Tooth wear final

Dentistry
Dentist
Treatment planing

1. Tooth Wear Mohammed Aldosari ID: 421100905

2. Outline: Introduction Types and Etiology Management and Prevention Restorative and Prosthetic Treatment Mohammed Aldosari, DMD

3. Tooth Wear “ Defined as the surface loss of dental hard tissues from causes other than dental caries, trauma or as a result of developmental disorders. “ 1 Tooth wear is normal physiological proses related to aging 2 , but it can be accelerated by unusual endogenous or exogenous factors. Hattab F, Yassin O. Etiology and diagnosis of tooth wear: a literature review and presentation of selected cases. Int J Prosthodont 2000; 13: 101–107. Lambrechts P, Braem M, Vuylsteke-Wauters M, et al: Quantitative in vivo wear of human enamel. J Dent Res 1989;68:1752-1754 Mohammed Aldosari, DMD

4. Types of Tooth Wear Attrition: Tooth to tooth contact Erosion: loss of tooth surface by a chemical process that does not involve bacterial action   Abrasion  Abfraction Verrett RG. Analyzing the etiology of an extremely worn dentition. Journal of Prosthodontics. 2001 Dec 1;10(4):224-33. Mohammed Aldosari, DMD

5. Types of Tooth Wear   Abrasion: The wear of tooth structure through some unusual or abnormal mechanical process other than tooth-to- tooth contact (1)   Abfraction : The loss of hard tissue from eccentric occlusal loads leading to compressive and tensile stresses at the cervical fulcrum area of the tooth. 2 Glossary of Prosthodontic Terms, ed 7. J Prosthet Dent 1999;81:48 Braem M, Lambrechts P, Vanherle G. Stress induced cervical lesions. J Prosthet Dent 1992; 67: 718–722. Mohammed Aldosari, DMD

6. Tooth Wear Other conditions that may increase incident and severity: Amelogenesis Imperfecta: is a hereditary defect of dental enamel that occurs in a ratio of 1/14000 persons . 1 Hypoplasia, Hypomaturation , Hypocalcified Dentinogenesis Imperfecta: It is a genetic disorder of tooth development. 1- Turner KA, Missirlian DM. Restoration of the extremely worn dentition. The Journal of prosthetic dentistry. 1984 Oct 1;52(4):467-74. 2- Hattab F, Yassin O. Etiology and diagnosis of tooth wear: a literature review and presentation of selected cases. Int J Prosthodont 2000; 13: 101–107. 3- Illustrated Dental Embryology, Histology, and Anatomy, Bath- Balogh and Fehrenbach , Elsevier, 2011, page 64 Mohammed Aldosari, DMD

7. Consequences of loss of (VDO) • Appearance • Neuromuscular system • dental occlusion • masticatory efficiency • TMJ Functional surfaces of teeth: flatter and wider, disrupting the occlusal plane Over closure and deep bite Over contraction of muscles Thinning of the lips Forward position of mandible causing chin prominence Mohammed Aldosari, DMD

8. Turner’s classification The loss of tooth structure may or may not result in an increase in the Freeway space. Following an evaluation of the existing vertical dimension of occlusion (OVD) patients presenting with generalized wear may be assigned to three categories according to Turner classification: Category 1 – excessive wear with loss of vertical dimension of occlusion Category 2 – excessive wear without loss of vertical dimension of occlusion, but with space available Category 3 – excessive wear without loss of vertical dimension, but with limited space. Mohammed Aldosari, DMD

9. Category 1: Excessive wear with loss of VDO Closest speaking space is more than 1mm Interocclusal space is more than 4 mm Loss of facial contour Drooping the corners of the mouth Mehta, S. B., Banerji , S., Millar, B. J., & Suarez- Feito , J. M. (2012). Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear.  British dental journal ,  212 (1), 17-27. Mohammed Aldosari, DMD

10. Category 2: excessive wear without loss of VDO But with space available History of gradual wear: Bruxism Moderate oral habits Environmental factors OVD maintained by continuous eruption Tooth prep to establish retention & resistance (critical) Gingivoplasty ( gain clinical crown length) Enameloplasty of the opposing posterior teeth Mohammed Aldosari, DMD

11. Category 3: Excessive wear without loss of VDO But with limited space Excessive wear of anterior teeth Minimal wear of posterior teeth CR = CO Closest speaking space = 1mm Interocclusal distance = 2-3 mm Vertical space obtained by Orthodontic movement Restorative repositioning Surgical repositioning segment Mohammed Aldosari, DMD

12. Management & Prevention

13. TREATMENT PLANNING FOR CASES OF TSL Treatment planning for cases TSL follows the same basic as for the planning for the regular restorative dental care for any other case. The first management of acute conditions. Simple adjustment of a sharp cusp or incisal edge to the application of a desensitising agent or glass ionomer cement over an area of exposed dentine. Pulpal extirpation, or in severe cases a dental extraction, may need to be considered. In some cases where aesthetics may have been compromised a composite resin can be provisionally applied. Mohammed Aldosari, DMD

14. The next stage is prevention. Next phase would be the definitive dental restorations. The final stage involves monitoring and maintenance. Mohammed Aldosari, DMD

15. Several researchers appear to support that once tooth wear has been diagnosed wear progression appears to occur relatively slow rate particularly in cases where preventative advice has been successfully implemented. The benefits of fluoride in reducing the efficacy of soft drinks in promoting erosive tooth wear has been reported by a multitude of in vitro studies Hemmings K, Truman A, Shah S, Chauhan R. Tooth wear guidelines for the bsrd part 3: removable management of tooth wear. Dental Update. 2018 Sep 2;45(8):687-96 . Sorvari R, Kiviranta I, Luonia H. Erosive effects of a sport drink mixture with and without the addition of fluoride and magnesium on the molar teeth of rats. Scand J Dent Res 1988; 96: 336–231. Mohammed Aldosari, DMD

16. Desensitising therapy – Potassium containing toothpastes also considered to be appropriate for the management of sensitive dentine. Dietary counselling Shafer W, Hine M, Levy B. A textbook of oral pathology. pp 318–323. Philadelphia: WB Saunders, 1983. Mohammed Aldosari, DMD

17. Splint therapy – a full coverage hard acrylic occlusal splint should be constructed An example is a Michigan splint or a Tanner appliance, as shown. The splint should be fabricated to provide an ideal occlusion incorporating the presence of even centric. Canine guidance to provide posterior tooth separation during lateral excursive and protrusive mandibular movements. Mohammed Aldosari, DMD

18. 6. Sealant restorations – The application of dentine bonding agents and fissure sealant to eroded areas may be helpful in providing some level of protection and reduce dentinal hypersensitivity. Whilst the results of a study by Sundaram et al.38 showed the longevity of sealants in the form of dentine bonding agents applied to teeth displaying severe wear to be relatively short lived, they may help to reduce the rate of wear on applied surfaces up to a period of nine months following application Similarly, glass ionomer cements can be readily applied to worn surfaces for the same purposes. Bartlett D, Sundaram G, Moazzez R. Trial of protective effect of fissure sealants, in vivo, on the palatal surfaces of anterior teeth, in patients suffering from erosion. Journal of dentistry. 2011 Jan 1;39(1):26-9 . Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 4. An overview of the restorative techniques and dental materials commonly applied for the management of tooth wear. British dental journal. 2012 Feb;212(4):169-77. Mohammed Aldosari, DMD

19. 7. Referral to a medical practitioner – This is considered appropriate when the dental operator suspects a case of bulimia or reflux disease. Medication can be used to reduce gastric reflux and acid production such as omeprazole and ranitidine. Mohammed Aldosari, DMD

20. MONITORING STRATEGIES The primary goal for the management of any patient presenting with tooth wear is to prevent further pathological wear It is desirable to avoid restorative intervention where possible because undoubtedly it will commit the patient to costly long term maintenance care. Monitoring the progression of tooth wear is can be undertaken by high quality sequential clinical photographs and by the periodic study casts at approximately 6-12 monthly intervention. Both of the two methods of monitoring are not very sensitive but can provide a gross subjective estimate of the rate of tooth wear. Hanif A, Rashid H, Nasim M. Tooth surface loss revisited: Classification, etiology, and management. Journal of Restorative Dentistry. 2015 May 1;3(2):37. Mohammed Aldosari, DMD

21. Restorative & Prosthetic Treatment

22. THE NEED FOR ACTIVE RESTORATIVE INTERVENTION There maybe esthetic concern Symptoms of pain or discomfort Functional difficulties Unstable occlusion The rate of teeth wear is extreme concern of the patient or the dentist a preventative program and a period of monitoring of 6-12 months before embarking upon what usually involves complex, technically demanding restorative dentistry. Mohammed Aldosari, DMD

23. LOCALISED MAXILLARY ANTERIOR TOOTH WEAR Maxillary anterior teeth are most commonly involved in localized tooth wear, especially where erosion is a major factor. The decision on how to optimally restore these teeth will depend on five factors: 1. The pattern of anterior, maxillary tooth surface loss 2. Inter-occlusal space availability 3. Space requirements of the dental restorations being proposed 4. The quantity and quality of available dental hard tissue and enamel respectively 5. The aesthetic demands of the patient. Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 1. Assessment, treatment planning and strategies for the prevention and the passive management of tooth wear. British dental journal. 2012 Jan;212(1):17-27. Mohammed Aldosari, DMD

24. Inter-occlusal space availability In the majority of patients, tooth wear is accompanied by dentoalveolar compensation. The physiological compensatory mechanism allows occlusal contacts to be maintained, in order to attempt to preserve the efficacy of the masticatory system. In some cases, particularly where the rate of tooth wear may be very rapid, or compensatory mechanisms evolve at a relatively slower rate, or in the case of a patient with an anterior open bite, deep overbite or increased overjet adequate space may be available between the upper and lower dentition in centric occlusion(CO) Mohammed Aldosari, DMD

25. Mohammed Aldosari, DMD

26. Adhesive restorations may simply be bonded into the available space in order to restore form, aesthetics and function, while conventional restorations may require minimal reduction of the affected surfaces. One option would be to follow traditional prosthodontic protocols and to create space to accommodate restorations/restorative materials through the process of tooth reduction and to conform to the existing occlusion. The aggressive loss of dental hard tissue through tooth preparation, particularly among severely worn teeth, may also lead to a significantly reduced axial height Mohammed Aldosari, DMD

27. In some cases, the required inter-occlusal clearance may be present in centric relation (CR). This is often best confirmed by the means of accurate study casts mounted in centric relation on a semi-adjustable articulator, with the aid of diagnostic wax mock-ups. the space created by such a reorganized approach may be sufficient to permit the use of more rigid materials such as metallic alloys which require less bulk thickness to ensure longevity, but not enough for the use of more elastic materials such as resin composite . resin composite restorations to display longevity, in areas of occlusal loading, they should be placed at a minimal thickness of 1.5 to 2.0 mm Mohammed Aldosari, DMD

28. The Dahl concept This concept is frequently referred to in dental literature as a means of gaining space in cases of localized tooth wear, where there is insufficient space available in either CO or CR. described the use of a removable anterior bite platform, fabricated from cobalt chromium, retained by clasps in the canine and premolar regions to create inter-occlusal space in a patient with tooth wear localized to the anterior maxillary segment. The appliance was designed to cover the cingulum areas of the affected teeth and increase the occlusal vertical dimension in the region of 2-3 mm. Mohammed Aldosari, DMD

29. occlusal contacts were only present between the mandibular anterior teeth and the bite platform. The actual Dahl concept refers to the relative axial tooth movement that is observed to occur when a localized appliance or localized restoration(s) are placed in supra-occlusion and the occlusion re-establishes full arch contacts over a period of time. It was reported by Dahl and Krungstad that the inter-occlusal space created occurs through a process of combined intrusion(40%) and extrusion (60%). Mohammed Aldosari, DMD

30. success rate of between 94-100% has been reported. Furthermore, the level of space creation was consistently found to be irrespective of age and sex. failures also occur in patients with gross class III malocclusions and in cases with mandibular facial asymmetry that had a lack of stable occlusal contacts in either CO or CR. Patients who may present with bony ankyloses, dental implants, conventional fixed bridgework and those with anterior open bites, will all have limited eruptive potential. Mohammed Aldosari, DMD

31. great caution with patients who may have active/a past history of periodontal disease, temporomandibular joint pain dysfunction syndrome, where endodontically teeth may be involved, in cases post-orthodontic treatment and among patients who may be taking oral or IV bisphosphonate drugs. Mohammed Aldosari, DMD

32. Mohammed Aldosari, DMD

33. The use of metal posts has been well documented to be associated with the risks of root fracture, which may be exaggerated in cases where due to parafunctional habits, excessive occlusal loading has been applied. The more recent advent of fiber-resin posts has been suggested to overcome this concern. Common area of fracture at post-core interface . Mohammed Aldosari, DMD

34. LOCALISED ANTERIOR MANDIBULAR TOOTH WEAR If both upper and lower teeth are affected, then space should be gained through the process of the Dahl concept and the lower dentition restored before the upper. Localized anterior mandibular wear is often seen among patients who have been provided with maxillary metal-ceramic crowns, particularly with porcelain occluding surfaces which have been adjusted to accommodate the occlusion and left unpolished. Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 2. Active restorative care 1: the management of localised tooth wear. British dental journal. 2012 Jan;212(2):73. Mohammed Aldosari, DMD

35. restoring a localized worn lower dentition follows the same basic tenets as the restoration of worn maxillary anterior teeth. The application of less invasive, dentine bonded crowns may have a promising role in the management of worn lower anterior teeth. However, the risks of fracture among patients who display parafunctional tooth grinding habits remain a concern. Mohammed Aldosari, DMD

36. LOCALISED POSTERIOR WEAR T he aim of restorative care being to provide posterior disocclusion and canine guidance, and to prevent the affected tooth from further wear. The placement of restorations in supra-occlusion should be avoided among periodontally involved or endodontically treated teeth, as well as among cases which display signs of limited eruptive potential or TMJ dysfunction. The use of resin composite onlays has been shown by Bartlett et al. to be associated with a high level of failure, with a failure rate of 28% for direct composite onlays and 21% for indirectly fabricated composite onlays after an observation period of three years Mohammed Aldosari, DMD

37. Generalized tooth wear The indications for active restorative intervention for a patient presenting with pathological tooth wear!! the restorative management of patients presenting with generalized tooth wear will be considered according to the three categories described by Turner and Missirilian : Category 1 – excessive wear with loss of vertical dimension of occlusion Category 2 – excessive wear without loss of vertical dimension, but with space available Category 3 – excessive wear without loss of vertical dimension, but with limited space. Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 3. Active restorative care 2: the management of generalised tooth wear. British dental journal. 2012 Feb;212(3):121-7 . Mehta SB, Banerji S, Millar BJ, Suarez- Feito JM. Current concepts on the management of tooth wear: part 4. An overview of the restorative techniques and dental materials commonly applied for the management of tooth wear. British dental journal. 2012 Feb;212(4):169-77. Mohammed Aldosari, DMD

38. The desired increase in OVD will primarily be determined by what is necessary to produce functionally stable, aesthetic dental restorations and an adequate freeway space. Clinically this can be estimated by measurement of the existing OVD of the worn dentition and the face height with the mandible at rest with an adequate lip seal; the difference between the two measurements needs to accommodate the desired increase in the OVD and the freeway space. T he planned increase may be programmed into the articulator (by raising the pin on the articulator), and a diagnostic wax up fabricated accordingly(preferably on duplicate casts). Mohammed Aldosari, DMD

39. The diagnostic wax up should take account of basic aesthetic principles (such as tooth shape, length, inclination and relationship of the incisal edge to the lip line) final occlusal scheme should provide: Simultaneous stable bilateral tooth contacts Centric relation (CR) coincident with centric occlusion (CO) Disclusion of the posterior teeth, upon lateral and protrusive mandibular movements Anterior teeth disclusion , when posterior teeth are in maximum intercuspation Shared/even anterior guidance Canine guided occlusion, with planned group function Mohammed Aldosari, DMD

40. RESTORATIVE TECHNIQUES - ADHESIVE VS CONVENTIONAL Conventional restorative techniques (those which depend on mechanical tooth preparation features to provide retention and resistance form) have traditionally been the mainstay for the management of tooth surface loss. In recent times, with improvements in adhesive technology and the availability of superior resin composites, adhesive retained restorations have become ever increasingly popular. Mohammed Aldosari, DMD

41. Conventional VS Adhesive restorations Conventional restorations will require the copious removal of sound dental hard tissue (from tooth structure which will have already been compromised by the process of TW).Adhesive preparations in contrast are minimally invasive Conventional, full coverage restorations have been associated with high risks of loss of pulp tissue vitality. Conventional tooth preparations are irreversible Conventional restorations require careful tooth preparation to provide adequate resistance and retention form. The success of adhesive restorations is dependent to a large extent on the presence of a copious quantity of high quality tooth enamel. Mohammed Aldosari, DMD

42. Cont. Adhesive techniques are highly operative sensitive and require meticulous moisture control Conventional techniques are dependent on the need for provisional restorations, which is not required when using adhesive restorations Conventional restorations are associated with higher initial financial costs Conventional restorations may offer superior levels of longevity when compared to adhesive restorations, however failures in the longer term tend to be catastrophic and often unamenable to repair. In opposite to adhesive restorations Mohammed Aldosari, DMD

43. A dhesive restorations may very effectively serve as medium term restorations, where eventually they may be replaced with conventional techniques, having established the patient’s tolerance and adaptability to their new occlusal scheme Mohammed Aldosari, DMD

44. CATEGORY 1 PATIENTS: ‘EXCESSIVETOOTH WEAR, TOGETHER WITH A LOSS IN THE OVD’ Such cases may be considered the most straight forward of all three categories to manage. A full coverage, hard acrylic stabilization splint, such as a Michigan splint, can be used to evaluate the patient’s tolerance/ adaptability to the planned occlusal changes Mohammed Aldosari, DMD

45. Ideally, half the increase in OVD should be incorporated into each arch, but this depends on the pattern of wear, and the desired aesthetic outcome. Where the increase in OVD is shared equally between the dental arches, it will not only allow for a better distribution of the increase in crown to root ratio, but also make the increase in OVD less abrupt, there by improving the chances of successful adaptation. (usually the arch with the greatest discrepancy will be prepared first) Mohammed Aldosari, DMD

46. Mohammed Aldosari, DMD

47. CATEGORY 2: ‘EXCESSIVE WEARWITHOUT LOSS OF OVD, BUT WITHLIMITED SPACE AVAILABLE’ In such cases, a discrepancy will usually exist between centric occlusion (CO)and centric relation (CR). CR may provide space to accommodate restorative materials; however, it might not always be fully adequate and there may be a need to plan an increase in the OVD. For such cases, the patient should be provided with a full coverage, hard acrylic occlusal splint, which will provide an increase in the OVD to the required range, while the mandible is manipulated into its retrieve arch of closure. Mohammed Aldosari, DMD

48. The occlusal prescription of the splint should aim to provide a removable mutually protective scheme. The patient should be instructed to wear the splint continually for a period of one month (at all times other than when eating) to evaluate the tolerance of the increase in OVD. Mohammed Aldosari, DMD

49. resin based restorations may be applied ‘directly’ to reduce costs, this approach is very time and skill demanding and indeed, it may be impossible to attain the desired dynamic occlusal scheme particularly for complex posterior restorations, which will need to be placed in a supraocclual position (at the desired new vertical dimension). Mohammed Aldosari, DMD

50. CATEGORY 3: ‘NO LOSS OF OVD,WITH INSUFFICIENT SPACE FOR RESTORATIVE MATERIALS’ such cases, every effort should be made to obtain space by means other than an increase in the OVD. Only if such methods fail to provide enough space, would an increase in the OVD Other methods which may be used to create space include: Surgical crown lengthening, with osseous recontouring . ‘black triangles’ Elective endodontics may be considered to permit the application of a post and core system. Parafunctional habits Orthodontic tooth movements Mehta, S.B., Banerji, S., Millar, B.J. and Suarez- Feito , J.M., 2012. Current concepts on the management of tooth wear: part 4. An overview of the restorative techniques and dental materials commonly applied for the management of tooth wear.  British dental journal ,  212 (4), pp.169-177. Mohammed Aldosari, DMD

51. RESTORATIVE MATERIALS/ RESTORATIONS COMMONLY USED IN THE MANAGEMENT OF TOOTH WEAR Advances in adhesive dentistry a number of other options have become available, including: Direct composite resin restorations Indirect composite resin restorations Cast adhesive alloys (metal palatal veneers and metal adhesive onlays ) Adhesive ceramic restorations. Mohammed Aldosari, DMD

52. Thank you Questions?