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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)
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“ Rehabilitation of dentition is not all about restoring the mouth with 28 crowns or an aesthetic smile ”
“Itz about Cosmetic Functional Oral Rehabilitation”
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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
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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
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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
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Tooth wear’s multi-factorial aetiology
ABRASION
ABFRACTION
ATTRITION
EROSION
Clinically however, it is difficult (if not at times impossible) to isolate a single aetio logical factor when a patient presents with tooth wear
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Excessive abrasion
(attrition) and erosion
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
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COMBINED ETIOLOGIES
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 DENTISTRYVOLUME 6 • NUMBER 1 • SPRING 2011
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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
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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
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A modern treatment model involves three steps:
1) Comprehensive etiological clinical investigation
2) Treatment planning and execution
3) Maintenance
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 • NUMBER 1 • SPRING 2011
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RESTORATIVE OPTIONS
•Conventional fixed restorations
•Removable onlay/overlay prosthesis
•Minimal preparation adhesive restorations
Tooth wear and sensitivity-clinical advances in restorative dentistry; Martin Dunitz
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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 )
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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
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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
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Occupational/Oral Habits causing Abrasion :
Pipe smoking
Depression abrasion
Tobacco
Betel nut
bobby pin opening
Nail biting
Holding Musicians-Instruments mouthpieces
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Location and pattern of abrasion may be related to the cause :
Proximal root abrasion
Pica syndrome
Iatrogenic tooth abrasions
Tongue piercing
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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
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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
Site:
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
Lesions show varying degrees of depth like
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Lesion:
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.
Hypersensitivity:
Intermittent in character In slowly progressive defects, reparative dentin formation occurs over a period of time making them asymptomatic
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TREATMENT OF ABRASION
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
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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)
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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
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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
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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
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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
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ABFRACTION
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)
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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
Coined by Grippo in 1990
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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
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Mechanism of Formation of Abfraction Lesion:
Compressive forces Tensile forces
Kornfeld indicated that the cervical surface lesions tended to occur on the part of the tooth opposing the side that had developed an occlusal wear facet caused by attrition
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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)
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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
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Classification of ABFRACTION
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 )
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TREATMENT OF ABFRACTION
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
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ATTRITION
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%.
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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)
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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)
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PROXIMAL SURFACE TOOTH LOSS
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
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Occluding surface attrition
Occlusal Wear
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
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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
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(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
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SMITH AND KNIGHT 1984 TOOTH WEAR INDEX:
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CLINICAL FEATURES
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
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TREATMENT MODALITIES
Depends on the degree of Attrition:
MILD
MODERATE
SEVERE
If surface attrition
Slower Intrapulpal
dentin deposition
Faster Pulpal
exposures
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In case of mild-moderate Attrition
MONITORING PHASE
1. Periodically Checkup
2. Instructions for oral hygiene
3. FLUORIDE application
4. Hard plastic interocclusal device
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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)
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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
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BRUXISM
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)
IntroductionAbrasionAbfractionAttrition BruxismErosionCombined mechanismsSeverity of wear
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2 Aetiological Models :
IntroductionAbrasionAbfractionAttrition BruxismErosionCombined mechanismsSeverity 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
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Clinical
Presentation
• 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
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TREATMENT , rather
say PREVENTION
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
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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”
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THE CULPRITS BEHIND DENTAL EROSIONS…..
SOFT DRINKS
BULIMIA NERVOSA
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wine-tasters ASPRIN
Lemon suckingCOKE SWISHING
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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)
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Clinical picture
Polished / Melted appearance
Maxillary palatal surface involvement common
Cervical shoulder formation
“Inverted V-sign” (with unaffected mandibular anteriors)
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Inactive sitesActive erosion sites
“ski slope” like depressions
Proud amalgam
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CUPPING (depending on severity)
Pulp visible through dentin (in severe cases)
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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
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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
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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 challenge2. Enhance the defense mechanisms of the body (increase salivary flow and pellicle formation) 3. Enhance acid resistance, remineralization and rehardening of the tooth surfaces4. Improve chemical protection5. Decrease abrasive forces6. Provide mechanical protection7. 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
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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
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mechanismsSeverity of wear
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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
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mechanismsSeverity of wear
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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
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MULTIFACTORIAL NATURE OF TOOTHWEAR
Toothwear: ABC of the worn dentition; 1st ed
IntroductionAbrasionAbfractionAttritionBruxismErosion Combined
mechanismsSeverity of wear
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MULTIFACTORIAL NATURE OF TOOTHWEAR
Toothwear: ABC of the worn dentition; 1st ed
IntroductionAbrasionAbfractionAttritionBruxismErosion Combined
mechanismsSeverity of wear
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SEVERITY OF TOOTH WEAR
Tooth Wear Index by Smith & Knight
Received criticism
BDJ; VOL-212; NO.1;2012
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wear
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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
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BDJ; VOL-212; NO.1;2012
THE ACE Classification
(Vialati & Bresler)
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STAGES OF TOOTH WEAR (Khan et al & Young)
Stage A Attrition Wear facets formed tooth to tooth
Stage B Bowl shape erosion
On incisal edges & cusp tips
Stage C Cervical lesion On a tooth with occlusal attrition or erosion
Stage D Degradation Occlusal attrition or erosion merged with cervical lesion
Stage E Near exposure Pink pulp shinning through
Stage F Frank exposure The pulp open to the oral environment
Toothwear: ABC of the worn dentition; 1st ed
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wear
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