International Journal of Clinical Dentistry ISSN: 1939-5833

Volume 12, Issue 1 © 2019 Nova Science Publishers, Inc.

INCREASE IN OCCLUSAL VERTICAL DIMENSION

USING PREHEATED RESINS AS LONG-TERM INTERIM
RESTORATIONS: A CLINICAL REPORT

José M. Olivares1,†, DDS, Eduardo Pino1, DDS,

and Dafna Benadof2, DDS, PhD
1
Facultad de Odontología, Especialización en Implantología Buco maxilofacial,
2
Facultad de Odontología
Universidad Andres Bello, Santiago, Chile

ABSTRACT
A decrease in the occlusal vertical dimension can negatively affect patients’ facial
esthetics, chewing, phonetics, and social relationships. Traditional prosthetic treatment
consists of determining the ideal vertical dimension of occlusion through objective and
subjective methods, then a diagnostic waxing is made on this new position; followed by
tooth preparations associated with interim restorations for occlusal stabilization; and,
finally, removable partial denture or fixed definitive restorations. This case report presents
a new method to reestablish and maintain the vertical dimension throughout a long-term
interim restoration stage. It describes the results of direct bonded restorations with
preheated compactable resins, applied to transparent silicone matrixes made from a
diagnostic waxing. The main advantages of this procedure are that it is fast, reversible, and
low cost.
This manuscript shows a case report resolved by means of a defined clinical protocol
for vertical dimension increase and evaluation, during the interim restoration stage. This
procedure is performed using widely available materials as composite resins, modifying its
viscosity and improving their mechanical properties by a preheating procedure and then
applied to transparent silicone matrixes made from a diagnostic waxing. This protocol
allows restorations that are easy to perform, accurate, reversible, low cost and repairable
by any dentist. Although this technique has been previously described in the literature, this
manuscript contributes to the current knowledge by describing a sound restorative protocol
and informing the clinical properties of preheated composite resins.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit
sectors. Nevertheless, Ivoclar Vivadent provided the materials for restorations free of charge.
† Professor. Corresponding Author’s E-mail: j.olivaresruckholdt@uandresbello.edu.
64 José M. Olivares, Eduardo Pino and Dafna Benadof

INTRODUCTION
The vertical dimension of occlusion (VDO) is defined as the distance between two selected
anatomic or marked points (usually the tip of the nose and the chin) when in maximal
intercuspal position [1]. A decrease in the VDO can negatively affect patients’ quality of life
and social interactions by altering their facial esthetics, chewing, and phonetics. The literature
reports mixed results regarding the association of changes to the VDO and potentially
detrimental alterations of the temporomandibular joint and masticatory muscles [2, 3]. All these
effects show the relevance of reestablishing the VDO in people.
To evaluate the degree of loss in VDO there are objective and subjective methods, which
must be complemented with esthetic, phonetic, facial profile, muscular, temporomandibular
joint, and intraoral asssesments [4-8]. The first step to reestablish the VDO is to decide if the
treatment will be done in centric relation or in maximal intercuspal position. Then, a diagnostic
waxing must be made, followed by tooth preparation and the installation of interim restorations,
traditionally, acrylic crowns. Finally, definitive removable denture or fixed restorations are
made and installed [9, 10].
Published literature on the adaptation process of the stomatognathic system to modified
VDO are scarce and usually report short-term follow-ups [5, 11, 12]. The negative
consequences of increasing VDO (up to 5 mm) are minimal and reversible, and the reported
signs and symptoms are usually resolved within two weeks.5 Even though it is advisable to
monitor patients’ adaptation to the restored VDO, by using interim restorations, there is no
consensus regarding the duration of the observation period needed to ensure long-term stability.
Indeed, existing studies present patient evaluation periods ranging from a few weeks to various
months, while others fail to mention a follow-up period [9, 10, 13-17].
Acrylic interim restorations require tooth preparations to provide adequate thickness and
retention for the definite restoration. Different studies show that they can have potential
negative consequences such as: material fracture, dissolution of the tooth/cement interface,
sensitivity, percolation, and secondary caries formation [18]. An alternative to this type of
interim restorations are direct bonded restorations. These restorations require minimal or no
tooth preparations and have different application techniques and consistencies for the used
materials [14-17, 19-20].
The primary difficulty of using direct bonded interim restorations is to have a result that is
true to the diagnostic waxing. To address this issue, conventional silicone matrixes loaded with
resin composite have been used. Nevertheless, this approach has some challenges, namely
achieving the material to flow against all surfaces of the teeth, and obtaining a correct
polymerization. These difficulties can be explained because of its consistency at room
temperature and on the account of the opaque nature of the silicone, respectively.
In this context, the recent development of clear silicone matrixes can be used as a new
approach to facilitate intraoral light polymerization of composite resins, through the silicone
matrix. By using this method prior limitations of using only autopolymerizing materials such
as acrylic or bis-acryl resins can be resolved, thus permitting the clinical use of composite resins
as an interim material. Furthermore, by preheating the composite resins physical and
biomechanical properties are modified, which translates into a more fluid consistency, easier
manipulation within the silicone matrix, and homogenous flow against all of the involved tooth
surfaces [21, 22]. Some commonly cited advantages include a greater monomer to polymer
 Increase in Occlusal Vertical Dimension Using Preheated Resins … 65

conversion than room temperature resins, better color stability, more micro-hardness, decreased
film thickness, and improved marginal adaptation [23-29]. However, long-term clinical studies
are needed to confirm these prior findings.
This clinical report describes the restorative treatment of a patient with decreased VDO
and who additionally required an implant assisted prosthetic rehabilitation of the anterior
maxilla. Preheated compactable resins applied through transparent silicone matrixes were used
as the interim treatment approach. This method resulted in a conservative and reversible
increase in VDO over a long period of time, thus removing the need for tooth preparations and
interim acrylic resin crowns during the adaptation period.

CLINICAL REPORT
A 47-year-old male was referred to the postgraduate program in oral implantology, of the
Andrés Bello National University, in Santiago, Chile for evaluation and treatment. The patient
used a removable partial denture and consulted because he was concerned about esthetic and
functional aspects of his teeth. In particular, the patient was missing his superior incisors and
requested a fixed treatment option.
Treatment began by reviewing the clinical history of the patient, followed by a clinical
examination. Objective and subjective parameters, applied during facial examination,
determined a 2 mm decrease in VDO and a concave facial profile. Intraoral examination
revealed partial edentulism in both maxillaries, malocclusion with supraeruption of the inferior
incisors, limited prosthesis space in the anteriorsuperior sector, denture stomatitis, caries, and
defective restorations (Figures 1-3). A two-stage treatment plan was designed based on the
patient’s concerns and on the observations made during clinical examination. The first stage
included the study of mounted casts in a semi-adjustable articulator; diagnostic waxing of the
new VDO position; increasing the vertical dimension through interim restorations; repairing
the existing removable prosthesis; and treating the denture stomatitis. The second stage
considered implant surgery, and definitive restorations.
Conventional treatment considers that tooth preparations must be made for definitive fixed
restorations and/or onlays. Interim acrylic crowns must be kept in position during the entire
implant treatment and osseintegration period, until being replaced by definitive restorations
[18]. The limitation of this approach is that during the adaptation process teeth can undergo
occlusal adjustments. Indeed, discrepancies can exist between initial tooth preparations and the
definitive restorations.
To prevent tooth reductions needed for interim acrylic resin crowns, the following
technique proposes to create long-term composite direct bonded interim restorations that could
be used until achieving patient’s stabilization. This procedure has the following stages:

Initial Assessment and Preparation of Silicone Matrix

Treatment began with a full review of the patient’s clinical history. This was followed by
clinical examination, assessing the temporomandibular joint, neuromusculature, VDO, and
initial working position in the centric relation [30] Diagnostic photographs and impressions
66 José M. Olivares, Eduardo Pino and Dafna Benadof

were taken. The study models were mounted in a semi-adjustable articulator (Model 2240
Articulator; Whip Mix Corp), and a diagnostic wax-up in the new position and VDO was
performed aiming to achieve occlusal stability. Attention was strictly given to adding wax only
on the tooth surfaces requiring modification, whereas alterations were avoided for the surfaces
supporting the removable prosthesis components, in order not to alter its intraoral position.
Once approved, a stock tray was used to make an impression with transparent silicone (Elite
Glass; Zhermack) of the waxed-up models of both maxillaries (Figure 4). The silicone was
removed from the tray and sectioned into two separate segments. Excess silicone and retentive
undercuts were removed with a #15 sterile surgical blade (15# Surgical Blade; Dochem). This
process resulted in two findividual silicone matrixes that allowed for light-induced
polymerization of the composite resin [14, 16, 20].

Figure 1. Intraoral frontal photograph showing missing maxillary incisors and decreased prosthetic
space.

Figure 2. Intraoral upper occlusal photograph.

Figure 3. Intraoral lower occlusal photograph.

 Increase in Occlusal Vertical Dimension Using Preheated Resins … 67

Figure 4. Clear silicone impression of diagnostic cast waxing.

Figure 5. Each tooth was isolated with polytetrafluoroethylene tape from neighboring teeth.

Clinical Bonding Protocol

Amalgam fillings were removed, only in teeth requiring an occlusal increase, using
diamond burs (Gold Diamons; DiaTech). Teeth were prepared to receive the preheated
composite resins through a conventional adhesion method [31]. Each tooth needing
intervention underwent individual relative isolation, with the interproximal areas of adjacent
teeth covered by polytetrafluoroethylene tape (Tape;Stretto) (Figure 5). Then, the surfaces of
teeth selected for treatment were etched with 37% orthophosphoric acid for 30 seconds and
washed for 1 minute. After air drying, the adhesive system was applied (OptiBond FL; Kerr
Corp). Each surface was polymerized for 20 seconds (Bluephase Style N; Ivoclar Vivadent
AG). Then, A3 compactable composite resin (Tetric N Ceram; Ivoclar Vivadent AG), was
applied on the cavity floor of teeth where the amalgam fillings were removed.
68 José M. Olivares, Eduardo Pino and Dafna Benadof

Application of Preheated Composite Resin

Afterwards, the following process was separately performed for each tooth: the A3
compactable composite resin (Tetric N Ceram; Ivoclar Vivadent AG) was plasticized at 58 oC
for 5 min in a laboratory wax heater (Wax Heater Pot 4; Denshine), and the resulting fluid-
consistency resin was transferred to the transparent silicone matrix.32 The silicone matrix was
positioned in the mouth, using constant, firm pressure to maintain positioning. Each tooth
surface was polymerized for 60 seconds. Then the matrix was removed, and the polymerization
cycle was repeated (Figure 6). Any excess was removed with a #12 sterile surgical blade (#12
Surgical Blade; Dochem Dental) and rotary instrument (Gold Diamonds; DiaTech). Then, a
surface sealant (Fortify; Bisco) was applied for 20 seconds to each restoration individually;
polymerizing each side for 20 seconds. Glycerin jelly was applied to remove the superficial
inhibition layer, followed by an additional 60 seconds of polymerization. Occlusal adjustments
were made, and the restorations were finished with disks (Optidisc; Kerr Dental), interproximal
finishing (Sof-Lex Finishing Strips; 3M ESPE), rubber points (Astropol; Ivoclar Vivadent AG)
and diamond paste (Diamond Excel; FGM) (Figures 7-8). Then the removable partial denture
was repaired and installed.

Protection Devices and Follow-Up

A mouth guard was created for nocturnal use, thereby protecting the restorations and
achieving equilibrated contact between all teeth during the stabilization period. Clinical follow-
ups were scheduled at 7 days, 14 days, and 1, 3, and 6 months. Excellent maintenance of the
rehabilitation was evidenced, obtaining an Alpha score, according to the Ryge-USPHS criteria
stablished for direct clinical evaluation of restoration. The only reported incident was a partial
fracture of the restoration at the 2-month follow-up visit, which was reshaped [17, 33-35].
Occlusal stability was checked at every session requiring minimal adjustment at the first 14
days and then it was maintained throughout the following appointments, observing repeated
occlusal contact points patterns.

Figure 6. After adhesion, preheated resin (58°C) was applied into the silicone matrix and firmly
positioned intraorally. Each surface was polymerized for 60 seconds. Restoration developed
individually for each tooth.
 Increase in Occlusal Vertical Dimension Using Preheated Resins … 69

Figure 7. Intraoral postoperative lower occlusal photograph.

Figure 8. Intraoral postoperative frontal photograph.

DISCUSSION
Patients with a decreased VDO traditionally are treated with interim crowns made of
acrylic resin or removable prostheses. These are maintained for an indeterminate amount of
time, which can range from weeks to months, until neuromuscular, joint, and occlusal
adaptation are achieved. Only then definitive restoration treatment can be prepared and installed
[5, 11, 18]. During this adaptation period, occlusal adjustments and anatomic corrections of the
restorations are frequently needed, but these needs do not always coincide with the previously
performed tooth preparations. Consequently, tooth wear may be insufficient or exaggerated,
depending on the clinical situation. Furthermore, the use of interim restorations for a long
period of time can give rise to potential complications, such as sensitivity and caries formation
[18].
Previous studies have reported the results of increasing the VDO through directly bonded
restorations using silicone matrixes. Nevertheless, these have been limited to the assessment of
splinted interim restorations in the short- to mid-term. Therefore, scarce information exists
regarding performance of individual restorations using this technique [10, 14-16]. Ramseyer et
al. in 2015 analyzed 98 restorations in 7 patients over a follow-up period of 40 months. Good
70 José M. Olivares, Eduardo Pino and Dafna Benadof

results were reported according to modified USPHS criteria. However, more studies with
standardized methodologies are needed to corroborate these findings [17, 34].
In the present clinical report, interim restorations were created using preheated
compactable composite resin, a material with superior physical and biomechanical properties
as compared to flow resins or room temperature compactable resins [36]. Using preheated
resins removed the need for dental preparations in the interim stage, in addition to providing a
minimally invasive way to assess long term patient adaptation [22, 26]. Furthermore, the
applied procedure fully captured the information obtained from the diagnostic waxing,
achieving a precise transference of the designed teeth anatomy and occlusal contacts. These
traits translate into a technique that is quick, reversible, and reproducible [20].
The innovation of the treatment provided for this patient relays in the transparent silicon
used for making two separate matrixes that were taken to the mouth without a tray. This
procedure, which is similar to clinical reports by other authors, facilitates intraoral positioning
of the matrixes sections and prevents the tray from blocking light during polymerization [14,
15, 37]. On the other hand, since this process did not considered the use of a rigid element, such
as a containment tray, and the consistency of the silicone used is flexible, deformation could
easily occur during the intraoral insertion of the matrix. Indeed, this technique is particularly
pressure sensitive. One solution for this particular problem could be to use individual vacum-
formed trays or transparent acrylic resin trays as a containing material for the clear silicone
[19].
Other procedure described in this technique is the removal of resin excess. Given the
hardness of the compactable composite resin, excess was individually removed using a #12
surgical blade and polishing stones from each restoration. Splinting was avoided to facilitate
hygiene maintenance by the patient, thus reducing risks for caries and periodontal inflammation
during the stabilization period. Marginal adaptation of the impression, should always be
verified to decrease the flow of excesses.
Laboratory-based research have recently reported contradicting results in regards to the
properties of preheated compactable resins [25, 27, 28]. These results could be explained by
the use of different composite resin brands that differ in the chemical composition and filler
percentages [24]. On the other hand the existing literature shows that preheating resin
composites reduces its viscosity, thus facilitating handling and adaptation [21, 22]. There is
also an increase in micro-hardness that could be explained by a larger degree of monomer to
polymer conversion observed in preheated resins compared to room-temperature resins. Film
thickness decreases and marginal adaptation increases, while, translating into better adjustment
than with traditional methods [21, 22, 28].
One of the limitations of this approach, is that preheated resins produce a slight transitory
increase in intrapulpal temperature compared to the room temperature composite resins.
Nevertheless this thermal increase is less than the one caused by light-induced polymerization
[24].
The limitations of this clinical report are that the technique was implemented in a single
patient and that the follow-up period was short. Future randomized controlled trials should be
conducted to evaluate the long-term benefits and drawbacks of preheated resins, its adaptation
and its stability in time.
 Increase in Occlusal Vertical Dimension Using Preheated Resins … 71

CONCLUSION
This clinical report describes the case of a 47-year-old man with a decreased occlusal
vertical dimension, partial edentulism, and missing anterior maxillary teeth. The patient
required combined restorative and implant rehabilitation. Treatment consisted in direct bonded
preheated composite resin restorations applied by using a clear silicone matrix. This initial
stabilization phase of interim restorative treatment represents a conservative, reversible, and
predictable approach for long term interim restorations.

ACKNOWLEDGMENTS
The authors thank Ivoclar for providing their materials for restorations.

ETHICAL COMPLIANCE
1) Sources of Funding
This clinical report didn’t received any funding.
2) Potential conflicts of interest
Disclosure of Interest: The authors declare that they have no conflict of interest.
3) Informed Consent
Informed consent was obtained from the participant involved in this clinical
report.
4) Statement of human rights
This study was conducted in accordance with the 1964 Declaration of Helsinki
and its subsequent amendments.
5) Statement of animal wellfare
No animals were involved in this clinical report

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