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cosmetic dentistry Italian Edition Vol. 2, 2017

logical consequences, too. Objective symptoms or complaints reported by patients are shorten- ing of teeth, discoloration, tooth displacement, dentin sensitivity, as well as an increased risk of decay and premature loss of marginal adapta- tion of the restoration. The significant impact of tooth wear on occlusion, function and aesthetics leads the patient to seek advice and intervention. The biomechanical challenge shall entail a range of treatments involving different specialties, from preventive measures to full-mouth reha- bilitation. Intermediate stages (slight to mod- erate erosion or abrasion) require other clinical measures, such as various forms of adhesive and partial restorations. The aim of this paper is to present a sound clinical concept for addressing various forms of early restorative intervention and their potential to restrict ongoing tissue de- struction. _A comprehensive treatment approach The modern approach to the treatment of tooth wear aims to stop its progression before full prosthetic rehabilitation becomes indicat- ed, which would require the removal of large amounts of additional tooth substance with potential biological complications10,11 and a rath- er inadequate biomechanical rationale. The ap- proach involves three steps: 1_ a comprehensive etiological clinical in- vestigation, including diet analysis and identification of general/ medical and lo- cal risk factors; 2_ treatment planning and execution, inclu- ding a proper functional and aesthetic wax-up defining the new smile line and tooth anatomy, transferred then to the mouth with a combination of direct and indirect restorations; 3_ a maintenance program, including a pro- tective night guard and, potentially, re- pair or replacement of restorations over a medium- or long-term time frame. case report _ aesthetic and restorative dentistry The restorative options at hand comprise direct partial composite restorations, indirect partial composite or ceramic restorations, and indirect full-ceramic restorations. Considering the more dramatic failure patterns observed with conventional prosthetic restoration,10,11 us- ing more conservative restorations, such as par- tial direct and indirect restorations, appears to have irrefutable advantages and promising out- comes in the treatment of severe abrasion and erosion.12-14 _Dahl’s concept and controlling the vertical dimension of occlusion The idea of increasing the vertical dimension of occlusion (VDO) to treat or restore patients with abnormal tooth wear has been described and applied for a long time; one of the first cli- nicians to promote this technique was Dahl, who published many articles on this topic.15 His ap- proach was to use a metal appliance to elevate the occlusion and allow teeth to move passively until they are again in occlusion and then cre- ate space to restore the teeth stabilised by the appliance.15 The dental movements are intended Fig. 1_Comprehensive treatment scheme for anterior and posterior tooth wear or erosion. The length of the anterior teeth is reduced by combined wear or erosion (1). The VDO needs to be augmented (2). On the models and based on a wax-up, a new anterior guidance and smile line are established (3), from which an index is made and transferred to the mouth when proceeding with posterior restorations (4). Three different conditions are encountered in the posterior areas: (a) no or minimal tooth loss (occlusal stops are made with composite of any type); (b) moderate tooth loss and/ or small to mediumsized restorations (occlusal morphology is re- established with a hybrid composite and direct technique); and (c) severe tooth loss and large metal-based restorations (occlusal morphology is re-established with indirect tooth- coloured restorations —overlay). Fig. 2a Figs. 2a-c_Pre-op situation showing moderate to severe tooth wear, due to combined abrasion and erosion aetiologies. However, the amount of tissue loss does not speak in favour of a conventional prosthetic solution; rather, an interceptive solution using direct composite restorations would be used in this case. Fig. 2b Fig. 2c cosmetic dentistry 2_2017 15

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