Clinical Research

Update on the ‘index technique’ in

worn dentition: a no-prep restorative
approach with a digital workflow
Riccardo Ammannato, DDS
Private Practice, Genova, Italy

Daniele Rondoni, CDT

Private Practice, Savona, Italy

Federico Ferraris, DDS

Private Practice, Alessandria, Italy

Correspondence to: Dr Riccardo Ammannato

Salita S Caterina 2/6, Genoa, 16123, Italy; Tel: +39 010 3742354, Mobile: +39 347 47734\19; Email: [email protected];

www.studioammannato.com

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Abstract to each tooth: direct and indirect partial

restorations or full crowns. It is essential
Following the guidelines of the ‘index to diagnose and treat tooth surface loss
technique’ that were published in this in order to properly restore biomechan-
journal in 2015, this article presents the ics, function, and esthetics by means
‘digital index technique,’ an updated no- of adhesive restorations. This article
prep restorative approach to the man- proposes that the update of the index
agement of worn dentition. Patients with technique through the digital workflow
minimal, moderate, and severe hard tis- is a fast and conservative approach for
sue wear can be treated based on the ap- the planning and management of a full-
plication of minimally invasive or nonin- mouth adhesive restoration in all cases
vasive adhesive composite restorations of light, moderate, and severe worn den-
on posterior and anterior worn dentition. tition. The technique is based on a ‘copy-
The technique allows for a purely addi- and-paste’ guided approach, stamping
tive treatment without sacrificing healthy composite resin directly onto the tooth
hard tooth tissue. It follows the principles surface by means of a transparent in-
of biodentistry (maximum conservation dex created from a full-mouth digital re-
of healthy tissue), and the reinforcing storative wax-up, following an initially
of residual dental structure. Depend- planned increase in occlusal vertical di-
ing on the severity of the enamel and mension (OVD) through an esthetic and
dentin wear, the number of caries, and functional analysis.
the size of the existing restorations, dif-
ferent treatment options can be applied (Int J Esthet Dent 2018;13:2–24)

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Introduction In cases where increasing the occlusal

vertical dimension (OVD) is carried out
The following factors should be consid- with the index technique, BruxChecker
ered during the initial diagnosis: loss of (Scheu Dental) is used to investigate fur-
enamel/dentin, loss of periodontal sup- ther friction and/or the patient’s dynamic
port, periapical lesions or insufficient movements while sleeping.4 This device
root canal treatments, insufficient exist- is also used for the same reasons after
ing restorations, and any recurrent or the case has been finalized. This infor-
new decay. All of the urgent/emergency mation is essential for the clinician and
treatment should be carried out prior to dental technician to properly evaluate
the planning of the index technique. the patient before being able to plan an
A precise diagnosis for the cause of esthetically and functionally driven digi-
the dental wear should be established in tal restorative wax-up that evaluates the
order to understand whether the origin is occlusal plane, anterior guidance, ca-
physical (bruxism or attrition) or chem- nine guidance, and occlusal stability on
ical (erosion due to endogenous or ex- the posterior sextants.5,6
ogenous substances).1 In recent years, The index technique is developed
the increase of tooth wear has been a through a ‘reorganizational’ approach,
major concern among dental profes- where the OVD requires altering to cre-
sionals.1 The multifactorial causes that ate the correct interocclusal space for
trigger tooth erosion include behavioral the restorations to be carried out. In or-
changes and an unbalanced diet, and der to record the centric relation (CR),
various medical conditions such as acid the patient is ‘deprogrammed’ by means
regurgitation and medications that influ- of a leaf gauge,7,8 aiding the condyles
ence saliva composition and flow rate.2 in a superior/anterior position through a
Furthermore, bruxism (awake and sleep) self-induced technique.
is a widespread functional disorder that Following this, wax records are taken
also induces severe tissue attrition. All with a heated, folded sheet or a silicone-
these factors must be taken into consid- based material on the posterior quad-
eration when managing worn dentition. rants, with the leaf gauge in between
Before a restorative procedure takes sextants  2 and  5, in order to register a
place, patients should begin a strict oral new OVD in CR.
hygiene and maintenance protocol, in- The dental technician receives from
cluding the use of fluoride and chlorhexi- the clinician a file of the digital impres-
dine to reduce the risk of caries. Dietary sion of the two dental arches, and an-
habits need to be examined, and acidic other file with the two arches while biting
food and drink intake reduced.3 on the wax record of the new OVD in CR.
A full esthetic evaluation is carried The final restorative steps of this tech-
out, with photographs and a video repro- nique can start from the anterior or pos-
ducing the face and smile in a dynamic terior sextants.
situation. A digital smile project is also Early diagnosis of tooth wear is es-
performed to better evaluate the esthet- sential in order for the clinician to restore
ics and communicate with the patient. the teeth with an adhesive technique by

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means of direct and indirect partial res- treat all four posterior sextants, ie, it is
torations to recreate tooth anatomy, func- enough to treat only the two mandibular
tion, and esthetics as well as to prevent posterior sextants due to moderate wear
further tooth loss. The approach pre- with an inverted Curve of Spee.29
sented in this article (following that pub- Wherever possible, according to the
lished in this journal in 2015),9 avoids or indications and when the residual tooth
at least postpones a more complex and tissue allows, a direct restoration using
invasive prosthetic rehabilitation, like full composite resin to restore worn dental
or partial indirect restorations, ultimately surfaces9 will always be performed us-
having a positive biomechanical impact ing the protocol described in this arti-
on long-term maintenance.10-13 Many cle. Various degrees of wear have been
authors have suggested, and proven classified, each requiring different types
through follow-ups, that it is reliable to of restorations. In some cases, only oc-
use adhesive systems and composite clusal, linguopalatal, or buccal restor-
resin (direct and indirect) in all cases ations will need to be placed. Where
of worn dentition.14-27 The behavior of large and deep cavities are present on
composite resin with the opposing natu- posterior teeth, performing the index
ral enamel should also be considered, technique following adhesion could be
since its wear is four times faster, given very stressful for residual sound tissue
also that ceramic wears three times slow- due to an unfavorable ‘C factor’ situa-
er when opposing natural dentition.28 tion.30 Hence, to minimize shrinkage, the
Lithium disilicate has become a valid first part of the layering is done accord-
alternative to composite resin restor- ing to a conventional approach (free-
ations in recent years due to its mechan- hand layering), while the last occlusal
ical properties. part is performed with the index tech-
The digital workflow in the clinic, but nique.9 However, with evolving techno-
especially in the laboratory, has the ad- logy there are now composites on the
vantage of speeding up all the restora- market that allow for thicker layers, lower
tive procedures. volume shrinkage, lower weight contrac-
tion stress, and a good chromatic inte-
gration (Tetric EvoCeram Bulk Fill, Ivo-
Treatment guidelines clar Vivadent).
In situations where the ‘C factor’ com-
The evaluation and selection of suitable ponent is more favorable (small cavi-
restorations to be placed in each pos- ties, and moderately worn posterior and
terior sextant has to be done taking into anterior dentition), the standard index
consideration the amount of healthy re- technique9 protocol is routinely applied
sidual hard tissue, the thicknesses of the following the initial adhesive steps.
present enamel and dentin, the endo- Generally, sextant 1 can be treated
dontic and periodontal implications, and during the first appointment, sextant 3
the amount of OVD that needs to be in- during the second, sextant 4 during the
creased. However, it is important to note third, and sextant 6 during the fourth
that in some cases it is not necessary to appointment. It is also possible to treat

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two antagonist sextants during the same advice due to a previous treatment that
appointment, or all posterior sextants at had been completed 2 years previous-
the same time, depending on the time ly. Her posterior teeth were sensitive to
available. temperature, and her anterior teeth were
Where there is an indication for indi- short, especially in sextant 5. Her four
rect restorations varying from ceramic wisdom teeth were extracted. A com-
or composite onlays to full-coverage ce- plete esthetic and functional analysis
ramic crowns, the conventional prosthet- was carried out in order to perform a di-
ic techniques are carried out by means agnosis, prognosis, and treatment plan.
of standard impressions or computer-
aided design/computer-aided manufac- The laboratory digital workflow
turing (CAD/CAM) technology.
There is no ‘correct’ clinical sequence Once the digital impression of the two
when applying indirect restorations, arches and the file with the bite registra-
since all the direct restorations will al- tion interposition in CR at the new OVD
ready have been carried out and a sta- (STL files) (Figs 1  to  4) were received
ble occlusion achieved. The canines will from the clinician, they were checked to
always be the guidelines for the occlu- ensure that all the information and de-
sion, with bilateral contacts holding shim tails had been detected in order to prop-
stock and articulating paper. erly finalize the digital wax-up.
The digital models were then mount-
ed on a digital semi-adjustable articula-
A clinical case tor (Artex CR, Amann Girrbach) (Fig 5)
in CR at the new OVD. A digital facebow
The main complaint of this 23-year-old was also included for an arbitrary es-
female patient was sensitivity due to ero- thetic plan. The digital order form was
sion in the posterior teeth, and a slight ten- then filled in and the digital project could
sion in the cheek muscles on awakening begin. Each tooth to be restored was se-
in the morning. Due to these symptoms, lected on the order form by clicking on
magnetic resonance imaging (MRI) was ‘temporary prepared model’ in order to
performed to evaluate the temporoman- create the shape without applying any
dibular joints (TMJs). The patient also finishing lines and having no limits from
wanted to change the shape and size the software regarding the thickness,
of her anterior teeth without them being offset, and margin lines. The teeth selec-
touched. The slight muscle tension was tion is also very important for the correct
managed by bite therapy prior to the insertion axis. This is checked automati-
start of treatment, as it is only possible to cally by the software, which eventually
proceed with treatment once this tension cuts out important parts of the model.
has been resolved. The patient was ad- The most suitable library is then se-
vised to undergo orthodontic treatment lected based on the patient’s age and
to achieve a correct overbite and over- tooth shape as well as the outcome of
jet prior to considering any restorative the digital smile virtual model performed
procedure; however, she declined this in the diagnostic phase. In this case, a

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Fig 1    Initial impression (STL file) of the mandibu- Fig 2    Initial impression (STL file) of the maxillary
lar arch. arch.

Fig 3    The patient is deprogrammed by means of a leaf gauge through a self-induced technique in order
to record the CR.

Fig 4    Initial impression (STL file) with the bite reg- Fig 5    Static and dynamic occlusal contact points
istration interposition and the leaf gauge (which the are checked.
software is able to remove) in CR at the new OVD,
based on the functional and esthetic analysis.

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triangular shape library and an adult age Alternatively, a transparent or individual

model were selected. impression tray can be used. In this way,
The elements were positioned one by the material viscosity can be properly
one following an esthetic guide and a managed, as can polymerization, thick-
correct occlusal plane in order to achieve nesses, and the uniformity needed to
a good functional and esthetic project guarantee elastic memory.
(teeth 17 and 27 were not included in Two bar pressure polymerization was
the project because they were intact). then carried out by means of a hydro-
Once modeling had been carried out, thermal polymerization process to guar-
the static and dynamic occlusal con- antee compactness and the total ab-
tact points were checked by means of sence of microbubbles (Fig 9).
a virtual semi-adjustable articulator (3
Shape), with settings that can be par- Anterior and posterior temporary
tially customized (Figs 5 and 6). The fi- mock-up
nal goal for the project was to achieve
a stable posterior occlusion and an ef- When raising the OVD in such cases, it
ficient anterior guidance. is also possible to try the mock-up on
By clicking on the two-dimensional the four posterior sextants for a certain
(2D)  option, it was possible to section period, together with the anterior mock-
each element and model, checking up. This is done to test esthetics (to see
thicknesses, contact areas, and distanc- whether the amount of OVD raised is
es from antagonist of the entire digital suitable for that specific case) as well
wax-up. This process can also help the as to check function and static and dy-
clinician and technician to choose the namic occlusion outside of the clinic in
correct restorative material by checking ‘normal’ life. These are essential steps in
the thicknesses of all the occlusal sur- the therapy, since the patient, clinician,
faces (Fig 7). and technician can start to visualize the
A virtual sectioning for micromodel mill- planned outcome, with everything being
ing was performed and imported into the easily reversible or alterable.
CAM, where in this case a monochromat- Each posterior mock-up was deliv-
ic polymethylmethacrylate (PMMA) was ered, stamping a flowable compos-
selected. Then, the milling parameters ite (Tetric EvoFlow Bulk Fill, Ivoclar Vi-
were set and the milling carried out, lead- vadent) or a temporary resin through the
ing to six (three each for the maxilla and clear silicone index, sextant by sextant,
mandible) PMMA-milled micromodels leading to a connected temporary res-
(Fig 8). On each micromodel, a 72-shore toration that remains in place thanks to
transparent silicone index (Memosil 2, the undercuts below the contact points
Kulzer or Temp Silk, Micerium) was built and eventually a spot-etching tech-
by means of a dispenser syringe (Fig 9). nique (Figs 9 to 11). The occlusion was
For better finishing, the index surface can checked and balanced.
be manually smoothened with a drop For the index technique, in addition
of liquid soap on a finger before chem- to a conventional prosthesis, it is cru-
ical curing, if the index is built freehand. cial to perform a try-in of the final digital

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Fig 7    By clicking on the 2D option, it is possible

to section each element and model, checking thick-
nesses, contact areas, and distance from antago-
Fig 6    Occlusal points are checked and trimmed. nist of the entire digital wax-up.

Fig 8    The PMMA-milled micromodels performed Fig 9    The transparent index is built on the PMMA-
through CAM and created from the STL file. milled micromodel.

Fig 10    The initial situation showing moderate to Fig 11    The temporary mock-up that will stay in
severe dental wear due to erosion. place for a certain period, delivered by stamping
(sextant by sextant) with a flowable composite or
a temporary resin through the clear silicone index.
The mock-up will stay in place thanks to the under-
cuts and a spot-etching technique.

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wax-up with an anterior mock-up to eval-

uate phonetics and esthetics and to give
the clinician, technician, and patient a
better understanding of the preview. A
direct composite mock-up from tooth
15  to  25 was made from a transparent
silicone key fabricated on the digital re-
storative wax-up models performed with
a molding machine or 3D printer (Figs 8,
12, and 13).
Fig 12    The transparent silicone key filled with a
flowable composite or temporary resin material ready A few weeks later, once esthetics,
to be molded on sextant 2. Note that just for the tem- phonetics, and static and dynamic oc-
porary phase the indices are not cut into single keys. clusion had been evaluated (as well as
the muscles and the TMJ after the rais-
ing of the OVD), the provisional restor-
ations on the six sextants were removed
with a scaler (Fig 14).
Following the mock-up evaluations,
the correct alterations of shape and
length, if needed, can be carried out on
the digital restorative wax-up files prior
to the final index construction.
The keys of each sextant were cut
Fig 13    The temporary mock-up made of flow­ with a surgical blade to achieve six sin-
able composite or temporary resin through the clear gle transparent indices on sextants 2
silicone index that will stay in place for a certain
and 5 (from canine to canine), and four
period thanks to the undercuts and a spot-etching
technique. After some time, after checking phonetic on sextants 1, 3, 4, and 6 (two premolars
function and the esthetics of the new VDO, the tem- and two molars for each sextant).
porary restoration can be removed, and the molding
The index technique can begin on the
process can take place through the single indices.
anterior or posterior sextants, depend-
ing on the diagnostic findings phase. To
avoid any problems, the correct series
of appointments should be scheduled at
the start of treatment so that the entire
therapy can be carried out in the shortest
possible time to avoid leaving the patient
in an uncomfortable occlusal situation.

Posterior index technique

Fig 14    After a period of time, once the phonetic
­restorations
function and esthetics of the new VDO have been
checked, the temporary restoration on the six sex- The index was created by injecting
tants is removed with a scaler. the material over the digital restorative

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Fig 15    The clear index created on the PMMA digi- Fig 16    The full index is cut with a surgical blade in
tal wax-up sectional model. It can be removed from the interproximal area to achieve four single indices.
the model after curing.

Fig 17    For each single index there is a try-in on

the cast to check the landmarks at the buccolin-
gual equatorial regions. The fitting and the inter-
proximal adaptation around the marginal ridge are
also checked.

wax-up sectional cast, previously carried to perform and achieve a predictable

out when planning the full rehabilitation copy-and-paste restoration. For teeth
through an esthetic and functional analys- that only have to be lengthened (usually
is. When curing was completed (3 min, the posterior sextants, and sextant 5),
with Shore A hardness 72) (Fig 15), the the landmarks for the index are located
index was removed from the cast and at the tooth equator on the buccal and
trimmed with a surgical blade. Care was linguopalatal aspects (Fig 19). The fit of
taken to separate the single elements to
achieve a single index for each tooth re-
quiring restoration (Fig 16). Each single
index was tried on the cast to check the
fit around each digital restorative waxing
(Fig 17).
The teeth involved in the rehabilitation
were isolated with rubber dam (Fig 18),
and each transparent index was tried in
the mouth and eventually modified with a
surgical blade to achieve a very precise
fit to the landmarks. Checking the land-
Fig 18    After rubber dam isolation, the index fit is
marks is very important for the correct checked before and after the sectional matrices,
positioning of each single index in order and wedges are placed.

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Fig 19    On the posterior sextants, the index land- Fig 20    Being a no-prep technique, the enamel
marks are located at the tooth equatorial on the buc- and dentin are cleansed before the adhesive pro-
colingual aspect. Note that the mesiodistal sectional cedures with pumice and chlorhexidine to remove
matrices are within the key in order to have better the biofilm.
composite control during the molding process.

each index was also checked by placing tooth center after the heated composite
two matrices interproximally to achieve a resin was placed on the occlusal surface
proper tooth separation, a proper prox- (and partially on the linguopalatal and
imal shape, and less excess material buccal surfaces) with a spatula. This
flow during the molding process. If re- was done to achieve a better proximal
quired, the indices are again trimmed composite shape while molding, and to
until a proper fit is achieved (Fig 19). have less composite excess during the
The teeth were not prepared with ro- finishing steps. The single transparent
tary instruments but were cleansed with index, previously tried and modified ac-
pumice and chlorhexidine on the enam- cordingly, was fitted on the top prior to
el and dentin (Fig 20). polymerization, ensuring that the matri-
Furthermore, as a pretreatment, sand- ces were within the index. Keeping two
blasting was carried out with alumina ox- fingers on the key and using a probe, the
ide 50 μ for 5 s on the aprismatic enamel clinician removed the excess composite
or no-prepped enamel (Fig 21), while on that flowed out at the equatorial region.
the eroded dentin a slight bur prepar- Thereafter, light curing was performed
ation was carried out to achieve better for 60 s through the key, and for another
adhesion31 (Fig 22). A three-step etch- 120 s after the removal of the key.
and-rinse technique was performed32,33 Finishing was performed with inter-
on one tooth at a time, followed by light proximal metal strips, paper discs, fine
curing for 60 s. diamond burs, and an Eva handpiece
The preheated composite was ap- (Fig 23). Once the clinician had com-
plied on the tooth with a spatula (the pleted the index technique direct restor-
enamel on the perimeter and the dentin ation, the same steps could be carried
on the central occlusal part). Then, the out on the adjacent teeth to finalize the
two matrices that were placed to protect planned rehabilitation of that sextant.
the adjacent teeth were bent toward the After checking the occlusion, polishing

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Fig 21    As a pretreatment, the aprismatic or no- Fig 22    On eroded dentin, a slight bur preparation
prepped enamel is sandblasted with alumina oxide is carried out to achieve better adhesion.
50 μ for 5 s. This step leads to better adhesion.

Fig 23    The second molar has been restored with Fig 24    Occlusal view of the sextant restored with
the index technique protocol. One by one, all the the index technique protocol at a follow-up.
other teeth of this sextant will be restored in the
same session.

Fig 25    Lingual view of the sextant restored with the index technique protocol at a follow-up.

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Fig 26    Initial situation at sextant 2. Fig 27    The clear silicone extruded on the PMMA
digital wax-up sectional model.

Fig 28    For the final molding process, the sextant Fig 29    The six single indices placed on the sex-
2 index is cut with a surgical blade, which is ac- tant 2 PMMA digital wax-up sectional model.
curate in the proximal area, in order to achieve 6
single keys.

was carried out with rubber burs and alu- the undercuts below the contact areas
minum oxide paste (Figs 24 and 25).34 for retention (see Figs 9 and 11). As an
Usually, in the same appointment, the alternative, only the first molars, which
antagonist sextant is also restored using have not yet been restored with the in-
the same protocol. dex technique protocol, can be tempor-
It is possible at this stage, before dis- ary restored with the indices. This would
missing the patient, to provisionally re- allow for improved posterior occlusal
store the posterior sextants that have not stability in the interim period between
been restored with the index technique appointments.
protocol. This is done with a loaded
flowable or acrylic resin material without Anterior index technique
performing an adhesive protocol, or by ­restorations
spot etching on the buccal and linguo-
palatal surfaces through the transparent According to the article on the index
indices built on the posterior sextants of technique published in this journal in
the digital wax-up, taking advantage of 2015,9 there are three options to manage

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sextant 2: incisal edge (IE); palatal/incis- index was tried in the mouth to check
al (PI); and full veneering (FV). The op- for proper fit, and eventually trimmed
tion selected for this case was FV, which with a surgical blade. For esthetic rea-
allows for the restoration of teeth that sons only, a bevel can be performed on
have lost volume three-dimensionally on the buccoincisal edge to achieve bet-
the incisal, buccal, and palatal aspects ter chromatic integration (in this case,
(Fig 26). no bevel was carried out). The teeth
A transparent silicone key (Memosil were not prepared with rotary instru-
2 or Temp Silk) of the final wax-up was ments, but cleansing with pumice and
made on sextant 2 (Fig 27). Following chlorhexidine on the enamel and dentin
chemical curing at 2  bar pressure for was carried out (Fig 33). Furthermore,
20 min, the key was cut with a surgical as a pretreatment, sandblasting was
blade to achieve six single transparent performed with alumina oxide 50  μ for
indices (Figs 28  and  29). Each index 5 s on the aprismatic (or no-prepped)
was tried on the cast to check for the cor- enamel, whereas on the eroded dentin
rect proximal and marginal fit (Fig 30). a slight bur preparation was carried out
Where it is more convenient (usually only to achieve better adhesion.31
on sextant 2), a small hole can be made Two sectional matrices (3D Fusion,
with a bur on each transparent index, on Garrison Dental) and wedges were
the buccal and palatal middle-third ar- placed interproximally in order to set up
ea, to allow for better flow of the excess a correct shape for the molding process,
composite during the molding process to protect the adjacent teeth, and to have
(Fig 31). less excess material to remove during
Rubber dam was then placed to the finishing steps. Where required, the
treat sextant 2 (Fig 32), and each single key was again trimmed until a proper

Fig 30    Checking the proximal fit of the single in- Fig 31    Two small holes (only on the sextant 2 sin-
dex. While on the marginal area (palatal and buccal) gle indices) can be made with a bur on the buccal
– since the digital wax-up is performed 1.5 to 2 mm and palatal middle-third to allow for a better flow of
away from the sulcus – the index is also cut coro- excess composite during the molding process.
nally to achieve a good fit without interference with
the rubber dam during the molding process.

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Fig 32    Rubber dam is placed on sextant 2.

Fig 33    Since this is a no-prep technique, cleans- Fig 34    After sandblasting, a no-prep etching of
ing with pumice and chlorhexidine on enamel and the tooth tissue is carried out.
dentin is carried out before the adhesive steps only
to remove the biofilm. For esthetic reasons only, a
bevel on the buccoincisal edge can be performed.
In this case, no bevel was carried out.

fit was achieved, also with the matrices prior to placing the increments on each
in place. A three-step etch-and-rinse tooth. The two matrices that were placed
technique was performed32,33 (Figs 34 to protect the adjacent teeth were bent
and 35) on one tooth at a time, followed toward the tooth center. The preheated
by light curing for 60 s on the buccal and composite resin was then layered with a
palatal surfaces, or simultaneously with spatula (dentin cervical-third to middle-
two devices on both surfaces (Fig 36). third, and enamel middle-third to incis-
Composite shades were chosen prior to al-third) on both the buccal and palatal
rubber dam placement, and then heated surfaces (Fig 37), to achieve a better

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Fig 35    A bonding agent is placed on the no-prep Fig 36    Light curing for 60 s on each surface with
buccal and palatal surfaces. one device or 60 s with two devices simultaneously
on both surfaces.

proximal composite shape while mold-

ing as well as less composite excess
during the finishing steps. A layering op-
tion on sextant 2, in a molding approach,
can also be performed with the ‘index
cut back technique.’35
The index was then placed on the
first tooth. This is usually done starting
from tooth 11 or 21. Extra care should
be taken when placing the transpar-
ent silicone indices, since the only true Fig 37    After placing the matrices and wedges,
landmarks for checking for correct fit the preheated composite is layered (dentin on cer-
vical-third to middle-third, and enamel on middle-
are both palatally and buccally at the
third to incisal-third) on both the buccal and palatal
emergence level near the gingival mar- surfaces.
gin where the rubber dam ligatures are
placed (Fig 38), since in this case all
of the clinical crown required restoring. light cured, according to the previous
A similar amount of enamel and dentin article published in this journal in 2015,9
composite was pressed off at the cer- with two devices through the silicone in-
vical proximal areas and through the dex, initially for 60 s (Fig 39), and then for
holes, performed with a bur during the a further 120 s on both surfaces follow-
molding process. Finger pressure was ing index removal. Finishing of the com-
maintained buccally and palatally while posite excess was performed with inter-
the excess composite was removed with proximal metal strips, paper discs, fine
a probe or spatula. The site was then diamond burs, and an Eva handpiece.

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Fig 38    The single key that was tried before and Fig 39    Once the excess composite has been re-
eventually modified with the surgical blade is placed moved at the cervical margins with a probe, light
on the tooth. The index landmarks are located buc- curing takes place for 60 s on each surface through
copalatally at the cervical region where the rubber the index or for 60 s with two devices placed on the
dam ligatures are placed, and the matrices are buccal and palatal surfaces.
within the key.

Fig 40    After the finishing steps on  tooth 11 are

carried out with paper discs, metal strips, diamond
burs, and an Eva handpiece, the molding process
can take place on the adjacent tooth using preheat-
ed composite, with the same protocol described
previously.

Fig 41    Initial situation on sextant 5.

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 Ammannato et al

Fig 42    Checking the correct fit at the proximal Fig 43    The preheated composite (dentin and
area and the buccolingual equatorial landmarks as enamel) is placed after the wedges, matrices, and
the posterior sextants. adhesion protocol.

This protocol was then carried out for all

the other teeth of sextant 2 (Fig 40).
This protocol was also performed on
sextant 5 (Fig 41) in the same appoint-
ment, the only difference being that
only the incisal edges and the buccal
surfaces up to the equatorial region re-
quired lengthening and volume increase
with the index technique, based on the
previously developed digital wax-up
(Figs 42 to 45). The ultimate goal at the Fig 44    The index that was previously tried is then
end of this appointment was to have a placed, and the index technique can be carried out
through a copy-and-paste approach.
simultaneous bilateral contact on the
canines,36 and only a shimming contact

Fig 45    The final situation at a follow-up, after the six index technique restorations have been performed.

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Fig 46    Lateral view of the anterior sextants re- Fig 47    Lateral view of sextant 2, checking pho-
stored with the index technique protocol. On sextant netics and esthetics within the inferior lip context.
2, it is possible to see the finishing line of the restor-
ations at the cervical region, which is approximately
2 mm coronal from the soft tissue.

Fig 48    Final situation, frontal view.

on the incisors that could be checked Complications and repair

with 8 µm shim stock (Hanel ShimStock,
Coltene) and 12 µm articulating paper One of the significant benefits of using
(Hanel Occlusion Foil, Coltene). composite resin for a full-mouth rehabili-
tation with the index technique is that the
most likely complications are wear and
chipping, while full loss or detachment

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 Ammannato et al

of the restoration is an unlikely occur-

rence. Partial failure can easily be re-
paired with fresh composite following
proper surface treatment: sandblasting,
silanization, and the bonding of all sur-
faces.2
Nanohybrid composite has good
wear characteristics,37 and a superficial
gloss is maintained in the long term fol-
lowing polishing (Figs 46 to 53). Further,
it is very easy to repolish this material
during patient recall visits.

Fig 49    Final situation, occlusal view.

Fig 50    Initial situation, palatal view. Fig 51    Final situation, palatal view.

Fig 52    Final situation, maxillary arch. Fig 53    Final situation, mandibular arch.

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Conclusions any reason, this becomes necessary),

although it should be borne in mind that
The digital index technique protocol pro- composite removal after adhesive proto-
poses a conservative and alternative cols is not easy to perform due to bond-
approach for the treatment of moderate ing strength and composite chromatic
and severe tooth wear, based mainly integration with the natural tooth.
on minimally or non-invasive copy-and- Another positive characteristic of
paste composite restorations on both this technique is the relative ease with
anterior and posterior teeth. which chipping or restorative failure can
Ideally, dentistry should be additive be managed by applying a simple ad-
whenever possible, not subtractive-ad- hesive protocol. This makes the overall
ditive. Increasing the OVD leads to less treatment fairly simple. A further benefit
tooth structure removal and improved over traditional prosthetic rehabilitations
biomechanics.38 Adhesion and com- is that this technique requires shorter
posite resin have become very reliable,39 clinical time to finalize a case, which in
allowing restorations to be retained with- turn influences management costs. The
out the need for retentive cavity prep- only real expense for the clinician is the
arations. Furthermore, especially on the digital or analog restorative wax-up car-
anterior sextants where undercuts show ried out by the technician for the pur-
up a direct molding technique, this pro- poses of correct treatment planning and
tocol allows the clinician to be extremely to obtain the required transparent index.
conservative. With indirect restorations, Finally, the driving force behind this
however, a preparation should be per- approach is to intercept tissue destruc-
formed. tion and avoid or postpone a more bio-
Total reversibility is another important logically invasive and financially costly
characteristic of this technique. It allows prosthetic solution.1 Long-term studies
the clinician to restore the patient’s initial are needed to further understand the
situation at the end of treatment (if, for potential of this technique.

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