Managing tooth wear: Loss of posterior support
I thought it would be fun to go thought the management of a wear case stage by stage.
This is the type of case that can come up as a tricky finals case study or indeed restorative viva. It is also the kind of case that is tricky to treat in practice especially keeping the costs down.
There are several ways to approach the case and I will try to outline them and why I have done the case the way I have. There is no right answer for this, so feel free to argue but the principles stay the same no matter how you approach it. Some methods are cheaper, some get a better aesthetic result and some are more conservative of tooth tissue. Which you use is a combination of operator preference, patient wishes and budget.
In the books you will see that for any wear case you need to ascertain the cause. This could be erosion, abrasion or attrition. If there is a lot of erosion then it is best to try to stop the cause before treatment starts… This means stopping acid reflux or eating disorders or coke (cola) addictions.
You also should also try to get the periodontal condition stable before you start and caries. You need to work on firm foundations. So before I took these pictures I had already given the patient a course of treatment. This involved removing some grossly carious upper right molars and some simple cons lower left. I did a full mouth gross scale and gave some oral hygiene instruction (although it is still not the best!)
So let’s diagnose the wear. We can see that there are no posterior contacts at all so the patient has been forced to chew in between his anterior teeth. There is an initial contact between the 43 and 13 but this is unstable so the patient grinds forward and to the left to get some chomp on the food. If you look at the wear you can see how this slide has taken place over many years grinding away the enamel.
There may be an erosive element to the wear but it pales into insignificance compared to the attritional wear caused by loss of posterior support and an unstable occlusion. Note that this patient suffers from attrition but he is not necessarily a bruxist. A bruxist would grind even with a stable occlusion and as this patient has anything but that it is impossible to tell.
Of all the wear you see this is the most common: attrition caused by loss of posterior support. The management for this and so many other cases follows the same aims these are:
- Improve aesthetics by increasing the length of incisors
- Establish a stable occlusion
- Provide some posterior support to maintain this occlusion
I’ve just about completed the initial stages of this patient’s treatment so I can show you the pictures of how I treated him as we talk through managing the wear.
This case was relatively straight forward to treat, in terms of the functional problem (aesthetics more difficult). However in cases where the wear is caused by bruxism or an occlusal interference and there are still several units of posterior support then treatment becomes far more difficult. These cases tend to require some kind of Dahl appliance or posterior shims/crowns to resolve the functional and aesthetic problems and need to be treated a little differently. I will attempt to outline this a little as I ruminate but I don’t currently have any cases on the go to show as examples.
It’s important to be able to spot the difference between these cases early as they need to be treated with different levels of caution and techniques.
I’m going to go through this case in stages as I think the endo thesis was a bit much all in one go and I need a little time to collect some more pictures. I should get through the case in 4 or 5 blogs, so stay tuned.
All the best
Chris
p.s. To see the pictures better just click on them!
