The patient has a relatively high lip line , with the gingival margins just visible when smiling . There was around 1mm of upper incisor visible at rest . The upper incisor teeth were quite worn , and were 7mm in height and 7mm in width , making them appear short and square .
The patient was asked to complete a diet sheet for 2 week days and 1 weekend day , in order to assess whether she had a high intake of acidic drinks which might be contributing to the tooth surface loss .
DIAGNOSES The diagnoses were as follows :
• Mild plaque induced gingivitis in all sextants , with calculus evident on lingual surface of lower anterior teeth
• Bruxism – the patient was aware that she was grinding her teeth during the night and was not wearing any form of splint
• Frictional keratosis bilaterally on buccal mucosae along occlusal line , likely due to patient ’ s bruxism
• Moderate pathological non-carious tooth surface loss predominantly affecting the upper anterior teeth , which appears to be due to attrition from bruxism and erosion from an acidic diet .
• Worn and discoloured composite restorations with poor margins in UR3 UR2 UR1 UL1 UL2 UL3 LR5 LR4 LR3 LR2 LR1 LL1 LL2 LL2 LL4 LL5 , also general yellow discolouration of teeth
It is important with TSL cases to ensure that the causes have been identified and addressed . The patient was advised to minimise her intake of acidic foods and drinks in order to minimise further erosion and a soft splint was to be made after the occlusion becomes re-established in order to protect from damage from bruxism .
TREATMENT OPTIONS Porcelain veneers The advantage of porcelain veneers is that they provide improved aesthetics and a natural appearance , and have good colour stability when compared to composite . 4 The disadvantage of veneers is the biological cost due to the preparation required , and the increased financial cost for the patient .
FULL COVERAGE CROWNS We also discussed crowning these teeth , but these restorations would now be seen as quite an aggressive treatment option here . Around 19 % of crowned teeth show evidence of periradicular disease , 5 showing that the crowning of teeth often leads to pulpal and periapical disease . A study by Smales et al 6 compared direct and indirect restorations provided for the treatment of anterior tooth wear . They showed that where crowns are used to treat tooth wear , when they fracture it is more likely to involve the underlying tooth , and the teeth are more likely to need root canal treatment or extraction when the failure occurs .
DIRECT PLACEMENT COMPOSITE We also discussed the option of using direct placement composite , using a stent constructed from a diagnostic wax-up . A study by Gulamali et al 7 showed a median survival rate for composite restorations of 5.8 years when used to treat anterior tooth wear . When these restorations fail , it is typically due to wear , discolouration or fracture that doesn ’ t involve the underlying tooth . Therefore , when they do fail , in most instances , they can simply be polished or repaired . They can be placed without preparing the tooth , and therefore have the lowest biological cost of the options discussed here , and also the financial cost involved is lower . It is difficult to achieve the same aesthetic result as with veneers or crowns , but if care is taken during placement , good aesthetic results can be achieved .
Fig . 2 : pre-operative retracted frontal view
Fig . 3 : pre-operative upper occlusal view
CONFORM OR RE-ORGANISE ? In order to improve the aesthetics by restoring the upper anterior teeth to the desired morphology , an increase in occluso-vertical dimension would be required . Therefore the conformative approach could not be used , and a reorganised approach is indicated . 10
The wear in this case was mainly affecting the upper anterior teeth . The posterior teeth were largely unaffected – they had sustained little if any tooth surface loss compared to the anterior teeth , and therefore treatment was not currently indicated for these teeth . We discussed using the Dahl technique . The benefit is that the worn anterior teeth are restored and the occlusion should then re-establish , without the need to also restore the posterior teeth . u
58 Dental Practice Magazine