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THE PROBLEMS OF
TOOTH SURFACE LOSS A CASE HISTORY
BY MATTHEW CONDON
Matthew qualified from Sheffield Dental School in 2010 , and completed the Diploma of Membership of the Joint Dental Faculties of the Royal College of Surgeons of England in 2012 . He then worked as a Senior House Officer in Oral and Maxillofacial Surgery at Pinderfields Hospital in Wakefield , and now works at Farsley Dental Practice in Leeds , where he has recently completed the FGDP Diploma in Restorative Dentistry
M anagement of tooth surface loss ( TSL ) is a major issue facing dentists – it has been shown that 11 % of adults have moderate wear with extensive dentine involvement , and 1 % have severe wear . 1 TSL is often accompanied by dento-alveolar compensation which ensures the teeth still occlude , which is useful as it allows continued function . However , this means there is often insufficient occlusal space to restore the teeth .
The Dahl concept was first described nearly 40 years ago , using planned axial tooth movements to aid restoration of worn down anterior teeth . The technique is very successful , with the literature reporting success rates of 94-100 % 2 which does not seem to be affected by the patient ’ s age or sex . The occlusion is generally re-established over an average of 6 months , but may take up to 18-24 months . 2 In the rare event that the occlusion is not re-established , most patients will tolerate the reduction in occlusal contacts and no further treatment is necessary . If the patient requires more occluding teeth posteriorly , this can be achieved using adhesive techniques .
The original removable cobalt chrome ‘ Dahl appliance ’ was unaesthetic and not well tolerated and , therefore , is no longer
Fig . 1 : pre-operative frontal view smiling commonly used . More cases are now being carried out using direct placement composite at an increased occluso-vertical dimension , placed using a stent constructed from a diagnostic wax-up . If carried out carefully this can have good aesthetics while being minimally invasive . This is seen as a medium-term option as the composite can discolour and fracture , although this is less likely if placed in sufficient thickness . This case study describes a case that was treated using this technique .
HISTORY AND EXAMINATION This case history describes the treatment of a 45-year old lady who attended for an examination complaining of worn down and discoloured teeth , and of multiple discoloured fillings . She reported that she thought that she may be grinding her teeth at night time .
Medically , she was generally fit and well , and used to smoke 20 cigarettes a day until the age of 35 which may account for some of the staining around the existing fillings .
On examination , no extra-oral abnormalities were detected . There was some mild marginal gingivitis and faint white patches bilaterally on the buccal mucosae along the occlusal lines , which had the appearance of frictional keratosis .
There were multiple worn-down and stained composite restorations in the anterior teeth , as can be seen in the preoperative photographs . There was moderate pathological non-carious tooth surface loss which appeared to be due to attrition and erosion , which was mainly affecting the upper anterior teeth . A full assessment of the tooth surface loss was made using the Smith and Knight index . 3 ( Figs . 1,2 and 3 )
The oral hygiene was generally good – there was some supragingival calculus evident around the lingual surfaces of the lower anterior teeth , with some minimal soft plaque deposits and minimal bleeding on probing elsewhere in the mouth . u
56 Dental Practice Magazine