Enhanced CPD DO C
Salman Pirmomahed
Minimally Invasive Management
of Erosive Tooth Surface Loss
Using a Combined Direct and
Indirect Approach: A Case Report
Abstract: This article describes the management of a patient with generalized (primarily erosive) tooth surface loss. It specifically looks
at minimally invasive techniques using improvements in material science to achieve this in an efficient and predictable manner within a
general dental practice setting.
CPD/Clinical Relevance: The use of minimally invasive techniques within a general dental practice setting are highlighted.
Dent Update 2021; 48: 541–544
With an increasingly elderly population who
are retaining teeth for longer, the prevalence
of tooth surface loss is on the increase. The
most recent Adult Dental Health Survey
(2009) revealed that 77% of dentate adults
exhibited wear into dentine.1 Tooth surface
loss can be attributed to either erosion,
attrition or abrasion. However, it is commonly
multifactorial in aetiology.2
Preventive management of tooth surface
loss is the cornerstone of care for these
patients, and screening tools such as the Basic
Erosive Wear Examination (BEWE) should
be employed at recall examinations for all
patients.3 Tooth surface loss can be classified
as being physiological or pathological.
However, both groups may need restorative
management in cases of:4
Salman Pirmohamed, BDS (Hons),
MJDF RCS (Eng), Specialty Trainee
in Prosthodontics, Eastman Dental
Hospital and Institute, Field End Dental
Practice, Pinner.
email: salman.pirmohamed.20@ucl.ac.uk
July/August 2021 DentalUpdate 541
 Compromised aesthetics;
 Increased sensitivity of teeth;
 Functional problems.
The traditional restorative management
of tooth surface loss involved full mouth
reconstructions using indirect restorations,
which often resulted in a high treatment
burden to teeth, and accelerated their path
along the restorative cycle.2 This report
presents a case that demonstrates the
management of generalized tooth surface
loss using a combination of direct and indirect
composite restorations, with almost no tooth
removal required.
Case report
History and examination
A 37-year-old gentleman presented to the
practice in 2018 as a new patient with both
aesthetic and functional concerns. He was
experiencing generalized sensitivity to cold
drinks and was unhappy with the appearance
of his ‘chipped’ and ‘worn’ front teeth. The
patient had realistic aesthetic expectations
of mainly wanting more teeth to show when
RestorativeDentistry
smiling. Medically, he was fit and well, but
reported consumption of more than 1 litre of
diet coke every day for the previous 5 years,
along with a moderate sugar intake. A diet
sheet later confirmed that the patient was
consuming five cans of diet coke throughout
the day. The patient reported no history of
bruxism or other parafunction and had no
obvious markers for this.
Examination revealed a fair level of oral
hygiene, but marked evidence of tooth surface
loss with dentine exposure on all teeth except
the lower incisors. Several areas of shadowing,
indicating caries, were noted, and confirmed
by radiographs (Figures 1 and 2). Tables 1 and 2
present the BPE and BEWE scores, respectively.
Pre-operative aesthetic evaluation noted
a cant going up to the right-hand side in the
upper arch. The incisal edges were chipped,
with no incisal show at rest. No obvious
dento-alveolar compensation had occurred,
but a slight reduction in the lower facial third
was noted.
After a thorough history, examination, and
special investigations the following diagnoses
were reached:
 RestorativeDentistry
a a
b
c
d
Figure 2. (a, b) Pre-operative
bitewing radiographs
completely cutting out carbonated drinks
from his diet. The patient had been unaware
of the dental implications of diet cola and had
assumed this was better than normal cola
Figure 1. (a–d) Pre-operative photographs. for his teeth. This highlights the importance
of patient education in managing tooth
surface loss. Fluoride supplementation by a
 Generalized, plaque-induced gingivitis; high fluoride toothpaste (Duraphat 5000ppm,
 Caries and reversible pulpitis affecting: LL6 Colgate, UK) was to be used twice daily, along
DO, LR5 DO, LR6 MO, UR6 MO; with a daily fluoride mouth rinse (FluoriGard
 Generalized moderate tooth surface loss Daily Rinse 225ppm, Colgate, UK) to reduce
with a primarily erosive component. the patient’s caries and tooth surface loss risk.
The patient showed excellent motivation in
adhering to the preventive advice given.
2 1 1
1 2 1 Treatment options
Table 1. BPE scores. After adherence to preventive advice was
confirmed, a long discussion was held with the
patient on options for further treatment.
2 3 2
A reorganizational approach was chosen
3 1 3 because of the generalized tooth surface
Table 2. BEWE scores. loss affecting almost all the teeth, and a
lack of interocclusal space to restore the
teeth. A variety of material options was
Prevention discussed with the patient, but he had a
Periodontal management involved tailored oral strong preference for all the restorations to
hygiene instructions and debridement. Dietary be tooth coloured, including those on the
advice was given, and resulted in the patient posterior teeth.
542 DentalUpdate July/August 2021
a
Figure 3. (a, b) Facebow and occlusal records.
Figure 4. Whipmix Esthetic CrossRef.
As the tooth surface loss was primarily
erosive in nature and the causative factor
had been stopped, composite was chosen to
restore the anterior teeth. This was seen as
a good balance between an aesthetic and a
minimally invasive approach, and there is a
strong evidence base supporting its use as a
medium-term solution.5,6 Metal backings, for
which there is also a strong evidence base that
supports their use, may be an option for less
aesthetically concerned patients.7 A 'sandwich'
approach of indirect palatal composite
backings and direct labial composite veneers
was chosen for the upper anterior teeth.
Indirect palatal backings were selected to allow
better management of occlusion, and greater
strength in this area to preserve planned
anterior guidance in a mutually protected
occlusal scheme. Furthermore, direct palatal
composite build-ups can be challenging
to carry out and the indirect backings also
allowed for a 'matrix' against which the labial

a b
Figure 5. Mock try-in.
a
Figure 8. (a–d) Restoration of posterior teeth with direct composite build-ups and concurrent
b management of caries.
The use of posterior direct composites in
managing tooth surface loss is under debate
because of the greater occlusal forces in these
areas, although there is some promising
c evidence showing good success with newer
hybrid composites.9 The presence of a good
enamel rim on the posterior teeth for bonding,
as well as supragingival margins for isolation,
were deemed positive factors supporting its use
in this case. Furthermore, financial constraints
Figure 6. (a–c) Cementation of indirect made this a more viable option for the patient,
palatal veneers. especially because of the number of teeth that
required treatment. The patient was made aware
a of the possibility that these would need to be
changed to indirect restorations with time (eg
ceramic or gold).
Once posterior composites had been chosen
for the tooth surface loss, it was decided to
b manage the carious lesions concurrently. This
had the advantage of the composite being used
in a single visit, which meant that old composite
was not being bonded to and there was an
overall reduced chairtime for the patient.
Figure 7. (a, b) Pre-operative and immediate
post-operative view of anterior labial
Planning phase
segment after placement of freehand direct The preliminary planning involved making
labial composite. upper and lower impressions in alginate for
study casts. A retruded axis position (RAP)
record was then taken at an occluso-vertical
composite could be placed. The patient dimension (OVD) that would allow for an
was made aware of the longevity of direct adequate thickness of restorative material
composites in these areas, and the need for posteriorly. Ensuring to take the RAP record at
repairs and replacement with time. Superior the desired OVD is important because it limits
aesthetics could have been achieved with the the number of inaccuracies created in opening
use of porcelain veneers as shown by Vailati et and closing the pin on the articulator.
al by the sandwich technique, but the patient The facebow record taken was helpful in
and dentist preferred a non-invasive solution.8 guiding the technician in addressing the canted
July/August 2021 DentalUpdate 543
RestorativeDentistry
c
d
smile line (Figure 3). However, if there had been
facial asymmetry with ear positions, it should
be noted other techniques would have had to
be used. For example, the Whipmix Esthetic
CrossRef allows accurate transfer of midline and
horizontal planes to the articulated study casts
(Figure 4).
The above records were sent to the
laboratory and a wax-up of the upper anteriors
at ideal proportions was requested at the
desired OVD. The palatal wax-up was planned
to allow for vertical stops to ensure that forces
would be direct through the long axis of the
upper anteriors. An increase in incisal length of
2 mm was also requested to improve the incisal
show for the patient, because this was one of
his main concerns.10
Once the wax-up was received, a mock-up
was completed using bisacryl resin (Protemp,
3M, USA) and a putty matrix (Figure 5).
Aesthetics and occlusion were verified at this
stage with the patient, and he consented
to proceed with the restorative phase of
treatment. The working impressions were taken
in polyvinylsiloxane for construction of the
upper indirect palatal composite backings.
Treatment phase
The first restorative appointment involved
cementation of the indirect composite (TWiNY,
Yamakin, Japan) palatal backings under rubber
dam isolation for the six upper anterior teeth
(Figure 6). TWINY is a light- and heat-cured
indirect composite resin material chosen for
the reasons outlined previously. The palatal
backings extended over the incisal edge
of the upper anteriors and up to the labial
 RestorativeDentistry
a composite (G-ænial, Universal Flo, GC Europe,
b excursion. Good posterior disclusion was created
c Compliance with Ethical Standards
d management of the carious lesions was also
e walls, so incremental layering was required.
Figure 9. (a–e) Two-year post-operative
photographs showing minimal wear to
composite restorations.
surface. This meant they could then be used as a
palatal matrix for the freehand labial composite
(Figure 7). The indirect composite backings were
pre-treated by sandblasting with 50-micron
aluminium oxide and application of a silane-
containing dentine bonding agent (Scotchbond
Universal Adhesive, 3M, UK). Cementation
was carried out with a high-strength flowable
544 DentalUpdate July/August 2021
Belgium). Labial direct composite was applied
to restore the erosive wear that had occurred,
as well as to disguise the join line between the
tooth and indirect composite (GC Gradia Direct,
GC Europe, Belgium). After minor adjustments,
equal static contacts were confirmed on all
six upper anterior teeth, with even protrusive
guidance and canine guidance in lateral
after the first appointment. To reduce the effect
of relative axial movement (Dahl effect), the
patient was called back for restoration of the
posterior teeth within the same week. Another
option could have been to place posterior
occlusal stops with direct restorations to preserve
this space. The patient was extremely happy with
the aesthetic outcome after this appointment
and tolerated the increased OVD well.
The reconstruction of the posterior teeth
was completed over two appointments and
involved direct composite build-ups to rebuild
lost tooth tissue and cover over any areas of
dentine exposure (GC Gradia Direct). Concurrent
completed, and this was the only part of the
patient’s entire treatment that involved some
removal of tooth structure. Another option
with the direct build-ups could have been to
use a transparent matrix to transfer a posterior
wax-up over to the mouth. The decision to do
the build-ups freehand was because of the
good anatomical contour of the remaining
teeth, and the need to rebuild several proximal
Furthermore, the indirect backings had already
set up good canine guidance, so final occlusion
for the posteriors was relatively straightforward
to achieve with static occlusal contacts and no
further contact in lateral excursions.
Final outcome
The patient was initially placed on a
3-monthly high-risk recall pathway owing to
his susceptibility to tooth surface loss and
caries. However, after regular attendance for
2 years, the most recent review showed good
adaptation of the composite with very little
wear occurring and no chipping (Figure 9).
During this time, he continued to adhere to
the preventive regimen initially prescribed. The
patient was aware that the direct composite
restorations might need to be replaced by
indirect restorations in the future, but that
these should be possible to provide via a
straightforward conformative approach.
Discussion and conclusion
This case showed how advances in bonding
chemistry have allowed for traditionally
destructive care plans to be provided in
a minimally invasive way. Furthermore,
preserving tooth tissue slows the passage
of teeth through the restorative cycle, and
allows for fallback options in the future to be
provided. Good consent and discussion of
the various options is key before beginning
the treatment journey, so patients know
the expected longevity of the restorations
provided. With regards to tooth surface
loss, managing the aetiological factor and a
continued emphasis on prevention allows
provision of predictable dentistry for patients.
Conflict of Interest: The authors declare that
they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
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