Tooth wear is an increasingly common problem in general dental practice. It causes aesthetic, functional, structural and biologic problems and is also often accompanied by a lack of space to restore the remaining dentition. Multiple teeth may also be affected creating two other problems to be dealt with: the occlusion often needs to be reorganised and treatment can be costly for the patient.
Traditionally many such cases were treated by conventional crown and bridge restoration. This not only involves considerable cost to the patient but also further removal of tooth structure from already compromised teeth. Research shows that 19% of crowned teeth will eventually develop a periapical problem and so a more preservative treatment may be sought. With the development of new materials and a desire to conserve tooth tissue, new techniques have been developed to restore the worn dentition.
Steps to success
In complex cases it is vitally important to understand why the patient has attended and what results they are looking to achieve. Managing the patient’s expectations is perhaps the most critical part of the process. Failure can occur for functional, aesthetic or biologic reasons but can also occur because the patient’s desires were not met.
Once we understand the patient’s chief complaint we can then take a further history, carry out a detailed examination and take any further necessary records. From this information a diagnosis is made and we can start developing the treatment plan. Firstly we visualise treatment possibilities using photographs and then turn this into a three dimensional plan using a simple diagnositc wax up. This will be the blue print for the patient’s future treatment. To help the patient visualise the potential result a silicone matrix is made of the diagnostic wax up, filled with provisional crown material and placed over the patient’s teeth. Once approved, treatment options to deliver the plan are discussed. In this way a plan that suits the patients needs, desires and budget can be developed. Many patients wish to schedule the treatment over time and/or wish to achieve a result as economically as possible. In such cases it is possible to place composite restorations via a matrix rapidly and cost effectively. This type of procedure can be used either in the short term, in the medium term, so that treatment can be easily scheduled, or even over a slightly longer term, to allow the patient to assess function appearance and also to schedule the treatment whether that is for clinical or financial reasons.
A clear acrylic special tray was made although clear acrylic stock trays can also be used. An impression of the wax up, upper and lower was then taken with a clear silicone material. The teeth to be treated are cleaned, etched, bonded and the matrix is loaded with composite material. There are several ways of ensuring that the teeth do not get stuck together. The composite is light cured through the tray and then the tray is removed and curing continued through the silicone material.
Next the upper central incisors and canines are restored, using the matrix, and then the other upper lateral incisors. Once the upper and lower anterior teeth are in place, the aesthetics and function were checked and finalised. This sets the vertical dimension and establishes anterior guidance and envelope of function. Often these restorations can be placed with no preparation and no anaesthetic. Then the posterior quadrants are restored in turn. Once all restorations have been placed and polished the occlusion and aesthetics were rechecked to make sure that all original goals have been fulfilled. The procedure usually takes about three hours and the cost to the patient is usually considered to be very reasonable.
There are many ways of restoring the worn dentition and many ways of gaining space, but most patients would like to maintain as much of their own tooth substance as possible and also to schedule treatment over time. Using techniques as described will allow both patient and practitioner to develop a plan over time, enabling a complex treatment to be delivered in a simple, less stressful manner. One of the features of using composite is that, although there may be some failure in time, it is relatively easy to repair as and when necessary. If there is a desire either clinically or for aesthetic reasons to make the restoration more beautiful, then again both the patient and clinician can move forward towards a predictable result. Utilising this method allows tooth structure to be preserved, the patient’s needs and desires to be fulfilled and allows the scheduling of complex treatment over as much time as is necessary.
Dr Ian Buckle, BDS, runs a private practice in the picturesque village of Thornton Hough on the Wirral concentrating on comprehensive reconstructive, aesthetic and implant dentistry. He is director of The Dawson Academy UK and teaches dentists around the world the foundations of ‘complete dentistry’, as well as lecturing internationally on functional and aesthetic dentistry.
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