Wear 3

Question 1

Why is composite build ups considered the first choice for restoring anterior tooth wear?

Answer 1

It is conservative and reversible

Question 2

What is the advantage of having an enamel ring when fixing tooth wear?

Answer 2

Enamel provides better bonding
-> more retention

Question 3

Why is fixing Lower anterior tooth wear more difficult?

Answer 3

As there is less enamel and a smaller bonding area
-> lingual surface may need to be utilised

Question 4

How is lower anterior wear treated?

Answer 4

Aim to improve aesthetics but not increase OVD

If uppers and lowers required- do lower first as they are more likely to debond (same technique as uppers)

Question 5

What can be used as reference point for incisal height?

Answer 5

Height of tallest remaining incisor

Question 6

When is localised posterior wear found?

Answer 6

Ruminating patients

Bullimia

Alcoholics

Question 7

How is localised posterior wear treated?

Answer 7

If asymptomatic- prevention and monitoring

Erosive wear can be filled directly with composite with no change in occlusion

Question 8

What can be causing posterior wear to occur? How can it be treated?

Answer 8

Loss of canine guidance (group function)

-> Add composite to palatal surfaces of upper canines to increase the canine rise and disclude the posteriors during lateral and protrusive excursions (restore guidance)

Question 9

What techniques can be used to restore guidance to treat posterior wear?

Answer 9

Freehand

Diagnostic wax up/template

Question 10

What are the methods for doing composite build ups?

Answer 10

Alginate impressions- produce cast

-> Wax up

-> Putty Matrix OR Vacuum formed splint

Question 11

What are the advantages of composite build ups?

Answer 11

Generally good patient satisfaction

Posterior occlusion is normally re-achieved

Seldom TMJ problems

No detrimental effect on Pulpal health

No worsening of Periodontal condition

Good medium term option (like most of dentistry)- 70% success over 10 yrs

Easy repair and maintenance

Question 12

Why do maxillary restorations last longer than mandibular

Answer 12

Due to increased bonding area

Question 13

Why are maxillary teeth more prone to wear than mandibular?

Answer 13

Tongue and saliva protects lowers

Question 14

Why are composite build ups considered biological management?

Answer 14

Not removing sound tissue (preserves it- adding not removing)

Question 15

Why must aesthetic goals be pragmatic?

Answer 15

To prevent unrealistic expectations in patients

Question 16

What information should be provided for patients receiving composite build ups for treating localised tooth wear?

Answer 16

Restored with tooth coloured material to cover exposed and reduced surface- prevents further wear

Procedure is done with no LA- no/minimal need for drilling

Aesthetic improvements should be achievable

Bite may feel strange for a few days
-> only anteriors willl touch (posteriors will come together but can take 3-6 months)

Stick to a softer diet cut into smaller pieces for first week as bite adjusts

Question 17

Information for patients for composite build ups for treating localised tooth wear (CNTD):

Answer 17

Front teeth may be tender initially- slight intrusion (compare to Ortho movement)

May lisp initially

May notice lip and tongue biting initially (different occlusion)

If you have crowns/bridges or partial dentures at the back of your mouth it is likely that these will need to be replaced

Question 18

What information about longevity of composite build ups should be discussed with patients?

Answer 18

Should be good but there is potential for debonding
-> can be replaced with no damage to teeth

Repair and Maintenance is part of the process- materials are not as good as tooth structure (will have a cost)
-> will requiring occasional polishing
-> chipping may occur

Question 19

How does most cases of generalised tooth wear begin?

Answer 19

As localised anterior tooth wear (especially if this goes untreated)

Question 20

Why is treatment of generalised tooth wear so much more complex?

Answer 20

Need to provide a totally new occlusal scheme (replacing teeth in front and back)

Question 21

What are the categories of generalised tooth wear?

Answer 21

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

Question 22

What can be done to see how patient copes with new occlusal scheme?

Answer 22

Splints/adhesive restorations can be made at this new OVD to see how patient copes

-> If conventional preparations are required at a later date these adhesive additions may form the bulk of the removed material- Preserving tooth structure

Question 23

What is done to treat excessive wear with loss of OVD? (Easiest but least common)

Answer 23

A splint can be used to assess the patients’ tolerance of the new face height (may not be necessary if an adhesive approach is being used)

You can go straight to increase in face height with ‘permanent’ bonded restorations (mixture of adhesive and conventional)

-> Ideally half the OVD increase should be maxillary and half mandibular

Dentures may be required to provide posterior support at the new OVD- can prevent composite breaking off (can come after Tx in some cases)

Question 24

How is excessive tooth wear without loss of OVD But with Limited Space available treated? (more complicated)

Answer 24

Re-organisation of occlusion may be required

A splint should be considered as an increase in occlusal face height is required (most patients accommodate change)

Restoration of anterior and posterior teeth is then carried out at the new occlusal face height (should be minimally prepped adhesives)

Question 25

What are the options for generalised excessive wear with no space available? (most complex and most common)

Answer 25

REFER for specialist management:

Increase OVD with splints/overdentures (if lack of posterior support)

Elective Endo- post crowns

Crown lengthening surgery

Orthodontics

Question 26

What is the purpose of crown lengthening surgery?

Answer 26

Used to increase the amount of coronal tooth substance available

-> Peel gingivae back, remove bone

-> Margin goes 3-5mm further up tooth and allows more tooth substance to be visible

Question 27

What are the drawbacks of CLS?

Answer 27

 Elective bone loss- black triangles (recession of ID papilla)

 Sensitivity- taking root under bone and exposing it to oral environment

 Crown preps subsequently are further up root surface (can get close to the pulp)- issue if significant coronal-cervical taper

Question 28

When can overdentures be utilised? What is the benefit?

Answer 28

If teeth are down to bone level and restoration is impossible (maintains proprioreception)

Question 29

What are the issues with overdentures?

Answer 29

Bulky, difficult to get aesthetics correct, difficult to clean

Question 30

What are the general issues with treating generalised tooth wear?

Answer 30

Demanding

Difficult- must be realistic

Lengthy

Expensive

-> Unless you have expertise in these cases a second opinion and TP is required

Question 31

What are examples of good practice when treating generalised tooth wear in terms of risk/liability management?

Answer 31

 As long as patient is aware and it is recorded in notes- monitoring tooth wear is fine

 Give advice and counselling and note what you tell patients (this is still treatment)

 Note any non-compliance- make it clear (tell them that their cooperation leads to favourable outcome)

 Record decisions to use topical F etc- what the patient thinks of this treatment

 CONSENT- discuss operative and passive preventive (patient must understand risks, benefits, consequences and be willing )

 Make sure patient knows if treatment is temporary- let them know if you plan to do something permanent in the future (or if you will wait and see)

 Any referral documentation must be copied and retained