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Conservative restoration of the worn dentition - the anatomically driven

direct approach (ADA)

Article in The International Journal of Esthetic Dentistry · January 2018

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 CLINICAL RESEARCH

Conservative restoration of the worn

dentition – the anatomically driven
direct approach (ADA)
Rui Negrão, DMD
Private Practice in Porto, Espinho, and Lisbon, Portugal
Postgraduate in Esthetic Dentistry, ISCS Egas Moniz, Lisbon, Portugal

Jorge André Cardoso, DMD

Private Practice in Espinho and Porto, Portugal
MClinDent Prosthodontics, King’s College London
Honorary Clinical Teacher, King’s College London

Nuno Braz de Oliveira, DMD

Private Practice in Lisbon, Portugal
Postgraduate in Orthodontics, NYU, New York

Paulo Julio Almeida, DMD, PhD

Private Practice in Porto, Portugal
Assistant Professor, Prosthodontics, Porto University, Portugal

Teresa Taveira, DMD

Private Practice in Espinho, Portugal
MSc, Aesthetic Dentistry, King’s College London

Oleg Blashkiv, CDT

Private Practice in Porto, Portugal
Lviv University, Ukraine

Correspondence to: Dr Jorge André Cardoso

Ora Clinic, Rua 23, 344, 3 C, 4500-142 Espinho, Portugal; Tel: +351 916 121312; Email: jorge.andre@ora.pt

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Abstract
The treatment or management of tooth
wear with composite resins can be chal-
lenging because significant alterations
in the patient’s occlusion are usually
required. Comprehensive approaches
include the use of facebows, articulator-
mounted casts, laboratory-made wax-
ups, and silicone indexes to deliver the
restorations. Even though this sequence
of steps is recommended, in many cases
it is not applied. The reason for this is re-
lated to the complexity and time required
for these steps, which are normally ap-
plied in indirect restorations like ceram-
ics but not properly used in direct com-
posite resin rehabilitations. Moreover, a
large portion of these patients, clinicians,
and technicians in many countries may
not have the resources and/or tools to
undertake a full comprehensive ap-
proach. In order to aid clinicians to use
NEGRÃO ET AL
an exclusively direct method to manage
these patients for whatever reasons, the
authors propose in this article a thought
process applied to diagnosis and treat-
ment planning that allows the restoration
of extensively worn dentitions in a logi-
cal clinical sequence. The first goal is
to provide a clear and organized vision
of the functional, biologic, and esthetic
principles of treatment planning based
on the most current, evidence-based no-
tions and clarified insights from experts.
These are principles that should be ap-
plied universally in any comprehensive
treatment plan. The second goal is to
propose the application of these prin-
ciples to direct restorations even when
no individualized articulator mounting
or appropriate laboratory wax-ups are
available – the anatomically driven di-
rect approach (ADA).
(Int J Esthet Dent 2018;13:16–48)
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 CLINICAL RESEARCH
Introduction
Tooth wear results from mechanical
(abrasion, attrition, and abfraction) and
chemical (erosion) processes,1 quite
often acting in synergy.2 The incidence
of people with pathological or acceler-
ated tooth wear is rising,3,4 and this in-
creased prevalence is even more evi-
dent in young people,5,6 probably due
to modern lifestyle behaviors such as
frequent ingestion of acidic beverages,
stress-aggravated diseases like brux-
ism and gastric reflux, or psychological
disorders like bulimia.7 Therefore, the
emphasis should be on early diagnosis
to address the causes and prevent dis-
ease progression.8
Dentin is more prone to erosive and
mechanical wear than enamel, thus the
consequences of tooth wear are worse
on exposed dentin.9 A more or less con-
sensual recommendation is to perform a
restoration or dentin sealing as soon as
there is exposure.10-12 Traditional treat-
ments that remove most of the remain-
ing enamel with excessive tissue prep-
aration for retention principles do not
seem to favor the lifespan of the denti-
tion. There is increasing evidence sup-
porting minimally or noninvasive adhe-
sive approaches to worn dentitions.13-15
Several restorative strategies have been
described using a diagnostic wax-up to
aid the clinician in the treatment strat-
egy. The use of direct approaches with-
out a wax-up has also been described;
however, they have been based on the
empirical technical skill of the clinician
and do not rely on any one specific pro-
tocol.16,17 The present article describes
a direct restorative strategy based on
anatomical, functional, and esthetic
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parameters specific to wear cases that
can be especially helpful when a wax-up
is not available.
Clinical management
of generalized tooth wear
What was a few decades ago consid-
ered a complex treatment is today sig-
nificantly clearer due to a better under-
standing of adhesion and functional
occlusion. In the past, long-established
approaches would require extensive
preparations, sometimes involving root
canal treatments, to provide mechani-
cal retention for restorations with high in-
trinsic strength such as porcelain fused
to metal or porcelain fused to zirconia.
However, more recent research shows
that adhesive dentistry can provide ac-
ceptable clinical outcomes and limit the
ongoing wear process.15
#PUI
DFSBNJD
BOE
DPNQPTJUF
SFTJO

materials have been applied in the mini-
mally invasive treatment of tooth wear.
Although composite resin materials pre-
sent physical limitations in terms of co-
hesive strength, oral degradation, and
color stability, they can provide an im-
portant alternative to ceramics for many
patients.18-20 Some authors consider
composite resin to be the material of first
choice for posterior teeth as it provides
good clinical performance at a lower
cost; is easier to fabricate and more pre-
dictable to repair;21 causes less wear
on the opposing dentition compared to
ceramics;22 and may have load-absorb-
ing properties when used from milled,
highly polymerized computer-aided
design/computer-aided manufacturing
(CAD/CAM) materials.23,24 Although it
 NEGRÃO ET AL

a b c

d e f

g h i

Fig 1 Clinical case provisionally restored with noninvasive composite resin restorations following the ideal
workflow: comprehensive wax-up on articulated mounted casts using a facebow, and customized incisal
table based on original anterior guidance path. The wax-up was then transferred to the restorations using
one of the many available techniques – transparent silicone with individual matrixes according to the “index
technique” by Ammannato et al.31

is clear that ceramic restorations, espe-
cially monolithic glass ceramics such as
lithium disilicate, have high long-term
survival rates in posterior teeth, there is
ongoing debate regarding the clinical
performance of composite resin versus
ceramic due to the lack of consistent
clinical trials.25,26
Since the rehabilitation of extensive
tooth wear frequently results in signifi-
cant occlusal alterations, many of the
rules and guidelines that were once
strictly adhered to without proper scien-
tific evidence are now being questioned
and replaced by more clinically oriented
and evidence-based approaches. Vailati
BOE
#FMTFS27-29 contributed significantly
to this debate around the management
of worn dentitions with their description
of the three-step technique: occlusal
plane, posterior support, and anterior
guidance. This approach combines di-
verse scientific knowledge with logical
clinical steps to offer a practical guide
for treatment.
Anatomically driven direct
approach (ADA)
When using direct composite restor-
ations, a comprehensive wax-up made
from articulated casts guided by effec-
tive clinician–technician communication
is always desirable (Fig 1). This can fa-
cilitate diagnosis, optimize laboratory

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 CLINICAL RESEARCH
Inter- Occlusal Occlusal
maxillary vertical plane
Relation & dimension
Guidance (OVD)
Fig 2 The eight basic parameters that should be considered for diagnosis and treatment planning of
extensively worn dentitions: intermaxillary relation, mandibular guidance, occlusal vertical dimension, oc-
clusal plane, tooth display, phonetics, gingival levels, and posterior tooth anatomy.
communication, and provide a better
anatomy of the final restorations. Trans-
ferring the anatomy created in the wax-
up into the mouth can be performed
using several techniques, including the
use of transparent vacuum-formed30 or
silicone matrixes31 applied to full-arch,
quadrant sections or sequential single
teeth (Fig 1).
With the increasing number of wear
cases, a legitimate question can be
asked: In the case of a lack of laboratory
resources, financial limitations or a clini-
cian’s preferences, are there predictable
treatment workflows and approaches
that allow for the restoration of these ex-
tensive cases directly with composite
resin? With this question in mind, the au-
thors suggest that whenever a compre-
hensive wax-up is not available, a direct
approach can be adopted, based on
the anatomy of the remaining dentition
as well as the esthetic and functional
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Tooth Gingival Posterior
display and levels tooth
Phonetics anatomy
parameters evaluated chairside with the
patient.
Diagnosis and treatment planning
A clear understanding of the critical
parameters is important when plan-
ning extensive restorative treatment ap-
proaches (Fig 2).
Temporomandibular disorders (TMDs)
A preliminary diagnosis regarding TMDs
related to masticatory muscles or joints is
mandatory. Muscular or joint pain should
be dealt with before any functional diag-
nosis or treatment is performed.32 Mus-
cular function or hyperactivity problems
will prevent the correct assessment of in-
termaxillary relations. Temporomandibu-
lar joint problems that have not healed
or adapted properly may continue to
cause pain and occlusal instability.33
The history of an unstable bite (eg, as a

result of a joint problem such as osteoar-
thritis) is also a contraindication for any
final restorative procedure.34 In case of
doubt, a referral to a TMD specialist is
highly advisable before any restorative
treatment takes place.
Intermaxillary relation
Although there is still debate about the
clinical advantages of restoring patients
into centric relation (CR), its use is tech-
nically helpful as it provides a predict-
able rotation axis when all occlusal
contacts are lost.35 Using the difference
from CR to maximum intercuspation (MI)
has the following important advantage:
the posterior rotation of the mandible
will, in many cases, provide the anterior
restorative space that is often lacking.
This results in an increase of the occlusal
vertical dimension (OVD) while avoiding
the stretching of the mandibular eleva-
tor muscles.36 However, in some cases,
the difference from CR to MI is so exten-
sive that a non-physiologic anatomy of
the restorations would be expected for
correct anterior guidance and support.
For example, in large CR-MI slides, res-
toring the patient in CR may result in
bulky palatal surfaces on the maxillary
anterior teeth so that the mandibular in-
cisors can maintain contact. This situa-
tion will certainly impact on phonetics.
Additionally, in some patients, this CR-
MI difference can result in a retrusive
facial profile. More importantly, it can
promote an extensive retrusive mandib-
ular movement that may reduce airway
volume in the upper respiratory tract.
This needs to be considered because it
can, eventually, be important in patients
with obstructive sleep apnea. In sum-
mary, CR should be the first choice for
NEGRÃO ET AL
an intermaxillary relation unless it pre-
sents a difficult prosthetic, physiologic,
or esthetic challenge. Since CR influ-
ences the OVD so directly, it is the most
significant parameter influencing the
treatment plan. It is therefore manda-
tory to check it early in the examination.
#FTJEFT
B
DPSSFDU
NBOVBM
NBOJQVMBUJPO

complementary tools such as occlusal
jigs or splints may be used for short (or
longer) periods, providing muscle de-
programming so that a correct CR can
be determined.37,38
Occlusal vertical dimension (OVD)
Compensatory eruption is usually pre-
sent in worn dentitions maintaining the
OVD.39-41 Losses of OVD can only be
suspected when: 1) posterior dental
support is lost (missing tooth pairs on
both sides), making it difficult for the
anterior teeth to support the vertical di-
mension; or 2) when the wear is faster
than the compensatory eruption, which
is always a subjective diagnosis.42 Al-
though it may be interesting to know how
much OVD has been lost, what is of real
importance is knowing how much more
will be needed for restorative, functional,
and esthetic purposes. The increase of
OVD is dictated by the space needed
for a favorable overbite and overjet (both
around 2 to 4 mm43) on anterior restor-
ations. It is good to bear in mind when
planning treatment that increasing the
OVD and/or repositioning the mandible
into CR will reduce the overbite and in-
crease the overjet, and vice versa.44,45
Reasonable increases in OVD to cre-
ate restorative space do not seem to
cause TMDs and are considered safe
procedures.46,47 There are several tech-
niques for increasing the OVD, and it is
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 CLINICAL RESEARCH

Normal alveolar bone

Possible bone
remodelation
with teeth intrusion

Dense alveolar bone

Maximum ↑ OVD
Difficult bone
intercuspation (MI)
remodelation,
= Muscle
fractures and
Centric relation (CR) stretching
symptoms
more likely
Increased
muscular activity

Fig 3 Possible consequences of increasing the vertical dimension in patients where MI and CR coincide,
based on Dawson.36

Maximum Posterior mandibular No increased

intercuspation (MI) rotation to CR muscular activity,
≠ reduced risk
Centric relation (CR) ↑ OVD

Muscle
shortening

Fig 4 Consequences of increasing the vertical dimension in patients where CR is significantly different
from MI, based on Dawson.36

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subnasale ƃ Ƃ
stomion 45% 30%
55% 70%
menton
Fig 5 Facial proportions based on soft tissue landmarks related to vertical dimension in females and
males according to modern anthropometric measurements.
the restorative need that should quan-
tify the amount of increase.48 Two dif-
ferent philosophies regarding the ef-
fects of increasing the OVD need to be
considered: 1) That muscle adaptation
occurs for the new stretched position;
2) That muscles do not adapt, and the
same initial length will try to be main-
tained with increased muscle activity.42
If we consider that there is no muscu-
lar adaptation, it means we assume that
the bone will remodel with the intrusion/
extrusion of teeth as a consequence of
elevator muscle activity. Examples of
these phenomena include orthodontic
movements, occlusal bite planes (such
as the Dhal concept), and premature
contacts. This remodulation is what
seems to happen in most cases when
the OVD is increased (Fig 3).49 In a case
where bone remodeling is not possible
NEGRÃO ET AL
trichion
30%
glabella
30%
40%
due to increased bone density, the con-
sequences may be unpredictable, eg,
fractures, mobility, and muscular symp-
toms (Fig 3). Increased bone density
may be suspected in severe bruxers
with muscle hypertrophy, dense or scle-
rotic bone, enlarged alveolar processes,
and exostoses. However, these risks are
minimized when there is a significant
difference between CR and MI. Relo-
cating/rotating the mandible to CR will
provide interdental space, especially in
the anterior region, without stretching
the elevator muscles (Fig 4).36 In sum-
mary, if a difference between CR and
MI exists it can be used to relocate the
mandible and gain space without mus-
cle stretching (Fig 4). If no MI-CR differ-
ence exists, then an increase of OVD
will necessarily cause stretching of the
elevator muscles. As these muscles try
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 CLINICAL RESEARCH
to return to their original positions, the
consequences are usually not problem-
atic, since alveolar bone remodulation
will accommodate the intrusion of the
teeth. However, in cases of increased
bone density, these compensations will
not take place, therefore restorative fail-
ures and muscle symptoms are more
likely to occur (Fig 3).36
Although there are several methods
for accessing the vertical dimension, the
authors suggest using facial esthetic par-
ameters as the primary method. There is
a classic belief that the facial thirds are
of the same proportions; however, hu-
man measurements show that the lower
third is about 10% longer than the mid-
dle and upper thirds. There are also dif-
ferent proportions between the maxillary
and mandibular areas on the lower facial
third according to gender50 (Fig 5).
Occlusal plane
There are two important components to
the occlusal plane: esthetics and func-
tion. The functional occlusal plane, which
is a simplified reference to the Curve of
Spee, should allow the bilateral simulta-
neous contact of teeth in their long axis.
The esthetic occlusal plane should be
in harmony (parallel) with the interpu-
pillary line from the frontal view, but an
asymmetric lip movement and chin may
further influence the position of the oc-
clusal plane from the frontal view. While
frontal view errors are usually detected
early and corrected, lateral view errors
are unfortunately common. Establishing
the esthetics of the occlusal plane from
the lateral view, parallel to Camper’s
Plane, is a critical step in dental reha-
bilitations.51 According to the authors,
these errors can have a very negative
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effect on esthetics, as this is a major par-
ameter in facial and smile perception.
In some cases, the functional occlusal
plane does not match the visual percep-
tion of the plane and some corrections
(that do not necessarily affect the palatal
cusps or the functional occlusal plane)
may need to be performed on the buc-
cal cusps of the maxillary teeth to im-
prove esthetics.
Tooth display
There are several studies focusing on
incisal edge display52,53 and anterior
tooth dimensions.54,55 Using average
incisal edge display at rest as an ini-
tial mock-up suggestion is an excellent
starting point. Having a patient in a rest-
ed position is important. There are sev-
eral methods to achieve this, the most
accurate (from the authors’ perspective)
is to first ensure that all facial muscles
are tension-free, then ask the patient to
“open the mouth and drop the lower jaw
without smiling.” This will provide a good
observation of not only the maxillary in-
cisal edge position but also the mandib-
ular incisal edge display, as long as the
mandible is within a pure rotation axis
without translation movements. Asking
the patient to continuously say the let-
ter ‘m’ and then stop will also result in a
relaxed patient position.
For orientation purposes, the average
maxillary incisal edge display is around
3 mm for females during their third dec-
ade of life. With aging, this is reduced
about 1 mm per decade. Comparative-
ly, males show 1 mm less than females
for the same age group.53 Conversely,
mandibular incisal edge display pro-
gressively increases with age. During
their 20s, the mandibular incisal edges

of females have about the same vertical
position as the lower lip at rest, which
would be considered a 0-mm exposure.
This exposure increases 1 mm per dec-
ade. Males will show about 1 mm more
of their mandibular incisors than females
of the same age.52 The reason for these
variations with age relate to the obvious
downward shift of facial tissue through-
out life.56 Averages values often repre-
sent a small sample of the population
and should only be regarded as starting
points to be integrated with the patient’s
facial dynamics, personality, and treat-
ment goals. A patient may, legitimately,
want to look younger, and an increase
in maxillary tooth display for his or her
age may be provided as long as it is es-
thetically, functionally, and phonetically
viable.
Once the incisal edge display of the
central incisors has been established,
it is fairly easy to integrate the relative
dimensions of the lateral incisors and
canines.54,55 In terms of horizontal pos-
ition, a practical guideline is not to place
the incisal edges so that they invade the
dry portion of the lower lip. The transition
from the wet to the dry area of the lower
lip is the most buccal limit for positioning
maxillary central incisors.57
Phonetics
It is important to test the phonetic impli-
cations in extensive rehabilitations in an
objective manner. If speech impairment
is heard in a specific sound, the clinician
should be aware of the most common
changes needed.
The first step is to test for the ‘f’ and ‘v’
sounds and provide adjustments. When
the patient is making these sounds,
the maxillary incisal edge should only
NEGRÃO ET AL
slightly touch the lower lip, and never go
beyond the wet zone.58 The next step
would be to test the ‘s’ sound which can
be influenced by horizontal or vertical
volume alterations on the anterior teeth.
Some patients pronounce ‘s’ with an
upward vertical movement of the man-
dible, with the mandibular incisors be-
hind the maxillary ones.59 The speech
of these patients is impaired mainly
when the horizontal volume of the anter-
ior teeth is incorrect – upper palatal or
lower buccal. The most typical problem
is excessive volume on the palatal area
of the maxillary incisors. In other pa-
tients, the ‘s’ sound is pronounced with
a downward horizontal movement of the
mandible, placing the incisors edge to
edge. These are less tolerant to vertical
volume additions on the anterior teeth.60
Additionally, ‘s’ sounds can be helpful to
test the OVD.61,62 If the posterior teeth
touch during the pronunciation of ‘s’, the
OVD certainly needs to be reduced. The
patient should be allowed a few days
for neuromuscular adaptation between
adjustments.
Gingival levels
The gingival levels provide clues for
evaluating the wear pattern as they can
show compensatory eruption of worn
teeth (Fig 6).63 When the gingival level
is similar between the anterior and pos-
terior teeth, the wear has a generalized
pattern. In cases where there is a dif-
ferential anteroposterior gingival level,
more compensatory eruption has oc-
curred in the areas where the gingiva is
more coronal.
Crown lengthening procedures may
be considered in cases of excessive gin-
gival display, as long as no root exposure
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a b

c d

Fig 6 Illustration of different types of tooth wear and their effects on teeth and gingival levels. (a) Unworn
dentition. (b) Generalized wear and compensatory eruption. (c) Anterior wear with anterior compensatory
eruption. (d) Posterior wear with posterior compensatory eruption.

occurs as a consequence. If the exces- of the anatomical crowns (measured from

sive soft tissue display is due only to the
occlusal movement of the gingival mar-
gin from the compensatory eruption as
a response to wear, the amount of tissue
that can be removed without resulting
in root exposure is limited. Moreover,
restoring root-exposed dentin and ce-
mentum areas with adhesive materials
may not be biomechanically stable in
the long term.64
Posterior teeth guidelines –
height dimensions
In an ADA, it is important to consider the
usual shapes and dimensions of teeth.
The clinician should visualize the amount
of tooth that has been worn in order to re-
store the occlusal shape. Reducing the
average size of the soft tissue coverage
the cementoenamel junction), we can
calculate that premolar teeth have clin-
ical crowns that range from 7 to 8 mm,65
and those of molars from 6 to 7 mm.66
In addition to the clinical crown di-
mensions, it is important to have no-
tions of posterior tooth anatomy, which
goes beyond the scope of this article.
Special attention should be paid to the
interproximal contact points; their pres-
ence should be confirmed before start-
ing, and, when deficient, they should be
anatomically reestablished.
Mandibular guidance
From a simplified perspective, the ana-
tomy and histology of human teeth seem
to indicate that anterior teeth are pre-
pared to receive horizontal forces, while

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 NEGRÃO ET AL

Fig 7 Some degree of freedom from MI that allows mandibular incisors to close slightly forward without
causing horizontal forces on the maxillary anteriors (fremitus) is a well established and clinically relevant
concept.

posterior teeth have evolved to support
stronger vertical loads.67 In the widely
accepted concept of mutually pro-
tected occlusion, anterior teeth protect
posterior teeth from horizontal forces
by disclusion in eccentric mandibular
movements – mandibular guidance.
Also, posterior teeth provide most of
the support from vertical forces, limiting
the amount of stress on anterior teeth in
MI. There seems to be consistent evi-
dence that this ‘ideal’ occlusion princi-
ple is much more helpful in protecting
the teeth themselves than in preventing
TMDs,68,69 muscular dysfunction70 or
parafunctional activity,71 since the main
etiologies of these are not occlusal.
From a generic point of view, guid-
ance in eccentric movements can be
obtained with anterior guidance, canine
guidance, and group function. Anter-
ior guidance will, ideally, distribute the
loads during protrusive movements
on all incisor teeth. In the initial path of
movement all the incisors make con-
tact. As the mandible moves forward,
these contacts become progressively
exclusive of the central incisors, as they
are usually longer. One important fea-
ture to be incorporated in anterior teeth
is the ability of the mandible to close in
a rested (and usually slightly forward)
position without causing any fremitus
– a horizontal shift or vibration of teeth
indicating instability (Fig 7).72 Fremitus
on the anterior teeth indicates a lack of
overjet in the MI occlusal stop in the cin-
gulum of the maxillary teeth. It is also in
line with ‘centric freedom’ or ‘long cen-
tric’ concepts, which maintain stabilizing

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 CLINICAL RESEARCH
Fig 8 Anterior guidance and group function oc-
clusal contacts achieved in clinical practice (left)
versus an ideal occlusal scheme (right). An ideal
occlusal scheme is more of a concept to work to-
wards rather than something precisely achievable
in clinical reality.
contacts in the first 1 to 1.5 mm of move-
ment. This feature has been consistently
considered in literature reviews on this
topic,72-74 and the authors believe it to
be an essential step that is often over-
looked in the adjustments of orthodontic
and restorative treatments, causing re-
striction in mandibular movements and
unnecessary stress on anterior teeth.
Once MI stops are defined, this ‘cen-
tric freedom’ is easily accomplished in
protrusive movement by asking the pa-
tient, in the upright position in the dental
chair, to continuously open and close
the mouth, in a relaxed position but at
a fast pace. When the clinician applies
very soft finger touch on the buccal sur-
face of the anterior teeth, those teeth in
stress will transmit an evident vibration.
These contacts need to be identified,
adjusted, and reviewed during subse-
quent appointments until the fremitus
completely disappears.
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While the anterior guidance scheme
is more or less consensual, the deci-
sion about which lateral guidance to
choose for a specific patient requires
some flexibility.73 Canine guidance may
promote the complete absence of hori-
zontal loads in posterior teeth, is easy to
create and has been linked to reduced
muscular activity.75,76 Not only is it more
prevalent in Class II occlusions (more
inclined occlusal plane), but also easier
to do in these patients than in Class I
or III patients (more horizontal occlusal
plane).73 In group function, more com-
mon in older patients,74 contacts occur
from the canine to the mesial cusp of the
first molar during the initial part of move-
ment, while progressively being trans-
ferred anteriorly until only the canines
touch when reaching edge to edge.
It has been pointed out that canine
guidance is the usual scheme to try to
implement first. This is especially true in
orthodontic treatment, when no restor-
ations are to be performed.74 However,
canine guidance does not reduce ex-
cessive parafunctional activity in many
patients, and stress may be induced on
the canines. In addition to tooth-related
problems, this stress can cause fractures
of the restorative materials. In cases with
a natural functioning canine guidance
where a significant anterior-only attrition
is already seen, parafunctional activity is
suspected to continue. In these cases it
is likely that group function will promote
better load distribution on more fragile
restorative materials.
In addition to the above recommenda-
tions, it is important to state that occlusal
schemes are highly variable in nature,
and patients usually adapt well to either
canine guidance or group function.77

Table 1 Occlusal concepts to implement
Maximum intercuspation (MI)
Anterior guidance
Canine guidance
Lateral guidance
Group function
Freedom in mandibular movement
Patient comfort, simplicity,
and minimal invasiveness
From the authors’ perspective, it is ir-
rational to believe that absolute ideal
occlusal contacts can be achieved in
patients, as this is a concept to work to-
wards rather than a clinical reality (Fig 8).
Instead of complicating treatment with
strict occlusal schemes, it is preferable
to provide patient comfort; simplicity of
treatment; less-invasive strategies; and
a focus on generic, evidence-based
guidelines such as posterior disclusion,
freedom in centric, load distribution, and
NEGRÃO ET AL
#JMBUFSBM
TZNNFUSJDBM
DPOUBDUT
JO
BMM
UFFUI
MFTT
JOUFOTF

on anterior teeth
Discludes all posterior teeth during protrusive move-
ments
Discludes all posterior teeth during excursive move-
ments
Easier to implement
More common in younger and Class II patients
Potential to reduce muscle activity in some patients
Higher stress on canine teeth
Progressively discludes posterior teeth during excur-
sions
More difficult to implement
More common in older and Class I and III patients
Potential to better distribute loads on several teeth and
therefore reduce stress on restorations
Provides some degree of movement from MI (centric
freedom) before any disclusion
Removes damaging horizontal forces on anterior teeth
with a relaxed mandibular closure
Since no clear advantages exist to select rigid occlusal
schemes, comfort, simplicity, and being minimally
invasive or noninvasive are essential principles when
providing an occlusal scheme
the avoidance of non-working side con-
tacts on restorations.48,77 Table 1 sum-
marizes the essential occlusal concepts
to implement.
Treatment sequence
There are many sequential approaches
when doing a full-mouth wax-up in the
laboratory. In most cases, the final pos-
ition of the maxillary incisal edge is de-
termined at the start of the procedure,
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1 2

3 4

Fig 9 Treatment sequence according to the ADA: Stage 1: Mandibular teeth to establish a new functional
occlusal plane. Stage 2: Maxillary posterior teeth establishing the new vertical dimension. Stage 3: Anterior
guidance. Stage 4: Esthetics on the buccal areas of the maxillary teeth.

based on the mock-up or digital smile
design provided by the clinician. Then,
all the remaining teeth are waxed. In a
direct approach, a different sequence
needs to be applied to provide a sys-
tematic, organized, and efficient use of
time, whether the treatment is carried
out in one long or several shorter ap-
pointments. A few points must be con-
sidered in the promotion of a different
approach:
„Trial-and-error composite resin place-
ment should be avoided. Subtractive
changes of trial vertical dimensions
are easier to perform than additive
changes, for obvious reasons. So
the principle for a direct approach
is always to add composite resin to
create an unworn anatomy on the res-
torations and then to remove it, where
necessary.
„Considering the above principle, the
palatal surface of maxillary anteriors
can only be finished after the final ver-
tical dimension and incisal edges of
the mandibular anteriors have been
established. For the same reason, the
esthetic layering of maxillary anteriors
is only possible after the palatal sur-
face has been established.
With these specifications inherent to a
full-mouth ADA, the most efficient treat-
ment sequence, according to the au-
thors, is performed in five stages (Fig 9;
Table 2):

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Table 2 ADA treatment sequence
Stage Main goal
Stage 0 Diagnosis and planning
Stage 1 Functional occlusal plane
Stage 2 Vertical dimension
Stage 3 Guidance
Stage 4 Esthetics and phonetics
„Stage 0: Diagnosis and planning –
evaluate critical aspects such as CR-
MI slide, wear pattern, and incisal
edge position.
„Stage 1: Functional occlusal plane –
restore mandibular teeth to establish
a new functional occlusal plane.
„Stage 2: Vertical dimension – restore
maxillary posterior teeth, establishing
the new vertical dimension.
„Stage 3: Guidance – restore palatal
surfaces of maxillary anteriors and
mandibular guidance.
„Stage 4: Esthetic and phonetics –
perform a mock-up, test for phonet-
ics, and restore the incisal and buccal
areas of the maxillary teeth.
NEGRÃO ET AL
Procedures
Evaluate difference from CR to MI; identify wear pattern;
observe tooth display and gingival levels
Restore the mandibular teeth to establish a new functional
occlusal plane
Mandibular incisal edge display can be used as a starting
reference point
The patient is left with a provisional vertical dimension
Restore the maxillary posterior teeth and perform the occlus-
al adjustments from a functional perspective, establishing
the final vertical dimension with static occlusal contacts
Construct and adjust the palatal surfaces of maxillary an-
teriors for a correct anterior guidance with posterior tooth
disclusion
A direct mock-up of the maxillary incisal edges provides a
perspective of the new occlusal plane, tooth display, and
phonetics
Adjustments are made if needed
Using a modified silicone matrix made from the mock-up,
incisal edges and maxillary buccal areas are finally restored
It is also important to think about the dif-
ferent wear patterns since they require
some specific considerations.
Generalized wear
A generalized wear pattern can be
identified by a flattened occlusal plane
and Curve of Spee (Figs 6 and 10). In
Stage 1, all the mandibular teeth should
be raised to what is thought to be the
most adequate anatomy. To do so, the
mandibular incisal display should be
taken into account. After the Stage 1
direct restorations, if an excessive dis-
play is observed, adjustments should be
made to create a new occlusal plane.
If the next stage is to be performed at
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a b
Fig 10 Examples of generalized wear (a), anterior wear (b), and posterior wear (c).
the next appointment, at least one tooth
from each side should have simultan-
eous contacts for mandibular stability at
this new provisional vertical dimension.
To achieve this, the clinician may need
to add a provisional restoration on a sin-
gle maxillary tooth. It is also important
that the next stage is performed within a
few days to minimize the risk of fractures
and patient discomfort.
During Stage 2, the maxillary teeth are
restored to create a functional occlusal
plane and new vertical dimension. To
do this, restorations are initially applied
on the molars and bicuspids, providing
the lost anatomy on these teeth on both
sides. Rubber dam is then removed and
the occlusion adjusted. The occlusal
adjustment in this phase will provide a
vertical dimension that is close to final.
Adjustment must accomplish bilateral
simultaneous contacts on all the poster-
ior teeth, leaving a minimum of 2 mm of
space in the anterior region for the maxil-
lary palatal restorations while providing
esthetically acceptable facial propor-
tions (Fig 9).
During Stage 3, with bilateral con-
tacts and a stabilized mandibular pos-
ition, the palatal surface of the anterior
maxillary teeth are restored and adjusted
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c
accordingly. In most cases, these palatal
restorations are performed over intact,
non-worn, palatal enamel to provide new
static contacts with the mandibular teeth.
During Stage 4, the buccal esthetic
parameters of the maxillary teeth are
established and phonetics tested. A
mock-up will allow for the testing of
tooth display and any interference in
speech. If critical phonetic problems are
present, it is important to correct them
at this stage with the necessary sub-
tractive adjustments. Patients will usu-
ally overcome minor speech problems
within a few days. In case of doubt, it
makes more sense to finalize the restor-
ations and reevaluate. Any subtractive
adjustments can always be performed
later on.
This final stage will integrate the fi-
nal esthetic parameters, especially in-
cisal edge positions, with the anatomy
previously created in the palatal areas
(Fig 11). A smooth transition from inter-
cuspation contact, guidance path, and
incisal edge should be provided. The fol-
lowing steps allow the clinician to create
this functional–esthetic harmony in the
anterior guidance (Fig 11):
„A direct esthetic mock-up is made to
establish the desired incisal edge.
 NEGRÃO ET AL

a b

c d

Fig 11 Details of the final stage. (a) Situation at the end of Stage 3, with composite resin on the palatal
surfaces of the maxillary anteriors. (b) An esthetic mock-up is performed and a silicone matrix is con-
structed to capture the incisal position. (c) The silicone matrix is adjusted with a bur to smoothen the tran-
sition between the palatal anatomy and the new incisal edge. (d) Part of the previous palatal restoration
is removed, and final restorations are performed with the adjusted silicone matrix. A small palatal chamfer
with which the new material can engage will probably improve retention.

„A silicone matrix is constructed with
this direct mock-up to capture the
incisal position in order to guide the
final restorations as well as the previ-
ously created palatal anatomy.
„The silicone matrix is adjusted with
a bur to smoothen the transition be-
tween the palatal anatomy created
in Stage 3 with the new incisal edge
position to be created in Stage 4. It
is important to leave the incisal edge
with at least 1-mm thickness, as ex-
plained later in the discussion.
„The customized silicone matrix will
then serve to guide the palatal and
incisal anatomy of the final esthet-
ic restorations. Part of the previous
palatal restoration may need to be
removed for esthetic layering. In this
case, overall retention will probably
be improved by a small palatal cham-
fer with which the new restorative ma-
terial can engage.78
Once all areas are restored, small chang-
es and adjustments may be needed. If
so, it is usually simple to provide further
adjustments without the need for addi-
tive composite resin, which is an essen-
tial premise of the concept.

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Anterior wear
A very common situation is anterior wear
with unworn posterior teeth (Figs 6 and
10). In these cases, the anterior teeth
usually undergo compensatory eruption,
showing more coronal gingival levels
relative to the posterior teeth. The treat-
ment of choice should be orthodontic
intrusion on the over-erupted segment,
which places the gingival level at its cor-
rect position, followed by restorations.
This is the best approach because un-
worn posterior teeth indicate that there is
no loss of vertical dimension; therefore,
restoration of the posterior teeth could
be avoided.
If no orthodontic treatment is per-
formed, all mandibular teeth may need
to be restored, the OVD raised, and a
new occlusal plane established. If there
is a significant difference from CR to MI,
this will make the case easier because
anterior space is automatically created
and fewer posterior teeth will need to be
restored. The amount of additive mater-
ial in the mandible (Stage 1) is limited by
the maximum display of the mandibular
incisors to be esthetically acceptable.
In cases of anterior wear, the vertical
dimension is assessed before additive
restorations are performed on the maxil-
lary teeth (Stage 2). This is because any
additional volume on unworn posterior
teeth should be limited, since they do
not actually need restorative protection.
So, before proceeding to Stage 2, ad-
justments are made in the mandibular
posterior restorations until the patient
has about 2 mm of anterior space for a
final corrected overbite and overjet (both
around 2 to 4 mm). After this, only the
maxillary posterior teeth that do not con-
tact at this new vertical dimension will
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be restored, to provide posterior stabil-
ity (Stage 2). Once the posterior teeth
and palatal surfaces are restored on the
maxillary teeth, Stages 3 and 4 (anterior
guidance and esthetics) are performed
as for generalized wear, as previously
mentioned.
Posterior wear
Wear cases limited to posterior teeth
(far less common) are highly challeng-
ing (Figs 6 and 10). Attrition wear exclu-
sive of the posterior teeth occurs when
anterior teeth do not contact, eg, open
bites and Class II or III with severe over-
bites and overjets. In these cases, any
approach that does not include ortho-
dontics should be seen as a temporary
resolution.
One option would be to restore the
posterior teeth, leaving the same dys-
functional anterior guidance and main-
taining the same occlusal scheme. If a
correct anterior guidance is attempted,
the same treatment sequence used for
generalized wear can be applied. How-
ever, only a minimum amount of poster-
ior restorative volume is recommended,
otherwise the anterior space may be-
come excessive and a correct anterior
guidance would be impossible to pro-
vide. Therefore, these patients should
be monitored closely for repairs, since
reduced composite resin thicknesses
can be highly prone to further wear and
fracture due to the absence of anterior
guidance.
Exclusive posterior wear also occurs
in cases with a significant difference be-
tween CR and MI, combined with grind-
ing only in CR. Contrary to horizontal
movements in the anterior wear pattern,
these patients grind their teeth within the

Fig 12 Initial situation: portrait.
limited posterior area of the first contacts
around CR. The grinding usually occurs
during the night, with a retruded man-
dible. During the day, the mandible ad-
vances, finding a more stable position
with more contacts in MI. This explains
why these patients have anterior con-
tacts but wear is only seen in the pos-
terior teeth. The ideal treatment would
be orthodontic intrusion of over-erupted
posterior teeth (which usually requires
efficient skeletal anchorage devices),79
and restoration of the lost posterior
structure. An alternative to the ortho-
dontic solution is to restore these cases
as previously described for generalized
wear cases. As mentioned, if the centric
slide is extensive it may be preferable
to use MI instead of CR to provide an
NEGRÃO ET AL
Fig 13 Initial situation: smile. Teeth seem to have
worn around 20% to 30% of their initial length. Com-
pensatory eruption also seems to have occurred.
Fig 14 Initial situation: intraoral view.
acceptable anterior guidance without
overbulking the palatal surfaces of the
maxillary anterior teeth.
Case presentation
A 21-year-old female presented with
complaints about her smile and gener-
alized teeth hypersensitivity (Figs 12 to
16). She said she displayed nervous bu-
limia behavior on average twice a week,
or whenever she was particularly anx-
ious. She had been in psychotherapy
for the past year and attended regular
psychiatry, psychology, and gastroen-
terology appointments.
Clinical examination revealed gener-
alized loss of tooth structure, including
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Fig 15 Initial situation: detailed view of worn maxillary dentition. Clinical history revealed that acid erosion
due to bulimic behavior, aggravated by parafunctional attrition and abrasion from aggressive toothbrush-
ing, were the most likely etiologic factors.

Fig 16 Maxillary and mandibular occlusal views. Palatal surfaces of the anterior maxillary teeth and oc-
clusal surfaces were the most affected areas.

dentin, involving all the teeth, with mini-
mum wear on the mandibular anterior
teeth. The maxillary anterior teeth con-
GPSNFE
UP
B
7BJMBUJ#FMTFS27-29 Class V
erosion classification: a loss of more
than 2 mm of incisal edge, extensively
exposed dentin and enamel loss on the
palatal areas, and distinctively reduced
facial enamel (Figs 14 to 16). The tooth
wear pattern confirmed the etiology of
acid erosion combined with parafunc-
tional activity, mainly affecting the palatal
surfaces of the maxillary teeth and the
occlusal surface of the maxillary mo-
lars.14 Tooth 25 was missing.
No TMDs were diagnosed, nor was
there a significant difference between
CR and MI. The periodontal parameters
were normal, with a good oral hygiene.
There were obvious esthetic conse-
quences, such as short and discrete
teeth, and secondary eruption causing
a slightly excessive gingival display.

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Treatment plan discussion

Due to the extent of the tooth structure

loss, only conservative approaches with
minimal or no tooth preparation were rec-
ommended to the patient. Although ce-
ramic restorations were presented as the
best long-term solution, the final decision
was to use composite resins, for financial
reasons. Moreover, it also made sense to
gain time to evaluate the bulimic disorder
progression. This type of case demands
the use of some sort of restorative solu-
Fig 17 Stage 1: In the initial stage, the mandibu-
tion, otherwise further worsening of the lar posterior teeth are restored up to their supposed
condition is likely to occur. original anatomy.
It is difficult to determine if the OVD
was lost in this case. Although the pos-
terior teeth were worn, there seemed to
be a degree of compensatory eruption.
Despite this, the treatment would have
to provide an increased vertical dimen-
sion, since no space could be created
with a CR-MI difference.
This case was approached accord-
ing to the guidelines described for a
generalized wear case. The mandibular Fig 18 Stage 1: The mandibular teeth from the
first premolar to the first molar on each quadrant
occlusal plane indicated an overerup-
are restored. After rubber dam removal, the patient
tion of the anterior teeth. The cause for is left with a least one occlusal contact on each side
this is related to the Class II division 2 at this provisional vertical dimension.

occlusal pattern. The erosion of the

palatal surfaces of the maxillary anter-
ior teeth may also have played a role in
this. The maxillary occlusal plane was
flattened, with generalized wear. There-
fore, it was planned to correct the man-
dibular occlusal plane, increasing the
posterior teeth and leaving the anteriors
untouched. Once that was performed,
the maxillary posterior teeth would be
restored, increasing the vertical dimen-
sion. And finally, the anterior guidance
and maxillary buccal esthetics would be
addressed.
An implant with a provisional crown
was planned to replace missing tooth
25. The implant-supported provisional
crown allows time for the evaluation of
the clinical performance of the compos-
ite resin restorations before a definitive
ceramic crown is delivered.
Treatment
In the first appointment, all the posterior
mandibular teeth from the first premolar

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Fig 19 Stage 2: At the second appointment, the
direct reconstruction of the occlusal surfaces of the
maxillary posterior teeth to their original anatomy is
done. Occlusal adjustments are then performed to
create a stable static occlusion at this new vertical
dimension.
Fig 20 Stage 3: Palatal surfaces of the maxillary
anterior teeth are restored to provide contacts at the
vertical dimension created in the previous stage.
to the first molar in each quadrant were
restored with a microhybrid direct com-
posite resin, based on their lost anatomy
(Figs 14 and 15). There was no tooth
preparation, only the direct application
of the material. The mandibular incisors
were not restored as they were over-
erupted due to the increased overjet.
At this stage, the patient was left with a
transitory vertical dimension, where pro-
visional tooth contacts should provide
mandibular stability.
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A second appointment was planned
for the direct reconstruction of the oc-
clusal surfaces of the maxillary poster-
ior teeth from the first premolar to the
first molar (Fig 16). Once the occlusal
contacts were adjusted, the new vertical
dimension was established.
During the third appointment, all
the maxillary anterior palatal surfaces
were reconstructed, with the new anter-
ior guidance with posterior disclusion
(Figs 17 and 18).
In the fourth appointment, the maxil-
lary anterior gingivectomy and impres-
sions for home bleaching with 10% car-
bamide were performed, since all the
dentin was now protected. Two weeks
after the bleaching process, a mock-up
of the maxillary anterior teeth was per-
formed directly in the mouth. The direct
mock-up basically previews the buccal
anatomy and incisal edges (Fig 19). A
silicone matrix was made to record the
desired incisal length on the mock-up.
During the final sessions, all the buc-
cal surfaces and incisal edges of the
anterior teeth were layered with the aid
of the silicone matrix, providing an es-
thetic occlusal plane. In order to smooth
the transition from the palatal composite
resin created in the previous stage and
the final incisal edge based on the mock-
up, the silicone matrix needed to be ad-
justed with a carbide bur (Figs 8, 20, and
21). In this way, the final anterior restor-
ations preserve the occlusal contacts
in MI and the functional path of the an-
terior guidance, while adopting the new
incisal edge tested in the mock-up. The
palatal composite resin can be partially
removed to help in the layering process.
Occlusal adjustments were carefully
made to provide posterior disclusion in
 NEGRÃO ET AL

Fig 21 Stage 3: At the end of this stage, both static occlusion and anterior guidance have been created
for the patient. The anterior guidance is adjusted to provide posterior teeth disclusion. From the buccal view,
one can see that the transition between the palatal restoration and the buccal surface is still unrestored.

a b

Fig 22 Stage 4: Esthetic direct mock-up to evaluate final incisal edge position. Incisal display at rest ac-
cording to age and lip movement will determine the most natural position for each patient.

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Fig 23 The silicone matrix, previously custom-
ized with the direct mock-up, serves to guide the
final esthetic restorations.
Fig 24 After the palatal and incisal anatomy are
established in the palatal shell, the resin stratifica-
tion is performed.
Fig 25 Final occlusal adjustment should provide
centric stops on all teeth (stronger on posteriors)
and an anterior guidance that provides posterior
disclusion.
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all mandibular movements (Fig 19). The
primary anatomy, contours and line an-
gles, initial polishing, secondary anato-
my (macro and micro-texture), and refin-
ing polishing were distributed over two
appointments (Fig 20). The final results
were very satisfactory for the patient
(Figs 21 to 25).
Discussion
In this clinical case, a good esthetic re-
sult was achieved with direct composite
resin restorations (Figs 26 to 31). Since
bulimia is a disorder with a strong psy-
chological component, a complete cure
is difficult to achieve; therefore, higher
maintenance is necessary. This should
be explained to the patient.
The traditional wax-up approach is
undoubtedly the most strongly recom-
NFOEFE
TUSBUFHZ
#FJOH
BCMF
UP
QFSGPSN

try-ins can certainly prevent problems
and help the dental team to visualize the
final result. This is especially true in com-
prehensive interdisciplinary cases com-
bining wax-ups and orthodontic setups.
The present article, however, is focused
on the direct, noninvasive reestablish-
ment of function and esthetics of a worn
dentition. Although this is not a new con-
cept,16,17 the proposed step-by-step
thought process – based on consistent,
evidence-based principles – clarifies
essential steps and guides the clinician
to achieve a predictable result.
The proposed method does present
disadvantages compared to a wax-up-
based strategy, these being the clini-
cian’s technical limitations, longer ap-
pointments, and a suboptimal occlusal
definition (Table 3). However, when a
 NEGRÃO ET AL

Table 3 Different techniques for restoring worn dentitions

Wax-up-based Wax-up-based Direct treatment

direct restorations indirect restorations without wax-up (ADA)

A detailed anatomical, func-

Treatment planning is facilitated with mounted
Treatment
casts since there is a better visualization of avail-
planning
able space and distribution of restorative volumes
tional and esthetic clinical
evaluation needs to be per-
formed before starting the re-
storative stage because there
is no try-in of the wax-up

Direct restoration of the man-

Wax-up is made based on clinical indications, usu-
Starting dibular arch using the man-
ally using the desired maxillary incisal edge display
point dibular incisal edge display
as a reference
as a reference

In order to provide a logical

and optimized workflow, the
The wax-up is tested in the mouth through a principle is that compos-
mock-up with silicone indexes before initiating the ite resin is added until the
Possibility of rehabilitation desired anatomy and then
corrections
#PUI
BEEJUJWF
BOE
TVCUSBDUJWF
DIBOHFT
DBO
CF
reduced to accommodate oc-
made by the clinician or dental technician clusal limitations; therefore, no
additive changes are usually
needed

Knowledge of anatomy, and

Technical Ability to work with articulators, a facebow, impres-
the ability to sculpt and stratify
demand sions, and eventually preparations
composite resins

Occlusal
Potentially higher Potentially lower
precision

Minimally invasive or Depends on the prepar- Minimally invasive or non-

Invasiveness
noninvasive ation design invasive

Depends on the wax-

Esthetic Depends on the clinical ap-
up quality and clinical Highest with ceramics
outcome plication
application

More prone to fractures More prone to fractures and

and staining Highest longevity and staining
Longevity
High maintenance stability with ceramics High maintenance require-
requirement ment

Costs Higher laboratory fees Highest laboratory fees Higher chair time fees

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Fig 26 Silver powder can be very helpful to es-
tablish a natural texture according to the patient’s
age as well as provide natural asymmetries in sizes,
shapes, and rotations.
wax-up is performed, several visits are
mandatory (eg, mock-up or digital smile
design, facebow registration, intermax-
illary records, and wax-up try-in). An
important advantage of the direct tech-
nique is the possibility of doing a com-
plete rehabilitation without the need for
any laboratory steps. While chair time
is regarded as the most significant cost
in more-developed western countries,
it is important to realize that in many
countries the laboratory costs are actu-
ally more impactful. Additionally, many
clinicians do not have access to dental
technicians who are capable of perform-
ing comprehensive wax-ups.
An interesting debate was raised re-
garding the real need for facebow reg-
istration in the fabrication of complete
dentures, with increasing evidence of
its clinical irrelevance.80-83 A facebow
serves two purposes: 1) to provide a
more or less accurate rotation axis of
mandibular closure, potentially improv-
ing occlusal accuracy; and 2) to help in
the spatial orientation of the maxillary cast
for esthetic purposes. The main lesson
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learnt from recent literature may be that
occlusal and functional parameters are
not improved in complete dentures when
a facebow articulation is used. Also, in
practical terms, every extensive reha-
bilitation (fixed or removable) can be
esthetically tested and readjusted in the
patient’s mouth without the need for the
previous facebow mounting of casts.
However, it is incorrect to believe that
facebow articulation will not save clinic-
al time by improving the communication
with the technician regarding esthetics,
especially the orientation of the occlusal
plane. With these two important insights
in mind, we can also assume that using a
direct approach in extensive wear cases
can potentially achieve a similar func-
tional quality to indirect or wax-up-based
strategies. However, this is not to say that
wax-ups on facebow-mounted articulat-
ed casts will not optimize the process,
because they do help significantly.
In the wax-up-based indirect strategy,
the maxillary arch is first transformed
into the desired shape based on the
mock-up. Then, the mandibular teeth
are adapted to the transformed maxil-
lary teeth for a correct vertical dimen-
sion, overjet, and overbite. This is the
traditional planning approach in com-
plete dentures and even in orthognathic
surgery. It is critical to understand this
notion, since it provides a mental aid to
plan extensive cases with indirect restor-
ations – the maxilla guides the esthetics
and then the mandible will adapt, when-
ever possible, providing the function.
However, in the direct approach pro-
posed in this article, the mandibular arch
is established first, leaving the esthetics
for the final steps. This is the exact op-
posite of an indirect wax-up strategy. As
 NEGRÃO ET AL

Fig 27 Final result: smile frontal view. Fig 28 Final result: smile lateral view.

Fig 29 Final result: intraoral view of maxillary anteriors.

Fig 30 Occlusal view at 2 years showing some wear and small areas of chipping, common in extensive
restorations with composite resin. An implant with a provisional restoration was placed on tooth 25.

43
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 CLINICAL RESEARCH
Fig 31 Final result: portrait view.
mentioned previously, the main reason
for this is that the anterior maxillary res-
torations cannot be completed without
a correct establishment of the final pos-
ition of the mandibular incisal edges.
A common misconception is the po-
tential negative effect of the patient be-
ing left with unstable occlusion between
appointments due to the sequential ap-
proach. In case this happens, a mini-
mum time between each treatment stage
should be planned – never more than a
few days. However, in cases of increased
vertical dimension, where the mandible
is left stable with bilateral simultaneous
contacts, there is usually no concern.49
This is, for example, a common situation
during orthodontic treatments.84
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Mechanical limitations in composite
resins make these restorations suscep-
tible to fractures, and they require high
maintenance.85 In fact, both polishing
and small repairs should be expected in
the esthetic zones during the first 3 to 5
years.86 It is a common assumption that
the same incisal thickness should be
provided in the composite material as
the original volume of the intact, unworn
tooth. Although this can be recommend-
able with ceramic veneers, from the au-
thor’s experience it is not advisable with
DPNQPTJUF
SFTJOT
#POEFE
GFMETQBUIJD

ceramic, for example, has an elastic
modulus similar to enamel,87 while that
of composite resin is much lower.88 This
makes it susceptible to fractures, espe-
cially when applied in extensive restor-
ations. To increase its cohesive fracture
resistance, the authors recommend as
large a volume as possible of composite
resin in the incisal edge, within the obvi-
ous esthetic limitations (at least 1 mm).
Understanding broad functional par-
ameters and biomechanics of tooth
wear is more important than blindly fol-
lowing any specific advocated tech-
nique or material. A comprehensive,
well-planned approach will optimize
time and results with most techniques.
In cases of attrition wear, occlusal splints
should always be used once the restora-
tive phase is concluded. Even though
the use of splints has low patient compli-
ance if no TMD symptoms are present,89
they should nevertheless be provided.
Information regarding specific etiology
of wear is of paramount importance in
trying to improve patient collaboration
and behavioral change, when needed.90
Patients should also be informed about
possible contingency plans in case of
 NEGRÃO ET AL

treatment failure. Nevertheless, these occlusal principles. The use of virtual

restorations are easy to repair,4 biologic
complications are rare, and the level of
patient satisfaction is high.85
From a conceptual point of view, one
needs to consider that a laboratory wax-
up is made using the same principles
outlined in this article, the only differ-
ence being the capacity for trial-and-er-
ror corrections with both subtractive and
additive changes in the wax. This can
also be performed in the mouth, as long
as the additive changes are reduced
or eliminated. This means the clinician
needs to provide an intact anatomy with
composite resin and then reduce for a
correct visual and functional integra-
tion. The process is certainly achieva-
ble when the clinician has the necessary
knowledge of esthetic, anatomical, and
CAD wax-ups91 is likely to increase in
the future. In this sense, it is also impor-
tant for clinicians to diagnose and per-
form treatment planning for extensive
cases based on what is examined with
the patient chairside.
Even though the described direct
technique does present some challeng-
es, it can be a good alternative for many
clinicians to provide extensive rehabili-
tations that would otherwise not likely be
performed.
Acknowledgments
Figures 2 to 4 and 6 to 11 were designed
using elements from Perfect Tooth soft-
ware (eHuman).

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