Diagnosis and Research of Dental Wear

Diagnosis and Research of Dental Wear

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All of those things can enter in to the patient
who has significant tooth wear. So what I’d like to do just to introduce the concept and
sort of start our entire discussion around wear is simply look at what it is about wear
patients that, in fact, scares us, if you will. And so this is not an uncommon patient
for me to be brought if I was doing a lecture someplace. And it’s pretty common that in
fact somebody will come up to a set of models and they’ll say, “Would you mind taking
a look at this?” What they’re really asking is, “I’m not exactly sure what to do.”
And you take a look at this person’s upper teeth and lower teeth as well. Obviously he
has very significant tooth wear. If we continue looking throughout his mouth, his lower incisors
actually look pretty good but the problem is the posterior teeth have really severe
wear and when he bites down the posterior teeth are in occlusion. So then you start
thinking, “Well, maybe do I need to open his vertical dimension? I wonder if he’s
lost vertical dimension?” Those are all the kinds of things that start happening when
we start thinking about wear cases. There’s so many things that go on in a patient when
their teeth wear away that some people do need their bite opened. But guess what so
people don’t need their bite opened at all. And so the challenge we face is understanding
what are the possibilities that can occur when somebody’s teeth wear and how to I
know which of those possibilities actually happened? And again if we just keep looking
around, you know, his left central incisor doesn’t look too bad. The lingual of it’s
got a huge amount of wear but the incisal edge doesn’t look that far off from a normal
tooth. The lower incisors don’t look that bad. So you start saying to yourself, “Why
in the world would somebody’s teeth wear like this? How come there’s some much wear
on the back teeth but we don’t see as much on the front?” And in fact we see almost
none on the lower incisors but we see quite a bit on the lingual of the upper incisors.
And so as we move into this series we’re going to be talking about patterns of wear
and what things we learned from patterns of tooth wear because it teaches us a lot about
the etiology of the wear. In addition if you look at him he has a very interesting pattern
in that he has far more wear on his right side in the posterior than he does on his
left side in the posterior. So now you start saying, “Well, how can somebody do that?
How can they get more wear on the right than the left?” And again, we’re going to walk
through all of that in different modules of this series as we progress. Ultimately if
you also look carefully on the right side you’ll notice there’s some composite restorations
on the first and second molar that in fact are sticking way above the tooth structure.
So then you start saying, “Well how can you get tooth wear when in fact the restoration
actually didn’t wear away but the tooth did?” And obviously it’s because there’s
multiple different etiologies that can be responsible for tooth wear. Now, interestingly
enough on the opposite side we don’t see that same amount of wear surrounding the composite
restorations that have been there about the same length of time in this patient. So, what
I thought we’d do for a moment is just really look at what is it that makes this kind of
patient so difficult. What is it that challenges us in treatment planning, in treatment, in
all those things we do? And I think for sure there’s fear. When dentists come to me and
they bring me a set of models, what they’re really asking is, “I don’t know what to
do and I don’t want to do anything if it’s not going to work because I don’t want the
patient angry at me because things fail.” In addition, in severe wear cases, you often
have to treat almost every tooth so there’s this huge financial component to it. Plus,
simply, the complexity and confidence of feeling like, “Well, I know how to do that, I could
treat every tooth.” Wear cases tend to bring up a lot of uncertainty because the dentist
isn’t exactly sure what to do. “Should I or shouldn’t I open the bite? Should I
or shouldn’t I crown lengthen those teeth?” So, there’s that not knowing what to do
piece in the wear cases. Then you start having the actual restorative problems. So in this
person’s posterior teeth, there is not a lot of tooth structure. His maxillary premolars
are very, very short. So then you go, “Well, how in the world … I can’t even put a
restoration on there. If I prep the tooth, there’s no tooth left.” So we often have
structural issues in wear cases to deal with. In addition, if you look at it you’d say,
“Well, how in the world? There’s no space for restorative material; I have to open his
bite.” And the answer is sometimes “yes” sometimes “no.” These are the kinds of
things that introduce difficulty in wear cases. And as I said there is the whole question
of do you or don’t you alter vertical dimension. Now on top of all of those concerns there’s
the fear factor. And what is it that we are really afraid of typically? Broken porcelain,
broken preparations, broken implants, broken solder joints on bridges, basically failure
of what we do and probably the biggest one of all is just the unknown. Is treating a
patient without really knowing, is it going to work, is it going to be predictable or
not? And that can be very unsettling. Now, is there a reason we should be afraid? And
the answer obviously is absolutely. So this is a patient I treated in 1985. He’s a young
fellow, 21 years old. He’d lost the right lateral cusped and premolars in an accident.
He’d opened his mother’s or grandmother’s garage door and the big spring that held the
door broke and it sprung out, hit him in the face and took out these teeth and a bunch
of bone. If you look, for age 21, he has really significant wear on his central incisors and
particularly his right central. He likes grinding off to the right a lot and he’s only 21
years old. But of course in 1985 I certainly didn’t look at things the way I do now.
So the oral surgeon was able to get some implants in there. I did a restoration. We cantilevered
the lateral off of the cusped and two bicuspid implants and honestly I was very happy with
the result. Until he called one day and he said, “You know, my bridge is loose.”
Now typically loose to me means you take a screw driver and tighten the implant screws.
In his case “loose” was he handed me the bridge. And I looked at it because I realized
when he handed it to me he handed it to me with the abutments connected to it. In other
words there were no loose screws here but there were broken abutments. When you looked
up in his mouth there were abutment screws still in the implants. So yes, there are patients
that in fact, there’s a good reason to be concerned. There’s good reason to be fearful
about what can happen. And another example, this is a patient I treated in 1983/1984,
right when implants kind of first came into the U.S. market. I did a reconstruction on
him, we did some implants on the lower right to replace his first molar and a poor quality
second premolar. But on the upper left we didn’t have a lot of bone grafting techniques
in those days at all, there was really only enough room to get one implant in the upper
second premolar site on his left side. So I restored the upper left with just a second
bicuspid occlusion. Now, he called me one day and said, “You know, that tooth is loose.”
The only problem was the implants in this one weren’t screw retained. In other words
the abutments didn’t use screws, you actually cemented them into the implants. So I thought,
“Well, maybe the cement came loose.” So when he came in, I wiggled the tooth, wiggled
the tooth to see if I could figure out what was wiggling and all of the sudden pop and
I looked in his mouth with a mirror and this is what I was looking at, and what he had
done is he had broken the implant in half. And in fact the abutment had remained cemented
to the top of the implant. So absolutely there are patients that we need to be fearful about.

2 thoughts on “Diagnosis and Research of Dental Wear”

  1. oh here we go again All this lecture on what could happen and find out more by paying. Only from The US dentists. Today there are hundreds of forums and FB pages that share for free keep stuck in your little world where everything is about money..

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