|Year : 2013 | Volume
| Issue : 1 | Page : 54-57
Simplified management of anterior worn dentition
Haroon Rashid1, Fahim Ahmed Vohra2, Mohsin Nazir1
1 Department of Dentistry, Ziauddin University Hospital, Karachi, Pakistan
2 Department of Dentistry, King Saud University, Saudi Arabia
|Date of Web Publication||20-Jun-2013|
Department of Prosthodontics, Ziauddin College of Dentistry, Ziauddin University, Karachi
Source of Support: None, Conflict of Interest: None
Tooth wear has started to affect a greater number of younger people. Its precautions, symptoms, and treatment modalities therefore have to be well understood. This case study presents a patient with severe tooth wear that had led to displeasing esthetics. Surgical crown lengthening and composite restorations were performed after the provision of a stabilizing splint. This helped to improve the esthetics considerably leaving the patient satisfied. The aim of this case study is to portray an approach to how even a patient with severe tooth wear can have access to an esthetically pleasing dentition.
Keywords: Bruxism, composite restorations, crown lengthening, tooth wear
|How to cite this article:|
Rashid H, Vohra FA, Nazir M. Simplified management of anterior worn dentition. J Orofac Sci 2013;5:54-7
| Introduction|| |
A topic that has intrigued dental professionals for a very long time is tooth wear. From its causes, to how it goes unnoticed at times, to its symptoms, and its treatment have all been a theme of countless research papers. Bruxism is one of the commonest causes of tooth wear and the American Academy of Orofacial Pain defines it as a "total parafunctional daily or nightly activity that includes grinding, gnashing, or clenching of the teeth. It takes place in the absence of subjective consciousness and it can be diagnosed by the presence of tooth wear facets which have not resulted from the chewing function". 
The troubling fact of the matter is that in recent times tooth wear has been on the rise in younger patients for various reasons.  With patients wanting to retain their natural dentition while desiring optimum esthetics, general dental practitioners and specialists alike are posed with tough challenges whenever treatment is accompanied with high expectations.
When it comes to treating a patient with severe tooth wear, there are many treatment options that have been prescribed by various texts. The factor that needs least ignorance is inter-occlusal clearance. If restorative treatment is needed at an existing occlusal vertical dimension, inter-occlusal clearance becomes a dilemma. For such cases, surgical crown lengthening is indicated. Another way of obtaining adequate inter-occlusal clearance is by increasing the patient's occlusal vertical dimension. Both of these methods have their own limits and are conjoined, depending upon the case, to create ample crown height and acceptable inter-occlusal clearance. ,,
Surgical crown lengthening can be performed in a lot of clinical scenarios, such as sub-gingival fractures, sub-gingival caries, endodontic/pin/post perforations, root resorption, inadequate axial height for restoration retention, unequal gingival levels, altered passive eruption, and esthetically short crowns due to tooth wear. The latter is of interest to this article. Once the operator has judged the clinical crown height needed to restore the teeth, adequate bone should be eliminated and the biological width must be taken into account. Failure to do so could lead to unfavorable consequences. ,,
Esthetically compromised patients with pronounced tooth wear should be treated with care. Tooth protection, function, minimal preparation, and conservation of the natural tissues should be kept in mind from start to finish. The invention and utilization of composite resin for anterior teeth has permitted dentists to fulfill these compulsions while adequately maintaining control of the contour and shade of the composite. Hence, direct and indirect composites are preferred in the treatment of tooth wear. ,,,
The aim of this case study is to demonstrate an approach to how a patient with severe tooth wear can be led to obtaining an esthetically desired dentition with the help of surgical crown lengthening and maximally conservative composite restorations.
| Case Report|| |
A 39-year-old male patient was referred to the dental practice with the chief complain of rapid tooth wear of the anterior teeth that had led the patient into becoming conscious of his appearance [Figure 1]a and b. He noticed the problem around 2 to 3 years before attending the clinic but did not pay heed to his gradually degrading dental esthetics. The tribulations of his excessive tooth wear had led to the endodontic treatment of the UL1. He also felt tenderness of the jaw muscles and temporomandibular joint (TMJ) clicking.
Upon extra-oral examination, there were no abnormalities detected besides the clicking sound of the TMJ upon opening and closing movements.
Intra-oral examination revealed acceptable oral hygiene with presence of various amalgam restorations. There was also a metal ceramic crown detected on LL2, but the most pronounced problem that existed was the significant tooth wear seen on the upper arch from canine to canine giving the patient an edge-to-edge incisal relationship and compromised esthetics.
| Treatment|| |
In accordance to the consent of the patient, the treatment began with the provision of a maxillary repositioning splint. Impressions of the upper and the lower arches were taken, a face bow record and retruded contact position (RCP) was recorded. This was all sent to the lab for processing. In the following visit, the lab fabricated splint was adjusted in the mouth and due instructions were provided to the patient.
The treatment plan aimed at restoration of the anterior teeth, thus it was important to evaluate the status of UL1. The quality of the root filling as seen in the periapical radiograph was satisfactory and since it was performed recently, a decision to continue with the treatment was opted for.
The patient was reviewed on a couple of occasions during 8 weeks after the splint was prescribed. It was noticed that further tooth wear was negligible. The splint also helped to reduce the temporomandibular joint discomfort (TMD), discomfort which the patient had been experiencing. It was noted at this stage that the patient could easily adopt RCP and this would give adequate space for increasing the length of the worn anterior teeth.
In due time, and as expected, the splint was gradually performing its desired function. On the procedural queue next was surgical crown lengthening with osseous re-contouring of UL1, UL2, UR1, and UR2 [Figure 2]. So, under local anesthesia, approximately 2mm of bone was removed from the labial cortical plate of the incisors. On the palatal side of the same teeth, there was enough tooth structure present, and hence, only gingivectomy was performed.
The patient was reviewed after 8 weeks and showed excellent gingival healing [Figure 3]. Thereafter, the continuation of the treatment plan required composite restorations with A3.5 shade. This would be less invasive than performing crown preparations and would save the much needed expense of the patient under treatment. Composite restorations were placed successfully on the maxillary teeth from canine to canine using a Memosil matrix constructed from a diagnostic wax up on study models. By using this indirect wax-up and a direct intra-oral approach, optimum esthetics were achieved [Figure 4]a and b, and at the same time, maximum conservation of the tooth structure was possible.
|Figure 2: Post-operative crown lengthening after suture removal (anterior)|
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The final step in the treatment plan was to provide a night guard to the patient so as to counter bruxism and cause lesser tooth wear in the long run.
The patient was reviewed again after 4 weeks. On this visit, the composite restorations appeared in excellent condition. The patient was highly satisfied with the esthetic outcome as well. Moreover, surgical crown lengthening had enhanced the gingival contour and harmony. The patient was kept under regular checkups for a period of 1 year because crown work still remained an option for further treatment if, in case, the composite restorations did not meet the mark. Also, UL1 showed no further need for treatment after 6 months.
| Discussion|| |
Night grinding or Bruxism is a common cause of tooth wear.  Usually, the worn surfaces exhibit a uniform pattern particularly on the incisal aspect of the anterior teeth. In this case, the patient exhibited typical signs of attrition on the anterior aspect of his incisors on both upper and lower arches. The patient had an edge-to-edge incisor relationship which added to further loss of the tooth structure.
The provision of a stabilization splint helps in the treatment of patients who exhibit tooth wear related to Bruxism and also those suffering from TMJ problems. , In this scenario, a splint was provided and the patient was regularly reviewed to see if the treatment was working according to the plan. It was observed that the tooth wear did not get any worse. The splint also helped to reduce the TMJ discomfort which the patient had been experiencing. At this stage of the treatment, the patient could easily adopt RCP and this gave space for increasing the length of the worn anterior teeth.
The patient had unpleasant esthetics. It was observed that some compensatory alveolar growth may have occurred in the anterior sextant producing a disharmonious gingival contour and level. Hemmings et al.,  stated that tooth wear can cause an unacceptable reduction of the inter-occlusal space. There was significant loss of tooth structure anteriorly, hence, space was required but as mentioned, the patient could gain his RCP very easily. It was decided that composite restorations should be placed initially and if they led to subsequent failure, crown work could be performed. Prior to that, crown lengthening was required to enhance the esthetics, and to optimize the retention of the crowns should they be fabricated in future. Crown lengthening is considered to be an appropriate procedure which facilitates caries removal, provides additional retention to the restorations, establishes the biological width, and improves esthetics. ,
After the crown lengthening with osseous recontouring was performed, composite restorations were placed on the maxillary teeth from canine to canine, using a Memosil matrix constructed from a diagnostic wax up on study models. This technique for composite build ups has been described by Mizrahi in 2004.  By using this indirect wax-up and a direct intra-oral approach, good esthetics are achieved and simultaneously, conservation of the tooth structure is possible.
On the review, after the provision of a night guard, the restorations appeared to perform very well. The patient was very content with the esthetic outcome. Furthermore, crown lengthening had enhanced the gingival contour and harmony. As the composite restorations were performing well, it was decided in the review that possible crown work on the restored teeth need not be performed as composite placements provide a conservative way of improving esthetics and additions to composites can be performed anytime if required. On the other hand, crown work requires significant tooth reduction and is a less conservative option. The situation can now be kept under review and crown work remains an option for the future.
| Conclusion|| |
Tooth wear is a common issue that affects countless individuals in our society. Hence, a dental practitioner should be well-equipped with the knowledge of its precautions, symptoms, diagnosis, and treatment. The method of treatment described in this case study is easily replicable and should be brought into regular practice when a clinician is confronted with a patient with moderate to severe tooth wear.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]