Tooth wear final

ToothWear
MohammedAldosari
ID: 421100905

Outline:
■ Introduction
■ Types and Etiology
■ Management and Prevention
■ Restorative and ProstheticTreatment
Mohammed Aldosari, DMD

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.
1. Hattab F,Yassin O. Etiology and diagnosis of tooth wear: a literature review and presentation of selected cases. IntJ Prosthodont
2000; 13: 101–107.
2. Lambrechts P, Braem M,Vuylsteke-Wauters M, et al: Quantitative in vivo wear of human enamel. J Dent Res 1989;68:1752-1754

Types ofTooth 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.

Types ofTooth 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
1. Glossary of ProsthodonticTerms, ed 7. J Prosthet Dent 1999;81:48
2. Braem M, Lambrechts P,Vanherle G. Stress induced cervical lesions. J Prosthet Dent 1992; 67: 718–722.

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. IntJ Prosthodont 2000; 13:
101–107.
3- Illustrated Dental Embryology, Histology, andAnatomy, Bath-Balogh and Fehrenbach, Elsevier, 2011, page 64

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

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.

Category 1: Excessive wear with loss ofVDO
■ 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.

Category 2: excessive wear without loss ofVDO
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

Category 3: Excessive wear without loss ofVDO
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

TREATMENT PLANNING FOR CASES OF
TSL
■ Treatment planning for casesTSL 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.

■ The next stage is prevention.
■ Next phase would be the definitive dental
restorations.
■ The final stage involves monitoring and maintenance.

■ 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.

■ 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.

■ 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.

■ 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.

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.

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.

RESTORATIVE
&
PROSTHETIC
TREATMENT

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.

LOCALISED MAXILLARYANTERIOR
TOOTHWEAR
■ 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.

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)

■ 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

■ 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

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.

■ 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%).

■ 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.

■ 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.

■ 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.

LOCALISEDANTERIOR MANDIBULAR
TOOTHWEAR
■ 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.

■ 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.

LOCALISED POSTERIORWEAR
■ The 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 orTMJ 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

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 byTurner 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.

■ 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.
■ The 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).

■ 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

RESTORATIVETECHNIQUES - 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.

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.

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

■ Adhesive 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

CATEGORY 1 PATIENTS:
‘EXCESSIVETOOTH WEAR,TOGETHER
WITH A LOSS INTHE 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

■ 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)

CATEGORY 2: ‘EXCESSIVEWEARWITHOUT
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.

■ 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.

■ 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).

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.

RESTORATIVE MATERIALS/ RESTORATIONS
COMMONLY USED INTHE 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.

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