Direct composite veneers for erosive-abrasive lesions – case report

Introduction

Oral health is a very important aspect in the general context of human health, so it must be given a special attention. Although most people report to the dentist accusing dental pain and in need for emergency treatment, there are also a number of patients who require dental medicine for aesthetic reasons.

Nowadays, dentistry is in a continuous evolution, combining art with science. Thus, the practitioner, in addition to the theoretical notions, must possess skills, creativity, meticulousness and aesthetic approach, in order to render as harmonious the aspect of the patient’s teeth related to his physiognomy. A proper aesthetic aspect is a necessity in modern society⁽¹⁾.

Dental lesions take two major forms, depending on their etiology: carious and non-carious. Although dental lesions of carious etiology are the most commonly encountered situations which affect hard dental substance, the non-carious lesions are of particular importance. The changes in our nutrition and modern life have led to an increase in the prevalence of non-carious dental lesions, such as abrasion and dental erosion, especially in the anterior region of the dental arch, affecting the aesthetic function^(2,3).

Abrasion is a form of dental wear in which interdental contacts are not involved. It represents the disappearance of the dental tissues by friction with an abrasive body, the most common and known etiological factor being the incorrect dental brushing. The abrasion lesions are accentuated with age, the prevalence being higher in patients over 35 years old.

Dental erosion represents the loss of enamel and/or dentine by dissolution under the action of acids, other than those from the bacterial dental plaque. Excessive consumption of citrus fruits, carbonated drinks or gastroesophageal reflux are the main causes. If repeated exposure to acid attack exceeds the reparative and compensatory capacity of the oral cavity, the homeostatic balance of the tooth’s mineral content at its interface with the local environment may be impaired. In the early stages, erosion lesions are difficult to identify and pass unobserved both by dentists and patients, but their prevalence is high⁽⁴⁾. Therefore, prevention and education programs for patients can drastically decrease the occurrence and evolution of lesions of this type.

The association with other pathological factors (abrasion, parafunctions) increases the rate of the tooth wear progression. Thus, combined lesions, with mixed etiology, erosive-abrasive, are often encountered in the clinic. For example, the erosion process is amplified if the teeth are brushed when the acid is still present in the oral cavity, because the demineralization of the dental structure leaves the organic matrix of dentine or enamel exposed, without support of mineral ions. Dental brushing at this time will remove the organic matrix so that remineralization can no longer take place. If brushing is done 2 to 3 hours after the ingestion of acid products, then remineralization is possible through calcium ions and salivary phosphates.

The complications of erosive-abrasive lesions are not only aesthetic, but they can affect, through their progression, the vitality of dental pulp. Also, the massive absence of the coronary tooth tissue can cause fracture, leading to the loss of the respective tooth from dental arch. The treatment of erosive-abrasive lesions is conservative, having as objective the morphofunctional restoration of the tooth and the prevention of pulpal complications. Among the modern restoration materials that can be used, resin composites represent the first choice^(5,6).

Erosive and/or abrasive lesions in the anterior region of dental arcades benefit from direct and indirect laminate veneer restorations with composite materials. In the direct method, in chair technique, the veneers are made by simply inserting the material into the dental preparation, in one session^(7,8). Thus, the reduced time required, the simple working maneuver, the very good aesthetic results as well as low costs make them the first treatment option. In the indirect technique, composite veneers are prepared in the dental laboratory and then applied on the dental surface⁽⁹⁾.

Case report

A 41-year-old male patient presented to the dental practice for the dental treatment of important loss of both enamel and dentin on vestibular face in anterior upper incisors, especially in teeth 11 and 21. The clinical aspect was characterized by the complete absence of the enamel and dentin tissue also affected, on the entire facial surfaces. The teeth had been previously treated using direct resin composite restorations in their cervical areas, but the actual aesthetic aspect was completely unsatisfactory for the patient right then because the abrasive-erosive lesions continued to involve the entire facial face. The anamnesis revealed the excessive brushing with hard toothbrushes and the daily intake of carbonated beverages.

In this article, we present the treatment using direct composite veneers for restoration of tooth 11 (Figure 1).
 

The massive loss of hard dental tissues led us to the decision of restoring using composite veneers. We chose the direct laminate resin composites technique, which is easily achieved in dental office, provides good results with minimal time consuming and financial costs for the patient.

In order to perform the treatment, we started with professional brushing for removing the dental plaque. Also, we indentified on the Vita scale the proper color shades of resin composites which will be used in restoring the natural aesthetically aspect of the tooth. The old incorrect restoration present in the cervical area has been removed and the specific preparation for the direct composite veneer has been done. The entirely facial face of tooth 11 was prepared to offer a thickness of 0.8 mm for the resin composite material. The cervical border of the veneer preparation is juxtagingival for a better result, both in terms of aesthetic, but also to provide good adhesion to dental tissues for composites. The mesial and distal contact points were preserved (Figure 2).
 

For direct composite veneer we use Charisma Diamond® (Kulzer), which was recently launched on dental material market. It presents nano-hybrid filler system and improved physical and chemical properties, so the result is a more natural-looking restoration and a longer life span. The adhesion step: we applied 37% phosphoric acid (ScotchbondTM Universal Etchant 3M), both on enamel (30 seconds) and dentin (15 seconds), and we rinsed with water and dried. The adhesive we used was GlumaR Bond Universal® (Kultzer), applied on the entire surface of prepa­ration and light-cured (Figures 3 and 4).
 

The next step of the treatment was to insert the restoration material into the veneer preparation, first an opaque layer, then the resin composite in previously chosen shade and light-cured (Figure 5).
 

For the last stage of the treatment, flexible finishing and polishing instruments: Sof – LexTM Finishing Dics (3M ESPE) were used in order to provide the final aesthetic and natural aspect of the composite veneer (Figure 6).
 

The result of restorative treatment in this type of lesions has to be correlated with the patient’s education about the proper oral hygiene⁽¹⁰⁾. This means he needs to acquire a correct dental brushing technique, respecting the types of movements and their succession and using soft toothbrush. Also, the patient was instructed to change his alimentary habits and especially to avoid the consumption of acidic drinks.

In the next session, the left maxillary central incisor received also a direct laminate composite veneer and the abrasive-erosive lesions presented in teeth 12 and 22 were restored.

Conclusions

Direct composite veneer technique using resin composite materials is a simple yet efficient way of treatment for erosive-abrasive lesions, taking into considerations the multiple advantages it presents: one-session treatment, excellent aesthetic results, simple working technique, low financial costs, and long-term results when the restoration is also sustain by the prevention and education program for the patient⁽¹¹⁾.   n

Acknowledgements: All the authors have equal contributions for this article.

Conflicts of interests: The authors declare no conflict of interests.