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Restorative management of worn dentition (PART 1)- AETIOLOGY

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WORN DENTITION MANAGEMENT

WORN DENTITION MANAGEMENT

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  • 1. POSTGRADUATE DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS SEMINAR TOPIC:- RESTORATIVE MANAGEMENT OF WORN DENTITION - I (AETIOLOGY ) Presented by-Ashish Choudhary PG student UNDER GUIDANCE OF :- Prof. Dr Riyaz Farooq (HOD) Dr Aamir Rashid (Asst. Prof.) Dr Fayaz Ahmed (lecturer)
  • 2. “ Rehabilitation of dentition is not all about restoring the mouth with 28 crowns or an aesthetic smile ” “Itz about Cosmetic Functional Oral Rehabilitation”
  • 3. CONTENTS • Introduction • Abrasion • Abfraction • Attrition • Bruxism • Erosion • Combined Mechanisms • Severity of wear • Diagnosis of tooth wear • Role of wear in occlusion • Restoration of worn dentition • Rehabilitation of worn dentition
  • 4. INTRODUCTION The term ‘tooth wear’ (TW) is a general term that can be used to describe the surface loss of dental hard tissues from causes other than dental caries, trauma or as a result of developmental disorders (Hattab F, Yassin O) Int J Prosthodont 2000; 13: 101–107  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 5. It is a normal physiological process that is macroscopically irreversible and is cumulative with age Lambrechts et al. in 1989 estimated the normal vertical loss of enamel from physiological wear to be approximately 20-38 μm per annum J Dent Res 1989; 68: 1752–1754  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 6. Tooth wear’s multi-factorial aetiology ABRASION ABFRACTION ATTRITION EROSION Clinically however, it is difficult (if not at times impossible) to isolate a single aetiological factor when a patient presents with tooth wear  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 7. A growing challenge in dentistry It therefore implies continuous monitoring to control related pathologies Quintessence Int 2003;34:435-446 J Oral Rehabil 2008;35:476-494  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 8. Multifactorial preventive & Restorative approach  involve different specialties,  starting with preventive measures &  ending up with full-mouth rehabilitation  adhesive and partial restorations for intermediate stages THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 6 • NUMBER 1 • SPRING 2011  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 9. Aspects which compound difficulties associated with tooth wear management include: • Deriving an accurate diagnosis !! • When to implement active restorative intervention?? • How to restore such severely worn dentitions, with the aim of ultimately attaining a functionally and aesthetically stable restored dentition?? •A lack of knowledge relating to the availability of contemporary materials and their respective techniques of application!!! BDJ;2012 ; VOLUME 212 NO. 1  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 10. A modern approach to the treatment of tooth wear is to prevent the progression of this disease before a full prosthetic rehabilitation would be needed Such a treatment approach would become totally ineffective because of potential biological complications and inadequate biomechanical rationale J Prosthet Dent 2003;90:31-41  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 11. A modern treatment model involves three steps: 1) Comprehensive etiological clinical investigation 2) Treatment planning and execution 3) Maintenance THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 6 • NUMBER 1 • SPRING 2011  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 12. RESTORATIVE OPTIONS •Conventional fixed restorations •Removable onlay/overlay prosthesis •Minimal preparation adhesive restorations Tooth wear and sensitivity-clinical advances in restorative dentistry; Martin Dunitz  Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 13. AETIOLOGY ABRASION  derived from the Latin word abrasum (to scrape off)  can be defined as the surface loss of tooth structure resulting from direct frictional forces between the teeth and external objects or from frictional forces between contacting components in the presence of an abrasive medium (Marzouk ) Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 14. Hard Toothbrush Abrasive Toothpaste Intensive Horizontal brushing technique “well-defined, V-shaped notches” in the cervical regions of one or more facial tooth surface Location of the abrasion (three-body wear) lesions depends on tooth alignment and/or which hand is holding the toothbrush Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 15.  In case of toothpaste abuse, the anatomical detail of the affected surfaces is faded with a sandblasted appearance  When the enamel wears through to the dentine, cupping or cratering will form Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 16. Occupational/Oral Habits causing Abrasion : Depression abrasion Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 17. Location and pattern of abrasion may be related to the cause : Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 18. Classification: (Vimal Sikri) a) Notch N / V shaped  Oblique occlusal and cervical walls meet at certain depth.  No definite axial wall. b) C shaped defect (C)  Cross section C shaped with rounded floors c) Undercut concave (UC)  Occlusal & cervical walls intersect with definite axial wall d) Divergent box (DB)  Axial wall present  Occlusal and cervical walls diverge Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 19. 1) Shallow (S): 0.1 - 0.5 mm in depth 2) Deep (D): More than 0.5mm. but no pulp exposure 3) Exposure (E): Pulp is exposed  Premolars > Canines > Maxillary first molars  Lingual surfaces are rarely affected  Localized lesions may be present on teeth or tooth placed facial to the remaining dental arch Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 20.  Initially may be linear lesion  As lesion progresses, peripheries become more angularly demarcated from adjoining areas  Extremely smooth & polished surface of lesion  Sometimes surface may exhibit scratches in it  Surrounding walls tend to make a V shape  Probing or application of heat, cold or sweets can elicit pain.  Intermittent in character  In slowly progressive defects, reparative dentin formation occurs over a period of time making them asymptomatic Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 21. Diagnose the cause of presented abrasion Treat the cause: Habit : Break the habit Iatrogenic : correct it If the habit cannot be broken , the Restorative treatment can by-pass the effect of habit Desensitization by F-solution (NaP/SnF 8- 30% for 4-8 min) or iontophoresis. Restorative treatment Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 22. Restorative protocol ABRASION Anterior tooth or Facially conspicuous area of posterior tooth Inconspicuous area in posterior tooth Adhesive tooth coloured materials Metallic restoration (but if cavity preparation would compromise the PD organ vitality) Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 23. Surgical retraction for restoration of non carious cervical lesion -  By doing miniflap surgical retraction, it provides access to the subgingival lesions.  Small vertical incisions are made on the mesial & distal to the lesion and not involving the papilla The incision should be made such a way that it should not extend to the mucogingival junction Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 24. Noncarious Cervical Lesions: graft or restore When to graft:  No attached gingiva  No enamel defect  Class I or II recession i.e. there is no loss of interdental bone or soft tissue  Papilla length and fullness are adequate  Esthetics is important Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 25. When to restore:  Adequate attached gingiva  Defect is mainly in enamel  Lesion is deeper than 2 mm horizontally  Class III recession i.e. there is some loss of interdental bone height or soft tissue fullness, making complete root coverage not possible  Esthetics is not of primary importance Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 26. When to graft and restore:  No attached gingiva  Defect in the enamel only  Recession is significant (more or equal 2mm)  Papilla length and fullness are inadequate  Esthetics is important Introduction  Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 27.  Concept of “stress induced cervical lesion”  derived from Latin words ab – away, plus “fractio” – breaking  Synonyms : Idiopathic cervical erosion (Grippo) Abfraction is the microstructural loss of tooth substance in areas of stress concentration (JADA2004) Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 28. Abfractions are described as “ wedge shaped defects” in the cervical region of the tooth  Loss of tooth structure resulting from repeated tooth (enamel & dentin) flexure produced by occlusal stresses Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 29.  Occurs most commonly in the cervical region of teeth, where flexure may lead to a breaking away of the extremely thin layer of enamel rods, as well as microfracture of cementum & dentin  These lesions, frequently have a crescent form along the cervical line, where this brittle and fragile enamel layer exists Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 30. Mechanism of Formation of Abfraction Lesion: Compressive forces Tensile forces Kornfeld indicated that the cervical surface lesions tended to occur on the part ofthe tooth opposing the side that had developed an occlusal wearfacet caused by attrition Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 31. Characteristics of Abfraction Lesion:  Wedge-shaped defects limited to cervical area  Deep, narrow, V-shaped  Single tooth or Sometimes subgingival  More common in mandibular dentition and among those with bruxism, hyper or malocclusion Rate of progression : 1 m per day (Xhonga et al) Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 32. How it is different from Abrasion????  A single tooth (but not adjacent teeth) is affected  The deep, narrow, “V-shaped notch” does not allow the toothbrush to contact the base of the defect  Gingivitis is present
  • 33. ENAMEL DENTIN  Hairline cracks  Striations / molecular slip planes” or “Lines of Luder”  Saucer shaped  Semilunar shaped  Cusps tip invagination  Gingival - “McCoy notches”  Circumferential  Multiple  Sub-gingival  Lingual  Interproximal  Alternate  Angular  Crown margin  Restoration margin Jol. Esthetic Dentistry Vol. No. 3, No. 1 ; 1991 (McCoy )
  • 34. Treat the cause before restoring Occlusal loading on the tooth can be tested in centric occlusion and in excursive movements with occlusal marking paper RESTORATIVE TREATMENT Introduction Abrasion  Abfraction Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 35.  derived from the ‘Latin’ word attritum  Surface tooth structure loss resulting from direct frictional forces between contacting teeth (Marzouk)  Attrition is mechanical wear of the incisal or occlusal surface as a result of functional or parafunctional movements of mandible (Sturdevant) Prevalence of Attrition : 13% to 98%. Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 36.  Attrition process begins from the time it erupts in the mouth and makes contact with reciprocating tooth surface  While a certain amount of attrition is physiologic, excessive destruction of tooth structure is not physiologic Occlusal wear that renders itself vulnerable even to normal function loading cannot be regarded as normal If occlusal wear occurs at a rate faster than compensatory physiologic mechanisms, this is not physiologic (Russel) Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 37.  Multifactorial etiology with age  Canine guidance having significant influence  Other Factors:  Para functional habits such as bruxism & clenching  Crowding  Occlusal slides  Cross bites  Chewing habits and Diet ATTRITION  Continuing and Slow process (vertical loss of enamel rarely exceeds 50 m / year) Dental attrition has been used in archaeology and forensic sciences to estimate human age Teeth continue to erupt in adulthood even in the absence of masticatory function and concomitant attrition (Newman) Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 38. Widening of the proximal contact area Surface area Susceptible to decay Proximal surface attrition (proximal surface faceting) M-D dimension decreases Drifting of teeth Decrease Arch length Altered Occlusion ↓ Embrasure space Alteration of physiology of interdental papilla Difficult plaque control Periodontitis Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 39. Occluding surface attrition Flattening/Faceting of occluding elements In severe cases, dentine wears faster than enamel leaving “scooped area” surrounded by peripheral rim of enamel Reverse cusping If the wear is severe, generalized & accomplished in a relatively short time Vertical loss might be imparted on the face as a Loss of Vertical Dimension Strain in stomato gnathic system If attrition over a longer period of time vertical dimension loss will be confined to the teeth but not imparted to the face
  • 40. Consequences of tooth wear  Deficient masticatory capabilities of the teeth  Cheek biting (cotton roll cheeks)  Gingival irritation  Decay  Tooth sensitivity  Interfering / deflecting points  Predominantly horizontal masticatory movement / TMJ problems Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 41. (modified from Richards and Brown) Attrition index: o - No wear 1- Minimal wear 2 - Noticable flattening , parallel to the occluding planes 3 - Flattening of cusps / grooves 4 - Total loss of contour / dentin exposure Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 42. SMITH AND KNIGHT 1984TOOTH WEAR INDEX: Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 43.  Diminished vermillion borders and drooping commisures  Wear facets with sharply defined line angles  Restorations that wear at same rates as adjacent enamel  Asymptomatic teeth usually  History of parafunctional habits Loss of posterior teeth Traumatic Anterior Occlusion * Role of Occlusal prematurities Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 44. TREATMENT MODALITIES  Depends on the degree of Attrition: MILD MODERATE SEVERE  If surface attrition Slower  Intrapulpal dentin deposition Faster  Pulpal exposures
  • 45. In case of mild-moderate Attrition MONITORING PHASE 1. Periodically Checkup 2. Instructions for oral hygiene 3. FLUORIDE application 4. Hard plastic interocclusal device Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 46. BUT if its severe!!! 1. Endodontic therapy or Extraction, (in case of pulpally involved teeth) 2. Disocluding-protecting occlusal splints (to control parafunctional activities) 3. DIAGNOSE & RESOLVE Myofunctional, TMJ, or any other symptoms in the stomatognathic system 4. Occlusal equilibration (Selective grinding, coinciding RCP with ICP)  During the last three procedures  Use of Fluorides  Use of Temporary Restorations  Evaluation of PERIODONTAL health (fortunately favourable) Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 47. RESTORATIVE OPTIONS (ONLY METALLIC!!!!!) That too WHEN…….  Noticeable loss of vertical dimension that has not been compensated  Extensive loss of tooth structure (localized or generalized)  Reshaping not effective!!  Superimposed decay  Concern over proper maintainence of Periodontium  Cracked or Endodontically treated Introduction Abrasion Abfraction  Attrition Bruxism Erosion Combined mechanisms Severity of wear
  • 48.  OCCLUSAL PARAFUNCTIONAL HABIT May be: Sleep bruxism or Awake bruxism  It is defined as the grinding of teeth during non functional movements of the masticatory system: it is a mandibular parafunction Mechanical wear resulting from bruxism often results in progressively greater wear towards the anterior teeth ( with open bite as exception) Introduction Abrasion Abfraction Attrition  Bruxism Erosion Combined mechanisms Severity of wear
  • 49. 2 Aetiological Models : Introduction Abrasion Abfraction Attrition  Bruxism Erosion Combined mechanisms Severity of wear STRUCTURAL FUNCTIONAL  Occlusal Interferences  Altered maxillo-mandibular relationships  STRESS  Children Brux Bruxism produces surface loss, which is related to the duration and force & frequency of parafunction
  • 50. • Grooving of lateral borders of tongue • Cheek biting • Fractured porcelain restorations •Cupping or cratering of occlusal surface •Teeth grinding or clenching •Teeth are worn down, flattened or chipped •Increased tooth sensitivity •Jaw pain or tightness in jaw muscles •Earache •Dull morning headache •Chronic facial pain Introduction Abrasion Abfraction Attrition  Bruxism Erosion Combined mechanisms Severity of wear
  • 51.  No accepted cure as yet  wearing of a full-width acrylic NIGHT GUARD  Occlusal therapy should only be carried out after successful stabilization splint usage, and careful 'mock' equilibration on accurately mounted study models IMPORTANCE OF USING INTRERMITTENT SPLINTS
  • 52.  derived from latin verb erosum ( to corrode) EROSION  defined as loss of tooth structure resulting from chemico mechanical acts in the absence of specific microorganisms (Marzouk) “If it is not abrasion or attrition, it must be erosion” Introduction Abrasion Abfraction Attrition Bruxism  Erosion Combined mechanisms Severity of wear
  • 53. THE CULPRITS BEHIND DENTAL EROSIONS….. SOFT DRINKS BULIMIA NERVOSA
  • 54. wine-tastersASPRIN Lemon suckingCOKE SWISHING
  • 55. HIATUS HERNIA RUMINATION + GERD OTHERS: diabetes, high blood pressure, cerebral palsy, salivary gland agenesis, Sj¨ogren’s and Down syndromes, and drug abuse GERD (Gastroesophageal reflux disease)
  • 56. Polished / Melted appearance Maxillary palatal surface involvement common Cervical shoulder formation “Inverted V-sign” (with unaffected mandibular anteriors)
  • 57. Inactive sitesActive erosion sites “ski slope” like depressions Proud amalgam
  • 58. CUPPING (depending on severity) Pulp visible through dentin (in severe cases)
  • 59. Classification of dental erosion Grade 1 Early erosion, Early stage loss of enamel structures minimal loss of enamel only just measurable Dull surface appearance (active) Smooth/shiny (chronic) Grade 2  Erosion in enamel  Obvious loss of enamel, dentin not exposed
  • 60. Grade 3  Erosion in dentin  Localized lesions involving dentin for less than one third of the surface Grade 4  1/3-2/3 rd of tooth surface has exposed dentin Grade 5  more than 2/3 rd of tooth surface has exposed dentin and/or the pulp is exposed
  • 61. Management of EROSION Treatment of aetiology Preventive measures RESTORATIVE options  Complete analysis of diet, occlusion, habits, environmental factors  Every attempt to correlate to a cause  Try to eliminate the probable cause  Diagnostic modalities  Patient education  Counseling  Physcian consultation  Use of sugarless chewing gum  Pilocarpine  Do not rush to restore  Observe the progression of lesion (WATCH strategy) 1. Diminish the frequency and severity of the acid challenge 2. Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation) 3. Enhance acid resistance, remineralization and rehardening of the tooth surfaces 4. Improve chemical protection 5. Decrease abrasive forces 6. Provide mechanical protection 7. Monitor stability  Desensitisation by using fluoride rinses, gels, and varnishes as well as high-fluoride toothpastes and remineralizing toothpastes  Tooth coloured filling material  FULL COVERAGE RESTORATIONS  Endodontic intervention, if required  FULL MOUTH REHABILITATION
  • 62. COMBINED MECHANISMS OF TOOTH WEAR Attrition-abfraction: joint action of stress and friction when teeth are in tooth-to-tooth contact Abrasion-abfraction: loss of tooth substance caused by friction from an external material on an area in which stress concentration due to loading forces may cause tooth substance to break away Toothwear: ABC of the worn dentition; 1st ed Introduction Abrasion Abfraction Attrition Bruxism Erosion  Combined mechanisms Severity of wear
  • 63. Corrosion-abfraction: loss of tooth substance due to the synergistic action of a chemical corrodent on areas of stress concentration Attrition-corrosion: loss of tooth substance due to the action of a corrodent in areas in which tooth-to-tooth wear occurs. This process may lead to a loss of vertical dimension, especially in patients with GERD or gastric regurgitation Abrasion-corrosion: synergistic activity of corrosion and friction from an external material. This could occur from the frictional effects of a toothbrush on the superficially softened surface of a tooth that has been demineralized by a corrosive agent Toothwear: ABC of the worn dentition; 1st ed Introduction Abrasion Abfraction Attrition Bruxism Erosion  Combined mechanisms Severity of wear
  • 64. Biocorrosion (caries)-abfraction: pathological loss of tooth structure associated with the caries process, where an area is micromechanically and physicochemically breaking away due to stress concentration.  A common site for this synergistic activity is the cervical area of the tooth, where it may be manifested as root or radicular caries. Articulating paper markings indicate eccentric loading, which induced stress concentration in the cervical region (abfraction) and may have exacerbated the caries (biocorrosion). Toothwear: ABC of the worn dentition; 1st ed
  • 65. MULTIFACTORIAL NATURE OF TOOTHWEAR Toothwear: ABC of the worn dentition; 1st ed Introduction Abrasion Abfraction Attrition Bruxism Erosion  Combined mechanisms Severity of wear
  • 66. MULTIFACTORIAL NATURE OF TOOTHWEAR Toothwear: ABC of the worn dentition; 1st ed Introduction Abrasion Abfraction Attrition Bruxism Erosion  Combined mechanisms Severity of wear
  • 67. SEVERITY OF TOOTH WEAR Tooth Wear Index by Smith & Knight  Received criticism BDJ; VOL-212; NO.1;2012 Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms  Severity of wear
  • 68. BEWE (Basic Erosive Wear Examination) (Bartlett ;2010)  Scale from 0 to 3 for each sextant 0 (no wear), 1 (initial loss of surface texture), 2 (less than 50% loss of surface) and 3 (greater than 50% loss of surface)  Tooth most severely affected in a particular sextant is the one for which the score is based on  On completion of the BEWE, an aggregate score is reached for all sextants  The latter score can be used as a guide to the clinical management of the patient concerned  However, further studies are needed BDJ; VOL-212; NO.1;2012 Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms  Severity of wear
  • 69. BDJ; VOL-212; NO.1;2012 THE ACE Classification (Vialati & Bresler)
  • 70. STAGES OF TOOTH WEAR (Khan et al & Young) Toothwear: ABC of the worn dentition; 1st ed Introduction Abrasion Abfraction Attrition Bruxism Erosion Combined mechanisms  Severity of wear

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