Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions| Reviewers

  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 503    

Table of Contents   
Year : 2018  |  Volume : 8  |  Issue : 5  |  Page : 469-474
Four-year follow-up of increased vertical dimension of occlusion using resin composites

Department of Restorative Dentistry, Lebanese University, Beirut, Lebanon

Date of Submission03-Jul-2018
Date of Acceptance25-Jul-2018
Date of Web Publication8-Oct-2018

Correspondence Address:
Dr. Cendrella Assaf
Department of Restorative and Aesthetic Dentistry, School of Dentistry, Hadath Campus. Lebanese University, Beirut
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jispcd.JISPCD_233_18

Rights and Permissions


The objectives of this case report were to treat a severe loss of the vertical dimension of occlusion with indirect composite and to evaluate the durability of the restorations. A 55-year-old male complains from severe wear of teeth, leading to a change in normal occlusal plane. Two major treatment modalities were proposed to this patient; a conventional invasive crown placement with root canal treatments or a minimally invasive approach relying on adhesion. The latter was adopted and used to treat this patient. This paper describes a step-by-step approach of the different treatment phases starting with teeth preparation, then provisional prostheses, and ending with the placement of indirect anterior veneers and posterior onlays, all made with laboratory resin composite. Satisfactory clinical results were observed over the 4-year follow-up, with minimum failures limited to one partial fracture of inlay treated with direct adhesive repair.

Keywords: Bruxism, full arch rehabilitation, vertical dimension of occlusion

How to cite this article:
Assaf C, Fahd JC, Sabbagh J. Four-year follow-up of increased vertical dimension of occlusion using resin composites. J Int Soc Prevent Communit Dent 2018;8:469-74

How to cite this URL:
Assaf C, Fahd JC, Sabbagh J. Four-year follow-up of increased vertical dimension of occlusion using resin composites. J Int Soc Prevent Communit Dent [serial online] 2018 [cited 2023 Jan 30];8:469-74. Available from: https://www.jispcd.org/text.asp?2018/8/5/469/242868

   Introduction Top

Awake and sleep bruxism, associated with functional disorders, became a widespread disease nowadays.[1] Its intensity varies from mild to severe, and its impact on teeth may present different clinical signs varying from asymptomatic cracks, to severe erosion and teeth wear leading to a loss of the vertical dimension of occlusion (VDO).

VDO is an important factor in facial esthetics and symmetry. It is defined as the relationship of the mandible and maxilla when the jaw is closed, and the teeth are in contact.[2]

The idea of increasing VDO was described by Dhal,[3],[4] since dental treatment improves the patient's oral hygiene, reduces thermal hypersensitivity, and prevents pulpal involvements and further abrasion.[5] In case of severe tooth wear, Dahl proposed to use only indirect restorations (veneers and crowns) to restore the lost dental tissues.[3],[4]

Patients with excessive teeth abrasion require an exact estimation of the VDO to achieve an accurate replacement of lost dimension while reestablishing anatomy and function and to adapt the patient to the change of occlusion. Tolerance to vertical dimension changes is confirmed by the absence of clinical symptoms, during the temporary phase corresponding to the placement of provisional prosthesis.[6]

Traditionally, a full mouth rehabilitation based on full-crown coverage was recommended due to their good mechanical properties and sustainability. Nowadays, adhesive techniques improved while indications for metal-ceramic crowns decreased, consequently a more conservative approach is preferred.[7]

This paper presents a case report of exclusive conservative rehabilitation in a patient with a generalized tooth wear.

   Case Report Top

A 55-year-old patient presented with two chief complaints: deterioration of dental function and esthetics. Clinical examination revealed a loss of the vertical dimension and the presence of severe bruxism placing him in Category 1 according to Turner and Missirlian; Category 2 describes individuals with excessive tooth wear without loss of VDO but with enough space for restorative materials, whereas Category 3 describes individuals with excessive wear without loss of VDO but with limited space for restorative materials.[8]

Before establishing a treatment plan, various examinations and analysis were undertaken including extra- and intra-oral photographs, as well as periodontal and radiographic examinations.

Pictures taken using a reflex camera, to evaluate the profile of the patient, showed a deformation of the bite and a collapse of his upper and lower lips.

The patient had no signs of pain or tenderness in the head or neck area, neither clicking nor tenderness in the temporomandibular joint (TMJ).

Intraoral examination showed attrition and erosion of most of the teeth. There were four interproximal caries due to the loss of the contact points and five other teeth restored with amalgam and resin composite. All the teeth revealed hypercalcified dentin [Figure 1] and [Figure 2].
Figure 1: Lingual view of the tooth wear

Click here to view
Figure 2: Palatal view of the tooth wear

Click here to view

A radiographic examination was undertaken, neither periapical nor periodontal lesions were present. Pulp chambers and root canals were retracted as a result of chronic tooth wear [Figure 3].
Figure 3: Full mouth preoperative X-rays

Click here to view

After thorough explanations given to the patient about the different treatment modalities, he agreed to restore his teeth using a minimally invasive procedure, and a written consent was obtained from him.

Before starting the treatment, he was informed of the possibility of wear of the material, fracture, or debonding of the composite which are liable to occur in such a treatment.

During the first clinical session, alginate impressions were taken, and the models were mounted on a semi-adjustable articulator reproducing patient's VDO.

A new VDO was decided on the articulator, taking into consideration both the posterior and anterior teeth, with the goal of retaining as much tooth structure as possible and to reestablish fair anterior contacts and adequate related anterior guidance.[7] A full mouth wax-up was made. In one session, all the anterior teeth were prepared for veneers and all the posteriors for onlays, in a conservative way, using cylindrical round tip burs with different diamond grids (to prepare and finish the surfaces). Afterward, temporaries were made using acrylic resin powder and liquid (Alike GC, Japan) and cemented using Temp-Bond NE (Kerr, Orange, USA).

During several sessions, the vertical dimension was gradually increased up to 3–4 mm by adding resin-based paste on the occlusal surfaces of the temporary crowns, to ensure painless and harmless transitional phase. There were no signs of discomfort were reported by the patient during his rehabilitation process.

The achieved increase of the vertical dimension by the end of the occlusal treatment was about 6 mm [Figure 4].
Figure 4: Model showing the increase of the vertical dimension

Click here to view

The case was stabilized and assessed for 2 months to control the patient's parafunctions and the well-being of his TMJ. By the end of this period, impressions were taken and sent to the laboratory.

The permanent restorations were made using indirect laboratory composite (Premise Indirect, Kerr, Orange, USA).

Luting of the restorations was made in two stages: teeth preparation and prostheses treatment.

Teeth preparation consisted in cleaning temporary cement, etching using phosphoric acid (37%), and applying a fifth-generation adhesive system, single bond (3M-ESPE, St Paul, USA) on teeth surfaces.

The internal surfaces of the veneers and onlays were treated with hydrofluoric acid (6%) for 1 min and then rinsed and dried. Two layers of silane were applied to the internal surfaces to enhance the organo-mineral adhesion.

A dual-cure resin cement (Calibra, DENTSPLY, Konstanz, Germany) was used for luting the restorations. Finally, the occlusion was checked to get a group bilateral contact as mentioned.

[Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9] show the final result compared to the initial situation.
Figure 5: Patient's preoperative profile picture

Click here to view
Figure 6: Patient's postoperative profile picture

Click here to view
Figure 7: Preoperative status

Click here to view
Figure 8: Postoperative result

Click here to view
Figure 9: Full mouth postoperative X-rays

Click here to view

One week later, a lower impression was taken to prepare a night guard (made of 2 mm thickness silicone) as prevention from any subsequent fractures due to bruxism [Figure 10].
Figure 10: Night guard applied on the lower arch

Click here to view

Patient was followed up for 4 years.

One year later, no failure was detected except a gingival redness on his lower anterior quadrant due to plaque accumulation as well as a light composite wear. The patient did not report any specific complaint. A photography was taken [Figure 11] to record his dental conditions and compare them to the initial situation.
Figure 11: Picture of the restorations at 1 year

Click here to view

Four years later, the patient is still satisfied from the results. The VDO remained constant [Figure 12] and [Figure 13].
Figure 12: Restorations at 4 years (opened occlusion)

Click here to view
Figure 13: Restorations at 4 years (closed occlusion)

Click here to view

Only one cohesive fracture in tooth number 25 (2nd upper left premolar) was recorded. It was repaired by adding some microhybrid universal composite [Figure 14].
Figure 14: Direct composite repair at tooth 25

Click here to view

   Discussion Top

All reconstructive procedure must start with a determined treatment plan and a goal to achieve.

VDO affects greatly facial esthetics and symmetry; it is defined as the height of the lower part of the face between the infranasal point and the gnathion where the arches are in occlusion in maximal intercuspation position.[9]

Individuals with collapsed facial appearance, improper lip support, changes in phonetics, nasolabial fold prominence, and reduction in muscle tone often demonstrate an advanced loss in VDO combined to severe teeth abrasion.[10] Some studies revealed an increase in lower facial height by 0.63 mm for every 1.0 mm increase in VDO.[10] In addition to facial benefits, increasing VDO aims to recreate enough space between the arches allowing for sufficient materials' thickness and resistance.[11] VDO could be increased gradually without causing harm or pain as long as the change is combined with simultaneous equal intensity contacts in centric relation.[11] Temporary restorations help to improve and maintain a proper vertical dimension and the patient's mental well-being.[12]

In severe teeth wear, reestablishing anatomy and function can be achieved either with conventional full crowns or with adhesive techniques using resin composites.

Since the 1980s, indirect resin composites (IRCs) were introduced in dentistry.[13] Later, in 1990, second-generation indirect composite resins were developed with differences in structure, composition, polymerization technique, and filler reinforcement to optimize their mechanical and esthetical properties.[13]

Composite restorations have a number of distinct advantages over metal ceramic crowns that can be summarized as follows:

  • Minimally invasive[14],[15],[16],[17]
  • Patient acceptance and adaptation is good on medium term[18],[19]
  • Reduced costs and treatment time[14],[18],[20]
  • Better stress distribution[13],[21]
  • Amelioration in the esthetics with reduced sensitivity[22]
  • Kinder to the opposing dentition compared to ceramics[23],[24]
  • Reparability in case of marginal breakage or chipping.[13],[20],[22],[25],[26]

Composite restorations often fail due to fracture of the material itself, while metal ceramic crowns from complete loss.[27],[28],[29],[30]

Moreover, the color stability of indirect composite commonly criticized as unpredictable and proved to be acceptable in several in vitro trials.[13],[31],[32],[33],[34]

The adhesive technologies currently available allow bonding of veneer or onlay restorations to the remaining tooth structures even if the remaining structure is <3 mm. Although adhesive restorations offer several advantages, significant care must be taken while bonding the restoration to dentin.[35],[36]

Managing mutilated teeth presents a substantial challenge to dentists. By being aware of the different etiologies, the factors relative to the occlusal vertical dimension, and the various modalities of treatments, the practitioner can set a proper diagnosis and decide of the ultimate treatment plan that respects the esthetics, the well-functioning, the patient's comfort, and the longevity of the rehabilitation.

Since bonding with composite material is a conservative concept to restore a worn dentition, the goal of this case study is to have the reader consider using adhesive approaches as an acceptable medium-term solution in treating severely worn teeth.

Nevertheless, more in vitro and especially clinical trials are needed to verify the longevity of IRCs.

Declaration of patient consent

The authors certify that they have obtained necessary institutional approval and patient consent forms (Lebanese Uni/Dentistry/03/460556). In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Dietschi D, Argente A. A comprehensive and conservative approach for the restoration of abrasion and erosion. Part I: Concepts and clinical rationale for early intervention using adhesive techniques. Eur J Esthet Dent 2011;6:20-33.  Back to cited text no. 1
The glossary of prosthodontic terms. J Prosthet Dent 2005;94:10-92.  Back to cited text no. 2
Dietschi D, Argente A. A global and conservative approach for the restoration of abrasions and erosions. Part II:clinical procedures and a case presentation. Eur J Esteth Dent 2011;6:144-61.  Back to cited text no. 3
Dahl BL, Krogstad O. The effect of a partial bite raising splint on the occlusal face height. An X-ray cephalometric study in human adults. Acta Odontol Scand 1982;40:17-24.  Back to cited text no. 4
Reis A, Higashi C, Loguercio AD. Re-anatomization of anterior eroded teeth by stratification with direct composite resin. J Esthet Restor Dent 2009;21:304-16.  Back to cited text no. 5
Song MY, Park JM, Park EJ. Full mouth rehabilitation of the patient with severely worn dentition: A case report. J Adv Prosthodont 2010;2:106-10.  Back to cited text no. 6
Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a severely eroded dentition: The three-step technique. Part 2. Eur J Esthet Dent 2008;3:128-46.  Back to cited text no. 7
Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74.  Back to cited text no. 8
Rebibo M, Darmouni L, Jouvin J, Orthlieb JD. Vertical dimension of occlusion: The keys to decision. We may play with the VDO if we know some game's rules. J Stomatol Occup Med 2009;2:147-59.  Back to cited text no. 9
Orenstein NP. Changes in Facial Esthetics and Lower Facial Height with Increases in Occlusal Vertical Dimension in Dentate Models. University of Connecticut Graduate School Master's Theses; 2013.  Back to cited text no. 10
Dawson PE. Functional Occlusion – From TMJ to Smile Design. 1st ed. New York: Elsevier Inc; 2008. p. 430-52.  Back to cited text no. 11
Chidambaram R, Grover M, Veeravalli PT. Full mouth rehabilitation of a worn out dentition using multidisciplinary approach. J Orofac Res 2001;3:54-6.  Back to cited text no. 12
Petropoulou A, Pantzari F, Nomikos N, Chronopoulos V, Kourtis S. The use of indirect resin composites in clinical practice: A case series. Dentistry 2013;3:173.  Back to cited text no. 13
Robinson S, Nixon PJ, Gahan MJ, Chan MF. Techniques for restoring worn anterior teeth with direct composite resin. Dent Update 2008;35:551-2, 555-8.  Back to cited text no. 14
Milosevic A. Clinical guidance and an evidence-based approach for restoration of worn dentition by direct composite resin. Br Dent J 2018;224:301-10.  Back to cited text no. 15
Veneziani M. Posterior indirect adhesive restorations: Updated indications and the morphology driven Preparation technique. Int J Esthet Dent 2017;12:204-30.  Back to cited text no. 16
Milosevic A. Direct placement composite: The treatment modality of choice to restore the worn or eroded dentition in primary dental care. Prim Dent J 2016;5:25-9.  Back to cited text no. 17
Smithson J, Newsome P, Reaney D, Owen S. Direct or indirect restorations. Int Dent Afr Ed 2011;1:70-80.  Back to cited text no. 18
Cone MR. Rethinking the traditional full-mouth rehabilitation by applying minimal prosthetic dentistry for maximum patient benefit. Gen Dent 2016;64:46-53.  Back to cited text no. 19
Shah K. Complex restoration of failing dentition with direct composites. Int J Dent Med Res 2015;1:102-5.  Back to cited text no. 20
Yang H, Park C, Shin JH, Yun KD, Lim HP, Park SW, et al. Stress distribution in premolars restored with inlays or onlays: 3D finite element analysis. J Adv Prosthodont 2018;10:184-90.  Back to cited text no. 21
Gulamali AB, Hemmings KW, Tredwin CJ, Petrie A. Survival analysis of composite Dahl restorations provided to manage localised anterior tooth wear (ten year follow-up). Br Dent J 2011;211:E9.  Back to cited text no. 22
Magne P, Belser UC. Porcelain versus composite inlays/onlays: Effects of mechanical loads on stress distribution, adhesion, and crown flexure. Int J Periodontics Restorative Dent 2003;23:543-55.  Back to cited text no. 23
Rashid H, Sheikh Z, Misbahuddin S, Kazmi MR, Qureshi S, Uddin MZ, et al. Advancements in all-ceramics for dental restorations and their effect on the wear of opposing dentition. Eur J Dent 2016;10:583-8.  Back to cited text no. 24
[PUBMED]  [Full text]  
Patel M. Treating tooth surface loss: Adhesive restoration of the worn anterior dentition. Prim Dent J 2016;5:43-57.  Back to cited text no. 25
Brunton PA, Ghazali A, Tarif ZH, Loch C, Lynch C, Wilson N, et al. Repair vs replacement of direct composite restorations: A survey of teaching and operative techniques in Oceania. J Dent 2017;59:62-7.  Back to cited text no. 26
Smales RJ, Berekally TL. Long-term survival of direct and indirect restorations placed for the treatment of advanced tooth wear. Eur J Prosthodont Restor Dent 2007;15:2-6.  Back to cited text no. 27
Milosevic A, Burnside G. The survival of direct composite restorations in the management of severe tooth wear including attrition and erosion: A prospective 8-year study. J Dent 2016;44:13-9.  Back to cited text no. 28
Dhadwal AS, Hurst D. No difference in the long-term clinical performance of direct and indirect inlay/onlay composite restorations in posterior teeth. Evid Based Dent 2017;18:121-2.  Back to cited text no. 29
Angeletaki F, Gkogkos A, Papazoglou E, Kloukos D. Direct versus indirect inlay/onlay composite restorations in posterior teeth. A systematic review and meta-analysis. J Dent 2016;53:12-21.  Back to cited text no. 30
Douglas RD. Color stability of new-generation indirect resins for prosthodontic application. J Prosthet Dent 2000;83:166-70.  Back to cited text no. 31
Stawarczyk B, Egli R, Roos M, Ozcan M, Hämmerle CH. The impact of in vitro aging on the mechanical and optical properties of indirect veneering composite resins. J Prosthet Dent 2011;106:386-398.  Back to cited text no. 32
Haralur SB, Alfaifi M, Almuaddi A, Al-Yazeedi M, Al-Ahmari A. The effect of accelerated aging on the colour stability of composite resin luting cements using different bonding techniques. J Clin Diagn Res 2017;11:ZC57-60.  Back to cited text no. 33
El Gezawi M, Kaisarly D, Al-Saleh H, ArRejaie A, Al-Harbi F, Kunzelmann KH, et al. Degradation potential of bulk versus incrementally applied and indirect composites: Color, microhardness, and surface deterioration. Oper Dent 2016;41:e195-208.  Back to cited text no. 34
Abduo J, Lyons K. Increasing occlusal vertical dimension. Dent Abstr 2013;58:81-3.  Back to cited text no. 35
Hardy CM, Bebelman S, Leloup G, Hadis MA, Palin WM, Leprince JG, et al. Investigating the limits of resin-based luting composite photopolymerization through various thicknesses of indirect restorative materials. Dent Mater 2018. pii: S0109-5641(17) 31368-4.  Back to cited text no. 36


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

This article has been cited by
1 Clinical outcomes and influence of material parameters on the behavior and survival rate of thin and ultrathin occlusal veneers: A systematic review
Mohamed A. A. Ahmed, Ahmed Yaseen Al-qutaibi, Sebastian Wille, Matthias Kern
Journal of Prosthodontic Research. 2022;
[Pubmed] | [DOI]
2 Restoration of the dentition in a patient with a history of bruxism and amelogenesis imperfecta: A clinical report
Yuyao Tang,Tiandong Cao,Ling Zhang,Guangjie Bao,Hong Kang
Clinical Case Reports. 2021; 9(2): 898
[Pubmed] | [DOI]


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (3,591 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded561    
    Comments [Add]    
    Cited by others 2    

Recommend this journal