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Abrasion and Erosion | Human Tooth | Dentistry Branches

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CLINICAL APPLICATION A Comprehensive and Conservative Approach for the Restoration of Abrasion and Erosion. Part I: Concepts and Clinical Rationale for Early Intervention Using Adhesive Techniques Didier Dietschi Senior Lecturer, Department of Cariology and Endodontics, School of Dentistry, University of Geneva, Switzerland Adjunct Professor, Department of Comprehensive Care, Case Western University, Cleveland, Ohio, USA Private practice and Education Center – The Geneva Smile Center, Switzerla
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  CLINICAL APPLICATION 2 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 ã NUMBER 1 ã SPRING 2011 A Comprehensive and ConservativeApproach for the Restorationof Abrasion and Erosion.Part I: Concepts and ClinicalRationale for Early InterventionUsing Adhesive Techniques Didier Dietschi Senior Lecturer, Department of Cariology and Endodontics, School of Dentistry,University of Geneva, SwitzerlandAdjunct Professor, Department of Comprehensive Care, Case Western University,Cleveland, Ohio, USAPrivate practice and Education Center – The Geneva Smile Center, Switzerland Ana Argente Assistant, Department of Cariology and Endodontics and Lecturer,Department of Prosthodontics, School of Dentistry, University of Geneva, Switzerland Correspondence to: Didier Dietschi Deptartment of Cariology and Endodontics, School of Dentistry, 19 Rue Barthélémy Menn, 1205 Geneva, SwitzerlandTel: +41.22.38.29.165/150; Fax:+41.22.39.29.990; e-mail: ddietschi@unige.ch or ddietschi@genevasmilecenter.ch  DIETSCHI/ARGENTE 3 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 ã NUMBER 1 ã SPRING 2011   Abstract Tooth wear represents a frequent pathol-ogy with multifactorial origins. Behavior-al changes, unbalanced diet, variousmedical conditions and medications in-ducing acid regurgitation or inuencingsaliva composition and ow rate, triggertooth erosion. Awake and sleep bruxism,which are widespread nowadays withfunctional disorders, induce attrition. Ithas become increasingly important todiagnose early signs of tooth wear sothat proper preventive, and if needed,restorative measures are taken. Suchdisorders have biological, functional,and also esthetic consequences. Fol-lowing a comprehensive clinical evalu-ation, treatment objectives, such as aproper occlusal and anatomical schemeas well as a pleasing smile line, are usu-ally set on models with an anterior teethfull-mouth waxup, depending on the se-verity of tissue loss. Based on the newvertical dimension of occlusion (VDO),combinations of direct and indirect res-torations can then help to reestablishanatomy and function.The use of adhesive techniques andresin composites has demonstrated itspotential, in particular for the treatmentof moderate tooth wear. Part I of this ar-ticle reviews recent knowledge and clin-ical concepts dealing with the variousforms of early restorative interventionsand their potential to restrict ongoing tis-sue destruction. (Eur J Esthet Dent 2011;6:XXX–XXX)  3 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 ã NUMBER 1 ã SPRING 2011  CLINICAL APPLICATION 4 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 ã NUMBER 1 ã SPRING 2011 Introduction Excessive abrasion (attrition) and ero-sion are two common issues of dentalhard tissues, which affect an increas-ing number of patients. 1-2 It can alsobe considered a growing challengein dentistry, because in such patients(particularly those affected by severeparafunctions) the etiology can rarelybe successfully and permanently elimi-nated. 3-5 It therefore implies continuousmonitoring to control related patholo-gies. The most frequent causes of ero-sion are unbalanced dietary habits withhigh consumption of acidic food anddrinks (carbonated drinks, fruits, fruitjuices, vinegar; etc.) as well as abnor-mal intrinsic acid production in disor-ders such as in bulimia nervosa, acidregurgitation, and hiatal hernia. Insuf-cient saliva ow rate or buffer capac-ity and in general saliva compositionchanges induced by various diseases,medications, and aging are other etio-logical co-factors. 6-9  Regarding abrasion and attrition,awake and sleep bruxisms are two differ-ent forms of parafunctional activities thatcan severely impact tooth integrity; 4-5  preventive and restorative measures aremandatory to correct and limit the extentof further tissue and restoration destruc-tion. An important clinical nding is thata large number of patients with hard tis-sue loss present combined etiologies,challenging the dental team to provide amultifactorial preventive and restorativeapproach. 1-9 The dental consequences of abrasionand erosion are manifold:  loss of enamel with progressive ex-posure of large dentin surfaces  loss of occlusal, facial, and lingualtooth anatomy with impact on func-tion and esthetics  shortening of teeth with impact onfunction and esthetics (ie, change insmile line, loss of embrasures)  adaptive teeth displacement withimpact on occlusion and esthetics  discoloration of exposed dentin sur-faces  tooth sensitivity and pulpal compli-cations  increased risk of decay  loss of restoration marginal adapta-tion and restoration fracture.Due to the signicant impact of abnor-mal abrasion and erosion on dental bio-mechanics and health, the challenge isthat prevention and treatment should in-volve different specialties, starting withpreventive measures and ending upwith full-mouth rehabilitation. Intermedi-ate stages (slight to moderate erosion/ abrasion) require other clinical meas-ures, such as various forms of adhesiveand partial restorations.The aim of Part I of this article is toreview recent knowledge and clinicalconcepts dealing with the various formsof early restorative interventions andtheir potential to restrict ongoing tissuedestruction. The impact of different re-storative techniques on remaining toothstructure and biology will also be ad-dressed.  DIETSCHI/ARGENTE 5 THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRYVOLUME 6 ã NUMBER 1 ã SPRING 2011 A comprehensive treat-ment approach with focuson early intervention A modern approach to the treatment oftooth wear is to prevent the progressionof this disease before a full prostheticrehabilitation would be needed, causinglarge amounts of additional tooth sub-stance to be removed. Such a treatmentapproach would become totally ineffec-tive because of potential biological com-plications 10-11 and inadequate biome-chanical rationale. A modern treatmentmodel involves three steps: 1) Comprehensive etiologicalclinical investigation:  diet analysis  identication of general/medicalrisks or disorders (ie, bulimia ner-vosa, gastric reux, hiatal hernia,medications)  identication of local risk factors,such as:- bruxism (awake and sleep bruxisms,other habits);- abnormal occlusal conditions;- carious activity;- periodontal diseases;- insufcient saliva ow, buffer capac-ity, compositional changes. 2) Treatment planning andexecution:  full case analysis on mounted models  partial or full waxup  setup of a new vertical dimension ofocclusion (VDO)  setup of a new smile line  posterior (direct or indirect) restora-tions  anterior (direct or indirect) restora-tions. 3) Maintenance:  protective night guard or other thera-peutic appliance  regular checkups  repair or replacement of restorations  additional restorations.This treatment sequence enables themanagement of severe tooth wear anderosion as it represents a logical thera-peutic approach. It starts with a detailedetiology search and then continues witha full functional and esthetic analysis (onmodels), which, based on the amountand location of missing tissue, helps toselect the best restorative procedureand to program the adequate teeth anat-omy, smile line, and occlusal scheme.The restorative options at hand com-prise:  direct partial composite restorations  indirect partial restorations  indirect, partial ceramic restorations  indirect, full ceramic restorations.The obvious disadvantages of indirectceramic/porcelain-fused-to-metal (PFM)restorations are the rather invasive ap-proach combined with more dramaticfailure patterns 12 (Fig 1). Therefore, us-ing more conservative restorations suchas partially direct and indirect restora-tions, seems to have an undeniable ad-vantage and promising impact on thetreatment of severe abrasion and ero-sion. 13-18
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