Wear 3 Flashcards
Why is composite build ups considered the first choice for restoring anterior tooth wear?
It is conservative and reversible
What is the advantage of having an enamel ring when fixing tooth wear?
Enamel provides better bonding
-> more retention
Why is fixing Lower anterior tooth wear more difficult?
As there is less enamel and a smaller bonding area
-> lingual surface may need to be utilised
How is lower anterior wear treated?
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)
What can be used as reference point for incisal height?
Height of tallest remaining incisor
When is localised posterior wear found?
Ruminating patients
Bullimia
Alcoholics
How is localised posterior wear treated?
If asymptomatic- prevention and monitoring
Erosive wear can be filled directly with composite with no change in occlusion
What can be causing posterior wear to occur? How can it be treated?
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)
What techniques can be used to restore guidance to treat posterior wear?
Freehand
Diagnostic wax up/template
What are the methods for doing composite build ups?
Alginate impressions- produce cast
-> Wax up
-> Putty Matrix OR Vacuum formed splint
What are the advantages of composite build ups?
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
Why do maxillary restorations last longer than mandibular
Due to increased bonding area
Why are maxillary teeth more prone to wear than mandibular?
Tongue and saliva protects lowers
Why are composite build ups considered biological management?
Not removing sound tissue (preserves it- adding not removing)
Why must aesthetic goals be pragmatic?
To prevent unrealistic expectations in patients
What information should be provided for patients receiving composite build ups for treating localised tooth wear?
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
Information for patients for composite build ups for treating localised tooth wear (CNTD):
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
What information about longevity of composite build ups should be discussed with patients?
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
How does most cases of generalised tooth wear begin?
As localised anterior tooth wear (especially if this goes untreated)
Why is treatment of generalised tooth wear so much more complex?
Need to provide a totally new occlusal scheme (replacing teeth in front and back)
What are the categories of generalised tooth wear?
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
What can be done to see how patient copes with new occlusal scheme?
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
What is done to treat excessive wear with loss of OVD? (Easiest but least common)
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)
How is excessive tooth wear without loss of OVD But with Limited Space available treated? (more complicated)
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)
What are the options for generalised excessive wear with no space available? (most complex and most common)
REFER for specialist management:
Increase OVD with splints/overdentures (if lack of posterior support)
Elective Endo- post crowns
Crown lengthening surgery
Orthodontics
What is the purpose of crown lengthening surgery?
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
What are the drawbacks of CLS?
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
When can overdentures be utilised? What is the benefit?
If teeth are down to bone level and restoration is impossible (maintains proprioreception)
What are the issues with overdentures?
Bulky, difficult to get aesthetics correct, difficult to clean
What are the general issues with treating generalised tooth wear?
Demanding
Difficult- must be realistic
Lengthy
Expensive
-> Unless you have expertise in these cases a second opinion and TP is required
What are examples of good practice when treating generalised tooth wear in terms of risk/liability management?
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
