5.5-year-survival of CAD/CAM resin-based composite restorations in severe tooth wear patients.

OBJECTIVES: Aim of this prospective study was to assess full mouth rehabilitation of severe tooth wear patients using minimally invasive CAD/CAM resin-based composite (RBC) restorations and direct veneers by evaluating restoration survival up to 5.5-years. METHODS: Twenty-two patients with generalized severe tooth wear with functional and/or esthetic problems were included. Following minimally invasive preparation, CAD/CAM RBC restorations (LAVA Ultimate,3M) were adhesively luted, direct RBC veneers (Filtek Supreme XTE, 3M) were applied in the aesthetic region. Patients were recalled after 1m,1y,3y,5y and seen in between recalls by their general dentists or at the clinical study center if complaints occurred. Failures were categorized as F1 (severe deficiencies requiring replacement/extraction), F2 (localized deficiencies requiring re-cementation/repair) and F3 (small chippings requiring refurbishment/monitoring). Survival of indirect restorations was evaluated using lifetables and Kaplan-Meier-graphs, distinguishing between failure categories and tooth type (front teeth=FT, premolars=PM, molars=M). F1 + F2 and F1 + F2 + F3 failures were analyzed using Cox regression on the variables tooth type/ location, age, gender and VDO increase (p < 0.05). RESULTS: 568 indirect restorations and 200 direct veneers in 21 patients evaluated for up to 5.5-years. For indirect restorations, 96 failures were recorded (F1:6;F2:41;F3:49) and annual failure rates were 0.29%(FT), 1.56%(PM), 2.93%(M) for F1 +F2 and 0.53%(FT), 2.42%(PM), 6.11%(M) for F1 + F2 + F3. Reasons for failure were chipping fracture (48), adhesive fracture (32), complete debonding (7), caries (4), endodontic treatment (1) and reasons unknown (documentation general dentists, 4). Molar tooth type had a statistically significantly increased probability of failure compared with front teeth and premolars for F1 + F2 + F3 (p < 0.006). Direct veneer restorations showed 18 failures (F1:2;F2:9;F3:7). SIGNIFICANCE: Minimally invasive CAD/CAM RBC restorations combined with direct RBC veneers showed an acceptable clinical mid-term survival for restorative rehabilitation of severely worn dentitions.

Chewing performance of patients with worn dentition before and after restorations: A scoping review.

BACKGROUND: Tooth wear is a multifactorial complex process related to the loss of dental tissue, due to chemical or mechanical processes, by abrasion, attrition, erosion. Restorative treatment represents an attempt to rebuild and recreate the lost structure. OBJECTIVE: This scoping review aims to investigate whether restorative treatment of worn dentition (either with direct or indirect adhesive composite adhesive procedures or with prosthetic techniques) can have an impact on the masticatory performance parameters. METHODS: A scoping review was conducted on multiple databases (Pubmed, Medline CENTRAL, ICTRP), following the PRISMA guidelines. Abstracts of research papers were screened for suitability, and full-text articles were obtained for those who satisfied the inclusion and exclusion criteria. RESULTS: Only one article meet the inclusion criteria of the review. Restorative treatment of worn dentition although have a positive impact on the self-report ability to chew, has no effect on the masticatory performance test. CONCLUSION: At the moment, not enough evidence to comment on the actual therapeutic role of restorative treatment on tooth wear is available. Clinicians, before taking any clinical decision, should carefully discuss with patients the needs and expectations of the treatment plan.

The longevity of tooth-coloUred materials used for restoration of tooth wear: an evidence-based approach.

Patients with tooth wear are commonly encountered in general dental practice. When indicated, restorative rehabilitation is often accompanied by a request from the patient for an aesthetic, tooth-coloured outcome. This article seeks to provide an evidence-based approach, focussing on the longevity of the materials which can be used for the restorative treatment of tooth wear, as well as their modes of failure and observed performance.

Treatment planning for patients with tooth wear.

Providing restorative dental care for patients with tooth wear can, at times, seem complex and demanding. The key to this process lies in a systematic approach that breaks down the component parts. In this chapter, the importance of a comprehensive assessment at the outset will be highlighted. This should include identification of the patient's chief complaint, taking a thorough history, completing the clinical examination, undertaking any special tests and arriving at clinical diagnoses. Together, this information will influence the treatment planning process, identify appropriate treatment concepts and options available and the individual stages that may be involved. The process should be both holistic and thorough to enable the patient and clinician to build a clear pathway and vision. In parallel, and with patient input throughout, it is essential to manage patient expectations as best as possible whilst remaining pragmatic and honest about treatment outcomes, longevity of restorations and the risks of failure.

[Restorative treatment of generalized tooth wear]. / Restauratieve behandeling van gegeneraliseerde gebitsslijtage.

A 24-year-old patient with generalized tooth wear was referred to the Radboud Tooth Wear Project. The tooth wear had a chemical aetiology, caused by gastro-oesophageal reflux and resulting in functional problems of the masticatory system and a reduced quality of life. The treatment of the patient was minimally invasive, with directly applied composite restorations on all teeth, by means of which an increase of vertical dimension of occlusion was introduced. The restorative treatment was not preceded by testing of the new vertical dimension of occlusion. The patient was able to function well again after restorative treatment.

[Direct adhesive reconstructions for restoration of posterior teeth with erosive tooth wear]. / Direkte Restaurationstechnik im Seitenzahnbereich zur Versorgung von erosionsbedingtem Zahnhartsubstanzverlust.

The restorative treatment of dental hard tissue loss, e.g., due to erosion, and the rehabilitation of the original vertical bite dimension confronts the dentist with problems when implementing the therapy. Traditionally, this therapy is conducted with laboratory-fabricated workpieces made of ceramics which usually require a preparation of the remaining tooth substance and also causes high costs for the patient. Therefore, alternative methods should be considered. This article presents the use of direct adhesive composite restorations as a way of reconstructing a dentition severely altered by erosion. To reconstruct the occlusal surfaces, transfer splints are used that are made on the basis of individual wax-up models. The procedure described is a well-researched and proven method for restoring teeth with erosion-related loss of hard tooth substance. As with all new procedures, there will be a certain learning curve for the practical dentist after which high-quality restorations can be implemented with this technique.

Mandibular Distalisation for Tooth Wear in Patients Requiring Mandibular Protrusion for Sleep Apnoea.

BACKGROUND: Pathological tooth wear is an increasing concern and may require intervention and occlusal rehabilitation. Often the treatment includes distalisaton of the mandible to restore the dentition in centric relation. Obstructive sleep apnoea (OSA) is another condition treated my mandibular repositioning but in this case by an advancement appliance. The authors have a concern that there could be a group of patients with both conditions where distalisation for their tooth wear management would be contrary to their OSA treatment. This paper aims to look at this potential risk. METHODS: A literature search was carried out using the following keywords (OSA or sleep apnoea or apnea or snoring or AHI or Epworth score) and for tooth surface loss (TSL or distalisation or centric relation or tooth wear or full mouth rehabilitation). RESULTS: No studies were identified which considered the effect of mandibular distalisation on OSA. CONCLUSION: There is a theoretical risk that dental treatment involving distalisation may adversely affect patients at risk of OSA or worsening their condition due to the modification of airway patency. Further study is recommended.

Clinical factors to consider in definitive treatment planning for patients with tooth wear.

Diagnosis, disease control and prevention are the precursors to successful definitive restorative treatment of pathological tooth wear. This case series illustrates how proposed key clinical features can influence treatment complexity and provide the clinician with a logical sequence of treatment options for definitive management of tooth wear.

Occlusal records in the production of mounted study casts for tooth wear planning and management.

This article forms part of a series looking at management of patients with tooth wear. Articulated study casts can be essential in assisting the clinician to plan and communicate proposed treatment to the dental technician and patient. Their production is often seen as straightforward, but a lack of attention to detail can quickly lead to articulated casts that do not replicate the patient clinical presentation. This in turn will lead to inaccurate planning and potentially a suboptimal treatment outcome. This article discusses a collection of the clinical records needed to produce accurate articulated study casts, which can be utilised for tooth wear planning. It also aims to present the evidence base for the recommendations outlined.

Indications for the use of direct composite restorations in the management of tooth wear.

The increasing prevalence of tooth surface loss has been widely reported. Patients present with varying degrees of tooth wear and consideration is given to whether a prevention and monitoring approach, or a treatment and restoration approach, is appropriate. A missed diagnosis or excessively prolonged monitoring risks progression to the detriment of a successful outcome, with the potential compromise on the quality and quantity of tooth structure available for predictable adhesive dentistry. Direct composite resin (DCR) restorations can be considered as a viable treatment option for all extents of tooth wear, including cases that have progressed to a severe degree. This paper aims to review the indications for DCR restorations in the management of tooth wear, using clinical cases to demonstrate their effectiveness.

Clinical considerations in the application of direct composite for tooth wear.

Various techniques are available for the application of composite to restore worn teeth. Different techniques may be chosen based on the clinical presentation or clinician preference. However, for composite to be successful, there are numerous factors which must be considered in order to optimise the outcome. Pre-treatment steps, such as isolation for optimal moisture control and adequate surface preparation of the tooth, as well as the post build-up objectives of achieving a stable occlusion, good marginal adaptation and final aesthetics, are discussed in the paper.

Rehabilitating a severely worn dentition with removable prosthodontics.

In the next part of this series on tooth wear management, we discuss the indications and clinical stages for the provision of removable prostheses for the treatment of severely worn and depleted dentitions. The general design features of a complex prosthesis are described for reorganised occlusal schemes and maintenance guidelines are explained. In addition, the clinical stages for three different situations are described: removable-only approaches, and combined fixed and removable in the same arch and separate arches. The value of providing removable prostheses in worn dentitions allows the immediate rehabilitation of severely worn teeth taking a non-invasive and retrievable approach when the remaining dentition is of poor quality or structure and/or there are missing teeth.

Digital workflows for the management of tooth wear.

For patients affected by tooth wear who require treatment to restore their dentition, the methods chosen can increasingly involve digital technology, with potentially less use of traditional, analogue treatment methods. Digital technology has transformed clinical photography and dental radiology, and is now available for most of the stages required for managing these patients. Continuous development of these digital technologies, both in the system capability and in the clinician interface, has brought the digital workflow within reach of more clinicians and therefore, for the treatment of more patients. While it is recognised that the comprehensive use of digital technologies is currently most likely to be used in clinical practice by specialist and private practitioners, it is expected that interest in and understanding of digital workflows will increase throughout the dental profession.This paper provides a step-by-step overview of the digital workflow, for both simple and complex cases.

Gastrointestinal conditions related to tooth wear.

Gastro-oesophageal reflux disease (GORD) is a relatively common condition that occurs in adults and less commonly in children. It develops when the reflux of stomach contents into the oesophagus causes troublesome symptoms and/or complications. Signs and symptoms include heartburn, retrosternal discomfort, epigastric pain and hoarseness, dental erosion, chronic cough, burning mouth syndrome, halitosis and laryngitis. A proportion of patients will, however, have silent reflux. Strongly associated risk factors include family history, age, hiatus hernia, obesity and neurological conditions, such as cerebral palsy. There are different treatment options which may be considered for GORD, consisting of conservative, medical and surgical therapy. Dentists should be aware of the symptoms of GORD and dental signs of intrinsic erosion indicative of possible GORD so that they can question patients about this and, if appropriate, initiate a referral to a general medical practitioner.

Managing tooth wear with respect to quality of life: an evidence-based decision on when to intervene.

Patients with more severe forms of tooth wear may require restorative rehabilitation. The decision to commence treatment must be taken carefully and there are a multitude of factors to consider. Alongside the clinical signs and symptoms typically associated with tooth wear, there is also the need to assess the impact of the condition on the patient's oral health-related quality of life. As part of the discussions relating to the attainment of informed consent for the restoration of the worn dentition, not only is it relevant to appropriately appraise the risks, benefits, costs, reasonable alternatives and likely prognosis of the proposed treatments, but to also elaborate on the expected impact of the intervention on the patient's oral health-related quality of life. The aim of this article is to review the evidence relating to the impact of the quality of life with the management of tooth wear, with the introduction of the concept of an evidence-based approach to decision-making when planning care.

The opinions of GDPs on the challenges of managing tooth wear in primary dental care.

As patients access most of their dental care within the primary care setting, it is relevant to consider how the experience and opinions of general dental practitioners (GDPs) influence the diagnosis, monitoring and treatment of their patients with tooth wear. This paper records the agreed outcomes of semi-structured discussions with three experienced GDPs. The aim is to continue the broader debate about how patients with tooth wear currently are and ideally could be managed within the primary care settings in England. The outcomes are also likely to be applicable to other countries, regardless of the local funding models for routine patient care.

Posterior Dahl: A Minimally Invasive Method for the Treatment of Localized Posterior Tooth Wear.

PURPOSE: This retrospective case series of 9 patients aimed to describe clinical outcomes and patient satisfaction following the implementation of the posterior Dahl concept to manage localized posterior tooth wear. MATERIALS AND METHODS: Localized occlusal space was created in the posterior dentition. Supra-occluding direct restorations were placed bilaterally for the restoration of molars. Intraoral scans were taken at the pre-treatment stage, immediately post-restoration, and during follow-up appointments. Scans were used to undertake analysis of any occlusal changes and re-establishment of the occlusion. A questionnaire was used to assess patient satisfaction, alleviation of any pre-treatment concerns, and evaluation of post-treatment complaints. RESULTS: Immediately post-treatment, all patients showed an increase in the vertical dimension. Opening of the bite in the untreated areas following restoration of worn posterior molars resulted either in a tendency towards or the actual reestablishment of the occlusion. One patient completely lacked compensatory vertical tooth movement in the untreated areas, culminating in the persistence of a vertical open bite. One restoration displayed cohesive fracture after 4 months. Pre-treatment problems (eg, sensitivity) were fully resolved amongst all patients after 6 months. Post-treatment complaints were minor and demonstrated resolution within a relatively short period of time. Eight patients reported being "very satisfied" with their treatment outcomes. CONCLUSION: Application of the posterior Dahl concept appears to offer a promising, relatively simple, minimally invasive and effective approach for the management of localized posterior tooth wear, which is well accepted by patients.

Randomised controlled trial on testing an increased vertical dimension of occlusion prior to restorative treatment of tooth wear.

BACKGROUND: Evaluation of a new vertical dimension of occlusion (VDO) in complex restorative treatments is considered a necessary step prior to placement of restorations. OBJECTIVES: This randomised controlled trial (RCT) aimed to assess the effects of using an evaluation of a VDO increase before restorative treatment in patients with moderate-to-severe tooth wear, on OHRQoL, freeway space (FWS) and interventions to restorations. METHODS: Forty-two patients with tooth wear were included and randomly allocated to either a test phase with a Removable Appliance (RA) or no test phase. Restorative treatment consisted of restoration of all teeth using composite restorations in an increased VDO. OHIP-score, freeway space (FWS) and clinical acceptability of restorations were assessed at baseline and at recall appointments (1 month and 1 year). Intervention to restoration was scored in case of material chipping or when the abutment tooth had increased sensitivity that could be linked to occlusal overloading. ANCOVA analyses, Univariate Cox regression, t-tests and descriptive analyses were performed (p < .05). RESULTS: Clinical follow-up after 1 year was completed for 41 patients. No significant effect of testing the VDO with a RA could be found on the OHIP-score (p = .14). Reduction of FWS in the RA group, compared to the control group, was significantly lower at 1 year (p = .01, 95% CI -1.09 to -0.15). No effect on early interventions to restorations was found (p = .94). CONCLUSION: This RCT showed that a removable appliance is not indicated to functionally test the increased VDO prior to restorative treatment in patients with tooth wear.