restorative management of worn dentition (part 1)- aetiology

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)

“ Rehabilitation of dentition is not all about restoring the mouth with 28 crowns or an aesthetic smile ”

“Itz about Cosmetic Functional Oral Rehabilitation”

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

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

IntroductionAbrasionAbfractionAttritionBruxismErosionCombined mechanismsSeverity of wear

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


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


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


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


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


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


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


RESTORATIVE OPTIONS

•Conventional fixed restorations

•Removable onlay/overlay prosthesis

•Minimal preparation adhesive restorations

Tooth wear and sensitivity-clinical advances in restorative dentistry; Martin Dunitz


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 AbrasionAbfractionAttritionBruxismErosionCombined mechanismsSeverity of wear

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


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


Occupational/Oral Habits causing Abrasion :

Pipe smoking

Depression abrasion

Tobacco

Betel nut

bobby pin opening

Nail biting

Holding Musicians-Instruments mouthpieces


Location and pattern of abrasion may be related to the cause :

Proximal root abrasion

Pica syndrome

Iatrogenic tooth abrasions

Tongue piercing


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


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


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


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


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)


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


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


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


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


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)

IntroductionAbrasion AbfractionAttritionBruxismErosionCombined mechanismsSeverity of wear

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


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


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


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)


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

http://www.nature.com/bdj/journal/v192/n1/fig_tab/4801278a_F3.html

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 )

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


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%.

IntroductionAbrasionAbfraction AttritionBruxismErosionCombined mechanismsSeverity of wear

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)


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)


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


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

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


(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


SMITH AND KNIGHT 1984 TOOTH WEAR INDEX:


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


TREATMENT MODALITIES

Depends on the degree of Attrition:

MILD

MODERATE

SEVERE

If surface attrition

Slower Intrapulpal

dentin deposition

Faster Pulpal

exposures

In case of mild-moderate Attrition

MONITORING PHASE

1. Periodically Checkup

2. Instructions for oral hygiene

3. FLUORIDE application

4. Hard plastic interocclusal device


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)


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


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

2 Aetiological Models :


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

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


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

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”

IntroductionAbrasionAbfractionAttritionBruxism ErosionCombined mechanismsSeverity of wear

THE CULPRITS BEHIND DENTAL EROSIONS…..

SOFT DRINKS

BULIMIA NERVOSA

wine-tasters ASPRIN

Lemon suckingCOKE SWISHING

http://jada.ada.org/content/vol135/issue7/images/large/911fig3.jpeg

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)

Clinical picture

Polished / Melted appearance

Maxillary palatal surface involvement common

Cervical shoulder formation

“Inverted V-sign” (with unaffected mandibular anteriors)

Inactive sitesActive erosion sites

“ski slope” like depressions

Proud amalgam

CUPPING (depending on severity)

Pulp visible through dentin (in severe cases)

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

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

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

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

IntroductionAbrasionAbfractionAttritionBruxismErosion Combined

mechanismsSeverity of wear

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



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).


MULTIFACTORIAL NATURE OF TOOTHWEAR




http://jada.ada.org/content/vol135/issue8/images/large/1109fig10.jpeg

MULTIFACTORIAL NATURE OF TOOTHWEAR




SEVERITY OF TOOTH WEAR

Tooth Wear Index by Smith & Knight

Received criticism

BDJ; VOL-212; NO.1;2012

IntroductionAbrasionAbfractionAttritionBruxismErosionCombined mechanisms Severity of

wear

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


wear

BDJ; VOL-212; NO.1;2012

THE ACE Classification

(Vialati & Bresler)

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



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restorative management of worn dentition (part 1)- aetiology

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