References

Tjan AH, Miller GD. The JG: Some aesthetic factors in a smile. J Prosthet Dent. 1984; 51:24-28
Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008; 12:65-68
Cairo F, Carnevale G, Buti J, Nieri M, Mervelt J, Tonelli P, Pagavino G, Tonetti M. Soft-tissue re-growth following fibre retention osseous resective surgery or osseous resective surgery: a multilevel analysis. J Clin Periodontol. 2015; 42:373-379
Chana H, Kelleher M, Briggs P, Hooper R. Clinical evaluation of resin-bonded gold alloy veneers. J Prosthet Dent. 2000; 83:294-300
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A contemporary approach for the management of generalized tooth wear

From Volume 45, Issue 6, June 2018 | Pages 569-577

Authors

Mohammad Habib Aldashti

BDS, MFD RCSI

MClindent in Prosthodontics, Membership in Prosthodontics, RCS(Ed), Fellow, Implant Department, Loma Linda Dental School, 11092 Anderson St, Loma Linda, CA 92350, USA

Articles by Mohammad Habib Aldashti

Abstract

Abstract: This paper describes the treatment of a 39-year-old female patient with generalized tooth wear. The causes of the tooth wear were identified and controlled. Following diagnostic planning, a full mouth reconstruction at an increased vertical dimension utilizing a reorganized approach was carried out. Crown lengthening surgery was performed on the maxillary anterior teeth prior to the restorative phase. The restorative treatment included a combination of indirect and direct composite resin restorations and adhesive cast restorations. Very satisfactory functional and aesthetic outcomes were achieved.

CPD/Clinical Relevance: This paper demonstrates a practicable approach that can be applied for patients with tooth wear. The approach is conservative which eliminates the need for full coverage crowns to restore aesthetics and function.

Article

Mohammad Habib Aldashti

Section 1. Pre-treatment assessment

Patient details

  • Gender: Female;
  • Age at start of treatment: 39.
  • Initial referral

  • Referred to the teaching dental hospital by her general dental practitioner (GDP) for the management of generalized tooth wear.
  • Patient complaints

  • ‘My teeth are short and I have gummy smile’;
  • ‘Avoid smiling’;
  • ‘Worried about the progression of wear’;
  • Teeth slightly sensitive to hot and cold drinks.
  • History of presenting complaint

  • Patient aware of the tooth wear about 5 years ago;
  • Her teeth have been getting progressively worse;
  • Her consumption of an erosive diet is moderate;
  • She had a history of gastric acid reflux for 5 years, now controlled;
  • She gets moderate, short-lasting sensitivity from hot and cold drinks.
  • Relevant medical history

  • Fit and well.
  • Past dental history

  • Regular dental attendee;
  • Brushes her teeth twice daily;
  • Does not use mouthwash or floss;
  • Had multiple amalgam and composite restorations and endodontic treatment of UR1 by GDP.
  • Social history

  • Non-smoker;
  • 1–2 units of alcohol per month;
  • Work – Yoga teacher;
  • Lives with her partner.
  • Clinical examination: extra-oral features (Figure 1)

    Figure 1. Anterior view: smile.
  • No abnormalities detected in facial symmetry, muscles of mastication, lymph nodes, mandibular movements or temporomandibular joints;
  • Competent lips;
  • Class II skeletal base.
  • Smile assessment

  • High smile line;1
  • Maximum teeth display when smiling UR6–UL6;
  • No maxillary central incisal display at rest.
  • Clinical examination: intra-oral features

    Periodontal status

  • Basic Periodontal Examination:
  • Oral hygiene: Fair (plaque score (PS) – 25%; bleeding score (BS) – 31%);
  • Gingival biotype: Mixed gingival biotype and scalloped;
  • Attached gingiva: band of 3–5 mm.
  • Charted teeth present (Figure 2) General dental findings

    Figure 2. Charted teeth present.
  • Tooth wear
  • Multifactorial (mainly due to erosion and attrition).
  • Basic Erosive Wear Examination:2
  • Occlusal features

    Static occlusion

  • Class I incisal relationship;
  • Overbite = 0.5–1 mm;
  • Overjet = 1 mm;
  • Retruded contact position (RCP) noted at UR7–LR7;
  • Shim holds in ICP: all teeth.
  • Dynamic occlusion

  • Protrusive guidance:
  • Lateral excursions – group function on the right- and on the left-hand side;
  • Retruded contact position (RCP) to inter-cuspal position (ICP) slide of 1.5 mm horizontally and 1 mm vertically, RCP is between UR7 and LR7.
  • Right guidance: (group function) (Figure 3).
  • Left Guidance: (group function) (Figure 4).
  • Figure 3. Right lateral excursion.
    Figure 4. Left lateral excursion.

    Pre-treatment views – intra-oral (Figures 57) Other special investigations

    Figure 5. Anterior intra-oral view.
    Figure 6. (a) Right lateral intra-oral view. (b) Left lateral intra-oral view.
    Figure 7. (a) Maxillary occlusal view. (b) Mandibular occlusal view.

    Sensitivity tests: All teeth excluding (UR1) tested positive to Endo-lce and electrical pulp testing.

    Percussion test: None of the teeth was tender to percussion.

    Pre-treatment radiographic examination (Figure 8)

    Figure 8. Full mouth periapical radiographs.

    Relevant radiographic observations

    Root fillings

  • UR1 – well condensed and obturated;
  • Heavily restored posterior dentition.
  • Diagnosis

  • Localized plaque-induced gingivitis;
  • Generalized moderate/severe tooth surface loss (multi-factorial in nature, mainly due to erosion and attrition);
  • Dentine hypersensitivity;
  • Early enamel lesion LR5 and LR6;
  • Secondary caries UR6, UL5, UL6, UL7, LL4, LL6, LL7, LR6 and LR7.
  • Aims and objectives of treatment

  • Oral hygiene instruction (OHI) to improve plaque control;
  • Restore form, aesthetics and function;
  • Maintenance in conjunction with GDP.
  • Treatment plan

    1. Immediate

  • OHI.
  • Diet analysis.
  • Full mouth supra- and sub-gingival scaling.
  • Caries stabilization.
  • Articulated study casts in retruded axis position (RAP) and occlusal analysis.
  • Individual tooth assessment (core investigation).
  • Construction of maxillary hard occlusal splint.
  • Review and assessment.
  • 2. Transitional

  • Jaw registration in RAP.
  • Diagnostic wax-up.
  • Mock try-in of the diagnostic wax-up to assess aesthetics prior to crown lengthening surgery.
  • Planning for crown lengthening surgery.
  • Crown lengthening surgery from UR4 to UL5.
  • Post crown lengthening diagnostic wax-up and mock try-in.
  • 3. Reconstruction

  • Anterior composite resin restorations at an increased occlusal vertical dimension (OVD) as determined by the diagnostic wax-up.
  • Posterior stabilization with occlusal stops.
  • Posterior teeth preparation and cementation of provisional cuspal coverage restorations.
  • Assessment of provisional restorations.
  • Posterior definitive restorations comprising:
  • Adhesive gold onlays (All first and second molars);
  • Composite resin restoration (All premolars and third molars).
  • 4. Maintenance

  • Supportive periodontal therapy and review with patient's GDP.
  • Post-treatment maxillary hard occlusal splint.
  • Section 2. Treatment

    Key stages in treatment progress

    Immediate phase

  • Oral hygiene instruction and non-surgical periodontal treatment Instructions regarding oral hygiene were given to the patient to improve the level of oral hygiene. In addition, supragingival and subgingival debridement was performed. Throughout the course of treatment the patient's periodontal health was monitored.
  • Diet analysis The patient showed moderate consumption of an acidic and sugary diet. Advice was given to modify the dietary intake of acids and sugars.
  • Articulated study casts in RAP and occlusal analysis Pre-treatment study casts were obtained from primary alginate impressions for treatment planning, occlusal analysis and baseline record (Figure 9).
  • Caries stabilization Secondary caries removed and cavity restored with composite resin restoration on UR6, UL5, UL6, UL7, LL4, LL6, LL7, LR6 and LR7 (Figure 10)
  • Construction of maxillary splint A heat cured stabilization splint was fabricated and fitted.
  • Review and assessment Patient showed a significant improvement in her oral hygiene. In addition, both acidic and sugar content of her diet was reduced. All teeth showed good prognosis and restorability, re-assessment was positive (PS and BS <10%).
  • Figure 9. Mounted study casts at RAP.
    Figure 10. (a, b) Restoration of carious LR6 and LR7.

    Transitional phase

  • Post splint therapy jaw registration and diagnostic wax-up New impressions and registration of three interocclusal records in RAP were recorded. This was followed by pre-crown lengthening diagnostic wax-up and mock tooth try- in. The diagnostic wax-up was based on the aesthetics, function and phonetics need (Figure 11). Several parameters were used as a guide to establish the new working occlusal vertical dimension. These were: free-way space, amount of incisal display at rest, gingival outline display whilst smiling and the restorative space needed for posterior teeth (Figure 12).
  • Upper anterior crown lengthening surgery Circumferential crown lengthening surgery was planned and performed for the UR4 to UL5. A surgical guide based on the diagnostic wax-up was used to aid the CL surgery (Figure 13). Alveolar bone was removed to ensure a 3 mm distance between the bone and future restoration margins.
  • Review Soft tissue was assessed for healing up to 6 months post CL (Figure 14).
  • Post crown lengthening diagnostic wax-up and mock try-in Full diagnostic wax-up was completed followed by anterior mock tooth try-in (Figure 15).
  • Figure 11. Diagnostic wax-up.
    Figure 12. (a, b) Smile view without and with mock tooth try-in.
    Figure 13. (a, b) Crown lengthening surgery.
    Figure 14. Healing at 6 months post CL surgery.
    Figure 15. (a, b) Anterior intra-oral view with mock tooth try-in and at rest view.

    Reconstruction phase

    The maxillary anterior teeth (UR3 to UL3) were restored with a combination of indirect palatal composite resin veneers and direct labial composite resin build-up restorations (Figure 12). The mandibular anterior teeth (LR3 to LL3) were restored with direct composite resin with the aid of a clear silicone index (based on the diagnostic wax-up) (Figures 16-20).

    Figure 16. Rubber dam isolation from UR5 to UL5.
    Figure 17. Bonded palatal composite veneers.
    Figure 18. (a, b) UR1 is isolated and dentine composite resin layer is placed.
    Figure 19. Enamel layer is added.
    Figure 20. (a, b) Composite resin restoration of maxillary anterior teeth is completed.

    Following restoration of the anterior dentition, the posteriors were stabilized with resin-modified glass ionomer occlusal stops (Figure 21).

    Figure 21. (a, b) Posterior stabilization with occlusal stops.

    An impression was taken and wax-up was completed to proceed with the posterior reconstruction. All 1st and 2nd molars were restored to the established OVD with adhesive gold onlays (Figure 22).

    Figure 22. (a, b) Preparation and gold onlays restoration (UL6 and UL7).

    Following the completion of 1st and 2nd molars, definitive restorations, all premolars (Figure 23) and third molars were restored directly with composite resin with the aid of a clear silicone index of the diagnostic wax-up.

    Figure 23. (a, b) Composite resin restoration - LR4 and LR5.

    Maintenance

    Post-treatment a maxillary hard occlusal splint was fitted (Figure 24). The patient was then on supportive periodontal therapy and review with her GDP.

    Figure 24. Delivery of maxillary splint.

    Post-treatment views (Figures 2529)

    Figure 25. Anterior intra-oral view.
    Figure 26. Right lateral intra-oral view.
    Figure 27. Left lateral intra-oral view.
    Figure 28. (a, b) Maxillary occlusal view and mandibular occlusal view.
    Figure 29. (a, b) Anterior smile view pre-treatment and post-treatment.

    Discussion

    The patient presented with tooth wear affecting her anterior and posterior dentition. The tooth wear was moderate to severe and had affected the buccal and palatal surfaces of the anterior dentition and the occlusal surfaces of the posterior dentition. The patient was concerned with the appearance of her front teeth, gummy smile and the wear of her posterior teeth. She had suffered from acid reflux for some years and was treated medically by proton pump inhibitors.

    The objectives were to highlight and assist the patient in reducing the cariogenic/erosive dietary intake and optimize oral hygiene level. The aim was to restore the patient's dentition to a stable and functionally comfortable occlusion with a pleasing appearance. Informed consent was given by the patient to the proposed treatment.

    The generalized tooth wear seems to have been accompanied by dento-alveolar compensation. As a result of this, there was insufficient interocclusal space for restoring the worn down dentition. The lack of space anteriorly and the need for multiple posterior teeth restorations dictated that the case used a reorganized approach working in the retruded axis position (RAP) at an increased occlusal vertical dimension. A pre-operative hard maxillary occlusal splint was fabricated to assess the new planned occlusal vertical dimension and to achieve muscle relaxation to allow reproducible closing at retruded axis position. Jaw registration was carried out in RAP at increased vertical occlusal dimension post splint therapy. The working occlusal vertical dimension was established from the diagnostic wax-up and a mock try-in. In addition, a mock try-in was aimed to assess the aesthetics prior to crown lengthening surgery and phonetics.

    A crown lengthening procedure, including resective osseous surgery, was completed in order both to improve the gingival contour as well as gain sufficient coronal tooth structure for the build-up of the composite resin restorations. The surgery was guided by an acrylic stent fabricated from the diagnostic wax-up. A period of six months after surgery was allowed for the stability of the gingival margin prior to composite resin restoration.2

    The patient was treated in a conservative manner with predictable restorations in order to enhance both her oral function and aesthetics. A rim of enamel was present around the margins of all teeth, thereby improving the predictability of the bonding of the resin-based material to the tooth structure. The anterior teeth were restored with composite resin restorations, which are based on good survival time and provide a non-destructive option.4

    The posterior dentition was minimally prepared for restoration with adhesive cast gold onlays, which have been considered to have 89% survival probability at 60 months.3 Following the definitive phase of treatment the patient was given a post-operative occlusal maxillary splint to protect the restorations.

    A good prognosis can be expected if the oral hygiene level is kept optimal. The patient was advised of the necessity for a regular need for composite resin polish, repair and occasional replacement. At the conclusion of the treatment the patient was very pleased with the appearance and functionally comfortable.