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ePaper created 2018-02-16, 10:54:19 | version 1.38.0
aesthetic and restorative dentistry case report | patterns observed with conventional prosthetic res toration,10, 11 using more conservative restorations, such as partial direct and indirect restorations, ap pears to have irrefutable advantages and promising outcomes in the treatment of severe abrasion and erosion.12–14 Dahl’s concept and controlling the vertical dimension of occlusion The idea of increasing the vertical dimension of occlu sion (VDO) to treat or restore patients with abnormal tooth wear has been described and applied for a long time; one of the first clinicians to promote this tech nique was Dahl, who published many articles on this topic.15 His approach was to use a metal appliance to elevate the occlusion and allow teeth to move pas sively until they are again in occlusion and then create space to restore the teeth stabilised by the appli ance.15 The dental movements are intended to occur by combined supraeruption of occlusally free teeth together with simultaneous alveolar growth and in trusion of teeth maintaining contacts. It was shown that such phenomena would occur in a significant proportion of patients treated according to this con cept16 and the outcomes of such treatment have been Fig. 1: Comprehensive treatment scheme for anterior and posterior tooth wear or erosion. The length of the anterior teeth is reduced by combined wear or erosion (1). The VDO needs to be augmented (2). On the models and based on a wax-up, a new anterior guidance and smile line are established (3), from which an index is made and transferred to the mouth when proceeding with posterior restorations (4). Three different conditions are encountered in the posterior areas: (a) no or minimal tooth loss (occlusal stops are made with composite of any type); (b) moderate tooth loss and/or small to mediumsized restorations (occlusal morphology is re-established with a hybrid composite and direct technique); and (c) severe tooth loss and large metal-based restorations (occlusal morphology is re-established with indirect tooth-coloured restorations —overlay). ment, dentin sensitivity, as well as an increased risk of decay and premature loss of marginal adaptation of the restoration. The significant impact of tooth wear on occlusion, function and aesthetics leads the patient to seek advice and intervention. The bio mechanical challenge shall entail a range of treat ments involving different specialties, from preventive measures to fullmouth rehabilitation. Intermediate stages (slight to moderate erosion or abrasion) re quire other clinical measures, such as various forms of adhesive and partial restorations. The aim of this paper is to present a sound clinical concept for ad dressing various forms of early restorative interven tion and their potential to restrict ongoing tissue destruction. A comprehensive treatment approach The modern approach to the treatment of tooth wear aims to stop its progression before full prosthetic re habilitation becomes indicated, which would require the removal of large amounts of additional tooth sub stance with potential biological complications10, 11 and a rather inadequate biomechanical rationale. The approach involves three steps: 1. a comprehensive etiological clinical investigation, including diet analysis and identification of gen eral/medical and local risk factors; 2. treatment planning and execution, including a proper functional and aesthetic waxup defining the new smile line and tooth anatomy, transferred then to the mouth with a combination of direct and indirect restorations; and 3. a maintenance program, including a protective night guard and, potentially, repair or replacement of restorations over a medium or longterm time frame. The restorative options at hand comprise direct par tial composite restorations, indirect partial compos ite or ceramic restorations, and indirect fullceramic restorations. Considering the more dramatic failure Fig. 2a Figs. 2a–c: Pre-op situation showing moderate to severe tooth wear, due to combined abrasion and erosion aetiologies. However, the amount of tissue loss does not speak in favour of a conventional prosthetic solution; rather, an interceptive solution using direct composite restorations would be used in this case. Fig. 2b Fig. 2c cosmetic dentistry 1 2017 27