Journal of
Clinical Medicine
Article
Total Rehabilitation Using Adhesive Dental Restorations in
Patients with Severe Tooth Wear: A 5-Year Retrospective Case
Series Study
Álvaro Ferrando Cascales 1 , Salvatore Sauro 2,3 , Ronaldo Hirata 4 , Daniela Astudillo-Rubio 5 ,
Raúl Ferrando Cascales 1 , Rubén Agustín-Panadero 6, * and Andrés Delgado-Gaete 5
Citation: Ferrando Cascales, Á.;
Sauro, S.; Hirata, R.; Astudillo-Rubio,
D.; Ferrando Cascales, R.;
Agustín-Panadero, R.;
Delgado-Gaete, A. Total
Rehabilitation Using Adhesive
Dental Restorations in Patients with
Severe Tooth Wear: A 5-Year
Retrospective Case Series Study. J.
Clin. Med. 2023, 12, 5222. https://
doi.org/10.3390/jcm12165222
Academic Editor: Peter Rammelsberg
Received: 14 May 2023
Revised: 29 July 2023
Accepted: 1 August 2023
Published: 10 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
J. Clin. Med. 2023, 12, 5222. https://doi.org/10.3390/jcm12165222
1 Department of Biomaterials Engineering, Faculty of Medicine, UCAM, Universidad Católica de Murcia,
Campus Los Jerónimos, 135 Guadalupe, 30107 Murcia, Spain; aferrando@ucam.edu (Á.F.C.);
rferrando@ucam.edu (R.F.C.)
2 Dental Biomaterials and Minimally Invasive Dentistry, Department of Dentistry, University CEU Cardenal
Herrera, C/Santiago Ramón y Cajal, s/n, Alfara del Patriarca, 46115 Valencia, Spain;
salvatore.sauro@uchceu.es
3 Department of Therapeutic Dentistry, I. M. Sechenov First Moscow State Medical University,
119146 Moscow, Russia
4 Department of Biomaterials and Biomimetics, New York University College of Dentistry,
New York, NY 10010, USA; rh1694@nyu.edu
5 Division of Prosthodontics, School of Dentistry, Universidad Católica de Cuenca, Cuenca 010107, Ecuador;
dastudillor87@gmail.com (D.A.-R.); andydg86@gmail.com (A.D.-G.)
6 Prosthodontic and Occlusion Unit, Department of Stomatology, Faculty of Medicine and Dentistry,
Universitat de València, 46010 Valencia, Spain
* Correspondence: ruben.agustin@uv.es
Abstract: Introduction: Currently, there is little clinical evidence to support the medium- and long-
term survival and clinical performance of ultraconservative approaches using adhesive restorations
in full-mouth restorations. The aim of this case series study was to evaluate the medium-term
clinical performance of anterior and posterior adhesive restorations applied with direct and indirect
techniques using resin composites and glass-ceramic-based materials. Materials and Methods: The
inclusion criteria were an esthetic problem as the main reason for consultation and severe generalized
wear of grade 2 to 4 according to the Tooth Wear Evaluation System (TWES 2.0). In addition, at
each follow-up appointment, patients were required to submit a clinical-parameter-monitoring
record according to the modified United States Public Health Service (USPHS) criteria. Results:
Eight patients with severe tooth wear were treated through full rehabilitation in a private dental
clinic in Spain by a single operator (AFC). A total of 212 restorations were performed, which were
distributed as follows: 66 occlusal veneers, 26 palatal veneers and 120 vestibular veneers. No signs of
marginal microleakage or postoperative sensitivity were observed in any occlusal, vestibular and/or
palatal restoration after the follow-up period. The estimated survival rate of the 212 restorations
was 90.1% over 60 months of observation, with a survival time of 57.6 months. Only 21 restorations
had complications, which were mostly resolved with a direct composite resin. The dichotomous
variables of the restoration type (posterior veneer, anterior veneer) and the type of restored tooth
(anterior, posterior) were the risk predictors with statistically significant influences (p < 0.005) on the
survival of the restorations. Conclusion: According to the results of this study, there is a significantly
higher risk of restorative complications in posterior teeth compared to anterior teeth. Also, it can be
concluded that the indication of adhesive anterior and posterior restorations is justified in the total
oral rehabilitation of patients with severe multifactorial tooth wear, as they are associated with a low
risk of failure.
Keywords: increasing vertical dimension; minimally invasive dentistry; tooth wear; ceramic veneers;
lithium disilicate; composite
https://www.mdpi.com/journal/jcm
J. Clin. Med. 2023, 12, 5222 2 of 14

1. Introduction
The current therapeutic approaches for the treatment of patients with severe tooth
wear deriving from minimally interventionist dentistry base their clinical application on the
excellent biomimetics and optimal mechanical and optical properties of both silica-based
glass ceramics and composite resin-based restorations. Due to their physical characteristics,
these materials achieve adequate adhesive strength when combined with different con-
temporary adhesive systems [1–7]. Due to the great development that adhesive dentistry
has undergone, teeth affected by wear require minimal or no tooth preparation to achieve
optimal aesthetic and functional results, with minimal sacrifice of the remaining structure
by increasing the vertical dimension of occlusion (VDO) [8].
Dentition that has been subject to severe tooth wear because of chemical and/or
mechanical causes requires interceptive dental procedures to limit future caries or endodon-
tic treatments. These procedures are encompassed within full oral rehabilitations that
frequently involve an increase in VDO [8–10].
Regarding material selection, lithium disilicate has a high long-term stability and
better performance than composite resins [11,12]. However, in most studies, the financial
means of patients are not considered. Although it is certainly necessary to assume a
medium- to long-term re-intervention when choosing a composite resin, this is a feasible
option from both a biological and economic point of view [13–16]. Several techniques
using direct/indirect restorations of composite, ceramic or hybrid CAD/CAM materials
to reconstruct worn teeth and restore a functional occlusal pattern in a stable mandibular
position have been described [2,7,9,11,12].
In patients with severe dental wear, etiology is a risk factor for the restorative treatment
if it is not controlled. For example, patients with occlusal parafunction may exceed the
fatigue limits of different materials, which will increase the risk of fractures, or wear of
chemical origin may also compromise marginal integrity and increase microleakage [1,9].
Currently, there is little clinical evidence to support the medium- and long-term sur-
vival and clinical performance of ultraconservative approaches using adhesive restorations
in full-mouth restorations [15–19]. The aim of this study was to evaluate the medium-term
clinical performance of anterior and posterior adhesive restorations performed with direct
and indirect techniques using composite resins and glass-ceramic-based materials, both
feldspathic and lithium disilicate, applied in patients with severe tooth wear who required
an interdisciplinary approach with increased VDO.

2. Materials and Methods

The study protocol was approved by the Catholic University of Cuenca (Cuenca,
Ecuador) Ethics Committee for Research Involving Humans (CEISH-UCACUE-2023-037).
The study protocol complied with the guidelines established in the Declaration of Helsinki.
All study participants received complete information on the objectives of the study, the
procedures involved, alternative treatment options and the risks involved. All study
participants gave informed consent to participate in the study.
The inclusion criteria were an esthetic problem as the main reason for consultation
and severe generalized wear of grade 2 to 4 according to the Tooth Wear Evaluation System
(TWES 2.0), which offers a complete taxonomy of tooth wear [20], including previous
indirect restorations in the anterior and posterior sectors and patients who had received
restorative treatment for at least 5 years. The patients’ medical records had to include initial
and final photographs, type IV plaster models mounted on a semi-adjustable articulator
(Panadent magentic PSH, Colton, CA, USA) or digital models with the initial and final
VDO after treatment.
Finally, a detailed description of the teeth treated, as well as the materials used in each
restoration, can be found in Refs. [7,8], including marginal adaptation, surface roughness,
restoration fracture, tooth fracture, secondary caries and postoperative sensitivity. No
exclusions were made based on the following factors: the etiology of wear (severe bruxism,
J. Clin. Med. 2023, 12, 5222 3 of 14

gastroesophageal reflux, etc.) and orthodontic and/or endodontic treatment prior to the
restorative process.
All patients were treated by an experienced operator, Álvaro Ferrando Cascales, DDS,
PhD (AFC), using a semi-additive restorative approach that included the following clinical
sequence:
1. An esthetic diagnosis using Digital Smile Design (DSD) [21].
2. The determination of VDO by means of an articulator set-up of the maxilla with a
Kois dentofacial analyzer [22] (Panadent magentic PSH, Colton, CA, USA) and of the
intermaxillary relations with the power centric manual induction technique [5].
3. Posterior sector: the diagnostic wax-up, fabrication and cementation of occlusal
restorations in maxillary and/or mandibular posterior teeth to achieve a balanced oc-
clusion with bilateral and simultaneous posterior contacts, thus restoring an adequate
height to the lower facial third [2–4].
4. Anterior guide: treatment using maxillary palatal veneers without dental preparation
and anteroinferior vestibular veneers for the provision of anterior guidance [3,4].
5. Final esthetics: anterosuperior vestibular veneers to achieve our final esthetic goals
planned in the diagnostic process.
The criteria for exclusion were patients with localized tooth wear of grade 1 accord-
ing to the TWES 2.0 criteria, periodontitis, severe gingival inflammation and a lack of
cooperation regarding hygiene instructions.
Clinical and photographic information from the medical records was collected indepen-
dently by two investigators, Andrés Delgado-Gaete, DDS, MsC, and Daniela Astudillo-Rubio,
DDS, MsC (ADG, DAR), from January to October 2022. The clinical characteristics collected
from the patients were sex, age, TWES 2.0 classification, whether or not they received or-
thodontic treatment, the type of treatment per tooth (occlusal veneer, facial veneer or palatal
veneer), parafunction, the type of failure, time to failure and the solution (Table 1).

Table 1. Univariable comparisons of predictor factors for the failure of restorations.

Hazard Ratio (95% CI), and p-Value

Variable No Failure Failure
(Cox Regression)
Posterior Veneer (indicator) 53 14
0.143 (CI 0.034–0.601) p = 0.008
Anterior Veneer (pacial, palatal) 138 6
Composite, Direct/Indirect
83 13
(indicator) 1.703 (CI 0.491–5.903) p = 0.401
Ceramic 108 7
Bite Guard NO (indicator) 45 7
0.658 (CI 0.222–1.949) p = 0.450
Bite Guard YES 146 13
TWES 2.0 2 (Indicator) 44 6
1.362 (CI 0.529–3.512) p = 0.522
TWES 2.0 3–4 147 14
Class I 124 10
2.355 (CI 0.992–5.591) p = 0.052
Class II–III (indicator) 67 10
Maxilla (indicator) 106 11
0.494 (CI 0.177–1.380) p = 0.179
Mandible 85 9
Orthodontic Treatment YES
87 10
(indicator) 1.303 (CI 0.553–3.067) p = 0.545
Orthodontic Treatment NO 104 10

The survival rate was the main outcome variable, and the evaluation form for this
variable was determined by the survival time. It was defined as the time elapsed from the
successful adjustment of the restoration to the time when the restoration and/or restored
tooth presented a failure that required dental intervention. For the evaluation, survival
failures were considered as absolute when they met the following scores, according to the
J. Clin. Med. 2023, 12, 5222 4 of 14

modified USPHS criteria [23,24]: a fracture restoration score of 2 (minor chipping on the
restoration (1/4 of the restoration)), 3 (moderate chipping on the restoration (1/2 of the
restoration)), 4 (severe chipping (3/4 of the restoration)) or 5 (debonding of the restoration);
a secondary caries score of 1 (caries evidently continuous with the margin); a tooth fracture
score of 2 (minor chipping on the tooth (1/4 of the crown)), 3 (moderate chipping of the
tooth (1/2 of the crown)) or 4 (crown fracture near the cementum enamel line (extraction));
a surface roughness score of 2 (rough, cannot be refinished) or 3 (surface deeply pitted,
irregular grooves); and a postoperative sensitivity score of 1 (slight sensitivity).
Survival analyses were performed with statistical software (SPSS 24.0; SPSS Inc.,
Chicago, IL, USA). Kaplan–Meier and log-rank (Mantel-Cox) tests were used to obtain the
estimated survival and failure rates of the restorations at various time intervals, with the
following variables: the restoration material (composite and ceramic), treatment type (pos-
terior veneer and anterior veneer), parafunction (yes, no), TWES index (2, 3, 4), occlusion
type (classes I, II, III), dental arch (upper, lower) and orthodontic treatment (yes, no). The
univariate models were adjusted for each potential predictor using a Cox regression model,
transforming the variables into dichotomous variables and including the variable patient
as a random effect.

3. Results
This retrospective case series study included eight patients with a mean age of 46.6 years,
or six men with a mean age of 45.5 years and two women with a mean age of 50 years.
Four patients (50%) received orthodontic treatment (Figures 1–3 prior to the restorative
process with the aim of improving their sagittal, transverse and vertical maxillomandibular
J. Clin. Med. 2023, 12, x FOR PEERrelations,
REVIEW as well as dental alignment. Six patients (75%) also presented with 5 ofocclusal
15
parafunction.

Figure 1. Patient 1. Generalized extreme pathological tooth wear (TWES 2.0). (A) Intraoral initial
Figure 1. Patient 1. Generalized extreme pathological tooth wear (TWES 2.0). (A) Intraoral initial aspect
aspect of one Sjogren’s syndrome diagnosed. Deep-bite occlusal relationships and severely worn
of anterior
one Sjogren’s syndrome
teeth and diagnosed.staining
severe tetracycline Deep-bite
can be occlusal relationships
appreciated. and severely
(B) Intraoral worn
aspect after anterior
ortho-
teeth
dontic and restorative treatment, emphasizing great aesthetic and functional improvement. Oc- and
and severe tetracycline staining can be appreciated. (B) Intraoral aspect after orthodontic
clusal-vestibular
restorative veneers
treatment, from 1.6 to
emphasizing 2.6 and
great from 3.1
aesthetic andtofunctional
4.2. In the improvement.
posteroinferior sectors (3.3–3.7
Occlusal-vestibular
and 4.3–4.7), CAD-CAM nanoceramic resins were used. (C) A 5-year follow-up photograph.
veneers from 1.6 to 2.6 and from 3.1 to 4.2. In the posteroinferior sectors (3.3–3.7 and 4.3–4.7), CAD-CAM Note
the maintenance of occlusal contact relationships, although there is slight wear of the posteroinfe-
nanoceramic resins were used. (C) A 5-year follow-up photograph. Note the maintenance of occlusal
rior sectors, as seen in the flattening of the cusps. (D) Initial orthopantomography. (E) Final or-
contact relationships, although
thopantomography there
showing the is slight wear
supplement of allofteeth
the posteroinferior sectors,
with an endodontic as seeninin
treatment 4.5the flattening
due to
of previous
the cusps.necrosis.
(D) Initial orthopantomography. (E) Final orthopantomography showing the supplement
of all teeth with an endodontic treatment in 4.5 due to previous necrosis.

J. Clin. Med. 2023, 12, 5222
anterior teeth and severe tetracycline staining can be appreciated. (B) Intraoral aspect after ortho-
dontic and restorative treatment, emphasizing great aesthetic and functional improvement. Oc-
clusal-vestibular veneers from 1.6 to 2.6 and from 3.1 to 4.2. In the posteroinferior sectors (3.3–3.7
and 4.3–4.7), CAD-CAM nanoceramic resins were used. (C) A 5-year follow-up photograph. Note
the maintenance of occlusal contact relationships, although there is slight wear of the posteroinfe-
rior sectors, as seen in the flattening of the cusps. (D) Initial orthopantomography. (E) Final or- 5 of 14
thopantomography showing the supplement of all teeth with an endodontic treatment in 4.5 due to
previous necrosis.

Figure 2. Patient 2. Generalized severe pathological tooth wear (TWES 2.0). (A) Pre-orthodontic
Figure 2. Patient 2. Generalized severe pathological tooth wear (TWES 2.0). (A) Pre-orthodontic in-
intraoral situation showing a class II, division 2 occlusal relationship accompanied by severe
traoral situation
crowding in the showing a class
mandible. (B) II, divisionafter
Occlusion 2 occlusal relationship
orthodontic accompanied
and restorative by severe
treatment, crowding
showing
J. Clin. Med. 2023, 12, x FOR PEERin the mandible.
considerable
REVIEW (B) Occlusion
aesthetic after orthodontic
and functional improvement.and(C) restorative treatment,
A 5-year follow-up showing
photograph toconsiderable
under-
6 of 15
line theand
aesthetic maintenance
functionalofimprovement.
occlusal contact(C)
relationships. Slight chronic
A 5-year follow-up gingivitistodue
photograph to plaque
underline theac-
mainte-
cumulation
nance of occlusalcancontact
be observed. (D) Initial
relationships. orthopantomography.
Slight chronic gingivitis (E)
dueFinal orthopantomography
to plaque accumulation can be
observed.
showing(D) Initial orthopantomography.
supplementation (E) from
from 1.6 to 2.6 and Final3.6
orthopantomography showing
to 4.6 by means of occlusal andsupplementation
vestibular
from 1.6 todisilicate
lithium 2.6 and veneers.
from 3.6 to 4.6 by means of occlusal and vestibular lithium disilicate veneers.

Figure 3. Patient 3. Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
Figure 3. Patient 3. Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
deep bite and occlusal relationships shown by a patient with severely worn anterior teeth. (B) Oc-
deep bite and
clusion afterocclusal relationships
orthodontic showntreatment,
and restorative by a patient with severely
indicating aestheticworn anterior teeth.
and functional (B) Occlu-
improve-
sion afterFelspathic
ment. orthodontic and restorative
vestibular treatment,
veneers from 1.5 to 2.5,indicating
CAD-CAMaesthetic and palatal
nanoceramic functional improvement.
veneers from
1.3 to 2.3,
Felspathic lithium disilicate
vestibular veneers veneers
from 1.5from 3.3CAD-CAM
to 2.5, to 4.3 and ananoceramic
direct stamped composite
palatal veneersresin in 1.3
from the to 2.3,
posteroinferior sectors (3.4–3.6 and 4.4–4.6). (C) A 5-year follow-up photograph. Note the mainte-
lithium disilicate veneers from 3.3 to 4.3 and a direct stamped composite resin in the posteroinferior
nance of occlusal contact relationships. (D) Initial orthopantomography. (E) Final orthopantomog-
sectors
raphy(3.4–3.6
showing and
the4.4–4.6). (C) A 5-year
supplementation of all follow-up photograph.
teeth with an endodontic Note the maintenance
treatment of occlusal
in 1.4 due to previ-
contact relationships. (D) Initial orthopantomography. (E) Final orthopantomography showing the
ous necrosis.
supplementation of all teeth with an endodontic treatment in 1.4 due to previous necrosis.
A total of 212 restorations were performed, which were distributed as follows: 66
A total
occlusal of 212
veneers, 26 restorations
palatal veneerswere
and 120performed,
vestibular which
veneers.were distributed as follows:
The occlusal and palatal veneers were fabricated
66 occlusal veneers, 26 palatal veneers and 120 vestibular with aveneers.
CAD-CAM milled indirect
composite resin (Cerasmart.GC, Tokyo, Japan). The vestibular veneers were fabricated
with a classic feldspathic ceramic (Creation, Creation Willi Geller International GmbH,
Meiningen, Germany) and reinforced with lithium disilicate (E.max Press, Ivoclar Viva-
dent, Schaan, Liechtenstein). The adhesive cementation of the restorations was per-
formed with a light-cured resin cement (Calibra veneer bleach, Dentsply sirona. Kon-
J. Clin. Med. 2023, 12, 5222 6 of 14

The occlusal and palatal veneers were fabricated with a CAD-CAM milled indirect
composite resin (Cerasmart.GC, Tokyo, Japan). The vestibular veneers were fabricated
with a classic feldspathic ceramic (Creation, Creation Willi Geller International GmbH,
Meiningen, Germany) and reinforced with lithium disilicate (E.max Press, Ivoclar Vivadent,
Schaan, Liechtenstein). The adhesive cementation of the restorations was performed with
a light-cured resin cement (Calibra veneer bleach, Dentsply sirona. Konstanz, Germany)
(Figures 4–6).
The clinical parameters of the 212 restorations studied with the modified USPHS
criteria for occlusal veneers, facial veneers and palatal veneers and their respective materials
are described in Table 1.
No signs of marginal microleakage or postoperative sensitivity were observed in any
of the occlusal, vestibular and/or palatal restorations after the follow-up period. The
hypersensitivity presenting in some patients before treatment was efficaciously eliminated
upon finishing the restorations. The surface roughness of all the restorations was within
the USPHS score range 0 and 1, and no failures were considered in the survival analysis.
The fracture of the restoration, according to the USPHS criteria, represented the highest
number of complications (18 of 212). Seventeen restorations showed slight chipping of 1/4
of the restoration (USPHS criteria, restoration score 2) which required clinician intervention,
and the defects were repaired with a composite resin. One restoration had decementation
(USPHS criteria, restoration score 5) and was recemented. We found one fractured tooth
(USPHS criteria, restoration score 4), which required extraction and the placement of a
dental implant to replace it. Finally, secondary caries lesions were found in two teeth
J. Clin. Med. 2023, 12, x FOR PEER(USPHS
REVIEW criteria, caries score 1), one of which required root canal treatment and7composite
of 15
resin repair, while the other required only composite resin repair.

Figure Patient
4. 4.
Figure Patient4:4:Generalized
Generalizedsevere
severe pathological toothwear
pathological tooth wear(TWES
(TWES2.0).2.0).(A)
(A) Intraoral
Intraoral situation: in-
situation:
inverted
verted occlusal
occlusal planeplane
shown shown
for afor a patient
patient withwith extremely
extremely wornworn anterior
anterior teeth
teeth associated
associated with
with a
a compen-
compensatory extrusion of the mandibular anterior teeth. (B) Occlusion after treatment, high-
satory extrusion of the mandibular anterior teeth. (B) Occlusion after treatment, highlighting aesthetic
lighting aesthetic and functional improvement. (C) A 5-year follow-up photograph showing excel-
andlent
functional improvement.
periodontal health with the(C) total
A 5-year follow-up
absence photograph
of recession, showing
highlighting excellent periodontal
the maintenance of occlusalhealth
with the total absence of recession, highlighting the maintenance of occlusal
contact relationships. (D) Initial orthopantomography. (E) Final orthopantomography showing contact relationships.
the
supplementation of all teeth without endodontic treatments. Felspathic vestibular
(D) Initial orthopantomography. (E) Final orthopantomography showing the supplementation veneers from 1.2 of
to 2.2, CAD-CAM nanoceramic resin palatal veneers from 1.3 to 2.3, and occlusal
all teeth without endodontic treatments. Felspathic vestibular veneers from 1.2 to 2.2, CAD-CAM and vestibular
veneers on 1.5, 1.4, 2.4 and 2.5. Finally, lithium disilicate veneers from 3.5 to 4.5 and 3.7, 4.7.
nanoceramic resin palatal veneers from 1.3 to 2.3, and occlusal and vestibular veneers on 1.5, 1.4, 2.4
and 2.5. Finally, lithium disilicate veneers from 3.5 to 4.5 and 3.7, 4.7.

J. Clin. Med. 2023, 12, 5222
inverted occlusal plane shown for a patient with extremely worn anterior teeth associated with a
compensatory extrusion of the mandibular anterior teeth. (B) Occlusion after treatment, high-
lighting aesthetic and functional improvement. (C) A 5-year follow-up photograph showing excel-
lent periodontal health with the total absence of recession, highlighting the maintenance of occlusal
contact relationships. (D) Initial orthopantomography. (E) Final orthopantomography showing the
supplementation of all teeth without endodontic treatments. Felspathic vestibular veneers from 1.2 7 of 14
to 2.2, CAD-CAM nanoceramic resin palatal veneers from 1.3 to 2.3, and occlusal and vestibular
veneers on 1.5, 1.4, 2.4 and 2.5. Finally, lithium disilicate veneers from 3.5 to 4.5 and 3.7, 4.7.

Figure 5. Patient 5: Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
Figure 5. Patient
edge-to-edge bite5:and
Generalized severe pathological
occlusal relationships shown bytooth wearwith
a patient (TWES 2.0). worn
severely (A) Intraoral situation:
anterior teeth,
edge-to-edge
(B) Intraoral bite
J. Clin. Med. 2023, 12, x FOR PEER REVIEW and occlusal
appearance relationships
at 1 year. shown
The aesthetic andby a patientimprovement
functional with severelyis worn anterior
remarkable, teeth,
8 ofalt-
15
(B)hough
Intraoral
thereappearance at 1 year.
is considerable plaqueThe aesthetic and(C)
accumulation. functional
Follow-up improvement
photograph is atremarkable, although
5 years, showing
there is considerable plaque accumulation. (C) Follow-up photograph at 5 years, showing acute
gingivitis, which was
acute gingivitis, treated
which successfully
was treated with a tartrectomy
successfully and theand
with a tartrectomy reinforcement of hygienic
the reinforcement of hy-mea-
gienic measures. (D) Initial orthopantomography. (E) Final orthopantomography
sures. (D) Initial orthopantomography. (E) Final orthopantomography showing the supplementation showing the
supplementation of all teeth. Lithium disilicate veneers from 1.4 to 2.3, CAD-CAM
of all teeth. Lithium disilicate veneers from 1.4 to 2.3, CAD-CAM nanoceramic palatal veneers from nanoceramic
palatal veneers from 1.3 to 2.3, occlusal and vestibular direct composites on 1.5 and 2.5. Lithium
1.3 to 2.3, occlusal and vestibular direct composites on 1.5 and 2.5. Lithium disilicate veneers from
disilicate veneers from 3.2 to 4.2, direct stamped composite resin in the posteroinferior sectors
3.2(3.3–3.4
to 4.2, and
direct stamped composite resin in the posteroinferior sectors (3.3–3.4 and 4.3–4.7). One
4.3–4.7). One implant in 1.5 and the change of the prosthesis on implants 3.5 and 3.6
implant in 1.5 and the change
can be noted. Finally, we must ofmention
the prosthesis
a root on implants
canal treatment 3.5 applied
and 3.6 can be noted.
the teeth Finally,
that had we must
previous
mention
crowns.a root canal treatment applied the teeth that had previous crowns.

Figure 6. Patient 6: Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
Figure 6. Patient 6: Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
edge-to-edge bite and occlusal relationships shown by a patient with severely worn anterior teeth.
edge-to-edge bite and
A compensatory occlusal
extrusion relationships
of the mandibularshown by abepatient
teeth can with severely
appreciated worn after
(B) Occlusion anterior teeth.
treat-
A ment,
compensatory extrusion of the mandibular teeth can be appreciated (B) Occlusion after
showing considerable esthetic and functional improvement. (C) Follow-up photograph at 5 treatment,
showing considerable
years just esthetic
after bicarbonate andtreatment,
spray functionalshowing
improvement. (C) Follow-up
the maintenance photograph
of periodontal at at
health 5 years
5
years. (D) Initial orthopantomography. (E) Final orthopantomography showing facial veneers from
1.6 to 2.6 and free-hand direct composites in the mandible (3.6–4.6).

The clinical parameters of the 212 restorations studied with the modified USPHS
criteria for occlusal veneers, facial veneers and palatal veneers and their respective ma-
terials are described in Table 1.
 J. Clin. Med. 2023, 12, 5222 8 of 14

J. Clin. Med. 2023, 12, x FOR PEER REVIEW

just after bicarbonate spray treatment, showing the maintenance of periodontal health at95ofyears.
15
(D) Initial orthopantomography. (E) Final orthopantomography showing facial veneers from 1.6 to
2.6 and free-hand direct composites in the mandible (3.6–4.6).
The
Theestimated
estimatedsurvival
survivalrate
rateofofthe
the 212
212 restorations was 90.1%
restorations was 90.1% during
duringthethe60
60months
monthsof
ofobservation,
observation,withwitha asurvival
survivaltime
time of 57.6 months. Only 21 restorations had complica-
of 57.6 months. Only 21 restorations had complications
tions requiring
requiring further
further intervention
intervention (Scheme
(Scheme 1). Most
1). Most complications
complications occurred
occurred at 2 and
at 2 and 5
5 years
years of follow-up, with estimated failure rates of 5% (10 restorations) and 6%
of follow-up, with estimated failure rates of 5% (10 restorations) and 6% (6 restorations), (6 restora-
tions), respectively,
respectively, followed
followed by a failure
by a failure rate ofrate
2%of(42% (4 restorations)
restorations) in thein theyear
3rd 3rdand
yeara and a
failure
failure
rate ofrate
1% of(1 1% (1 restoration)
restoration) in the in
4ththe 4thofyear
year of follow-up.
follow-up.

Kaplan–Meier plot
Scheme1.1.Kaplan–Meier
Scheme plot showing
showing the
thesurvival
survivalcurves
curvesof of
allall
restorations at 60atmonths
restorations of follow-up.
60 months of fol-
low-up.
The type of treatment (occlusal veneer, facial veneer, palatal veneer) had a statistically
significant
The type influence on the
of treatment estimated
(occlusal survival
veneer, rate
facial (p < 0.000).
veneer, palatalOcclusal
veneer) veneers had an
had a statisti-
estimated survival rate of 79.1%, with rates of 94.1% for vestibular veneers
cally significant influence on the estimated survival rate (p < 0.000). Occlusal veneers had and 100% for
palatal veneers (Scheme 2). Composite resin restorations had a mean survival
an estimated survival rate of 79.1%, with rates of 94.1% for vestibular veneers and 100% rate of 86.3%,
while
for ceramic
palatal restorations
veneers (Scheme had a survival rate
2). Composite resinofrestorations
93.1% (p = 0.107)
had a (Scheme 3).
mean survival rate of
86.3%,The
whilevariables
ceramicstudied, tooth wear
restorations had aclassification,
survival ratetype of occlusion,
of 93.1% dental
(p = 0.107) arch, 3).
(Scheme previous
orthodontic treatment, and use of occlusal splints did not have a statistically significant
influence on the estimated survival rate of the restorations at 60 months of follow-up
(p > 0.05). Teeth with a generalized tooth wear index of grade 2 or 3 had estimated survival
rates of 91.4% and 85.7%, respectively (p = 0.603). Restorations in patients with a class
II occlusion had a survival rate of 81.8% versus 92.6% and 95.2% in patients with class I
and III occlusions, respectively (p = 0.058). The survival rates for restorations placed in
the upper and lower jaw were 89.7% and 90.5%, respectively (p = 0.828). Restorations
placed in patients who received orthodontic treatment prior to the restorative phase had a
survival rate of 88.7% versus 91.2% for patients who had not received orthodontic treatment
(p = 0.540). Lastly, the survival of restorations in patients who wore occlusal bite guards
was 91.8%, while in those who did not, it was 84.6%, (p = 0.138).
J. Clin. Med. 2023, 12, x FOR PEER REVIEW 10 of 15
J. J.
Clin. Med.
Clin. 2023,
Med. 12,12,
2023, x FOR
5222 PEER REVIEW 10 of 1514
9 of

Scheme
Scheme2.2.Kaplan–Meier
Kaplan–Meierplot showing
plot showingthe
thesurvival
survivalcurves
curvesofofdifferent
differenttypes
typesofoftreatment.
treatment.
Scheme 2. Kaplan–Meier plot showing the survival curves of different types of treatment.

Scheme
Scheme3.3.Kaplan–Meier
Kaplan–Meierplot showing
plot showingthe
thesurvival
survivalcurves
curvesofofdifferent
differenttypes
typesofofmaterials.
materials.

Thevariables
The
Scheme 3.univariate risk plot
studied,
Kaplan–Meier analysis
tooth of the
wear
showing predictors affecting
classification,
the typeofof
survival curves the survival
occlusion,
different of restorations
dental
types arch, pre-is
of materials.
shown
vious in Table 1.treatment,
orthodontic The dichotomous
and usevariable of restoration
of occlusal splints did type
not(posterior veneer, anterior
have a statistically sig-
veneer)
nificantThe was the risk
variables
influence predictor
on studied, with a statistically
toothsurvival
the estimated significant
wear classification, influence
type of occlusion,
rate of the restorations (p < dental
0.005)ofon
at 60 months thepre-
arch,
fol-
survival
low-up
vious (p of the restorations.
> 0.05). Teeth
orthodontic The use
with a generalized
treatment, of
and use of a bite
tooth guard, type
wear index
occlusal of
splintsofdidocclusion,
gradenot2 have dental
or 3 had arch and
estimated sig-
a statistically
orthodontic
survival rates treatment
of 91.4% were
and not
85.7%,observed as predictor
respectively (p = variables
0.603). with statistically
Restorations
nificant influence on the estimated survival rate of the restorations at 60 months in significant
patients with aof fol-
influences
class on
II occlusionthe survival
had of the
a survival restorations.
rate of 81.8%tooth
versus 92.6% andof95.2%
low-up (p > 0.05). Teeth with a generalized wear index gradein2 or
patients
3 had with
estimated
survival rates of 91.4% and 85.7%, respectively (p = 0.603). Restorations in patients with a
class II occlusion had a survival rate of 81.8% versus 92.6% and 95.2% in patients with
J. Clin. Med. 2023, 12, 5222 10 of 14

4. Discussion
Consensus in clinical management guidelines and evidence-based recommendations for
the choice of material and restoration type in this group of patients are limited [1,5,11–16].
Currently, the literature is sparse in terms of indications and scarce in evaluations of the
survival rates and clinical performance of different types of materials and restorations used to
perform full oral rehabilitations [7,9–19]. For example, the systematic review conducted by
Mesko et al. in 2016 [18] did not render an open picture, concluding that there is no strong
evidence to suggest that one material is better than another. Direct or indirect materials may
be feasible options to restore severely worn teeth [2,14–17].
There is no doubt that in vivo clinical studies allow for the testing of intraoral con-
ditions that cannot be fully reproduced in vitro, thus allowing for a true evaluation of
the behavior of new materials and techniques currently being performed in patients with
severe multifactorial tooth wear and, therefore, the extrapolation of specific indications. In
this regard, it is worth noting the prospective trial conducted by Gúth JF et al. on 12 patients
in 2020 [25], in which significantly less occlusal wear of lithium disilicate, as compared to
CAD-CAM composites, was observed over a follow-up of only 2 years.
In our study, although retrospective, ceramic and composite materials (anterior and
posterior) were equally evaluated over a controlled clinical follow-up of 5 years [6]. The
high cumulative survival rates are similar or slightly lower than the results obtained
in similar studies involving all types of adhesive restorations. Of note is the study by
Torosyan A et al. published in 2022, with an overall survival rate of 99% at 6 years for
406 restorations [26]. The 6-year survival rates were 97.3% for direct composites (anterior–
posterior); 98.2% for onlays, both composite and ceramic; and 100% for veneers, again both
composite and ceramic (p > 0.05). No differences were found between the materials and
locations of the restorations. The total of 19 technical complications included 14 partial
fractures, 3 fissures, 1 wear, and 1 decementation. The USPHS evaluation showed good
technical outcomes.
Nevertheless, our results, as in the case of Torosyan A et al., are in accordance with
the main conclusion of the study conducted by Loomans. B and Opdam. N in 2018 [14].
Restorations, including composites and veneers or crowns, do not prevent wear processes;
they simply modify the rate, location and nature of wear. Additionally, most restorations
that are considered “definitive” may have a limited service life in cases with severe tooth
wear due to bruxism and erosion. One of the most important aspects is the notion that
possible treatment options and anticipated complications should be explained to patients
in the informed consent process.
The literature is conclusive regarding the use of occlusal bite guards. Faus V et al., in
2020 [27], reported that bruxism patients who used bite guards showed a survival rate of
89.1% after 7 years, whereas the survival rate in bruxism patients who did not use guards
was 63.9% (p < 0.05). In the study by Torosyan et al. [26], the presence or absence of bite
guards did determine survival (p = 0.003). In our study, survival was 90.1% at 60 months of
observation, and the application of an occlusal bite guard had a positive influence on the
cumulative survival of restorations (hazard ratio 1.91; p < 0.149).
In our case series, all 212 restorations evaluated showed excellent clinical behavior
at the 5-year follow-up, while only 18 restorations showed 1/4 chipping (USPHS criteria,
restoration score 2). This very low failure rate is in accordance with the studies included in
the systematic review by Mesko et al., 2016 [28], and the survival rate reported by Milosevic
et al., 2016, at eight years [19]. The complications were easily repairable by the clinician
(AFC) (Figures 7 and 8), following an established evidence-based protocol [6,7,18,19].
This included 50-micron aluminum oxide sandblasting (Dento-prep. Ronvig, Daugaard,
Denmark) for the composite resin and hydrofluoric acid etching (Porcelain etch. Ultradent
Products, Inc., South Jordan, UT, USA) for the ceramic, followed by active cleaning with
37% orthophosphoric acid (Ultra-etch. Ultradent Products, Inc., South Jordan, UT, USA) for
2 min and the application of a silane-based bonding agent, which was heat-activated for
one minute with an LED polymerization lamp (Smartlite Pro. Dentsply Sirona, Konstanz,
 losevic et al., 2016, at eight years [19]. The complications were easily repairable by the
clinician (AFC) (Figures 7 and 8), following an established evidence-based protocol
[6,7,18,19]. This included 50-micron aluminum oxide sandblasting (Dento-prep. Ronvig,
Daugaard, Denmark) for the composite resin and hydrofluoric acid etching (Porcelain
etch. Ultradent Products, Inc., South Jordan, UT, USA) for the ceramic, followed by active
J. Clin. Med. 2023, 12, 5222 cleaning with 37% orthophosphoric acid (Ultra-etch. Ultradent Products, Inc., South 11 of 14
Jordan, UT, USA) for 2 min and the application of a silane-based bonding agent, which
was heat-activated for one minute with an LED polymerization lamp (Smartlite Pro.
Dentsply Finally,
Germany). Sirona, aKonstanz, Germany).
bonding agent Finally,
belonging to aa fourth-generation
bonding agent belongingadhesive to a
system
fourth-generation adhesive system (Heliobond, Ivoclar
(Heliobond, Ivoclar Vivaldent, Schaan, Liechtenstein) was applied. Vivaldent, Schaan, Liechtenstein)
wasTheapplied.
survival rate, based on the type of treatment performed (occlusal veneer, facial
veneer, The survival rate, based on the type of treatment performed (occlusal veneer, facial
palatal veneer), also showed statistically significant differences (p < 0.05) with the
veneer, palatal veneer), also showed statistically significant differences (p < 0.05) with the
estimated survival rate, being lower for occlusal veneers compared to vestibular and palatal
estimated survival rate, being lower for occlusal veneers compared to vestibular and
veneers. This is probably because posterior restorations are subject to more fatigue and/or
palatal veneers. This is probably because posterior restorations are subject to more fa-
wear than anterior restorations [29].
tigue and/or wear than anterior restorations [29].
TheTherestoration
restorationofofworn
worndentitions
dentitions isis widely describedininthe
widely described theliterature
literature [1–19].
[1–19]. With With
thethe
main advantage of adhesive restorations being the fact that a semi-
main advantage of adhesive restorations being the fact that a semi- or fully additive or fully additive
approach
approach is is
adopted,
adopted,thethestudy
studyby by Fradeani
Fradeani et et al.,
al.,conducted
conductedinin2021,2021, concluded
concluded thatthat
the the
cumulative
cumulative survival rate recorded was 99.15%, with a ten-year survival probability 96.5%.
survival rate recorded was 99.15%, with a ten-year survival probability of of
These remarkable
96.5%. results strongly
These remarkable supportsupport
results strongly the usethe ofuse
a Minimally Invasive
of a Minimally Preparation
Invasive Prep-
Procedure (MIPP) as(MIPP)
aration Procedure a restorative option for
as a restorative severely
option worn dentitions
for severely [12]. [12].
worn dentitions
In In
contrast, conventional
contrast, classical
conventional tooth tooth
classical preparation approaches
preparation based onbased
approaches crown-type
on
restorations
crown-type compromise
restorationsmore of the already
compromise more ofdeteriorated
the already tooth structure
deteriorated [30].
tooth Although
structure
they[30].
haveAlthough they have
demonstrated demonstrated
equal equal long-term
long-term success, success, with
with 15–20-year 15–20-year
survival sur-
rates ranging
vival rates
between 50 andranging between
80% [31], they50 and 80%
deviate from[31],
thethey deviate established
guidelines from the guidelines established
in the latest European
in the latest
consensus European
statement consensus
on the treatmentstatement on theworn
of severely treatment of severely
teeth [1] worn teeth
that advocate for the[1]use
that advocate
of adhesive, foror
direct the use of techniques,
indirect adhesive, direct
whichor indirect
usually techniques,
allow for a which
secondusually
chanceallow
in cases
for afailure
of the secondand/or
chancewear
in cases of the
of the failure and/or
previous wear of
restoration the previous restoration [32].
[32].

J. Clin. Med. 2023, 12, x FOR PEER REVIEW 13 of 15

Figure Patient
7. 7.
Figure Patient7.7.Generalized
Generalized severe pathologicaltooth
severe pathological tooth wear
wear (TWES
(TWES 2.0).
2.0). (A) (A) Intraoral
Intraoral situation:
situation:
edge-to-edgebite
edge-to-edge biteand
andocclusal
occlusal relationships
relationships shown
shownbybya apatient
patientwith severely
with severelyworn anterior
worn teeth.teeth.
anterior
WeWe can observe a class III malocclusion that was solved with an extraction of the lower right central
can observe a class III malocclusion that was solved with an extraction of the lower right cen-
incisor (4.1) associated with a complete orthodontic treatment prior to the restorative phase. (B)
tralOcclusion
incisor (4.1) associated with a complete orthodontic treatment prior to the restorative phase.
after orthodontic treatment (the extraction of 4.1 was necessary to alleviate crowding).
(B)Restorative
Occlusion treatment
after orthodontic treatment
was performed with(the extraction
composites of 4.1
in the was necessary
mandible to alleviate
and feldesphatics crowding).
ceramics
Restorative treatment
in the maxilla. The was performed
aesthetic with composites
and functional in theismandible
improvement and (C)
noteworthy. feldesphatics
Resolutionceramics
of the in
thefracture with
maxilla. Thea aesthetic
direct composite resin. Note
and functional the maintenance
improvement of occlusal(C)
is noteworthy. contact relationships
Resolution of the and
fracture
periodontal health at 5 years. (D) Initial orthopantomography. (E) Follow-up at 4 years. Fracture of
the incisal edge of the ceramic veneer on 2.1 due to trauma with a glass bottle. (F) Final orthopan-
tomography showing direct stamped composite resin supplementation in the posteroinferior sec-
tors (3.3–3.7 and 4.3–4.7) and feldesphatics veneers from 1.5 to 2.5 and on 4.2, 3.1 and 3.2.
 Figure 7. Patient 7. Generalized severe pathological tooth wear (TWES 2.0). (A) Intraoral situation:
edge-to-edge bite and occlusal relationships shown by a patient with severely worn anterior teeth.
We can observe a class III malocclusion that was solved with an extraction of the lower right central
J. Clin. Med. 2023, 12, 5222 incisor (4.1) associated with a complete orthodontic treatment prior to the restorative phase.12(B) of 14
Occlusion after orthodontic treatment (the extraction of 4.1 was necessary to alleviate crowding).
Restorative treatment was performed with composites in the mandible and feldesphatics ceramics
in the maxilla. The aesthetic and functional improvement is noteworthy. (C) Resolution of the
with a direct composite resin. Note the maintenance of occlusal contact relationships and periodontal
fracture with a direct composite resin. Note the maintenance of occlusal contact relationships and
health at 5 years. (D) Initial orthopantomography. (E) Follow-up at 4 years. Fracture of the incisal
periodontal health at 5 years. (D) Initial orthopantomography. (E) Follow-up at 4 years. Fracture of
edge of the edge
the incisal ceramic veneer
of the on 2.1
ceramic due on
veneer to trauma
2.1 due with a glass
to trauma withbottle. (F) bottle.
a glass Final orthopantomography
(F) Final orthopan-
showing directshowing
tomography stampeddirect
composite resin
stamped supplementation
composite in the posteroinferior
resin supplementation sectors (3.3–3.7
in the posteroinferior sec-and
tors (3.3–3.7
4.3–4.7) and 4.3–4.7) and
and feldesphatics feldesphatics
veneers from 1.5 veneers from
to 2.5 and on1.5
4.2,to3.1
2.5and
and3.2.
on 4.2, 3.1 and 3.2.

Figure8.8.Patient
Figure Patient8.8. Generalized
Generalized severe
severe pathological
pathologicaltooth
toothwear
wear(TWES
(TWES 2.0). (A)(A)
2.0). Intraoral
Intraoralsituation:
situation:
deepoverbite
deep overbiteand
and occlusal
occlusal relationships
relationships shownshownby byaapatient
patientwith
withseverely
severely worn
worn anterior
anteriorteeth and
teeth and
severe tetracycline staining. (B) Occlusion after restorative treatment from 1.6 to 2.6 with feld-
severe tetracycline staining. (B) Occlusion after restorative treatment from 1.6 to 2.6 with feldsphatic
sphatic veneers in the maxilla and from 3.2 to 4.2. CAD-CAM indirect nanoceramic resins were
veneers
used for inthe
thepalatal
maxillaveneers
and from 3.2 to and
(1.3–2.3) 4.2. in
CAD-CAM indirect
the mandible nanoceramic resins
(occlusal–vestibular fromwere used
3.3 to 3.7 for
andthe
palatal veneers (1.3–2.3) and in the mandible (occlusal–vestibular from 3.3 to 3.7
from 4.3 to 4.7). From a patient perspective, the aesthetic and functional improvement is out- and from 4.3 to 4.7).
From a patient
standing. perspective,
(C) Follow-up the aesthetic
photograph at 5and functional
years. Note theimprovement
maintenance is of outstanding.
occlusal contact(C)relation-
Follow-up
ships and periodontal
photograph health,
at 5 years. Note thealthough there of
maintenance is recession in 1.3 and
occlusal contact 1.2. (D) Fracture
relationships of CAD-CAM
and periodontal health,
composite nanoceramic resin in 3.6 at 4 years. (E) Detail of the fractured fragment.
although there is recession in 1.3 and 1.2. (D) Fracture of CAD-CAM composite nanoceramic resin in (F) Re-bonding
of the fractured fragment.
3.6 at 4 years. (E) Detail of the fractured fragment. (F) Re-bonding of the fractured fragment.

5. Conclusions
According to the results of this study, there is a significantly higher risk of restorative
complications in posterior teeth compared to anterior teeth (p < 0.005). However, the best
treatment for defective and/or partially fractured restorations is conservative management
based on direct repair. Replacements should be limited to very extensive fractures that
themselves compromise the restorations’ survival [33].
Considering the limitations of this study, including the sample size and great biological
variability in wear, it can be concluded that the indication of anterior and posterior adhesive
restorations is justified in the total oral rehabilitation of patients with severe multifactorial
tooth wear.
The adhesive restorative approach, regardless of the material chosen, presents a low
risk of failure at 5 years. The complications are sustainable in daily clinical practice.

Author Contributions: Conceptualization, Á.F.C., R.F.C., A.D.-G., D.A.-R., S.S., R.H. and R.A.-P.;
methodology, D.A.-R., A.D.-G., Á.F.C., R.H. and R.A.-P.; validation Á.F.C., R.F.C., S.S. and R.A.-
P.; formal analysis, Á.F.C., A.D.-G., D.A.-R. and S.S.; investigation, A.D.-G., D.A.-R. and Á.F.C.;
resources, Á.F.C. and R.F.C.; writing—original draft preparation, Á.F.C., R.F.C., R.H., A.D.-G. and
D.A.-R.; writing—review and editing Á.F.C., R.H., R.A.-P. and S.S.; supervision, Á.F.C., R.F.C., S.S.,
R.H. and R.A.-P.; project administration, Á.F.C., R.F.C., A.D.-G. and D.A.-R.; funding acquisition
A.D.-G. and D.A.-R. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
J. Clin. Med. 2023, 12, 5222 13 of 14

Informed Consent Statement: CEISH-UCACUE-2023-037.

Data Availability Statement: Information is available on request in accordance with any relevant
restrictions (e.g., privacy or ethical).
Conflicts of Interest: The authors declare no conflict of interest.

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