3.treatment planning restorative management of worn dentition (2)

POSTGRADUATE DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS

SEMINAR TOPIC:-

RESTORATIVE MANAGEMENT OF WORN DENTITION - III

(TREATMENT PLANNING)

Presenter- Ashish ChoudharyPG student

UNDER GUIDANCE OF :-

Prof. Dr Riyaz Farooq (HOD)Dr Aamir Rashid (Asst. Prof.)Dr Fayaz Ahmed (lecturer)

RESTORATION OF WORN DENTITION-I(Aetiology)

CONTENTS

• Introduction• Abrasion• Abfraction• Attrition• Bruxism• Erosion• Combined Mechanisms• Severity of wear

CONTENTS

PATIENT’S HISTORY

EXAMINATION OF WEAR’s PATIENT

DIAGNOSIS

MEASUREMENT OF SEVERITY & PROGRESSION OF WEAR

DILEMA OF OCCLUSION

RESTORATION OF WORN DENTITION-II(Assesment & Role of Occlusion in tooth wear)

MOUNTING CAST (Inter-occlusal Records, Articulators and Facebow Transfer)

PROBLEM OF SPACES (Increasing Vertical Dimension)

RESTORATION OF WORN DENTITION (Restorative Options)

REHABILITATION OF WORN DENTITION (Localized Anterior & Posterior Wear and Generalized Toothwear management Including Case Studies)

RESTORATION OF WORN DENTITION-III( Treatment Planning)

CONTENTS

MAINTENANCE PHASE

CONCLUSION

REFERENCES

RESTORATION OF WORN DENTITION-III( Treatment Planning)

CONTENTS

MOUNTING CASTPROBLEM OF SPACESRESTORATIONREHABILITATIONMAINTENANCECONCLUSION

MOUNTING CAST

INTER-OCCLUSAL RECORDS :

relate the mandibular and maxillary diagnostic and working casts

Extra hard base plate wax is suitable.

Other materials include zinc oxide and eugenol paste,elastomers and impression plaster.

Dent Update 2003; 30: 150-157

THE TECHNIQUES……..

1. Waxbite Procedures

2. Anterior Stop Technique

3. Use Of Pre-adapted Bases

4. Central Bearing Point Device

Dent Update 2003; 30: 150-157

Softened interocclusalwax record

Buccal cusps visible on record

Record relined with temporary cement

Rigid, stable, accurate record

Acrylic base with wax rims

located with zinc oxide and eugenol paste

# Gimmicks don’t do your work but certainly make your work easier….

MOUNTING CAST

ARTICULATORS :

“A mechanical instrument thatrepresents the temporomandibular jointsand jaws, to which maxillary andmandibular casts may be attached tosimulate some or all mandibularmovements”

Glossary Of Prosthodontic Terms

TYPES OF ARTICULATORS…..

Articulator Design….

Arcon - condylar element on lower

Non Arcon - condylarelement on upper

DETERMINANTS OFOCCLUSION

Posterior

1) Right TMJ2) Left TMJ

Anterior1) Anterior Teeth

Posterior Determinants of Occlusion

Condylar guidance isa fixed factor, andthe TMJs are theposterior controllingfactor in mandibularmovement.

Posterior Determinants

1) Right TMJ2) Left TMJ

Anterior Determinants of Occlusion

The anterior teeth:

Determine the movement of the anterior portion of the mandible.

Anterior guidance is variable since it can be altered by: restorations, extractions, orthodontics, attrition, etc.

Programming The Articulator

(Hanau Modular Arcon Articulator)

POSTERIOR ARTICULATOR GUIDES

• Horizontal Condylar Guide

– Angle of Condyle descent

• Protrusive Wax Record

• Bite Registration Materials

• Bennett Angle (there may or may not be associated Bennett Movement or Side Shift with lat. Mandibular Movement)

– Associated with Mediotrusiveside during Laterotrusivemovement

• Lateral Wax Check Bites

• Pre-programmed In Your Articulator

ANTERIOR GUIDE TABLE

• Maintain the relationship between casts – Protecting the cast from wear

• Uses of articulated casts– Evaluation of occlusion– Evaluation of tooth position– Evaluation of tooth form– Evaluation of gingival tissues– Fabrication of indirect restorations

Purpose of Guide Table

WHAT ABOUT THIS ?????

Programming the condylarguidance

Horizontal condylar guidanceUse protrusive record (protrude mandible 6mm)

Lateral condylar guidanceUse lateral record or Hanau’s Formula (H/8 +12)

Programing the incisalguidanceHorizontal guidance controls the anteroposterior movement of the lower jaw

Lateral guidance influence lateral movement of the jaw (canine guidance)

CAST ORIENTATION

• Hinge Axis is a repeatable reference

• For the highest possible accuracy cast should be mounted as close to this axis of rotation as possible.

CAST ORIENTATION:Centric Relation vs. Maximum

Intercuspation

If the patient is asymptomatic, and has asufficient number of teeth to consistently closeinto maximum intercuspation, then maximumintercuspation should be used for castorientation.

CAST ORIENTATION

• To Orient the Maxillary Cast – Facebow

• To Orient the Mandibular Cast- Interocclusal record

MOUNTING CAST

MOUNTING CASTPROBLEM OF SPACESRESTORATIONREHABILITATIONMAINTENANCECONCLUSIONFACEBOW TRANSFER :

“A facebow is a caliper-like device that is usedto record the relationship of the jaws to the TMJand to orient the same relationshipto the opening axis of the articulator”.

Glossary Of Prosthodontic Terms

2 types of facebows are :

1) Kinematic facebow or

Hinge-axis facebow

2) Arbitary facebow

To record patient’s hinge axis

The Arbitrary Hinge Axis is adequate for most clinical procedures

It is located 13 mm from the tip of the tragus ofthe ear on a line joining this point to the outercanthus of the eye.

To record 3rd reference pointsome facebows use the infra-orbitalnotch and others have a plastic‘nose piece’ that rests on the bridgeof the nose during the recording

Finger cots can be used as a infection control measure.

Orient in external auditory meatus

Patient can assist with placement and orientation in external auditory meatus

Slide facebowinto bitefork

Extend nasionsupport & tighten

Tighten all wrenches of facebow

Loosen these tighteners. Release the recordbase by breaking the seal, and removing the facebow.

Place facebowsupport on transfer jig and attach to indirect mount

Remove incisal pin and set the centric latch

Attach the maxillary cast to the articulator via plaster

Mandibular Cast Orientation

• Hand articulation when patient has sufficient number of teeth to place casts into MI

• Interocclusal records• -Bimanual manipulation

• -With insufficient number of teeth to establish a reproducible relationship

ARTICULATED MANDIBULAR CAST

Clean Up as you go

SET THECONDYLARINCLINATION(WITH THE HELP OFCHECK BITES)

SET THE ANTERIORGUIDANCE

PROBLEM OF SPACES(INCREASING VERTICAL DIMENSIONS)

The vertical dimension of occlusion refers to the vertical positionof the mandible in relation to the maxilla when the upper &lower teeth are intercuspated at the most closed position

Mandible goes repetitiously to the position dictated by thecontracted elevator muscles

Vertical position of each tooth is adaptable to the spaceprovided, not vice versa, & that the capacity of the teeth to eruptor intrude is present throughout life

2 important aspects of vertical dimension :

Dawson PE. Evaluation, Diagnosis & Treatment of Occlusal Problems;2nd ed; St Louis: Mosby; 1989; 56-71

The fact that a patient has severely abradedtheir teeth does not indicate a loss of VDO nordoes it indicate that they have not loss verticaldimension

In treatment planning the critical issue is whether a patientcan be restored at a different vertical dimension that is stillwithin the adaptive range & whether the patient will accept thetherapeutic occlusion created

Charles McNeill. Science & Practice of Occlusion

Assessing the existing Vertical Dimension

Posterior teeth :

If posterior teeth in both arches haveunworn occlusal surfaces & normal axialinclinations that oppose each other inocclusion, it would be very difficult for thepatient to have lost vertical dimension

Assessing the existing Vertical Dimension

Gingivalevels:

in a patient who exhibits severe anterior wear& subsequent eruption of anterior teeth withoutposterior wear or vertical closure, the gingivalmargins on the central & lateral incisors areoften significantly coronal to the canines, whichis evidence that these teeth have erupted

DETERMINING VERTICAL DIMENSION

Niswoger’s method

Willis method

Use of electronics to monitor muscle function ( oscilloscope )

use of phonetics (sibilant or ‘s’ sound ) / concept of closest speaking space

Provisionals followed by speech evaluation

Trial splints

STABILITY OF VERTICAL DIMENSION

AN AREA OF CONCERN

1. THE DIMENSION OF ANTERIOR TEETH

2. THE LENGTH OF THE MASSETER MUSCLE

3. THE DIMENSION OF THE TEMPEROMANDIBULAR JOINT

The key to understanding the stability of verticalalterations is to determine if the change increases thecontracted muscle length

STABILITY OF VERTICAL DIMENSION

Because the joint & the muscle are very closetogether , seating the condyle 1mm results innearly a 1mm decrease in contracted musclelength This means that if the patient presents with slide from CR toICP, one can calculate how far the anterior teeth can beopened with no change in contracted muscle length bydetermining how far the condyle moves superiorly whenplaced in centric relation

According to McNeil, for every 1mm of condylar seating (by

using SAM Mandibular Position indicator) , it is possible to open theanterior teeth 2mm

An Appraisal on Increasing the Occlusal Vertical Dimension (OVD)*

ESTABLISMENT OF OVD / LOSS OF OVD WITH TOOTH WEAR

Dawson, Thompson stated that loss of VD is compensated bytooth eruption, alveolar bone expansion & muscle action

After loss or alteration of OVD, muscles tend to restore OVD toits original level by tooth intrusion or extrusion(FUNCTIONAL MATRIX THEORY)

OVD is preserved by the adaptive mechanism of stomatognathicsystem. So the term ‘to restore lost OVD’ is a misnomer and anysuch attempt will be actually ‘bite raising’ resulting in increasedOVD *J Indian Prosthodont Soc ;2011 11(2):77–81

Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis

J Am Dent Assoc 33:151

CONSTANT VERTICAL DIMENSION

VDR and OVD are changeable and adaptableto certain extent

Atwood stated that VDR remains constant even following lossof tooth contacts

The establishment of position and length of muscle aftermandibular osteotomy surgery substantiates the position ofinconstant OVD

Hellsing study on adaptability of the stomatognathic systemfor temporary increase in the OVD by splints in TMJ disordersconfirms this belief

J Prosthet Dent 8:698

J Prosthet Dent 52:867–870

MAXIMUM MASTICATORY FORCE

Boos stated that optimum masticatory force occurs in OVD

But Manns stated that high masticatory force is exerted at 7 mm mouth opening followed by a decrease in biting force between 7 and 15 mm and maximum force at 15 to 20 mm mouth opening

J Am Dent Assoc 27:1193–1199

Encroaching Into Freeway Space

Increasing OVD and encroaching thefreeway space is detrimental and is considered to resultin elongation and increased activity of stomatognathicmuscles

Thus increasing OVD up to VDR can be advantageousin relieving symptoms in TMJ and muscle disorders

Weinberg’s , Herbert proved that there is minimal muscleactivity in VDR and encroaching into freeway results inreduced muscle activity

J Prosthet Dent 47:290 J Prosthet Dent 14:635

Decreased OVD: Costen Syndrome

Costen concluded through clinical observations thatdecreasing OVD resulted in condylar displacement posteriorlycausing compression of chorda tympani, auriculotemporalnerves and eustachian tubes

Beyron contradicted deliberation and proved thatcondyles are not displaced posteriorly by decrease in OVD

Ann Otol Rhinol Laryngol 43:1

J Am Dental Asssoc 48:648–656

Factors Indicating Loss of OVD

Decreased crown height and deep anteriorover bite

Hence these two factors cannot be considered as valuablefactors indicating loss of OVD

Increased overbite may also be because of continuousteeth eruption and over closure

Attrition can cause short crowns in spite of continuouseruption of tooth

EXACT LOCATION OF OVD

Warren stated that OVD, like any otherquantifiable aspect of the body functions such as BP,pulse, etc., is a highly variable entity and the exactrestoration of OVD is near impracticable

MUSCULAR DYSFUNCTION

Manns et al. , Kovaleski showed that increase in OVD bysplint therapy up to VDR reduces muscle activity and relievessymptoms of muscle dysfunction syndromes

J Prosthet Dent 50:700–709 J Prosthet Dent 33:321–327

‘Unloading’ of Condyles

Dawson , Weinberg stated that bite raisingincreases the OVD, not by displacing thecondyle away from the eminence, but rather by rotating thecondyle, hence TMJ remains ‘loaded’ during bite raising

Condylar Access to Centric

Dawson stated that as far as the starting point of centricrelation is maintained during bite raising, condylar access tothis position is not disturbed

Evaluation, diagnosis and treatment of occlusal problems, 2 edn. Mosby, St. Louis

Comfortable Jaw Position

Tryde et al. revealed that its not a comfort zone and had an interval of 1.3 mm on average around VDO

Any discomfort in this position can be due to centricdiscrepancy or TMJ disorder or bruxism

In these conditions, comfort can be achieved by correction ofthe disorder or by OVD alteration

With adequate evidence available currently from variousstudieS, the comfort zone can be proved to be wide of the mark

J Oral Rehabil 4:9–15

Bite Raising in Full Occlusal Rehabilitation

From the critical reviewing, it is ascertained that restoringOVD to original level rather than increasing is needed andpatient’s response should be tested during each stage ofincrease in OVD

J Indian Prosthodont Soc ;2011 11(2):77–81

By exploring the various controversies andmyths regarding vertical dimension and itsalteration, discarding the erroneous beliefs andaccepting the essentials, two logical hypothesescan be arrived, they are:

(1) OVD is not altered following tooth wear (except in case of amelogenesis / dentinogenesis imperfecta)Any method to restore OVD will result in increased OVD

(2) Free way space can be manipulated and new VDR will get established if OVD is not increased beyond pre-existing rest position

“OVD is almost always preserved”

Effects of Increasing Vertical Dimension

When OVD is increased within or equal to thepre-existing VDR position, muscle activity/tonusis kept to minimal levels and hence there is nomuscular tendency to rebound

If OVD is increased above VDR, muscles tend to re-establishthe original dimension by compressing tooth into the socketresults in tooth mobility, bone resorption, tooth intrusion,strain or fatigue of muscles and bruxing tendency

Harper documented that increase in OVD leads to encroachment of freeway space causing exaggerated respiratory problems

Quintessence Int 31:275–280

The inference that can be arrived by studyingthe effects of altering OVD is that any attemptto restore OVD in excessively worn dentitionresults in increasing the OVD

Effects of Increasing Vertical Dimension

This increase will ultimately lead to adaptive recoil ofmuscles resulting in tooth intrusion and OVD will return topre-treatment level

Indications for Increasing OVD

Inadequate space for the restoration

For temporarily relieving the symptoms in intracapsular TMJ disorders

Functional Adaptation

TMJ & MUSCLES

PERIODONTIUM OCCLUSALMORPHOLOGY

Clinically, it can be related as: OVD increase within VDR will get adapted only if occlusion is stable without interferences and stabilized in new OVD position

Quintessence Int 31:275–280

Principles Behind Increasing Vertical Dimension

(1) Starting point for reconstruction/increase inOVD must be with in centric relation

(2) Reconstruction to be within the range of thepatient’s neuromuscular adaptation

Category 1 excessive wear with loss of vertical dimension ofocclusion

TURNER AND MISSIRLIANClassification of tooth wear :

J Prosthet Dent 1984; 52: 467–474

Exact location of OVD must be identified andrestored by full occlusal rehabilitation

Category 2 excessive wear without loss of verticaldimension of occlusion, but with space available

J Prosthet Dent 1984; 52: 467–474

Conventional fixed/removable restorative treatmentstowards full occlusal rehabilitation can be done withoutaltering OVD

If the demand for aesthetic enhancement is present thencrown lengthening can be performed

Category 3 excessive wear without loss of verticaldimension, but with limited space

J Prosthet Dent 1984; 52: 467–474

Bite raising with OVD not encroaching VDR can bemade followed by full occlusal rehabilitation

THE PROBLEM OF SPACE……..

The localized loss of anterior tooth tissue isoften accompanied by alveolar bone growth,which maintains contact between the opposingdentitions. This is called dento-alveolarcompensation

As result of this compensationtooth Eruption and alveolar bonegrowth the Occlusal verticaldimension (OVD) is maintainedand the inter-occlusal spaceremains constant

Dent Update 2003; 30: 150-157

Considerations of vertical dimensions

Dent Update 2003; 30: 150-157

A number of methods can be employed tocreate space for restorations. These may besubdivided into methods based on using:

Conformative occlusion Reorganized occlusion

Existing position of mandibularclosure is maintained Suitable for restoration ofsingle tooth or small group ofteeth e.g,

1. reducing the teeth in same oropposing arch

2. surgical lengthening of thecrown

Postion of mandibular closureis altered Suitable for full mouthrehabilitaion e.g,

1. mandibular repostioning2. localized minor axial tooth

movements3. increasing the vertical

dimension of occlusion

CREATION OF LOCALISED INTER-OCCLUSAL SPACE

Increasing the occlusal verticaldimension (OVD)

Reduction of teeth in same / opposing arch

Occlusal reorganization

Elective root treatment & placement of post crowns

Surgical crown lengthening

Orthodontics

Dahl appliancesDental update; 2004 (31)

Generalized tooth wear restored with PFM crownsin the anterior and posterior segments at an overall increase in OVD

Increasing the occlusal vertical dimension (OVD) :

Dental update; 2004 (31)

Reduction of teeth in same / opposing arch :

Occlusal reorganization :

undesirable in a dentition where there has already been loss of tooth tissue

for single unit restorations

It is suitable in those patients who have a large horizontal discrepancy between ICP and the retruded axis position

Surgical crown lengthening…..

Periodontal surgical crownlengthening on worn loweranterior teeth prior to theconstruction of a fixed bridgeprosthesis.

requires a period of healing, of ideally 3 months

Surgical crown lengthening…..

invasive procedure….1. postoperative

sensitivity 2. proximal spacing3. crown margins on

Triangular spaces

Elective root treatment & placement of post crowns :

post-retained crown high risk of endodontic failure and root fracture

Orthodontics :

Conservative method of providing inter-occlusal space Extended treatment time and poor patient compliance intrusion associated with root resorption

Dahl appliances……

simple orthodontic appliance acting as an anterior bite platform

Principle: Coverage of the palatal surfaces of the anterior teeth causes posterior disclusion.

The thickness of this material placed should directly relate to the required amount of inter-occlusal space

Removable FIXED appliance

Irish Dentist July 2011

Localized anterior tooth wear

Dahl appliance cemented in place

Posterior disclusion

Regained posterior tooth contacts after 6 months

Inter-incisal space recreated following the removal of the Dahl appliance

Following periodontalsurgical crown lengthening,teeth prepared for PFMcrowns

RECENT TRENDS IN

“THE DAHL CONCEPT”

Individual Definitive Adhesive Restorations

Maxillary arch following placement of 6 palatal gold veneers

RECENT TRENDS IN “THE DAHL

CONCEPT”

Increasingly, composite resin is being used as a Dahl appliance, as well as acting as a semi-permanent restoration of worn anterior teeth.

RESTORATIVE MANAGEMENT OF WORN DENTITION

To restore or not to restore is a central question???

Biological

Loss of tooth substance

Pulpal exposure

Weakening of tooth

structure

Functional

reduced masticatory efficiency

Aesthetic

Toothwear: ABC of the worn dentition; 1st ed

Oral environment at the time of presentation

UNBALANCED BALANCED

Sensitivity Shiney facets Little or no calculus Little or no staining Frothy or bubbly saliva Dry mucosaMucosal changesMissing restorations

No sensitivityMatt/dull surfaces Significant calculus Staining present Pooling salivaMoist mucosa existing restorations intact

Heavy preventive emphasis

Only proceed if underlying aetiologycannot be controlled

Restore/Rehabilitate Restore/Rehabilitate

Toothwear: ABC of the worn dentition; 1st ed

How to provide restorative care ?

A multidisciplinary approach

Patient’s Oral Condition & Degree Of Compliance evaluated

For restorative treatment planning, the patient should beassessed in terms of Periodontal, Endodontic, Coronal, Occlusal,Functional and Aesthetic (PECOFA) factors

A systematic treatment approach

Dent Update 2002; 29: 162–168

RESTORATIVE OPTIONS :

• Conventional Fixed Restorations

• Removable Onlay/Overlay Prosthesis

• Minimal Preparation Adhesive Restorations

Tooth Wear And Sensitivity - ClinicalAdvances In Restorative Dentistry; Martin Dunitz; first ed.

Conventional Fixed Restorations

Porcelain-fused to metal crowns

All metal crowns

Durable but invasive!!!

Need to recreate inter-occlusal space lost as a result of dento-alveolar compensation

Conventional Fixed Restorations

Anterior crowns constructed to conform to the existing worn teeth without recreation of lost inter-incisal space resulting in poor aesthetics and retention form.

Removable Onlay/Overlay Prosthesis

simple, non invasive and cost effective

particularly when missing strategic teeth to be replaced

As a provisional restoration to assess the predictability of treatment plan

avoid any significant tooth preparation

Available space determines ,whether or not an anterior labial flange can be used, or alternatively gingival fitting and/or butt-fitting tooth facings

Final decision may to some extent depend on the patient’s aesthetic demands & desire to avoid or limit any necessary tooth reduction

Gingival fitting anteriortooth facings on removableprosthesis

Butt fitting anterior tooth facings

Fractures common

Acrylic resin facings which were then replaced with a metal framework

Minimal Preparation AdhesiveRestorations

CERVICAL TOOTH WEAR :

Composite resin or glass ionomer-based, or a combination of both

use of a microfine or polishable densified composite resin, in conjunction with acid etched enamel

DBA’s + composite resins / GIC / RMGIC

Minimal Preparation AdhesiveRestorations

ANTERIOR TOOTH WEAR

Palatal tooth wear :

Resin-bonded palatal metal alloy veneers

Either heat treated gold alloys or nickel-chromium alloys, as used in resin bonded bridge frameworks

an opaque resin based cement

Creation of inter-occlusal space by Dahl’s appliance or veneers at inc OVD

Nickel-chromium Alloy Resin Bonded Palatal Veneers

Labial demonstrating re-establishment of posterior occlusal contacts

Incisal/palatal tooth wear :

Direct acid-etch retained composite resin

Incisal/palatal tooth wear :

Resin bonded porcelain laminate veneers used to restore the incisal and palatal aspects of maxillary central incisor teeth, with resin bonded gold alloy palatal veneers used for the remaning worn anterior teeth.

Labial/incisal/palatal wear :

Labial porcelain laminate veneer + metal alloy veneer,

Resin bonded minimal ceramic crown, or

An adhesive metal-ceramic crown restoration

Direct composite resin at an increased OVD

Posterior (generalized)

tooth wear:

Resin bonded heat treated gold alloy restoration

Resin bonded ceramic or indirect composite resin onlay, if aesthetic concerns

Resin-bonded ceramic restorations

Direct acid-etch retained composite resin materials at an increased OVD

Resin bonded gold alloy and indirect compositeresin onlays used to restore the mandibularposterior teeth in conjunction withconventional PFM crowns for the maxillaryanterior teeth at an increased in OVD

Resin-bonded laminate porcelain veneers forthe anterior teeth, and resin-bonded bridgesand onlays for the posterior teeth at anoverall increase in OVD.

REHABILITATION OF WORN DENTITION

Management of :

Localized Anterior Tooth Wear

Localized Posterior Tooth Wear

Generalized Tooth Wear

Managementof localizedanteriortooth wear

Dent Update 2002; 29: 214–222

Case study I :

27yrs femaleMild sensitivityNo medical historyStressful jobConsume citrus juices

localized anterior palatal tooth wear with dentine exposure Enamel chipping of 1|1 little discrepancy between RCP and the intercuspal position (ICP)

Treatment planning for case I:

Soft Vinyl Occlusal Splint Home-use Fluoride Gel Application Dietary Advice And A 6-month Monitoring Period,

Incisal Edges Of 1|1 Were Repaired With Resin Composite

Palatal surfaces were restored with nickel-chromium veneers at an increased OVD (0.5 mm)

Ni-Cr palatal veneers with palatal platform

Frontal view after placement of the palatal veneers

Right & left buccal view showing posterior occlusion after 4 weeks

Managementof localizedposteriortooth wear

Dent Update 2002; 29: 267–272

Case study I:

21-year malePainful |7Carious

|7 was associated with marginal gingivitis pulp was exposed,minimal remaining clinical crown length no interocclusal space between the

overerupted |7 and the worn |7 in theintercuspal position

patient declined fixed orthodontictreatment

restoration of |7 only

Treatment planning :

Aims included the restoration of |7 to its original occlusal plane

and intrusion of |7.

Crown lengthening surgery was performed on |7 after initialendodontic instrumentation and dressing

4 wks later, obturation done Radicular resin composite core was placed using a packable

composite Orthodontic separators were then placed mesial and distal to |6 4 months after the

periodontal surgery, anonlay preparation wascarried out on |7

working impression was taken with an orthodonticband on|6 supra occluding cast onlay with a soldered buccaltube was cemented on |7 a rectangular wire was used to splint |6 and |7together

Follow-up :

Reviewed 1 week later and had no discomfort, except for some difficulty in chewing

All teeth were in contact again after 2 months

Orthodontic band and buccaltube were removed at the endof treatment

Managementof generalizedtooth wear

Dent Update 2002; 29: 318–324

PRACTICAL CONSIDERATIONS OF

ORAL REHABILITATION

Use a reversible device, such as a hard maxillary occlusal splint or removable overlay denture

For examination of the occlusion in RCP recommendations for splint wear have varied from 24 hours to as much of the day and night as possible for 3 weeks

a sequential posterior-anterior- posterior approach (PAP) can be adopted for full mouth reconstruction

Case study I :

67-year-old man • severe pain from 6|

Exposed 6| Dentine sensitivityMinimal difference between ICP and RCP Incisors were responsible for mandibular protrusion, while the canines and all posterior teeth were involved in lateral excursions.

Treatment Planning:

Endodontic treatment of 6|

Occlusal splint was constructed at a 4 mm increase of OVD

‘Mutually protected’ occlusalscheme was used

Canine guidance was used for lateral excursions

Temporary nickel chromium palatal veneers were constructed on 3| and |3 according to an incisal guidance table fabricated with the occlusal splint

Amount of anterior & posterior space created by palatal veneers bonded on upper canines

Resin compositebuild-up for posteriorstability

Anterior guidance was re-established with:

Gold palatal veneers on 21|12,

Labial porcelain veneers on 1|1 and

Incisal resin composite restorations on 2|2

One month after anterior guidance was re-established the

premolars and molars on both sides were prepared in two visits.

Full-arch impressions were taken for the construction of

adhesive gold onlays on 654|6 and |56, full gold crowns on 76|

and a cantilever conventional ceramometal bridge to replace a

missing first premolar.

After cementation of all posteriorrestorations with a resin cementthe palatal veneers on 3|3 weredebonded and it was confirmedthat group function could beachieved in the absence of canineguidance.

Incisal edges of the lower canines were then restored

with resin composite, and two gold palatal veneers

without incisal overlap were cemented on 3|3.

Frontal view of the restored dentition at increased OVD

MAINTENANCE PHASE

Aim should be to maintain stability in the oral environment

Regular review of the rehabilitated dentition (atleast 6-12 months )

Clinical and radiographic examination of abutments

Sequential clinical photographs & Periodic study casts

Sectional silicone index used as a reference guide

Use of computerised software to map changes in tooth surface profiles

CONCLUSION

The most obvious feature of tooth wear is shortened clinicalcrowns, generally accompanied by dento-alveolar compensation.This may complicate definitive conventional rehabilitation,although research, newer technologies and materials offer broaderpossibilities for rationalizing treatment modalities.

Tooth wear is a multifactorial process which canmake it difficult to identify a single cause at the individualpatient level.

Recognition of the early signs of tooth wear, and especially erosion, could bring about timely prevention and improve the life span of teeth.

CONCLUSION

Rehabilitation of worn teeth will be needed in only some

patients, and the measures with which need for treatment is

assessed is one of the keys to a successful outcome.

In broad terms, the decision to restore or not should be guided

by the patient’s stated and/or perceived need, severity of the

wear as determined by morphological changes and potential for

progression in the context of the patient’s age.

CONCLUSION

The combination of appropriate preventive and maintenancemeasures has the best potential as a treatment concept torestore and stabilize tooth biomechanics, and avoid orpostpone a more costly and invasive prosthetic solution

The converse of this, namely disregarding the consequences ofpoor diagnosis, inappropriate management, overambitiousintervention and uncertainty about prognosis, can only augurfor very unfortunate outcomes.

CONCLUSION

Nonetheless, rehabilitation of the worn dentition,

whilst challenging, can be rewarding and satisfying to both the

patients and the clinician if careful and thorough lead up work has

been completed in line with the The ABC OF WORN DENTITION.

“Rehabilitation of dentition is not all about restoring the mouth

with 28 crowns or an aesthetic smile”

“Itz about Cosmetic Functional Oral Rehabilitation”

REFERENCES…..

• Tooth Wear And Sensitivity - Clinical Advances In Restorative

Dentistry; Martin Dunitz; first ed.

• Toothwear: The Abc Of Worn Dentition; First Ed; Farid Khan

And William George Young.

• PETER E. DAWSON; Evaluation, diagnosis & treatment of

occlusal problems; 2ND EDITION.

• Occlusion in Restorative Dentistry: Technique and Theory;

Martin D. Gross; 1st edition.

• Science and Practice of Occlusion; Charles McNeill.

REFERENCES…..

• Fundamentals of Occlusion and Temperomandibular Disorders;

Jeffrey P. Okeson.

• Text book of Operative Dentistry; Marzouk.

• Sturdevant’s Art and Science of Operative Dentistry; Theodore

M. Roberson; Harald O. Heymann; Edward J. Swift;5th edition.

• Summit’s Fundamentals of Operative Dentistry; 3rd edition.

• Restorative management of worn dentition: I.Aetiology and

Diagnosis; Dent Update 2002; 29: 162–168.

REFERENCES…..

• Restorative management of worn dentition: 2.Localized

Anterior Tooth wear; Dent Update 2002; 29: 214–222.

• Restorative management of worn dentition: 3.Localized

Posterior Tooth wear; Dent Update 2002; 29: 267–272.

• Restorative management of worn dentition:

4.Generalized Tooth wear; Dent Update 2002; 29: 318–

• Conformative, Reorganized Or Unorganized; Dent

Update 2004; 31 No.6; Page334.

• British Dental Journal;2012;212: 17-27.

REFERENCES…..

• Didier Dietschi; Ana Argente; The European Journal Of

Esthetic Dentistry; Vol.6 No.2; Summer2011.

• An appraisal on increasing the occlusal vertical dimension in

full occlusal rehabilitation and its outcome. N. Gopi Chander;

R. Venkat; J Indian Prosthodont Soc (Apr-June 2011) 11(2):77–

• Making Occlusion Work: I. Terminology, Occlusal

Assessment And Recording; Dent Update 2003; 30: 150-157

• The dahl principle revisited; Irish Dentist July 2011

• Functional occlusion : I. A Review; JO Vol.28 no.1.

3.treatment planning restorative management of worn dentition (2)

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anterior guidance

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occlus records

mandibular casts

arcon condylar element

posterior controlling

eugenol paste

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