Advanced tooth wear: restoration using a double-veneer technique

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Caitlin Walsh
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1 Advanced tooth wear: restoration using a double-veneer technique J. FOLEY, D.J.P. EVANS SUMMARY. The present case describes the management of significant tooth wear in a 13-year-old boy who presented following excessive consumption of carbonated drinks, accompanied by a frothing habit. The case demonstrates an alternative approach to the management of tooth wear, using a double-veneer technique, and emphasises the importance of recognition and early intervention in cases of dental erosion. KEY WORDS. Advanced tooth wear, Veneer technique. Introduction Tooth wear is common in adolescents: with recent dental surveys reporting tooth wear with dentine exposure in nearly 30% of 14-year-olds [O Brien, 1994; Bartlett et al., 1998]. Furthermore, the problem of tooth wear in children and adolescents appears to be increasing, as highlighted by the National Child Dental Health Survey [O Brien, 1994] and other surveys [Bartlett, 1998]. The major aetiological factor appears to be erosion from acidic drinks, either as pure fruit juices, squash or as carbonated drinks [Asher and Read, 1987; Shaw and Smith, 1994; Zero, 1996]. Tooth wear is characterised by tooth surfaces that are smooth, polished and rounded. It is imperative that signs of tooth wear are recognised early, allowing preventive measures to be instituted, with identification of aetiological factors [Nunn et al., 1996]. This emphasises the importance of regular attendance for check-ups and early recognition of tooth wear by the clinician. When treatment planning, aetiological factors need to be addressed first, prior to complex and expensive restorative techniques. The present case details the restoration of advanced tooth wear using a double-veneer technique, which requires minimal tooth preparation and conserves the remaining tooth structure. Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee, UK Case report A 13-year-old Caucasian male was referred by his general dental practitioner concerning tooth wear affecting his maxillary central and lateral permanent incisor teeth. The patient s main complaint was the appearance of these teeth and the thermal sensitivity he experienced when eating. His dietary history revealed excessive consumption of carbonated drinks at regular intervals, throughout most days. Further, he had the habit of frothing the drink around his teeth prior to swallowing. History revealed neither evidence of gastro-oesophageal reflux nor of any eating disorder. The reason for the delay in presentation for dental treatment remains unknown, given the patient s apparent regular attendance for dental inspections. It may be significant, however, that the patient had recently changed dentist and his new dental practitioner who recognised the problem was a recent dental graduate. Medically, the patient had Nail-Patella syndrome, an autosomal dominant trait characterised by dysplastic nails, absent or hypoplastic patellae, iliac horns and in some cases, nephropathy. Osteoarthritis is a complication that develops in adult life. Otherwise his medical history was unremarkable. Extra-oral examination revealed no abnormalities. Intra-oral examination revealed the following teeth to be present (FDI notation): EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/

$There was marked tooth wear affecting the palatal surfaces of 11 and 21, with near pulpal exposure of 21, and fracture of the incisal edges with a consequent loss of overbite and an edge-to-edge$

2 J. FOLEY, D.J.P. EVANS 17, 16, 15, 14, 13, 12, 11, 21, 22, 23, 24, 25, 26, 27; 37, 36, 35, 34, 33, 32, 31, 41, 42, 43, 44, 45, 46, 47. Oral hygiene was only fair and there was a marginal gingivitis, which was a persistent problem throughout treatment. Caries was present in 16, 26 and 46, and 36 presented as carious retained roots. Evidence of enamel decalcification was seen labially in 12 and 22 at the cervical margins. There was marked tooth wear affecting the palatal surfaces of 11 and 21, with near pulpal exposure of 21, and fracture of the incisal edges with a consequent loss of overbite and an edge-to-edge anterior occlusal relationship (Fig. 1, 2). There were no other areas of tooth wear.the patient had a Class I occlusion, although there was a crossbite affecting 12 and 42 and a unilateral posterior cross-bite without displacement on the right. All anterior teeth gave positive responses to electric and thermal pulp testing, although 21 subsequently became non-vital with abscess formation. Uncomplicated crown fractures affected 31, 32 and 41, with no signs or symptoms of loss of vitality in these teeth. Radiographic examination revealed that all permanent teeth were present. The following treatment plan was formulated. - Dietary analysis and advice. - Temporary restoration of 11 and 21 palatal surfaces. - Restoration of 31, 32 and Upper removable appliance (URA) to correct crossbite 12 and decrease the overbite. - Restoration of 11 and 21 using gold palatal veneers and labial ceramic veneers. - Extraction of 36 retained roots, using inhalation sedation and local anaesthetic. Review The patient s general dental practitioner was asked to provide preventive care and restorative treatment for the caries affecting 16, 26 and 46 as well as removal of the carious roots of 36. Following dietary analysis, advice was given regarding limitation of carbonated drink intake to meal-times and its substitution with either milk or water. The patient was also advised to drink any carbonated drinks through a straw, positioning the straw posteriorly in the mouth and to avoid toothbrushing for 20 minutes after juice ingestion. In addition, a daily neutral sodium fluoride mouthwash was prescribed. A conventional glass ionomer cement [Chemfil Superior ] was used as a temporary restoration of the palatal surfaces of 11, 21. Subsequently, 31, 32 and 41 were restored with composite resin [Spectrum ], under rubber dam, and an upper removable appliance was fitted to decrease the overbite and to correct the crossbite affecting 12, with appropriate care instructions being given. During the orthodontic treatment period, the patient presented with pain in the upper left dental quadrant. Clinical examination revealed a fluctuant swelling associated with 21 and radiographic examination revealed a periapical radiolucency associated with 21. The pulp of 21 was extirpated under local analgesia and a calcium hydroxide intracanal dressing [Hypocal ] was placed. At the end of orthodontic treatment (after 3 months) the 21 was permanently obturated with multiple gutta percha points and root canal sealant [Tubliseal ] (Fig. 3). Minimal tooth preparation of 11 and 21 was undertaken and an impression taken using an FIG.1- Labial view showing fracture of the incisal edges of 11 and 21 and loss of overbite at initial presentation. FIG.2- Occlusal view showing palatal wear of 11 and 12 with near pulpal exposure of 21 at initial presentation. 140 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/2001

RESTORATION OF ADVANCED TOOTH WEAR addition silicone impression material [Express ] in a non-perforated, close-fitting special tray.

Cast metal palatal restorations were fabricated using a gold alloy [Mattident 60 ] whose fitting surfaces were sandblasted, and the veneers cemented with a dual-affinity resin [Panavia-21 ] (Fig. 4).

Labial ceramic veneers [Vita Omega 900 ] were fabricated, silane coated and cemented using a dual-cure FIG.3- Periapical radiograph of 21 following endodontic treatment at 24 months.

3 RESTORATION OF ADVANCED TOOTH WEAR addition silicone impression material [Express ] in a non-perforated, close-fitting special tray. The working cast was mounted on a semi-adjustable articulator opposite the study cast of the mandibular arch. Cast metal palatal restorations were fabricated using a gold alloy [Mattident 60 ] whose fitting surfaces were sandblasted, and the veneers cemented with a dual-affinity resin [Panavia-21 ] (Fig. 4). In those areas that extended past the natural tooth tissue, core porcelain [Vita Omega Core Opaquer ] was bonded to the casting (Fig. 5). Labial ceramic veneers [Vita Omega 900 ] were fabricated, silane coated and cemented using a dual-cure FIG.3- Periapical radiograph of 21 following endodontic treatment at 24 months. cement [Duo Cure ]. At the final visit, the retained carious roots of 36 were elevated using local anaesthetic under inhalation sedation, as the patient was apprehensive about dental extractions. At 24-month review, all restorations remained functional and aesthetically acceptable (Fig. 6), although there was the continuing problem of poor oral hygiene which persisted at 48-month review. Despite this, the restorations at 48 months were still satisfactory (Fig. 7). Discussion Tooth wear is common in adolescents, with the major aetiological factor being erosion from acidic drinks, either as pure fruit juices, fruit squash or as carbonated drinks [Asher and Read, 1987; Shaw and Smith, 1987; Zero, 1996]. Indeed, data supplied by the Soft Drinks Manufacturers demonstrates a doubling of sales of soft drinks in the United Kingdom since 1970 and a seven-fold increase since 1950 [British Soft Drinks Association, 1991; Shaw and Smith, 1994]. Sales to adolescents and children account for 65% of this total [Rugg-Gunn et al., 1984; Shaw and Smith, 1994]. Soft drinks have been reported to provide as much as one fifth of added sugars in the diet of year old children [Rugg-Gunn et al., 1986]. In recent years there has also been an increasing popularity in so called designer drinks, with increased consumption of sports drinks and alcoholic soft drinks, both of which have been associated with higher levels of dental erosion [Hughes et al., 1997; Milosevic et al., 1997; O Sullivan and Curzon, 1998]. It is highly likely FIG. 4 - Palatal view of 11 and 21 showing gold palatal restorations at 24 months. FIG. 5 - Labial view of 11 and 21 showing core porcelain bonded to the palatal metal castings. EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/

J. FOLEY, D.J.P. EVANS FIG. 6 - Labial view of 11 and 21 after coronal restoration at 24 months. FIG. 7 - Labial view of 11 and 21 after coronal restoration at 48 months.

This was undoubtedly the situation with the present case, as opposed to other causes of erosion, such as eating disorders [Burke et al.

4 J. FOLEY, D.J.P. EVANS FIG. 6 - Labial view of 11 and 21 after coronal restoration at 24 months. FIG. 7 - Labial view of 11 and 21 after coronal restoration at 48 months. that the increase in availability and consumption of soft drinks accounts for the high incidence of tooth wear observed in the UK [O Brien, 1994; Nunn, 1997]. This was undoubtedly the situation with the present case, as opposed to other causes of erosion, such as eating disorders [Burke et al., 1996]; rumination [Gilmour and Beckett, 1994]; gastro-oesophageal reflux [Barlett et al., 1996a; Bartlett et al., 1996b]; and the recent surge in the use of designer drugs [Duxbury, 1993]. In the present case, in addition to tooth wear being attributed to excessive ingestion of carbonated drinks, the problem was compounded by the patient frothing the drink between his teeth prior to swallowing. As such, the initial aim was to prevent acid reaching his teeth. Specific recommendations which were made included reducing the frequency of fizzy drink intake; drinking more water or milk; not to froth drink between the teeth; avoiding sipping drinks and to use a straw positioned palatal to the upper incisors [Edwards et al., 1998]; not drinking carbonated drinks prior to bedtime [Millward et al., 1994] and avoiding brushing for 20 minutes after drinking [Davies and Winter, 1980]. In addition, a neutral daily sodium fluoride mouthwash was prescribed [Kelly and Smith, 1988]. Prior to restoring 11 and 21, the overbite was reduced using an URA to reduce the overbite [Rickett and Smith, 1993; Hussey et al., 1994]. Additionally, a Z spring was incorporated into the appliance to procline 12. The principle of creating space between the upper and lower incisors is based upon the Dahl appliance [Dahl and Krogstad, 1982; Dahl and Krogstad, 1983]. Having decreased the overbite and corrected the crossbite with an URA, 11 and 21 were restored using separate labial and palatal adhesive restorations [Bishop et al., 1996]. This technique requires minimal tooth preparation and conserves the remaining tooth structure. Furthermore, the metal coverage of the palatal surfaces provides a durable and non-abrasive occluding surface [Al- Hiyasat et al., 1998]. To overcome the aesthetically unacceptable grey-out [Saunders, 1989] that occurs with the extension of metal beyond the incisal edge even with opaque resin cements, core porcelain was added to the areas of metal extending beyond the natural tooth structure. Nickel-chrome veneers are an alternative and in one series, over 300 such veneers were placed in a Paediatric Department using Panavia-21 and over a 10-year period, it was reported that only two of these veneers debonded [Harley, 1999]. Separate labial ceramic veneers were chosen to ensure a good aesthetic result. Ceramics are routinely treated to allow their use as an adhesive restoration [Walls, 1995] resulting in reports of very low levels of failure after up to five years in use [McLaughlin and Morrison, 1988]. An alternative to the double-veneer technique in the treatment of tooth wear is the dentine-bonded crown, which also makes use of adhesive techniques. Advantages include excellent aesthetics and minimal tooth preparation [Burke et al., 1995], as well as good fracture resistance [Burke and Watts, 1994], minimal pulpal effects [Milosovic and Jones, 1996] and reduced microleakage [Saunders et al., 1997]. They are not, however, suitable for crown preparations with subgingival margins. To date, assessment of the clinical performance of dentine-bonded crowns 142 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/2001

5 RESTORATION OF ADVANCED TOOTH WEAR appears promising [McLaughlin and Morrison, 1988; Qualtrough et al., 1997], although their longterm success is unknown as no clinical trials have been carried out. The question of maintaining good oral hygiene is pertinent to this case. Oral hygiene was not as good as desirable but at the same time there was a severe problem with the loss of tooth tissue of the anterior teeth. While it is usual not to place veneers unless the oral hygiene is very good, sometimes the longer term care of a patient s dentition requires immediate restorative treatment. In the present case while oral hygiene has improved it could still be better. Nevertheless, this young man is now a better dental patient and is beginning to take more care of his teeth. This might well not have been the case if his anterior maxillary teeth had been left untreated. This case illustrates the importance of early recognition of tooth wear to prevent the need for complex and expensive restorative techniques which subject the patient to a lifetime of restorative care. It also demonstrates the management of tooth wear using an adhesive double-veneer technique and emphasises that prevention remains the cornerstone in the management of dental erosion. References Al-Hiyasat AS, Saunders WP, Sharkey SW, Smith GN, Gilmour WH. Investigation of human enamel wear against four dental ceramics and gold. J Dent 1998; 26: Asher R, Read MJF. Early enamel erosion in children associated with the excessive consumption of citric acid. Brit Dent J 1987; 162: Bartlett DW, Evans DF, Anggiansah A, Smith BGN. A study of the association between gastro-oesophageal reflux and palatal dental erosion. Brit Dent J 1996a; 181: Bartlett DW, Evans DF, Smith BGN. The relationship between gastro-oesophageal reflux disease and dental erosion. J Oral Rehab 1996b; 23: Bartlett DW, Coward PY, Nikkah C, Wilson PF. The prevalence of tooth wear in a cluster sample of adolescent schoolchildren and its relationship with potential explanatory factors. Brit Dent J 1998; 184: Bishop K, Bell M, Briggs P, Kelleher M. Restoration of a worn dentition using a double-veneer technique. Brit Dent J 1996; 181; 123. British Soft Drinks Association. Report of Seminar in Heidelberg, 1991; Factsheet number Burke FJT, Watts DC. Fracture resistance of teeth restored with dentine-bonded crowns. Quintess Intern 1994; 25: Burke FJT, Qualtrough AJE, Hale RW. The dentine-bonded ceramic crown: an ideal restoration? Brit Dent J 1995; 179: Burke FJT, Bell TJ, Ismail N, Hartley P. Bulimia implications for the practising dentist. Brit Dent J 1996; 18: Dahl B L, Krogstad O.The effect of a partial bite-raising splint on the occlusal face height. Acta Odont Scand 1982; 40: Dahl BL, Krogstad O. The effect of a partial bite-raising splint on the inclination of upper and lower front teeth. Acta Odont Scand 1983; 41: Davies WB, Winter PJ. The effect of abrasion on enamel and dentine after exposure to dietary acid. Brit Dent J 1980; 148: Duxbury AJ. Ecstasy dental implications. Brit Dent J 1993; 175: 38. Edwards M, Ashwood RA, Littlewood SJ, Brocklebank LM, Fung DE. A videofluoroscopic comparison of straw and cup drinking: the potential influence on dental erosion. Brit Dent J 1998; 185: Gilmour AG, Beckett HA. The voluntary reflux phenomenon. Brit Dent J 1994; 175: Harley K.Tooth wear in the child and youth. Brit Dent J 1999; 186: Hughes K, Mackintosh AM, Hastings G, Wheeler C, Watson J, Inglis J. Young people, alcohol and designer drinks: quantitative and qualitative study. Brit Med J 1997; 314: Hussey DL, Owain CR, Kime DL. Treatment of anterior tooth wear with gold palatal veneers. Brit Dent J 1994: 176: Kelly MP, Smith BGN. The effect of remineralising solutions on tooth wear in vitro. J Dent 1988; 16: McLaughlin G, Morrison JE. Porcelain fused to tooth the state of the art. Restorat Dent 1988; 4: Millward A, Shaw L, Smith AJ, Rippin JW, Harrington E. The distribution and severity of tooth wear and the relationship between erosion and dietary constituents in a group of children. International J Paed Dent 1994; 4: Milosevic A, Jones C. Use of resin-bonded ceramic crowns in a bulimic patient with severe tooth erosion. Quintess Intern 1996; 27: Milosevic A, Kelly MJ, McLean AN. Sports supplement drinks and dental health in competitive swimmers and cyclists. Brit Dent J 1997; 182: Nunn JH, Shaw L, Smith AJ. Tooth wear dental erosion. Brit Dent J 1996; 180: Nunn JH. Prevalence of dental erosion and the implications for oral health. Eur J Oral Scien 1997; 104: O Brien M. Children s dental health in the United Kingdom London: Office of Population Censuses and Surveys; O Sullivan EA, Curzon MEJ. Dental erosion associated with the use of alcopop a case report. Brit Dent J 1998; 184: EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/

6 J. FOLEY, D.J.P. EVANS Qualtrough AJE, Burke FJT, Wilson NHG. A retrospective evaluation of resin-bonded ceramic crowns. J Dent Res 1997; 76: Rickett DNJ, Smith BGN. Minor axial tooth movement in preparation for fixed prostheses. Europ J Prosthod Resorat Dent 1993; 1: Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent school children. Arch Oral Biol 1984; 29: Rugg-Gunn AJ, Lennon MA, Brown J. Sugar consumption in the United Kingdom. Brit Dent J 1986; 161: Saunders WP. Resin bonded bridgework: a review. J Dent 1989; 17: Saunders WP, Patel SN, Burke FJT. Microleakage of dentinebonded crowns. J Dent 1997; 76: 1047, Abs Shaw L, Smith AJ. Erosion in children: an increasing clinical problem? Dent Update 1994; 21: Walls AWG. The use of adhesively retained all-porcelain veneers during the management of fractured and worn anterior teeth: part 2. Clinical results after 5 years of followup. Brit Dent J 1995; 178: Zero DT. Aetiology of dental erosion extrinsic factors. Eur J Oral Scien 1996; 104; EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY 3/2001

Restoration of the worn dentition

Clin Dent Rev (2017) 1:4 https://doi.org/10.1007/s41894-017-0003-3 TREATMENT Restoration of the worn dentition Paul King 1 Received: 16 March 2017 / Accepted: 31 May 2017 / Published online: 30 June 2017