toothwear - PCS Flashcards
1
Q
tooth surface loss can be due to
A
caries
trauma
developmental problems
tooth wear
2
Q
non carious tooth surface loss includes
A
trauma
developmental problems
toothwear
3
Q
types of toothwear
A
physiological
pathological
4
Q
physiological toothwear
A
increases with age
normal wear associated with normal function varies between 20-38um per annum
not neccessary/appropriate to tx it
5
Q
pathological toothwear
A
occurs when remaining tooth structure or pulpal health is compromised or the rate of tooth wear is in excess of what would be expected for that age
or
pt experiences a masticatory or aeshtetic deficit
6
Q
4 causes of toothwear
A
attrition
abrsaion
erosion
abfraction
7
Q
attrition defintion
A
physiological wearing away of toothstructure as a result of tooth to tooth contact
8
Q
attrition lesions found
A
on occlusal and incisal contacting surfaces
9
Q
progression of attritive lesions
A
start as polished facet on a cusp or slight flattening of an incisal edge
progresses to reduction in cusp height and flattening of occlusal inclined planes
can be shortening of teh crown on incisors and canines
10
Q
cause of attrition
A
majority parafunctional habits (bruxism - grinding at night)
can see if can line up facets in non-functional position
11
Q
restorations in attrition
A
show the same wear as tooth structures
12
Q
abrasion defintion
A
physical wear of tooth substance through abnormal mechanical process independent of occlusion
involves a foreign object or substance repeatedly contacting the tooth
13
Q
sites of abrasion
due to
A
The site and pattern of tooth loss is related to the abrasive element.
- Commonest area is labial/buccal, cervical on canine and premolar teeth
- V shaped or rounded lesions (cervical area as dentine wears away faster than enamel)
- Sharp margin at enamel edge where dentine is worn away preferentially
Commonest cause is tooth brushing
Can manifest as notching of the incisal edges
- Related to habits/lifestyle/occupation
- Pins, nails, electrical wire stripping, fishing line, thread, pipe smoking
14
Q
e-cigarettes and toothwear
A
Heavier than pipes : Getting bigger
- MUCH BIGGER – abrasive toothwear risk
Acidic liquid:
- They should be alkaline as this gives more free nicotine but not all are
15
Q
erosion defintion
A
The loss of tooth surface by a chemical process that does not involve bacterial action.
most common cause of pathological tooth wear and is increasing in prevalence.
16
Q
erosion cause
A
chronic exposure of dental hard tissues to acidic substances which can be extrinsic or intrinsic
17
Q
erosion progression
A
Early stages enamel surface is affected, there is loss of surface detail, surfaces become flat and smooth (shiny)
- Typically bilateral, concave lesions without chalky appearance of bacterial acid decalcification (unlike caries)
Later dentine becomes exposed (margin of enamel with dentine in the middle)
Preferential wear of dentine leads to ‘cupping’ of the occlusal surfaces of the molars and incisal edges of the anteriors
18
Q
erosion appearance
A
- Typically bilateral, concave lesions without chalky appearance of bacterial acid decalcification (unlike caries)
- Preferential wear of dentine leads to ‘cupping’ of the occlusal surfaces of the molars and incisal edges of the anteriors
- Increased translucency of incisal edges (can appear dark – pt complaint)
- Restorations stand proud
- no tooth staining present - washed away by acids
19
Q
erosion site
A
Exact position and severity of erosive wear is dependent on the source, type and frequency of exposure to the acid.
- Bulimia, vomit – anterior
- Ruminate, GORD – posterior
20
Q
abfraction defintion
A
loss of hard tissue from eccentric occlusal forces leading to compressive and tensile stresses at the cervical fulcrum areas of the tooth
21
Q
2 theories behind abfraction
A
- Abfraction if the basic cause of all non-carious cervical lesions (Grippo 1991)
- Multifactorial aetiology. A combination of occlusal stress, abrasion and erosion (Lee and Eakle 1984)
22
Q
basic cause of abfraction
A
Pathological loss of tooth substance at the cervical margin
Caused by biomechanical loading forces
Forces result in flexure and failure of the enamel and dentine at a location away from the loading
- Disruption of the ordered crystalline structure of the enamel and dentine by cyclic fatigue.
- Cracks in tooth substance which causes tooth substance to chip out.
- This theory is based on engineering principles which demonstrate stress concentrations in these areas of the tooth during loading
V shaped tooth loss where the tooth is under tension. CLASSICALLY SHARP RIM AT THE AMELO-CEMENTAL JUNCTION Similar to toothbrush abrasion - multifactorial
23
Q
abfraction appearance
A
V shaped tooth loss where the tooth is under tension. CLASSICALLY SHARP RIM AT THE AMELO-CEMENTAL JUNCTION Similar to toothbrush abrasion - multifactorial
24
Q
possible causes of cervical wear lesions
A
multifactorial
- ? Overzealous Tooth brushing
- Lesions mainly in premolar and molars on the buccal surface almost never lingually
- Good OH and this wear pattern go together
- Restorations in this area wear at the same rate as the tooth structure
- ? Abrasion the most important factor in these areas?
- Likely to be a combination of erosion, abrasion +/- abfraction
- No definitive, conclusive studies
25
epidemiology of toothwear
* Tooth wear increases with increase in age
* The most common type of tooth wear in older patients is physiological
* There has been an increase in prevalence across all age ranges over the past 20 years.
* This increase is not uniform.
* There is a greater, relative, increase amongst young adults and children over this period
* This tooth wear can be considered to be pathological
26
prevelance of toothwear in adults
* 2009 Adult Dental Health Survey
* 77% of Adult patients had some wear of their anterior teeth involving some dentine
* More prevalent in males than females (70% vs 60%)
* 15% had moderate wear, involving significant amounts of dentine
* Moderate wear had increased from 11% to 15% over the previous 10 years
* 2% had severe wear
* Severe tooth wear was rare but had increased since the previous survey
27
prevalance of toothwear in children
* Children’s Dental Health survey 2013
* Findings show a continued increase in prevalence of wear from 2003 survey. (2003 showed an increase from 1993)
* \>50% of 5-year-olds exhibit some wear on their primary incisors
* Increase in wear in permanent incisors (Lingual/palatal surfaces - erosive)
* Age 12 30% à 38% since last survey in 2003
* Age 15 33% à 44% since last survey in 2003
* Very few children exhibited severe wear involving dentine or the pulp
* *But if they have mild, will progress to severe quicker than in past*
28
assessment for toothwear
includes
Successful management is based on deriving an accurate diagnosis
* In order to prevent or reduce tooth loss due to wear you must:
* Recognize the problem is present
* Grade its’ severity
* Diagnose the likely cause or causes
* Monitor the progression of the disease
* Is it active or historic *grinding could have occurred in the past in a particularly stressful period in their life*
* Are preventative measures working or is active restorative treatment required
29
stages in pt hx
find out their chief complaint
MHx
DHx
social Hx
30
possible chief complaint for toothwear pts
* Aesthetic impairment
* Functional difficulties (masticatory efficiency, biting of tongue or lips)
* Pain;
* Relatively uncommon in patients with wear unless it is rapidly progressing or there is pulpal involvement
* Wear is slow, secondary dentine formation in that time
31
MHx things to check for toothwear pt
* Often gives an insight into the aetiology of wear, particularly where erosion is involved
* Medications with low pH
* Medications which dry the mouth
* Eating Disorders
* Alcoholism
* Heartburn
* GORD
* Hiatus Hernia
* Rumination
* Pregnancy - transient
* Patients are not always aware of reflux
* Patients may require referral to GMP. You must get consent to do this.
32
DHx thinks to check for toothwear pt
* Previous patient attendance, regular or not
* A non-regular poorly motivated patient is not a good candidate for complex treatment. Nor are phobic patients
* Previous experience of treatment
* Complex or simple treatments
* Removable appliances/Dentures
* Oral Hygiene Habits
* Poor oral hygiene
* Toothbrushing In Abrasive wear
* Frequency
* Intensity
* Duration
* Type of toothpaste
33
social history things to check for toothwear pt
* Lifestyle stresses
* Bruxism (before tx wear)
* Occupational details
* Alcohol consumption (acidic component)
* Dietary analysis
* Habits – pipe smoking, chewing pens etc
* Sports – endurance athletes – gels stick to teeth and little fluid, weightlifting grind teeth (mouthguard)
34
extra oral examination things to check for toothwear pt
* Must examine TMJ for restriction of movement, clicking, crepitus
* Examine musculature for hypertrophy
* Examine mouth opening for restriction (\<4cm) and deviation during movement
* ? Parotid hypertrophy (perhaps if bulimic)
* Overclosure ?
* Lip Line
* Smile line – how much tooth they have and how much they can show with where lip goes (gummy smile)
* Occlusion
* Freeway space should be assessed
* Record the OVD and resting face height
* Has their been dento-alveolar compensation? *Normal toothwear is slow*
* Bone grows down as teeth wear so incisal level will stay in roughly same place
* Teeth shorter but distance from nose to central incisor is similar
* Record overbite and overjet
* Are there stable contacts in centric relation
* Have they gone into class III due to wear
* What are tooth contacts like in excursive movements
35
occlusion checks for toothwear pt
* Freeway space should be assessed
* Record the OVD and resting face height
* Has their been dento-alveolar compensation? *Normal toothwear is slow*
* Bone grows down as teeth wear so incisal level will stay in roughly same place
* Teeth shorter but distance from nose to central incisor is similar
* Record overbite and overjet
* Are there stable contacts in centric relation
* Have they gone into class III due to wear
* What are tooth contacts like in excursive movements
36
IO checks for toothwear pt
* Freeway space should be assessed
* Soft Tissues
* Dry? - erosion
* Buccal keratosis or lingual scalloping - bruxism
* Oral Hygiene
* Perio assessment BPE +/- pocket chart
* Dental charting
37
wear exam components
* Location
* Anterior/posteriorà indicates cause
* generalised
* Severity
* Enamel only
* Into dentine
* Severe
38
2 wear indices examples
Smith and Knight *(subjective)*
**BEWE** - British Erosive Wear Exam *(like BPE for toothwear)*
39
Smith and Knight
Grade 0
no loss of enamel surface characteristics
40
Smith and Knight
Grade 1
loss of surface enamel characteristics
41
Smith and Knight
Grade 2
buccal, lingual and occlusal loss of enamel, exposing dentine for _less than 1/3_ of teh surface
incisal loss of enamel
minimal dentine exposure
42
Smith and Knight
Grade 3
buccal, lingual and occlusal loss of enamel, exposing fentine for _more than 1/3_ of the surface
incisal loss of enamel
substantial dentine exposure
43
Smith and Knight
Grade 4
buccal, lingyual and occlusal _complete loss_ of enamel, pulpal exposure or exposure of secondary dentien
(incisal pulp exposure)
44
BEWE score 0
no eroisive wear
45
BEWE score 1
initial loss of surface texture
46
BEWE score 2
distinct defect; hard tissue loss \<50% of surface
47
BEWE score 3
hard tissue loss \>50% of the surface area
48
BEWE risk level
none
cumulative score of all sxtant less than or equal to 2
49
BEWE risk level
low
cumulative score of all sextants between 3-8
50
BEWE risk level
medium
cumulateive score of all sextants between 9-13
51
BEWE risk level
high
cumulative score of all sextants 14+
52
possible special tests for toothwear
* Sensibility testing
* Radiographs
* Articulated study models
* Intra-oral photographs
* ? Salivary analysis
* Diagnostic Wax-up
* Dietary analysis
53
Dx for toothwear
* Almost all Tooth Wear is Multifactorial
* Attrition
* Abrasion
* Erosion
* Abfraction
* Determine the primary causative factor
* Decide on ‘best fit’
what is pt primary concern/problem
54
pattern of toothwear can be
* Localised *most starts as this and then becomes generlised*
* Generalised
is there Dento-alveolar compensation
* Important in treatment planning
55
3 types of generalised toothwear
* Wear with loss of OVD
* Wear without loss of OVD but with space available
* E.g. pt is class 3 div 1 still have some space that you can alter their occlusion from RCP to ICP
* Wear without loss of OVD but with limited space
* Most – alveolar compensation to close space lost due to shorter teeth
56
immediate tx planning for toothwear pt
Deal with pain
* Sensitivity
* Desensitising agents
* Fluorides, bonding agents GIC coverage of exposed dentine
* Pulp extripation
* If wear has compromised pulpal health
* Smooth sharp edges
* Prevent trauma to cheeks and tongue
* Extraction
* Pain from unrestorable/non-functional tooth
* TMJ pain
* Important in attrition, acute symptoms need to be controlled
* *Splint, Ultrasound, jaw exercises, common – relax*
57
initial tx planning for toothwear pt
Stabilise the existing dentition
* Deal with caries
* Deal with perio condition
* Oro-mucosal
Wear is important but treat the whole mouth and whole patient
Once you have a diagnosis and have identified the primary causative factor
* Institute a preventative regime
* No point in treating a problem that is ongoing
* Treatment without prevention will fail
* *Filling will fail if cause of wear still present*
58
prevention in toothwear pt
Most patients’ tooth wear progresses slowly
* Especially true if a successful preventative regime is in place
_Need for monitoring_
* Baseline wear recording is required *refer back to*
* Wear indices: Smith and Knight, BEWE
* Models
* Photos
If you are monitoring adequately you will identify whether wear is progressing or if it is historic
* If it is historic and not problematic, active restorative treatment is probably not required
* If it is active and progressive treatment is required
Treatment includes prevention
* Prevention comes first
KEY ELEMENT TO PREVENTION IS REMOVAL OF CAUSE
59
prevention for abrasion
* Remove the ‘foreign object or substance’ involved in causing the abrasive wear
* Change toothpaste
* Alter tooth brushing habits
* Change habits
* Nail biting
* Wire stripping
* Piercing biting
* Pen chewing etc.
* Probably easiest to address and alter
60
cervical toothbrush abrasion restoration
Simple RMGIC, GIC or composite restorations can almost be considered as a preventative measure
* They can be placed with no tooth preparation
* The patient then wears through the restoration rather than damaging their tooth.
* Simple and effective measure for this type of cavity
Evidence for use of RMGIC as first choice of filling for abrasion cavities it appears to have the best survival rate (Burke. Dental Update 2015,42,829 – 839)
* Composite may look better but its’ higher modulus may compromise its’ retention
* Possibly where abfraction is a genuine factor
* Flowable composite may be another option (tends to be translucent, can be not good for dentine showing area)
You have to balance aesthetics vs possible retention
61
attrition prevention
More difficult to address
Generally related to a parafunctional habit
Parafunction is generally centrally mediated response to life stressors
* Cognitive Behavioural Therapy
* Hypnosis
* Hypnosis clinic in GDH
Splints can be used
* All work by being softer than teeth.
* Wear away in preference to tooth
* Cause no damage to the opposing teeth
* May be habit breaker
Different views on which type is best
* Hard vs Soft
* Soft splint can be used as a diagnostic device
* The splint will wear rapidly and show wear facets as scrapes and gouges in the surface of the splint
* Hard splints are more robust and can be used over longer term, but more timely to make
* Michigan Splint
* Popular type of hard splint
* Provides an ‘ideal occlusion’ with even centric stops
* Has canine rise which provide disclusion in eccentric mandibular movements
* Canine guidance
Erosion and splints do not go together – *esp intrinsic, gets stuck under splint*
62
erosion prevention
* Some aspects of prevention are dependent on the source of the acid
* Extrinsic or intrinsic?
* Fluorides
* densitising agents
* Not really prevention, more symptomatic relief
* Dietary management
* Habit Changes
* Swilling drinks around in mouth
* Drinking from cans
* Use a straw
* Rumination
* ‘Health eating’
* 5…7...10 a day?
* Vegan diet?
* Sports drinks/gels
* Medical
* Control gastric acid
* GORD
* Reflux
* Haitus Hernia
* Xerostomia
* Anorexia and Bulimia
You may require discussions with the patients doctor. You must gain consent to contact GMP
* Subsequent referral to specialist
* Gastroenterologist; GORD
* Psychiatrist/psychologist: Anorexia/Bulemia
* Change in drugs may not be possible
* Beware Proton Pump rebound
63
abfraction prevention
* Assess occlusion on teeth with abfraction lesions
* Consider occlusal equilibration
* Fill cavities with low modulus restorative materials
* RMGIC
* Flowable composite.
64
passive management for toothwear
* Prevention and monitoring
* Should be the first part of any treatment of dental wear
* Most patients, in practice, will be in this phase for at least 6 months
* For many patients this is all that is required
65
when to progress to active management for toothwear pts
*When to progress to*
Intervention threshold
* Simple restorative intervention
* Covering exposed dentine, filling cupped defects in molars or incisors
* The requirements for more extensive definitive restoration are not always clear
* Wear leading to further complications
* Aesthetics have gone beyond patient acceptability
* Leaving intervention may cause more complex treatments to be required.
Evidence for ‘best practice’ is lacking
66
tx goal for toothwear pts (4)
* should be preservation of the remaining tooth structure
* A pragmatic improvement in aesthetics
* A functioning occlusion
* Stability
67
what is easier to tx
localised or generalised
toothwear
Treatment of localised tooth wear is much easier than generalised
* Most generalised starts off as localised à monitoring of patients with wear and correct timing of intervention is required.
68
most common location for toothwear
localised maxiallary anterior toothwear
69
active management for maxiallary anterior localised toothwear
based on what 5 factors and their inter-relations
* The pattern of anterior maxillary tooth wear
* Inter-occlusal space
* Space required for the restorations being planned
* Quality and quantity of remaining tooth tissue, particularly enamel
* The aesthetic demands of the patient
* Pragmatic – pt needs to know what to expect realistically
70
3 categories pattern of maxillary incisor toothwear
* Tooth wear limited to the palatal surfaces only
* Tooth wear involving the palatal and incisal edges with reduced clinical crown height
* Tooth wear limited to labial surfaces *odd*
71
active management for maxillary anterior toothwear when there is adequate inter-incisal space
* If teeth wear rapidly and there is no time for alveolar compensation
* Where there is an anterior open bite
* Where there is an increased overjet *class 2 div 1*
* In these cases there can be available space for restorations with no change in OVD
1. This is quite unusual but these cases are the easiest to treat
72
active management maxillary anteriors when there is no increase in freeway space *(natural)*
Traditional fixed prosthodontic teaching would be to create space for traditional restorations (*crowns)* but Little tooth tissue to begin with
* Poor retention due to short axial walls
Good chance of pulpal damage due to short clinical crowns
* New materials offer a better more conservative approach in these cases
* Composite more conservative - better
How else can you make space?
* Increase OVD: multiple posterior extra-coronal restorations. Reorganised approach
* Complex, Destructive, Expensive, Difficult, Unnecessary tx on posterior teeth
* Occlusal reorganisation from ICP to RCP
* Complicated, can be destructive, specialist treatment
* Surgical Crown lengthening
* Doesn’t really create more space but can improve aesthetics
* Elective RCT and post crowns
* Very destructive
* Conventional Orthodontics
* Lengthy treatment, pts tend to be older and not wanting ortho
73
how can you make space if there is no inter-incisal space
* Increase OVD: multiple posterior extra-coronal restorations. Reorganised approach
* Complex, Destructive, Expensive, Difficult, Unnecessary tx on posterior teeth
* Occlusal reorganisation from ICP to RCP
* Complicated, can be destructive, specialist treatment
* Surgical Crown lengthening
* Doesn’t really create more space but can improve aesthetics
* Elective RCT and post crowns
* Very destructive
* Conventional Orthodontics
* Lengthy treatment, pts tend to be older and not wanting ortho
74
why in maxiallary anterior toothwear cases is there a loss in interincisal space
There is compensation for the loss of tooth substance by dento-alveolar bone growth
* This maintains masticatory efficiency and is a good thing…. Except
* Leaves no space for restorations to be placed
75
surgical crown lengthening
* Exposes more of the crown for retention of final restoration
* Repositioning of gingivae apically generally with removal of bone
* Warn pt not pleasant surgery
* Sensitivity
* Still need occlusal reduction
76
DAHL Technique
Method of gaining space in cases of localised tooth wear
* Originally a removable CoCr anterior bite plane
* Covering palatal surfaces and allowing occlusion on raised cingulum
* Resulted in posterior disclusion and increase in OVD of 2-3mm
* Occlusal contacts only on incisor/canine teeth (anterior)
Over a period of 3-6 months you gain space between incisor teeth
* Interiors intrude
* Posteriors erupt
Results in space between upper and lower anteriors allowing restoration with no need for occlusal reduction (AOB)
Generally carried out in composite now
* Better aesthetics
* Better compliance – not removable
* Easier to adjust than CoCr
* Can be immediate, definitive treatment
* Make anterior teeth look better immediately with composite and over time posterior teeth come into occlusion
77
DAHL technique success rate
* faster in younger patients
* Variable degree
* If no movement in 6 months it is not going to work
* Monitor progress
* Good success rate 90+%
* Occlusion is disorganised at first but re-establishes with time
78
pts not suitable for DAHL technqiue (6)
* Active periodontal disease – overloading anterior teeth
* TMJ problems
* Post Orthodontics
* Biphosphonates – slow turnover bone, but need quick turnover of bone as essentially giving them ortho tx
* If dental implants present (ankylosed)
* If existing conventional bridges (not move like normal induvial teeth)
79
DAHL technique movement
* Covering palatal surfaces and allowing occlusion on raised cingulum
* Resulted in posterior disclusion and increase in OVD of 2-3mm
* Occlusal contacts only on incisor/canine teeth (anterior)
Over a period of 3-6 months you gain space between incisor teeth
* Interiors intrude
* Posteriors erupt
80
active tx of choice for localised anteiror tooth wear
DAHL technique with composite
*no invasive*
If destruction is relatively minimal and limited to the palatal surfaces the teeth can be restored definitively with a high degree of confidence
* There is no evidence to guide decisions where a substantial amount of tooth is lost
81
2 contraindications for DAHL technique tx
* Short roots *overload risk*
* Reduced periodontal support due to periodontal disease. *overload risk*
82
what condition will lower success rate of DAHL technqiue
lack of remaining enamel reduces the success rate significantly *bonding poor*
* Remaining Enamel ‘Ring of Confidence’
* Has very positive influence on retention
83
lower anterior toothwear tx
Generally in conjunction with maxillary wear
* More difficult to fix
* Less enamel, smaller bonding area. Usually need to come over to lingual side as well as incisive edge
If possible _improve aesthetics but do not increase OVD_ with lowers ***mask colour***
If you have to build them up do this first before the uppers *more likely to break*
* Same techniques as uppers
84
localised posterior toothwear incidence
Unusual on its’ own
* Sometimes erosive in ruminating patients
* Erosive in bulimic and alcoholic patients
If localised and asymptomatic, prevention and monitoring are appropriate
85
localised posterior toothwear tx
If localised and asymptomatic, prevention and monitoring are appropriate
Occlusal erosive wear can be filled directly with composite with no change in occlusion
Restorative care can be aimed at providing sufficient canine guidance to ensure posterior disclusion
* Composite resin can be added to the palatal of the upper canines to increase the canine rise and disclude the posteriors during lateral and protrusive excursions
* Often there is canine wear which has removed guidance and led to posterior wear.
* Correct the canine wear and the posterior will be saved from further damage
*Canine is restored to original length. This results in disclusion of the posterior teeth in lateral excursions*
* *Simple, effective, reversible technique*
* *Can be freehand or with use of diagnostic wax and template*
86
2 methods of composite build up
direct build up with composite putty matrix
clear vacuum formed matrix
87
stages in direct build up with putty matrix for anterior teeth
* Alginate impressions
* Wax up
* Putty matrix
88
stages in clear vacuum formed matrix build up
* Alginate impression
* Diagnostic wax
* Impression of this poured in stone.
* Vacuum formed clear plastic matrix formed on this
* Cut to size and used as mould for build up
89
5 success points of composite build ups for anterior teeth
* Generally good patient satisfaction
* Posterior occlusion is normally re-achieved
* Seldom TMJ problems
* No detrimental effect on Pulpal health
* No worsening of Periodontal condition
*Composite resin restorations placed at an increased occlusal vertical dimension may be a viable and minimally invasive treatment option for the treatment of localised anterior tooth wear. (Burke 2014)*
90
longevity of composite anterior restorations for toothwear
Viable medium-term option
* Requires repair and maintenance
Maxillary restorations last better than mandibular
* Probably due to increased bonding area
* Maxillary wear more common
* Tongue and saliva protect lowers
No definitive figures, perhaps around 70% over 10 years *(no tooth destruction this is good)*
* BUT if these fail they can be replaced or repaired and no tooth destruction occurred during there placement
91
likely aesthetic outcome for anterior toothwear restored with composite
Aesthetic results are good but not the highest achievable. - pragmatic
but
* No further damage to already worn teeth
* Biologically based management
Unrealistic expectations of patients – need to manage, more ‘perfect/hollywood’ smiles are destructive so should be 2nd option
* *‘Daughter Test’ – would you do it to your family member?*
* *If you wouldn’t, don’t do it to someone else.*
* *Replace teeth with porcelain and metal wise when could keep biologic teeth and build in composite and bleech?*
92
9 points of information for anterior toothwear pts getting composite build ups
* Your front teeth will receive tooth coloured fillings to cover the exposed and worn tooth surface
* This will prevent them from wearing more
* This is the main reason for your treatment
* This procedure will be carried out without local anaesthetic as there will be no, or minimal drilling to your teeth
* We add on to your teeth, not remove any tooth
* An improvement in the appearance of your teeth should be possible
* Your ‘bite’ will feel strange for a few days and you may have difficulty chewing
* Only your front teeth will touch together
* Your back teeth will gradually come back together but this will take 3 – 6 months
* All normal
* Over a week or so you will become accustomed to your new ‘bite’ and will be able to eat more normally
* Initially though you may have to cut your food into small pieces to help with swallowing and digestion
* The change in the shape of your front teeth may cause lisping for a few days
* Your front teeth may feel a little tender to bite on for a few days
* Like if you have a brace and it has been tighten
* You may bite your lips and tongue initially – will settle
* If you have crowns/bridges or partial dentures at the back of your mouth it is likely that these will need to be replaced *(probable, more upper than lower)*
93
information about the upkeep and longevity of composite restorations on anterior teeth (4)
* The longevity of these restorations should be good, but there is a small potential for restorations to debond and fall off.
* They can be replaced with no damage to your remaining tooth
* These restorations will require maintenance - costs
* The margins of these restorations will require occasional polishing
* Occasional chipping of restorations may occur
94
3 categories for generalised toothwear
same as localised
* Excessive wear with loss of OVD
* Excessive wear without loss of OVD but with available space
* Excessive wear without loss of OVD and with no space available
95
first tx for generalised toothwear
an adhesive approach should be used in these cases
* They can be used to assess the patients tolerance of a new occlusal scheme as a medium term restoration
* ideally 50:50 OVD increase mandibular and maxillary
If conventional preparations are required at a later date these adhesive additions may form the bulk of the removed material - Preserving tooth structure
96
what can be considered to increase pt face height/OVD in generalised toothwear cases
splint
97
limited space available, no loss in OVD, generalised toothwear
tx options
ideally - minimal tooth prep and adhesive restoration at a new face height (splint first to adjust)
98
excessive generalised toothwear with loss of OVD
tx
splint to adjust to new face height (or adhesive restorations)
then a mixture of adhesive and conventional restorations are required often
* Dentures may be required to provide posterior support at the new OVD
99
generalised toothwear with no loss in OVD and no space available
tx
tricky - specialist tx
* Attempt to increase OVD by use of splints+/- dentures if there is lack of posterior support
* As there often is in these cases
* Crown lengthening surgery
* Elective endodontics
* Destructive and posts and cores and attrition do not go together
* Orthodontics
100
issues with crown lengthing
*Used to increase the amount of coronal tooth substance available.*
* May result in ‘black triangles’ between the teeth where the ID papilla is further down
* Bone loss like periodontal disease
* Can lead to unfavourable crown to root ratio
* Increased chance of loosening or tooth movement if tooth is loaded subsequently
* Took too much away
* Often post op sensitivity *exposed root*
* Any subsequent conventional crown preparation will be further down the root
* Problem if the tooth has a significant coronal-cervical taper.
* Greater chance of pulpal damage
101
overdentures
Preserves tooth substance and bone for support of denture when teeth as so worn down that restoration is impossible
* Can be bulky for patient to wear
* Difficulties with keeping teeth/gingivae healthy beneath the prosthesis *candida,caries*
102
toothwear tx guide
103
toothwear tx risk managment
* Any failure to recognise or manage tooth wear in an appropriate fashion which results in the condition deteriorating unecessarily can leave the clinician open to criticism.
* Where wear has been present for some time and is not progressing it is sufficient, in most cases, to record that it has been recognised, pointed out to the patient and is being monitored
* Preventative Advice/Counselling
* Advice must be recorded and detailed in the patients notes (diet, habits etc)
* If the patient is not compliant, reluctant or unwilling to follow a recommended course of action this must be recorded
* Any surface treatments, eg topical fluoride, must be recorded on each occasion.
* It is important to record if the patient complied with repeat applications.
* Consent
* The patient must understand the proposed treatment, Including passive preventative
* The patient must understand their part in the treatment and how their cooperation is integral to a favourable outcome
* The patient must understand the consequences of not following the advice given – wear will get worse
* Provisional Treatment (often passive preventative)
* The importance of this treatment in establishing a definitive diagnosis must be explained to and understood by the patient, and establish baseline for their wear
* If this is temporary this must be explained to the patient as must the reason for not providing definitive treatment at that time *(e.g. increasing OVD prior to placing anything permanent in a new occlusion)*
* Definitive Treatment
* Minimum intervention treatments should be tried before considering a more radical interventive approach *(composite first then crowns)*
* If in doubt a second opinion from a restorative specialist is sensible
* Any referral documentation must be copied and retained in the patients’
## Footnote
**All discussions must be recorded clearly in the patients’ notes**
104
tx here
composite DAHL and CoCr denture (need to make denture quickly after placing composite fillings to help prevent anterior composites breaking off)
105
tx here
Composite anterior
Porcelain and Metal onlays posteriorly
No tx on mandible
