Toothwear Flashcards
What are the causes of non various tooth surface loss?
Trauma
Developmental problems
Tooth wear
What is the difference between normal and pathological tooth wear?
Normal- wear associated with normal function (20-38 um per annum)
Pathological- when remaining tooth structure or pulpal health is compromised/ excessive rate/ masticatory or aesthetic deficit
What are the 4 causes of toothwear?
Attrition - result of tooth to tooth contact
Abrasion - through an abnormal mechanical process independent of occlusion (foreign object)
Erosion - by a chemical process that does not involve bacterial action
Abfraction - loss of hard tissue from eccentric occlusal forces leading to stresses at cervical fulcrum areas
What is the most common cause of attrition?
Parafunctional habit
What is the clinical presentation of attrition?
Polished facet on cusps/ flattening incisal edges
Progression to reduction in cusp height/ shortening of clinical crown
Where is abrasion most common?
Labial/ buccal, cervical on canine and premolar teeth (V shaped lesions)
What is the most common cause of abrasion?
Toothbrushing
How does erosion present clinically?
Loss of surface detail
Bilateral, concave lesions (without chalky appearance of bacterial decalcification)
Progression - dentine becomes affected, preferential wear of dentine leads to cupping of occlusal surfaces and incisal edges. Increased translucency of incisal edges, restorations sit proud, no tooth staining present
What causes abfraction?
combination of occlusal stress (loading forces), abrasion and erosion leading to loss of substance at the cervical margin.
Loading forces result in flexure and failing of enamel and dentine at a location away from the loading- causing cracks in the tooth which chip out
How prevelant is toothwear in adults?
77% have wear in their anteriors involving dentine
How prevelant is toothwear in children?
> 50% of 5 year olds exhibit tooth wear on their primary incisors
Why is masticatory deficiency uncommon in toothwear?
Toothwear generally happens slowly- time for passive eruption to maintain occlusion
What would be relevant MH to tooth wear?
Medication with low pH/ which cause dry mouth
Eating disorder
Alcoholism
Heartburn/GORD
Hiatus hernia
Rumination
Pregnancy
When examining the patient, what should you look for - extra oral
TMJ (restriction, clicking, crepitus?)
Musculature (hypertrophy)
Mouth opening restriction? (<4cm) and deviation on movement
Parotid hypertrophy
Overclosure
Lip line, smile line
IO:
FWS and OVDS
Stable contacts in centric relation? Tooth contacts in excursion movements?
Describe BEWE classification
0- no erosive wear
1- initial loss of surface
2- distinct defect, <50% hard tissue loss
3- hard tissue loss>50%
Count up scores for each sextant
<2 - no risk
3-8 - low risk
9-13 - med risk
>14 - high risk
Which special tests are appropriate for tooth wear treatment planning?
Sensibility (pulpal damage rare due to deposition of 3ry dentine over a period of time)
Radiographs- AP related to toothwear if lost 1/3 -1/2 tooth
Articulated study models
Intra oral photographs
Diagnostic wax up
Dietary analysis
How is toothwear diagnosed?
Pattern:
- localised
- generalised: wear with loss OVD, wear without loss OVD but space, wear without loss OVD with no space
Dento-alveolar compensation- important for tx planning
Immediate treatment of toothwear?
Address pain:
- sensitivity (desens, fluoride, GIC over exposed dentine)
- pulp extripation (if required)
- smooth sharp edges (prevent trauma)
- extraction (unrestorable/ non-functional teeth)
- TMJ pain (needs to be controlled before restorations)
Initial treatment of toothwear
Stabilise existing dentition
Deal with caries, perio etc (treat other problems as well as toothwear as wear is a slow progress)
Diagnosis and identify causative factor - institute preventative regime (prevention)
Preventative treatment of tooth wear
Baseline wear recording (BEWE/ pictures/ models)
Monitor (restoration required if active)
Remove cause
Prevention for abrasion
Remove foreign object/ habit
RMGIC restoration at cervical margin- pt will wear through this rather than tooth (better bond to dentine than composite, YM similar to tooth)
Prevention for attrition
Address parafunctional habit- CBT, hypnosis
Splints- wear away in preference to tooth, can be used as a habit breaker (can also be sued as diagnostic device), Michigan splint has canine rise to provide disclusion in eccentric mandibular movements.
Prevention for erosion
Establish if intrinsic or extrinsic?
Fluoride- sensory energy, tooth mousse, duraphat
Desensitising agents- more symptomatic relief
Dietary management- fruit juice, fizzy juice, acidic foods
Gastric acid control- GORD, reflux, hiatus hernia (refer to GP)
Prevention of abfraction
Fill cavities with RMGIC/ flowable composite
What is passive management of tooth wear
Prevention and monitoring (6 months)
What is active management?
Simple restorative intervention- cover exposed dentine
Composite restorations (aesthetic)- should be >2mm to prevent de bond
What are the 5 considerations when treatment planning for active management of maxillary anterior toothwear
Pattern of tooth wear
Inter occlusal space
Space required
Quality and quantities of remaining enamel
Aesthetic demands of patient
What are the 3 main patterns of anterior maxillary tooth wear
Limited to palatal surfaces (vomiting etc)
Involving palatial and incisal edges with reduced crown height
Limited to labial surfaces (holding juice in mouth, uncommon)
What are the tx options for anterior maxillary wear?
Increase OVD- reorganised approach (complex)
Reorganisation from ICP to RCP
Surgical crown lengthening
Elective RCT and post crowns
Conventional ortho
Dahl technique
What is the Dahl technique
Method of gaining space in localised tooth wear
Composite covering palatal surfaces and allowing occlusion on a raised cingulum - resulting in posterior disclusion and increase in OVD (2-3mm)
Over 3-6 months gain space between incisors (passive eruption)
Definitive treatment
90% success rate (if no movement in 6 months, not going to work)
Contraindications for Dahl technique
Active perio
TMD
Post ortho
Bisphosphonates (poor bone turnover)
Implants- ankylosis to bone so wont continue to erupt
Existing conventional bridges- not likely to continue to erupt
Contraindications for composite build ups
Short roots (will be increasing tooth length with already decreased support)
Reduced periodontal support due to perio disease
Lack of enamel - not contraindication but reduces success rate
What is the ring of confidence?
Thickness of remaining enamel- has a positive relationship on retention
Reasons why mandibular anterior builds are less successful than maxillary?
Less enamel, smaller bonding area
Harder to achieve moisture control
Management of localised posterior tooth wear?
Unusual on its own
Fill directly with composite with no change in OVD
Composite added to palatal of canines to disclude posteriors- often canine wear resulted in the posterior wear (saves from further damage)
Methods of composite build ups?
Direct build up- alginate imps, wax up, putty matrix
Clear vacuum formed matrix- alginate imps, wax up, impression of wax up poured in stone, clear plastic matrix formed and cut to size
What is the first treatment option for toothwear?
Composite resin restoration (minimally invasive)
Information for patients getting composite build ups
- tooth coloured fillings on front teeth to prevent wearing more (no LA, minimal drilling- no tooth substance is removed)
- bite will feel strange for a couple of days, will resolve (only front teeth will come together, back teeth will come together within 3-6 months)
- may cause lisp for a few days
- front teeth may feel tender for a few days
- may accidentally bit tongue/ lips over next few days
- crowns/ bridges/ dentures at back of mouth will need replaced
- longevity should be good although small chance de bonds- will require maintenance (including cost)
3 categories of generalised tooth wear
Excessive wear with loss of OVD
Excessive wear without loss OVD but with space
Excessive wear without loss OVD and no space
Management of generalised toothwear - excessive loss with loss of OVD
Easiest to treat but least common
Splint to assess pt tolerance to new face height
Half OVD increase maxillary and half mandibular
Alveolar compensation
Management of generalised toothwear - without loss of OVD with limited space
Re-organisation of occlusion
Splint
Then restoration of anterior and posterior teeth at new face height (minimal prep adhesive restorations)
Management of generalised toothwear - loss of OVD and no space
Refer to specialist
Attempt to increase OVD by use of splints/ dentures if lack of posterior support (as there is often in these cases)
Crown lengthening- increases amount of coronal tooth substance (black triangles where ID papilla is further down) - unfavourable crown to root ratio
Over-dentures (although can be bulky for pt to wear)
