Computer-Aided Design/Computer-Assisted Manufacture

Monolithic Restorations for Severely Worn Dentition:

A Case History Report
Samir Abou-Ayash, Dr Med Dent, DDS1/Johannes Boldt, Dr Med Dent, DDS2/Alexander Vuck, Dr Med Dent, DDS2

Full-arch rehabilitation of patients with severe tooth wear due to parafunctional behavior is
a challenge for dentists and dental technicians, especially when a highly esthetic outcome is
desired. A variety of different treatment options and prosthetic materials are available for such
a clinical undertaking. The ongoing progress of computer-aided design/computer-assisted
manufacture technologies in combination with all-ceramic materials provides a predictable
workflow for these complex cases. This case history report describes a comprehensive, step-
by-step treatment protocol leading to an optimally predictable treatment outcome for an
esthetically compromised patient. Int J Prosthodont 2017;30:530–532. doi: 10.11607/ijp.5500

S evere tooth wear (level 3 or 4 according to the tooth

 wear index [TWI]) is an increasing problem, with a
prevalence ranging from 3% to 17% in adults.1 Major
causes of increased tooth wear include parafunction-
al behaviors, dietary considerations, reflux disorders,
and augmented chewing factors. Since technical fail-
ures such as fractures or chipping (particularly with
bilayer systems) are more likely to occur in patients
with bruxism,2 prosthetic rehabilitation with monolithic
all-ceramic restorations appears to be a reliable treat-
ment option. However, scientific evidence for prescrib-
ing all-ceramic treatment concepts for bruxism patients
is rare. The digital treatment planning, selection of
restorative materials, and computer-aided design/
computer-assisted manufacture (CAD/CAM)–based
workflow for a partially edentulous patient with exten-
sive tooth wear due to parafunctional behavior is pre-
sented and discussed in this case history report.
Case History
The major concern of this healthy 47-year-old female
patient was discolored restorations and the resulting
compromised esthetics. She had high esthetic de-
mands and requested a metal-free, fixed rehabilita-
tion. The patient reported a history of nocturnal teeth
grinding.
Extra- and intraoral examinations (Fig 1) were
followed by a digital smile design (DSD)3 analysis,
1Assistant Professor, Department of Prosthodontics, School of Dentistry,
Albert Ludwigs University of Freiburg, Freiburg, Germany.
2Assistant Professor, Department of Prosthodontics, School of Dentistry,
Heinrich Heine University, Duesseldorf, Germany.
Correspondence to: Dr Samir Abou-Ayash, Department of Recon-
structive Dentistry and Gerodontology, Freiburgstrasse 7, CH-3010 Bern,
Germany. Fax: +41316324933. Email: samir.abou-ayash@zmk.unibe.ch
©2017 by Quintessence Publishing Co Inc.
showing a high smile line and irregular interincisal an-
gles, axial inclinations, and gingival margins. All tooth
axes were misaligned, and width-length proportions
of teeth 12 to 22 (11 and 21 = 1.24; 12 and 22 = 1.03)
were unfavorable (Fig 2a).
Pretreatment included replacement of flawed res-
torations, treatment of caries lesions, and endodon-
tic treatment of mandibular molars 36 and 47. Based
on the DSD, a wax-up was made with an ideal tooth
shape and an increased vertical distance of occlu-
sion (VDO; 3 mm) to outline a template for the final
CAD/CAM restorations (Fig 2). Final tooth-supported,
all-ceramic restorations were then planned.
The corrections of the high smile line and gingival
display were addressed by periodontal surgery with
an apical repositioning flap (ARF) and a subsequent
external gingivectomy 6 months after the initial pro-
cedure (Fig 3). After a healing period of 1 month, all
abutment teeth were prepared. The mandibular ante-
rior incisors received an overlap veneer preparation.
Defect-oriented partial crown preparation designs
were selected for the posterior mandibular teeth 44,
47, and 37. All other teeth were prepared for full-
coverage crowns. Splinted CAD/CAM–fabricated,
egg-shell provisionals remained in situ for another 3
months to test function and esthetics.
The increased VDO did not result in any functional
impairment. Conventional vinyl siloxane ether impres-
sions (Identium light/heavy; Kettenbach) were taken.
Bite registration was performed using the cross-
mounting technique in maximum intercuspation. All
restorations were digitally designed in full contour
based on the archived DSD outline. The anterior res-
torations of the maxilla and mandible, including tooth
14, were milled from monolithic lithium-disilicate
CAD/CAM blocks (IPS emax CAD, Ivoclar Vivadent).
All posterior restorations were fabricated using
monolithic multilayered translucent zirconia discs

530 The International Journal of Prosthodontics

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
 Abou-Ayash et al

Fig 1  Patient’s preoperative examinations:

(a–c) extraoral, (d–f) intraoral, and (g) ra-
diologic.

a b

c d e

(Katana Zirconia ML; Kuraray

Noritake Dental). No additional
veneering was performed. The
lithium-disilicate restorations were f g
cemented using a dual-curing lut-
ing composite (Variolink II; Ivoclar
Vivadent). The monolithic zirconia
restorations were inserted using a
chemical-curing resin cement with
a 10-methacryloyloxydecyl dihydro-
gen phosphate (MDP)–containing a
silane (Panavia 21; Kuraray Europe).
Static occlusion and dynamic oc-
clusion with incisal/canine guid-
ance were obtained. Finally, the
patient was provided with an oc- b c
clusal splint as a protective way to Fig 2   Digital dental analysis according to the
ensure the long-term success of protocol of (a) Coachman’s digital smile de-
the prosthodontic management. sign and (b) digital treatment plan, which was
transferred to (c) a wax-up and (d) an intraoral
At the 1-year follow-up examina- mock-up.
tion, all restorations were still in situ.
d
Discussion

In complex case histories such as

the one presented here, CAD/CAM
technologies offer a wide range of
novel treatment and planning op-
tions and are therefore able to gen-
erate highly predictable treatment a b
outcomes. Furthermore, the DSD
tool enables the visualization of the
prospective treatment outcome at a
very early stage of treatment. Given
the different mean maximum bite
forces between anterior and poste- c d
rior regions, two distinct restorative Fig 3   Apical repositional flap. Situation (a) before and (b, c) after bone contouring, (d) with
materials were selected. Survival subsequent external gingivectomy.

Volume 30, Number 6, 2017 531

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CAD/CAM Monolithic Restorations for Severely Worn Dentition

restorations are a predictable and

time- and cost-effective alterna-
tive for traditional bilayer restora-
tions. The concept of monolithic
all-ceramic restorations for pa-
tients with parafunctional behav-
iors must be confirmed in further
prospective studies.
c d
Acknowledgments

The authors thank Dentallabor Woerner

(Freiburg, Germany) and MDT Wolf
Woerner for technical assistance. The
authors declare no conflicts of interest.
e f

Fig 4  Final monolithic restorations (a, b) References

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532 The International Journal of Prosthodontics

© 2017 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.