prepared for porce- Fig 31 Mandibular polyvinylsiloxane impression of
lain veneers. Note slight separation of teeth accom- anterior teeth and teeth 37 and 47. Note no tearing of
plished with diamond disk to allow accurate capture of impression material between anterior teeth due to inter-
margins in impression. proximal disking.
Fig 32 Shrink-fit bis-acryl provisional veneers in Fig 33 Maxillary arch ready for impression of pos-
place, opposing provisional maxillary acrylic resin terior teeth.
crowns.
Fig 34 Mandibular porcelain veneers and gold onlays Fig 35 Maxillary porcelain and gold onlays on work-
on working cast. The teeth in-between the restorations ing cast.
have been waxed up to their planned definite shape.
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Cementation 1 The maxillary arch now contained ss e n c e
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Following try-in and prior to bonding, the sional crowns on the anterior teeth and the
porcelain surfaces were treated according definitive porcelain and gold onlays on the
to the protocol outlined by Magne, as fol- posterior teeth. In the mandibular arch, the
lows:22 anterior teeth contained porcelain veneers,
1. Etch for 90 seconds with 9% hydrofluor- and teeth 37 and 47 contained bonded
ic acid gold onlays (Figs 39 and 40).
2. Rinse with water for 20 seconds Occlusal adjustment, predominantly on
3. Clean with 37% phosphoric acid – gen- the provisional restorations, was carried
tle brushing with microbrush for 1 minute out following cementation.
4. Rinse with water for 20 seconds
5. Immerse in 95% alcohol in ultrasonic Impressions 2
bath for 5 minutes The next stage of treatment involved mak-
6. Apply silane and dry thoroughly ing definitive impressions of the maxillary
7. Cementation. anterior teeth and the bilateral mandibular
premolar and first molar teeth. The same
All the adhesive restorations were bonded impression technique as described earlier
under rubber dam. The gold onlays were was used (Fig 41). New JRRs and a face-
bonded using a chemically cured resin bow recording were also made.
23
cement (Panavia EX, Kuraray). The ce- In the laboratory, all-ceramic crowns
ramic onlays were bonded using a dual- were fabricated for the maxillary anterior
cured resin cement (Rely X ARC, 3M teeth (WOL-CERAM (AlO), WOL-DENT)
ESPE). The mandibular porcelain veneers (Fig 42).
were bonded using a light-cured resin ce-
ment (Rely X Veneer Cement, 3M ESPE)
(Figs 36 to 38).
Fig 36 Isolation of preparations in first quadrant Fig 37 Cementation of restorations in first quadrant.
prior to cementation.
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Fig 38 Definitive mandibular porcelain veneers Fig 39 Maxillary arch with anterior provisional
against maxillary provisional crowns. Mandible is in crowns and posterior definitive restorations.
protrusive position.
Fig 40 Mandibular arch with definitive porcelain ve- Fig 41 Maxillary impression of anterior teeth.
neers on anterior teeth, provisional restorations on teeth
34 to 36 and 44 to 46, and definitive bonded gold on-
lays on teeth 27 and 47.
Fig 42 WOL-CERAM (AlO) all-ceramic crowns at Fig 43 Esthetic try-in of maxillary crowns in bisque
bisque bake stage. bake stage.
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Fig 44 Occlusal refinement in bisque bake stage. Fig 45 Pick-up impression of bisque bake crowns
for soft tissue cast.
Fig 46 Working cast with nonretracted soft tissues Fig 47 Definitive anterior crowns.
and removable dies.
An esthetic try-in of the maxillary crowns in

a bisque bake stage was carried out and
assessed jointly by the patient, dentist, and
technician (Fig 43). Occlusal accuracy was
verified and minor occlusal adjustment
was carried out (Fig 44). The crowns were
then picked up in a polyvinylsiloxane im-
pression to obtain a cast of the soft tissues
in their natural nonretracted state (Figs 45
to 47).
Fig 48 Mandibular porcelain onlays and metal-

ceramic crown (tooth 36).
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The mandibular porcelain onlays were ionomer luting cement (GC Fuji Plus, ss e n c e
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fabricated using the same technique and Europe). The porcelain onlays were bond-
materials as the other porcelain onlays. A ed under rubber dam, as described
metal-ceramic crown was fabricated for above.
tooth 36 (Fig 48). Final occlusal adjustment and polish
were carried out once all the restorations
Cementation 2 had been cemented (Figs 49 to 54). A
The maxillary all-ceramic crowns and the maxillary “Michigan” style maxillary protec-
metal-ceramic crown on tooth 36 were ce- tive bite splint was made for the patient to
mented using a resin-reinforced glass- wear at night while sleeping.
Fig 49 Maxillary arch postoperative view. Fig 50 Mandibular arch postoperative view.
Fig 51 Right lateral postoperative view. Fig 52 Left lateral postoperative view.
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ss e n c e
fo r
Fig 53 Anterior retracted postoperative view. Fig 54 Postoperative view of smile.
Discussion Acknowledgement
Conservation of tooth structure is a major Thanks to Mr Salvatore Sgro of L’Eccellenza Odon-
totecnica, Rome, Italy for the esthetic and technical pre-
goal of restorative treatment, and with the
cision of all the laboratory work shown. I am privileged
advent of adhesive dentistry this goal has to work with a true genius in both the art and science
become even more attainable. However, it of dental technology.
is important to understand the limitations
associated with adhesive dentistry and not
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Combining Traditional and Adhesive Dentistry To Reconstruct The Excessively Worn Dentition

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Combining Traditional and Adhesive Dentistry To Reconstruct The Excessively Worn Dentition

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CLINICAL APPLICATION pyrig

Adhesive Dentistry to Reconstruct

Basil Mizrahi, BDS, MSc, MEd

Correspondence to: Dr Basil Mizrahi

Fig 15 Maxillary definitive waxup. Fig 16 Mandibular definitive waxup.

Fig 21 Laboratory-processed acrylic

crowns and the mandibular composite The advantages of making a secondary

An esthetic try-in of the maxillary crowns in

Fig 48 Mandibular porcelain onlays and metal-

Fig 53 Anterior retracted postoperative view. Fig 54 Postoperative view of smile.

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