Quality Resource Guide
l
Managing the Patient with a Worn Dentition 3rd Edition
5
www.metdental.com
In contrast to the even wear on the existing teeth
in
Figure 1
, we see uneven wear of the teeth in
Figure 3
, with obvious thin enamel shards which
are very friable due to the thinness of the tooth,
yet these delicate tooth fragments are not abraded
and fractured.
The two contrasting examples
show the variety of wear.
Vertical Bruxism
Vertical bruxism causes excessive wear to the
anterior teeth while the posterior teeth retain their
natural shape. Vertical bruxism is a term used
by Spear
27
to describe a difference in types of
bruxism. Often the clinician will notice sharp areas
of enamel on the teeth that are not supported by
underlying tooth structure (
Figure 3)
.
If the patient
were a horizontal bruxer, these areas would be
worn flat. Instead we see the incisal edges of the
maxillary anterior teeth become extremely thin and
fragile while the posterior teeth often exhibit little
tooth loss.
These cases can be difficult to restore as the
anterior teeth continue to erupt as tooth structure
is lost, but the posterior teeth remain unworn
with no loss of vertical dimension of occlusion
(
Figures 16-19
). This condition occurs when the
initial occlusal contact during closure is on a mesial
incline of a maxillary tooth (
Figure 21
).
24
As the
mandible closes into maximum intercuspation, the
premature inclined contact forces the mandible
forward overloading the anterior teeth and causing
wear or loosening
24
(
Figure 20
).
Initiating reconstructive dentistry for a patient
with a worn dentition can be difficult due to the
aggressive nature of the restorative process and
the cost to the patient. When a patient seeks care
because of pain or loss of tooth structure due to
bruxism, and has the financial resources to rebuild
their occlusion, the decision is easy. When a patient
is unaware of any problems, and/ or has limited
finances, treatment decisions are much more
difficult. The dentist has the obligation to record
loss of tooth structure for a patient who comes into
the general practice and is conscientious about
recall visits. Once the incisal edges of the anterior
teeth or the lingual of the anterior teeth begin to
show wear or wear facets, the patient needs to be
informed of their problem. Classification systems,
described in the literature, may aid the clinician in
decision making as to when, or if, to intervene, with
therapy. Smith and Knight
29
, Eccles
30
and Lussi
31
have developed index systems. The clinician must
be able to determine etiology before beginning any
preventive or interceding treatment.
Figure 16
Frontal view of vertical bruxism patient.
Figure 17
Tooth structure loss to lingual of maxillary incisors.
Figure 18
Posterior teeth show no loss of vertical.
Thin
areas of enamel remain, severe wear to
maxillary anterior teeth while the posterior teeth
retain the original occlusal height.
Figure 19
Contralateral side.
Wear facets due to bruxism can begin to show in
the teenage years. After growth is completed, use
of an occlusal guard may be necessary to prevent
progressive tooth wear. The patient needs to be
made aware of their bruxism habit and the need
to use the guard. Both the dentist and the patient
need to be aware of known risk factors that may
increase bruxism. Smoking, caffeine consumption,
heavy alcohol drinking, type A personality – anxiety,
sleep disorders such as snoring and sleep apnea,
psychotropic medication, and antidepressants have
been documented to increase bruxism activity.
25
Construction of an orthotic appliance for patients
who demonstrate wear will aid in preventing further
destruction of their teeth.
32
Continued evaluation
and documentation over the years will alert the
general practioner to changes in the amount of
wear for the patient. If concerns are present for
either the patient or the dentist, a mounting of
accurate gypsum casts and evaluation of the
occlusal contacts are warranted. A clinical decision
can be made to equilibrate the patient to try and
prevent further wear.
It is common for a gross premature contact
to be present in patients with a worn dentition
(
Figure 20
). This type of contact is often difficult
to detect in a routine examination, and may go
unnoticed by both the patient and the restoring
dentist. Only a diagnostic mounting in CR will reveal
the contact.
Diagram demonstrates the mechanism for
vertical bruxism and the wear to the anterior
teeth.
Figure 20