CLINICAL RESEARCH

Adhesively restored anterior

maxillary dentitions affected by
severe erosion: up to 6-year results
of a prospective clinical study
Francesca Vailati, MD, DMD, MS
Senior Lecturer, Department of Fixed Prosthodontics and Occlusion,
School of Dental Medicine, University of Geneva, Switzerland
Private practice, Geneva Dental Team, Switzerland

Linda Gruetter, DMD, MSc

Senior Lecturer, Department of Fixed Prosthodontics and Occlusion, School of Dental
Medicine, University of Geneva, Switzerland; Private practice, Geneva, Switzerland

Urs Christoph Belser, DMD, Prof Dr med dent

Chairman emeritus, Department of Fixed Prosthodontics and Occlusion,
School of Dental Medicine, University of Geneva, Switzerland

Correspondence to: Francesca Vailati MD, DMD, MS

Senior Lecturer, Department of Fixed Prosthodontics and Occlusion, School of Dental Medicine, rue Barthelemy-Menn 19,

University of Geneva, 1205 Geneva, Switzerland; E-mail: [email protected]; Web: www.genevadentalteam.com

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Abstract absence of infiltration), status of pulp vi-

tality, postoperative sensitivity, esthetics,
In case of severe dental erosion, the max- and restoration success/failure, were the
illary anterior teeth are often particularly principal clinical parameters analyzed.
affected. Restoring such teeth conven- Results: After an up to 6-year observation
tionally (ie, crowns) would frequently in- time (mean observation time 50.3 months
volve elective endodontic therapy and for the palatal veneers and 49.6 months for
major additional loss of tooth structure. A the facial veneers), no complete or major
novel, minimally invasive approach to re- failure of the restorations was encountered.
store eroded teeth has been developed On the basis of the criteria used, most of
and is currently being tested in the form the veneers rated Alpha for marginal ad-
of a prospective clinical trial, termed The aptation and marginal seal. Secondary
Geneva Erosion Study. To avoid crowns, caries or endodontic complications were
two separate veneers with different paths not detected. Using visual analogue scale
of insertion have been used to restore the analysis, the patient-centered satisfaction
affected anterior maxillary teeth, regard- revealed a high esthetic and functional ac-
less of clinical crown length and amount of ceptance of 94.6%.
remaining enamel. This treatment is called Conclusions: Compared to conventional
The Sandwich Approach. crown preparation, restoring compro-
Objectives: The purpose of this case se- mised maxillary anterior teeth by means
ries study was to analyze the mid-term of 2 veneers prevents excessive tooth
clinical outcome of maxillary anterior teeth structure removal and loss of tooth vital-
affected by severe dental erosion that ity. Questions on the longevity of this new
were restored following the Sandwich Ap- treatment arise, due to the nonfavorable
proach. initial status of the teeth to be restored (eg,
Materials and methods: Twelve consecu- lack of enamel, sclerotic dentin substrate
tively consulting patients (mean age: 39.4 and short clinical crowns). The clinical
years) suffering from advanced dental performance of the teeth treated following
erosion have been enrolled in the study the Sandwich Approach seems promis-
and were subsequently treated. Due to ing, since none of the treated teeth lost
the late interception of the disease, all pa- their vitality, no failure of any of the res-
tients needed a full-mouth rehabilitation, torations was detected, and the patients’
which was performed without any conven- overall satisfaction was high. Even though
tional crowns. At the level of the maxillary further investigation is needed to deter-
anterior teeth, a total of 70 palatal indirect mine the clinical long-term performance
composite restorations and 64 facial feld- of the described treatment modality, the
spathic ceramic veneers were delivered. encouraging mid-term results (biological,
Both types of veneers were adhesively esthetic, and mechanical success) clearly
luted with a hybrid composite. Clinical question if conventional crowns in the an-
reevaluations were performed 6  months terior maxillary segments can still continue
after insertion of the veneers, and then an- to be considered the best and only op-
nually, using modified United States Pub- tion to treat this particular population of
lic Health Service (USPHS) criteria. Mar- patients.
ginal adaptation, marginal integrity (seal, (Eur J Esthet Dent 2013;8:506–530)

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a b

Fig 1 Sixteen-year-old patient with a very “healthy” oral condition. No caries or periodontal pathologies
were detected. However, at attentive examination, both mandibular first molars revealed a loss of enamel,
dentin exposure, and missing antagonistic contacts. The patient suffered from early dental erosion related
to an excessive consumption of acidic beverages.

Introduction ingly aware of the need to adequately

counsel and treat these patients. Never-
The loss of tooth structure related to the theless, confusion persists on when and
presence of acids not produced by bac- how the therapy should best be per-
teria is called dental erosion. The first formed (Fig 1).
article that could be found in MEDLINE
about this subject is from 1945.1 Since
then, several authors have been inves- Dental erosion and tooth
tigating the mechanisms of the acid at-
destruction
tack, the co-factors responsible and the
preventive measures for avoiding the Spontaneously, patients most often seek
tooth destruction.2-9 dental treatment only when they have
In contrast, only few articles have pain or if there is an esthetic concern.
been published on the clinical treatment Since patients affected by dental ero-
of this condition, mostly only at the level sion rarely present symptoms of thermal
of case reports.10-32 or tactile sensitivity (except patients af-
This discrepancy reflects both a cer- fected by psychiatric problems, such as
tain confusion and a lack of awareness bulimia), esthetics is the most common
among clinicians, not yet ready to rec- reason to seek a dental consultation.
ognize and treat dental erosion with the In case of dental erosion, typically the
same strict measures implemented for palatal aspect of the maxillary anterior
other diseases, such as dental caries. teeth appears to be the most affected
Nowadays, however, due to the ver- part of the dentition, particularly in case
tiginous increase of the prevalence of of an intrinsic etiology (eg, gastric re-
dental erosion, especially among young flux, psychiatric diseases)33 (Fig 2).
individuals, clinicians become increas- At an early stage, the acid-caused de-

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a b

Fig 2 Palatal aspect of two different patients affected by dental erosion. In the less severe case (left), the
incisal edges are thinner, but still maintained; in the second example (right), the undermining of the palatal
surfaces was more conspicuous and the incisal edges had completely fractured off. Often a diagnosis of
eventual parafunctional habits is used to justify the tooth structure loss. However, looking at the contact
points with the antagonistic dentition, in this second patient, it was impossible to identify wear facets.

a b

Fig 3 Patient affected by severe dental erosion. The two central incisors have lost almost half of their original
clinical crown length. The patient was unaware of the degree of their destruction, since the slow supraerup-
tion of the teeth had kept their incisal edges always at an almost correct position. Unusually, in this patient the
mandibular anterior teeth did not supraerupt. Furthermore, the patient developed a gummy smile.

struction can be very subtle and thus aware of the amount of tooth destruc-
difficult to discover due to the somewhat tion. In fact, due to compensatory su-
hidden location of the palatal tooth sur- praeruption, the fractured incisal edges
faces, especially where there is a slow may remain positioned almost at the
progression of the disease. Eventually, same place of the original incisal edges
the palatal destruction will affect the fa- (Figs 3 and 4).
cial aspect of the teeth, leading to the In addition, due to the scarcity of in-
weakening and ultimately shortening of formation about dental erosion, patients
the incisal edges. However, due to the do normally not associate the changing
slow change, patients may not be fully of the shape of the anterior teeth with the

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a b

Fig 4 Smiles of three different patients affected by

severe dental erosion. All of them sought treatment
for esthetic reasons. None of them reported thermal
of tactile sensitivity. Even though they were aware of
the changes in their dentition, they did not realize to
what extent. This lack of ability to analyze the tooth
damage is explained by both the supraeruption of
the maxillary anterior teeth (fractured incisal edges
almost aligned with the other teeth) and by the con-
servative way of smiling acquired with time (tight lips
c and teeth in contact).

etiology of the excessive presence of become aware of their dental problem

acid in their mouth (eg, bulimia, gastroe- (esthetic awareness). As a result, pa-
sophageal reflux, excessive consum- tients only seek treatment spontaneous-
mation of acidic beverages and food). ly when irreversible damage has already
On the contrary, many of them report taken place and costly restorative treat-
a previous diagnosis of parafunctional ments are required (Fig 6).
habits (ie, bruxism) done by clinicians to The interception of cases of dental
justify the fracturing of the incisal edges. erosion at an early stage (thinning of
This diagnosis is often difficult to accept, the palatal enamel layer), when preven-
since corresponding wear facets on an- tive measures are the only necessary
tagonistic teeth are missing (Fig 5). treatment, would be ideal and clinicians
Only when the labial tooth structure should attentively examine every pa-
– undermined by the destructive combi- tient, especially the young ones, for ini-
nation of erosion and the focal attrition of tial signs of loss of tooth structure (ero-
the antagonistic teeth – fractures off and sive wear). In case of late diagnosis or
the clinical crowns suddenly appear ex- voluntarily postponed treatment, when
tremely reduced in length, do patients both the palatal aspects and the incisal

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a b

Fig 5 Thirty-year-old patient. Ten years earlier, a diagnosis of bruxism was made to explain the degrada-
tion of the patient’s dentition. An occlusal guard was prescribed and worn constantly, as illustrated in (b).
During our consultation, not only were there no corresponding wear facets on the antagonistic teeth, but
the patient could not even bring the opposing occlusal surfaces in close antagonistic contact. Hence, the
parafunctional habit was not the correct diagnosis. On the contrary, the patient was suffering of dental ero-
sion related to an excessive consumption of acidic beverages.

a b

Fig 6 Intraoral view of a patient affected by severe dental erosion at the initial consultation. His chief
complaint was the changing of the shape of his anterior teeth. Even though the maxillary anterior teeth were
severely damaged, the patient did not report any symptoms of pain. He also presented the typical signs of
instability of the occlusion due to severe loss of tooth structure, a supereruption of the mandibular anterior
teeth and the altered occlusal plane (reverse smile), accompanied by an accentuated curve of Spee.

edges of the maxillary anterior teeth are might be surprised about how little of
compromised, conventional crowns for the original tooth is left after conven-
all involved teeth are often proposed to tional crown preparation (Fig 7). What
the patient. still remains of these maxillary anterior
In case of severe dental erosion, teeth after years of degradation would
however, the amount of the remaining be removed, in the case of crown thera-
tooth structure (especially in deep bite py, to guarantee the path of insertion of
patients) could be misleading and one the crowns (mesial and distal aspects)

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a b

Fig 7 Deep bite patient suffering from erosion. The facial aspect of the teeth is almost intact but very
undermined. In this patient, crown preparation would lead to the almost complete removal of the coronal
part of the tooth and elective endodontic treatment would then be necessary.

and to provide sufficient space for the Geneva Erosion Study

esthetic ceramic veneer (facial surface).
After completing the tooth prepar- Since 2005, a clinical trial has been un-
ation, there may be insufficient tooth derway at the School of Dental Medi-
structure left to provide adequate reten- cine, termed the Geneva Erosion Study.
tion and resistance form for conventional The unique feature of this prospective
crown restorations. clinical study is that it comprises pa-
As a consequence, elective endodon- tients affected by dental erosion, from
tic therapy may become necessary. This the most severe to the very early stages
would currently be considered a bio- of the disease.
logical failure. Due to the young age of Hence, to be included in the study,
these patients, before delivering crowns, it is sufficient to present signs of dentin
clinicians should take in consideration exposure related to dental erosion. An-
that problems may arise in the long run, other important aspect of the study is
especially in cases of devitalized teeth. that all treatments are exclusively based
Furthermore, maxillary anterior teeth af- on adhesive technology, following the
fected by erosion that are subsequently principle of minimal invasiveness. No
devitalized and prepared for crowns conventional crowns are delivered, un-
may not feature a sufficient ferrule. This less already present, and needed to be
may significantly increase the long-term replaced.
risk of root fracture (mechanical failure). Since only minimally invasive treat-
In addition, the darker color of the de- ments are considered in the Geneva
vitalized roots may later become visible Erosion Study, to fully preserve the re-
due to gingival recession, frequently as- maining tooth structure despite the trian-
sociated with crown therapy, leading to gular shape of the affected maxillary an-
an esthetic failure. terior teeth, two distinctly different paths

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of insertion are necessary to restore the

palatal and the facial aspects without
sacrificing interproximal tooth struc-
ture. This specific technique, termed
the Sandwich Approach, consists in re-
Fig 8 Sandwich
constructing the palatal aspect first with Approach (or bi-
a composite palatal veneer, indirect or laminar approach).

direct (IPV/DPV), followed by the restor- Palatal composite

veneer and facial
ation of the labial aspect in the form of a
ceramic veneer. On-
ceramic facial veneer (FV) (Fig 8). ly with two separate
Thanks to adhesive technology, there restorations and two
different paths of in-
is no need for retention of these restor-
sertion, the triangu-
ations by friction in 360 degrees as is lar shape of eroded
needed for conventional crowns. On the maxillary anterior
contrary, the tooth structure must be pre- teeth can be re-
stored without un-
served to a maximum to have a larger
necessary sacrifice
surface for adhesion, even by preserv- of tooth structure.
ing unsupported enamel on the facial as-
pect. As a result of its minimal or, ideally,
absent tooth preparation, the described
Sandwich Approach is also clearly less
traumatizing in terms of maintaining the
vitality of compromised pulps. the thin facial veneer is easily achieved
Moreover, even if the presence of suf- in the context of the sandwich approach.
ficient remaining tooth structure could This is a notable advantage, not only be-
avoid elective endodontic treatments, cause eroded teeth are always at higher
crown preparation could still be too ag- risk to spontaneously lose their vitality,
gressive, under the light of various ad- but also because endodontic therapy
ditional procedures, such as provisional can be achieved through the palatal
fabrication, impression, bisque try-in, composite veneer, without jeopardizing
and final cementation, which all require the remainder of the restored tooth.
the exposure of the prepared tooth to the This is not possible, for instance, in
oral cavity, including inevitable dehydra- cases of all-ceramic crowns, where the
tion of the dentin (Fig 9). endodontic access on the palatal as-
In accordance with several studies, pect may lead to microfractures of the
a loss of vitality after the completion of core and subsequent failure of the res-
conventional crown therapy may be part toration.41 To decide which treatment is
of possible adverse events (postponed best indicated for the maxillary anterior
biological failure). The incidence of vi- teeth affected by dental erosion, the An-
tality loss is generally underestimated terior Clinical Erosion (ACE) classifica-
because of the difficulty in testing pulp tion had been developed and was con-
vitality with crowns in place.34-40 In con- sequently implemented in this study42
trast, testing of the tooth vitality through (Fig 10).

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a b

Fig 9 Patient affected by severe dental erosion re-

stored with conventional crowns. Although elective
endodontic therapy was not planned, the left maxil-
lary central incisor lost its vitality during the treat-
ment. Note the alteration (swelling, texture, color) of
the marginal gingiva (right) in comparison with the
c initial status.

a b

Fig 10 Maxillary occlusal view of the palatal aspect of two patients, both affected by dental erosion.
Intercepting an ACE class I patient (a), when the enamel is thinner, but still intact, will lead to the complete
resolution of the dental problem, since only preventive measures are necessary at this stage. An ACE class
IV patient (b), instead, needs a full-mouth rehabilitation. The difference of age between these two patients
was only 10 years. The dental erosion etiology was the same (bulimia).

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The ACE classification is based on 5 veneers) are necessary to complete the

clinical parameters considered funda- treatment. This is the case of ACE class-
mental for the evaluation of the severity es IV and V where the incisal edges are
of the erosion damage and the progno- fractured more than 2 mm and the Sand-
sis of the treatment. wich Approach is recommended.
Considering the loss of palatal and fa- Finally, patients are classified ACE
cial enamel, the exposure of the dentin class VI when they present at least one
on the palatal aspect, the fracture of the devitalized tooth among the maxillary
incisal edges, and the loss of vitality, the anterior dentition. The loss of pulp vital-
ACE classification divides the patients ity could be related to both severe tooth
into 6 categories. destruction and severe intensity of the
ACE class I patients, who present on- acid attack, as it is the case in bulimic
ly a thinning of their palatal enamel, are patients. For ACE class VI patients the
not treated, but informed and instructed Sandwich Approach is also indicated, to
to prevent further damage of their den- avoid the devitalization of the remaining
tition. Hence, this category of patients teeth. Following an identical clinical pro-
was not enrolled in the study. tocol, 12 ACE class IV to VI patients have
ACE class II patients, who only feature been consecutively treated and followed
initial signs of dentin exposure on the up at the School of Dental Medicine of
palatal aspect of the maxillary anterior the University of Geneva, from 2006 to
teeth, were included in the study, as they 2012. All procedures were performed by
required a protective type of treatment. the same clinician (FV). The aim of the
The rationale behind this very early present prospective case series study
intervention is to preserve the incisal was to evaluate the clinical performance
edges from further damage. Early non- up to 6 years of the restored maxillary
invasive restorations (composite restor- anterior teeth.
ations) are preferred in comparison to
conventional crowns delivered later in
life to these patients. Materials and methods
ACE class III patients, characterized
by fractured incisal edges (but less than Seven men and five women with a mean
2 mm of the original length), and by an age of 39.4 years (range 27 to 64 years)
extensive exposure of the palatal dentin, volunteered in this study. All patients
were also included in the Geneva ero- presented to the University of Geneva,
sion study. Direct or indirect composite School of Dental Medicine with the com-
restorations are perfectly suited for this mon chief complaint that their teeth were
category of patients to reconstruct the deteriorating functionally and estheti-
palatal aspect without tooth preparation. cally, namely the incisal edges of the
However, in case of significant short- maxillary anterior teeth. At the baseline
ening of the clinical crown, palatal ve- examination, all patients were suffering
neers may be insufficient to satisfy the severe dental erosion; the anterior teeth
patient’s esthetic request. Consequent- were the most affected, with conspicu-
ly, additional restorations (ceramic facial ous damage of the incisal edges.

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Table 1 List of the patients classified according to their gender, age, ACE classification and time of func-
tion of the final restorations, delivered at the level of the maxillary anterior teeth

Patients Gender Age ACE Teeth Teeth treated Time of clinical

(years) classi- treated with PV service (months)
fication with FV (tooth no.) PV & FV
(tooth no.)

  FV PV

Indi-
Direct Direct Indirect
rect

1 M 31 V 13–23 13–23 65 68

13–11
2 M 46 IV 13–23 22 68 72 72
21, 23

3 M 50 V 13–23 13–23 48 53

4 F 42 IV 13–23 13–23 66 67

5 M 64 VI 13–23 13–23 67 71

6 F 35 IV 13-23 13–23 76 71

7 F 27 IV 12–22 13–23 24 18

8 F 36 V 12–22 13–23 33 36

9 F 31 IV 12–22 12–22 44 47

10 M 40 IV 13–23 13–23 50 54

11 M 34 IV 12–22 13–23 23 43

12 M 37 IV 13–23 13–23 31 32

8 IV 3 V
Total 5F 7M 64 19 D 51 ID
1 VI

MEAN 39.4 70 49.6 50.3

Interestingly, before entering the Ge- were not sent for an evaluation of their
neva Erosion Study, only three patients digestive system. For all the others an
were aware that the cause of their dental upper gastrointestinal endoscopy and
status was related to acidity in the oral 24 hour pH monitoring were performed.
cavity. According to the ACE classifica- The respective investigations confirmed
tion, there were eight ACE class IV, three in 6 patients the presence of gastroe-
ACE class V, and one ACE class VI pa- sophageal reflux and those individuals
tients (Table 1). received medical treatment accordingly
Before starting the treatment, a con- (proton pump inhibitors therapy). For the
sultation with an expert in cranioman- remaining patient, the only possible eti-
dibular disorders and one with a gas- ology of the observed erosion was ex-
troenterologist were provided. Only the cessive ingestion of acidic beverages
patients affected by bulimia (5 out of 12) (eg, carbonated sodas), a habit con-

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firmed later by the patient. For all pa- Following an equal protocol, after 1
tients, dental treatment started before month of functioning without anterior
the erosive process was under control. guidance, six palatal composite restor-
The rationale behind this choice was ations were placed and the anterior con-
to cover and seal the exposed dentin tacts reestablished (step 3 of the 3-step
as soon as possible, and thereby pro- technique). According to the given in-
tecting the involved teeth from further terocclusal space, it was decided for
damage caused by both the acid attack each individual patient whether direct
and the attrition of the antagonistic teeth or indirect restorations were best suited.
(dentin and pulp protection). When the distance to the antagonistic
A vitality test was performed using teeth was more than 1 mm, an indirect
cotton pellets soaked with coolant approach was preferred. Overall, 51 in-
(Endo-Ice Refrigerant Spray, Coltène/ direct and 19 direct restorations were
Whaledent) on all the teeth (except when placed.
radiographies confirmed a previous root When the indirect approach was se-
canal treatment), and surprisingly the lected, the palatal aspect of the max-
majority of teeth were still vital, despite illary anterior teeth was prepared ac-
the advanced loss of tooth structure. cording to the same protocol as for the
Interestingly, only three patients com- direct approach, before taking the final
plained about thermal tooth sensitivity. impression. First, the palatal dentin was
A concomitant diagnosis of parafunc- cleaned with a nonfluoride-containing
tional habits (bruxism and/or clenching) pumice prophylaxis paste. The exposed
was registered for 4 of the 12 patients; sclerotic dentin was gently roughened
however, before treatment only 2 pa- with a coarse diamond bur, to remove the
tients were wearing an occlusal appli- most superficial layer, and then immedi-
ance (guard). ately sealed. The surface was etched for
Three patients were also smokers. 15 seconds with 37% phosphoric acid,
This is particularly important information abundantly rinsed with water, dried, and
when it comes to the evaluation of the then the primer and the bond were ap-
status of the periodontal tissues. plied, following the manufacturer’s in-
All 12 patients received a full-mouth ad- structions (Optibond FL, Kerr). A flow-
hesive rehabilitation, following the same able composite was subsequently used
protocol (the 3-step technique).43-45. to thicken the hybrid layer (Tetric flow T,
An increase in vertical dimension Ivoclar Vivadent). Prior to taking the fi-
of occlusion (VDO) was arbitrarily de- nal impression, the periphery of the pre-
cided on the casts articulated in max- pared surface was gently touched with
imum intercuspation position (MIP), and a slowly rotating diamond bur to remove
transferred to the mouth by means of any eventual adhesive resin from the
posterior provisional composite restor- enamel finish line.46-50
ations (step 2 of the 3-step technique). Also still prior to impression taking,
Due to the presence of these posterior the interproximal contact zones between
restorations, an anterior open bite was the maxillary anterior teeth were slightly
created. opened using thin diamond strips, and

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the incisal edges smoothened by mini- presence of a composite “hook” at the

mally removing the unsupported enamel level of the incisal edges, it was easier to
prisms. Both interventions were carried achieve correct positioning, even on the
out to facilitate the fabrication of optimal “slippery” palatal surfaces. The hooks
working casts. Anesthesia was not ne- were subsequently removed during fin-
cessary for the described procedure, ishing and polishing. The described res-
except in the case of one bulimic pa- toration of the palatal aspect of the max-
tient who presented tooth hypersensitiv- illary anterior teeth provided the patients
ity before the treatment. No provisional with both inter-maxillary centric occlu-
restorations were delivered after the fi- sion contacts and anterior guidance.
nal impression was taken. This is a clear Restoration of the labial aspect of the
indication that sealing of the exposed maxillary anterior teeth was completed
dentin was highly efficient in terms of with ceramic facial veneers (FV), carried
oppressing potential thermal sensitivity, out generally a few weeks after the inser-
and that the absence of any incisal edge tion of the palatal composite restorations.
preparation did logically not affect es- As a preparatory measure, alginate im-
thetic appearance. After one week, the pressions of the maxillary arch were tak-
IPVs were adhesively inserted, one at a en and an additive wax-up of the facial
time, under rubber dam insulation. The aspect of the six or four maxillary anterior
previously sealed palatal dentin was air teeth was performed. Each patient was
abraded (Cojet, 3M, Espe), the periph- then scheduled for a so-called mock-up
eral enamel etched (37% phosphoric visit, where the final shape of the facial
acid for 30 s), and the adhesive resin veneers was tested and determined ac-
(Optibond FL) applied, but not cured cording to esthetic and functional cri-
to avoid the risk for incomplete seating. teria. Once the patient’s approval was
The composite veneers were also air obtained, respective tooth preparation
abraded (Cojet), subsequently cleaned was performed following the same pro-
in an ultrasonic alcohol-containing bath, tocol. The interproximal contact areas,
prior to the application of three coats of kept open after bonding of the palatal
silane (Silicup, Heraeus, or Monobond veneers, were further adjusted with an
plus, Ivoclar Vivadent), and dried in the abrasive diamond-coated metallic strip.
oven for 1 min at 100ºC. An adhesive A light chamfer was prepared at the
layer (Optibond FL) was then applied to cervical level, following the curve of the
the silanized surface without light curing. marginal gingiva, with no need for ex-
A warmed-up hybrid composite (Miris, tending the preparation to the gingival
Coltène/Whaledent) was subsequently sulcus, since the color of the underlying
placed to the cementation surface of tooth structure was perfectly natural. As
the restorations, used as a luting agent the palatal aspects, previously restored
and light cured (90 s for each surface). with composite veneers, were consid-
The open interproximal contact areas ered an integral part of the respective
facilitated the described bonding pro- teeth, no particular effort was made to
cedures, from positioning of the palatal place the preparation margins on tooth
veneer to excess removal. Thanks to the structure. In the present study, the incis-

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al edge was shortened and the length pared teeth was air abraded (Cojet, 3M
created by the palatal veneer was re- Espe), and the existing enamel etched
moved (butt joint preparation). Particular (37% phosphoric acid) for 30 seconds.
attention was paid to rounding off all the A coat of adhesive resin (Optibond FL)
line angles. In case of dentin exposure, was applied, but not cured before seating
immediate dentin sealing (Optibond FL the restoration. A warmed-up compos-
and Tetric flow) was performed, as pre- ite was then applied to the restorations
viously explained. A retraction cord size (Miris, Coltene/Whaledent), before pos-
zero was applied (GingiBraid, DuxDen- itioning them on the teeth and light cur-
tal), and the impression taken (Express ing. Any excess of the luting composite
2 3M ESPE). Temporary restorations was carefully removed before the poly-
were performed chairside using a provi- merization; however, after removal of the
sional composite material (Telio, Ivoclar rubber dam, additional cleaning of the
Vivadent), molded to the prepared teeth gingival margins was performed if ne-
with a well-adapted silicon key, previ- cessary, but only using a scalpel. No ro-
ously used for the diagnostic mock-up. tary instruments were used. Finally, stat-
Since no cement was utilized, sufficient ic and dynamic occlusion was checked
retention for two weeks of clinical service and adjusted if indicated.
was achieved by both the contraction of After the restoration of the maxillary
the product and the presence of minimal anterior teeth, the patients’ treatment
interproximal excess. A total of 64 FVs continued with the replacement of the
were fabricated in the laboratory using provisional posterior restorations by final
feldspathic porcelain (Creation CC, Willi adhesive restorations (full-mouth adhe-
Geller International), following standard sive rehabilitation).
laboratory procedures, including refrac- Finally, at the end of the treatment, a
tory dies. Three different commercial Michigan-type occlusal appliance was
dental laboratories were involved. delivered to patients also affected by
The bonding of the facial veneers was parafunctional habits (4 out of the 12
carried out 2 weeks after impression tak- patients). All the patients enrolled in
ing, and followed the protocol developed the Geneva Erosion Study are sched-
and published by Magne et al.51-54 The uled for an annual check-up where
rubber dam was placed and each ven- intra- and extraoral photographs are
eer was bonded individually. The intag- taken, occlusion is controlled and sev-
lio surfaces of the ceramic veneers were eral clinical parameters are evaluated;
etched for 60 s with hydrofluoric acid, consequently all the records of the pa-
and then placed in alcohol and ultrason- tients participating in this study were
ically cleaned for 6 min. Subsequently, updated yearly. All clinical evaluations
three coats of silane (Silicup, Heraeus, were performed using standard dental
or Mondobond plus, Ivoclar Vivadent) diagnostic instruments and visual in-
were applied and dried in the oven for spection with the aid of magnification
1 min at 100ºC. Finally, a coat of bond (x2.5) (ErgoVision HD Telescope; Sur-
(Optibond FL, Kerr) was applied without giTel) and a state-of-the-art dental unit
curing. The sealed dentin on the pre- with overhead lighting.

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Table 2 Modified USPHS Criteria applied for the Table 3 Detailed description of the teeth restored
clinical evaluation of five clinical parameters select- with various types of palatal and facial veneers
ed for the study

Teeth Palatal Veneers Facial

Characteristics Rating Criteria Veneers

Alpha No defect Direct Indirect

 
(DPV) (IPV)
Marginal Bravo Minor defect
adaptation Canines 6 16 16
Charlie Major defect
Lateral
Delta Margin fracture 7 17 24
incisors
Alpha No discoloration
Central
6 18 24
Superficial incisors
Bravo
discoloration
Total 19 51
Marginal seal Deep
Charlie restorations 70 64
discoloration

Secondary
Delta
decay
The subjective patient satisfaction is
Alpha None measured by using visual analogue
Bravo Discrete crack scales (VAS).
Restoration failure
Charlie Chipping The VAS analyzed not only the pa-
Delta Bulk fracture tient’s satisfaction from an esthetic point
Alpha None of view, but it also took into considera-
Postoperative tion the patient’s perception of the over-
Bravo Moderate
Sensitivity (air)
all treatment time, how the treatment
Charlie Severe
was structured, and how the different
therapeutic phases were handled by the
clinician. Descriptive statistical methods
The restorations were analyzed fol- were implemented to analyze the data
lowing the well-established US Pub- collected from this clinical trial.
lic Health Service (USPHS) evaluation
method.55,56 The scoring system is de-
fined as follows (Table 2): Results
Alpha: excellent result, restorations
without changes or clinically ideal. A total of 70 palatal and 64 facial restor-
Bravo: acceptable result, restorations ations were delivered to the 12 patients
with changes that are clinically ac- participating in the study (Table 3).
ceptable and do not require replace- The noticeable discrepancy between
ment. the number of PV and FV (70 versus
Charlie: unacceptable, restorations 64) is explained by the systematically
with major changes that require re- applied strategy of minimally invasive
placement to prevent further deterio- dentistry adopted in the Geneva Ero-
ration. sion Study. In fact, 2 of the 24 canines
Delta: unacceptable, immediate re- did not require palatal veneers, and 6
placement necessary. (25%) of the same 24 canines did not

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need facial veneers. When it comes

Veneers
Clinical results for the palatal veneers (PVs). Numbers 1 to 12 correspond to the patients examined (I= Indirect; D=Direct)

50

50

51
to the central and lateral maxillary

1
I
incisors, however, all had to be re-

19

19

19
stored with both palatal and facial

D
veneers, due to the advanced state

6
I
of dental erosion.

12

D
Six of the 24 maxillary canines in-
volved in the study were considered

6
I
perfectly rehabilitated after the res-

11

D
toration of their palatal aspect with

6
palatal veneers. Consequently, no

I
10
further treatment was considered

D
necessary for these teeth.

4
I
To avoid bias, the recall assess-

D
9
ments were not performed by the
same clinician who had placed the

6
restorations. Seventy palatal ve- I
D
8

neers were delivered, 51 were cre-

ated indirectly in the laboratory (in-
6

6
I

direct palatal veneers, IPV) and 19

D
7

fabricated directly in the patient’s

I

mouth (direct palatal veneers, DPV).

D
6

6
The mean observation time of the
palatal veneers was 50.3 months
I

(range: 1.5 to 6 years of follow-up).

D
5

6
The results of the clinical evaluation
are presented in Table 4. As for the
I

palatal composite veneers, the over-

D
4

whelming part of the scores corre-

6

6
I

sponded to “Alpha”, one can con-

D
3

sider the overall clinical integration

of these restorations as excellent.
5

5
5
I

In fact, all PVs were rated “Alpha”

D
2

for all the four clinical parameters,

except for two restorations.
6

6
6
I

In patient number 10, one palatal

D
1

veneer was rated “Bravo”, due to a

Rating

Charlie

Charlie

Charlie
Bravo
Alpha

Bravo

Alpha

Alpha

Bravo

slight defect at the palatal junction

Delta

Delta

Delta

between the facial and the palatal

veneers, detected at the 3-year
Marginal

Marginal
adapta-
Table 4

follow-up. The observed defec-

Restor-

failure
ation
seal 

tive margin, however, did not show

tion 
PV

signs of infiltration.

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In patient number nine, in-

Veneers
stead, the marginal seal of

63

58

63

64
one of the six PVs was rated

1
“Bravo”, because it was con-
sidered to be superficially
discolored.
12

6
The clinical performance
of the 64 FVs over a period of
11

1
3
4

4
1.9 to 6.3 years was favora-
ble too. The mean observa-
10

tion time was 49.6 months.

1

1
5
5

6
All FV restorations were rat-
ed “Alpha” for the marginal
9

4
4

4
adaptation, except one, rat-
ed “Bravo”.
The marginal seal of all
8

2
2
4

4
the FV was rated “Alpha”,
except for six teeth, where
7

1
3
4

the veneers showed a su-

perficial discoloration at the
6

cervical margin (“Bravo”)

6
6

at the 3-year follow-up. The

described discolorations
5

6
6

were subsequently removed

by superficial polishing
4

6
6

(Table 5).
None of the restorations
(FV and PV) failed over the
3

6
6

6
Clinical results for the facial veneers

observation period of the

present study. One facial
2

6
6

veneer was rated “Bravo”,

due to the presence of a
crack, visible two weeks after
1

6
6

cementation. At the 2-year

follow-up the crack was sta-
Rating

Charlie

Charlie

Charlie

Charlie

ble and not discolored. The

Alpha
Alpha

Bravo

Bravo

Alpha

Bravo

Alpha

Bravo
Delta

Delta

Delta

patient was not capable to

detect it, unless deliberate
Postoperative

dehydration of the restor-

Marginal sea
Marginal ad-

Restoration

ation was provoked using air

sensitivity
aptation
Table 5

stream. Thermal testing was

failure

performed using a cotton

FV

pellet soaked with coolant

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a b

Fig 11 Palatal view, initial status and 6-year follow-up of a heavy smoker patient included in the Geneva
Erosion Study. Note the no infiltrated margins between the composite palatal and the ceramic facial ve-
neers. The picture was taken without any previous cleaning of the restorations.

(Endo-Ice® Refrigerant Spray; Coltène/ Table 6 Summary of gingival and plaque record-
ings.
Whaledent). Thanks to the ultrathin facial
veneers, it was possible to reliably as-
Patient details N = 12
sess the vitality of all the restored teeth.
None of them lost their vitality during the BOP 13.3%

treatment or the following observation PCR 9.8%

time (Figs 11 to 14).
No signs of postoperative sensitivity
were observed, and the hypersensitiv- treatment or thereafter. Bonded porce-
ity present in some patients before the lain veneers represent a highly reliable
treatment, was successfully eliminated treatment modality when it comes to
after completion of the restorations. the restoration of either structurally or
Gingival and plaque indices were re- esthetically compromised maxillary an-
corded using standardized techniques terior teeth. This is particularly true for
assisted by periodontal probe and ex- the related esthetic outcome (esthetic
plorer. Assessment of the biologic par- success), as documented by numer-
ameters, ie, bleeding on probing (BOP) ous clinical studies.57-61 Various authors
and plaque control record (PCR), con- have shown survival rates above 90%
firmed favorable conditions. over a period of 10 years of clinical ser-
BOP was below 20% for 11 of the 12 pa- vice for this type of restorations. Only mi-
tients with an average of 13.3%, and the nor problems, which did not require the
PCR was only above 20% in one patient, replacement of the restoration (mech-
with an average of 9.8% (Table 6). The fa- anical success), were reported.57,58,62
vorable clinical outcomes were confirmed Moreover, contemporary facial porce-
with a high mean VAS score of 94.6%. lain veneers are clearly less traumatizing
Finally, neither muscular discomfort for the pulp than traditional full coverage
nor temporomandibular joint problems preparations, due to the reduced amount
became apparent at any moment of of tooth structure removed during prep-

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a b

Fig 12 (a and b) Initial status and after 3-year follow-up of a bulimic patient included in the Geneva Erosion
Study.

a b

Fig 13 (a and b) Initial status and 5 year folllow-up. This patient was the most extreme case included in
the Geneva erosion study. The maxillary anterior teeth were restored with two veneers (palatal and facial),
with minimal if any tooth preparation. After 5 years of clinical service, the veneers presented still excellent
conditions, despite the initial lack of facial enamel, the type of occlusion, and reduced clinical crown hight.
None of the teeth lost their vitality.

aration (biological success).63 However,

clinicians are still reluctant to extend the
indications for veneers to more severely
compromised anterior maxillary denti-
tions. Veneers have been, in fact, ad-
vocated to change only minimally the
shape and/or color of slightly affected
teeth, since the presence of a high per-
centage of enamel as well as the initial
height of the surface to be restored are
considered crucial for long-term suc-
Fig 14 Bonding procedure of six facial ceramic
veneers in the patient illustrated in Fig 13. Note the cess.64-69 Consequently, in case of se-
conspicuous increase of length obtained with the vere dental erosion, 360 degree prepar-
veneers.

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ation and the establishment of adequate tremely compromised tooth structure, ie,
retention and resistance form are still mainly eroded sclerotic dentin.
considered by numerous clinicians as In fact, the dentin was often extensive-
being more reliable than bonding. This ly exposed on both the palatal and the
conception was, and still is, leading to a facial aspect, and its quality was all but
high number of crowns delivered to re- ideal for predictable bonding, due to its
store such teeth. Unfortunately, accord- either sclerotic or over-etched character.
ing to this strategy aiming to provide Before 2012, there was literally no robust
more long lasting restorations, addition- scientific documentation available as a
al precious tooth structure must be sac- basis for determining the correct way of
rificed. In this study the involved anter- bonding to such eroded dentin.70
ior maxillary teeth were all ranging from Without adequate literature support, it
ACE class IV to VI, representing a real was decided – in the context of the Ge-
challenge for the restorative dentist. The neva Erosion Study – to apply a uniform
population of patients treated featured protocol consisting of the gentle removal
not only extensive dentin exposure, but of the most superficial dentinal layer, fol-
frequently also short clinical crowns. In lowed by etching the remaining dentin
fact, the final restoration length often al- for only 15 s, and to subsequently seal
most doubled the initial one. For the ma- this conditioned surface. The follow-
jority of the teeth involved in this study, up examination confirmed the efficacy
endodontic treatment would have been of the described approach in terms of
required, as well as crown lengthening, thermal isolation as no postdelivery sen-
to obtain adequate retention and resist- sitivity of the restorations was reported.
ance form for the restorations if con- Interestingly, in case of existing tooth
ventional crown preparation had been sensitivity before treatment, it was large-
performed (biological failure). In order ly improved, if not completely eliminated
to preserve the remaining tooth structure after completion of the restorations.
to a maximum and to not further weaken In retrospect, the choice of maintain-
the already compromised dentition, two ing a maximum of the remaining tooth
separate veneers (a palatal and a facial structure, and the strategy of placing two
one) were delivered for each maxillary independent restorations with two differ-
anterior tooth treated. While there is a ent paths of insertion (no problem with
strong body of evidence in the litera- undercuts and therefore no need for re-
ture regarding the longevity of so-called moval of the mesial and distal marginal
classical facial veneers, reliable data on ridges) has been validated by the favora-
the clinical performance of dual veneer ble outcome in terms of biological suc-
restorations is still lacking. cess presented in this study. All the teeth
When the present study was initiated, that had tested vital before treatment kept
concerns were raised on how two ve- their vitality throughout all follow-up ex-
neers, made of different materials (com- aminations. It should be underlined that
posite on the one hand and ceramics on several of the restored teeth presented
the other) could be predictably bonded, an initial clinical crown height that was
not only between them, but also to ex- almost doubled by the final veneers.

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This was even the case in some patients a more recent in vitro study published by
where occlusal parafunctional habits had Gresnigt et al,76 it was concluded that
been diagnosed at the initial examination. ceramic veneers bonded to composite
Also under these specific conditions, no restorations provided favorable results,
failure of the described adhesive restor- supporting the previous clinical findings
ations was observed to date, indicating of the same group.77
that the patients were obviously compli- Only one tooth in the present study
ant in terms of systematically wearing was rated “Bravo”, the defect was con-
their occlusal appliances. sidered acceptable in the palatal junc-
In terms of longevity of anterior bond- tion between the facial and the palatal
ed ceramic restorations, Magne et al71 veneer and it did not require repair.
reported a 0% frequency of clinically un- However, since Peumans et al59 re-
acceptable fractures (ie, fractures that ported that veneers with restoration
would require a complete replacement margins located in composite fillings
of the restoration. These findings were showed a secondary caries incidence
also confirmed by other authors, who of 10% after 10 years, long-term follow-
published similar low failure percent- ups are needed to determine how the
ages.72-74 In the present study, only one union between the two veneers will age.
patient presented a crack at the the me- Despite the rather short observa-
sial surface level of a central incisor’s tion time of this study and considering
facial veneer. The crack was discovered the severely compromised initial status
after the delivery of the restoration at the of the teeth involved, the combination
1-week follow-up. of separate palatal and facial veneers
The respective veneer was extremely showed very promising results up to 6
thin, due to the current tendency to limit years of follow-up, revealing a survival
tooth preparation to a minimum. Poly- rate of 100%.
merization shrinkage of the luting com- Thanks to the Sandwich Approach,
posite could have led to critical stress the remaining tooth structure was pre-
concentrations between the adhesive served to a maximum, no respective
interface and the ceramic subsurface.75 mucogingival surgery was necessary
The crack was stable at the 2-year (except one case, done for esthetic rea-
follow-up, revealing an intact adhesive sons) and no elective endodontic tre-
bond between tooth, composite and watment was performed.
ceramic. This finding is in line with ob- At the level of the anterior teeth, the
servations reported by other authors on enamel was reduced but still present at
the presence and evolution of cracks in the cervical (palatally), mesial, distal and
ceramic veneers, and similarities drawn facial aspects providing a strong scaf-
relative to cracks in enamel. Secondary fold for the restorations. Thanks to the
caries did not occur at any of the ven- Sandwich Approach this enamel frame-
eer restorations, despite the fact that work was almost completely preserved.
the ceramic facial veneers were exten- In 2008, Vailati and Belser formulated
sively in contact with the palatal com- the Tennis Racket theory,43 to justify the
posite veneers at the palatal aspect. In bilaminar technique. According to this

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theory, the author believes that the pres- comprehensive dental treatment plan. In
ence of an enamel framework is crucial this context, three different success cri-
for the strength of the anterior teeth, like teria should be considered, ie, biological,
the marginal ridges in the premolars. mechanical, and esthetic success.
Any attempt to remove it may lead to a It appears obvious that a restoration
weakening of the entire structure and an should integrate as close as possible
increase of the tooth flexibility. The pala- to the adjacent dentition (esthetic suc-
tal veneers not only reinforce the tooth, cess) and it should also be sufficiently
but most of all stop the progression of resistant to last a reasonable amount of
its destruction. Thanks to the bonding to time (mechanical success).
the remaining peripheral enamel, these What is not always explained correctly
restorations show a very satisfactory to patients is the amount of tooth struc-
mid- to long-term clinical performance. ture “iatrogenically” removed to achieve
Finally, all the teeth maintained pulp the two above-mentioned elements of
vitality, even when the erosive destruc- success and the associated negative
tion of the palatal aspect had almost ex- consequences in the long run.
posed the pulp. No hypersensitivity was In fact, preservation of mineralized
developed and, if present before the tooth structure and maintenance of pulp
treatment, the tooth protection related vitality (both directly linked to biological
to the adhesive techniques had clearly success), are not often considered by
improved the original symptoms. patients as key factors at the moment
It could be concluded that the early of accepting proposed dental therapies.
intervention to protect the pulp without Typically, patients affected by severe
waiting for the erosive pathology to be dental erosion present an already exten-
under control played a key role in the sive loss of mineralized tooth structure.
tooth vitality preservation. Hence, their restorative therapy should
The purely additive strategy utilized be even more based on a minimal inva-
in case of the palatal veneers, which re- sive approach to guarantee the so cru-
quired no tooth preparation, proved its cial biological success.
validity as translated by 100% biological As conventional crowns are clearly
success. Despite the recommendations considered a too aggressive approach,
made by several authors,78 in the au- this cohort of patients affected by den-
thors’ opinion dental treatment should tal erosion have been treated in accord-
be initiated as soon as possible in case ance with the guidelines of the “3-step
of erosion patients, even when the path- technique,” using exclusively adhesive
ology is still active, as in the case of bu- techniques with the maximum preserva-
limic patients. tion of tooth structure.
In this article, the up to 6-year fol-
low-up of 12 patients affected by se-
Conclusion vere dental erosion and subsequently
treated with minimally invasive adhe-
The promotion of long-lasting oral func- sive techniques, is illustrated. Based
tion should be the primary objective in any on the mid-term results, it has been

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shown that two separate veneers (one tive in comparison to full crowns. These
facial, one palatal) can reliably restore encouraging results from a biological,
a maxillary anterior tooth, even in case mechanical, and esthetic success point
of severely compromised eroded denti- of view, should seriously question if con-
tion. Thus the described treatment ap- ventional full crowns in the anterior sex-
proach clearly represents an excellent tants are still indicated to treat this par-
and tooth structure-preserving alterna- ticular population of patients.

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