Toothwear 3

Question 1

contraindications to anterior build ups

Answer 1

1. short roots; increasing crown root ratio can increase orthodontic movement of teeth due to force and can put extra pressure on pdl
2. reduced perio support due to perio disease
   also - not necessarily a contraindication but lack of remaining enamel reduces the success rate significantly

Question 2

strong indication for replacing anterior tooth wear

Answer 2

presence of a remaining enamel ‘ring of confidence’
has very positive influence on retention

Question 3

lower anterior tooth wear

Answer 3

generally in conjunction with maxillary wear
more difficult to fix as less enamel, smaller bonding area & moisture control more difficult in lower teeth
same technique as uppers

Question 4

localised posterior tooth wear

Answer 4

unusual on its own
if localised & asymptomatic; prevention and monitoring are appropriate
occlusal erosive wear can be filled directly with composite with not change in occlusion
sometimes erosive in ruminating pt
erosive in bulimic & alcoholic pt

Question 5

when doing anterior build ups which is done first; lower or upper?

Answer 5

if doing both lower and upper do lowers first as they are more likely to fail so can redo them again when the come in for uppers
if choosing between doing 1 of lower or upper do the uppers
*take composite up over labial surface to increase amount of enamel available to bond onto

Question 6

tx of localised posterior tooth wear

Answer 6

aim is to provide sufficient canine guidance to ensure posterior disclusion
composite added to palatal of upper canines to increase canine rise & disclude posteriors during lateral & protrusive excursions
often there is canine wear which has removed guidance and led to posterior wear so if you correct canine wear the posterior is saved from further damage
simple, effective, reversible technique
can be freehand or with use of diagnostic wax and template

Question 7

method of composite build up

Answer 7

alginate impressions
wax up
putty matrix
restore

Question 8

clear vacuum formed matrix

Answer 8

alginate impression
diagnostic wax up
impression poured in stone
vacuum formed clear plastic matrix formed on this
cut to size & use as mould to build up

Question 9

success of composite build up

Answer 9

generally good pt satisfaction
posterior occlusion normally reachieved
seldom tmj problems
no detrimental effect on pulpal health
no worsening of perio condition

Question 10

longevity of composite build ups

Answer 10

viable medium term option
requires repair & maintenance
maxillary restorations last better (due to increased bonding area but maxillary wear more common)
no tooth destruction during placement so easily replaced

Question 11

why is maxillary wear more common than mandibular wear

Answer 11

tongue and saliva protect lower teeth

Question 12

how to explain the procedure to pt

Answer 12

• front teeth receive tooth coloured fillings to cover exposed & worn tooth surface
• no LA as no or minimal drilling to teeth, only adding to teeth not taking away
• improvement in appearance should be possible
• bite will feel strange for a few days & may have difficulty chewing
• only front teeth will touch but back teeth will eventually come back together after 3-6mths
• may have to cut food into small pieces for 1st week
• change may cause lisping for 1st few days
• front teeth may be tender to bite on for a day or 2
• may bite lips & tongue initially
• crowns/bridges/partial dentures at back of mouth likely will need replacing
• longevity is good but potential for them to de bond and fall off needing replacement so require maintenance

Question 13

how does generalised tooth wear start

Answer 13

begins as localised anterior tooth wear
so if we don’t treat it will progress
considerably more complicated in these cases
identify wear early, treat it preventatively and monitor; intervene and avoid it getting to this stage

Question 14

categories of generalised tooth wear

Answer 14

1. excessive wear with loss of OVD
2. excessive wear without loss of OVD but with available space
3. excessive wear without loss of OVD and with no space available
   (same as localised anterior)

Question 15

generalised tooth wear with excessive tooth wear & loss of OVD

Answer 15

• easiest to treat but least common
• splint can be used to assess pt tolerance to new face height
• may not be necessary if adhesive approach being used i.e. can go straight to increase in face height with permanent restorations
• ideally 1/2 OVD increase should be maxillary and 1/2 mandibular
• often mixture of adhesive & conventional restorations required
• dentures may be required to provide posterior support at new OVD

Question 16

generalised tooth wear with excessive tooth wear without loss of OVD but with limited space available

Answer 16

• much more complicated to treat
• can involve reorganisation of occlusion
• splint should be considered as an increase in occlusal face height is required
• most pt accommodate to this increase
• restoration of anterior & posterior teeth is then carried out at new occlusal face height
• if possible this should involve minimal prep adhesive restorations

Question 17

generalised tooth wear with excessive tooth wear without loss of OVD with no space available

Answer 17

• most severe type
• most difficult to treat
• probably require specialist opinion prior to commencing tx
• attempt to increase OVD by use of splints+/- dentures if there is lack of posterior support
• crown lengthening surgery
• elective endo (destructive & post crown and attrition do not go together)
• orthodontics

Question 18

crown lengthening when excessive tooth loss without loss of OVD and no space available

Answer 18

increases amount of coronal tooth substance available
may result in black triangles between teeth where ID papilla is further down
can lead to unfavourable crown to root ratio (increased chance of loosening or tooth movement if tooth loaded subsequently)
often post op sensitivity
any subsequent conventional crown prep will be further down the root (problem if tooth has significant coronal cervical taper & greater chance of pulpal damage)

Question 19

overdentures when excessive tooth loss without loss of OVD and no space available

Answer 19

preserves tooth substance & bone for support of denture when teeth are so worn down that restoration is not possible
can be bulky for pt to wear
difficulties with keeping teeth & gingivae healthy beneath prosthesis

Question 20

problems with generalised tooth wear

Answer 20

demanding, difficult, lengthy, expensive, may need specialist 2nd opinion & must have realistic expectations of what is achievable